Targeted Therapies: Symptom Management

 Laurl at ONS 

Welcome to the ONS Hot Topic Chats! Today’s expert is Mary Pat Lynch, who will be talking with us about any and all questions you have regarding targeted therapies. Welcome Mary Pat!

 marypatlynch 

Hi everyone, nice to see so many people here this morning. Please send your questions!

 marypatlynch 

We are talking about targeted therapies this morning. I like this definition: Surgery and radiation therapy are considered physical solutions to a biological problem, chemo can be viewed as a chemical solution. And now we have targeted therapies...

 marypatlynch 

Targeted therapies are a general term that refers to a med or drug that targets a specific pathway in the growth and development of a tumor.

 marypatlynch 

By blocking these targets, the therapy helps fight the tumor itself. This should cause less side effects to the normal tissues than we see with chemo or RT.

 marypatlynch 

How many of you are using targeted therapies in your treatment setting?

 marypatlynch 

Are you in an outpatient setting? What kind of issues are you running into?

 oncnurselovesjc 

I work for Oncology Rx Care Advantage Pharmacy and we only dispense oncology specialty medications

 genna 

Yes, OP setting. One issue is just how long patient should be on tx?

 marypatlynch 

So you must see a fair amount of these types of therapy.

 marypatlynch 

How long patients should be on treatment varies, could you clarify?

 oncnurselovesjc 

yes, i get to talk to many patients taking targeted therapy meds

 genna 

Drug info and reps suggest staying on until disease progression. Our med/onc doesn't do this. It seems as though they always reoccur after stopping tx.

 marypatlynch 

What kind of issues do your patients complain of?

 marypatlynch 

Which drug are you referring to Genna?

 genna 

aAastin

 oncnurselovesjc 

Most common issues for the orals are dermatologic, diarrhea, fatigue

 marypatlynch 

RE: Avasting: Yes, the literature says that you can stay on Avastin till progression, but there are multiple protocols that physicians may be following.

 marypatlynch 

What are you doing for the derm side effects? These seem to be the most common and most frustrating for patients.

 oncnurselovesjc 

Just from experience, prophylactic treatment with a mild cleanser and moisturizing well twice daily with an unscented alcohol-free moisturizer helps with the severity of rashe.s

 sokolts 

Antibiotics and steroids for derm reactions at our clinic- as well as topicals that are non-irritating to the skin.

 oncnurselovesjc 

1% hydrocortisone creme if they develop redness and irritation or "bumps".

 sokolts 

Is it true that derm reactions are considered a therapeutic response?

 marypatlynch 

Prophylactic treatment is important, our nurses usually tell patients to start using any hypoallergenic moisturizer at start of treatment. We add topical hydrocortisone 1 - 2% at the first sign of erythema.

 oncnurselovesjc 

I agree, it's very important to start at the beginning of treatment

 marypatlynch 

RE: therapeutic response: There are some studies out there that say that the derm reaction shows that the drug is working. The skin reaction is felt to be due to an inflammatory response to the EGFR inhibition in the skin. It certainly can help the patient to stick with the treatment if they know it is helping their disease.

 oncnurselovesjc 

sokolts,( re: Therapeutic response):  I have heard that's true but to be completely honest, I’m not sure I'm buying it.

 marypatlynch 

Are there specific moisturizers that you recommend to your patients?

 oncnurselovesjc 

M.any patients like Eucerin or Aquaphor (although it's very greasy). Also recommend Cetaphil, Keri, Curel...

 oncnurselovesjc 

Gold Bond Intensive Therapy is also good

 marypatlynch 

It’s important the the moisturizer not have an alcohol base, which is more drying to the skin. All those you mentioned should be okay. How about sun screen? Are you recommending that to your patients as well?

 sokolts 

I second Aquaphor- we had one patient who claims this was the only thing that really helped.

 oncnurselovesjc 

We don't recommend sunscreen but do caution patients to avoid sun exposure.

 sokolts 

Should sunscreen be recommended as it's often very irritating to the skin?

 oncnurselovesjc 

That's why i don't recommend it

 marypatlynch 

We recommend a good sunscreen like N’eutrogena suncare with helioplex if they are going to be in the sun, but not regularly, its easier just to avoid the sun.

 marypatlynch 

Has anyone had to stop treatment due to skin reactions? Or delay treatment?

 sokolts 

Yes!

 marypatlynch 

Is that common?

 oncnurselovesjc 

We've had patients that did have to stop therapy due to grade 4 skin reactions, not that many though. Often if the doc will hold therapy for 7-10 days then resume and possibly lower the dose, most patients are able to resume therapy with few problems thereafter.

 wilcox 

Has anyone ever had a patient whose entire face looked and felt like a "blow torch"?

 sokolts 

I think if you identify the problem early enough, you can treat it with antibiotics and steroid combo.

 oncnurselovesjc 

wilcox, I've never heard that term ( blow torch) specifically but  do frequently hear patients say the skin feels very tight and very raw.

 oncnurselovesjc 

with Tarceva specifically, derm side effects are generally worse during the first month of therapy.

 marypatlynch 

Re: “blow torch”:I haven't not seen that severe of a reaction but I know it does happen. We usually start them on topical clindamycin lotion if pustules start and then if the rash is bad, we add oral antibiotic such as doxycycline.

 wilcox 

I did not get to finish my question...sorry, a blow torch effect and not a generalized rash that you typically see..

 marypatlynch 

Regarding blow torch, I have not seen that. What did you do about it?

 marypatlynch 

Agree that the side effects generally start within the first 10 days of therapy.

 wilcox 

The usual moisturizers without alcohol, 1% hydrocortisone.  It dissipated in the usual 6 weeks, but it was quite unusual and extremely uncomfortable.

 marypatlynch 

Sounds like it would be uncomfortable! Did it require pain management too?

 wilcox 

No, although we offered.

 oncnurselovesjc 

iIve never heard of the blow torch effect. Can you explain that?

 marypatlynch 

Often our patients find it psychologically distressing to have these rashes, have your patients had body image issues with this side effect?

 Laurl at ONS 

Mary Pat, how have you managed diarrhea side effect? When do you see it occur most frequently?

 wilcox 

I have a question regarding oral agent tracking and pt. teaching. Do you find it difficult to track patients that begin oral therapies, and do you have established policies to do so? We are just now trying to get all of this in place at our clinic. Tough job...

 marypatlynch 

RE: tracking compliance: Great question! We have a task force working on compliance with oral meds right now, trying to find best practices.

 marypatlynch 

We are working on a form that our patients can fill out to remind them of their doses and to help us to track that they are taking the meds as ordered. Does anyone else have such a system in place?

 marypatlynch 

Compliance is an issue for oral meds systemically. ONS has some good references on oral meds that we can post to the transcript tomorrow.

 oncnurselovesjc 

I think a big issue with regard to compliance is follow up

 marypatlynch 

Regarding diarrhea, again we try to prevent first, with recommendations for limit spicy foods and eat mild foods. We don't see it as too big a problem with these drugs and manage it with OTC meds.

 oncnurselovesjc 

RE: compliance: the program I work with at Care Advantage, Medication Therapy Management, we call patients weekly through the first 1-2 months of therapy.

 marypatlynch 

Follow up is the key, we are working on documentation. Its so different from giving IV meds and we need to change our practice as the meds are changing.

 oncnurselovesjc 

Helps with compliance by managing side effects and providing accountability

 marypatlynch 

Calling is definitely a good way to follow up, but it can be difficult if staffing does not allow this. We have a program for our older adult cancer patients (over age 70) who get additional calls but it is difficult for the clinic staff to find the time to make the calls sometimes.

 wilcox 

We have been using the ONS guidelines especially with regard to safety with disposal in the home. Some of the drug companies seem to be putting into place systems that have nurses who contact the patients at regular intervals, it helps.

 oncnurselovesjc 

I have worked in outpatient oncology clinics and you are most definitely correct regarding not having time! That's why our program is such a great extension for the practices.

 marypatlynch 

Regarding disposal, this is an issue as well that we need to educate our patients about. There are some good articles out there on compliance.

 marypatlynch 

What do you tell your patients to do about disposal of oral meds?

 wilcox 

We send home hazardous waste zip locks and gloves with our patients at teaching time and instruct them to bring any unused meds or empty containers in to the clinic and we dispose of them for the patient.

 marypatlynch 

That is what we do as well. I think it covers us and keeps the patient safe, it’s sometimes hard for people to think of oral meds as chemo or hazardous waste, again it goes back to patient education.

 marypatlynch 

Another issue we have seen increasing lately is the ability of patients to cover the cost of the drugs. Sometimes the co-pay is too high, even if they have insurance. Our social workers spend a lot of time trying to get assistance for these patients.

 wilcox 

I have had patients that battle incontinence, you cannot believe what we went through trying to figure out what to instruct patients to do with urine soaked disposable pads....any thoughts??

 jank 

I believe our local garbage collection service can set the patient up with a special disposal system if they are aware of it. I think they will even pick up contaminated needles. That would be a good place to check.

 marypatlynch 

RE: disposal issue: I haven't had that come up yet, but can understand it could be difficult. I would probably ask them to bag up the pads and treat like a gown or sheet that is soiled. Perhaps one of the red biohazard bags, bring back to the clinic and disposed with other chemo. Could be a real issue if its a lot of pads though.

 marypatlynch 

Great idea jank!

 jank 

We're a hospital-based outpatient clinic and are not allowed to accept any garbage (or needles) back from the client. I can't remember if this is an internal or external regulation.

 marypatlynch 

Interesting. What do you tell your patients to do ?

 jank 

Arrange a private pick-up from the garbage collection service.

 marypatlynch 

There are municipalities who consider this transport of hazardous waste when patients bring materials back to the clinic, as it is supposed to be done by licensed workers. Its best to check with the local municipality as you are developing guidelines for your clinic.

 marypatlynch 

jank, is that done by the local collection service? Does the clinic pay or does the patient pay?

 jank 

The patient pays.

 jank 

This particular service is one who collects our waste from the hospital, though, so they might be unique in their ability to do this.

 marypatlynch 

This is helpful info, does anyone else have a service such as this?

 Laurl at ONS 

We have about 5 more minutes - please continue to ask your questions! Also, at the end of today’s chat, please take a moment to cut and paste this URL into your browser and take our very brief survey -we’d love to hear what you think of these chats! The URL is: http://research.zarca.com/k/RsTUTRsSPYsXYTSTsPsP THANK YOU!

 marypatlynch 

Any last questions today?

 Laurl at ONS 

Welcome! We are just about at the end of the chat, but would love to hear if you have any questions for Mary Pat!

 Laurl at ONS 

The transcript for today's chat will be available tomorrow sometime. Please be sure to check to ONS website for it -

 Laurl at ONS 

And don't forget to take the survey! (it'll be posted in the transcript too)

 marypatlynch 

Thank you all for joining us today!

 wilcox 

Thank you!

 Laurl at ONS 

Thank you all for attending! This concludes today's chat. If you know of others who you think would enjoy the chat topic or would like to attend again, the next chat is tomorrow night at 7pm - ET. We hope to to see you there!

 marypatlynch 

Have a good day!