carol s. viele rn ms ocn clinical nurse specialist hematology-oncology-bone marrow transplant ucsf...
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Carol S. Viele RN MS OCNClinical Nurse Specialist
Hematology-Oncology-Bone Marrow TransplantUCSF
Associate Clinical; ProfessorDepartment of Physiological Nursing
UCSF School of Nursing
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OverviewHeld in Boston, MassachusettsApril 29-May 1, 201155 sessions over 3.5 days of the meetingSession topics included:
Infection, Sepsis UpdateClinical Trials/ Protocol IssuesInternational OncologyEthicsPreparing for the future of Oncology NursingBMT ToxicitiesSafe Handling IssuesGenotype directed therapyGenetics
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Highlights in Crash Course in BMTPresenters from Johns Hopkins, Seattle Cancer Care Alliance and
Stanford UniversityTopics: Pulmonary Issues, Hepatic Toxicity and Hepatic GVHD and
Skin ToxicityPulmonary Issues
Incidence 30-60% Cause of death 60% Diagnosis
Bronchoscopy Lung biopsy
Risk Factors/Etiology Aspergillus CMV Pneumocystis jiroveci Bronchiolitis Obliterans BOOP DAH
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Highlights in Crash Course in BMTInterventions
AntibioticsAntifungalsAntiviralsSteroidsAnxiolytics
Benzodiazepines
Dypsnea management
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Highlights in Crash Course in BMTHepatic Complications
Sinusoidal obstruction syndromeGraft versus host diseaseDrug induced lung injuryInfections
Bacterial Fungal Viral
Cholecystitis
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Highlights in Crash Course in BMTDiagnostic tests
Laboratory dataImagingLiver biopsy
PreventionUrsodiolAntifungalsAntiviralsConditioning regimens
Decreased intensity regimens No cytoxan
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Highlights in Crash Course in BMTTreatments
Low dose tissue plasminogen activator20% response
Antithrombin IIIDefibrotide
> 36 % response rate
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Highlights in Crash Course BMTHepatic Graft versus Host disease
Onset 2-4 weeks post BMTJaundice and increased LFT’sStaging directly related to level of bilirubinPrevention and Treatment
Calcineurin inhibitors Mycophenolate mofetil Methotrexate Ursodiol Steroids ATG Sirolimus Rapamycin Monoclonal antibodies
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Highlights Genotype Directed Therapy Lung CancerBy Lecia Sequist MD, MPHNSCL Cancer therapy
Chemotherapy- modestly successfulMolecular targetingKey pieces to understand the cell biology of each
individual’s tumorTreatment effective against the particular biology of
tumor EGFR dysregulation
Tyrosine kinase inhibitors in lung Gefitinib- Iressa Erlotinib- Tarceva
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Highlights Gene Directed Therapy Lung CancerTreatment:
Find EGFR mutations in patients10% of lung cancer patient have EGFR mutationsResponse rates as high as 70% in this group of patients 1
Based on the Mok trial US is looking at need for molecular testing of tumors
More common in: Women Never smokers Little smoking history
Mok 2009 NEJM
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Highlights Gene Directed Therapy Lung CancerTargeted therapy eventually develops resistanceMass General is doing repeat biopsies to track
resistance development in tumorsInitial response is usually 12 monthsLooking at another pathway the MET inhibitorAdding a MET inhibitor with ErlotinibAnother pathway is ALK translocation
First described in 2007Can be responsible for lung cancer progression
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Highlights Gene Directed Therapy Lung CancerCrizotinib – a new agent being trialed and the target
is ALKPhase I study150 PatientsDramatic responses? FDA approval in 2011
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Highlights Gene Directed Therapy Lung CancerFuture genotype directed therapy in lung cancer
KRASALKBRAFMETPDGFREGFR
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Highlights Biology of Pediatric and Adult CancersJohn Maris MD Children’s Hospital PhiladelphiaBelinda Mandrell PhD RN PNPThe future in cancer treatment is a “ personal
approach”Need to understand hereditary cancersGenomic profilingPractical and ethical implications
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Highlights Biology of Pediatric and Adult CancersChildhood cancers
Continue to cause significant morbidity and mortalityCure rates are stagnantLate effects are significantChildhood cancers represent a microcosm of cancers
in generalCancer is the leading cause of death in children
except for accidents2/3 of children who survive have life long disabilities1/4 of the children who survive have significant life
long disabilities such as CHF and hearing loss
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Highlights Biology of Pediatric and Adult CancersMolecularly targeted agents
Increase the cure ratesDecrease the toxicity rates
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Highlights Biology of Pediatric and Adult CancersNeuroblastoma
Median age at diagnosis 17 months15% of childhood mortalityInduces significant morbidity30% of cases spontaneously resolve50% of cases are high risk diseaseNeed to define the molecular targets
Genetic basis of diseaseDefine the oncogenic drivers of this disease
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Highlights Biology of Pediatric and adult CancersGenomic profiling
ALK (Anaplastic lymphoma kinase) gene is the major familial neuroblastoma gene and is located on chromosome 2 Occurs in 80% of familial disease
PHOX 2B occurs in 10% of Familial neuroblastoma
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Highlights Biology of Pediatric and adult CancersGenomic Profiling includes:
DNA copy numbers- Single Nucleotide Polymorphism arrays
RNA copy numbers – Expression arraysMutations- Sequencing analysis
Vision for all patients they will all have DNA sequencing done at diagnosis. As we treat patients mutations will occur and moving forward we can profile the DNA and RNA alterations
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Highlights Biology of Pediatric and Adult CancersGenetic Profiling Considerations
Family history may suggest a genetic cancer syndrome
Tests need to be adequately interpretedConsent for testing must occurPre and Post counseling needs to occurPatients need to know the results may affect
their ability to obtain life insurance not health insurance
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Highlights Biology of Pediatric and Adult CancersInformed Consent Issues:
Clinical ImplicationsImportance for childrenAccuracy of testingFeesPsychological issuesConfidentiality issuesInsurance issues
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