Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice


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It is with great pride that we introduce the first edition of the Oncology Nursing Society’s Chemotherapy and Immuno-
therapy Guidelines and Recommendations for Practice. This book is an update of the classic foundational volume, Chemother-
apy and Biotherapy Guidelines and Recommendations for Practice, which had four editions published. The new title empha-
sizes the existence of many new categories of drugs that use the immune system to support or treat patients with cancer.
In fact, the book has been completely reorganized to include a new chapter on immunotherapy. This chapter details
six categories of immunotherapeutic approaches: checkpoint inhibitors, chimeric antigen receptor T-cell therapy, cyto-
kines, monoclonal antibodies (including radioimmunotherapy), immunomodulators, and oncolytic viral therapies.
Other chapters that have been added or expanded include those on chemotherapy agents, molecularly targeted anti-
neoplastic agents, and hormone therapy. Drug tables in each chapter include detailed information to guide nurses dur-
ing administration of antineoplastic therapy and supportive care medications. New figures, tables, and algorithms are
included to provide quick access to content.
The pathophysiology and management of toxicities related to antineoplastic treatment are extensively detailed within
individual chapters, with evidence-based guidelines to direct nursing practice. The timely addition of the unique side
effects of immunotherapy agents and their management is important, as nurses gain knowledge to expertly recognize
and manage these serious and potentially life-threatening toxicities. Safe administration of cancer therapies, including
a chapter to guide oncology nurses in the prevention and management of infusion-related reactions (e.g., hypersensi-
tivity, cytokine release syndrome, infiltration and extravasation), is included, with current evidence-based strategies.
The new volume provides content on professional considerations such as scope and standards, professional educa-
tion, policies and procedures, antineoplastic medication safety, ethical and legal issues, and patient education. Adher-
ing to national, state, and institutional standards is a fundamental responsibility of all nurses. The guidelines explain
and reference standards that oncology nurses should be aware of and follow. Each section details the requirements of
these standards for nurses.
The editors want to thank all the contributors who came forward to make this publication a reality. This work builds
upon the knowledge of many generations of oncology nurses and has been used both nationally and internationally
to inform oncology nursing practice. We are proud to continue to serve oncology nurses throughout the world with an
essential resource to guide their practice.

Professional Practice
A. Scope and standards

1. Administration of chemotherapy, targeted ther-
apy, and immunotherapy in a variety of settings

is within the oncology nurse’s scope of practice
(Brant & Wickham, 2013).

2. Professional nursing practice is defined and reg-
ulated at four levels (American Nurses Associa-
tion, 2015).

a) Practice is defined nationally through the
scopes and standards of practice, codes of
ethics, and specialty certifications.
b) States regulate practice through boards of
nursing and nurse practice acts.
c) Institutions outline policies and procedures.

d) Nurses are individually licensed and conse-
quently are responsible for their individual

decisions and actions.

3. In 2008, the American Society of Clinical Oncol-
ogy (ASCO) and the Oncology Nursing Society

(ONS) began an ongoing collaboration to define

and later revise safety standards for chemother-
apy and other antineoplastic agents. The ASCO/

ONS Chemotherapy Administration Safety Stan-
dards (Neuss et al., 2016) address staffing-related

issues, antineoplastic therapy planning, docu-
mentation, orders, preparation, patient educa-
tion, administration, and monitoring, with appli-
cation to all settings and patient populations.

B. Professional education
1. To promote a safe level of care for individuals
receiving chemotherapy, targeted therapy, and
immunotherapy, each institution or supporting
agency should provide specialized education
and preparation consisting of didactic learning
followed by successful completion of a clinical
practicum (ONS, 2017).
2. Didactic content is comprehensive, current, and

evidence based. At the conclusion of the didac-
tic course, the nurse demonstrates an under-
standing of the following, as identified in the

ONS (2017) position statement on the educa-
tion of the nurse who administers chemotherapy,

targeted therapy, and immunotherapy:

a) Types, classifications, and routes of admin-

b) Pharmacology of agents, regardless of indi-
cations for use

c) Pertinent molecular biomarkers
d) Chemotherapy and radiation therapy

e) Principles of safe preparation, storage, label-
ing, transportation, and disposal of agents

f) Administration procedures

g) Appropriate use and disposal of personal pro-
tective equipment (PPE)

h) Assessment, monitoring, and management of
patients receiving therapy in the care setting
i) Patient and family education for these agents,
specific to side effects and related symptom
management, and process for urgent and
ongoing follow-up

j) Assessment of, education on, and man-
agement of post-treatment care, including

follow-up care procedures, late or long-term
side effects, and physical and psychosocial
aspects of survivorship
3. The clinical practicum allows the nurse to apply

the knowledge gained in the didactic compo-
nent to direct patient care situations. Empha-
sis is placed on the clinical skills that a nurse

must demonstrate prior to being deemed com-
petent to administer chemotherapy, targeted

therapy, and immunotherapy (see Appendi-
ces A and B). At the completion of the clinical

practicum, the nurse will be able to perform
the following:
a) Demonstrate proficiency regarding the safe

preparation (when applicable), storage, trans-
port, handling, spill management, adminis-

Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice
tration, and disposal of antineoplastic drugs

and equipment.
b) Identify appropriate physical and laboratory
assessments for specific agents.

c) Demonstrate skill in venipuncture, includ- ing vein selection and maintenance of the site during and after drug administration. d) Demonstrate skill in the care and use of var- ious vascular access devices. e) Identify patient and family education needs in relation to agents. f) Identify acute local or systemic reactions (including extravasation and anaphylaxis) in association with antineoplastic drugs, and identify appropriate interventions. g) Demonstrate proficiency in the safe admin- istration of hazardous drugs (HDs) and dis- posal of contaminated waste and equipment. h) Demonstrate knowledge of institutional pol- icies and procedures regarding antineoplas- tic administration. i) Document pertinent information in the med- ical record. 4. Clinical activities a) Pair nurses who are new to antineoplastic drug administration with an experienced nurse who can serve as preceptor, providing clinical supervision and instruction (Lock- hart, 2016). b) The preceptor and the nurse establish spe- cific objectives at the beginning of the clini- cal practicum. Ideally, the nurse and precep- tor select an assignment of patients, and the nurse assumes responsibility for planning and providing care for these patients under the guidance and supervision of the preceptor. c) The length of time spent in the clinical practicum should be individualized depend- ing on the nurse’s ability and skill in meet- ing the specific objectives and institutional requirements. d) The nurse should become proficient and independent in administering nonvesicants before progressing to vesicant administra- tion. e) Various clinical settings can be used for the nurse to demonstrate competence in anti- neoplastic drug administration. It may not be realistic for all settings or agencies to provide on-site education and training. Alternative methods can be used, such as the following: (1) Contracting with larger institutions for didactic education or clinical experi- ence, including experience for spe- cific needs (e.g., vesicant, nonvesi- cant, IV push, short infusion, contin- uous infusion) (2) Creating or using a simulated labora- tory to substitute for the clinical com- ponent 5. Evaluation: An evaluation tool based on the desired outcomes should be used to document the nurse’s knowledge of and competency in the following: a) Agents and the associated nursing implica- tions b) Technical skills required for the administra- tion of agents (e.g., dose calculation, veni- puncture, access device management) c) Patient and family education about the treat- ment regimen d) Steps to take in the event of an untoward response following drug administration (e.g., anaphylaxis, hypersensitivity reaction, extravasation) 6. Competency may be verified in a simulated set- ting (e.g., skills laboratory) or as a precepted experience in the clinical setting. Individualize the evaluation/documentation tool to meet the needs of the new nurse and the practice setting, including a minimum number of observed and documented antineoplastic drug administra- tions. Observed administration of at least three different agents, types, and routes (i.e., nonvesi- cant and vesicant; IV push and short-term infu- sion) is recommended. 7. Annual continuing education and ongoing com- petency assessment are required of staff who order, prepare, and administer antineoplastic agents (Neuss et al., 2016). a) Educational content should be designed to meet the needs of staff in the healthcare set- ting and emphasize new information available. (1) Methods that may be used to identify needs include but are not limited to clinical observation, literature review, staff or patient survey, chart audits, and quality improvement studies. (2) Potential topics include new drugs or drug delivery, reinforcement or train- ing on policies and procedures, and prevention and management of treat- ment toxicities. b) Competency assessment is ongoing, may be done by peers or supervisory staff, and is measured in several ways (Lockhart, 2016). Examples include the following: (1) Testing: Provide a packet of articles for the staff to read or a live educational
program followed by an open-book


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