Discussion Board

We are so excited to have you! Tell us a little about yourself--where you work, why you're attending, etc. :)

Hello! 

We are happy to announce that the ONS Bridge Roundtable Sessions from Wednesday, September 11th are now available under the recorded sessions tab.  As a reminder, these sessions do not provide NCPD.  

Enjoy! 

Good Afternoon everyone! 

Thank you again for your attendance in the Radiation Oncology 101 session. We were not able to get to the questions since we ran out of time, but Dr. Denniston graciously answered them and provided additional information below. 

What resources for skin care algorithms to guide treatment and interventions related to radiation site toxicity do you use in your organization?

Is there a standard of care for treatment of Radiation "burns" example creams, etc?

There are many different skin care products and recommendations. There has never been one single agent proven to be significantly better than others. This has led to guidelines typically being more broad/general and recommending bland, topical emollients/moisturizers. Commonly used products include aquaphor, calendula based skin creams (ie miaderm), but again, none is clearly superior. There is recent data that supports the addition of topical corticosteroids to standard emollient based skin care to help minimize acute reactions and I commonly use moderate strength corticosteroids (ie 1% betamethasone valerate cream) in my practice.

Specifically in our practice, we recommend transitioning to a mild/moisturizing soap in the area of treatment during the course (ie dove sensitive skin). We then start daily or BID emollient (most commonly aquaphor, but with allowance for patient preference). I add topical corticosteroids with any onset of pruritic or tender dermatitis. In the setting of more pronounced dermatitis, specifically moist desquamation, we alter skin care to include protective dressings (ie mepilex), silver sulfadiazine/zinc oxide, and saline soaks, which help keep the treatment field debrided and clean. There is a lot of room for individual provider and patient preference with these general strategies.

For adjuvant RT, how is the GTV determined/measured when the actual tumor was already removed?

In the setting of adjuvant treatments you are exactly correct. Since the tumor has been removed, there is no “GTV” to speak of. Oftentimes, we use the concept of a pre-operative or “virtual” GTV based upon pre-surgery imaging to help identify the operative bed. Also, post treatment imaging is crucial in helping define the surgical site and any residual areas at risk. Finally, clips left at the time of surgery and close collaboration and discussion with our surgical colleagues is also vitally important to help identify the highest risk regions and define post-operative CTVs.

When nurse navigator is doing initial intake/assessment for a patient with prior radiation (e.g., recurrence, new primary cancer), what are the key two or three things the radiation oncologist would want to know about the patient and/or prior treatment?

I think the most important data in this situation are as many specifics from the prior treatment as possible. The prior treatment site, dose and fractionation used, and how long.

ago this treatment took place are all crucial pieces of information, but often times not available to a nurse navigator. Fortunately, in the modern times of computerized planning and fast internet speeds, DICOM treatment data can often be shared between departments. This allows for direct review of prior radiotherapy plans and dosimetry data AND allows us to overlay the prior treatments on current patient imaging to best quantify any potential overlap, and assess the safety of any proposed re-irradiation.

Is hair loss common with radiation?

Hair loss is common with radiation, but only in the treated field. For example, head and neck radiotherapy can cause facial hair loss, breast cancer radiation can cause axillary hair loss, and pelvic radiation pubic hair loss.

Is there a life max of radiation treatment people can get? Is there any risk to the family's regarding radiation exposure?

Limits on lifetime radiation exposure are imposed by the tolerance of the tissues in the region of treatment. The traditional mantra was that “once an area is irradiated it can’t be treated again.” This concept is much more nuanced with modern technology and understanding, and re-irradiation is much more common, but remains a much more complicated situation.

Are other types of radiation, besides thoracic, affected by concurrent immunotherapy?

This is very site specific.

We have data from the breast cancer population that demonstrates no increased risk of toxicity with concurrent radiation and pembrolizumab. Pembrolizumab for Early Triple-Negative Breast Cancer | New England Journal of Medicine (nejm.org)

A recent study in head and neck cancer (Avelumab plus standard-of-care chemoradiotherapy versus chemoradiotherapy alone in patients with locally advanced squamous cell carcinoma of the head and neck: a randomised, double-blind, placebo-controlled, multicentre, phase 3 trial - PubMed (nih.gov) demonstrates no increased toxicity risk, but no improved efficacy with the addition of avelumab to standard chemoRT.

In cervical cancer, a recent study shows improved progression free survival with combined pembrolizumab + chemoRT. Pembrolizumab or placebo with chemoradiotherapy followed by pembrolizumab or placebo for newly diagnosed, high-risk, locally advanced cervical cancer (ENGOT-cx11/GOG-3047/KEYNOTE-A18): a randomised, double-blind, phase 3 clinical trial - PubMed (nih.gov)

The data in this space continues to grow and evolve due to the widespread addition of immunotherapy in the treatment paradigm for many malignancies.

With hospitals having more stringent requirements for pRBC transfusion, how do you manage patients receiving concurrent chemo/RT? Oxygenation is definitely decreased with Hgb below 8. Many institutions will not transfuse unless Hgb is less than 7.

This is an excellent question. There is data in both the head and neck and cervical cancer populations specifically that outcomes are worse for patients with anemia during treatment. Impact of tumor hypoxia and anemia on radiation therapy outcomes - PubMed (nih.gov) This is a good editorial.

However, there was a randomized trial that attempted to correct anemia through transfusions for cervical cancer patients, which did not show clinical benefit despite correction of anemia.

This interplay remains very complex and controversial, and the very strict transfusion thresholds used by many US healthcare systems now do make this even more difficult.

What is a radiation treatment "boost" and why is it useful in some but not other breast cancer patients?

We use the term “boost” in radiation to describe a location/site receiving higher dose treatment than others. I do not know where this term came from and have had many patients take issue with the term over the years, but it has been common parlance as long as I have been practicing. We use ‘boost” treatments, both concomitantly and sequentially in a number of different situations.

Specifically for our breast cancer patients treated with breast conserving surgery and radiation, lumpectomy bed boost treatments have been shown to improve local control outcomes. To my knowledge, the best study evaluating this is from the EORTC (Whole-breast irradiation with or without a boost for patients treated with breast-conserving surgery for early breast cancer: 20-year follow-up of a randomised phase 3 trial - PubMed (nih.gov). The improved control comes at the risk of worsened chronic breast fibrosis. 

Due to the modest benefit in most women with low/standard risk breast cancer, boost therapy is not recommended for everyone.

We give a lot of chemo/XRT for head and neck. How soon before/after radiation is ideal for the chemo to be given?

I had to look this one up. To my knowledge the best investigated drug is cisplatin (pertinent to head and neck cancer as in the question). The highest concentrations of cisplatin are immediately after infusion, so, ideally, radiation would start within 1 hour post-infusion. Such tight timing is often not feasible in the real world, but the consensus “best practice” seems to be that cisplatin and RT start on the same day, with the chemo first.

There are also theoretical radiation biology advantages to starting treatment on Monday versus other days of the week, as this allows for 5 fractions in a row prior to a weekend “break.” This allows for shorter overall treatment time and helps to counter accelerated repopulation (as does the addition of cisplatin to RT).

Both the exact timing of chemo and RT, and the superiority of Monday versus other day starts are theoretical optimizations, without strong/firm data.

Thank you for the amazing questions, we very much appreciate your active participation and questions submitted throughout the session! 

Hello! We had such an engaging session, and so we weren't able to get to the questions. Here are the questions and answers from our expert, Colleen Erb. 

1. Once AML is diagnosed, how quickly would you want a patient to get a bone marrow transplant if that’s the best treatment option?We would consult the transplant team when they start the first cycle of therapy so they can be seen and start the work-up for HCT. Ideally, if the patient achieves an MRD- CR after cycle 1, we would proceed to transplant right away to have the best chance of long-term remission. We really like patients to be MRD- before going to transplant, so if that takes more than one cycle, they will at least have a work-up and we would proceed to HCT as soon as they achieve that MRD-status.2. Is the post-transplant sorafenib lifelong or just for a finite period?It is given for 24 months total (from the beginning of maintenance which is usually started within 3-6 months after transplant)3. Can you talk more about oral azacitidine? I have never heard of it. We give IV or SC.For induction therapy, we use IV or SC. Oral azacitidine is only used in certain circumstances. For maintenance, either after induction therapy - patients ≥55 years with AML with intermediate or adverse risk who were not felt to becandidates for HCT. Most of the patients in the studies received at least 1 cycle of consolidation prior to starting oral azacitidine. It is also used for maintenance after HCT. It is not used for induction/consolidation therapy.4. If the pediatric trials have been so successful why don’t adults mirror with additional phases of therapy such as interim maintenance (1 and 2) and delayed intensification?We do – in those who are eligible for the AYA regimens they receive almost the exact pediatric regimens (tailored dosing to adults); in those > 40 years old – there are still regimens that include remission induction, consolidation, interim maintenance, and delay intensification, they are just structured slightly differently from the pediatric regimens and the dose/drugs are slightly different for adults and older adults, but they still include multiple phases.5. You may have already said this but can you tell which treatment is given for CNS prophylaxis in ALLAlmost all patients receive intrathecal methotrexate and/or cytarabine during induction and consolidation therapy for ALL for CNS prophylaxis. The timing and dosages are a little dependent on the regimen being used, but those 2 drugs are the mainstay of therapy for CNS prophylaxis.

For those that attended the session USP 800 and Best Practices for Safe Handling of Hazardous Agents, Kerri and Susie have answered the remaining questions. Please see below. 

These are all great questions. We would recommend everyone check out the ONS Safe Handling of Hazardous Drugs Learning Library and the Safe Handling of Hazardous Drugs (4th ed.) for a deeper dive into this information.

1. Have had chemo spills. The question was posed when the room is releasable to housekeeping. according to what i could understand is that it was once there were no moist surfaces. How much cleaning does nursing do. walls, windows, cabinets, we clean bed and rails, night table, sink. the obvious spill is absorbed. is there a substance that renders the site of spill inert? but when is a room releasable?

• This is a great question with a lot of nuance to it. Every organization will have their own policy regarding who are the individuals designated to perform hazardous drug cleaning. This might include nursing, pharmacy or hazardous material response teams. In general, the areas recommend to be cleaned would involve any surfaces that were contaminated. So if the walls or windows were involved in the spill, those areas would be cleaned, but if the spill was contained to the floor, then that area of the floor would be cleaned as part of the spill. As far as agents to be used for cleaning, “a bleach solution has been shown to be the most effective of readily available cleaning agents”, as long as the surface can tolerate bleach (p.77, Olsen, M. & Walton, A. (Eds.). (2024). Safe handling of hazardous drugs (4th ed.). Oncology Nursing Society). If you were able to remove patients from the room/area, the room would be able to be used again once the area has been cleaned with the bleach/detergent, and then rinsed with water several times. (Olsen, M. & Walton, A. (Eds.). (2024). Safe handling of hazardous drugs (4th ed.). Oncology Nursing Society)

2. We use a yellow card we hang outside the room to indicate precautions when a patient is receiving chemotherapy. What does the alert in the electronic medical record look like? I like that idea and haven't seen this before. thanks.

• You should work with your IT teams to see what is possible. One option that could be created in EPIC, involves adding a banner under the patient’s name or within active treatments and this automatically populates when you scan the hazardous drug and stays on the account for 48 hours and crosses encounters.

3. What type of detergent do you suggest for spill cleanup? We are instructed to use hand soap from the wall dispenser and water without a decontamination step. Do you have recommendations on a better process or products?

• This is answered in question 1, but a bleach solution has been shown to be the most effective of readily available cleaning agents”, as long as the surface can tolerate bleach. You could work with your occupational health and safety teams to see what you can get access to. USP <800> also provides examples of agents that contain peroxide formulations or sodium hypochlorite. (https://www.usp.org/compounding/general-chapter-hazardous-drugs-handling-healthcare)

4. How long do we maintain Hazardous Drug precautions once pt has completed oral chemotherapy?

• This is going to depend on the oral agent being administered, but in general 48 hours after the last dose is administered. (Olsen, M. & Walton, A. (Eds.). (2024). P.68-69, Safe handling of hazardous drugs (4th ed.). Oncology Nursing Society)

5. Do you have a brand of surface wipes that you like to use?

• No specific recommendations here.

6. I have a question related to cleaning up a chemo spill on a carpeted surface. Could I contact one of you directly after the conference?

• Absolutely, but this is an area where the research is lacking. Many healthcare systems have removed carpets from patient care areas.

7. Do you recommend a filter cartridge type of respiratory mask for the list of HDs that can vaporize at room temperature? Also, do you recommend a fit-tested N95 mask for the administration and removal of intravesical chemotherapy?

• The literature is limited in this area in what the best respiratory protection is for drugs that have the potential to vaporize. Considerations will need to be discussed to see what is available within your organization. The Safe Handling Guidelines recommend that a combination respirator that contains N95/N100 component will provide dual protection. For intravesical administration, fit-tested N95 is best for protection against potential aerosols.

8. For post operative HIPEC patients, is it necessary to use a HD tested chemo gown to handle excreta, or is a "standard precaution" gown sufficient for 48 hours? In our institution, these patients are cared for throughout the hospital, not just on the oncology floor.

• Yes. These patients should be managed as all patients receiving hazardous drugs should be. Some organizations may have traveling safe handling kits/carts with the appropriate PPE and a list for when to use the PPE for areas that don’t manage patients receiving hazardous drugs with great frequency.

9. Would you recommend pharmacy spiking the bags with closed system devices or should nurses be doing this on the units?

• USP <800> states that protective techniques must be used. One such technique is the spiking or priming of IV tubing with a non-HD solution in a C-PEC. One area where this gets a bit tricky, is when you introduce circle priming. More research really is needed in this area, but if this is a practice that your organization allows for, there needs to be strict policies and monitoring to ensuring this is being done safely. (Olsen, M. & Walton, A. (Eds.). (2024). P.54, Safe handling of hazardous drugs (4th ed.). Oncology Nursing Society)

10. At our institution pharmacy has a list of HD divided into Category 1, 2, and 3 types. I get asked a lot which patients need private rooms. Is this included in USP 800?

• No, USP<800>, nor any other guidelines, provide any guidance on this.

11. When removing/hanging chemo, a nurse is wearing a disposable gown and is double cloved. When finished, gloves are removed and she washes her hands. If the gown is not soiled in any way, can she double glove and hang/remove chemo for another pt? It seems everything always happens all at once in the treatment room, and changing gowns each time when 3 patients are done at the same time feels so wasteful and time consuming.

• We get asked this question a lot. Our guidelines don’t get quite this granular. To the first question, once gowns are removed, they should be disposed of and not hung in between for re-use. We have seen practices, such as infusion centers, where patients are all closely arranged, such as pods, where nurses will go from patient to patient to do their chemotherapy administrations, in bulk if you will, and do just as you said, remove gloves and wash hands and replace gloves. This requires one to specifically go from patient to patient and not leave the care area though. However, if the nurse leaves the administration area, the gown should be removed.

Tell us what you want to learn about at 2025 ONS Bridge! What challenges are you facing in your practice? Where are the knowledge gaps? Submit your ideas using this link by November 7, 2024. 

Hello central Illinois, first time bridge conference for me. Live 40 miles south of Springfield!

Anyone on from this area??

I’m so excited to see everyone at Bridge tomorrow and Thursday!