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Immune checkpoint inhibitors target suppressor receptors, including cytotoxic T-lymphocyte–associated antigen 4 (CTLA-4), programmed cell death protein 1 (PD-1), and programmed cell death ligand 1 (PD-L1). The activated T cells are not antigen specific; therefore, the blockade of the immune checkpoint may result in the development of autoimmune adverse events. The most common immune-related adverse events (irAEs) are rash, colitis, and endocrinopathies. However, irAEs that affect the hematologic system are rare and can affect red blood cells (e.g., autoimmune hemolytic anemia), white blood cells, and platelets (e.g., immune thrombocytopenia). Usually one cell line is affected; however, in some cases, multiple cell lines can be affected. Other changes in the hematologic system can also be affected (e.g., cryoglobulinemia, cytokine release syndrome). Due to the rarity and lack of recognition of these AEs, the timing, spectrum of events, and clinical presentation are poorly understood. Management of hematologic irAEs usually involves the use of steroids; however, other agents (e.g., IVIG, cyclosporine, rituximab) or procedures (e.g., plasma exchange, transfusions) can also be used.

Constipation is a prevalent and distressing symptom affecting people with cancer. It may be a chronic condition, or it may be caused by the effects of the disease, its treatment, or the side effects of symptom management, including the use of opioids. These evidence-based guidelines can assist clinicians in the decision-making process, guiding patients to effective interventions to decrease the incidence and severity of constipation.

Purpose This evidence-based guideline intends to support clinicians, patients, and others in decisions regarding the treatment of constipation in patients with cancer. Methodologic approach An interprofessional panel of healthcare professionals with patient representation prioritized clinical questions and patient outcomes for the management of cancer-related constipation. Systematic reviews of the literature were conducted. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to assess the evidence and make recommendations. Findings The panel agreed on 13 recommendations for the management of opioid-induced and non-opioid-related constipation in patients with cancer. Implications for nursing The panel conditionally recommended a bowel regimen in addition to lifestyle education as first-line treatment for constipation. For patients starting opioids, the panel suggests a bowel regimen as prophylaxis. Pharmaceutical interventions are available and recommended if a bowel regimen has failed. Acupuncture and electroacupuncture for non-opioid-related constipation are recommended in the context of a clinical trial. Supplementary material can be found at https //bit.ly/30y29sI.

Background Oxaliplatin is used extensively for the treatment of gastrointestinal cancer and other malignancies, with increased frequency of use in recent years. Hypersensitivity reactions (HSRs) can pose a major problem in clinical practice because they can limit the use of oxaliplatin in the care of malignancies in which it has proven efficacy. Nurses play an integral role in the administration of oxaliplatin; therefore, they need to be well educated in the prevention, detection, and management of HSRs. Objectives This article reviews the symptoms of HSRs associated with oxaliplatin, the specific management of HSRs associated with oxaliplatin, the role of desensitization, and the potential use of skin testing to better identify patients at risk for HSR. Methods This article reviews the literature related to the diagnosis, prevention, and management of HSRs associated with oxaliplatin and outlines nurses' role. Findings Oxaliplatin HSRs can occur at any cycle, but patients are at highest risk after they have received six prior infusions of oxaliplatin.

Hematologic B-cell malignancies, which have varying behavior patterns, disease processes, and treatment responses, include non-Hodgkin lymphoma, leukemias, and myeloma. Although monoclonal antibodies and other agents have led to dramatic advances in the treatment of B-cell malignancies, the development of small molecules have enhanced the ability to treat and manage these malignancies and their adverse events (AEs). Oncology nurses need to be educated on the unique side effects for each class of these agents so that they can administer interventions to prevent and manage AEs in patients.

Objective To understand the role of the genetic changes and bone marrow microenvironment on the development, progression, and staging of multiple myeloma (MM). Data Sources Peer-reviewed articles and clinical guidelines. Conclusion The acquisition of genetic changes and the bone marrow microenvironment in which myeloma cells develop both influence the pathogenic potential of these malignant cells and is reflected in staging of the disease, risk of progression, and predicted response to treatment. Implications for Nursing Practice Treatment of multiple myeloma is largely dependent on risk factors in which specific genetic alterations play a large role. Clinicians should be aware of these genetic changes and how they may influence the individual treatment plan for each patient.

Background Cancer-related pain is a major health problem because of its magnitude, the subjective nature of the pain experience, and the complexity of the disease, making it difficult to assess and control. When assessment is not performed, poor pain control can result. . Objectives This article provides an overview of the components of a comprehensive cancer pain assessment. . Methods A review of the healthcare literature was performed. . Findings Nurses play a key role in pain assessment by establishing patient trust and rapport, which helps to break down barriers that may stand in the way of effective pain assessment and management.

Pancreatitis is a rare immune-related adverse event (irAE) associated with the use of immune checkpoint inhibitors (ICIs). It is more often associated with combined immunotherapy than by any single agent. Early signs of pancreatitis may only include elevation of lipase and amylase. Additional symptoms associated with pancreatitis include symptoms such as severe epigastric abdominal pain (that may radiate to the back, chest, or flank), nausea and/or vomiting, or dyspnea, and may indicate more advanced disease. Some researchers note that the presence of symptoms is not an indicator of more severe pancreatitis or long-term adverse outcomes. Radiologic changes can be useful in the diagnostic workup of ICI-associated pancreatitis, but radiologic tests may not show any changes in some patients with active pancreatitis. The management of ICI-associated pancreatitis can include those interventions used to manage acute pancreatitis (e.g., IV fluids, holding the agent, antibiotics, and steroids). The National Comprehensive Cancer Network Guidelines only recommend intervention for moderate to severe pancreatitis. Holding the associated ICI(s) is the most commonly used intervention when patients experience pancreatitis that is thought to be related to ICIs. Steroids are usually used in the management of irAEs associated with checkpoint inhibitors; however, there are no studies available at this time to indicate that this is the best method to treat pancreatitis associated with ICIs. Additional studies are needed to determine if steroids are the best method to manage irAE-associated pancreatitis or if additional management strategies are important in the management of pancreatitis in patients receiving checkpoint inhibitors.

Introduction. A chronic lymphocytic leukemia (CLL) diagnosis can be a frightening and confusing experience for both patients and caregivers. Understanding the patient experience can help identify challenges patients face and allow for the development of action plans to guide their journey. Methods. A group of patients, caregivers, and thought leaders from key advocacy organizations and cancer centers held a roundtable on November 13, 2018, in New York City to discuss the patient experience for individuals diagnosed with CLL. The objective of this roundtable was to agree on strategies to optimize the patient journey for those diagnosed with CLL. Results. Gaps identified in the experience of patients with CLL included limited opportunities to ask questions at diagnosis (especially if given the information over the phone), availability of second opinions, inadequate time with their physician/care team, variability in the quality and quantity of available educational resources, lack of awareness with regard to biomarker testing, inadequate discussion of treatment options and clinical trials, financial concerns, and lack of emotional support. Roundtable attendees selected five of these challenges to discuss in detail and proposed strategies to address them: 1) Development of a medical team fact sheet was proposed to help patients understand who is involved in their medical care and identify the appropriate team member to whom they can address specific questions with regard to their disease and treatment. Such a resource could help ensure patients' questions are answered in a healthcare setting where physicians' time is increasingly limited; 2) Educating patients and physicians on the importance of early access to emotional support and providing them with information on how to find these resources was identified as another important goal. Fact sheets and resources on the benefits of emotional support as well as directories to help patients access social workers/counselors, psychosocial oncology providers, or support groups would help ensure patients receive the emotional support they need; 3) To address lack of awareness of biomarker testing, roundtable attendees suggested the creation of a fact sheet on biomarker testing (common mutations, required tests, etc) to ensure all physicians and patients know what tests are needed, and when they should be done. Implementation of strategies to increase biomarker testing will help ensure that the best treatment option is identified for each patient; 4) Patients are often unaware of financial assistance that may be available to them, and databases (eg, CancerFAC.org) that serve as resources for financial assistance are often not updated frequently enough to keep up with the constantly evolving financial landscape. Creating a system for regular updates of CancerFAC.org, a financial resource database hosted by CancerCare and other advocacy organizations such as The Leukemia & Lymphoma Society and the Lymphoma Research Foundation, and ensuring patients are aware of this resource, would help patients navigate the financial options available to them at any given time; 5) Finally, development of plain language (sixth-grade reading level), accessible information on the potential benefits of clinical trials, easy-to-navigate listings of ongoing trials, and connections for patients to nurse navigators could help address lack of patient understanding of what clinical trials are and when and if they might be appropriate for each individual patient. Conclusion. Appropriate information and guidance from the healthcare team and access to up-to-date and easy-to-use resources can help alleviate anxiety and improve the patient journey for those diagnosed with CLL. Roundtable participants developed strategies and action plans to help meet several important needs of patients with CLL at the time of diagnosis. Funding was provided by Pharmacyclics LLC, an AbbVie Company, and Janssen Biotech, Inc, administered by Janssen Scientific Affairs, LLC. Disclosures Khan: Seattle Genetics: Research Funding; Janssen: Honoraria; Pharmacyclics: Honoraria; Bristol Myers Squibb: Research Funding; Celgene: Research Funding. Rogers:Jannsen: Honoraria; Daiichi Sankyo: Honoraria; Merck: Honoraria; AstraZeneca: Speakers Bureau; Genentech: Speakers Bureau; Seattle Genetics: Speakers Bureau; Cardinal Health: Honoraria; Abbvie: Speakers Bureau; Celgene: Honoraria; Coherus: Speakers Bureau; Sanofi: Honoraria; Mylan: Honoraria.

Background: Individuals with acute myeloid leukemia (AML) are at risk for significant physical and psychological burden related to their illness. While overall survival rates are improving, treatments may be associated with lengthy hospitalizations, and the risk of relapse remains substantial. This study explores cancer-related distress and concerns among AML survivors, as well as supportive care received from their healthcare team. Methods: 58 AML patients and survivors enrolled in the Cancer Support Community's online Cancer Experience Registry; 38 completed CancerSupportSource® (CSS) questions, a 25-item distress screening tool in which they rated their level of concern (0=Not at all; 4=Very seriously) about emotional well-being, symptom burden and impact, body image and healthy lifestyle, healthcare team communication, and relationships and intimacy. CSS includes validated subscales that identify individuals at risk for clinically significant depression and anxiety. Participants also completed questions about their unmet needs and desired help. Pearson's correlation coefficients were used to explore bivariate associations between socio-demographic variables and clinical history with overall distress (sum of CSS ratings) in AML respondents. Results: Mean (SD) age was 50 (14) years (range: 18-77); mean time since diagnosis was 5.6 years. Participants were 87% White and 64% female. 33% were receiving treatment at the time of taking the survey; 23% had ever experienced a recurrence of their cancer. Participants' greatest concerns (% rated Moderately to Very seriously) included: eating and nutrition (61%); exercising (57%); fatigue (53%); worry about the future and what lies ahead (51%); feeling irritable (51%); health insurance or money worries (49%); sleep problems (47%); changes or disruptions in work, school, or home life (46%); and feeling sad or depressed (45%). Based on responses to CSS risk screening subscales, more than half of participants (54%) were at risk for clinically significant level of anxiety; 42% were at risk for clinically significant levels of depression. Over half of respondents indicated their healthcare team asked about emotional concerns (58%); half said they were asked about lifestyle concerns such as diet and exercise (50%) and about financial concerns (e.g., out-of-pocket costs) (50%); roughly two-out-of-five had a health professional talk to them about employment concerns (40%) or family (42%). A majority of participants wished they had received more help with managing emotions related to cancer (67%), managing short-term (50%) and long-term (61%) side effects and symptoms, changing lifestyle behaviors (53%), and financial advice/assistance (47%). In bivariate analysis, greater overall distress was associated with younger age (r=-.49; p Conclusions: This exploratory study demonstrates that substantial proportions of AML survivors express concerns about emotional distress, symptom burden and impact, and practical matters including finances. Yet, many report they are not counseled about these concerns, and the majority wish for more help to address these needs. Efforts are needed to enhance social and emotional support and improve access to integrated supportive care for individuals with AML, to reduce the potential impact of illness burden and distress on quality of life, treatment adherence, and other illness outcomes. Future research will examine multivariate predictors of distress and unmet needs. Disclosures Zaleta: Pfizer: Research Funding; Gilead: Research Funding; Athenex: Research Funding. Albrecht:Cancer Support Community: Membership on an entity's Board of Directors or advisory committees; Oncology Nursing Society: Honoraria; Carevive: Research Funding. LeBlanc:Medtronic: Membership on an entity's Board of Directors or advisory committees; NINR/NIH: Research Funding; Astra Zeneca: Consultancy, Research Funding; Amgen: Membership on an entity's Board of Directors or advisory committees; CareVive: Consultancy; Celgene: Honoraria; Daiichi-Sankyo: Membership on an entity's Board of Directors or advisory committees; Helsinn: Consultancy; Heron: Membership on an entity's Board of Directors or advisory committees; Agios: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Otsuka: Consultancy, Membership on an entity's Board of Directors or advisory committees; Seattle Genetics: Consultancy, Research Funding; American Cancer Society: Research Funding; Duke University: Research Funding; Jazz Pharmaceuticals: Research Funding; Flatiron: Consultancy; AbbVie: Membership on an entity's Board of Directors or advisory committees; Pfizer Inc: Consultancy. Liesveld:Abbvie: Membership on an entity's Board of Directors or advisory committees; Onconova: Other: Data safety monitoring board. Rogers:Teva: Speakers Bureau; Takeda: Honoraria; Genentech: Speakers Bureau; Seattle Genetics: Speakers Bureau; Abbvie: Speakers Bureau; Cardinal Health: Honoraria; Genentech: Honoraria; Mylan: Honoraria; Coherus: Speakers Bureau.

Background: The Association of Community Cancer Centers (ACCC) is an education and advocacy organization with a diverse membership, representing all cancer program types with the largest majority (75%) being community-based cancer programs and private practices. Beyond the academic setting, ACCC seeks to expand education on the advancements in all cancer care and since measurable residual disease (MRD) is the most important prognostic factor that guides the therapy for patients with acute lymphoblastic leukemia (ALL), this project aimed to emphasize the importance of MRD testing for adult patients with ALL in the community oncology setting. Objective: The ACCC led a national initiative, in partnership with the Leukemia & Lymphoma Society (LLS), to improve the diagnosis, treatment and management of adult patients diagnosed with ALL in community oncology practices. This educational program focused on understanding the benefits of knowing patients' MRD testing and interpretation and the need to integrate this testing into standard of care practice in community oncology practice settings. Methods: This one-year programmatic initiative was designed by a group of multidisciplinary oncology faculty and structured around a peer-to-peer learning format that enabled ALL expert faculty to share effective practices for the treatment, care coordination and management of adult patients with ALL. An environmental scan was conducted to understand the landscape for utilization of MRD data in the community setting. Challenges and barriers identified in six key areas ((Initial Diagnostic Workup, Shared Decision Making, MRD Testing, Patient Access, Cost, and Reimbursement, Side-effect Management and Transitions in Care) were addressed by the development of healthcare professional-focused educational tools. Results: The educational material developed as part of the program include an environmental scan, blog series and webinar series that was viewed over 300 times by engaged ACCC members representing more than 75 cancer programs across 27 states. The four-part blog series covered a pathologist's perspective on the importance of MRD testing, a pharmacist's views on incorporating health literacy for patients, and social work and nursing perspectives on challenges with helping adult patients manage an ALL diagnosis. The three-part webinar series included an informative ASH 2018 update that included key abstracts and findings, a webinar that included a patient and care providers which shed light on the support needed along a patient's journey, and a webinar that explored critical insights for treating adult ALL from the perspective of a pharmacist, pathologist and oncologist. These enduring resources are available on-demand for the multidisciplinary care team. Conclusions: This program demonstrated the success of adopting a peer-to-peer educational learning platform to educate the multidisciplinary team providing care for adult patients diagnosed with ALL. Given rapid technological advances and emerging indications, the comprehensive educational materials developed were useful for the education of both the treating team and the patients in the community oncology setting. Disclosures Emadi: Jazz Pharmaceuticals: Research Funding; NewLink Genetics: Research Funding; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; KinaRx: Membership on an entity's Board of Directors or advisory committees, Other: Co-Founder and Scientific Advisor, Patents & Royalties; Genentech: Consultancy, Honoraria. Jabbour:Takeda: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Adaptive: Consultancy, Research Funding; Amgen: Consultancy, Research Funding; AbbVie: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Cyclacel LTD: Research Funding. Kendall:Eli Lilly: Speakers Bureau; Novartis: Speakers Bureau; Pfizer: Speakers Bureau. Rogers:Teva: Speakers Bureau; Takeda: Honoraria; Genentech: Speakers Bureau; Seattle Genetics: Speakers Bureau; Abbvie: Speakers Bureau; Cardinal Health: Honoraria; Genentech: Honoraria; Mylan: Honoraria; Coherus: Speakers Bureau.

The combination of carboplatin and paclitaxel is an active regimen in non-small cell lung cancer (NSCLC). Historically, patients with stage III disease have manifested higher response rates than patients with metastatic disease, and patients achieving a pathologic complete response to induction chemoradiation therapy prior to surgery have shown better long-term outcome. Based upon our pilot data using high-dose carboplatin and paclitaxel, we designed a phase II trial in patients with marginally resectable stage IIIA NSCLC. Ten patients, with bulky nodal stage IIIA disease, initially received etoposide (2 g/m 2 ) and granulocyte colony-stimulating factor (G-CSF) to mobilize peripheral blood stem cells (PBSC). Two cycles, 28 days apart, of carboplatin (AUC 12 in seven patients; AUC 16 in three patients) and paclitaxel (250 mg/m 2 ) were administered with filgrastim (5 μg/kg) and PBSC support. After re-evaluation, patients underwent a thoracotomy followed by radiotherapy (44–60 Gy) if deemed resectable, or radiotherapy alone (60 Gy) if not resectable. The median age was 58.5 years (48–66) with a median ECOG performance status of 0 (0–1). Histology was adenocarcinoma in seven patients; the remainder had either squamous cell, large cell or bronchoalveolar carcinoma. Based on CT radiography, the overall response rate was 40%. Eight of ten patients underwent resection with four right pneumonectomies, three right upper lobectomies and one wedge resection of the right upper lobe. Six patients had a complete resection. Of eight patients resected, four were downstaged by induction therapy, three remained unchanged and one was found to have more extensive disease. The remaining two patients developed metastatic disease while receiving chemotherapy. The median dose of postoperative radiotherapy was 54 Gy (35–66 Gy). Actual median follow-up for all patients was 89 weeks (25 to 136+). The actuarial median overall survival was 124 weeks (25 to 136+) and time to progression was 57 weeks (17 to 136+). The median dose of carboplatin delivered expressed as mg/m 2 was 779 (615–1540). Neutropenic fever occurred in two patients during the initial mobilization cycle only. The median number of units of RBC and/or platelets transfused was 0 (0–2 and 0–6, respectively). There were no significant non-hematologic toxicities. High-dose induction chemotherapy with stem cell rescue is feasible and safe with an acceptable response rate. Thoracotomy, including pneumonectomy and postoperative radiotherapy, were well tolerated by patients after undergoing high-dose induction chemotherapy with no apparent increase in peri-operative morbidity. The pathologic complete response rate was low — one out of ten patients. These results indicate that dose escalation of induction chemotherapy does not improve response rates even in this highly selected patient population. Accordingly, the complexity and potential toxicity of high-dose chemotherapy, as delivered in this trial as neoadjuvant treatment of non-small cell lung cancer, is not warranted.

Paclitaxel is an antimicrotubule agent that was recently approved by the Food and Drug Administration (FDA). Because it is insoluble in water, it is mixed with Cremophor EL (polyoxyethylated castor oil). The addition of Cremophor requires the use of glass bottles or polyolefin or polypropylene bags and polypropylene-lined tubings for the administration of paclitaxel. In addition, 0.22 micron in-line filters are necessary. The potential side effects of paclitaxel during its infusion include hypersensitivity reaction (HSR), cardiotoxicity, infiltration, diarrhea, and nausea, whereas myelosuppression, neurotoxicity, myalgias, arthralgias, alopecia, fatigue, headache, taste changes, and minor alterations in renal and liver function tests can occur after its administration. Premedications including an H2 blocker, a corticosteroid, and an antihistamine are necessary to minimize the occurrences of HSRs. Vital signs should be monitored throughout the infusion to assess for HSRs and cardiotoxicity. Paclitaxel has been shown to be safe in both the inpatient and outpatient settings. Nursing care includes the administration of the drug, the assessment and management of side effects, and psychosocial support of patients receiving the drug.

PURPOSE/OBJECTIVES To update oncology nurses on new developments in the care of older adult patients with acute myeloid leukemia (AML). DATA SOURCES Clinical trial data, published guidelines, review articles, and conference proceedings. DATA SYNTHESIS Therapies for older adult patients with AML include cytarabine-based intensive-induction chemotherapy, investigational therapy, and supportive care. Nonmyeloablative allogeneic hematopoietic stem cell transplantation may provide the best opportunity for cure following remission if a human leukocyte antigen-matched hematopoietic stem cell donor is available. Careful assessment of patient- and disease-related factors is critical in determining the appropriate treatment modality for individuals. Assessment tools and algorithms may identify patients likely to be intolerant of intensive therapies. Supportive care may improve treatment tolerance and quality of life. CONCLUSIONS Survival outcomes have not improved significantly for older adult patients with AML. Novel therapies, coupled with better understanding of prognostic factors, may allow more highly individualized care. Performance status or comorbidity score may provide insights regarding outcome, particularly when combined with age, cytogenetic risk, or molecular markers. Efforts to improve transplantation safety may increase use in the older adult patient population. IMPLICATIONS FOR NURSING Nurses provide disease and treatment information, manage adverse effects, and offer emotional support. Knowledge of the key management issues for older adult patients with AML is critical in fulfilling this role.

Objectives To provide an overview of non-Hodgkin’s lymphoma (NHL). Data Sources Review and research articles. Conclusion NHLs are divided primarily into two main categories based on their rate of growth: aggressive and indolent. Within these two groups are various subtypes that have various clinical features. Prognostic features have been useful in determining the potential outcome of treatment of patients with NHL. Implications for Nursing Practice Nurses play an important role in the education of patients regarding the type of lymphoma they have and the steps necessary to make an accurate diagnosis, which is important in determining the appropriate treatment.

PURPOSE: To determine the safety and feasibility of delivering multiple cycles of front-line high-dose carboplatin, paclitaxel, and topotecan with peripheral-blood stem-cell (PBSC) support. PATIENTS AND METHODS: Patients were required to have a malignant solid tumor for which they had received no prior chemotherapy. Mobilization of PBSC was achieved with either filgrastim alone or in combination with cyclophosphamide and paclitaxel. Patients then received three or four cycles of high-dose carboplatin (area under the concentration-time curve [AUC] 16), paclitaxel (250 mg/m2), and topotecan (10-15 mg/m2), with the latter two agents administered as 24-hour infusions and supported with PBSC and filgrastim. Cycles were repeated every 28 days. RESULTS: Twenty patients were enrolled onto the trial and were assessable for toxicity and clinical outcome. Dose-limiting toxicities were stomatitis and prolonged hematopoietic recovery. The maximum-tolerated dose of topotecan was 12.5 mg/m2 when given with high-dose carboplatin and paclitaxel for three cycles. Four cycles were able to be given with a dose of topotecan of 10 mg/m2. The pharmacokinetics of each compound were not affected by the other agents. Eleven (85%) of 13 patients with assessable disease responded. CONCLUSION: Multiple cycles of high-dose carboplatin, paclitaxel, and topotecan can be safely administered with filgrastim and PBSC support. The recommended doses for phase II study are carboplatin AUC 16, paclitaxel 250 mg/m2, and topotecan 10 mg/m2. Trials are currently being conducted with this regimen as front-line treatment in patients with advanced ovarian cancer and extensive small-cell carcinoma. This approach remains experimental and should be used only in the context of a clinical trial.