Fatigue is one of the most common symptoms reported by gynecologic cancer survivors, with about half (49%) of women presenting with clinically significant fatigue at diagnosis, and 42% experiencing persisting fatigue a year later.  

, oncology nurses might want to ask their patients about their social support system, as well as present the idea of cognitive behavioral therapy (CBT), which may be able to help, according to research conducted at the Dana-Farber Cancer Institute and the Netherlands Comprehensive Cancer Organisation.

“My experience in managing patients who experience cancer-related fatigue is that it’s often one of the most burdensome symptoms, and it impacts many aspects of their lives,” said Hanneke Poort, PhD, a psychologist and post-doctoral research fellow in the Department of Psychosocial Psychology and Palliative Care at the Dana-Farber Cancer Institute.

“Patients often don’t know that this is something that can be addressed, so they either 

 to their doctors, or they feel that it is just something they have to live with. But fortunately, there are interventions that we can use to reduce [fatigue].”

While previous research has shown that exercise can benefit patients experiencing fatigue, Poort focused on CBT, which focuses on cancer-related factors — like fatigue – that persist over time.

Poort noted that patients with cancer can often catastrophize their fatigue and see it as an awful symptom that may never get better. Or, especially for those with advanced disease, individuals are burdened with a feeling of uncertainty about their illness and treatment. These two factors can exacerbate fatigue, but CBT may be able to help.

Additionally, social support systems may play a role in fatigue as well, Poort explained.

“Fatigue is a very invisible symptom, and it can be hard for patients — especially if they receive cancer treatments for a long time – to receive the support that they want,” Poort said. “We would talk to them about the potential discrepancy between the actual and perceived social support, and also teach them how they can communicate more assertively about the things that they might need in terms of support.”

Addressing the psychological side of fatigue is key in combatting the malady. In their study — which looked at 312 women with ovarian or endometrial cancer – the most important factor contributing to fatigue at baseline was depressive symptoms.

“Fortunately, there are interventions focusing on the psychological factors that have been shown to be helpful in reducing fatigue,” Poort said. “So, at Dana-Farber, we are currently adapting the CBT intervention that we previously tested in a larger sample of patients for women taking PARP inhibitors for advanced ovarian cancer. I think this is a really exciting study because it would be great if we can improve the quality of life for women taking these new, promising treatments.”

As new cancer treatments like PARP inhibitors continue to become available for women with gynecologic cancer, it is crucial to gain a better understanding of how patients tolerate the drugs, and any adverse events — like severe or chronic fatigue – that they might have.

These advancements, Poort said, may be laying the groundwork for future research.

“I also think that one of the new areas that would be really interesting for research is to look more into tolerance of uncertainty while being on these prolonged therapies,” she said. “There’s going to be many changes in the course of treatment where they might not respond to treatment anymore, and they might have to adjust. We don’t know a lot about how patients deal with these changes for a longer period of time.”

Articles

Cognitive behavioral therapy help to improve the lives of patients experiencing cancer-related fatigue.

Psychosocial Support May Improve Cancer-Related Fatigue

Researchers have noticed a new clinical syndrome for patients treated with immune checkpoint inhibitors: myocarditis, explained Javid J. Moslehi, MD, director of cardio-oncology at the Vanderbilt University Medical Center.

The syndrome involves inflammation of the myocardium (heart muscle), and has mostly been seen in patients who are on combination drug regimens. The most aggressive cases of myocarditis usually occur after the first or second dose of immunotherapy, making this a crucial time for oncology nurses to monitor patients who may be at risk.

We've been very interested, as these syndromes the immune checkpoint inhibitor-associated myocarditis is a new clinical syndrome. Our first job has been to better characterize what this syndrome really consists of. We have shown by pathology that it includes inflammation in the heart itself, in the myocardium, in the classic definition of myocarditis. These are mostly T cells and macrophages.

We've described better which cancer syndromes and with which drugs they go with. It seems like if you combine therapies, you have a much higher risk of having myocarditis. We don't see a signal with one drug, so it all seems to be doing this. As best as we can tell, this is a class effect. In addition, most of the fulminant, very aggressive myocarditis cases that come about occur after the first or second dose. That's really important to note, and that provides some guidelines with how we may screen patients or do surveillance for patients who are at high risk.

Videos

Nurses should be aware of patients who are at risk for immunotherapy-related myocarditis.

Immunotherapy-Related Myocarditis

Oncology nurses can get creative when it comes to helping patients who face financial toxicity, explained Angee Kilmer, BSN, RN-BC, nursing supervisor of radiation oncology for the University of Kansas Cancer Centers and 

When patients are having trouble paying for their medications, it is crucial that they talk to someone on their healthcare teams -- and that person is usually an oncology nurse. Nurses should always be open to the conversation, and assure the patient that there are things they can do to help, be it asking for samples or finding drug co-pay assistance programs. 

Oncology nurses must ensure that patients are discussing issues they face when it comes to paying for medication.

Nurses Get Creative When Addressing Financial Toxicity

The most valuable thing that healthcare providers can do to ensure quality multidisciplinary care is communicate with one another, explained Susan Weiss Behrend, RN, MSN, AOCN, an advanced practice nurse at the Fox Chase Cancer Center.

Nowadays, providers typically talk to each other electronically, be it through electronic medical records or email, but it is also important that nurses attend tumor boards and clinical chart rounds and, “ensure that you have a seat at the table,” when it comes to patient care, according to Behrend. Streamlined communication among members of the healthcare team can result in more benefits and less anxiety for the patients.

Communication is key to ensure the best quality patient care.

Cancer Care Providers: Don't Work in Silos

Older adults represent a rapidly growing proportion of our population, and that’s one reason advanced care practitioners need to know how best to treat them in the cancer clinic.

Advanced practice nurses must be aware of the unique risks faced by seniors and how to assess them for health issues that might factor into their treatment plans, said three experts who addressed the topic in a presentation at the ONS 44

Their talk covered the ins and outs of a geriatric assessment, predicting chemotherapy toxicity, and evaluating polypharmacy.

, of Memorial Sloan Kettering Cancer Center (MSK); 

Cope, director of nursing and an oncology nurse practitioner at Florida Cancer Specialists and Research Institute in Fort Myers, Florida, offered statistics to explain the need for attention to this population.

While there are 46 million adults over age 65 in the U.S. today, totaling 15% of the population, that number will grow to 98 million by 2060, totaling 24% of the population, she said.

The fastest rise in growth is occurring in the group aged 85 to 94, she said, and between 2010 and 2050, it’s expected that the number of adults aged 85 and older will grow from 5.5 million to 19 million. By 2030, an estimated 70% of all cancers will occur in people aged 65 or older, Cope said.

Yet, when she asked a large room full of advanced practitioners if they use a geriatric assessment to determine the fitness of older patients for cancer treatment, nearly all indicated they do not.

McMillan, a nurse practitioner in the department of geriatric medicine at MSK, in New York City, described a “multidimensional, interdisciplinary” geriatric evaluation that can determine a patient’s functional versus chronological age and should be done at baseline and at transition points such as disease progression or treatment changes. She said the evaluation should identify reversible or irreversible deficits, pinpoint health issues before they are exacerbated, and determine which patients face an increased risk of toxicities or other harms from cancer treatment.

The goal of the evaluation is to guide treatment, she said.

Determining the patient’s cognitive status—normal, mild impairment, dementia or delirium&mdash;is crucial, because some forms of cancer therapy can have long-term cognitive impact, compounding existing issues. In addition, McMillan said, cognitive dysfunction may affect patients’ adherence to treatments or ability to make decisions.

To assess a patient’s cognitive state, McMillan recommended the Mini-Cog, a quick, brief screening tool that tests the ability to remember words.

If patients score abnormally, she recommended further assessment; ruling out reversible causes; using cognitive rehabilitation techniques (remediation and compensation—adaptive techniques to help restore function); and determining how cognitive deficits are affecting daily life.

Determining a patient’s level of frailty—reduced physiologic reserves that put the patient at higher risk of poor outcomes after a stressor&mdash;is also key, McMillan said. Testing this can include assessing activities of daily living (ADL) performance and instrumental activities of daily living (IADLs), as well as administering the Timed-Up-And-Go (TUG) exercise, she said.

ADLs are the basic activities of living: eating, bathing, dressing, transferring in and out of bed, toileting, walking, and moving around. IADLs are activities including cooking, cleaning the house, taking medication, doing laundry, going shopping, handling personal finances, making phone calls, and taking care of transportation needs.

The TUG tests how long it takes a patient to stand up, walk 10 feet at a normal pace, return and sit down again. If this takes a patient 12 seconds or more, it means he or she faces a high risk of falling, McMillan said. These patients should be referred to physical or occupational therapy for prescribed exercise, assistive device training, education, and/or home safety modifications, she said.

Understanding a patient’s psychological status is also important, McMillan said. The Geriatric Depression scale, which asks about satisfaction with life and level of motivation, has very high sensitivity and specificity for depression in this population, which is not a normal part of aging, she said. She noted that depression in these patients may present atypically with physical complaints such as gastrointestinal symptoms and sleep disturbance, but a lack of sadness.

For those whose scores indicate depression, nurses should assess safety and look for suicidal ideation. Patients should be referred to social workers or psychologists, and/or for cognitive behavior therapy, McMillan said. Medications may be indicated.

She emphasized that older patients can differ widely in their health and functionality. Inpatient or outpatient geriatric assessment can pick up problems that might otherwise be missed, allowing for prompt intervention that can improve quality of life and clinical outcomes for patients.

Predicting Chemotherapy Toxicity in Older Adults

While older adults get as much benefit from chemotherapy as younger people, practitioners are less likely to offer it to them, Cope said. One reason may be that 49% to 64% of older patients experience at least one grade 3 toxicity during treatment with cytotoxic agents, she said.

A complicating factor is that more than half of older adults have 3 or more chronic diseases, Cope said. They may be taking numerous medications, but also could have decreased physiological function that changes the way their bodies absorb, distribute, metabolize, and eliminate those drugs.

Besides assessing chronologic age, nurses must remember that the rate of organ decline and overall health status are more predictive of chemotherapy tolerance, Cope said.

Four typical tests—oncologist’s assessment, Karnofsky performance status, Eastern Cooperative Oncology Group (ECOG) performance status and geriatric assessment&mdash;may have some value but are not validated in this setting, she said.

The Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) toxicity tool considers hematologic and non-hematologic risk factors, rating patients on their IADL capabilities, liver function, levels of diastolic blood pressure, lactate dehydrogenase and white blood cells, and also on their ECOG performance status, Mini-Mental State Exam and Mini Nutritional Assessment results, finally giving a chemotoxicity score. CRASH and other oncology assessment tools for seniors can be found at the Moffit Cancer Center 

The Prediction Tool for Chemotherapy Toxicity was created by the Cancer and Aging Research Group (CARG). This 

 asks 11 questions, including patient age, number of chemotherapy drugs, dosing, laboratory values, and geriatric assessment factors: ADL, IADL and Karnofsky performance status.

In incorporating the results into treatment, she said, patients should be advised of their personalized risks and benefits of chemotherapy, and practitioners should seek their perspectives and those of their caregivers.

In deciding which tools to use, nurses should consider what is quick and easy for both them and patients, Cope said—but should not overlook the task.

“We can’t turn our backs on this,” she said, “because it’s going to be at our doorstep very soon.”

Polypharmacy has many definitions, said Schwartz, associate professor of pharmacy practice at the University of Cincinnati James L. Winkle College of Pharmacy in Cincinnati, Ohio. It can mean one patient’s use of 5 or more medicines, multiple pharmacies, or inappropriate medicines; the underuse of medication; or drug duplication.

Any of these issues can cause adverse drug reactions or interactions, she said, as well as contributing to increased complexity and cost of care.

Drugs can interact with other drugs or with food and can aggravate comorbidities or affect functionality. Even combinations of over-the-counter drugs can result in issues such as fatigue or dizziness, Schwartz said. In oncology, she said, concerns are that drugs taken for other conditions might decrease or increase the effects of an anticancer medication or contribute to cumulative toxicities. When polypharmacy is a factor, she added, lack of adherence also may arise.

Practitioners trying to help patients can actually harm them via polypharmacy, Schwartz continued. For instance, she said, nurse practitioners might unwittingly dampen the effectiveness of an anticancer drug when they medicate comorbidities—for instance, by giving medication for depression to patients who are taking tamoxifen.

A key way to avoid some of these interactions is to identify and deprescribe potentially inappropriate medications, which are a common problem among older patients, Schwartz said. A Brazilian study in the hematology/oncology setting found that 48 percent of older adults were using at least one potentially inappropriate medication.

As a result, it’s crucial for practitioners to conduct drug interaction evaluations regularly in their older patients with cancer, Schwartz said. She noted that drug interactions in these patients can change from day to day, as chemotherapy and treatments for its side effects may be episodic. That’s why drug interaction evaluations should occur any time a drug is started, changed, or discontinued. Schwartz goes as far as to ask all her patients to call her whenever they start or change a medication or dose, so she can evaluate whether there’s likely to be a problem. And she calls patients’ primary care physicians and pharmacies if they’re about to start oral anticancer drugs, so that everyone involved is aware of the medications being administered.

To deprescribe, nurses need to determine treatment goals, review medications being taken, evaluate medication appropriateness, identify medication that should be discontinued, create a deprescribing plan, and then monitor and review, she said.

There are some tools that can help practitioners evaluate a patient’s drug profile, she added.

The American Geriatric Society Beers Criteria provides lists of drugs and their classes that may be inappropriate for older people. It includes a rationale explaining why each drug is potentially inappropriate, a ranking of whether the evidence is low, moderate or high, and a recommendation ranked as insufficient, weak or strong.

The Screening Tool of Older People’s Prescription (STOPP) was developed to address limitations of the Beers Criteria, which in some instances makes controversial recommendations. The tool is a list, categorized by body system, of 65 prescribing practices that are inappropriate in older people, with rationales. The list was devised by a panel of 18 experts in geriatric pharmacotherapy.

The Medication Appropriateness Index gives practitioners a checklist of issues to consider when prescribing a medication to an older person. The list includes the medicine’s indication, effectiveness, dose, duration, cost effectiveness, and potential drug and disease interactions.

Finally, a member of the audience recommended a database offered by MSK, 

, which can help practitioners guide patients in avoiding herb/drug interactions.

McMillan S, Cope D, Scwartz R. Managing the unique needs of the older adult with cancer. Presented at: ONS 44

 Annual Congress; April 11-14, 2019; Anaheim, California. Abstract 2069.

Conducting a geriatric assessment, predicting chemotherapy toxicity, and considering polypharmacy are all crucial in this growing population, experts say.

Special Assessments Are Needed When Treating Older Adults With Cancer

Nurses play a key role in helping to manage the chronic adverse events (AEs) associated with radiation, even into survivorship, according to Hilda Haynes-Lewis, PhD, ANP-BC, AOCNP.

“Treatment techniques and comorbidities have a significant impact on the severity of chronic side effects,” said Haynes-Lewis, a nurse practitioner at Montefiore Einstein Center for Cancer Care. “Nurses should work with the patients to develop a plan to manage chronic side effects that optimize quality of life.”

To start, she added, knowing the difference between late AEs (those that occur or begin after therapy is completed and may occur months to year post-treatment) and long-term AEs (prolonged effects that begin during treatment and continue beyond the end of treatment) is important.

In her presentation, Haynes-Lewis focused on the management of chronic late side effects among patients with cancer.

Disease sites under this category can include the brain and spinal cord, from which the tissue are late reacting. Therefore, these changes are found, not in the clinic, but through imaging.

AEs of the central nervous system include increased atherosclerosis of the blood vessels in the brain, increased incidence of secondary brain tumors, radiation necrosis, cognitive decline, hormonal deficits, vision changes, hearing loss, and radiation myopathy.

“This is where nurses come in because we really need to educate, educate, educate the patients and their families,” Haynes-Lewis said. “We need to talk to them about the symptoms of stroke, incidents of what it looked like if you had a tumor — headaches, changes in vision, changes in gait, changes in mental status – those are all things that we need to talk to the patient about. A lot of times I tell them, maybe you just don’t feel right because there aren’t any words. And if they don’t feel right, I tell them to call their provider. Sometimes that is what happens.”

AEs associated with the central nervous system are often treated with steroids, bevacizumab (Avastin), hyperbaric oxygen therapy, surgical resection, memantine, donepezil (Aricept), cognitive rehabilitation, cochlear implants, hormonal replacement, and pentoxifylline.

These AEs can occur in the nasopharynx, oral cavity, salivary glands, or neck. They include xerostomia, dysgeusia, fibrosis, lymphedema, dysphagia, dental caries, osteoradionecrosis, hearing loss, neuropathy, and changes in voice quality.

“These side effects affect every part of your life and your quality of life,” Haynes-Lewis said.

Management of these AEs can include acupuncture and massage, therapy (physical therapy, decongestive therapy, swallowing rehabilitation), and medications such as pentoxifylline, vitamin E, analgesics, saliva substitutes and stimulants, conservative debridement, hyperbaric oxygen, surgical resection and reconstruction, hearing aids, tympanostomy and aspiration, myringotomy and grommet insertion, voice therapy, and injection larynoplasty.

“You need to help (the patients) by just putting 2 and 2 together,” Haynes-Lewis said. “If you have a dry mouth, what does that do? It can affect your teeth, so we need to make sure (the patient) is seeing the dentist, that they are doing good oral hygiene and that they understand what that is and how to do it.”

AEs of the chest can occur in the breast, lung, mediastinal or axillary adenopathy, or esophagus. In this area of the body, risk factors for chronic AEs include age, gender, treatment techniques, concurrent chemotherapy, lung disease, history of smoking, and poor performance status.

Chest AEs from radiation include exacerbation or worsening of underlying comorbid lung disease, lung fibrosis, chest wall fibrosis, esophageal stricture, telangiectasias, pain, lymphedema, brachial plexopathy, and cardiotoxicity. These can be managed with dietary and behavioral modifications, pulmonary rehabilitation and physical therapy, esophageal dilation, and medications such as steroids, anti-inflammatories, gabapentin, pentoxifylline, vitamin E, prokinetic agents, and oxygen therapy.

In disease sites of the abdomen (gastric, liver, pancreas, colon, stomach, and small bowel), radiation therapy is commonly used in neoadjuvant and adjuvant treatment, as well as effective palliation for pain, bleeding, and obstruction.

AEs include dysmotility, stricture, fistula, obstruction, ulceration or perforation, and bleeding. To manage these, Haynes-Lewis recommended for dietary modifications; medications like analgesics, enzyme supplementation, anti-diarrheal, antiemetics, and proton pump inhibitors; endoscopic dilation; percutaneous endoscopic gastrostomy tube; and surgical intervention.

Sites for these AEs can include the prostate, bladder, cervix, ovaries, and colon, for which chronic toxicity can be correlated with the volume of radiation received.

These AEs—including diarrhea, hemorrhoids, proctitis, leakage of fecal incontinence, fistula or stricture, and obstruction–can be managed with dietary modifications; bowel rest; medications such as anti-diarrheal, sucralfate enemas, steroid suppositories and creams, and topical lidocaine; endoscopic interventions; hyperbaric oxygen therapy; and surgical resection.

These AEs can include telangiectasia, chronic dermatitis, pigmentation changes, atrophy, fibrosis, ulceration, bone fractures, alopecia, and edema. In addition, they are often managed with antihistamines, colloidal oatmeal treatments, aloe, massages, physical therapy, and wound care.

In addition, Haynes-Lewis noted that global chronic AEs, such as fatigue, depression, insomnia, pain, anxiety, and post-traumatic stress disorder, exist across all cancer types, adding that these can be managed with medications, exercise, energy conservation, mind-body techniques, therapy, and referral to a survivorship program.

“Nurses should be at the forefront of chronic side effect management as part of survivorship care as the number of cancer survivors continue to increase,” she concluded.

Nurses play a key role in helping to manage the chronic adverse events (AEs) associated with radiation, even into survivorship, according to Hilda Haynes-Lewis, PhD, ANP-BC, AOCNP.
 

Understanding the Management of Chronic AEs After Radiation Therapy

It takes a team to treat patients with myelodysplastic syndrome (MDS), explained Nancy Corbitt, BSN, RN, OCN, CRNI, survivorship nurse navigator at the University of Maryland Greenbaum Cancer Center and member of the AAMDS International Foundation. 

At the ONS Annual Congress, Corbitt discussed some of the key players in caring for those with MDS. They include the physician, who will discuss diagnosis and treatments, the oncology nurses who often focus on adverse event management, as well as palliative and advanced care planning specialists. 

There are multiple key players, including oncology nurses, in the treatment of patients with myelodysplastic syndrome.

MDS Treatment Takes a Team

Live teaching sessions seem more promising than a library as a way of teaching patients and their caregivers about issues such as symptom management, infection prevention and chemotherapy safety, a group of nurses from Penn State Health Hershey Medical Center determined in a study.

Lead author Julianne Jordan, B.S.N., RN, OCN, presented the findings at the ONS 44

 Annual Congress in Anaheim, California, April 13.

The need for education to help patients understand their disease, treatments and related challenges has been long established, as it is known to help prevent unexpected hospital readmissions and minimize complications, the study’s authors pointed out. Patient education can also decrease patient anxiety, enhance the ability to manage side effects, and ensure safe discharges, Jordan said. However, in the inpatient setting, bedside nurses struggle to find enough time to assess gaps in patient and caregiver education and reinforce the necessary messages, the team noted.

As a result, last year, the education council for Hersey Medical Center’s 39-bed oncology unit designed a patient and family resource room that offers evidence-based, standardized and self-guided educational materials that are always accessible. In addition to other materials, the room features a screen that shows PowerPoint presentations on a loop throughout the day, addressing a different topic each day of the week. Topics include skin, hair, nails and mouth care; pain management and the role of the palliative care team; chemotherapy safety at home; thrombocytopenia and neutropenia; explaining your cancer diagnosis; central line catheter care; and managing nausea and vomiting.

While this library helped close the educational gap, an informal assessment proved it was being underutilized.

As a result, the council developed a plan to offer live group education sessions twice a month for patients and caregivers in the resource room. Two bedside nurses are pulled from staffing for four hours on those two days to plan and instruct on topics of interest. The nurses make rounds and check with bedside nurses to identify patients and caregivers who would benefit from this education. They choose one or more topics according to the standardized patient education developed when the resource room was opened, but can tailor these depending on patients’ care plans. Sessions run for about 45 minutes, and when they conclude, patients and caregivers can ask questions, and all participants can learn from the answers.

Patients and caregivers fill out evaluation forms after the sessions and give feedback about the information that was offered. “Thus far, attendees have provided overwhelmingly positive feedback when asked if the topics were helpful and easy to understand,” the nurses wrote in an abstract.

The team determined that having a dedicated nurse provide education increases the amount of time spent on key concepts and reinforcement of knowledge. They concluded that, “Through implementation of live teaching sessions, clinical nurses are able to better meet the educational needs of patients and caregivers.”

Challenges in offering the program include making busy staff members available (although it helps for nurses to schedule their teaching days far in advance), timing the sessions so that they work for both nurses and patients, and controlling group discussions so that they don’t veer off topic, Jordan said.

While the institution is still evaluating the initiative, its ongoing goals will be a reduction in hospital readmissions, a decrease in infection rates and increased patient satisfaction, Jordan said.

The institution hopes to add more topics to the program, increase the number of sessions, get more staff involved and offer education prior to hospital admission for chemotherapy, she said.

Jordan J, Melcher J, Carrillo MJ. Improving patient education: live teaching sessions in an inpatient hematology/oncology unit. Presented at: Oncology Nursing Society 44

 Annual Congress; Anaheim, California; April 11-14, 2019. Abstract No. 5489.

Nurse educators are more effective than electronic guides in ensuring that patients with cancer are safely discharged from the hospital without readmissions, a study found.

Live Classes Teach Patients and Caregivers What to Expect During Treatment

Administering chimeric antigen receptor (CAR)-T cell therapy is a complex process that must be performed properly to ensure that the very expensive single-dose, potentially curative treatment is as effective and safe as possible.

To ensure that commercial CAR-T cell products are administered appropriately and that patients are thoroughly monitored, the Food and Drug Administration (FDA) requires that care teams adhere to specific guidelines. Staff members at Baylor University Medical Center (BUMC), in Dallas, Texas, have created a detailed checklist to make sure that these guidelines are followed, and they conduct a comprehensive audit after CAR-T therapy is administered to identify any problems that may have occurred during the process.

Christina Barrow, BSN, RN, BMTCN, a professional development educator at BUMC, documented that process and shared her findings at the ONS 44

 Annual Congress in Anaheim, California, April 13. Her most important finding was that two overlooked aspects of CAR-T cell-associated care were due to staff failing to refer to a detailed checklist of tasks.

CAR-T is a novel type of immunotherapy that uses genetically engineered T cells to target cancer cells for destruction by a patient’s immune system.

BUMC has been approved since January 2018 to administer axicabtagene ciloleucel (Yescarta), which is approved to treat young adults with B cell precursor acute lymphoblastic leukemia and adults with relapsed large B cell lymphoma. Seven patients have received treatment with the product at BUMC, and audits of their charts were conducted to assess compliance with required program components, Barrow said.

The medical center recently received approval to administer another commercial CAR-T product, tisagenlecleucel (Kymriah), to patients with B cell precursor acute lymphoblastic leukemia, but has yet to administer the treatment, Barrow added.

The audits of CAR-T administration at BUMC, Barrow said, identified opportunities for improvement in two areas: nursing documentation of patient education, and inpatient availability of Actemra (tociluzimab)—given if immune cells attack patients’ healthy organs, causing cytokine release syndrome. According to the checklist, two doses of tociluzimab must be on hand before a patient’s treatment with CAR-T therapy begins.

Both these aspects of care are included on the institution’s CAR-T infusion checklist, and Barrow concluded that making sure to refer to the list before each treatment step will prevent employees from overlooking these areas in the future.

The checklist for drug administration and patient monitoring was designed to ensure administration of all the components of a Risk Evaluation and Mitigation Strategy program required by the FDA; it’s designed to manage side effects and ensure that the benefits of these treatments outweigh the risks. The checklist also prompts compliance with product inserts and BUMC program standards. Among other elements, the list reminds nurses to provide patient education, meet prerequisites for drug administration, give each patient a wallet card outlining potential side effects of axicabtagene ciloleucel that is to be shown to all treating doctors, and set aside two doses of tociluzimab. Also detailed on the list are steps on thawing and infusing the cellular product, checking a patient’s vital signs, giving premedications, and administering the product.

Because CAR-T is a new technology, staff members from the institution’s Blood and Marrow Transplant (BMT) program developed the checklist based on practices from its stem cell infusion processes, Barrow said. Baylor staff have been trained to use the checklist, which is available in a CAR-T resource binder for bedside staff.

Quarterly audits of patient charts identified a few barriers to meeting these requirements, Barrow reported: The products are made by different manufacturers, all CAR-T products are different because they include the cells of individual patients, and there’s no standard industry process for administering these drugs.

To improve compliance, BUMC has created a core group of CAR-T champions identified by the unit’s nursing manager. They have re-educated staff on facets of CAR-T administration including use of the checklist, and they act as a resource on the unit about administration issues. In addition, components of the process are being built into the cancer center’s new electronic health record.

Administration is ongoing as part of BMT program standards and REMS requirements, Barrow said.

Barrow, C. Developing a checklist to ensure staff compliance to chimeric antigen receptor (CAR) T cell infusion requirements. Presented at: ONS 44

 Annual Congress; April 11-14, 2019; Anaheim, California. Abstract 5415.

An audit of one institution's administration shows that adhering to a detailed list of tasks prevents missed steps in a complicated process.

Sticking to a Checklist Ensures Proper Administration of CAR-T Cell Therapies

The more severe their symptoms, the less likely women with ovarian cancer are to report the discomforts to their oncologists, a study found.

Women with high symptom severity scores at the start of the study were 37% less likely to appropriately communicate those issues compared to women with low symptom severity scores, researchers found. A member of the research team from the University of Pittsburgh shared the findings at the ONS 44

Women with ovarian cancer tend to have multiple concurrent symptoms that negatively affect their quality of life, functionality and treatment adherence, making the need for communication very important, said lead author Teresa Thomas, PhD, BA, RN, an assistant professor in the university’s School of Nursing. Symptoms often include abdominal pain, bloating, cramping, fear of recurrence or disease progression, indigestion, sexual dysfunction, vomiting, weight gain, weight loss, and neurological problems, she said, adding that underreported symptoms may be the ones that are most difficult for patients to talk about, or for practitioners to manage.

The study hinged on previous evidence that women with ovarian cancer often struggle to communicate their cancer- and treatment-related symptoms to their healthcare providers. Research shows that just 61% of these patients have discussed their most-noticed symptom with a provider in any given month, and among those who have, 50% have not received a management recommendation, Thomas said. She added that 53% of the symptoms considered by patients to be top priorities have not been documented by providers.

The study sought to learn the patient characteristics associated with varying levels of appropriate symptom communication at baseline, thus creating a predictive model. The study also sought to reveal the association between symptom communication and severity over time.

The researchers recruited women with recurrent ovarian cancer from 68 sites of a randomized clinical trial called the Written Representational Intervention to Ease Symptoms (WRITE), sponsored by the Gynecological Oncology Group. They selected 497 participants with ovarian cancer and at least 3 symptoms. In the WRITE study, the patients had been randomized into 3 groups, with 1 getting usual care, another self-documenting symptoms and a third having symptoms documented by nurses.

The groups documenting their symptoms used monthly questionnaires including the Symptom Representation Questionnaire, which rates the severity of 28 symptoms on an 11-point scale. These patients prioritized 3 symptoms over which they wanted to gain better control. A 4-item questionnaire assessed their communication of these symptoms with providers. Based on patients' assessments of symptom severity, their communication was ranked as “appropriate” (severity of 0-10 and any level of communication) or “inappropriate” (severity of 5-10 and no or limited communication).

At the outset of the study, the researchers used a mathematical model to predict inappropriate symptom communication styles, controlling for age, education, optimism, anxiety, depression, and social support. In addition, they analyzed changes in symptoms and communication over time by calculating score differences and correlations between severity and communication appropriateness at each time point (baseline and 4, 8 ,and 12 weeks).

The team found that appropriate communication occurred for 42% to 94% of women’s top symptoms. Symptom severity was the strongest predictor of appropriate communication at baseline, with women who had high symptom severity scores 37% less likely to appropriately communicate compared with women who had low symptom severity scores. From baseline to 12 weeks, symptom severity decreased overall and appropriateness of communication increased overall. However, symptom severity remained negatively associated with appropriate communication during that time period.

“These results demonstrate that symptom severity was inversely related to appropriate communication,” the researchers wrote. “Women experiencing severe symptom severity were less likely to report having appropriate communication about that symptom with their healthcare provider. This study underscores the need for health care providers to break the cycle of inappropriate symptom communication to ensure patients’ symptoms are adequately discussed and managed throughout women’s cancer experience.”

Thomas T, Schenker Y, Cohen S, et al. Symptom severity is negatively associated with symptom communication over time among ovarian cancer survivors: establishing the need for appropriate symptom communication. Presented at: Oncology Nursing Society 44

 Annual Congress; Anaheim, California; April 11-14, 2019. Abstract No. 4486.

Health care providers need to break the cycle of inappropriate symptom communication to help improve patients’ quality of life.

ONS Annual Congress