Brachytherapy: Increased Use in Patients With Intermediate- and High-Risk Prostate Cancers.

BACKGROUND: Brachytherapy is a well-established and effective primary treatment modality for low- and favorable intermediate-risk prostate cancers. Although the benefits of brachytherapy in unfavorable intermediate- and high-risk prostate cancers have not been as clear, research suggests that brachytherapy boost may improve biochemical progression-free survival in these patients. OBJECTIVES: This article aims to discuss evidence for the revival of brachytherapy use in unfavorable intermediate- and high-risk prostate cancers and specific nursing implications in the management of these patients. METHODS: The literature on brachytherapy and its use to treat localized prostate cancers was reviewed. FINDINGS: Nurses should be knowledgeable about the indications for brachytherapy, patient eligibility, anticipated side effects, and symptom management.

Extension of overall survival beyond objective responses in patients with metastatic renal cell carcinoma treated with high-dose interleukin-2.

PURPOSE: In metastatic renal cell carcinoma (mRCC), survival benefit associated with objective response rates of 16-20 % with high-dose interleukin-2 (HDIL-2) is well established and discussed. Based on recently emerged data on efficacy of cancer immunotherapy, we hypothesized that the survival benefit with HDIL-2 extends beyond those achieving objective responses, i.e., to those who achieve stable disease as the best response to treatment. MATERIALS AND METHODS: All sequential treatment naïve mRCC patients treated with HDIL-2 at the University of Utah (1988-2013) and University of Michigan (1997-2013) were included. Best responses on treatment were associated with survival outcomes using log-rank and COX regression with a landmark analysis at 2 months. RESULTS: 391 patients (75 % male; median age 55 years) were included and belonged to the following prognostic risk categories: 20 % good, 64 % intermediate, and 15 % poor. Best responses on treatment were complete response (9 %), partial response (10 %), stable disease (32 %), progressive disease (42 %), and not evaluable for response (7 %). No significant differences in progression-free survival (HR 0.74, 95 % CI 0.48-1.1, p = 0.14) or overall survival (HR 0.66, 95 % CI 0.39-1.09, p = 0.11) were observed between patients achieving partial response versus stable disease. Significant differences in progression-free survival (HR 0.13, 95 % CI 0.09-0.22, p < 0.0001) and overall survival (HR 0.33, 95 % CI 0.23-0.48, p < 0.0001) were observed between patients achieving stable disease compared to those with progressive disease and who were not evaluable. CONCLUSIONS: Survival benefit with HDIL-2 is achieved in ~50 % patients and extends beyond those achieving objective responses.

Early Recognition and Management of Posterior Reversible Encephalopathy Syndrome: A Newly Recognized Complication in Patients Receiving Tyrosine Kinase Inhibitors.

BACKGROUND: Adult patients with cancer receiving antineoplastic, targeted, and other immunosuppressive therapies are at risk for severe side effects. Studies link posterior reversible encephalopathy syndrome (PRES) with immunosuppressants used for patients undergoing transplantation, as well as select tyrosine kinase inhibitors (TKIs) and other targeted therapies used in patients with cancer. PRES is a reversible condition with early recognition and management; however, permanent neurologic toxicities have been reported. OBJECTIVES: This article aims to educate oncology nurses on signs, symptoms, and management of PRES in patients receiving TKIs. METHODS: The literature was reviewed to develop an educational session about causes, manifestations, pathophysiology, and management of PRES. Using a case study and flipped classroom model, staff participated in an online lecture and concept engagement exercise. Education for nurses included frequent neurologic and mental status assessments, blood pressure monitoring with mean arterial blood pressure goal, and seizure precautions. Nursing knowledge was evaluated with pre- and post-testing. FINDINGS: Evaluation revealed improved knowledge in recognizing and managing patients with PRES related to TKIs. The flipped classroom approach was perceived as a valuable tool for busy staff nurses.

Improving documentation of quality measures in the electronic health record.

PURPOSE: Oncology quality measures provide an important tool to evaluate care received by cancer patients. These measures are frequently addressed by oncology nurse practitioners (NPs). NP documentation of quality oncology practice initiative (QOPI) measures in the electronic health record (EHR) is evaluated in this study. DATA SOURCES: NP documentation of specific QOPI measures before and after an educational intervention (EI) was evaluated. EHR shortcuts, called "SmartPhrases," were used to increase efficiency in documentation of these measures. CONCLUSIONS: Preintervention chart audits found compliance <80% in the multiple measurement areas. Following the EI, NPs surveyed identified greater understanding of QOPI measures and an interest in using "SmartPhrases" to aid in measure documentation. The postintervention audit demonstrated improvement in all areas addressed during the EI noting the use of "SmartPhrases" based on descriptive findings. IMPLICATIONS FOR PRACTICE: NPs play a significant role in providing quality care for oncology patients. By increasing knowledge related to the documentation of quality measures and providing tools to increase the efficiency associated with their documentation, a positive impact can be made in efforts to promote quality patient care.

Identifying strategies to optimize care with oral cancer therapy.

More cancer therapies are being administered via an oral route. This paradigm shift in providing cancer treatment has been met with both excitement and significant challenges for oncology practitioners. Multiple factors can impact the ability for patients to initiate and stay on oral cancer therapy. A major factor in patient adherence with oral cancer therapies is management of side effects. Side effects from therapy not only have a negative impact on a patient's quality of life but also can cause serious complications. In addition, they can impact the patient's ability to stay on therapy at optimal doses. New strategies must be designed for educating patients and caregivers, as well as for patient management and follow-up. When side effects are not managed appropriately, patients are less likely to want or be able to adhere to established treatment plans. This article explores several challenges related to the use of oral cancer therapies, with a focus on side effects seen with various classes of new targeted agents. Evidence-based practice strategies and areas in need of additional exploration and research are reviewed.

2013 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards including standards for the safe administration and management of oral chemotherapy.

In 2009, ASCO and the Oncology Nursing Society (ONS) published standards for the safe use of parenteral chemotherapy in the outpatient setting, including issues of practitioner orders, preparation, and administration of medication. In 2011, these were updated to include inpatient facilities. In December 2011, a multistakeholder workgroup met to address the issues associated with orally administered antineoplastics, under the leadership of ASCO and ONS. The workgroup participants developed recommended standards, which were presented for public comment. Public comments informed final edits, and the final standards were reviewed and approved by the ASCO and ONS Boards of Directors. Significant newly identified recommendations include those associated with drug prescription and the necessity of ascertaining that prescriptions are filled. In addition, the importance of patient and family education regarding administration schedules, exception procedures, disposal of unused oral medication, and aspects of continuity of care across settings were identified. This article presents the newly developed standards.

2013 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards including standards for the safe administration and management of oral chemotherapy.

In 2009, the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) published standards for the safe use of parenteral chemotherapy in the outpatient setting, including issues of practitioner orders, preparation, and administration of medication. In 2011, these were updated to include inpatient facilities. In December 2011, a multistakeholder workgroup met to address the issues associated with orally administered antineoplastics, under the leadership of ASCO and ONS. The workgroup participants developed recommended standards, which were presented for public comment. Public comments informed final edits, and the final standards were reviewed and approved by the ASCO and ONS Boards of Directors. Significant newly identified recommendations include those associated with drug prescription and the necessity of ascertaining that prescriptions are filled. In addition, the importance of patient and family education regarding administration schedules, exception procedures, disposal of unused oral medication, and aspects of continuity of care across settings were identified. This article presents the newly developed standards.

Concepts in advanced renal carcinoma.

OBJECTIVES: Treatment options for advanced renal cell carcinoma have increased dramatically over the past 6 years as a result of improved understanding of the biology of renal cancer and the development of therapies to target pathways relevant to tumor progression. DATA SOURCES: Research-based articles. CONCLUSION: New therapies to treat advanced renal cell cancer results in a need for evidence-based decision making when discussing treatment choices. IMPLICATIONS FOR NURSING PRACTICE: Knowledge of therapeutic strategies, their proposed mechanism of action, potential adverse events, and management strategies provides nurses with a foundation to provide appropriate patient education and effective management of treatment-related side effects, assisting patients to maximize clinical outcomes.

Revisions to the 2009 american society of clinical oncology/oncology nursing society chemotherapy administration safety standards: expanding the scope to include inpatient settings.

In November 2009, ASCO and the Oncology Nursing Society (ONS) jointly published a set of 31 voluntary chemotherapy safety standards for adult patients with cancer, as the end result of a highly structured, multistakeholder process. The standards were explicitly created to address patient safety in the administration of parenteral and oral chemotherapeutic agents in outpatient oncology settings. In January 2011, a workgroup consisting of ASCO and ONS members was convened to review feedback received since publication of the standards, to address interim changes in practice, and to modify the standards as needed. The most significant change to the standards is to extend their scope to the inpatient setting. This change reflects the conviction that the same standards for chemotherapy administration safety should apply in all settings. The proposed set of standards has been approved by the Board of Directors for both ASCO and ONS and has been posted for public comment. Comments were used as the basis for final editing of the revised standards. The workgroup recognizes that the safety of oral chemotherapy usage, nononcology medication reconciliation, and home chemotherapy administration are not adequately addressed in the original or revised standards. A separate process, cosponsored by ASCO and ONS, will address the development of safety standards for these areas.

Revisions to the 2009 American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards: expanding the scope to include inpatient settings.

In November 2009, the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) jointly published a set of 31 voluntary chemotherapy safety standards for adult patients with cancer, as the end result of a highly structured, multistakeholder process. The standards were explicitly created to address patient safety in the administration of parenteral and oral chemotherapeutic agents in outpatient oncology settings. In January 2011, a workgroup consisting of ASCO and ONS members was convened to review feedback received since publication of the standards, to address interim changes in practice, and to modify the standards as needed. The most significant change to the standards is to extend their scope to the inpatient setting. This change reflects the conviction that the same standards for chemotherapy administration safety should apply in all settings. The proposed set of standards has been approved by the Board of Directors for both ASCO and ONS and has been posted for public comment. Comments were used as the basis for final editing of the revised standards. The workgroup recognizes that the safety of oral chemotherapy usage, nononcology medication reconciliation, and home chemotherapy administration are not adequately addressed in the original or revised standards. A separate process, cosponsored by ASCO and ONS, will address the development of safety standards for these areas.

NCCN Task Force report: optimizing treatment of advanced renal cell carcinoma with molecular targeted therapy.

The outcome of patients with metastatic renal cell carcinoma has been substantially improved with administration of the currently available molecularly targeted therapies. However, proper selection of therapy and management of toxicities remain challenging. NCCN convened a multidisciplinary task force panel to address the clinical issues associated with these therapies in attempt to help practicing oncologists optimize patient outcomes. This report summarizes the background data presented at the task force meeting and the ensuing discussion.

Symptom clusters in individuals living with advanced cancer.

OBJECTIVES: To discuss issues related to symptom clusters in patients living with advanced cancer. DATA SOURCES: Research and review articles. CONCLUSION: The importance for symptom cluster evaluation in oncology has been documented; however, there remain a number of inconsistencies in the literature as to the best way to accomplish this. Individuals living with advanced cancer are often dealing with symptoms from their disease, as well as prior and current therapies. Research related to patients receiving long-term cancer therapies and the symptom clusters experienced by this group of individuals is needed. IMPLICATIONS FOR NURSING PRACTICE: Understanding the intricacies of symptom clusters in this population is an area for future research.

Immune modulation in melanoma and advanced cancer therapy: anti-cytotoxic T lymphocyte-associated antigen 4 monoclonal antibodies.

Two fully human monoclonal antibodies (mAbs) that target cytotoxic T lymphocyte-associated antigen 4 (CTLA4), tremelimumab and ipilimumab, are in clinical development for the treatment of advanced cancers. The investigational agents enhance T-cell activation and are hypothesized to generate antitumor immunity. Clinical data have shown that treatment with an anti-CTLA4 mAb is tolerable in most patients. In addition, enhanced antitumor activity was observed in some patients. As expected with an agent that enhances the immune response, immune-related adverse events are observed frequently in treated patients. The immune-related adverse events are not observed with standard chemotherapy agents, so many nurses may be unfamiliar with their management. Early recognition and management of immune-related adverse events by oncology nurses is an essential component of effective treatment with an anti-CTLA4 mAb. As immunomodulatory agents such as anti-CTLA4 mAbs are introduced in oncology treatment, nurses will need a greater understanding of the complexities associated with the therapies. Knowledge of immune system functions and how altering the functions may affect the development of side effects will enhance safety and quality of care for patients receiving anti-CTLA4 mAbs.

Phase Ib trial assessing autologous, tumor-pulsed dendritic cells as a vaccine administered with or without IL-2 in patients with metastatic melanoma.

Twenty-four subjects with metastatic melanoma were treated on a randomized Phase Ib trial evaluating an autologous tumor lysate-pulsed dendritic cell (DC) vaccine with or without interleukin (IL)-2. The vaccine consisted of autologous DCs obtained from peripheral blood mononuclear cells (PBMCs) cultured in granulocyte macrophage-colony stimulating factor and IL-4 then pulsed with autologous tumor cell lysate and keyhole limpet hemocyanin (KLH). The primary end points of the trial were safety and immune response to vaccine. Subjects were randomized to vaccine administered every other week times 3, vaccine x 3 followed by low-dose IL-2, or vaccine x 3 followed by high-dose IL-2. Immune response was monitored pretreatment and at 2 and 4 weeks after the third vaccine administration. Disease evaluation was performed at 4 weeks after the third vaccination. Therapy was well tolerated with no local vaccine toxicity greater than grade 1 in any arm. IL-2 toxicity was as expected without additional toxicity from the addition of IL-2 to vaccine. Immune response defined as delayed-type hypersensitivity, PBMC interferon-gamma enzyme-linked immunosorbent spot, and PBMC proliferation, to both autologous tumor and KLH were detected in all arms. Interferon-gamma enzyme-linked immunosorbent spot response to KLH (7 of 10 patients) and autologous tumor (4 of 10 patients) were also detected in subjects with available vaccine draining lymph node cells. There were no differences in immune response between treatment arms. No clinical responses were seen. Autologous tumor lysate-pulsed DC vaccine with or without IL-2 was well tolerated and immunogenic but failed to induce clinical response in patients with advanced melanoma.

What kind of rash is it?: deciphering the dermatologic toxicities of biologic and targeted therapies.

An overwhelming number of new agents, including targeted agents with unique mechanisms of action, are available in oncology practice today. Along with the benefit of new treatments for patients comes the unfamiliarity of associated toxicities and learning the best methods to minimize side effects. One such toxicity has been the spectrum of dermatologic reactions from some of the newer small-molecule inhibitors and monoclonal antibodies. Scientific evidence describing the unique rashes and methodologies to treat various cutaneous toxicities with specific agents is extremely limited. This article reviews the currently available literature related to dermatologic toxicities observed with many newer targeted therapies. Current recommendations for management are based on practices implemented during clinical trials and postmarketing practices. Additional research is needed to further elucidate the most efficacious methods for treating side effects observed with newer targeted therapies.

Symptom clusters in advanced illness.

OBJECTIVES: To review the four sets of symptom clusters commonly seen in patients with advanced illness, and their definitions, associated symptomatology, and management. DATA SOURCES: Research and review articles and textbooks. CONCLUSION: Symptoms of patients with advanced illness tend to occur not isolation, but in symptom clusters. The ability to cluster symptoms in both assessment and management reduces the use of polypharmacy, systemic toxicities, and improves the patient's quality of life. IMPLICATIONS FOR NURSING PRACTICE: It is important that the nurse providing symptom management for the oncology patient understand the importance of clustering certain symptoms together.

Validation of the FACT-BRM with interferon-alpha treated melanoma patients.

The somatic, neurocognitive, and psychiatric side effects of biological response modifiers (BRMs) have been documented in specific patient samples. Although these side effects likely have a predictable impact on patients quality of life (QOL), no instrument currently measures the cumulative effect of the various complaints patients' report. The current study investigated the reliability and validity of the Functional Assessment of Cancer Treatment-Biological Response Modifier (FACT-BRM) scale for measuring QOL in a sample of melanoma patients receiving interferon. Measures of distress, depression, and fatigue were also obtained using standardized, well-validated instruments. Results indicate increased symptom burden, depression, and fatigue, and decreased quality of life over 4 months of IFN therapy. The FACT-BRM demonstrated good psychometrics and sensitivity to change, and thus appears to be a good instrument for measuring QOL in patients receiving BRMs.

Longitudinal course of depression, fatigue, and quality of life in patients with high risk melanoma receiving adjuvant interferon.

PURPOSE: Treatment of malignant melanoma with interferon-alpha has been associated with a variety of side effects ranging from fatigue to depression, and a concomitant impact on quality of life (QOL), in a variety of case reports and cross-sectional clinical trials. Few, if any, studies have been conducted with the express purpose of assessing the longitudinal course of depression, fatigue, and QOL before and during interferon therapy. DESCRIPTION OF STUDY: The current study reports on 16 patients who were assessed at 6 points in time: baseline, post high dose, and 1, 2, 3, and 6 months post high dose treatment with interferon-alpha with the Brief Symptom Inventory, Beck Depression Inventory, Revised Piper Fatigue Scale, and Functional Assessment of Cancer Therapy-Biological Response Modifiers. RESULTS: Results revealed consistent changes from baseline through 6 month assessment. Specifically, increased somatic complaints, depression, and fatigue were observed on the BSI, BDI, and RPFS, respectively. Additional reductions in QOL on the FACT-BRM were also identified. CLINICAL IMPLICATIONS: The findings suggest that IFN has a significant effect on QOL, but that it may be the somatic symptoms of fatigue that contribute to changes on measures of mood. Limiting the amount of fatigue and depression would appear to be significant if individuals are to successfully complete IFN therapy.