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Symptom Management of Treatment Toxicities in Early Breast Cancer Patients

Symptom Management of Treatment Toxicities in Early Breast Cancer Patients. Frances M. Palmieri, RN, MSN, OCN Clinical Nurse Specialist Manager, Multidisciplinary Breast Clinic and Breast Cancer Program Mayo Clinic Jacksonville, FL. Overview. Introduction to EBC

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Symptom Management of Treatment Toxicities in Early Breast Cancer Patients

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  1. Symptom Management of Treatment Toxicities in Early Breast Cancer Patients Frances M. Palmieri, RN, MSN, OCN Clinical Nurse Specialist Manager, Multidisciplinary Breast Clinic and Breast Cancer Program Mayo Clinic Jacksonville, FL

  2. Overview • Introduction to EBC • Taxanes in HER2 Overexpressing Breast Cancer • Symptom Management and Patient Support Strategies • Hematologic; Focus on Non-Hematologic Toxicities: • Fatigue • Chemotherapy induced sensory peripheral neuropathy, alopecia, arthralgia/myalgia, mucositis and hypersensitivity reactions EBC = early breast cancer. HER2 = human epidermal growth factor receptor 2.

  3. Breast Cancer Statistics Jemal A et al. CA: A Cancer Journal for Clinicians. 2006; 56(2):106-130

  4. Invasive Early Breast Cancer Demographics • Incidence increases with age • Postmenopausal women make up 80% of all patients with BC • Incidence BC remains high, but mortality rates have declined in the United States • Reflects advances in early detection, diagnosis, and treatment, such as novel treatment therapies and advanced imaging/screening • Digital Mammography or MRI • 5-year relative survival rates range from 92% for stage IIA disease to 54% for stage IIIB disease BC = breast cancer; MRI = magnetic resonance imaging. American Cancer Society. Cancer Facts and Figures 2006. http://www.cancer.org. Accessed December 31, 2007.

  5. Different Types of Breast Cancer • Early stage vs metastatic • HER2+ • Hormone receptor positive (ER+, PR+) • Triple negative • Inherited breast cancer • BRCA1, BRCA2, and other genes • New classifications of BC are being defined using gene profiling techniques • Luminal, HER2, basal BRCA1 = breast cancer 1, early onset. BRCA2 = breast cancer 2, early onset. ER+ = estrogen receptor positive. PR+ = progesterone receptor positive. Trastuzumab [prescribing information]. South San Francisco, CA: Genentech, Inc; 2006

  6. Breast Cancer Subtypes by Gene Profiling • Normal-like • Luminal-like • A • B • ERBB2 • Basal-like Good prognosis ER+ ER+ or ER- Bad prognosis ER-, PR-, HER2- ER- = estrogen receptor negative; ERBB2 = v-erb-b2 erythroblastic leukemia viral oncogene homolog 2, neuro/glioblastoma derived oncogene homolog (avian); PR - = progesterone receptor positive. Pegram et al. Cancer Treat Res. 2000;103:57. Romond et al. N Engl J Med. 2005; 353:1673.

  7. Prognostic Factors Risk factors of BC recurrence: • Tumor size • Nodal status • Grade • Hormone receptor status • Age of patient (35 yo) • HER2/neu oncogene overexpression National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology™; 2006. Goldhirsch et al. 2005.

  8. Recent Development Timeline: Breast Cancer Chemotherapy • Before anthracyclines • CMF, CMFVP • With anthracyclines • Combinations: AC, FAC, AVCMF, FEC, CEF • Sequence and alternating • Dose intensity, dose density, HDCT • Taxanes (paclitaxel/docetaxel) • Sequential monotherapy • Combinations • Biologic modifiers (trastuzumab, bevacizumab) • Integration in chemotherapy strategies 1970s 1980s 1990s 2000 + AC = doxorubicin/cyclophosphamide; AVCMF = doxorubicin, vincristine, cyclophosphamide, methotrexate, and fluorouracil; CEF = cyclophosphamide, epirubicin, and fluorouracil; CMF = cyclophosphamide, methotrexate, and fluorouracil; CMFVP = cyclophosphamide, methotrexate, fluorouracil, vincristine, and prednisone; FAC = fluorouracil, doxorubicin, and cyclophosphamide; FEC = flourouracil, epirubicin, and cyclophosphamide; HDCT = high-dose chemotherapy with stem-cell support. Giordano SH et al. Cancer. 2004;100:44-52.

  9. HematologicToxicities and Management • Neutropenia: most common hematologic toxicity • ASCO guidelines 2006 for prophylactic CSFs strategic guide • CSFs reserved for patients considered at high risk for FN defined as ≥20% risk, or special circumstances—bone marrow compromise • Or after a documented occurrence of FN or prolonged period of neutropenia in an earlier cycle of chemotherapy • Especially if excessive dose reductions or delay in chemo ASCO = American Society of Clinical Oncology. CSF = colony stimulating factor. FN = febrile neutropenia. ASCO. ASCO Guidelines. http://www.asco.org. Accessed December 31, 2006.

  10. Overview • Introduction to EBC • Taxanes in HER2 Overexpressing Breast Cancer • Symptom Management and Patient Support Strategies • Hematological Toxicities • Nonhematological Toxicities: • Chemotherapy induced sensory peripheral neuropathy, fatigue, alopecia, arthralgia/myalgia, hypersensitivity reactions, nausea and vomiting, mucositis, and cardiac dysfunction

  11. NonhematologicPeripheral Neurotoxicity • Caused by peripheral neurodegeneration • Damage to sensory axons and myelin sheath • Presents with loss of sensation—may progress to weakness and motor changes • Numbness, tingling, or burning pain • Most distal to medial axon effects • Bilateral, stocking-glove distribution • Can be cumulative • Short and long term symptoms Wickham R. Clini J Oncol Nurs. 2007;11: 361-376.

  12. Diagnostic StrategiesChemotherapy Induced Neuropathy Lee JJ, Swain SM. J Clin Oncol. 2006;24:1633-1642.

  13. Careful Assessment and History • Assess factors increasing risk, mobility, self-care, and fine-motor skill abilities • Careful history, writing, buttoning; functional impairment of ADLs • Accurate assessment is key to decision making regarding dose modifications, length of administration time, and discontinuation • Teach patients to report any change in status • Numbness, burning, and/or tingling of extremities • “Overadherence” issue • Manage pain • PT, OT, and/or medications ADL = activity of daily living; OT = occupational therapy; PT = physical therapy. Wickham R. Clini J Oncol Nurs. 2007;11:361-376.

  14. Arthralgia/Myalgia • Incidence • Docetaxel 10% • Paclitaxel 8% • Nab-paclitaxel 7% • Ixabepilone 8% • Occurs few days post treatment with resolution in 2–6 days • Shoulder and paraspinal muscles commonly affected • Prophylactic or treatment analgesics such as ibuprofen, acetaminophen, or narcotics Wickham R. Clin J Oncol Nurs. 2007;11:361-376. Perez EA et al. J Clin Oncol. 2007;25:3407-3414. Paclitaxel protein-bound [prescribing information]. Schaumburg, IL: American Pharmaceutical Partners, Inc; 2005. Icabepilone [prescribing information]. Princeton, NJ: Bristol Myers Squibb Company; 2007.

  15. Fatigue • Reported as one of the most problematic side effects over time related to treatment for BC • Adds to the severity of other symptoms of chemotherapy • Diminishing quality of life, ability to manage self-care • Symptoms may include • Lethargy—weakness or total lack of energy, malaise • Sleeplessness • Anxiety • Difficulty with concentration, thinking clearly, making decisions • Muscle pain, other constitutional symptoms National Comprehensive Cancer Network. Cancer-Related Fatigue Guidelines. http://www.cancersymptoms.org/peripheralneuropathy/overview. Accessed December 31, 2006.

  16. Fatigue NCCN: Cancer-related fatigue guidelines • Treatment algorithm to identify and treat fatigue • Patients evaluated using a brief screening instrument • Evaluate level of distress • Assess if fatigue is interfering with daily activities or functioning National Comprehensive Cancer Network. Cancer-Related Fatigue Guidelines. http://www.cancersymptoms.org/peripheralneuropathy/overview. Accessed December 31, 2006.

  17. Fatigue • Additional interventions that help alleviate fatigue • Correct known causes of fatigue • Anemia, nutritional deficits, sleep disorders • Encourage regular exercise • Assess current medications • Pain, antidepressant and anti-anxiety • Other lifestyle modifications • Attention-restoring activities • Psychological counseling • Physical therapy National Comprehensive Cancer Network. Cancer-Related Fatigue Guidelines. http://www.cancersymptoms.org/peripheralneuropathy/overview. Accessed December 31, 2006.

  18. Hypersensitivity Reactions • Occur in response to antigens that trigger antibody production: Infrequent but potentially serious reactions • Characterized by facial flush, pruritis, rash, dyspnea with bronchospasm, and hypotension • Pre-medication: • Availability of hypersensitivity reaction guidelines/protocol at infusion site • Appropriate equipment and medications • epinephrine, corticosteriods, antihistamines, bronchodilators Perez EA et al. J Clin Oncol. 2007;25:3407-3414. Docetaxel [prescribing information]. Bridgewater, NJ: Sanofi-Aventis, LLC; 2007. Icabepilone [prescribing information]. Princeton, NJ: Bristol Myers Squibb Company; 2007. Paclitaxel protein-bound [prescribing information]. Schaumburg, IL: American Pharmaceutical Partners, Inc; 2005.

  19. Nausea and Vomiting Common Toxicity Criteria v 3 IV = intravenous; TPN = total parenteral nutrition.

  20. Mucositis • Cause: Destroyed cell proliferation throughout GI tract • Interventions • Good oral hygiene and soft toothbrush • Soda mouthwash • Adequate fluid intake • Treat with magic mouthwash p.r.n.

  21. Cardiac Monitoring • Thorough baseline cardiac assessment, • Including history, physical examination, and assessment of LVEF by echocardiogram or MUGA scan • Frequent monitoring for left ventricular function during and after trastuzumab treatment • More frequent monitoring should be employed if treatment is withheld in patients who develop significant left ventricular cardiac dysfunction LVEF = left ventricular ejection fraction. MUGA = multigated acquisition.

  22. Patient Teaching • Create environment in which patients are likely to report symptoms • Promote self-care measures • www.cancersymptoms.org • www.cancersupportivecare.com • www.chemocare.com • www.canceradocacy.org Wickham R. Clin J Oncol Nurs. 2007;11:361-376. Armstrong, 2005,ONF

  23. Educational Considerations • Teaching patients to manage the effects of treatment is demonstrated to decrease symptom distress • Oncology nursing role to provide the education needed to assist patients in performing effective self-care

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