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


Establishing Treatment Guidelines For Supportive Care In Patients With Cancer


GOAL
To provide oncologists, hematologists, hospital decision makers, oncology nurses, and oncology pharmacists with information on the need for and the recent advances in the supportive care of patients with cancer.

TARGET AUDIENCE
This activity is designed for oncologists, hematologists, hospital decision makers, oncology nurses, and oncology pharmacists. 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, participants should be able to:

  • Discuss the need for supportive care in cancer therapy in terms of complications from anemia, neutropenia, nausea and emesis, and oral mucositis.
  • Identify the advantages and disadvantages of available treatments for anemia, neutropenia, nausea and emesis, and oral mucositis.
  • Discuss the differences between the NCCN and ASCO/ASH guidelines as they relate to supportive care in patients with cancer.
  • Recognize the importance of standardization of care at the local level for patients with cancer.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Institute for Johns Hopkins Nursing is accredited by the American Nurses Credentialing Center's Commission on Accreditation to provide continuing education for nurses. The University of Tennessee College of Pharmacy is approved by the American Council on Pharmaceutical Education as a provider of continuing pharmaceutical education.

CREDIT DESIGNATION STATEMENT
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.

The Institute for Johns Hopkins Nursing designates this educational activity for a maximum of 2 contact hours.

This program is approved for 2 hours (0.2 CEUs) and is cosponsored by the University of Tennessee College of Pharmacy, which is approved by the American Council on Pharmaceutical Education as a provider of continuing pharmaceutical education. A statement of CE credit will be mailed within 4 weeks of successful completion and evaluation of the program. ACPE program #064-999-04-217-H01.

Each participant 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: March 15, 2004. Expiration date: March 15, 2006.

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 activity is supported by an unrestricted educational grant from Amgen Inc.

Full Disclosure Policy Affecting CME Activities:
As sponsors accredited by the Accreditation Council for Continuing Medical Education (ACCME) and the American Council on Pharmaceutical Education (ACPE), it is the policy of Johns Hopkins University School of Medicine and the University of Tennessee College of Pharmacy 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 Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

    Jerry L. Spivak, MD
    Professor of Medicine and Oncology
    Johns Hopkins University School of Medicine
    Baltimore, Maryland
    Dr Spivak reports serving as a consultant to Amgen Inc, Novartis Corporation, Ortho Biotech, Roche, and Shire Pharmaceuticals Group plc.

PARTICIPATING FACULTY

    John H. Fetting III, MD
    Associate Director of Clinical Practice
    Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
    Associate Professor of Oncology and Medicine
    Johns Hopkins University School of Medicine
    Baltimore, Maryland
    Dr Fetting reports having no financial or advisory relationships with corporate
    organizations related to this activity.

    Stephen J. Noga, MD, PhD
    Director, Division of Hematology and Medical Oncology
    Alvin and Lois Lapidus Cancer Institute
    Sinai Hospital of Baltimore
    Associate Professor of Oncology and Pathology
    Johns Hopkins University School of Medicine
    Baltimore, Maryland
    Dr Noga reports serving as a consultant to Amgen Inc, Aventis Pharmaceuticals Inc, Gambro BCT, Inc, Idec, Novartis Corporation, and Ortho Biotech.

Notice:
In accordance with the ACCME, ANCC, and the ACPE Standards for Commercial Support, the audience is advised that one or more articles in this continuing medical education activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices.

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.

Why Do We Care About Supportive Care in Patients With Cancer?
Jerry L. Spivak, MD*

Generally speaking, patients who have anemia as a comorbidity are more likely to have an adverse outcome compared with patients without anemia. This fact has been shown in patients with Hodgkin's disease, non-Hodgkin's lymphoma, heart disease, HIV, and renal disease, with different mechanisms in each–but it is unequivocal in cancer. If a patient is anemic during cancer therapy, that patient will not do as well. Depending on the cancer study, local renal control, metastases, and survival are worse in patients with anemia compared with patients who are not anemic during therapy.

Anemia is common in patients with cancer, and its causes are many. Anemia is important as a sign of disease; it might be the first harbinger of cancer or indicate a comorbid condition that needs to be treated before cancer therapy can begin. Patients who are anemic during cancer therapy are more symptomatic in terms of fatigue and lack of energy, which has a definite impact on quality of life. Anemic patients undergoing chemotherapy are more likely to require blood transfusions, which has an obvious impact on survival. In cases involving other diseases and in which anemia has been corrected, survival has been improved. Improved survival hasn't  yet been proven in patients with cancer, but it has been shown that with radiotherapy, correcting anemia does make a difference in outcome.
 
We now have pharmacologic means for correcting anemia without resorting to transfusion, and the side effects are negligible. How can we best take advantage of these therapies to improve quality of life and outcome in our patients? First we must be sure there are no other correctable causes of anemia, then we must choose the appropriate situation in which improving anemia will alleviate patient symptoms.

Similarly, neutropenia, which commonly follows myelosuppressive chemotherapy, affects both quality of life and outcome in patients with cancer. The cost of treatment and the danger of the infections that follow neutropenia demand that we use preventive measures when appropriate and the best available treatments when neutropenia does occur.

The most important recent development in preventing and treating neutropenia has been the development of colony-stimulating factors, or cytokines, which decrease the incidence and duration of febrile neutropenia. Especially in older patients, cytokines as a supportive care option allow us to offer chemotherapy to patients who would have been directed to hospice care only a few years ago. In patients of all ages, once fever or infection occurs, cancer treatment must either be delayed or given with reduced dosages. Cytokines, however, are allowing clinicians to keep patients on time and at full dose with their chemotherapy, which has a direct effect on mortality risk.

Supportive care for other conditions–notably nausea, emesis, and mucositis–is undergoing positive change as well. The majority of patients undergoing chemotherapy experience nausea and/or vomiting, which are among the most common causes of patient morbidity. Nausea and vomiting might also cause discontinuation of chemotherapy, significantly influencing patient outcomes. Preventive treatment that diminishes acute nausea and vomiting is now available, and other treatments are showing good effect in delayed nausea. Research continues into treatments for oral mucositis-a condition also often associated with the discontinuation or reduction of cancer therapy, with resultant negative effect on outcomes. Several lines of inquiry are showing promise.

This issue of Advanced Studies in Medicine  includes a review article by Dr Stephen J. Noga discussing the importance of supportive care in patients with cancer as well as recent advances in this therapeutic area. Dr Noga reviews the risks and complications of anemia, neutropenia, nausea and emesis, and oral mucositis, as well as the prevention of and available treatment for each.

Dr Noga and I also participate in a joint clinician interview, which is preceded by a brief review of the national supportive care guidelines. We discuss the need for supportive care as it relates to patient quality of life, the strengths and weaknesses of the national guidelines, and how our individual practices at Johns Hopkins differ from those guidelines.

The joint interview is followed by an interview with Dr John H. Fetting III, who is heavily involved in the development of the supportive care guidelines at Hopkins. He discusses the motivation behind the development of the guidelines and the importance of standardizing care from both the quality-of-care and cost-effectiveness perspectives. The issue concludes with 2 case studies that demonstrate supportive care for anemia and neutropenia in patients undergoing chemotherapy.

The emergence of successful, evidence-based treatments for anemia and neutropenia offers hope that increasing numbers of patients with cancer can experience improved health-related quality of life and, perhaps, improved clinical outcomes. New treatments for nausea, emesis, and mucositis are also showing improved results, suggesting that these side effects of cancer treatment need no longer go untreated or undertreated. It is critical that as clinicians we make ourselves aware of the need for supportive care in cancer and keep ourselves up to date on the available and emerging treatments for the conditions that so commonly result from cancer therapy.

*Professor of Medicine and Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Address correspondence to: Jerry L. Spivak, MD, Johns Hopkins University School of Medicine, Traylor 924 - Hematology, 600 North Wolfe St, Baltimore, MD 21287. E-mail: jspivak@jhmi.edu.





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.