About this course:
Oncology, cancer, cancer nursing, oncology nursing, chemotherapy, treatment, side effects, immunotherapy, targeted therapy, biologic therapy, infusion, monoclonal antibody, hypersensitivity reactions, oncologic emergencies.
This 2-part module series provides an overview of oncology nursing, outlining the core aspects of cancer diagnosis, staging, and treatment. In addition, it describes oncology nurses’ roles, responsibilities, and professional performance. Part 1 discusses the pathophysiology of cancer, early detection, prevention, and unique care considerations related to surgical and radiation oncology. Part 2 builds on these concepts focusing on systemic therapies, side effect management, patient education, and oncologic emergencies.
At the end of this module, learners will be able to:
- discuss the role of chemotherapy in cancer treatment, common side effects, the basic principles of safe chemotherapy handling and administration, and nursing implications
- recognize the significant classes of targeted therapies and their side effects, and discuss the nursing implications of each option
- identify the signs of hypersensitivity reactions and cytokine release syndrome, as well as appropriate nursing interventions
- recognize the signs and symptoms of the most common oncologic emergencies and discuss evidence-based interventions
- describe a nurse’s role in patient advocacy and end-of-life care
Oncology nurses are responsible for all aspects of care related to safe handling, administering, and monitoring of anti-cancer therapies. Thus, they must remain knowledgeable of treatment regimens, drug actions, and side effect profiles. Nurses safeguard patient care by evaluating and interpreting laboratory data, calculating drug dosages to certify accuracy, and responding promptly to hypersensitivity reactions (HSRs) and infusion reactions. Hypersensitivity reactions are oncologic emergencies because they can rapidly progress to life-threatening situations. Oncology nurses manage intravenous (IV) lines, including central venous devices (CVD), which require ongoing monitoring. Nurses educate patients and caregivers about anti-cancer drugs, their side effects, and the signs and symptoms to monitor and report. Proficient assessment and triage skills are necessary, as the signs of infection in immunocompromised patients are vague. Finally, nurses support patients emotionally, frequently reassessing their physical and mental health, advocating for their needs, and coordinating care (Neuss et al., 2017; Yarbro et al., 2018).
The American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) formed a collaborative in 2008 to create safety standards for administering anti-cancer agents. The ASCO/ONS Chemotherapy Administration Safety Standards were last revised in 2017 and address oncology practice-related issues and standards for oncology nurses to promote safe care for patients receiving chemotherapy, targeted therapy, and immunotherapy. These standards apply across settings and patient populations and serve as the gold standard for oncology nursing practice. In alignment with these practice standards, this course will discuss safe administration procedures, including the appropriate use and disposal of personal protective equipment (PPE) and assessing, monitoring, and managing patients receiving systemic therapies. Furthermore, patient and family education on treatment-related side effects and the management of post-treatment care will be explored (Neuss et al., 2017; ONS, 2016).
Cancer chemotherapy, also called cytotoxic or antineoplastic therapy, refers to a group of high-risk, hazardous drugs intended to destroy cancer cells with as minimal effect on healthy cells as possible. Chemotherapy drugs are distributed throughout the body via the bloodstream and can cause significant morbidity and mortality. Therefore, specialized education, training, and certification are required for oncology nurses who administer chemotherapy and other hazardous cancer medications. While each chemotherapy class has a unique mechanism of action, they generally work by interfering with the normal cell cycle to impair deoxyribonucleic acid (DNA) synthesis and prevent cell replication. Chemotherapy is given with varying intents, and oncology nurses must understand the rationale for each. Neoadjuvant chemotherapy is administered to shrink a tumor, so the primary treatment (e.g., surgery) is less extensive. Adjuvant chemotherapy is given after the primary treatment to prevent recurrence and reduce micro-metastases (i.e., tiny cancer cells too small to appear on diagnostic tests). For potentially curative treatment regimens, maximum tolerated doses of drugs are delivered on a specific schedule to achieve the greatest efficacy. Palliative chemotherapy is administered for symptom control and to improve quality of life. Chemoprevention is the use of medications to prevent cancer in high-risk individuals. Myeloablation obliterates bone marrow in preparation for stem cell or bone marrow transplantation with high-dose, intensive chemotherapy (American Cancer Society [ACS], 2019b; Nettina, 2019; Olsen et al., 2019; Yarbro et al., 2018).
Classification of Chemotherapy Agents
A basic understanding of the cell cycle is required to comprehend how chemotherapy works against cancer. The cell cycle is a 5-stage process of reproduction that occurs in healthy and cancerous cells. Gap 0 (G0) is also called quiescence and is the resting stage in which cells are temporarily out of the cell cycle. During this stage, cellular activity continues to occur except for reproduction. During Gap 1 (G1), ribonucleic acid (RNA) and protein synthesis occur. This stage is considered the gap between resting and DNA synthesis. Synthesis (S) is when cellular DNA is duplicated in preparation for division. Protein and RNA syntheses continue during Gap 2 (G2) as the cell constructs the mitotic apparatus. Finally, Mitosis (M) is cellular division. Figure 1 depicts the steps in the cell cycle (McCance & Heuther, 2019; Yarbroet al., 2018).
Chemotherapy agents are typically classified according to their mechanism and phase of action during the cell cycle. Cell cycle-specific drugs exert cytotoxic effects at particular stages within the cycle. These agents are not active against cancer cells during the G0 phase and are schedule-dependent, meaning they are most effective when administered in divided doses or by continuous infusion. Continuous infusion may occur for up to 7 days at a slower rate, allowing the drug to reach more cells when actively dividing and amenable to being targeted. Cell cycle-nonspecific drugs exert a broader impact, as they are active during all cell-cycle phases. In addition, nonspecific agents are dose-dependent and are most effective as bolus doses; the cell kill is directly proportional to the amount of drug given. Table 1 displays the classification of the most common chemotherapy agents according to their mechanism of action and effect on the cell cycle (ACS, 2019b; Olsen et al., 2019).
Drug resistance occurs when cancer stops responding to the prescribed treatment and starts to grow again. It is a significant barrier to curing cancer, as tumors develop the ability to resist the effects of chemotherapy agents. For instance, a patient may have an initial robust response to treatment, but eventually, the medication could stop working. Drug failure in cancers attributed to resistance can have various causes, and it is common for multiple resistance mechanisms to occur. For example, intrinsic resistance occurs when cancer
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Drug resistance is the primary reason cancer drugs are given in combination. Since cancer cells are destructively efficient in their division, replication, and spread patterns, combining therapies with diverging mechanisms of action can overcome resistance. Further, as cancer progresses, it develops new mutations. If cancer becomes resistant to a drug or a group of drugs, it is more likely to become resistant to others. Thus, adhering to evidence-based treatment guidelines is vital, as the most effective treatment protocol should always be administered first (Konieczkowski et al., 2019; Yarbro et al., 2018).
Administration of IV Chemotherapy
Chemotherapy administration should be viewed as a process rather than an isolated act of medication administration. Oncology nurses must attain in-depth knowledge andunderstanding of the mechanism of action and expected side effects of each drug to ensure patient safety. ONS (2019) offers the ONS/ONCC Chemotherapy/Immunotherapy Certificate Course, which provides updated evidence-based resources for oncology nurses. ONS (2016, 2019) outlines competencies required for nurses to administer these agents, including in-depth knowledge of cancer medications and infusion therapy practices. Most accredited cancer centers and hospitals throughout the US mandate that nurses hold specialized oncology and chemotherapy certifications. The ONS (2016) standards support registered nurses (RNs) as the minimum appropriate licensure to administer chemotherapy and biotherapy. They recommend educational requirements for nurses, which are the same regardless of treatment indications, clinical settings, routes of administration, and patient population. Due to the unique safety considerations of these drugs, specialized education is needed for all nurses who administer chemotherapy or other anti-cancer agents. ONS offers online courses for initial didactic preparation and knowledge maintenance for nurses who administer chemotherapy and immune-based treatments (ONS, 2019). However, each institution or practice must determine how to assess competence in performing various chemotherapy-related skills (ONS, 2016). An oncology nurse's scope of practice is further defined and regulated by state laws and the nursing practice act. In addition, ASCO and ONS conduct ongoing collaborative projects using rigorous, consensus-based processes to develop standards for the safe administration of chemotherapy as the treatment landscape evolves. These guidelines address chemotherapy administration in outpatient and inpatient settings to reduce the risk of error and provide a framework for best practices in cancer care (Neuss et al., 2017; ONS, 2016, 2019).
Chemotherapy is most commonly administered by IV or mouth, but certain drugs may be administered via other routes such as:
- subcutaneous injection (under the skin)
- intramuscular injection (deep into the muscle)
- intrathecal (into the central nervous system [CNS])
- intravesicular (into the bladder)
- intraperitoneal (into the intraabdominal cavity; Yarbro et al., 2018)
Since chemotherapy can cause severe irritation, damage, and injury to the veins and subcutaneous tissue, many patients have an implantable CVD (e.g., port). A port is a small device surgically implanted under the skin, usually in the chest wall, allowing easy access to the bloodstream (see Figure 2). The port is used to draw blood, infuse chemotherapy, and administer other medications (Nettina, 2019; Olsen et al., 2019).
Refer to the NursingCE course on Vascular Access Devices to learn more about this topic.
Certain types of chemotherapy known as vesicants should only be given through a port, as they are too caustic to be administrated through a peripheral vein. Vesicants can lead to severe soft tissue necrosis or the formation of blisters when they leak or infuse outside the vein and into the soft tissue (i.e., extravasation). The severity of extravasation depends on the drug's type, amount, and concentration. Initial symptoms can present as acute burning, pain, and swelling at the infusion site. These symptoms become increasingly severe in the hours, days, and weeks following the initial injury. Patients may develop blisters, which usually begin within 3-5 days and may be followed by peeling or sloughing of the skin with invasion and destruction of deeper structures. Tissue necrosis usually occurs within 2-3 weeks. In the most severe cases, damage can reach tendons, nerves, and joints, leading to functional and sensory impairment of the area, disfigurement, or loss of the limb entirely. Examples of vesicants include doxorubicin (Adriamycin), dactinomycin (Cosmegen), and vincristine (Oncovin). Peripheral IV sites must be assessed before, during, and after the infusion for signs of erythema, swelling, or loss of blood return. Patients must be counseled to report any pain, burning, or other abnormal sensations during the infusion. There are specific guidelines governing the management of peripheral IV sites for chemotherapy, such as location, placement, monitoring parameters, and frequency of evaluations of blood return. In general, all chemotherapy agents should be considered irritants, as they all have the potential to cause inflammation, pain, or irritation. Table 3 provides an overview of the responsibilities of oncology nurses in the administration of chemotherapy (ACS, 2019b; Nettina, 2019; Olsen etal., 2019).
Chemotherapy Side Effects
The side effects of chemotherapy are broad. Since it is devised to kill cells that divide quickly, it harms healthy cells alongside cancerous cells. Thus, chemotherapy most commonly impacts the gastrointestinal (GI) tract, skin, hair, and bone marrow. As a result, most patients will experience some degree of bone marrow suppression (low blood counts), nausea/vomiting, diarrhea, fatigue, hair loss, and mouth sores. However, not all patients respond in the same way, and not all chemotherapy agents pose the same risks. Therefore, assessment and education are critical to ensure timely recognition, intervention, and management of side effects. Specific side effects, such as nausea, can be averted with prevention strategies and medications. Oncology nurses are experts in symptom management and have many tools to offer. Table 4 provides a broad overview of some of the most common chemotherapy side effects and critical teaching points (ACS, 2019b; Olsen et al., 2019).
Oral Cancer Drugs
An oral cancer drug is any medication taken by mouth (in liquid, tablet, or capsule formulation) to treat cancer. These include chemotherapy, targeted therapies, and some hormone therapies. Oral medications offer the convenience of at-home administration without sacrificing strength or effectiveness when compared to injectables. Although along with the increased flexibility come unique safety challenges. Nurses must ensure patients understand how to safely handle and dispose of these drugs. One of the most challenging issues with oral cancer treatment is poor adherence, which substantially impacts the drug’s efficacy, safety, side effects, and toxicities. Oral cancer medications are prescribed at defined intervals based on the drug's mechanism of action, half-life (the amount of time it takes for 50% of the drug to be excreted from the body), and side effect profile. Oncology nurses must educate patients on the significance of taking the medication consistently as prescribed to ensure a constant level of the drug remains in the body to kill the cancer cells. Even a slight increase or decrease in the dose level can impair the drug's efficacy or lead to superfluous side effects. These medications can quickly become dangerous if not taken as prescribed. Patients must be counseled not to crush, chew, or split oral cancer pills, as this can affect how the medication works. Establishing a routine can help patients remain consistent with their medication dosing schedule. Some strategies may include filling pillboxes each week, setting pill reminders on smartphones or tablets, enrolling in electronic medication reminders through a pharmacy, or using a simple paper pill diary to avoid overdosing. Oral cancer drugs are potentially hazardous and require special precautions for safe handling, especially for caregivers. As described by the 2016 ASCO and ONS chemotherapy administration standards, nurses should educate patients and caregivers on drug safety before patients receive prescribed oral cancer medications. A summary of these key teaching points appears in Table 5 (Neuss et al., 2017; Olsen et al., 2019; Weingart et al., 2018).
Scientific advancements and treatment breakthroughs have revolutionized how cancer is treated, leading to innovative fields such as precision (personalized) medicine with the advent of targeted therapies. Targeted therapies include many categories, such as hormonal therapy, monoclonal antibodies, and immunotherapy. Precision medicine uses the genomic profiling of a tumor to identify its genetic mutations. This information allows treatment to be tailored to the features of cancer. Targeted therapies block the growth and spread of cancer by interfering with specific genes, proteins, or blood vessels that allow cancer cells to replicate, grow, and spread. Immune-based therapies help the immune system identify cancer cells and attack them like an infection, virus, or other potential threat. Immunotherapies include checkpoint inhibitors and chimeric antigen receptor T-cell (CAR-T) therapy. These agents work very differently than chemotherapy and carry unique side effect profiles. Oncology nurses must understand how these medications work, their side effects, and management options for adverse events. Even though biological therapies are not chemotherapy, they are still high-risk, hazardous medications that can induce severe morbidity and mortality if not used correctly and safely (National Cancer Institute [NCI], 2022b; Olsen et al., 2019; Schirrmacher, 2019; Yarbro et al., 2018).
In 2003, the completion of the Human Genome Project marked a dramatic shift in the understanding of cancer and other diseases. Researchers mapped the entire human genetic code and discovered that every human cell contains 20,000 to 30,000 genes. As a result, novel approaches to treating cancer and new drug discovery have exploded over the last two decades. Targeted agents are crafted to attack specific parts of cancer cells. Numerous proteins located on the cellular membranes (i.e., growth factor receptors) connect the external and internal cellular environments and are essential for cell growth and development. Alterations in genes lead to changes in these cellular proteins, stimulating the disruption of normal processes, inducing malfunction, and enabling cancer growth. Targeted therapies impede cancer growth through unique and distinctive pathways. Some targeted therapies focus on the external components and functioning of the cell, whereas others use small molecules to enter the cell to disrupt its function. There are various mechanisms by which targeted therapies function, including:
blocking or turning off chemical signals that tell the cancer cell to grow and divide
altering proteins within the cancer cells, so the cells die
starving the tumor by cutting off its blood supply and preventing the formation of new blood vessels
helping the immune system to destroy cancer cells
carrying toxins or poison to the cancer cells directly to kill them without harming healthy, normal cells
starving the cancer of the hormones it needs to grow (NCI, 2022b; National Human Genome Research Institute [NHGRI], 2018)
Hormones fuel cancer growth in some cases, and treatment often includes hormone-blocking therapies. Hormonal therapies are targeted agents that block circulating hormones from reaching cancer cells or prevent the body from producing the hormones altogether. The most common hormone-dependent cancers include breast, prostate, uterine, ovarian, and neuroendocrine. For breast cancer, hormonal therapy is often prescribed long-term, with an average of 5 to 10 years; however, it may extend longer for patients with recurrent, advanced, or Stage IV malignancies. Side effects of hormonal treatments can prominently impact sexual health and the reproductive system, with distinct differences between genders. Females may experience vasomotor symptoms like menopause, such as hot flashes, night sweats, loss of libido, weight gain, and vaginal dryness. Other common side effects may include joint aches or pains, mood changes, hair loss, and bone thinning (osteopenia or osteoporosis). Males may experience hot flashes, impotence (an inability to have or maintain an erection), shrinking of the testicles, and gynecomastia (enlargement of breast tissue). Due to the risk of bone thinning for females on hormonal therapy, they should receive counseling on the importance of following a calcium-rich diet with at least 1,200 mg of dietary calcium daily and engaging in regular weight-bearing exercises. Patients who cannot get the recommended amount of calcium in their diet should consider calcium supplementation (Nettina, 2019; Olsen et al., 2019).
Monoclonal antibodies are artificial proteins manufactured to behave like natural human antibodies. They attach to targets on the surface of cancer cells and inject their contents into the cell, causing them to die. Cells that do not have the target are not harmed. Antibodies are part of the adaptive immune system. The body creates antibodies in response to an antigen (e.g., bacteria) that enters the body. The antibodies attach to the antigen to mark it for destruction by the body's immune system. In the laboratory, scientists analyze specific antigens on the surface of cancer cells to determine a protein to match the antigen. Then, using protein specimens from animals and humans, they create a unique antibody that will attach to the target antigen as a key fits into a lock. This technology allows treatment to target specific cells, causing less toxicity to healthy cells. Monoclonal antibody therapy can be performed only for cancers in which antigens (and the respective antibodies) have been identified. Monoclonal antibodies work on cancer cells in the same way natural antibodies function—by identifying and binding to the target cells and then alerting other cells in the immune system to the presence of the cancer cells (ACS, 2019c; Olsen et al., 2019; Yarbro et al., 2018).
The nomenclature of monoclonal antibodies provides clues to their composition and function. Monoclonal antibodies always end with the stem “-mab.” The term “-mab” is used when receptor targets are overexpressed on the outer layer of the cells. Monoclonal antibodies have an additional layer of classification within their sub stem, representing how the drug is comprised. For example, murine monoclonal antibodies end in “-momab” (e.g., ibritumomab [Zevalin]). Murines are composed of mouse proteins and include conjugated antibodies, which are physically attached to antitumor agents such as radioisotopes, chemotherapy, toxic drugs, and other biologic agents. Murines have the highest risk of HSRs due to their high mouse content. Conjugate monoclonal antibodies present the highest risk for bone marrow suppression and additional side effects since they are physically attached to a toxic or poisonous agent. Chimeric monoclonals end with “-ximab” (e.g., rituximab [Rituxan]). Chimerics are primarily comprised of mouse proteins with a small human protein component. Therefore, chimerics have a relatively high risk of HSR. Humanized monoclonals, which end in “-zumab” (e.g., bevacizumab [Avastin]), include a small number of mouse proteins, and the rest are human components. Humanized agents induce less severe HSRs. Fully human monoclonals end with “-mumab” (i.e., panitumumab [Vectibix]). Since these options are fully human, HSRs are rare. Some monoclonal antibodies include additional information in their naming classification that denotes their primary target. For example, the “li” in ipilimumab (Yervoy) identifies the immune system as the target. The “tu” in rituximab (Rituxan) indicates the target is the tumor. The “ci” in bevacizumab (Avastin) identifies the circulatory system as the drug’s target (ACS, 2019c; Olsen et al., 2019; Yarbro et al., 2018). Commonly, monoclonal antibodies infusion reactions include flu-like symptoms, rash, pruritus, headaches, joint aches, nausea, diarrhea, hypotension, bleeding, and delayed wound healing. Patients are usually premedicated with acetaminophen (Tylenol) and diphenhydramine (Benadryl) to prevent HSR and infusion reactions. Table 6 compares HSRs and infusion reactions and discusses appropriate interventions (ACS, 2019c; Olsen et al., 2019; Yarbro et al., 2018).
Immunotherapy produces antitumor effects by rousing natural defense mechanisms. These drugs prime the immune system’s sensitivity to cancer cells, helping it learn how to identify, attack, and kill them. The connection between cancer and the immune system was discovered about 100 years ago by Dr. William Coley, who is known as the father of immunotherapy. Dr. Coley found that malignant tumors disappeared in patients who contracted streptococcal infections. Immune checkpoints are proteins that act as “brakes” on a normally functioning immune system. Immune checkpoint inhibitors target these proteins, block them, and stimulate the immune system to attack the cancer cells by taking off the brakes. Some forms of immunotherapy are so highly specialized that they only target a single receptor on the surface of tumor cells. Although immunotherapy is among the most promising approaches since the development of chemotherapy, it is not equally effective against all cancers at this stage in development (NCI, 2019; Olsen et al., 2019).
Given the tremendous rise in the routine use of immunotherapies, oncology nurses must understand their unique side effect profiles and toxicities. Adverse reactions and toxicities are graded according to the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE, 2017) Version 5 scale. They are managed by medication guidelines put forth through expert consensus and the drug manufacturer’s package insert (NCI, 2017). Removing the immune system's brakes increases the risk of autoimmune-like symptoms and systemic inflammation. Inflammation of any organ system is possible and can progress to life-threatening situations if not promptly recognized and managed. For example, inflammation in the GI tract (colitis) can initially present as abdominal pain, cramping, and diarrhea. If untreated, colitis can become fatal. Other examples include endocrinopathy (adrenal insufficiency or hypothyroidism), pneumonitis (inflammation of lung tissue), hepatitis (inflammation of the liver), pancreatitis (inflammation of the pancreas), and uveitis (inflammation of the eye). Patients with clinical signs of hepatitis or transaminitis (elevated liver enzymes) should avoid excessive use of acetaminophen (Tylenol), which can exacerbate these conditions. If diagnosed early, most immune-related adverse events (irAEs) are reversible with interruption of the offending therapy and temporary administration of corticosteroids. However, toxicities must be graded appropriately, monitored cautiously, and managed per guidelines formulated by manufacturers in collaboration with the US Food & Drug Administration (FDA). Severe irAEs should prompt discontinuation of the immunotherapy and long-term corticosteroids. In extreme cases, immunosuppressive agents such as infliximab (Remicade) are given to manage symptoms (NCI, 2019; Olsen et al., 2019; Schneider et al., 2021).
CAR-T cell therapy is the most novel immunotherapy sector, with only a handful of FDA-approved options (e.g., tisagenlecleucel [Kymriah] and axicabtagene ciloleucel [Yescarta]). CAR-T is a synthetic receptor created in a laboratory using the patient’s T-cells. It is designed to attach to specific proteins on cancer cells. CAR-T therapy is a complex process with many steps. First, the patient’s T-cells are collected and isolated from the other blood components via leukapheresis. Next, the cells are sent to a specialized laboratory where they are genetically modified. The gene for CAR is added to them, which helps the T cells attach to a specific cancer cell antigen. Over a few weeks, the CAR cells grow and multiply in the lab. Once enough cells are produced, they are shipped back and infused intravenously into the patient. Common side effects include low blood counts, allergic reactions, and immunosuppression. However, CAR-T cell therapy can cause serious side effects of cytokine release syndrome (CRS) and neurotoxicity. As the CAR-T cells multiply in the body, they release large amounts of chemicals called cytokines into the bloodstream, causing many symptoms and potential complications (see Table 6). Neurotoxicity can present with headaches, cognitive changes, confusion, agitation, tremors, seizures, and speech and balance difficulties. Patients are typically hospitalized for the infusion and monitored closely (ACS, 2022; Morris et al., 2021; Olsen et al., 2019; Schneider et al., 2021).
HSR and CRS
HSRs occur when the immune system is overstimulated by a foreign substance and forms antibodies that cause an immune response. HSRs can occur with all anti-cancer therapies but are most common with monoclonal antibodies and certain types of chemotherapy. HSRs can occur during the initial chemotherapy infusion or subsequent administrations of the same agent. Most HSRs arise during the first 15 minutes of the infusion, but reactions can occur outside this time frame. Therefore, oncology nurses must monitor vigilantly for signs of HSR and ensure they are prepared to intervene immediately. Refer to Table 6 for an overview of the clinical manifestations and management of HSRs. Nurses should also be familiar with their institution's specific chemotherapy HSR protocols and policies (Morris et al., 2021; Nettina, 2019; Olsen et al., 2019).
CRS is a systemic inflammatory response induced by the rapid release of cytokines from cancer cells during cell lysis following contact with the drug. Clinical manifestations may vary from mild, flu-like symptoms to severe life-threatening manifestations in an excessive inflammatory response. Respiratory symptoms may initially present as a mild cough and tachypnea but can rapidly progress to acute respiratory distress syndrome (ARDS) with dyspnea, hypoxemia, and a chest x-ray revealing bilateral opacities. ARDS may necessitate mechanical ventilation. In addition, patients with severe CRS can develop cardiac dysfunction with a reduced ejection fraction. Also, patients with severe CRS frequently exhibit vascular leakage with peripheral and pulmonary edema and renal failure. Laboratory abnormalities frequently seen in patients with CRS include cytopenia (a low white blood cell, red blood cell, and platelet count), reduced kidney function, elevated liver enzymes, and unbalanced coagulation parameters. Most patients are premedicated with acetaminophen (Tylenol) and diphenhydramine (Benadryl) to reduce the risk of infusion reactions (e.g., fevers, chills, and rigors). Slowing down the infusion rate can also reduce the risk of prolonged rigors. Many institutions have policies outlining the importance of slowly titrating the infusion rate of all monoclonal antibodies to reduce the risk of rigors, chills, and fevers. The nursing management of CRS has distinct differences from the typical HSR management, which further emphasizes the importance of the oncology nurse's knowledge base regarding biologic therapies. Table 6 compares the features and management of HSR and CRS (Morris et al., 2021; Nettina, 2019; Olsen et al., 2019; Shimabukuro-Vornhagen et al., 2018).
Before administering a cytotoxic or biologic therapy, the nurse should inform the patient and their family about the potential for immediate complications. In addition, the patient should be instructed to report any signs or symptoms that may indicate an HSR, including flushing, warmth, chills, itching, redness, discomfort, chest pain, shortness of breath, or nonspecific symptoms such as impending doom or anxiety. While Table 6 provides guidance on the most common signs and symptoms of HSR and CRS, they can also present in various other ways. Therefore, it is essential to educate each patient and their family to report any abnormalities during an infusion. Delayed reactions or symptoms occurring after the infusion and once the patient arrives home are less common but have been reported (Morris et al., 2021; Nettina, 2019; Olsen et al., 2019).
Sexual Health and Cancer
Sexual health challenges are common among patients and survivors, as cancer and its treatment can affect patients physically and emotionally. Sexuality is a challenging topic for many patients to approach, as it is often accompanied by feelings of shame, embarrassment, and anxiety. Patients often have many questions, fears, and concerns about their sexuality and the impact of cancer treatment on their sexual function. However, they typically feel uncomfortable bringing up the topic or asking these questions. Oncology nurses can often develop strong rapport and therapeutic relationships with patients throughout their disease trajectory. Therefore, they are in a unique position to initiate conversations on sensitive topics such as sexuality. Nurses should approach these topics with empathy, compassion, and no judgment, inviting patients to express their concerns comfortably and ask honest questions. Patients should be counseled on the impact of cancer treatment on their sexuality and forewarned that when sexual changes do occur, they typically do not improve right away. Treatment-related sexual changes may be long-term or permanent. Patients may endure irregular bleeding while on cancer therapy but must be advised that it may still be possible to conceive a child during treatment. Pregnancy is contraindicated while on anti-cancer therapy due to the risk of fetal harm; therefore, patients and their partners must be counseled on taking necessary precautions to prevent pregnancy. Females of childbearing age desiring fertility preservation must be counseled on the potential for infertility and premature ovarian failure due to treatment. Females should be advised on fertility preservation options and referred to reproductive health specialists. Likewise, males may desire sperm banking before starting therapy (Bober et al., 2019; Yarbro et al., 2018).
The most common sexual health issue for females with cancer is menopause, which may be induced by surgery to remove the ovaries due to cancer, chemotherapy, radiation therapy, or hormone-blocking agents. Treatment-induced menopause can be temporary or permanent, depending on the type of treatment and the patient's age when treatment was received. Patients who endure premature menopause due to cancer therapy are at risk for sexual and vaginal complications. Some of these symptoms may include vaginal atrophy (thinning, drying, and inflammation of the vaginal walls due to a reduction in estrogen) and dyspareunia (pain during intercourse). Other symptoms include difficulty with sexual arousal, a loss of libido, and vasomotor symptoms such as hot flashes and night sweats. In addition, many patients report mood changes due to the abrupt loss of hormones, describing feelings of anxiety, sadness, loss, and a lack of interest in sexual contact with their partners. Males may experience erectile dysfunction, an inability to achieve or maintain an erection, fertility problems related to low testosterone levels, and premature or delayed ejaculation. Physical limitations, such as Peyronie's disease (curvature of the penis during an erection), can occur due to specific treatments for prostate cancer. Patients should be counseled that finding the most helpful remedy may take time and requires patience and open communication with partners. Both psychological and physical factors can cause sexual changes. Nurses can help by offering practical, realistic, and cost-effective strategies and interventions to alleviate some of these potential adverse effects or help connect patients with appropriate resources (Bober et al., 2019; Yarbro et al., 2018). Table 7 cites some key teaching points and interventions for some of the most common symptoms and sexual alterations experienced by patients with cancer.
Safety and Exposure
In addition to patient safety, cytotoxic drugs can be equally hazardous to nurses and other healthcare workers, so it is critical to adhere to standards and practices of dangerous drug handling to minimize any occupational exposure. Exposure to hazardous medication is linked to an increased risk for several malignancies, and exposure can occur through various sources, including workplace surface contamination (ONS, 2016; ONS, 2019). According to Neuss and colleagues (2017), oncology nurses must wear appropriate PPE whenever there is a risk of chemotherapy being released into the environment. Exposure risk occurs during chemotherapy preparation, spiking or priming IV tubing, and handling body fluids or chemotherapy spills. These guidelines also describe hazardous drug handling as posing reproductive risks, so healthcare workers who are pregnant, breastfeeding, or trying to conceive must notify their employer. These individuals should not be handling hazardous medications such as chemotherapy. Chemotherapy medications must be mixed and spiked/primed under an approved filtered hood to reduce the risk of aerosolized exposure. Gloves tested for use with hazardous drugs are required, and reusing gloves is prohibited. Nurses should wear disposable, lint-free gowns made of low-permeability fabric when administering chemotherapy, and spill kits should be available in all areas where chemotherapy is stored, prepared, and administered. Gloves and gowns should be discarded in leak-proof containers marked as contaminated or hazardous waste. Linens or clothes contaminated with chemotherapy or bodily fluids from patients who have received chemotherapy within 48 hours should be contained in labeled hazardous waste bags. If any chemotherapy medication spills on clothes in the clinic, the items should be thrown away or double-bagged in plastic for transport home. The clothing must then be washed separately in hot water with regular detergent (Neuss et al., 2017; ONS, 2016; ONS, 2019).
Nursing Implications in Oncologic Emergencies
Early recognition and prompt intervention of oncologic emergencies are critical to patients' quality of life and survival. The symptoms of oncologic emergencies may be obvious or subtle in presentation and potentially overlooked, contributing to increased morbidity and mortality. Oncology nurses are vital to improving patient outcomes when an oncologic emergency occurs to limit devastating functional losses, preserve the quality of life, and thwart progression to a life-threatening emergency. Eight of the most common oncologic emergencies are outlined below in Table 8.
Survivorship is the process of learning how to live with cancer and beyond. There are an estimated 16.9 million cancer survivors in the US, representing 5% of the population; these numbers are projected to increase to 22.2 million by 2030 and 26.1 million by 2040. Currently, 64% of survivors are 65 years or older, and an estimated 73% of survivors in the US will be 65 years or older by 2040 (ACS, 2019a).
A patient-centered approach to cancer survivorship is at the forefront of accreditation standards for comprehensive cancer programs as mandated by the American College of Surgeons (2022). In addition, there has been a national target toward ensuring survivorship care planning becomes the standard of care since the Institute of Medicine (IOM)'s 2006 report entitled From Cancer Patient to Cancer Survivor: Lost in Transition. The report exposed the unmet needs of the growing population of cancer survivors, endorsing a call to action for every survivor to receive an individualized post-treatment care plan (IOM, 2006).
The goals of cancer survivorship focus on the prevention of recurrent and new cancers, surveillance for cancer spread or recurrence; assessment of late medical and psychological effects of therapy, adherence, and interventions for consequences of cancer and its treatment; and coordination between oncologists, specialty providers, and primary care physicians. Composed of guidelines for monitoring and maintaining health, survivorship care planning strives to improve the quality of care and long-term outcomes of survivors. These recommendations reinforce the need for survivors to maintain a healthy weight, consume a well-balanced diet, and engage in regular physical exercise, regardless of tumor type. Cancer survivorship literature demonstrates that physical inactivity, poor nutrition, and resulting obesity are the most critical risk factors (aside from tobacco use) for cancer recurrence, morbidity, and premature death after curative treatment (ACS, 2019a; ASCO, 2022; Basen-Engquist et al., 2018).
Oncology nurses are uniquely positioned to use the diagnosis and treatment of cancer as an opportunity to educate patients on cancer survivorship, initiate healthy lifestyle counseling, and offer guidance on interventions focused on cancer prevention. Many patients have difficulty adjusting to life after cancer treatment, as cancer can cause long-term physical and psychological consequences. Nurses should provide education regarding the signs and symptoms of cancer recurrence, identification of late side effects, and information on adopting healthier lifestyles. In addition, adolescents and young adult cancer survivors are prone to developing second cancers, especially lung cancer. Therefore, patients must be educated on the risk for secondary malignancies to ensure they receive adequate surveillance and screening long-term (Palmer et al., 2021). Nurses help coordinate referrals to specialists and ensure each patient's primary care physician receives a copy of their survivorship care plan to promote continuity of care within the healthcare community. Despite the successes in cancer treatment, providers must also address the needs of survivors who experience the deleterious consequences of cancer treatment and help them restore their health as they transition to survivorship (ACS, 2019a; ASCO, 2022; Basen-Engquist et al., 2018).
Refer to the Cancer Survivorship NursingCE course for more information on this topic.
End-of-Life Issues in Cancer Care
Palliative cancer care addresses each person as a whole, striving to promote quality of life and relieve suffering throughout the disease trajectory, not just at the end of life. Palliative care should be a standard component of cancer care for all patients. It should be initiated at diagnosis and used throughout treatment. The goals are to prevent or manage cancer symptoms and side effects of treatment, provide comfort, and preserve the quality of life. It also addresses cancer's psychological, social, and spiritual complications. Whereas palliative can begin at any point along the cancer continuum, hospice care begins when curative treatment is no longer the goal. Treatment is withdrawn, and the focus shifts to promoting comfort through the end of life. Hospice eligibility begins when life expectancy is 6 months or fewer. The goal is a comfortable, peaceful, and pain-free death. Despite the distinctions between these care domains, they also overlap in a few ways. Palliative care helps patients develop care goals and advanced directives. Palliative care teams support patients and families as they learn to cope with different concerns and emotional issues in considering a hospice transition. Early referrals of patients to palliative care and hospice improve symptoms, quality of life, and survival (Kaasa et al., 2018; NCI, 2022a; Nettina, 2019).
End-of-life issues should be addressed early in the disease trajectory, readdressed as the patient's clinical status changes, and concentrated on their care goals. Oncology nurses are essential drivers of these conversations, which should be avoided during life-threatening events when the patient and family feel distressed and pressured to decide. As advocates, nurses encourage patients to express their preferences regarding end-of-life care to their medical team and family. Wishes should be supported by appropriate legal documents, such as advance directives, medical orders for life-sustaining treatment, healthcare proxy, and durable power of attorney. Nurses are critical in educating patients and families about these vital decisions, explaining options, ensuring decisions align with care goals, and assisting patients and families with making decisions about withholding or withdrawing life-sustaining therapies. While preparing for end-of-life and making decisions about treatment and preferences can be challenging and distressing for patients and their families, failing to plan for these events can be even more devastating. Patients without predetermined plans for a transition to end-of-life endure increased psychological distress and are routinely subjected to medical treatments incongruent with their preferences. In addition, families and caregivers experience heightened emotional pain accompanying the decision-making process and endure a more difficult bereavement period. As a result, the cost of care and utilization of burdensome and expensive healthcare services and resources offering minimal therapeutic benefits are also heightened. Each state outlines how individual rights determining one’s healthcare treatment are guaranteed. In addition, nurses serve fundamental roles in ensuring symptoms are managed, connecting patients to necessary resources, and implementing measures that promote quality of life. Nurses make referrals for respite care, counseling, pastoral care, and bereavement services (Kaasa et al., 2018; NCI, 2022a; Nettina, 2019).
Oncology nurses have several ethical, legal, and professional responsibilities. They must ensure patient safety, protect patients from harm, verify hazardous medications for errors, and adhere to the guidelines of safe handling, delivery, and disposal of cytotoxic drugs. Nurses have a right to feel competent in their roles and the procedures delineated by their employing organization. They are ethically and morally bound by their position in advocacy, protecting patients' rights, and ensuring patients have a voice and are educated to make informed decisions. Oncology nurses are commonly faced with moral dilemmas and endure personal distress in this challenging field. Regardless of their personal beliefs, they must support patient choices and uphold patient wishes, even when family members disagree. Finally, oncology nurses are champions for patients and families opting to forgo further treatment; oncology nurses promote the decision to transition to hospice as courageous, not weak. Continuing education is essential for nurses to remain current in their knowledge of evidence-based practice, reduce legal liability, and provide high-quality care. Oncology nurses face various legal and ethical dilemmas when delivering care, particularly with evolving technological advancements, a high emphasis on innovative devices and electronic health records, and changing state and federal laws. Ethical dilemmas may include medical treatment that extends life without considering its quality, disparities in care goals between patients and their families, fertility preservation, withdrawing care at the end of life, and medical futility. Most hospitals have ethics committees and ethics consultation services to assist staff, patients, and families in navigating these challenging scenarios. Ethical principles can guide oncology nurses in complicated clinical dilemmas (NCI, 2022a; Nettina, 2019; Yarbro et al., 2018).
Refer to the Palliative Care for RNs and LPNs and End-of-Life Care and Pain Management (with Ethical Issues) NursingCE courses for more information on these topics.
The Financial Burden of Cancer Care
Beyond the sweeping life impacts of a cancer diagnosis, the high cost of treatment can be equally catastrophic for patients and their families. As novel agents and new oral drugs become available, the price increases. One of the most significant barriers to successful cancer treatment today is not the proper treatment but the patient's access to it: access is limited by cost. Oral therapies offer several advantages over traditional intravenous therapies. They should be less expensive due to the lower cost of self-administration of the medication, yet the opposite is true. Oral cancer drugs are costly and may not be covered entirely by insurance and prescription plans. The financial burden is among the most common reasons for non-compliance with oral medications. Most private insurers consider oral anti-cancer medications to be a prescription drug benefit, using a tiered structure that increases each patient's cost-sharing responsibility as the price of the medication increases. As a result, patients on oral anti-cancer treatment face high out-of-pocket costs and often need to decide between financial ruin and continued treatment. The economic burden of oral cancer treatment leads to delays in treatment initiation, contributes to non-compliance, and provokes premature discontinuation of therapy. These have negative consequences on treatment benefits, quality of life, and survival. Studies show that many patients opt to forego treatment altogether due to the substantial cost burden and inaccessibility (Gilligan et al., 2018; Thomas et al., 2019).
Oncology nurses should encourage patients to speak to their healthcare providers if they have difficulty affording their medication before stopping. Some manufacturers offer co-pay assistance programs or have grants to fund lower-cost or free drugs (e.g., compassionate use programs or need-based cost programs). In addition, some states have passed laws that require insurance companies to cover oral cancer medications as they would cover other treatments. Oncology nurses should help patients fight high medical costs by connecting them with available resources. The Association of Community Cancer Centers (2019) has published The Patient Assistance and Reimbursement Guide, which provides a detailed account for connecting patients with valuable resources to reduce the financial burden incurred with cancer treatment. Oncology nurses should provide patients with reputable and reliable financial resources to help them receive the medicines they need and reduce some of the financial toxicity of cancer. These resources extend beyond co-pay assistance and include drug discount cards, rebates, patient advocate programs, aid with housing expenses, and even electric bills for those in need who are actively undergoing cancer treatment (Gilligan et al., 2018; Thomas et al., 2019).
Refer to the Financial Toxicity in Cancer Care NursingCE course for more information.
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