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Expanding the Role of the Registered Nurse in Interventional Oncology
Interventional Oncology (IO) is a growing subspecialty of interventional radiology (IR) with focus on minimally invasive locoregional treatments, such as transarterial chemoembolization (TACE) of liver malignancies, percutaneous ablations, and other palliative procedures. The advances in medicine and technology have led to an increase of minimally invasive procedures and techniques to treat many diseases and a growing number of patients are being referred to IR for consultations for management of their malignancies. In 2008, IO treatments of the liver made up the largest part, 64%, of all IO procedures.1
This subspecialty of IR will continue to grow, with interventional radiologists continuing to introduce new innovative oncology therapies into the IR suite. Along with the growth of IO, the role of the registered nurse in IR will need to advance in order to have increased knowledge and understanding in caring for the oncology patient. Considering that an estimated 1.6 million new cases of cancer will be diagnosed in 2014, it will be no surprise that a portion of these diagnoses will undergo an IO procedure at some point for management of their disease.2
Traditionally, registered nurses in the radiology and imaging setting have needed to have knowledge and experience in critical care nursing and/or emergency nursing to be able to competently function in IR and manage patients in the pre-, intra- and postprocedure settings.3 However, the specialty of radiology and imaging nursing is relatively new to the nursing world considering that IR itself began as a specialty about 40 years ago. This being said, the continued growth of IO will require the registered nurse working in the IR environment to be competent in evaluation and care of oncology patients when those patients undergo an IO-related procedure.
Nursing Care of Interventional Oncology Patients
The care of the oncology patient is multifaceted. Special attention needs to be given to the patient’s clinical presentation, diagnosis, associated symptoms, and how laboratory values are impacted. Specific systemic chemotherapeutic agents can cause a decrease in patients’ various hematologic values, which can affect whether a patient undergoes an IR procedure. The registered nurse should be aware of the implication of low platelets in an oncology patient and how it can affect undergoing an IR procedure. Low platelet counts increase the risk of bleeding. When levels decrease to less than 150 x 10(3) per µL it is known as thrombocytopenia.4 Patients with thrombocytopenia may be asymptomatic however; patients with platelet counts less than 50 x 10(3) per µL can manifest symptoms not limited to petechiae, ecchymosis, and prolonged bleeding.5 A patient experiencing thrombocytopenia is at greater risk of bleeding when undergoing any kind of minimally invasive procedure. Typically, patients with counts of less than 50 x 10(3) per µL can be managed by transfusions prior to undergoing an IR procedure.
A second hematologic value that can be significantly affected by systemic therapy is the white blood cell (WBC) count. The various components of WBCs (basophils, eosinophils, monocytes, neutrophils) help to combat infection, toxins, and allergic reactions. The neutrophil accounts for 50% to 60% of circulating WBCs.5 A patient with low WBC (<4 x 109/L) signifies a weakened immune system and of the four components that make up the WBC, the absolute neutrophil count indicates the state of immunity a patient has to fight off infections. A patient with neutropenia has a count of less than 1.5 x 109/L or 1,500 cells/µL.6 This count is important for the registered nurse in IR to know because depending on the level of neutropenia, a procedure can pose a greater risk than benefit to the oncology patient. Patients with moderate (<1.0) or severe neutropenia (<0.5) are at the greatest risk. A few symptoms exhibited by neutropenic patients can manifest as fever, chills, fatigue, and/or redness at the site of the existing catheter, if present.
Other laboratory values can impact patients about to undergo an IO procedure. Assessment of the patient’s liver function is important to knowing the risk of hepatic injury or hepatotoxicity. The liver has multiple functions from metabolizing protein, carbohydrates, and fat to converting medications/drugs to active metabolites. Often, oncology patients are on multiple drug regimens, from multiple systemic chemotherapy agents, which they receive on a weekly, biweekly, or monthly basis, to medications to manage symptoms brought on by the cancer drugs. Adherence to the many different medications can affect the function of the liver. It is also important to mention that a large part of IO procedures are liver-directed therapies in patients that already have primary liver cancer attributed to a hepatitis diagnosis, or a secondary diagnosis of metastasis to the liver from the primary cancer diagnosis. Elevated liver enzymes alanine aminotransferase and aspartate transaminase are found in the bloodstream indicating an injury to the liver as well as elevated bilirubin levels. It is important to monitor these levels during the pre-procedure phase as well as during the post-procedure phase.
The status of kidney function in most patients undergoing an IR procedure is critical, considering that the majority of IR procedures require a contrast medium. Creatinine, blood urea nitrogen, and glomerular filtration rate indicate the state of a patient’s kidney function. The elevation of these laboratory values from the normal ranges indicates increased risk of nephrotoxicity. Various clinical conditions can exist with oncology patients undergoing a contrast-based procedure. First, the systemic chemotherapeutic agent may be nephrotoxic, putting patients at higher risk for additional kidney injury with contrast administration. Second, due to underlying clinical disease, patients may only have one functional kidney. Third, patients may not be well hydrated due to side effects from systemic therapy including lack of appetite or oral mucositis. Dehydration in oncology patients can increase chances of nephrotoxicity when administering contrast media.7 Finally, underlying medical illnesses such as renal or liver disease or a longstanding history of hypertension or diabetes can affect the function of the kidneys.
For these reasons evaluation of kidney function by the registered nurse in the preprocedure setting can assess whether additional intervention, such as intravenous hydration or a facility-approved renal protection protocol, is warranted prior to the IO procedure.
Treating Side Effects
Cancer symptoms and side effects of cancer therapy can be numerous. Frequently, patients have disease-related pain which may be difficult to control, chemotherapy-induced nausea and vomiting, fatigue, and anxiety. Many systemic chemotherapy agents can also affect the immune system increasing chances of bleeding and/or infection. As the registered nurse preparing a patient to undergo an IO procedure, it is important that he or she be aware of the implications the patient’s systemic therapy may have post-procedure. For example, laboratory values can be affected by a patient’s disease process or systemic treatment exacerbating the symptoms of the IO procedure. The familiarization with key components of the patient’s latest blood work (specifically platelet counts, absolute neutrophil count, and liver function) is valuable information for the registered nurse along with renal function and coagulation studies. Understanding the clinical presentation and communicating it to the interventional radiology team allows for optimal management.
Locoregional IO procedures offered by clinical interventional radiologists are not without their own clinical manifestations. For example, liver-directed therapies such as TACE can impose or exacerbate already present symptoms in many patients such as fatigue, pain, and nausea and vomiting. The registered nurse caring for patients undergoing TACE can provide supportive care by administration of antiemetic drugs prior to the procedure and ensuring comfort and minimal pain throughout the procedure and post procedure. There are also effects from TACE on liver function or the contrast medium effects on the kidneys. Both of these sets of values can become elevated post TACE and need to be monitored closely. Understanding the potential symptoms and risks patients can experience allows the radiology nurse to adequately assess and manage the patient before, during, and after the IO procedure through communication and guidance from the interventional radiologist.
Inquiring with the patient’s medical oncology team about scheduled and as-needed medications currently prescribed to manage symptoms also provides additional support for the radiology nurse in the provision of care while the patient is in IR.
Future Considerations
In closing, interventional oncology will continue to grow, bringing forth new therapies in cancer management. The registered nurse in this arena plays a key role in caring for patients undergoing IO therapies and will need to have knowledge and competency in caring for the oncology patient. A combined knowledge of both radiology nursing and oncology nursing will evolve the role of the registered nurse in IO, adding to the quality care patients experience in the IR suite.
Editor’s note: Disclosures: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The author reports no conflicts of interest regarding the content herein.
Address for correspondence: Evelyn P. Wempe, MBA, MSN, ACNP-BC, AOCNP, University of Miami - Miller School of Medicine, Sylvester Comprehensive Cancer Center, 1475 N.W. 12th Avenue, Miami, Florida 33136, United States. Email: ewempe@med.miami.edu
Suggested citation: Wempe E. Expanding the role of the registered nurse in interventional oncology. Intervent Onc 360. 2014;2(8):E63-E66.
References
1. Kwan SW, Kerlan Jr. RK, Sunshine JH. Utilization of interventional oncology treatments in the United States. J Vasc Interv Radiol. 2010;21(7):1054-1060.
2. American Cancer Society. Cancer facts and figures 2014. www.cancer.org.
3. Association for Radiologic & Imaging Nursing. Orientation Manual for Radiologic and Imaging Nursing. Pensacola, FL: Author; 2008.
4. Gauer RL, Braun MM. Thrombocytopenia. Am Fam Physician. 2012;85(6):612-622.
5. Camp-Sorrell D, Hawkins RA, eds. Clinical Manual for the Oncology Advanced Practice Nurse. Pittsburgh, PA: Oncology Nursing Society; 2014.
6. Reagan JL, Castillo JJ. Why is my patient neutropenic? Hematol Oncol Clin North Am. 2012;26(2):253-266.
7. Gross KA, Costa N. Contrast media. In KA Gross, ed. Core Curriculum for Radiologic and Imaging Nursing. Hillsborough, NJ: Association for Radiologic & Imaging Nursing; 2014.
