Included in the treatment plan for approximately 50% of all patients with cancer, radiotherapy (RT) is a significant component of cancer care. RT is a technology-driven oncology modality, which means it has continually evolved since being introduced in cancer care in the early 20th century.
Recent decades have brought significant improvements to RT, and two ONS members explained what all oncology nurses need to understand about the new therapies and those coming down the pike.
A Consistent Evolution
“I have been in radiation oncology since 2007 and have witnessed the evolution of technology, which has improved our treatment techniques resulting in better patient outcomes and decreased side effects,” ONS member William (Trey) Woods, III, MSN, NP-C, faculty administrator and instructor of radiation oncology at the University of Mississippi Medical Center (UMMC) in Jackson and member of the ONS Central Mississippi Chapter, said.
Woods pointed out the shift toward hypofractionation, which now delivers the same treatments in fewer (sometimes single) doses with the same or fewer side effects.
ONS member Dorothy Pierce, DNP, NP-C, CRN, nurse practitioner of radiation oncology at Rutgers University Cancer Institute of New Jersey and member of the ONS Central New Jersey Chapter, listed the innovative methods and devices for administering RT that she’s seen during her career:
- Gamma knife
- Proton therapy
- Stereotactic body RT
- Image-guided RT
- Improved dose planning
“Experts in the field are constantly looking at new, innovative technology and treatment techniques to become more efficient and improve patient outcomes,” Woods said. “At UMMC, we are currently exploring how we can use machine learning and technology to improve the treatment planning and delivery process. Education is also integrated into our clinical mission and reflected in multidisciplinary tumor boards and patient teaching.”
One of the most novel treatments in RT is lutetium lu-177, an internal (radiopharmaceutical) targeted radioactive therapy approved by the U.S. Food and Drug Administration in 2018 for gastroenteropancreatic neuroendocrine tumors. Pierce’s institution offers lutetium lu-177 treatments. However, she said that the drug presents some challenges and special considerations.
Before implementation, the medical oncology department, radiation safety officer, nuclear medicine radiologist, nurses, lead nuclear technologist, and pharmaceutical representative conduct multiple meetings. Pierce also said that because of the risk to a developing fetus, prior to starting radiopharmaceuticals, women of childbearing potential must have their pregnancy status confirmed and agree to use contraception throughout treatment and for four months after the last dose. Additionally, laboratory studies conducted at four weeks and one week prior to treatment must assess kidney function to ensure patients are able to excrete the drug from their system. Patients with any issues related to urinary incontinence must be evaluated before the day of the procedure to plan radiation safety precautions. Prior to each lutetium lu-177 infusion, oncology nurses must administer pretreatment medications such as antiemetics and amino acids.
“Lutetium lu-177 treatments help make cancer grow more slowly when it travels through the patient’s body and delivers radiation directly to or near the disease site,” Pierce said. “The treatment must be administered by trained staff who follow radionuclide safety protocols. Therefore, nuclear medicine personnel must understand how to administer radioactive therapy while radiation nursing provides quality patient care safely.
“The treatment takes around 45 minutes to an hour,” Pierce continued. “After the patient is transferred to their room on the oncology unit, and after a few hours, the patient receives an octreotide injection before being discharged home.”
Radiation from a lutetium lu-177 infusion is detectable for up to 30 days, Pierce said, so nurses and family caregivers need to follow safe-handling protocols when helping the patient use the bathroom or handling their excretions. Patients must follow post-treatment precautions such as:
- Hydrating for at least three days post-treatment
- Limiting exposure to others, especially pregnant women and children
- Avoiding public transit and facilities
- If traveling by air or entering federal facilities, showing written verification of the new therapy
Radiation Technologies on the Horizon
Experts in the field continue to explore opportunities to improve radiation delivery techniques to cancer cells while sparing normal healthy cells, Woods said.
“Two clinical trials are looking at combining idronoxil with radiation to treat prostate cancer,” Woods said. “Both studies use various dosing regimens and treatment schedules with the goal of potentially expanding our treatment options for patients with metastatic prostate cancer.”
Direct and Abscopal Response to Radiotherapy (DAART) is a phase I study targeting patients with late-stage prostate cancer who have exhausted conventional treatment options and are seeking palliative treatment.
Woods said that the study is evaluating whether idronoxil plus external beam radiation will lead to an improved direct response to the targeted site in the radiation treatment field and improved abscopal response to tumor cells outside of the radiation field.
Lu-PSMA IN Conjunction With Idronoxil (LuPIN) is a phase Ib study also targeting patients with late-stage prostate cancer.
“This particular study is evaluating the combination of idronoxil with a radionuclide (lutetium lu-177) injected intravenously,” Woods said.
Outside of these studies, Woods made some projections about other possibities in the future. “I anticipate artificial intelligence and machine learning will play a significant role as we continue to leverage technology to improve our planning and treatment techniques,” he said. “I also anticipate that we will continue to see a trend in radiation toward single fractionation and hypofractionation.”
An APN’s Role in Radiation Research
“APNs in radiation oncology are vital members of the multidisciplinary team, helping with coordinating patients’ care during radiation treatments,” Pierce said. “There are many gaps in research that radiation nurses would be best suited to explore, for instance, long-term toxicity, the management of skin changes and quality-of-life issues, and sexual health.”
“To date, there is no standard of care for radiation skincare management and products used, and most radiation departments have no standard skincare policy currently. Most rely on personal experiences and expert opinions,” Pierce said.
In November 2020, ONS will release its GuidelinesTM for Cancer Treatment-Related Radiodermatitis, which will help alleviate some of the uncertainty by providing evidence-based recommendations based on a full systematic review for clinicians to use in practice. Read the full guideline in the November issue of the Oncology Nursing Forum.
The ONS Guideline also provides recommendations for nurse scientists conducting new research on radiodermatitis, and Pierce listed other ways that APNs in radiation oncology can best contribute to radiation oncology research, including:
- Investigate skincare guidelines.
- Investigate clinician practices about skincare products.
- Improve radiation nursing workflow and efficiency in the work environment.
- Increase interaction between nurses and therapist.
- Study how patients receiving concurrent chemoradiation are handled.
- Develop quality measures for patients, such as exercise programs.
- Assess and intervene in psychosocial distress, sleep-wake disturbances, goal setting, patient reports, and health-related quality measures.
What Every Oncology Nurse Needs to Understand About RT
“Radiation is often misunderstood by people outside of the radiation community,” Woods said. “Radiation is a very precise and effective treatment tool that requires specialized planning and delivery. Oncology nurses need to have a basic understanding of radiation oncology, including the planning process, daily treatment delivery process, and potential short- and long-term side effects.
“Oncology nurses can help nurses in radiation oncology by effectively communicating and coordinating patient care,” he continued. “Radiation treatments are frequently delivered sequentially or concurrently with other treatment modalities, and patients on those treatment plans often require extra planning, coordination, and communication.”
Pierce encouraged radiation oncology nurses to educate other oncology nurse colleagues on the different procedures to perform in radiation and how to assess for and manage critical side effects. In addition to the side effects that Woods noted, Pierce recommended that oncology nurses understand radiation safety precautions and nursing care during procedures.
“The key is to get some experience in understanding the modality,” Pierce said. “It is a different way of thinking, it is a different skill set, although there is some overlap, and we have such a significant need for oncology nurses who are willing and able to do both.”