Palliative and Supportive Care

When Kristin Cawley, RN, bgins her day at Memorial Sloan-Kettering Cancer Center (MKSCC) in New York City, she has two essential tools at her fingertips: a set of telephone triage protocols and a standard documentation form. In the next 10 hours, she will see patients and confer with their physicians. But like the 400 other RNs in ambulatory care at MSKCC, she will also talk to dozens of patients on the phone. Most of those calls will concern symptoms and will draw on Cawley's specially honed skills in telephone triage.

Physical exam revealed an enlarged spleen and right axillary lymph node. Her bloodwork is remarkable for an elevated lactate dehydrogenase (LDH) of 550 U/L and a creatinine of 2.0 mg/dL. Mrs. Reynolds is a retired actress and lifelong nonsmoker who drinks 1 to 2 glasses of wine a week and denies illicit drug use. Her health history includes the vaginal delivery of two healthy babies in her 20s and hypercholesterolemia, which has been controlled by diet.

The intent of this article is to provide oncology nurses with practical information on the pharmacologic management of pain. The use of chemotherapy, radiation therapy, and surgery in pain management will not be addressed in this article. It is the second in a three-part series on cancer pain management. The first in the series (September 2006) addressed cancer pain assessment. In a future issue, the third in the series will address nonpharmacologic approaches to cancer pain management.

In a phase III study, darbepoetin alfa (Aranesp) was ineffective in reducing red blood cell (RBC) transfusions in cancer patients with anemia not due to concurrent chemotherapy, and patients receiving darbepoetin had higher mortality.

Patients with transfusion-related iron overload with an insufficient initial response to lower doses of deferasirox (Exjade) respond long term to higher doses

Patients with late-stage non-small-cell lung cancer (NSCLC) treated with palliative radiation derive greater value from a longer, less intense course of therapy

Hormone-refractory prostate cancer (HRCaP) is both heterogeneous and lethal. Multiple treatment options exist, including secondary hormonal manipulations, chemotherapy, experimental options, and best supportive care. Choosing the appropriate therapy for an individual patient depends on several important clinical factors such as the presence or absence of symptomatic metastatic disease, age and comorbidities, and prostate-specific antigen velocity. While only docetaxel (Taxotere)-based chemotherapy has been proven to improve survival in this setting, a wide range of therapies may be effective for any individual. Palliative maneuvers, such as external-beam radiation, bisphosphonate therapy, radiopharmaceuticals, and pain management are critical for appropriate patient management. Several promising novel therapies are in late-stage testing and will hopefully provide more treatment options for these patients.

The National Comprehensive Cancer Network (NCCN) recently announced updates to the NCCN Antiemesis Guidelines. The NCCN Clinical Practice Guidelines in Oncology are used extensively by managed care companies and by Medicare as the basis for coverage policies. The guidelines have a new recommendation for breakthrough treatment—Nabilone (Cesamet, Valeant)—for chemotherapy-induced nausea/vomiting.

Hormone-refractory prostate cancer (HRCaP) is both heterogeneous and lethal. Multiple treatment options exist, including secondary hormonal manipulations, chemotherapy, experimental options, and best supportive care. Choosing the appropriate therapy for an individual patient depends on several important clinical factors such as the presence or absence of symptomatic metastatic disease, age and comorbidities, and prostate-specific antigen velocity. While only docetaxel (Taxotere)-based chemotherapy has been proven to improve survival in this setting, a wide range of therapies may be effective for any individual. Palliative maneuvers, such as external-beam radiation, bisphosphonate therapy, radiopharmaceuticals, and pain management are critical for appropriate patient management. Several promising novel therapies are in late-stage testing and will hopefully provide more treatment options for these patients.

Hormone-refractory prostate cancer (HRCaP) is both heterogeneous and lethal. Multiple treatment options exist, including secondary hormonal manipulations, chemotherapy, experimental options, and best supportive care. Choosing the appropriate therapy for an individual patient depends on several important clinical factors such as the presence or absence of symptomatic metastatic disease, age and comorbidities, and prostate-specific antigen velocity. While only docetaxel (Taxotere)-based chemotherapy has been proven to improve survival in this setting, a wide range of therapies may be effective for any individual. Palliative maneuvers, such as external-beam radiation, bisphosphonate therapy, radiopharmaceuticals, and pain management are critical for appropriate patient management. Several promising novel therapies are in late-stage testing and will hopefully provide more treatment options for these patients.

A striking black-and-white photograph (see Figure) of nursing student Katherine Wilson, a nonsmoker who lived 5 years with small-cell lung cancer before dying in 2005 at age 28, won the Best of the United States first prize in the 2006 Lilly Oncology on Canvas: Expressions of a Cancer Journey International Art Competition and Exhibition. The US competition finale was held at the Metropolitan Pavilion, New York, with Lilly President and COO John C. Lechleiter, PhD, presenting the top three US finalists with their awards.

Bisphosphonates are an important part of managing bony metastasis of prostate, breast, lung, and other cancers but can cause osteonecrosis of the jaw (ONJ) in some patients.

Anemia raises special concerns in older cancer patients. This review addresses the prevalence, causes, and mechanisms of anemia in older individuals, the complications of anemia in this population (including its impact on cancer treatment), and the appropriate management of anemia in the elderly.

In RTOG 9111, a randomized phase III trial in locally advanced laryngeal cancer, there was no difference in overall survival between the three arms, but disease-free survival, locoregional control, and preservation of the larynx were better in patients receiving induction chemotherapy plus radiation or concurrent chemoradiation, compared with radiation therapy alone.

Synchronized every-3-week delivery of myelosuppressive chemotherapy and an erythropoiesis-stimulating protein (ESP) to prevent chemotherapy-induced anemia is convenient for patients and feasible using darbepoetin alfa (Aranesp), but researchers have worried that it could affect efficacy and safety, since myelosuppressive chemotherapy is known to be associated with a rapid and transient increase in circulating erythropoietin levels.

Just how are new plans to share care of cancer survivors being greeted by oncologists, primary care physicians, and patients? Some speakers on a cancer survivorship panel at the Second Annual Oncology Congress said it would be a big adjustment.

Patients hospitalized for treatment of cancer or other medical conditions who are diabetic or become diabetic need aggressive glycemic control, MiKaela Olsen, RN, MSN, OCN, said at the Oncology Nursing Society 31st Annual Congress

Hospitalized oncology patients are at particular risk for acute venous thromboembolism (VTE); however, more often than not, a standard for VTE prophylaxis does not exist, according to Jerelyn Osoria, RN, OCN, of Memorial Sloan-Kettering Cancer Center. Ms. Osoria reported at the Oncology Nursing Society 31st Annual Congress (abstract 113) that an electronic medical orders system and better nursing documentation have helped improve this situation at her institution's Gynecology (GYN) oncology inpatient nursing unit.

Who will watch over the burgeoning numbers of cancer survivors and provide the surveillance, general medical care, education, and psycho-social support that the upwards of 10 million survivors in America need and demand? Pilot programs and survivorship care guidelines may be shifting some responsibilities away from oncologists

The US Food and Drug Administration (FDA) has approved the first generic versions of Zofran (ondansetron, GlaxoSmithKline). Marketing approval has been granted to Teva Pharmaceuticals USA for ondansetron for injection and to SICOR Pharmaceuticals for ondansetron injection premixed.

This comprehensive guidebook is an invaluable reference for patients and health professionals as they navigate the murky waters of cancer treatment and survivorship. While several other books address only specific aspects of living with cancer and its aftermath, Silver's reference covers all aspects of life during and after cancer, touching on issues that range from pain management to responding to children's questions about cancer such as, "Are you going to die?"

Myelosuppression and particularly neutropenia and associated complications, including febrile neutropenia, continue to represent the major dose-limiting toxicity of cancer chemotherapy.

This report describes the Food and Drug Administration's review of data and analyses leading to the approval of the oral iron chelator, deferasirox for the treatment of chronic iron overload due to transfusional hemosiderosis.

The chemotherapy of most cancers may be beneficial to older individuals as long as patients are selected on the basis of their life expectancy and functional reserve, conditions that may interfere with the tolerance of chemotherapy are corrected, and adequate doses of chemotherapy are administered. Prevention of neutropenia-related infection may both improve the outcome of cancer and reduce the risk of toxic deaths in older patients. The prophylactic use of myelopoietic growth factors is recommended in individuals aged 65 and older when the risk of chemotherapy-induced neutropenic infection is at least 10% or higher. In this article we explore the management of neutropenia and neutropenic infections in older cancer patients, as well as review the causes and the risk of this complication.

It has been more than 15 years since the initial approval of myeloid growth factors to reduce febrile neutropenia in cancer patients receiving myelosuppressive chemotherapy.[1] As with other novel therapeutics, the approval of filgrastim (Neupogen) did not mark the end of research in this area, but rather the beginning.

Acute myeloid leukemia (AML) is a disease of the elderly, with the majority of patients diagnosed in their 6th and 7th decade of life. Older patients with AML are less likely to achieve complete remission after induction chemotherapy, and they suffer from higher rates of leukemia relapse compared to younger cohorts. Suboptimal outcomes are the result of adverse biologic characteristics of leukemia in the elderly, as well as the presence of medical comorbidities and patient or physician preferences as to initiating treatment. In addition, there is a distinct lack of randomized, prospective data to guide management decisions for the treatment of AML in the elderly. Patients who are over age 75, with poor performance status, multiple comorbidities, or poor prognostic features, should be considered for a clinical trial or palliative therapy. Elderly patients who are candidates for standard induction chemotherapy and achieve complete remission are unlikely to benefit from intensive postremission therapy and should be referred to a clinical trial when possible. Further prospective trials are needed to identify a tolerable, effective treatment regimen for older patients with AML.

Acute myeloid leukemia (AML) is a disease of the elderly, with the majority of patients diagnosed in their 6th and 7th decade of life. Older patients with AML are less likely to achieve complete remission after induction chemotherapy, and they suffer from higher rates of leukemia relapse compared to younger cohorts. Suboptimal outcomes are the result of adverse biologic characteristics of leukemia in the elderly, as well as the presence of medical comorbidities and patient or physician preferences as to initiating treatment. In addition, there is a distinct lack of randomized, prospective data to guide management decisions for the treatment of AML in the elderly. Patients who are over age 75, with poor performance status, multiple comorbidities, or poor prognostic features, should be considered for a clinical trial or palliative therapy. Elderly patients who are candidates for standard induction chemotherapy and achieve complete remission are unlikely to benefit from intensive postremission therapy and should be referred to a clinical trial when possible. Further prospective trials are needed to identify a tolerable, effective treatment regimen for older patients with AML.

cancer is the second leading cause of death in the United States, with more than 500,000 men, women, and children succumbing to the disease each year. The idea, then, that we can eliminate the suffering and death due to cancer in the United States by the year 2015 may appear impractical, if not irrational and impossible. It seems inconceivable that in the first part of the 21st century every patient could survive cancer. Doubt can be attributed to awareness of the biologic complexity of cancer and seeing the pace of clinical progress through the prism of the 20th century.

Colorectal cancer is the second most common cause of cancer death in the United States. It is estimated that about 55,000 patients will die this year due to advanced colorectal cancer. These grim statistics persist despite a marked increase in the rate of screening colonoscopies and improvements in adjuvant chemotherapy. Successful chemoprevention strategies may reduce the risk of new colorectal cancers, thus decreasing related overall morbidity and mortality.

Acute myeloid leukemia (AML) is a disease of the elderly, with the majority of patients diagnosed in their 6th and 7th decade of life. Older patients with AML are less likely to achieve complete remission after induction chemotherapy, and they suffer from higher rates of leukemia relapse compared to younger cohorts. Suboptimal outcomes are the result of adverse biologic characteristics of leukemia in the elderly, as well as the presence of medical comorbidities and patient or physician preferences as to initiating treatment. In addition, there is a distinct lack of randomized, prospective data to guide management decisions for the treatment of AML in the elderly. Patients who are over age 75, with poor performance status, multiple comorbidities, or poor prognostic features, should be considered for a clinical trial or palliative therapy. Elderly patients who are candidates for standard induction chemotherapy and achieve complete remission are unlikely to benefit from intensive postremission therapy and should be referred to a clinical trial when possible. Further prospective trials are needed to identify a tolerable, effective treatment regimen for older patients with AML.