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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Understanding and Implementing the 2005 NCCN Guidelines in the Supportive Care Setting


GOAL
To provide advanced practice nurses and physician assistants with up-to-date information on the management of anemia and neutropenia.

TARGET AUDIENCE
This activity is designed for advanced practice nurses and physician assistants. No prerequisites required.

LEARNING OBJECTIVES
The Institute for Johns Hopkins Nursing and Johns Hopkins University School of Medicine take responsibility for the content, quality, and scientific integrity of this CE activity. At the conclusion of this activity, the participant should be able to:

  • Examine the role of the advanced practice nurse and physician assistant in providing supportive care to patients with cancer.
  • Outline proper implementation of the National Comprehensive Cancer Network Guidelines for Supportive Care, with respect to the management of anemia and neutropenia.
  • Discuss the importance of relative dose intensity and risk assessment in patients undergoing chemotherapy.
  • Identify current and emerging treatment strategies for chemotherapy-induced anemia and neutropenia.

ACCREDITATION STATEMENTS
The Institute for Johns Hopkins Nursing is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center’s Commission on Accreditation.

The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Institute for Johns Hopkins Nursing designates this activity for a maximum of 2.4 contact hours.
Claim only those contact hours actually spent in the activity.
(50 minutes of contact = 1 contact hour.)

The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 category 1 credits toward the AMA Physician’s Recognition Award.
Each physician should claim only those credits that he/she actually spent in the activity.

The estimated time to complete this educational activity: 2 hours.

Release date: November 15, 2005. Expiration date: November 15, 2007.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Institute for Johns Hopkins Nursing and the Johns Hopkins University School of Medicine names implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Amgen, Inc.

Full Disclosure Policy Affecting CE Activities:
As a provider accredited by the American Nurses Credentialing Center (ANCC), it is the policy of The Institute for Johns Hopkins Nursing to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Directors and Participating Faculty reported the following:

PROGRAM DIRECTORS

Mikaela Olsen, RN, MS, OCN
Oncology and BMT Clinical Nurse Specialist
Sidney Kimmel Comprehensive Cancer Center
Johns Hopkins Hospital
Baltimore, Maryland
Ms Olsen reports serving as a consultant for Amgen Inc. and GlaxoSmithKline.

Jerry L. Spivak, MD
Professor of Medicine and Oncology
Johns Hopkins University School of Medicine
Director, Center for Chronic Myeloproliferative Disorders
The Johns Hopkins Hospital
Baltimore, Maryland
Dr Spivak reports serving as a consultant for Novartis and Roche.

PARTICIPATING FACULTY

Theresa Wicklin Gillespie, PhD, RN
Department of Surgery and Winship Cancer Institute
Emory University School of Medicine
Health Services Research and Development
Atlanta Veterans Affairs Medical Center, Surgical Oncology
Atlanta, Georgia
Dr Gillespie reports having no financial or advisory relationships with corporate organizations related to this activity.

Shannon B. Holloway, MHS, PA-C
Division of Hematology and Medical Oncology Solid Tumor Service
New York Presbyterian Hospital
Department of Medicine
Weill Medical College
New York, New York
Ms Holloway reports receiving honoraria from Amgen Inc.


Notice: No faculty member has indicated that his/her article will reference unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Nursing provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Nursing does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Understanding and Implementing the 2005 NCCN Guidelines in the Supportive Care Setting
Mikaela Olsen, RN, MS, OCN,* and Jerry L. Spivak, MD†

With the advent of potent multidrug chemotherapy regimens used in the treatment of patients with cancer, 64% of cancer patients today in the United States survive 5 years or longer beyond diagnosis. Overall use of chemotherapy has increased significantly for many types of cancer. Patients are usually treated with several cycles of chemotherapy over the course of many months and the resulting myelosuppression increases risk of adverse events. Neutropenia is one of the most common complications of cytotoxic chemotherapy, occurring when myelosuppressive chemotherapy reduces the absolute neutrophil count. Incidence of neutropenia varies greatly based on tumor type, treatment prescribed, and host factors. Neutropenia, which often requires hospitalization for treatment in severe cases, is known to increase the risk of potentially life-threatening infections, particularly from gram-negative bacilli, gram-positive cocci, and fungi. Neutropenia can interfere with optimal cancer management by causing chemotherapy dose reductions, delays, or even sometimes complete discontinuation, negatively impacting response rates and survival. The financial burden of neutropenia hospitalization is high. Recent studies report that the mean cost for neutropenia hospitalization ranges from approximately $12 000 to $38 000 per stay, depending upon the type of cancer.1-3 A recent retrospective study of chemotherapy-induced neutropenia hospitalizations projected an incidence of more than 60 000 cases occurring nationally for the year 1999.4 The estimated mortality rate from the same study was 1 death for every 14 hospitalized patients (6.8%).

Anemia is another complication of chemotherapy and is known to occur in more than 50% of patients with cancer. Patients with lung cancer and ovarian cancer experience particularly high rates of anemia (52% and 51%, respectively), and patients with breast and other cancers frequently require at least 1 blood transfusion to treat their anemia.5 Although anemia can be a result of the cancer itself, it often occurs as an adverse event after cytotoxic chemotherapy. Severe fatigue associated with anemia is known to adversely affect quality of life, and data also suggest anemia has a role in poor clinical outcomes for patients with cancer. As with neutropenia, anemia can compromise patients’ tolerance of chemotherapy treatments, resulting in a need to reduce duration or intensity of treatments. Red blood cell transfusion was formerly the only option for the treatment of anemia in patients with cancer, but advances in anemia treatment in the past decade now provide patients with more therapeutic options having better risk-benefit profiles.

It is fair to say that some of the advances in cancer treatment in the past 2 decades have been made possible by the progress seen in supportive care. However, those who frequently work with patients with cancer often have little practical guidance on the most up-to-date treatments in supportive care. Because oncology nurses and physician assistants are on the front lines of supportive care for chemotherapy patients, it is important that they review the latest evidence-based information on these supportive care issues to provide appropriate patient education, explore realistic treatment goals, and ensure the most complete cancer care.

The National Comprehensive Cancer Network (NCCN) recently issued guidelines advocating the use of growth factors in certain patients with cancer to manage the complications of neutropenia and anemia. These guidelines present the best current clinical evidence regarding neutropenia and anemia, and may be especially useful for clinical practices seeking to formulate their own best practice guidelines.

This issue of Advanced Studies in Nursing includes a review article by Theresa W. Gillespie, PhD, RN, discussing the use of practice guidelines in supportive care. Dr Gillespie first reviews the etiology of anemia and neutropenia following cancer therapy, presents several different sets of guidelines and their genesis, and then discusses strategies for the management of anemia and neutropenia in patients with cancer using the NCCN guidelines. She concludes with an approach for oncology nurses to use to implement the NCCN guidelines in their own practice setting.

This issue also features a clinician interview with Shannon B. Holloway, MHS, PA-C, in which she discusses the role of the physician assistant and advanced practice nurse in cancer care, with an emphasis on the management of neutropenia and anemia and patient education concerning cancer treatment and potential adverse events that may arise after treatment. She also answers questions regarding recent trends in therapy and the importance of optimizing and implementing a current understanding of the benefits of risk assessment, early intervention, and appropriate use of growth factors in anemia and neutropenia.

The clinician interview is followed by 3 case studies. The first, contributed by Mikaela Olsen, RN, MS, OCN, presents a 66-year-old man with a history of chronic lymphocytic leukemia who has developed febrile neutropenia. The second case study, contributed by Dr Gillespie, involves a 68-year-old man diagnosed with stage IIIB squamous cell carcinoma and his treatment, including supportive care. The last case study, contributed by Ms Holloway, presents a 63-year-old woman diagnosed with adenocarcinoma of the colon who had a hemoglobin level consistent with moderate anemia and her course of treatment.

The role of advanced practice nurses, oncology nurses, and oncology physician assistants in anemia and neutropenia symptom identification and management is crucial to the maintenance of quality of life, and possibly also to clinical outcomes, in patients with cancer. It is essential that we as practitioners remain up to date on emerging evidence-based treatments for anemia and neutropenia to provide the highest possible standard of care to our patients undergoing cancer therapy.

REFERENCE

1. Uyl-de Groot CA, Vellenga E, Rutten FF. An economic model to assess the savings from a clinical application of haema-topoietic growth factor. Eur J Cancer. 1996;32A:57-62.

2. Kuderer NM, Cosler L, Crawford J, et al. Cost and mortality associated with febrile neutropenia in adult cancer patients [abstract]. Proc Am Soc Clin Oncol. 2002;21:250a.

3. Kuderer NM, Cosler L, Crawford J, et al. Mortality and economic impact of hospitalization with febrile neutropenia in patients with breast cancer: analysis of a nationwide database [abstract]. Proc Am Soc Clin Oncol. 2002;21:250a.

4. Caggiano V, Weiss RV, Rickert TS, et al. Incidence, cost and mortality of neutropenia hospitalization associated with chemotherapy. Cancer. 2005;103:1916-1924.

5. Gillespie TW. Effects of cancer-related anemia on clinical and quality-of-life outcomes. Clin J Oncol Nurs. 2002;6:206-211.

*Oncology and BMT Clinical Nurse Specialist, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, Baltimore, Maryland.
†Professor of Medicine and Oncology, Johns Hopkins University School of Medicine, Director, Center for Chronic Myeloproliferative Disorders, The Johns Hopkins Hospital, Baltimore, Maryland.

Address correspondence to: Mikaela Olsen, RN, MS, OCN, Oncology and BMT Clinical Nurse Specialist, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, The Harry & Jeannette Weinberg Building, Suite 1100, 401 North Broadway, Baltimore, MD 21231.
E-mail:
olsenmi@jhmi.edu..





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