Post-Conference Session Summaries

Clinical Hot Topics

Instructional Session 12, presented Wednesday, April 25

Cathleen Goetsch, MSN, ARNP, AOCNP, began the session with a discussion of developments in genetic profiling, which compares tumor profiles to normal genetic profiles to show the difference between gene expression on tumors and normal cells.

Onco type DX™ (Genomic Health) is one genetic profiling test that estimates the recurrence of estrogen receptor–positive breast cancer and the benefit of tamoxifen versus chemotherapy. The test looks at a 21-gene set, where 5 genes are used as controls, and classifies patients as low, intermediate, or high risk. MammaPrint^® (Molecular Profiling Institute, Inc.) is another test that has been cleared by the U.S. Food and Drug Administration for use as a prognostic tool in patients with breast cancer. MammaPrint uses a different gene array than Onco type DX that consists of a 70-gene profile. MammaPrint classifies patients as just low or high risk, and it predicts recurrence but not treatment benefit.

Healthcare providers should consider ordering a genetic profiling test when patients are node negative with 1 cm or greater tumors and they are uncertain about patients' prognosis or whether to administer adjuvant therapy. Providers need to keep in mind, however, that the tests are associated with uncertainties, can be expensive, and may not be covered by insurances.

Genetic profiling tests are being studied for other cancers, including colon, lung, ovarian, and prostate. The Lung Metagene Score predicts the recurrence of non-small cell lung cancer, and other gene profiling tests are predicting tumor sensitivity to treatment and validating new targets for treatment.

Catherine Levy, MS, BSN, RN, discussed early detection and management of immune-related events associated with ipilimumab therapy. Ipilimumab is a fully human monoclonal antibody that has the potential to enhance immune response against cancer by inhibiting T cell production. Common adverse events associated with its administration are dermatitis with or without pruritis, enterocolitis, and hypophysitis.

Dermatitis is the most common side effect, and treatment includes nonsteroidal topical lotions and systemic measures such as diphenhydramine and hydroxyzine. Enterocolitis usually manifests as diarrhea, and diagnosis is confirmed with colonoscopy and endoscopy biopsies. Treatment includes nothing by mouth and giving IV fluids, administering IV dexamethasone, converting to oral dexamethasone with graft-versus-host diet, then initiating steroid taper and advancing diet. Hypophysitis is an enlargement of the pituitary gland; early signs include fatigue, headache, and low TSH and cortisol levels. Treatment involves dexamethasone with taper to oral hydrocortisone, thyroid hormone, and testosterone patch for male patients. Although patients may be weaned off thyroid and testosterone, most will need to continue hydrocortisone because the pituitary gland does not fully recover.

Christine E. Smith, RN, MSN, CNOR, presented advances in surgical and interventional procedure oncology. Surgery has become minimally invasive, which has advantages (e.g., enhanced imaging, less stress immune response, decreased abdominal wall disruption) and disadvantages (e.g., ergonomically challenging, no tactile sensation, some movements must be done with the nondominant hand) for oncology.

Technology also has improved imaging diagnostics, such as those used for colorectal cancer screening. Tools such as wireless capsule endoscopy and computed tomography colonography need little patient preparation, and nurses may be able to interpret some of the images. Combined modalities such as intraoperative chemotherapy and radiation therapy also are being used. Third-generation robotics offer advantages in surgery. Additional technologies are still undergoing experimentation, such as natural orifice transluminal endoscopic surgery.

The introduction of these technologies means that nurses, as mid-level practitioners, may be able to perform certain procedures and make diagnoses. According to Smith, new technologies will have an impact on the education and training nurses receive, and it may affect clinician shortages.