This article originally appeared in the June 2013 issue of The Oncology Nurse-APN/PA®, and is used with permission. It contains valuable information for the practice manager on the importance of comprehensive oral chemotherapy protocols in the oncology practice in order to keep both providers and patients safe.
Take-Home Messages
- Written treatment plans and chemotherapy orders should be documented
- The importance of follow-up visits and laboratory monitoring should be emphasized with every patient receiving oral chemotherapy
- A patient calendar should include start and stop dates for therapy, dates for lab testing, and dates for follow-up appointments
- Electronic health records can help streamline the communication of changes in orders between providers and prescribers
Oral chemotherapy presents unique issues, including safety and toxicity, and advance planning is essential, stated Kristine B. LeFebvre, MSN, RN, AOCN, nurse planner and project manager at the Oncology Nursing Society (ONS). She spoke about the nurse’s role in delivering oral chemotherapy at the ONS 38th Annual Congress.
“Oral chemotherapy is not just pills. It is important to give the right drug to the right patient at the right dose and the right time,” she emphasized.
In recognition of the issues particular to oral chemotherapy, the American Society of Clinical Oncology and ONS have recently published administration safety standards for oral chemotherapy (Oncology Nursing Forum, May 2013; Journal of Oncology Practice, March 2013) to optimize care, LeFebvre said.
She suggested providing both oral and written instructions to patients undergoing oral chemotherapy. It is essential to document a written treatment plan and chemotherapy orders and to provide a summary treatment plan at the initial patient encounter. In addition, “verbal orders can only be used for holding/stopping medications, but any dose adjustments must be documented in the patient’s records,” she emphasized. “This is essential with oral chemotherapy.”
“Stress the importance of follow-up visits, and emphasize the need for laboratory monitoring. Many patients may not realize they will need monitoring when they are taking pills,” she stated.
A patient calendar should include start and stop dates for therapy, dates for lab testing, and dates for follow-up appointments. Issues of insurance coverage and access to the drug should be discussed with the patient.
The nurse also needs to assess the patient’s ability to take the drug, including the ability to swallow, cognitive function, and the need for caregiver or family member assistance. Systems should be in place for managing dose or schedule adjustments. Other needs include triage guidelines or algorithms for changes in patient status and symptoms, and a method for communicating with prescribers. “Electronic medical records should help streamline communication,” LeFebvre stated.
Safe handling is important, she continued. “Many oral antineoplastic agents are hazardous. The staff and patients require education and training. Personal protective equipment may be required, as well as hand washing and gloves for family members,” she continued.
“Nurses need to know which drugs require safe handling. A list would be helpful, and hazardous drugs should be labeled as such,” she said.
Drugs such as sorafenib, everolimus, capecitabine, erlotinib, pazopanib, gefitinib, and lapatinib have been associated with increased toxicity, including grade 3 and 4 adverse events, compared with the control arm in randomized controlled trials, she noted.
When the nurse administers the drug, independent double-checking of the appropriateness of therapy should be conducted.
“We must monitor clinical status and adherence, manage toxicity, educate patients about drug-drug and drug-food interactions, and ensure that treatment is coordinated in different treatment settings,” she explained.
Assessments should be drug and regimen specific. With oral treatment, document that the patient received the drug. Medication reconciliation is important, as are potential interactions. The orders should incorporate tests that may be needed: for example, with axitinib, orders should automatically include hepatic, thyroid, and urine testing.
“If a patient is admitted to the hospital, you need to know whether the drug should be continued [while there],” LeFebvre noted. A system is needed to notify the emergency department or the hospital that the patient is taking oral chemotherapy when he or she is admitted for other reasons.
At the same session, Kathleen Leifeste, RN, MSN, AOCN, oncology nurse educator at Overlook Medical Center in Summit, New Jersey, discussed additional considerations with oral chemotherapy.
New oral chemotherapy agents are [continually] being approved. In fact, 25% of all antineoplastic agents are oral now. We need to be concerned with side effects, safe handling, and adherence, and we need to be proactive in following these standards. Serious side effects can occur, including handfoot syndrome, nausea, vomiting, diarrhea, and skin problems,” Leifeste told the audience.
Barriers to patient adherence include the complexity of regimens, need for behavioral change, fear of side effects (including constipation and weight gain), lack of belief in efficacy, and financial limitations. Inadequate understanding of directions and difficulty reaching the healthcare provider can also interfere with compliance.
“If a patient is not adhering and you don’t know it, [and] if there is a recurrence or poor response, you may think the drug isn’t working,” she added.
Although some of the principles discussed by both nurses seem self-evident, Leifeste noted that a survey reported that almost half of nurses had no education on oral chemotherapy and more than half did not have patient education materials. This emphasizes the need for better education and attention to this issue.
Reference
1. LeFebvre K, Leifeste K. Oral chemo, not just another pill: implications for staff education and practice. Presented at: 38th Annual Congress of the Oncology Nursing Society; April 26, 2013; Washington, DC.