Continuing Education: June 2021

Release Date: June 22, 2021 Expiration Date: June 22, 2022

This activity is provided free of charge

STATEMENT OF NEED

This CE article is designed to serve as an update on cancer detection and prevention and to facilitate clinical awareness of current and new research regarding state-of-the-art care for those with or at risk for cancer.

TARGET AUDIENCE

Advanced practice nurses, registered nurses, and other health care professionals who care for cancer patients may participate in this CE activity.

EDUCATIONAL OBJECTIVE

Upon completion, participants should be able to:

• describe new preventive options and treatments for patients with cancer

• identify options for individualizing the treatment for patients with cancer

• assess new evidence to facilitate survivorship and supportive care for patients with cancer

ACCREDITATION/CREDIT DESIGNATION STATEMENT
Physicians’ Education Resource®, LLC, is approved by the California Board of Registered Nursing, Provider #16669, for 1 Contact Hour.

DISCLOSURES/RESOLUTION OF COI

It is the policy of Physicians’ Education Resource®, LLC (PER®), to ensure the fair balance, independence, objectivity, and scientific objectivity in all of our CE activities. Everyone who is in a position to control the content of an educational activity is required to disclose all relevant financial relationships with any commercial interest as part of the activity planning process. PER® has implemented mechanisms to identify and resolve all conflicts of interest prior to release of this activity.The planners and authors of this CE activity have disclosed no relevant financial relation-ships with any commercial interests pertaining to this activity.

METHOD OF PARTICIPATION

1. Read the articles in this section in their entirety.

2. Go to gotoper.com/go/June21.

3. Complete and submit the CE posttest and activity evaluation.

4. Download/print your CE Certificate.

OFF-LABEL DISCLOSURE/DISCLAIMER

This CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CE activity is for continuing medical nursing purposes only and is not meant to substitute for the independent medical judgment of a nurse or other health care provider relative to diagnostic, treatment, or management options for a specific patient’s medical condition.

The opinions expressed in the content are solely those of the individual authors and do not reflect those of PER®.

Awareness of Tepotinib-Associated Adverse Events May Optimize NSCLC Outcomes

Nurse-specific recommendations highlighting potential adverse events associated with tepotinib treatment may help increase time on treatment and lead to improved outcomes.

By Darlene Dobkowski, MA

Guidance created for nurses provides strategies to identify and manage common adverse events (AEs) in patients receiving tepotinib (Tepmetko) to treat non–small cell lung cancer (NSCLC) with MET exon 14 (METex14) skipping, according to a poster presented at the 46th Annual Oncology Nursing Society Congress, held April 20 to 29, 2021.

Tepotinib is a MET tyrosine kinase inhibitor recently approved for the treatment of patients with NSCLC with METex14 skipping, which occurs in 3% to 4% of patients with this cancer.

“As with any anti-cancer therapy, it is important to promptly identify, prevent, and manage any adverse events,” Terri Alexander, MS, research nurse supervisor at The University of Texas MD Anderson Cancer Center in Houston, said during the presentation. “This can help minimize dose modifications [and] discontinuations and ensure that patients get maximal benefit from therapy. Effective AE management can also support patient quality of life. Within the multi-disciplinary team, nurses play an important role in AE management.”

Alexander and colleagues developed nurse-specific visual guidance for the early identification and management of the most common AEs associated with tepotinib therapy for NSCLC. This guidance was based on an analysis of AEs observed in 255 patients with METex14-skipping NSCLC in the VISION trial (NCT02864992), in addition to real-world nursing experience.

The AEs included in the guidance are peripheral edema; creatinine increase; gastro-intestinal AEs such as diarrhea, vomiting, and nausea; pleural effusion; interstitial lung disease; and liver enzyme elevations. Information about the frequency of each AE is provided, and strategies for monitoring and management are recommended.For example, the investigators note that low-grade peripheral edema is a common AE, even in fit patients; however, progression to established edema can make treatment more difficult. By routinely performing the monitoring steps described in the guidance (such as checking for skin erosions and weight gain), nurses can identify edema early and mitigate it using the suggested conservative management approaches, which include compression stockings and limb elevation.

“These recommendations can support nurses in timely and effective management of AEs with tepotinib,” Alexander said during the presentation. “Proactive approaches to mitigate AEs may help to improve quality of life. In addition, by increasing time on treatment, AE management may help improve outcomes for this elderly patient population.”

Reference

Alexander T, Ahn L, Berghoff K, Vlassak S, Lemmens L. Managing side effects of tepotinib treatment to optimize outcomes for patients with non-small cell lung cancer harboring METexon 14 skipping: expert guidance based on clinical experience. Presented at: 46th Annual Oncology Nursing Society Congress; April 20-29, 2021; Virtual. Abstract 8970. Accessed April 15, 2021. https://ons.confex.com/ons/2021/meetingapp.cgi/Paper/8970

NPs Play Crucial Role in Helping Patients With uHCC Avoid Premature Discontinuation of Lenvatinib

Nurse practitioners should educate patients and caregivers about how to manage key adverse reactions associated with lenvatinib to help ensure patients remain on treatment to maximize benefit.

By Ryan McDonald

Nurse practitioners (NPs) should routinely follow up with patients with unresectable hepatocellular carcinoma (uHCC) who are receiving treatment with lenvatinib (Lenvima) to help prevent premature discontinuation of therapy as a result of serious adverse events (AEs), according to study results presented in a poster at the 46th Annual Oncology Nursing Society Congress, held April 20 to 29, 2021.

“Nurse practitioners play a critical role in providing education, as well as monitoring for and managing adverse reactions that may arise during therapy, thereby alleviating patients’ and caregivers’ concerns about initiating and maintaining treatment,” said lead study author Anna Jones, FNP-C, of Pacific Hematology Oncology Associates in San Francisco, California, during a recorded presentation of the data.

Jones and colleagues conducted a post hoc analysis of data from the phase 3 REFLECT trial (NCT01761266), which led to the FDA approval of lenvatinib in previously untreated patients, to characterize key AEs associated with treatment and assess strategies to manage them. A focus of their report was the crucial role NPs play in educating patients regarding the management of AEs.

Jones noted that although lenvatinib was found to be noninferior to sorafenib (Nexavar) in terms of median overall survival, the primary end point of the REFLECT trial (13.6 months vs 12.3 months; HR, 0.92; 95% CI, 0.79-1.06), important secondary end points, such as progression-free survival, time to progression, and objective response rate, improved significantly with lenvatinib treatment (P < .0001).

Almost all (99%) of the 476 patients treated with lenvatinib in the REFLECT trial experienced treatment-emergent adverse events (TEAEs), with 75% of patients experiencing TEAEs of grade 3 or higher. The most common TEAEs were hypertension (45%), diarrhea (39%), and decreased appetite (34%). An evaluation of dose modifications due to treatment-related AEs revealed a 40% rate of dose interruptions, 37% dose reductions, and 9% premature treatment discontinuation among patients taking lenvatinib. Early AE recognition and management, Jones emphasized, is imperative to ensuring patients remain on therapy to maximize the benefits of lenvatinib.

Characterization of Adverse Reactions and Their Frequency

Jones and colleagues reviewed the key adverse reactions (ARs; grouping of AEs per FDA definitions) that most frequently resulted in either dose reductions or interruptions of lenvatinib treatment. These ARs included fatigue, hyper-tension, palmar-plantar erythrodysesthesia syndrome, proteinuria, decreased appetite, and diarrhea. Of note, the investigators determined that these ARs all had a median time to first onset that was less than 10 weeks after treatment initiation. Median time to first onset was shortest for fatigue (3.4 weeks) and hypertension (3.7 weeks) and was longest for diarrhea (9.6 weeks) and decreased appetite (6.8 weeks).

Among the key ARs, proteinuria (7%) and fatigue (6%) most often led to lenvatinib dose interruptions; fatigue (7%), decreased appetite (6%), and diarrhea (6%) most frequently led to dose reductions.“

Knowledge of this information is crucial for nurse practitioners to make patients and care-givers aware of when to expect these [adverse] effects and to review ways to alleviate them, as well as when to contact the health care team,” explained Jones. “Through identification of potentially problematic comorbidities and routine check-ins, nurse practitioners [can] ensure that patients do not discontinue lenvatinib prematurely.”

NP Suggestions for Managing Key Adverse Reactions

Jones highlighted sections of the poster featuring NP perspectives on how to manage hypertension, diarrhea, and fatigue—ARs that may negatively impact on quality of life and result in premature lenvatinib discontinuation. The recommendations for hypertension management included identifying patients with preexisting hypertension and making sure the condition was controlled before initiating lenvatinib.

Among strategies for fatigue management was a recommendation that preexisting fatigue due to a treatable cause should be addressed both before and during therapy. Moreover, NPs should be mindful that fatigue may be caused by a patient’s decreased appetite (which may be an effect of lenvatinib therapy). Lenvatinib-associated fatigue may be managed by treatment modification, which should depend on the severity of the patient’s fatigue.

Appropriate dosing of concomitant medications such as lactulose is critical for prevention of diarrhea. For patients who nonetheless experience this AR, NPs may suggest the “bananas, rice, apples, and toast (BRAT)” diet to solidify stools. Additionally, patients should be counseled on the importance of sufficient hydration to replenish electrolytes lost through diarrhea.

Patient Education Considerations

Because they are often the primary point of contact for patient education, NPs are well positioned to reassure patients that they will receive the best tolerated dose of lenvatinib. According to the investigators, this will help patients stay on treatment longer to derive the maximum therapeutic benefit.

A crucial aspect of patient education by NPs is discussing common ARs patients may experience and offering suggestions for managing them at home. It is also important for NPs to help patients identify situations that require a call or visit to the clinic or emergency services for symptom management.

“I hope this presentation will provide meaningful information to further advance your clinical practice and enhance patient understanding and adherence of lenvatinib treatment for uHCC,” concluded Jones.

Reference

Jones A, Moore A, Robbins C, Amaya-Chanaga C, Sung MW, Baron AD. Patient education and management of adverse reactions in patients with unresectable hepatocellular carcinoma (uHCC) treated with lenvatinib: nurse practitioners’ perspective. Presented at: 46th Annual Oncology Nursing Society Congress; April 20-29, 2021; Virtual. Abstract 9403. https://ons.confex.com/ons/2021/meetingapp.cgi/Paper/9403