Better Education Needed to Recognize and Manage Adverse Effects

TON - January 2017, Vol 10, No 1 - Conference Correspondent
Alice Goodman

Copenhagen, Denmark—The findings of 2 separate studies presented at the recent European Society for Medical Oncology (ESMO) Congress suggest that oncology nurses need more education and training on how to manage adverse effects from cancer and its treatment. The first study (Abstract 1444P) revealed a knowledge gap among nurses regarding antiemetic guidelines and control of chemotherapy-induced nausea and vomiting (CINV). The results of the second study (Abstract 1483P) showed a substantial lack of knowledge among healthcare providers regarding the management of malnutrition and cachexia.

Chemotherapy-Induced Nausea and Vomiting

A survey of 531 nurses—primarily oncology nurses—practicing in the United States found that a large proportion were unaware of antiemetic guidelines for CINV, and that nurses in the outpatient setting were generally more familiar with guidelines and confident in managing CINV compared with those in inpatient and other settings. Furthermore, CINV was not optimally controlled, and a high number of patients with uncontrolled CINV went to the emergency department for visits or hospitalizations. CINV resulted in alterations in planned chemotherapy, which could lead to decreased response and survival.

Approximately 67% of the respondents were oncology certified. Approximately 100% were full-time nurses, with 64% practicing in outpatient settings and 31.5% practicing in inpatient settings (the remainder practiced in “other” settings).

The antiemetic guidelines from the National Comprehensive Cancer Network were the most widely recognized and used (73%); 48% of respondents recognized and used the American Society of Clinical Oncology guidelines; and 31% used individual institution guidelines.

Only 17% of the respondents reported that >75% of their patients who had CINV were optimally controlled. More than half of the respondents said that 0% to 5% of their patients required alterations in chemotherapy as a result of CINV, 39% said that this was true for 6% to 20% of their patients, and 9% said that it was true for >20% of their patients. Sixty-one percent reported that their patients required emergency department visits or hospitalizations for poorly controlled CINV.

The greatest challenges, according to the respondents, included control of CINV in the delayed phase (86.7%), and the impact of CINV on patients’ quality of life (65.2%).

In the setting of highly emetogenic chemotherapy, some guidelines were not uniformly followed. These included the underutilization of neurokinin-1 receptor antagonists on day 1 (19%), and the use of serotonin receptor antagonists (78%) on day 2 and beyond, instead of the guideline recommendation for dexamethasone and a follow-up of a neurokinin-1 receptor antagonist if oral aprepitant was used on day 1. However, 77% said that antiemetics used in their practices were consistent with guideline recommendations.

In the setting of moderately emetogenic chemotherapy, dexamethasone was underused, whereas the use of phenothiazines (47%) and benzodiazepines (60%) on day 2 and beyond was inconsistent with antiemetogenic guidelines. Guideline adherence was suboptimal in the highly and moderately emetogenic chemotherapy settings.

“Physician preference” was identified by 70% of the respondents as a barrier interfering with guideline-recommended antiemetic prophylaxes.

Lead investigator Cynthia Rittenberg, RN, MN, AOCN, FAAN, President, Rittenberg Oncology Consulting, Metairie, LA, and co-investigators stated that the results of this survey reveal opportunities to overcome perceived barriers and increase awareness and education about evidence-based antiemetic guidelines.

“Participation in multidisciplinary efforts to increase adherence to guidelines is needed. This should improve CINV control and quality of life for patients, while decreasing emergency department visits and hospitalizations for CINV, allowing patients to complete their chemotherapy as planned,” they wrote.

Malnutrition and Cachexia

A survey of 963 healthcare providers, conducted by Florian Strasser, MD, ABHPM, Head of Oncological Palliative Medicine, Cantonal Hospital, St. Gallen, Switzerland, and colleagues, showed a substantial lack of awareness of the effects of malnutrition and cachexia on a patient’s quality of life and function, and the negative impact of these conditions on anticancer treatment. Approximately 50% of the respondents were unaware of the impact of malnutrition and cachexia on cancer care outcomes. Even more worrisome, a large proportion of the respondents do not monitor these outcomes.

Among the respondents, 72% were medical oncologists and the remainder were “other” healthcare providers; 56% of the responders were based in Europe, and 44% were from North America, South America, and Asia. The survey was conducted among attendees at the ESMO 2015 Congress, with similar surveys conducted among attendees at the ESMO 2013 Congress and the ESMO 2014 Congress.

Of the survey respondents at ESMO 2015, 44% said they routinely assess for malnutrition before initiating anticancer treatment, 30% said they routinely manage malnutrition during anticancer treatment, and 9% said they routinely monitor malnutrition after curative anticancer treatment and during survivorship care. A total of 25% of respondents were unaware of standards regarding the type of nutritional support to prescribe, or protocols for when to prescribe it.

The results were somewhat encouraging in the noncurative setting, where the respondents appeared to have increasing awareness, compared with the results of previous surveys of this audience; 37% said they deliver nutritional care in the end-of-life setting.

The investigators noted that there is still substantial underuse of nutritional care in the noncurative setting, “and further studies should attempt to identify reasons for this.”

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Last modified: February 2, 2017