The fourth edition of the Oncology Nursing Society (ONS) Chemo-therapy and Biotherapy Guidelines and Recommendations for Practice weighs in at almost 500 pages and has some important updates since the last edition was published. At the ONS 39th Annual Congress, Martha Polovich, PhD, RN, AOCN, of Georgia State University in Jonesboro, and MiKaela Olsen, MS, RN, AOCNS, of Johns Hopkins Hospital in Baltimore, Maryland, reviewed important changes in the new guidelines.
The guidelines are available in print and online through ONS and in an electronic format for iPad users through iTunes. Also, ONS offers an online course about the guidelines at https://www.ons.org/chemo-provider-course/register-or-renew. ONS is currently fine-tuning the online course to make it more user-friendly.
A major change to the guidelines is reorganization of the entire content into chapters based on similarities in content.
“We put like content together,” said Polovich. “This is a big improvement.”
There are now 11 chapters in the updated guidelines. Chapter 5 focuses on nursing considerations in cancer treatment and includes all of the safety information in one place; this chapter covers ethical and legal issues, American Society of Clinical Oncology and ONS chemotherapy administration safety standards, patient safety, and safe handling and disposal of hazardous drugs.
Chapter 10 focuses on posttreatment care and incorporates monitoring; this chapter covers survivorship, late effects of treatment, collaborative management, nursing assessment, screening recommendations, and patient education.
New additions to the guidelines include information on chemotherapy sequencing as well as dosing in obese patients, Polovich continued. The addition of sequencing information is important, because the order of drug administration may affect the toxicity or clinical benefit of chemotherapy. A sequencing table is included. Chemotherapy dosing in obese patients is another topic that needs clarification. The updated guidelines state the following:
“If you don’t use full weight-based doses you may be compromising survival. This is the first time this precaution appears in the guidelines,” Polovich told listeners.
Olsen cited all the new drugs added to the guidelines: 10 new chemotherapy agents, 13 new small molecules, 6 new monoclonal antibodies, and 3 new other biologic therapies. New chemotherapy agents are bendamustine, cabazitaxel, clofarabine, decitabine, eribulin, nelarabine, omacetaxine, pralatrexate, romidepsin, and vorinostat. The small molecules are axitinib, bosutinib, cabozantinib, carfilzomib, crizotinib, everolimus, pazopanib, regorafenib, ruxolitinib, vandetanib, vemurafenib, vismodegib, and zivaflibercept. New monoclonal antibodies are ado-trastuzumab, brentuximab, denosumab, ipilimumab, ofatumumab, and pertuzumab. The new “other” biologics are plerixafor, pomalidomide, and sipuleucel-T.
Another change pertains to labeling. In the past, some red labels listed a route that should not be used. This was confusing, and some healthcare providers may mistakenly see only the route mentioned in the labeling, not the “DON’T” part. So now labels for drugs that should not be given intrathecally will be required to state “FOR INTRAVENOUS USE ONLY. FATAL IF GIVEN BY OTHER ROUTES.”
The guidelines also state that vincristine and other vinca alkaloids should be administered intravenously using a minibag. Olsen said she was resistant to this change at first, but not one single extravasation has occurred since they switched to minibags.
“Vinca alkaloids and bortezomib can be fatal if administered in a route other than IV. Go back and look at your labels,” she told listeners.
Another change is information on intrathecal (IT) medications. These should never be administered in the same room as intravenous (IV) chemotherapy, she said. IT drugs should be given on different days and in different settings than IV medications. Only healthcare providers with specialized education should prescribe, prepare, and administer IT chemotherapy. Orders for IT drugs should be written on a separate form from those for IV chemotherapy, and institutions should have a list of drugs that cannot be be given intrathecally. Furthermore, IT drugs should be prepared as close to the time of administration as possible. They should be packaged, transported, and stored in designated containers separately from IV or other drugs. They need to be clearly labeled “FOR INTRATHECAL USE.”
“Conduct a timeout immediately before IT chemotherapy administration and a 2-person check with a chemotherapy-competent nurse,” Olsen stated.
A new and simplified rating system for emetogenicity of drugs is included in the guidelines as follows: high emetogenicity, 90%-100%; moderate emetogenicity, 30%-90%; low emetogenicity, 10%-30%; and minimal emetogenicity, <10%. Also, the guidelines include a new table on the emetogenicity of oral medications as well as treatment guidelines for each level of emetogenicity. Fosaprepitant is the only new antiemetic agent included in the guidelines.
“These 500-page guidelines are not written by one individual. Many contributors wrote specific chapters. Then these evidence-based guidelines go to field reviewers. This is a project that comes out every 5 or 6 years. We thank everyone involved,” Polovich said.
Polovich, Olsen, and Kristine B. LeFebvre, MSN, RN, AOCN, served as editors of the fourth edition of the ONS Chemotherapy and Biotherapy Guidelines and Recommendations for Practice.
Reference Olsen M, Polovich M. 2014 chemotherapy and biotherapy guidelines: here’s what’s new. Presented at: Oncology Nursing Society 39th Annual Congress; May 1-4, 2014; Anaheim, CA.
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