A new approach to managing chemotherapy-related anemia: nursing implications of epoetin alfa.

PURPOSE/OBJECTIVE: To review the role of epoetin alfa (recombinant human erythropoietin) in the treatment of chemotherapy-related anemia and the nursing management of patients receiving this form of therapy. DATA SOURCES: Published books, journal articles, and monographs as well as clinical experience. DATA SYNTHESIS: Anemia is a common problem for patients with cancer. Successful management of anemia associated with cancer chemotherapy can lead to improved quality of life for patients during therapy. CONCLUSIONS: The use of epoetin alfa to treat the anemia associated with cancer chemotherapy represents a viable new therapeutic alternative to the use of transfusions. Oncology nurses play an important role in shaping care strategies for patients receiving cancer therapy. IMPLICATIONS FOR NURSING PRACTICE: The nurse's role in assessment, administration, monitoring and patient education provides the foundation for effective management of patients receiving epoetin alfa therapy.

Future strategies in the control of myelosuppression: the use of colony-stimulating factors.

Recombinant technology has been harnessed to produce sufficient quantities of colony-stimulating factors (CSFs)--also known as hematopoietic growth factors--to make clinical trials with these agents possible. Endogenous CSFs are hormone-like glycoproteins that bind to receptors on target cells and stimulate processes within these cells that mediate their proliferation, maturation, differentiation, and functional activation. Several such CSFs cloned by recombinant DNA technology now are being tested clinically. Some are multilineage growth factors, such as interleukin-3 (IL-3) and granulocyte-macrophage colony-stimulating factor (GM-CSF), which tend to affect cells early in the hematopoietic hierarchy. Others, such as granulocyte colony-stimulating factor (G-CSF), primarily stimulate the formation of neutrophilic granulocytes. Macrophage CSF predominantly affects monocytes/macrophages. These are late-stage, single-lineage growth factors. Numerous clinical trials with all of these agents are under way. The granulopoietic agents, including GM-CSF and G-CSF, are being tested for their potential use in preventing or ameliorating myelosuppression related to AIDS, antineoplastic chemotherapy, bone marrow transplantation, myelodysplastic syndromes, and aplastic anemia. Clinical trial results on G-CSF and GM-CSF are encouraging thus far. However, it is too early to characterize the effects of IL-3, which is just entering clinical trials.

Maintenance treatment of patients with myelodysplastic syndromes using recombinant human granulocyte colony-stimulating factor.

Myelodysplastic syndromes (MDS) are characterized by chronic refractory cytopenias resulting in increased risk of infection, bleeding, and conversion to acute leukemia. In an effort to improve these cytopenias we have treated 18 patients over a 6- to 8-week period with increasing daily subcutaneous doses of recombinant human granulocyte colony-stimulating factor (G-CSF). Sixteen patients responded with improvement in neutrophil counts. On cessation of treatment these counts returned to baseline values over a 2- to 4-week period. To maintain these improved blood counts 11 patients were treated with G-CSF for more prolonged periods. Ten patients again responded with an increase in total leukocyte counts (1.6- to 6.4-fold) and absolute neutrophil counts (ANC) (3.6- to 16.3-fold), with responses persisting for 3 to 16 months. A significantly decreased risk of developing bacterial infections was noted during periods with ANC greater than 1,500/mm3 as compared with periods of time with ANC less than 1,500/mm3. Two anemic patients had a greater than 20% rise in hematocrit over the study period, and 2 additional patients had a decrease in red blood cell transfusion requirements during G-CSF treatment. Bone marrow myeloid maturation improved in 7 of 9 maintenance phase patients. Three patients progressed to acute myeloid leukemia during treatment. The drug was generally well-tolerated and no severe toxicities were noted. These data demonstrated that G-CSF administered to MDS patients by daily subcutaneous administration was well-tolerated and effective in causing persistent improvement of the neutrophil levels and marrow myeloid maturation. These effects were associated with a decreased risk of infection and, in some patients, with decreased red blood cell transfusion requirements.

Recent advances in the management of biotherapy-related side effects: fatigue.

Limited information about fatigue patterns in patients with cancer exists in the biotherapy literature. When fatigue is mentioned, it is usually to state whether or not it was a dose-limiting side effect. No further data are provided on how fatigue was measured; which patterns were noted and when; and which relationships were found between fatigue and demographic characteristics, type of biologic response modifier, route of administration, or cumulative dose. Thus, there is little available in the biotherapy literature to guide nursing practice in managing this side effect. Theory that guides practice, however, often emanates from the personal experiences of the patients and from the clinical observations and intuitive hunches of the nurses and physicians participating in clinical trials. These individuals have been most generous in sharing their insights and unpublished data with the authors. This paper presents a comprehensive view of current knowledge on fatigue to guide present nursing practice with patients receiving biotherapy and to provide direction for future nursing and clinical trial research.

Recent advances in the management of biotherapy-related side effects: flu-like syndrome.

A principal side effect of biological response modifiers (BRMs) is a constellation of constitutional symptoms often referred to as a "flu-like syndrome" (FLS). Precisely what this syndrome encompasses is frequently unclear, but its major components appear to be fever, chills, rigors, myalgias, and headache. Other components variously included are anorexia, nausea, upper respiratory symptoms such as nasal congestion and cough, and the ill-defined symptom, malaise. The manner in which the "flu-like" syndrome manifests itself during treatment with interferon (IFN), interleukin-2 (IL-2), tumor necrosis factor (TNF), monoclonal antibodies (MoAbs), and colony stimulating factors (CSFs) will be described with attention to frequency, duration and severity. The common mechanisms underlying the appearance of a flu-like syndrome during biotherapy will be elucidated with emphasis on the role of endogenous pyrogens and prostaglandins and on the physiology of the process. Methods to prevent or alleviate these uncomfortable side effects, including medical interventions such as alterations in schedule/route/dose of BRM administration and premedication with a variety of agents, as well as nursing measures such as patient education will be discussed.

Treatment of myelodysplastic syndromes with recombinant human granulocyte colony-stimulating factor. A phase I-II trial.

STUDY OBJECTIVE: To determine the hematopoietic effects and toxicity of recombinant human granulocyte colony-stimulating factor (G-CSF) in patients with myelodysplastic syndromes. DESIGN: The G-CSF was administered by daily subcutaneous injection to outpatients in a phase I-II trial. Dose was escalated every 2 weeks between 0.1 to 3.0 micrograms/kg body weight.d over an 8-week treatment period. SETTING: Outpatient clinical research center at a university hospital. PATIENTS: Twelve consecutive patients with myelodysplastic syndromes: two refractory anemia, seven refractory anemia with excess of blasts, three refractory anemia with excess of blasts in transformation. MEASUREMENTS AND MAIN RESULTS: In 10 of 12 patients, elevations in blood leukocyte counts (2- to 10-fold) and absolute neutrophil counts (5- to 40-fold) were seen over the 8-week treatment period. Five of seven severely neutropenic patients (absolute neutrophil count, less than 0.5 x 10(9)/L) had a rise in count to 1.2 to 16.3 x 10(9)/L. Increased reticulocyte counts occurred in 5 patients, and were associated with decreased transfusion requirements in 2 of 9 erythrocyte transfusion-dependent patients. Treatment with G-CSF enhanced marrow myeloid cell maturation in 9 of 11 evaluable patients. Neutrophil chemotaxis and phagocytosis in vitro were improved or unchanged after treatment in 6 of 8 patients tested. In 11 of 12 patients, there were no substantial changes in platelet, lymphocyte, eosinophil, or monocyte counts. Three responding patients initially had abnormal cytogenetics that persisted after G-CSF therapy, suggesting induced differentiation of the abnormal clone. The therapy was associated with minimal toxicity. None of the patients' conditions converted to acute leukemia during treatment or in short-term follow-up. CONCLUSIONS: Treatment with G-CSF administered by subcutaneous injection is well tolerated and effective for improving the neutropenia, and less commonly the transfusion-dependent anemia, over 6 to 8 weeks in patients with myelodysplastic syndromes.

Hemopoietic colony stimulating factors: an overview.

Hemopoiesis is the process by which the various blood cell lineages proliferate, differentiate, and mature. Colony stimulating factors (CSFs) are a group of glycoproteins that are extensively involved in hemopoiesis at every level. In recent years, a number of these agents have been identified. They now are being produced in large enough quantities to make possible the in-depth exploration not only of their functions but, more importantly from a clinical perspective, of their therapeutic potential. This article reviews the role of the CSFs in hemopoiesis and summarizes some of the current research concerning their therapeutic applications. In particular, it emphasizes the CSFs involved in granulopoiesis and their uses in hematology/oncology patient populations.