Oncology Nursing Support for Safe and Effective Use of Eribulin in Metastatic Breast Cancer
the ONA take:
National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology (NCCN Guidelines) recommend several agents as a preferred single agent for recurrent or metastatic breast cancer, including the microtubule inhibitor eribulin. The authors review five case studies of women with metastatic breast cancer who were managed successfully with eribulin mesylate in late lines of therapy after at least two chemotherapeutic regimens for advanced breast cancer. The side effects experienced by at least some of the women, and discussed in the patient cases, were neutropenia, fatigue, liver metastases, and renal impairment. The cases highlight the importance of oncology nurse practitioners’role in early recognition and proactive management of adverse events.
Clinical Medicine Insights: Oncology
Nurse practitioners play important roles in breast cancer prevention, early detection, therapeutic efficacy, and surveillance. Assessment of a patient's health status is part of the nine nurse practitioner core competencies updated in 2012 by the National Organization of Nurse Practitioner Faculties. Although adverse events are common in treatment for metastatic breast cancer (MBC), proactive management strategies can limit the number and/or severity of adverse events. Additionally, knowledge of common metastatic sites and clinical signs/symptoms of recurrence provides one of the first-line strategies for successful treatment. We review five case studies of women with MBC who were managed successfully with eribulin mesylate in late lines of therapy after at least two chemotherapeutic regimens for advanced breast cancer that included both an anthracycline and a taxane in either the adjuvant or metastatic setting.
Keywords: eribulin, metastatic breast cancer, distant breast cancer metastases, eribulin-related AE management
The probability of a woman developing invasive breast cancer over her lifetime is one in eight.1 It was estimated that there will be 232,340 new cases of invasive breast cancer in women in the United States in 2013, with almost 40,000 estimated deaths.2 The five-year survival rate when patients are diagnosed with localized disease is 98%, which drops to 23% when diagnosed with distant metastases.1
The liver is a common site of distant breast cancer metastases in addition to bone and lung. In a study by Tampellini et al.,3 the liver was the leading site of metastasis for up to 25% of patients with metastatic breast cancer (MBC). An analysis of tumor registry data collected by the University of Texas MD Anderson Cancer Center between 1994 and 1997 from 784 adult patients with confirmed adenocarcinoma revealed that 30% of breast cancers metastasized to the liver.4
Determining appropriate treatment requires accurate pathology reports for a full understanding of the extent and biological features of the disease.5 Patient history, prior breast biopsies, prior irradiation to the chest, pregnancy status, microcalcifications detected through mammography, state of lymph nodes, presence of inflammatory changes or skin abnormalities, and previous treatments all need to be discussed with the pathologist. It is important to orient biopsies appropriately and to request specific biomarker statuses (estrogen receptor, progesterone receptor, human epithelial growth factor receptor 2) during these discussions.
Preferred single agents for recurrent breast cancer or MBC in the 2014 National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology (NCCN Guidelines®) are anthracyclines (doxorubicin and pegylated liposomal doxorubicin), taxanes (paclitaxel), antimetabolites (capecitabine and gemcitabine), and microtubule inhibitors (vinorelbine and eribulin).5 The choice of therapy is often guided by treatment history of MBC to circumvent resistance.6
Managing and monitoring therapy
Assessment of a patient's health status is part of the nine nurse practitioner core competencies updated in 2012 by the National Organization of Nurse Practitioner Faculties.7 Health promotion, health protection, and disease prevention in previously diagnosed and undiagnosed patients may include appropriate screening activities, anticipatory guidance, and recommended environmental and/or lifestyle modifications.8 Thus, the oncology nurse practitioner (ONP) plays an important role in managing MBC therapy to help minimize complications and maximize therapeutic potential.8 The ONP may perform physical examinations, assess symptoms, and order laboratory tests to aid in monitoring the patient.8 Laboratory tests may include a complete blood count (CBC), electrocardiogram, liver function tests (LFTs), a Child-Pugh score, urinalysis, kidney function tests (such as blood urea nitrogen or creatinine clearance [CrCl]), and measures of magnesium and potassium levels.
The optimal frequency for monitoring is based on experience in clinical trials. Recommendations from the prescribing information for the selected chemotherapy should be followed; however, if a sign or symptom associated with disease progression is detected, an immediate reassessment is recommended.5 The 2014 NCCN Guidelines® for Breast Cancer provides suggested intervals of follow-up when monitoring therapy for metastatic disease (for further information, go to http://www.NCCN.org)5; however, these guidelines should be modified for individual patients based on disease and treatment history.