Oncology Nursing Part 2: Chemotherapy and Oncologic Emergencies Nursing CE Course

5.0 ANCC Contact Hours AACN Category A

Syllabus

At the end of this module, the learner will be able to:

  • Recognize the most common side effects of chemotherapy and biologic therapies and discuss the nursing implications of each.
  • Identify the signs of chemotherapy hypersensitivity reaction and cytokine release syndrome, and appropriate nursing interventions for each.
  • Demonstrate understanding of the basic principles of safe handling, administration, storage and disposal of cytotoxic medications.
  • Recognize the signs and symptoms of the most common oncologic emergencies and identify critical management interventions.
  • Describe the nurse’s role in patient education, advocacy, and common ethical/legal issues in cancer care.

Purpose

The purpose of this module is to provide an overview of the field of oncology nursing, outlining the role, responsibilities, and professional performance of the oncology infusion nurse in the administration of chemotherapy. Emphasis is on the nurse's role in symptom management, patient education, and recognition of the critical signs of adverse effects of treatments and oncologic emergencies.

Chemotherapy

Chemotherapy, also called cytotoxic or antineoplastic therapy, encompasses a group of high-risk, hazardous drugs with the intent to destroy as many cancer cells with as minimal effect on healthy cells as possible. Premised on the concepts of cellular kinetics, chemotherapy generally works by interfering with the normal cell cycle, impairing DNA synthesis and cell replication, which thereby prevents cancer cells from dividing, multiplying, and forming into new cancer cells (Yarbro, Wujcik, & Gobel, 2018). Chemotherapy is prescribed with varying intents, so oncology nurses need to understand the rationale for each. Neoadjuvant chemotherapy is given to shrink a tumor so that the primary treatment, usually surgical intervention in these cases, may not need to be as extensive. Adjuvant chemotherapy is given after the primary treatment and aims to prevent recurrence and reduce micro-metastases. For potentially curative treatment regimens, maximum tolerated doses of drugs are delivered on a specific schedule to achieve the greatest efficacy. Chemotherapy may also be used for palliation. Palliative chemotherapy aims to relieve or delay cancer symptoms, focusing on comfort, symptom management, and improving quality of life. Chemoprevention is the use of selected pharmaceutical agents to prevent cancer in high-risk individuals. Myeloablation is the obliteration of bone marrow in preparation for stem cell or bone marrow transplantation with high-dose, intensive chemotherapy (Itano, 2016). Chemotherapy drugs are distributed throughout the body by the bloodstream and have the potential to cause significant morbidity and mortality if not used correctly and cautiously, thereby heightening the critical importance of the oncology nurse's education, training, and chemotherapy certifications. Chemotherapy may be used as a single agent or in combination with other drugs, but it is more commonly used in combination for greater efficacy against cancer and to reduce the potential for drug resistance. While the most common route of chemotherapy administration is intravenous, it may also be administered via other routes, including oral, subcutaneous (injection), intramuscular (injection), intrathecal (directly into central nervous system), intravesicular (directly into the bladder by urinary catheter), or intraperitoneal (infused directly into the intraabdominal cavity) (Itano, 2016). 

Nursing Implications in Chemotherapy Treatment

Administration of IV Chemotherapy

Administering cytotoxic drugs should be viewed more as a process rather than the isolated act of simply administering medications to patients. Oncology nurses are often responsible for the administration of chemotherapy drugs to patients, so they must attain in-depth knowledge and understanding of the mechanism of action and expected side effects of each treatment as it is their duty to ensure that patients receive their chemotherapy treatments safely. Since cancer cells tend to divide rapidly, chemotherapy targets cells that divide quickly. As a result, it also impacts healthy cells that divide quickly, such as those within the gastrointestinal tract, skin/hair cells, and bone marrow (Olsen, LeFebvre, & Brassil, 2019).  This is why the most common chemotherapy side effects include bone marrow suppression, nausea, vomiting, diarrhea, fatigue, hair loss, and mucositis (Itano, 2016). Specialized education, preparation, and training are required for oncology nurses who administer chemotherapy and other hazardous cancer medications to ensure a safe level of care (Nettina, 2019). 

The ONS (2019a) offers the ONS/ONCC Chemotherapy/Immunotherapy Certificate Course and provides current evidence-based resources. The ONS also outlines competencies required for nurses to administer these agents, including in-depth knowledge of cancer medications and infusion therapy practices. The vast majority of accredited cancer centers and hospitals throughout the United States require oncology nurses to hold proper certification before being deemed competent to administer these medications. The ONS provides a standard of care guideline and extensive checklist outlining competencies required for chemotherapy administration certification (ONS, 2016). Also, the American Society of Clinical Oncology's (ASCO) quality oncology practice initiative certification program requires that hospitals, infusion centers, and physician practices comply with safety standards for chemotherapy administration (ASCO, 2019; Neuss et al., 2017). ASCO and ONS conduct ongoing collaborative projects using a rigorous, consensus-based process to develop standards for the safe administration of chemotherapy. The first set of guidelines was published in 2009 and has been revised and updated several times. The most recent set of guidelines were updated in 2016 and address the safety of chemotherapy administration in the outpatient and inpatient settings with the intent to reduce the risk of error and to provide a framework for best practices in cancer care (Neuss et al., 2016). Table 5 provides an overview of the responsibilities of the oncology nurse in the administration of chemotherapy.

Table 5. Standard of Care Guidelines for Administering IV Chemotherapy

Prior to Administration

  • Patient assessment, confirm allergies, and evaluate any preexisting symptoms.
  • Verify signed consent for treatment was obtained and signed by provider and patient.
  • Monitor laboratory values and verify laboratory values within acceptable range for dosing.
  • Take measures to prevent medication errors:

    • Perform independent double-check of original orders with a second chemotherapy-certified RN.
    • Double check for accuracy of treatment regimen, chemotherapy agent, dose, calculations of body surface area, schedule, and route of administration.
  • Recalculate chemotherapy doses independently for accuracy.
  • Verify appropriate pre-medication and pre-hydration orders.
  • Ensure patient education completed and address outstanding patient questions.

Administration

  • Dual nurse verification and sign off at the bedside:

    • Compare original order to dispensed drug label at the bedside with another chemotherapy-certified RN and verify patient identity.
  • Safe handling of hazardous medications; reduce exposure to self and others.
  • Intravenous line management: insertion, evaluation, and assessment.

    • Check patency of IV site for brisk blood return immediately prior to connecting hazardous agent to the patient and as indicated during infusion.
    • Continuous monitoring for infiltration, phlebitis, extravasation, or infection.
  • Continuous patient monitoring for acute/adverse drug effects and allergic reactions.
  • Prompt recognition and management of hypersensitivity reactions.
  • Safe handling and management of chemotherapy spills.

After Administration

  • Flush IV line, ensure brisk blood return prior to removing peripheral IV device, flush/maintain vascular access device according to institution policy.
  • Safe handling and disposal of hazardous waste according to institution policy.
  • Document in medical record the medications given, patient education, and patient response, including any adverse events.
  • Ensure patient has appropriate discharge instructions, anti-nausea medications, and education, and emergency contact information of physician’s office in event of emergency.

(Neuss et al., 2016; ONS, 2016)

Intravenous Access

Chemotherapy agents pose a risk for severe irritation, damage, and injury to the veins and subcutaneous tissue, and therefore, many patients undergo placement of a central venous catheter (i.e., implanted port). A port is a small device that is surgically placed under the skin, usually in the chest wall, to allow for easy access to the bloodstream. Certain chemotherapy medications, such as vesicants, can only be given through a port, as they are too caustic to be delivered through a peripheral vein. Vesicants are drugs that can lead to severe soft tissue necrosis or formation of blisters when they leak or infuse outside the vein and into the soft tissue; called extravasation. A range of symptoms and severity can manifest with a chemotherapy extravasation varies according to the type, amount, and concentration of the drug. The nurse must remain attentive to the appearance and function of the intravenous site (peripheral or implanted port) in which the chemotherapy is infusing, as extravasation requires immediate and urgent action (Kreidieh, Moukadem, & El Saghir, 2016). Initial symptoms of chemotherapy extravasation can include acute burning pain or swelling at the infusion site, but often become increasingly severe in the hours, days, and weeks following the initial injury. Patients may develop blisters, which usually begin within three to five days, and may be followed by peeling or sloughing of the skin with invasion and destruction of deeper structures. Tissue necrosis usually occurs within two to three weeks (Itano, 2016). 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 (Kreidieh et al., 2016). Nurses should counsel patients on the importance of immediately reporting any pain, burning, or other abnormal sensations during the infusion (Olsen et al., 2019). Specific guidelines are in place surrounding the management of peripheral IV sites for chemotherapy, such as location, placement, monitoring parameters, and how often blood return must be evaluated (Itano, 2016). There are also specific guidelines on the management of chemotherapy extravasation, which may include administration of an antidote medication, application of heat or cold to the site, as well as surgery consultation. In general, all chemotherapy agents should be considered irritants, as they all have the potential to cause inflammation, pain, or irritation (Kreidieh et al., 2016).

Chemotherapy Side Effects

Side effects of chemotherapy are inevitable due to the nonspecific nature of cytotoxic therapy and how it simultaneously impacts healthy cells along with cancerous cells. However, not all patients respond in the same way, and not all chemotherapy agents pose the same risks. Assessment and education are the most critical components to ensuring timely recognition, intervention, and management of side effects as experienced by each patient. Specific side effects, such as nausea, can be primarily thwarted by implementing appropriate prevention strategies and medications. Oncology nurses are highly skilled in symptom management through keen assessment, monitoring, and timely intervention (Olsen et al., 2019). Table 6 provides a broad overview of some of the most common chemotherapy side effects and critical teaching points for the nurse.

Table 6. Chemotherapy Side Effect and Key Teaching Points

Side Effects by System

Patient Education - Evidenced-Based Interventions

The oncology nurse should educate the patient to…

Generalized

Fatigue, lack of energy

  • Fatigue during chemotherapy is different from everyday fatigue. Symptoms may include feeling worn out, drained, or an overall lack of energy that does not go away with rest or sleep. 
  • The patient should focus on sleep hygiene. Take short naps as needed, but do not nap for longer than one hour. Long naps make it harder to sleep at night.
  • Cluster activities, and take frequent periods of rest.
  • Consume a well-balanced diet with foods rich in protein, iron, and vitamins and stay adequately hydrated at all times.
  • Engage in light exercise as tolerated throughout the week.

Hematopoietic 

Bone marrow suppression 



 






Neutropenia

  • Abnormally low levels of white blood cells (neutrophils).
  • Absolute neutrophil count (ANC) of 1,500/mm3 or less.
  • High risk for infection when ANC < 500/mm3.
  • The immune system is suppressed, increasing susceptibility to infection, which can rapidly progress to bloodstream infection. 
  • Fever is most the common sign of infection in neutropenic patient.
  • Highest risk for infection is seven to ten days after the last chemotherapy treatment, which is the point where the white blood cells are at their lowest (chemotherapy nadir).
  • The nurse should educate the patient to avoid sick contacts.
  • The best way to prevent infection is routine hand hygiene.
  • Wear a mask when out in the community. 
  • May require an injection to stimulate white blood cell production.

Febrile neutropenia: 

  • Fever in the setting of neutropenia is a medical emergency that can lead to life-threatening sepsis. It requires prompt evaluation, work up, and initiation of empiric antibiotics. 
  • The nurse should encourage patients to immediately report symptoms of fever ≥ 100.4, cough, chest pain, shortness of breath, dysuria. 
  • Implement food preparation, cooking, and storage precautions:

    • Wash fruits/vegetables well to remove germs/pesticides.
    • Avoid eating raw or undercooked food as they may have bacteria that can cause infection.
    • Refrigerate all leftover foods.

Thrombocytopenia

  • Low platelet count (blood clotting factors), risk for bleeding.
  • Risk of bleeding when platelet count < 50,000/mm3.
  • High risk when platelet count < 20,000/mm3.
  • Critical risk when platelet count < 10,000/mm3.
  • May require platelet transfusion when count is < 20,000mm/m3
  • Patients should monitor for signs of bleeding or easy bruising,
  • Use a soft toothbrush, avoid flossing, no contact sports or activities that increase risk for injury, and blow nose gently.
  • Any falls with head trauma must be evaluated by clinician due to risk for hemorrhage in the brain.
  • Avoid blood thinners: aspirin, non-steroidal anti-inflammatory drugs (NSAIDs).
  • Do not use any rectal suppositories and avoid dental work.

Anemia

  • Low red blood cell count, may require red blood cell transfusion or injection of erythropoietin.
  • Symptoms may include: fatigue, weakness, pallor, chest pain, shortness of breath, activity intolerance.
  • Patients should consume an iron-rich diet, take iron supplementation

Integumentary


Alopecia (hair loss), dermatitis/skin rash, folliculitis, 

urticaria (hives), pruritis (itching), nail changes, hyperpigmentation (skin discoloration), radiation recall 

  • Not all chemotherapy agents cause hair loss; usually begins about 7-15 days after the first dose.
  • Patients should be told to avoid harsh shampoos or soaps on bare scalp as these can cause irritation and folliculitis.
  • Wash and clean any lacerations with warm water and soap, cover the area with a clean bandage.
  • Inform doctor or nurse if wound has any signs of infection (redness, swelling, warmth, exudate). 
  • Use mild, moisturizing soap and lotion frequently to reduce skin dryness, itching and irritation. 
  • Avoid showering/bathing with hot water, gently pat skin dry. 
  • Nail changes may occur: disruption of nailbed, nails may become discolored or ridged.
  • Avoid nail salons due to risk for nail infection.
  • Skin darkening may occur and is usually not harmful and does not require intervention.
  • Photosensitivity: educate regarding proper precautions in the sun to avoid sunburn.
  • Radiation recall can occur; usually managed with topical steroids and by discontinuing the offending agent

Gastrointestinal


Nausea,

vomiting, 

diarrhea, constipation, anorexia, mucositis/stomatitis (ulcers in mouth or throughout GI tract), dysgeusia (altered taste), dry mouth,

dyspepsia (heartburn)

  • The nurse should educate the patient to take anti-nausea medications and steroids as prescribed.
  • If eating is difficult, eat small, frequent high-calorie meals and drinks throughout the day instead of three large meals. 
  • Add high-protein shakes and supplements.
  • Avoid foods that are spicy, greasy or have strong odors.
  • Stay adequately hydrated at all times.
  • Add electrolyte sport drinks for oral rehydration and to prevent dehydration due to diarrhea.
  • Report foul-smelling, continuous, liquid stools, as this may indicate a GI infection such as C. difficile.
  • Take loperamide (Imodium) for diarrhea (if approved by provider).
  • For constipation, patients should increase dietary fiber and add stool softener, such as Docusate Sodium (Colace) or laxative, such as Senna (Senokot) as needed.
  • Eat with plastic utensils to help reduce any metallic taste in the mouth. 
  • Avoid alcohol-based mouthwashes due to their drying effects.
  • To preserve the integrity of oral mucosa, patients should rinse mouth with salt water (normal saline solution) often, especially before and after meals to keep mouth clean. 
  • Patients can prepare homemade mouth rinse by mixing 1 cup of warm water with 1⁄2 teaspoon of salt or baking soda. Swish the rinse mouth for at least 30 seconds and spit out. 
  • For painful mouth sores, patients should be given special oral rinses (Magic Mouthwash) which contain topical analgesics to relieve pain

Genitourinary


Acute kidney injury, renal failure, cystitis,

hematuria

  • Encourage patients to stay adequately hydrated at all times to protect the kidneys
  • Urine should be clear to light yellow in color. 
  • Report any blood in urine or any painful urination, flank pain, pelvic pressure, reduced urine output or dark-colored urine.

Neurologic


Peripheral neuropathy (altered sensation in the hands/feet),

central neurotoxicity, ototoxicity (ringing in the ears)

  • It is important for the nurse to encourage all patients to report any symptoms in this category in order to ensure proper assessment and management.
  • Painful neuropathy may require intervention with medication and/or referral to neurologist.
  • Progressive neuropathy may require interruption or discontinuation of offending chemotherapy agent.
  • The patient should take measures to prevent falls: Wear closed toe footwear with rubber soles, non-slip mats in bathroom, remove tripping hazards in home; consider use of cane or other mobility devices to steady oneself when walking.
  • Take caution not to cut or burn oneself when preparing and cooking food, or when handling hot water/coffee.
  • Make sure the water temperature is not too hot while washing dishes or bathing.

Cardiovascular


Weakening of heart muscle, heart failure, venous fibrosis, peripheral edema


  • The nurse should educate all patients to immediately report any symptoms of shortness of breath, leg swelling, chest pain, chest tightness, or finger swelling.
  • Mild leg swelling induced by chemotherapy can be managed with elevating legs above heart level and reducing dietary sodium/salt intake.
  • Assess for signs and symptoms of heart failure or irregular apical or radial pulses.
  • Some cardiotoxic chemotherapy agents require evaluation of baseline cardiac studies (i.e. electrocardiogram, multiple-gated acquisition scan/ejection fraction) before administering such as doxorubicin (Adriamycin) or trastuzumab (Herceptin).


Vascular


Phlebitis, Vein Sclerosis (scarring), Infiltration, Extravasation

  • Nurses should reassure patients that discoloration and erythema at the intravenous site is common. Mild discomfort can be managed by applying warm packs to the affected site for 15 minutes, 4 times daily.
  • Veins may at times become permanently damaged and scarred due to chemotherapy.
  • Advise patients to immediately report pain, burning, swelling, or other abnormal sensation at the IV site.

    • Serious complications include chemotherapy infiltration and extravasation.
    • Prompt recognition and intervention are critical .

Pulmonary


Pulmonary fibrosis, pneumonitis, pulmonary edema


  • Patients at risk for pulmonary complications of chemotherapy include those over age 60, former and current smokers, those receiving or having had pulmonary radiation, or those with any pre-existing lung disease.
  • Certain chemotherapy agents have a high risk for pulmonary toxicity, i.e. bleomycin (Blenoxane), and pulmonary function tests must be performed prior to each treatment, and cumulative dosing must be monitored.
  • The nurse should encourage the patient to immediately report any shortness of breath, fever, productive cough with pink/red mucus, difficulty taking a deep breath, feeling easily winded, or feeling like you are ‘under water’.


Reproductive/Sexuality


Infertility, loss of libido, impotence, erectile dysfunction, amenorrhea, induced premature ovarian failure or early menopause

  • For patients of child bearing age: the nurse should ensure that discussions regarding fertility preservation (egg harvesting or sperm banking) occur prior to starting treatment.
  • The nurse should make referrals to fertility clinics and specialists as indicated.
  • Patients should be told to engage in safe sex practices, such as use of a barrier method (i.e. condom) to avoid exposure to partners during intercourse and prevent pregnancy while on chemotherapy. Chemotherapy can induce significant harm to the fetus.
  • Patients should speak openly with their partner about sexual problems and fears.
  • Females: avoid douching, as well as using soaps, bubble bath and creams that can irritate the vulva and vagina. 
  • Water-based moisturizers may be used for vaginal dryness.
  • Wear cotton underwear, as cotton releases sweat and moisture to reduce the chance of infection. 

Psychiatric

Anxiety, depression, 

anger, fear, grief/loss, body image distortion

  • Symptoms of anxiety and depression are common in patients with complex disease progresses such as cancer.
  • Active listening and empathy are critical skills for oncology nurses.
  • The nurse should assess patient needs and connect to and coordinate referrals to psychosocial services as appropriate: psychiatrist/psychologist, therapist, or social workers.
  • The patient should consider complementary and alternative medicine modalities to reduce anxiety (i.e. imagery, relaxation, reiki therapy).
  • The patient should also consider joining a support group.
  • Antidepressants and anxiolytics may be offered.
  • Light physical exercise can help improve mood through endorphin release.

(Nettina, 2019; Olsen et al., 2019; Polovich, at al., 2014)

Oral Cancer Drugs

An oral cancer drug is any medication taken by mouth (in liquid, tablet, or capsule formulation) to treat cancer. Advancement in cancer treatment has led to the development of many new oral agents to treat cancer, which offers the convenience of taking the medication at home, with less time spent traveling to and from the doctors' offices and clinics. Oral cancer drugs are equally as strong and effective as intravenous or injected agents. Although oral administration offers increased flexibility and convenience for patients, there are several special considerations with oral cancer treatments, as they pose unique safety challenges compared to traditional intravenous therapies. Nurses are a critical part of ensuring that patients have the information necessary to ensure proper drug adherence, as well as safe drug handling and disposal (Olsen et al., 2019). One of the most challenging issues with oral cancer treatment involves poor adherence, which has been consistently reported to have a substantial impact on the success of the treatment, side effects, toxicity, and safety. Oral cancer medications are prescribed at defined intervals based on the mechanism of action of the drug, the drug's half-life (the amount of time it takes for 50% of the drug to be excreted from the body), and side effect profiles (Weingart, Zhang, Sweeney, & Hassett, 2018). Oncology nurses must educate patients to consistently take the medication 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 be harmful, impact the drug's efficacy, or lead to unwarranted 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 these actions can affect how the medication works. Establishing a routine can help keep patients on track with their medication dosing schedule. Some strategies may include pillboxes that are filled each week, setting pill reminders on smartphones or tablets, enrolling in electronic medication reminders through a pharmacy, or using a simple paper pill diary, marking down when the pill was taken to avoid overdosing (Olsen et al., 2019). 

Safe Medication Handling

Oral cancer drugs are potentially hazardous and require special precautions to stay safe when handling, especially for caregivers. As described by the 2016 ASCO and ONS chemotherapy administration safety standards, nurses should educate patients and caregivers on drug safety before oral cancer medications are prescribed. A summary of these key teaching points is highlighted in Table 7 (Neuss et al., 2017).


Table 7. Oral Chemotherapy: Key Teaching Points

The oncology nurse should educate the patient to:

General Safety Guidelines

  • Keep cancer drugs in original packaging until used or placed within the daily pill box.
  • Do not mix chemotherapy medications with other medications in the pill box. They should always remain separate from other medications.
  • Perform hand hygiene (soap and water) before and after handling all medications.
  • Do not let the medication come in contact with household surfaces (countertops, tables). If they do, clean the surface thoroughly to remove all traces of the drug.
  • Store medications in a cool, dry place, away from excess heat or sunlight exposure.

Safe Medication Disposal

  • Never discard cancer medications in household trash, place down the drain, or flush down the toilet. 
  • Ask your provider or pharmacist where to return unused and left-over medication.
  • Empty pill bottles may be put in household trash. Do not recycle the bottles.
  • Never reuse cancer medication pill bottles.

Exposure to household contacts

  • When possible, the patient should handle their medication themselves.
  • If anyone other than the patient comes in contact with cancer pills, wash the affected area with soap and water immediately. If rash/skin changes occur, the patient should contact their provider.
  • Caregivers should transfer the medication into a cup or spoon when handling the medication. If picking up the medication with their hand is unavoidable, wear disposable gloves to prevent any unnecessary exposure (i.e. absorption via the skin).
  • If there is any contact with bodily fluids, household trash should be double-bagged.
  • A small amount of medication may be present the patient’s urine, stool, vomit, or blood. 

    • Caregivers should wear disposable gloves when handling body fluids. 
    • Items soiled with body fluids should be kept in plastic bags until washed.
    • These items should be washed separately from other laundry in hot water.
    • Pregnant women should not come in contact with medications or body fluids.
    • Low-pressure toilets should be double-flushed after each use by patients on oral cancer medications. 

      • The toilet lid should always be closed prior to flushing the toilet.
      • If any fluids splash from the toilet, the surface should be wiped down with disinfectant cleaner (wearing gloves).
      • Take precautions to ensure pets do not drink from the toilet.
  • Gloves should never be re-used. Discard gloves in household trash after one use.

 (Neuss et al., 2017; Olsen et al., 2019)

Biologic Therapies

Biologic therapies is a relatively new sector of cancer treatment that is quickly gaining popularity throughout the cancer community over the last few years. Biologic therapies include several classes of cancer medications, which are broadly categorized into three main groups: targeted therapy, monoclonal antibody therapy, and immunotherapy. These treatment modalities are premised on the concepts of precision medicine, genomic profiling, and using one's immune system to attack cancer. They work very differently than chemotherapy to fight cancer and carry unique side effect profiles. It is critical for the oncology nurse to understand how these medications work, appropriate assessment of side effects and adverse event management, care coordination, and the importance of continuous learning. Even though biologic therapies are not cytotoxic chemotherapy, they are still high-risk, hazardous medications with the potential to induce severe morbidity and mortality if not used correctly and safely. Routine laboratory monitoring, clinical assessment, and symptom management are critical in patients receiving treatment with biologic therapies. See Table 8 below for a brief overview of the mechanism of action and commonly seen adverse effects of the three main groups of biologic therapies (Olsen et al., 2019). 

Table 8. Overview of Biologic Therapies


Targeted Agents

Monoclonal Antibodies

Immune-Based Therapies (Immunotherapies)

Mechanism of action

  • Attacks specific parts of cancer cells
  • Blocks or turns off chemical signals that tell the cancer cell to grow and divide
  • Starves the tumor by cutting off blood supply and/or by preventing the formation of new blood vessels
  • Carries toxins or poison directly to the cancer cells, killing them without harming normal cells
  • Strategically targets receptors, and cells that do not have the target will not be harmed
  • Sole agent or may be combined with toxins, chemotherapy drugs, and/or radiation
  • Can only be given to cancers in which antigens (and the respective antibodies) have been identified
  • Stimulates the body’s own immune system to fight cancer
  • Primes the own immune system to become sensitive to cancer cells by learning how to identify, attack, and kill them
  • Produces antitumor effects through natural host defense mechanisms

Side Effects

Skin rash, pruritus (itching), nausea/vomiting, diarrhea, liver toxicities, renal injury, xerostomia (dry mouth)

Infusion reactions, Flu-like symptoms, rash, pruritus, diarrhea, bleeding, delayed wound healing (patients should avoid surgery 6 weeks prior to/after drug administration due to increased risk)

 

Inflammation of nearly any organ may occur, leading to potentially serious clinical sequelae. 

(Olsen et al., 2019; Miliotou & Papadopoulou, 2018)


Given the tremendous rise in the routine use of these medications, the oncology nurse must also be well versed in the unique side effect profile and potential toxicities of biologic therapies. All adverse reactions and toxicities are graded according to the National Cancer Institute's Common terminology criteria for adverse events (CTCAE) Version 5 (2017) scale and managed per specific medication guidelines put forth through expert consensus and the drug manufacturer’s package insert (NCI, 2017).  Immune checkpoints are proteins that function as ‘brakes' on a normally functioning immune system. Immunotherapies, or immune checkpoint inhibitors, target these proteins to block them, essentially stimulating the immune system to attack the cancer cells by taking the ‘brakes' off. Removing the brakes of the immune system poses a risk for autoimmune-like symptoms or conditions that are centered on inflammation. Inflammation of nearly any organ system may occur and can progress to clinical sequelae that may be life-threatening if not recognized and managed in a timely and effective manner. One example includes inflammation in the gastrointestinal tract (colitis), which may initially present as abdominal pain, cramping, and diarrhea. Untreated, this can become a potentially fatal condition. Other examples include endocrinopathies (adrenal insufficiency, hyperthyroidism/hypothyroidism), pneumonitis (inflammation of the lung tissue), hepatitis (inflammation of the liver), transaminitis (elevation of liver function enzymes), pancreatitis (inflammation of the pancreas), uveitis (inflammation of the eye), and so forth. If diagnosed early, most immune-related adverse events (irAEs) are reversible with interruption of the offending therapy and temporary administration of immunosuppressive agents, such as glucocorticoids. However, toxicities must be graded appropriately, monitored cautiously, and managed per guidelines formulated by manufacturers in collaboration with the FDA. Severe irAEs may require treatment with long-term glucocorticoids, discontinuation of the immunotherapy agent, or additional immunosuppressive agents such as infliximab (Remicade) to control the symptoms (Kumar, et al., 2017).

Hypersensitivity Reactions

A hypersensitivity reaction (HSR) occurs when the immune system is overstimulated by a foreign substance (i.e., chemotherapy) and forms antibodies that cause an immune response. Hypersensitivity reactions can occur with chemotherapy and immune-based therapies. 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 may occur outside of this time frame as well. Oncology nurses must monitor vigilantly for signs of HSR and ensure they are prepared to intervene immediately. Refer to Table 9 for an overview of the clinical manifestations and management of HSRs (Nettina, 2019). Nurses should also be familiar with their own institution's specific chemotherapy HSR protocols and policies for further information and instruction (ONS, 2019a).

Cytokine Release Syndrome (CRS)

Cytokine Release Syndrome (CRS), often referred to as an infusion reaction, is a systemic inflammatory response that can be triggered by certain drugs, such as various biologic therapies. CRS is a symptom complex induced by the rapid release of cytokines from targeted cells in response to cell lysis upon contact with the biologic agent. Clinical manifestations may vary, ranging from mild, flu-like symptoms to severe life-threatening manifestations of the 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 progress to the point of necessitating mechanical ventilation. Patients with severe CRS can display signs of cardiac dysfunction with a reduced ejection fraction. Also, patients with severe CRS frequently display vascular leakage with peripheral and pulmonary edema and renal failure (Shimabukuro-Vornhagen).

Laboratory abnormalities are commonly seen in patients with CRS such as cytopenias (a low white blood cell, red blood cell, and platelet counts), reduced kidney function, elevated liver enzymes, and unbalanced coagulation parameters (Shimabukuro-Vornhagen et al., 2018). To reduce the risk of infusion reactions, particularly fevers, chills and rigors during the infusion, it is generally recommended that patients are pre-medicated with acetaminophen (Tylenol) and an antihistamine, such as diphenhydramine (Benadryl) (Olsen et al., 2019). 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 (Shimabukuro-Vornhagen et al., 2018). Table 9 displays a side-by-side comparison of HSR and CRS.


Table 9. Comparison Chart of the Management of HSR versus CRS


Hypersensitivity Reaction (HSR)

Cytokine Release Syndrome (CRS)

Common Cause

Chemotherapy/cytotoxic therapy

Biologic Agents (most commonly targeted therapies and monoclonal antibodies)

Risks

  • Preexisting allergies to foods, drugs, or bee stings,
  • Prior exposure to the agent,
  • Failure to administer effective prophylactic medications.

Risk Reduction

Pre-medicating patients with a combination of agents, such as corticosteroids, acetaminophen, antihistamines (h1/h2-receptor antagonists)

Safety

The nurse should ensure emergency equipment and medications are always available prior to starting any chemotherapy treatment.

Clinical Signs

  • Initial signs and symptoms can include: hives, urticaria, pruritis, swelling, back pain, facial flushing, rhinitis, abdominal cramping, chills, and anxiety.

 

  • Symptoms may suddenly progress to life-threatening hypotension, wheezing, bronchospasm, stridor, angioedema (swelling of the oral cavity, lips and/or tongue), anaphylaxis, and septic shock. 


  • Mild-moderate reactions may include: fever, shaking chills/rigors, fatigue, headache, rash, arthralgia, and myalgia.
  • Severe reactions include rapid onset of symptoms such as hypotension, high fever, and tachycardia. Can progress to an uncontrolled systemic inflammatory response with circulatory shock requiring vasopressor administration, vascular leakage with pulmonary and peripheral edema, disseminated intravascular coagulation (DIC), ARDS, and/or multi-organ system failure.

Management

The nurse should…

  • Stop the infusion immediately.
  • Maintain the IV line.
  • Administer normal saline.
  • Stay with the patient and have another team member notify the health care provider.
  • Monitor the patient closely, including vital signs, applying supplemental oxygen as needed.
  • Administer emergency medications as indicated and according to institution policy or physician orders (may include antihistamines, corticosteroids, and/or nebulized breathing treatments).


The nurse should…

  • Stop the infusion immediately.
  • Maintain the IV line.
  • Administer additional histamine blockers (antihistamines) as ordered.
  • Observe the patient until symptoms resolve (usually within 30 minutes).
  • Monitor the patient closely, including vital signs, applying supplemental oxygen as needed.
  • Patients enduring shaking chills and rigors may require medication with agents such as meperidine (Demerol) and/or corticosteroids. 
  • Once symptoms have resolved entirely, resume the infusion at a slower rate (usually 50%) and titrate the infusion rate slowly.
  • If severe symptoms of respiratory distress and hypotension occur, notify provider and administer emergency medications as indicated. Restarting the infusion in these patients is contraindicated.


Anaphylaxis

For signs of anaphylaxis (hypotension, bronchial constriction), administer Epinephrine 0.1-0.5 mg (1:10,000 solution for adult patients) via IV push or subcutaneous injection. 

Important note: symptoms of anaphylaxis may recur hours after initial intervention, therefore patients who have experienced a severe reaction must be hospitalized and monitored for at least 24 hours.


(Nettina,2019; Olsen et al., 2019; Shimabukuro-Vornhagen et al., 2018)

Before administering cytotoxic or biology therapy, the nurse should inform the patient and family about the potential for immediate complications. The patient should be instructed to report any signs and symptoms that may be indicative of a hypersensitivity or infusion reaction, including any symptoms of flushing, warmth, chills, itching, redness, discomfort, chest pain, shortness of breath, or nonspecific symptoms such as impending doom or anxiety. While Table 9 (above) provides a guide for the most common signs and symptoms of HSR and CRS reactions, they may also present in a variety of other ways. Therefore, it is essential to educate the patient and family to report any abnormalities during the infusion. Delayed reactions or symptoms occurring after the infusion is completed, and once the patient arrives home, are less common but have been reported (Nettina, 2019; Olsen et al., 2019).

Hormonal Therapy

Some types of cancers are fueled by hormones and are treated with hormonal therapies. Hormonal treatments are targeted agents that work by blocking the hormones from reaching the cancer cells or by preventing the body from producing the hormones altogether (Nettina, 2019). The most common hormone-dependent cancers include breast and prostate but can also include certain uterine, kidney, and ovarian cancer types (Itano, 2016). Side effects of hormonal treatments prominently impact sexual health and the reproductive system, with distinct differences between males and females. Females may experience hot flashes, night sweats, loss of libido, weight gain, vaginal dryness/atrophic vaginitis, joint aches or pains, mood changes, weight gain, and thinning or weakening of the bones (osteopenia or osteoporosis). Men may experience hot flashes, impotence (inability to have or maintain an erection), shrinking of the testicles, and gynecomastia (enlargement of breast tissue). Due to the risk for bone thinning in 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 routine weight-bearing exercises. Patients who are unable to get this recommended amount of calcium in their diet should consider calcium supplementation (Olsen et al., 2019).

Sexual Health and Cancer

Sexual health challenges are common among cancer patients and survivors, as the disease and its treatment can affect patients both physically and emotionally. Sexuality is a difficult topic for many patients to approach, as it is often accompanied by feelings of shame, embarrassment, and anxiety. Cancer patients customarily have many questions, fears, and concerns about their sexuality and impact of cancer treatment on their sexual function, but do not feel comfortable bringing up the topic or asking their oncologist these questions. Oncology nurses often develop strong rapport and therapeutic relationships with cancer patients throughout their disease trajectory and therefore are in unique positions to utilize their role to initiate conversations surrounding sensitive topics such as sexuality. Nurses should approach these topics with empathy, compassion, and without judgment, inviting the patient to feel comfortable in expressing their concerns by asking open, honest questions (Yarbro et al., 2018).

Patients should be counseled on the impact of cancer treatment on their sexuality and should be forewarned that when sexual changes do occur, they typically do not improve right away. Treatment-related sexual changes may be long-term or permanent. Hormonal therapy is often prescribed long-term, with the average duration ranging from 5 to 10 years, but may extend beyond that for those with recurrent, advanced, or Stage IV malignancies. For females of childbearing age or desiring fertility preservation, they must be counseled on the potential for infertility and premature ovarian failure due to chemotherapy and/or hormonal therapy. Patients may endure irregular bleeding while on cancer therapy, but must be advised that it may still be possible to conceive a child on treatment. Pregnancy is contraindicated due to the potential for fetal harm and teratogenicity, and therefore, patients and their partners must be counseled on taking necessary precautions to prevent pregnancy. Females should be counseled on fertility preservation options and referred to reproductive health specialists as indicated. Similarly, males may desire sperm banking before starting therapy (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. Every patient who endures premature menopause as a byproduct of cancer therapy is 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), inducing discomfort and pain during intercourse. Other symptoms include difficulty with sexual arousal, loss of libido, and vasomotor symptoms such as hot flashes and night sweats. Many patients report mood changes due to the abrupt loss of hormones, describing an overt emotional impact with feelings of anxiety, sadness, loss, and a lack of interest in sexual contact with their partners. Males may experience erectile dysfunction, or the inability to achieve or maintain an erection, fertility problems related to low testosterone levels, and premature or delayed ejaculation. Physical deformities, such as Peyronie's disease (curvature of the penis during erection), can occur as a result of 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. The nurse can offer practical, realistic, and cost-effective strategies and interventions to alleviate some of these potential adverse effects or help connect patients with appropriate resources (Yarbro et al., 2018). Table 10 cites some key teaching points and interventions for some of the most common symptoms and sexual alterations experienced by patients with cancer.

Table 10. Sexual Health and Cancer: Key Teaching Points

General Counseling

  • Psychosocial and/or psychosexual counseling should be offered to all patients with cancer, with the goal of improving body image, intimacy, relationship issues, and overall sexual health, function, and satisfaction. Any identifiable medical and treatable contributing factors should be addressed first.

Vaginal Atrophy 

  • Water-based vaginal lubricants, gels, or creams.
  • May be applied 2-3 times a week, regardless of sexual activity. These are estrogen-free and work to help the vaginal tissue regain its natural moisture.  
  • Vaginal estrogen suppository or cream.

Note: vaginal estrogen is largely contraindicated in hormone-driven cancers.

Vaginal Stenosis (loss of elasticity) due to radiation 

  • Vaginal dilator is a tube-shaped device used to stretch the vagina (increase the elasticity of the vaginal mucosa) after radiation therapy.
  • Allows healthcare providers to perform a pelvic exam and reduces discomfort.
  • Lessens discomfort with sexual activity.
  • Prevents vaginal agglutination (adhesion of vaginal labia to each other).

Vasomotor Symptoms 

  • Antidepressants may be used to manage symptoms (i.e. venlafaxine [Effexor]).
  • Treatments that help patients cope with stress and anxiety may help manage hot flashes, such as hypnosis and acupuncture.

Erectile Dysfunction 

  • Oral medications include PDE5 inhibitors such as sildenafil (Viagra) or tadalafil (Cialis) can help.
  • Assistive devices are available for erectile dysfunction that is not responsive to oral medications, such as a vacuum pump device.
  • Address any psychological components that may be contributing.

General Precautions

  • Herbs and dietary supplements should be used with caution.

    • Black cohosh is an herb that is often marketed to women as managing menopausal symptoms, such as reducing hot flashes. However, this drug should not be taken by women who have estrogen-receptor-positive (hormone positive) cancers as it may have estrogenic effects.
  • Avoid petroleum jelly-based products (Vaseline) or skin lotion as a lubricant for the vagina or penis. These can damage condoms and may raise the risk of yeast infection.
  • Avoid vaginal lubricants, gels, or creams that contain fragrances, flavors or herbal ingredients as these can be irritating to the vaginal mucosa.

(DeVita et al., 2015; Yarbro et al., 2018)

Safety and Exposure 

In addition to patient safety, cytotoxic drugs can be equally hazardous to nurses and other health care workers, so it is critical to adhere to standards and practices of hazardous drug handling to minimize any occupational exposure (ONS, 2016; ONS, 2019a). Exposure to hazardous medication is linked to an increased risk for several types of malignancies, and exposure can occur through various sources, including workplace surface contamination (Polovich et al., 2014). According to the 2016 updated ASCO and ONS chemotherapy administration safety standards as outlined by Neuss and colleagues (2017), nurses must wear appropriate personal protective equipment whenever there is a risk of chemotherapy being released into the environment such as during preparation or mixing of chemotherapy, spiking/priming of IV tubing, administering the drug, and when 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, as these individuals should not be handling hazardous medications such as chemotherapy. 

Chemotherapy medications must be mixed, spiked/primed under an approved filtered hood to reduce the risk of aerosolized exposure. Gloves that have been tested for use with hazardous drugs are required, and the reuse of 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, which should be 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 specially-marked hazardous waste bags. If any chemotherapy medication were to spill on clothes in the clinic, clothing should be thrown away or double-bagged in a plastic bag sealed for transport home. The clothing must then be washed separately in hot water with regular detergent (Neuss et al., 2017). 

The ONS (2016) has standards that address the education of nurses who administer and care for patients receiving chemotherapy, biotherapy, and immunotherapy agents. The standards support the registered nurse (RN) as the minimum appropriate licensure for nurses who 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, 2019a). However, each institution or practice must determine how it will assess nursing competence in performing various chemotherapy-related skills (ONS, 2016).

Nursing Implications in Oncologic Emergencies 

Early recognition and prompt intervention of oncologic emergencies are critical to the quality of life and survival of cancer patients. The symptoms of oncologic emergencies may be obvious or subtle in presentation and may be overlooked, contributing to increased morbidity and mortality. Oncology nurses are vital to improving patient outcomes when an oncologic emergency occurs, as devastating functional losses may be limited, quality of life may be preserved, and the actions of skilled nurses can thwart progression to a life-threatening emergency. Eight of the most common oncologic emergencies are outlined below in Table 11. 

Table 11. Oncologic Emergencies

Hypercalcemia of Malignancy (HCM)

  • This is a complex metabolic disorder resulting from destruction of bone and/or elevated renal absorption of calcium.
  • It is one of the most common life-threatening complications of malignancy. Found most commonly in solid tumors, especially breast cancer, squamous cell lung cancer, and multiple myeloma.
  • Symptoms: usually vague; anorexia, nausea, vomiting, constipation, malaise, polyuria, polydipsia, lethargy, confusion, coma
  • Treatment: Initial management involves aggressive IV fluid administration, followed by use of loop diuretics and administration of bisphosphonates, which are bone modifying agents that lower calcium levels by inhibiting osteoclasts and stabilizing bone matrix by binding to calcium phosphate.

Spinal Cord Compression (SCC)

  • Compression of the spinal cord by malignant tumor invasion into the epidural space.
  • Most common cause is metastatic tumor invasion into the spine. The thoracic spine is the most frequent site of metastases that cause SCC, but they may occur at any level.
  • Preferred diagnostic studies: Plain x-ray films initially, then bone scan, MRI, or CT scan 
  • Symptoms: back pain that worsens in the supine recumbent position and may be relieved by sitting, neurologic dysfunction such as numbness, passing very little urine or unable to urinate, incontinence (bladder or bowel), constipation, difficulty ambulating, unsteady gait
  • Treatment: Initial treatment is critical and involves administration of corticosteroids to reduce vasogenic edema in the spinal cord, thereby improving neurologic dysfunction and relieving pain, followed by definitive treatment with either radiation therapy or surgery.

Cardiac Tamponade

  • Extensive fluid can accumulate in the pericardial sac surrounding the heart and exert extrinsic pressure on the cardiac chambers, obstructing the flow of blood into the ventricles, interfering with cardiac function, and leading to decreased cardiac output and decreased systemic perfusion.
  • The most common cause is lymphoma.
  • Symptoms: palpitations, muffled heart rate, premature ventricular contractions (PVCs), tachycardia, confusion, hypotension, dyspnea/shortness of breath, lightheadedness, fainting, restlessness and anxiety, sharp chest pain radiating to the neck, shoulders or back, or swelling in the extremities
  • Treatment: pericardiocentesis (removal of pericardial fluid) and restoration of hemodynamic stability through administration of intravenous fluid, blood, and plasma.

Superior Vena Cava Syndrome (SVCS)

  • SVCS results from compression of the superior vena cava by a nearby tumor or enlarged lymph nodes, or as a result of intrinsic obstruction by thrombosis or tumor growth within the vein itself.
  • The most common causes include non-Hodgkin’s lymphoma and advanced lung cancer.
  • Preferred diagnostic studies include MRI or CT scan.
  • Symptoms: jugular vein distention, swelling of the face, neck, and upper thorax due to decreased circulation, dyspnea, tachycardia, and a ruddy facial complexion.
  • Treatment: Goal is to treat (shrink) the underlying disease with chemotherapy or radiation.

Disseminated Intravascular Coagulation (DIC)

  • DIC involves extensive triggering of the coagulation system, resulting in abnormal activation of thrombin formation; clotting factors are depleted and fibrinolysis and clotting pathways continue at rapid rates.
  • The most common causes in cancer patients include infection and sepsis, acute leukemias, and certain mucin-producing adenocarcinomas.
  • Preferred diagnostic tests include D-dimer assay and fibrinogen degradation products (FDP) titer.
  • Symptoms: bleeding from at least 3 unrelated sites (such as gums, blood in urine or stool, nosebleeds, hemoptysis), seizures, hallucinations, shortness of breath, easy bruising, pallor, petechiae, blood clots, hypoxia, shortness of breath, or fever.
  • Treatment: primary management is to treat the underlying cause while managing the acute symptoms.

Tumor Lysis Syndrome (TLS)

  • TLS is a group of metabolic abnormalities that occur as a complication of administering chemotherapy, where large amounts of tumor cells are killed at the same time. They release their contents (potassium, uric acid, phosphorus) into the bloodstream, inducing a constellation of electrolyte imbalances (hyperkalemia, hyperphosphatemia, and hyperuricemia), which leads to serious consequences such as renal failure and alterations in cardiac function.
  • TLS most commonly occurs due to treatment of lymphomas and leukemias that are rapidly dividing, have a high disease burden, and large bulky disease.
  • Hyperkalemia is usually the initial symptom and is the most life-threatening aspect of TLS.
  • Symptoms: nausea, vomiting, diarrhea, muscle cramps, numbness, tingling, twitching, decreased urination, restlessness, irritability, confusion, weakness, or fatigue.
  • Prevention is key: the nurse should ensure adequate pre-hydration (to optimize renal function) and initiate allopurinol (to prevent the build-up of uric acid) prior to starting chemotherapy.
  • Treatment incudes correct electrolyte imbalances, cardiac monitoring, hydration, and supportive medications as indicated.

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

  • Otherwise referred to as ‘water intoxication’, this endocrine disorder is characterized by the abnormal production and secretion of antidiuretic hormone (ADH), which causes disturbances in normal fluid and electrolyte balance. The kidney absorbs free water despite normal intravascular osmolality and blood volume, inducing low serum sodium levels (hyponatremia) and inappropriately concentrated urine. Free water in the body is distributed into vascular spaces, diluting plasma and causing hypoosmolality and hyponatremia.
  • The most common cause is small cell lung cancer but may also be medication-induced.
  • Symptoms: hyponatremia and associated symptoms of headache, nausea, vomiting, confusion, cerebral edema, seizures, coma, brain stem herniation, respiratory arrest, or death.
  • Treatment: identify and treat underlying etiology to correct the hyponatremia: restrict fluids, treat the cancer, or withdraw the offending medication agent.

Febrile Neutropenia 

  • One of most common oncologic emergencies, febrile neutropenia occurs during chemotherapy when the immune system is suppressed, which allows bacteria to invade the body. The degree of neutropenia ranges between mild, moderate, severe, and profound.
  • It is most common 7-10 days after cytotoxic chemotherapy administration when the blood counts reach their nadir.
  • Symptoms: fever of 100.4 or greater, hypotension, tachycardia, dysuria, or any other sign of infection, including altered mental status/confusion.
  • Treatment: blood cultures (usually 2 sets of blood cultures), chest x-ray, urine culture, blood work (including complete blood count (CBC), culture of any implanted lines, tubes, drains, or open wounds and initiation of empiric antibiotic coverage until culture results are available, along with supportive therapies (hydration, medications to maintain blood pressure, etc.).
  • Without treatment, febrile neutropenia can rapidly progress to life-threatening bacteremia and sepsis.

(Kaplan, 2018; Klemencic & Perkins, 2019)

Clinical Trials

Cancer clinical trials are the basis for demonstrating the effectiveness of new ways to prevent, diagnose, and treat patients with cancer. Clinical trials are the foundation for innovative drug development, bringing forth new treatment regimens, and providing participants with early access to promising interventions (Flocke et al., 2017). The role of the oncology nurse in clinical trials is multifaceted as the nurse needs to ensure informed consent has been obtained, assess the patient's level of understanding, ensure clarity of all information, and help the patient navigate through the process. Above all, the nurse's primary responsibility in clinical trials is to advocate for the patient. 

Survivorship Care 

A patient-centered approach to cancer survivorship is at the forefront of accreditation standards for comprehensive cancer programs as mandated by the Commission on Cancer (CoC) of the American College of Surgeons (2019). There is a national target toward ensuring survivorship care planning becomes the standard of care for all patients since the Institute of Medicine (IOM)'s 2006 report—From Cancer Patient to Cancer Survivor: Lost in Transition. The report exposed the unmet needs of a growing population of cancer survivors, endorsing a call to action for every survivor to receive an individualized post-treatment care plan (IOM, 2006). Composed of guidelines for monitoring and maintaining health, the intent of survivorship care planning is to improve the quality of care and long-term outcomes of survivors, with recommendations that sharply accentuate the need for survivors to maintain a healthy weight, consume a well-balanced diet, and engage in regular physical exercise; regardless of tumor type (ASCO, 2017). 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 (Basen-Engquist et al., 2018). It has taken more than a decade for this standard to come to fruition and the need has multiplied as the population of cancer survivors in the U.S. has grown from 10 million to 16.9 million; which now represents 5% of the population. The number of cancer survivors is expected to grow to 21.7 million by 2029 and 26.1 million by 2040 (ACS, 2019). In 2017, the CoC issued the following statement: "Effective December 11, 2017, required for CoC-compliance with Standard 3.3, all CoC-accredited programs will be expected to meet or exceed the delivery of survivorship care plans to 50% of eligible patients by the end of 2018" (American College of Surgeons, 2019)In 2018, the CoC issued an updated statement increasing the percentage of survivorship care plans to 75% of eligible patients; required for institutions to earn and/or maintain their CoC-accreditation (American College of Surgeons, 2019). 

Survivorship care is the process of learning how to live with cancer and beyond. The goals of cancer survivorship focus on the prevention of recurrent and new cancers, the 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 oncologist, specialty providers, and primary care physicians (ASCO, 2019). There is a compelling body of evidence to support the critical need for lifestyle modifications and weight loss in the cancer population, yet research consistently describes a knowledge deficit in both the public and patients regarding the detrimental relationship between cancer and excess fat tissue. Survey studies have demonstrated that the majority of adults in the U.S. are not aware of obesity-associated risks contributing to cancer development. Since obesity is correlated with increased risk for many cancers, and body weight is modifiable, there is the potential for cancer prevention and improved long-term survival (Lennon, Sperrin, Badrick, & Renehan, 2016). Cancer Survivorship Care Planning continues to emphasize the importance of incorporating weight management efforts throughout cancer care, yet obesity remains inadequately addressed in the clinical setting (ASCO, 2017). Studies have shown that cancer patients do not routinely receive any counseling and education regarding the impact of obesity and the dire need for weight loss. Therein lays a tremendous opportunity for obesity to be addressed during patient interactions, starting at screening and continuing through diagnosis, treatment, and long-term follow-up. Oncology nurses are in a unique position to use the diagnosis and treatment of cancer as an opportunity to educate patients on cancer survivorship proactively, initiate healthy lifestyle counseling and guide patients on interventions focused on cancer prevention. Many patients have difficulty adjusting to life after cancer treatment, as many struggle with the physical and psychological consequences of cancer treatment. Nurses should provide education regarding the signs and symptoms of cancer recurrence, identification of late side effects, and information on how to adopt healthier lifestyles. The nurse can also help coordinate referrals to specialists as needed and ensure the patient's primary care physician receives a copy of the survivorship care plan to promote continuity of care within the patient's healthcare community. Further, as the obesity epidemic continues to expand, interventions must be developed to help patients understand the colossal impact obesity has on overall health outcomes to motivate change (WHO, 2016). As we celebrate the successes in cancer treatment, we 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 (Basen-Engquist et al., 2018). 

Palliative Cancer Care and Hospice Care

There are several misconceptions regarding the distinctions between the terms ‘palliative care' and ‘hospice care,' as they are often mistakenly viewed as synonyms. Palliative cancer care is an approach to care that addresses the person as a whole, striving to promote quality of life and relieve suffering throughout the disease trajectory; not just at the end of life (Nettina, 2019). While palliative care does not focus on treating the cancer itself, it is recommended as a standard part of care for all cancer patients and should be initiated as early as possible in the course of a cancer diagnosis; used in conjunction with the cancer treatment. The supreme goal is to prevent or manage the symptoms and side effects of cancer and its treatment, to provide comfort and maintain the highest possible quality of life for as long as possible. It also focuses on addressing and alleviating any related psychological, social, and spiritual problems (Kaasa et al., 2018). Whereas palliative can begin at any point along the cancer care continuum, hospice care begins when curative treatment is no longer the goal of care, and the sole focus is on quality of life and comfort through the end of life. Hospice eligibility generally begins only when a patient has a life expectancy of 6 months or less, and focuses solely on care at the end of life, with the terminal goal being a comfortable, peaceful, and pain-free death. However, despite the distinct differences between the two domains of care, there is also some overlap between palliative care and hospice care (Nettina, 2019). Palliative care can help patients and their loved ones make the transition from treatment meant to cure or control the disease to hospice care by preparing them for physical changes that may occur near the end of life, helping them cope with the different concerns and emotional issues that arise, and provide support for family members. Early referrals of patients to palliative care and hospice care not only improve patient's symptoms and quality of life but also improves survival (Kaasa et al., 2018).

Nursing Implications at the End of Life

The oncology nurse serves a fundamental role in ensuring symptoms are managed throughout the cancer continuum, connecting patients to necessary resources, and implementing measures to promote quality of life. Nurses also play enormous roles in ensuring a patient advocates for themselves and their wishes. Oncologists and nurses need to have open and frank discussions with patients about their preferences regarding end-of-life care. End-of-life issues must be addressed early on in the patient's treatment, readdressed as the patient's clinical status changes, and premised on the patient's goals of care. It is ideal to avoid having this discussion during a life-threatening event when the patient and family are distressed and feel pressured and rushed to decide. Oncology nurses are essential drivers of these conversations and should encourage patients to express their preferences about end-of-life care to their medical team, physicians, family members, caregivers, and loved ones in the form of legal documentation, such as advance directives, medical orders for life-sustaining treatment, health care proxy, and durable power of attorney. Oncology nurses bridge communication between team members and family members, so the oncology nurse must acquire practical communication skills to navigate these conversations. The nurse should make referrals for respite care, counseling, pastoral care, and bereavement services, assisting patients and families with decisions for withholding or withdrawing life-sustaining therapies. Oncology nurses are critical in educating patients and families about these vital decisions, explaining options, and ensuring decisions are aligned with the patient's goals of care (Coyle et al., 2016).

The Financial Burden of Cancer Care

Beyond the sweeping life impacts of a cancer diagnosis, it has become equally financially catastrophic for patients and families due to the high cost of treatment. As new targeted oral agents and progressive drugs become increasingly prominent, so does the cost. One of the most significant barriers to successful cancer treatment today often isn't the existence of the right treatment, but the patient's access to it; and access is often limited based on cost. Oral therapies offer several advantages over traditional intravenous therapies and should be less expensive due to the lower cost associated with self-administration of the medication, yet the opposite is true. Oral cancer drugs are highly expensive and may not be covered entirely by insurance and prescription plans. The financial burden is one of the most common reasons for noncompliance with oral medications among cancer patients (Kaisaeng, Harpe, & Carroll, 2014). The majority of private insurers treat oral anti-cancer medications as a prescription drug benefit, using a 'tiered' structure that increases the patient's cost-sharing responsibility as the price of the medication increases (Kirchner et al., 2016). As a result, patients on oral anti-cancer treatment are routinely faced with unreasonable out-of-pocket costs, and often have to decide between financial ruin and continued treatment. The economic burden of oral cancer treatment leads to delays in treatment initiation, contribute to patient non-adherence and noncompliance with medication dosing, and lead to premature discontinuation of treatment, which has negative consequences on treatment benefit, quality of life, and survival (Paolella et al., 2018). Studies show that many cancer patients opt to forego treatment altogether due to the substantial cost burden and the inability to afford it (Kircher et al., 2016). Up to 50% of patients abandon cancer therapy when out-of-pocket costs reach more than $2,000 which is not uncommon (Dusetzina, Winn, Avel, Huskamp, & Keating, 2014). In stark contrast, insurers routinely cover the cost of intravenous chemotherapy received on an outpatient basis as part of the patient's medical benefits coverage, and the cost is usually the co-pay for an office, averaging $20 to $50. 

Oncology nurses should encourage patients to speak to their healthcare providers if they are having difficulty affording their medication before stopping. Some manufacturers offer co-pay assistance programs or have grants to fund free-drug/compassionate use programs. Some states have passed laws that require insurance companies to cover oral cancer medications in the same way they would cover intravenous cancer treatments. Oncology nurses should help patients fight high medical costs by connecting them with available resources. The Association of Community Cancer Centers (ACCC, 2019) has published The Patient Assistance and Reimbursement Guide, which provides a detailed account for connecting patients with valuable resources to help reduce the financial burden incurred with cancer treatment. Oncology nurses should provide patients with reputable and reliable financial resources to help them receive the treatments 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 (Christensen, 2017).

Ethical and Legal Issues in Cancer Care

Oncology nurses have several ethical, legal, and professional responsibilities with regard to caring for cancer patients. Nurses must ensure patient safety, protect patients from harm, double-check hazardous medications for errors, and adhere to all the guidelines of safe handling, delivery, and disposal of cytotoxic drugs. Nurses have a right to feel competent in their roles and the procedures laid down by the organization within which they work. Nurses are ethically and morally bound by their role in advocacy; protecting patients' rights, 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 emotionally taxing field of medicine. They must support patients in their decisions, despite their own beliefs, and this may include communicating patient’s wishes to family members who disagree. Oncology nurses must engage in collaboration and shared decision making with the oncology team, as these partnerships are essential for successful outcomes. Oncology nurses support patients with their decisions for end-of-life and hospice care; serving as champions for patients and families opting to forgo further treatment. Oncology nurses promote the decision to transition to hospice as courageous and brave; not a sign of ‘giving up' (Coyle et al., 2016).

Continuing education is essential for nurses to remain current on evidence-based practice, reduce legal liability, and provide high-quality care. Oncology nurses face various legal and ethical dilemmas when delivering care, particularly in our present century of evolving technological advancements, high emphasis on technology and electronic health records, changing state and federal laws, and the expanding cancer survivorship population. Therefore, the ethical and legal issues oncology nurses will encounter when caring for patients will continue to evolve alongside these changes. However, despite changes to come, oncology nurses must remain grounded in their skills, education, and practice. Some common ethical dilemmas faced by oncology nurses may include: medical treatment that extends life without considering its quality, disparities in wishes or goals of care between the patient and family, caring for patients who opt for a risky decision, fertility preservation, pain management at the end of life, and withdrawing care (Lievrouw et al., 2016). Many cancer centers and hospitals have ethics committees and ethics consultation services to assist staff, patients, and families work through these scenarios. Multidisciplinary committees can offer unique views to every situation that includes ethical questions. Ethics rounds and nursing ethics committees also are opportunities for healthcare providers to discuss morally distressing situations and to identify strategies for coping. Ethical principles can be a source of guidance for oncology nurses as they navigate through complicated clinical dilemmas. 

Closing Thoughts

For more information on cancer and a detailed review of the pharmacology of various oral and intravenous cancer treatment modalities, including chemotherapy, targeted agents, biologic and immune-mediated therapies, hormonal treatments, and chemoprevention, please refer to the module, Oncology Prescribing: An Overview of Oral and Intravenous Cancer Treatment Modalities, which includes 7.0 ANCC contact hours.

Oncology Nursing References

American Cancer Society. (2018a). Cancer Statistics Center. Retrieved from https://cancerstatisticscenter.cancer.org/

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