Fluoropyrimidines in Colorectal Cancer: Past, Present, and Future

Ms. Viele is a clinical nurse specialist in hematology/oncology/bone marrow transplant, and assistant clinical professor in the Department of Physiological Nursing at the University of California, San Francisco (UCSF). She received her BSN and MS from the University of Michigan, Ann Arbor, and is licensed as a registered nurse in Michigan, Missouri, and California.

Carol S. Viele, MS, RN, CNS, has a financial interest/relationship or affiliation in the form of: Speakers’ Bureau, Novartis Inc., Merck & Co., Inc., sanofi-aventis U. S., MedImmune, Inc., & Pfizer, Inc.

The Role of Fluoropyrimidines in Colorectal Cancer Treatment: Past, Present, and Future

Colorectal cancer (CRC) is a significant health issue for the American population. It is the third most common malignancy in both men and women. Because this disease is so common, it has been a research priority to develop new treatment modalities. New agents have been discovered throughout the last decade, and this has led to longer survival and an enhanced quality of life for patients with CRC. In the current treatment armamentarium, there are multiple agents that are used at variable doses and schedules, each having unique toxicities. Using a case-based approach, this program will focus on two of the most common toxicities experienced by patients undergoing therapy for CRC: diarrhea and mucositis, which may lead to significant distress and a decrease in quality of life. Case presentations will illustrate the side-effect profile and pathophysiology of diarrhea and mucositis, along with the most current evidence-based literature to treat and manage them. Nursing interventions and patient education information will also be described.

Nursing plays a unique role in side-effect management because patients will frequently discuss these two side effects with their nurse but will be reluctant to discuss them with the physician due to their fear of treatment being held or permanently discontinued. This program will provide nurses with the most up-to-date literature and treatment information to manage these side effects while allowing patients to continue therapy.

 

Dr. Chu is professor of medicine and pharmacology at the Yale University School of Medicine in New Haven, Connecticut. He received his docter of medicine from Brown University, where he also completed his residency training in internal medicine. Dr. Chu’s research focuses on the design and development of novel treatments for colorectal and other cancers. His studies have provided insights into how tumors become resistant to the effects of chemotherapy. Dr. Chu is the founding editor-in-chief of the journal Clinical Colorectal Cancer.

Edward Chu, MD, has a financial interest/relationship or affiliation in the form of: Consultant, Roche Laboratories, Inc, Pfizer Inc., Bristol-Myers Squibb Company, & ImClone Systems Incorporated.

Case Studies of Fluoropyrimidine Use in Colorectal Cancer: Oncology Nursing Implications for Chemotherapy-Induced Diarrhea and Oral Mucositis

Colorectal cancer (CRC) is a worldwide public health problem with nearly one million new cases diagnosed each year, resulting in approximately 500,000 deaths. In the United States, it is the second leading cause of cancer mortality, and approximately 52,000 deaths will be attributed to this disease in 2007.

Chemotherapy has been the mainstay approach for patients with advanced CRC. For nearly 40 years, the fluoropyrimidine 5-fluorouracil (5-FU) was the primary drug used to treat patients with CRC, and 2007 marks the 50th anniversary of the synthesis of this agent. Within the past two decades—and especially within the past 5 years—significant advances have been made in treatment options. Since the late 1990s, the United States Food & Drug Administration (FDA) approved three new chemotherapeutic agents for the treatment of CRC: irinotecan, oxaliplatin, and capecitabine; and within the last 3 years, it has approved three novel biologic agents: the antiepidermal growth factor receptor antibodies cetuximab and panitumumab, and the antivascular endothelial growth factor bevacizumab.

With the increasing availability of active treatments for patients with metastatic CRC, there are several important issues that must be addressed on a daily basis, including optimal cytotoxic chemotherapy regimen, the role of oral versus intravenous 5-FU chemotherapy as the backbone for combination regimens, continuous versus intermittent chemotherapy, and the integration of targeted therapies with cytotoxic chemotherapy regimens.

Ms. Viale is an assistant clinical professor in the Department of Physiological Nursing at the UCSF. She received her master’s degree in oncology nursing and her post-master’s adult nurse practitioner certificate from UCSF. Ms. Viale has lectured nationally on oncology nursing subjects, authored journal articles on oncology nursing, and presented at local and national Oncology Nursing Society (ONS) meetings. She recently served as the associate editor for nursing education for the ONS Web site and is a member of the editorial advisory board for the ONCOLOGY Nurse Edition publication. Ms. Viale also serves as an expert panel member for the ManageCRC.com Web site, which provides information on CRC for nursing professionals.

Pamela Hallquist Viale, MS, RN, CS, ANP, AOCNP^®, has a financial interest/relationship or affiliation in the form of: Consultant, Institute for Medical Education & Research, Novartis, Inc., and Meniscus Limited; Speakers’ Bureau, Institute for Medical Education & Research, Novartis, Inc., Meniscus Limited, Amgen, Inc., Merck & Co., Inc., & Bristol-Myers Squibb Company.

Palmar-Plantar Erythrodysesthesia and Compliance With Oral Chemotherapy: Case Studies and Management Strategies

Oncology nurses are paramount in the successful management of patients receiving fluoropyrimidine therapy, which is commonly given in the forms of either continuous and bolus 5-fluorouracil (5-FU) or oral capecitabine, a prodrug of 5-FU. By changing the method of administration for 5-FU, the side-effect profile of the drug is also altered. Bolus 5-FU is associated with myelosuppression, diarrhea, and mucositis, while administering the drug in continuous infusion causes palmar-plantar erythrodysesthesia (PPE) or hand-foot syndrome. Oral administration of capecitabine, while associated with myelosuppression, diarrhea, and mucositis, can cause PPE as well, and it is known as a dose-limiting side effect of this form of chemotherapy, necessitating dosage reductions or even interruption of therapy if patients develop greater than a grade 1 toxicity.

Because capecitabine is an orally administered therapy, adherence can be a problem. Historically, adherence to medications in chronic illness runs approximately 50% (Osterberg & Blaschke, 2005). In patients with cancer, one might assume that adherence would be 100% given the seriousness of the diagnosis, however there are clinical trial data showing that patients with cancer are often nonadherent to medication administration.Women on tamoxifen have been shown to have reduced adherence with medication administration, and adherence continues to drop steadily with each year of drug therapy (Partidge, Wang, Winer, & Avorn, 2003). This nonadherence has also been noted with chemotherapy agents such as cyclophosphamide (Lebovits et al.,1990). As the use of oral therapies increases, adherence becomes even more important. Strategies for improving adherence to oral antineoplastic agents have been discussed and oncology nurses should employ them with patients who are prescribed oral therapies. These strategies include reinforcement of patient education, the use of pill counts, calendars, patient diaries, and improved communication (Moore, 2007; Viele, 2007; Osterberg, & Blaschke, 2005). This presentation will discuss background on both PPE and adherence to medications and will use case studies to illustrate management strategies.