Therapies to treat hematologic malignancies ( including cytotoxic chemotherapies , targeted therapies , immunotherapies , radiation , and hematopoietic cell transplantation [ HCT ]) continue to improve outcomes and extend the lives of our patients . However , nearly all patients will experience some side effects of these life-saving treatments . Treatmentrelated adverse events ( AEs ) affect patients ’ overall health , including quality of life , and may lead to treatment delays or interruptions that can affect clinical outcomes .

Early identification is key to managing AEs . Establishing rapport and maintaining open communication with our patients is of the utmost importance for being clued in early to any potential side effects , allowing for easier management and lessening severity . As advanced practice providers ( APPs ), our clinical knowledge and experience , together with our close relationships with patients , put us on the frontline of identifying and managing AEs .

Knowing What to Expect I practice in both inpatient and outpatient settings , supporting all physicians in our HCT program . This means I see patients with a variety of underlying hematologic malignancies at varying stages in their treatment receiving a broad range of

therapies – each with their own side effect profile .

To support clinicians in the management of AEs , our program developed comprehensive guidelines of chemotherapy regimens and their anticipated side effects . These guidelines are largely based on the AEs outlined in the package inserts ( PIs ) approved by the U . S . Food and Drug Administration , as well as in published clinical trials data . Management can involve holding the drug , reducing its dose , delaying treatment , or introducing new therapies to treat AEs . Specific parameters requiring dose reductions or delaying treatment are usually specified in the PIs .

Before a patient visit , my first step is to review his or her treatment plan and our guidelines to help identify potential issues that could arise during treatment . I also refer to drug databases to identify the AEs experienced during the clinical trials that led to the guideline ’ s recommendations .

Because I also manage patients who are enrolled in clinical trials at our institution , I carefully review the trial protocols to identify potential pitfalls and AEs we might encounter . Our clinical research coordinators , pharmacists , and primary investigators also are invaluable resources for identifying and managing AEs in our patient population . With the advent of newer targeted therapies and immunotherapies such as checkpoint inhibitors and chimeric antigen receptor T-cell therapies , we are seeing a whole new set of toxicities and AEs .

While clinicians are accustomed to handling the “ traditional ” side effects of cytotoxic therapies ( e . g ., infections , gastrointestinal toxicity , mucositis , and nausea ), novel mechanisms of action mean different AE profiles and different management strategies . We are now seeing more “ non-traditional ” and immune-related AEs ( such as cytokine release syndrome , neurotoxicity , endocrinopathies and other previously uncommon inflammatory sequelae ) that require educating ourselves about the toxicity profiles of these new therapies and the medications to manage them .

Calling in the Troops To manage our patients with hematologic malignancies , we rely on our whole team and expect everybody in the group to practice to the best of his or her ability .

Before seeing a patient , I touch base with our nursing staff . Our nurses do an excellent job of obtaining patient histories , reviewing symptoms , and identifying problems early during treatment . I rely on their input and make sure that we , as a team , are abreast of any clinical changes our patients may be experiencing .

Once we identify any AEs , we typically go through our standard management guidelines . If the AEs are atypical or not “ clear-cut ,” I confer with my APP colleagues and our clinical pharmacist or check in with the primary hematologist / oncologist for advice on how to manage the AE .

In the outpatient setting , our APPs staff the clinic and infusion center and are heavily involved in caring for patients . We also have a proactive system for non-visit follow-ups ; a triage nurse checks in with patients a day or two following the identification of an AE to monitor for any progression of symptoms or failure of our interventions . In addition , we provide our patients with educational materials and a phone number to reach us at 24 / 7 if any changes occur . We work closely with our inpatient team should the patient require hospitalization for further toxicity management .

Every APP has a different threshold for deciding what should be reported to the attending hematologist / oncologist immediately . For me , the urgency to notify the physician is guided by the severity of the toxicity or if I anticipate it will require management changes such as delaying or adjusting treatment .

In our practice , APPs typically handle acute symptom management . For example , if a patient experiences a common or mild AE ( like gastrointestinal toxicity with nausea , vomiting , constipation , or diarrhea ), the management is up to my clinical discretion . For rare AEs that aren ’ t thoroughly covered in previous literature or clinical trial experience , or for serious AEs that can affect the treatment plan , I discuss the situation with the hematologist / oncologist and develop a plan as to how to proceed .

Fortunately , our program fosters open communication and great working relationships across our entire team , and APPs are often not even faced with the question of whether to notify the primary hematologist / oncologist of an AE , regardless of severity . Our collaborative approach ultimately enables us to standardize the management of treatmentrelated AEs , overcoming the challenges that arise with both traditional and novel therapies to provide optimal care for our patients . ●