Monday 22nd September 2014
Mac Voice, the magazine for Macmillan professionals: Autumn 2014
Rachel Duncan writes about the issues that can arise when new cancer drugs are introduced into a service
Newly licensed drugs are welcomed by both people with cancer and health professionals. They may improve survival and quality of life, provide better treatment choice, have fewer side effects or be easier to administer. There may also be cost benefits. However, their introduction into a service can present challenges. This article outlines the challenges faced by a skin cancer nursing service, but it may be relevant to any service.
Knowledge and confidence
Acquiring the necessary knowledge about a drug is a prerequisite to its safe introduction. Pharmaceutical companies often have a medical support team to help with this.
Despite having knowledge, health professionals may lack confidence when faced with difficult clinical situations. For example, people who receive a new drug in the ‘real world’ rather than the controlled trial setting may be a different population, ie they may have multiple co-morbidities. Or algorithms to manage adverse events that look easy to use on paper may, in reality, be unhelpful as the problem doesn’t quite ‘fit the box’. Health professionals may then become preoccupied with the drug rather than the person they are treating as a whole. Attending relevant conferences to network, visiting units already using the drug or joining webinars (online seminars) can be invaluable, increasing confidence over time.
People receiving treatment also need knowledge, especially regarding the importance of reporting adverse effects early. However, they may be reluctant to do this due to concerns that treatment could be stopped or the drug dose reduced: actions they perceive as reducing their hope of cure. Assigning a named nurse to each person being treated, which enables a supportive rapport to be built up, can be useful.
Words commonly used to describe new drugs in the newspapers and on the internet include ‘wonder drug’, ‘transform’, ‘hope’, and ‘miracle’. These can fuel unrealistic expectations of treatments, a well-documented concept which may prevent people from making well-informed choices. This is particularly important towards the end of life, when pursuing a drug therapy could reduce quality of life. Health professionals need to describe the expected outcomes of any treatment and help patients to understand the broader implications of their decision. The impact of professionals’ views on treatment, excited by remarkable developments in areas where there have been few previously, should not be underestimated.
Impact on a skin cancer service
In 2012, two new drugs for advanced melanoma: ipilimumab (Yervoy), a monoclonal antibody, and vemurafenib (Zelboraf), a kinase inhibitor, were introduced at the Lilac Centre, a nurse-led chemotherapy unit at St Helens Hospital.
These drugs have gradually led to a larger cohort of patients with complex needs for the two skin cancer clinical nurse specialists (CNSs), because it is possible to continue treatment where previously it would have been stopped.
When cancers have spread, it can give rise to a variety of symptoms at various parts of the body, and the numerous side effects from the drugs may require prompt intervention from many specialists. Coordinating referrals and maintaining effective communication between specialties, often over a large geographical area, is time-consuming and disproportionate to the small number of patients supported. This has had implications for the support available for larger groups such those newly diagnosed with melanoma. A Macmillan service review in 2013 helped to secure funding for additional staff to address this issue.
Psychological impact on CNS
Dacarbazine has been the mainstay of advanced melanoma treatment for the past 20 years. Its poor response rate is well documented. However, the introduction of vemurafenib has led to observations that poorly patients who are weeks or days from death are seen to dramatically improve. This has been referred to as the ‘Lazarus effect’. Regrettably, resistance often develops within 6–9 months and the person’s health declines once again. Likewise a small number of people treated with ipilimumab appear to have long-lasting treatment responses months after treatment. Supporting people and their families through the highs and lows of treatment responses can have a negative impact on the CNS’s mental well-being. Access to regular clinical supervision, a national cancer peer review measure, and good peer support is essential.
New drugs will continuously enter our clinical settings. Being aware of some of the challenges can help prepare teams for their introduction.
Macmillan produces information about cancer drugs. Visit be.macmillan.org.uk/cancerinfosheets
Macmillan Clinical Nurse Specialist Skin Cancer
St Helens and Knowsley Teaching Hospitals NHS Trust