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CONTINUING EDUCATION PROGRAM P10060 • RELEASE DATE: SEPTEMBER 15, 2010 • EXPIRATION DATE: SEPTEMBER 15, 2011 ESTIMATED TIME TO COMPLETE: 1.0 HOUR
Implications of Recent Guideline Updates on the Management of Chemotherapy-induced Nausea and Vomiting TARGET AUDIENCE
This activity was developed for pharmacists who wish to enhance their competence concerning the treatment of patients with chemotherapy-induced nausea and vomiting (CINV). LEARNING OBJECTIVES
Upon completion of this activity, participants will be able to: • Describe recent advances and emerging therapies in the treatment of patients with CINV • Compare key recommendations from updated clinical practice guidelines for the management of CINV, including those established by ASCO, NCCN, MASCC, and ONS • Examine effective treatment strategies for preventing CINV and improving patient outcomes
C
hemotherapy, the mainstay of treatment for many patients with cancer, has prolonged countless lives, but is also associated with potentially serious side effects, including nausea and vomiting. Although chemotherapy-induced nausea and vomiting (CINV) is preventable in the majority of patients receiving emetogenic chemotherapy, approximately 70% to 80% still experience some form of symptoms.1 Uncontrolled CINV can impose a substantial burden on patients, affecting their daily functional activity and overall quality of life.2 It may also lead to poor treatment adherence, delays in life-saving therapy, and increased healthcare costs and resource utilization.1,2 PHARMACISTS DESIGNATION
Medical Learning Institute, Inc., is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. Completion of this activity provides for 1.0 contact hour (0.1 CEU) of continuing education credit. The universal activity number for this activity is 04689999-10-042-H01-P. INSTRUCTIONS FOR CREDIT
1. Read the article in its entirety 2. Log on to www.TheOncologyPharmacist.com 3. Select “Continuing Education” 4. Click on this article’s title from the list shown 5. Select “Click here to complete the posttest and obtain a CE certificate online” 6. Complete and submit the CE posttest and CE Activity Evaluation 7. Print your Statement of Completion
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There are several barriers to the optimal control of CINV that must be identified and addressed. An ongoing challenge is the tendency of health providers to underestimate the incidence of CINV, particularly with regard to delayed symptoms.3,4 There also appears to be a gap in knowledge regarding the latest evidence-based CINV guidelines from organizations such as the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN), and the Multinational Association of Sup portive Care in Cancer (MASCC).3 Although these recommendations have limitations, they provide an important framework for delivering high-quality supportive care and are often linked to Medicare reimbursement or other thirdparty payment.5 To improve patient outcomes, clinicians must be aware of the most recent CINV guidelines, as well as safety and efficacy data regarding novel antiemetic agents and regimens. This knowledge, combined with the implementation of accurate patient-assessment tools and careful consideration of cost and reimbursement issues, will allow for prudent evidence-based decisions that will minimize complications, thereby reducing the burden and cost of uncontrolled CINV. Burden and cost of CINV CINV can negatively impact a patient’s quality of life and lead to potenThis activity is provided free of charge to participants. Upon completion of the evaluation and scoring 70% or better on the posttest, you will immediately receive your certificate online. If you do not achieve a score of 70% or better on the posttest, you will be asked to take it again. Please retain a copy of the certificate for your records. FACULTY DISCLOSURES
Before the activity, all faculty will disclose the existence of any financial interest and/or relationship(s) they might have with the manufacturer(s) of any commercial product(s) to be discussed during their presentation(s): honoraria, expenses, grants, consulting roles, speaker’s bureau membership, stock ownership, or other special relationships. Presenters will inform participants of any off-label discussions. The associates of Medical Learning Institute, Inc., and Center of Excellence Media, LLC, have no financial relationships to disclose. Sally Barbour, PharmD, BCOP, CPP, has nothing to disclose.*
tially serious physiologic consequences, including metabolic imbalances, nutrient depletion, anorexia, esophageal tears, wound dehiscence, and degeneration of functional ability and self-care.1 Furthermore, uncontrolled CINV may result in diminished adherence to chemotherapy treatment and delays in, or withdrawal from, potentially beneficial or curative anticancer therapy.1,2 In a recent study of patients receiving cisplatin-based chemotherapy, more than 90% of those who experienced both acute and delayed CINV reported that it had an impact on their daily lives.6 According to a report by Shih and colleagues, working-age patients with
CINV can negatively impact a patient’s quality of life and lead to potentially serious physiologic consequences. uncontrolled CINV lost nearly 3 more work days than patients with controlled CINV, and incurred direct medical costs per patient per month of more than $1300 (30% higher) than patients with controlled CINV.7 In addition, indirect monthly costs per patient were $433 higher for those in the uncontrolled CINV group.7
Furthermore, a 4-year retrospective cohort study based on data from 19,139 patients treated at 256 outpatient hospital facilities was conducted to determine CINV-associated costs and healthcare visits following an initial cycle of highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC).8 All patients received at least one antiemetic agent on the chemotherapy administration visit, per the inclusion criteria. Results of this study revealed that 2641 patients (13.8%) required a CINV-related follow-up hospital visit after the first cycle of HEC or MEC.8 The estimated mean cost of the hospital visit was $5300 (or $750 when averaged across all patients with and without a visit), and costs were highest for patients receiving HEC. Moreover, nearly all hospital visits took place during the delayed CINV phase following chemotherapy. Uncontrolled CINV not only imposes a significant clinical and economic burden on patients, but it also has an adverse economic impact on oncology practices, as demonstrated in a study by Vanscoy and colleagues.9 Their analysis of data from 20 community oncologist practices showed that managing one extreme CINV event required an average of 255 minutes of labor time—the equivalent of approximately $175 (2005 dollars).9 In this study, the definition of an extreme CINV event included: nausea or vomiting coded as a grade 2 or higher toxicity; visits to the oncol-
Carrie Tompkins Stricker, PhD, RN, has nothing to disclose.*
COMMERCIAL SUPPORT ACKNOWLEDGMENT
*Content will include non–FDA-approved uses.
This activity is supported by an educational grant from Eisai, Inc.
PEER REVIEWER
Jayshree Shah, RN, APN-C, MSN, BSN, BS, is on the speaker’s bureau for Bristol-Myers Squibb, Celgene, Merck, and Novartis, and is on the advisory board for Bristol-Myers Squibb and Novartis. DISCLAIMER
The information provided in this CE activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition. SPONSOR
FACULTY
Sally Barbour, PharmD, BCOP, CPP Clinical Oncology Pharmacist Duke Comprehensive Cancer Center Pharmaceutical Research Service/Duke Cancer Care Research Program Durham, NC Carrie Tompkins Stricker, PhD, RN Oncology Nurse Practitioner Clinical Assistant Professor of Nursing Abramson Cancer Center University of Pennsylvania Philadelphia, PA
This activity is jointly sponsored by Medical Learning Institute, Inc., a non-profit medical accreditation company, and Center of Excellence Media, LLC.
www.TheOncologyPharmacist.com