Treatment with ≥ 2L cabozantinib (Cabometyx), compared with ≥ 2L axitinib (Inlyta) improved survival outcomes in patients with advanced renal cell carcinoma (RCC) who received prior VEGF-targeted therapy, according to a retrospective cohort study of data from Public Health England’s Cancer Analysis System (CAS), presented at the 2021 ESMO Congress.

The study analyzed outcomes of adults who were diagnosed with stage III or IV RCC between January 1, 2011 and December 31, 2018, with follow-up lasting until January 31, 2020. A total of 440 patients received cabozantinib treatment, while 1045 received axitinib.

Median duration of treatment was longer for those who received cabozantinib (5.52 months; IQR, 2.73-11.74) than those on axitinib (4.60 months; IQR, 1.45-12.36).

Patients on cabozantinib – a TKI inhibitor – also had numerically longer median overall survival (OS) than patients given axitinib. In the unweighted analysis, median OS for cabozantinib was 11.41 months (IQR, 5.65-27.32) compared with 9.60 months (4.54-20.32). Similar results were found in the IPW analysis, with average OS lengths of 11.24 months (IQR, 5.65-27.98) and 10.39 months (IQR, 4.70-20.03) for the cabozantinib and axitinib arms, respectively.

“Both agents have been approved in the U.K. as second or later line treatment options for patients with advanced RCC – axitinib since 2012, and cabozantinib since 2016,” said study author Janet Brown, MB BS, MSc, MD, FRCP, Professor of Translational Medical Oncology at University of Sheffield, in her presentation of the data.

Notably, patients in the cabozantinib arm tended to have a more recent diagnosis, with 65% receiving a diagnosis between 2016 and 2018. Conversely, 80% of those on axitinib were diagnosed before 2016. In the United States, cabozantinib was approved by the FDA in December 2017 for first-line treatment, based on findings from the CABOSUN (NCT01835158) trial, which showed improved progression-free survival over sunitinib (Sutent), at 8.6 months and 5.3 months, respectively.

Characteristics between the cabozantinib and axitinib patient groups were otherwise balanced, with the average age being 62.5 years and 63.0 years, respectively. At diagnosis, 58.6% of patients in the cabozantinib cohort and 53.2% of those on the axitinib cohort had metastases, while 91.4% and 90.3%, respectively, had clear-cell histology. Regarding tumor size at diagnosis, 69.3% and 68.8% were 4.00 mm or smaller, in the cabozantinib and axitinib arms, respectively; 5.9% and 7.1% had tumors larger than 4.00 mm, and the remainder (24.8% and 24.1%) of patients had missing tumor sizes.

At diagnosis, 28.2% of patients given cabozantinib had an ECOG score of 0-1, compared with 20.4% of those on axitinib.

“Real-world evidence complements the results of randomized controlled trials,” Brown said. “This study demonstrates the potential for cabozantinib for conducting clinically relevant real-world research in England.”

Brown J, Harrow B, Marciniak A, McCarthy C, Cirneanu L, Protheroe A. Cabozantinib and axitinib after vascular endothelial growth factor therapy in patients with advanced renal cell carcinoma: a retrospective cohort study. Presented at: ESMO Congress 2021. September 16-21, 2021. Virtual. E-Poster 680P

Articles

Patients with advanced RCC who received prior VEGF-targeted therapy tend to have longer survival outcomes with cabozantinib than with axitinib.

UK Study of Real-World Data Shows Survival Benefit of Cabozantinib vs Axitinib in Pre-Treated RCC 

For this episode of “The Vitals,” we spoke with Chastity Washington, MPH, CHES, Center for Cancer Health Equity, Ohio State University, about how the COVID-19 pandemic has exacerbated preexisting disparities in cancer care. Chastity spoke to our team about the direct and indirect impacts of COVID 19 on disadvantaged communities, vaccine hesitancy amongst those communities, and more.

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“We’ve had periods of time where things were shut down. We do have telemedicine, that was expanded, but telemedicine doesn’t work for everyone. If you don’t have internet access, if you don’t have the ability to understand the technology….”


COVID-19 Pandemic Emphasizes Disparities in Cancer Care

Although chimeric antigen receptor (CAR) T-cell therapies like ciltacabtagene autoleucel (cilta-cel; JNJ-68284528) can lead to neurologic adverse events (AEs) in patients with relapsed/refractory multiple myeloma, the toxicities can be managed without long-term effects as long as they are treated promptly, according to findings from CARTITUDE-2 presented at the European Hematology Association 2021 Virtual Congress.

“To date, more than 100 patients across the CARTITUDE study program have been dosed with cilta-cel. When implemented, patient [treatment] strategies have reduced the incidence of neurotoxicity, including movement and neurocognitive events,” said Hermann Einsele, MD, FRCP, professor and chair of the Department of Internal Medicine at the Julius Maximilians University of Würzburg in Germany, during a presentation of the study findings.

The open-label, phase 2, multicohort CARTITUDE-2 (NCT04133636) trial evaluated the efficacy and safety of cilta-cel in patients with multiple myeloma. For the purpose of studying adverse vents (AEs), the investigators analyzed cohort A, which involved patients with multiple myeloma who progressed after 1 to 3 lines of therapy, including a proteasome inhibitor or an immunomodulatory drug.

Eligible patients were adults with measurable disease and ECOG performance status of 0 or 1. Their disease had to be refractory to lenalidomide (Revlimid) and not previously treated with another BCMA-targeted drug.

Patients received cilta-cel (0.75 × 106 [range: 0.5-1.0 × 106] CAR+ viable T cells/kg) as a single infusion 5 to 7 days after the initiation of lymphodepletion (cyclophosphamide 300 mg/m2 + fludarabine 30 mg/m2 daily for 3 days).

“Patient [treatment] strategies included more effective bridging therapy to reduce baseline tumor burden, early aggressive treatment of [cytokine release syndrome] and [immune effector cell-associated neurotoxicity], as well as handwriting assessment for early detection of symptoms of neurotoxicity,” Einsele said. “These strategies have been successfully implemented across the CARTITUDE program.”

At a median follow-up of 5.8 months (range, 2.5-9.8), 20 patients in cohort A received cilta-cel, of which 4 (20%) experienced at least 1 neurotoxicity. Three patients had grade 1/2 immune effector cell-associated neurotoxicity (ICANS) along with cytokine release syndrome. The median time to symptom onset was 8 days (range, 7-11), and, on average, symptoms lasted 2 days. Two patients received supportive measure for their ICANS, including levetiracetam and steroids.

One patient experienced isolated grade 2 facial paralysis on day 29. The patient recovered 51 days later after being treated with dexamethasone for 28 days. Overall, there were no movement or neurocognitive disorders reported within cohort A.

“Importantly, none of the patients in the cohort A of the CARTITUDE study experienced other neurotoxicities that were seen in CARTITUDE-1 (NCT03548207),” Einsele said.

Einsele H, Parekh S, Madduri D, et al. Incidence, mitigation, and management of neurologic adverse events in the phase 2 CARTITUDE-2 study of ciltacabtagene autoleucel in patients with multiple myeloma. Presented at: 2021 European Hematology Association Congress. June 9-17, 2021; virtual. Abstract EP1003.

In the cohort of patients with multiple myeloma, there were no grade 3 or higher neurotoxicities. 


Neurotoxicity With Cilta-cel: Early Intervention Can Improve Outcomes in R/R Myeloma

Oral cancer therapies can be appealing to patients, particularly during the COVID-19 era, because they can be taken at home. However, at-home medication can also pose a threat to adherence. Oncology nurses therefore need to remain diligent in educating their patients and monitoring their adherence.

“You avoid intravenous infusions; I’m all about that. And patients feel empowered [taking their medication at home], but we have to give them the tools to succeed,” said Patricia Jakel, MN, RN, AOCN, a clinical nurse specialist in the Solid Tumor Program at UCLA Medical Center, at the 5th Annual School of Oncology Nursing Annual Meeting.

Patients may be burdened with complicated medication schedules, that could include taking 1 drug to ensure that another works properly, as well as adverse event management. Add chemotherapy-related cognitive impairments – commonly referred to as “chemo brain” – and clinicians may be surprised to see how many patients are struggling with their medications. Jakel admitted she has struggled with chemo brain.

“I’m a breast cancer patient [who was] on treatment for the last 4 years. Oral adherence was not the best for me, so I have personal experience with it,” Jakel said. She joked, “I used to be smart. I used to be really smart, and chemo brain has really affected me. It doesn’t matter if you’re taking oral agents, IV agents, or anti-estrogen agents. [Chemo brain] is really real to patients.”

Cancer treatments can affect memory, executive functioning, and a patient’s ability to organize their thoughts. Their ability to pay attention or processing speed may be affected, too. Jakel said that cognitive training, which could be as simple as doing puzzles or keeping up to date on the latest news in an area of interest, can help curb the effects of chemo brain, as can complementary treatment methods such as acupuncture.

“Poor adherence decreases clinical benefits and overall effectiveness of the healthcare system,” she said. “It not only affects the patient, but these patients who are non-adherence actually end up back in the hospital and end up with other complications.”

Strikingly, 20%-30% of medication prescriptions are never filled. And according to Jakel, there are factors besides chemo brain that contribute to non-adherence.

In her experience, Jakel has seen patients stop taking their medications once they start to feel better or that the drug is working. Others may be experiencing cost barriers or psychosocial issues that prevent them from taking their medication as prescribed. “Make sure you talk to your patients about … the reasons why they’re not taking [their medication.]”

There are steps that clinicians can take to help their patients improve medication adherence. Some are simple, like calling and checking in on them, asking them to keep a drug diary, or conducting pill counts. Doctors can also encourage patients to use apps or alarms on their phone that reminds them to take their drugs.

When discussing medication adherence, clinicians should be careful of their word choice, Jakel said.

“What I say [to patients] is ‘Tell me how you’re taking your medication.’ I don’t say ‘Are you taking it?’” Jakel said. “I think that’s very important to have them talk to you.”

Additionally, caregivers should be educated on proper drug handling, scheduling, and potential drug-drug interactions.

“Make sure that education is done for the family and the caregiver,” Jakel said. “Hopefully the patient has a caregiver or a friend or family member helping them, because that’s critical for adherence.”

Ultimately, when patients do not take their cancer drugs properly, it can lead to a barrage of other complications that will have negative consequences both for the individual with cancer and the healthcare system.

Jakel P. Breast Cancer Supportive Care in 2021. Presented at: 5th Annual School of Nursing Oncology. August 6-7, 2021. Virtual.

With a newfound abundance of available oral cancer therapies, it has become necessary for oncology nurses to ensure that their patients are adhering to treatment. 



Oncology Nurses Must Stress Importance of Medication Adherence 

Data from CARTITUDE-2 suggests that patients with relapsed/refractory multiple myeloma who experience adverse events (AEs) as a result of CAR T-cell therapies such as ciltacabtagene autoleucel (Cilta-cel or JNJ-68284528) can manage those symptoms without long-term lasting effects, so long as they are caught and treated promptly.

“To date, more than 100 patients across the CARTITUDE study program have been dosed with cilta-cel. So when implemented, patient management strategies have reduced the incidence of neurotoxicity, including movement and neurocognitive events,” said Hermann Einsele, MD, FRCP, professor of internal medicine at the Julius Maximillians University of Würzburg in Germany, while presenting the study findings.

The open-label, phase 2, multicohort CARTITUDE-2 (NCT04133636) trial evaluated the efficacy and safety of cilta-cel in patients with myeloma. For the purpose of studying AEs, the researchers analyzed cohort A, which involved patients with myeloma that progressed after 1-3 lines of therapy, including a proteasome inhibitor and an immunomodulary drug.

Eligible patients were adults with measurable disease and ECOG performance status of 0 or 1. Their disease was refractory to lenalidomide (Revlimid) and was not previously treated with another BCMA-targeted drug.

Patients received cilta-cel (0.75×10 6 [range: 0.5–1.0×10 6] CAR+ viable T cells/kg) as a single infusion 5–7 days after the initiation of lymphodepletion (cyclophosphamide 300 mg/m2 + fludarabine 30 mg/m2 daily for 3 days).

“Patient management strategies included more effective bridging therapy to reduce baseline tumor burden, early aggressive treatment of [cytokine release syndrome] and [immune effector cell-associated neurotoxicity], as well as handwriting assessment for early detection of symptoms of neurotoxicity,” Einsele said. “These strategies have been successfully implemented across the CARTITUDE proves.”

At a median follow-up of 5.8 months (range, 2.5-9.8 months), 20 patients in cohort A received cilta-cell, and 4 (20%) experienced at least 1 neurotoxicity. Three patients had grade 1/2 immune effector cell-associated neurotoxicity (ICANS) alongside cytokine release syndrome. The median time to symptom onset was 8 days (range, 7-11), and, on average, symptoms lasted 2 days. Two patients received supportive measure for their ICANS, including levetiracetam and steroids.

There was 1 patient who experienced isolated grade 2 facial paralysis on day 29. The patient recovered 51 days later after being treated with dexamethasone for 28 days. Overall, there were no movement or neurocognitive disorders that were reported within Cohort A of the study.

“Importantly, none of the patients in the cohort A of the CARTITUDE study experienced other neurotoxicities that were seen in CARTITUDE-1,” Einsele said.

Einsele H, Parekh S, Madduri D, et al. Incidence, mitigation, and management of neurologic adverse events in the phase 2 CARTITUDE-2 study of ciltacabtagene autoleucel in patients with multiple myeloma. Presented at: 2021 European Hematology Association Congress. June 9-17, 2021. Virtual. Abstract EP1003.

This article was originally published on OncLive as 

“Early Intervention For Neurotoxicity Can Improve Outcomes With Cilta-Cel in Relapsed/Refractory Multiple Myeloma”

Data presented at the European Hematology Association 2021 Virtual Meeting revealed that CAR T-cell therapy-related adverse effects can be managed.

Prompt Treatment of CAR T-Cell Therapy-Related AEs Can Prevent Long-Term Lasting Effects 

Updated data from the phase 3 CheckMate-648 trial (NCT03143153) revealed that the addition of nivolumab (Opdivo) to either ipilimumab (Yervoy) or chemotherapy was associated with improved survival outcomes in the frontline treatment of patients with unreselectable advanced or metastatic esophageal squamous cell carcinoma (ESCC) in comparison to chemotherapy alone, according to a presscast presentation ahead of the 2021 ASCO Annual Meeting.

“Advanced esophageal squamous cell carcinoma carries a poor prognosis, with a median survival of around 10 months,” said Ian Chau, MD, FRCP, consultant medical oncologist at the Royal Mardsen Hospital in the United Kingdom, while presenting the findings during the presscast.

CheckMate-648 is a randomized phase III trial that was presented at a presscast ahead of the 2021 American Society of Clinical Oncology (ASCO) Annual Meeting evaluating the efficacy of the following treatment regimens in adult patients with histologically confirmed squamous cell carcinoma or adenosquamous cell carcinoma of the esophagus that is deemed inoperable and cannot be treated with chemoradiation with curative intent:

: nivolumab 240 mg on day 1 and day 15; fluorouracil 800 mg/m2 per day on day 1 through day 5, for 5 days; and cisplatin 80 mg/m2 on day 1 of the 4-week cycle (n = 321).

: nivolumab 3 mg/kg every 2 weeks, followed by ipilimumab 1mg/kg every 6 weeks until unacceptable toxicity or disease progression (n = 325).

Eligible patients had an ECOG PS score of 0 to 1, measurable disease, and no prior systemic treatment for advanced disease. The primary end points in the trial were overall survival (OS) and progression-free survival (PFS) in patients whose tumors had PD-L1 expression ≥ 1%. Secondary end points were OS and PFS in all patients, as well as objective response rate (ORR), both in patients with PD-L1 ≥ 1% and all patients.

At a minimum follow-up of 12.9 months, median OS in patients with PD-L1 ≥ 1% in the nivolumab plus chemotherapy arm (n = 158) was 15.4 months (95% CI, 11.9-19.5), and was 13.7 months (95% CI, 11.2-17.0) in the nivolumab plus ipilimumab arm (n = 158). In the PD-L1-positive patients in the chemotherapy alone arm (n = 157) median OS was 9.1 months (95% CI, 7.7-10.0; 

“This translates into over 6 months [of] improvement in median overall survival [when comparing nivolumab plus chemotherapy to chemotherapy alone],” Chau said. “But importantly, if you look at the latter parts of the overall survival curve, they’re widely separated in favor of nivolumab plus chemo, meaning that there were more patients with prolonged overall survival.”

In the overall study population–regardless of PD-L1 expression–the median OS in the nivolumab plus chemotherapy arm was 13.2 months (95% CI, 11.1-15.7); 12.8 months in the nivolumab plus ipilimumab arm (95% CI, 11.3-15.5 months); and 10.7 months in the chemotherapy arm (95% CI, 9.4-11.9; 

The primary end point of PFS per blind independent committee review (BICR) was not met in patients whose tumors were PD-L1 positive (HR, 1.02; 95% CI, 0.73-1.43).

The ORR in patients with PD-L1-positive tumors given nivolumab plus ipilimumab was 35% (95% CI, 28-43). In the chemotherapy arm it was 20% (95% CI, 14-27). In all patients, ORR was 28% (95% CI, 23-33) and 27% (95% CI, 22-32) in the nivolumab plus ipilimumab and nivolumab plus chemotherapy arms, respectively.

Regarding safety, the most common (occurring in 10% or more) treatment-related adverse events (TRAEs) for the chemotherapy-containing arms were nausea, decreased appetite, and stomatitis. For the nivolumab/ipilimumab arm, common TRAEs were rash, pruitis, and hypothyroidism. Notably, incidence of TRAEs was consistent with all treated patients across all arms for patients whose tumor cell had PD-L1 expression ≥ 1%.

Ultimately, nivolumab-containing regimens have the potential to drastically improve outcomes in patients with unresectable advanced or metastatic esophageal squamous cell carcinoma–a group that tends to have poor prognoses.

“Nivolumab plus chemotherapy [and] nivolumab plus ipilimumab each represents a new potential first-line standard of care for patients with advanced esophageal squamous cell carcinoma, based on the results of CheckMate-648, the largest randomized control trial conducted in this setting to date,” Chau said.

Chau I. First results from the CheckMate 648 study evaluating nivolumab plus ipilimumab or nivolumab plus chemotherapy versus chemotherapy as first-line treatment for advanced esophageal squamous cell carcinoma. Presented at: 2021 ASCO Annual Meeting Press Program, May 28, 2021.

A study to evaluate efficacy in subjects with esophageal cancer treated with nivolumab and ipilimumab or nivolumab combined with fluoraucil plus cisplatin versus fluorouracil plus cisplatin (CheckMate648). Clinicaltrials.gov. Updated May 7, 2021. Accessed June 1, 2021. 

https://clinicaltrials.gov/ct2/show/NCT03143153

This article was originally published on OncLive as “Frontline Nivolumab Plus Ipilimumab or Chemo Improves Survival Outcomes in Advanced ESCC"

Survival outcomes in the frontline treatment of patients with unresectable advanced or metastatic esophageal squamous cell carcinoma were improved when nivolumab was added alongside either ipilimumab or chemotherapy.

Patients With Advanced ESCC Experience Improved Survival Outcomes With Addition of Nivolumab to Ipilimumab or Chemotherapy 

As news headlines warn the public about potential myocarditis from the COVID-19 vaccine, patients with cancer may be even more apprehensive to get immunized. However, it’s not “a close call at all” when outweighing the risks versus benefits in this population, according to Brahm Segal, MD, who advocates for everyone eligible to be vaccinated.

“Serious toxicities in the general public are few… and so far, there’s no obvious safety concern with patients with cancer that would argue that the vaccine is less safe among them compared to the general public,” said Segal, chair of Internal Medicine and chief of Infectious Diseases at Roswell Park Comprehensive Cancer Center.

Segal mentioned that many cancer treatments – including checkpoint inhibitors, which are widely prescribed across many cancer types – also run the risk of patients developing cardiotoxicity. Additionally, if patients are not immunized against COVID-19 and contract the virus, the disease itself carries risks to the heart.

“The heart is one of the organs that can be affected in a big way,” Segal said.

Segal also stressed that it is important not only for patients with cancer to get the vaccine, but also their loved ones with whom they are in close contact.

“Family members and their household members and friends should all be immunized as well, because in patients with cancer, some of the cancers and some of the therapies for cancer can disable the vaccine from being fully effective,” Segal explained. “So even though they’ve been vaccinated, they may not get the same protection that people with a normal immune system have. The way to address that is for the patients to be immunized, but also – as much as possible – the people around them to be vaccinated, too.”

While most patients should get vaccinated, those who should delay their shots are “few and far between,” Segal said.

“People who are having a stem cell transplant don’t want to have a vaccine right before transplant, right during, or in the immediate [period after] transplant period, because it’s extremely unlikely that there’ll be a lasting response,” he said.

Segal explained that there are specific guidelines for when patients undergoing transplants should be vaccinated, “But for the vast majority of patients with cancer, there’s no reason to wait. They should get immunized,” he said.

Many patients with cancer may feel uneasy about the COVID-19 vaccines, especially as new stories break about potential heart complications. However, most patients should get the shot as soon as possible, says Brahm Segal, MD.

COVID-19 Vaccine Benefits Outweigh Risk, Despite Cardiac Concerns, Expert Says

The FDA approved avapritinib (Ayvakit) for the treatment of adults with advanced systemic mastocytosis (AdvSM), including those with mast cell leukemia (MCL), aggressive systemic mastocytosism (ASM), or systemic mastocytosis with an associated hematological neoplasm (SM-AHN), according to the agency.1

The approval marks the first targeted therapy that inhibits D816V mutant KIT, which is a main driver of AdvSM.

"Advanced systemic mastocytosis is a debilitating disease characterized by extensive damage in multiple organ systems due to mast cell infiltration, and new treatment options are urgently needed to address these life-threatening complications," said Daniel DeAngelo, MD, PhD, Chief of the Division of Leukemia at Dana-Farber Cancer Institute, in a statement.2 "Avapritinib will clearly establish a new standard of care for patients with advanced systemic mastocytosis. The FDA approval was based on data showing robust and durable responses, including complete remissions, and a favorable safety profile. For advanced SM patients, the approval of avapritinib shifts the treatment paradigm toward precision therapy that targets the primary driver of mastocytosis."

The approval was based on findings from the multi-center, open-label, single-arm EXPLORER and PATHFINDER clinical trials. The primary endpoint was overall response rate (ORR) per modified IWG-MRT-ECNM criteria, as adjudicated by a central committee. Other endpoints included duration of response (DOR), time to response, and changes in individual measures of mast-cell burden.

The trials included 53 patients who received daily avapritinib at doses up to 200 mg.

"As shown in two clinical trials, AYVAKIT provides remarkable clinical efficacy to patients with advanced systemic mastocytosis, and this approval solidifies the therapy's strong value proposition in this population. With a deep commitment to driving continued research innovation in collaboration with the mast cell disease community, we are now building on this progress with the goal of bringing the benefits of precision therapy to a broader range of patients through our ongoing and planned clinical trials for non-advanced systemic mastocytosis,” said Jeff Albers, CEO of Blueprint Medicines, the manufacturer or avapritinib, in a statement.

Between both trials, there was a 57% IRR (95% CI, 42,70), which included 28% complete remissions and 28% partial remissions. Average DOR Was 38.3 months (95% CI 19-not estimable), and the median time to patient response was 2.1 months.

Most common adverse events that occurred in 20% or more of patients were edema, diarrhea, nausea, and fatigue/asthenia.

"This milestone is also the culmination of many years of work across the systemic mastocytosis community, and we're proud of the contributions The Mast Cell Disease Society has made to improve the understanding of this disease, pioneer new approaches to measuring the impact of therapeutic interventions, and support the development of important medicines like AYVAKIT," said Lauren Denton, Executive Director of The Mast Cell Disease Society.

FDA. FDA approves avapritinib for advanced systemic mastocytosis. June 16, 2021. 

https://www.fda.gov/drugs/drug-approvals-and-databases/fda-approves-avapritinib-advanced-systemic-mastocytosis?utm_medium=email&utm_source=govdelivery

Blueprint Medicine. FDA Approves Blueprint Medicines’ AYVAKIT (avapritinib) for the Treatment of Adults with Advanced Systemic Mastocytosis. June 16, 2021

The FDA approved avapritinib (Ayvakit) for the treatment of adults with advanced systemic mastocytosis (AdvSM), including those with mast cell leukemia (MCL), aggressive systemic mastocytosism (ASM), or systemic mastocytosis with an associated hematological neoplasm (SM-AHN). 

FDA Approves Avapritinib for Rare Blood Disease


After hearing about the difficulties a transgender man faced in receiving a cancer diagnosis, Kelly S. Haviland, PhD, FNP-BC, found her calling. In this episode, Haviland, nurse research scientist and family nurse practitioner at Memorial Sloan Kettering Cancer Center, discusses how LGBTQ treatment has changed over the years, though there is still much more work to be done.

Two-Part Questions Can Improve Care in LGBTQ Patients

After hearing about the difficulties a transgender man faced in receiving a cancer diagnosis, Kelly S. Haviland, PhD, FNP-BC, found her calling.

Oncology Nurse Talks Pride Month, LGBTQ Disparities

In the United States, there is a growing number of patients with cancer and those who have survived cancer. This, coupled with increased access to health care through the Affordable Care Act and a shortage of oncologists, highlights the importance of and need for advanced practice providers (APPs) in the cancer space.

APPs such as nurse practitioners (NPs) are essential members of the health care team when it comes to educating, monitoring, and (where allowed) diagnosing cancer and prescribing drugs to patients with the disease. Currently, NPs have full practice authority in 24 states, meaning they can evaluate patients, give diagnoses, order and interpret diagnostic tests, and prescribe and manage treatments. Sixteen states, however, require NPs to collaborate with physicians, and 11 states have restricted practice so that NPs must be supervised, delegated, or managed by an outside health discipline.

“When we think about ordering or prescribing oncologic therapies, it’s not 1-size-fits-all. It requires immense critical thinking and many considerations need to be [discussed] throughout the whole process,” said Kim Noonan, DNP, ANP-BC, AOCN, chief nurse practitioner at Dana-Farber Cancer Institute.

Noonan and Suzanne McGettigan, MSN, ANP-BC, AOCN, a nurse practitioner and clinical manager at Penn Medicine, discussed the role of APPs in prescribing oncologic agents in a presentation at the 46th Annual Oncology Nursing Society Congress. State laws, hospital policies, and patient status are the 3 aspects that APPs must consider when prescribing cancer care, Noonan said.

As NP practice authority varies from state to state, differences also exist among institutions. Organizations can regard the act of prescribing chemotherapy as a core competency, meaning the provider has the knowledge, skill, and educational background to complete the task, or as a privilege, meaning practitioners apply for the right to complete such a task. The institution will make a decision based on the person’s credentials and performance.

NPs must consider many patient-safety aspects when prescribing chemotherapy, because cancer therapies are high-risk drugs.

“We know that cancer therapy is very high risk. There has been a lot published about the number of medication errors [and] dosage errors with chemotherapy,” McGettigan said. “It is essential that we are cognizant of all these aspects of patient care as we are filling these orders and prescribing these therapies.”

First the NP must review the pathology, confirm the disease and stage, and talk with the patient to understand their goals of care.

Then they must complete a medical history review, including any patient allergies; complete and document patient education and/or informed consent; and complete a chemotherapy plan. The plan includes the drugs the patient will receive and the dosage, treatment duration, and how the patient will be monitored.

The hard work is not over once the patient has signed the informed consent forms and the NP has prescribed treatment. Now the NP must work with the entire oncology team to implement ongoing patient and family education and monitor for toxicities. When adverse events occur, NPs should take the lead on documenting the toxicity and its grade, and adjusting therapy if needed.

“Oncology NPs are educated, trained, and experienced and can play a very essential part in therapy for patients with cancer,” Noonan said.

Nurse practitioners play a key role in prescribing cancer drugs and educating patients about their therapies.

Brielle Benyon