April is caring for a patient with biliary cancer. She receives a new chemotherapy order for cisplatin followed by gemcitabine on days 1 and 8 every three weeks. The standard sequence in April’s hospital is to administer platinum agents last. However, the order clearly states to administer the cisplatin first.

What Would You Do? Renal toxicity is a well-established side effect of cisplatin. In addition, administration prior to other antineoplastic agents such as bleomycin, ifosfamide, and paclitaxel can significantly alter their excretion. For this reason, it is common to administer cisplatin after other agents when used in combination chemotherapy regimens.

The physician was correct in documenting the order in which the drugs should be administered, as per the updated American Society of Clinical Oncology (ASCO)/Oncology Nursing Society guidelines. However, the hospital’s chemotherapy prescribing policy also required all nonstandard chemotherapy regimens to be supported by literature or other documentation.

April called the physician, who provided an ASCO abstract describing the rationale and results of the reverse-order regimen. The abstract was then placed in the chart as a reference for subsequent doses.