Thursday, June 8, 2023
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Nurse Practitioner
Evelyn H. Lauder Breast Center
Memorial Sloan Kettering Cancer Center
New York, New York
This activity has been peer reviewed and the reviewer has no relevant financial relationships.
Nurses - 0.25 ANCC Contact Hour(s) (0.25 contact hours are in the area of pharmacology)
This activity is intended for nurses, nurse practitioners, and physician assistants.
The goal of this activity is that learners will be better able to monitor and communicate with patients and implement practices that will improve adherence to adjuvant therapy for patients with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative EBC.
Upon completion of this activity, participants will:
Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.
Disclosures for additional planners can be found here.
Nurse Practitioner
Evelyn H. Lauder Breast Center
Memorial Sloan Kettering Cancer Center
New York, New York
This activity has been peer reviewed and the reviewer has no relevant financial relationships.
Awarded 0.25 contact hour(s) of nursing continuing professional development for RNs and APNs; 0.25 contact hour(s) are in the area of pharmacology.
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CE Released: 9/26/2022
Valid for credit through: 9/26/2023
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Susan is a 44-year-old, premenopausal woman with no family history of breast cancer. Genetic testing showed she is BRCA-negative. Diagnostic testing and imaging revealed locally advanced breast cancer. Her tumor was determined to be 5.5 cm, located in the left breast. The pathology results showed the tumor was ER+ 90%, PR+ 70%, HER2-negative, Ki-67 22%. Susan underwent neoadjuvant therapy with dose-dense doxorubicin, cyclophosphamide, and paclitaxel (ddAC-T). She also underwent a left mastectomy and axillary lymph node dissection. Staging showed residual disease of ypT3N2. She completed her chemotherapy 3 months ago and radiation therapy 3 weeks ago and has now come to see her nurse practitioner.
Nurse: Susan, it's so nice to see you again! I know we touched base briefly prior to your surgery and radiotherapy. How are you feeling now?
Patient: Well, after chemo, surgery, and radiation I was exhausted, but about a week ago I finally started to feel more like my old self again. Now I am worried I am going to feel sick again.
Nurse: I know – the side effects of those therapies can be tough. We are now entering the next phase of your treatment with endocrine-based therapy.
Patient: Yes, I met with the oncologist, Dr Chambers, and she said I would need a more aggressive therapy than we originally talked about. (looking worried) I was already nervous about the antiestrogen therapy, and now we have to add something more aggressive? I’ve been through so much -- chemo, surgery, and radiation. Is this really necessary?
Nurse: I understand your concerns, you have been through a lot already! Your breast cancer is considered high risk, both at presentation and the amount of residual disease at the time of surgery, so we need to do everything possible now to lessen the chance of the cancer coming back. That is why this part of the adjuvant therapy, which includes antiestrogen therapy and a newer targeted therapy, is extremely important.
Patient: OK -- but didn't the surgeon get all the cancer out during surgery?
Nurse: Surgery does remove the primary tumor and lymph nodes that remained after your chemotherapy. However, microscopic cells that can't be detected may have escaped the breast and lymph nodes. These cells can plant themselves and grow elsewhere in your body (such as in other organs), so the goal of treatment at this point is to try and starve these cells of estrogen to decrease the probability of this occurring.
Patient: That sounds a bit reassuring -- knowing that I have options to keep my cancer from returning; but what medicine will I be given now? Are you sure it will work? And ... what are the side effects? I'm scared that this new treatment might make me feel worse given what I've already been through with prior treatments.
Nurse: Regarding side effects of treatment, let's discuss that shortly.
Karen Drucker, RN, NP: Hi. My name is Karen Drucker and I'm a nurse practitioner on the Breast Medicine Service at Memorial Sloan Kettering Cancer Center. Let's begin with a brief overview of hormone-positive, HER2-negative, early-stage breast cancer. Hormone positive indicates the tumor has a certain percentage of estrogen and, often, progesterone receptors, which indicate that estrogen is fueling the growth and potential spread of the cancer. HER2-negative means there is not an over-amplification of HER2 new proteins on the tumor and therefore not a driver of the tumor's growth.
There are several factors associated with risk for recurrence, sometimes called poor prognostic indicators. Hormone receptor expression level and a lower percentage of estrogen positivity can indicate more aggressive disease: larger tumor size, higher tumor grade, nodal involvement, lymphovascular invasion, higher Ki-67 level. There are also gene expression assays such as Oncotype and MammaPrint. Oncotype, a 21-gene assay recurrent score, helps identify chemotherapy sensitivity; less frequently used though when there are multiple high-risk factors evident.
Adjuvant endocrine therapy with tamoxifen or an aromatase inhibitor with or without ovarian suppression is the standard of care for hormone-positive breast cancer. Adjuvant chemotherapy is a standard of care for hormone-positive breast cancer with higher risk features and/or a high Oncotype-DX recurrent score. Recent data, based on 2 different practice changing clinical trials, have been added to the NCCN compendium. Data from the monarchE trial identified high-risk patients who will benefit from adding 2 years of abemaciclib to their endocrine therapy.
They define high risk as ≥ 4 positive lymph nodes or 1 to 3 lymph nodes with 1 or more of the following: grade 3 disease, tumor size > 5 cm, or Ki-67 ≥ 20%. Data from the Olympia trial identified women with similar high-risk disease but also have a BRCA1 or 2 germline mutation. This showed benefit from adding 1 year of olaparib PARP inhibitor to their endocrine therapy.
Let's rejoin Susan and our oncology nurse practitioner as they discuss concerns about treatment-related side effects.
Nurse: Let's talk about the most common side effects you may experience from this therapy. The therapy includes ovarian suppression, endocrine therapy, and the targeted therapy, abemaciclib, and each of these therapies may cause certain side effects. With ovarian suppression and endocrine therapy, the side effects can overlap; you might experience hot flashes, night sweats, vaginal dryness, joint aches, and mood changes. With abemaciclib, some of the more common side effects include diarrhea, nausea and vomiting, low white blood cell counts, and fatigue.
Patient: Ugh ... You mentioned diarrhea. I currently work as a retail manager, and I have to interact with both vendors and customers on a daily basis -- I can’t afford to be in the bathroom all the time at work ...
Nurse: That is an understandable concern. We will monitor that closely. You should let us know right away if you have problematic diarrhea.
Patient: What can we do if diarrhea DOES become a problem for me? What about nausea? I had some trouble with that during chemo as well.
Nurse: There are several strategies we can try. You will leave here today with an initial plan on how to deal with diarrhea, the most common, but often time limited, side effect. You should let us know right away if you have diarrhea that is not controlled by the loperamide schedule or if you develop subsequent constipation. We will work together to adjust the loperamide dose until you feel adequate relief. There are additional medicines we can use if loperamide is not effective. We would also ask you to increase your fluid intake to prevent dehydration and improve electrolyte balance by eating foods like bananas. Diarrhea is reversible and generally improves within the first few months. As for nausea, we can prescribe medication to help ease this quickly. You will leave today with a prescription to have on hand. It’s also important to remember, every individual responds differently to treatment. You may have very few side effects, but if you do have any issues, our cancer care team will work with you to address them promptly.
Patient: Thank you for acknowledging my concerns -- I feel a bit more at ease. Now, will I be taking these medicines intravenously like I did for chemotherapy?
Nurse: (smiling) No, other than the monthly ovarian suppression injection, these medicines are oral -- both will be taken every day by mouth, with or without food.
Patient: That sounds great! So, I'll return to see you in about 2 weeks for my next bloodwork and follow-up, right?
Nurse: Yes -- please let our team know if you have any concerns or questions regarding your medicines and we can discuss them further. I look forward to seeing how you are coming along next time we meet.
Karen Drucker, RN, NP: Let's discuss some factors related to non-adherence. Unpleasant side effects, forgetfulness, competing priorities, financial toxicities, polypharmacy, co-morbidities, poor relationship with the healthcare team, and lack of trust in science. How should you best approach these? Side effects and forgetfulness are two common causes of non-adherence. Keep in close contact with patients, especially in the first few months of a new therapy. Monitor the schedule when abemaciclib or olaparib are used in the adjuvant setting. Ensure patients are up-to-date with refills. Ask them if they are taking the medication as prescribed at every encounter.
Ensure the patient has been well educated regarding potential common adverse events. The education should be informative but not overwhelming. The education should be ongoing when appropriate.
The most common adverse events associated with the addition of abemaciclib are diarrhea, abdominal cramping, nausea, vomiting, fatigue, neutropenia, and anemia. The most common adverse events associated with the use of olaparib therapy are nausea, fatigue, anemia, neutropenia, vomiting, and headache. Ask about side effects at every visit. Encourage patients to call for bothersome side effects between visits. Reinforce adequate hydration, exercise, healthy eating, and use of anti-diarrheals and anti-emetics as needed.
Susan follows up with her nurse practitioner after starting abemaciclib and letrozole therapy. She discusses her concerns and some bothersome symptoms she's been experiencing that have interfered with her adhering to a strict medication schedule.
Nurse: Hello, Susan! I'm glad to see you back -- How are you feeling?
Patient: To be honest ... the medicines are taxing my energy and its tiring having to constantly take all these medicines back-to-back ... day-to-day. Plus, with my busy schedule at work, it’s hard to remember which medicines to take and when ... so I might have missed several doses since we last met ...
Nurse: Yes, that is understandable. However, it's important to maintain your medication schedule as prescribed so we can get the best possible outcome. Remember, the goal of adjuvant therapy is to decrease the risk of your breast cancer coming back.
Patient: Yeah ... on top of feeling fatigued all the time, I got too busy and forgot to go to the pharmacy to pick up my last refill.
Nurse: That would explain why your current white blood cell counts are also near normal -- given the medicines you are taking -- we expect to see a little dip in your white blood cell levels, since it’s a common side effect of abemaciclib therapy.
Patient: Well, what can I do to stay on top of taking my medicines, but also feel good while doing so?
Nurse: You could set an alarm or use a phone app to remind you of when you need to take your medicines. We can make you a calendar to check off your morning and evening medication doses. It is also important to eat healthy and get adequate sleep -- and daily exercise can help decrease fatigue and give you more energy to perform daily activities. You might also consider acupuncture to manage side effects as it has been beneficial for some. What symptoms have been the most bothersome for you since starting your new treatment?
Patient: I've been having diarrhea as you mentioned might happen -- I had been experiencing about 4 to 6 watery bowel movements a day, so I started taking 1 loperamide in the morning and that seemed to help a bit, but I still have intermittent episodes during the day.
Nurse: Thanks for letting me know – let’s try adding another dose of the loperamide in the afternoon and see if that will help you get some more relief but if it causes constipation, you should hold and call us for guidance. Hopefully the gastrointestinal (GI) discomfort will subside, or we will get you on the right balance of antidiarrheal to keep you feeling regular.
Patient: Thank you! Hopefully the diarrhea and fatigue will continue to improve. I'll set a reminder on my phone right now to help me remember to take my medications every day.
Nurse: Great! We will work as a team to keep you in good shape -- we will see you in another 2 weeks or so for your next follow-up visit.
Patient: Great, thanks again.
Karen Drucker, RN, NP: There are multiple predictors of adherence and nonadherence. Discussing adherence at every encounter is a helpful tool. Utilize compassionate communication strategies when checking compliance. Try not to be judgmental. For example, "Susan, are you taking the letrozole every day and abemaciclib twice a day, every day, without a problem?" Or, "Susan, let's review your medication regimen to make sure we have the dosing and schedule correct."
Addressing and mitigating adverse events as well as removing barriers, when able, can add to therapy adherence and is an important nursing role. In summary of today's program, the nurse has an essential role in monitoring and communication with patients during their breast cancer treatment. Today we highlighted high-risk, early-stage, hormone-positive, HER2-negative breast cancer treatments. As discussed, there are several prognostic factors indicative of high-risk, early-stage breast cancer. This includes tumor size, tumor grade, nodal involvement, lymphovascular invasion, and Ki-67 level.
Abemaciclib can be added to adjuvant endocrine therapy to improve outcomes in high-risk, hormone-positive, HER2-negative, early-stage breast cancer. Alternatively, olaparib should be considered for this high-risk population if they have deleterious BRCA1 and/or BRCA2 mutations. When a targeted agent like abemaciclib or olaparib are added to endocrine therapy, patients need to be monitored more frequently to ensure adherence and safety and to manage side effects, with a goal of helping patients maintain their quality of life. The nurse plays a critical role engaging patient's adherence and educating the patients on strategies to remain compliant and resolve adverse events associated with therapy.
This is done by addressing the patients with more frequency, if needed. For instance, monitor patients for burdensome side effects at each follow-up and finding interventions to improve these when possible. Review periodic lab tests to identify potential blood count abnormalities needing intervention, and by providing ongoing supportive care for unwanted symptoms and complications. This can be done by using supportive medications such as antidiarrheals and antiemetics, and finally, by encouraging modifiable lifestyle strategies such as exercising, healthy eating habits, working towards or maintaining an ideal body mass index (BMI), and getting adequate sleep.
This transcript has been edited for style and clarity.
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