Palliative and Supportive Care

Monoclonal antibodies are increasingly becoming a standard part of clinical cancer treatment. Eight monoclonal antibodies are approved by the Food and Drug Administration for the treatment of cancer in the United States. Oncology nurses are expected to be familiar with these agents, their indications, and their adverse effects, to provide appropriate care and symptom management to patients receiving these agents, and to adequately educate patients and families about these treatments and their specific and overlapping side effects. Monoclonal antibody mechanisms of action and indications, infusion guidelines, and symptom management are outlined in this article.

Major deficiencies in the management of cancer-related pain are well documented and impact all dimensions of the patient's life, including physical, psychological, social, and spiritual well-being.

Pain is a very individual experience so it is important for you to help doctors and nurses know if you are in pain. Please be sure to describe your pain and rate it on the 0 = no pain to 10 = worst pain scale.

With the trend toward the use of oral rather than intravenous therapies for cancer, nonadherence to treatment has become an increasing concern. Advanced practice nurses are in a good position to assess and monitor adherence to oral endocrine therapies. Research on adherence has been limited; to date there are no specific published guidelines for ensuring adherence to endocrine regimens. However, studies have identified many factors that may lead to nonadherence, including demographic, social, and psychological characteristics of the patient; characteristics of the disease and the treatment regimen; and the nature and quality of the patient/clinician relationship. These factors provide a framework that advanced practice nurses can use to identify potential problems and to work collaboratively with patients.

Dr. Ann Berger does an excellent job of writing to the chronic pain sufferer in her book Healing Pain. Health-care providers and family caregivers will also find it an excellent resource and can benefit greatly from reading this work. Throughout the book the author maintains a true sense of hope for the individual experiencing significant pain. Her ability to communicate this sense of hope will be rather contagious for the health-care provider who may have become less than enamored with our ability to accomplish pain management in individuals with complex pain syndromes.

In an ideal world, palliative care would be integrated into therapeutic care from the time of cancer diagnosis—not limited to hospice or end-of-life care.

Merck & Co.'s antiemetic Emend (aprepitant) has been granted expanded approval by the FDA to prevent postoperative nausea and vomiting (PONV). Emend, a substance P/neurokinin 1 (NK-1) receptor antagonist, works through a mechanism distinct from that of the 5-HT3 receptor antagonists. Approval was based on two randomized double-blind studies of 1,658 patients undergoing open abdominal surgery. Emend was previously approved for the prevention of chemotherapy-induced nausea and vomiting.

Bioavailability studies show that oral spray delivery of the antiemetic 5-HT3 antagonist ondansetron is equivalent to oral delivery with ondansetron tablets (Zofran), Wayne Yates, MBA, and Greg Berk, MD, of Hana Biosciences, said at the American Society of Clinical Oncology 42nd Annual Meeting (abstract 8622). Hana Biosciences has submitted a New Drug Application to the FDA for the oral spray (brand name Zensana) for the prevention of nausea and vomiting associated with chemotherapy or radiotherapy, and the prevention of postoperatively induced nausea and vomiting.

The aromatase inhibitors (AIs) anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin) are significantly more effective than the selective estrogen-receptor modulator (SERM) tamoxifen in preventing recurrence in estrogen receptor-positive early breast cancer. Aromatase inhibitors are likely to replace SERMs as first-line adjuvant therapy for many patients. However, AIs are associated with significantly more osteoporotic fractures and greater bone mineral loss. As antiresorptive agents, oral and intravenous bisphosphonates such as alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), pamidronate (Aredia), and zoledronic acid (Zometa) have efficacy in preventing postmenopausal osteoporosis, cancer treatment-related bone loss, or skeletal complications of metastatic disease. Clinical practice guidelines recommend baseline and annual follow-up bone density monitoring for all patients initiating AI therapy. Bisphosphonate therapy should be prescribed for patients with osteoporosis (T score < -2.5) and considered on an individual basis for those with osteopenia (T score < -1). Modifiable lifestyle behaviors including adequate calcium and vitamin D intake, weight-bearing exercise, and smoking cessation should be addressed. Adverse events associated with bisphosphonates include gastrointestinal toxicity, renal toxicity, and osteonecrosis of the jaw. These safety concerns should be balanced with the potential of bisphosphonates to minimize or prevent the debilitating effects of AI-associated bone loss in patients with early, hormone receptor-positive breast cancer.

The aromatase inhibitors (AIs) anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin) are significantly more effective than the selective estrogen-receptor modulator (SERM) tamoxifen in preventing recurrence in estrogen receptor-positive early breast cancer. Aromatase inhibitors are likely to replace SERMs as first-line adjuvant therapy for many patients. However, AIs are associated with significantly more osteoporotic fractures and greater bone mineral loss. As antiresorptive agents, oral and intravenous bisphosphonates such as alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), pamidronate (Aredia), and zoledronic acid (Zometa) have efficacy in preventing postmenopausal osteoporosis, cancer treatment-related bone loss, or skeletal complications of metastatic disease. Clinical practice guidelines recommend baseline and annual follow-up bone density monitoring for all patients initiating AI therapy. Bisphosphonate therapy should be prescribed for patients with osteoporosis (T score < -2.5) and considered on an individual basis for those with osteopenia (T score < -1). Modifiable lifestyle behaviors including adequate calcium and vitamin D intake, weight-bearing exercise, and smoking cessation should be addressed. Adverse events associated with bisphosphonates include gastrointestinal toxicity, renal toxicity, and osteonecrosis of the jaw. These safety concerns should be balanced with the potential of bisphosphonates to minimize or prevent the debilitating effects of AI-associated bone loss in patients with early, hormone receptor-positive breast cancer.

The aromatase inhibitors (AIs) anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin) are significantly more effective than the selective estrogen-receptor modulator (SERM) tamoxifen in preventing recurrence in estrogen receptor-positive early breast cancer. Aromatase inhibitors are likely to replace SERMs as first-line adjuvant therapy for many patients. However, AIs are associated with significantly more osteoporotic fractures and greater bone mineral loss. As antiresorptive agents, oral and intravenous bisphosphonates such as alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), pamidronate (Aredia), and zoledronic acid (Zometa) have efficacy in preventing postmenopausal osteoporosis, cancer treatment-related bone loss, or skeletal complications of metastatic disease. Clinical practice guidelines recommend baseline and annual follow-up bone density monitoring for all patients initiating AI therapy. Bisphosphonate therapy should be prescribed for patients with osteoporosis (T score < -2.5) and considered on an individual basis for those with osteopenia (T score < -1). Modifiable lifestyle behaviors including adequate calcium and vitamin D intake, weight-bearing exercise, and smoking cessation should be addressed. Adverse events associated with bisphosphonates include gastrointestinal toxicity, renal toxicity, and osteonecrosis of the jaw. These safety concerns should be balanced with the potential of bisphosphonates to minimize or prevent the debilitating effects of AI-associated bone loss in patients with early, hormone receptor-positive breast cancer.

In a pivotal phase III trial, more than 70% of seriously ill patients with opioid-induced constipation responded to the investigational agent methylnaltrexone (MNTX) by the end of the first week of treatment. Neil Slatkin, MD, DABPN, reported the results at Digestive Disease Week (DDW) 2006 (abstract 686e).

There are no clinically significant differences in the safety and efficacy of epoetin alfa (Epogen, Procrit) and darbepoetin alfa (Aranesp), the two drugs most commonly used to treat anemia in cancer patients undergoing chemotherapy or radiation treatments, according to a new report by the Agency for Healthcare Research and Quality (AHRQ). The two drugs both reduce the need for blood transfusions, but the report found no evidence that either drug improved survival when added to a cancer treatment; it warned that significant questions remain about the safety and best uses of both agents.

Peri- and premenopausal women may be more at risk for cognitive impairment than postmenopausal women as a result of adjuvant chemotherapy for breast cancer, according to preliminary data presented at the American Psychosocial Oncology Society (APOS) Third Annual Conference (abstract P3-5).

Anemia is common in many patients with cancer treated with chemotherapy. One option for managing chemotherapy-induced anemia (CIA) is erythropoiesis-stimulating proteins (ESPs), which are indicated for the treatment of CIA in patients with most types of cancer. They have been shown to be safe and effective in numerous well-documented studies, and their side effects are well known. The rate of thrombotic events with the long-acting ESP darbepoetin alfa (Aranesp) has been consistent in studies conducted before and after its approval. The association of thrombotic events with high hemoglobin levels or rapid increases in its levels in patients with cancer remains controversial. Adjusting the dose of the ESP to maintain and monitor a target hemoglobin level of 11 to 12 g/dL is certainly prudent and may help prevent or minimize these events. Chemotherapy-induced anemia has been associated with shorter survival in patients with cancer, and the relation is likely multifactorial. Data on the treatment of CIA with ESPs have not shown a consistent effect on survival. Two studies in patients with hemoglobin levels above the target level showed that survival was shorter in the patients treated with ESPs. A review of data from other trials found no effect of ESPs on survival, and other trials suggested a positive effect. This article reviews data on survival in patients treated with ESPs and discusses five large randomized controlled trials of darbepoetin alfa that are addressing this issue.

Many factors can affect decisions about chemotherapy and supportive care, including disease outcome, patient quality of life, and drug toxicities. Chemotherapy and supportive therapy may require numerous medical visits that may significantly affect patients and their caregivers. It has recently been shown that practice resources should also be considered in evaluating the full impact of medical visits. To this end, increasing the efficiency of a practice may help ensure the viability of delivering quality care. Greater efficiency can lead to improvements in the quality of life of patients and their caregivers, lower practice operating expenditures, and increase practice capacity and productivity. Chemotherapy-induced anemia is common in patients with cancer, and erythropoiesis-stimulating proteins (ESPs) can lessen its incidence and severity but may require many additional medical visits. This article discusses the importance of establishing efficiency in the oncology practice and considers the role of coordinating tests and procedures, specifically the role of available scheduling options for growth factors. Synchronizing treatments with ESPs and chemotherapy may increase patient convenience and improve practice efficiencies.

Anemia is common in patients with hematologic malignancies, and it has negative effects on their quality of life. The current clinical practice guidelines recommend erythropoietic therapy in patients with cancer- or chemotherapy-related anemia, but anemia is often undertreated in patients with hematologic malignancies. Several randomized controlled trials have shown that treatment with erythropoiesis-stimulating proteins such as epoetin alfa (Procrit), epoetin beta, and darbepoetin alfa (Aranesp) increases hemoglobin levels, reduces the need for red blood cell transfusions, and improves quality of life in patients with hematologic malignancies and anemia receiving chemotherapy. Furthermore, preliminary data from a recent open-label study suggest that early treatment of mild anemia in patients with hematologic malignancies treated with chemotherapy produces marked improvements in quality of life and productivity. Increasing patients' hemoglobin levels may also improve their cognitive function. These findings support the use of erythropoietic therapy to manage anemia in patients with hematologic malignancies who are treated with chemotherapy.

Patients with cancer may have an absolute or functional iron deficiency as a result of their disease or its treatment. These conditions can lead to an insufficient supply of iron for incorporation into erythrocytes during supportive care with erythropoiesis-stimulating proteins for chemotherapy. The use of supplemental iron therapy is well established in patients with chronic kidney disease and anemia, but less well studied in the oncology/hematology setting. Furthermore, the use of oral iron formulations in patients with cancer and anemia is limited by poor absorption in the duodenum, arduous dosing requirements (three times a day), and a high likelihood of gastrointestinal side effects. Two recent studies have shown that intravenous (IV) iron (iron dextran or ferric gluconate) increases the hematopoietic response rates in cancer patients who were receiving chemotherapy and treated with epoetin alfa (Procrit) for anemia. The effects on hemoglobin levels and measures of iron metabolism were notably greater with IV iron formulations than with oral iron formulations. The results from several ongoing trials of IV iron in patients treated with epoetin alfa or darbepoetin alfa (Aranesp) for chemotherapy-induced anemia should lead to a greater understanding of the role of IV iron supplementation in improving the hematopoietic responses in these patients.

Fatigue is common in cancer patients treated with chemotherapy, and it has detrimental effects on their quality of life. Chemotherapy-induced anemia, however, is often under-recognized and under-treated. There is a clear association between hemoglobin (Hgb) levels and fatigue, with fatigue being greater in patients with lower Hgb levels. Managing fatigue requires that its causes be determined and corrected, and it is important that patients report their fatigue. Patients, however, are unlikely to mention such adverse events unless they are asked about them. In addition, busy practitioners generally have very little time to discuss anemia-related fatigue with their patients. Many studies have used the validated quality-of-life instrument Functional Assessment of Cancer Therapy-Fatigue (FACT-F) to assess fatigue and quality of life in patients treated with chemotherapy; these studies have shown a relationship between chemotherapy-induced anemia, fatigue, and quality of life. Studies of erythropoiesis-stimulating proteins to treat chemotherapy-induced anemia have shown increases in patients' hemoglobin levels, improvement in their FACT-F and FACT-General scores, and improvements in their quality of life.

Anemia is common in patients treated with chemotherapy for both solid and hematologic malignancies, contributing to fatigue and diminished quality of life and exposing them to the inherent risks of red blood cell transfusions. Erythropoiesis-stimulating proteins have been shown to increase hemoglobin levels, reduce the need for transfusions, and improve quality of life. The current practice guidelines recommend treating moderate to severe chemotherapy-induced anemia with erythropoiesis-stimulating proteins, but the risk of transfusions may be less with earlier intervention at higher hemoglobin levels. A review of the literature suggests that treating mild chemotherapy-induced anemia with erythropoiesis-stimulating proteins reduces the risks of transfusions and the development of more-severe anemia. Weighing the clinical evidence together with other clinical and economic considerations should provide greater insight into the benefits of treating mild anemia in patients treated with chemotherapy.

The use of erythropoietic growth factors to treat chemotherapy-induced anemia (CIA) has been increasing as clinicians become more aware of the ability of these drugs to improve the quality of life of patients with cancer. The cost associated with erythropoietic growth factor therapy makes its appropriate use a practical issue for physicians and hospitals. Clinical practice guidelines can benefit physicians by increasing practice efficiency, reducing medical errors, increasing the quality of medical care, and decreasing reimbursement problems. The American Society of Clinical Oncology and the American Society of Hematology, the European Organisation for Research and Treatment of Cancer, and the National Comprehensive Cancer Network (NCCN) have all published guidelines for using erythropoietic growth factors to treat CIA, and this article reviews and summarizes those guidelines. Of the three guidelines for the use of erythropoietic growth factors in CIA, the NCCN guidelines are based on the most recent data. Current evidence indicates that erythropoietic growth factors can increase hemoglobin levels, reduce the need for red blood cell transfusions, and improve quality of life; the effect of erythropoietic therapy on outcomes in patients with CIA is still being investigated.

Chemotherapy-induced anemia is common in patients who have cancer. Erythropoiesis-stimulating proteins such as epoetin alfa (Procrit) and darbepoetin alfa (Aranesp) have been shown to improve hematologic and clinical outcomes in these patients. Darbepoetin alfa has a longer serum half-life than epoetin alfa, making less frequent administration possible and offering the possibility of synchronizing the administration of erythropoietic therapy and chemotherapy. Several clinical trials have evaluated the utility of darbepoetin alfa given every 3 weeks (q3wk) in patients with chemotherapy-induced anemia. An exploratory study showed that darbepoetin alfa q3wk stabilized hemoglobin levels and reduced transfusion requirements. It was also shown that giving darbepoetin alfa q3wk at the same time as the chemotherapy produced hematopoietic benefits similar to those observed when it is given later in the chemotherapy cycle. The q3wk dosing schedule was effective in patients with mild and moderate anemia, and treatment goals were achieved in most of them. The equivalence of q3wk and qwk darbepoetin alfa has also been established. Synchronous administration of darbepoetin alfa with chemotherapy is a convenient option for patients with chemotherapy-induced anemia, with clinical trials showing it to be an effective treatment strategy.

Amgen announced interim phase III data suggesting darbepoetin alfa (Aranesp) administered every 3 weeks with intravenous (IV) iron has the potential to further enhance the effectiveness of increasing patient hemoglobin levels to the recommended target of greater than or equal to 11 g/dL and reducing the need for red blood cell transfusions in cancer patients with chemotherapy-induced anemia.

The emerging field of integrative oncology now has a definitive textbook, thanks to the Herculean effort of Matthew P. Mumber. Dr. Mumber regards integrative oncology as "the next step in the evolution of cancer care [including] the use of evidence based-tools [that] have their origin both in Western, conventional medicine and in complementary and alternative medicine (CAM) traditions."

Image-guided thermal ablation can provide much needed relief of chronic pain in chest wall tumor patients. According to research presented at the annual meeting of the Society of Interventional Radiology (abstract 168), thermal ablation not only relieves pain but may even contribute to longer survival. In addition, ablation may have synergistic effects with radiation therapy.

The Lung Cancer Alliance applauded a recent court decision on the rights of terminally ill cancer patients to take experimental drugs. In 2003, The Abigail Alliance and the Washington Legal Foundation filed suit against the Food and Drug Administration (FDA) in order to give terminally ill cancer patients access to drugs that have passed initial safety tests but not the full regalia of clinical trials normally required for approval.

Valeant Pharmaceuticals International announced that the US Food and Drug Administration (FDA) has given marketing approval for nabilone (Cesamet, CII) oral capsules. Nabilone is used to treat nausea and vomiting associated with cancer chemotherapy in patients who have failed to respond adequately to conventional antiemetic treatments.

Patients receiving chemotherapy for cancer often develop anemia, which can contribute to increased morbidity and reduced quality of life.[1] It is important for clinicians to be aware of current clinical studies in the treatment of chemotherapy-induced anemia. In patients with nonmyeloid malignancies, chemotherapy-induced anemia can be successfully treated using erythropoiesis-stimulating agents (ESAs). The application of these agents has evolved from more frequent to less frequent administration and from weight-based to single, fixed doses. Emerging data show that ESAs can be given safely on the same day as chemotherapy without loss of efficacy,[2] and that these agents may be administered as infrequently as every 3 weeks.[3,4] The every-3-week schedule is convenient and may reduce the burden on patients and their caregivers by reducing the number of visits to the clinic.

As a 20-plus-year cancer survivor, I have been heartened to see the number of cancer survivors increase (currently estimated at well over 10 million Americans), and new attention paid to the unique, wide-ranging, and long-term issues that follow the diagnosis and treatment of cancer. This volume reflects that trend. It reports the work of an Institute of Medicine (IOM) and National Research Council (NRC) of the National Academies "Committee on Cancer Survivorship: Improving Care and Quality of Life."

The Food and Drug Administration (FDA) has approved a new every-3-week dosing schedule for Amgen's erythropoiesis-stimulating agent Aranesp (darbepoetin alfa) used in the treatment of chemotherapy-induced anemia in patients with nonmyeloid malignancies. Of the estimated 1.3 million cancer patients who will receive chemotherapy in the United States this year, about 800,000 will develop anemia, one of the most common adverse events associated with the treatment of malignancies.