Page 28 Complete Your CE Test Online - Click Here 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 (i.e. those that are not currently listed in the Adverse Effects section of the label) and report these to the U.S. 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 “apps” 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 following cytoprotectant drugs [100]: ● ● 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 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 issues like nausea, pain, dyspnea, anxiety, etc. 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 patient 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 [214]. 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 co-management 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. Below are just a few of the more common symptoms patients with cancer face during treatment, most of them due to 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 zero to ten with zero representing no fatigue and ten representing the worst imaginable fatigue [206]. Nurses can help patients prepare for fatigue by [163]: ● ● Recommending that patients ask someone to drive them to and from chemotherapy. ● ● Plan time to rest during chemotherapy. ● ● Suggest that patients ask for help with meals, shopping, housework, and childcare (i.e. delegate tasks and conserve energy). ● ● Making a referral to a physical therapist for a consult on an appropriate exercise regimen, with consideration of physical limitations and co-morbidities. Fatigue can affect a patient’s work, sense of self, and many other aspects of quality of life, and sometimes extends well past completion of cancer treatment [163]. When fatigue begins, it is important to teach people to pace themselves, set realistic expectations, and continue to delegate tasks to others as much as possible. Distraction such as games, music, and socializing can be used to help with management, along with scheduling important activities for time when they have the most energy. Some patients find yoga or massage to be helpful. Referral to a mental health professional for assistance with cognitive behavioral therapy, expressive therapies, support groups, etc. may help with fatigue management. People with suspicious sleep problems should be assessed for sleep apnea, which can be precipitated or worsened by cancer treatment. Sleep hygiene instruction is also important for sleeping issues, such as keeping regular sleeping hours, keeping the bedroom dark and quiet, limiting daytime naps to less than one hour, and avoiding caffeine and alcohol within six hours of bedtime [206]. Identification and management of possible contributing causes is often a good starting point for helping with fatigue. Chemotherapy-induced anemia is a well-understood factor, and can be at least somewhat corrected with transfusion, and in some cases with colony-stimulating factors. Nutritional factors can contribute as well, given that the body may be less able to process nutrients at a time when intake may be decreased and energy requirements are often increased. Expert dietary consultation may be helpful [163]. Other underlying causes that can be corrected might include hypothyroidism, hypogonadism, dehydration, and electrolyte imbalances. Pain relief can help some people with fatigue [249]. Consider referral to occupational therapy and physical medicine as well as physical therapy for help in ameliorating and coping with fatigue. If the patient is near end of life and other causes of fatigue have been ruled out, the NCCN recommends consideration of psychostimulants such as methylphenidate, or even treatment with corticosteroids [206]. Nursing consideration: Thus far, the best-proven method of managing fatigue, beyond managing underlying causes, is exercise [163]. Get referrals for physical therapy or professional exercise program to help patients remain active or become even more active during cancer treatment. Encourage patients to make exercise plans a priority.