There has been an increasing number of approvals for targeted therapies in oncology in the past decade, changing the treatment paradigm for many solid tumors and hematologic malignancies. At JADPRO Live 2023, presenters provided an in-depth review of cancer biomarkers, including testing methodology, recommended therapies, and how advanced practitioners can integrate results into clinical decision-making.
Background: Occupational exhaustion, or burnout, is characterized with three components: emotional exhaustion, depersonalization, and sense of decreased personal accomplishment. Advanced practice providers (APPs) in oncology care are at particular risk for burnout.
Methods: This was a prospective, comparative, descriptive study utilizing a convenience sample of oncology APPs who completed the Advanced Practice Provider Oncology Web Education Resource (AP-POWER; formerly Oncology Nurse Practitioner Web Education Resource, or ONc-PoWER), developed to provide educational content for new oncology APPs. The study purpose was to utilize the AP-POWER alumni to describe the level of burnout (Maslach Burnout Inventory) as well as resilience (Brief Resilience Scale) after at least 1 year in oncology practice, and to compare these scores according to the number of APP oncology practice years.
Results: Of the 133 questionnaires emailed, 30 were returned (22.6% response) and 27 completed (20.3%). Within the Maslach Burnout Inventory, the mean score of the emotional exhaustion subscale was 25.19 (standard deviation [SD] 12.74; high degree of occupational exhaustion), depersonalization 7.74 (SD 5.98; moderate degree), and personal achievement 31.85 (SD 6.20; low degree). The resilience scores had a mean of 22.52 (SD 3.37; normal range). Resiliency was positively associated with personal accomplishment. There was no difference in burnout among newer (< 3 years) and more experienced (> 3 years) oncology APPs.
Discussion: Oncology APPs report key indications of burnout, including a high degree of emotional exhaustion and moderate depersonalization, which was not mitigated through resiliency.
Conclusions/implications: The results are worrisome. Burnout scores for oncology APPs are high. Resiliency is present but is not protective for burnout. Strategies must be developed institutionally to support these key cancer care providers.
Infusion-related reactions (IRRs) are a recognized concern for chemotherapy, biologic agents, and newer immunotherapies. Antihistamines are frequently recommended to prevent or manage these reactions. For over 60 years, diphenhydramine has been the only H1 antihistamine for intravenous (IV) administration. It has been considered the standard of care as part of premedication regimens to prevent IRRs associated with these therapies despite the lack of a US Food and Drug Administration (FDA)-approved indication and no evidence of efficacy data. Intravenous cetirizine was approved in 2019 for acute urticaria treatment, making it the only second-generation H1 antihistamine that can be administered intravenously. Compared with diphenhydramine, cetirizine has an improved safety profile with less sedation, fewer contraindications, lower incidence of anticholinergic side effects, and minimal risk of adverse events in elderly patients. A head-to-head study demonstrated that IV cetirizine is as effective as IV diphenhydramine in reducing IRRs and may decrease chair time, treatment center visits, and the need for rescue medication. Over the past 3 decades, the FDA has addressed the issue of IRRs by mandating language regarding the requirement or recommendation for premedication in the label of over 50 FDA-approved infusion products. As more therapeutics have premedication required or recommended, IV cetirizine should be considered an antihistamine for preventing and treating IRRs. In this article, we describe a patient whose IRR was successfully managed with IV cetirizine and discuss first- vs. second-generation H1 antihistamines and their use in treating and preventing IRRs.
Purpose: The purpose of this integrative literature review was to determine factors that increase the risk of immune checkpoint inhibitor (ICI)-related myocarditis in the cancer patient population.
Methods: A literature review was conducted using the following databases: PubMed, Scopus, and Cochrane Review. Dates searched were from inception through March 1, 2022. Inclusion criteria included English language, cancer patients receiving ICI treatment, and risk factors for myocarditis. Articles were excluded if they were a non-human study, duplicate, had an irrelevant title or content, or were a review or commentary.
Results: Patients with cancer who receive ICIs have an associated increased risk of myocarditis if they are older than 64 years, have a body mass index (BMI) greater than 28, and have a history of cardiovascular medication use.
Conclusions: Myocarditis remains a rare cardiovascular adverse effect of ICIs. However, the mortality risk among this subset of patients remains high. Additional prospective randomized-controlled trials would be beneficial to further determine a causal relationship between risk factors for ICI-related myocarditis. Risk stratification tools may allow oncology medical providers to identify patients at a higher risk of ICI-related myocarditis to increase earlier surveillance.
Once an individual has been identified as a carrier of an inherited cancer-predisposing gene or pathogenic germline variant (PGV), there are measures that have been proven to prevent and diagnose the associated cancers at an earlier, more curable stage. Consequently, patients who are offered and undergo testing are afforded opportunities and health-care information that profoundly affect their lives and the lives of their family members who choose to be tested as well. For years, the debate over the controversial topic of whether all patients should be offered germline testing for cancer-predisposing PGVs centered around questions of the analytical sensitivity of the assays (i.e., the ability of the test to correctly identify those who carry a PGV), legal implications for those identified as PGV carriers, cost to the health-care system, and the uncertain management implications of test results. Currently, the standard of care is to offer testing to individuals where the anticipated benefits of testing outweigh the harms. Here, the ethical question of whether all patients have the right to testing for PGVs is considered.
Background: Advanced practice providers (APPs) who care for patients with hematologic malignancies perform bone marrow aspiration and biopsies (BMBXs). Invasive bedside procedures are often taught through the observational training method, which can lead to inconsistencies.
Problem: The purpose of this project was to create and evaluate a standardized educational curriculum incorporating simulation with a task trainer for bone marrow transplant (BMT) APPs. The project aimed to reduce BMBX incident reporting events, improve BMBX knowledge, and increase APP self-reported confidence.
Methods: Pre- and post-test surveys were utilized for knowledge assessment of BMBX procedures and specimen allocation. Program delivery occurred on five occasions to accommodate the needs of the team. Each program was delivered over 3 hours and included an educational Microsoft PowerPoint and three breakout sessions: BMBX kit review; simulation on task trainer; and review of BMBX specimen collection procedures. Knowledge assessment surveys were compared through descriptive and statistical analysis.
Results: BMBX incident reporting events decreased from 1.92 events per month pre-implementation to 1.2 events per month post-implementation. Overall, BMBX knowledge increased from 41.02% on pre-test surveys to 65.72% on post-test surveys. Participant self-reported confidence improved by a mean difference of -1.85 based on a 5-point Likert scale, t(12) = -1.85 (p ≤ .0001, 95% confidence interval = -2.49 to -1.2).
Implications: This project suggests that the use of simulation with task trainers is beneficial when paired with a standardized educational curriculum. Simulation training for APPs who perform BMBX improves procedural knowledge, increases self-reported confidence, and can reduce incident reporting events.
In the randomized phase II DREAMM-2 study, single-agent belantamab mafodotin demonstrated deep and durable responses and a manageable safety profile in triple-class refractory relapsed/refractory multiple myeloma (RRMM). We present patient-reported outcomes (PROs) from this study for patients treated with the approved dose of belantamab mafodotin (2.5 mg/kg q3w). Disease and treatment-related symptoms, health-related quality of life (HRQOL), functioning, and patient-reported ocular changes were assessed using questionnaires (European Organisation for Research and Treatment of Cancer Quality of Life questionnaires EORTC-QLQ-C30 and EORTC-QLQ-MY20, Ocular Surface Disease Index [OSDI], and the National Eye Institute Visual Functioning Questionnaire 25 [NEI VFQ-25]) at baseline, during treatment (every 3 or 6 weeks), and at the end of treatment (EOT). Eye examinations were conducted at baseline, prior to each treatment cycle, and at EOT. Patients reported ocular symptoms in the OSDI and NEI VFQ-25 questionnaires, with the median time to worst severity of 45 to 64 days depending on symptoms considered. Some limitations in driving and reading were reported. Ocular symptoms were improved and median time to recovery was 23.5 to 44.0 days. EORTC-QLQ-C30 data suggest core MM symptoms (including fatigue and pain), overall HRQOL, and patient functioning were maintained while patients continued belantamab mafodotin treatment, even if meaningful worsening of vision-related symptoms occurred. These PRO results, together with the clinical efficacy of belantamab mafodotin, support its use in patients with RRMM and further evaluation of its use at earlier lines of therapy.
Gastrointestinal stromal tumors (GISTs) are considered rare, but they are one of the most common malignant mesenchymal tumors within the gastrointestinal tract, affecting 4,000 to 6,000 adults in the United States each year. Because gastrointestinal bleeding is often the initial symptom, a thorough and timely diagnostic workup is imperative to accurately diagnose a potentially deadly tumor. Endoscopic ultrasound is helpful when working through a differential diagnosis of subepithelial lesions and can help identify which mucosal layer the lesion originates from, as well as the density of the lesion; however, surgical resection is the standard of care for the treatment of a resectable nonmetastatic GIST. For recurrent GISTs, metastatic disease, or GISTs not amendable to resection, tyrosine kinase inhibitors are frequently used, with imatinib being used in the first-line setting. A multimodal treatment approach is often necessary to increase the chances of a permanent cure.
Pancreatic cancer is the third leading cause of cancer deaths in the United States. It has a 95% mortality rate within 5 years of the initial diagnosis. Pancreatic ductal adenocarcinoma is the most commonly diagnosed histotype. The average age at diagnosis is 70 years. Familial forms of pancreatic cancer have been associated with pathogenic variants in predisposing genes, including ATM, BRCA1, BRCA2, PALB2, CDKN2A, STK11, MLH1, and MSH2. Collecting information on the patient's family history may serve as a primary tool to screen an individual's risk for familial pancreatic cancer. More advanced screening options for individuals at risk include endoscopic ultrasonography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography. Due to pancreatic cancer's high mortality rate, routine screening of individuals at risk for developing familial pancreatic cancer may result in early diagnosis and improved survivability. This review aims to characterize the genetic risk factors associated with pancreatic cancer and recognize available screening options for at-risk individuals.
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