Transcript ONS Congress 2016

ONS Congress 2016
SAN ANTONIO, TEXAS APRIL 28-MAY 1, 2016
TRISHA CAMPBELL, RN, BSN, OCN
5-Fluorouracil and Capecitabine Emergencies
• Drugs widely used to treat solid tumors or colorectal, gastric, esophageal, head
and neck, pancreatic and breast cancer
• Linked to severe toxicities and overdoses
• These lethal toxicities may result in delayed cancer treatment
5-FU and Capecitabine Overdose Causes
• Pump issues – malfunctioning or incorrect programming
• Pharmacy issues – incorrect dose, given as a bolus vs continuous infusion,
transcription/order error
• Accidental overdose – pediatric patients inadvertently taking medication in error
5-FU and Capecitabine Toxicities
• Common
• GI – Mucositis, Diarrhea, Nausea, Vomiting, Anorexia
• Hematologic – Neutropenia, Thrombocytopenia, Anemia
• Dermal – hand-foot syndrome
Toxicities
• Less Common
• Rapid onset of serious-severe GI, Hematologic, or Dermal Toxicities
• Cardiac – arrhythmias, chest pain, MI, Acute Pulmonary Edema, CHF, Cardiac arrest
• Neurologic – Cerebellar syndrome, Encephalopathy, Seizures, Coma, development of
Septic Shock, Organ failure
Increased incidence of 5-FU Toxicities are linked
to…
• Impaired clearance
• Dihyropyrimide Dehydrogenase Deficiency (DPD) – 3-5% of patients
• Renal impairment
• 5-FU Anabolism
• Elevated Orotate Phosphoribosyltransferase (OPRT) – the principal enzyme
converting 5-FU to toxic intracellular 5-Fluorouridine nucleotides
Vistogard (Uridine Triacetate)
• First and only antidote recently FDA approved in the treatment of accidental 5FU and Capecitabine overdoses in adults and pediatric patients
• Indication – following 5-FU and Capecitabine overdose , administered within 96
hours
• NOT recommended for non-emergent treatment of adverse reactions (may
decrease efficacy)
• Safety of Vistogard administered after 96 hours has not been established
Vistogard
• Pro-drug of uridine, which is a natural nucleoside involved in RNA synthesis
• Oral administered Vistogard is quickly converted to uridine, greatly increasing
circulating intracellular levels of uridine
• High concentrations of uridine inhibit cell death damage and cell death caused
by toxic concentrations of 5-FU or Capecitabine
Vistogard dosing
• Adult – 10 Gm (1 packet) every 6 hours x 20 doses
• Pediatric – 6.2 Gm/m2 of BSA (not to exceed 10 Gm) every 6 hours x 20 doses
• Given without regards to meals
• Administered ASAP after overdose, even without symptoms
• Take all 20 doses even if feeling well
Vistogard dosing
• Comes as orange flavored granules and should be mixed with 3-4 oz of soft food
(applesauce, yogurt, or pudding)
• To be ingested within 30 minutes and drink at least 4 oz of water with each dose
• Granules should NOT be chewed, as they are very bitter
Blinatumomab
• Monoclonal antibody, a “targeted” cancer therapy
• Bispecific T-cell engager antibody, working by directing the body’s T-cells to
target and bind with the CD19 protein on the surface of a B-cell leukemia or
lymphoma cell
• Indication – Acute Lymphoblastic Leukemia (ALL)
Blinatumomab Administration
• Continuous infusion over 28 days
• Cycle 1 – Days 1-7 is 9 mcg/hour continuous, Days 8-28 is 28 mcg/hour continuous followed by
a 2 week break
• Cycle 2 – 28 mcg/hour continuous
• Premedication – Dexamethasone 20 mg x 1 hour prior
• Use 0.2 Micron in-line filter on primary tubing at 9 mcg/hour or 28 mcg/hour
• If administration is interrupted for more then 4 hours, repeat premedication is required
One Cycle is typically needed to put a patient in remission to go to transplant
Blackbox warnings
• Cytokine Release Syndrome
• Occuring when T-cells are activated by Blinuatumomab, causing the T-cells to release
cytokines.
• The release of cytokines causes symptoms of
• Headache
Flushing
• Pyrexia
Shortness of Breath
• Nausea
Hives
• Hypotension
Rash
• Chills
Increased Liver enzymes
Blackbox warning
• Neurologic toxicity
• Can occur at any time
• Symptoms
• Seizures
• Confusion
• Disorientation
• Difficulty speaking or slurred speech
• Loss of balance
Educating Nurses Administering Chemotherapy
and Biotherapy
• Nurses administering Chemo/Biotherapy must hold an ONS Chemo/Bio
administration certification with a validated ONS Provider Card
• There are three course tracks available based on the education needed
• ONS/ONCC Chemotherapy Biotherapy Fundamentals of Administration – 10 hours
• ONS/ONCC Chemotherapy Biotherapy Certificate Course – 15 hours
• ONS/ONCC Chemotherapy Biotherapy Certificate Renewal – 5 hours
ONS/ONCC Chemotherapy Biotherapy
Fundamentals of Administration
• Intended for nurses and healthcare professionals new to oncology who are, or
plan on administering chemotherapy/biotherapy
• Provides the fundamentals of administration regardless of the volume or
frequency administered
ONS/ONCC Chemotherapy Biotherapy Certificate
• Intended for nurses who have knowledge of cancer basics and are in a position
who regularly administer chemotherapy and biotherapy
• Builds on a foundation of cancer knowledge, with the learner earning an ONCC
certificate of added qualification upon successful completion
• NOT an introductory program
ONS/ONCC Chemotherapy Biotherapy Certificate
Renewal
• Intended as a renewal of the Chemotherapy Biotherapy Certificate course when
up for renewal every 2 years
Obtaining Nursing Education Credit
• To obtain continuing nursing education credits, the provider card, and the
certificate of added qualification, course participants must
• Complete all course lessons
• Successfully complete all discussion posts
• Successfully complete the post-test with a score of 80% or higher
ONS/ONCC courses
• Courses are designed to provide interaction between learners with varying levels of
expertise
• Opportunity to interact with course facilitators
• Facilitators review information posted by learners and may ask for additional detail
and/or correct information that may be incorrect
• Learners have two opportunities to successfully past the post-test; attempts must be
completed prior to the class closing date
• Discussion posts are graded as a PASS/FAIL and are hand graded within a few days
Aurora process
• ONS/ONCC class vouchers are available to Aurora, as organizations may purchase a
greater quantity at a lower cost
• When you are due to take the course, an email will be sent from Sue Smith with
directions as to the process for registration with the voucher number
• Once Youa Xiong has given you a test date to take the course, you may start the class
• Upon completion of the course, a copy of your new ONS Provider Card should be
faxed to Sue Smith and you should update your Learning Connection with the new
dates of validation
CINV: Considerations for Nurses
• Ineffective management and control of CINV plays a big role in a patients
response to treatment
• Ineffective control or persistent CINV affects QOL, treatment outcomes, and can
lead to economic burden
• QOL – difficulty enjoying life, performing ADLs
• Physiologic – dehydration, electrolyte imbalance, poor nutrition
• Financial – loss of work, decreased productivity at work, increased medical costs
Types of Emesis
• Acute – occurring within 24 hours of chemotherapy
• Delayed – occurring after 24 hours of chemotherapy
• Breakthrough – occurring within 5 days despite prophylaxis, requiring
additional medication
• Refractory – occurring with subsequent cycles despite prophylaxis
• Anticipatory – occurring with anticipation of treatment due to poorly controlled
CINV
Emesis causes with Cancer patients
• GI – Gastroparesis, Liver metastases
• Vestibular dysfunction
• Increased ICP due to Brain metastases
• Metabolic imbalance
• Psychophysiologic
Neurotransmitters involved in CINV
• Dopamine
• 5-HT3 – proemetic transmitter and receptor involved with acute CINV
• Substance P – Binds to NK-1 receptors
• Endocannabinoids
CINV Risk Factors
• < 50
• Women > Men
• History of morning sickness, motion sickness, light alcohol consumption,
anxiety, poor prior chemotherapy experience or personal experience with
someone who has had CINV, poor performance status, GI malignancy associated
obstruction, gastroparesis, liver or brain mets, use of Opioids or NSAIDS,
constipation, metabolic abnormalities
Treatment Risk Factors
• Type of Chemotherapy
• Schedule of Chemotherapy – Dose Dense, multiple day regimens
• Combination Chemotherapy
• Route
Chemotherapy Emetic risk potential
• Minimal – Level 1, < 10% frequency
• Low – Level 2, 10-30% frequency
• Moderate – Level 3, 31-90% frequency
• High – Level 4, > 90% frequency
Anti-emetic Drug Classes
• Steroids – Dexamethasone
• Antipsychotics – Prochloperazine, Olanzapine
• Dopamine receptor antagonists – Metoclopramide
• Serotonin 5HT3 antagonists – Dolasetron, Granisetron, Ondansetron,
Palonosetron
• NK-1 receptor antagonists – Aprepitant, Fosaprepiant, Rolapitant, Netupitant
Anti-emetics for ACUTE CINV
• Minimal – no routine prophylaxis
• Low – Dexamethasone or 5HT3 or Dopamine receptor antagonist
• Moderate – Dexamethasone + 5HT3
• High – Dexamethasone + 5HT3 + NK-1
Anti-emetics for DELAYED CINV
• Minimal – no routine prophylaxis
• Low – no routine prophylaxis
• Moderate – Dexamethasone
• AC regimen – NK-1 +/- Dexamethasone
• High – Dexamethasone + NK-1 or none
New Treatments for CINV
• Fosaprepitant IV (in combination with other anti-emetics)
• Rolapitant PO – 1-2 hours prior to chemotherapy (in combination with other
anti-emetics)
• Netupitant/Palonosetron (NEPA) PO – 1 hour prior to chemotherapy (in
combination with NK-1 and 5HT3)
• Granisetron (AP530) SQ – PENDING FDA approval (in combination with 5HT3)
Rolapitant
• Newly approved NK-1 (9/2015)
• Fewer drug-drug interactions
NEPA
• Fixed dose combaination of oral Netupitant + Palonosetron
• PO – 1 hour prior to chemotherapy
• Given in combination with NK-1 and 5HT3
ER Granisetron (AP530)
• PENDING FDA approval
• Designed to deliver Granisetron over 5 days
CINV ongoing issues
• Delayed nausea continues to be an ongoing issue
• Inadequate clinician-patient communication
• Poor patient adherence – incorrect timing, pill burden, fear that swallowing will
induce nausea and vomiting
CINV Goals
• Prevention and management
• Effective communication with the multidisciplinary team
• Appropriate follow-up care
Assessing and Preventing Critical Situations
• Critical situations and emergencies are specifically related to the type of
malignancy
• Malignancies are classified as either Solid Tumor or Hematologic Malignancies
Solid Tumor
• Grow by cell-to-cell transfer
• Invade soft tissue and vessels with infection and bleeding
• Interfere with organ function
• Long term, Chronic illness
• Pain – common issue
• Tumors cause Hypercoagulability
Hematologic Malignancies
• Diffuse body-wide disease at onset
• Multi-system failure is common
• Hematopoietic cell abnormalities lead to infection, bleeding, and debilitating
rapidly proliferative
Progression
• SIRS – System Inflammatory Response Syndrome. Two or more of the following:
Temperature >38.3 C or <36 C, HR>90, RR>20, WBC>12 or <4 or >10% bands
• SEPSIS – two SIRS criteria + a known or suspected bacterial, viral, or fungal infection
• SEVERE SEPSIS – Sepsis + at least one sign of end organ dysfunction (altered mental
status, decreased urinary output, thrombocytopenia, SBP<90, MAP<65 prior to fluid
resuscitation
• SEPTIC SHOCK – hypotension and elevated Lactate >4 may be signs of
hypoperfusion/septic shock. Septic shock is persistent hypotension despite adequate
fluid resuscitation
Sepsis
• 10th leading cause of death and most common nonmalignant death in Oncology
• 14% Oncology patients have severe sepsis with 30-40% deaths from severe sepsis
or septic shock
• Early recognition is key, therefore Nurses play an important role in prevention
Hemorrhagic Cystitis
• Erosion of the inner mucosal lining of the bladder
• Due to exposure to toxic metabolites
• Due to medications (Cytoxan, Ifosfamide)
• Due to Infections (CMV)
Symptoms
• Hematuria
• Dysuria
• Bladder spasms
• Fever
• Retained bloody urine
Treatment
• IV Fluids – high rate, brisk volume, Normal Saline
• CBI – Normal Saline, Albumin, Prostaglandin ES
• Interventional Procedures – Cystoscopy, Cautery, Silver Nitrate
• Mesna
Pancreatitis
• Inflammation of the pancreas with varying clinical manifestations from mildhemorrhagic
Pancreatitis classifications
• Acute – single attack from a previously normal gland
• Recurrent acute – repeated episodes without long-term functional damage
• Recurrent chronic – recurring episodes with progressive damage to the gland
• Hemorrhagic – auto-necrosis of the gland with erosion and bleeding of vessels
from within
Epidemiology
• Affecting 25,000-40,000 people each year with 20,000 deaths per year
• 70-85% have mild disease
• 15-30% becoming critically ill
• Women – common cause of Biliary Tract Disease
• Men – common cause of Alcohol abuse
Symptoms
• Food intolerance – anorexia, vomiting, jaundice, weight loss, alkalosis
• Inflammation – epigastric or substernal pain radiating to back, fever, abdominal
distention, fluid shifts with edema, ascites, pleural effusion, hypotension,
paralytic ileus
• Hemorrhagic – bruising on flank and umbilicus, hyper/hypoglycemia, life
threatening electrolyte imbalances (hypocalcemia, hypomagnesemia,
hypokalemia, hyperkalemia), GI Bleeding
Treatment
• Promote pancreatic blood flow and inhibit pancreatic secretion
• NPO and NG to suction
• IVF – to ensure adequate circulating volume and monitor urine output
• Comfort measures
• Central nutrition
• Pain control
• Anti-emetics
Dental Oncology
• Discipline within Dentistry, providing general dentistry, oral medicine, oral
pathology and maxillofacial prosthetics for the cancer patient
• Consults should be done prior to initiating therapy to allow ample time for
healing, allow time to evaluate patient history and ability to perform
recommendations
Head and Neck Cancer Patients
• Significant issues with
• Mucositis
• Pain
• Hypoguesia (decreased ability to taste)
• Dysphasia
• Erythema
• Opportunistic infections
• Trismus
• Osteoradionecrosis
Osteoradionecrosis
• Delayed healing of the bone (typically the mandible)
• Leading to fracture
• Stages
• Stage 0 – nonspecific (no exposed bone, radiographic change, or pain)
• Stage 1 – exposed asymptomatic bone, no evidence of infection
• Stage 2 – exposed bone, erythema, symptomatic (pain), evidence of infection
• Stage 3 – exposed bone, pain, infection, extending beyond alveolar bone, possible
pathologic fracture
Treatment
• Topical antiseptics (chlorexadine)
• Antibiotics – Penicillin V, Clindamycin
• Symptoms management – hyperbaric oxygen, sequestrectomy, vascularized free
tissue transfer
Bisphosphonate Therapy
• Administered in Oncology for treatment of Osteoporosis, Paget’s disease and
metastatic lesions secondary to cancer
• Inhibitor of osteoclast function and result in areas of exposed bone and necrosis
• Reported in 2.9-11% of cancer patients
• Necrosis may also be caused by
• Denosumab
• Bevacizumab
• Suitinib
Prevention
• Good assessment and dental history, social habits, and current dental practices
• Thorough assessment
• Referral to Dentistry prior to starting Bisphosphonate therapy
Protection Against Hazardous Drugs
• Current recommendations
• Double glove with ASTM-tested chemotherapy gloves
• Chemotherapy-resistant gown, to be worn during preparation, administration, and
disposal. Should be “single-use” and NOT to be saved to be reused
• Closed System Transfer Device used for all compounding and administration
• Crushing or cutting oral chemotherapy done inside a biologic safety cabinet
• IV bags spiked with a neutral solution
• Spill Kit available
• All personnel trained in hazardous drug handling
USP Chapter 800
• USP Chapter 800 (United States Pharmacopeial) sets standards for hazardous
drug handling from delivery to disposal
• Enforced by each states Board of Pharmacy and tied to CMS and reimbursement
• Reinforcing appropriate respiratory protection for drugs that vaporize at room
temperature. A closed system transfer device is required for administration for
these drugs. These are designed to “restrict hazardous drug liquid or vapor from
escaping into the environment.”
• Aurora utilizes the “Texium” system to follow this guideline
DOSH Inspections
• The Division of Occupational Safety and Health inspects staff, may take
samples/photographs/videotapes/audiotapes and conduct tests/interviews to
check compliance
• Citations with non-compliance may result in $5,000-$70,000 fines
Intervention Management
• In order to improve nurse-sensitive patient outcomes, ONS has provided
evidence based resources utilizing PEP cards
• Goal of PEP – identify the best available scientific evidence to help nurse
improve nurse-sensitive patient outcomes
• Audience of PEP
• Nurses
• Useful to other disciplines as well
History of PEP
• 1998 – ONS members defined Oncology nursing-sensitive patient outcomes
• 2006 – first volume of PEP topics/resources were made available as pocket cards
(CINV, fatigue, infection prevention, sleep-wake disturbances)
• 2009 – Volume 2 PEP cards were released (including: caregiver strain and burden,
constipation, depression, dyspnea, mucositis, peripheral neuropathy, pain, bleeding
prevention, anorexia, diarrhea, lymphedema)
• 2011 – PEP updated (including: cognitive impairment, hot flashes, radiodermatitis,
skin effects)
• 2014 – PEP Pocket Guides were updated to include all 20 topics
PEP Pocket Guides
Green
• Green = GO
• The evidence supports the consideration of these interventions in practice
Yellow
• Yellow = CAUTION
• There is not sufficient evidence to say whether these interventions are effective
or not
Red
• Red = STOP
• The evidence indicates there interventions are either not effective or may cause
harm
Cognitive and Behavioral Interventions
• Utilized with
• Sleep-wake disturbances
• Depression/Anxiety
• Caregiver burden
• Fatigue
Principals of Cognitive Behavioral Interventions
• Identifying negative or unhelpful thoughts
• Examine association between thoughts, feelings, and behaviors
• Recognize helpful and unhelpful behaviors
• Establish goals to apply new behaviors that facilitate effective coping
• Develop problem solving skills
Progressive Muscle Relaxation
• Therapy created to help with anxiety
• Technique to monitor and control muscle tension
• Self or professional trained
• BID utilizing 16 different muscle groups
• Contraindicated for those with Thought disorders that distort reality
(Schizophrenia)
Exercise and Physical Activity Prescription
• Cancer patients should engage in regular physical activity, aiming at 150 minutes
per week
• Reduces fatigue, maintains QOL, improves overall prognosis and survival
• There is an association between exercise and disease recurrence
• Less then <40% of patients actually meet the recommended physical activity
levels, therefore there is a vital need to find effective ways to inform and
motivate patients to be physically active
Treatment
• General education about exercise and physical activity during cancer treatment is
vital
• Obtain consent by oncology team prior to starting treatment
• Consider waiting until Cycle 2 before beginning exercise if patient has not been
regularly active
• Vitals should be monitored regularly
• Exercise with a partner for safety
• Avoid swimming if undergoing Radiation or if a Central Venous Access device is
present
Pharmacology Update for 2015-2016
• Many new drugs were introduced in 2015-2016
Updates
• Non-small cell lung cancer
• Alectinib (ALK Positive)
• Gefitinib (EGFR positive)
• Osimertinib (EGFR T790M positive)
• Necitumumab (squamous cell)
• Pembrolizumab (progressed on or after platinum based treatment) New indication
• Crizotinib (metastatic with PD-L1 expression) New indication
• Palbociclib (with letrozole first line ER+/HER2-)
• Palbociclib (with fulvestrant for pretreated ER+HER2-) New indication
Updates
Colorectal
Trifluradine tipiracil
Ramucirumab (with FOLFIRI) New indication
Pancreatic
Irinotecan Liposomal
Melanoma
Cobimetinib (with Vemurafenib for unresectable/metastatic BRAF V600E or V600K mutation +)
Talimogene Laherparepvec (TVEC) (for unrectable cutaneous/subcutaneous and nodal lesions)
Pembrolizumab (initial use and patients with prior treatment unresectable/metastatic) New indication
Trametinib and Dabrafenib (combination for metastatic BRAF V600E or V600 K mutation +) New indication
Ipilimumab (with one node + and resected) New indication
Ipilimumab and Nivolumab (combination in BRAF wild type unresectable/metastatic) NEW indication
Updates
Thyroid
Lenvatinib
Basal Cell
Sonidegib
Neuroblastoma
Dinutuximab
Sarcoma
Trabectedin (Liposarcoma or Leiomyosarcoma
Eribulin (Liposarcoma) New indication
Updates
Renal Cell
Nivolumab (expanded indication for RCC after anti-angiogenic therapy)
New indication
Non-Hodgkin Follicular Lymphoma
Obinutuzumab – New indication
Hodgkin Lymphoma
Brentuximab vedotin (post autologous HSCT consolidation) New
indication
Updates
Chronic Lymphocytic Leukemia
Ibrutinib – New indication
Ofatumumab (2nd and 3rd indications for CLL) New indication
Waldenstroms macroglobulinemia
Ibrutinib – New indication
Multile Myeloma
Elotuzumab
Ixazomib
Daratumumab
Panobinostsat
Carfilzomiab (combination with lenalidomiade and dexamethasone) NEW indication
Biosimilars
• Biological product that is approved based on a showing that it is highly similar
to an already approved biological product
• Only minor differences in clinically inactive components are allowed
• Example – Filgastrim-sndz (Zarxio injection) Sandoz – biosimilar to Neupogen for
the same five indications. The formulations differ in one active ingredient
Helpful tips in remembering the new cancer
therapies
• Know the type of drug (small molecule, monoclonal antibody, vaccine, cytoxic)
• Know the Generic name
• Know the target and what it normally does in the body
• Know if the drug is “personalized” to tumors genomic profile
TINIBS
• Small molecule; tyrosine kinase inhibitors
• Oral – adherence, possible food/food, food/drug interaction, patient education
• Target – EGFR, VEGFR
• Example – ErloTINIB, SuniTINIB, PonaTINIB, ImaTINIB, DasaTINIB
RAFENIB, METANIB
• Small molecule; kinase inhibitor
• Oral
• Targets – RAF, RAS, MET pathway
• Example – SoRAFENIB, DabRAFENIB, TraMETANIB, VermuRAFENIB
LISIB
• Small molecule; PI3 kinase inhibitor
• Oral
• Example - IdelaLISIB
DEGIBS
• Small molecule; sonic hedgehog pathway inhibitor
• Oral
• Example – SoniDEGIB, VismoDEGIB
CICLIBS
• Small molecule; inhibitor of cyclin dependent kinase (CDK4 and CDK6)
• Oral
• Example - PalboCICLIB
ZOMIBS
• Small molecule; proteasome inhibitors
• IV, SQ, or oral
• Slight chance of infusion reaction
• Example – BorteZOMIB, CarfilZOMIB
INOSTAT
• Small molecule; HDAC inhibitor
• IV or Oral
• Slight change of infusion reaction
• Example – VorINOSTAT, BelINOSTAT
Monoclonal Antibody = MAB
TosituMOmab and iodine 131
MO = Mouse
RituXImab
XI = Chimeric (cross between mouse and human)
TrastuZUmab, BevaciZUmab
ZU = Humanized
PanitumUmab
U = fully human
Continued
T or TU = Tumor
TrasTUzumab
CI = Circulatory
BevaCIzumab
LI or I = Immunomodulator
IpiLImumab
Sexuality
• When discussing sexuality, nurses often lack specific knowledge, leading to a
lack of confidence
• Barriers to the discussion of sexuality are
• Conservation attitudes
• Fear of embarrassment
• Fear of offending
• Denial of responsibility
• Lack of awareness
Misconceptions
• “If patients want to know, they will ask”
• In reality – if the nurse doesn’t ask, the patient will not bring it up
Sexuality and Cancer
• There is a lack of knowledge and patients are typically not well informed of
potential problems related to sexuality
• Cancer affects sexuality, as cancer affects the brain which stimulates thoughts,
feelings, and desires
• Men and Women are both affected sexually, however are affected quite
differently
Men and Sexuality
• Men tend to have problems with Erectile Dysfunction
• Treatment
• Sildenafil – increases blood flow to the penis during sexual stimulation. This
increased blood flow will produce an erection
• Alprostadil injection – relaxes certain muscles in the penis and widens blood vessels,
resulting in increased blood flow to the penis causing an erection. This is an actual
injection that the patient is taught to inject and typically works within 5-20 minutes
lasting 30-60 minutes
• Fleshlight – masturbatory aid, penis is inserted into the opening
Women and Sexuality
• Treatment for women revolves around lubricants and moisturizers
• Help with friction and irritation
• Types of lubrication
• Water
• Silicone
• Oil
Lubricants
• Patients should be taught to look at osmolality on the package insert and buy a
lubricant with similar osmolality to the area they need lubricated
• When something has a different osmolality to what your body is accustomed to,
specifically when is has a higher measure (hyper osmotic) the epithelial cells of the
mucous membrane then expel the liquid, drying up and sloughing off. This is
irritating and can leave the patient more susceptible to infection
• Hypo-osmotic lubricants have cells that absorb excess liquid, potentially resulting in
bursting if taking in too much fluid
• Ideally lubricants should be iso-osmotic so there is little or no osmosis
Osmolality
• The Vagina has an osmolality of 280 mOsm/kg, therefore lubricants should have
a similar osmolality
Osmolality of OTC Lubricants
• Good Clean Love – 269 mOsm/kg
• K-Y Jelly – 2424 mOsm/kg
• ID Glide – 3429 mOsm/kg
• Astroglyde – 6113 mOsm/kg
• K-Y warming jelly – 10,300 mOsm/kg
• Slippery Stuff Liquid – 26 mOsm/kg
• Sliquid Organics – 106 mOsm/kg
• Tap water – 3 mOsm/kg
Dilators
• Women who have had radiation, or are on an Aromatase inhibitors should be
instructed to use a vaginal dilator to prevent internal adhesions
• Vaginal stenosis can be significant preventing future pelvic exams
• Daily x 10 minutes
Skin Toxicity Management
• Dermatologic side effects secondary to EGFR inhibitor therapy can be very
emotional and have a significant impact on their QOL and drug adherence
• Nurses play a vital role in education, suggesting coping strategies and providing
supportive care needing to promote understanding and management of the
toxicities
• Patient education is vital, leading to better management and treatment
adherence
EGFR signaling
• EGFR signaling is tightly regulated in normal cells, however in cancer cells there
is a dysregulation and EGFR is over expressed
• There are many epidermal changes with EGFR inhibitor therapy
• Cells don’t get the signal to “grow”
• Skin becomes thin with less moisture
• Resulting in skin toxicities
Dermatological Toxicities
• Papulapusular rash – papules and pustules on face, scalp, neck, check, back
• Pruritis – intense itching
• Xerosis – flaky, paper-thin, dry skin. Can progress to fissures or xerotic eczema
• Paronychia – infections involving the tissues around the nails
• Oral Mucositis/Stomatitis – ulceration or inflammation of oral mucosa
Papulopustular Rash Grading
• The rash is graded according to severity and treatment is based on the grade
• Grade 1 – Papules/pustules covering <10% BSA, localized, minimally symptomatic, no
infection. Keep skin moisturized, no dose changes
• Grade 2 – Papules/pustules covering 10-30% BSA, limiting ADL, psychosocial impact,
mild pruritis, tenderness, no infections, topical corticosteroids and oral antibiotics, no
change in dose
• Grade 3 – Papules/pustules covering >30% BSA, associated with superinfection, limiting
self care ADL, severe symptoms, decrease EGFR dosing, continue with topical
corticosteroids and antibiotics, if worsens medication may need to be DCd
• Grade 4 – Papules/pustules covering any percentage of BSA, associated with extensive
superinfection and life threatening consequences
Rash Management
• Apply alcohol free, fragrance free, hypoallergenic moisturizer daily on hands and feet
• Drink plenty of fluids to stay hydrated
• Apply SPF 30 containing Zinc Oxide or Titanium Dioxide and wear protective clothing (decreases inflammation)
• Avoid hot showers, walking barefoot, and wearing tight fitting footwear
• Wear hypoallergenic makeup
• Use mild detergents and skin cleaners
• Don’t use OTC anti-acne medications (only irritate rash)
• Apply OTC corticosteroids to areas of risk
• Use prophylactic tetracycline antibiotcs
Pruritis
• Itching skin graded according to severity
• Grade 1 – mild or localized, treatment with topical anti-itch creams, cold compresses
• Grade 2 – intense or wide spread, intermittent, skin changes from scratching, limiting
ADL, treatment with oral anti-histamine, anti-epileptics, or anti-depressants
• Grade 3 – intense or wide spread, constant, limiting self care ADL and/or sleep. To
prevent dry skin, minimize soap, increase emollients, and avoid alcohol based agents
Xerosis
• Dry skin is graded according to severity
• Grade 1 – covering <10% BSA with no associated redness or itching, treat with
emollients without fragrances/irritants, exfoliants, zinc oxide, petroleum jelly
• Grade 2 – covering 10-30% BSA and associated with redness and itching, limiting
ADL
• Grade 3 – covering >30% BSA and associated with itching, limiting ADL, treat with
topical medium-to-high potency corticosteroids
Paronychia
• Nail infections to fingers and toes. Graded according to severity
• Grade 1 – Nail fold edema or redness, disruption of the cuticle
• Grade 2 – Nail fold edema or redness with pain, associated with discharge or nail
plate separation, limits ADL, treated with local and oral interventions
(corticosteroids, tetracycline antibiotics)
Oral Mucositis
• Grading
• Grade 1 – Asymptomatic or mild symptoms
• Grade 2 – Moderate pain, not interfering with oral intake
• Grade 3 – Severe pain, interfering with oral intake
• Grade 4 – Life threatening consequences
• Grade 5 – limits ADL, surgical intervention or IV antibiotics indicated
Survivorship Care
Quality organizations that focus on Survivorship
Institute of Medicine
Commission on Cancer
ASCO Quality Oncology Practice Initiative
Survivor needs
• Physical (long term effects of fatigue, pain)
• Psychosocial (depression, anxiety with fear of recurrenc)
• Management of late/long term side effects from treatment
• Follow-up care
• Information
Survivorship Behaviors
• Many healthy behaviors have been shown to decrease the risk of cancer
recurrence, increase survival, and strengthen QOL
• Despite the research
• 15% of cancer survivors continue to smoke
• 27.5% continue to be obese
• 31.5% do not participate in regular physical activity
Survivorship Care plan
• Every survivor should have a personalized comprehensive survivorship care
plan
• Plan A – Treatment received
• Plan B – Post Treatment needs
Plan A
• Treatment received
• Diagnostic tests performed/results
• Tumor characteristics
• Dates of treatment – initiation and completion
• Therapies provided – including treatment response and toxicities experienced during
treatment
• Psychosocial, Nutritional, Supportive Care provided
• Full contact information of treating institutions with individual providers
• Key point of contact and coordinator for continuing care
Plan B
• Follow-up care
• Course of recovery and possible late/long term effects
• Need for any ongoing maintenance therapy
• Recommended cancer screenings and other periodic testing/examinations
• Information on possible signs of recurrence and secondary malignancy
• Recommendations for healthy behaviors
• Referrals to follow-up care providers and support groups
• A listing of cancer related resources and information
Quality Survivorship Care
• Coordination – between specialists and PCP
• Prevention – of recurrent and new cancers and late effects
• Surveillance – of cancer spread, recurrence, or second cancers
• Intervention – for effects of cancer and its treatment