When attending to patients with lymphoma receiving multi-agent chemotherapy regimens, Gretchen McNally, PhD, ANP-BC, AOCNP, acknowledges that there a variety of factors to pay attention. However, she argues that nurses should be conscience of the risk of chemotherapy-induced peripheral neuropathy (CIPN) and be diligent in querying about their physical functioning in terms of buttoning, zipping, or writing.

“Historically, peripheral neuropathy is [more] well-studied, in different types of cancer,” McNally, who is a nurse practitioner in hematology at The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (OSUCCC), said in an interview with 

®. “For example, it is better understood in patients with breast cancer receiving taxanes or patients with colorectal cancer receiving oxaliplatin.”

However, according to McNally, although a smaller subset of patients with lymphoma might experience chemotherapy-induced neuropathy, this does not mean their symptoms are less substantial.

“I primarily work in hematology, and focus on lymphomas,” she said. “I noticed several years ago that one of the [adverse] effects that my patients experience if they had aggressive lymphoma and were treated with R-CHOP was peripheral neuropathy.”

“These patients can have severe peripheral neuropathy, which means that it is impacting their activities of daily living, [where] they cannot button, [or], if it’s in their feet, they are at an increased risk falls, [or] they can’t stand and are not able to work,” she explained. “So, it’s a really a huge issue, long term and short term.”

McNally acknowledges that there has not been great clinical-rated or patient-reported outcome (PRO) measurement data for this adverse event in this population. Thus, she decided to launch a study to assess how this is affecting her patients.

The prospective pilot study will enroll up to 23 individuals with lymphoma receiving vincristine containing regimens. Using the European Organization for Research and Treatment of Cancer-Quality of Life Questionnaire–CIPN-20 (EORTC QLQ CIPN 20) and the Brief Pain Inventory Short Form (BPI-SF), clinicians will collect and assess PROs. Clinician-rated outcomes will be assessed via the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE v 5.0). Neurofilament light chains (NF-L) will be assessed as a possible serum biomarker.

The correlation between NF-L levels and future CIPN 20, CTCAE, and BPI scores will be evaluated via Spearman’s correlation. Linear and ordinal regression models will be utilized to assess the effects on future CIPN.

CIPN, including vincristine neurotoxicity, is a high priority research area for the NCI. This progressive, debilitating adverse effect of cancer treatment potentially negatively affects both disease outcomes as well as the long-term quality of life of cancer survivors. 

Investigators believe that vincristine’s interference with microtubule formation is the driving force behind neuropathy, as the interference with these critical components of nerve fiber axons leads to mitotic arrest and cell death.

“We’re collecting a serum blood samples from patients that we’ll be sending that for neurofilament analysis,” McNally said. “Neurofilament is thought to be a biomarker of vincristine induced peripheral neuropathy because it [is induced by] the axonal breakdown that is triggered by neuropathy.”

The trial is ongoing, and McNally’s team is still in the process of data analysis; however, she is optimistic that it will help garner some goof baseline data for this patient population.

“Hopefully, we’ll get some good baseline data for the next study and will be able to [take a closer look] at neuropathy causing medication or chemotherapy medications in lymphoma,” she concluded. “Then we can [focus more] on interventions.”

McNally G, Manring C, Gault C, et al. Evaluating vincristine induced peripheral neuropathy outcomes in patients with lymphoma. Presented at: 47th Annual Oncology Nursing Society Congress; April 27-May 1, 2022, Anaheim, CA. Abstract P344.

Articles

Gretchen McNally, PhD, ANP-BC, AOCNP, discusses the rationale behind a pilot study which will assess patient reported outcomes for patients with lymphoma who develop chemotherapy-induced peripheral lymphoma.

McNally Spotlights Need for Better CIPN Research in Aggressive Lymphomas

Oncology nurses and advanced practice providers (APPs) are interested in learning about naloxone, says Gretchen McNally PhD, ANP-BC, AOCN.

McNally, who is a nurse practitioner in hematology at The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (OSUCCC), recently shared findings from a single-center study at the 47th Oncology Nursing Society Congress. McNally and colleagues evaluated oncology provider’s knowledge and perception of naloxone and opioid use disorders.

Findings demonstrated that most respondents would be open to receiving training on naloxone and would feel comfortable administering naloxone with that training. For example, most nurses (64.2%; n = 309) and APPs (60.1%; n = 104) expressed interest in naloxone training classes.

Providing educational materials on opioid abuse and treatment strategies would position oncology nurses and APPs in a role to identify and address opioid use disorders in patients with cancer. Regarding the use of naloxone, McNally notes that although it is similar to a fire extinguisher in that it should only be used in emergencies, it is a great example of an opportunity to reduce harm to patients.

The insights gained through this study present an opportunity to develop innovative strategies to train health care providers and nurses, McNally says. These professionals can also take the skills learned in the clinic setting and bring them to the wider community, McNally adds.

“As an oncology nurse or provider, you [may] not really think that addiction affects your patients, [but] it affects so many people, and if we can just make a small difference and save 1 life, we’re making an impact.”

Videos

Gretchen McNally PhD, ANP-BC, AOCN, spotlights the value that naloxone training for oncology nurses and providers could have for patients who are at a high-risk of overdose. 

Gretchen McNally Speaks to the Role of Oncology Nurses in the Opioid Epidemic

Similar to chemotherapy, myelosuppression and gastrointestinal (GI) toxicities are common in patients with acute myeloid leukemia (AML) receiving venetoclax (Venclexta), explains Ilene Galinsky, BSN, MSN, ANP-C.

Galinsky recently presented on the topic of

practical treatment considerations with BCL2 inhibitors at the 47th Annual Oncology Nursing Society Congress. In an interview with 

 she discusses different management strategies for patients who experience adverse events with the therapy.

Patients who experience myelosuppression may become transfusion dependent, according to Galsinky. Therefore, it is advisable to bring patients in twice weekly for lab assessments, and potentially transfusions, during their first month of treatment with venetoclax.

Neutropenia is also a risk factor for patients receiving the BCL2 inhibitor, and it can significantly increase their risk of infection. Some providers may prescribe prophylactic antibiotic therapy if their patients develop neutropenia.

“In my institute, we do not do that,” Galinksy says. “It is not wrong to do that, but if you do, you have to be mindful that you [will] have to decrease the dose of venetoclax.”


Finally, grade 1/2 GI toxicities are common in this treatment population. Antiemetics or antidiarrheals may be effective symptom reduction strategies; however, some patients may also benefit from taking medication at different times of day.

“It is recommended to take [venetoclax] in the morning, but, in my experience, some [individuals] have found that they have less GI toxicities when they take it later in the day,” she says. “If they are not on a clinical trial, I let patients [experiment to find] what works best for them.”

Ilene Galinsky, BSN, MSN, ANP-C, underscores effective symptom management strategies when prescribing venetoclax to patients with acute myeloid leukemia. 

Galinsky Breaks Down Venetoclax Symptom Management in AML

Naloxone (Narcan) training for oncology nurses and advanced practiced providers (APPs) may be an opportunity to decrease addiction stigma and save lives, according to Gretchen McNally, PhD, ANP-BC, AOCNP.

McNally, who is a nurse practitioner in hematology at The Ohio State University Comprehensive Cancer Center– Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (OSUCCC), recently presented during the 47th Annual Oncology Nursing Society (ONS) about how oncology nurses might have the opportunity to save lives with proper naloxone training. Responses obtained from nurses and APPs at McNally’s institution demonstrated that they would feel comfortable administering naloxone, provided they had the proper training, and would be interested in pursuing educational trainings on the agent.

“This represents an opportunity for oncology nurses and APPs to positively impact the opioid epidemic, for not only patients affected by cancer, but there may be a positive trickle-down effect on families and communities,” said McNally in a presentation of the findings.

®, McNally walked through the background of Project Dawn, which stands for “deaths avoided with naloxone,” the significance of the findings of her research, and what oncology nurses should understand about naloxone’s role in the opioid epidemic.

“[Project Dawn] is partnered with several of the health care systems, including Ohio State,” McNally said. “Project Dawn supplies free naloxone to [individuals] at risk of an opioid overdose—patients who have an opioid use disorder, [have had] a previous overdose, or [are receiving] a high dose of pain medications,” she explained. 

“In October of 2021, [Project Dawn was] rolled out at the [OSUCCC]. I thought it was very innovative. They had a short 14-minute video that went through recognizing an opioid overdose and how to administer the naloxone, which in the community is usually [administered] as a nasal spray [but in] the hospital or it’s usually administered intravenously or intramuscularly.”

“I think that this is an opportunity to develop creative or innovative strategies to train health care providers and nurses,” she added. “If you think of how many nurses work at the hospital, and then go into the communities, they could really make a huge difference.”

“I always go back to thinking about Jan Rader, who was a fire chief in West Virginia. She gave a TED talk in 2019 [and] said, ‘We all have a role to play in ending the opioid epidemic, and what role will you play?’ As an oncology nurse or provider, you [may] not really think that addiction affects your patients, [but] it affects so many people, and if we can just make a small difference and save 1 life, we’re making an impact.”

McNally and coinvestigators conducted a hospital-wide survey of multidisciplinary oncology health care providers over a 4-week period. Respondents were queried about their experience and knowledge surrounding opioid use disorders. The results presented during ONS highlighted responses on the providers’ knowledge of naloxone administration.


Overall, 698 participants were included in the sample. Among these were 180 APPs and 518 nurses, and the response rates were 50% and 43%, respectively. The mean age of participants was 40.2 years for APPs and 38.4 years for nurses. Most participants were female (n = 641, 91.8%) and White (n = 631, 90.4%). The percentage of respondents who had worked in oncology for over 5 years was 62.3% for APPs and 49.7% for nurses.

Participants were asked to respond to the following statements:

“I feel comfortable administering naloxone in the community”

“I would feel comfortable with training”

“Would you be interested in attending a naloxone training class?”

For the first question, “I feel comfortable administering naloxone in the community”, a greater number of APPs (39.4%; n = 69) compared with nurses (29.1%; n = 145) responded “no.” However, the majority of both nurses (64.2%; n = 309) and APPs (60.1%; n = 104) answered “yes” to the second question, “I would feel comfortable with training.”

Moreover, most nurses (64.2%; n = 309) and APPs (60.1%; n = 104) expressed interest in naloxone training classes.

McNally concluded the conversation noting that with the enthusiasm exhibited by nurses in regards to naloxone training, it is important to understand it’s specific value in reducing harm.

“Naloxone is a reversal agent. I like to think of it as a fire extinguisher—only to be used in times of emergency,” she said. “It’s a great example of harm reduction. It recognizes that opioid use is going to continue, [however, with it] we can potentially save a life.”

McNally G, McLaughin E, Baiochhi R, Rosselet R. Naloxone training: an opportunity for oncology nurses to save lives. Presented at: 47th Annual Oncology Nursing Society Congress; April 27-May 1, 2022, Anaheim, CA. Abstract P147.

Gretchen McNally PhD, ANP-BC, AOCNP, discusses the potential impact advanced practice providers and nurses could have in the opioid pandemic if the correct educational opportunities were available. 

Are Oncology Nurses Underutilized in Positively Affecting the Opioid Epidemic?

Pulmonary embolism is easily treatable, but only when it is detected early, according to Laura J. Zitella, MS, RN, ACNP-BC, AOCN. Therefore, knowing the appropriate work-up to perform when a patient with cancer begins to experience shortness of breath is crucial.

Zitella, who is a hematology/oncology nurse practitioner and associate clinical professor in the Department of Physiological Nursing at the University of California San Francisco (UCSF), recently presented with her colleague, Mary Petrofsky, NP, MSN, a nurse practitioner with the UCSF, on the subject of acute complications of cancer and cancer treatment, at the 

47th Annual Oncology Nursing Society Congress.

 During the session, they highlighted relevant cases, and what the differential diagnosis, evaluation, and treatment would be for each of these acute complications.

 Zitella discussed the case of a 50-year-old woman with osteosarcoma who was receiving chemotherapy and presented with shortness of breath.

“When I have a patient who presents with shortness of breath, there are a number of things I look at,” Zitella said. “First of all, the vital signs: I want to know if the patient is febrile, I want to know if the patient has tachycardia, and what the blood pressure is, and of course, their respiratory rate.

“I also want to get a set of labs, I think it’s really important to look at the [complete blood count and] if the white count is elevated or decreased, because that could indicate that [there] is infection. I want to know what the hemoglobin is to see if there’s any level of anemia. I would also want to check a comprehensive metabolic panel to see if there are any electrolyte abnormalities, to see what the kidney function is, and to see what the liver function is.”

In addition to vital signs, a provider should determine O

 saturation, Zitella added, because that will help indicate the possibility of pneumonia, pulmonary embolism, or pneumonitis and [will] also demonstrate the severity of illness and how critically ill a patient is or is not.

For this patient, a CT angiography was obtained and results were helpful in ruling out a number of different diagnoses.

“A CT angiography [will] tell you if the patient had pneumonia, [or] pulmonary embolus, [and] it can tell you if the patient has pulmonary edema, or a pleural effusion. It can [also indicate] heart failure because on a CT of the lungs, you [can] see an enlarged heart, which might be associated with heart failure, and would also [indicate] pericardial effusion. It is a really nice test that can help confirm the correct diagnosis.”

The CT angiography revealed that the patient had pulmonary embolus. According to Zitella, the 2 biggest signs indicating pulmonary emboli among patients with this malignancy are when a patient has low oxygen saturation and is tachycardic. Unfortunately, this condition, when left untreated, can be fatal. However, if caught early, it is easily treatable, and Zitella urged nurses and advanced practice providers to be vigilant in suspecting this complication in patients with these symptoms.

In terms of treatment, both low molecular weight heparin or a direct oral anticoagulant are good options, Zitella said. The benefit of both these treatments are that they work immediately. So, the moment a patient receives their dose, the medication will start working to bring them to a therapeutic level.

“The other advantages are [that] both of these can be done in an outpatient [setting],” added Zitella, noting that a patient does not necessarily need to be admitted for this condition. “Most patients that I see in my practice can safely be started on therapy and continue on therapy as an outpatient.”

Laura J. Zitella, MS, RN, ACNP-BC, AOCN, presents a case study of a patient receiving chemotherapy for osteosarcoma who begins experiencing shortness of breath. 

How To Respond When a Patient on Chemotherapy Presents With Pulmonary Embolism

Targeted therapy has changed the treatment landscape for acute myeloid leukemia (AML), according to Ilene Galinsky, BSN, MSN, ANP-C, senior leukemia protocol research nurse practitioner at Dana-Farber Cancer Institute.

As Galinsky explained in an interview with Oncology Nursing News®, the first targeted therapy for AML was imatinib (Gleevac), which was tested in clinical trials in the late 1990s and approved in 2001.

 Later, in 2017, the FDA approved midostaurin (Rydapt) for the treatment of FLT3-positiveAML. This approval was supported by findings from the international RATIFY trial (NCT00651261), which demonstrated the efficacy of targeted therapy compared with placebo in this patient population.

“That [trial] started a snowball effect of targeted therapy, either by mutations, or by flow cytometry markers like [with] gemtuzumab ozogamicin [Myolotarg],” Galinsky said. “Since that time, 7 or 8 drugs have been 

 [for pediatric and adult patients], all of which target a different aspect of the disease.”

The BCL2 inhibitor venetoclax (Venclexta) was approved by the FDA for adult patients with newly diagnosed AML aged 75 years or older and for patients who had preexisting conditions that precluded them from the use of intensive chemotherapy. This includes patients with an ECOG performance status of 2 or 3 and severe comorbidities including cardiac or hepatic impairment.

The agent is approved at a dose of 400 mg daily in combination with azacitadine (Vidaza), decitabine, or low-dose cytarabine.

Galinsky recently presented on the efficacy and practical treatment considerations with BCL2 inhibitors at the 47th Annual Oncology Nursing Society Congress. In an interview with 

®, she discusses important considerations when prescribing venetoclax, and why the evolution of targeted therapy is significant for patients with AML.

Prescribing Considerations With BLC2 Inhibition

When prescribing or administering venetoclax, it is important to keep a patient’s disease burden top of mind, Galinsky said.

Venetoclax should not be initiated if a patient has a high white blood count and hydroxyurea should be used to achieve counts below 25,000 cells/μL. Further, tumor lysis syndrome, though rare, was observed during the ramp-up phase in the original clinical trials. Nurses, therefore, are encouraged to monitor laboratory tumor lysis counts, either in the inpatient or outpatient setting, 6 to 8 hours after administering venetoclax.

“The ramp-up period to get to that targeted dose is 3 days,” Galinsky said. “Once you are at that target dose, we check [labs] another time—24 hours later.”

Hydration can also be key in reducing the risk of tumor lysis syndrome and can be effectively achieved through either oral intake or intravenous (IV) fluid, she said. “You can put your patients on an antihyperuricemia agent such as allopurinol, or rasburicase [Elitek]. These are preventative measures [for] tumor lysis syndrome.”

Concomitant medications are another important factor to consider, Galinsky said.CYP3A4 inhibitors can affect the pharmacokinetics of venetoclax, she said. If a patient is receiving one of those drugs, dose modifications may be necessary to get the patient to their target venetoclax dose.

“Those are the important key factors to think about when you’re using venetoclax in AML. The other factor is we know that it causes myelosuppression just like a chemotherapy agent.”

A mid-cycle bone marrow biopsy is recommended between days 21 to 28 to dictate if—and when—the second 28-day cycle can begin.

If a patient is not in remission after 1 cycle, treatment should be continued despite low blood counts, and a second bone marrow biopsy should be repeated, she said. If a patient is in remission and has neutropenia, providers should wait until the patient has recovered to grade 1 or 2 neutropenia before initiating a second dose. If, following a second dose, neutropenia is persisting, providers should hold the dose and upon resuming prescribe a 21-day cycle instead of a 28-day cycle.

With the myelosuppression, patients also may be transfusion dependent until their counts normalize or respond to therapy. Therefore, Galinsky typically has her patients come in twice a week during their first month of therapy for laboratory assessments and possible transfusions.

If patients have neutropenia, there is an increased risk of infections and, in the VIALE-A trial (NCT02993523), there was an increased risk of pneumonia. Therefore, some providers prescribe either antifungals, or antibacterial prophylactic antibiotic therapy.

“In my institute, we do not do that,” Galinsky said. “It is not wrong to do that, but if you do, you have to be mindful when you’re adding an azole that you have to decrease the dose of venetoclax.”

Moreover, like with chemotherapy agents, gastrointestinal (GI) toxicities are common.

“With this therapy, [GI toxicities are] usually grade 1 or 2, and manageable with antiemetics, but some [individuals] do [experience] diarrhea, so antidiarrheal [medicines] can be used as well,” she explained.

Adjusting the timing of the dose can be an effective strategy as well, Galinsky continued.

“It is recommended to take [venetoclax] in the morning, but, in my experience, some [individuals] have found that they have less GI toxicities when they take it later in the day,” she said. “If they are not on a clinical trial, I let patients [experiment to find] what works best for them.”

Overall, it’s an exciting time to be working in AML, Galinsky concluded.

“In the past several years there have been changes in therapies that have [made them] less toxic and have improved overall survival in our patients with AML,” she said. “Prior to midostaurin, it didn’t matter what a patient’s molecular makeup was. You gave them induction chemotherapy and hoped for the best.

“Now we have the technology and the ability to find why there’s specific abnormalities, how to target those specific abnormalities, and how best to improve overall survival and quality of life.”

1. How imatinib transformed leukemia treatment and cancer research. National Cancer Institute. UpdatedApril 11, 2018. Accessed June 21, 2022. https://bit.ly/2FdcgWt

2. Stone RM, Mandrekar SJ, Sanford BL, et al. Midostaurin plus chemotherapy for acute myeloid leukemia with a FLT3 mutation. 

. 2017;377(5):454-464. doi:10.1056/NEJMoa1614359

3. Venclexta. Prescribing information. AbbVie Inc; 2020. Accessed June 21, 2022. https://bit.ly/3ye5i2c

Ilene Galinsky, BSN, MSN, ANP-C, discusses the evolution of targeted therapy in acute myeloid leukemia treatment, and how venetoclax plays into the treatment paradigm.

Galinsky Clarifies Best Practices With Venetoclax in the AML Setting

Creating a Safe Space Is The First Step in Initiating Sexual Health Conversations With Patients With Cancer 

Although not every patient with cancer will experience a sexual health crisis during treatment, each will experience some form of sexual health change, according to Sage Bolte, PhD, LCSW, CST.

 Therefore, it is important that oncology nurses establish that a patient can turn to them if and when they want to discuss issues related to their sexual health. 

“Every single one of them will have sexual changes,” said Bolte, chief philanthropy officer and president of the Inova Health Foundation. “They will have questions, whether it’s during treatment, after treatment, or 3 years after treatment. [Nurses] will be the ones that they reach out to so that they don’t feel scared and isolated and confused when those issues come up.” 

She added that with some patient populations, it is still not “necessarily generationally appropriate [to have these conversations], and it may be uncomfortable for them. So, it is [often] our providers [who need] to be the ones to bring forward the conversation.” 

In a presentation during the 47th Annual Oncology Nursing Society Congress, Bolte, along with Elaine Wittenberg, PhD, FACH, an associate professor at California State University, Los Angeles, and Joy Goldsmith, PhD, a professor of communication studies, at the University of Memphis in Tennessee, 

 strategies that oncology nurses can use in addressing sensitive topics with patients. 

To better engage with patients, oncology nurses may need to ask themselves: “What is my comfort level discussing sexual health?” and “What are my particular strengths in helping patients and their partners reclaim their own bodies?” Nurses may also need to reflect further on how comfortable they are with their own body and sexuality, their own positive image, and whether they are at a place of peace to overcome personal barriers and initiate these conversations. “It is OK if you’re uncomfortable with those words,” Bolte noted. “We’re taught to be a little uncomfortable with those words. [But] we have to look at what triggers that discomfort so we can show up for our patients without showing that discomfort.” 

Furthermore, nurses can help promote more meaningful dialogue by keeping the conversation positive and centered on the patient. For example, Bolte said it is a better approach to tell a patient, “Cancer and its treatments have such significant impacts on all aspects of our lives, including our sexual health. This is normal. I would love to provide you with some information,” rather than telling them, “You can discuss sexual failure with me” or “I am trained not to laugh.” Overall, Bolte recommended looking for “very simple, nonthreatening ways to open a conversation with the information that [the patient] is providing.”

Bolte S, Goldsmith JV, Wittenberg E. Tools of the trade: communicating sensitive topics. Presented at: 47th Annual Oncology Nursing Society Congress; April 27-May 1, 2022; Anaheim, CA.

Patients With Cancer Share Mixed Experiences With Immunotherapy 

Patients with cancer are divided on their expectations with checkpoint inhibitors, 

according to findings from a patient survey

 that were presented during the 47th Annual Oncology Nursing Society Congress.

Results revealed that 27% of patients believe that their immunotherapy treatment will “help [them] live longer,” whereas 19% believe the therapy will “cure the cancer,” and 15% believe it will “improve [their] life quality.” 

More than a quarter of patients expressed conviction that this treatment strategy would be “effective” against their disease, and another 25% felt it would be “very effective.” Fifteen percent were unsure whether it would be effective, 14% thought it would be somewhat effective, and 11% had no expectations. Other patients responded that they believed the treatment would allow them “to have less [adverse] effects [AEs] than chemotherapy,” “to stop the tumor from growing,” and “to delay the need for stronger chemotherapy.” 

In terms of symptoms, tiredness was found to be the most common AE. For those who experience an AE, calling the oncologist was the most common response (21%). However, 15% of patients responded by calling their oncology nurse, 10% discussed the AE with family, and 9% chose to manage the AE alone. Eight percent of patients reported that they ignored their symptoms. 

“We believe that the findings of this study will help improve the management of immunotherapy [AEs] and inform immunotherapy patient education and [AE] reporting,” Maryellen Potts, PhD, University of Kansas School of Nursing, explained in a poster presentation of the findings.

Potts M, Fleer R, Dionisi L, et al. Immunotherapy patient 20 Oncology Nursing News® June 2022 CLINICAL INSIGHTS experience: a cross-sectional survey of patient knowledge, expectations, and information seeking strategies. Presented at: 47th Annual Oncology Nursing Society Congress; April 27-May 1, 2022; Anaheim, CA.

Cannabis Use May Help Decrease Opioid Need in Patients With Cancer

Medical cannabis in conjunction with opioids may be an effective treatment strategy to reduce pain burden in patients with cancer, 

 at the 47th Annual Oncology Nursing Society Congress.

Furthermore, health care providers should continue to educate patients and caregivers about the potential benefits and risks associated with medical cannabis and keep them informed with current available evidence and emerging data to recommend efficacious dosing and formulations. 

In doing so, nurses can proactively care for patients experiencing pain burden by identifying which patients might benefit from this treatment based on current conditions, symptomology, and efficacy of previous therapeutics. Amber Nenner, BSN, RN; Felita Salim, BSN, RN, OCN; and Ryan Sandler, MS, RN, all of Columbia University School of Nursing in New York, New York, presented on the findings in a poster during this year’s congress. 

The authors noted that there is a wide range of symptoms that can affect patients with advanced cancer, including chronic pain, anorexia, chemotherapy-induced nausea and vomiting (CINV), anxiety, and diminished quality of life (QOL). Notably, dronabinol, a pharmaceutical form of Δ-9-tetrahydrocannabinol (THC), and nabilone, a synthetically made cannabinoid, are FDA approved to treat patients with certain conditions, including CINV.

Will Medical Cannabis Replace Opioid Use?

The cumulative evidence does not suggest that medical cannabis will replace standard opioid therapy, the authors concluded. However, it was found to be an effective adjunct among those who were opioid refractory and helped to reduce the overall need for opioid consumption by reducing pain intensity. 

In addition, THC-CBD formulations improved the conditions of patients with CINV, and THC/cannabidiol (CBD) tablets increased the weight and appetites of patients with anorexia and cachexia. The wide range of cannabinoid receptors in the body ultimately responded to the drugs and resulted in improved QOL by improving sleep, depression, and anxiety. 

Common AEs associated with cannabis included central nervous system [effects], dizziness, somnolence, disorientation, gastrointestinal disturbances, hallucinations, and altered functional status.

Nenner A, Salim F, Sandler R, et al. Cannabis and symptom management in cancer, efficacy, and implications for clinical use. Presented at: 47th Annual Oncology Nursing Society Congress; April 27-May 1, 2022; Anaheim, CA.

Catheter Represents Preferred Administration Equipment vs Injection Needle for Subcutaneous Immunotherapy Infusions 

The use of catheters instead of injection needles to administer intravenous (IV) immunotherapy is linked with increased comfort and satisfaction for patients and infusion nurses, according to 

 presented at the 47th Annual Oncology Nursing Society Congress.

“The BD Saf-T-Intima butterfly catheter is specifically geared toward subcutaneous administration of medications,” Georgina Rodgers, BSN, RN, OCN, NE-BC, of Cleveland Clinic Taussig Cancer Center, said in a poster presentation during the congress. “The nice thing about this particular piece of equipment is that once it is inserted into the patient, you remove the needle stylet—making it needle-less once you remove it from the patient, and what is left in the patient is a flexible catheter for administration.” 

Multiple large volume IV infusion immunotherapies have recently been converted to large volume subcutaneous formula infusions of 15 mL and whose administration time lasts up to 8 minutes. The therapy is administered with hyaluronidase to enhance absorption; however, erythema, edema, pruritus or itching, and rash at the injection sites continue to represent potential complications, which can occur up to 24 hours following injection. The large volume and duration time, as well as the difficulty of maintaining needle stability for 8 minutes and the lack of safety, cause nurses to voice concerns. 

Compared with traditional infusion via an injection needle, the use of a catheter was associated with a lack of occlusion, an overall reduction in injection site complications, and reports of nurse satisfaction and comfort with the procedure. Specifically, nurses can attach a syringe to the end of the catheter, creating more space between the patient and nurse and, in turn, increasing nurses’ comfort. In addition, because the catheter allows for slower infusion times, the injection site stability was increased and absorption enhanced.

Colvin C, Rodgers G. A novel approach to subcutaneous immunotherapy administration. Presented at: 47th Annual Oncology Nursing Society Congress; April 27-May 1, 2022; Anaheim, CA.

Nurses Help Bridge Patients Undergoing Chemotherapy to Scalp Cooling Therapy

A nurse-driven program successfully connected patients undergoing chemotherapy with scalp cooling treatment, according to 

 during the 47th Annual Oncology Nursing Society Congress.

Furthermore, patients who completed the program expressed high satisfaction levels with scalp cooling and retained 50% more hair than anticipated with this type of treatment.

More than 75% of patients with cancer fear experiencing alopecia because of chemotherapy. Since the FDA approved the expanded use of a cooling cap in 2017, patients and oncology care teams have become interested in its ability to reduce the volume of hair loss induced by treatment. 

Following favorable efficacy and safety data with scalp cooling, a team of oncology nurses piloted a scalp cooling program at a community-based cancer center connected to the Froedtert & the Medical College of Wisconsin in Milwaukee. 

Overall, 15 patients elected to undergo scalp cooling therapy and more than 80 treatments were administered since June 2021. Although 2 patients stopped treatment because they felt overwhelmed, patients who completed all cycles expressed high levels of satisfaction, according to the study authors.

In addition, the nursing staff reported satisfaction with the amount of training and resources provided during implementation and “are proud” that scalp cooling is offered at their institution. Many patients expressed gratitude for being connected to the therapy through testimonials. “It really sucks to go through cancer treatment; I am so glad I had scalp cooling…I am so appreciative I was given the chance to save my hair and keep a part of my identity,” a patient shared in a testimonial. 

“Nurses are at the forefront of promoting and educating patients throughout the care continuum for supportive care interventions, such as scalp cooling,” Linda Amacher, BSN, RN, OCN, of Froedtert & the Medical College of Wisconsin, added in a presentation of the findings. “[In this case,] there was quick adoption by nurses, and processes were integrated into clinic and infusion workflows without significant challenges.”

Amacher L, Herriges D, Portz D, et al. Hairs the deal: implementing scalp cooling for chemotherapy-induced alopecia at a community-based cancer center. Presented at: 47th Annual Oncology Nursing Society Congress; April 27-May 1, 2022; Anaheim, CA.

This year’s congress showcased strategies for communicating sensitive topics, patient experiences with immunotherapy treatments, updates in the utility of
medical cannabis, and more. 

ONS Annual Congress Focuses on Increasing Nurse Comfort and Patient Understanding in Cancer Care

It is important to keep tolerability top of mind when considering best treatment strategies for patients with hematologic malignancies, according to Laura J. Zitella, MS, RN, ACNP-BC, AOCN.

 for patients with chronic lymphocytic leukemia (CLL) since 2018, but risk stratification and tumor lysis prevention strategies remain of interest to providers and strategies may differ for those with acute myeloid leukemia or multiple myeloma. Similarly, with the addition of multiple new agents for second- or third-line diffuse large b-cell lymphoma (DLBCL), such as 

 the treatment landscape has become more difficult to navigate.

®, Zitella, a hematology/oncology nurse practitioner and associate clinical professor in the Department of Physiological Nursing at the University of California San Francisco, who previously served as the lead advanced practice provider for inpatient hematology/oncology at Stanford Health Care, discusses risk management with venetoclax in patients with CLL, and treatment options for the third-line treatment of patients with DLBCL. Additionally, she discusses the importance of clinical trial enrollment in continuing to advance the treatment landscape for patients.

Zitella recently gave presentations during the 

47th Annual Oncology Nursing Society Congress

 on the practical management of BCL2 inhibitors in CLL and integrating novel therapies into later-line DLBCL care. These presentations centered on correct dosing, risk assessment, and the safety of various drug classes across these different disease types.

Please highlight what optimal dosing with BCL2 inhibitors looks like for patients with CLL.

For patients with CLL, we use a BCL2 inhibitor, and the BCL2 inhibitor that is approved for CLL is venetoclax [Venclexta]. Venetoclax is generally used in combination with an anti-CD20 monoclonal antibody, either obinutuzumab [Gazyva] or rituximab [Rituxan].

One of the adverse effects that we need to be aware of is the risk of tumor lysis. There are a number of different strategies that [may be] implemented in order to prevent tumor lysis syndrome. One of the first things that you do when you are considering using treatment with venetoclax is assess the risk of tumor lysis syndrome. You can classify the risk as low, medium, or high risk. Based on that risk, there are specific guidelines, which are nicely outlined in the package insert, about how much hydration patients need. In addition to hydration, every patient is going to receive allopurinol–unless of course there’s a contraindication or [they have an] allergy to allopurinol. Allopurinol [treatment] starts [approximately one] week before therapy, and then continues throughout the [period of] risk of tumor lysis. For patients who are at very high risk of tumor lysis, they need to be admitted [to the hospital] for the first 2 doses of the dose ramp-up.

Dose ramp up is another one of the strategies to prevent tumor lysis. With venetoclax, there is a dose ramp up over a period of 5 weeks. In the first week, the patient will take 20 mg a day for a week; in the second week, [they will take] 50 mg for a week; [in the third week], 100 mg for a week; [in the fourth week], 200 mg for a week and then, [in the fifth week], 400 mg. The optimal dose of venetoclax for patients with CLL is 400 mg.

By using this dose ramp-up approach, tumor lysis prevention—such as hydration—lab monitoring, and the use of allopurinol, for patients who are very high risk, most cases of significant tumor lysis can be prevented. In clinical trials using all these strategies, only [approximately] 1% of patients had evidence of tumor lysis.

Please discuss how third-line agents may play a role in the treatment of DLBCL.

The standard of care for DLBCL for the past 40 years has been R-CHOP [rituximab plus cyclophosphamide, doxorubicin hydrochloride, vincristine, and prednisone], which achieves a cure for approximately 60% of patients. For patients whose disease is not cured with R-CHOP chemotherapy, the standard of care has been to use salvage chemotherapy followed by autologous transplant. However, we now have CAR T-cell therapy.

CAR T-cell therapy is basically taking out the patient’s own T cells, sending them to the lab and making them into “killer” T cells. After reintroducing them into the patient, those T cells then proliferate and expand in the body and attack the lymphoma cells. CAR T-cell therapy has really been a major advance and now has moved into the second line setting so that we have an option of using CAR T-cell therapy or salvage chemotherapy, plus transplant for patients. With these approaches, we can cure approximately 30% to 40% more patients.

Patients who progress after autologous transplant or CAR T-cell therapy or who are ineligible for these therapies have a poor prognosis. Recent data show that these patients have an overall survival of approximately 6 months. For that reason, we need additional agents to [address] this unmet need for patients in this situation, unfortunately.

There are a number of new agents that are available and that are beneficial for this patient population. One of those is called loncastuximab tesirine. Some of the primary adverse effects are myelosuppression and the possibility of effusions and elevated gamma-glutamyl transferase. Patients generally [require] steroids the day before treatment, the day of treatment, and the day after treatment. It is administered as an IV [intravenous] infusion.

Another option that we have in this in this setting is tafasitamab-cxix [Monjuvi] and lenalidomide [Revlimid]. This combination has also shown benefit for patients in the third line setting. It is generally well tolerated. Some of the major adverse effects that we see are myelosuppression, rash, and infusion reactions.

The third option in this setting is rituximab, bendamustine [Bendeka], and polatuzumab vedotin [Polivy]. This combination uses rituximab and bendamustine, which is a regimen that we commonly use in lymphoma, in combination with a newer monoclonal antibody-drug conjugate called polatuzumab [which] is a monoclonal antibody directed against CD79, and it is linked to a cytotoxic [payload]. This also increases cytotoxicity.

With this combination, again, a [common] adverse effect would be myelosuppression. You can also see some peripheral neuropathy with polatuzumab and with bendamustine, you do see profound lymphocyte dysfunction—so patients need antibiotic prophylaxis against PJP [pneumocystis jiroveci pneumonia] and also antiviral prophylaxis to prevent herpes simplex virus or varicella-zoster virus.

What is the role of clinical trials in increasing treatment options for patients with hematologic malignancies?

Over the last decade, the rapidity of advances has increased dramatically. And it’s been so exciting to see so many novel therapies [become] available to treat patients and really improve outcomes and improve quality of life.

None of those advances would have been possible without clinical trials. I would encourage every nurse out there to be aware of the available clinical trials and to be educated about clinical trials so that if patients have questions, we can serve as a resource to help encourage them to enroll in clinical trials. I think that’s always a really good treatment option for patients and I think it’s important that patients have access to be able to participate in clinical trials.

Laura J. Zitella, MS, RN, ACNP-BC, AOCN, recounts key nursing considerations with targeted therapy for chronic lymphocytic leukemia, and third-line diffuse large b-cell lymphoma options.  

Zitella Weighs In On Overarching Treatment Strategies in Hematologic Malignancies

Starting the conversation is a simple, yet important, step to draw attention to DEI—diversity, equity, and inclusion—in oncology nurse leadership, according to Aliènne Salleroli, MS, BSN, RN, OCN.

Salleroli, an assistant patient services manager at Yale-New Haven Health Smilow Cancer Hospital, and cochair of the Yale New Haven Hospital Diversity, Equity, and Inclusion Nursing Task Force, recently spoke on the topic of how racial diversity within oncology leadership is linked with positive outcomes at the 47th Annual Oncology Nursing Society Congress.

®, Salleroli explains that although opening dialogue can be uncomfortable, it yields important results.

“Leadership needs to understand that this is going to be an uncomfortable conversation and part of leadership is becoming comfortable with the uncomfortable,” she said. “But having these conversations [is] actually what bridge[s] that gap. Discussing things like micro-aggressions, implicit biases, language being used… that’s what brings [individuals] together.”

Open dialogue is key to establishing unity across an organization, Salleroli said, adding that these conversations can also inspire local change. For example, once leadership starts the conversation, heads of other teams can bring that information down to their home departments and perpetuate a domino effect.

“We need to walk before we can run,” she concluded.

Aliènne Salleroli, MS, BSN, RN, OCN, underscores the importance of open dialogue surrounding diversity, equity, and inclusion in oncology leadership. 

Aliènne Salleroli on Starting the DEI Conversation in Oncology Nursing

The risk factors associated with venetoclax (Venclexta) differ for patients with acute myeloid leukemia (AML) compared with other hematologic malignancies, such as chronic lymphocytic leukemia and multiple myeloma, explains Ilene Galinsky, BSN, MSN, ANP-C.

Galinsky, who is the senior leukemia protocol research nurse practitioner, at Dana-Farber Cancer Institute, presented on the efficacy and practical treatment considerations with BCL2 inhibitors at the 47th Annual Oncology Nursing Society Congress. In an interview with 

 she highlights optimal dosing strategies with venetoclax.

Important factors to consider include a patient’s disease burden and concomitant medications, Galinsky said. Venetoclax should not be initiated if a patient has a high white blood count and hydroxyurea should be used to achieve counts below 25,000 cells/μL. Further, tumor lysis syndrome, though rare, has been observed with venetoclax, and providers should closely monitor patients’ hydration levels during ramp up to reduce that risk of occurrence.

CYP3A4 inhibitors can also affect the pharmacokinetics of venetoclax, she said. If a patient is receiving one of those drugs, dose modifications may be necessary to get the patient to their target venetoclax dose.

Another important consideration is the likelihood of myelosuppression, she added. A mid-cycle bone marrow biopsy is recommended between days 21 to 28 to dictate if–and when–the second 28-day cycle can begin.

If a patient is not in remission after 1 cycle, treatment should be continued despite low blood counts, and a second barrow biopsy should be repeated, she said. If a patient is in remission, and has neutropenia, providers should wait until the patient has recovered to grade 1 or 2 neutropenia before initiating a second dose. If, following a second dose, neutropenia is persisting, providers should hold the dose and, upon resuming, prescribe a 21-day cycle instead of a 28-day cycle.

Ilene Galinsky, BSN, MSN, ANP-C, senior leukemia protocol research nurse practitioner at Dana-Farber Cancer Institute, underscores key prescribing considerations with venetoclax. 

ONS Annual Congress