Care coordination, appropriate adverse event assessment and treatment, and rapid, continuous learning are essential priorities for oncology nurses to care for patients receiving immunotherapy, according to the experts who participated in ONS’s immunotherapy summit in March 2018. 

Although immunotherapy has a unique set of toxicities compared to traditional chemotherapy, in general, grade 3 or 4 toxicities are rare—with the exception of grade 3 diarrhea and colitis. The mechanisms by which immune-related diarrhea and colitis occur are not clear. However, T-cell activation leads to high levels of CD4 T-helper cell cytokines and cytolytic CD8 T-cell tissue infiltration. Some research suggests that depleting regulatory T cells also induces autoimmunity.

After completing neoadjuvant chemotherapy for triple-negative invasive breast cancer, Madeline, age 32, had a bilateral mastectomy with reconstructive surgery. Final pathology showed residual disease in the breast and one lymph node, and her oncologist recommended adjuvant therapy with capecitabine (1,500 mg twice a day for 14 days, off for 7 days). Five weeks postoperatively, she started cycle 1. Eight days later, her husband called the cancer clinic reporting that over the past two days, his wife developed profound weakness, unremitting diarrhea despite using diphenoxylate and atropine as directed, and painful, red, swollen hands and feet. Her symptoms represented a drastic change from her usual routine and energy level.

Immunotherapy may place patients at risk for distinctive toxicities that differ from traditional chemotherapy. One example is endocrine dysfunction, including hypophysitis, hypo- or hyperthyroidism, type 1 diabetes, and primary adrenal insufficiency. 

As the use of oxaliplatin in the treatment of gastrointestinal, gynecologic, and other cancers continues to grow, so too does the incidence of hypersensitivity reactions connected to the drug. Because the development of HSRs may require patients to discontinue oxaliplatin even if it’s effective against their cancer, oncology nurses need to be able to prevent or minimize reactions whenever possible.

Immunotherapy has a unique set of toxicities in comparison to traditional chemotherapy. Endocrine dysfunction, including hypo- or hyperthyroidism, hypophysitis, type-1 diabetes, and primary adrenal insufficiency, may occur. Advanced practice RNs (APRNs) have a role in monitoring and treating patients for endocrine-related toxicities.

Ongoing therapy with afatinib—an oral, irreversible ErbB family blocker—for as long as it is effective and tolerable is considered first-line treatment for metastatic non-small cell lung cancer in patients with EGFR mutations. In their article in the October 2018 issue of the Clinical Journal of Oncology Nursing, Edwards, Adan, Lalla, Lacouture, O’Brien, and Sequist discussed the most common adverse events (AEs) associated with afatinib and their real-life experiences managing them in clinical practice to keep patients on therapy.

Although immunotherapy is changing the face of cancer care, it’s not exempt from side effects. As researchers and clinicians work to understand immune-related adverse events and how to manage them, a new challenge is emerging: reporting and grading them to get an accurate grasp on incidence rates and to standardize care to ensure better outcomes for patients. The Common Terminology Criteria for Adverse Events (CTCAE) is one tool that’s helping researchers and bedside nurses do just that. 

Ibrutinib is a first-in-class Bruton’s tyrosine kinase inhibitor that is approved by the U.S. Food and Drug Administration to treat chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL). The drug’s approval was based on results from the multicenter, open-label, phase III RESONATE trial.

Mrs. Jones is a 66-year-old postmenopausal woman who developed left breast pain and a palpable mass. A mammogram and ultrasound showed a 4.6 cm mass with an enlarged axillary node. A core biopsy revealed invasive ductal carcinoma that is estrogen receptor positive, progesterone receptor positive, and HER2 negative. Positron-emission tomography and computed tomography scans revealed metastatic disease.

Adverse events and traumatic moments send shockwaves through the entire care team. As families grieve the loss of a loved one, providers can often suffer from feelings of overwhelming guilt, remorse, or helplessness. When clinicians struggle with the aftermath of a tragic care event, they become known as second victims. Second victim experiences can lead to lapses in safety and care and could be potentially dangerous for future patients.

Because the treatment of symptoms, side effects, and adverse events associated with immunotherapies can differ greatly from the standard of care, the American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN)—along with experts from ONS staff and membership—collaborated to develop guidelines to inform clinicians about managing immune-related adverse events associated with checkpoint inhibitor therapy.

As September winds down, ONS, a partner in the Centers for Disease Control and Prevention’s (CDC’s) and American Nurses Association’s Nursing Infection Control Education Network, is raising awareness of Sepsis Awareness Month by highlighting resources and strategies for oncology nurses who are deeply rooted in preventing and treating sepsis in patients with cancer.

New targeted and immunotherapy drug approvals have offered improved survival and disease outcomes for patients with melanoma, but the new therapies are also associated with a range of adverse events (AEs) that differ from those associated with chemotherapy. Oncology nurses will need to shift their thinking to best manage those AEs.

Between administering antineoplastic agents, monitoring patient vitals, and preparing patients for treatment, oncology nurses are required to balance their attention between many intricate tasks. Chief among the division of duties is that oncology nurses closely monitor their patients for hypersensitivity reactions (HSRs) to prescribed agents.

Five to Ten Percent of patients with cancer will need to visit the intensive care unit (ICU) for a life-threatening condition. In fact, estimates suggest that nearly 30% of patients with esophageal cancer or acute leukemia and those undergoing allogenic stem cell transplantation will need ICU care.

On June 23, 2017, the U.S. Food and Drug Administration (FDA) approved betrixaban (Bevyxxa, Portola) for the prophylaxis of venous thromboembolism (VTE) in adult patients hospitalized for an acute medical illness who are at risk for thromboembolic complications due to moderate or severe restricted mobility and other risk factors for VTE.

Chimeric antigen receptor (CAR) T-cell therapy offers options for pediatric patients with relapsed or refractory acute lymphoblastic leukemia, but it comes with a unique set of side effects that can range from mild to severe. As the primary patient providers, oncology nurses are often the first to identify signs and symptoms of adverse events and acute changes in patients’ status. Understanding what to watch for can improve outcomes and help nurses deliver safe, effective care.