Chemotherapy Is Still a Staple in Treatment Plans. Here’s a Fresh Look at a Familiar Treatment Option
Despite all of the new drugs approved in recent years—particularly immunotherapies, oral agents, and biosimilars—that have forced nurses to consider many novel approaches to patient care, the importance of chemotherapy in cancer treatment has remained a constant. In a field where it feels like no two days are the same and new drugs emerge on a rolling basis, chemotherapy continues to be a staple in cancer treatment plans and safety and administration principles remain constant.
Chemotherapy Competence
ONS and the American Society of Clinical Oncology (ASCO) use the term “chemotherapy competence” to describe the skillset and education a practitioner needs to safely administer chemotherapy. Each institution must develop standard operating procedures or policies articulating what will be required of nurses involved in the care of patients receiving chemotherapy; however, ONS’s position is that providers should be educated (https://www.ons.org/advocacy-policy/positions/education/chemotherapy-biotherapy) with didactic training followed by a competency validation or clinical practicum under the auspices of the nurses’ institution or supporting agency.
Regardless of practice setting or indication for treatment, chemotherapy agents have complicated administration regimens with high risk for error and intolerance to therapy. Furthermore, nurses need to consider many assessment paramaters following administration. For these reasons, ASCO and ONS endorse ongoing chemotherapy competence for nurses (https://doi.org/10.1188/17.ONF.31-43) involved in caring for patients undergoing chemotherapy for both oncology and non-oncology indications.
Combination Therapies
Chemotherapy is used in single or multiple agent regimens as well as in combination with targeted and immunotherapy to combat drug resistance or potentiate mechanism of action of some agents. This adds a level of complexity to assessing severity and determining management strategies. For example, if a patient receiving a chemotherapy in combination with a checkpoint inhibitor presents to clinic with diarrhea that interfers with activities of daily life, the nurse, as part of the interprofessional care team, should identify when the side effect developed to determine the causative agent. Treatment strategies for chemotherapy-induced adverse events and immune-related adverse events are drastically different.
The appropriate sequence of administration for multidrug regimens should be included as part of the order set (https://doi.org/10.1188/17.ONF.31-43). The order set should also reference the publication (http://www.jhoponline.com/jhop-issue-archive/2011-issues/march-vol-1-no-1/13240-top-13240) summarizing the original research to determine sequence of administration used in the clinical trial for the regimen.
Oral Chemotherapy
The number of available oral chemotherapy agents continues to grow, as does the number of oral agents in drug development. The convenience and added quality of life that oral agents give patients must be balanced with the risks associated with medication error and exposure to hazardous drugs.
Nurses have a critical role in ensuring that patients and caregivers understand not only the drug administration schedule, but also the implications of nonadherence. Complex oral dosing regimens vary from several times a day administration to three weeks on, one week off, which can be confusing for patients and caregivers to follow. Fewer inpatient stays and clinic visits leave more opportunity for errors in dosing schedule.
Safe handling education for patients and caregivers is another priority. ONS guidelines indicate that oral chemotherapy agents should not be stored in pill boxes with other drugs. If patients are handling the drug themselves, they do not need to wear gloves, but they must wash their hands with soap and water after. Caregivers should wear gloves when handling oral agents. Unless contaminated with body fluids, clothes and linens can be washed normally (https://ebooks.ons.org/book/chemotherapy-and-biotherapy-guidelines-and-recommendations-practice-fourth-edition) with other laundry.
Patient Education
For patients to understand their treatment, make informed decisions, and manage the side effects they are experiencing, clinicians need to use the correct terminology when reviewing and obtaining informed consent for chemotherapy, targeted agents, and immunotherapy as treatment options. The mechanism of action of different classes, effects on cytotoxicity and tumor cell specificity, and associated side effects are critical to patient education.