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M. Hesdorffer
Moderator of
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NU04 - Managing Toxicity (ID 278)
- Event: WCLC 2016
- Type: Nurses Session
- Track: Nurses
- Presentations: 3
- Moderators:M. Hesdorffer, M. Davies
- Coordinates: 12/06/2016, 14:30 - 15:45, Schubert 5
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NU04.01 - Management of Toxicities Associated with Immunotherapy in the Lung Cancer Patients (ID 6478)
14:30 - 14:50 | Author(s): M. Davies
- Abstract
- Presentation
Abstract:
Abstract – IASLC – 2016 Vienna, Austria Chronicity is a word that over the past few years has been utilized when talking about lung cancer treatments. From the developments of the TKIs in the early 2000’s to the approval of immunotherapy for lung cancer in 2015, we are seeing that progression free survival and in some instances overall survival continues to be on the rise. So what does this mean for the medical oncology community? Patients can be on therapies longer than a year and sometimes for several years. We now as providers face the challenge of becoming experts in the management of long-term toxicity of these agents. Side effects of the targeted and immunotherapy drugs are not as predictable as their chemotherapy predecessors, and we are now dealing onset times ranging from days to years after beginning therapy. Immunotherapy drugs are the newest treatment craze and rightfully so, as we have seen documented 12 month overall survival in both non-squamous and squamous cell carcinoma for some of these agents and even up to 24 months for some patients. Although this has brought optimism to both providers and patients alike, it has also brought forth a multitude of side effects that remind us that we are still novices in this field and necessitate the collaboration with our non-oncologic colleagues as some of these side effects can be life-long. This lecture will review the mechanism of action of the immunotherapy agents as well as review those that are currently available for NSCLC with review of the data leading to their approval and the current and potential future challenges that lie ahead.
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NU04.02 - Experience of Lung Cancer Patients Receiving Immunotherapy (ID 6479)
14:50 - 15:10 | Author(s): R. Thomas
- Abstract
- Presentation
Abstract:
With the emergence of immunotherapy in lung cancer, patients now have access to treatments that have the potential to improve prognosis. Patients diagnosed with advanced non-small cell lung cancer (NSCLC) (either squamous or non-squamous) have previously had limited treatment options. With the emergence of new drugs, particularly in the immune-oncology setting, this is now changing. Recent clinical trial evidence demonstrates that compared with docetaxel, patients who received Nivolumab or Pembrolizamab had better overall survival and also significantly fewer Grade 3-4 adverse events (AEs). However the nursing experience of caring for lung cancer patients on an immunotherapy remains quite limited. Up to recent times immunotherapy drugs were limited to the clinical trial setting or early patient access schemes. Often patients on clinical trials are managed and monitored by research nurses which can further limit the experience for Lung Cancer Clinical Nurse Specialists caring for patients on immunotherapy. The two main clinical trials for immunotherapy in the UK were CHECKMATE (Nivolumab) and KEYTRUDA (Pembrolizamab). The aim of this presentation is to look at two patient case studies and review their experience of taking an immunotherapy. The presentation will focus on how immunotherapy has impacted on their lung cancer and also on their life. As part of the patient case studies there will be a focus on the nursing role in supporting and caring for patients on immunotherapy in a safe and effective manner. The presentation will examine the main adverse event profiles of immunotherapy and how these differ to chemotherapy. The presentation will open with a brief synopsis of the mode of action of immunotherapy which is a 2 minute film. The main focus of the presentation however, will be on the patient experience and the nurses’ role. Currently in the UK there is a scarcity of information available to oncology nurses on the nursing care of patients on immune-oncology treatments. However, there are many transferable skills which can be utilised when caring and supporting patients and their carers who either about to commence on immune-oncology. According to Reiger (2003) oncology nurses have a better opportunity than any other member of the healthcare team to develop the required rapport for effective educational pre-treatment consultations with both the patient and the carer. With regards to lung cancer clinical nurse specialists this rapport is often developed from the point of meeting the patient and carer at diagnosis and then supporting them through first line treatment and beyond to follow up. Often oncology nurses will build a rapport with patients when they attend to undergo treatment and are often a point of contact for patients to report side effects to. Including the patient’s carer in pre-treatment consultations and at key points in the patient pathway is very important. Often patients will be receive a lot of information about their diagnosis and proposed treatment plans and this can be very overwhelming (Malton 2002). Having the carer present means that they can ask questions about treatment side effects, how long the intended benefit of the treatment is and how the patient will be monitored during treatment. The pre-treatment consultation should be undertaken separately to the consent to treatment appointment to allow both the patient and the carer to digest information and write down any questions about the treatment they may have. In the current setting patient information for Nivolumab is under design meaning there may be limited information available to give the patient. There are patient alert cards which patients can keep in their wallets which detail the main side effects of Nivolumab. However, it is also important the nurse undertaking the pre-treatment consultation has a good understanding of Nivolumab, how it works and the potential side effects to monitor for so that they can counsel the patient and their carer accordingly and be able to answer any questions they may have. A clear and concise approach should be used in the pre-treatment consultation with key communication skills of planning, preparation and delivering the message, listening and questioning skills should also be implemented (Wiffen 2007). References. Malton S (2012) How to counsel cancer patients about their oral chemotherapy. Clinical Pharmacist 4: 171 Wiffen P, Mitchell M, Snelling M, Stoner N (2007) Oxford Handbook of Clinical Pharmacy. 1st edn. Oxford University Press, Oxford Rieger P, Yarbro C (2003) Role of the oncology nurse. In: Cancer Medicine. 6th edn. Kufe DW, Pollock RE, Weichselbaum RR, eds. BC Decker, Hamilton
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NU04.03 - Where are we With TKI Toxicities (ID 6480)
15:10 - 15:30 | Author(s): B. Eaby-Sandy
- Abstract
- Presentation
Abstract:
Where Are We With TKI Toxicities? (Extended Abstract) Thoracic oncology nursing is now entering over 10 years of experience with managing tyrosine kinase inhibitor (TKI) toxicities, most notably, epidermal growth factor receptor (EGFR) inhibitor associated rash. The three approved EGFR inhibitors used to treat non-small cell lung cancer (NSCLC) are afatinib, erlotinib, and gefitinib. Most recently, the drug Osimertinib, for EGFR mutation resistance known as T790M, has now been approved for use. Grading of the EGFRI rash has been difficult due to its inconsistency in comparison to non-EGFRI rashes in the general medical community and other oncologic rashes. Consensus guidelines for the management of EGFR inhibitor associated rash have been produced and disseminated in the oncology community.[1,2] There is a correlation between EGFRI rash and overall survival in NSCLC patients, making it imperative to keep patients with rash on the EGFRI therapy.[3,4] It remains a challenge for oncology nurses to understand and manage this sometimes severe rash (see figure 1). Figure 1. Other cutaneous toxicities such as scalp rash, paronychia, hypertrichosis- namely trichomegaly (see figure 2), fissuring, pruritis, and xerosis have all been reported. The Multinational Association for the Supportive Care in Cancer (MASCC) has produced recommendations for these toxicities as well.[2] While they are often a minor annoyance, they can sometimes also become severe and cause dose reductions and a significant impact on activities of daily living (ADL’s). Identification, prevention, and management are important tasks for oncology nurses to master to allow patients to remain on therapy. Figure 2. Other classes of TKI toxicities include the Anaplastic Leukemia Kinase (ALK) inhibitors, where there are currently 3 drugs approved for use, alectinib, ceritinib, and crizotinib. Each of the ALK inhibitors carries different yet important toxicities, ranging from nausea/vomiting, diarrhea, edema, bradycardia, pneumonitis, myalgias with elevated CPK levels, and hepatotoxicity. Several other TKI’s are in development for potential use in lung cancer, such as HER2 inhibitors, BRAF inhibitors, and drugs targeting pathways dealing with RET, MET and KRAS (see table 1).[5-7]
It is important for thoracic oncology nurses to have a firm understanding of these drugs and their toxicities. Management strategies must be tailored to the patient’s symptoms and side effects, as well as to the specific drug and dosage. References: 1. Burtness B, Anadkat M, Basti S, et al (2009). NCCN task force report: management of dermatologic and other toxicities associated with EGFR inhibition in patients with cancer. JNCCN, 7(suppl 1):S5-S21. Available at http://www.nccn.org/JNCCN/PDF/2009_Derm_Tox_TF.pdf 2. Lacouture ME, Anadkat MJ, Bensadoun RJ, et al (2011). Clinical practice guidelines for the prevention and treatment of EGFR inhibitor-associated dermatologic toxicities. Support Care Cancer, 19(8):1079-1095. DOI:10.1007/s00520-011-1197-6 3. Lee SM, Khan I, Upadhayay S, et al (2012). First-line erlotinib in patients with advanced non-small-cell lung cancer unsuitable for chemotherapy (TOPICAL): a double-blind, placebo-controlled, phase 3 trial. Lancet Oncol, 13(11):1161-1170. DOI:10.1016/S1470=2045(12)70412-6 4. Liu H, Wu Y, Lv T, et al (2013). Skin rash could predict the response to EGFR tyrosine kinase inhibitor and the prognosis for patients with non-small cell lung cancer: a systematic review and meta-analysis. PLOS One. DOI:10.1371/journal.pone.0055128 5. Cardarella S, Ogino A, Nishino M, et al. (2013). Clinical, pathologic, and biologic features associated with BRAF mutations in non-small cell lung cancer. Clin Cancer Res. 2013; 19:4532-4540. 6. Tsuta K, Khono T, Yoshida A, et al. (2014). RET-rearranged non-small-cell lung carcinoma: a clinicopathological and molecular analysis. Br J Cancer. 110:1571-1578. 7. Awad MM, Oxnard GR, Jackman DM, et al. (2016). MET Exon 14 mutations in Non-small-cell lung cancer are associated with advanced age and stage dependent MET genomic amplification and c-MET overexpression. J Clin Oncol. 34(7):721-30.BRAF mutations 4% NSCLC Most common is V600E Drugs in trials: dabrafenib, vemurafenib, dasatinib, RET rearrangements 1-2% NSCLC Highly associated with young, never-smokers Drugs in trials: vandetanib, cabozantinib, sunitinib, ponatinib MET amplification Drugs in trials: crizotinib, tivantinib, onartuzumab, MET inhibitors HER2 mutations Drugs in trials: trastuzumab, afatinib, dacomitinib, neratinib KRAS mutations 25-30% NSCLC, most common mutation MEK, PI3K, FAK inhibitors
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