There is only one “king of the road” when it comes to dealing with the adverse side effects of oral cancer drugs, and that is not the healthcare professional, according to Christine B. Boers-Doets, MSc, of the Netherlands Leiden University Medical Center, author of The TARGET System, and creator of the 7 Pillars of Ultimate Drug Success formula. She discussed this topic at the recent ESMO International Consensus Conference for Advanced Breast Cancer in Lisbon, Portugal.
“There’s a human behind the patient, and he can tell us what he needs,” she said. “He’s really the expert in the field.”
Shifting the Burden of Medication Administration
As many drugs have shifted from intravenous delivery in the infusion center to oral use at home, so has the burden of medication adherence and administration. In the home setting, patients and other members of their support network bear the responsibility of proper medication use.
In the wake of this shift, Ms Boers-Doets stressed the importance of dealing with oral drug administration and side effects as an interdisciplinary team, rather than letting the responsibility fall solely to the oncology nurse.
“We are trained for years to be experts in our fields, but when patients in life-threatening situations are responsible for administering their own treatments, they have to become experts in 1 minute,” she said. “This is very challenging, so we need the support of the entire team, not only physicians and nurses, but also pharmacists and pharmaceutical companies.”
After initiating treatment with a targeted therapy or immunotherapy drug, Ms Boers-Doets encourages waiting only 48 hours until checking in with the patient to evaluate whether the treatment was effective.
“It makes no sense to wait 3 to 4 weeks to get a patient back in your office and ask how everything is going,” she said. “If it doesn’t work within 48 hours, it won’t work later.”
Avoiding Common Mix-Ups
Empowering the patient is a vital component of managing adverse events, Ms Boers-Doets stressed. Patients can take steps to make their skin and mucosa more resistant to these events; applying a greasy cream is very effective (thick enough so that an opened pot of the cream turned upside down would not spill out), and its effects can be intensified when covered with cling film. “You might not think this is very important, but it is,” she stated. “If you make the skin more resistant, fewer side effects will appear.”
Oral Side Effects
Mouth rinses are vital to managing adverse events such as stomatitis and mucositis.
“We’ve learned that it’s only important to rinse the mouth, and it doesn’t matter with what. Plain water is okay,” Ms Boers-Doets advised. The more side effects that appear in the oral cavity, the more often the patient should rinse his or her mouth.
She stressed the importance of understanding the differences between oral mucositis and stomatitis. “Oral mucositis is an adverse event only associated with chemotherapy and radiation therapy,” Ms Boers-Doets noted. “So we cannot use this term when referring to side effects of targeted, hormonal, or immunotherapies.”
Other Adverse Events
Hand-foot syndrome and hand-foot skin reactions are often mixed up in the literature as well, but should be treated very differently, she pointed out. And the same goes for diarrhea; according to Ms Boers-Doets, 90% to 95% of patients who think they have diarrhea actually only have mushy or loose stool, and should be treated accordingly. “Managing side effects is actually very easy,” she said. “You just have to know what you’re facing.”
Remember Your TARGET
Ms Boers-Doets encourages the use of the pneumonic TARGET—a systematic 6-step approach to tackling adverse events and continuing therapy as planned.
This strategy can be applied in day-to-day practice and in clinical trials.
The steps of this strategy are roughly outlined using the pneumonic TARGET:
- Term—Using the right diagnosis of the adverse-event subtype
- Assess—Assessing the signs and symptoms of the adverse event and its potential impact on a particular patient
- Report—Reporting details of an adverse-event subtype to inform an appropriate intervention
- Grade—Using appropriate grading tools to guide you to the best treatment option for a particular adverse-event subtype
- Evaluate—Determining whether you are on the right path with your measures or if you are approaching the wrong target
- Tackle—When the previous steps have been applied, tackling the adverse event becomes the easiest step in adverse-event management.
“You have to follow all 6 steps, and when you do, the tackling of adverse effects is so easy,” Ms Boers-Doets said. “Everyone can do it.”
“I can go to as many conferences and read as much literature as I can, but the real answers can only be found in the human behind the patient,” she continued. “I used to inform, inform, inform, but now I ask, ask, ask, and I achieve so much more.”