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Acknowledgment of Commercial Support
This activity is supported by educational grants from BTG International, Inc. and Sanofi Genzyme.
Advances In™ Supportive Care: An Onco-Nurses Guide to Managing Cancer Treatment-Related Toxicities
Release Date: June 29, 2018
Expiration Date: June 29, 2019
Media: Internet - based
Acknowledgment of Commercial SupportThis activity is supported by educational grants from BTG International, Inc. and Sanofi Genzyme.
Instructions for This Activity and Receiving Credit
This educational program is directed toward nurses and other healthcare professionals who treat patients with cancer.
- Describe the impact and occurrence of cancer-related morbidity related to use of chemotherapy, including chemotoxicity, chemotherapy-induced nausea and vomiting, venous thromboembolism, hematologic deficiencies, and anorexia-cachexia.
- Discuss emerging clinical trial data and evidence-based recommendations on supportive care strategies as they apply to the management of cancer-related morbidity and treatment-related toxicities.
- Apply clinical practice guidelines in the context of specific patient cases to optimize supportive care to optimize patient awareness, appropriate monitoring, and optimal management of treatment-related adverse events in at-risk patients.
- Optimize multidisciplinary supportive care strategies in the total oncologic care of patients with solid tumors and hematologic malignancies through patient counseling, education, and a caring approach.
Thoracic Oncology Nurse Practitioner
Abramson Cancer Center
Hospital of the University of Pennsylvania
Disclosures: Consultant: AbbVie; Speaker’s Bureau: Helsinn, Merck, AstraZeneca, Takeda
Nurse Practitioner, Malignant Hematology
Moffitt Cancer Center
Disclosure: Dr. Sara Tinsley has no relevant financial relationships with commercial interests to disclose.
The staff of Physicians’ Education Resource®, LLC, have no relevant financial relationships with commercial interests to disclose.
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As a sponsor accredited by the ACCME, it is the policy of PER® to ensure fair balance, independence, objectivity, and scientific rigor in all of its CME/CE activities. In compliance with ACCME guidelines, PER® requires everyone who is in a position to control the content of a CME/CE activity to disclose all relevant financial relationships with commercial interests. The ACCME defines “relevant financial relationships” as financial relationships in any amount occurring within the past 12 months that creates a COI.
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Off-Label Disclosure and Disclaimer
This CME/CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME/CE activity is for continuing medical and nursing education purposes only, and is not meant to substitute for the independent clinical judgment of a physician or nurse relative to diagnostic, treatment, or management options for a specific patient’s medical condition. The opinions expressed in the content are solely those of the individual faculty members, and do not reflect those of PER® or any of the companies that provided commercial support for this activity.
PER Pulse Recap™PER Pulse Recap (1 of 3)
This first of 3 PER Pulse™ Recaps reviews the management of CINV and chemotherapy-induced peripheral neuropathy (CIPN). Below are some highlights from the activity, featuring video clips from Beth Eaby-Sandy, MSN, CRNP, OCN:
For patients receiving highly emetogenic chemotherapy, a 3-drug regimen of a neurokinin-1 (NK-1) receptor antagonist, a 5-HT3 receptor antagonist, and dexamethasone is typically administered on day 1 prior to chemotherapy initiation to prevent acute emesis, and further treatment is given on days 2, 3, and 4 to prevent delayed emesis.
- Similar regimens are often used for moderately emetogenic treatment, but the NK-1 receptor antagonist may be skipped on day 1, and delayed emesis treatment is recommended only on days 2 and 3.
- Breakthrough CINV, occurring within 5 days of chemotherapy administration despite appropriate prophylaxis, can be treated by adding another agent to the current regimen, provided it is from a different drug class, such as an antipsychotic (ie, olanzapine), a benzodiazepine (ie, lorazepam), a cannabinoid (eg, dronabinol), a phenothiazine (eg, prochlorperazine), and a dopamine antagonist (ie, haloperidol or metoclopramide).
CIPN occurs in approximately 30% to 40% of patients treated with neurotoxic chemotherapy, such as platinum agents, taxanes, and vinca alkaloids.
- Symptoms can range from numbness or tingling, to paresthesia, to burning pain, and most commonly develops in a dose-dependent fashion after several cycles of therapy.
- The majority of CIPN is reversible, but 30% of patients may still have some level of CIPN at least 6 months after completion of chemotherapy.
- No regimens have been discovered to prevent CIPN, and only duloxetine has been shown to modestly reduce neuropathic pain due to CIPN. Both pregabalin and gabapentin are also sometimes used to treat CIPN because they have activity in patients with diabetic peripheral neuropathy.
PER Pulse Recap (2 of 3)
This second of 3 PER Pulse™ Recaps reviews the management of TLS and methotrexate toxicity. Below are some highlights from the activity, featuring video clips from Sara Tinsley, PhD, ARNP, AOCN:
TLS is a serious metabolic complication that can occur after the initiation of cancer therapy as a result of rapid cell lysis, causing hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia, which can lead to severe renal impairment, cardiac dysfunction, seizure, or even death.
- TLS is associated with a large number of risk factors related to the patient, the tumor, and the treatment.
- TLS can occur as either laboratory TLS (without symptoms) or clinical TLS (with symptoms). Both require treatment to resolve the TLS, but clinical TLS requires more urgent management.
- Treatment of TLS includes hydration, electrolyte monitoring, and correction as needed, and management of hyperuricemia with allopurinol or rasburicase. Allopurinol requires treatment 2 or 3 days prior to chemotherapy and continuation for 10 to 14 days after treatment initiation, whereas 1 dose may be all that is needed with rasburicase, which is indicated for patients with high-risk TLS features.
- A retrospective study showed that patients receiving rasburicase in a real-world setting were more successfully treated for hyperuricemia and had shorter hospital stays and lower costs than patients treated with allopurinol.
High-dose methotrexate (>500 mg/m2) can result in toxicity across organ systems, including gastrointestinal, hematologic, hepatic, pulmonary, and renal toxicities.
- To prevent unacceptable toxicity, high-dose methotrexate is administered with supportive care measures that generally include intravenous hydration, urine alkalinization, leucovorin rescue, and suspension of other drugs that might interfere with methotrexate clearance.
- Because methotrexate is excreted by the kidneys, patients with impaired renal function who are taking methotrexate are at particular risk of acute kidney injury due to intratubular crystal formation.
- For patients with toxic plasma methotrexate levels, a single dose of glucarpidase, the only agent indicated for the treatment of toxic plasma methotrexate concentrations, can be administered. Glucarpidase approval was based on safety results from 290 patients from 2 single-arm, multicenter trials and efficacy results from a subset of 22 evaluable patients from 1 of the 2 trials. Among patients with methotrexate toxicity, administration of glucarpidase resulted in >97% reduction in methotrexate levels within 15 minutes.
PER Pulse Recap (3 of 3)
This third of 3 PER Pulse™ Recaps reviews the management of hematologic deficiencies and venous thromboembolism (VTE). Below are some highlights from the activity, featuring video clips from both Beth Eaby-Sandy, MSN, CRNP, OCN, and Sara Tinsley, PhD, ARNP, AOCN:
Because chemotherapy is typically myelosuppressive, cytopenias in the myeloid lineage—specifically, neutropenia, anemia, and thrombocytopenia—are well documented among patients receiving chemotherapy.
- Myeloid growth factors (granulocyte colony-stimulating factor [eg, filgrastim] and granulocyte-macrophage colony-stimulating factor [ie, sargramostim] are commonly used to treat neutropenia or febrile neutropenia, a major dose-limiting toxicity that occurs in 25% to 40% of patients receiving first-line chemotherapy.
- Anemia occurs in 30% to 90% of patients with cancer and is treated either with erythropoiesis-stimulating agents or transfusion with packed red blood cells.
VTE is a common but dangerous condition among patients with cancer. In a recent retrospective analysis, VTE developed in 13% of patients within 1 year of initiating outpatient chemotherapy. Moreover, VTE is the most frequent cause of death among patients with cancer in the first 30 days after surgery.
- VTE risk factors for patients with cancer can be divided into patient-related (eg, advanced age, obesity), cancer-related (eg, presence of metastases), and treatment-related (eg, chemotherapy, central venous access device) factors.
- Anticoagulation can be used prophylactically for patients at increased risk of VTE or for treatment of diagnosed VTE. The National Comprehensive Cancer Network recommends low-molecular-weight heparins (LMWHs; dalteparin and enoxaparin), fondaparinux, and unfractionated heparin for patients with cancer, regardless of whether the goal is VTE prophylaxis or treatment. Although all of these therapies are category 1 recommendations for prophylaxis, only dalteparin is a category 1 recommendation for therapeutic anticoagulation. For patients with diagnosed VTE who cannot or will not take LMWH, direct oral anticoagulants (DOACs)—edoxaban, apixaban, and rivaroxaban—are acceptable alternatives.
- LMWHs are often used because they are easily reversible and therapeutic monitoring is not needed, but daily or twice-daily subcutaneous administration is not appropriate for or acceptable to all patients. The DOACs are convenient due to their oral administration and no requirement for therapeutic monitoring, but they may be associated with a small but significantly increased risk of major bleeding compared with LMWHs.
For additional commentary about this topic and the Advances in™ Supportive Care: An Onco-Nurse’s Guide to Managing Cancer Treatment‒Related Toxicities activity, please visit www.gotoper.com.
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