Managing toxicities and adverse events (AEs) so that patients can continue to stay on effective treatments is essential to improving outcomes.

Catherine Hill, BSN, RN, OCN®, at the James Radiation Oncology Clinic in Columbus, OH, Margaret Blaney, RN, BSN, at the University of Rochester Medical Center in New York; Ashley Layton, BSN, RN, OCN®, at the University of Pittsburgh Medical Center (UPMC) at Shadyside Hospital in Pennsylvania; and Kaddie Lopez, BSN, RN, OCN®, PHN, at the City of Hope National Medical Center in Duarte, CA, discussed ways to manage and prevent symptoms in cancer care during a session at the 43rd Annual Congress in Washington, DC.

Alternative Pain Relief for Brachytherapy

Hill discussed the symptoms associated with brachytherapy and cervical cancer, specifically cramping, visceral pain, and lumbar pain. She said that 40% of women who undergo brachytherapy develop post-traumatic stress disorder (PTSD) because of the intimate nature of the treatment. She reported that aromatherapy and foot reflexology could improve pain and anxiety in patients receiving brachytherapy, when combined with standard care.

Hill cited a 2015–2016 study of 49 patients receiving brachytherapy, where pain and anxiety medications were administered in addition to anesthesia for the first fraction. The medications included:

  • Lorazepam
  • Morphine sulfate
  • Ketorolac
  • Hydromorphone
  • Hydrocodone
  • Oxycodone

In the study, patients had the option to pick their aromatherapy scent (i.e., lemon, lavender, or peppermint). Patients were also offered reflexology, the use of manual techniques on points of the feet for pain relief.

Patients were given assessment tools to share their experiences with aromatherapy and reflexology. The findings showed that using aromatherapy and reflexology helped manage pain and improve patient outcomes.

The use of these types of nonpharmacologic interventions is relatively inexpensive to supply and should be considered in practice, Hill said.

Patient Education for CAR T-Cell Therapy

Blaney outlined chimeric antigen receptor (CAR) T-cell therapy and the development of education and guidelines for immune effector cell administration.

Immune effector cell therapy uses the power of a patient’s own immune system to combat disease. T cells are collected and genetically engineered in a laboratory to recognize and attack tumors by producing special receptors on their surface, called CARs, then infused back into the patient.

To properly administer cellular therapy, Blaney said providers need to abide by all federal and state regulations and develop practice standards to support the therapy. The blood and marrow transplant (BMT) program took it a step further, and had in place:

  • An adherence to federal, state, and Foundation for the Accreditation of Cellular Therapy regulations
  • High quality care practices
  • Care standards
  • Staff educated in cellular therapy administration

To develop standards of care, BMT and lymphoma teams should collaborate in creating training protocols, institutional guidelines, and education for other services.

In terms of the management of toxicities, Blaney noted that some AEs are similar to those that patients may experience with BMT, including neutropenic fever, sepsis, and thrombocytopenia. However, some AEs are very specific to CAR T-cell therapy and include cytokine release syndrome (CRS) and neurotoxicity. For CRS, treatment is dependent on a grading assessment (see Table 1). Additionally, even when AEs seem similar to those from other treatments (e.g., BMT, chemotherapy), they must be managed very differently when caused by immunotherapies such as CAR T-cell therapy.

“The severity of AEs can be quite upsetting for patients and families,” Blaney added.

Oral Mucositis Prevention

Layton reported the results of a study of patients who received a hematopoietic stem cell transplant (HSCT) and how using low-level laser therapy (LLLT) could prevent oral mucositis (OM). Oral mucositis is a very common, but very painful, complication of cancer treatment—particularly with HSCT. OM can create problems for patients by delaying treatment, increasing cost of care, and impacting patient survival.

In May 2014, the Multinational Association of Supportive Care in Care/International Society of Oral Oncology (MASCC/ISOO) released new recommendations were released that explained the benefit of using LLLT to prevent OM in patients receiving stem cell transplantations:

  • Increasing endorphins to reduce pain
  • Reducing inflammation via reduction in interleukin‐1 and C‐reactive protein
  • Promoting tissue healing through increased neovascularization and macrophage activity

Layton said that 97% of patients receiving busulfan will experience OM. The study measured the effect of preventative LLLT in a group of 19 patients who received busulfan. Each patient’s OM toxicity level and need for a patient-controlled analgesic (PCA) were measured. The study had LLLT treatments administered on Mondays, Wednesdays, and Fridays (MWFs). If busulfan was administered on any other day of the week, LLLT treatment was initiated the following MWF closest to the first day of busulfan administration. Patients also practiced proper oral hygiene, which included a saline swish after each meal and before bedtime, the use of sodium bicarbonate toothpaste, and mouth inspections.

Results showed that six patients (33.3%) required a PCA for pain control and that LLLT prevented OM in patients.

 “As with everything, we did notice a few challenges,” including clinician confusion between esophagitis and OM, the difficulty determining toxicity grading from RN to RN, and clinician difficulty identifying thrush versus OM, Layton said.

Chemo-Induced Alopecia Prevention

Chemo-induced alopecia (CIA) is caused by damage to the hair follicles from specific chemotherapies and continues to be a well-known and highly publicized potential AE of chemotherapy treatment, Lopez explained in her presentation.

Scalp hypothermia is used to prevent hair loss by cooling or freezing the scalp during chemotherapy infusion to prevent tissue damage. Companies provide various methods to administer the treatment, and the cost is 100% out-of-pocket, Lopez said.

To test the effectiveness of scalp cooling, Lopez and colleagues studied its use in infusion rooms; 64% of participants lost less than 50% of hair with scalp cooling, but “more research should be done to gauge treatment effectiveness,” she added.

Table 1. Cytokine Release Syndrome Grading Assessment


Presence of Extensive Comorbidities or Older Age


Grade 1:

• Fever (defined as ≥ 38.3°C)

• Constitutional symptoms


  • Vigilant supportive care
  • Assess for infection
  • Treat fever and neutropenia if present, monitor fluid balance, use antipyretics or analgesics as needed

Grade 2:

• Hypotension: responds to fluids or one low dose


• Hypoxia: responds to less than 40% oxygen

• Organ toxicity: grade 2


• All of the treatments for grade 1, as well as:

    • Monitor organ function closely
    • Monitor with continuous cardiac telemetry and pulse oximetry

Grade 2:

• Hypotension: responds to fluids or one low dose


• Hypoxia: responds to less than 40% oxygen

• Organ toxicity: grade 2


• All of the treatments for grade 2 with no comorbidities or older age, as well as:

    • Consider tocilizumab (8 mg/kg, not to exceed 800 mg) with or without corticosteroids (e.g., methylprednisolone 1 mg/kg twice daily or dexamethasone 10 mg every six hours)

Grade 3:

• Hypotension: requires multiple vasopressors or

high dose vasopressors A

• Hypoxia: requires more than 40% oxygen

• Organ toxicity: grade 3 or grade 4 transaminitis


• All of the treatments for grade 2, as well as:

    • Consider tocilizumab (8 mg/kg, not to exceed 800 mg) with or without corticosteroids (e.g., methylprednisolone 1 mg/kg twice daily or dexamethasone 10 mg every six hours)

Grade 4

• Mechanical ventilation

• Organ toxicity: grade 4 excluding transaminitis


  • All of the treatments for grade 3, as well as:
    • Corticosteroids (e.g., methylprednisolone 1 g/day for three days, followed by a rapid taper consisting of 250 mg twice a day for two days, 125 mg twice a day for two days and then 60 mg twice a day for two days)