About this course:
The purpose of this activity is to enable the learner to acquire a better understanding 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.
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.
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, 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
(Neuss et al., 2016; ONS, 2016)
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…
Fatigue, lack of energy
Bone marrow suppression
Alopecia (hair loss), dermatitis/skin rash, folliculitis,
urticaria (hives), pruritis (itching), nail changes, hyperpigmentation (skin discoloration), radiation recall
diarrhea, constipation, anorexia, mucositis/stomatitis (ulcers in mouth or throughout GI tract), dysgeusia (altered taste), dry mouth,
Acute kidney injury, renal failure, cystitis,
Peripheral neuropathy (altered sensation in the hands/feet),
central neurotoxicity, ototoxicity (ringing in the ears)
Weakening of heart muscle, heart failure, venous fibrosis, peripheral edema
Phlebitis, Vein Sclerosis (scarring), Infiltration, Extravasation
Pulmonary fibrosis, pneumonitis, pulmonary edema
Infertility, loss of libido, impotence, erectile dysfunction, amenorrhea, induced premature ovarian failure or early menopause
anger, fear, grief/loss, body image distortion
(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
Safe Medication Disposal
Exposure to household contacts
(Neuss et al., 2017; Olsen et al., 2019)
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
Immune-Based Therapies (Immunotherapies)
Mechanism of action
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).
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)
Biologic Agents (most commonly targeted therapies and monoclonal antibodies)
Pre-medicating patients with a combination of agents, such as corticosteroids, acetaminophen, antihistamines (h1/h2-receptor antagonists)
The nurse should ensure emergency equipment and medications are always available prior to starting any chemotherapy treatment.
The nurse should…
The nurse should…
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).
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
Note: vaginal estrogen is largely contraindicated in hormone-driven cancers.
Vaginal Stenosis (loss of elasticity) due to radiation
(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)
Spinal Cord Compression (SCC)
Superior Vena Cava Syndrome (SVCS)
Disseminated Intravascular Coagulation (DIC)
Tumor Lysis Syndrome (TLS)
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
(Kaplan, 2018; Klemencic & Perkins, 2019)
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.
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.
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.
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