Chronic lymphocytic leukemia (CLL) has a heterogenous disease course, and questions remain regarding when to initiate therapy, the application of prognostic markers, and the optimal regimens and sequences of agents for individual patients. At the Oncology Nursing Society 43rd Annual Congress in Washington, DC, i3 Health spoke with Adrianne Janicik, BSN, RN, OCN®, from Vanderbilt University Medical Center, about advances in immunotherapy for CLL and the importance of ensuring therapy adherence.
What was the problem you investigated?
Adrianne Janicik, BSN, RN, OCN: The problem, in theory, is the use of traditional chemotherapies that are so toxic to almost all of our CLL patients, causing neutropenia and other dose-limiting side effects. I was looking at the introduction of new immunotherapies and how those compare to the traditional therapies in terms of which works better. Is it feasible to use immunotherapies as a primary modality and just bypass the chemotherapy altogether? That was my main question.
One of the challenges you mentioned with immunotherapies is that so many are oral. Do you think there is a problem with adherence to oral therapies?
Ms. Janicik: Yes. That's certainly an issue and it's multifactorial. Cost can be a contributing factor to nonadherence. If patients can't afford their medication, they're very unlikely to take it as it's prescribed, if at all. Side effects are another issue to consider. If they're not comfortable with the diarrhea or the abdominal pain that it might cause them, they're also unlikely to take their medication.
It's really important for nurses, advanced practice nurses in particular, to develop strategies for ensuring patients adhere to their oral therapy so that it does work. Studies have shown that if you discontinue your therapy for more than a week, your disease will come right back, especially in CLL. So it's very, very important to encourage oral adherence.
Can you just talk a little bit about the importance of patient education regarding immunotherapies?
Ms. Janicik: Patient education on oral therapy, in particular, is important because we don't necessarily watch patients take their drugs every day to make sure that they're doing it the way that they're supposed to. It's crucial for providers and nurses who encounter their patients on a daily basis to ask those questions every time they see that patient:
"Are you taking your drugs the way that they are prescribed?"
"Why aren't you taking them the way that they're prescribed?"
"Do you have questions about the side effects?"
"Do you have questions about how your medication works?"
As a training nurse, I like to ask those questions every single time I see that patient. Even if I get the eye roll and "Yes, I know we talked about this last time," it helps me make sure that they know how to take care of themselves when I can't watch them.
Do you think immunotherapy will eventually take over as the standard of care for CLL?
Ms. Janicik: I really hope so. I'm a big advocate for goals-of-care discussions and expectations of therapy. Quality of life is a huge concern for cancer patients, so I think it's really important to have that conversation early on. If we can discuss immunotherapy with patients and help them see that it might provide them more time at home with their kids and a bit better control of their activities of daily living, we might be able to use it as opposed to traditional chemotherapy.
Cost and insurance coverage is going to continue to be an issue, but I'm hoping that with the change in the health care climate and changes in health policy that it might still push forward.
About Ms. Janicik
Adrianne Janicik, BSN, RN, OCN, is an outpatient chemotherapy infusion nurse at Vanderbilt University Medical Center. She is currently seeking a master's degree in nursing as an Adult-Gerontology Acute Care Nurse Practitioner with a focus on hematology.
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