Among the various types of treatment that a patient with cancer may undergo, chemotherapy is associated with the greatest concerns with respect to side effects. Although patients may comprehend the importance of receiving chemotherapy as a key component of their treatment plan, the fear of adverse events (AEs) is always foremost on their minds. This third issue of Conquering the Cancer Care Continuum™ focuses on this topic, and provides insight into the critical role played by oncology pharmacists and nurses in the management of treatment-related side effects. Without the effective management of such complications as chemotherapy-induced nausea and vomiting (CINV), peripheral neuropathy, fatigue, and insomnia, a patient may decide to discontinue therapy prematurely. This could likely result in that individual not receiving the intended benefits of treatment. Such side effects do not merely disrupt a patient’s quality of life (QOL), they can also result in an individual’s life becoming totally derailed. For example, a patient may need to work for financial reasons while undergoing chemotherapy. If the AEs experienced during and following each treatment cycle are associated with the patient not being able to function well physically and/or mentally, this may become a barrier to adherence.
We must also be mindful of asking patients what their life goals are and of striving on their behalf to dovetail those goals into the treatment plan. For example, if an individual is studying to become a concert pianist and his or her scheduled chemotherapy regimen includes agents that are known to induce long-term neuropathy, we would be potentially robbing that individual of important career goals. Thus, there are numerous issues to consider when selecting a combination of agents and planning for the administration of therapy, with the goal being for the patient to take the regimen as prescribed while, at the same time, having his or her side effects minimized to the best of our ability.
In this publication, several drug classifications will be discussed by an oncology pharmacist who is an expert on side effect management. An oncology nurse will also provide her perspective on the important role played by nurses in caring for patients undergoing chemotherapy. Whenever possible, we want to proactively prevent AEs from occurring. If that is not possible, then minimizing symptoms so they are manageable and do not disrupt a patient’s daily routine is the next desired outcome. Educating patients on what to expect and on the management of AEs is imperative as we prepare them for each phase of treatment.
As more agents for the management of side effects transition from intravenous (IV) to oral drugs, the need for effective patient education must be recognized. We are placing the responsibility on the patient and on his or her family members to take oral medications as prescribed. This may be difficult for some individuals if they have memory problems, an unusual work schedule, or other barriers that might result in them not receiving the medications at the right time in the right dosage and in the right sequence. For this reason, nurses must be proactive and follow up with their patients by phone, rather than waiting for them to call the clinic or show up for their next appointment.
Novel agents are being developed for the management of CINV, and it is important for oncology specialists to remain informed about what is coming down the research pike. In the last 2 to 3 decades, we have witnessed great improvements in the development and standardization of US Food and Drug Administration–approved drugs that have improved QOL among patients undergoing chemotherapy. It is very important to share these advances with our patients so they can make informed decisions regarding their care.
One issue remains, however, and for an ironic reason. Third-party payment for IV medications remains a covered service. However, some very effective antiemetic agents are administered orally. In certain cases, these medications are not covered by insurance because they are oral medications. We need to push this issue from a regulatory perspective. It is very advantageous to have patients empowered to manage their side effects at home, and this can often be done safely with the use of oral drugs designed for that purpose. If the out-of-pocket expenses exceed what is financially realistic for a patient to handle, however, oncologists must then default to having that patient continue to visit an oncology facility and receive older IV medications. This is just not logical. I am a believer in having a patient’s voice heard when changes in regulations are needed. When a pharmaceutical company speaks, there is a high probability that its voice is not heard, because this would probably be considered a conflict of interest. When an oncology specialist speaks, there also may be an assumption that this in some way benefits the cancer care team. When a patient describes his or her experience, however, people listen.
It is my hope that the following articles will provide useful information that you can use to advocate for your patients, and provide them with the tools they need to reap the benefits of treatment while maintaining QOL throughout the continuum of care.