The use of oral oncolytic agents is on the rise, and these medications now account for a large percentage of all prescribed cancer treatments. Although oral agents offer a convenient alternative to traditional intravenous (IV) chemotherapy, they present new and unique challenges to caregivers (Marshall V, Vachon E, Given B, unpublished data, 2017).

Family caregivers perceive oral agents differently from how they view IV chemotherapy (Marshall V, Vachon E, Given B, unpublished data, 2017). They appreciate the convenience oral agents offer, such as cutting back on travel to oncology clinics for treatment and enabling patients to administer the drugs themselves.

 However, caregivers face a significant and greater responsibility to make sure that patients are self-administering oral agents as prescribed.2 When caregivers need to assist with administration, they are confronted with safe handling of toxic medication.

Managing symptoms and adverse effects without the close supervision of oncology professionals can weigh heavily on caregivers who feel unprepared to offer this assistance.

 Oncology professionals must ensure that caregivers receive appropriate and trusted oncology resources regarding how to identify and manage symptoms and adverse effects at home and when to contact oncology personnel.

The challenges of managing complex oral agent regimens include dosage changes, interruptions, and stoppages (Marshall V, Vachon E, Given B, unpublished data, 2017).

 Caregivers may not be aware of the potential need for changes to the original regimen during the treatment trajectory.

 Every effort should be made to discuss the complexity of oral agent treatment regimens with caregivers and reasons the dose may be decreased, increased, interrupted, or stopped.

Caregivers of those receiving oral agents also must deal with the cost.

 Financial assistance may be available, but its duration may be unknown and cause the stress of financial burden.

 Some oral agents may not be covered under insurance plans, and the patient’s state of residency may not have parity laws, which require that the oral agent be covered under the same medical benefit as IV chemotherapy, instead of the pharmaceutical benefits, which makes the medication more affordable.

 Caregivers should be referred to assistance programs, as well as social workers specializing in oncology care, to reduce the stress of financial burden.

In addition, caregivers may encounter pharmacy-related issues, because several oral agents are dispensed by specialty pharmacies. Before shipping the medication, a specialty pharmacy must verify the patient’s insurance coverage and eligibility of drug formulary criteria.

 That process could create a lag between the time the oral agent was prescribed and when it is delivered, delaying initiation or disrupting continuity of treatment. Shipping expensive oral agents also requires a signature upon delivery, which necessitates coordination of availability among caregivers.

Oncology nurses are positioned to address the numerous challenges and concerns to reduce the negative impact on caregivers.

 Evaluating and addressing caregivers’ educational needs surrounding oral agents, as well as offering referrals to trusted oncology resources and professional services for funding of oral agents, can help ease the burdens and enhance effective caregiving.

is a PhD nursing student and graduate research assistant at the Michigan State University College of Nursing. She is also an American Nurses Foundation Scholar.

1. Given BA, Spoelstra SL, Grant M. The challenges of oral agents as antineoplastic treatments. 

. 2011;27(2):93-103. doi: 10.1016/j.soncn.2011.02.003.

2. Marshall V, Vachon E, Given B, Lehto, R. (2017). 

The Impact of Oral Cancer Medication from a Family Caregiver's Perspective

. In Press. Paper presented at: International Conference on Oncology Nursing; July 10, 2017; Anaheim, CA.

3. Kircher SM, Meeker CR, Nimeiri H, et al. The parity paradigm: Can legislation help reduce the cost burden of oral anticancer medications? 

. 2016;19(1):88-98. doi: 10.1016/j.jval.2015.10.005.

4. Wang L, Tao T, Hamilton N. Turning tides: trends in oncology market access. InVentivHealth website. 

http://consulting.inventivhealth.com/article. s/Campbell%20Alliance%20-%20Turning%20Tides%20-%20August%202012.pdf

Articles

Partner Perspectives

The use of oral oncolytic agents is on the rise, and these medications now account for a large percentage of all prescribed cancer treatments. Although oral agents offer a convenient alternative to traditional intravenous (IV) chemotherapy, they present new and unique challenges to caregivers.

Oral Oncolytic Agents: New Caregiver Challenges

Social media has become a way of life. Posts, tweets, videos—these are ways in which many people now communicate with one another. I especially know how ingrained it is in our lives, as I have a teenage son who can barely live without his smartphone during mealtime.

Social media refers to any Web-based or mobile technology such as Facebook, YouTube, Instagram, Vimeo, LinkedIn, Twitter, and CaringBridge.

As we explore common boundary crossings, we delve into the blurred world of social media. In the past issue, we defined a professional boundary crossing as a “brief excursion across professional lines of behavior.” Boundary crossings can not only damage relationships but also lead to negative outcomes.

It’s only natural that patients or caregivers will reach out to their oncology nurses through social media. And this is where oncology nurses can unintentionally blur the lines between professional and personal lives.

Think about the effects of being friends with patients or their caregivers on Facebook. You have access to all personal and family information, which creates more of a personal relationship than a professional, therapeutic one. For many reasons, you would never be the nurse assigned to care for a family member. It’s too easy to lose your objectivity. When you move toward a personal relationship or friendship with your patients or their caregivers, the same issues of objectivity arise.

Use of social media can easily violate patient confidentiality. The National Council of State Boards of Nursing (NCSBN) social media guidelines state that “it is imperative not to mention patients by name or provide any information or details that could possibly identify them in order to protect patients’ right to privacy.” Nurses have a legal and ethical responsibility to maintain patient privacy and confidentiality.

Disclosure is often unintentional. Your posts are not private. Someone can simply take a screenshot of the information and send it on or upload it to the Internet. Posts never truly disappear. Even if a post is deleted, it lives somewhere on a server that can be discovered in a court of law.

To protect your nursing license, consider the downstream legal effects.

Examine how this content might be viewed by others in the following posts:

WHAT IF…a patient posts that she had a great weekend with family visiting but is now feeling really tired. Is the fatigue from overactivity or related to anemia or even a sign of recurrence? Are you legally obligated to report if you see something about her health that is concerning? What if it’s a behavior that could pose a health risk? For instance, she posts a picture of herself drinking wine when you know she is on medication that should not be taken with alcohol.

The challenge with this scenario is to know your legal and ethical responsibilities. Now that you have this piece of information, what do you do with it?

WHAT IF…your former stem cell transplant patient, who almost didn’t live, comes back to your inpatient unit to celebrate his transplant anniversary with his nurses. You take a picture of him with your colleagues and post it with the caption “This is why I became a nurse.”

This scenario could result in a HIPAA violation and disciplinary action by the Board of Nursing as well as your employer. Most organizations have guidelines about taking photos of any person who works in their facility or who received any services.

A written formal consent for photos is usually required, and it needs to be obtained from everyone in the photo. So another patient in the background of the photo or a pictured arm with a tattoo that could be even remotely linked to another patient could create a messy legal situation.

WHAT IF…you’re simply sharing about your day with a colleague. You mention in your post that you went to the coffee shop and bought coffee for two of your patients. No names mentioned, no photos, no negative comments…No violation, right? What’s the problem? Although your gesture was one of kindness for your patients, using your personal money to buy items for a patient can cause feelings of unequal care and unrealistic expectations for your colleagues.

Can you do this for all your patients? Does this post have the potential to impair your work relationships?

So how do you avoid potential boundary crossings on social media? Below are 2 action steps:

1. Politely decline friend requests. If a patient or caregiver finds you on Facebook and sends you a friend request (even if the patient has returned to the care of the referring provider), politely decline the request. Tell them that your institution has strict policies regarding social media, so you have to respectfully decline their request. Most do. If not, the NCSBN and the American Nurses Association (ANA) do.

2. Unfriend current patients/caregivers. If you are already using social media to communicate with patients and caregivers and the site is not work related, consider letting them know that you will be unfriending them. Tell them that you realize there could be a perception of a conflict or a blur between your personal and professional lives.

Importantly, find out whether there is a policy on social media where you work and then review it. If there isn’t, consider being on the team to help develop one. Read the NCSBN and ANA guides to social media and know what your particular state advises. Not only do these guidelines apply to your current role, but they can also affect your reputation for any potential future employment or educational institution admission.

Feature Story

Use of social media can easily violate patient confidentiality.

What to Do When Social Media Lines Are Blurred

Prior to accessing an implanted port or administering a patient’s first dose of chemotherapy, every oncology nurse should consult a trusted evidence-based resource to ensure that an intervention or skill is being carried out according to the standard of care. However, after a nurse spends a certain amount of time on the job, the pieces start to click into place, repeatedly performed tasks become old hat, and that quick resource review might fall by the wayside.

Now, think back to when you were a new nurse or just beginning your career in oncology nursing. Everything was overwhelming, and you spent each shift trying to learn the routine of a busy inpatient unit, infusion center, or clinic. Hopefully, you had a preceptor who taught you to slow down long enough to review resources before rushing into an unfamiliar task. However, many new nurses report that a skill is often taught by demonstration alone, with little or no consultation of a current evidence-based resource.

This situation and countless others are a reality in oncology practice settings where new RNs are making the transition into practice. How can we seasoned oncology nurses shift the paradigm of the way we mentor new nurses? From encouraging evidence-based practice to promoting self-care, there are a multitude of ways to support the newest generation of oncology nurses.

Realistically, oncology practice settings don’t allow a lot of time for formal on-the-job education. But that doesn’t mean learning can’t happen in other ways.

If you consult a reference text or electronic resource before administering a new medication, a new nurse will follow your example and adopt the same practice.

New nurses will observe how you interact with oncologists and ancillary healthcare providers—how positive or negative&mdash; and that can influence the way they develop their own communication skills.

Your low-acuity patient assignment lends the perfect opportunity to demonstrate effective teamwork and collaboration by offering to help a colleague who has a busy, high-acuity patient assignment. The new oncology nurse will know he or she can count on your support and will reciprocate during your high-stress shifts.

It’s difficult to recognize our own burnout signals (compassion fatigue, insomnia, anxiety, depression, anger, etc), but it’s in our nature as oncology nurses to pick up on distress signals from our patients. Why not extend that radar to include the new nurses in your practice? Information overload, adjusting to shift work, and the transition from student to nurse can quickly take a toll on novice RNs.

While you may not have developed a close relationship with the new nurse(s) yet, reaching out to provide encouragement and support will help them feel included and valued as part of the team. Whether it means a cup of coffee, a quick hug, or a lunchtime chat, go the extra mile to show that you remember what it was like to be in their shoes.

As nurses, we recognize that our profession calls us to be lifelong learners. There’s always new information to learn about the latest treatments and standards, but basic knowledge from childhood can sometimes make the biggest impact when it comes to mentoring new nurses. It’s time to dust off the adage from your preschool and kindergarten days: Treat others as you would like to be treated.

It can take several months to a year before a novice oncology nurse feels confident in his or her ability to practice independently. That time of transition and learning is decidedly uncomfortable and isn’t made any easier by the incivility of experienced nurses.

Before you heave an exaggerated sigh at a frenzied request for help from a new nurse or roll your eyes when asked a seemingly simple question, think back to when you were a novice. Recall your memories of those nurses who patiently mentored you until you could stand on your own.

Now, take a deep breath…and pass them on.

Melissa Grier, MSN, APRN, ACNS-BC Melissa Grier is a clinical nurse specialist at Via Christi Health in Wichita, Kansas, where she supports the Via Christi Cancer Institute, as well as the medical/surgical cardiac, resource pool, emergency department, and oncology service line.

Fast Facts for the Frontline

Seasoned nurses know the ins and outs of the job, therefore they can be the best resource for those who are just beginning their career.

Be a Mentor for New Oncology Nurses

Advances in oral chemotherapies provide patients with more convenient treatment options, but these improvements also create challenges for clinicians, particularly in medication adherence.

Current data reveal nonadherence rates as high as 46%, a definite cause for concern and an urgent call to action. The problem is multifaceted, manifested by a variety of factors, including individual patient characteristics, disease type, treatment specifics, and provider and system components. Although some of these elements exist beyond the scope of influence, improvement in adherence is nonetheless attainable through application of a process-based approach consisting of strategic interdisciplinary planning, collaborative implementation, and dedicated follow-through.

The approval and availability of oral chemotherapy agents over the past 20 years has changed how cancer treatment is delivered, providing many patients the convenience of at-home administration while reducing the frequency of clinic visits for intravenous therapy. What hasn’t changed: the need for accurate monitoring, ongoing communication, education, evaluation, and reassessment of patient response to ensure best outcomes.

®, Jody Pelusi, PhD, FNP, AOCNP, the first nonphysician member of the FDA's Oncologic Drugs Advisory Committee and a highly regarded expert in oral adherence, recalls her concerns about the way patients would be educated, monitored, and managed when capecitabine first received approval for use in 1998. She realized the importance of having a process for community practices and the institutional management of patients taking oral agents and, in response, developed a 13-step drug management program. Her process remains as relevant now as it was then.

A process, defined as a series of actions and steps taken to achieve a particular end, to improve adherence begins by evaluating current flow patterns to determine if:

• The practice environment ensures staff competency, satisfaction, and support

• The emotional, physical, educational, safety, and financial needs of patients and caregivers are met

• The intent of guidelines and recommendations is achieved

• Outcomes are consistently documented and easily evaluated

In addition, providers and care team members should revisit their commitment to patients, including their responsibility to reduce or eliminate misinformation, misunderstanding, and other aspects of disconnect that might, and do, occur.

With flow patterns identified and commitment to patients and communication renewed, the work of pulling together a comprehensive and proven process can begin.

Oral adherence toolkits provide easyto- use information directed at patient assessment and education, ordering standards and pharmacy concerns, reimbursement and assistance programs, and other factors affecting adherence. However, it is process that provides the mechanism for putting these tools to good work. “If we have all our steps in place—if we stick to the process&mdash;then people don’t get left out,” says Pelusi, who works at Honor Health Research Institute in Scottsdale, Arizona.

Process allows clinicians to use adherence tools properly and consistently when aligned to each practice’s unique services and needs, beginning with the fulcrum of quality patient care: staff education.

For education to be most effective, it must be complete, inclusive, and consistent. Patients are best served when all staff members understand the process for managing oral chemotherapy adherence and when education is ongoing, evaluated, and part of required competency training. “Educating the entire staff on oral drugs that are utilized becomes very important, so anyone who picks up the phone knows what to ask and when to ask, and what to look for,” says Pelusi. “All of those things are part of the process.”

Pelusi’s process-based approach also includes evaluating patient candidacy for oral therapy from a variety of perspectives, including complexity of care, personal and medical history, and other factors that may influence adherence success, as well as the pros and cons of specific treatment options. Patient selection lends itself to following steps, each of which builds upon the former, further propelling the process:

• Pretreatment evaluation • Medication authorization and acquisition

• Development and dissemination of the treatment plan (including its goal) With the treatment plan in progress, the process for monitoring and follow-up begins.

Providers and care team members must determine how to monitor and how often, as well as the most appropriate follow-up strategies to employ. Adherence tools aid in determining the what, why, and how of decision making.

Patient and caregiver education is a main component as the process advances and presents many challenges for all member of the health-care team. Working out the details and taking care to identify which information the patient must know, should know, and like to know helps clinicians prioritize and plan education.

“Adherence is more than just taking the pill,” Pelusi says. “It’s taking it the right way.” Patients need to understand why and how a drug is taken. To prevent incompatibilities with other prescriptions, primary physicians need to know what other drugs patients are taking, such as antibiotics, heart medications, or diabetes management agents. Tying together all the pieces of the patient care management includes developing processes for accurate and complete documentation, communication, and evaluation, all of which should be done consistently and with care.

Lastly, it is important to create and maintain policies, procedures, and variance reporting mechanisms geared toward medication adherence, including management approval and buy-in to ensure adequate support and continuance.

Achieving optimal patient outcomes depends on adherence. “It’s the clinician’s responsibility to make sure patients understand how taking their medications as ordered will help them reach their goal, whether it be for cure, to slow tumor progression, prevention, or palliation,” Pelusi says.

Forming partnerships with patients and seeking ways to help them manage their oral therapy are crucial for treatment to work as intended.

Pelusi recognizes the nurse as pivotal in the patient partnership. “Oral therapy is not going away. This is our future,” she says. “Nurses need to embrace this. This is nursing. You have to assess the patient. You have to educate the patient. You have to monitor the patient.”

“Everything the nurse does is basically what we need for oral adherence,” Pelusi continues. “Don’t give away the nursing component, because that is what is going to get the patient adherent. It’s the nurse who has the ability and the knowledge to manage symptoms so patients can stay on the drug. Don’t give that away.”

As more oral chemotherapy agents are developed and approved, physicians, nurses, pharmacists, and other members of cancer care teams must have a system in place that promotes the same high level of management for patients receiving oral treatment at home as those receiving intravenous therapy in clinic.

Pelusi strongly feels that the key to meeting patient and provider goals for treatment is having a workable process in place that weaves all the components of care together: “Believe it or not, once you have the process, oral therapy can run like clockwork.”

Cover Story

A process-based approach pulls together the components of care, ensuring a smoother journey for patients.

Improving Adherence to Oral Therapies

Strong interdisciplinary relationships between healthcare providers, specifically pharmacy and nursing, can play a crucial role in patient success with oral chemotherapy regimens.

Combining the vast knowledge of the pharmacist with nurse-led comprehensive patient education can ultimately lead to best effective practice.

“Healthcare professionals need to be aware that patients tend to think of oral chemotherapy as ‘safer’ and common nonlife threatening side effects as an inconvenience,” says Jerry Wu, PharmD. “These factors lead to missed doses, self-initiated dose reductions, or discontinuation. Patients need to be educated to take as directed to maximize the therapeutic benefits and encouraged to report any adverse events, no matter how minor.”

Discussion of safe handling practices is imperative to prevent unwanted adverse effects and exposure to caregivers and family members. This time should also be used to dispel any incorrect misconceptions surrounding the safety of the medication.

• If possible, pregnant caregivers should not handle medication to decrease potential exposure.

• Caregivers should be sure to wash their hands thoroughly pre-and post-administration, ideally wearing gloves.

• Medication should be provided to the patient in a plastic cup or syringe, and never crushed or broken, as this can aerosolize the drug.

• Ensuring patients are able to swallow medication in pill form prior to the initial dose can prevent incorrect dosing related to chewing medication.

In addition, it is vital that patients and caregivers know how to store medication appropriately. Oral chemotherapy should be stored in places avoiding heat and sources of light, as well as kept out of reach from children and pets. It should be kept in prepackaging, if possible, and never mixed in pill boxes with other medications.

Jaclyn Aremka, PharmD Candidate 2018 at Drake University adds, “Storage of medication is important to make certain the patient is getting the full benefit of the medication by protecting it from degradation. Medication can degrade in a variety of different ways, but one of the most common form is moisture.”

“Most patients tend to store their medications in the ‘medicine cabinet’ located in the bathroom. Bathrooms cause moisture to accumulate not only on the mirrors, but also on medications,” she says.

Disposal instructions may vary with differing medications, however standard practice includes never flushing medication down the toilet or placing in a regular garbage bin.

Patients should be advised/provided with disposal regulations specific to their state of residence, as pharmaceutical waste practices can differ. Encourage patients to ask their pharmacy if any prescription take back programs are offered, where the issue of proper disposal is handled for them. Examining lifestyle factors and anticipating patient issues surrounding adherence to long-term oral therapies can be much more comprehensive when using the combined knowledge of pharmacy and nursing. Together, these two departments can foresee and tackle many preventable issues related to noncompliance and dosing discrepancies, providing thorough patient and family education.

The Importance of Interdisciplinary Relationships and Oral Adherence

Nintedanib, an angiogenesis inhibitor, is being investigated as a first-line treatment for patients with unresectable malignant pleural mesothelioma (MPM). Although it is estimated that malignant mesothelioma represents less than 1% of all cancers, it is a fatal asbestos-associated malignancy, and patients with MPM tend to be difficult to treat.

The drug, which targets multiple receptors including vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF), and platelet-derived growth factor (PDGF), is being administered in combination with pemetrexed and cisplatin in the phase III, multicenter, international LUME-Meso clinical trial (NCT01907100).

“The current median survival of epithelioid MPM is about 15 months for most patients. Other trials have shown an improvement in overall survival, perhaps partially due to improved supportive care and secondary therapy,” said Nicholas J. Vogelzang, MD, a medical oncologist at the Comprehensive Cancer Centers of Nevada in Las Vegas, the medical director for the Genitourinary Research Committee through US Oncology Research, and the vice chair of SWOG, a clinical trials network.

Vogelzang, who is the primary investigator for LUME-Meso in the United States, noted that there are no secondary therapies approved by regulatory agencies to treat patients with epithelioid MPM. Currently, the only approved treatment regimen is combined pemetrexed and cisplatin. However, the prior MAPS study showed that the addition of bevacizumab (Avastin), an anti-VEGF monoclonal antibody, improved survival in patients with MPM,2 which prompted investigators to look into other combination treatments with VEGF inhibitors.

Participants in the trial will be randomized in a 1:1 ratio to receive either oral nintedanib twice daily at 200 mg per dose combined with intravenous pemetrexed and cisplatin, or pemetrexed and cisplatin with a placebo, followed by maintenance therapy. Notably, patients will also receive vitamin supplements, including daily oral folic acid and vitamin B12 given every 8 to 9 weeks.

The LUME-Meso trial is currently enrolling patients who have epithelioid subtype MPM; patients with biphasic or sarcomatoid subtype will be excluded.

The FDA has approved nintedanib under the trade name Ofev for the treatment of idiopathic pulmonary fibrosis. As a small-molecule drug, nintedanib binds competitively to the adenosine triphosphate binding pocket of the VEGF and PDGF receptors, blocking intracellular signaling needed for the proliferation, migration, and transformation of fibroblasts that are essential to the growth of MPM. It also inhibits the Lck, Lyn, and Src nonreceptor tyrosine kinases. Data from the phase II LUME-Meso trial demonstrated improved progression- free survival (PFS) with nintedanib therapy in patients with MPM. For the overall population, the median PFS was 9.4 months with the nintedanib combination versus 5.7 months with pemetrexed and cisplatin alone (HR, 0.54; 95% CI, 0.33-0.87; P = .010). The median overall survival (OS) was 18.3 months with nintedanib versus 14.2 months with chemotherapy alone. However, this finding was not statistically significant (HR, 0.77; 95% CI, 0.46-1.29; P = .319).4 The objective response rate was 57% with nintedanib and 44% with chemotherapy (odds ratio, 1.66; 95% CI, 0.72-3.92).

A greater benefit was observed in patients with epithelioid histology, the target population of the phase III study. Among these patients, the median OS was 20.6 months with nintedanib versus 15.2 months with chemotherapy (HR, 0.70; 95% CI, 0.40-1.21; P = .197). The median PFS was 9.7 months with nintedanib versus 5.7 months with chemotherapy (HR, 0.49; 95% CI, 0.30-0.82; P = .006).

In terms of adverse events (AEs), nintedanib has a profile similar to that of other VEGF inhibitors. In the phase II study, the most common grade ≥3 AEs were neutropenia, increased gamma-glutamyl transferase, increased alanine aminotransferase, and electrolyte imbalance. Febrile neutropenia was experienced by 2.3% of patients in the nintedanib arm versus none of those in the placebo group.

There are also some risks of bleeding, gastrointestinal toxicities such as diarrhea and bowel perforation, and thrombosis. However, these AEs are familiar to those who have used other VEGF inhibitors.

Clinical Trials in Progress

Although it is estimated that malignant mesothelioma represents less than 1% of all cancers, it is a fatal asbestos-associated malignancy, and patients with MPM tend to be difficult to treat.

Angiogenesis Inhibitor Tested in Mesothelioma Trial

Perhaps one of the most nerve-racking moments in an oncology nurse’s career is when a vesicant extravasation is suspected. These leakages can occur despite a nurse’s best efforts. For instance, intravenous (IV) devices can malfunction or break, patients can move and dislodge them, and device securement methods can fail. Extravasations also can occur when nurses deviate from the standard of care and institutional policies, such as when a vesicant is administered and there is no blood return or other evidence of correct IV device placement and patency.

Fortunately, vesicant extravasations are rare events. How rare? Much of what we know about their incidence comes from single-institution studies conducted decades ago. In the years since that research was published, oncology nursing practice has evolved, IV devices have improved (eg, rigid “butterfly” steel needles are no longer used for chemotherapy administration), and much more has been learned about vesicants and their potential to destroy tissue. There is no national data depository for vesicant extravasations, however, so how often they occur in day-to-day clinical practice remains unknown.

When members from National Cancer Institute (NCI)-desig nated cancer centers created a nursing consortium in 2011, they chose to evaluate vesicant chemotherapy extravasation incidence at 11 of the centers as their first project. Incidence was defined as the number of extravasation events (numerator) over the number of drug infusions given for each chemotherapy agent (denominator). The group collected and analyzed data on 10 vesicants, as well as 14 agents classified as irritants or irritants with vesicant potential. A total of 739,812 doses of vesicant and irritant chemotherapy infusions were administered to adult patients and included in the evaluation. The incidence of extravasation events was 0.07% for vesicant chemotherapy and 0.09% for the irritant chemotherapy. A total of 673 events occurred during the 4-year data collection period. Extravasations from peripheral IVs accounted for 87.7% of the total vesicant extravasations and 96.7% of the total irritant infiltrations. The project confirmed that extravasations are indeed rare occurrences.

The consortium focused on vesicant extravasation incidence and appropriately included suspected cases—when in doubt, these should be managed in accordance with guidelines. There is little to no harm in treating a suspected extravasation, but, in contrast, patients can be harmed when vesicant extravasations, especially DNA-binding anthracycline extravasations, go untreated.

While more is now known about the incidence of infiltration of irritant chemotherapy and irritants with vesicant potential, the outcome of these events remains unclear. The term “irritants with vesicant potential,” which is used by the manufacturers of these agents, can be confusing to clinicians administering these agents. While it is suspected that these irritants have the potential to cause tissue destruction, many questions remain. At what volume and concentration do these agents cause necrosis when infiltrated? Does the severity of injury also depend on placement of the IV device?

Do immediate interventions, such as applying heat or topical cooling, mitigate tissue damage when “irritants with vesicant potential” extravasate?

The consortium reviewed factors causing or contributing to the 673 events. Patient movement, including ambulating to the restroom, was associated with dislodgment of peripheral IVs. Longer durations and larger volumes of peripherally administered chemotherapy also were associated with extravasations and infiltrations. This, too, confirms what nurses in clinical practice have observed. Peripheral IVs should be assessed when patients return to infusion chairs after ambulating. Patients also need to be instructed to report any unusual pulling or tugging on IV tubing, as well as signs and symptoms of irritant chemotherapy irritation and vesicant chemotherapy extravasation.

The consortium collected data at NCI-designated cancer centers. It could be asserted that their extravasation incidence should be very low because they are exclusively cancer centers, where all nurses are specially trained and routinely administer chemotherapy. However, the data confirm what many of us in clinical practice have observed: Vesicant extravasations are rare events.

Another way to look at the data is to calculate how many doses of vesicants, irritants, and irritants with vesicant potential were safely and successfully administered, and it’s 99.9%. If you work in a facility that tracks vesicant extravasation incidence, I encourage you to also collect and provide the data on the number of doses safely and successfully administered. This number validates the important work of oncology nurses in safely administering chemotherapy.

Jackson-Rose J, Del Monte J, Groman A, et al. Chemotherapy extravasation: establishing a national benchmark for incidence among cancer centers. Clin J Oncol Nurs. 2017;21(4):438-445. doi: 10.1188/17. CJON.438-445.

Nurse's Notes

Incidence evaluated at 11 National Cancer Institute–designated cancer centers reveals more about occurrence in day-to-day clinical practice.

How Often Do Vesicant Extravasations Occur?

Discoveries are made every day in the treatment of cancer. Fortunately, many are now in the form of oral drugs, which offer convenience to patients, who can take them from the comfort of their home instead of having to travel to a cancer center. But that easy accessibility comes with a cost: nonadherence.

Most recent data find nonadherence rates as high as 46%. Whether it be the price of a treatment, forgetfulness, or fear over potential adverse events, there are a number of reasons why patients may skip their medications.

In our cover story this month, Ellen Rice Tichich, MFA, MSN, RN-BC, discusses how to improve oral adherence—starting with nurses. She presents the basics of a process-based approach and speaks with Jody Pelusi, PhD, FNP, AOCNP, who has become a highly regarded expert in oral adherence.

Pelusi recognized the need for patient education, monitoring, and management when the first oral therapy was approved nearly 20 years ago. She created a 13-step drug management program— something that is just as important today. In this issue of Oncology Nursing News®, we examine the barriers to clinical trials. These are often faced by minorities and elderly patients and can give an inaccurate depiction of whether treatments, devices, or drugs affect some groups differently from how others do. Our feature shares how nurses can help the industry overcome this lack of diversity.

We also feature some everyday practical information on 2 gray areas: mentoring new oncology nurses and friending a patient on social media.

It may be difficult to think back to your first day on the job, but if you can picture it, think about what it was like. Perhaps overwhelming, chaotic, stressful, or even scary. However, leading by example and offering friendly advice to newcomers can give them the reassurance that is needed to fill such an important role.

Social media, like Facebook, Twitter, and Instagram, has become the norm in society. But is it ever OK to accept a friend request from a patient or to send one? Our second Professionally Speaking column addresses the blurred lines and advises fellow nurses on how to avoid any boundary crossings between professional and personal lives.

Also inside: the truth about how often vesicant extravasations occur, the potential risks of extended use of aromatase inhibitors, and the latest from the European Society for Medical Oncology 2017 Congress. We hope you find these articles informative, and as always, thank you for reading.

From the Chairman