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

Antineoplastic Therapy Administration Safety Standards for Adult and Pediatric Oncology: ASCO-ONS Standards

PURPOSE

To update the ASCO-Oncology Nursing Society (ONS) standards for antineoplastic therapy administration safety in adult and pediatric oncology and highlight current standards for antineoplastic therapy for adult and pediatric populations with various routes of administration and location.

METHODS

ASCO and ONS convened a multidisciplinary Expert Panel with representation of multiple organizations to conduct literature reviews and add to the standards as needed. The evidence base was combined with the opinion of the ASCO-ONS Expert Panel to develop antineoplastic safety standards and guidance. Public comments were solicited and considered in preparation of the final manuscript.

RESULTS

The standards presented here include clarification and expansion of existing standards to include home administration and other changes in processes of ordering, preparing, and administering antineoplastic therapy; the advent of immune effector cellular therapy; the importance of social determinants of health; fertility preservation; and pregnancy avoidance. In addition, the standards have added a fourth verification.

STANDARDS

Standards are provided for which health care organizations and those involved in all aspects of patient care can safely deliver antineoplastic therapy, increase the quality of care, and reduce medical errors.Additional information is available at www.asco.org/standards and www.ons.org/onf.

Pilot study evaluating feasibility and utility of pharmacist-driven oral antineoplastic agent monitoring program

INTRODUCTION

Oncologists are increasingly prescribing oral antineoplastic agents which have benefits and challenges impacting patient outcomes. Practice guidelines recommend monitoring symptoms and adherence without outlining any specific tools or methods for monitoring. Pharmacists are successful in monitoring patients on therapy and improving outcomes. We aimed to assess the feasibility and utility of a pharmacist-delivered and medical record-integrated adherence and symptom monitoring program for patients on oral antineoplastic agents.

METHODS

This single-center, prospective, interventional study designed and implemented an adherence and monitoring program. A pharmacist contacted patients twice between clinic visits for three months. During telephone encounters, patients were verbally screened for medication adherence and assessed for new or changing symptoms using the Edmonton Symptom Assessment System as a signal of possible adverse events. We measured feasibility via patient enrollment, completed proportion of scheduled contacts, and pharmacist time. Utility was assessed through patient adherence, satisfaction surveys, healthcare resource utilization, and pharmacist interventions (i.e., patient education, adherence assistance, and symptom management).

RESULTS

Fifty-one patients participated. Ninety-one percent of scheduled patient contacts were completed. Edmonton Symptom Assessment System was administered by pharmacy personnel 102 times. Patient-reported adherence was 100%. Overall satisfaction was 85% and 100%, for patients and physicians, respectively. Fifty-one (98%) pharmacist recommendations were accepted. There were 14 total utilizations of healthcare resources-5.2 per 1000 patient days.

CONCLUSIONS

This study suggests a pharmacist monitoring program for patients taking oral antineoplastic agents is feasible and provides utility. Further research is needed to evaluate whether this program improves safety, adherence, and outcomes in patients using oral antineoplastic agents.

Evaluation of an Interprofessional Training Program to Improve Cancer Drug Therapy Safety

PURPOSE

Drug therapy for cancer is a high-risk, high-volume clinical intervention that requires interprofessional teams. Given the complexity of anticancer drug therapy and safety concerns, an interdisciplinary team developed a novel training program for oncology registered nurses and pharmacists to improve cancer drug safety.

METHODS

Participants completed preworkshop learning assessments and received access to web-based modules on six topics: hazardous drug handling, drug extravasation, hypersensitivity reaction management, sepsis recognition, immune checkpoint inhibitor toxicities, and oral oncolytic adherence. In a 7-hour workshop, participants applied module content in interactive exercises and high-fidelity simulations. Preworkshop and postworkshop questionnaires assessed changes in knowledge and confidence in each topic. Program satisfaction and changes to clinical practice or policies were assessed 3 months after the workshop.

RESULTS

Two hundred ninety-two nurses and 82 pharmacists applied to participate, and 103 (35%) and 44 (54%) have participated, respectively. Long-term follow-up data were available on 133 (90%) participants. Change scores in confidence to meet program objectives increased between pre- and postworkshop (range of increase 0.6-0.8, P < .01). Knowledge scores increased significantly between pre- and postworkshop (average improvement of 3.2 points, P < .01). Overall program satisfaction was high (mean 5.0, standard deviation [0.2] on a five-point scale). Seventy-seven (60%) reported that they had made at least one clinical practice or institutional policy change at 3 months.

CONCLUSION

An interprofessional education program with online modules, in-person interactive sessions, and simulation activities is a promising strategy to deliver cancer drug safety content to practicing oncology clinicians.

Evaluation of a Nurse-Delivered Pre-Chemotherapy Educational Intervention to Increase Knowledge and Reduce Anxiety Among Ethnically Diverse Patients

Patients who are undergoing chemotherapy for cancer often have high-unmet information and psychological needs at the beginning of their treatment. Pre-chemotherapy education is an oncology nursing standard of care. However, few pre-chemotherapy education interventions have reported on their effectiveness among ethnically diverse samples. The aim of the study was to evaluate the implementation of an oncology nurse-led pre-chemotherapy intervention delivered to an ethnically diverse sample of patients treated at a comprehensive cancer center on day one of their first chemotherapy cycle. The aim of the intervention was to increase knowledge about treatment in order to improve patient self-management and to reduce treatment-related anxiety. We found that the intervention was effective in improving patient self-reported knowledge and decreasing treatment-related anxiety; however, differential effects were found for Hispanic/Latino patients, whose anxiety increased post-intervention, as well as for patients who reported poorer health status. These findings suggest that further research should investigate what factors trigger an increase in anxiety among diverse patient populations, and how these factors can be mitigated through development of tailored and culturally competent interventions.

[Evaluation of the practice of prescribing oral chemotherapy type "Capecitabine" by medical oncologist: A first study from Morocco]

INTRODUCTION

Oral anticancer therapy is becoming increasingly developed; their prescription has become a common practice in oncology. However, there is a variability and diversity in prescription practice. Its magnitude has been very little studied in scientific literature. To our knowledge, this is the first study in Morocco and North Africa to evaluate the practice of prescribing oral chemotherapy.

METHODS

The authors conducted a national exhaustive cross-sectional survey, to evaluate the practice of the oral chemotherapy "Capecitabine" type prescription by Moroccan oncologists and to identify strategies to promote an adherence to oral anti-neoplasic therapy.

RESULTS

Ninety-one medical oncologists answered out of 118, from public oncology centres (29.7%), Hospital University (58.2%), and private sector (12.1%). Thirty-four of the oncologists replied by email, 33 through phone conversation and 24 by filling paper questionnaires. In total, 32% of the cases were handwritten prescriptions, and 51.6% electronically generated. Forty-six percent of medical oncologists dedicated more time to the oral chemotherapy type Capecitabine prescription versus its intravenous equivalent 5FU. However, 33% medical oncologists take less time to this prescription, and 20.9% of them take the same time. Adherence to oral chemotherapy was evaluated by simply questioning of patients in most of the cases (94%) and 4% of medical oncologist declared that they did not evaluate this adherence. In total, 87.9% of Moroccan medical oncologists revealed that they have not received any specific training in the therapeutic education of the patient with oral anti-cancer treatment.

CONCLUSION

In Morocco, there is a great variability in prescription and follow-up practice for patients receiving oral chemotherapy. There is a lack of a national standardization with regards to the procedures of prescribing and monitoring patients to ensure the quality and safety of the oral chemotherapy prescription.

Larotrectinib: A Targeted Therapy for Solid Tumors

BACKGROUND

Although neurotrophic tyrosine receptor kinase (NTRK) gene fusions are not common in most cancers, they are present in more than 90% of some rare tumors. The U.S. Food and Drug Administration has approved larotrectinib for patients with NTRK gene fusion-positive cancers that meet certain criteria. With ongoing advancements in tumor sequencing, it is anticipated that cancer treatment will be determined by genetic variants rather than by cancer type in the future.

OBJECTIVES

This article provides an overview of larotrectinib, a targeted therapy.

METHODS

This article reviews clinical trial results and highlights implications for oncology nurses caring for patients taking larotrectinib.

FINDINGS

Larotrectinib is an effective treatment option for some patients with NTRK gene fusion-positive cancers. Oncology nurses are key to educating patients on dosing, administration, side effects, and precautions.

Patient Experiences With Oral Chemotherapy: Adherence, Symptoms, and Quality of Life

BACKGROUND

Oral therapies are increasingly common in oncology care. However, data are lacking regarding the physical and psychologic symptoms patients experience, or how these factors relate to medication adherence and quality of life (QoL).

MATERIALS AND METHODS

From December 2014 through August 2016, a total of 181 adult patients who were prescribed oral targeted therapy or chemotherapy enrolled in a randomized study of adherence and symptom management at Massachusetts General Hospital Cancer Center. Patients completed baseline assessments of adherence with electronic pill cap, QoL, symptom severity, mood, social support, fatigue, and satisfaction with clinicians and treatment. Relationships among these factors were examined using Pearson product-moment correlations and multivariable linear regression.

RESULTS

At baseline, the mean electronic pill cap adherence rate showed that patients took 85.57% of their oral therapy. The most commonly reported cancer-related symptoms were fatigue (88.60%), drowsiness (76.50%), disturbed sleep (68.20%), memory problems (63.10%), and emotional distress (60.80%). Patients who reported greater cancer-related symptom severity had lower adherence (r= -0.20). In a multivariable regression, greater depressive and anxiety symptoms, worse fatigue, less social support, lower satisfaction with clinicians and treatment, and higher symptom burden were associated with worse QoL (F[10, 146]=50.53; adjusted R2=0.77). Anxiety symptoms were most strongly associated with clinically meaningful decrements in QoL (β= -7.10; SE=0.22).

CONCLUSIONS

Patients prescribed oral therapies struggle with adherence, and cancer-related symptom burden is high and related to worse adherence and QoL. Given perceptions that oral therapies are less impairing, these data underscore the strong need to address adherence issues, symptom burden, and QoL for these patients.

Patient and provider perspectives on delivery of oral cancer therapies

OBJECTIVE

The introduction of oral cancer therapies presents new challenges to delivery of quality cancer care. Little is known about how patients and providers address and overcome these challenges. We conducted a qualitative study exploring the range of patient and provider perspectives on oral cancer therapies.

METHODS

We conducted semi-structured interviews with patients and providers at a tertiary referral center and county safety-net hospital in Dallas, TX. Interviews probed perspectives on differences between parenteral chemotherapy and oral therapies, adherence, communication, and cost/insurance. Interview transcripts were analyzed thematically using a deductively-driven coding scheme corresponding to the interview guide.

RESULTS

We conducted 22 patient (13 at tertiary referral center, 9 at safety-net hospital) and 10 provider (7 oncologists, 2 nurses, 1 pharmacist) interviews. Key themes from interviews included: (1) differences in parenteral chemotherapy vs. oral therapy; (2) adherence and dosing; and (3) experiences related to cost and communication.

CONCLUSIONS

Nearly all providers described challenges engaging with and educating patients about oral cancer therapies. Despite our initial hypothesis, safety-net patients encountered few barriers accessing oral therapies compared to patients receiving care in the tertiary referral center.

PRACTICE IMPLICATIONS

Our findings will guide future interventions to monitor and support cancer patients receiving oral therapies.

Construction and validation of an instrument for nursing consultation in outpatient chemotherapy

OBJECTIVE

Construct and validate instrument content for nursing consultation in an adult chemotherapy outpatient clinic.

METHOD

Methodological study composed of two stages: elaboration of the instrument and validation of content. A literary review of the dimensions of customer care was carried out in the light of Theory of Basic Human Needs Theory, culminating in two instruments: one for admission consultation and other for follow-up. The content was validated by the evaluation of listed experts based on the adapted Fehring's Validation Model.

RESULTS

In the first round, two items of the admission instrument and three items of follow-up required reformulation. In the second round, there was an increase in agreement rate: 11% in the instrument of admission and 10% in follow-up.

FINAL CONSIDERATION

The instrument represents a guideline for the Nursing Process and future research, but it cannot be seen as a substitute for nurses' knowledge and clinical reasoning.

Adherence to Oral Anticancer Medications: Evolving Interprofessional Roles and Pharmacist Workforce Considerations

Interprofessional care is exhibited in outpatient oncology practices where practitioners from a myriad of specialties (e.g., oncology, nursing, pharmacy, health informatics and others) work collectively with patients to enhance therapeutic outcomes and minimize adverse effects. Historically, most ambulatory-based anticancer medication therapies have been administrated in infusion clinics or physician offices. Oral anticancer medications (OAMs) have become increasingly prevalent and preferred by patients for use in residential or other non-clinic settings. Self-administration of OAMs represents a significant shift in the management of cancer care and role responsibilities for patients and clinicians. While patients have a greater sense of empowerment and convenience when taking OAMs, adherence is a greater challenge than with intravenous therapies. This paper proposes use of a qualitative systems evaluation, based on theoretical frameworks for interdisciplinary team collaboration and systems science, to examine the social interactionism involved with the use of intravenous anticancer treatments and OAMs (as treatment technologies) by describing patient, organizational, and social systems considerations in communication, care, control, and context (i.e., Kaplan’s 4Cs). This conceptualization can help the healthcare system prepare for substantial workforce changes in cancer management, including increased utilization of oncology pharmacists.

Impact of a formal pharmacist-run oral antineoplastic monitoring program: A pilot study in an adult genitourinary oncology clinic

Background

In recent years, there has been a changing paradigm in the management of oncologic disease states from the use of intravenous therapies, requiring a visit to the infusion center or hospitalization, to new therapies that can be administered orally.1,2 Several publications have evaluated the role pharmacists may play in the initial prescribing of oral chemotherapy, however the impact of a formalized pharmacist follow-up program has not been well defined. This study evaluates the impact of a pilot pharmacist-run oral antineoplastic monitoring program.

Methods

This retrospective cohort analysis evaluated patients prescribed an oral antineoplastic in the genitourinary oncology clinic at an academic medical center between 1 July 2014 and 15 March 2017. Patients enrolled in the program were compared to a historical control group. The primary objective was adherence to pre-defined standards for monitoring. Secondary objectives include persistence on therapy, need to seek medical care, analysis of pharmacist interventions, patient satisfaction, and financial impact for the on-site retail pharmacy.

Results

In total, 33 patients were evaluated (11 cases, 22 controls). Average adherence to monitoring recommendations was significantly higher in the case group compared to controls (89% vs. 61%; p = 0.008). In total, 67 interventions were made by the clinical pharmacist with an average of 6 per patient.

Conclusions

This study shows that formalized pharmacist follow-up programs can improve patients’ adherence with antineoplastic monitoring standards. Additionally, pharmacists made clinically significant interventions and had high patient satisfaction, providing justification for expansion into other disease states.

Nursing Application of Oral Chemotherapy Safety Standards:An Informal Survey

As the use of oral chemotherapy continues to rise, new approaches are needed to ensure patient safety. To help address this issue, the American Society of Clinical Oncology/Oncology Nursing Society (ONS) Chemotherapy Administration Safety Standards were expanded in 2013 to include additional measures addressing oral anticancer drugs (OACs). Because minimal data assessing the application of these standards exist, ONS conducted an independent survey of oncology nurses to evaluate the application of these standards in practice as they relate to several areas of OAC use: assessment, consent, patient education, drug verification, and monitoring. The data revealed that, although the standards are followed in many settings, a large number of settings do not have processes in place to support safety standards and ensure patient safety when administering OACs. Information gained in this informal survey can be used to guide additional research and educational initiatives.

High Initiation of Adjuvant Hormonal Therapy Among Uninsured Stages I-III Breast Cancer Patients Treated in a Safety-Net Healthcare System

OBJECTIVE

Despite benefits of adjuvant hormonal therapy (AHT), many eligible breast cancer patients do not complete therapy as recommended. Patterns of AHT use have not been well studied among uninsured breast cancer patients who fall into coverage gaps or are ineligible for public insurance programs.

METHODS

We identified 291 patients newly diagnosed with stages I-III hormone receptor-positive breast cancer from January 2008 to December 2012. All patients were treated at a safety-net healthcare system and enrolled in an income-based medical assistance program that fills AHT prescriptions at low cost. We extracted and linked cancer registry, pharmacy claims, and medical record data to assess AHT initiation (defined as a new AHT prescription ≤18 months since diagnosis) and sociodemographic and healthcare utilization variables. Log-binomial regression was used to identify correlates of initiation.

RESULTS

Overall, 239 (82%) patients initiated AHT. Tamoxifen (42%) and anastrozole (55%) were most commonly prescribed. The mean copay was $4.90 for tamoxifen and $6.00 for anastrozole. Although crude analyses revealed small, statistically significant prevalence ratios for race/ethnicity (Hispanic vs. white, other vs. white), year of diagnosis (2008 vs. 2012), primary care visit before diagnosis (any vs. none), and smoking status (current vs. never), there were no significant correlates of initiation in the adjusted model.

CONCLUSION

Safety-net healthcare systems providing access to AHT (i.e., through reduced copays) could improve the number of eligible patients initiating therapy. Continuity and integration of care in these settings may reduce disparities frequently observed in uninsured, low-income breast cancer populations.

Factors Associated with Adherence to and Treatment Duration of Erlotinib Among Patients with Non-Small Cell Lung Cancer

BACKGROUND

In lung cancer, there is an increasing number of oral agents available for patients; however, little is known about the factors associated with adherence to and treatment duration on oral medications in non-small cell lung cancer (NSCLC).

OBJECTIVE

To evaluate the clinical and demographic factors associated with adherence and treatment discontinuation, respectively, to oral oncolytics among patients with NSCLC.

METHODS

A retrospective, claims-based analysis of the Humana Research Database supplemented with medical chart review was conducted among patients with NSCLC who started an oral oncolytic between January 1, 2008, and June 30, 2013. Patients were required to be enrolled at least 1 year before the start of oral oncolytics and have no evidence of any oral oncolytic use during this period. Logistic regression models and Cox proportional hazard models were used to identify predictors associated with medication adherence and treatment duration, respectively.

RESULTS

Among all oral oncolytics, only the cohort starting on erlotinib had sufficient sample size (n = 1,452). A wide variety of factors were found to be associated with adherence. Low-income subsidy status, previous use of intravenous chemotherapy, and lower total baseline health care costs were significantly related to decreasing adherence (each P < 0.05). Additionally, increasing patient out-of-pocket cost was associated with decreasing adherence to erlotinib (P < 0.0001). Factors significantly related to longer treatment duration included low-income subsidy status (P < 0.001) and having Medicare insurance, (P = 0.0004), dual eligibility (Medicare and Medicaid, P = 0.007), and higher erlotinib out-of-pocket costs (P < 0.0001).

CONCLUSIONS

There is a need for mechanisms to be in place to identify and address barriers to care. Future research should focus on evaluating and reducing any potential risk to patient outcomes that may be associated with low adherence to or shorter treatment duration on oral chemotherapy.

DISCLOSURES

This study was supported by funding from Eli Lilly and Company to Comprehensive Health Insights, a Humana company, as a collaborative research project involving employees of both companies. Hess, Winfree, Zhu, and Oton are employees of Eli Lilly and Company. Louder and Nair are employees of Comprehensive Health Insights, which received funding to complete this research. Study concept and design were contributed by Hess, Zhu, Winfree, and Oton. Nair and Louder collected the data, and data interpretation was performed by all the authors. The manuscript was written primarily by Hess, along with Nair, and revised by Hess, Nair, Louder, and Winfree, with assistance from Zhu and Louder.

Hepatic artery infusion pump in the treatment of liver metastases

BACKGROUND

Hepatic artery infusion pump (HAIP) use in chemotherapy started in the 1960s as a way to treat liver metastases that were not amendable to locoregional therapy or surgical resection. Because of complications and limited survival benefit, the use of HAIPs fell out of favor. A resurgence has occurred in the use of these pumps, but limited information is available in the literature guiding nursing care of these patients.

OBJECTIVES

The purpose of this study was to review the literature regarding the use, procedures, and nursing care of patients with HAIPs.

METHODS

A systematic literature review was conducted to obtain a comprehensive range of publications.

FINDINGS

Database searching resulted in 511 titles and abstracts. After eliminating duplicates and nonrelevant titles, 65 remained and were read in full. Of these, 20 were excluded because they did not fit the inclusion criteria.

Nurse Adherence to Safe-Handling Practices: Observation Versus Self-Assessment

BACKGROUND

Chemotherapy medications place nurses at risk for occupational exposure, a primary nursing safety concern. No literature was available on adherence to following chemotherapy handling practices and nurses' perceptions of safe-handling practices.

OBJECTIVES

The aims of the pilot study were to examine actual and subjective ambulatory oncology nurse adherence to chemotherapy safe-handling guideline recommendations that prevent chemotherapy exposure.

METHODS

A prospective, comparative mixed-methods study was used to compare objective and subjective nurse behaviors of expected safe chemotherapy handling-specifically, micro-ethnography and questionnaires. Fisher's exact test was used to assess differences in the rates of observations and questionnaire responses.

FINDINGS

Twenty-two cases of chemotherapy handling were observed, and 12 of 33 nurses completed self-assessments. Of observed practices, nurses completed three behaviors 100% of the time (disposing of gloves in a chemotherapy-approved container after initiating chemotherapy, discarding the chemotherapy bag and tubing after disconnecting chemotherapy infusions, and washing hands after chemotherapy was administered). When objective and subjective behavior adherence were compared, three behaviors were carried out with greater frequency than what nurses perceived on questionnaires (double gloving and gowning when disconnecting chemotherapy and properly discarding chemotherapy). Two behaviors were carried out with less frequency than nurses provided on questionnaires (double gloving and protecting work surfaces during administration).

Optimizing the Benefits of Self-Monitoring Among Patients With Cancer

PURPOSE/OBJECTIVES

To investigate oncology professionals' perspectives about, experience with, and envisioned feasibility of incorporating patient self-monitoring as a patient-centered practice. 
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RESEARCH APPROACH

An interpretive, descriptive study.
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SETTING

Four health systems and five cancer centers in three states. 
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PARTICIPANTS

38 nurses, nurse practitioners, oncologists, physician assistants, and radiation therapists.
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METHODOLOGIC APPROACH

Individual and focus group interviews.
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FINDINGS

Three themes were revealed.

CONCLUSIONS

This study uncovers the potential contribution of patient self-monitoring as a means of providing patient-generated data that informs clinical decision making, going beyond self-monitoring for self-management only. Because the term self-monitoring is not used by clinicians, adoption of an agreed-upon term is recommended as the first step toward developing and implementing a self-monitoring strategy. Findings support the need to reenvision patient education to ensure self-monitoring is clinically useful while preventing an excessive focus on the negative, which may contribute to patient anxiety.
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INTERPRETATION

The full potential for self-monitoring by patients is not entirely reached. Because nurses are charged with providing patient education, they are strategically positioned to adopt the term self-monitoring and integrate a self-monitoring strategy into patient-centered practice.

National Cancer Control Programme in India: Proposal for Organization of Chemotherapy and Systemic Therapy Services

Cancer is a major health problem in India, with an estimated incidence of 1 million cases in 2012 that is likely to double in 2035 to approximately 1.7 million. The majority of cases are diagnosed in advanced stages, and approximately two thirds of patients die as a result of their disease. The mortality-to-incidence ratio is 0.68 in India, which is far higher than that in developed countries (approximately 0.38). One of the important reasons for this discrepancy is inequitable distribution and inaccessibility of health care resources in India. One component of scarce health care resources is the low ratio of oncologists to patients with cancer (1:2,000), which leads to delivery of systemic anticancer therapy in many hospitals by health care professionals who do not have required training. Given these facts, there is a need to focus on organization of medical oncology services in terms of manpower and infrastructure to standardize the delivery of systemic anticancer therapy. Redistribution of resources can streamline the delivery of cancer care, preferably close to the patient's home. This article describes the blueprint for organization of medical oncology services and delivery of chemotherapy and other systemic therapies to Indian patients. The model uses existing health care services in the country and is a four-tiered system of increasing sophistication: District Hospitals, Medical College Hospitals, Regional Cancer Centres, and Apex Cancer Centres. Delivery of quality care to patients with cancer through standardized protocols is crucial in improving cancer outcomes in India.

Technology and the Transformation of Oncology Care

OBJECTIVES

To review different types of technology and technological advances applicable to oncology care.

DATA SOURCES

Peer-reviewed studies and guidelines, magazine articles, books, websites, and online product-specific information.

CONCLUSION

Technologies that have transformed oncology care include electronic health records, data analytics, operations-related technologies, oncology-related technologies, portable and wearable technologies, and emerging technologies.

IMPLICATIONS FOR NURSING PRACTICE

Technological innovations have transformed health care from a paternalistic, physician-driven system to a system that focuses on and engages the patient.

Fertility Preservation Before Cancer Treatment: Options, Strategies, and Resources

BACKGROUND

Loss of fertility is one of the many potential late effects of cancer treatment. For young men and women who have not yet started or completed building their families, this can be a source of considerable emotional distress. Advances in reproductive technology can enable many of these patients to preserve their fertility; however, discussions must be initiated early enough during treatment planning to enable them to take advantage of these options.

OBJECTIVES

The purpose of this article is to provide oncology nurses with information, strategies, and resources to discuss fertility with men and women starting cancer treatment.

METHODS

This article summarizes the literature on treatment-related fertility risks and fertility preservation options, and provides a systematic framework for nurses to integrate these discussions into practice.

FINDINGS

Oncology nurses can effectively collaborate with other members of the healthcare team to ensure that young men and women starting cancer treatment are informed of the potential risks to fertility from their planned treatment, understand options to preserve fertility before treatment, and, if interested, are referred to appropriate reproductive specialists.

Safe Implementation of Computerized Provider Order Entry for Adult Oncology

BACKGROUND

Oncology has lagged in CPOE adoption due to the narrow therapeutic index of chemotherapy drugs, individualized dosing based on weight and height, regimen complexity, and workflows that include hard stops where safety checks are performed and documented.

OBJECTIVES

We sought to establish CPOE for chemotherapy ordering and administration in an academic teaching institution using a commercially available CPOE system.

METHODS

A commercially available CPOE system was implemented throughout the hospital. A multidisciplinary team identified key safety gaps that required the development of a customized complex order display and a verification documentation workflow. Staff reported safety events were monitored for two years and compared to the year prior to go live.

RESULTS

A workflow was enabled to capture real-time provider verification status during the time from ordering to the administration of chemotherapy. A customized display system was embedded in the EMR to provide a single screen view of the relevant parameters of chemotherapy doses including current and previous patient measurements of height and weight, dose adjustments, provider verifications, prior chemotherapy regimens, and a synopsis of the standard regimen for reference. Our system went live with 127 chemotherapy plans and has been expanded to 189. Staff reported safety events decreased following implementation, particularly in the area of prescribing and transcribing by the second year of use.

CONCLUSIONS

We observed reduced staff reported safety events following implementation of CPOE for inpatient chemotherapy using an electronic verification workflow and an embedded custom clinical decision support page. This implementation demonstrates that CPOE can be safely used for inpatient chemotherapy, even in an extremely complex environment.

Towards safety of oral anti-cancer agents, the need to educate our pharmacists

Introduction: The global prevalence of cancer is rising. Use of oral anticancer medications has expanded exponentially. Knowledge about these medications as well as safe handling guidelines has not kept abreast with the rapidity these medications are applied in clinical practice. They pose serious hazards on all personal involved in handling these medications as well as on patients and their caregivers. We addressed the gaps in knowledge and safe handling of oral anticancer agents among pharmacists in institutional based cancer care. Materials and Methods: We used a 41 item questionnaire to explore three domains, pharmacists' knowledge, safe handling practice and confidence and self-improving strategies towards these agents among pharmacists in multicentre specialized cancer care. Results: Participants included 120 pharmacists dedicated to handle and dispense oral anticancer agents. About 20% of Pharmacists have adequate knowledge about oral anticancer agents. Less than 50% apply safe handling principles adequately. Only a quarter are confident in educating cancer patients and their caregivers about Oral Anti-Cancer Agents. Conclusions: Pharmacists' knowledge about Oral Anticancer agents needs to be improved. Safe handling and dispensing practice of these medications should be optimized. Pharmacists' confidence towards educating patients and their caregiver needs to be addressed. Enhancing safety of oral anticancer agents should be a priority. Involving all key players, research and quality improving projects are needed to improve all aspects of the safety of oral anticancer agents.

Eliminating extravasation events: a multidisciplinary approach

Administration of chemotherapy agents can give rise to many safety issues. Extravasation of a vesicant agent causes tissue blistering and necrosis. This complication of chemotherapy administration causes additional pain and suffering in patients who are already suffering with a diagnosis of cancer. Nurses hold key responsibilities for educating patients about administration issues and following practice standards to minimize the risk of extravasation. Defining a path of shared responsibilities among team members is a critical step in assuring the safe administration of drugs classified as vesicants. This article describes a clinical practice change that is used at a large midwestern academic medical cancer center. This practice and policy change has resulted in a 90% reduction in the administration of vesicant agents peripherally, with no occurrence of extravasations in the first 6 months of implementation.

Learning from disaster: patient safety and the role of oncology nurses

When the Oncology Nursing Society (ONS) was almost exactly half its present age, in November 1994, a Boston Globe health columnist named Betsy Lehman was admitted to the Dana-Farber Cancer Institute in Boston, Massachusetts, to receive an investigational regimen for breast cancer. Her treatment ended in disaster. In one of the most notorious patient safety failures of modern times, Lehman was given severe overdoses of cyclophosphamide during a four-day period. On each of those four days, nurses, physicians, and pharmacists at Dana-Farber failed to notice that Lehman was receiving doses four times greater than the intended amount (Aspden, Wolcott, Bootman, & Cronenwett, 2007). Lehman died of cyclophosphamide toxicity on December 3, 1994.
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Common questions regarding clinical use of axitinib in advanced renal cell carcinoma

PURPOSE

An overview of the responses to some of the most frequently asked questions regarding axitinib administration and dosage modifications used in clinical practice are presented.

SUMMARY

Axitinib was approved for second-line treatment of advanced renal cell carcinoma by the Food and Drug Administration on January 27, 2012. Inquiries received over the first six months after the approval date were reviewed. A large number of questions were related to administration of axitinib in different patient populations or in patients with various comorbidities, such as its (1) use in patients unable to swallow oral medication or administration of axitinib via a nasogastric tube, (2) use in patients with renal or hepatic impairment, (3) central nervous system penetration and use in patients with brain metastases, (4) drug interactions, particularly with anticoagulants, and (5) dosage modifications. Responses to these inquiries were provided based on the published literature or from data on file from the manufacturer. The dosage of axitinib can be adjusted for use in patients with hepatic impairment or in patients who cannot otherwise tolerate the usual regimen. Patients taking concomitant warfarin can also take axitinib, and patients who cannot swallow oral medications can receive a liquid formulation of the drug, though its efficacy and comparability to the tablet formulation has not been tested.

CONCLUSION

Based on the published literature and company data on file, the axitinib dosage may be modified to accommodate patients with renal or hepatic impairment, who cannot swallow oral medication, are receiving concomitant warfarin, or who cannot otherwise tolerate the standard dosage regimen. For patients who cannot swallow, an oral suspension can be prepared because crushing axitinib is not recommended.

Self-reported adherence to oral cancer therapy: relationships with symptom distress, depression, and personal characteristics

BACKGROUND

Therapeutic cancer chemotherapy is most successful when complete dosing is achieved. Because many newer therapeutic agents are oral and self-administered by the patient, adherence is a concern. The purpose of our analysis was to explore relationships between adherence, patient characteristics, and barriers to adherence.

METHODS

This secondary analysis utilized self-reported data from a randomized trial of self-care management conducted at two cancer centers in the US. Symptom distress was measured using the 15-item Symptom Distress Scale (SDS-15) and depression with the Patient Health Questionnaire-9 (PHQ-9). Adherence to oral medication was self-reported using the 8-item Morisky Medication Adherence Scale (MMAS-8). Measures were collected via Web-based, study-specific software ~8 weeks after treatment start date. Odds of low/medium adherence (score <8) were explored using univariate logistic regression. Given the number of factors and possible relationships among factors, a classification tree was built in lieu of a multivariable logistic regression model.

RESULTS

Of the eligible participants enrolled, 77 were on oral therapy and 70 had an MMAS score. Forty-nine (70%) reported a high adherence score (=8). Higher odds of low/medium adherence were associated with greater symptom distress (P=0.09), more depression (P=0.05), chemotherapy vs hormonal oral medication (P=0.03), being female (P=0.02), and being randomized to the control group in the parent trial (P=0.09). Conversely, high adherence was associated with working (P=0.08), being married/partnered (P=0.004), and being older (P=0.02). Factors identified as significantly related to low/medium adherence from the univariate logistic regression analyses were supported by the classification tree results.

CONCLUSION

Nonadherence to therapeutic oral medications in patients with cancer was associated with being unmarried/unpartnered, symptom distress, younger age, not working, and female sex. These findings may help to identify patients at risk for nonadherence and for whom supportive interventions to enhance adherence may be needed.

Current practice patterns for oral chemotherapy: results of a national survey

PURPOSE/OBJECTIVES

To describe current nursing practices in the United States regarding care and safety of patients taking oral chemotherapy.

DESIGN

This three-phase study consisted of development, validation, and implementation of a national online survey.

SETTING

Survey of oncology nurses in outpatient settings.

SAMPLE

577 oncology nurses.

METHODS

Surveys were emailed to 5,000 members of the Oncology Nursing Society. The survey included 17 forced-choice items and one free-text item. Descriptive statistics and content analysis were obtained.

MAIN RESEARCH VARIABLES

Patient care practices, nursing resources, and barriers to medication adherence.

FINDINGS

Fifty-one percent of the respondents worked in practices that had developed specific policies, procedures, and resources for patients on oral chemotherapy. Barriers to treatment adherence included cost (81%) and adverse effects (72%). Practices with specific policies differed in clinical and statistical significance from practices without policies on almost every survey item. Free-text responses revealed that many practices have erratic procedures and inadequate interdisciplinary communication.

CONCLUSIONS

Systematic reliable policies and procedures for patient education, documentation, and interdisciplinary communication are urgently needed.

IMPLICATIONS FOR NURSING

Nurses should provide education and repeated teaching to improve patient safety, adherence to the medication, and self-monitoring for adverse effects.

Skin toxicity predicts efficacy to sorafenib in patients with advanced hepatocellular carcinoma

AIM: To study the relationship between adverse events (AEs), efficacy, and nursing intervention for sorafenib therapy in patients with hepatocellular carcinoma (HCC).

METHODS: We enrolled 37 consecutive patients with advanced HCC who received sorafenib therapy. Relationships among baseline characteristics as well as AE occurrence and tumor response, overall survival (OS), and treatment duration were analyzed. The nursing intervention program consisted of education regarding self-monitoring and AEs management, and telephone follow-up was provided once in 1-2 wk.

RESULTS: A total of 37 patients were enrolled in the study, comprising 30 males (81%) with a median age of 71 years. The disease control rate at 3 mo was 41%, and the median OS and treatment duration were 259 and 108 d, respectively. Nursing intervention was given to 24 patients (65%). Every patient exhibited some kinds of AEs, but no patients experienced G4 AEs. Frequently observed AEs > G2 included anorexia (57%), skin toxicity (57%), and fatigue (54%). Factors significantly associated with longer OS in multivariate analysis demonstrated that age ≤ 70 years, presence of > G2 skin toxicity, and absence of > G2 hypoalbuminemia. The disease control rate in patients with > G2 skin toxicity was 13/20 (65%), which was significantly higher compared with that in patients with no or G1 skin toxicity. Multivariate analysis revealed that nursing intervention and > G2 skin toxicity were independent significant predictors for longer treatment duration.

CONCLUSION: Skin toxicity was associated with favorable outcomes with sorafenib therapy for advanced HCC. Nursing intervention contributed to better adherence, which may improve the efficacy of sorafenib.

Current nursing practice for patients on oral chemotherapy: a multicenter survey in Japan

BACKGROUND

With a paradigm shift toward a chronic care model in cancer, the issue of adherence is becoming increasingly important in oncology.

METHODS

We mailed two self-reported surveys on current nursing practices for patients on oral chemotherapy to all 309 designated cancer centers and 141 large general hospitals in Japan. The first survey was based on a nurse-based questionnaire containing 40 items concerning nurse's characteristics, nurse staffing at workplace, general nursing care for new patients on oral chemotherapy and those with refilled prescriptions, follow-up, and system-based approach. The second survey was based on a patient-based questionnaire containing 10 items about patient characteristics and adherence-related nursing practice for 249 patients taking oral chemotherapy of 903 systematically sampled. We used multivariate logistic regression to identify factors that were associated with adherence-related nursing practices.

RESULTS

A total of 62 nurses (mean age: 41.5 years) from 62 hospitals who consented participated in the both nurse-based survey and patient-based survey about 249 patients. The results of nurse-based survey indicated that practices varied, but nurses were less likely to ask adherence-related questions of patients with refilled prescriptions than of new patients. The results of patient-based survey found that questions on side effects, discussions about barriers to achieving balance between treatment and daily life activities, and medication management were all significantly related to the question about unused medicines. Logistic regression revealed that adherence-related nursing practices were associated with the nurse's background, type of treatment, and healthcare system-related factors. Patient orientation on oral chemotherapy, interdisciplinary learning, and having a system-based approach for detecting prescription errors were identified as healthcare system-related factors.

CONCLUSIONS

A more systematic approach must be developed to ensure patients receive safe and effective oral chemotherapy, while nurses should play significant roles in patient education and monitoring.

Oral chemotherapy practices at Ontario cancer centres

Purpose

The use of oral chemotherapy agents in cancer treatment is increasing. To better understand issues affecting the optimal use of these agents, Cancer Care Ontario conducted an environmental scan of current practices in Ontario related to prescribing, dispensing, patient education, and supporting regimen adherence.

Methods

A series of semi-structured interviews were conducted either by phone (11 regions) or via email (two regions) with Ontario’s Regional Cancer Centres over a 3-month period in 2012. A questionnaire was pre-circulated to the regions to guide the discussions.

Results

Responses were received from 13 of 14 regions. Considerable variation in practice was found. Of 13 responding regions, 12 (92%) lacked formal procedures or processes for the prescription of oral chemotherapy. Ten regions (77%) reported using either handwritten prescriptions or a mixture of methods with only three regions routinely using computerized order entry systems for oral chemotherapy prescribing. Oral chemotherapy was reported to be labeled as “chemotherapy” in 46% of the regions. Twenty-three percent indicated that they provide extensive patient education through a multi-disciplinary approach. A number of tools were used to encourage patient adherence in different regions. Patient education was identified as an area where more work could be done.

Conclusion

Results indicate a lack of formal policies and variable practices across all aspects of oral chemotherapy in many regions. However, some regions have developed and implemented successful initiatives. The results from this review are informing provincial priorities and being shared between regions to support collaborative learning.

Empowering individuals to self-manage chemotherapy side effects

Providing concise, consistent, and individually relevant patient education is critical. At one institution, patients and families attended a chemotherapy education class consisting of an 11-minute DVD and an oncology nurse-facilitated group discussion. Postclass and eight-week follow-up surveys assessing understanding of treatment side effects, self-care management, and confidence in managing side effects were administered. Quantitative and qualitative data suggested the DVD and oncology nurse-facilitated group discussion provided consistent information, flexibility, and expert knowledge in empowering patients and families to self-manage chemotherapy side effects.

Documentation of oral versus intravenous chemotherapy plans in patients with metastatic non-small-cell lung cancer

PURPOSE

Using the ASCO Quality Oncology Practice Initiative (QOPI) guidelines for assessing quality cancer care, we examined differences in clinician documentation of patient consent and treatment plans for oral versus intravenous chemotherapy among patients with metastatic non-small-cell lung cancer (NSCLC).

MATERIALS AND METHODS

We conducted a retrospective review of the electronic health records of 175 patients diagnosed with metastatic NSCLC whose initial systemic treatment consisted of either oral or intravenous chemotherapy. Specifically, we collected data on whether oncology clinicians documented discussions of the intent of chemotherapy (eg, palliative v curative), the number of cycles or anticipated duration of the chemotherapy, and patient consent for the chemotherapy in the practitioner note.

RESULTS

Of the 175 patients in the sample (54.3% female; mean age = 61.96 years, standard deviation = 10.81 years), 119 (68%) received intravenous chemotherapy, and 56 (32%) were prescribed oral agents for first-line chemotherapy. Compared with those who received intravenous chemotherapy, patients prescribed oral chemotherapy had lower rates of documented treatment plans, including intent (23.3% v 45.4%, P = .005) and anticipated duration of therapy (8.9% v 32.8%, P = .001). The rate of documentation of discussions regarding patient consent for chemotherapy did not differ significantly between groups (57.1% v 69.7, P = .13).

CONCLUSION

Documentation of discussions regarding the goals and course of chemotherapy administration for patients with metastatic NSCLC does not meet ASCO QOPI quality standards, especially for individuals prescribed oral agents. Considering the increasing numbers of targeted oral therapies used in oncology practice, further work is needed to ensure appropriate discussion and documentation of chemotherapy plans.

Quality care: where we came from and where we must go

The focus of this new column will be to showcase innovative work that has advanced quality in areas of practice and care delivery that are of interest to the practicing oncology nurse. Examples include, but are not limited to, practice environment innovation, patient outcomes and experiences of care, team effectiveness, and unit-based or institutionwide system changes.