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Antibody–drug conjugate (ADC) therapy is a transformative development in oncology, offering a targeted mechanism that combines monoclonal antibodies with cytotoxic agents.1 This therapeutic strategy allows for the selective delivery of cytotoxic payloads to malignant cells, reducing the systemic toxicity typically associated with conventional chemotherapy.1 However, despite its precision, ADC therapy is associated with a range of adverse events (AEs), which, if not properly managed, can compromise both patient quality of life and treatment efficacy. Several randomized controlled trials demonstrated that patients utilizing ADC therapy may have AEs such as interstitial lung disease (ILD), ocular toxicity, and hematologic side effects.2 Nurses play an essential role in managing these AEs throughout the patient’s therapy, making critical interventions that ensure patients navigate the treatment process safely and with optimal outcomes.
The AE profile of ADC therapy is shaped by the duality of its mechanism of action. While the targeting antibody minimizes systemic toxicity, the cytotoxic payload can trigger treatment-related toxicities.3,4 Common AEs seen in patients utilizing ADC therapy include nausea, diarrhea, fatigue, and neutropenia.2 In rare cases, severe complications such as ILD may be seen.5 AEs may present acutely, be delayed in presentation, or may occur cumulatively over the course of many cycles. Acute AEs, such as infusion-related reactions, often manifest during or shortly after administration and include symptoms like fever, chills, hypotension, or dyspnea.5 Nurses are responsible for recognizing these reactions promptly and implementing corrective measures, such as adjusting the infusion rate, administering corticosteroids or antihistamines, or pausing the infusion if necessary.
AEs such as diarrhea, neutropenia, and nausea, may appear after the patient has been on ADC therapy for some time. For example, neutropenia often develops approximately 3 to 7 days after administration of most cytotoxic agents, requiring close hematologic monitoring and timely intervention.6 Cumulative AEs, such as cardiotoxicity or chronic fatigue, develop progressively over repeated treatment cycles and may necessitate additional monitoring, dose modifications, or therapy interruptions. Nurses play a crucial role in the short- and long-term monitoring of these various stages of AEs, using their clinical expertise to detect early warning signs and intervene promptly to prevent escalation of symptom severity.
A key responsibility of nurses is patient education and preparing patients for potential AEs. This begins with setting clear expectations about the possible side effects of ADC therapy. Nurses ensure that patients are informed about what symptoms to monitor for and provide strategies to manage them effectively. For instance, nurses can educate patients on dietary modifications to mitigate symptoms such as nausea. Advanced nurse practitioner, Tajuana Bradley, MS, FNP-BC, often advises patients on home interventions for nausea, such as drinking ginger tea or avoiding greasy foods. Patients are also often advised to eat smaller, more frequent meals and incorporate bland, easily digestible options like crackers or toast into their diets.7 Similar dietary recommendations exist for diarrhea management, and in some cases, nurses may suggest the use of medications such as loperamide.8 Ms Bradley emphasizes this role, stating that setting expectations, looking for ways to manage the disease effectively and in line with the patient’s goals of care, and maintaining quality of life will be key.
Nurses also emphasize the importance of early symptom reporting, encouraging patients to communicate any new or worsening side effects promptly. This proactive approach is particularly important in ADC therapy, where early intervention can prevent minor symptoms from escalating into severe complications. Nurses often advise patients to monitor their breathing and report any respiratory changes immediately, as it may be a sign of possible ILD. Ms Bradley encourages patients to be very open with clinical team members and have a dialogue from one visit to the next to understand what the patient is experiencing and be able to grade potential toxicities. By fostering open communication, nurses help create a collaborative care environment where patients feel supported and equipped to manage their treatment.
Another vital aspect of a nurse’s role is the early detection and monitoring of AEs. Nurses conduct regular assessments to evaluate patients’ symptoms and detect changes that may indicate emerging toxicities. For instance, in the case of ILD, nurses carefully monitor for early signs such as a persistent cough, dyspnea, or chest discomfort, and fever.9 Identifying these symptoms early allows for prompt escalation to the multidisciplinary care team and initiation of appropriate interventions, such as interruptions in therapy, dose reductions, or corticosteroid or possible immunosuppressive therapy.9 Early detection is also crucial for managing other AEs, such as neutropenia, where timely administration of granulocyte colony-stimulating factor or antibiotics can mitigate infection risk and ensure treatment continuity.10
In addition to clinical monitoring, nurses provide emotional and psychological support to patients coping with the impact of AEs. Ms Bradley notes that patients often strive to be 'good patients' on their own, without fully engaging the support of the healthcare team. However, she encourages patients to lean on the team so that AEs can be managed proactively, and treatment adherence can be optimized. In the example of fatigue, some patients may not want to report it out of fear of treatment stoppage. However, if the patient reports the AE, nurses help patients develop individualized strategies to manage fatigue, such as incorporating scheduled rest periods, delegating household responsibilities, and engaging in light physical activity to sustain energy levels, all while keeping the patient on therapy.
Care coordination is another critical domain in which nurses contribute to the AE management journey. ADC therapy often requires input from multiple medical disciplines, particularly in cases of severe or cumulative toxicities. For example, a patient experiencing cardiac symptoms may require evaluation by additional team members to assess cardiac parameters and labs, then to determine whether dose adjustments are necessary. Similarly, a patient presenting with respiratory symptoms suggestive of ILD may require pulmonary evaluation and imaging studies. Nurses serve as the central point of contact, ensuring that AEs are documented comprehensively and communicated effectively across the care team. Ms Bradley stated that documentation is particularly important, as it not only informs clinical decision-making but also facilitates a longitudinal understanding of the patient’s treatment journey, enabling more personalized and adaptive care.
Managing less common but serious AEs, such as ILD, requires a particularly high level of clinical vigilance. Nurses are responsible for educating patients about the importance of reporting respiratory symptoms, even if they appear minor. This education is crucial, as untreated ILD can progress rapidly and lead to significant morbidity. Nurses also collaborate with other members of the healthcare team to ensure that diagnostic evaluations, such as chest imaging, are conducted promptly when symptoms arise. By taking these proactive measures, nurses play a key role in safeguarding patient safety and preserving the continuity of treatment.
Throughout the AE management journey, nurses act as advocates for their patients, ensuring that their needs are met and that their voices are heard. This advocacy extends beyond clinical care to include emotional and psychological support, as well as practical guidance on managing daily life while undergoing therapy. Nurses recognize that each patient’s experience is unique and tailor their interventions to meet individual needs. By doing so, they not only address the physical aspects of AEs but also help patients maintain a sense of control and dignity during a challenging time.
In conclusion, the management of AEs in ADC therapy is a complex and multifaceted process that demands the expertise and dedication of nurses. Ms Bradley emphasized that nurses are the bridge that brings everything together, and that responsibilities extend beyond monitoring and intervention to include education, emotional support, and care coordination. By proactively identifying and addressing AEs, nurses ensure that patients can continue therapy with minimal disruptions while maintaining their quality of life. As ADC therapies continue to evolve, the critical role of nurses in managing their unique challenges will remain indispensable. The contributions of nurses are integral to the success of ADC therapy, ensuring that patients receive the best possible care throughout their cancer journey.
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