As more and more novel therapies are added to the treatment paradigm for hematologic malignancies, the frequency and variety of side effects continue to increase. As a result, nursing interventions are more crucial than ever, according to Carol Viele, RN, MS, Clinical Nurse Specialist at the University of California San Francisco School of Nursing.
“It’s long-term toxicity that we need to think about,” Ms Viele told attendees at the Academy of Oncology Nurse & Patient Navigators 2019 Midyear Conference. “And since your role is to follow patients throughout the entire disease trajectory, it’s important to know the big ones: fatigue, neuropathy, cardiac complications, pulmonary complications, and quality-of-life issues.”
Fatigue and Neuropathy
Fatigue is a significant problem in patients and survivors. First, treat all underlying and reversible causes of fatigue, including comorbidities, alcohol/substance abuse, endocrine dysfunction, emotional distress, and nutritional or sleep issues, she advised.
“The important caveat in fatigue is, we know that the more we can get patients to actually stay active, the less fatigue they’ll have,” she noted.
Interventions can be nonpharmacologic: encouraging patients to prioritize and pace activities, delegate tasks as much as possible, or begin an exercise program. “Like I tell my patients, ‘You don’t have to go to spinning class,’” she said. “The idea is, can you walk to your mailbox and down the driveway? Can you start from that point and work up?”
Yoga, even “chair yoga,” is especially important for survivors because it targets both the mind and the body, Ms Viele added.
Pharmacologic interventions for fatigue include psychostimulants (methylphenidate, dexmethylphenidate, modafinil) and glucocorticoids. “When in doubt, use steroids,” she said. “Depending on where they are in their disease trajectory, low-dose steroids can significantly improve patients’ quality of life.”
Antidepressants can also be effective in treating this side effect. “It was originally thought, Well, of course people are depressed...they’ve got cancer, right?” she said. “But we know now that not treating depression enhances fatigue.”
Peripheral neuropathy is another common adverse event in patients with hematologic cancers, and it is typically dose-dependent and cumulative. Preventive approaches include antidepressants and anticonvulsants, and treatment should be focused on physical therapy and rehab. Pharmacologic agents used to treat neuropathy include gabapentin, pregabalin, nortriptyline, desipramine, and duloxetine.
“I always tell people: what’s important to know is, if I put a dime on the table when I’m examining a patient, and they can’t pick up the dime, they already have grade 2 neuropathy,” Ms Viele said.
Cardiac and Pulmonary Complications
Cardiac complications are usually delayed by 10 to 20 years after therapy. Risk factors include hypertension, cigarette smoking, obesity, physical inactivity, and family history, to name a few. First-line treatments are ACE inhibitors, angiotensin receptor blockers, and dihydropyridine calcium channel blockers; second-line therapies include beta-blockers and diuretics.
“The important part is, we have to treat their hypertension,” she stressed. “The higher the blood pressure goes, the more stress it puts on the myocardium and the less functional the patient gets.”
All patients with hematologic malignancies have the potential to experience cardiac dysfunction, so efforts at prevention should focus on aspirin, blood pressure, and cholesterol control, and emphasis on exercise and healthy diet, followed up by an echo and EKG. “With cardiovascular toxicity, patients can survive their cancer but become a cardiac cripple,” Ms Viele warned.
When it comes to pulmonary toxicity, treatment is empiric rather than evidence-based. Discontinue the drug, administer steroids to assist with healing in the lungs, and deliver supportive care with supplemental oxygen, inhaled bronchodilators, and mechanical ventilation.
“Pulmonary complications can develop well after treatment has been completed,” she said. “So educate patients to avoid smoking and vaping, and to exercise and maintain a healthy lifestyle and weight.”
Preserving Quality of Life
Quality of life is measured in 4 domains. Physical well-being refers to the control or relief of symptoms and maintenance of function and independence; psychological well-being is the attempt to maintain a sense of control in the face of an overwhelming illness; social well-being is the effort to deal with the impact of cancer on individuals, their roles, and relationships; and spiritual well-being is characterized by the ability to maintain hope and derive meaning from the cancer experience itself.
Cancer survivors live with incredible uncertainty because they never know if the disease will come back. They’re watching for late and long-term effects, dealing with issues of mortality, and trying to overcome obstacles like financial stability and job security, all while adapting to a changing healthcare system (will they have the same provider or insurance? How much is this going to cost?).
“When we think of quality of life, we want to think of the needs of cancer survivors,” said Ms Viele. “We want to help them maintain a positive outlook.”