ASCO Guidelines

Dr. Bradley Hunter, MD, MPH and Ms. Amy Evers, BSN, RN, OCN, MBA join us on the latest episode of the ASCO Guidelines Podcast to share key points and insights on the updated ASCO-ONS antineoplastic therapy administration safety standards for adult and pediatric oncology standards. They highlight key updates across the four standards domains: (1) creating a safe environment, (2) patient consent and patient education, (3) ordering, preparing, dispensing, and administering oral and parenteral antineoplastic therapies in a health care facility, organization, or in the home, and (4) monitoring during and after antineoplastic therapy is administered, including adherence, toxicity, and complications. They also comment on the importance of these standards to provide a framework for optimal safe and effective care for all patients.
Read the standards, “Antineoplastic Therapy Administration Safety Standards for Adult and Pediatric Oncology: ASCO-ONS Standards” at www.asco.org/standards.

TRANSCRIPT

These standards, clinical tools, and resources are available at www.asco.org/standards. Read the full text of the guideline and review authors’ disclosures of potential conflicts of interest in the JCO Oncology Practice, https://ascopubs.org/doi/10.1200/OP.24.00216

Brittany Harvey: Hello and welcome to the ASCO Guidelines podcast, one of ASCO's podcasts delivering timely information to keep you up to date on the latest changes, challenges, and advances in oncology. You can find all the shows, including this one, at asco.org/podcasts.

My name is Brittany Harvey, and today I'm interviewing Dr. Bradley Hunter from Intermountain Health and Amy Evers from the University of Pennsylvania, authors on “Antineoplastic Therapy Administration Safety Standards for Adult and Pediatric Oncology: American Society of Clinical Oncology – Oncology Nursing Society Standards.” Thank you both for being here.

Dr. Bradley Hunter: Yeah, thanks. Good to be with you.

Amy Evers: Thank you.

Brittany Harvey: Now, before we discuss these standards, I'd like to note that ASCO takes great care in the development of its guidance products and ensuring that the ASCO Conflict of Interest Policy is followed for all standards. The disclosures of potential conflicts of interest for the expert panel are available online with the publication of the standards in the JCO Oncology Practice, which is linked in the show notes.

So then to start us off, Dr. Hunter, what prompted an update to the ASCO-ONS standards? And what is the scope of this update?

Dr. Bradley Hunter: The last guidelines were published in 2016. And just thinking about in the world of oncology, so much has changed since that time. There are a lot of therapies that have become commonplace now that were really not used too much before, including oral genomically determined targeted therapies, immunomodulatory agents, CAR T cell therapy, bispecific antibodies, etc. So there's really been a need to just talk about how do we navigate those therapies and how do we create systems of care in which they are delivered safely. Additionally, the sites of care have changed. I think all of us, eight years ago, wouldn’t have imagined a global pandemic, and how that would have changed the way that we needed to deliver oncology care. So there's been a huge influx of telehealth, including tele-oncology centers, where the oncologist and the patient may never even meet face to face, but just by video. And so it relies on a team approach for that sort of an outreach setting. Intermountain Health spans seven states, there are so many sites like this that we have and I know that we are not unique. This is an issue and a global thing now. Additionally, patients are even getting chemo in their own homes, so that has changed and we need to figure out how to address that so that everyone could be able to have that site of care so they can get there and they can get their therapy in a safe manner.

So, these varied care settings present a challenge to us as oncology providers to ensure that a standard of quality of care is maintained, and that the therapies can be given to patients no matter where they live and that we maximize benefit while minimizing risk to the patient. So I mean, just thinking where we are now, I can't imagine where we're going to be eight years from now or the next time these guidelines are updated.

Brittany Harvey: Absolutely. Thank you for setting the stage and the impetus for this update. It sounds like a lot has changed in the last few years to impact these standards.

So then I'd like to review the key points of the standards and the key updates for our listeners. There are four domains of standards. Starting with domain one, Amy, what are the key points of the standards for creating a safe environment for all routes of antineoplastic therapy?

Amy Evers: So domain one is all about who can write chemotherapy orders, who can prepare chemotherapy and then who can administer that chemotherapy and then what their competencies are both initial and then ongoing. So looking at the existing standards, we did end up making a few updates mainly on how providers discuss and document pregnancy status and fertility preservation with patients. And I think this is really timely given that we're seeing a big uptick in younger patients that are being diagnosed with cancers that were typically considered “old person diseases”. And I think we can and we should do better in ensuring that patients who want to preserve their ability to have a family one day can do so before they start treatment.

The update also included the addition of an assessment for social determinants of health, calling out financial and logistical constraints that patients may face as part of their cancer journey, which I think is extremely important making sure that we have equitable access to care regardless of a patient's background, their financial status, everybody's receiving the highest quality of care they can in their community.

And the last change that we made was to highlight an accurate measurement of height and weight using metric units, which is important when we're calculating the doses of drugs for some of these very high risk medications.

Brittany Harvey: Excellent. Thank you for reviewing those important points for our listeners.

So following those standards, for domain two, Dr. Hunter, what are the key standards for patient consent and patient education?

Dr. Bradley Hunter: In domain two, we’re really seeking to figure out what policies around treatment planning, patient consent and patient's education are shown to result in fewer medical errors and reduce preventable harm? But one of the big things we've found is having a really detailed understanding of exactly what a patient is taking in terms of medications, including over the counters and supplements and herbal remedies, really helps reduce medical errors. You know, some of the research and literature we came across suggest that upwards of 80% of the time when you see a patient's medication there are discrepancies between what's on that list and what patients are actually taking. So being able to sit down as part of a consent discussion and ongoing care and talk about everything that a patient's taking is really important.

My background, I am a bone marrow transplant, stem cell transplant and cellular therapist. Just this last weekend I was on the inpatient service and a patient had brought in food from home which we completely are supportive of. The patient brought in a bunch of superfood shakes that she had bought at Costco and then some CBD tea and she asked us if it was okay if she could take those. And as we reviewed them and what was in all of those shakes and then what was in the CBD tea, there were major interactions between those supplements or those herbal remedies, and then what was in the medications we were giving in the hospital, so it was important. And she told us - it wasn't like I sat down and and was the shining example here, but it was helpful that we were able to take her global picture of what she was taking from a medication standpoint and be able to make sure that we were treating her in a safe manner and making sure that we weren't inadvertently causing harm.

So, those are some of the things that we talked about. So, at every patient visit, and especially the first time you meet a patient you’re going to start therapy to be able to go over all of the different substances that patients are taking to make sure that they're safe.

Brittany Harvey: Thank you so much for reviewing those key standards and key updates and that example of how important it is to review all of medications and herbal supplements that patients are taking to ensure safe care for our patients.

So then following that, Amy, for domain three, what are the key points regarding ordering, preparing, dispensing and administering oral and parenteral antineoplastic therapy in a healthcare facility organization or in the home?

Amy Evers: So, domain three, actually, it was the domain that had probably the biggest discussion and fruitful debate between the panel members, but I think that we had some really great discussions and I think we had brought some really good changes and updates to the standards here. So domain three is where all of the verification standards live. So this is for practices who would either have been through the QOPI certification process or have been QOPI certified. This is where the surveyor actually will observe in real time how the clinical orders are reviewed by staff, how the drugs are prepared by pharmacy, and then how the drugs are checked one final time at the chair side or bedside immediately prior to administration.

So as I mentioned earlier, antineoplastic therapies are being given more frequently in the home or in settings where there may not be two clinical staff members present. In this post-COVID world, we're finding patients can be treated safely in the home, but the standards didn't really reflect kind of these changes in where patients are receiving treatment. And often, more and more practices are relying on technology to supplement the verification process both either in the pharmacy setting where there may be a centralized pharmacist verifying the drug mixing process for multiple sites, or in the actual home setting where a nurse can connect virtually with another clinician to verify a drug immediately or administration. So the standards were updated to include these workflows. And I think it's becoming more and more commonplace, but how do we do this in a safe and effective way where we're ensuring that all of these same safe handling processes are completed, regardless of where the patient may be seeking treatment?

So previous versions of the standards had three verifications. The first was before the actual preparation of the drug that someone other than the provider who wrote the order is verifying the order for all of the correct elements. The second verification is what usually happens in the pharmacy, upon preparation, what's being checked by the pharmacist or pharmacy technician who's preparing the drug. And then a third verification is done at, generally, the chair side where they're doing one final check of the orders to the drug to the patient.

So with this update, we actually broke out that third verification into a fourth verification. So the third verification is that check with the drug in the order by the administering and then a second verifier. And then the fourth verification is actually the one where the patient’s involved in the verification. So there are two clinicians making that final double check with the patient immediately upon preparation, which I think is important and is reflective of this change that we're seeing more drugs being administered in the home setting. The chair side or bedside final verification was also expanded to include a visual inspection of the administration tubing, this is sometimes referred to as tracing the lines, which ensures that the drug is being accurately infused, that there aren't any loose connections, that the clamps are open etc. And I think this is something that most nurses do in their normal clinical practice, but I think adding this as an actual check in the verification process, is really important. And I know personally, I was really happy to see this added in as a formal check.

Dr. Bradley Hunter: Yes, thanks, Amy. One other new standard within domain three is regarding immunomodulatory or immune effector cell therapies that have the risk of cytokine release syndrome and how we build a framework to try to mitigate those toxicities. We really wanted to try to make a set of standards that would apply whether or not you’re at a coronary care center, like Penn or whether you were at a center, like within Intermountain Health, it's a small rural outreach center that you're trying to be able to get patients to care. So really, the main thing within dealing with therapies that have the risk of cytokine release syndrome is really just building a framework that there's a management policy that's present from the institution, and that it's up to date, it's following what we know will work for these therapies in order to mitigate their toxicity, and then also making sure that adequate antidote therapy, whether for example, for cytokine release syndrome, it could be tocilizumab or anakinra or other therapies, and that order sets are present to be able to follow along with the policy guidelines to guide clinicians wherever they are practicing to help mitigate cytokine release syndrome, neurologic toxicity, ICANS, or other sorts of therapies that are associated with these novel agents.

Brittany Harvey: So for or the last domain, domain four, what are the key points for monitoring during and after antineoplastic therapy is administered, including adherence, toxicity, and complications?

Amy Evers: So domain four is pretty straightforward. It discusses the importance of assessing adherence and toxicities related to antineoplastic treatments. There wasn’t a whole lot of updates here. We did include having emerging treatment plans or equipment in the home and the healthcare setting. But what I really think is important and we need to underscore both with patients and clinicians, particularly as we've seen this rise in oral chemotherapy agents, is that a lot of times patients forget that this is the same chemotherapy that they're getting in the infusion suite. They're just taking it in a pill form. And I think patients forget that their adherence is just as important in taking that pill regularly and as prescribed. Financial toxicity is a real problem for most of our patients. Some of these drugs cost hundreds if not thousands of dollars for one treatment plan. As clinicians we've all heard stories of these patients who try to extend their prescription so they'll take a pill every other day instead of daily as prescribed, which really doesn't let the drug do what it's supposed to do. So I think when we talk about adherence, it's not just asking a patient whether they've taken their drug, it's about whether or not oral therapy is even appropriate for that particular patient. Do they have memory problems? Do they have metastatic disease to the brain where they may not be able to follow a complicated oral regimen? Do they have arthritis where opening a pill container is difficult? So having these conversations before a drug is even prescribed and making sure that it's the right route of administration for a patient is just as important as ensuring that they're maintaining their adherence to that drug.

And oftentimes, the toxicities of these oral drugs are worse than what's actually being administered in some of the infusion clinics, and so making sure that we're checking in on these patients regularly to ensure that they're not having any toxicities that aren't being managed appropriately. Or if there may be toxicities that would require a dose reduction, or perhaps switching to a different drug entirely. So, even though it's a pretty simple and straightforward domain, I think it's really important that we're educating our clinicians and our patients about the importance of adherence.

Dr. Bradley Hunter: I completely agree with what Amy said. She said it so well. I just want to echo back a couple of things that she said. Historically, we use the word non-compliant, which I think kind of sounds terrible to describe the patient's adherence to medication. I think part of this domain is recognizing that there is an entire environment that has to do with the patient that influences the way they're able to take their medication whether that's financial toxicity; we were talking to two people in our clinic who are professional financial toxicologists, and their entire job description is to help people get drugs for less so that they can actually take the side effects. If a patient feels terrible at that time, they’re not going to take it. So, understanding these barriers and really understanding the patient's entire picture, when you're figuring out how is the treatment plan going to match up with their reality, I think is super important.

When it comes to site of care, we just want to make sure also that whether you're getting chemo at home or you’re getting chemo in the clinic down the street, or in a coronary care center, that there is a policy in place to respond to an emergency, but also the equipment available in all of those sites of care that you can respond. And that's another aspect that we wanted to make sure we hit in the domain as there's been so many changes in how patients get care in the last eight years.

Brittany Harvey: Absolutely. Recognizing the barriers and factors that impact the ability of an individual to receive the right therapy is crucial. And I want to thank you both for reviewing all of the standards and updates through all four domains.

So then following that, in your view, how will these updated standards impact clinicians?

Dr. Bradley Hunter: It's our hope that these standards will guide the development of treatment infrastructure and help clinicians avoid error prone environments. We hope they're going to guide training efforts and that they will help clinicians ensure that they have relevant and accurate information about their patients and are able to respond appropriately when emergencies or even urgencies arise. Because of COVID, there's been such high staff turnover. And in the midst of all of this change, it's difficult to maintain a culture of safety when you've lost a lot of institutional knowledge of how to deal with that. And so, really trying to help bring people together again to have an infrastructure in place that makes training as seamless as possible and deal with the historical high staff turnover we’ve had.

So we're again, hopeful that we're helping to create a framework that cancer centers, treatment centers can use, whether they are a coronary care center in a large academic space, or whether they're in a rural tele-oncology space to be able to use the standards to create a space and a place and experience for cancer patients in which they’re kept safe and we’re maximizing the benefit of their chemotherapy, their antineoplastic agents, and also minimizing the risk just to optimize benefits for the patient.

Brittany Harvey: Definitely. Those are key points to provide a framework for clinicians.

So then along those same lines, finally, what does this update mean for patients receiving antineoplastic therapy?

Amy Evers: So while these standards are not necessarily patient facing, what I hope that this update will do, or actually not do, is that a patient shouldn't recognize any change in how they are cared for, regardless of what setting that they're receiving treatment. So whether it's at home, whether it's an ambulatory infusion center or in the hospital, they're still going to receive that same level of high quality care while they're receiving treatment. And I think that that's the most important thing that they should take away from this.

Brittany Harvey: Absolutely.

So I want to thank you both so much for all of your work on these standards to ensure patients receive optimal safe and effective care. And I want to thank you both so much for your time today.

Amy Evers: Thank you so much.

Dr. Bradley Hunter: Yeah, thank you. It’s really great to talk about this stuff.

Brittany Harvey: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast. To read the complete standards go to www.asco.org/standards. If you have enjoyed what you've heard today, please rate and review the podcast and be sure to subscribe so you never miss an episode.

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