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NU03.04 Supportive Care in Patients Receiving Systemic Therapy
January 2017
Management System is one of the most evolved remote patient monitoring systems in cancer care. This presentation will initially focus on remote patient monitoring within the context of lung cancer before considering the implications for the future and the ultimate vision of connected health for all. Keywords: Technology, connected health, lung cancer, supportive care
NU03.04 Supportive Care in Patients Receiving Systemic Therapy Tanja Cufer Medical Oncology Unit, University Clinic Golnik, Golnik/Slovenia Introduction Systemic therapy (ST) with chemotherapy (Cht), targeted agents or immunotherapy (IT) represents the mainstay therapy for patients with advanced lung cancer; while adjuvant systemic therapy is recommended in a majority of patients with operable and locally advanced disease. The goal of ST is to prolong life without compromising quality of life (QoL). Despite the ability of ST to prolong life or even cure patients, QoL and life span might be compromised due treatment toxicity. In addition, uncontrolled adverse events (AEs) might lead to treatment interruption or discontinuation. Therefore, effective management of adverse events of anti-cancer drugs, the so-called “supportive care to systemic therapy” is extremely important for a true benefit, i.e. treatment effectiveness in a routine practice. During the last decade several improvements in prevention, treatment and amelioration of ST AEs been achieved. To implement them in everyday clinic practice a good understanding of adverse events, supportive care measures and professional skills of all team members are needed. Registered nurses, specialized in the oncology, the so called “oncology nurses” are key providers of supportive care in everyday clinical practice. Supportive care for prevention and treatment of adverse events Chemotherapy-induced nausea and vomiting (CINV) has been a priority in the supportive care of cancer patients ever since the first use of Cht.1 The introduction of 5-HT3 and NK1 antagonists into anti-emetic therapy resulted in much better control of CINV in lung cancer patients receiving highly emetogenic, platinum-based therapy. With proper use of available drugs complete control of vomiting could be achieved in up to 90% of these patients. However, despite the efficacy of new anti-emetic therapies a proper us of anti-emetics and other preventive measures are vital. Chemotherapy-induced neutropenia with febrile neutropenia (FN) as its ultimate and most serious complication are often observed in
Abstracts
S203
patients receiving Cht. The risk of FN can be predicted by assessing patient characteristics and mylotoxicity of the Cht regimen; and granulocyte-colony-stimulating factors (G-CSF) can be used to prevent it.2 Even thought, most of the regimens for lung cancer do not classify to high, i.e. more than 20% risk of febrile neutropenia, the primary prophylaxis with G-CSF is often necessary due to high comorbidity index, poor PS or extensive disease often present in lung cancer patients. In case of FN, a riskbased approach provided by MASCC helps us to decide which patients need hospitalization and which can be treated by antimicrobial therapy at home.3 Oral mucositis and diarrhea related to mucosal damage are frequent complications of Cht as well as targeted therapy with TKIs that can significantly affect patient’s QoL and the ability to deliver full doses and complete therapy. Oral care protocols are essential components in prevention and treatment of stomatitis, while intensive local therapy protocols with antibiotics, anesthetics and/or corticosteroids help to ameliorative symptoms.4 Diarrhea is quite common in lung cancer patients receiving Cht with an even higher occurrence in patients treated with TKIs.5 It could be life threatening in elderly, fragile patients and in patients with concurrent neutropenia, thus requiring a rapid and effective control. When dietary strategy does not work, or when patients present with severe grade 3/4 diarrhea pharmacologic intervention with loperamide or even somatostatin analogues should be initiated quickly. Skin changes (rash, dry skin, paronychia) are the most frequent AEs associated with targeted therapy for lung cancer next to diarrhea. Even though, they are usually mild or moderate they hava negative impact on patient’s QoL and might lead to dose modifications or even discontinuation. Prophylactic measures with regular use of moisturizing products, sunshine protection and careful skin hygiene are necessary. In case of severe but still localized changes topical corticosteroids/antibiotics are indicated while a severe and prolonged toxicity usually requires TKIs dose interruptions.6 Fatigue is a common symptom reported in up to 80% of LC patients. In most cases it is impossible to distinguish to what extend it is the adverse event of ST and to what of disease. It is increasingly reported in patients receiving targeted therapy or immunotherapy, and major improvements in recognition and treatment of fatigue have been achieved recently.7 Immunotherapy with checkpoint inhibitors (CPIs) represents a novel approach. By breaking of immune self-tolerance it might lead to autoimmune/ inflammatory adverse events, designated as immunerelated adverse events (irAEs), mainly including rash, diarrhea, hepatitis and endocrinopathies.8 Although most of irAEs are of low grade, some of them progress rapidly and prompt medical attention with treatment
S204
interruption and the administration of glucocorticoids is critical. Implications for nursing Oncology nurses should have in-depth knowledge on adverse events of systemic therapy and must be familiar with the supportive care protocols. Nursing interventions for prevention and treatment of particular adverse events are presented in Table 1. Oncology nurses play a key role in continuous education of patients, their families and caregivers on adverse events. They are valuable members of the multidisciplinary team performing ongoing assessment of AEs and monitoring of patients and actively discussing potential solutions and improvements with other team members, thus providing a high-quality patient-centered care.
Journal of Thoracic Oncology
Vol. 12 No. 1S
we are seeing that progression free survival and in some instances overall survival continues to be on the rise. So what does this mean for the medical oncology community? Patients can be on therapies longer than a year and sometimes for several years. We now as providers face the challenge of becoming experts in the management of long-term toxicity of these agents. Side effects of the targeted and immunotherapy drugs are not as predictable as their chemotherapy predecessors, and we are now dealing onset times ranging from days to years after beginning therapy. Immunotherapy drugs are the newest treatment craze and rightfully so, as we have seen documented 12 month overall survival in both nonsquamous and squamous cell carcinoma for some of these agents and even up to 24 months for some patients. Although this has brought optimism to both providers and patients alike, it has also brought forth a multitude of side effects that remind us that we are still novices in this field and necessitate the collaboration with our non-oncologic colleagues as some of these side effects can be life-long. This lecture will review the mechanism of action of the immunotherapy agents as well as review those that are currently available for NSCLC with review of the data leading to their approval and the current and potential future challenges that lie ahead. Keywords: Chronicity, immunotherapy, lung cancer
NU04.02 Experience of Lung Cancer Patients Receiving Immunotherapy Rachel Thomas Palliative Care, Guy’s and St Thomas’ NHS Trust, London/United Kingdom Keywords: Systemic therapy, supportive care, Nursing implications
NU04.01 Management of Toxicities Associated with Immunotherapy in the Lung Cancer Patients Michelle Turner Radiation Oncology, Maryland Proton Treatment Center Affiliated with the Marlene & Stewart Greenebaum Cancer Center, Baltimore/MD/United States of America Chronicity is a word that over the past few years has been utilized when talking about lung cancer treatments. From the developments of the TKIs in the early 2000’s to the approval of immunotherapy for lung cancer in 2015,
With the emergence of immunotherapy in lung cancer, patients now have access to treatments that have the potential to improve prognosis. Patients diagnosed with advanced non-small cell lung cancer (NSCLC) (either squamous or non-squamous) have previously had limited treatment options. With the emergence of new drugs, particularly in the immune-oncology setting, this is now changing. Recent clinical trial evidence demonstrates that compared with docetaxel, patients who received Nivolumab or Pembrolizamab had better overall survival and also significantly fewer Grade 3-4 adverse events (AEs). However the nursing experience of caring for lung cancer patients on an immunotherapy remains quite limited. Up to recent times immunotherapy drugs were limited to the clinical trial setting or early patient access schemes. Often patients on clinical trials are managed and monitored by research nurses which can further limit the experience for Lung Cancer
Management System is one of the most evolved remote patient monitoring systems in cancer care. This presentation will initially focus on remote patient monitoring within the context of lung cancer before considering the implications for the future and the ultimate vision of connected health for all. Keywords: Technology, connected health, lung cancer, supportive care
NU03.04 Supportive Care in Patients Receiving Systemic Therapy Tanja Cufer Medical Oncology Unit, University Clinic Golnik, Golnik/Slovenia Introduction Systemic therapy (ST) with chemotherapy (Cht), targeted agents or immunotherapy (IT) represents the mainstay therapy for patients with advanced lung cancer; while adjuvant systemic therapy is recommended in a majority of patients with operable and locally advanced disease. The goal of ST is to prolong life without compromising quality of life (QoL). Despite the ability of ST to prolong life or even cure patients, QoL and life span might be compromised due treatment toxicity. In addition, uncontrolled adverse events (AEs) might lead to treatment interruption or discontinuation. Therefore, effective management of adverse events of anti-cancer drugs, the so-called “supportive care to systemic therapy” is extremely important for a true benefit, i.e. treatment effectiveness in a routine practice. During the last decade several improvements in prevention, treatment and amelioration of ST AEs been achieved. To implement them in everyday clinic practice a good understanding of adverse events, supportive care measures and professional skills of all team members are needed. Registered nurses, specialized in the oncology, the so called “oncology nurses” are key providers of supportive care in everyday clinical practice. Supportive care for prevention and treatment of adverse events Chemotherapy-induced nausea and vomiting (CINV) has been a priority in the supportive care of cancer patients ever since the first use of Cht.1 The introduction of 5-HT3 and NK1 antagonists into anti-emetic therapy resulted in much better control of CINV in lung cancer patients receiving highly emetogenic, platinum-based therapy. With proper use of available drugs complete control of vomiting could be achieved in up to 90% of these patients. However, despite the efficacy of new anti-emetic therapies a proper us of anti-emetics and other preventive measures are vital. Chemotherapy-induced neutropenia with febrile neutropenia (FN) as its ultimate and most serious complication are often observed in
Abstracts
S203
patients receiving Cht. The risk of FN can be predicted by assessing patient characteristics and mylotoxicity of the Cht regimen; and granulocyte-colony-stimulating factors (G-CSF) can be used to prevent it.2 Even thought, most of the regimens for lung cancer do not classify to high, i.e. more than 20% risk of febrile neutropenia, the primary prophylaxis with G-CSF is often necessary due to high comorbidity index, poor PS or extensive disease often present in lung cancer patients. In case of FN, a riskbased approach provided by MASCC helps us to decide which patients need hospitalization and which can be treated by antimicrobial therapy at home.3 Oral mucositis and diarrhea related to mucosal damage are frequent complications of Cht as well as targeted therapy with TKIs that can significantly affect patient’s QoL and the ability to deliver full doses and complete therapy. Oral care protocols are essential components in prevention and treatment of stomatitis, while intensive local therapy protocols with antibiotics, anesthetics and/or corticosteroids help to ameliorative symptoms.4 Diarrhea is quite common in lung cancer patients receiving Cht with an even higher occurrence in patients treated with TKIs.5 It could be life threatening in elderly, fragile patients and in patients with concurrent neutropenia, thus requiring a rapid and effective control. When dietary strategy does not work, or when patients present with severe grade 3/4 diarrhea pharmacologic intervention with loperamide or even somatostatin analogues should be initiated quickly. Skin changes (rash, dry skin, paronychia) are the most frequent AEs associated with targeted therapy for lung cancer next to diarrhea. Even though, they are usually mild or moderate they hava negative impact on patient’s QoL and might lead to dose modifications or even discontinuation. Prophylactic measures with regular use of moisturizing products, sunshine protection and careful skin hygiene are necessary. In case of severe but still localized changes topical corticosteroids/antibiotics are indicated while a severe and prolonged toxicity usually requires TKIs dose interruptions.6 Fatigue is a common symptom reported in up to 80% of LC patients. In most cases it is impossible to distinguish to what extend it is the adverse event of ST and to what of disease. It is increasingly reported in patients receiving targeted therapy or immunotherapy, and major improvements in recognition and treatment of fatigue have been achieved recently.7 Immunotherapy with checkpoint inhibitors (CPIs) represents a novel approach. By breaking of immune self-tolerance it might lead to autoimmune/ inflammatory adverse events, designated as immunerelated adverse events (irAEs), mainly including rash, diarrhea, hepatitis and endocrinopathies.8 Although most of irAEs are of low grade, some of them progress rapidly and prompt medical attention with treatment
S204
interruption and the administration of glucocorticoids is critical. Implications for nursing Oncology nurses should have in-depth knowledge on adverse events of systemic therapy and must be familiar with the supportive care protocols. Nursing interventions for prevention and treatment of particular adverse events are presented in Table 1. Oncology nurses play a key role in continuous education of patients, their families and caregivers on adverse events. They are valuable members of the multidisciplinary team performing ongoing assessment of AEs and monitoring of patients and actively discussing potential solutions and improvements with other team members, thus providing a high-quality patient-centered care.
Journal of Thoracic Oncology
Vol. 12 No. 1S
we are seeing that progression free survival and in some instances overall survival continues to be on the rise. So what does this mean for the medical oncology community? Patients can be on therapies longer than a year and sometimes for several years. We now as providers face the challenge of becoming experts in the management of long-term toxicity of these agents. Side effects of the targeted and immunotherapy drugs are not as predictable as their chemotherapy predecessors, and we are now dealing onset times ranging from days to years after beginning therapy. Immunotherapy drugs are the newest treatment craze and rightfully so, as we have seen documented 12 month overall survival in both nonsquamous and squamous cell carcinoma for some of these agents and even up to 24 months for some patients. Although this has brought optimism to both providers and patients alike, it has also brought forth a multitude of side effects that remind us that we are still novices in this field and necessitate the collaboration with our non-oncologic colleagues as some of these side effects can be life-long. This lecture will review the mechanism of action of the immunotherapy agents as well as review those that are currently available for NSCLC with review of the data leading to their approval and the current and potential future challenges that lie ahead. Keywords: Chronicity, immunotherapy, lung cancer
NU04.02 Experience of Lung Cancer Patients Receiving Immunotherapy Rachel Thomas Palliative Care, Guy’s and St Thomas’ NHS Trust, London/United Kingdom Keywords: Systemic therapy, supportive care, Nursing implications
NU04.01 Management of Toxicities Associated with Immunotherapy in the Lung Cancer Patients Michelle Turner Radiation Oncology, Maryland Proton Treatment Center Affiliated with the Marlene & Stewart Greenebaum Cancer Center, Baltimore/MD/United States of America Chronicity is a word that over the past few years has been utilized when talking about lung cancer treatments. From the developments of the TKIs in the early 2000’s to the approval of immunotherapy for lung cancer in 2015,
With the emergence of immunotherapy in lung cancer, patients now have access to treatments that have the potential to improve prognosis. Patients diagnosed with advanced non-small cell lung cancer (NSCLC) (either squamous or non-squamous) have previously had limited treatment options. With the emergence of new drugs, particularly in the immune-oncology setting, this is now changing. Recent clinical trial evidence demonstrates that compared with docetaxel, patients who received Nivolumab or Pembrolizamab had better overall survival and also significantly fewer Grade 3-4 adverse events (AEs). However the nursing experience of caring for lung cancer patients on an immunotherapy remains quite limited. Up to recent times immunotherapy drugs were limited to the clinical trial setting or early patient access schemes. Often patients on clinical trials are managed and monitored by research nurses which can further limit the experience for Lung Cancer