Assessment and epidemiologic issues related to fatigue.

At The University of Texas M. D. Anderson Cancer Center, a multidisciplinary workgroup was assembled to review issues, current research, and areas of future research related to the assessment and epidemiology of cancer-related fatigue. Interactive discussion facilitated by a moderator determined the major areas of focus for future research in this arena. The group's ideas were presented to the entire conference following the session. Several gaps in current research related to the assessment and epidemiology of cancer-related fatigue were identified.

Oncology nurses' knowledge, practice, and educational needs regarding cancer genetics.

This study evaluated oncology nurses' knowledge of cancer genetics and related topics, and identified current practice patterns and perceived educational needs in this area. A 54-item study questionnaire was mailed to a random sample of 1,200 Oncology Nursing Society (ONS) members and 75 members of the ONS-Cancer Genetics Special Interest Group; 656 (51%) of those eligible responded. After exclusions, we analyzed 573 responses. Most respondents were Caucasian, female, and worked in hospital or outpatient settings. Half were staff nurses and 8% specialized in cancer genetics. Respondents with higher levels of nursing education or with continuing education in cancer genetics, who worked in positions other than staff nurses, and whose primary practice area was cancer genetics had significantly higher mean scores overall on questions measuring knowledge of cancer genetics and related areas. Higher perceived educational needs to improve knowledge or practice related to cancer genetics at basic, intermediate or advanced levels were associated with all or some of the following variables: lower education; hospital/ outpatient or managed care/private practice settings; lack of continuing education in cancer genetics, and positions other than advanced practice nurses. Although nearly half of the respondents had received patient inquiries regarding cancer genetics, only 35% were aware of referral resources and 26% had made such referrals. These findings may be used to develop targeted educational approaches that prepare oncology nurses to incorporate cancer genetics into any level of practice.

The role of oncology nurses in gene therapy.

In February 2001, the Human Genome Project international consortium announced the publication of a draft sequence and initial analysis of the human genome. Although a definitive count of human genes must await further experimental and computational analysis, scientists now estimate that the human genome contains 30000-35000 genes--a much smaller number than initially estimated. The advances in treatment which will result from this research and our improved understanding of cancer at a molecular level will rapidly change the management of cancer. Gene therapy represents one new approach to treatment, but is currently still experimental. This article reviews the important role of the oncology nurse as a member of the multidisciplinary team caring for patients who receive gene therapy as part of a clinical trial.

Cancer genetics and nursing practice: what every gastroenterology nurse needs to know.

Most nurses will care for and provide health information about cancer to a patient at some point in their careers. Cancer care will change dramatically in the coming years as a result of the translation of information gained from the Human Genome Project into clinical practice and the enhanced understanding of cancer at a molecular level. A select group of cancers, known as hereditary cancers, result from mutations in the germline that confer a greatly increased lifetime risk of developing cancer. Advances in technology and discoveries stemming from the Human Genome Project now provide the means to test individuals for the presence of mutations associated with some known hereditary cancer syndromes. Of particular importance to gastroenterology nurses are hereditary colorectal cancer syndromes. Although many ethical, legal, and psychosocial issues associated with testing remain unresolved, predisposition genetic testing is having a significant impact on health care. Nurses will have vital roles in the future assessing patients and their family members for increased cancer risk, educating them about the availability of testing, making referrals for cancer genetic counseling and risk assessment, and providing follow-up care in the community for patients found to be at increased risk.

Recent advances in immunotherapy and monoclonal antibody treatment of cancer.

OBJECTIVES: To review the immune response and tumor immunology, and to provide an update on the success and obstacles to targeted therapy using monoclonal antibodies and antibody conjugates. DATA SOURCES: Research articles and textbooks. CONCLUSIONS: Ongoing studies are exploiting the targeting properties of the immune system to improve anticancer therapy. Both monoclonal antibodies and immunoconjugates have shown promise in treatment of specific diseases. IMPLICATIONS FOR NURSING PRACTICE: The rapid growth of molecular techniques has allowed for the development of new anticancer therapies. Since nurses are intimately involved in the delivery of such therapy as well as in educating patients regarding risks and benefits, they must be knowledgeable.

Genetic testing and informed consent.

OBJECTIVES: To discuss unique issues related to cancer predisposition genetic testing and informed consent. DATA SOURCES: Published professional articles, review articles, research articles, clinical practice, position statements, websites, and textbooks. CONCLUSIONS: The discovery of germline mutations that confer a predisposition for the development of cancer will continue. The provision of adequate information is central to the process of genetic counseling and testing so that individuals may give informed consent and make choices appropriate to their own specific circumstances. IMPLICATIONS FOR NURSING PRACTICE: The use of genetic information for the management of cancer will impact the practice of all oncology nurses in the coming years. Knowledge of genes that predispose for cancer and standards that delineate essential components of quality care during the informed consent process is vital.

Overview of cancer and genetics: implications for nurse practitioners.

The understanding of cancer at a molecular level and of the contribution of certain genetic mutations to the development of cancer is progressing at an unparalleled rate. Advances in technology and discoveries stemming from the Human Genome Project now provide the means to test individuals for the presence of mutations associated with some known hereditary cancer syndromes. Although many ethical, legal, and psychosocial issues associated with testing remain unresolved, predisposition genetic testing is having and will continue to have a significant impact on health care. Nurse practitioners will play a vital role in assessing clients for increased risk of developing cancer, educating clients about the availability of testing, making referrals for cancer genetic counseling and risk assessment, and providing follow-up care in the community for patients found to be at increased risk.

Emerging strategies in the management of cancer.

PURPOSE/OBJECTIVES: To review advances in understanding the biology of cancer that will lead to new prognostic indicators and approaches for treating cancer and its metastases and to explore the implications of these developments for oncology nurses. DATA SOURCES: Published papers, abstracts, research result, package inserts, books, and personal experience. DATA SYNTHESIS: Understanding is evolving that cancer is a genetic disease that occurs when a single cell and its progeny are remarkably changed by a series of genetic mutations. A new paradigm for managing cancer is emerging that is based on new prognostic indicators, intracellular and intercellular communication, and biologic control. Potential new therapeutic strategies include gene-directed therapy, control of cellular proliferation, exploitation of cell death, inhibition of metastasis, and reversal of multidrug resistance. Many of these therapies are only beginning to enter phase I/II clinical trials. CONCLUSIONS: With continued progress, doctors will be able to identify patients with the highest likelihood of experiencing recurrent or progressive disease and formulate therapeutic strategies specific for their disease and even for their individual genetic makeup. IMPLICATIONS FOR NURSING PRACTICE: To remain abreast of these new and increasingly sophisticated treatments, oncology nurses must be knowledgeable about cell and cancer biology, human genetics, the immune system, a how advances in these fields are forming the foundation for new therapies. Nurses with creativity and drive will continue to lead the way in developing management strategies for patients receiving these new therapies.

Effect of recombinant alpha-interferon on pharmacokinetics, biodistribution, toxicity, and efficacy of 131I-labeled monoclonal antibody CC49 in breast cancer: a phase II trial.

Preclinical studies have demonstrated that recombinant IFN-alpha (rIFN-alpha) can enhance the tumor associated glycoprotein 72 (TAG-72) on tumors. To determine whether rIFN-alpha could enhance TAG-72 expression in vivo in patients, 15 women with breast cancer were randomized to receive daily injections of rIFN-alpha (3 x 10(6) units/m2 for 14 days) beginning on day 1 (group 1 = 7 patients) or on day 6 (group 2 = 8 patients). On day 3, all patients received a 10-20-mCi tracer dose of 131I-CC49, a high-affinity murine monoclonal antibody reactive against TAG-72, followed by a therapy dose of 60-75 mCi/m2 of 131I-CC49 on day 6. Whole body and single-photon emission computed tomography scans along with whole blood pharmacokinetics were performed following tracer and treatment phases. Hematological toxicity was considerable; reversible grade 3-4 neutropenia and thrombocytopenia was observed in 12 of 15 patients. Twelve of 14 patients tested developed human antimouse antibodies 3-6 weeks after treatment. For group 1 patients, whole blood residence time increased significantly between that predicted from the tracer doses and therapy doses (42.6 +/- 4.7 versus 51.5 +/- 4.8 h, respectively; P < 0.01). The calculated radiation absorbed dose to red marrow from therapy compared to tracer activity was also significantly higher for this group (1.25 +/- 0.35 versus 1. 07 +/- 0.26 cGy/mCi; P < 0.05). Treatment with rIFN-alpha was found to enhance TAG-72 expression in tumors from patients receiving rIFN-alpha (group 1) by 46 +/- 19% (P < 0.05) compared to only 1.3 +/- 0.95% in patients not initially receiving IFN (group 2). The uptake of CC49 in tumors was also significantly increased in rIFN-alpha-treated patients. One partial and two minor tumor responses were seen. In summary, rIFN-alpha treatment altered the pharmacokinetics and tumor uptake of 131I-CC49 in patients at the expense of increased toxicity.

Future projections in biotherapy.

OBJECTIVES: To review barriers to effective biotherapy and future trends in biotherapy and the expertise needed by oncology nurses to address the challenges that will result from these changes. DATA SOURCES: Review articles and book chapters related to biotherapy. CONCLUSIONS: To sustain the progress made in biotherapy, barriers that limit the effectiveness of treatment must be addressed and basic research continued. Targeted areas for new biotherapy strategies are interference with cellular communication, control of the cell cycle, and interference with the process of metastasis. IMPLICATIONS FOR NURSING PRACTICE: Nurses with creativity and motivation will continue to lead the way in developing management strategies for patients receiving future therapies.

Phase Ia/Ib trial of anti-GD2 chimeric monoclonal antibody 14.18 (ch14.18) and recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) in metastatic melanoma.

We performed a phase Ia/Ib trial of chimeric anti-GD2 monoclonal antibody 14.18 (ch14.18) in combination with recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) to determine the maximum tolerated dose as well as immunologic and biologic responses to the regimen. Sixteen patients with metastatic malignant melanoma received escalating doses of ch14.18 (15-60 mg/m2) administered intravenously for 4 h on day 1. Twenty-four hours later, subcutaneous injections of rhGM-CSF were administered daily for a total of 14 days. Significant side effects were related to ch14.18 infusion and consisted of moderate to severe abdominal and/or extremity pain, blood pressure changes, headache, nausea, diarrhea, peripheral nerve dysesthesias, myalgias, and weakness. Dose-limiting toxicity was observed at 60 mg/m2 and consisted of severe hypertension, hypotension, and atrial fibrillation in one patient each, respectively. Significant increases in white blood cell count, granulocyte count, eosinophil count, and monocyte count occurred after rhGM-CSF treatment. Significant enhancement of in vitro and in vivo monocyte and neutrophil tumoricidal activity and antibody-dependent cellular cytotoxicity along with significant elevations in C-reactive protein and neopterin were observed. Despite these immunological and biological changes, no antitumor activity was seen. In short, the combination of ch14.18 and rhGM-CSF resulted in toxicity similar to that observed with ch14.18 alone without improvement in tumor response.

Interferon-alpha: a clinical update.

The use of interferon-alpha (IFN-alpha) for the treatment of cancer has continued to expand since the initiation of clinical trials in the early 1980s. Regulatory approval of IFN-alpha was first granted in 1986, and many investigational trials continue. Expanded approvals are anticipated during the next few years as the clinical benefits of IFN-alpha are further delineated. Many in the field of oncology care for patients who are receiving IFN-alpha therapy. Management of these patients offers a challenge; providing comprehensive care in diverse areas, particularly patient support and the management of side effects. Reassurance that many of the side effects associated with IFN-alpha therapy will diminish as treatment continues and that others can be managed assists patients in continuing therapy. Educating patients about the disease and treatment can reduce their anxieties and increase their level of comfort with therapy. Actions taken by the healthcare team toward side effect intervention, patient advocacy, social support and patient education and motivation can allow patients to stay the course of IFN-alpha therapy and achieve a therapeutic response.

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.