Download Symptom Management of Treatment Toxicities in Metastatic Breast

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
• 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.
Breast Cancer Statistics
United States
Deaths per year
40 970
(212 per day )
Diagnoses per year
212 920
(583 per day)
Jemal A et al. CA: A Cancer Journal for Clinicians. 2006; 56(2):106-130
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.
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
Breast Cancer Subtypes by
Gene Profiling
• Normal-like
Good prognosis
• Luminal-like
–A
–B
• ERBB2
• Basal-like
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.
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.
Recent Development Timeline:
Breast Cancer Chemotherapy
• Before anthracyclines
– CMF, CMFVP
1970s
• With anthracyclines
– Combinations: AC, FAC, AVCMF, FEC, CEF
– Sequence and alternating
– Dose intensity, dose density, HDCT
1980s
• Taxanes (paclitaxel/docetaxel)
–
–
–
–
Sequential monotherapy
Combinations
Biologic modifiers (trastuzumab, bevacizumab)
Integration in chemotherapy strategies
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.
Hematologic Toxicities 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.
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
Nonhematologic
Peripheral 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.
Diagnostic Strategies
Chemotherapy Induced Neuropathy
Test
Comments
Assessment of symptoms
and clinical examination
Inter- and intra- observer variation
Vibration threshold
Simple, non-invasive, and easily
repeated but less sensitive than a clinical
assessment
Monofilament test
Jebsen test of hand
function
Grooved Pegboard test
Overall evaluation of neurologic function
Needs valuation in chemotherapyinduced neuropathy
Nerve conduction study
Needle electromyography
Objective evidence of neuropathy
Needs more study for sensitivity and
specificity
Lee JJ, Swain SM. J Clin Oncol. 2006;24:1633-1642.
Careful Assessment and History
• Assess factors increasing risk, mobility, selfcare, 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.
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.
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.
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.
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.
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:
Paclitaxel, Docetaxel
Dexamethasone, Oral/IV H1 and H2 blockers
Docetaxel
Additional Dexamethasone premed,
Dexamethasone, Oral/IV H1 and H2 blockers
Nab-paclitaxel
None (No solvent)
Ixabepilone
Oral/IV H1 and H2 blockers (↓ Total dose of
Cremophor EL)
• 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.
Nausea and Vomiting Common
Toxicity Criteria v 3
Adverse
Event
Nausea
Vomiting
Grade 1
Loss of appetite without alteration
in eating habits
1 episode in 24 hrs
Grade 2
Oral intake decreased without
significant weight loss,
dehydration or malnutrition; IV
fluids indicated <24 hrs
2–5 episodes in 24 hrs; IV
fluids indicated <24 hrs
Grade 3
Inadequate oral caloric or fluid
intake; IV fluids, tube feedings, or
TPN indicated >24 hrs
≥6 episodes in 24 hrs; IV
fluids, or TPN indicated
≥24 hrs
Grade 4
Life-threatening
consequences
Life-threatening
consequences
Grade 5
Death
Death
IV = intravenous; TPN = total parenteral nutrition.
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.
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.
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
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