Conquering the Cancer Care Continuum – Series Three: Third Issue

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Side Effect Management: A Nurse’s Perspective

Beth Faiman, PhD(c), MSN, APRN-BC, AOCN 

It is inevitable that patients with cancer will experience some side effects associated with treatment. Recommendations for managing and minimizing these complications are critical to patients’ well-being and can impact overall clinical outcomes. Adherence to therapy (or the ability to remain on treatment as recommended) is negatively affected when cancer symptoms and adverse events (AEs) are inappropriately managed. Although it is assumed that cancer is a devastating diagnosis and patients will adhere to therapy despite side effects, some patients may select quality of life (QOL) over highly toxic therapies. Lack of adherence to treatment is an unfortunate consequence of ineffective AE management. Side effects related to chemotherapy will often vary among patients with hematologic and solid tumor cancers. However, common AEs associated with the use of many chemotherapeutic regimens include fatigue, insomnia, neuropathy, and pain.1

Cancer-related fatigue (CRF) affects 60% to 90% of patients with cancer.1 It is very rare to encounter an individual undergoing chemotherapy who does not complain of this condition. Although the etiology is poorly understood, fatigue negatively impacts the QOL of most patients with cancer. In addition, CRF can impair a person’s ability to perform activities of daily living (eg, hygiene, preparing or shopping for food) and limit his or her employment. CRF can affect patients both physically and psychologically, which may lead to depression.2

The multifactorial and complex nature of fatigue demands comprehensive management of chronic anemia and pain, physical deconditioning, emotional stress, depression, and sleep disturbances.3 Nurses play a key role in screening patients to determine modifiable causes of fatigue and implementing interventions to improve health outcomes (Figure).4,5 
Guidelines on fatigue from the National Comprehensive Cancer Network5 suggest that central nervous system stimulants may be used for the treatment of moderate to severe fatigue, but conflicting evidence exists.6-8Nonpharmacologic treatments such as rest (but not too much rest during the day), adequate nutrition, and exercise remain reasonable recommendations for patients with CRF, along with dose modification of the offending drug when possible.

Insomnia, or difficulty sleeping, is often multifactorial and can be associated with cancer pain, depression, or corticosteroid use for the treatment of hematologic cancers. Poor sleep and poor sleep quality negatively impact a patient’s QOL.9 Benzodiazepines and nonbenzodiazepine hypnotics are commonly administered in combination with nonpharmacologic management, such as sleep hygiene (avoidance of caffeine and exercise before bedtime, regular exercise routine) and the avoidance of daytime naps. The use of cognitive behavioral therapy and relaxation therapy has become more common in recent years, and can address insomnia with a variety of nonpharmacologic approaches.9 Ensuring that a patient with insomnia does not have sleep apnea or another potentially serious health condition is an important nursing consideration. 

Peripheral neuropathy (PN) is characterized by numbness and tingling or pain in 1 or more extremities in patients with cancer.1,10 Damage to the peripheral nerves from chemotherapy or from the disease itself can prevent an individual from successfully receiving treatment. Although no known preventive strategy exists for PN, the Oncology Nursing Society has created guidelines for the management of this condition.10 Exercise seems to be an effective nonpharmacologic intervention, possibly by stimulating oxygen and blood flow to nerve endings to help with regeneration of damaged nerve fibers from a variety of etiologies.11 Other nonpharmacologic strategies such as the use of glutamine have also been studied, with varied results.12-14 To date, the only pharmacologic agent shown to improve painful PN in patients receiving chemotherapy is a serotonin-norepinephrine reuptake inhibitor antidepressant.15 Additional research is ongoing and targets the investigation of genetic factors that predispose an individual to develop neuropathy. 

Many patients with cancer experience pain at some point during the course of their disease. Pain management continues to be a major issue among cancer survivors. The World Health Organization pain ladder has been used for years to help clinicians manage pain in their patients.16 However, because pain can be neuropathic (affecting nerves) or nociceptive (affecting pain receptors) and is often multifactorial in nature, an accurate diagnosis of pain etiology is critical to determine proper treatment. Opioids are effective for the management of pain (once a good pain history has been obtained), but nonpharmacologic management of pain with hypnosis, acupuncture, and behavioral therapy has also been studied and can be effective in some patients.17,18

Nurses play a vital role in caring for patients and are important members of the treatment team. It is important for all nurses, regardless of whether they are able to prescribe medications, to be aware of current side effect management strategies. Understanding and implementing these strategies can benefit patients and improve outcomes.

References

  1. Pachman DR, Barton DL, Swetz KM, Loprinzi CL. Troublesome symptoms in cancer survivors: fatigue, insomnia, neuropathy, and pain. J Clin Oncol. 2012;30:3687-3696.
  2. Berger AM, Abernethy AP, Atkinson A, et al. Cancer-related fatigue. J Natl Compr Canc Netw. 2010;8:904-931.
  3. Coleman EA, Goodwin JA, Coon SK, et al. Fatigue, sleep, pain, mood and performance status in patients with multiple myeloma. Cancer Nurs. 2011;34:219-227.
  4. Carroll JK, Kohli S, Mustian KM, et al. Pharmacologic treatment of cancer-related fatigue. Oncologist.2007;12(suppl 1):43-51.
  5. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Cancer-Related Fatigue. Version 1.2014. https://www.nccn.org/store/login/login.aspx?ReturnURL=http://www.nccn.org/professionals/physician_gls/pdf/fatigue.pdf. Accessed October 17, 2014.
  6. Spathis A, Fife K, Blackhall F, et al. Modafinil for the treatment of fatigue in lung cancer: results of a placebo-controlled, double-blind, randomized trial. J Clin Oncol. 2014;32:1882-1888.
  7. Hovey E, de Souza P, Marx G, et al; MOTIF Investigators. Phase III, randomized, double-blind, placebo-controlled study of modafinil for fatigue in patients treated with docetaxel-based chemotherapy. Support Care Cancer. 2014;22:1233-1242.
  8. Ruddy KJ, Barton D, Loprinzi CL. Laying to rest psychostimulants for cancer-related fatigue? J Clin Oncol.2014;32:1865-1867.
  9. Dickerson SS, Connors LM, Fayad A, Dean GE. Sleep–wake disturbances in cancer patients: narrative review of literature focusing on improving quality of life outcomes. Nat Sci Sleep. 2014;6:85-100.
  10. Oncology Nursing Society; Visovsky C, Collins ML. Peripheral neuropathy; 2009. https://www.ons.org/practice-resources/pep/peripheral-neuropathy. Accessed October 7, 2014. 
  11. Dobson JL, McMillan J, Li L. Benefits of exercise intervention in reducing neuropathic pain. Front Cell Neurosci. 2014;8:102.
  12. Savarese DMF, Savy G, Vahdat L, Wischmeyer PE, Corey B. Prevention of chemotherapy and radiation toxicity with glutamine. Cancer Treat Rev. 2003;29:501-513.
  13. Stubblefield MD, Vahdat LT, Balmaceda CM, Troxel AB, Hesdorffer CS, Gooch CL. Glutamine as a neuroprotective agent in high-dose paclitaxel-induced peripheral neuropathy: a clinical and electrophysiologic study. Clin Oncol (R Coll Radiol). 2005;17:271-276.
  14. Wang W-S, Lin J-K, Lin T-C, et al. Oral glutamine is effective for preventing oxaliplatin-induced neuropathy in colorectal cancer patients. Oncologist. 2007;12:312-319.
  15. Smith EML, Pang H, Cirrincione C, et al; the Alliance for Clinical Trials in Oncology. Effect of duloxetine on pain, function, and quality of life among patients with chemotherapy-induced painful peripheral neuropathy: a randomized clinical trial. JAMA. 2013;309:1359-1367.
  16. World Health Organization. Cancer pain relief and palliative care: report of a WHO Expert Committee. World Health Organization Technical Report Series 804. Geneva, Switzerland: World Health Organization; 1990.
  17. Pachman DR, Watson JC, Loprinzi CL. Therapeutic strategies for cancer treatment related peripheral neuropathies. Curr Treat Options Oncol. 2014 Aug 14 [Epub ahead of print].
  18. Kravits K. Hypnosis: adjunct therapy for cancer pain management. J Adv Pract Oncol. 2013;4:83-88.
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