Page 27 Complete Your CE Test Online - Click Here patient will often share information that gives the cancer team a clearer picture of how fatigue, nausea, pain, and other symptoms are affecting the patient’s and family’s life. Sometimes the oncology nurse may get a more forthright answer if the patient is not in the room. The caregiver may be taking over more and more of the patient’s care on days that the patient is having trouble taking care of himself, which the patient is sometimes reluctant to share. Caregivers often are the first observers to report mental status changes, such as confusion and delirium, of which the patient may be unaware or embarrassed to bring up. In-home and family caregiving will not be covered in this course, but there is a list of resources at the end of this module that can help prepare the caregiver for the sometimes stressful job of caring for a loved one at home during a serious illness. It is important to include caregivers in care planning, teaching, and assessment. Side effects of cancer treatment Chemotherapy and radiation not only kill fast-growing cancer cells but also can kill or slow the growth of healthy cells that grow and divide quickly, such as those that line the mouth and gut, or hair follicles. Damage to these healthy cells often causes side effects, such as mouth sores, nausea, and hair loss. These kinds of side effects can sometimes be controlled with medications and other measures, and they usually disappear after chemotherapy is finished. There are innumerable side effects of chemotherapy, from the bothersome (such as alopecia or dry skin) to the life-threatening (such as tumor lysis syndrome or Stevens-Johnson syndrome, a blistering, desquamating rash). Some of these are rare and unexpected, some are predictable and preventable, but nearly all respond best to early recognition and intervention. Chemotherapy can be life-threatening for some people. Side effects profiles are different for every cancer drug, and oncology nurses must spend time reviewing them. Of course, some patients pose the challenge of having side effects that are not on the drug’s adverse effects list. Most of the common symptoms oncology nurses deal with are drug side effects, although some, such as pain, are sometimes in part caused by the cancer. Frequent new drug approvals complicate recognition of side effects Adding to the difficulty of assessment is the fact that there are many new drugs introduced for cancer treatment every year. For example, 24 drugs were on the newly FDA-approved list for cancer indications in 2014 and 2015 (total for both years). Out of the 24 drugs that were approved for actual cancer treatment over those two years, seven were for primary cancer treatment as well as second-line treatments. Seven were for specific genetic alterations of a cancer. Eleven were for relapsed, locally advanced, previously treated, refractory, or metastatic cancers (one of these also had a gene-specific type so it counts in two categories). Two additional drugs for symptom management were oral antiemetics, one as a combination and one meant to be given in combination with a previously approved drug. Some of the newer drugs were approved on a fast track, which means that less information is available on their side effects and adverse outcomes than the older ones with which professionals have had more observation time and experience. This means more responsibility on cancer care teams to identify potentially serious new problems with these drugs (those that are not currently listed in the Adverse Effects section of the label) and report these to the FDA. The nurse can report previously unlisted adverse effects or unexpected serious outcomes directly to MedWatch by calling 1-800-FDA-1088 or going online for the reporting forms at Select “Professionals”; then “Report a Medical Product Problem to FDA” (see “Resources for Nurses”). Clearly, no cancer update or cancer drug guide is likely to keep up with this flood of new medications. With the pace of new drug approvals, the nurse who is managing the patient or giving the medications might be looking up a new drug an average of once a month. For nurses who want a head start on new drugs, there are online app for tablets and smartphones that have complete drug information, and new product information can be found on the FDA website or the drug manufacturer’s site (see “Resources for Nurses”). Side effect prevention: Cytoprotectant drugs There are just a few drugs available that help reduce the risk or severity of certain side effects from chemotherapy, although research in this area continues. In 2008, the American Society of Clinical Oncology (ASCO) recommended use of the cytoprotectant drugs dexrazoxane, amifostine, mesna, and palifermin. Dexrazoxane is recommended only in metastatic breast cancer for those who have received high doses of doxorubicin but are likely to have continued benefit from it. They also recommend continued cardiac monitoring while those patients receive the drug. Amifostine can be considered to prevent cisplatin nephrotoxicity and reduce high-grade neutropenia from various chemotherapy drugs as well as decrease xerostomia for people receiving radiotherapy alone for head and neck cancer. The ASCO does not recommend it for host of other complications for which it sometimes is thought to be helpful, as evidence does not support its use. Mesna is given in divided doses once before and twice after standard and higher ifosfamide doses, although there are concerns about the optimal dosing schedule in very high dose ifosfamide. Mesna can also be used in cyclophosphamide treatments along with saline diuresis. IV mesna is standard, but oral dosing can also be used. Palifermin is recommended for stem cell transplants patients who are getting total body irradiation conditioning regimens. A discussion of the data and other considerations can be found on the ASCO publications website at T2.expansion.html SYMPTOM MANAGEMENT AND PALLIATIVE CARE Palliative care is any measure intended to promote comfort or help with pain and symptom relief, but that is not intended to cure the disease. Oncology nurses have been providing palliative care (or what has been called “supportive care”) ever since cancer treatment began for nausea, pain, dyspnea, anxiety, and other issues. Although the term palliative care is often associated with advanced cancer and end of life, it is used throughout cancer treatment. The difference is that at the end of life, palliative care is usually given by itself rather than along with curative treatments. The nurse’s goal is to keep patients’ suffering to a minimum while maximizing their comfort throughout cancer treatment and even beyond. Hospice care nurses and social workers also offer palliative care for the family’s emotional pain and bereavement after the patient’s death. In recent years, palliative care teams have formed to help busy cancer treatment teams with a more systematic approach to palliative care. These teams are available for consultation and comanagement in some facilities. If such a team is available, patients with complex needs might benefit from consulting earlier the palliative care team rather than later. Following are just a few of the more common symptoms patients with cancer face during treatment, most of them caused by the treatments themselves. The list of actual symptoms and side effects is essentially endless, requiring constant communication and diligent observation. Fatigue The most common side effect of chemotherapy treatment is fatigue. Fatigue is not the usual tiredness that goes away with rest, but a persistent sense of exhaustion that interferes with normal function. It rarely occurs in isolation, and is often accompanied by pain, emotional distress, anemia, and sleep disturbances. It is important to assess fatigue before, during, and after treatment. As with pain, fatigue can be ranked on a numeric scale from 0 to 10, with 0 representing no fatigue and 10 representing the worst imaginable fatigue. Nurses can help patients prepare for fatigue the following ways: ● ● Recommending that patients ask someone to drive them to and from chemotherapy. ● ● Planning time to rest during chemotherapy.