Chapter 11
Oncology: Nursing management in cancer care
263
in combination with other substances (adjuvants) that can
augment or boost immune responses.
Autologous
vaccines are
made from the patient’s own cancer cells, which are obtained
during diagnostic biopsy or surgery. The cancer cells are killed
and prepared for injection back into the patient.
Allogeneic
vaccines are made from cancer cells that are obtained from
other people who have a specific type of cancer. These cancer
cells are grown in a laboratory and eventually killed and
prepared for injection.
Prophylactic
vaccines are given to prevent disease. Quad
rivalent human papilloma virus (HPV) recombinant vaccine
(Gardasil) protects against HPV types 6, 11, 16 and 18 associ-
ated with common genital warts (types 6 and 11) and develop
ment of cervical cancer (types 16 and 18). It is administered
over a series of three doses to females aged 9 to 26 (McLemore,
2006).
Therapeutic
vaccines are given to kill existing cancer cells
and to provide long-lasting immunity against further cancer
development. Challenges to the therapeutic activity of cancer
vaccines include the size of the tumour burden, the mecha-
nisms that allow tumour cells to avoid recognition as ‘non-self’
by the immune system, and immune tolerance as the result of
previous exposure to the tumour antigens. Multiple clinical
trials are being conducted to develop therapeutic vaccines
for cancers of the prostate, breast, kidney and lung, as well as
for melanoma, myeloma and lymphoma (Schlom, Arlen &
Gulley, 2007).
Nursing management in biological response modifier therapy
Patients receiving BRM therapy have many of the same needs
as cancer patients undergoing other treatment approaches.
However, some BRM therapies are still investigational and
considered a last-chance effort by many patients who have not
responded to standard treatments. Consequently, it is essen-
tial that the nurse assess the need for education, support and
guidance for both the patient and family and assist in planning
and evaluating patient care.
Monitoring therapeutic and adverse effects.
Nurses need
to be familiar with each agent given and the potential effects.
Adverse effects, such as fever, myalgia, nausea and vomiting, as
seen with IFN therapy, may not be life-threatening. However,
nurses must be aware of the impact of these side effects on
the patient’s quality of life. Other life-threatening adverse
effects (e.g. capillary leak syndrome, pulmonary oedema and
hypotension) may occur with IL-2 therapy. Nurses must work
closely with doctors to assess and manage potential toxicities
of BRM therapy. Because of the investigational nature of
many of these agents, the nurse will be administering them
in a research setting. Accurate observations and careful docu-
mentation are essential components of patient assessment and
data collection.
Promoting home- and community-based care
Teaching patients self-care.
Some BRMs, such as IFN, EPO
and G-CSF, can be administered by the patient or family in the
home. Nurses educate patients and families, as needed, about
how to administer these agents through subcutaneous injec-
tions. They provide instructions about side effects and assist
patients and families to identify strategies to manage many
of the common side effects of BRM therapy, such as fatigue,
anorexia and flu-like symptoms.
stimulate the immune system or assist in preventing tumour
growth. The antitumour effects are dependent on the type
of IFN and the disease for which the IFN is being used. IFNs
enhance both lymphocyte and antibody production. They also
facilitate the cytolytic or cell destruction role of macrophages
and natural killer cells. Additionally, IFNs can inhibit cell
multiplication by increasing the duration of various phases
of the cell cycle. The effects of IFN have been demonstrated
in a variety of malignancies. IFN-
α
has been approved by
the TGA, MEDSAFE, FDA and PHARMAC for treating
hairy-cell leukaemia, Kaposi’s sarcoma, chronic myeloge-
nous leukaemia, high-grade non-Hodgkin’s lymphoma and
melanoma. Other positive responses have been seen in hae-
matological malignancies and renal carcinomas. IFN
α
, IFN
β
,
and IFN-
γ
have been approved by the TGA for the treatment
of several non-malignant diseases. IFN is administered through
subcutaneous, intramuscular, intravenous and intracavitary
routes. Efforts are underway to establish the effectiveness of
IFN for various malignancies in combination with other treat-
ment regimens.
Interleukins.
Interleukins are a subgroup of cytokines known
as lymphokines and monokines because they are primarily
produced by lymphocytes and monocytes. About 25 different
interleukins have been identified. They act by signalling and
coordinating other cells of the immune system. The TGA has
approved interleukin-2 (IL-2) as a treatment option for renal
cell cancer and metastatic melanoma in adults. Originally
referred to as T-cell growth factor, IL-2 is known to stimu-
late the production and activation of several different types
of lymphocytes. In addition, IL-2 enhances the production
of other types of cytokines and plays a role in influencing
both humoral and cell-mediated immunity. Side effects of ILs
include flu-like symptoms, fatigue and anorexia as well as seri-
ous side effects (e.g. profound diarrhoea, pulmonary oedema,
hypotension and oliguria). When combined with other cyto-
kines, IL-2 can cause hypersensitivity reactions or cardiac
dysrhythmias and hypotension (Tyre & Quan, 2007).
Clinical trials are being conducted on the role of ILs in
treating other cancers. Some early-stage clinical trials are
assessing the effects of interleukins in combination with
chemotherapy. In addition, interleukins are being investigated
for their role as growth factors for treating myelosuppression
after the use of some forms of chemotherapy.
Retinoids
Retinoids are vitamin A derivatives (retinol, all-
trans
retinoic
acid, and 13-
cis
-retinoic acid) that play a role in growth,
reproduction, epithelial cell differentiation and immune
function. Retinoids have many important and diverse func-
tions throughout the body including roles in vision, regula-
tion of cell proliferation and differentiation, growth of bone
tissue, immune function and activation of tumour suppressor
genes. Retinoids are being tested for treating both haemato-
logical cancers and solid tumours and for preventing a variety
of cancers such as prostate and brain cancers (Wilkes &
Barton-Burke, 2007).
Cancer vaccines
Cancer vaccines are used to mobilise the body’s immune
response to recognise and attack cancer cells. Cancer vaccines
contain either portions of cancer cells alone or portions of cells
