Oral Chemotherapy Leadership ProjectBy: Emily Mohr, SCSU Nursing Student

Topics to be addressed

Background Literature review Nursing implications Common oral

chemotherapies

Background & Goal

CCH Paynesville, Specialty Services-Oncology does not have a policy or protocol to follow for oral chemotherapy nurse follow-up.

Goal: to give recommendations for CCH Paynesville, Specialty Services-Oncology for

nurse follow-up and monitoring of patients on oral chemotherapy.

Background information

Predictions for the next 3 to 5 years

Oral chemotherapy advantages

Patient convenience

Elimination of the need for IV access

Ability to achieve sustained drug levels

Drawback

Distances patients from providers

Patient education and follow-up is key to successful oral chemotherapy treatment

Treatment plan:

Goal of therapy

Timing and dosing of therapy

Special considerations

Monitoring and follow-up

Symptom management

Jody Pelusi, PhD, FNP, AOCNP

Perceptions and Experiences of Patients Receiving Oral ChemotherapyBrett Simchowitz, BA, Lawrence Shiman, MPP, Justin Spencer, MPA, Daniela Brouillard, BA, Anne Gross, RN, PhD, Maureen Connor, RN, MPH, and Saul N. Weingart, MD, PhD

Participants preference of oral versus IV chemotherapy

Have more control

Want more information about side effects and their severity

Emphasized the value of having a friend or family member attend the appointment with them

Participants expressed a desire to have their doctor or nurse check in on them between appointments, especially to help manage their side effects

Patient Education: The Cornerstone of Successful Oral Chemotherapy TreatmentKristine Hartigan, RN, BA, OCN

Patients with cancer are thought to be highly motivated by the gravity of their disease

Non-compliance

WHO, WHEN, WHERE, WHAT

**Nurses play a key role in patient compliance

through education and follow-up**

WHO, WHEN, WHERE, WHAT:Tips for education

WHO: patient and/or family member

WHEN: Schedule education at a time when the patient is not overloaded with information

WHERE: Patients are less apt to ask questions/raise concerns if nurses appear stressed, tired, or too busy

WHAT: Verbal and written instructions should be provided and include:

Name of medication

Dose and schedule

How it is taken

Safety

Side effects

Symptom management

Are Patients on Oral Chemotherapy in Your Practice Setting Safe?Mendy Moody, RN, MSN, OCN and Joyce Jackowski, MS, FNP-BC, AOCNP

Many people incorrectly believe that oral chemotherapy medication are less toxic than IV chemotherapy

Because oral and IV chemotherapy medications have the potential to cause harm, nurses must be involved in the care of patients receiving either form

**Patient education by the nurse is the key to successful

treatment with oral chemotherapy**

Recommendations from the study

A 60-90 minute appointment should be made for a teaching session

Medication calendar and teaching materials

Education pieces to be included:

Medication name

Dosage

Frequency

Side effects

When to call the physician

How to contact the chemotherapy nurse during and after clinic hours

After education is complete, have patient reiterate the key points to confirm understanding of the information provided

MASCC Teaching Tool for Patients Receiving Oral Agents for Cancer

This teaching tool assists health care providers in the assessment and education of patients receiving oral agents as treatment for their cancer

Goal: to ensure patients know and understand their treatment and the importance of taking the pills as prescribed

Nursing Implications

Follow-up Nurse should be following-up with

patient by a phone call Weekly during the first month Every other week during the

second and third months (or more often as needed or as seen fit)

After the third month, calls are made to the patient on a monthly basis between visits (or more often as needed)

Monitoring Side-effects

Provide hand-outs from Oncology office of how to manage common side effects

Labs Adherence

Documentation Education Follow-up phone calls Phone-calls made by

patient Resources for patients and

nurses Co-pay assistance

resources CentraNet Micromedex Oncology Nursing Society

(ONS) www.chemocare.com

Documentation of Education

Information will be provided in your upcoming EPIC Refresher Course in April regarding how to document what patient education you performed

Strategies for Managing Patients Receiving Oral Therapies From ONS Connect March 2014 issue

Weekly call list

Documentation

Education appointments

Follow-up phone calls

Classes for nurses

Dedicate nurse to patients only on oral chemotherapy

Workflow

Oral chemotherapy Coordinator

Oral Chemotherapy Education handouts on CentraNet

1. Log on to Centra Net. Click on Patient Education on top header

1. Click on Medication

1. Scroll down and select Coborn Cancer Center

1. Select the appropriate oral chemotherapy and a printable education handout will be available

Stivarga (regorafenib)

Indication: Metastatic colorectal cancer (CRC), locally advanced, unresectable or metastatic gastrointestinal stromal tumor (GIST)

How it is taken: once daily with a low-fat breakfast for the first 21 days of each 28-day cycle; missed: take when remembered

**keep in original container—Do NOT place in daily or weekly pill containers** Any remaining tablets should be discarded 28 days after opening the bottle

Contraindication: None

Drug and food interactions: avoid drinking grapefruit juice and take St. John’s Wort while taking Stivarga

Adverse Effects: asthenia/fatigue, HFSR, diarrhea, decreased appetite/food intake, hypertension, mucositis, dysphonia, infection, pain, decreased weight, gastrointestinal and abdominal pain, rash, fever, nausea, liver damage, voice changes

Monitoring: monitor blood pressure every week for the first 6 weeks of starting Stivarga and then regularly, monitor liver function before and during treatment

Resources: www.stivarga-us.com

REACH support program (resources for expert assistance and care helpline)

Xtandi (enzalutamide) Indication: Metastatic castration-resistant

prostate cancer who have previously received docetaxel

How it is taken: Once daily, same time each day; with or without food; swallowed whole

Missed dose: take when remembered

If too much is taken, patient needs to call doctor or nurse right away or go to the ER

Contraindications: pregnancy

Drug interactions: cyclosporine, fentanyl, phenytoin, warfarin, omeprazole, rifampin, phenobarbital, St. John’s Wort

Adverse Effects: asthenia/fatigue, back pain, diarrhea, arthralgia, hot flash, peripheral edema, musculoskeletal pain, headache, URI, muscular weakness, dizziness, insomnia, LRI, spinal cord compression, hematuria, paresthesia, anxiety, and hypertension

Monitoring:

CBC and CMP prior to initiation of therapy and monitor monthly or as indicated

If patient is on Coumadin, additional INR monitoring should be conducted

Resources

www.xtandi.com/getting-xtandi

XTANDI Patient Savings Program

XTANDI treatment calendar is available on their website

Tarceva (erlotibib)

Indication:

Advanced-stage non-small cell lung cancer

Advanced-stage pancreatic cancer in combination with gemcitabine

How it is taken: once daily without food (meaning one hour before or two hours after a meal)

Do not eat grapefruit or drink grapefruit juice while on Tarceva

Smoking may affect how well Tarceva will work

If a dose is missed, may still take it up to 12 hours after the time normally taken—more than 12 hours, skip that dose

Contraindication: none

Adverse Effects: rash, diarrhea, nausea, cancer-related fatigue, neutropenia, loss of appetite, abdominal pain, bone pain, hair and nail changes

Monitoring: Lab work will be checked regularly, INR in patients taking Warfarin, liver function tests, renal function and electrolytes

Resources:

www.tarceva.com

Tarceva handout in oncology office

Tarceva Access Solutions, Genentech BioOncology Co-pay card program

Revlimid (lenalidomide) Indication:

Multiple myeloma (MM)

Myelodysplastic syndrome (MDS) where part of chromosome 5 is missing

How it is taken: once daily, every day for 21 days, then break for 7 days before starting again; taken same time each day with or without food; if dose is missed, may take within 12 hours normally taken

Contraindication: pregnancy and allergic reactions to lenalidomide

Adverse Effects: anemia, thrombocytopenia, neutropenia, diarrhea, cancer-related fatigue, constipation, nausea, dizziness, hypotension, edema, muscle cramping, tremor, rash

Monitoring:

MM: blood checks every 2 weeks for first 12 weeks then monthly

MDS: blood counts should be checked weekly during first 8 weeks of treatment and at least monthly thereafter

Resources:

www.revlimid.com

www.celgenepatientsupport.com/co-pay_assistance.aspx

Special considerations: To be able to receive Revlimid, patient must enroll in the RevAssist Program and sign a patient-physician agreement form.

Digoxin: Periodic monitoring of digoxin plasma levels is recommended

Patients taking concomitant therapies such as erythropoietin stimulating agents or estrogen containing therapies may increase their risk of VTE

Xeloda (capecitabine)

Indication: metastatic colorectal cancer, metastatic breast cancer, adjuvant colon cancer

How it is taken: twice daily (morning and evening), within 30 minutes after the end of a meal with water; if a dose is missed, may take up to 6 hours after time normally taken; usually taken for 14 days followed by 7 days of rest, for a 21 day cycle

Contraindication: Dihydropyrimidine dehydrogenase (DPD) deficiency, severe renal impairment, hypersensitivity

Drug interactions: anticoagulants, phenytoin, leucovorin, CYP2C9 substrates, folic acid, antacids

Adverse Effects: cancer-related fatigue, diarrhea, lowered WBC, RBC and platelets, hand-and-foot syndrome, hyperbilirubinemia, mouth sores, fever or infection, nausea, abdominal pain

Monitoring: regular blood checks, INR and PTT if on Warfarin and dose adjusted accordingly (can increase the effect of warfarin), can cause fetal harm-advise women of risk to fetus

Resources:

Xeloda-dosing instruction sheet in Oncology office

Xeloda Patient education checklist

www.genentech-access.com/xeloda/patients/search

Imbruvica (ibrutinib) Indication: Mantle cell lymphoma (MCL) who

has received at least one prior therapy; Chronic lymphocytic leukemia (CLL) who have received at least one prior therapy

How it is taken: MCL-four capsules once daily; CLL-three capsules once daily; taken same time each day with a glass of water Missed dose: take soon as remembered

Contraindication: pregnancy

Drug and food interactions: Do not drink grapefruit juice, eat grapefruit, or eat Seville oranges (often used in marmalades) because it can increase the amount of Imbruvica in your blood; do NOT take St. John’s Wort while on this medication

Adverse Effects: thrombocytopenia, diarrhea, neutropenia, fatigue, musculoskeletal pain, peripheral edema, upper respiratory tract infection, nausea, bruising, dyspnea, constipation, rash, abdominal pain, vomiting and decreased appetite, anemia, pyrexia, arthralgia, stomatitis, sinusitis, and dizziness

Monitoring:

Monitor for bleeding, fever and infections, renal function and maintain hydration

Check complete blood counts monthly

Second primary malignancies: other malignancies have occurred in patients, including skin cancers and other carcinomas

Resources: www.imbruvica.com

YOU&i Access program and support for patients

YOU&i Access instant savings program

Zytiga (abiraterone)

Indication: Metastatic castration-resistant prostate cancer

How it is taken: once daily on an empty stomach along with Prednisone 5mg twice daily—DO NOT TAKE WITH FOOD (may cause more of Zytiga to be absorbed in the body)

Contraindication: women who are or may become pregnant

Resources: www.zytiga.com

ZytigaOne support

ZytigaOne Support Instant Savings Program

Adverse Effects: fatigue, joint swelling or discomfort, edema, hot flash, diarrhea, vomiting, hypokalemia, cough, hypertension, dyspnea, UTI, contusion, anemia, high blood sugar levels, high blood cholesterol and triglycerides, and other abnormal blood tests

Monitoring: monitor blood pressure, serum potassium, symptoms of fluid retention, liver function, adrenal function, and blood work at least monthly

Gleevec (imatinib) Indication: Philadelphia Chromosome

positive Chronic Myeloid Leukemia (CML), Gastrointestinal stromal tumors (GIST) that cannot be surgically removed or has spread to other areas of the body

How it is taken: once daily, with a meal and a large glass of water; if unable to swallow, may be dissolved in apple juice or water; if a dose is missed, may take it up to 12 hours after the time normally taken

Contraindication: None

Drug and food interactions: warfarin, erythromycin, and phenytoin—avoid grapefruit

If taking or planning to take iron, doctor should be notified

Adverse Effects: Nausea, vomiting, cancer-related fatigue, diarrhea, rash/dry skin, appetite changes, changes in blood tests (anemia and neutropenia), headache, muscle cramps, generalized pain, edema, serious fluid retention, liver damage

Monitoring:

weigh patients and monitor regularly for signs and symptoms of fluid retention or unexpected weight gain

Cytopenias: test blood weekly for the first month, biweekly for the second month, and periodically thereafter

Liver: check liver function before beginning treatment and continue to monitor as needed throughout treatment

Hypothyroidism: can occur in patients taking levothyroxine replacement during treatment with Gleevec—monitor thyroid levels

Monitor GI symptoms at start of treatment; GI bleeding may occur

Resources: www.gleevec.com

Patient Assistance NOW Oncology

Hydrea (hydroxyurea) Indication: CML, ovarian cancer,

melanoma, certain types of head and neck cancers, sickle cell anemia, polycythemia vera

**these are only a few; it can be used for many reasons**

How it is taken: taken orally once daily on an empty stomach—one hour before meals or two hours after meals

Contraindication: patients with marked bone marrow depression, leukopenia or thrombocytopenia, or severe anemia

Adverse Effects: lowered white blood cell counts, loss of appetite, nausea and vomiting, mouth sores, diarrhea, constipation, headache, drowsiness, confusion, skin rash, hair loss, swollen feet, lowered red blood cell and platelet counts

Monitoring:

Complete status of the blood, including bone marrow examination, kidney function and liver function should be determined before and during treatment, repeatedly

Hemoglobin level, total leukocyte counts, and platelet counts should be performed at least once a week throughout therapy

Resources:

Micromedex

Hand-out in Oncology office

Afinitor (everolimus)

Indication: Advanced hormone receptor-positive, HER2-negative breast cancer, Advanced kidney cancer, Subependymal giant cell astrocytoma (SEGA), Pancreatic cancer known as pancreatic neuroendocrine tumor (PNET)

How it is taken: once daily with or without food with a glass of water; do not drink grapefruit juice or eat grapefruit while on this; if a dose is missed, may take up to 12 hours after time normally taken

Contraindication: hypersensitivity to Afinitor, to other rapamycin derivatives, or to any of the excipients (inactive ingredients)

Adverse Effects: anemia, neutropenia, mouth sores, rash/dry skin, diarrhea, cancer-related fatigue, nausea, vomiting, decreased appetite and taste changes, headache, edema

Monitoring: monitor lab work regularly; monitor renal function, blood glucose, lipids, and hematologic parameters prior to treatment and periodically thereafter; avoid live vaccines and close contact with those who have received live vaccines

Resources: www.afinitor.com

Afinitor co-pay card

Thalomid (thalidomide) Indication: Multiple myeloma How it is taken: once daily without

food, at least one hour after your evening meal—bedtime is preferred time to take this if a dose is missed, may still take it

up to 6 hours after the time you normally take it

Contraindication: pregnancy, hypersensitivity to the drug or its components

Adverse Effects: cancer-related fatigue, constipation, nerve damage, neutropenia, nausea, drowsiness, dizziness or decreased blood pressure, decreased appetite, tremor, anxiety, confusion, edema, bradycardia, serious skin reactions, seizures, tumor lysis syndrome (TLS), allergic reaction, birth defects

Resources: www.thalomid.com Special considerations: S.T.E.P.S

program

Monitoring: Check lab work regularly Peripheral neuropathy; examine patients

at monthly intervals for the first 3 months and periodically thereafter for signs and symptoms

Dizziness and orthostatic hypotension: advise patients to sit upright for a few minutes prior to standing up from a recumbent position

Monitor patients for bradycardia and possible syncope

Monitor blood pressure at every visit

Increased risk of venous thromboembolism and can increase when used in combination with standard chemotherapeutic agents such as dexamethasone

Watch for signs and symptoms of thromboembolism and instruct patient to seek medical care if they develop SOB, chest pain, or arm/leg swelling

Final Recommendations

Weekly follow-up phone calls for at minimum the first month of starting treatment

Follow-up phone calls should include:

Adherence, how tolerating, side effects, concerns, reminders to call if concerns come up any time, 24/7

Make reminders for follow-up phone calls on the calendar in the Oncology office

Sticky notes

Designate one or two nurses for follow-up phone calls

Keep a separate calendar or planner for oral chemotherapy follow-up phone calls

Have patient take daily blood pressures at home (if able to) and update nurse when the follow-up phone call is made

Give parameters when patient should call in before a nurse calls for follow-up

Communication!!

Keep specified notepad with each drug listed and if patients experience side-effects, write those down for easy reference

Document Patient Education in EPIC!!

References

Barefoot, J., Blecher, C., & Emery, R. (2009). Keeping pace with oral chemotherapy. OncologyIssues, 36-39. Retrieved from www.accc- cancer.org/oncology_issues/articles/mayjune09/...

Becze, E. (2014, March). U.S. survey reports oral chemotherapy practice and safety patterns. ONSConnect, 34-35.

Hartigan, K. (2003). Patient education: The cornerstone of successful oral chemotherapy treatment.Clinical Journal of Oncology Nursing, 7(6), 21-24. doi: 10.1188/03.CJON.S6.21 24

Mascc teaching tool for patients receiving oral agents for cancer. (2009). Retrieved fromhttp://www.mascc.org/index.php?option=com_content&view=article&id=148

Moody, M., & Jackowski, J. (2009). Are patients on oral chemotherapy in your practice settingsafe?. Clinical Journal of Oncology Nursing, 14(3), 339-346. doi: 10.1188/10.CJON.339-346

Pelusi, J. (n.d.). Managing oral oncology-hematology treatments in your practice. Retrieved fromwww.communityoncology.org/pdfs/Sat CL 2 930..

Simchowitz, B., Shiman, L., Spencer, J., Brouillard, D., Gross, A., Connor, M., & Weingart, S. (2009).Perceptions and experiences of patients receiving oral chemotherapy. Clinical Journal ofOncology Nursing, 14(4), 447-453. doi: 10.1188/10.CJON.447-453