Download Document

Renal Cell Carcinoma:
Nursing Considerations With
the Use of Targeted Therapy
Nancy Moldawer, RN, MSN
Clinical Research Operations Manager
Division of Medical Oncology and
Therapeutic Research
City of Hope
Duarte, California
Renal Cell Carcinoma (RCC)
• Originates in the renal cortex
• Most common solid lesion occurring in the kidney
(80-85% of all primary renal neoplasms)
Diseased Kidney
RCC Statistics
• US estimates for 20071
 51,190 individuals diagnosed with cancer of the kidney
and renal pelvis
 12,890 individuals died from cancer of the kidney and
renal pelvis
• 3rd most common genitourinary cancer after
prostate cancer and bladder cancer2
• Median age at diagnosis: 65 years (2000-2004)1
• Median age at death: 71 years (2000-2004)1
1. National Cancer Institute. SEER cancer statistics fact sheet: cancer of the kidney and renal pelvis. Accessed 2008.
2. Jemal A et al. CA Cancer J Clin. 2007;57:43.
RCC Statistics
• An estimated 240,266 US individuals with a history
of kidney and renal pelvis cancer were alive in
20041
• 5-year survival has improved2
 50.9% 19751977
 65.7% 19962003
1. National Cancer Institute. SEER cancer statistics fact sheet: cancer of the kidney and renal pelvis. Accessed 2008.
2. Ries LAG, et al. SEER Cancer Statistics Review. 2007;1975-2004.
Rate Per 100,000 Individuals
US Yearly Kidney and Renal Pelvis
Cancer Incidence and Mortality
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
1975
Incidence
Mortality
1980
1985
1990
1995
2000
Year
Ries LAG et al. SEER Cancer Statistics Review, 1975-2004;2007.
Etiology of RCC
• Environmental and clinical risk factors
 Smoking1,2
 Obesity1,3,4
 Acquired cystic disease of the kidney (usually in
association with dialysis)5,6
 Analgesic abuse nephropathy7,8
 Occupational exposure to toxic compounds9-11
 Genetic predisposition12
1. Setiawan VW et al. Am J Epidemiol. 2007;166:932. 2. Hunt JD et al. Int J Cancer. 2005;114:101. 3. Pischon T
et al. J Natl Cancer Inst. 2006;98:920. 4.Chow WH et al. N Engl J Med. 2000;343:1305. 5. Brennan JF et
al. Br J Urol. 1991;67:342. 6. Truong LD et al. Am J Kidney Dis. 1995;26:1. 7. Chow WH et al. Int J
Cancer. 1994;59:467. 8. Lornoy W et al. Lancet. 1986;1:1271. 9. Mandel JS et al. Cancer. 1995;61:601.
10. McLaughlin JK, Blot WJ. Int Arch Occup Environ Health. 1997;70:222.
11. Brauch H et al. Toxicol Lett. 2004;151:301. 12. Zbar B et al. J Urol. 2007;177:461.
Symptoms
• Many patients with RCC are asymptomatic and
have nonpalpable renal masses until late in
natural disease course1,2
• Common local symptoms
 Hematuria
 Ipsilateral flank or abdominal pain
 Palpable mass
1. Lee CT et al. Urol Oncol. 2002;7:135.
2. Patard JJ et al. Eur Urol. 2003;44:226.
Symptoms
• Common systemic symptoms
 Paraneoplastic disorders
– Hypertension
– Cachexia
– Weight loss
– Pyrexia
– Neuromyopathy
– Amyloidosis
– Elevated erythrocyte sedimentation rate
– Anemia
– Abnormal liver function
– Hypercalcemia
– Polycythemia
 Pain or mass related to metastatic disease
Physical Examination
• Plays a limited role in diagnosing RCC
• May be valuable in situations where there is




A palpable abdominal mass
A palpable cervical lymphadenopathy
Non-reducing varicocele
Bilateral lower extremity edema suggestive of
venous involvement
• Any of the above findings warrants radiologic
examination
Ljungberg B et al. Eur Urol. 2007;51:1502.
Extent of Disease at Diagnosis
Most renal cancers diagnosed when disease still
localized to primary site
Metastatic
Spread
20%
Locoregional
Spread
19%
Unknown
5%
Localized
Disease
56%
National Cancer Institute. SEER cancer statistics fact sheet: cancer of the kidney and renal pelvis. Accessed 2008.
Stages of RCC
Stage I: Cancer is in the
kidney only and size of
the tumor is ≤7.0 cm in
diameter
Stage II: Cancer is in
the kidney only, but
size of the tumor is
>7.0 cm in diameter
Stage III: Tumor in the
kidney may be any size,
but extends beyond layer
of tissue (Gerota’s fascia)
that encapsulates kidney
and adrenal gland.
Cancer may have spread
to blood vessels that
carry blood away from
kidney.
Stage IV: Tumor in the
kidney extends
beyond Gerota’s
fascia and/or cancer
has spread to one or
more lymph nodes
near kidney. Cancer
may have spread to
other organs such as
lungs, liver, brain, or
bones.
Oregon Health & Science University. Kidney Cancer Program. Available at: http://www.ohsu.edu/health/page.cfm?id=13584
RCC Subtypes1,2
Subtype
Prevalence
Tumor Features
Clear cell carcinoma
75–85%
Multinodular; yellow cut
surface with gray & white
foci
Chromophilic
(papillary) carcinomas
10–15%
Ball-shaped outline, dotted
pattern; beige, white, or
greasy brown
Chromophobic
carcinomas
5–10%
≥1 solid tumor nodule with
slightly lobulated surface;
orange cut surface
Oncocytomas
Uncommon
(≤2%)
Typically solitary, slightly
lobulated; tan-brown cut
surface
Collecting duct tumors
(a.k.a. Bellini’s duct)
Very rare
Large; cut surface firm,
white, interspersed with
necroses
Microscopic
Features
1. Thoenes W et al. Path Res Pract. 1986;181:125.
2. Störkel S, van den Berg E. World J Urol. 1995;13:153.
Prognostic Clinical Factors
• Several clinical factors associated with poor
survival in patients with RCC
 Poor performance status1,2
 Presence of RCC symptoms and/or paraneoplastic
syndrome1-6
– Anemia, hypercalcemia, hepatopathy, thrombocytosis,
fever, weight loss
 Obesity7
1. Zisman A et al. J Clin Oncol. 2001;19:1649.
2. Motzer RJ et al. J Clin Oncol. 1999;17:2530.
3. Suppiah R et al. Cancer. 2006;107:1793.
4. Bensalah K et al. J Urol 2006;175:859.
5. Fahn HJ et al. J Urol. 1991;145:248.
6. Patard JJ et al. J Urol. 2004;172:2167.
7. Calle EE et al. N Engl J Med. 2003;348:1625.
Recurrent/Metastatic RCC Prognosis
Patients with recurrent or metastatic RCC
have very poor prognosis
Factors Associated With Survival Outcomes1-4
Longer Survival
• Long interval between
nephrectomy & development of
distant metastases
• Single site of metastatic disease
• Absence of retroperitoneal
adenopathy
• Right involved kidney
Shorter Survival
•
•
•
•
•
Karnofsky performance status <80%
Lactose dehydrogenase >1.5 x ULN
Corrected serum calcium >10 g/dL
Hemoglobin <LLN
Absence of nephrectomy (ie, no
disease-free interval)
• Prior radiotherapy
1. Motzer RJ et al. J Clin Oncol. 1999;17:2530.
2. Mekhail TM et al. J Clin Oncol. 2005;23:832.
3. Choueiri TK et al. Ann Oncol. 2007;18:249. 4. Han KR et al. Urology. 2003;61:314.
Advanced RCC
• Treatment options other than surgery
 Radiotherapy
 Not an effective option
 Chemotherapy
– Not an effective option
 Immunotherapy
– Limited/some benefit
 Targeted therapy
– Clinical benefit; active area of research and further
refinement
1. National Cancer Institute. SEER cancer statistics fact sheet: cancer of the kidney and renal pelvis. Accessed 2008.
2. Janzen N et al. Urol Clin North Am. 2003;30:843.
Angiogenesis
• Angiogenesis is a key determinant in pathophysiology
of RCC1
• RCCs are most vascularized of all solid tumors2
Map of Blood Flow to a Metastatic RCC Lesion
1. Izawa JI, Dinney CP. CMAJ. 2001;164:662.
2. Cristofanilli M et al. Nat Rev Drug Discov. 2002;1:415.
Role of VEGF in Angiogenesis
Cristofanilli M et al. Nat Rev Drug Discov. 2002;1:415.
Growth Factors
• Vascular endothelial growth factor (VEGF) key
growth factor involved in angiogenesis1,2
 VEGF mRNA expression correlates with
vascularization
 VEGF is overexpressed in most clear-cell RCCs
• Platelet-derived growth factor (PDGF) and
epidermal growth factor (EGF) play role in
angiogenesis and oncogenesis
1. Cristofanilli M et al. Nat Rev Drug Discov. 2002;1:415.
2. De Mulder PH. Ann Oncol. 2007;18:ix98.
Targeting the
Molecular Pathways
of RCC Oncogenesis
Endothelial/
Tumor cells
Upregulation in response
to HIF-1 transcription
bevacizumab
sorafenib, sunitinib
PDGF
VEGF
EGF
gefitinib, cetuximab,
erlotinib, panitumumab
Ras
sorafenib
RAF
MEK
PI3K
Gene
expression
AKT
mTOR
ERK
Angiogenesis/Cell
proliferation/Cell survival
rapamycin,
temsirolimus,
everolimus
Stadler WM. Cancer. 2005;104:2323.
Clinically Available Targeted
Agents for Advanced RCC
4 targeted agents available for advanced RCC
Agent
Target
Efficacy in Randomized Phase III Trials
Comparison
Bevacizumab
VEGF
No.
Treated
ORR
TTP (mos)
Bevacizumab + IFN- vs
Placebo + IFN-1
649
31% vs 13%
10.2 vs 5.4;
P=.0001
Bevacizumab + IFN- vs
IFN-2
732
26% vs 13%
8.5 vs 5.2;
P<.0001
Sunitinib
VEGF
receptor
Sunitinib vs IFN-3
750
37% vs 9%
11.1 vs 5;
P=.00001
Sorafenib
VEGF
receptor
Sorafenib vs Placebo4
903
10% vs 2%
5.5 vs 2.8;
P=.000001
mTOR
Temsirolimus vs IFN- vs
both agents5
11% vs 7% vs 8%
3.7 vs 1.9
(IFN-);
P=.001
Temsirolimus
ORR=overall response rate; TTP=time to
progression
626
1. Escudier B et al. Lancet. 2007;370:2103.
2. Rini BI et al. 2008 ASCO Genitourinary Cancers Symposium. Abstract 350.
3. Motzer RJ et al. N Engl J Med. 2007;356:115.
4. Escudier B et al. N Engl J Med. 2007;356:125.
5. Hudes G et al. N EngJ Med. 2007;356:2271.
Integrating the Oncology Nurse Into
the New Paradigm of Targeted Therapy
• The new therapeutic paradigm of moleculartargeted therapy presents new challenges for
oncology nurses
 Induces tumor stabilization vs complete responses
 Controls disease vs curing disease
 Unique side-effect profiles
 As the landscape of RCC treatment continues to
evolve, the nurse remains on the forefront of drug
discovery, administration, and adverse event
monitoring
Moldawer N, Wood LS. Kidney Cancer J. 2006;4:25-32.
Sunitinib
• An orally administered tyrosine kinase inhibitor
• Approved for treatment of advanced RCC in
January 2006
• Potent inhibitor of VEGFR, PDGFR, and FLT-31
• Has demonstrated efficacy in clear-cell RCC as
second-line therapy after IL-23 and as first-line
therapy compared with interferon2
1. Abrams TJ, et al. Mol Cancer Ther. 2003;2:471-478.
2. Motzer RJ. JAMA. 2006;295:2516-2524.
Sunitinib: Dosing and Administration
50 mg QD
4 weeks on
2 weeks off1
• May be taken with or without food
• Sunitinib and its active metabolite metabolized primarily by
CYP3A4
• Requires dose adjustment when administered with
CYP3A4 inhibitors or inducers2
• Important to assess any concomitant medications patient is
taking
1.Faivre S, et al. J Clin Oncol. 2006;24:25-35.
2. Hiles JJ, Kolesar JM. Am J Health-Syst Pharm. 2008;65:123-131.
Sunitinib:
Most Common Adverse Events (≥20%)
Adverse Event
Fatigue
Diarrhea
Nausea
Altered taste
Mucositis/stomatitis
Anorexia
Hypertension
Bleeding
Vomiting
Dyspepsia
Rash
Abdominal pain
Hand-foot syndrome
All Grades (%)
58
58
49
44
43
38
30
30
28
28
27
22
21
Sutent® (sunitinib) Full Prescribing Information. Pfizer Inc. October 2007.
Sorafenib
• An orally administered multikinase inhibitor
• Approved for treatment of advanced RCC in
December 2005
• Inhibits VEGFR 1, 2, and 3, PDGFR, FLT-3, cKit, and RET kinases1,2
• Has demonstrated efficacy as second-line
monotherapy in metastatic RCC3,4
1.Bhojani N, et al. Eur Urol. 2008;53:917-930.
2. Wilhelm SM, et al. Cancer Res. 2004;64:7099-7109.
3. Ratain MJ, et al. J Clin Oncol. 2006;24:2505-2512.
4. Escudier B et al. N Engl J Med. 2007;356:125.
Sorafenib: Dosing and Administration
• Formulated as a 200-mg tablet
• Daily dosing of 400 mg BID
• If dose reduction is required, dose may be reduced to:
 400 mg QD, and subsequently to
 400 mg QOD
• Primarily metabolized by CYP3A4 and undergoes
glucuronidation
Moldawer N, Wood LS. Kidney Cancer J. 2006;4:25-32.
Sorafenib:
Most Common Adverse Events (≥20%)
Adverse Event
Diarrhea
Fatigue
Abdominal pain
Weight loss
Anorexia
Nausea
Hand-foot reaction
All Grades (%)
55
46
31
30
29
24
21
Nexavar® (sorafenib) Full Prescribing Information. Bayer HealthCare. 2008.
Sunitinib and Sorafenib Adverse Events:
Nursing Implications1,2
• Diarrhea
 Treat initially with diet modification (low residue) and loperamide
 If loperamide insufficient, give diphenoxylate HCl with atropine
 Additional options include tincture of opium, Culturelle (oral
probiotic), and Dannon yogurt containing bifidobacterium
• Fatigue
 Adjust activities to allow for rest periods and maximize fluid and
caloric intake
1. Wood LS. Oncology Nurs News. 2007;3:19-20.
2. Wood LS. Oncology Nurs News. 2007;4:37-38.
Sunitinib and Sorafenib Adverse Events:
Nursing Implications1,2 (cont.)
• Functional or clinical mucositis
Dietary modifications
 Avoidance of carbonated beverages and spicy foods
 Eating foods at room temperature
Medications
 Topical lidocaine or Xylocaine
 BMX Solution (Benadryl/Mylanta, Xylocaine)
 Rincinol (OTC topical solution containing aloe vera)
 Nystatin suspension or clotrimazole troches for clinical
mucositis
1. Wood LS. Oncology Nurs News. 2007;3:19-20.
2. Wood LS. Oncology Nurs News. 2007;4:37-38.
Sunitinib and Sorafenib Adverse Events:
Nursing Implications1,2 (cont.)
• Taste changes and anorexia
 Maximize caloric intake
 Encourage 6 small meals per day
 Use of flavorings and gravy to enhance food taste
• Hand-foot reaction
 Liberal use of emollients
 Avoid activities that cause pressure, abrasion, or irritation to hands
and feet
 Application of Udderly Smooth lotion BID
Other options include:
 Bag Balm
 Aveeno Skin Relief Moisturizing Cream
 Aveeno Intense Relief Foot Cream
 Kerasal ointment
 Keralec cream
 Zim’s Crack Crème
 Biafine Topical Emulsion
1. Wood LS. Oncology Nurs News. 2007;3:19-20.
2. Wood LS. Oncology Nurs News. 2007;4:37-38.
Bevacizumab
• Monoclonal antibody to VEGF active in multiple
tumor types
• First biological antiangiogenic agent approved by
US FDA
• Approved for use in colorectal, non-small cell lung,
and metastatic breast cancers1
• Phase 3 studies are evaluating bevacizumab in a
variety of solid tumor types2
1. Avastin® (bevacizumab) Full Prescribing Information. Genentech, Inc. March 2008.
2. National Cancer Institute website. http://www.cancer.gov/clinicaltrials/search.
Bevacizumab: Dosing and Administration
• Usual dosage of bevacizumab for treatment of
colorectal cancer is 5 mg/kg IV every 2 weeks
• Dosage in investigational trials of RCC has
generally been 10 mg/kg IV every 2 weeks1,2
• Can be associated with hypersensitivity reactions
1. Hainsworth JD, et al. J Clin Oncol. 2005;23:7889-7996.
2. Bukowski RM, et al. J Clin Oncol. 2007;25:4536-4541.
Bevacizumab:
Serious Adverse Events (≥10%)
Adverse Event
Epistaxis
Hypertension
Fever without infection
Malaise
Hematuria
Hyponatremia
Proteinuriab
Elevated ALT
Chest pain
Bevacizumab 10
mg/kg (N=39)
Bevacizumab 3 mg/kg
(N=37)
%
%
21
14
36 (21)a
3
10
3
33
13
8
64 (8)a
10
5 (5)a
16
3
11
41 (5)a
5
0
aPercent
of patients with grade 3 toxic effects
or ≥150 mg/24 hrs
Grade 3 hypertension was defined as hypertension not completely controlled by one standard medication
Grade 3 proteinuria was defined as urinary excretion of >3.5 g of protein per 24 hrs
b≥1+
Yang CH, et al. N Engl J Med. 2003;349:427-434.
Bevacizumab Adverse Events:
Nursing Implications
• Bleeding
 Obtain patient history of unusual bleeding or clotting, GI
perforation, and use of anticoagulants
 Avoid anticoagulant therapy if possible, especially
concomitant use of bevacizumab with warfarin and 5-FU
 Educate patient about signs of bleeding (ie, epistaxis,
bleeding gums during tooth brushing, red or black, tarry
stools, vomiting blood)
• Thrombosis
 Educate patient about signs of thrombosis that include
– Sudden chest pain
– Difficulty breathing
Ignoffo RJ. Am J Health-Syst Pharm. 2004;61(Suppl 5):21-26.
Bevacizumab Adverse Events:
Nursing Implications (cont.)
• Hypertension
 Establish baseline blood pressure (BP) and monitor weekly
during therapy
 Ensure that patient has a BP monitor at home
 Continue antiphypertensive therapy in patients already
taking it when bevacizumab is initiated
 Consult MD to initiate mild antihypertensive if patient
develops hypertension during bevacizumab therapy
 Consider using ACE inhibitor and avoid antihypertensive
agents that inhibit CYP3A4 (eg, verapamil, diltiazem)
• Proteinuria
 Monthly monitoring of renal function and serum protein
concentration
Ignoffo RJ. Am J Health-Syst Pharm. 2004;61(Suppl 5):21-26.
Temsirolimus
• An inhibitor of mammalian target of rapamycin
(mTOR) kinase, a component of intracellular
signaling pathways1
• Binds to an abundant intracellular protein FKBP12, forming a complex that inhibits mTOR2,3
• First mTOR inhibitor approved for treatment of
advanced RCC
• Approved by FDA on May 30, 2007
1. Schmelzle T, Hall MN. Cell. 2000;103:253-262.
2. Skotnicki JS, et al. Clin Cancer Res. 2001;7(Suppl):3749-3750.
3. Harding MW. Clin Cancer Res. 2003;9:2882-2886.
Temsirolimus: Dosing and Administration
• Approved dose for advanced RCC is 25 mg IV weekly over a
30- to 60-minute period
• Patients should receive prophylactic diphenhydramine 2550
mg IV prior to the start of each dose
• If patient develops a hypersensitivity reaction during infusion:




Stop infusion
Observe patient at least 3060 minutes
Notify MD
Treatment may be resumed at discretion of MD with administration of
an H1-receptor antagonist (eg, diphenhydramine), if not previously
administered, and/or an H2-receptor antagonist (eg, famotidine 20 mg
IV or ranitidine 50 mg IV) 30 minutes before restarting temsirolimus
 Extend infusion time to 60 minutes
Torisel™ (temsirolimus) Full Prescribing Information. Wyeth Pharmaceuticals. May 2007.
Temsirolimus:
Most Common Adverse Events (≥30%)
Adverse Event
Asthenia
Rash
Mucositis
Nausea
Edema
Anorexia
All Grades (%)
51
47
41
37
35
32
Torisel™ (temsirolimus) Full Prescribing Information. Wyeth Pharmaceuticals. May 2007.
Temsirolimus Adverse Events:
Nursing Implications
• Rash
 Observe for acne-like rash
 Consider antihistamines for itching
 Counsel patient to use skin emollients, avoid agents that
cause skin drying effects, and avoid sun exposure
• Anemia
 Monitor hemoglobin and hematocrit regularly during therapy
• Anorexia
 Maximize caloric intake
Temsirolimus Adverse Events:
Nursing Implications (cont.)
• Hyperlipidemia
 Monitor serum cholesterol and triglycerides prior to and
during therapy
• Hyperglycemia
 Monitor serum glucose prior to and periodically during
therapy
• Infection
 Monitor for sore throat, appearance of sputum, urine, and stool
 Monitor vital signs regularly
 Educate patient about recognizing signs of infection
Temsirolimus Adverse Events:
Nursing Implications (cont.)
• Interaction with CYP3A4 inhibitors
 Avoid concomitant use of temsirolimus with:
–
–
–
–
–
–
–
–
–
–
–
–
Grapefruit juice
Ketoconazole
Itraconazole
Clarithromycin
Atazanavir
Indinavir
Nefazodone
Nelfinavir
Ritonavir
Saquinavir
Telithromycin
Vorizonazole
Torisel™ (temsirolimus) Full Prescribing Information. Wyeth Pharmaceuticals. May 2007.
Temsirolimus Adverse Events:
Nursing Implications (cont.)
• Interaction with CYP3A4 inducers
 Avoid concomitant use of temsirolimus with:
–
–
–
–
–
–
Dexamethasone
Phenytoin
Carbamazepine
Phenobarbital
Rifampin
Rifabutin
Torisel™ (temsirolimus) Full Prescribing Information. Wyeth Pharmaceuticals. May 2007.
NCCN Guidelines:
Explanation of Categories of Evidence
• Category 1
 Recommendation based on high-level evidence (ie, high-powered
randomized clinical trials or meta-analyses)
 NCCN Guidelines Panel has reached uniform consensus that the
recommendation is indicated
• Category 2A
 Recommendation based on lower-level evidence
 Lower-level evidence is interpreted broadly and may range from phase
2 to large cohort studies to case studies
 In many instances, retrospective studies derived from clinical
experience of treating large numbers of patients and Guidelines Panel
members have first-hand knowledge of data
National Comprehensive Cancer Network. Available at: http://www.nccn.org.
NCCN Guidelines:
Explanation of Categories of Evidence
• Category 2B
 Recommendation based on lower-level evidence
 There is nonuniform consensus that the recommendation should be
made
 In these instances, institutions take different approaches to the
management of a particular clinical scenario
• Category 3
 Including the recommendation has engendered a major disagreement
among NCCN Guidelines Panel members
 Level of evidence not pertinent in this category because experts can
disagree about the significance of high-level trials
National Comprehensive Cancer Network. Available at: http://www.nccn.org.
NCCN Practice Guidelines in Oncology:
Kidney Cancer
FIRST-LINE THERAPY
Predominant
clear cell
histology
Relapse or
Stage IV and
medically or
surgically
unresectable
aTemsirolimus
indicated for poor-prognosis patients, defined as those
with ≥3 predictors of short survival
bBest supportive care can include palliative RT, metastasectomy or
biphosphonates for bony metastasis
Clinical trial
or
Sunitinib (category 1)
or
Temsirolimus for poor-prognosis
patientsa (category 1)
or
Bevacizumab + IFN
or
High-dose IL-2 for selected
patients
or
Sorafenib for selected patients
and
Best supportive careb
NCCN Clinical Practice Guidelines in Oncology.
2007;v. 1. 2008.
NCCN Practice Guidelines in Oncology:
Kidney Cancer
FIRST-LINE THERAPY (cont.)
Relapse or
Stage IV and
medically or
surgically
unresectable
Non clear cell
histology
Clinical trial (preferred)
or
Temsirolimusa (category 1 for
poor-prognosis, category 2A for
other risk groups)
or
Sorafenib
or
Sunitinib
or
Chemotherapy (category 3):
Gemcitabine or capecitabine or
floxuridine or 5-FU or doxorubicin
(in sarcomatoid only)
and
Best supportive careb
aTemsirolimus indicated for poor-prognosis patients, defined as those
with ≥3 predictors of short survival
bBest supportive care can include palliative RT, metastasectomy
or biphosphonates for bony metastasis
NCCN Clinical Practice Guidelines in Oncology. 2007;v. 1. 2008.
NCCN Practice Guidelines in Oncology:
Kidney Cancer
SUBSEQUENT THERAPY
Progression
aBest
Clinical trial (preferred)
or
Sorafenib (category 1 following cytokine
therapy and category 2A following TKI)
or
Sunitinib (category 1 following cytokine
therapy and category 2A following TKI)
or
Temsirolimus (category 2A following cytokine
therapy and category 2B following TKI)
or
IFN (category 2B)
or
High dose IL-2 (category 2B)
or
Low dose IL-2 + IFN (category 2B)
or
Bevacizumab
and
Best supportive carea
supportive care can include palliative RT, metastasectomy or
biphosphonates for bony metastasis
NCCN Clinical Practice Guidelines in Oncology. 2007;v. 1. 2008.
Targeted Therapies:
Patient Education and Management
• Assess patient at initiation of therapy
• Establish treatment schedule and regularly scheduled visits with
healthcare provider
• Ensure that patient sees an MD or RN at the beginning of each
treatment cycle
• Provide both written and verbal instructions about RCC
treatment and side effect management
• Patient should be instructed to contact healthcare provider
immediately when experiencing any side effects
• Document therapy and response to treatment on appropriate
medication flow sheets and nursing notes
Moore SH. Online educational activity – 2006.
Summary
• 3 targeted therapies are currently FDA-approved for
treatment of advanced RCC
• Targeted therapies have manageable side effects
with appropriate nursing interventions
• Patients have prolonged survival with control of
their cancer
• Identified prognostic factors correlate with prognosis
and treatment decisions (NCCN guidelines)
Future Considerations
• Do these targeted therapies have a role in the
adjuvant setting?
• Do combinations of these targeted therapies offer
better clinical results or cause increased toxicity?
• Patient preference: oral or IV therapy?