The Changing Kidney Cancer Treatment Landscape. Part 2. Changing the Role of the Oncology Nurse

The past 5 years have ushered in a new era in the treatment of kidney cancer, and new medications are giving patients more options than ever before. In addition, the traditional end points in oncology drug development, such as survival and tumor response, are changing when it comes to this tumor type. The goal of therapy now is to improve symptomatic and functional ability in patients with renal cell carcinoma (RCC).

Experts in this area say kidney cancer is becoming more of a chronic disease, similar to diabetes, and as such is managed in some of the same ways. For this very reason, patient reported outcomes (PROs) are becoming increasingly important to capture treatment benefits.

"The oncology nurse's role is huge in PROs," said David Cella, PhD, an associate director for cancer prevention and control at Northwestern University, Chicago. "Physical, functional, social, and emotional factors should be taken into consideration while assessing the general well-being of RCC patients."

He said that because oncology nurses have their fingers on the pulse of patients' needs, they are ideally suited for assessing PROs. Cella, a clinical psychologist specializing in cancer care, said medical interventions largely focus on symptom relief and the maintenance of physical functioning. Pain and emotional stress can be equally important, however, and that is where oncology nurses are now playing an ever more critical role.

Many RCC patients who are treated for metastatic disease experience problems with physical, social, and mental functioning. They may experience sleeping problems, lack of appetite, nausea, vomiting, and shortness of breath. Cella said oncology nurses can play a pivotal role in formally assessing these issues.

"Symptom patterns are vital and can signal tumor responses and disease progression," Cella said. "It is very important to measure symptoms and the patients' quality of life as they go through treatment. You need to measure these things, and there need to be standards." At his institution, Cella and his colleagues use a 15-statement type of evaluation that asks questions such as, "Do you lack energy?" Using this tool and similar ones that are available, it may be possible for nurses to know when treatment regimens are failing or need to be adjusted.

"The treatment options are unprecedented, and there has never been a better outlook," said Cella in an interview with The Oncology Nurse. "Nurses and pharmacists have an ever-increasing role in helping with oral medication compliance needs. Managing side effects and adjusting doses when necessary are some of the new roles that go beyond the old infusion times. There are daily medicine requirements, and the patients may have concerns arising between visits."

New agents require new management
New oral agents are changing how RCC patients are managed and the role of the oncology nurse. These new agents work through different mechanisms of actions, and each comes with its own side effect profile. Furthermore, these side effects may manifest differently in individual patients.

"Doctors may treat the disease, but it is the nurse who is the one who sees the patients, and it is critically important that oncology nurses know the side effects of each agent and how to manage each of the side effects," said William Bro, the CEO of the Kidney Cancer Association.

He said today RCC is very much like diabetes. Both conditions can be manageable, chronic illnesses that can impair a person's quality of life. With proper management, however, both illnesses can be controlled while maintaining a high quality of life.

"We have entered into a whole new era in kidney cancer. People think they are cured or not cured, but it would be better if they looked at it like it was a chronic condition that is managed like diabetes. Today, no one thinks of diabetes as a deadly disease, but that was not the case decades ago. That is the point where we are now headed," Bro said. "Oral agents are a tremendous new convenience. They are inherently better for everyone. We are moving into the area of personalized medicine, and so there needs to be an expertise and a familiarity by the nurse."

Bro said it is important that nurses address three areas of well-being that may be impacting the lives of patients with RCC. The three areas are emotional, physical, and practical. Emotional issues may include isolation and depression. Physical issues may involve symptoms, medication side effects, and functioning. Practical issues may in volve employment, financial problems, and end-of-life care.

He noted that it is not uncommon for RCC patients to isolate themselves, and this can often lead to depression, and "when this happens, the support system can quickly disintegrate." He said this common problem is one that nurses can detect and manage.

Bro added that it is important to address all forms of care aimed at supporting quality of life. This may encompass therapy, support groups, patient education, palliative care, developing nutrition plans, and physical therapy. He noted that nurses can play a key role in helping with referrals for these types of services. "Many people don't realize all the re sources that are available," Bro said. Another issue that nurses may need to discuss with their patients is alternative therapies they may be taking. Vitamin use is another area of concern. Some cancer patients may be taking megadoses of vitamins in the hope that it will help with their disease. Studies suggest, however, that taking megadoses of vitamin A or vitamin E may not be in the patients' best interest. In addition, megadoses of vitamin C can be hard on a remaining kidney and cause the formation of kidney stones in patients with RCC, most of whom have had a nephrectomy and have only one functioning kidney.

In just the past few years, PRO assessments have grown in credibility and, Cella said, in the area of kidney cancer it, is an assesment that may make a dramatic difference in terms of morbidity and mortality.

"What patients say has a way of defining the clinical landscape," said Cella. "It can be the most important factor in how someone does and whether they survive. Patients need to be brought into the clinical picture more."