Expanded Treatment Options for Leukemia/Lymphoma

Leukemias and lymphomas are estimated to contribute up to 7% of all new malignant cases in the United States.[1] Conventional and high-dose chemotherapy have provided improved outcomes, and even cures. For example, the 5-year relative survival rate for patients with leukemia has nearly quadrupled in the past five decades, from 14% in whites from 1960 to 1963 to 55.3% for all races from 1999 to 2006.[2]

As the intricacies of hematologic disorders become better understood, including molecular expressions and their clinical behaviors, targeted therapies are increasingly becoming part of the treatment arsenal. In 2005, rituximab (Rituxan), the first monoclonal antibody to be approved by the US Food and Drug Administration for cancer therapy, was shown to improve the 2-year progression-free survival of patients with diffuse large B-cell lymphoma from 51% to 69% when used with chemotherapy vs chemotherapy alone.[3] It remains an important standard of therapy today. Ongoing clinical trials will help to further define the role of targeted therapies in treatment trajectories for the hematologic malignancies and disorders.

Understanding the pharmacokinetics of these targeted therapies is crucial to safely administer these treatments and monitor the patients accordingly. Oncologic emergencies, such as tumor lysis syndrome, are often unveiled as these medications are given, or soon thereafter. The acute infusion reactions caused by the monoclonal antibodies, such as rituximab and alemtuzumab (Campath), cannot be understated. As monoclonal antibodies are developed, including those that are conjugated with other agents (brentuximab vedotin [Adcetris] or the radioimmune conjugates), nurses need to consider the nuances in providing care to patients receiving them. For example, some may have more or less neutropenia and/or immune suppression, whereas others may offer new side effects, such as neuropathies. In some, radiation safety measures need to be employed. As more research is concluded, routes and treatment schedules may be modified, changing nursing implications as well.

Use of tyrosine kinase inhibitors, starting with imatinib (Gleevec) in chronic myelogenous leukemia (CML), pioneered treatment aimed at a specific genetic translocation, BCR-ABL, or the “Philadelphia chromosome.”[4] These oral therapies have provided hope not only to patients with CML, but also to those with this genetic aberration in other malignancies, such as acute lymphoblastic leukemia (ALL). Although these medications are taken orally, they are not without risk and highlight potential drug-drug interactions, cardiac failure, QT prolongation, and the importance of monitoring electrolytes.

Histone deacetylase inhibitors are newer agents used for cutaneous T-cell lymphoma. These novel agents may have mild side effects in general, but patients should also be monitored for severe effects, such as pulmonary embolism and myelosuppression.

Hypermethylation inhibitors, such as azacitidine and decitabine, may be used for patients with myelodysplastic syndromes (MDS) and AML. These agents offer less intense treatment, particularly in elderly patients.[5] Aside from myelosuppression, constitutional symptoms, such as pyrexia, rigors, arthralgias, and painful stomatitis can occur. Proteasome inhibitors, such as bortezomib (Velcade), can cause peripheral neuropathy and thrombocytopenia, dizziness, headache, and anorexia. Implications for nursing include eliciting thorough reporting of symptoms from patients so that maximum comfort and tolerance is achieved.

Patient and family education is tantamount, as many of these treatments are provided in the outpatient setting and require the astute monitoring and reporting of symptoms by the patient and family. Whether it is taking a pill on time or reporting a rash, monitoring for infection, bleeding, weight gain, etc., the importance of whom to call and when cannot be understated.

Nursing care of patients with lymphoma and leukemia has grown from a few standard treatments with fairly predictable side effects and outcomes, to an entire library of agents used in the treatment armamentarium. As treatment targets continue to expand on a molecular level, oncology nurses will also continue to be challenged to understand their unique properties and translate that knowledge into safe and patient-centered quality care. Rogers provides a thorough review of these complex targeted therapies in a way that is understandable and clinically relevant. Tables provided within this article provide a nice reference for the bedside clinician.

Financial Disclosure: The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

References

1. Siegel R, Naishadmham D, Jemal A: Cancer Statistics, 2012. CA Cancer J Clin 62(1):10–29, 2012. Available at http://cacancerjournal.com.

2. Leukemia and Lymphoma Society: Leukemia. Available at http:://www.lls.org.

3. Sehn L, Donaldson J, Chhanabhai M, et al: Introduction of combined CHOP plus rituximab therapy dramatically improved outcome of diffuse large B-cell lymphoma in British Columbia. J Clin Oncol 23(22):5027–5033, 2005.

4. Kantarjian H, Sawyers C, Hochhaus A, et al: Hematologic and cytogeneic reponses to imatinib mesylate in chronic myelogenous leukemia. N Engl J Med 346:645–652, 2002. Available at: http://ww/ncbi.nlm.nih.gov/pubmed/1187024.

5. O’Donnell M, R. et al. Acute Myeloid Leukemia. NCCN Clinical Practice Guidelines in Oncology, version 2 (2011). Available at www.nccn.org.