Management of Venous Thromboembolism for Patients With Hematologic Malignancies.

Advanced practitioners are an integral part of the cancer care team. Therefore, it is imperative they are knowledgeable of risk factors associated with venous thromboembolism in the oncology setting, including signs or symptoms and management.

Multiple myeloma maintenance therapy: a review of the pharmacologic treatment.

Over the last decade, numerous drug therapies have emerged for the treatment of multiple myeloma including immunomodulating agents namely thalidomide, lenalidomide, and pomalidomide and proteasome inhibitors namely bortezomib and carfilzomib. These agents have transformed the treatment of multiple myeloma and the role of high-dose chemotherapy followed by stem cell transplantation in the treatment of the disease. There are now studies that evaluate the use of drug therapy as maintenance following autologous stem cell transplantation; these studies have shown improvements in surrogate endpoints such as progression-free survival. Studies that have evaluated thalidomide or lenalidomide maintenance therapy have demonstrated an overall survival (OS) benefit in individuals with multiple myeloma who received high-dose chemotherapy followed by stem cell transplantation. A meta-analysis of thalidomide maintenance therapy did show a possible late survival benefit. The use of dexamethasone, thalidomide, lenalidomide, or combination bortezomib with thalidomide in patients who did not undergo transplantation demonstrated progression-free survival benefit; although there was no OS advantage for these agents in this population. There are a number of important considerations when selecting a drug therapy strategy for maintenance therapy which includes practical considerations such as route of administration and frequency of administration. Additionally, patient-specific elements such as potential toxicities, end-organ function, quality of life, cytogenetics, and previous treatment should be considered. Additional studies are needed to elicit the timing for initiation and duration of maintenance therapy, determine the role of cytogenetics, further characterize possible resistance patterns, and determine the combinations necessary to achieve an optimal increase in OS. Until more data are available, the risks and benefits should be evaluated on a patient-specific basis when deciding to initiate maintenance therapy or observation.

Navigating the seasons of survivorship in community oncology.

Nurses have an important role in the development, implementation, and evaluation of cancer survivorship programs. Growing numbers of cancer survivors challenge community oncology practices to incorporate survivorship care according to new standards and guidelines. In response, one community-based oncology clinic created an advanced practice nurse (APN)-led survivorship program using the concept of Seasons of Survival as a guide. Survivorship care, when based on a more expansive definition of survivorship as beginning at the time of diagnosis, encompasses holistic nursing and multidisciplinary care. The APN assesses each patient's concerns and quality of life using a validated measure to tailor survivorship and supportive care. This article reviews the foundation and structure of the program in detail, describes program implementation using case studies, and outlines the program evaluation process and results.

Cancer- and chemotherapy-induced anemia.

Anemia is prevalent in 30% to 90% of patients with cancer. Anemia can be corrected through either treating the underlying cause or providing supportive care through transfusion with packed red blood cells or administration of erythropoiesis-stimulating agents (ESAs), with or without iron supplementation. Recent studies showing detrimental health effects of ESAs sparked a series of FDA label revisions and a sea change in the perception of these once commonly used agents. In light of this, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Cancer- and Chemotherapy-Induced Anemia underwent substantial revisions this year. The purpose of these NCCN Guidelines is twofold: 1) to operationalize the evaluation and treatment of anemia in adult cancer patients, with an emphasis on those who are receiving concomitant chemotherapy, and 2) to enable patients and clinicians to individualize anemia treatment options based on patient condition.

Antiemetics: American Society of Clinical Oncology clinical practice guideline update.

PURPOSE: To update the American Society of Clinical Oncology (ASCO) guideline for antiemetics in oncology. METHODS: A systematic review of the medical literature was completed to inform this update. MEDLINE, the Cochrane Collaboration Library, and meeting materials from ASCO and the Multinational Association for Supportive Care in Cancer were all searched. Primary outcomes of interest were complete response and rates of any vomiting or nausea. RESULTS: Thirty-seven trials met prespecified inclusion and exclusion criteria for this systematic review. Two systematic reviews from the Cochrane Collaboration were identified; one surveyed the pediatric literature. The other compared the relative efficacy of the 5-hydroxytryptamine-3 (5-HT(3)) receptor antagonists. RECOMMENDATIONS: Combined anthracycline and cyclophosphamide regimens were reclassified as highly emetic. Patients who receive this combination or any highly emetic agents should receive a 5-HT(3) receptor antagonist, dexamethasone, and a neurokinin 1 (NK(1)) receptor antagonist. A large trial validated the equivalency of fosaprepitant, a single-day intravenous formulation, with aprepitant; either therapy is appropriate. Preferential use of palonosetron is recommended for moderate emetic risk regimens, combined with dexamethasone. For low-risk agents, patients can be offered dexamethasone before the first dose of chemotherapy. Patients undergoing high emetic risk radiation therapy should receive a 5-HT(3) receptor antagonist before each fraction and for 24 hours after treatment and may receive a 5-day course of dexamethasone during fractions 1 to 5. The Update Committee noted the importance of continued symptom monitoring throughout therapy. Clinicians underestimate the incidence of nausea, which is not as well controlled as emesis.

NCCN Task Force Report: Specialty Pharmacy.

The use of specialty pharmacies is expanding in oncology pharmacy practice. Specialty pharmacies provide a channel for distributing drugs that, from the payor perspective, creates economies of scale and streamlines the delivery of expensive drugs. Proposed goals of specialty pharmacy include optimization of pharmaceutical care outcomes through ensuring appropriate medication use and maximizing adherence, and optimization of economic outcomes through avoiding unwarranted drug expenditure. In oncology practice, specialty pharmacies have become a distribution channel for various agents. The use of a specialty pharmacy, and the addition of the pharmacist from the specialty pharmacy to the health care team, may not only provide benefits for care but also present challenges in oncology practice. The NCCN Specialty Pharmacy Task Force met to identify and examine the impact of specialty pharmacy practice on the care of people with cancer, and to provide recommendations regarding issues discussed. This report provides recommendations within the following categories: education and training of specialty pharmacy practitioners who care for individuals with cancer, coordination of care, and patient safety. Areas for further evaluation are also identified.

Current and emerging treatments for multiple myeloma.

BACKGROUND: The prognosis and treatment of multiple myeloma (MM) has evolved greatly over the past decade. The development and incorporation of new agents such as immunomodulators and proteasome inhibitors into therapy has improved outcomes and is helping patients enjoy longer periods of remission. OBJECTIVE: To review current treatments for MM, including overview of drug therapy and management of adverse effects of therapy and comorbidities. Additionally, an overview of agents being studied and evaluated for use in MM and myeloma-related conditions, such as metastatic bone disease and venous thromboembolism, will be discussed. SUMMARY: Great strides have been made regarding the understanding of disease pathology in MM, leading to therapies that may be targeted to each individual, based on their unique biology of disease. Therapy is currently tailored based on patient issues and stage of disease, but may soon be tailored individually based on the cytogenetic profile of a patient. Recent treatment guidelines have been published by the National Comprehensive Cancer Network which were updated with impressive results from clinical trials involving agents such as immunomodulators and proteasome inhibitors. This guideline also provides information on the management of myeloma and treatment-related morbidities. As with the treatment of any cancer, clinicians must weigh risk versus benefit when determining the most appropriate therapy. Currently, corticosteroids, lenalidomide, thalidomide, and bortezomib are all used in patients with MM. The use of chemotherapy, including high-dose therapy with stem cell transplant, is an important component of treatment for many patients. The use of high-dose therapy is continually being evaluated, and the issue of risk versus benefit is weighed for individual patients. Depending on the prognosis, it may be of benefit to endure the toxicity of higher doses to achieve a better overall response and achieve longer remission periods. Although stem cell transplantation is often performed in MM to improve survival and remission rates, some patients are unable to undergo transplant for a variety of reasons, including age (older than 65 years), comorbidities, and/or organ dysfunction. Newer drug therapies and combinations of therapy are being evaluated to better manage this population and patients who previously received high-dose chemotherapy and a stem-cell transplant. Additionally, the management of relapsed, or refractory, disease continues to be a challenge in treating the myeloma patient. Despite aggressive and improved treatments, most myeloma patients will eventually have resistance to therapy or relapse. Treatment strategies in these patients are also evolving. CONCLUSION: Major advancements in the diagnosis, staging, and treatment of myeloma offer promise in the future for changing MM from a terminal illness into a chronic, manageable condition.

Management of early and advanced colorectal cancer: therapeutic issues.

PURPOSE: The staging of colorectal cancer, therapeutic decision making in the management of early and advanced colorectal cancer, and dilemmas posed by drug-related toxicity are discussed. SUMMARY: Staging of colorectal cancer occurs after surgery and is based on the extent of disease invasiveness and dissemination. Surgery is the primary treatment for stage I disease. Adjuvant chemotherapy is recommended after resection in selected high-risk patients with stage II disease and in all patients with stage III disease. Convenience of administration, tolerability, and patient factors not necessarily age may be considerations in decisions about adjuvant therapy after resection. Treatment of stage IV colorectal cancer is based on the type of prior therapy and patient-specific factors. Recently, significant improvements in survival have been achieved through the use of combination chemotherapy and monoclonal antibody regimens. Bevacizumab in combination with chemotherapy is first-line therapy for stage IV disease. Age alone should not preclude the use of chemotherapy in stage IV colorectal cancer, although the ability to tolerate drug-related toxicity may be a consideration. The optimal duration of chemotherapy in patients with early and metastatic colorectal cancer is unclear. CONCLUSION: The optimal approach to the treatment of colorectal cancer depends on several considerations, including patient-specific factors.

Anemia in patients with cancer: incidence, causes, impact, management, and use of treatment guidelines and protocols.

PURPOSE: The incidence, etiology, impact, and considerations in developing guidelines for treating anemia in patients with cancer are described. SUMMARY: Anemia is common in patients with cancer. The incidence and severity of anemia depend on the type and extent of the malignancy; the type, schedule, and intensity of cancer therapy; and patient age, gender, and comorbid conditions. Anemia may be the result of the malignancy itself, cancer treatment, blood losses, nutritional deficiencies, hemolysis, endocrine disorders, or inflammatory cytokines associated with chronic disease. Anemia can have a profound impact on physical and psychosocial function and quality of life. Guidelines and protocols for treating anemia should be evidence-based and take into consideration patient age, the type and extent of malignancy, comorbid conditions, and the etiology and impact of anemia. Patient-specific issues that guidelines should address include strategies for identifying patients with anemia, treating anemia, evaluating the response to treatment, and modifying treatment based on response. Erythropoietic agents are preferred over blood transfusions for patients whose anemia is chronic, although transfusions are indicated for acute, severe blood losses. Iron supplementation often is required in patients receiving erythropoietic therapy or with iron deficiency due to hemorrhage. CONCLUSION: The use of evidence-based guidelines and protocols that take into consideration the heterogeneity of patients with cancer can optimize anemia treatment.

Considerations and challenges with existing treatments for thrombosis in cancer patients.

PURPOSE: One of the standard treatments for cancer-associated thrombosis has been initial therapy with unfractionated heparin (UFH) followed by long-term therapy with an oral anticoagulant (i.e., warfarin). However, characteristics associated with these two agents may make them suboptimal for many cancer patients. This article will explore some of the considerations and limitations when using UFH and warfarin in the cancer population and will also utilize case studies to emphasize the importance of individualized care. SUMMARY: UFH is an effective anticoagulant when doses are adjusted to maintain the activated partial thromboplastin time (aPTT) within a specified therapeutic range. However, due to the complex pharmacokinetics of this agent, patients must undergo frequent monitoring to maintain a therapeutic aPTT. In addition, UFH can be associated with serious adverse events including osteoporosis, heparin-induced thrombocytopenia, and bleeding. Similar to UFH, warfarin requires frequent monitoring and dose adjustments to maintain the International Normalized Ratio (INR) within the therapeutic range of 2.0 to 3.0. Warfarin also has numerous drug-herbal, drug-food, and drug-drug interactions, including interactions with many commonly used anti-tumor therapies. Complications related to UFH and warfarin in the treatment of cancer-associated thrombosis have gradually been minimized with the increased use of low molecular weight heparins (LMWHs), which are associated with reduced incidence of bleeding, heparin-induced thrombocytopenia, and drug interactions. In addition, LMWHs allow for convenient daily dosing without requiring routine monitoring and the option of home therapy. CONCLUSION: When deciding on the optimal anticoagulant strategy, pharmacists must take into account the unique characteristics and needs of each individual patient as well as the specifics of the various anticoagulant therapies. Future strategies for the initial and long-term treatment of cancer-associated thrombosis may increasingly incorporate LMWHs because of factors related to safety and convenience.

Targeted therapies in the treatment of colorectal cancer: what managed care needs to know.

OBJECTIVE: This review is designed to explore the disease, its current treatment, the expanding field of antiangiogenic treatments, and the implications of these advances for the managed care patient. DATA SOURCES: This article is based, in part, on presentations given by the authors in a continuing education symposium presented during the Academy of Managed Care Pharmacy.s 16th Annual Meeting and Showcase, April 1, 2004, in San Francisco. CONCLUSIONS: Colorectal cancer (CRC) is the third most common cancer in the United States, and the second-leading non.gender-specific cause of cancer deaths. If the cancer is caught soon enough (before node involvement and metastasis occur), there is a strong chance of survival; however, only slightly more than one third of cases are detected that soon. Emerging treatments that target only the cancer cells are increasing the length of survival for those who are diagnosed at later stages of the disease.

Venous thromboembolism in patients with cancer. Part I. Survey of oncology nurses' attitudes and treatment practices for ambulatory settings.

Patients with cancer have a higher incidence of venous thromboembolism (VTE). Little information currently exists on VTE and the understanding and beliefs of oncology nurses. Therefore, the attitudes and treatment practices of ambulatory oncology nurses were surveyed to determine the current knowledge base of VTE in patients with cancer. Survey results are presented along with a thorough literature review of thromboembolism and the unique risk factors for this frequent complication in patients with cancer. The causes of VTE in this patient population often are multifactorial and include hypercoagulability, stasis, and vascular endothelial damage from procedures or the neoplastic process itself. In particular, chemotherapy administration can increase the risk of thrombosis considerably. New therapies, including thalidomide, require oncology nurses caring for these patients to have heightened awareness of the potential for thrombogenic complications. This is the first of two articles that address the problem of thromboembolism in patients with cancer, including the survey results. (See part II on page 465.) Oncology nurses are essential in the care of VTE in patients with cancer and can help with patient identification, treatment, and compliance for improved patient outcomes.

Venous thromboembolism in patients with cancer. Part II. Current treatment strategies.

Patients with cancer have an increased risk of thromboembolism. This complication is connected to a variety of different factors and is influenced by the conditions described in Virchow's triad: stasis, vascular endothelial damage, and hypercoagulability. Once thromboembolism is diagnosed, treatment in patients with cancer usually involves anticoagulation with unfractionated or low-molecular-weight heparin and progression to oral anticoagulant therapy. Duration of treatment is usually three to six months, with most patients receiving six months of anticoagulation. Patients with cancer may be at risk for recurrent thrombosis as well, despite optimal use of oral anticoagulant therapy, and some of these patients may require lifelong heparin therapy. This article describes the current treatment regimens to provide anticoagulation therapy to patients with cancer, including a discussion of the low-molecular-weight heparins and dosing parameters. Nursing interventions to help provide these treatments safely are discussed. Patients with cancer have a high rate of thromboembolism; oncology nurses should heighten their awareness of this important complication, treatment options, and appropriate nursing interventions.

Managing toxicities of high-dose interleukin-2.

Although high-dose interleukin-2 (IL-2, Proleukin), a highly toxic agent used in the treatment of renal cell carcinoma and melanoma, was initially associated with treatment-related mortality, it can, in the appropriate setting, be administered safely. High-dose IL-2 is associated with significant morbidity; however, the incidence and severity of toxicities have decreased as clinicians have gained experience with this agent and implemented toxicity prevention and management strategies. IL-2 toxicity can manifest in multiple organ systems, most significantly the heart, lungs, kidneys, and central nervous system. The most common manifestation of IL-2 toxicity is capillary leak syndrome, resulting in a hypovolemic state and fluid accumulation in the extravascular space. Capillary leak syndrome can contribute significantly to development of oliguria, ischemia, and confusion. Safe and effective administration of high-dose IL-2 consists of five key components: (1) administration by an experienced and knowledgeable health-care team, (2) adherence to strict patient-eligibility criteria, (3) implementation of standardized administration and patient assessment guidelines, (4) adherence to administration criteria, and (5) compliance with retreatment contraindications. This article reviews high-dose IL-2 toxicities and symptom management strategies and provides practical guidelines to facilitate the safe and effective administration of high-dose IL-2.

Chemotherapy-induced nausea and vomiting.

Nausea and vomiting (N&V) is among the most distressing side effects of chemotherapy, despite the development of more efficacious antiemetic agents. As many as 60% of patients who receive cancer chemotherapy experience some degree of N&V. However, the actual incidence is difficult to determine with accuracy because of the variety of drugs, doses, and health conditions of the patients who receive cancer treatments. This article examines the state of the science related to chemotherapy-induced nausea and vomiting and reviews both pharmacologic and behavioral strategies that have demonstrated efficacy in managing these distressing symptoms.