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


Emerging Paradigms in the Management of Leukemias and Lymphomas


GOAL
To provide pharmacists and nurses specializing in hematology/oncology with up-to-date information on the treatment and management of patients with hematologic malignancies.

TARGET AUDIENCE
This activity is designed for pharmacists and nurses specializing in hematology/oncology. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine, The Institute for Johns Hopkins Nursing, and The University of Tennessee College of Pharmacy 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:
  • Identify the new products for use in hematologic malignancies and describe their specific pharmacokinetic profiles.
  • Explain the pros and cons of each of the treatment options for acute myelogenous leukemia, myelodysplastic syndromes, acute promyelocytic leukemia, non-HodgkinÕs lymphoma, and multiple myeloma.
  • Apply the decision-making process for the selection of drugs in the different patient populations.
  • Describe the constraints that use of the different therapies brings to each of the disease states, including the side effects and risks associated with each of the agents.
ACCREDITATION STATEMENT
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Johns Hopkins University School of Medicine, The Institute for Johns Hopkins Nursing, and the University of Tennessee College of Pharmacy. The Johns Hopkins University School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

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

The University of Tennessee College of Pharmacy (UTCOP) is accredited by the Accreditation Council of Pharmacy Education (ACPE) to provide continuing education for pharmacists.

CREDIT DESIGNATION STATEMENT
This 2 contact hour Educational Activity (Provider Directed/Learner Paced) is provided by The Institute for Johns Hopkins Nursing. Claim only those contact hours actually spent in the activity.

This program is approved for 2 hours of credit (0.2 CEUs) and is sponsored by the University of Tennessee College of Pharmacy, which is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. ACPE program # 064-999-07-220-H01.

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

Release date: May 15, 2007. Expiration date: May 15, 2009.

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 Johns Hopkins University School of Medicine, The Institute for Johns Hopkins Nursing, and the University of Tennessee College of Pharmacy 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 Cephalon Oncology.Full Disclosure Policy Affecting CE Activities
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a provider 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
Amy Hatfield, PharmD, BCOP
Clinical Specialist, Hematologic Malignancies
Department of Pharmacy
Sidney Kimmel Comprehensive Cancer Center
The Johns Hopkins Hospital
Baltimore, Maryland
Dr Hatfield reports having no significant financial or advisory relationships with corporate organizations related to this activity.

MiKaela Olsen, RN, MS
Oncology and Stem Cell TransplantClinical Nurse Specialist
Sidney Kimmel Comprehensive Cancer Center
The Johns Hopkins Hospital
Baltimore, Maryland
Ms Olsen reports serving on the speakers' bureau for Amgen Inc and Chiron.
PARTICIPATING FACULTY
Sandy Allen-Bard, RN, MSN, NPc
Leukemia Service
Weill Cornell Medical Center
New York, New York
Ms Allen-Bard reports having no significant financial or advisory relationships with corporate organizations related to this activity.

Connie Zanzig Augustyniak, RN, BSN
Nurse Clinician
Robert H. Lurie Comprehensive Cancer Center
Northwestern University
Chicago, Illinois
Ms Augustyniak reports having no significant financial or advisory relationships with corporate organizations related to this activity.

Deborah Blamble, PharmD, BCOP
Clinical Specialist, Leukemia
University of Texas
MD Anderson Cancer Center
Houston, Texas
Dr Blamble reports having no significant financial or advisory relationships with corporate organizations related to this activity.

Chris Fausel, PharmD, BCOP
Clinical Pharmacist
Hematology/Oncology/BMT
Indiana University Cancer Center
Indianapolis, Indiana
Dr Fausel reports receiving honoraria from Amgen Inc.

Mollie Moran, MS, CNP
Nurse Practitioner/Hematologic Malignancies Program
Ohio State University
Arthur G. James Cancer Hospital
Columbus, Ohio
Ms Moran reports serving as a consultant for Berlex Oncology; and receiving honoraria for serving on the speakers' bureau for Genentech Biooncology and Novartis.

Amy Robbins, PharmD, BCOP
Clinical Specialist
Malignant Hematology/Stem Cell Transplant
Methodist Healthcare-University Hospital
Memphis, Tennessee
Dr Robbins reports having no significant financial or advisory relationships with corporate organizations related to this activity.
Notice: The following faculty member has disclosed that the article will reference unlabeled/unapproved drugs or products:

Dr Hatfield–5-azacytidine, arsenic, bortezomib, clofarabine, and decitabine.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Johns Hopkins Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins Advanced Studies in Medicine 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.

Emerging Paradigms in the Management of Leukemias and Lymphomas
Amy Hatfield, PharmD, BCOP,* and MiKaela Olsen, RN, MS

Leukemia, lymphoma, and multiple myeloma, collectively called hematologic malignancies, are all cancers of blood-forming organs. These diseases arise due to errors in the genetic information contained in immature blood cells. As a consequence of these errors, cell development is arrested so that rather than maturing, abnormal blood cells–primarily of the leukocyte (white blood cell or WBC) lineage–proliferate in an unregulated manner. Nearly every stage of blood cell development (ie, hematopoiesis) can give rise to a distinct type of hematologic malignancy. The common ground between different hematologic malignancies is improper or aberrant differentiation of blood cells and/or their precursors. In leukemia, cancerous leukocytes are found circulating in the blood and bone marrow, whereas in lymphoma, the cells tend to aggregate and form masses, or tumors, in lymphatic tissues. Multiple myeloma is characterized by the proliferation of a specific subset of WBCs called plasma cells, which release aberrant proteins into the blood and urine. Despite their similarities, the types of hematologic malignancies are also quite distinct, and vary significantly in their causes, molecular profiles, and natural progression.

In patients with leukemia, hematopoietic cells remain morphologically or functionally immature and multiply continuously, eventually crowding out healthy cells and thereby preventing normal development of WBCs, erythrocytes (red blood cells), and thrombocytes (platelets). The major types of leukemia are classified according to 2 parameters: onset/duration and predominant type of proliferating malignant cell. Leukemias can be either acute (having a sudden onset and rapidly intensifying from early signs and symptoms) or chronic (developing slowly, with signs and symptoms sometimes not appearing for years) and either lymphocytic (characterized by proliferation of aberrant lymphocytes) or myelogenous (characterized by proliferation of aberrant nonlymphocytic blood cells). Thus, the 4 major types of leukemia are acute lymphocytic leukemia, acute myelogenous leukemia (AML), chronic lymphocytic leukemia (CLL), and chronic myelogenous leukemia. These different types of leukemia have unique causes and affect different subpopulations (eg, some leukemias are more common in children whereas others primarily affect the elderly), and are therefore treated with distinct combinations of chemotherapeutic agents, targeted therapies, and other treatment modalities.

The lymphomas are a large group of cancers originating in lymphoid tissue. Hodgkin's lymphoma (or Hodgkin's disease) is a specific type of lymphoma named after the physician who first described it, Thomas Hodgkin; all other lymphomas are collectively called non-Hodgkin's lymphoma (NHL). There are at least 30 types of NHL, each of which is sensitive to different types of therapy. Although multiple myeloma is also a lymphoid malignancy and is sometimes categorized as a type of NHL, it is more commonly considered a separate entity. Myeloma is characterized by the proliferation of aberrant antibody-secreting plasma cells called myeloma cells. Whereas normal plasma cells produce and secrete the antibodies used to fight infection, myeloma cells release nonfunctional immunoglobulins, which literally clog up the bone marrow as well as other organs, such as the kidneys. As with other hematologic malignancies, a specific subset of therapies is used to treat myeloma.

Despite advances in diagnosis and treatment and improvements in patient survival, hematologic cancers continue to have a significant impact on the lives of Americans. Currently, approximately 700 000 people in the United States are living with leukemia, lymphoma, myeloma, and other blood cancers, and over 135 000 new cases are diagnosed each year (Table).1,2 Although mortality has declined and 5-year survival rates have increased among adults and children with certain forms of these diseases, an estimated 52 300 Americans will die from hematologic malignancy in 2007.2

As mentioned above, treatment of hematologic malignancies differs among the different diseases. However, common mainstays of treatment in the past few decades have been cytotoxic chemotherapy regimens and hematopoietic stem cell transplantation. In recent years, several targeted therapies have entered the hematologic malignancy treatment landscape. By directly interacting with the aberrant molecules responsible for cancer cell pathogenesis, these treatments have the potential to more effectively inhibit proliferation of aberrant cells and to be associated with less toxicity than traditional chemotherapeutic agents. Because a large proportion of the patient population with hematologic malignancy is elderly, treatment-associated toxicities are a major concern for patients as well as healthcare providers.

This issue of Johns Hopkins Advanced Studies in Medicine is based on proceedings from a roundtable  held in December 2006, in Orlando, Fla, at which it was our pleasure to serve as chairs. The discussion focused on patient management issues in the treatment of a subset of hematologic malignancies from a nursing and pharmacist perspective, with particular emphasis on current and investigational therapies. This monograph was developed by all participants at the roundtable, which in addition to ourselves included Sandy Allen-Bard, RN, MSN, NPc, Connie Zanzig Augustyniak, RN, BSN, Deborah Blamble, PharmD, BCOP, Chris Fausel, PharmD, BCOP, Mollie Moran, MS, CNP, and Amy Robbins, PharmD, BCOP.

The first section of this monograph addresses AML and 2 related conditions, promyelocytic leukemia and myelodysplastic syndromes, and subsequent sections cover the lymphoid malignancies CLL, NHL, and multiple myeloma. Each of these disease sections includes a discussion of the epidemiology, classification schemes, currently used treatment regimens, investigational therapies, and patient management issues related to the disease. The monograph ends with a brief discussion of reimbursement and management issues specific to targeted therapies for hematologic malignancies.

Table

REFERENCES

1.    Leukemia and Lymphoma Society. Understanding Drug Therapy and Managing Side Effects. Available at: http://www.leukemialymphoma.org/attachments/National/br_1095366690.pdf. Accessed January 21, 2007.
2.    American Cancer Society. Cancer Facts and Figures 2007. Atlanta, Ga: American Cancer Society; 2007.

*Clinical Specialist, Hematologic Malignancies, Department of Pharmacy, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Hospital, Baltimore, Maryland.

†Oncology and Stem Cell Transplant Clinical Nurse Specialist, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Hospital, Baltimore, Maryland.
Address correspondence to: Amy Hatfield, PharmD, BCOP, Clinical Specialist, Hematologic Malignancies, Department of Pharmacy, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Hospital, 600 North Wolfe Street, Carnegie 180, Baltimore, MD 21287-6180. E-mail: ahatfie2@jhmi.edu.

The content in this monograph was developed with the assistance of a medical writer. Each author had final approval of his/her article and all its contents.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.