BERKELEY, CA (UroToday.com) - Nurses represent an important interface between the patient and the physician.
As such, it is important that they understand the side effects associated with targeted therapies, such as sorafenib therapy, and know how to manage them effectively in order to encourage patient adherence to treatment and maximize clinical benefit. In recognition of this, a small group of European nurses with experience in treating patients with renal-cell carcinoma (RCC) and hepatocellular carcinoma (HCC) with targeted agents, as well as chemotherapies, convened to discuss the currently available strategies for managing sorafenib-related side effects. We concluded that there is currently a gap in the literature regarding effective management of these side effects. Thus, the aim of our article was to provide an overview of effective management strategies to assist nurses caring for patients receiving sorafenib. These management strategies were based on:
- our collective clinical experience,
- findings from a systematic literature review of management strategies for sorafenib-related side effects using PubMed and the Cochrane library (search was up to January 2010 and included a broad range of relevant, adverse events [AE], as well as therapy- and disease-related search terms),
- and (due to the paucity of publications in this field) reference to the wider literature for targeted therapies, in general, and for similar side effects experienced during conventional anti-cancer therapy.
Hand-foot-skin reaction (HFSR), diarrhea, fatige, rash, and mucositis are considered the most commonly reported, sorafenib-related side effects, which appear to fall into two general categories: "acute" and "delayed" onset. Although most sorafenib-related side effects present as acute onset, diarrhea may fall into both categories.
Strategies for managing each of these side effects were identified in the literature, although most reports were experience rather than evidence based. For HFSR, both prophylactic and symptomatic management strategies were identified. Symptomatic treatments included the use of emollients/creams, which, in our experience, are commonly used in clinical practice, together with cushions and appropriate footwear to reduce symptom severity. Use of emollients/creams has also been proposed as a preventative strategy.
- HFSR: A series of dose reductions, interruptions, and re-escalations to manage HFSR have also been published.
- Diarrhea: Vigilant assessment, monitoring, and patient education were considered important elements of effective management, based on findings from the literature and our clinical experience. In addition, symptomatic treatment strategies included the use of loperamide and/or diphenoxylate, as well as dietary modifications.
- Fatigue: As fatigue is a subjective symptom, effective management includes ruling out other conditions such as anemia, hypothyroidism, and depression. Patient diaries also allow nurses to closely assess and monitor fatigue.
- Mucositis: A range of symptomatic techniques to manage mucosistis were identified in the literature, including ice chips, topical lidocaine or xylocaine, BMX solution, rincinol, nystatin solution, or clotrimazole troche. However, based on our clinical experience, mucositis is generally mild and can be managed by maintaining good oral hygiene, although dose delays/reductions may be indicated for occasional episodes of grade 3 mucositis.
Taken together, findings reported in this article indicate that there are effective strategies to manage the most common sorafenib-related side effects, which can be utilized to improve patient tolerance and adherence to therapy in order to maximize clinical benefit. However, the current lack of data from controlled clinical studies highlights the need for further research in this area.
Kim Edmonds, RN., Et Al., as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Strategies for assessing and managing the adverse events of sorafenib and other targeted therapies in the treatment of renal cell and hepatocellular carcinoma: Recommendations from a European nursing task group - Abstract