A Quality Improvement Project to Increase Utilization of an Urgent Care Clinic for Cancer.

BACKGROUND: Nationally, patients with cancer experience high numbers of emergency department (ED) visits. Many ED visits may be prevented using cancer-specific urgent care services. OBJECTIVES: The purpose of this quality improvement initiative was to first assess the reasons that adult patients with cancer used the ED instead of an urgent care clinic for cancer (UCC-C). Second, an education program was developed and implemented to improve UCC-C use. METHODS: Using semistructured interviews pre- and postintervention (education program about ED/UCC-C use), this project described knowledge of adult patients with cancer about using the ED instead of the UCC-C. The project also evaluated the efficacy of the education intervention. FINDINGS: Pre- to postimplementation change showed an increase in patient UCC-C knowledge, patients who said they would present to the UCC-C, and patients who presented to the UCC-C for treatment. In addition, there was a decrease in adult patients with cancer who presented to the ED and were subsequently hospitalized.

Phase 2 study of CHOP-R-14 followed by 90Y-ibritumomab tiuxetan in patients with previously untreated diffuse large B-cell lymphoma.

The aim of this open-label, single-center, phase 2 study was to assess the efficacy and safety of dose-dense CHOP-R-14 followed by 90Y-ibritumomab radioimmunotherapy (RIT) in patients with previously untreated diffuse large B-cell lymphoma (DLBCL). A total of 20 patients, the majority presenting with high-risk characteristics, were enrolled to receive dose-dense cyclophosphamide, doxorubicin, vincristine, prednisone and rituximab every 14 days (CHOP-R-14), followed by 90Y-ibritumomab tiuxetan consolidation. Sixteen patients completed RIT consolidation (rituximab 250 mg/m2 on day 1 and day 7, 8, or 9, followed by a single injection of 90Y-ibritumomab). Complete response (CR) rates of 75 and 95% were observed after treatment with CHOP-R-14 and RIT, respectively; 4 of the 5 patients who achieved a partial response after CHOP-R-14 converted to CR following treatment with RIT. With a median follow-up of 89.7 months, the progression-free and overall survival rates for the cohort were 75 and 85%, respectively. Hematological adverse events were common following CHOP-R-14 and RIT, but they were manageable with treatment interruption. Therefore, this regimen achieved promising survival outcomes in high-risk DLBCL on long term follow-up, with manageable toxicity.

Granulocyte-macrophage colony stimulating factor-induced immune priming of cyclophosphamide, doxorubicin, vincristine, and prednisone with rituximab chemoimmunotherapy in previously untreated patients with diffuse large B-cell lymphoma and mantle cell lymphoma.

Granulocyte-macrophage colony stimulating factor (GM-CSF) has been shown to enhance CD20 antigen expression, augment antibody-dependent cell-mediated cytotoxicity, and stimulate immune cell proliferation. This may lead to an improved anti-tumor effect of rituximab while reducing the severity of chemotherapy-induced myelosuppression. We evaluated the safety and efficacy of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) in sequential combination with GM-CSF priming and rituximab in previously untreated patients (n = 39) with diffuse-large B-cell lymphoma (DLBCL) and mantle cell lymphoma (MCL). CHOP was administered every 21 days on day 1, GM-CSF 250 µg/m(2)/day on days 9 through 15, and rituximab 375 mg/m(2) on day 15 of each cycle. The overall response rate was 87%, with complete response in 64%. At a median follow-up of 84.3 months, the overall and progression-free survival rates were 54% and 49%, respectively. The most common toxicity was myelosuppression. Sequential combination of CHOP with GM-CSF priming and rituximab was feasible and effective, warranting further evaluation.

Safety and efficacy of combination therapy with fludarabine, mitoxantrone, and rituximab followed by yttrium-90 ibritumomab tiuxetan and maintenance rituximab as front-line therapy for patients with follicular or marginal zone lymphoma.

BACKGROUND: We conducted a single-institution phase II clinical trial evaluating the safety and efficacy of combination chemoimmunotherapy followed by radioimmunotherapy consolidation and rituximab maintenance as front-line treatment in indolent lymphomas. PATIENTS AND METHODS: We enrolled 20 patients with intermediate- to high-risk follicular lymphoma and 2 patients with marginal zone lymphoma. Treatment consisted of 4-6 cycles of FM (fludarabine 25 mg/m(2) on days 1-3, mitoxantrone 12 mg/m(2) on day 1 of each 28-day cycle). The protocol was amended after enrolling the first 4 patients to include rituximab 375 mg/m(2) on day 1. After 6-8 weeks, responders received (90)Y-ibritumomab tiuxetan (Zevalin) followed by maintenance rituximab (375 mg/m(2) weekly × 4 doses, repeated every 6 months for 2 years). RESULTS: After R-FM, the overall response rate was 95% with a complete response rate (CR) of 45% (n = 10), a partial response (PR) rate of 50% (n = 11), and stable disease in 1 patient. Nineteen patients received (90)Y-ibritumomab tiuxetan with a 60% conversion rate of PR to CR, resulting in an improved CR of 79% (n = 15) and a PR of 21% (n = 4). Fifteen patients proceeded to rituximab maintenance resulting in 3 patients with PR converting to CR. At median follow-up of 49.6 months, median progression-free survival (PFS) was 47.2 months and median overall survival (OS) was not reached in an intent-to-treat analysis. The most common adverse effects were hematologic, with 2 patients experiencing treatment-related myelodysplastic syndrome (MDS), evolving to acute myelogenous leukemia (AML) in 1 patient. CONCLUSION: R-FM with (90)Y-ibritumomab tiuxetan consolidation and rituximab maintenance is well tolerated, improving CR rates and maintaining durable responses in patients with untreated indolent lymphomas.

Efficacy and safety of rituximab combined with ESHAP chemotherapy for the treatment of relapsed/refractory aggressive B-cell non-Hodgkin lymphoma.

BACKGROUND: We evaluated the efficacy and safety of adding rituximab to nonanthracycline ESHAP (etoposide/methylprednisolone/cytarabine/cisplatin) chemotherapy for relapsed/refractory aggressive non-Hodgkin lymphoma (NHL). PATIENTS AND METHODS: Patients with intermediate- or high-grade NHL were to receive 6 rituximab doses and 6 ESHAP cycles. Rituximab 375 mg/m(2) was administered 1 week and 1 day before cycle 1 of standard ESHAP (etoposide 40 mg/m(2) on days 1-4; methylprednisolone 500 mg/m(2) on days 1-5; cytarabine 200 mg/m(2) on day 5; and cisplatin 25 mg/m(2) on days 1-4). Rituximab was repeated before the third and fifth 21-day ESHAP cycles (on days 48 and 90 of protocol, respectively), followed by 2 additional rituximab doses after cycle 6 (on days 134 and 141 of protocol). Use of growth factors was permitted. Thirteen patients were enrolled (median age, 56 years); all had previously treated NHL, 12 (92%) had diffuse large B-cell lymphoma, 10 (77%) had stage III/IV disease, and 2 (15%) had chemotherapy-refractory disease. RESULTS: The most common grade 3/4 toxicities were neutropenia and thrombocytopenia, with 3 cases of febrile neutropenia. Seven patients exhibited complete response (CR) and 3 had partial response, for an objective response rate of 77%. Median duration of response for all responders was 14 months (range, 2-51 months). Among 6 patients completing all 6 cycles, 4 (67%) had a CR, 1 had a partial response, and 1 had progressive disease. Three of the 4 CRs have remained for a median of 48 months (range, 46-51 months). CONCLUSION: Rituximab plus ESHAP led to durable responses with acceptable toxicity in patients with relapsed/refractory aggressive NHL, most of whom had advanced disease.

Patient-specific vaccine therapy for non-Hodgkin lymphoma.

Follicular non-Hodgkin lymphoma (NHL) is an indolent, or slow-growing, malignant disease of the lymphoid tissue, which usually responds to initial therapy. However, the disease is characterized by multiple relapses and remissions, eventually causing death. Several effective therapies are available, but improvement of overall survival in patients with follicular NHL has not been demonstrated. Stimulation of the immune system to recognize malignant lymphoma cells as foreign has been demonstrated as a viable treatment option for patients with follicular NHL. Patient-specific vaccine therapy is a new form of active immunotherapy being studied for NHL. Clinical trials have shown a benefit for patients receiving this type of therapy. This article will provide a foundation for nurses caring for patients receiving patient-specific vaccine therapy.

Current therapeutic approaches in the treatment of Non-Hodgkin's lymphoma.

OBJECTIVES: To review the causes, classification, treatment, and new treatment modalities of non-Hodgkin's lymphoma. DATA SOURCES: Published literature and experimental therapies. CONCLUSIONS: The increasing incidence of non-Hodgkin's lymphoma can be attributed to a growth in the number of immunodeficiency and autoimmune disorders, infectious agents, and human T-cell leukemia-lymphoma virus. Treatment options include watch-and-wait, radiation, chemotherapy, biologic therapy, and stem cell/bone marrow transplant. New therapies include the use of monoclonal antibodies and radioimmunotherapy. Experimental therapies include high-dose radioimmunotherapy and stem cell transplantation, vaccines, and antisense antiangiogensis agents. IMPLICATIONS FOR NURSING PRACTICE: Nurses will need to become versed in this modality, and will play an important part not only in therapy but also in patient education.