Safe Handling and Administration Considerations of Oral Anticancer Agents in the Clinical and Home Setting

A Concept Analysis of Oral Anticancer Agent Self-management

BACKGROUND

The rapid development and adoption of oral anticancer agents (OAAs) for cancer management have shifted patients' roles from recipient to owner of their care delivery, assuming their responsibilities for self-managing their OAA treatments at home, while the concept of oral anticancer agent self-management (OAA-SM) has not been well clarified and defined.

OBJECTIVE

This study was to clarify the concept of OAA-SM and identify major components, influential factors, and consequences of OAA-SM, as well as propose a representative conceptual model of OAA-SM.

METHODS

A literature review was conducted concerning the concept and application of OAA-SM. The Walker and Avant method for concept analysis was utilized to guide the examination of OAA-SM.

RESULTS

OAA-SM is a multifaceted and dynamic process that requires continuous adaptation by patients as multiple self-management challenges can emerge throughout OAA treatments. The defining attributes of OAA-SM include OAA adherence, adverse-effect self-management, patient-provider communication, and OAA safe storage, handling, and administration practices. Oral anticancer agent-SM is potentially influenced by a variety of patient-related, OAA-related, and healthcare system factors. Effective OAA-SM is associated with better patient and healthcare outcomes.

CONCLUSIONS

The clarification of the concept of OAA-SM and the identification of attributes of OAA-SM and their interrelationships contribute to the body of knowledge in OAA-SM.

IMPLICATIONS FOR PRACTICE

This concept analysis provides the foundation to increase healthcare providers' understanding of patients' needs for OAA-SM support and guides the development of patient-centered interventions to empower and engage patients and their families in effective OAA-SM, and improve patients' quality of life and care.

Oral Chemotherapy: An Evidence-Based Practice Change for Safe Handling of Patient Waste

BACKGROUND

Safe handling practices for patient waste have focused on patients receiving IV chemotherapy, but these practices do not address safe handling for patients receiving oral chemotherapy.

OBJECTIVES

The aim of this article is to evaluate evidence and formulate best practice recommendations for handling and disposing waste from patients receiving oral chemotherapy.

METHODS

A literature search established a framework for the project. For healthcare providers and staff, procedures were established to access biohazard supplies and to follow safe handling of patient waste post-oral chemotherapy administration. Supply cost utilization was evaluated pre- and postimplementation. Staff perceptions were assessed six months after project implementation.

FINDINGS

The cost of supplies per patient day increased minimally. Staff self-reported use of biohazard precautions when handling patients' waste increased. The majority of staff reported that they had access to supplies and were knowledgeable regarding safe handling procedures six months after this practice change.

From theory to practice: implementing a standardized, interactive education session on oral anticancer medication (OAM) for patients and their caregivers

PURPOSE

Self-administration at home and decreased visits to see health care professionals bring patients on oral anticancer medication (OAM) and their caregivers to become experts in handling medication, managing adverse events, and making sure that they adhere to treatment. This project aimed to implement a standardized education group session for patients starting an OAM regimen and their caregivers that would build new knowledge, validate comprehension of information, increase satisfaction, and empower participants in self-management.

MATERIALS AND METHODS

A group session led by an oncology nurse was developed. The theoretical section consisted of short videos that include both verbal and visual explanations. The practical component consisted of quizzes with electronic recordings and instant answers. Turning Point technology was used to compile and analyze the data.

RESULTS

Over a 2-year period, 124 patients and 79 caregivers participated in the group sessions. More than 111 h were saved by giving standardized group sessions instead of individual teachings. The participants' level of confidence regarding the essential concepts to master significantly increased following the group sessions. The results ranged from 18% of participants who answered 4 or 5 on a five-point Likert-type scale before the session to 100% who answered 4 or 5 after the group session. 94% of participants responded with a rating of 4 or 5 when asked if they were satisfied with the overall interactive group session.

CONCLUSION

It is crucial that caregivers participate in the initial OAM teaching. The involvement of the interdisciplinary team was crucial in meeting the informational needs of patients. A standardized group session accessible for viewing and use by all health care professionals and patients simplifies the process of sharing high-quality learning materials in a technological society.

Challenges of Caregivers of Cancer Patients who are on Oral Oncolytic Therapy

OBJECTIVE

To describe the major challenges faced by caregivers of patients receiving oral oncolytic therapy (OOT).

DATA SOURCES

Published literature, national clinical practice guidelines, standards of care.

CONCLUSION

Caregivers of patients receiving OOT have unmet needs. Caregivers need standardized OOT education and coping support to improve patient outcomes through enhanced drug safety practices, better management of complex treatment regimens and adherence, patient symptoms, treatment side effects, care decision-making, and financial assistance for costly OOT.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are well-positioned to take leadership roles in facilitating optimal utilization of multidisciplinary health care resources necessary to support caregivers and improve outcomes in patients receiving OOT.

Developing recommendations for the safe handling of oral anti-cancer drugs in community pharmacies: A pan-Canadian consensus approach

Purpose

To create a set of consensus-based and evidence-informed recommendations to provide guidance around the safe dispensing and handling of oral anti-cancer drugs in low-volume settings unique to the community pharmacy setting.

Methods

A review of published and grey literature (published in non-commercial domains such as national organizations and associations) documents and nine key informant interviews were conducted and a modified Delphi approach was taken to achieve consensus. The final list of 47 candidate recommendations was reviewed by a task force and validated by multi-disciplinary stakeholders. A draft of the statements was circulated broadly within the community pharmacy community in an effort to assess relevance and implementation feasibility.

Results

The final report included 44 recommendations that addressed 11 key areas germane to the safe handling of oral anti-cancer drugs in community pharmacies. Mean agreement increased from 70% to 95%. Early feedback from community pharmacy leaders during the external review suggests that many of the proposed recommendations can be feasibly implemented within a reasonable timeframe when released with appropriate education and resource materials.

Conclusions

A modified-Delphi approach supplemented by key informant interviews and a comprehensive external review resulted in a set of evidence-informed, community-driven recommendations for community pharmacies. The recommendations address a gap in existing literature to improve understanding of the risks associated with handling and dispensing oral anti-cancer drugs for both community pharmacy staff and management and offer mitigating strategies to reduce those risks. Incorporating feasibility assessment actions early (through the key informant interviews) and late (through the external review) ensures recommendations are grounded in practicality and support broad and early knowledge translation strategies.

Side Effects, Self-Management Activities, and Adherence to Oral Anticancer Agents

PURPOSE

There are growing concerns about patients' adherence to oral anticancer agents (OAAs), and the need for patients to engage in self-management of OAA-related side effects. We assessed associations among adherence, severity of side effects, and effectiveness of self-management of side effects in patients taking capecitabine.

METHODS

Adherence to capecitabine at 6 weeks was measured by the Medication Event Monitoring System among 50 patients with gastrointestinal cancers. Severity of side effects related to capecitabine and effectiveness of self-management of side effects were captured using the Modified Self-Care Diary at the time of enrollment and weekly for 6 weeks. Spearman's correlation, Mann-Whitney U-tests, and multiple linear regression were conducted, p<0.05.

RESULTS

Overall mean adherence rate was 85.4±14.1%. Adherence rate was not significantly correlated to the mean severity of total side effects at any time point and was correlated with the mean effectiveness of self-management of total side effects only at week 2 (rho=0.29, p=0.04). However, adherence rate was associated with the mean severity of one specific side effect, diarrhea, at 6 weeks (rho=0.36, p=0.01) and marginally correlated to the mean effectiveness of self-management of diarrhea at 6 weeks (rho=0.28, p=0.05). Mean severity of diarrhea at 6 weeks was an independent predictor of adherence rate (b=4.97, p=0.01), with the control of age (b=0.52, p=0.002), number of outpatient medications (b=1.12, p=0.007), health literacy (b=2.53, p=0.04), diagnosis of colorectal cancer (b=11.6, p=0.03), and capecitabine in combination with other chemotherapies (b=16.8, p=0.001) in the model.

CONCLUSION

This pilot study suggests ongoing examination of both severity and effectiveness of self-management of side effects in future studies of adherence to OAAs is merited. There is a need for future studies with larger sample sizes that explore the complex relationships among adherence, severity of side effects, and effectiveness of self-management of side effects in OAA therapy.

[Therapeutic education of patients taking oral chemotherapy at home]

Oral cancer drugs make the patient more active and autonomous. They reduce the number of hospital appointments and the risk of infection. However, they result in new problems such as the management of side effects. In this context, therapeutic education is essential. The first French therapeutic education programme for patients taking oral cancer drugs at home has been set up.

Surface contamination of counting tools after mock dispensing of cyclophosphamide in a simulated outpatient pharmacy

PURPOSE

The primary aim was to determine if dispensing of cyclophosphamide tablets resulted in accumulated residue on pharmacy counting tools during a simulated outpatient dispensing process. Secondary objectives included determining if cyclophosphamide contamination exceeded a defined threshold level of 1 ng/cm² and if a larger number of prescriptions dispensed resulted in increased contamination.

METHODS

Mock prescriptions of 40 cyclophosphamide 50 mg tablets were counted on clean trays in three scenarios using a simulated outpatient pharmacy after assaying five cleaned trays as controls. The three scenarios consisted of five simulated dispensings of one, three, or six prescriptions dispensed per scenario. Wipe samples of trays and spatulas were collected and assayed for all trays, including the five clean trays used as controls. Contamination was defined as an assayed cyclophosphamide level at or above 0.001 ng/cm² and levels above 1 ng/cm² were considered sufficient to cause risk of human uptake. Mean contamination for each scenario was calculated and compared using one-way analysis of variance. P-values of < 0.05 implied significance.

RESULTS

Mean cyclophosphamide contamination on trays used to count one, three, and six cyclophosphamide prescriptions was 0.51 ± 0.10 (p=0.0003), 1.02 ± 0.10 (p < 0.0001), and 1.82 ± 0.10 ng/cm² (p < 0.0001), respectively. Control trays did not show detectable cyclophosphamide contamination. Increasing the number of prescriptions dispensed from 1 to 3, 1 to 6, and 3 to 6 counts increased contamination by 0.51 ± 0.15 (p = 0.0140), 1.31 + 0.15 (p < 0.0001), and 0.80 ± 0.15 ng/cm² (p = 0.0004), respectively.

CONCLUSION

Dispensing one or more prescriptions of 40 cyclophosphamide 50 mg tablets contaminates pharmacy counting tools, and an increased number of prescriptions dispensed correlates with increased level of contamination. Counting out three or more prescriptions leads to trays having contamination that surpasses the threshold at which worker exposure may be increased. Pharmacies should consider devoting a separate tray to cyclophosphamide tablets, as cross-contamination could occur with other drugs and the efficacy of decontamination methods is unclear. Employee exposure could be minimized with the use of personal protective equipment, environmental controls, and cleaning trays between uses. Future investigation should assess the extent of drug powder dispersion, the effects of various cleaning methods, and the potential extent of contamination with different oral cytotoxic drugs.

Oral agents for cancer: safety challenges and recommendations

BACKGROUND

The lack of knowledge and standardization of safety practices related to prescribing, dispensing, administering, and monitoring oral agents for cancer (OACs) has created significant safety challenges for patients and healthcare providers. Problems identified with the use of OACs include possible medication errors, increased potential for toxicity, unintentional exposure of hazardous medications to healthcare providers and informal caregivers, and possible pollution of the environment.

OBJECTIVES

The purpose of this review is to provide information about the current state of knowledge and recommendations in the literature regarding safety concerns with OACs and strategies for risk reduction.

METHODS

Articles published from 2003-2014 were retrieved using PubMed, CINAHL®, and the Cochrane Library.

FINDINGS

As the number of OACs continues to increase, existing standards related to medication errors and safety will require ongoing revision to lessen the risks and hazards for patients, caregivers, and healthcare providers.

2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, Including Standards for Pediatric Oncology

Purpose

To update the American Society of Clinical Oncology (ASCO)/Oncology Nursing Society (ONS) Chemotherapy Administration Safety Standards and to highlight standards for pediatric oncology.

Methods

The ASCO/ONS Chemotherapy Administration Safety Standards were first published in 2009 and updated in 2011 to include inpatient settings. A subsequent 2013 revision expanded the standards to include the safe administration and management of oral chemotherapy. A joint ASCO/ONS workshop with stakeholder participation, including that of the Association of Pediatric Hematology Oncology Nurses and American Society of Pediatric Hematology/Oncology, was held on May 12, 2015, to review the 2013 standards. An extensive literature search was subsequently conducted, and public comments on the revised draft standards were solicited.

Results

The updated 2016 standards presented here include clarification and expansion of existing standards to include pediatric oncology and to introduce new standards: most notably, two-person verification of chemotherapy preparation processes, administration of vinca alkaloids via minibags in facilities in which intrathecal medications are administered, and labeling of medications dispensed from the health care setting to be taken by the patient at home. The standards were reordered and renumbered to align with the sequential processes of chemotherapy prescription, preparation, and administration. Several standards were separated into their respective components for clarity and to facilitate measurement of adherence to a standard.

Conclusion

As oncology practice has changed, so have chemotherapy administration safety standards. Advances in technology, cancer treatment, and education and training have prompted the need for periodic review and revision of the standards. Additional information is available at http://www.asco.org/chemo-standards.

2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, Including Standards for Pediatric Oncology

Purpose

To update the ASCO/Oncology Nursing Society (ONS) Chemotherapy Administration Safety Standards and to highlight standards for pediatric oncology.

Methods

The ASCO/ONS Chemotherapy Administration Safety Standards were first published in 2009 and updated in 2011 to include inpatient settings. A subsequent 2013 revision expanded the standards to include the safe administration and management of oral chemotherapy. A joint ASCO/ONS workshop with stakeholder participation, including that of the Association of Pediatric Hematology Oncology Nurses and American Society of Pediatric Hematology/Oncology, was held on May 12, 2015, to review the 2013 standards. An extensive literature search was subsequently conducted, and public comments on the revised draft standards were solicited.

Results

The updated 2016 standards presented here include clarification and expansion of existing standards to include pediatric oncology and to introduce new standards: most notably, two-person verification of chemotherapy preparation processes, administration of vinca alkaloids via minibags in facilities in which intrathecal medications are administered, and labeling of medications dispensed from the health care setting to be taken by the patient at home. The standards were reordered and renumbered to align with the sequential processes of chemotherapy prescription, preparation, and administration. Several standards were separated into their respective components for clarity and to facilitate measurement of adherence to a standard.

Conclusion

As oncology practice has changed, so have chemotherapy administration safety standards. Advances in technology, cancer treatment, and education and training have prompted the need for periodic review and revision of the standards. Additional information is available at http://www.asco.org/chemo-standards .

Safe handling of oral antineoplastic medications: Focus on targeted therapeutics in the home setting

Introduction With the growing number of oral targeted therapies being approved for use in cancer therapy, the potential for long-term administration of these drugs to cancer patients is expanding. The use of these drugs in the home setting has the potential to expose family members and caregivers to them either through direct contact with the drugs or indirectly by exposure to the parent compounds and/or their active metabolites in contaminated patients' waste. Methods A systematic literature review was performed and the known adverse health effect of 32 oral targeted therapeutics is summarized. In particular, the carcinogenicity, genotoxicity, and embryo-fetal toxicity, along with the route of excretion were evaluated. Results Carcinogenicity testing has not been performed on most of the oral targeted therapeutics and the genotoxicity data are mixed. However, the majority of these drugs exhibit adverse reproductive effects, some of which are severe. Currently, available data does not permit the possibility of a health hazard from inappropriate handling of drugs and contaminated patients waste to be ignored, especially in a long-term home setting. Further research is needed to understand these issues. Conclusions With the expanding use of targeted therapies in the home setting, family members and caregivers, especially those of reproductive risk age, are, potentially at risk. Overall basic education and related precautions should be taken to protect family members and caregivers from indirect or direct exposure from these drugs. Further investigations and discussion on this subject are warranted.

Pharmacovigilance in oncology: evaluation of current practice and future perspectives

RATIONALE, AIMS AND OBJECTIVES

Pharmacovigilance (PV), or drug safety monitoring, aims to improve patient safety through the detection and management of drug-related adverse reactions. It is implemented both by spontaneous reporting of adverse drug reactions (ADRs) and by careful detection of signals suggestive of drug toxicity. PV is an important clinical topic in clinical practice and pharmacotherapy, assuring the maintenance of a safe risk/benefit ratio throughout the commercial life cycle of a drug.

METHODS

We conducted a structured literature search on PubMed, Scopus, Cinahl and the Cochrane Library. We also performed manual searches in international databases of ADR individual reports to outline a structured profile on the topic. Our goal was to review key elements that affect safety monitoring of cancer drugs and their appropriate use, highlighting the strengths and weaknesses of PV in oncology.

RESULTS

This paper provides an understanding of the methodologies used by PV in current clinical practice and particularly in cancer drug therapy; a focus upon reporting of ADRs by health professionals and patients; and a focus upon methods used by PV to detect new signals of risk/harm related to medicines utilization.

CONCLUSION

To our knowledge, few articles focus upon the importance of PV and post-marketing surveillance of cancer drug therapies. Structured management of spontaneous reports of ADRs and data collection is essential to monitoring the safe use of drugs in this field in which pharmacotherapy is affected by high incidence of drug-related complications and by a narrow benefit/risk ratio.

Essentials of oral oncolytics: developing a nursing reference

A convenience sample of oncology clinicians from 17 practices throughout the northeastern United States participated in roundtable discussions. Discussions about oral adherence were initiated in multiple practices, and attendees were asked to describe what resources they currently use and what resources are lacking. A need for a new tool for oral adherence in oncology was identified during roundtable discussions. Essential information about oral oncolytics in a user-friendly format that is rapidly accessible and organized would be an ideal nursing resource. Review of the literature demonstrated a lack of usable tools, with one exception that was outdated. Desire for an oral oncolytic resource was consistently mentioned. Additional suggestions for the resource included severe drug reactions, initial dosing and dosing adjustments, and how the drug should be taken. The clinicians wanted the information to be organized in a condensed chart that remains current as approvals continue. A condensed resource, the Essentials of Oral Oncolytics Guide (EOOG), was developed to address this need and includes guidelines for starting oral oncolytics, scheduling of patient monitoring, and pertinent need-to-know aspects of each oral oncolytic. The EOOG includes newly approved oral oncolytics and new indications as of December 2013.

Chemotherapy safety in clinical veterinary oncology

Exposure to chemotherapy is a health hazard for all personnel in facilities that store, prepare, or administer antineoplastic agents. Contamination levels have been measured as much as 15 times higher in the veterinary medicine sector than in human facilities. Recent publications in human and veterinary medicine indicate that exposure extends beyond the clinic walls to affect the patient's home and family. This article provides an update on the advances in chemotherapy safety, the current issues, and the impact on cancer management in veterinary medicine.

Patient adherence with oral oncolytic therapies

OBJECTIVES

The use of oral chemotherapy has increased substantially. This adds a level of complexity beyond that of traditional intravenous chemotherapy. This article discusses challenges and strategies to meet patient needs.

DATA SOURCES

Research and peer-reviewed journal articles.

CONCLUSION

Adherence is a challenge for oral chemotherapy. A systematic approach serves as the best way to facilitate a comprehensive oral chemotherapy plan.

IMPLICATIONS FOR NURSING PRACTICE

Nurses' knowledge is required to support and monitor patient adherence. Nurses must master effective utilization of resources to monitor and positively impact successful patient outcomes.

The nurse liaison role in the cooperative group setting

OBJECTIVES

To review the history of nurse involvement within the cooperative group environment, define the role of the nurse liaison, identify challenges for the nurse in interdisciplinary research, and explore future trends of nurse involvement in cooperative group studies.

DATA SOURCES

Published articles, government reports, and Web sites.

CONCLUSION

Nurse liaisons provide a nursing perspective to the design of cooperative group trials and ensure that nursing and patient feasibility issues about the trial are addressed, and provide guidance to nurses at participating institutions, as well as their home institution.

IMPLICATIONS FOR NURSING PRACTICE

The nurse liaison must be committed to their cooperative group role. Because of their proximity in time and space to the patient, nurse liaisons have a unique vantage point that can provide meaningful feedback for all stages of protocol development, implementation, and evaluation.