EDITOR'S NOTE Neil Love, MD The right choice at the right time for the right patient

This audio series is produced by a medical oncologist (your trusty editor) and has a somewhat different educational objective than many or most continuing education programs for oncology nurses.

Our primary goal here is to provide information and perspectives on how medical oncologists provide care to patients and how the results of new clinical trials fit into the decision-making process. Our hope is that this will enable oncology nurses to interface more effectively with their physician partners as part of the interdisciplinary oncology team.

What is it about oncology that is so different from every other specialty and subspecialty in medicine? The answer to this complex question revolves around the disease process itself and the unusually intense and long-term outpatient treatments often utilized. Another very unusual characteristic of medical oncology practice is the rapid evolution of clinically significant research developments that can instantaneously affect treatment decisions.

Since 1988, our group in Miami has been producing educational programs for medical oncologists that focus primarily on the application of new research information to patient care. We have also produced programs for oncology nurses and hope to spend a lot more time doing this in the near future.

One key issue we cover in our programs for nurses is the clinical approach utilized by medical oncologists when making specific treatment recommendations to patients. We also cover other topics — particularly side effects of therapy and psychosocial issues in cancer care — but our main emphasis is clinical decision-making and how new research impacts these choices.

We firmly believe this aspect of oncology is relevant to oncology nurses, who often spend more time with patients than oncologists do. This increased “face time” provides a valuable opportunity for nurses to support treatment decision-making and, in many cases, to prepare patients to face the potential need to switch therapies.

On the enclosed program, we visit with two patients from the practice of medical oncologist Dr Richard Zelkowitz and his nurse colleague, Ms Nancy Sokolowski. As part of these two case discussions, we review several key decisions made in the care of these women and discuss how an oncology nurse can, and perhaps should, play a significant role in helping patients understand specific aspects of current and future treatment options, as follows:

Case 1: Should postmenopausal patients on adjuvant tamoxifen be switched to an aromatase inhibitor?

Mrs O was initially treated with ACT adjuvant chemotherapy. She then received tamoxifen, as have most postmenopausal patients with ER-positive tumors since 1985. Adjuvant endocrine therapy is almost always started after the completion of adjuvant chemotherapy, so for the oncology nurse caring for a patient receiving chemotherapy, this provides an excellent opportunity to explore and discuss postchemotherapy endocrine treatment options. In this case, the patient was diagnosed in 2002, just as several new studies were being reported on the use of aromatase inhibitors as adjuvant therapy for postmenopausal patients with ER-positive breast cancer.

The most important of these was the ATAC trial, which demonstrated not only a lower relapse rate for the aromatase inhibitor (AI) anastrozole compared to tamoxifen but also fewer serious complications associated with therapy.

Oncologists have different practice styles in terms of how much research data they require to change their treatment patterns, and in this situation, Dr Zelkowitz held off making a wholesale switch to AIs when the ATAC data were first reported.

However, after two years, he became convinced that this newer approach was preferable, specifically when he attended a major scientific meeting last year (the San Antonio Breast Cancer Symposium) and learned of several new study reports on AIs and more follow-up on several older ones, including ATAC.

Interestingly, upon returning from that conference, Rich was scheduled to meet with a breast cancer support group at his hospital to report on new research reports from San Antonio. One of the topics he reviewed was switching hormonal therapy from tamoxifen to an aromatase inhibitor in postmenopausal women, and in the audience was Mrs O. Remembering that she was currently on tamoxifen, Rich approached the woman after the meeting and said, “Why don’t you come to the office to discuss this?”

The ensuing clinic visit led to a switch in therapy to anastrozole, and the patient continues to do well, particularly with the knowledge that this treatment strategy will reduce her risk of relapse by about 40 percent more than tamoxifen.

Another new and fascinating intervention in the adjuvant setting, which is reviewed on this program by Rowan Chlebowski, is reduction in dietary fat intake. At the recent ASCO meeting in Orlando, Rowan gave one of the most discussed presentations — the first results of a randomized trial that demonstrated that postmenopausal women with early breast cancer who were counseled to reduce their fat intake had a 21 percent reduction in their risk of recurrence, above and beyond the benefits of chemotherapy and endocrine treatment. This is another fruitful, interesting and important topic for nurses to bring up in the infusion room and elsewhere.

Case 2: What is the optimal first-line chemotherapy for patients with metastatic breast cancer?

We have reviewed many cases in this series addressing the same question. Here, we meet Mrs G, a 46-year-old patient who received adjuvant chemotherapy with a doxorubicin-containing regimen 10 years ago and found it to be a difficult experience. Following her chemotherapy, she received adjuvant tamoxifen for five years, at which point metastatic disease was diagnosed, and she was treated with an aromatase inhibitor for three years and then fulvestrant. For the oncology nurse, a good discussion point during the somewhat prolonged time course of administration of fulvestrant intramuscular injections might be the next form of treatment — most likely chemotherapy.

In this case, when the tumor was no longer responsive to endocrine treatment, a decision was made to start chemotherapy, and capecitabine was chosen, which resulted in a dramatic improvement in the symptoms of pulmonary metastases with no side effects from the therapy.

Dr Zelkowitz commonly utilizes capecitabine as his first choice of chemotherapy for metastatic disease because the oral formulation allows greater f lexibility in lifestyle, particularly for busy patients like this mother of three teenagers. Dr Z also favors capecitabine because it lacks emetogenicity and does not cause alopecia, allowing patients to have a more normal quality of life.

Our group has done many patterns of care surveys of medical oncologists, and from our data, we know that the treatment decision points outlined in these two cases would very likely have been approached differently by different oncologists.

Oncology nurses are in a unique position to know when an important decision is upcoming and to act as an interface between patients with breast cancer and their medical oncologists with regard to that decision. Ideally, every woman receiving adjuvant chemotherapy should be approached and talked to not only about the potential choice of adjuvant endocrine therapy for ER-positive tumors but also about the possibility of using trastuzumab for HER2-positive disease.

In the metastatic setting, due to the chronic nature of this disease, oncology nurses should anticipate that at some point, the current therapy will be switched. Here, again, the topic of future treatment options, including participation in clinical trials, is of immense importance to all patients with breast cancer. For that reason, our series hopes to provide nurses the tools, knowledge base and comfort level they need to make the right suggestion for the right patient at the right time.

— Neil Love, MD
NLove@ResearchToPractice.net