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, where are you from?

 hope@ranieri-online.com 

Hi my name is Hope, I live in PA and work on an oncology floor @ Abington Hospital

 marypatlynch 

Hi Hope, I'm at Pennsylvania Hospital, in the cancer center, welcome. Do you have any questions for me?

 dhafner 

Hi my name is Donna and I work hem/onc inpatient in Arlington Virginia

 marypatlynch 

Hi Donna, welcome, please ask your questions.

 dhafner 

Can you explain a little about the KRAS mutation and Eribitux?

 marypatlynch 

Tumors with the KRAS mutation may have less response to Erbitux.

 marypatlynch 

Have you seen that in your practice?

 dhafner 

I have seen testing for the KRAS mutation but was wondering why if patients are negative for the KRAS Erbitux is not indicated.

 marypatlynch 

At the ASCO meeting in Chicago - 3 studies stated that colorectal cancer patients with mutated KRAS genes do not benefit from EGFR inhibitor like Erbitux. However, patients with tumors that are not mutated have significantly better results when Erbitux is added to FOLFIRI or FOLFOX protocol.

 marypatlynch 

Interesting, have you discussed with the physician?

 emjm19072 

When Erbitux first came on the market...we needed pt tumor tissue tested for egfr.....or the insurance would not pay....is this true with kras.???

 marypatlynch 

Regarding Erbitux, if you have the KRAS mutation it does not work, if they tested negative it should work.

 marypatlynch 

Emjm, I have not had that experience, have you?

 dhafner 

I have not discussed this with the oncologist but will. Another question I have is regarding Avastin. I have seen several patients that have received this as part of their regimen for metastatic colon cancer who have developed clots. Is there any recommendation for prophalactically treating for DVTs for this patient population receiving Avastin?

 marypatlynch 

Regarding Avastin, I know that nosebleeds can be an issue but have not seen clots.

 marypatlynch 

More re: Avastin: Also, hypertension is a side effect. Literature says that a thromboembolic event can be a serious side effect, and recommends that treatment with Avastin be stopped if that occurs.

 Deborah Marchica 

Mary Pat, my question does not pertain to this topic. However . I am on Pacific time and need to present a scenario on one of my patients who is post treatment for cervical cancer and has a real problem. Can I present this to all of you?

 marypatlynch 

Avastin is a monoclonal antibody that binds to and inhibits the activity of vascular endothelial growth factor, so it makes sense that clots and bleeding could be side effects.

 emjm19072 

Has anyone had a hypersensitivity allergic reaction during infusion with Avastin?

 dhafner 

True, patients have not been able to continue but given this can be a side effect I wondered if prevention of DVTs would be beneficial.

 marypatlynch 

Deborah, re: your patient to present- certainly if it is about targeted therapies I would love to hear it, especially if it pertains to side effects.

 marypatlynch 

Regarding hypersensitivity/Avastin, I have not had that experience and it’s not listed as a major side effect, but any drug can cause a hypersensitivity reaction. Have you had this experience?

 marypatlynch 

Regarding DVT, we don't routinely prophylactically treat, but this would be a great nursing research study!

 emjm19072 

No I never had any experience with reactions during Avastin infusion, but I thought because it is a strong drug that my experience was not universal..

 marypatlynch 

It is a monoclonal antibody and that will give it a greater potential for hypersensitivity reaction than traditional chemotherapy.

 Hope@ranieri-online.com 

We used to cardiac monitor pts a long time ago when they were rec'ing Avastin infusion, but no longer and I've yet to have a person react to....knock on wood.

 marypatlynch 

We used to do that as well, when the drug was new and we really didn't know what to expect. But as we have gotten away from that, we have not had problems (knock on wood too!)

 Hope@ranieri-online.com 

Exactly.... there was concern about cardiac issues but that was maybe 5 years ago.

 emjm19072 

What about urine protein? How often do you test?

 Deborah Marchica 

This is the case. Pt is a 39 y/o pt. is 2 years post chemo./RT for cervical ca, . Currently in remission. premature menopause due to treatment. On HRT. However problem is; after sexual activity, severe onset of physical illness. Pt will experience elevated temp up to 102 , nausea. diarrhea, general malaise for 2 days. Has been in ER on several occasions , all cultures negative each time. Including blood, cervical and urine. pt has been given trial of antibiotics to take prior to and immediately after relations. There is also no difference with or without the use of a condom. Same partner. Nothing seems to prevent this from occurring each time. Pt has even seen ID, still no answer. pt uses water-based lubricant , voids prior to and after relations. Has anyone ever had a patient with this problem?

 marypatlynch 

RE: rine testing - which drug are you referring to?

 marypatlynch 

Deborah - no, I haven't seen this

 emjm19072 

deb...you am sure she is negative for endometriosis?

 Deborah Marchica 

yes.

 Hope@ranieri-online.com 

I've heard about people having allergic reactions to their sexual partner, unrelated to cancer cases, but they were all found to be more psychological in nature.

 marypatlynch 

We were talking about Avastin, we don't routinely test urine, do you?

 dhafner 

Can you explain the mechanisms of action of Sutent for renal cancer? I have also seen it used as part of a clinical trial for metastatic breast cancer in combination with Taxol.

 emjm19072 

re Avastin...yes, we do get a baseline urine protein...if negative then q month..

 emjm19072 

re Avastin....if urine protein +2 then we need a 24hour urine...possibly stop drug

 Deborah Marchica 

RE; pt case: I am thinking of this also, however her physical symptoms are real and severe enough that she ends up in the ER. Its frustrating. ID also felt that could be the root of the problem. But I wanted to see if anyone else had ever had any of their patients experience something like this.

 marypatlynch 

RE: Avasting: One reference does recommend monitoring patients with worsening proteinuria with serial urinalysis. Perhaps due to risk of bleeding with this drug as it is a vascular endothelial growth factor inhibitor.

 marypatlynch 

Sutent is a tyrosine kinase inhibitor. Tyrosine kinase receptor is a molecular structure on the surface of a cell that binds with substances such as hormones, drugs, antigens. When it binds with one of these triggering substances, the receptor performs a chemical reaction which causes the cell to die. By blocking the receptor, the tumor can't survive.

 marypatlynch 

Sutent is indicated for advanced renal cancer and GIST. Have you used this drug? It has several drug interactions and can cause serious cardiac issues.

 susandegennaro 

Being in an acute care setting, we don't see the drug used often.

 dhafner 

I have seen it used in practice for a couple of patients one being in the clinical trial but not seen any cardiac issues yet.

 emjm19072 

In acute care setting, it would be important to know care in handling of pre hospital medications prescribed drugs

 emjm19072 

Some po chemo drugs should not be handled with out gloves, is Sutent one?

 marypatlynch 

Regarding cardiac for Sutent, it can decrease the LVEF including the development of CHF, many patients get hypertension and bleeding, usually epistaxis but even tumor related hemorrhage is reported. These can occur suddenly, especially in the case of pulmonary tumors. Also rarely, GI complications like perforation can occur.

 dhafner 

Are there recommended cardiac functions tests like a MUGA scan that is indicated before and during treatment? If so, how often should testing be done?

 susandegennaro 

Similar toxicities to herceptin and avastin. Is this drug antiangiogenic?

 marypatlynch 

RE: handling of Sutent: Good question, we are checking on that but basically, you should always use gloves when handling chemo, even oral drugs as there is no longitudial evidence of risk. Some people say that monoclonal antibodies are not really chemo, but again there is no long term study on this. NIOSH has a listing of what drugs are hazardous or not, you can Google NIOSH.

 marypatlynch 

Sutent is a small molecule multikinase inhibitor, targeting several receptor tyrosine kinases implicated in tumor growth, pathologic angiogenesis and metastatic progression of cancer.

 marypatlynch 

Regarding scans/Sutent, baseline and periodic evals of the LVEF are indeed recommended with this drug

 dhafner 

Are there standard recommendations for treating skin reactions from targeted therapies?

 marypatlynch 

Good question, this is one of the "hot topics" surrounding targeted therapies. We talked about this at length yesterday so you can check out that transcript when you get a chance. Basically, prevention is very important, starting at the start of treatment with non-alcohol based moisturizers, sun avoidance or sun screen, At the first sign of erythema, we usually recommend topical hydrocortisone 1%

 marypatlynch 

If pustules start, we usually add topical clindamycin lotion and if it worsens we may add oral antibiotic like doxycycline.

 marypatlynch 

There are two good articles on skin reactions associated with human epidermal growth factor receptor inhibitors, in the April 2008 issue of CJON and January issue of the Forum.

 dhafner 

If someone has a severe skin reaction and therapy is stopped, can it be resumed when the skin clears or is there a high incidence of recurring severe reactions?

 dhafner 

Thank you for those references, I will certainly read those.

 marypatlynch 

Good question, some people might dose reduce or delay treatment but they can certainly resume treatment, depending on the level of toxicity. There is some evidence that the skin reaction means the drug is working, so patients may be willing to deal with the side effect if it isn't too severe.

 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 

For some patients, the psychological effects of the skin rash can be significant and they may need help dealing with it.

 dhafner 

Thank you! The information you provided tonight has been very helpful.

 marypatlynch 

Thanks for joining us!

 Laurl at ONS 

Thank you for attending! Have a good evening!