Chemotherapy And Immunotherapy Guidelines And

Recommendations For Practice Second Edition

Second Mikaela Olsen download

https://ebookbell.com/product/chemotherapy-and-immunotherapy-
guidelines-and-recommendations-for-practice-second-edition-
second-mikaela-olsen-58451194

Explore and download more ebooks at ebookbell.com

Here are some recommended products that we believe you will be
interested in. You can click the link to download.

Chemotherapy And Immunotherapy In Urologic Oncology A Guide For The

Advanced Practice Provider 1st Ed Edouard J Trabulsi

https://ebookbell.com/product/chemotherapy-and-immunotherapy-in-
urologic-oncology-a-guide-for-the-advanced-practice-provider-1st-ed-
edouard-j-trabulsi-22503040

Cancer Chemotherapy Immunotherapy And Biotherapy Principles And

Practice 6th Edition Bruce A Chabner

https://ebookbell.com/product/cancer-chemotherapy-immunotherapy-and-
biotherapy-principles-and-practice-6th-edition-bruce-a-
chabner-10548966

Chemotherapy And Pharmacology For Leukemia In Pregnancy Guidelines And

Strategies For Best Practices 1st Ed Carolina Witchmichen Penteado
Schmidt

https://ebookbell.com/product/chemotherapy-and-pharmacology-for-
leukemia-in-pregnancy-guidelines-and-strategies-for-best-
practices-1st-ed-carolina-witchmichen-penteado-schmidt-22501956

Chemotherapy And Radiation For Dummies Alan P Lyss Humberto Fagundes

https://ebookbell.com/product/chemotherapy-and-radiation-for-dummies-
alan-p-lyss-humberto-fagundes-47121760
Cancer Chemotherapy And Biotherapy 5th Edition Bruce A Chabner

https://ebookbell.com/product/cancer-chemotherapy-and-biotherapy-5th-
edition-bruce-a-chabner-60924846

Cancer Chemotherapy And Biotherapy Principles And Practice Fourth

Bruce A Chabner

https://ebookbell.com/product/cancer-chemotherapy-and-biotherapy-
principles-and-practice-fourth-bruce-a-chabner-1651064

Coping With Chemotherapy And Radiation Therapy Everything You Need To

Know 4th Edition Daniel Cukier

https://ebookbell.com/product/coping-with-chemotherapy-and-radiation-
therapy-everything-you-need-to-know-4th-edition-daniel-cukier-2099334

Onconephrology Cancer Chemotherapy And The Kidney 1st Edition Kenar D

Jhaveri

https://ebookbell.com/product/onconephrology-cancer-chemotherapy-and-
the-kidney-1st-edition-kenar-d-jhaveri-5234026

Cancer Curing The Incurable Without Surgery Chemotherapy And Radiation

William Donald Kelley

https://ebookbell.com/product/cancer-curing-the-incurable-without-
surgery-chemotherapy-and-radiation-william-donald-kelley-50288516
 SECOND EDITION

CHEMOTHERAPY AND
IMMUNOTHERAPY
GUIDELINES AND RECOMMENDATIONS FOR PRACTICE

Edited by
MiKaela Olsen, DNP, APRN-CNS, AOCNS®, FAAN
Kristine B. LeFebvre, DNP, RN, NPD-BC, AOCN®
Suzanne L. Walker, PhD, CRNP, BC, AOCN®
Elizabeth Prechtel Dunphy, DNP, CRNP, BC, AOCN®
 SECOND EDITION

CHEMOTHERAPY AND
IMMUNOTHERAPY
GUIDELINES AND RECOMMENDATIONS FOR PRACTICE

Edited by
MiKaela Olsen, DNP, APRN-CNS, AOCNS®, FAAN
Kristine B. LeFebvre, DNP, RN, NPD-BC, AOCN®
Suzanne L. Walker, PhD, CRNP, BC, AOCN®
Elizabeth Prechtel Dunphy, DNP, CRNP, BC, AOCN®

Oncology Nursing Society

Pittsburgh, Pennsylvania
 ONS Publications Department
Publisher and Director of Publications: William A. Tony, BA, CQIA
Senior Editorial Manager: Sean Pieszak, BA
Acquisitions Editor: Dave Burns, BA
Staff Editor II: Andrew Petyak, BA
Staff Editor I: Casey S. Kennedy, BA
Design and Production Administrator: Dany Sjoen
Editorial Assistant: Kira Hall, BA

Copyright © 2023 by the Oncology Nursing Society. All rights reserved. No part of the material protected by this copyright may be reproduced or utilized
in any form, electronic or mechanical, including photocopying, recording, or by an information storage and retrieval system, without written permission
from the copyright owner. For information, visit www.ons.org/publications-journals/permissions-archives, or send an email to [email protected].

Cover illustration by George Schill.

First printing March 2023; second printing, June 2023; third printing, September 2023

Library of Congress Cataloging-in-Publication Data

Names: Olsen, MiKaela M., editor. | LeFebvre, Kristine B., editor. |
Walker, Suzanne (Suzanne L.), editor. | Dunphy, Elizabeth Prechtel,
editor. | Oncology Nursing Society, issuing body.
Title: Chemotherapy and immunotherapy guidelines and recommendations for
practice / edited by MiKaela Olsen, Kristine B. LeFebvre, Suzanne
Walker, and Elizabeth Prechtel Dunphy.
Description: Second edition. | Pittsburgh, Pennsylvania : Oncology Nursing
Society, [2022] | Includes bibliographical references and index. |
Identifiers: LCCN 2022057352 | ISBN 9781635930559 (paperback) | ISBN
9781635930566 (ebook)
Subjects: MESH: Neoplasms--nursing | Neoplasms--therapy | Antineoplastic
Agents--toxicity | Immunotherapy | Practice Guideline
Classification: LCC RC266 .C484 2022 | NLM WY 156 | DDC
616.99/40231--dc23/eng20230118
LC record available at https://lccn.loc.gov/2022057352

Publisher’s Note
This book is published by the Oncology Nursing Society (ONS). ONS neither represents nor guarantees that the practices described herein will, if fol-
lowed, ensure safe and effective patient care. The recommendations contained in this book reflect ONS’s judgment regarding the state of general knowledge
and practice in the field as of the date of publication. The recommendations may not be appropriate for use in all circumstances. Those who use this book
should make their own determinations regarding specific safe and appropriate patient care practices, taking into account the personnel, equipment, and
practices available at the hospital or other facility at which they are located. The editors and publisher cannot be held responsible for any liability incurred
as a consequence from the use or application of any of the contents of this book. Figures and tables are used as examples only. They are not meant to be
all-inclusive, nor do they represent endorsement of any particular institution by ONS. Mention of specific products and opinions related to those products
do not indicate or imply endorsement by ONS. Websites mentioned are provided for information only; the hosts are responsible for their own content and
availability. Unless otherwise indicated, dollar amounts reflect U.S. dollars.
ONS publications are originally published in English. Publishers wishing to translate ONS publications must contact ONS about licensing arrange-
ments. ONS publications cannot be translated without obtaining written permission from ONS. (Individual tables and figures that are reprinted or adapted
require additional permission from the original source.) Because translations from English may not always be accurate or precise, ONS disclaims any
responsibility for inaccuracies in words or meaning that may occur as a result of the translation. Readers relying on precise information should check the
original English version.

Printed in the United States of America

Innovation • Excellence • Advocacy • Inclusivity

 Contributors

Editors

MiKaela Olsen, DNP, APRN-CNS, AOCNS®, FAAN Elizabeth Prechtel Dunphy, DNP, CRNP, BC, AOCN®
Clinical Program Director, Oncology Nurse Practitioner, Senior Advanced Practice Provider
Johns Hopkins Hospital and Johns Hopkins Health System Coordinator Gastrointestinal Malignancies
Baltimore, Maryland Abramson Cancer Center at Penn Presbyterian Medical Center
Chapter 6. Chemotherapy; Chapter 17. Pulmonary Toxicities Advanced Senior Lecturer B, Biobehavioral and Health Sciences
Division
Kristine B. LeFebvre, DNP, RN, NPD-BC, AOCN® University of Pennsylvania School of Nursing
Oncology Clinical Specialist Philadelphia, Pennsylvania
Oncology Nursing Society Chapter 17. Pulmonary Toxicities
Pittsburgh, Pennsylvania
Chapter 1. Professional Practice Considerations; Chapter 17.
Pulmonary Toxicities

Suzanne L. Walker, PhD, CRNP, BC, AOCN®

Senior Advanced Practice Provider
Abramson Cancer Center at Penn Presbyterian Medical Center
Advanced Senior Lecturer
Adult Oncology Specialty Minor/Post-Master’s Certificate
University of Pennsylvania School of Nursing
Philadelphia, Pennsylvania
Chapter 17. Pulmonary Toxicities

Authors
Kristine D. Abueg, RN, MSN, OCN®, CBCN® Tom K. Bauer, MBA, RT(R)
Clinical Research Nurse Senior Director of Patient Education and Engagement
Kaiser Permanente Johns Hopkins Health System
Roseville, California Baltimore, Maryland
Chapter 9. Principles of the Immune System Chapter 3. Patient Education

Mary K. Anderson, BSN, RN, OCN® Veronica Joyce Brady, PhD, MSN, FNP-BC, BC-ADM, CDCES
Oral Oncolytic Nurse Navigator Assistant Professor
Norton Cancer Institute University of Texas Houston Cizik School of Nursing
Louisville, Kentucky Houston, Texas
Chapter 4. Overview of Cancer and Cancer Treatment Chapter 22. Endocrine Toxicities

Fedricker D. Barber, PhD, ANP-BC, AOCNP®, FAANP, FAAN Kelly G. Bugos, MSN, RN, ANP-BC, NPD-BC, AOCNP®
Manager, Advanced Practice Providers, Investigational Cancer Director of Advanced Practice-APP Fellowship and
Therapeutics Professional Development
University of Texas MD Anderson Cancer Center Center for Advanced Practice
Houston, Texas Stanford Health Care
Chapter 9. Principles of the Immune System Stanford, California
Chapter 26. Post-Treatment and Survivorship Care

iii
iv Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

Bradley Burton, PharmD, BCOP Jennifer Hadjar, MSN, RN, OCN®

Patient Safety Scientist, Oncology Director of Nursing
AstraZeneca Ambulatory Pediatric Hematology & Oncology
Gaithersburg, Maryland Ambulatory Adult Malignant Hematology
Chapter 7. Hormone Therapy Section of Transplant and Cell Therapy in the Division of Blood
Disorders
Donna Copeland, DNP, RN, NE-BC, CPN, CPON®, AE-C Rutgers Cancer Institute of New Jersey
Assistant Professor Chapter 20. Altered Sexual and Reproductive Functioning
University of South Alabama
Mobile, Alabama Natalie Jackson, APRN, FNP-C
Chapter 15. Gastrointestinal and Mucosal Toxicities Advanced Practice Nurse
University of Texas MD Anderson Cancer Center
Megan Corbett, MSN, RN, NPD-BC, OCN® Houston, Texas
Clinical Specialist Chapter 10. Immunotherapy
Dana-Farber Cancer Institute
Boston, Massachusetts Catherine Jansen, PhD, RN, AOCNS®
Chapter 13. Infusion-Related Complications Oncology Clinical Nurse Specialist
The Permanente Medical Group
Kerri A. Dalton, DNP, RN, AOCNS® San Francisco, California
Oncology Clinical Nurse Specialist Chapter 24. Neurologic Toxicities
Duke University Health System
Durham, North Carolina Alice S. Kerber, MN, APRN, ACNS-BC, AOCN®, ACGN
Chapter 15. Gastrointestinal and Mucosal Toxicities Oncology and Genetics Nurse Specialist
Atlanta, Georgia
Erin Dickman, MS, RN, OCN® Chapter 2. Ethical and Legal Issues
Oncology Clinical Specialist
Oncology Nursing Society Jerrica Knight-Doneghy, PS, PharmD
Pittsburgh, Pennsylvania Midland, Texas
Chapter 4. Overview of Cancer and Cancer Treatment Chapter 7. Hormone Therapy

Rebecca L. Duchman, MSN, MA, RN, NEA-BC Tracy Krause, BS, PharmD, BCOP
Director, Infusion/Treatment Services Unit-Based Clinical Pharmacist/Oncology Clinical Pharmacy Spe-
Nebraska Medicine, Buffett Cancer Center cialist
Omaha, Nebraska Hospital of the University of Pennsylvania
Chapter 24. Neurologic Toxicities Philadelphia, Pennsylvania
Chapter 10. Immunotherapy
Anecita Fadol, PhD, FNP-BC, FAANP, FAAN
Associate Professor, Departments of Nursing and Cardiology Brendan Mangan, PharmD, BCOP
University of Texas MD Anderson Cancer Center Hematology/Oncology Clinical Pharmacy Specialist
Houston, Texas Hospital of the University of Pennsylvania
Chapter 16. Cardiovascular Toxicities Philadelphia, Pennsylvania
Chapter 10. Immunotherapy
Dane Fritzsche, PharmD, BCOP
Oncology Clinical Pharmacist Ashley L. Martinez, NPD-BC, DNP, APRN, FNP-BC, AOCNP®,
University of Washington Medicine Fred Hutchinson Cancer Cen- CBCN®, CPHQ, NEA-BC
ter Director, Advanced Practice
Clinical Instructor University of Texas MD Anderson Cancer Center
University of Washington School of Pharmacy Houston, Texas
Seattle, Washington Chapter 10. Immunotherapy
Chapter 6. Chemotherapy
Alice Maupin, MSN, RN, AGCNS-BC, OCN®
RuthAnn Gordon, MSN, FNP-BC, OCN® Oncology Nurse Leader
Director, Clinical Trials Nursing Duke University Health System
Memorial Sloan Kettering Cancer Center Durham, North Carolina
New York, New York Chapter 15. Gastrointestinal and Mucosal Toxicities
Chapter 10. Immunotherapy
Sandra A. Mitchell, PhD, CRNP, AOCN®, FAAN
Theresa Gorman, MSN, RN, AOCNS®, BMTCN® Senior Scientist and Program Director
Quality Assurance Coordinator Outcomes Research Branch, Healthcare Delivery Research Pro-
Thomas Jefferson University Hospital gram
Philadelphia, Pennsylvania Division of Cancer Control and Population Sciences
Chapter 19. Genitourinary Toxicities National Cancer Institute
Rockville, Maryland
Chapter 23. Fatigue
 Contributors v

Kathy Mooney, MSN, RN, ACNS-BC, BMTCN®, OCN® Mary L. Schmitt, MS, APRN, FNP-BC, AOCNP®
Oncology Clinical Nurse Specialist Oncology Nurse Practitioner
Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins St. Joseph Hospital
Hospital Nashua, New Hampshire
Baltimore, Maryland Chapter 4. Overview of Cancer and Cancer Treatment
Chapter 21. Cutaneous Toxicities and Alopecia
Gary E.B. Shelton, DNP, MSN, NP, ANP-BC, AOCNP®
Amy E. Moore, MSN, RN, AOCNS®, WTA-C Adult Health Nurse Practitioner and Oncology Clinical Nurse Spe-
Clinical Nurse Specialist, Oncology/Autologous Bone Marrow cialist
Transplantation Mount Sinai Health System
Hospital of the University of Pennsylvania New York, New York
Philadelphia, Pennsylvania Chapter 25. Ocular Toxicities
Chapter 19. Genitourinary Toxicities
Lisa Hartkopf Smith, MS, RN, AOCN®, CHPN
Marylou Nesbitt, MS, RN, AOCN® Oncology Clinical Nurse Specialist
Clinical Specialist Ohio Health Riverside Methodist Hospital
Dana-Farber Cancer Institute Columbus, Ohio
Boston, Massachusetts Chapter 1. Professional Practice Considerations; Chapter 11.
Chapter 13. Infusion-Related Complications Administration Considerations

Elizabeth Ness, MS, BSN, RN, CRN-BC Caroll C. Tipian, MSN, RN, AGACNP-BC
Director, Office of Education and Compliance Adult Bone Marrow Transplant and Cellular Therapy Advanced
Center for Cancer Research Practice Provider
National Cancer Institute Memorial Sloan Kettering Cancer Center
National Institutes of Health New York, New York
Bethesda, Maryland Chapter 10. Immunotherapy
Chapter 5. Clinical Trials and Drug Development
AnnMarie L. Walton, PhD, MPH, RN, OCN®, CHES, FAAN
Shan Li O’Connor, PharmD, BCOP Associate Professor
Hematology Medical Science Liaison WA/AK Duke University School of Nursing
AbbVie US Medical Affairs Durham, North Carolina
Mettawa, Illinois Chapter 12. Safe Handling of Hazardous Drugs
Chapter 6. Chemotherapy
Justine Wang, PharmD, BCPS
Kim Peterson, MSN, APRN-CNS, ACCNS-AG, OCN® Clinical Pharmacy Specialist
Ambulatory Oncology Nurse Manager Pharmacy Clinical Programs
Marlene and Stewart Greenebaum Comprehensive Cancer University of Texas MD Anderson Cancer Center
Center Houston, Texas
University of Maryland Medical Center Chapter 16. Cardiovascular Toxicities
Baltimore, Maryland
Chapter 15. Gastrointestinal and Mucosal Toxicities Jaime Weimer, MSN, RN, AGCNS-BC, AOCNS®
Oncology Clinical Specialist
Michelle Y. Ranaghan, MSN, RN, CRNI®, OCN® Oncology Nursing Society
Clinical Specialist Pittsburgh, Pennsylvania
Dana-Farber Cancer Institute Chapter 15. Gastrointestinal and Mucosal Toxicities
Boston, Massachusetts
Chapter 13. Infusion-Related Complications Barbara J. Wilson, MS, RN, AOCN®, ACNS-BC
Director, Oncology Professional Practice
Zandra R. Rivera, DNP, APRN, ANP-BC, BMTCN® Wellstar Cancer Network
Supervisor, Advanced Practice Provider, Stem Cell Transplanta- Marietta, Georgia
tion Chapter 14. Myelosuppression
University of Texas MD Anderson Cancer Center
Houston, Texas Laurie Winkelbauer, BSN, RN, OCN®
Chapter 18. Hepatic Toxicities Manager, Infusion/Treatment Services
Nebraska Medicine, Buffett Cancer Center
Danielle Roman, PharmD, BCOP Omaha, Nebraska
Manager, Clinical Pharmacy Services Chapter 24. Neurologic Toxicities
PGY2 Oncology Pharmacy Residency Program Director
Allegheny Health Network Cancer Institute
Pittsburgh, Pennsylvania
Chapter 8. Targeted Therapy
vi Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

Disclosure
Editors and authors of books and guidelines provided by the Oncology Nursing Society are expected to disclose to the readers any
significant financial interest or other relationships with the manufacturer(s) of any commercial products.
A vested interest may be considered to exist if a contributor is affiliated with or has a financial interest in commercial organizations
that may have a direct or indirect interest in the subject matter. A “financial interest” may include, but is not limited to, being a share-
holder in the organization; being an employee of the commercial organization; serving on an organization’s speakers bureau; or receiving
research funding from the organization. An “affiliation” may be holding a position on an advisory board or some other role of benefit to
the commercial organization. Vested interest statements appear in the front matter for each publication.
Contributors are expected to disclose any unlabeled or investigational use of products discussed in their content. This information
is acknowledged solely for the information of the readers.
The contributors provided the following disclosure and vested interest information:
MiKaela Olsen, DNP, APRN-CNS, AOCNS®, FAAN: Beckinson, Dickinson and Company, honoraria
Kristine B. LeFebvre, DNP, RN, NPD-BC, AOCN®: American Nurses Credentialing Center, consultant or advisory role
Elizabeth Prechtel Dunphy, DNP, CRNP, BC, AOCN®: Incyte, honoraria
Bradley Burton, PharmD, BCOP: AstraZeneca, stock ownership
Alice S. Kerber, MN, APRN, ACNS-BC, AOCN®, ACGN: Myriad Genetics, Pfizer, honoraria
Ashley L. Martinez, DNP, APRN, FNP-BC, AOCNP®, CBCN®: American Nurses Credentialing Center, Curio, consultant or advisory role

Licensing Opportunities
The Oncology Nursing Society (ONS) produces some of the most highly respected educational resources in the field of oncology nursing,
including ONS’s award-winning journals, books, online courses, evidence-based resources, core competencies, videos, and information
available on the ONS website at www.ons.org. ONS welcomes opportunities to license reuse of these intellectual properties to other
organizations.

Licensing opportunities include the following:

• Reprints—Purchase high-quality reprints of ONS journal articles, book chapters, and other content directly from ONS, or obtain per-
mission to produce your own reprints.
• Translations—Translate and then resell or share ONS resources internationally.
• Integration—Purchase a license to incorporate ONS’s oncology-specific telephone triage protocols or other resources into your
institution’s EMR or EHR system.
• Cobranding—Display your company’s logo on ONS resources for distribution to your organization’s employees or customers.
• Educational reuse—Supplement your staff or student educational programs using ONS resources.
• Customization—Customize ONS intellectual property for inclusion in your own products or services.
• Bulk purchases—Buy ONS books and online courses in high quantities to receive great savings compared to regular pricing.

As you read through the pages of this book, think about whether any of these opportunities are the right fit for you as you consider reusing
ONS content—and the contents of this book—for your organization.
Contact [email protected] with your licensing questions or requests.
 Contents

PREFACE......................................................................................................... IX C. Chemotherapy classifications...............................................................68

D. Combination chemotherapy principles..............................................98
SECTION I. PROFESSIONAL PRACTICE CONSIDERATIONS.............. 1 References...........................................................................................................98

Chapter 1. Professional Practice Considerations.................................... 3 Chapter 7. Hormone Therapy.....................................................................101

A. Scope and standards.................................................................................. 3 A. Hormone therapy in the treatment of cancer...............................101
B. Professional education............................................................................... 3 B. Cancers treated with hormone therapy..........................................101
C. Policies and procedures............................................................................. 5 C. Hormone treatment categories.........................................................107
D. Antineoplastic medication safety........................................................... 6 References........................................................................................................110
E. Quality and safety monitoring.................................................................. 9
Chapter 8. Targeted Therapy......................................................................113
References............................................................................................................. 9
A. Targeted therapies in the treatment of cancer.............................113
Chapter 2. Ethical and Legal Issues.............................................................13 B. Adverse effects of targeted therapies............................................199
A. Ethical issues................................................................................................13 C. Drug–drug interactions.........................................................................199
B. Legal issues related to cancer therapy..............................................16 References........................................................................................................199
References...........................................................................................................19
Chapter 9. Principles of the Immune System........................................203
Chapter 3. Patient Education.........................................................................21 A. Overview of immunology......................................................................203
A. Patient education overview....................................................................21 B. Types of immune response.................................................................203
B. Short-term outcomes of patient education.....................................21 C. Organs of the immune system...........................................................204
C. Long-term outcomes of patient education......................................21 D. Cells of the immune system........................................................... 205
D. Barriers to patient education.................................................................22 E. Immune system proteins and receptors.........................................206
E. Methods of patient education...............................................................23 F. Phases of immune response...............................................................208
F. Scope of information.................................................................................24 G. Tumor escape mechanisms.................................................................208
G. Documentation............................................................................................24 References........................................................................................................210
References...........................................................................................................25
Chapter 10. Immunotherapy.......................................................................213
A. Overview.....................................................................................................213
SECTION II. CANCER AND CANCER TREATMENT...............................27 B. Modalities of immunotherapy.............................................................213
C. General patient and family education..............................................287
Chapter 4. Overview of Cancer and Cancer Treatment.......................29
References........................................................................................................287
A. Definition of cancer...................................................................................29
B. The Cancer Care Continuum framework...........................................31
C. Cancer staging and grading...................................................................33 SECTION IV. TREATMENT ADMINISTRATION AND SAFETY......... 291
D. Cancer treatment modalities.................................................................33
E. Treatment approaches.............................................................................37 Chapter 11. Administration Considerations..........................................293
F. Treatment strategies.................................................................................37 A. Components of safe and effective administration of
G. Measuring response..................................................................................39 cancer therapies......................................................................................293
H. Factors affecting treatment response................................................42 B. Pretreatment.............................................................................................293
I. Adherence.....................................................................................................44 C. Chemotherapy, targeted therapy, and immunotherapy
J. Toxicity grading and documentation...................................................48 dosing..........................................................................................................303
References...........................................................................................................49 D. Verification.................................................................................................306
E. Routes of chemotherapy, immunotherapy, and targeted
Chapter 5. Clinical Trials and Drug Development...................................53 therapy administration...........................................................................308
A. Clinical research..........................................................................................53 References .......................................................................................................334
B. Drug and biologic development process..........................................58
C. Expanded access ......................................................................................63 Chapter 12. Safe Handling of Hazardous Drugs..................................341
References...........................................................................................................63 A. Safe handling and disposal of hazardous drugs..........................341
B. Definition.....................................................................................................341
SECTION III. CANCER THERAPEUTICS..................................................65 C. Antineoplastic drugs..............................................................................341
D. NIOSH List of Antineoplastic and Other Hazardous Drugs
Chapter 6. Chemotherapy ..............................................................................67 in Healthcare Settings............................................................................342
A. Chemotherapy in the treatment of cancer........................................67 E. NIOSH List of Hazardous Drugs in Healthcare Settings...........342
B. Classification of chemotherapy agents.............................................68 F. Immunotherapy........................................................................................343

vii
viii Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

G. Routes of occupational exposure.....................................................343 E. Clinical manifestations..........................................................................584

H. Hierarchy of hazard controls...............................................................344 F. Pathologic manifestations associated with drug toxicity.........604
I. Guidelines for personal protective equipment.............................344 G. Assessment...............................................................................................606
J. Storage and labeling...............................................................................345 H. Collaborative management.................................................................608
K. Safe handling precautions during compounding........................347 I. Patient and family education...............................................................609
L. Transporting HDs.....................................................................................349 References........................................................................................................610
M. Safe handling precautions during administration.......................349
N. Special precautions for radiopharmaceuticals............................350 Chapter 19. Genitourinary Toxicities........................................................615
O. Handling body fluids...............................................................................350 A. Overview.....................................................................................................615
P. Handling patient linens..........................................................................351 B. Antineoplastic-associated genitourinary toxicities....................615
Q. Disposal of hazardous drugs and materials contaminated C. Drug-specific considerations.............................................................636
with hazardous drugs.............................................................................351 References........................................................................................................638
R. Procedures following acute hazardous drug exposure.............351 Chapter 20. Altered Sexual and Reproductive Functioning.............643
S. Spill management....................................................................................352 A. Alterations in sexual functioning........................................................643
T. Requirements for policies regarding the handling of B. Alterations in reproductive functioning...........................................650
hazardous drugs......................................................................................353 References........................................................................................................653
References........................................................................................................354
Chapter 21. Cutaneous Toxicities and Alopecia..................................657
Chapter 13. Infusion-Related Complications........................................359 A. Cutaneous toxicity..................................................................................657
A. Complications during or shortly after parenteral B. Alopecia......................................................................................................677
administration of cancer treatment..................................................359 References........................................................................................................681
B. Extravasation of vesicants resulting in potential
tissue damage..........................................................................................359 Chapter 22. Endocrine Toxicities...............................................................685
C. Irritation.......................................................................................................366 A. Overview.....................................................................................................685
D. Flare reaction.............................................................................................370 B. Drug-specific endocrinopathies........................................................685
E. Acute infusion-related reactions.......................................................370 C. Immune checkpoint inhibitor–related endocrinopathies.........694
F. Patient and caregiver education........................................................397 References........................................................................................................699
References........................................................................................................397
Chapter 23. Fatigue........................................................................................703
A. Overview.....................................................................................................703
SECTION V. TREATMENT-RELATED COMPLICATIONS................... 403 B. Pathophysiology......................................................................................703
Chapter 14. Myelosuppression..................................................................405 C. Incidence....................................................................................................705
A. Overview.....................................................................................................405 D. Assessment...............................................................................................705
B. Types of cytopenias...............................................................................406 E. Collaborative management.................................................................706
References........................................................................................................421 F. Principles of patient and family education and care planning.... 710
References........................................................................................................711
Chapter 15. Gastrointestinal and Mucosal Toxicities.........................425
A. Nausea and vomiting..............................................................................425 Chapter 24. Neurologic Toxicities ............................................................717
B. Anorexia and cachexia...........................................................................442 A. Overview.....................................................................................................717
C. Diarrhea.......................................................................................................446 B. Radiation-induced central nervous system toxicity...................717
D. Colitis...........................................................................................................457 C. Radiation-induced peripheral nervous system toxicity............725
E. Pancreatitis................................................................................................465 D. Chemotherapy-induced central nervous system toxicity........726
F. Mucositis.....................................................................................................467 E. Peripheral neuropathy...........................................................................735
G. Perirectal cellulitis...................................................................................475 F. Common antineoplastics conferring increased neurotoxicity....736
H. Constipation..............................................................................................476 G. Risk factors and prophylaxis...............................................................739
References........................................................................................................483 H. Cognitive impairment.............................................................................739
I. Patient and family education...............................................................744
Chapter 16. Cardiovascular Toxicities.....................................................493 References........................................................................................................746
A. Overview.....................................................................................................493
B. Conduction pathway disorders..........................................................493 Chapter 25. Ocular Toxicities......................................................................753
C. Vascular abnormalities..........................................................................530 A. Overview ....................................................................................................753
D. Venous thromboembolism...................................................................532 B. Pathophysiology......................................................................................753
E. Coronary artery disease.......................................................................532 C. Incidence....................................................................................................757
F. Left ventricular dysfunction and heart failure...............................534 D. Risk factors................................................................................................757
G. Myocarditis.................................................................................................537 E. Clinical manifestations..........................................................................757
References........................................................................................................539 F. Assessment...............................................................................................757
G. Collaborative management.................................................................767
Chapter 17. Pulmonary Toxicities..............................................................543 H. Patient and family education...............................................................767
A. Overview.....................................................................................................543 References........................................................................................................767
B. Interstitial lung disease..........................................................................543
C. Diffuse alveolar hemorrhage...............................................................573 SECTION VI. POST-TREATMENT........................................................... 771
D. Acute promyelocytic leukemia treatment–related
differentiation syndrome......................................................................574 Chapter 26. Post-Treatment and Survivorship Care...........................773
E. Pleural effusions......................................................................................575 A. Overview.....................................................................................................773
F. Patient and family education...............................................................576 B. Cancer survivorship care......................................................................774
References........................................................................................................577 C. Long-term and late effects of cancer treatment.........................775
References........................................................................................................786
Chapter 18. Hepatic Toxicities....................................................................583
A. Overview.....................................................................................................583
B. Pathophysiology......................................................................................583 APPENDICES.............................................................................................. 791
C. Incidence....................................................................................................584
D. Risk factors................................................................................................584 INDEX........................................................................................................... 803
 Preface

Oncology nursing is a unique specialty that requires continuous learning to stay up to date on cancer pathophysiology,
cutting-edge drugs, and the evidence-based management of cancer and cancer treatment–related toxicities. The Oncology
Nursing Society’s (ONS’s) second edition of Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice
provides nurses with the tools to understand how medications are used in cancer treatment, the effect of medication-related
toxicities, and evidence-based recommendations to manage and treat these toxicities. This edition features many new can-
cer therapies approved since the 2019 publication. Each drug is categorized as chemotherapy, hormone, targeted, or immu-
notherapy agents. Extensive drug tables in the book provide nurses with tips for managing patients receiving these drugs.
The expansion of oral antineoplastic therapies, alone or in combination with infusion therapy, requires that nurses review a
patient’s complete cancer treatment plan and consider the side effects, toxicities, and adherence to oral drugs to ensure patient
tolerance and efficacy.
This second edition has seen content expanded on the topic of genomics as we move forward in the world of personal-
ized oncology. Health equity is approached with information discussing financial distress, cultural disparities, and health lit-
eracy. The latest guidelines and recommendations for treatment, symptom management, and survivorship have been inte-
grated into this new text.
This edition features a QR code, provided with the purchase of this book, to download periodic drug updates. You will see
new evidence related to many aspects of cancer nursing care incorporated into this edition, such as hypersensitivity response,
safe handling of hazardous drugs, and more.
The editors want to thank all of the contributors who worked tirelessly, despite a pandemic, to make this new edition a
reality. This work builds on the knowledge of many generations of oncology nurses and has been used nationally and inter-
nationally to guide oncology nursing practice. We are proud to continue to serve oncology nurses worldwide with an essen-
tial resource to guide their practice.
MiKaela Olsen, DNP, APRN-CNS, AOCNS®, FAAN
Kristine B. LeFebvre, DNP, RN, NPD-BC, AOCN®
Suzanne L. Walker, PhD, CRNP, BC, AOCN®
Elizabeth Prechtel Dunphy, DNP, CRNP, BC, AOCN®

ix
Please scan the QR code to the right to receive
periodic updates to select drug tables listed within this
book. These updates will help oncology nurses stay up
to date with current research and findings related to
chemotherapy and immunotherapy guidelines.
 SECTION I

Professional Practice
Considerations
Chapter 1. Professional Practice Considerations
Chapter 2. Ethical and Legal Issues
Chapter 3. Patient Education
 CHAPTER 1

Professional Practice
Considerations

A. Scope and standards must demonstrate an understanding of the follow-

1. The safe administration of antineoplastic treatments ing (ONS, 2020):
in various settings is within the oncology nurse’s a) Types of antineoplastic medications, classifica-
scope of practice (Lubejko & Wilson, 2019). tions, and routes of administration
2. Professional nursing practice is defined and overseen b) Pharmacology of agents regardless of indications
through regulatory influencers and five integral com- for use
ponents (American Nurses Association, 2021). c) Pertinent molecular biomarkers, including
a) Evidence incorporates scientific and research genomic assays
findings, the expertise of the nurse, and the pref- d) Chemotherapy and radiation therapy protectants
erences of the individual. e) Principles of safe preparation, storage, labeling,
b) Nursing practice is the autonomous actions of the transportation, and disposal of agents
professional nurse in any role. f) Safe administration procedures
c) Influencers include state nurse practice acts, the g) Procedures for safe handling of hazardous drugs,
scope and standards that guide practice and spe- including spill management
cialty practice, and institutional policies and pro- h) Appropriate use and disposal of personal protec-
cedures. tive equipment
d) Safety measures protect the patient from harm or i) Use of engineering controls, if applicable to the
undesirable outcomes. practice setting, including the use of closed-
e) Quality strives to obtain desirable outcomes of system drug-transfer devices
nursing practice for patients, families, the orga- j) Assessment, monitoring, and management of
nization, and the profession. patients receiving therapy
3. In 2008, the American Society of Clinical Oncol- k) Medication safety and system safeguards, such as
ogy (ASCO) and the Oncology Nursing Society infusion pump safety features
(ONS) began an ongoing collaboration to define and l) Appropriate procedures for emergency prepared-
later revise safety standards for chemotherapy and ness, including infusion reactions and extravasation
other antineoplastic agents. The ASCO/ONS Chemo- m) Appropriate documentation of treatment
therapy Administration Safety Standards addressed administration, patient education, and planned
staffing-related issues, antineoplastic therapy plan- follow-up care and testing
ning, documentation, orders, preparation, patient n) Patient, family, and caregiver education for these
education, administration, and monitoring for all agents, specific to side effects and related symp-
settings and patient populations (Neuss et al., 2016). tom management, and the process for urgent and
ongoing follow-up
B. Professional education o) Education and coordination of post-treatment
1. To promote a safe level of care for individuals receiv- care and testing, adverse events, and long-term
ing chemotherapy, targeted therapy, and immuno- side effects; physical and psychosocial impacts of
therapy, each institution or supporting agency should a cancer diagnosis and treatment; and follow-up
provide specialized education and preparation con- care during survivorship
sisting of didactic learning followed by successful 3. Clinical practicum
completion of a clinical practicum (ONS, 2020). a) The clinical practicum allows the nurse to apply
2. Didactic content is comprehensive, current, and the knowledge gained in the didactic component
evidence based. After the didactic course, a nurse to direct patient care situations.
3
4 Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

b) Emphasis is placed on the clinical skills that the cation and training. Alternative methods can be
nurse must demonstrate prior to being deemed used, including the following:
competent to administer antineoplastic therapy (1) Contracting with larger institutions for
(see Appendices A and B). The nurse must also didactic education or clinical experience
display knowledge of organizational policies and for specific learning needs (e.g., vesicant,
procedures related to antineoplastic administra- nonvesicant, IV push, short infusion, con-
tion. tinuous infusion)
c) After the clinical practicum, the nurse will be (2) Creating or using a simulated laboratory
able to perform the following: to substitute for the clinical component
(1) Demonstrate proficiency regarding safe (3) Providing virtual simulation designed to
preparation (when applicable), storage, meet specific learning objectives (Konrad
transport, handling, spill management, et al., 2021)
administration, and disposal of antineo- 5. Use an evaluation tool based on the desired out-
plastic drugs and equipment. comes to document the nurse’s knowledge of and
(2) Identify appropriate physical and labora- competency in the following:
tory assessments for specific agents. a) Agents and associated nursing implications
(3) Demonstrate skill in venipuncture, includ- b) Technical skills required for the administration
ing vein selection and maintenance of the of agents (e.g., dose calculation, venipuncture,
site during and after drug administration. access device management)
(4) Demonstrate skill in the care and use of c) Patient and family education about the treatment
various vascular access devices. regimen
(5) Identify patient and family educational d) Steps to take in the event of an untoward
needs related to agents. response following drug administration (e.g.,
(6) Identify acute local or systemic reactions, anaphylaxis, hypersensitivity reaction, extrava-
including extravasation and anaphylaxis, sation)
associated with antineoplastic drugs and 6. Competency may be verified in a simulated setting
identify appropriate interventions. (e.g., skills laboratory) or as a precepted experience
(7) Demonstrate proficiency in the safe in the clinical setting.
administration of hazardous drugs and a) The evaluation or documentation tool should
disposal of contaminated waste and equip- meet the needs of the new nurse and the prac-
ment. tice setting, including a minimum number of
(8) Document pertinent information in the observed and documented antineoplastic drug
medical record. administrations.
4. Clinical activities b) Observed administration of at least three differ-
a) Pair a nurse new to antineoplastic drug adminis- ent agents, types, and routes (i.e., nonvesicant
tration with an experienced nurse who can serve and vesicant; IV push and short-term infusion)
as a preceptor and provide clinical supervision is recommended.
and instruction (Lockhart, 2016). c) Competency for nontechnical skills, such
b) The preceptor and the nurse establish specific as patient education, may be verified by
objectives at the beginning of the clinical pract- role-playing, case scenarios, and observation
icum. Ideally, the nurse and preceptor select (Wahl, 2017).
a patient assignment. The nurse assumes the 7. Annual continuing education and ongoing compe-
responsibility for planning and providing care tency assessment are required for staff who order,
for this patient under the guidance and supervi- prepare, and administer antineoplastic agents (Neuss
sion of the preceptor. et al., 2016).
c) The time spent in the clinical practicum is depen- a) Educational content should be designed to meet
dent on the nurse’s ability to meet specific objec- the needs of staff in the healthcare setting (e.g.,
tives and institutional requirements. identified practice problems; high-risk, low vol-
d) The nurse should become proficient and inde- ume procedures), and new information should
pendent in administering nonvesicants before be emphasized (Wahl, 2017).
progressing to vesicant administration. (1) Methods that may be used to identify
e) Various clinical settings can be used for the nurse needs include but are not limited to staff
to demonstrate competency in antineoplastic or patient surveys, chart audits, quality
drug administration. It may not be realistic for improvement studies, clinical observa-
all settings or agencies to provide on-site edu- tion, and literature review.
 Chapter 1. Professional Practice Considerations 5

(2) Potential topics include new drugs or drug side effects, toxicity, dosage range, rate of admin-
deliveries, reinforcement or training on istration, route of excretion, potential responses,
policies and procedures, and prevention and interactions with other medications and
and management of treatment toxicities. foods.
b) Competency assessment is ongoing, may be done c) The format, length, and specific focus of educa-
by peers or supervisory staff, and is measured in tional initiatives, both didactic education and
several ways (Lockhart, 2016; Wahl, 2017). clinical experience, may vary according to the
(1) Testing needs of the staff and setting. Select staff may
(a) Provide a packet of articles for the require drug- or disease-specific education,
staff to read or a live educational pro- whereas others require comprehensive educa-
gram followed by an open-book test tion for all antineoplastic medications.
to measure knowledge. d) The educational plan should be addressed for all
(b) Consider a pretest and post-test to individuals working with antineoplastic therapy
measure individual knowledge gains. within institutional policy.
(2) Return demonstration
(a) Competency checklists can be used C. Policies and procedures
to document the performance of 1. Policies should be developed using a systematic,
technical skills, such as the donning evidence-based approach to promote standardiza-
and doffing of personal protective tion of practice within an institution.
equipment used during drug admin- a) Policies identify and communicate practice
istration. expectations (Dols et al., 2017).
(b) Staff can also be observed and eval- b) Procedures are a step-by-step guide to perform-
uated using a scoring rubric with ing a specific task or operation (Esparza, 2019).
a checklist of criteria detailing the 2. Once a policy has been implemented, it must be
steps to take in practice. enforced and followed by staff.
(c) Examples include monitoring a nurse a) Individuals can be held liable if patient harm
administering a vesicant or complet- results from failure to follow a policy.
ing dose verification. b) Institutions can have liability if a policy is
(d) Actions can be observed in a practice unclear, contrasts with another policy, or could
or simulated environment and later be interpreted incorrectly.
debriefed. 3. Review policies and procedures at least every two
(3) Simulation years to ensure the practice is current with changing
(a) Simulation provides a safe environ- technology and evidence (Esparza, 2019).
ment for staff to practice clinical and 4. Collaboration between departments and profession-
critical-thinking skills. als is recommended when creating antineoplastic
(b) Staff can face a clinical challenge and policies and procedures. Input from the pharmacy,
problem-solve the steps to be fol- medicine, nursing, environmental services, occupa-
lowed, such as a patient experiencing tional health, and other departments will result in a
an infusion reaction or extravasation. more comprehensive policy.
(c) Asking nurses, “What would you do 5. Policies related to antineoplastic drug therapy
if . . .” challenges them to consider address processes designed to promote the safe and
the implications of their actions. efficient care of patients receiving these medications
(d) When a simulation lab is unavailable, regardless of setting or department. Topics include
it can be performed using role-play the following (Institute for Safe Medication Practices
and mock scenarios in nearly any [ISMP], 2022; Neuss et al., 2016):
location. a) Qualifications, including initial educational and
8. Antineoplastic medications administered outside ongoing competency requirements, credential-
designated oncology areas ing process, and documentation of staff who
a) The ONS (2020) position statement on the edu- order, prepare, and administer antineoplastic
cation of the nurse administering and providing therapies
care to patients receiving antineoplastic therapy b) Hazardous drug management, including safe
applies to antineoplastic drugs regardless of indi- drug receipt, storage, compounding, transport,
cation, route, patient population, or setting. use of personal protective equipment, adminis-
b) All nurses should be knowledgeable about the tration, post-treatment care, spill management,
drugs they administer, including mode of action, disposal, alternative duty, and medical surveil-
6 Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

lance (Coyne et al., 2019; Polovich & Olsen, 2018; ventricular function in patients receiving trastu-
U.S. Pharmacopeial Convention, 2019) zumab
c) Order writing and dose verification, including 4. Medication errors can occur after patient discharge
process, standard regimens, rounding, cumula- from hospital settings.
tive dose, order format, and communication of a) Nearly 50% of adult and older adult patients had
modifications medication errors or unintentional medication
d) Informed consent process discrepancies after hospital discharge, and 20%
e) Standardized documentation tools for assess- reported adverse drug events (Alqenae et al.,
ment and care 2020).
f) Toxicity monitoring, including standardized doc- b) Supportive medications for chemotherapy and
umentation and communication of toxicities immunotherapy (e.g., leucovorin rescue, anti­
g) Procedures for care in medical emergencies diarrheal agents, steroids, antiviral agents) taken
h) Communication of status during transitions of incorrectly in the home setting can lead to seri-
care ous consequences.
i) Reporting of adverse events and near misses c) Patient education, clear instructions, and calen-
dars can help prevent errors (Reinhardt et al.,
D. Antineoplastic medication safety 2019).
1. Published research has found that chemotherapy 5. Contributing factors to medication errors (Fyhr et
errors occur in at least 1%–3% of adult and pediat- al., 2015; ISMP, 2020; Prakash et al., 2014; Sessions et
ric patients (Reinhardt et al., 2019; Weingart et al., al., 2019; World Health Organization, 2016)
2018). a) Poor communication among healthcare profes-
a) Reinhardt et al. (2019) found a higher incidence sionals or with patients
of chemotherapy errors (3.6%) for modified or b) Look-alike, sound-alike medications
nonstandard orders. c) Batching or preparing more than one agent at
b) Other situations identified as a higher risk for a time
error include carboplatin, regimens with three or d) Distractions and interruptions
more agents, and oral chemotherapy (Reinhardt e) Heavy workload, fatigue, or stress
et al., 2019; Weingart et al., 2018). f) Lack of systematic processes or failure to follow
2. Chemotherapy and other antineoplastic drugs are safety processes
classified as high-alert medications, regardless of set- g) Medication supply and storage issues (e.g., drugs
ting, by ISMP (2021). These medications have nar- of similar names or dosage strengths stored in
row therapeutic indices (i.e., benefit versus toxicity), close proximity)
multiple potential toxicities, and often are adminis- h) Equipment failure
tered in complex regimens, protocols, and schedules i) Inadequate knowledge or experience of those
(Griffin et al., 2016; Reinhardt et al., 2019; Weingart ordering, preparing, or administering agents
et al., 2018). j) Patient factors, including literacy, language bar-
3. Errors may occur at any point during the drug deliv- riers, and complexity of care
ery process (Ashokkumar et al., 2018; Reinhardt et k) Ordering errors when using the computer order
al., 2019; Tariq et al., 2021; Weingart et al., 2018). entry system (e.g., errors due to cut and paste)
a) Ordering or prescribing errors, including 6. The following strategies have been used to reduce the
unclear, incomplete, or erroneous orders; drug risk of medication errors in antineoplastic admin-
calculation; dose modification; omission of anti- istration (Billstein-Leber et al., 2018; Coyne et al.,
neoplastic or supportive drugs or hydration; 2019; Goldspiel et al., 2015; ISMP, 2022; Kuitunen et
input and transcription; errors in cycle or day; al., 2020; Neuss et al., 2016; ONS, 2020).
and cumulative dose documentation or tracking a) Develop policies and procedures using interpro-
b) Drug preparation errors, including staging or fessional collaboration. Include a risk assessment
loading a biosafety cabinet with incorrect equip- policy and strategies to promote adherence.
ment and supplies, rounding doses, reconstitu- b) Establish a process of educational preparation
tion, compounding, label application, and dis- and competency of those administering, pre-
pensing (Gilbert et al., 2018) paring, or ordering antineoplastic medications.
c) Drug administration errors, including incorrect Nurses administering antineoplastic agents are
drug or dose, schedule or timing, patient identi- qualified by education and training.
fication, infusion rate, and route c) Ensure current drug information and resources
d) Drug monitoring errors, including serum meth- for drug dosing, administration, and side effects
otrexate level and failure to detect declining left are readily available.
 Chapter 1. Professional Practice Considerations 7

d) Measure and document weight in kilograms and ity of information about drug doses and
height in centimeters. schedules, automatic calculation of medi-
e) Use smart infusion pumps and barcode technol- cation doses, and alert and error-checking
ogy when available. functions (Knols et al., 2020; Rahimi et al.,
f) Follow standards regarding antineoplastic med- 2018; Weingart et al., 2018).
ication orders. (a) Errors in prescribing continue to
(1) Orders are signed manually or by elec- occur with computerized prescriber
tronic approval by credentialed prescrib- order entry, including dose errors,
ers (ISMP, 2017a; Neuss et al., 2016). medication choice, incomplete pre-
(2) Advanced practice providers (e.g., clini- scriptions, failure to acknowledge
cal nurse specialists, nurse practitioners, electronic alerts, and failure to val-
physician assistants) identify prescribing idate orders.
as one of the most significant parts of their (b) These errors are amplified with new
role (Bruinooge et al., 2018). The ability or occasional prescribers and as the
to prescribe antineoplastic medications is complexity of a treatment regimens
determined by the practice location (state increases (Weingart et al., 2018).
and institution) and patient status. (7) A policy should be in place for prescrib-
(3) Verbal orders for chemotherapy, targeted ing antineoplastic regimens that vary from
therapy, and immunotherapy medications standard regimens. For example, the pre-
are not permitted, except to hold or stop scriber may be required to document sup-
drugs (ISMP, 2017a; Neuss et al., 2016). porting references for the variance.
(4) Text messaging of patient care orders is g) Use safety measures provided in electronic health
not permitted (ISMP, 2017b; Joint Com- record systems, such as drug interaction alerts,
mission, 2021). cumulative dose calculation (when applicable),
(5) Standardized electronic or preprinted and override restrictions (Rahimi et al., 2018;
orders should be used for antineoplastic Reinhardt et al., 2019). In a study examining
therapies (Neuss et al., 2016). chemotherapy errors and electronic prescribing,
(a) Orders should be regimen based and Reinhardt et al. (2019) found that 61% could be
include the elements outlined by cur- avoided through further software development.
rent safety standards. h) Require at least two approved practitioners to
Use of standardized, regimen-based perform dose and drug verification for all routes
preprinted or electronic orders has of delivery before preparation, upon preparation,
shown to increase evidence-based and prior to administering antineoplastic medi-
oncology care and decrease errors cations (Neuss et al., 2016).
(Coyne et al., 2019; Srinivasamurthy (1) Independent dual verification (i.e., inde-
et al., 2021). The National Compre- pendent double checks) is a process in
hensive Cancer Network (www.nccn which a second person verifies the accu-
.org) provides disease-specific guide- racy of a prescribed therapy without
lines and chemotherapy order tem- revealing their findings to the other veri-
plates that include suggested patient fier until both have completed the process
monitoring for cancer type and stage (ISMP, 2019).
(e.g., type and timing of imaging) (2) Numerous studies have demonstrated the
and treatment regimen (e.g., toxic- ability of independent double checks to
ity monitoring). See Appendix C for detect up to 95% of errors (Alsulami et
an example of a chemotherapy order al., 2012; ISMP, 2019).
template. (3) Identifying areas of vulnerability, train-
(b) Abbreviations, acronyms, and other ing staff, and using checklists promotes
ambiguous methods of communi- an effective and consistent process (ISMP,
cating drug information should be 2019; Macias et al., 2018; Schwappach et
avoided. al., 2018; see Appendix D).
(6) Safety advantages reported with the use of (4) Prior to administering antineoplas-
computerized prescriber order entry sys- tic agents, the treatment plan should be
tems, along with clinical decision support reviewed. Orders, medication, patient
systems, include the removal of interpre- identification, and pump programming
tation or transcription errors, availabil- must also be verified (Neuss et al., 2016).
8 Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

See Chapter 11 for more information on immediate intervention without waiting

dose verification. for the provider’s order, with indications
(5) Conducting a comprehensive review of for each medication clearly defined (e.g.,
the medication orders, including com- epinephrine, diphenhydramine, steroids)
paring the previous cycle rather than com- (Shaker et al., 2020).
paring the product to the order, is invalu- (7) All team members should understand
able in catching prescribing errors (ISMP, their role and responsibilities in an emer-
2019; Reinhardt et al., 2019). gency.
(6) Drug and dose verification must be per- (8) Verify that emergency equipment and
formed in a distraction-free setting. Using supplies, including oxygen, are available
timeout and speaking-out-loud checks at and working and that staff are aware of
drug administration has increased safety their location. Infusion chairs functional
(Coyne et al., 2019; Kalo et al., 2019; to change position are recommended if
Prakash et al., 2014). needed.
(7) Creative staffing models can minimize (9) Policies, procedures, and standardized
interruptions with dose verification (Bald- orders should be established, with anti-
win & Rodriguez, 2016). dotes in place to manage vesicant extrava-
(8) Practitioner dose verification combined sation (Neuss et al., 2016; see Chapter 13).
with automated double checks (e.g., bar- (a) Staff must be knowledgeable regard-
code scanning) may improve safety (ISMP, ing the management of extravasa-
2019; Macias et al., 2018). tion, the location of orders, and the
i) Procedures for emergency preparedness should process for obtaining antidotes.
be established. (b) Coupled order sets, such as the inclu-
(1) 24–7 triage should be provided (e.g., sion of an order on the antineoplastic
on-call practitioners, emergency depart- therapy order set (e.g., initiate extrav-
ments) (Neuss et al., 2016). asation orders for suspected extrav-
(2) At least one clinical staff member certified asation), permit the prompt and
in basic life support must be present dur- evidence-based management of emer-
ing chemotherapy administration. Staff gencies such as extravasation (ISMP,
certified in advanced cardiac life support 2010).
or pediatric advanced life support may be (10) Antidotes or rescue agents (where appli-
indicated depending on the setting and cable) with directions for use should be
treatment delivered (Neuss et al., 2016). readily available.
(3) When antineoplastics are administered (11) Process improvement projects and edu-
in the healthcare setting, a licensed inde- cational programs should be designed
pendent practitioner must be on site and to provide patients with prompt,
immediately available to staff (Centers for evidence-based interventions.
Medicare and Medicaid Services, 2020; (a) Evaluate previous emergent situa-
Neuss et al., 2016). tions to determine what worked and
(4) Policies, procedures, and standardized areas for improvement.
orders should be in place to manage med- (b) Consider running mock codes and
ical emergencies (ISMP, 2022; Neuss et infusion reaction drills. Numerous
al., 2016; Shaker et al., 2020). Procedures studies have shown that these drills
include the process for monitoring and increase practitioner proficiency
tracking the availability and readiness of and confidence and decrease anxiety
emergency equipment and the expiration (Josey et al., 2018; LeBoeuf & Pritch-
date on medications, including antidotes ett, 2020; Sharour, 2019).
and rescue agents. j) Standardized processes should be designed to
(5) Staff should be educated regarding who to promote effective communication and handoffs
call and the process for contacting the pro- between care providers and care sites for patients
vider or healthcare team (e.g., outpatient receiving antineoplastic therapy (Coyne et al.,
nurses need to be clear as to whether to 2019; Neuss et al., 2016).
contact 911 or the institution’s code team). (1) The highest safety risk times during drug
(6) Orders for the treatment of infusion administration should be identified to
emergencies should be available to enable allow for clear communication.
 Chapter 1. Professional Practice Considerations 9

(2) Safety is improved with open interprofes- (b) Labor costs are associated with seek-
sional communication and a clear under- ing replacement supplies, managing
standing of roles, responsibilities, account- inventory, updating computer sys-
ability, and a process to de-escalate problems. tems for replacement medications,
(3) Nursing bedside rounds and interprofes- and educating staff. These costs are
sional rounds have been found to increase estimated at $359 million per year
communication and decrease errors (Dan- (Kacik, 2019).
iels, 2016). (c) Financial and emotional burdens
(4) Any missed patient appointments or placed on patients can negatively
treatments should be documented, and affect patient satisfaction.
follow-up should occur with the patient b) The Food and Drug Administration Safety and
and other healthcare team members. Innovation Act of 2012 requires pharmaceutical
(5) An accurate treatment summary must companies to notify FDA when a product may be
be documented, including history, previ- affected by production changes or manufacturing
ous cancer treatments, and current treat- interruptions (U.S. FDA, 2018).
ment when a patient is transferred to a c) FDA (n.d.) works with manufacturers to mini-
different healthcare setting. The ASCO mize the impact of drug shortages. A list of drugs
Institute for Quality provides exam- in short supply is maintained on the FDA web-
ple templates on its website (www​.inst site (www.accessdata.fda.gov/scripts/drugshort
ituteforquality​ . org​ / cancer​ - treatment ages/default.cfm).
​-plan​-and​-summary​-templates).
k) Ongoing patient education should be provided, E. Quality and safety monitoring and improvement programs
including information, motivation, and encour- are encouraged in each practice setting (Neuss et al., 2016).
agement to patients to become vigilant partners 1. Third-party assessments in oncology related to the
in safety measures (Coyne et al., 2019; Weingart delivery of antineoplastic medications include the
et al., 2018). following organizations:
7. Drug shortages in oncology care are multifactorial. a) American College of Surgeons Commission on
Driving forces include low profitability for manu- Cancer (ACoS CoC)
facturers of generic drugs, decreased drug quality b) ASCO Quality Oncology Practice Initiative Cer-
in production, mergers of manufacturers, complex tification Program (QOPI)
supply chains, natural disasters, and regulatory chal- c) Foundation for the Accreditation of Cellular
lenges (Jacob, 2020). Therapy (FACT)
a) Drug shortages can have significant clinical 2. Quality monitoring is encouraged in each setting,
effects (Alpert & Jacobson, 2019; ISMP, 2018b; using internal and external data to establish bench-
Unguru, 2020; U.S. Food and Drug Administra- marks (ISMP, 2022). Topics for monitoring should
tion [FDA], n.d.). meet the needs of the practice setting. Examples
(1) Treatment outcomes can be affected by include the following:
omitted or reduced doses from delays or a) Oral oncolytic management, including adher-
changes in treatment regimens. ence, education, and prescribing processes
(2) Medication errors b) Care coordination, including communication at
(a) Healthcare providers may not know the transition of care
about substitute medications when the c) Access device management, including with infec-
preferred drug is unavailable, poten- tions and occlusions
tially resulting in errors in dosing, d) Drug administration, including medication
adverse effects, and drug interactions. errors, safe handling of hazardous drugs, extrav-
(b) A different concentration or brand is asation, and infusion reactions
purchased, potentially affecting how
the dose is prepared, dispensed, and
administered.
(c) Look-alike or sound-alike medica- References
tions are purchased from a different
Alpert, A., & Jacobson, M. (2019). Impact of oncology drug shortages on
manufacturer.
chemotherapy treatment. Clinical Pharmacology and Therapeutics,
(3) Increased costs 106(2), 415–421. https://doi.org/10.1002/cpt.1390
(a) Cost of replacement medications Alqenae, F.A., Steinke, D., & Keers, R.N. (2020). Prevalence and nature of
may be significant. medication errors and medication-related harm following discharge
10 Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

from hospital to community settings: A systematic review. Drug Safety, Institute for Safe Medication Practices. (2017b, November 17). ISMP sur-
43(6), 517–537. https://doi.org/10.1007/s40264-020-00918-3 vey raises concerns about safety of text messaging medical orders. https://​
Alsulami, Z., Conroy, S., & Choonara, I. (2012). Double checking the admin- www.ismp.org/sites/default/files/attachments/2017-11/NR20171117.pdf
istration of medicines: What is the evidence? A systematic review. Institute for Safe Medication Practices. (2018a, January 11). Drug shortages
Archives of Disease in Childhood, 97(9), 833–837. https://doi.org/10​ continue to compromise patient care. https://www.ismp.org/resources​
.1136/archdischild-2011-301093 /drug-shortages-continue-compromise-patient-care?id=1185
American Nurses Association. (2021). Nursing: Scope and standards of prac- Institute for Safe Medication Practices. (2018b, August 23). High-alert med-
tice (4th ed.). ications in acute care settings. https://www.ismp.org/recommendations​
Ashokkumar, R., Srinivasamurthy, S., Kelly, J.J., Howard, S.C., Parasuraman, /high-alert-medications-acute-list
S., & Uppugunduri, C.S. (2018). Frequency of chemotherapy medica- Institute for Safe Medication Practices. (2019, June 6). Independent dou-
tion errors: A systematic review. Journal of Pharmacology and Phar- ble checks: Worth the effort if used judiciously and properly. https://www​
macotherapeutics, 9(2), 86–91. https://doi.org/10.4103/jpp.JPP_61_18 .ismp.org/resources/independent-double-checks-worth-effort-if-used​
Baldwin, A., & Rodriguez, E.S. (2016). Improving patient safety with error -judiciously-and-properly
identification in chemotherapy orders by verification nurses. Clinical Institute for Safe Medication Practices. (2020, June 18). The differences
Journal of Oncology Nursing, 20(1), 59–66. https://doi.org/10.1188/16​ between human error, at-risk behavior, and reckless behavior are key
.CJON.59-65 to a just culture. https://www.ismp.org/resources/differences-between​
Billstein-Leber, M., Carrillo, J.D., Cassano, A.T., Moline, K., & Robertson, -human-error-risk-behavior-and-reckless-behavior-are-key-just
J.J. (2018). ASHP guidelines on preventing medication errors in hospi- -culture
tals. American Journal of Health-System Pharmacy, 75(19), 1493–1517. Institute for Safe Medication Practices. (2021, September 30). High-alert
Bruinooge, S.S., Pickard, T.A., Vogel, W., Hanley, A., Schenkel, C., Garrett- medications in community/ambulatory care settings. https://www.ismp​
Mayer, E., … Williams, S.F. (2018). Understanding the role of advanced .org/recommendations/high-alert-medications-acute-list
practice providers in oncology in the United States. Journal of Oncol- Institute for Safe Medication Practices. (2022, February 22). Targeted medi-
ogy Practice, 14(9), e518–e532. https://doi.org/10.1200/JOP.18.00181 cation safety best practices for hospitals. https://www.ismp.org/guidelines​
Centers for Medicare and Medicaid Services. (2020, May 8). Hospital outpa- /best-practices-hospitals.
tient therapeutic services that have been evaluated for a change in super- Jacob, E.C. (2020). Factors involved in U.S. generic drug shortages. U.S.
vision level. https://www.cms.gov/Medicare/Medicare-Fee-for-Service​ Pharmacist, 45(6), 19–24. https://www.uspharmacist.com/article/factors​
-Payment/HospitalOutpatientPPS/Downloads/Hospital-Outpatient​ -involved-in-us-generic-drug-shortages
-Therapeutic-Services.pdf Joint Commission. (2021, October 22). Texting: Use of secure text messag-
Coyne, E., Northfield, S., Ash, K., & Brown-West, L. (2019). Current evi- ing for patient care orders. https://www.jointcommission.org/standards​
dence of education and safety requirements for the nursing adminis- /standard-faqs/home-care/leadership-ld/000002173
tration of chemotherapy: An integrative review. European Journal of Josey, K., Smith, M.L., Kayani, A.S., Young, G., Kasperski, M.D., Farrer, P., …
Oncology Nursing, 41, 24–32. https://doi.org/10.1016/j.ejon.2019.05.001 Raschke, R.A. (2018). Hospitals with more-active participation in con-
Daniels, J.F. (2016). Purposeful and timely nursing rounds: A best prac- ducting standardized in-situ mock codes have improved survival after
tice implementation project. JBI Database of Systematic Reviews and in-hospital cardiopulmonary arrest. Resuscitation, 133, 47–52. https://​
Implementation Reports, 14(1), 248–267. https://doi.org/10.11124/jbisrir​ doi.org/10.1016/j.resuscitation.2018.09.020
-2016-2537 Kacik, A. (2019). Drug shortages drain at least $359M from health systems.
Dols, J.D., Muñoz, L.R., Martinez, S.S., Mathers, N., Miller, P.S., Pomerleau, Modern Healthcare. https://www.modernhealthcare.com/finance/drug​
T.A., … White, S. (2017). Developing policies and protocols in the age -shortages-drain-least-359m-health-systems
of evidence-based practice. Journal of Continuing Education in Nursing, Kalo, K., Karius, D., Bena, J.F., Morrison, S.L., & Albert, N.M. (2019). Che-
48(2), 87–92. https://doi.org/10.3928/00220124-20170119-10 motherapy safety: Reducing errors with a nurse-led time-out process.
Esparza, D.M. (Ed.). (2019). Oncology policies and procedures (2nd ed.). Clinical Journal of Oncology Nursing, 23(2), 197–202. https://doi.org/10​
Oncology Nursing Society. .1188/19CJON.197-202
Fyhr, A., Ternov, S., & Ek, A. (2015). From a reactive to a proactive safety Knols, B., Louws, M., Hardenbol, A., Dehmeshki, J., & Askari, M. (2020).
approach. Analysis of medication errors in chemotherapy using general The usability aspects of medication-related decision support systems in
failure types. European Journal of Cancer Care, 26(1), e12348. https://​ the inpatient setting: A systematic review. Health Informatics Journal,
doi.org/10.1111/ecc.12348 26(1), 613–627. https://doi.org/10.1177/1460458219841167
Gilbert, R.E., Kozak, M.C., Dobish, R.B., Bourrier, V.C., Koke, P.M., Kukreti, Konrad, S., Fitzgerald, A., & Deckers, C. (2021). Nursing fundamentals—
V., … Trbovich, P.L. (2018). Intravenous chemotherapy compounding Supporting clinical competency online during the COVID-19 pan-
errors in a follow-up pan-Canadian observations study. Journal of Oncol- demic. Teaching and Learning in Nursing, 16(1), 53–56. https://doi
ogy Practice, 14(5), e295–e303. https://doi.org/10.1200/JOP.17.00007 .org/10.1016/j.teln.2020.07.005
Goldspiel, B., Hoffman, J.M., Griffith, N.L., Goodin, S., DeChristoforo, Kuitunen, S.K., Niittynen, I., Airaksinen, M., & Holmström, A.-R. (2020).
R., Montello, M., … Patel, J.T. (2015). ASHP guidelines on prevent- Systemic defenses to prevent intravenous medication errors in hospi-
ing medication errors with chemotherapy and biotherapy. American tals: A systematic review. Journal of Patient Safety, 17(8), e1669–e1680.
Journal of Health-System Pharmacy, 72(8), e6–e35. https://doi.org/10​ https://doi.org/10.1097/PTS.0000000000000688
.2146/sp150001 LeBoeuf, J., & Pritchett, W. (2020). Mock drills: Implementation for emer-
Griffin, M.C., Gilbert, R.E., Broadfield, L.H., Easty, A.E., & Trbovich, P.L. gency scenarios in the outpatient setting. Clinical Journal of Oncology
(2016). ReCAP: Comparison of independent error checks for oral ver- Nursing, 24(1), E7–E12. https://doi.org/10.1188/20.CJON.E7-E12
sus intravenous chemotherapy. Journal of Oncology Practice, 12(2), 168– Lockhart, J.S. (2016). Nursing professional development for clinical educators.
169, e180–e187. https://doi.org/10.1200/jop.2015.005892 Oncology Nursing Society.
Institute for Safe Medication Practices. (2010, January 10). ISMP’s guide- Lubejko, B.G., & Wilson, B.J. (2019). Oncology nursing scope and standards
lines for standard order sets. https://www.ismp.org/guidelines/standard​ of practice. Oncology Nursing Society.
-order-sets Macias, M., Bernabeu-Andreu, F.A., Arribas, I., Navarro, F., & Baldominos,
Institute for Safe Medication Practices. (2017a, May 18). Despite technology, G. (2018). Impact of a barcode medication administration system on
verbal orders persist, read back is not widespread, and errors continue. patient safety. Oncology Nursing Forum, 45(1), E1–E13. https://doi.org​
https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=1167 /10.1188/18.ONF.E1-E13
 Chapter 1. Professional Practice Considerations 11

Neuss, M.N., Gilmore, T.R., Belderson, K.M., Billett, A.L., Conti-Kalchik, Shaker, M.S., Wallace, D.V., Golden, D.B.K., Oppenheimer, J., Bernstein,
T., Harvey, B.E., … Polovich, M. (2016). 2016 updated American Society J.A., Campbell, R.L, … Wang, J. (2020). Anaphylaxis—A 2020 practice
of Clinical Oncology/Oncology Nursing Society chemotherapy admin- parameter update, systematic review, and Grading of Recommendations,
istration safety standards, including standards for pediatric oncology. Assessment, Development, and Evaluation (GRADE) analysis. Journal
Journal of Oncology Practice, 12(12), 1262–1271. https://doi.org/10.1200​ of Allergy and Clinical Immunology, 145(4), 1082–1123. https://doi.org​
/JOP.2016.017905 /10.1016/j.jaci.2020.01.017
Oncology Nursing Society. (2020, August). Education of the registered nurse Sharour, L.A. (2019). Implementing simulation in oncology emergencies
who administers and cares for the individual receiving antineoplastic ther- education: A quasi-experimental design. Technology and Health Care,
apies [Position statement]. https://www.ons.org/make-difference/ons​ 27(2), 223–232. https://doi.org/10.3233/THC-181543
-center-advocacy-and-health-policy/position-statements/education​ Srinivasamurthy, S.K., Ashokkumar, R., Kodidela, S., Howard, S.C., Samer,
-nurse-administers-antineoplastic-therapies C.F., & Rao, U.S.C. (2021). Impact of computerised physician order entry
Polovich, M., & Olsen, M.M. (Eds.). (2018). Safe handling of hazardous drugs (CPOE) on the incidence of chemotherapy-related medication errors:
(3rd ed.). Oncology Nursing Society. A systematic review. European Journal of Clinical Pharmacology, 77(8),
Prakash, V., Koczmara, C., Savage, P., Trip, K., Stewart, J., McCurdie, T., … 1123–1131.
Trbovich, P. (2014). Mitigating errors caused by interruptions during Tariq, R.A., Vashisht, R., Sinha, A., & Scherbak, Y. (2021). Medication dis-
medication verification and administration: Interventions in a simulated pensing errors and prevention. In StatPearls. StatPearls Publishing.
ambulatory chemotherapy setting. BMJ Quality and Safety, 23(11), 884– https://www.ncbi.nlm.nih​.gov/books/NBK519065
892. https://doi.org/10.1136/bmjqs-2013-002484 U.S. Food and Drug Administration. (n.d.). FDA Drug shortages. https://​
Rahimi, R., Kazemi, A., Moghaddasi, H., Arjmandi Rafsanjani, K., & www.accessdata.fda.gov/scripts/drugshortages
Bahoush, G. (2018). Specifications of computerized provider order U.S. Food and Drug Administration. (2018, November 30). Drug shortage
entry and clinical decision support systems for cancer patients under- management. https://www.fda.gov/media/72447/download
going chemotherapy: A systematic review. Chemotherapy, 63(3), 162– U.S. Pharmacopeial Convention. (2019). USP General Chapter <800>
171. https://doi.org/10.1159/000489503 Hazardous drugs–Handling in healthcare settings. https://www.usp.org
Reinhardt, H., Otte, P., Eggleton, A.G., Ruch, M., Wöhrl, S.A., Ajayi, S., /compounding/general-chapter-hazardous-drugs-handling-healthcare
… Engelhardt, M. (2019). Avoiding chemotherapy prescribing errors: Unguru, Y. (2020). In short supply. Hopkins Medicine. https://www​
Analysis and innovative strategies. Cancer, 125(9), 1547–1557. https://​ .hopkinsmedicine.org/news/publications/hopkins_medicine_magazine​
doi.org/10.1002/cncr.31950 /forum/in-short-supply
Schwappach, D.L.B., Taxis, K., & Pfeiffer, Y. (2018). Oncology nurses’ beliefs Wahl, S. (2017). Competency management. In P.S. Dickerson (Ed.), Core
and attitudes towards the double-check of chemotherapy medications: curriculum for nursing professional development (5th ed., pp. 308–317).
A cross-sectional survey study. BMC Health Services Research, 18, 123. Association for Nursing Professional Development.
https://doi.org/10.1186/s12913-018-2937-9 Weingart, S.N., Zhang, L., Sweeney, M., & Hassett, M. (2018). Chemother-
Sessions, L.C., Nemeth, L.S., Catchpole, K., & Kelechi, T.J. (2019). Nurses’ apy medication errors. Lancet Oncology, 19(4), e191–e199. https://doi​
perceptions of high-alert medication administration safety: A qualita- .org/10.1016/S1470-2045(18)30094-9
tive descriptive study. Journal of Advanced Nursing, 75(12), 3654–3667. World Health Organization. (2016). Medication errors: Technical series on
https://doi.org/10.1111/jan.14173 safer primary care. https://apps.who.int/iris/handle/10665/252274
 CHAPTER 2

Ethical and Legal Issues

A. Ethical issues for Healthcare Research and Quality, 2019;

1. The ever-changing healthcare environment necessi- Figueroa et al., 2019).
tates sensitivity to ethical and legal issues. Concerns b) The large number of underinsured and undocu-
arise in the care of all patients. However, they often mented individuals has led to ethical dilemmas
have heightened intensity and complexity in the can- in health care.
cer population, as patients, families, and healthcare (1) Even for people with health insurance,
professionals face frequent and potentially difficult co-payments or deductibles can lead to
moral choices. substantial debt (Yousuf Zafar, 2016).
2. Ethics is a term that describes what is expected as cor- (2) Financial toxicity is the unintended and
rect and principled behavior. Issues may arise when unanticipated financial burden experi-
conflicting values exist among individuals, groups, or enced by patients and is associated with
organizations (Beauchamp & Childress, 2019). negative consequences and increased risk
3. Ethical issues related to cancer therapy of mortality (Witte et al., 2019). This def-
a) Healthcare realities that present potential ethical inition includes a range of concerns from
issues include the following: minimal financial vulnerability and worry
(1) Major advances with increased availability to extreme financial toxicity.
and access to medical technology, height- (a) The adverse impact of a cancer diag-
ened expectations, and changing moral nosis on financial well-being may
attitudes combine to generate complex result from direct or indirect costs
ethical and legal problems related to can- and can be both objective and subjec-
cer and palliative care (Bressler et al., 2017; tive (Arastu et al., 2020; Coumoun-
Butts & Rich, 2020). In particular, the use douros et al., 2019; Edward, 2020;
of life-sustaining measures may raise ethi- Singleterry, 2017).
cal questions when healthcare professionals i. Material loss, including savings,
perform the following errors (Kates, 2017; home, loss of insurance, bank-
Marcelin et al., 2019; Sirilla et al., 2017; Sisk ruptcy
et al., 2016; Sullivan & Dickerson, 2016): ii. Balancing cancer care costs
(a) Fail to discuss patient requests before with family, food, housing,
a crisis develops child care, and transportation
(b) Are reluctant or fail to communi- iii. Psychological distress related to
cate medical treatment options with uncertainty and resource inse-
a stressed and grief-stricken family curity
(c) Fail to consider supportive care mea- iv. Maladaptive coping strategies
sures v. Sense of loss of control
(d) Experience moral distress related to vi. Sense of vulnerability
personal values or biases (b) Consequences of financial toxicity
(2) The changing healthcare environment may be immediate or long term.
(e.g., staffing shortages, reallocation of i. Treatment nonadherence
resources, consolidation, corporatization) ii. Decreased health-related qual-
has resulted in growing administrative ity of life
dominance over clinical practice (Agency iii. Bankruptcy
13
14 Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

iv. Increased risk of mortality (5) Clear discussion of goals, benefits, and
v. Changing family dynamics costs of care
c) Informal caregivers are the primary source of (6) Early referral to supportive services and
support for patients with cancer, assisting with navigation
household tasks, medical care, and emotional (7) Access to a National Cancer Institute com-
support (Coumoundouros et al., 2019). prehensive cancer center
(1) Responsibilities often result in high levels f) Improvement requires multilevel, coordinated
of emotional, physical, social, and finan- efforts among stakeholders, including patients,
cial burden for the caregiver. providers, health systems, payers, manufactur-
(2) The demand for informal cancer caregiv- ers, and policymakers (Edward, 2020; Lentz et
ers will increase as life expectancy rises al., 2019).
and cancer incidence increases. (1) Monitor the financial status of patient
(3) Care time is the greatest source of care- groups and their perceptions of subjective
giver cost and stress. Other sources include financial distress at different times (e.g.,
out-of-pocket and absenteeism costs. diagnosis, curative or palliative treatment,
d) Some groups are at higher risk for perceived sub- survivorship care).
jective financial distress resulting from objective (2) Evaluate the healthcare process by mea-
financial burden. suring changes in financial status in indi-
(1) Individuals with lower socioeconomic sta- vidual patients and groups.
tus and multiple comorbidities may strug- (3) Assess the seriousness of the financial sit-
gle to pay for daily living needs, such as uation at different time frames.
food, housing, and monthly bills (Zheng (4) Individualize information and counsel-
et al., 2020). ing needs.
(2) Children, younger cancer survivors, and g) Expanding awareness and appreciation of cul-
low-income families are most affected by tural diversity is essential (Bressler et al., 2017).
limited coverage and higher deductibles. (1) Cultural disparities in cancer care are
Payment for care must be addressed for unfavorable health outcomes related to
protected groups, such as incarcerated inequities in health insurance coverage,
and homeless individuals (Lyckholm & access to and use of care, and quality of
Glancey, 2016; Yousuf Zafar, 2016). care (Pirschel, 2020; Underwood, 2019).
(3) Some insurance plans do not cover select (a) Disparities adversely affect groups
diagnostic testing or more expensive that have systematically experienced
treatments, such as hematopoietic stem greater obstacles to health based on
cell transplantation, proton beam ther- race or ethnicity; language and com-
apy, clinical trials, or off-label use of med- munication skills; religion; socioeco-
ications (Brown et al., 2016; Centers for nomic status; gender; age; mental
Medicare and Medicaid Services, 2022). health; cognitive, sensory, or phys-
(4) Theoretical frameworks that incorporate ical disability; sexual orientation or
medical and nonmedical aspects of finan- gender identity; geographic location;
cial hardship are limited, making it chal- or other characteristics historically
lenging to fully understand the interre- linked to discrimination or exclu-
lationship between cancer survivors and sion (Office of Disease Prevention
those with no personal history of cancer. and Health Promotion, n.d.).
e) Strategies to anticipate and reduce financial con- (b) A society is considered to have cul-
cerns along the cancer trajectory include the fol- tural diversity if it has many differ-
lowing: ent cultural or ethnic groups. This
(1) Increased transparency concerning costs includes social status, culture, lan-
of office visits, diagnostics, treatment, and guage and communication skills,
palliative and other supportive care religion, personality, race and ethnic-
(2) Early discussion of payment options and ity, age, gender, sexual orientation,
financial assistance and decision-making ability (Betan-
(3) Follow-up on financial discussions as cir- cur et al., 2020; Underwood, 2019).
cumstances change (c) Social determinants of health are the
(4) Practical suggestions for keeping track of conditions in an environment that
precertifications, bills, and payments impact an individual’s health, func-
 Chapter 2. Ethical and Legal Issues 15

tioning, and quality of life (Office of explicit bias, prejudice, and discrim-
Disease Prevention and Health Pro- ination.
motion, n.d.). The five domains are (b) Apply efforts to counteract implicit
economic stability, education, health and explicit bias, prejudice, and dis-
care, neighborhood, and community crimination.
context. (c) Address root causes of disparities
(d) Cultural and communication differ- in cancer care, including insurance
ences and protections present chal- issues and access to care.
lenges from discussion of surveil- (d) Use alternative therapies.
lance, diagnosis, and prognosis to i. Evidence-based complemen-
decisions about who will provide tary and alternative medi-
long-term care (Agency for Health- cine, in conjunction with or as
care Research and Quality, 2019; a substitute for conventional
Bressler et al., 2017; Butts & Rich, treatment, is affected by vari-
2020). ations in individual response
(e) Implicit bias describes attitudes to cancer and its treatment,
toward or associated stereotypes with the need for a sense of control,
individuals or groups of people with- belief in individual rights and
out conscious knowledge. determination, and cultural
(f) Designated priority populations and spiritual beliefs. Caregiver
are the focus of federal efforts to beliefs often limit the use of
reduce disparities and include peo- such therapies.
ple of color, low-income popula- ii. In the search for cancer care
tions, women, children or adoles- with minimal side effects,
cents, older adults, individuals with survivors and families often
special healthcare needs, and indi- embark on unproven thera-
viduals living in rural and inner-city pies, which can cause adverse
areas (Agrawal & Enekwechi, 2020). outcomes and insurmountable
(2) Actions to improve cultural awareness costs (Johnson et al., 2017).
(Marcelin et al., 2019; Pirschel, 2020) iii. Oncology nurses must be edu-
(a) Begin the conversation during cated about alternative meth-
assessment and continue through- ods to provide education about
out the trajectory. reliable options (American
(b) Recognize personal biases. College of Surgeons Commis-
(c) Identify individuals at risk for devel- sion on Cancer, 2021; Butts &
oping preventable cancer. Rich, 2020; Cox et al., 2017).
(d) Allow a safe space for a conversation (e) Precision oncology: As biomarker
about concerns. testing that leads to the use of tar-
(e) Provide education about cultures. geted therapies becomes the stan-
(f) Provide translation services. dard of care, healthcare profession-
(g) Personalize surveillance and man- als are expected to apply this expand-
agement for cancer. ing science to practice and be aware
(h) Respect cultural differences. of biomarker-directed targeted ther-
(i) Display patient nondiscrimination apies and their mechanism of action,
policy and patient bill of rights. indications, and symptom manage-
(j) Encourage neutral language, asking ment.
for preferences. i. Understanding the technol-
(k) Be honest. ogy and options for biomarker
(l) Follow the tenets of the American testing and its impact on care
Nurses Association (2015) code of requires ongoing education.
ethics. ii. Reimbursement for testing
(3) Advocacy for patients of diverse back- and services, collection of an
grounds extensive family history, and
(a) Coordinate community efforts to costs of targeted and bio-
promote awareness of implicit and logic therapies offer addi-
16 Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

tional challenges to patients, 5. The Joint Commission (2020) requires accredited

healthcare systems, and pro- institutions to provide access to an ethics consul-
fessionals (American Nurses tation to assist in evaluating the decision-making
Association & International capacity of an individual and assist with problem
Society of Nurses in Genetics, resolution.
2016; Mohammed et al., 2016; 6. The ethical principles guiding decision-making are
Roeland et al., 2017). summarized in Table 2-1.
4. Ethical issues that oncology nurses face in daily prac- 7. The American Nurses Association (2015) code of
tice (de Groot et al., 2017; Fiore & Goodman, 2016; ethics serves as an ethical framework for practice,
Sisk et al., 2016; Sullivan & Dickerson, 2016) providing direction regarding ethical relationships,
a) Autonomy nursing responsibilities, appropriate behaviors, and
(1) Patient autonomy and decision-making decision-making. Components of the framework
capacity include the following:
(2) Informed consent a) Respect for the inherent dignity, worth, and
(3) Cancer risk reduction (e.g., prophylactic unique attributes of every person
surgeries) b) Primary commitment to the patient
(4) Treatment during pregnancy c) Protection of the rights, health, and safety of the
(5) The right to refuse treatment patient
(6) Disparities in the wishes of a patient and d) Authority, accountability, and responsibility for
their significant other nursing practice
(7) Advocating for individuals who exhibit e) Same duties owed to self as to others
risky behaviors or make choices with f) Establishment, maintenance, and improvement
which the caregiver disagrees of the ethical environment of the work setting
(8) Privacy in communications (e.g., medical and conditions of employment
records, messaging, telemedicine) g) Advancement of the profession through research
b) Healthcare environment and reform and scholarly inquiry
(1) Undertreatment of pain, particularly in h) Protection of human rights, promotion of health
light of the opioid crisis diplomacy, and reduction of health disparities
(2) Inequities in cancer care i) Articulation of nursing values, maintenance of
(3) Access to care and clinical trials the integrity of the profession, and integration
(4) Access to high-cost cancer drugs and drug of the principle of social justice
shortages
(5) Cultural diversity and potential bias B. Legal issues related to cancer therapy
(6) Balance and justice in cancer care 1. Adhering to national, state, and institutional stan-
(7) Expanding the use of telehealth dards is a fundamental responsibility of all nurses
c) End-of-life and prolongation-of-life decisions (American Nurses Association, 2015; Brown et al.,
(1) Assisted dying (legal in several states) 2016; Centers for Medicare and Medicaid Services,
(2) Treatment futility versus continuing 2022).
experimental treatment 2. Acts and standards guiding oncology nursing prac-
(3) Prognosis-related discussions tice are not all-inclusive, as the changing environ-
d) Confidentiality ment requires knowledge of specialty competencies
(1) Biomarker testing and disclosure of results depending on the practice setting.
(2) Scientific integrity a) Nurse practice acts are state laws that define
(3) Big data collection and warehousing nursing performance in fundamental terms
e) Conflict resolution and critical conversations for each state (American Nurses Association,
(1) Intrafamily conflicts 2021).
(2) Nurse–family conflicts b) The Oncology Nursing Society’s Scope and Stan-
(3) Nurse–physician conflicts dards of Oncology Nursing Practice explains the
(4) Physician–family conflicts minimum standard of care by which an oncol-
(5) Clarity in communications ogy nurse is expected to practice (Lubejko & Wil-
f) Professional boundaries son, 2019).
(1) Giving or receiving gifts c) The American Society of Clinical Oncology/Oncol-
(2) Social media (e.g., friend requests from ogy Nursing Society Chemotherapy Administra-
patients) tion Safety Standards detail the safety standards
(3) Electronic messaging for chemotherapy prescription, preparation,
 Chapter 2. Ethical and Legal Issues 17

TABLE 2-1. Ethical Principles

Principle Description Clinical Examples

Autonomy Independent decision-making by an indi- Respecting an individual’s choice, even when different from one’s
vidual following their own best interest own
Providing supportive services

Beneficence The duty to act in the best interest of the Personalizing care based on individual desires, culture, disease, and
involved person other factors
Providing evidence-based care

Fidelity Faithfulness to promises made Providing follow-up as promised

Providing survivorship care planning
Fostering collegiality

Justice Equitable distribution of available Offering or providing treatment regardless of ability to pay, culture,
resources or socioeconomic status
Assisting with or referring for financial support

Nonmaleficence The duty to do no harm Providing complete information

Providing survivorship services
Recognizing professional limitations and seeking consultation or
collaboration
Adhering to professional standards of care

Veracity Truth telling Explaining treatment in understandable terms before it is initiated

Providing accurate information and educational materials

Note. Based on information from Beauchamp & Childress, 2019.

administration, and monitoring in all practice 3. Common legal issues

settings (Neuss et al., 2016). a) Medication errors (see Chapter 1)
d) Genetics/Genomics Nursing: Scope and Standards b) Documentation issues: The duty to keep accu-
of Practice describes standards and scope of prac- rate records is a fundamental nursing responsi-
tice for general and advanced practice nurses bility. The medical record is scrutinized in the
addressing genetic and genomic issues with event of litigious action and is believed to reflect
examples from various practice settings (Ameri- the care rendered (Naidu & Alicia, 2019: Neuss
can Nurses Association & International Society et al., 2016).
of Nurses in Genetics, 2016). (1) Common documentation errors
e) The Oncology Nursing Society’s Access Device (a) Omitting significant observations
Standards of Practice for Oncology Nursing details (b) Failing to document response to an
the current standards for using access devices in intervention
cancer care (Camp-Sorrell & Matey, 2017). (c) Failing to document patient teaching
f) Infusion Therapy Standards of Practice explain the and understanding
current standards of nursing practice for IV ther- (d) Failing to document what was taught
apy (Infusion Nurses Society, 2021). and to whom
g) American College of Surgeons Commission on (2) Nursing actions to include in the docu-
Cancer’s (2022) Optimal Resources for Cancer mentation
Care encompasses the requirements that cancer (a) Telephone, text, or other digital com-
programs must meet to earn and maintain Com- munications or conversations, par-
mission on Cancer accreditation. ticularly those in which nurses give
h) Institution-specific standards may be outlined in patients instructions or advice
the following: (b) Fax and email communications, par-
(1) Standards of practice ticularly those in which the nurses
(2) Nursing policy and procedure manuals give patients instructions or advice
(3) Job descriptions (c) Virtual face-to-face communications,
(4) Institutional review board decisions and particularly those in which nurses
guidance give patients instructions or advice,
18 Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

including the type of communica- cal trial, or participation in nursing

tion, who was included, and the loca- research (Beauchamp & Childress,
tion (e.g., online meetings, forums, 2019; Butts & Rich, 2020; Klimasze-
email distribution lists, telemedicine) wski, 2016).
(Knudsen et al., 2021) (b) Except for research, each institution
(d) Pertinent conversations with determines its practice related to how
patients, families, or other caregivers and if a patient must provide writ-
(e) Interagency referrals, including tele- ten informed consent before receiv-
phone conversations with providers ing cancer treatment, such as antineo-
(f) Antineoplastic drug administration plastic agents, targeted therapies, or
(see Appendices A and B) immunotherapies (Neuss et al., 2016).
(g) Treatment-related documentation (c) It is essential to maintain consis-
i. Completion of independent tency between policy and practice
verification of drug and dose throughout the institution.
ii. Two unique patient identifi- (d) Regardless of the method used to
ers (e.g., name, medical record document informed consent, all
number, date of birth) needed elements of the informed
iii. Patient-specific measurements decision-making process must be
used to calculate doses (e.g., included. The following approaches
body surface area) have been used:
iv. Pertinent laboratory and diag- i. The patient signs a designated
nostic test results antineoplastic therapy consent
v. Date and time of therapy form explicitly designed for
vi. Drug name, dose, route, loca- administering chemotherapy,
tion of administration, and targeted therapy, or immuno-
infusion duration therapy. This document reflects
vii. Volume and type of IV fluids patient education, remains
administered part of the medical record,
viii. Assessment of the IV site before, and might be preferred by risk
during, and after infusion management. A sample tem-
ix. Information about the infu- plate for chemotherapy con-
sion device (e.g., vein selection, sent is provided in Appendix E.
needle size, type of device, ii. The general hospital consent to
infusion pump) treat serves as the signed per-
x. Verification of venous access mission to provide antineo-
device patency, including the plastic medications.
presence of a blood return iii. Some centers use a general
before, during, and after IV procedure consent form for
therapy (also any issues with cancer treatment.
venous access) iv. A specific form is not signed,
(h) Patient assessment and evaluation of but consent is documented
patient response to and tolerance of within the medical record.
treatment (2) Elements of consent (Elements of
(i) Patient and family education related Informed Consent, 2022)
to the drugs received, toxicities, tox- (a) Disclosure: The patient is informed
icity management, and follow-up of their cancer diagnosis, including
care (especially when and who to the type, location, and stage.
call with specific resource numbers (b) The patient is informed of the prog-
and times) nosis and goal of the proposed treat-
(j) Post-treatment or discharge instruc- ment (e.g., cure, control, palliation).
tions (c) Possible benefits of the treatment are
c) Informed consent discussed.
(1) Process (d) Possible risks and adverse effects
(a) Patients must give informed consent are discussed, including short- and
for treatment, enrollment in a clini- long-term side effects.
 Chapter 2. Ethical and Legal Issues 19

(e) Alternatives to treatment and associ- American Nurses Association and International Society of Nurses in Genet-
ated risks are covered. Palliative care ics. (2016). Genetics/genomics nursing: Scope and standards of practice
(2nd ed.).
should be offered as an option when Arastu, A., Patel, A., Mohile, S.G., Ciminelli, J., Kaushik, R., Wells, M., …
appropriate. Loh, K.P. (2020). Assessment of financial toxicity among older adults
(f) Patients younger than age 18 years with advanced cancer. JAMA Network Open, 3(12), e2025810. https://
may be legally able to give informed doi.org/10.1001/jamanetworkopen.2020.25810
consent if they are emancipated Beauchamp, T.L., & Childress, J.F. (2019). Principles of biomedical ethics (8th
ed.). Oxford University Press.
minors. Assent is the willingness to
Betancur, S., Walton, A.L., Smith-Miller, C., Wiesen, C., & Bryant, A.L.
participate in treatment by people (2020). Cultural awareness: Ensuring high-quality care for limited Eng-
who are, by definition, too young to lish proficient patients. Clinical Journal of Oncology Nursing, 24(5), 530–
give informed consent but are old 537. https://doi.org/10.1188/20.CJON.530-537
enough to understand the diagno- Bressler, T., Hanna, D.R., & Smith, E. (2017). Making sense of moral dis-
sis and proposed treatment (Neuss tress within cultural complexity. Journal of Hospice and Palliative Nurs-
ing, 19(1), 7–14. https://doi.org/10.1097/NJH.0000000000000308
et al., 2016). Brown, S., Markus, S., & Bales, C.A. (2016). Legal, regulatory, and legisla-
i. If assent is given, informed tive issues. In A.D. Klimaszewski, M. Bacon, J.A. Eggert, E. Ness, J.G.
consent must still be obtained Westendorp, & K. Willenberg (Eds.), Manual for clinical trials nursing
from the patient’s parents or (3rd ed., pp. 51–65). Oncology Nursing Society.
guardian. Butts, J.B., & Rich, K.L. (2020). Nursing ethics: Across the curriculum and
into practice (5th ed.). Jones and Bartlett Learning.
ii. The main goal of child assent
Camp-Sorrell, D., & Matey, L. (Eds.). (2017). Access device standards of prac-
is to protect children involved tice for oncology nursing. Oncology Nursing Society.
in clinical trials (Tait & Geisser, Centers for Medicare and Medicaid Services. (2022, January). Medicare cov-
2017). erage of cancer treatment services. https://www.medicare.gov/Pubs/pdf​
(3) Requirements /11931-Cancer-Treatment-Services.pdf
(a) The informed consent document must Coumoundouros, C., Ould Brahim, L., Lambert, S.D., & McCusker, J. (2019).
The direct and indirect financial costs of informal cancer care: A scop-
state the right of the patient to refuse ing review. Health and Social Care in the Community, 27(5), e622–e636.
or discontinue treatment at any time. https://doi.org/10.1111/hsc.12808
(b) The informed consent document Cox, A., Lucas, G., Marcu, A., Piano, M., Grosvenor, W., Mold, F., … Ream,
and, subsequently, healthcare pro- E. (2017). Cancer survivors’ experience with telehealth: A systematic
viders assure patients that ongoing review and thematic synthesis. Journal of Medical Internet Research,
19(1), e11. https://doi.org/10.2196/jmir.6575
support and care will be provided if
de Groot, F., Capri, S., Castanier, J.-C., Cunningham, D., Flamion, B., Flume,
they decline or discontinue treatment M., … Wong, O. (2017). Ethical hurdles in the prioritization of oncology
connected with the trial or research. care. Applied Health Economics and Health Policy, 15, 119–126. https://​
(c) Nurses and physicians have differ- doi.org/10.1007/s40258-016-0288-4
ent but complementary roles in the Edward, J. (2020). Effective cost conversations: Addressing financial toxic-
informed consent process. ity and cost-related health literacy. Clinical Journal of Oncology Nursing,
24(2), 209–213. https://doi.org/10.1188/20.CJON.209-213
(d) See Chapter 5 for additional infor- Elements of Informed Consent, 21 C.F.R. § 50.25 (2022, January 6). https://​
mation on the informed consent pro- www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?fr=50​.25
cess related to clinical trials and the Figueroa, C.A., Harrison, R., Chauhan, A., & Meyer, L. (2019). Priorities
nurse’s role. and challenges for health leadership and workforce management glob-
ally: A rapid review. BMC Health Services Research, 19, 239. https://​
doi.org/10.1186/s12913-019-4080-7
Fiore, R.N., & Goodman, K.W. (2016). Precision medicine ethics: Selected

References
issues and developments in next-generation sequencing, clinical oncol-
ogy, and ethics. Current Opinion in Oncology, 28(1), 83–87. https://doi​
.org/10.1097/CCO.0000000000000247
Agency for Healthcare Research and Quality. (2019). 2019 national health- Infusion Nurses Society. (2021). 2021 infusion therapy standards of prac-
care quality and disparities report. https://www.ahrq.gov/research​ tice. https://www.ins1.org/publications/infusion-therapy-standards-of​
/findings/nhqrdr/nhqdr19/index.html -practice
Agrawal, S., & Enekwechi, A. (2020, January 15). It’s time to address the role Johnson, S.B., Park, H.S.M., Gross, C.P., & Yu, J.B. (2017). Use of alterna-
of implicit bias within health care delivery. Health Affairs. https://www​ tive medicine for cancer and its impact on survival. International Jour-
.healthaffairs.org/do/10.1377/forefront.20200108.34515/abs nal of Radiation Oncology, Biology, Physics, 99(2, Suppl.), E401. https://
American College of Surgeons Commission on Cancer. (2022, April). doi.org/10.1016/j.ijrobp.2017.06.1562
Optimal resources for cancer care: 2020 standards. https://www.facs.org Joint Commission. (2020). 2020 hospital accreditation standards.
/media/whmfnppx/2020_coc_standards.pdf Kates, J. (2017). Advance care planning conversations. Journal for Nurse
American Nurses Association. (2015). Code of ethics for nurses with inter- Practitioners, 13(7), e321–e323. https://doi.org/10.1016/j.nurpra.2017​
pretive statements. .05.011
American Nurses Association. (2021). Nursing: Scope and standards of prac- Klimaszewski, A.D. (2016). Informed consent. In A.D. Klimaszewski, M.
tice (4th ed.). Bacon, J.A. Eggert, E. Ness, J.G. Westendorp, & K. Willenberg (Eds.),
20 Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

Manual for clinical trials nursing (3rd ed., pp. 113–125). Oncology Nurs- Roeland, E.J., Dullea, A.D., Hagmann, C.H., & Madlensky, L. (2017).
ing Society. Addressing hereditary cancer risk at the end of life. Journal of Oncology
Knudsen, K.E., Willman, C., & Winn, R. (2021). Optimizing the use of Practice, 13(10), e851–e856. https://doi.org/10.1200/JOP.2017.021980
telemedicine in oncology care: Postpandemic opportunities. Clinical Singleterry, J. (2017). The costs of cancer: Addressing patient
Cancer Research, 27(4), 933–936. https://doi.org/10.1158/1078-0432​ costs. American Cancer Society Cancer Action Network. https://
.CCR-20-3758 www.fightcancer.org​/sites/default/files/Costs%20of%20Cancer%20
Lentz, R., Benson, A.B., III, & Kircher, S. (2019). Financial toxicity in cancer -%20Final%20Web.pdf
care: Prevalence, causes, consequences, and reduction strategies. Journal Sirilla, J., Thompson, K., Yamokoski, T., Risser, M.D., & Chipps, E. (2017).
of Surgical Oncology, 120(1), 85–92. https://doi.org/10.1002/jso.25374 Moral distress in nurses providing direct patient care at an academic
Lubejko, B., & Wilson, B. (2019). Scope and standards of oncology nursing medical center. Worldviews on Evidence-Based Nursing, 14(2), 128–135.
practice. Oncology Nursing Society. https://doi.org/10.1111/wvn.12213
Lyckholm, L.J., & Glancey, C.L. (2016). Ethical issues in caring for prison Sisk, B., Frankel, R., Kodish, E., & Isaacson, J.H. (2016). The truth about
inmates with advanced cancer. Journal of Hospice and Palliative Nurs- truth-telling in American medicine: A brief history. Permanente Jour-
ing, 18(1), 7–12. https://nursing.ceconnection.com/ovidfiles/00129191​ nal, 20(3), 74–77. https://doi.org/10.7812/TPP/15-219
-201602000-00003.pdf Sullivan, S.S., & Dickerson, S.S. (2016). Facing death: A critical anal-
Marcelin, J.R., Siraj, D.S., Victor, R., Kotadia, S., & Maldonado, Y.A. (2019). ysis of advance care planning in the United States. Advances in
The impact of unconscious bias in healthcare: How to recognize and Nursing Science, 39(4), 320–332. https://doi.org/10.1097/ANS
mitigate it. Journal of Infectious Diseases, 220(Suppl. 2), 15, S62–S73. .0000000000000138
https://doi.org/10.1093/infdis/jiz214 Tait, A.R., & Geisser, M.E. (2017). Development of a consensus opera-
Mohammed, S., Peter, E., Gastaldo, D., & Howell, D. (2016). The “conflicted tional definition of child assent for research. BMC Medical Ethics, 18,
dying”: The active search for life extension in advanced cancer through 41. https://doi.org/10.1186/s12910-017-0199-4
biomedical treatment. Qualitative Health Research, 26(4), 555–567. Underwood, S. (2019). Reducing cancer-related health disparities: What
https://doi.org/10.1177/1049732315572772 nurses can do to effect change. In J. Payne & K. Murphy-Ende (Eds.),
Naidu, M., & Alicia, Y.L.Y. (2019). Impact of bar-code medication adminis- Current trends in oncology nursing (2nd ed., pp. 101–113). Oncology Nurs-
tration and electronic medication administration record system in clin- ing Society.
ical practice for an effective medication administration process. Health, Witte, J., Mehlis, K., Surmann, B., Lingnau, R., Damm, O., Greiner, W., &
11(5), 511–526. https://doi.org/10.4236/health.2019.115044 Winkler, E.C. (2019). Methods for measuring financial toxicity after
Neuss, M.N., Gilmore, T.R., Belderson, K.M., Billett, A.L., Conti-Kalchik, T., Har- cancer diagnosis and treatment: A systematic review and its implica-
vey, B.E., … Polovich, M. (2016). 2016 updated American Society of Clinical tions. Annals of Oncology, 30(7), 1061–1070. https://doi.org/10.1093​
Oncology/Oncology Nursing Society chemotherapy administration safety /annonc/mdz140
standards, including standards for pediatric oncology. Journal of Oncol- Yousuf Zafar, S. (2016). Financial toxicity of cancer care: It’s time to inter-
ogy Practice, 12(12), 1262–1271. https://doi.org/10.1200​/JOP.2016.017905 vene. Journal of the National Cancer Institute, 108(5), djv370. https://
Office of Disease Prevention and Health Promotion. (n.d.). Social determi- doi.org/10.1093/jnci/djv370
nants of health. https://health.gov/healthypeople/objectives-and-data​ Zheng, Z., Jemal, A., Tucker-Seeley, R., Banegas, M.P., Han, X., Rai, A., …
/social-determinants-health Yabroff, K. (2020). Worry about daily financial needs and food insecu-
Pirschel, C. (2020). LGBTQ patients with cancer: Nursing considerations rity among cancer survivors in the United States. Journal of the National
to reduce barriers to care. ONS Voice. https://voice.ons.org/news-and- Comprehensive Cancer Network, 18(3), 315–327. https://doi.org/10​
views/lgbtq-patients​-with-cancer .6004/jnccn.2019.7359
 CHAPTER 3

Patient Education

A. Patient education overview (2) Organizational health literacy is defined

1. Patient education includes learning experiences that by the Office of Disease Prevention and
empower individuals or communities with health Health Promotion (2021) as “the degree
information. This is combined with instructions to to which organizations equitably enable
help patients understand how to care for themselves individuals to find, understand, and
throughout the treatment trajectory, when to obtain use information and services to inform
help in their care, and the risks of illness and how to health-related decisions and actions for
prevent it. themselves and others” (para. 3).
2. Patient education is a continuous process throughout (3) According to the National Action Plan to
the cancer journey (Gidron, 2016; Vaartio-Rajalin et Improve Health Literacy, “nearly 9 out of
al., 2015). 10 adults have difficulty using the every-
a) Health education and promotion are key roles of day health information that is routinely
the nursing profession, especially for oncology available in our health care facilities, retail
nurses. Education is essential for patients, their outlets, media, and communities” (Office
significant others, and the public. of Disease Prevention and Health Promo-
(1) Using the models of patient engagement tion, 2010, p. 6).
and shared decision-making, all practitio- (4) Given the high prevalence of low health lit-
ners must be involved in health education eracy, the application of health literacy best
and promotion. practices should be universally applied to
(2) This requires open collaboration and all patients. To support these efforts, AHRQ
interprofessional communication across created the universal precautions approach
all healthcare settings (American Nurses to patient education (AHRQ, 2020).
Association, 2015; Blecher et al., 2016;
Brant & Wickham, 2013; Tariman et al., B. Short-term outcomes of patient education (Blecher et al.,
2016; Vaartio-Rajalin et al., 2015). 2016; Neuss et al., 2016)
b) The Agency for Healthcare Research and Quality 1. Empowerment of active participation in care
(AHRQ, 2020a) has identified universal precautions 2. Autonomous decision-making regarding treatment
for health literacy; steps aimed at improving the options or the right to refuse treatment
communication of healthcare information, leading 3. An understanding of diagnosis and treatment options
to improved comprehension and access; improving 4. Ability to communicate an understanding of the
patients’ ability to navigate the healthcare system; goals and duration of treatment
and supporting patients in their self-care. 5. Identification of short- and long-term side effects,
c) Health literacy can be divided into personal or including those that need to be reported
organizational health. 6. Demonstration of the ability to perform self-care or
(1) Personal health literacy is defined by the adapt to potential limitations
Office of Disease Prevention and Health 7. Promotion of adaptive skills in a life-threatening sit-
Promotion (2021) as “the degree to which uation
individuals have the ability to find, under- 8. Identification and use of community resources
stand, and use information and services to
make informed health-related decisions and C. Long-term outcomes of patient education (Joint Com-
actions for themselves and others” (para. 3). mission, 2021)
21
22 Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

1. Improvement in self-care behaviors viduals at an increased risk for educational

2. Improvement in health-related quality of life barriers (Swanson, 2010).
3. Decreased healthcare costs g) Effects of low health literacy (AHRQ, 2020b;
4. Increased customer satisfaction Centers for Disease Control and Prevention,
5. Improved ability to make informed healthcare deci- 2015, 2021; Joint Commission, 2021; Katz, 2017;
sions Nielsen-Bohlman et al., 2004)
(1) Poor patient outcomes
D. Barriers to patient education (2) Increased healthcare costs
1. Barriers should be assessed on an individual basis. A (3) Increased risk for medication errors
learning needs assessment should be performed and (4) Inability to follow treatment instructions
documented to identify obstacles that prevent the (5) Less success navigating the healthcare sys-
effective delivery of healthcare information (Gumu- tem
say et al., 2016; Joint Commission, 2021; Neuss et (6) Increased risk for hospitalization
al., 2016). h) Physical barriers, such as pain, visual distur-
2. Barriers to learning bances, auditory or cognitive impairments, and
a) The individual’s cognitive resources, including the inability to speak, can interfere with compre-
potential for problems with attention, work- hension (Joint Commission, 2021).
ing memory, or information processing related i) Access is reduced because of geographic barri-
to the disease or treatment (Jewitt et al., 2016; ers, such as the availability of transportation and
Vaartio-Rajalin et al., 2015) the distance from home to the treatment facility.
b) Lack of knowledge or understanding of the diag- j) Psychosocial or emotional issues may create bar-
nosis and treatment plan and differences in pro- riers to learning and need to be addressed before
fessional and patient knowledge expectations learning occurs (Joint Commission, 2021).
(Jewitt et al., 2016; Vaartio-Rajalin et al., 2015) k) Interprofessional care coordination and commu-
c) Differing expectations of the purpose of treat- nication barriers (Joint Commission, 2021; Tari-
ment between the patient, caregiver, and health- man et al., 2016; Vaartio-Rajalin et al., 2015)
care team (1) Ineffective communication among health-
d) Concerns or misconceptions regarding therapy care team members
due to prior experience or the experience of a (2) Ineffective communication among health-
friend or relative, which may deter the patient care facilities
from undergoing treatment (3) Differences among healthcare profession-
e) Language barriers als in their perceptions of the patient edu-
(1) Access to effective interpreter translation cation process
services in real time can be a barrier. l) Methods of overcoming barriers
(2) The 2020 U.S. Census concluded that (1) Facilitate time for patients to express con-
21.5% of residents speak a language other cerns and attempt to manage their anxiety.
than English in the home (U.S. Census (2) Assess cognitive resources and knowledge
Bureau, n.d.). expectations of the individuals being edu-
(3) Language barriers keep patients from cated, keeping in mind that educational
engaging in seamless conversations with level alone does not always give the com-
their doctors and interacting with the plete picture of an individual’s abilities.
healthcare industry. (3) Include the patient’s support system (e.g.,
f) Educational barriers family, friends, significant others) in the
(1) The national adjusted cohort graduation patient education process, providing sup-
rate for public high school students in port to the patient and help with learning.
2018–2019 was 86%. This represents the (4) Manage physical barriers, such as pain,
highest rate since its first measurement and ensure that learners have all neces-
in 2010–2011. Asian/Pacific Islander stu- sary assistive devices (e.g., glasses, hear-
dents had the highest rate (93%), fol- ing aids).
lowed by White (89%), Hispanic (82%), (5) Provide access to an interpreter, either in
Black (80%), and American Indian/Alaska person or through telecommunication
Native (74%) students (National Center (Joint Commission, 2021).
for Education Statistics, 2021). (a) Hospitals are required to ensure
(2) High school graduation rates were histor- the competency of interpreters and
ically low before 1950, putting older indi- translators.
 Chapter 3. Patient Education 23

(b) Use of significant others as trans- cess that ultimately reduces health
lators or interpreters is not recom- disparities and improves access to
mended because of role conflicts or high-quality health care.
inability to communicate complex (b) Cultural respect benefits consumers,
medical terminology. stakeholders, and communities.
(c) Cancer-related Spanish-language (c) Because several elements can influ-
literature is available through the ence health communication (e.g.,
National Cancer Institute (www behaviors, language, customs, beliefs,
.cancer.gov) and the American Can- perspectives), cultural respect is also
cer Society (www.cancer.org). Lan- critical for achieving accuracy in
guage preference can be toggled for medical research (National Institutes
these resources. of Health, n.d.).
(6) Offer explanations for any misconcep- 3. Barriers to educator effectiveness (AHRQ, 2020b;
tions concerning diagnosis, treatment, Blecher et al., 2016)
and follow-up care using teach-back tech- a) The educator’s expertise regarding the informa-
niques (AHRQ, 2020b). tion provided
(7) Perform and document a learning needs b) The educator’s understanding of teaching–
assessment that addresses cultural and learning principles
religious beliefs and preferences and the c) The educator’s understanding of differences in
desire and motivation to learn. The assess- learning styles
ment should also include emotional, phys- d) The methods available to the educator for patient
ical, cognitive, and communication bar- education
riers and limitations (Joint Commission, e) The educator’s ability to match the appropri-
2021). ate teaching methods and language to spe-
(8) Assess patients individually and tailor cific content and learning styles; the language
teaching to their level of understand- must be adapted to individual learning abilities,
ing. Use short and simple words, chunk- healthcare-related literacy, and ability to speak,
ing (short sections of information), active read, and understand English.
voice, and concrete examples (AHRQ, f) The educator’s ability to involve individuals in the
2020a; Cancer Patient Education Network, learning process
2013; Joint Commission, 2021; Office of g) The educator’s ability to communicate with other
Disease Prevention and Health Promo- members of the healthcare team to provide con-
tion, 2015). Cancer-related literature for tinuity of care between the various points of
low-literacy patients is available through care (e.g., hospital, physician practice, home,
the National Cancer Institute (www.cancer extended-care facilities)
.gov) and the American Cancer Society h) The decreased length of hospital stay and the
(www.cancer.org). increased need to deliver complex information
(9) Engage patients in the learning process to patients
with patient portals, interactive educa-
tional activities, shared decision-making, E. Methods of patient education (Blecher et al., 2016; Hop-
and patient-reported outcome measure- mans et al., 2014; Laszewski et al., 2016; LeFebvre &
ment. Felice, 2016; Neuss et al., 2016; Şahin & Ergüney, 2016;
(10) Effective care coordination and transition Sullivan et al., 2016)
may be facilitated through handoff tools to 1. Educational methods should be selected based on
improve continuity of care and collabora- preferences and abilities. They may include any com-
tion between professionals. Patient navi- bination of the following:
gators can be an effective link for patient a) Auditory, such as audiotapes, podcasts, or
and healthcare provider communication face-to-face live presentations
and satisfaction. b) Printed or visual materials, including animations,
(11) Cultural respect is a strategy that enables three-dimensional graphics, educational videos,
organizations to work effectively in booklets, chemotherapy cards, infographics,
cross-cultural situations. and printed instructions regarding procedures
(a) Developing and implementing a or self-care measures
cultural competency framework in c) Computer-based learning using three-
health systems is an extended pro- dimensional interactive animations, compact
24 Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

discs, flash drives, preloaded devices, screen treatment and number of cycles (length of ther-
sharing, or e-gaming apy); and the implications and plan for missed
d) Web-based learning, including patient portals, or delayed doses, especially with the use of oral
learning management systems, and reliable exter- anticancer medications
nal websites e) Supportive care medications, including generic
(1) National Cancer Institute (www.cancer and brand names, and their dose and frequency
.gov) f) Drug–drug and drug–food interactions based on
(2) American Cancer Society (www.cancer the most current medication list
.org) g) Potential short- and long-term adverse effects
(3) American Society of Clinical Oncology and the subsequent management strategies
(www.cancer.net) h) Contact information for and directions regarding
e) Demonstration and tactile methods using models communicating with healthcare team members
2. Patient education in any format includes teach-back i) Symptoms that require immediate discontinua-
techniques to reinforce learning and document strat- tion of self-administered medications or treat-
egies. ments
a) If the patient cannot teach back the message, a j) Procedures for handling medications in the
different mode of education should be consid- home, including safe storage, handling, and man-
ered when reteaching. agement of unused medication
b) For example, if the original message was con- k) Procedures for handling body secretions and
veyed orally, visualization or interactive modes waste in the home
of education should be considered in follow-up l) Procedures for disposing of medical waste sharps
efforts. per state or local guidelines
3. Patient education is the responsibility of all nurses m) Follow-up schedules, including laboratory and
and the entire healthcare team and continues as an healthcare provider visits
ongoing process throughout the cancer care contin- n) A list of credible resources where more informa-
uum (American Nurses Association, 2015). tion can be obtained if desired
4. Encourage patients to write down questions between
F. Scope of information visits and bring them to follow-up appointments.
1. Provide easily understandable verbal, video, audio, At each visit, healthcare providers should address
written, or web-based information (AHRQ, 2020b; patient and caregiver questions.
Frentsos, 2015; Iowa Health System et al., 2017; Nar- 5. Use tools such as the Patient Education Materials
wani et al., 2016; Truccolo, 2016). Assessment Tool (PEMAT) to evaluate patient edu-
a) If printed material is used, ensure that the sen- cation materials (AHRQ, 2020c)
tences and paragraphs are short.
b) Bullet points are helpful. G. Documentation
c) Always encourage patients and significant oth- 1. Nurses assess and document patient understanding
ers to ask questions, provide feedback, and par- of the education provided (Joint Commission, 2021).
ticipate actively. 2. Documentation of understanding includes the
2. Use the chunk and check method (AHRQ, 2020a). patient’s ability to verbalize or demonstrate learn-
a) Do not wait until the end of the visit to initiate ing and the need for information reinforcement.
teach-back. If patients cannot comprehend the information or
b) Chunk out information into small segments and refuse education, this must be documented with
have your patient teach it back. alternative plans.
c) Repeat several times during a visit. 3. Methods of assessing patient (and significant other)
d) This method minimizes the likelihood of over- understanding include the following (Iowa Health
whelming the learner. System et al., 2017; Joint Commission, 2021):
3. Include patients and significant others, and provide a) The patient or their significant other communi-
education on the following topics (Gumusay et al., cates an understanding of the information pre-
2016; LeFebvre & Felice, 2016; Neuss et al., 2016; sented, including medication names and the pur-
Şahin & Ergüney, 2016; Sullivan et al., 2016): pose of the therapy.
a) Disease and treatment plan b) The patient or their significant other identifies
b) Goals of treatment crucial instructions for self-care.
c) Duration and schedule of treatment c) The patient or their significant other identifies
d) Cancer medication names, including generic symptoms and side effects to report and how to
and brand names; the dose and frequency of the contact the providers if needed.
 Chapter 3. Patient Education 25

d) The patient brings new prescriptions to a Gidron, Y. (2016). Education, patient. In M. Gellman & J. Turner (Eds.),
follow-up visit and correctly states the instruc- Encyclopedia of Behavioral Medicine. Springer. https://doi.org/10.1007​
/978-1-4614-6439-6_105-2
tions for use. Gumusay, O., Cetin, B., Benekli, M., Gurcan, G., Ilhan, M.N., Bostankolu,
e) The patient performs a return demonstration of B., … Buyukberber, S. (2016). Factors influencing chemotherapy goal
procedures, such as temperature monitoring and perception in newly diagnosed cancer patients. Journal of Cancer Edu-
handwashing. cation, 31(2), 308–313. https://doi.org/10.1007/s13187-015-0827-y
f) The patient or their significant other accurately Hopmans, W., Damman, O.C., Timmermans, D.R.M., Haasbeek, C.J.A.,
Slotman, B.J., & Senan, S. (2014). Communicating cancer treatment
identifies the date and time of the next follow-up
information using the web: Utilizing the patient’s perspective in web-
visit. site development. BMC Medical Informatics and Decision Making, 14,
g) For oral agents, the patient or their significant 116. https://doi.org/10.1186/s12911-014-0116-4
other verbalizes the name of the medication, the Iowa Health System, Picker Institute, Des Moines University, & Health
correct procedure for administration (e.g., with Literacy Iowa. (2017). 10 elements of competence for using teach-back
or without food), and safe handling and disposal effectively. https://www.dartmouth.edu/cphs/tosubmit/teachback​
/teachback10elementsofcompetence.pdf
procedures. See Chapter 4 for a discussion on Jewitt, N., Hope, A.J., Milne, R., Le, L.W., Papadakos, J., Abdelmutti, N., …
adherence to oral antineoplastics. Giuliani, M.E. (2016). Development and evaluation of patient education
h) The patient or their significant other shares where materials for elderly lung cancer patients. Journal of Cancer Education,
or how to obtain additional information if desired. 31(1), 70–74. https://doi.org/10.1007/s13187-014-0780-1
i) The patient or their significant other communi- Joint Commission. (2021). Standards of patient education. https://www​
.jointcommission.org/standards
cates the need for additional teaching sessions if
Katz, A. (2017). Health literacy: What do you know? Oncology Nursing
issues are identified or if complex or multimodal Forum, 44(5), 521–522. https://doi.org/10.1188/17.ONF.521-522
treatments are planned. Laszewski, P., Zelko, C., Andriths, L., Cruz, E.V., Bauer, C., & Magnan, M.A.
(2016). Patient preference for instructional reinforcement regarding pre-
vention of radiation dermatitis. Clinical Journal of Oncology Nursing,
20(2), 187–191. https://doi.org/10.1188/16.CJON.187-191

References
LeFebvre, K.B., & Felice, T.L. (2016). Nursing application of oral chemo-
therapy safety standards: An informal survey. Clinical Journal of Oncol-
ogy Nursing, 20(3), 258–262. https://doi.org/10.1188/16.CJON.258-262
Agency for Healthcare Research and Quality. (2014). The SHARE approach— Narwani, V., Nalamada, K., Lee, M., Kothari, P., & Lakhani, R. (2016). Read-
Using the teach-back technique: A reference guide for health care provid- ability and quality assessment of internet-based patient education mate-
ers (workshop curriculum: tool 6). https://www.ahrq.gov/professionals​ rials related to laryngeal cancer. Head and Neck, 38(4), 601–605. https://​
/education/curriculum-tools/shareddecisionmaking/tools/tool-6/index​ doi.org/10.1002/hed.23939
.html National Center for Education Statistics. (2021). Public high school gradua-
Agency for Healthcare Research and Quality. (2020a). AHRQ Health Liter- tion rates. https://nces.ed.gov/programs/coe/indicator/coi#fn1
acy Universal Precautions Toolkit. https://www.ahrq.gov/health-literacy​ National Institutes of Health. (n.d.). Clear communication. https://www.nih​
/improve/precautions/index.html .gov/institutes-nih/nih-office-director/office-communications-public​
Agency for Healthcare Research and Quality. (2020b). Health literacy: Hid- -liaison/clear-communication
den barriers and practical strategies [PowerPoint slides]. https://www​ Neuss, M.N., Gilmore, T.R., Belderson, K.M., Billett, A.L., Conti-Kalchik,
.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools​ T., Harvey, B.E., … Polovich, M. (2016). 2016 updated American Society
/literacy-toolkit/tool3a/index.html of Clinical Oncology/Oncology Nursing Society chemotherapy admin-
Agency for Healthcare Research and Quality. (2020c). The Patient Educa- istration safety standards, including standards for pediatric oncology.
tion Materials Assessment Tool (PEMAT) and user’s guide. https://www​ Journal of Oncology Practice, 12(12), 1262–1271. https://doi.org/10.1200​
.ahrq.gov/health-literacy/patient-education/pemat.html /JOP.2016.017905
American Nurses Association. (2015). Nursing: Scope and standards of prac- Nielsen-Bohlman, L., Panzer, A.M., & Kindig, D.A. (Eds.). (2004). Health lit-
tice (3rd ed.). eracy: A prescription to end confusion. National Academies Press. https://​
Blecher, C.S., Ireland, A.M., & Watson, J.L. (2016). Standards of oncology doi.org/10.17226/10883
education: Patient/significant other and public (4th ed.). Oncology Nurs- Office of Disease Prevention and Health Promotion. (2010). National action
ing Society. plan to improve health literacy. https://health.gov/sites/default/files/2019​
Brant, J.M., & Wickham, R. (Eds.). (2013). Statement on the scope and stan- -09/Health_Literacy_Action_Plan.pdf
dards of oncology nursing practice: Generalist and advanced practice. Office of Disease Prevention and Health Promotion. (2015). Quick guide to
Oncology Nursing Society. health literacy. https://healthliteracycentre.eu/wp-content/uploads/2015​
Cancer Patient Education Network. (2013). Establishing comprehensive /11/Quick-guide-to-health-literacy.pdf
cancer patient education programs: Standards of practice. http://www​ Office of Disease Prevention and Health Promotion. (2021, August 24).
.cancerpatienteducation.org/docs/CPEN/Educator%20Resources​ Health literacy in Healthy People 2030. https://health.gov/our-work​
/CPENStandardsofPractice.Nov14.pdf /national-health-initiatives/healthy-people/healthy-people-2030/health​
Centers for Disease Control and Prevention. (2015). Healthy People 2010. -literacy-healthy-people-2030
https://www.cdc.gov/nchs/healthy_people/hp2010.htm Şahin, Z.A., & Ergüney, S. (2016). Effect on symptom management educa-
Centers for Disease Control and Prevention. (2021). What is health literacy? tion receiving patients of chemotherapy. Journal of Cancer Education,
https://www.cdc.gov/healthliteracy/learn/index.html 31(1), 101–107. https://doi.org/10.1007/s13187-015-0801-8
Frentsos, J.M. (2015). Use of videos as supplemental education tools across Sullivan, C.M., Dalby, C., Gross, A.H., Chesnulevich, K., Lilienfeld,
the cancer trajectory. Clinical Journal of Oncology Nursing, 19(6), E126– C.W., Hooper, C., … Kochanek, T. (2016). Oral chemotherapy edu-
E130. https://doi.org/10.1188/15.CJON.E126-E130 cation: Using innovation to ensure broad access. Clinical Journal of
26 Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

Oncology Nursing, 20(2), 126–128. https://doi.org/10.1188/16.CJON Truccolo, I. (2016). Providing patient information and education in prac-
.126-128 tice: The role of the health librarian. Health Information and Libraries
Swanson, C.B. (2010). U.S. graduation rate continues to decline. Education Journal, 33(2), 161–166. https://doi.org/10.1111/hir.12142
Week. https://www.edweek.org/teaching-learning/u-s-graduation-rate​ U.S. Census Bureau. (n.d.). Quick facts. https://www.census.gov/quickfacts​
-continues-decline/2010/06 /fact/table/US/PST045219
Tariman, J.D., Mehmeti, E., Spawn, N., McCarter, S.P., Bishop-Royse, J., Vaartio-Rajalin, H., Huumonen, T., Iire, L., Jekunen, A., Leino-Kilpi, H.,
Garcia, I., … Szubski, K. (2016). Oncology nursing and shared decision Minn, H., & Paloniemi, J. (2015). Patient education process in onco-
making for cancer treatment. Clinical Journal of Oncology Nursing, 20(5), logic context: What, why, and by whom? Nursing Research, 64(5), 381–
560–563. https://doi.org/10.1188/16.CJON.560-563 390. https://doi.org/10.1097/NNR.0000000000000114
 SECTION II

Cancer and Cancer

Treatment
Chapter 4. Overview of Cancer and Cancer Treatment
Chapter 5. Clinical Trials and Drug Development
 CHAPTER 4

Overview of Cancer and

Cancer Treatment

A. Definition of cancer throughout their life cycle and are con-

1. Cancer is fundamentally a disease of genomic alter- verted to cancer stem cells.
ation. c) Inflammation theory: Chronic inflammation is
a) Hanahan and Weinberg proposed the hallmarks a prolonged immune response triggered by per-
of cancer as a framework to describe eight func- sistent infection, hypersensitivity disease, and
tional characteristics acquired by cancer cells long-term exposure to toxic agents, leading to
during tumorigenesis (Devita et al., 2020; Hana- tissue damage and ultimately cancer (e.g., hepa-
han & Weinberg, 2011; see Table 4-1). titis B infection leading to liver cancer).
(1) Sustained proliferative signaling 3. Cancer genome
(2) Evading growth suppressors a) Cancer is a disease in which cells begin to divide
(3) Resisting cell death and grow uncontrollably through genomic alter-
(4) Enabling immortality ations in specific genes (Sanchez-Vega et al.,
(5) Inducing angiogenesis 2018).
(6) Activating invasion and metastasis b) Abnormal behaviors demonstrated by cancer cells
(7) Reprograming energy metabolism result from a cascade of pathogenic variations or
(8) Evading immune response alterations (formerly known as mutations) in the
b) The authors further described the developmental DNA of two types of key regulatory genes.
processes which foster the actuation of the origi- (1) Proto-oncogenes encode for protein prod-
nal eight functional characteristics with enabling ucts that stimulate cell growth and divi-
and emerging characteristics (Hanahan, 2022; sion. In their natural state, or wild-type,
Hanarahan & Weinburg, 2011). these genes are known as proto-oncogenes;
(1) Genome instability when DNA is altered, they become onco-
(2) Tumor-promoting inflammation genic and drive cancer growth.
(3) Unlocking phenotypic plasticity (2) Tumor suppressor genes encode for pro-
(4) Nonmutational epigenetic reprograming tein products that inhibit cellular divi-
(5) Polymorphic microbiomes sion, repair damaged DNA, and promote
(6) Senescent cells apoptosis (programmed cell death) for
2. Theories of cancer origins (Eggert, 2018) damaged or aging cells. When altered,
a) Clonal theory: Initial DNA changes result in these genes become inactivated and allow
benign growth, from which cloned cells accu- uncontrolled cancer growth.
mulate multiple genomic alterations over time, c) Oncogenic genes, known as driver variants, are
resulting in malignancy. activated during carcinogenesis. Many are genes
b) Cancer stem cell theories that govern growth factors, growth factor recep-
(1) In the cancer stem cell model, cancer tors, and cell signaling and, when altered, contin-
cells arise from cancer stem cells, which uously send signals to the nucleus of the cell to
may have limited proliferative capability, grow and divide (see Table 4-2).
and at least one cell line becomes tumor- d) Passenger variants, in contrast to driver variants,
igenic. arise during carcinogenesis and do not contrib-
(2) The plasticity model builds on the cancer ute directly to disease.
stem cell model, suggesting that noncan- e) Pathogenic variants inactivate tumor suppres-
cer stem cell versions of cells can change sor genes during carcinogenesis. Tumor sup-
29
30 Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

TABLE 4-1. Hallmarks of Cancer

Hallmark Healthy Cells Cancer Cells Example

Proliferative Healthy cells rely on external Cancer cells have the ability to BRAF is a protein involved in directing
signaling growth factor signaling to grow sustain continuous growth sig- cellular growth. Pathogenic variants in
and maintain homeostasis. naling and do not require external BRAF are therapeutic targets in treat-
stimulation to proliferate. ing melanoma and colon cancer.

Evading growth Cells react to signals from Cancer cells evade anti- Cyclin-dependent kinase 4/6 inhibitors
suppression tumor suppressor genes and growth signals by suppress- reduce the activity of cyclin-dependent
contact inhibition to govern ing the retinoblastoma protein kinases and restore the growth sup-
growth and division; growth and other proteins, which leads pression properties of the retinoblas-
suppression is regulated by a to the continuous activation of toma protein.
group of enzymes known as cyclin-dependent kinases.
cyclin-dependent kinases.

Resisting cell Apoptosis is preprogrammed Cancer cells evade apopto- The TP53 gene is responsible for
death cellular death for damaged or sis pathways to divide and grow repairing DNA damage; if repair is not
aging cells. uncontrollably. possible, apoptosis is induced. Clini-
cal trials targeting TP53 dysfunction in
cancer are ongoing.

Enabling Cells are programmed with a lim- Cancer cells become immortal, Telomerase reverse transcriptase
immortality ited number of growth-and- reversing the telomere shortening (TERT), an enzyme that reactivates
division cycles; DNA sequences process with the enzyme telom- telomerase, is being pursued as a
called telomeres, located at the erase. direct therapeutic target. Clinical trials
ends of chromosomes, control are ongoing.
the cell division limit through a
shortening process leading to
cell death.

Inducing Angiogenesis is how new blood The growth of a vascular network Vascular endothelial growth factor
angiogenesis vessels are formed, which is necessary for metastasis, as is a cytokine that stimulates vascu-
occurs only when needed dur- cancer cells require a supply of lar endothelial cells to form new blood
ing fetal development, men- nutrients and oxygen and a sys- vessels under normal conditions and in
strual cycle, and wound healing. tem for waste removal. tumor angiogenesis. It is a crucial ther-
apeutic target in the development of
antiangiogenic therapies.

Activating Unlike blood cells, other cells Invasion is the direct extension Alterations in the MET gene lead to
invasion and cannot travel throughout the and penetration by cancer cells tumor cell proliferation, migration, and
metastasis body, are governed by contact into neighboring tissue. Metasta- survival and are therapeutic targets in
inhibition, and do not invade sis is the ability of the cancer cells the treatment of non-small cell lung
other tissue. to penetrate lymph and blood ves- cancer.
sels to migrate and invade distant
tissue.

Reprogramming Cells generate energy through Cancer cells rely on glycolysis Mechanistic target of rapamycin is
energy the orderly process of glycoly- alone for energy production; in the a protein kinase that balances nutri-
metabolism sis, the Kreb cycle, and electron presence of oxygen, cancer cells ent and energy availability with cellular
transport. reprogram glucose metabolism by growth and is involved in the Warburg
aerobic glycolysis, known as the effect. These inhibitors are used to
Warburg effect. treat renal cell carcinoma and are being
studied in other cancers.

Evading immune Healthy cells develop immune Cancer cells exploit these immune Monoclonal antibodies block immune
destruction checkpoints to protect against checkpoints to evade immune checkpoint proteins, programmed
autoimmunity. detection and elimination cell death protein 1, programmed
cell death-ligand 1, and cytotoxic
T-lymphocyte antigen 4. The immune
system overcomes cancer’s ability to
resist immune responses and stimu-
lates the body’s mechanisms to defend
itself against cancer.

Note. Based on information from Devita et al., 2020; Hanahan & Weinberg, 2011.
 Chapter 4. Overview of Cancer and Cancer Treatment 31

missense, nonsense, and frameshift vari-

TABLE 4-2. Oncogenic Driver Variants
ants; DNA deletions; translocations;
Oncogene Function Tumor Types amplifications; and mismatched nucleo-
tide pairs, which accumulate and result in
ABL Increases cell prolif- Chronic myeloid
malignancy.
eration leukemia
g) Epigenetic changes (changes in genetic
BCL2 Regulates apoptosis Lymphoma expression rather than DNA sequence) can
BRAF Controls growth Colorectal and
affect the efficacy of DNA repair genes, alter-
signaling in MAPK gastric cancer ing specific gene expression and disrupting
pathway and melanoma healthy expression of proto-oncogenes and
tumor suppressor genes (e.g., DNA methyl-
Epidermal Cell surface recep- Amplified in
growth factor tor that activates colorectal, lung, ation).
receptor (EGFR; signaling pathways breast, head and h) Somatic cancer versus hereditary (germline) can-
ERBB1) within the cell, pro- neck, and pros- cer
moting cell growth, tate cancers (1) Most pathogenic alterations accumulate
division, and sur-
throughout the lifetime of human somatic
vival
cells, leading to sporadic cancer.
HER2 (ERBB2) Cell surface recep- Amplified in breast, (2) A small percentage of cancers, approx-
tor that activates gastric, lung, and imately 5%–10% depending on can-
signaling pathways colorectal can-
cer type, are caused by germline patho-
within the cell, pro- cers
moting cell growth, genic variants of tumor suppressor genes,
division, and sur- which are inherited DNA changes passed
vival between generations in the germ line
(sperm and ova) (National Cancer Insti-
MET Regulates cell Papillary renal cell
growth and motility and lung cancer tute [NCI], 2017).
4. Multiple factors often interact, leading to the devel-
MYC Family of regulator Burkett lymphoma opment of cancer. Healthy cells may change because
and transcription
of the following:
genes that con-
trol cell division and a) Spontaneous transformation: No causative agent
malignant formation is identified, but cellular traits are characteristic
of cancer cells.
RAS Family of genes that KRAS and NRAS:
b) Chronic or occupational exposure: Substances
govern signaling colorectal and
pathways in cells lung cancer such as asbestos, benzene, radiation, tobacco,
NRAS: melanoma arsenic, nickel, and some chemotherapy agents
are implicated in cancer development.
RET Cell signaling from Thyroid and mul-
outside and inside tiple endocrine
c) Changes in the microenvironment: Cancer cell
of the cell that pro- neoplasias plasticity, immune cell and signaling molecule
motes growth and involvement, and metabolic changes brought
maturation about by changes in oncogenes and tumor sup-
Note. Based on information from Devita et al., 2020; Wilkes, 2018.
pressor genes all contribute to the progression of
cancer growth (Eggert, 2018).
d) Exposure to viruses: Genetic changes can occur
to cells through viral infections (e.g., human pap-
pressor genes are associated with DNA repair, illomavirus [HPV] is the primary cause of cervi-
limit cell division, and control apoptosis (see cal cancer) (Inan et al., 2017).
Table 4-3).
f) Cancer cells are highly diverse or heterogeneous B. The Cancer Care Continuum framework illustrates the
and contain many different types of DNA dam- various stages and pathways of patient care (Young et al.,
age which constantly accumulate within the can- 2020).
cer genome. 1. Healthy lifestyles and the early detection of cancer
(1) Both large and small alterations can can prevent up to 50% of cancers.
impact cellular behavior. 2. Diagnosis and shared decision-making between the
(2) Damage in the genes associated with DNA healthcare team, patient, and family help determine
repair causes further genomic instability, the treatment plan and goals of care.
leading to errors. These errors include 3. Goals of cancer therapy
32 Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

ing, are associated with the devel-

TABLE 4-3. Tumor Suppressor Genes
opment of some cancers (Smith et
Tumor Associated al., 2018).
Suppressor Hereditary Cancer (2) Secondary cancer prevention includes
Gene Function Syndromes early detection and treatment of cancer
APC Controls cell divi- Familial adenoma- (e.g., mammogram, colonoscopy).
sion and contact tous polyposis (3) Tertiary cancer prevention includes mon-
inhibition itoring for or preventing recurrence of
ATM Controls rate of cell ATM-associated
the original cancer or second malignan-
growth and repairs breast cancer cies (e.g., rehabilitation and exercise pro-
damaged DNA grams, nutritional changes, psychosocial
support) (Smith et al., 2018).
BRCA1, BRCA2 DNA repair genes Hereditary breast,
ovarian, prostate,
c) Curative intent is a treatment that has the poten-
and pancreatic tial to eliminate disease (American Cancer Soci-
cancers ety [ACS], 2019a).
d) Control is when a cure is not possible. The goal
CDK4 Controls progres- Melanoma
sion through G1 may be to administer treatment to slow the
phase of cell cycle growth or spread of cancer and allow patients to
live longer than if therapy had not been given
MSH2, MSH6, Mismatch repair Hereditary nonpol-
(ACS, 2019a).
MLH1, PMS2, genes yposis colon can-
EPCAM cer (Lynch syn- e) Palliation is an interprofessional team-based
drome) approach that improves the quality of life for
patients and families through expert assessment
RB1 Controls cell cycle Retinoblastoma
and treatment of physical, spiritual, psychologi-
TP53 Most common Li-Fraumeni syn- cal, and social problems associated with severe
altered gene in drome and many illness (World Health Organization [WHO],
cancer; guard- solid tumors n.d.).
ian of the genome;
4. Cancer treatment and palliative care, which
detects DNA dam-
age and triggers includes many cancer treatment modalities,
apoptosis uses as a monotherapy or combination therapy
approach.
Note. Based on information from Devita et al., 2020; Wilkes, 2018.
a) Types of cancer treatment modalities include
surgery, radiation therapy, chemotherapy, hor-
mone therapy, immunotherapy, gene therapy, tar-
a) Treatment planning includes shared decision- geted therapy, and hematopoietic stem cell trans-
making that integrates the patient’s personal plantation.
goals, needs, and values as part of care planning b) Palliative care should be integrated early into
(Cranley et al., 2017). treatment plans and is key to effective patient
b) Prevention (Mahon, 2018) management. It can be provided in many care
(1) Primary cancer prevention includes mea- settings, including inpatient, outpatient, pri-
sures taken to avoid carcinogen exposure mary care, and community settings (WHO,
and promote health or prevent disease n.d.).
development. Examples include avoid- 5. Post-treatment care is referred to as survivorship care
ance of tobacco products and immuniza- (NCI, n.d.-b).
tion against HPV. a) Practicing cancer prevention and making healthy
(a) Chemoprevention may include lifestyle choices
tamoxifen for women at risk for b) Providing follow-up cancer screenings
breast cancer or HPV vaccination c) Addressing physical and psychosocial late effects
to protect against HPV infection, of treatment
which can cause cancers of the cer- d) Rehabilitating with monitoring and management
vix, vagina, penis, anus, and oro- of long-term treatment effects
pharynx. e) Assessing for concerns such as financial toxic-
(b) Lifestyle and behavioral modifi- ity and disability
cation of risk factors, including f) Transitioning to primary care management and
dietary choices, obesity, and smok- referring to other specialists if indicated
 Chapter 4. Overview of Cancer and Cancer Treatment 33

6. End-of-life care encompasses symptom management (2) The Rai staging system is used to stage
and remembrance. chronic lymphocytic leukemia.
(3) The International Staging System is used
C. Cancer staging and grading (American College of Sur- for multiple myeloma.
geons, n.d.; Amin et al., 2017; Vogel, 2018) 2. Grading
1. Staging a) Cellular differentiation is based on how closely
a) Staging verifies the extent of the disease by tumor cells resemble healthy cells in structure
assessing the location and size of the primary and maturity.
tumor and determining if it has spread to other b) Differentiation is graded from GX (cannot be
tissues or organs. assessed) to G4 (undifferentiated, where the par-
b) It informs prognosis, treatment planning, iden- ent cell is impossible to distinguish).
tification of suitable clinical trials, and treatment (1) Grade 1 tumor cells appear very similar to
response. healthy cells. They are referred to as low
c) Staging conventions provide a common language grade or well differentiated.
that the healthcare team can use to communicate (2) Grade 2 tumor cells show more differences
about a patient’s case. from healthy cells. They are referred to as
d) Criteria are unique for many types of can- intermediate grade or moderately differ-
cer (American College of Surgeons, n.d.; NCI, entiated.
2015). (3) Grade 3–4 tumor cells have minimal simi-
e) Four types of staging exist (American College of larities to healthy cells and are considered
Surgeons, n.d.; Amin et al., 2017). high grade or poorly differentiated.
(1) Clinical: based on physical examination, c) Cells are obtained by biopsy or surgical removal
imaging, and biopsy for microscopic examination by a pathologist.
(2) Pathologic: Based on tissue, fluids, or Cancer cell differentiation can vary over time,
exploration during surgery; is combined and cells with several differentiation grades can
with clinical staging exist within a single tumor.
(3) Post-therapy/post–neoadjuvant therapy: d) Tumor grade is a prognostic indicator used in
used for confirming cancer remaining treatment planning. A higher grade indicates a
after systemic chemotherapy or hor- more aggressive tumor (Vogel, 2018).
mone therapy, radiation therapy prior
to surgery, or when no surgery is per- D. Cancer treatment modalities
formed 1. Table 4-4 summarizes the history and evolution of
(4) Restaging: used for determining the extent antineoplastic therapy.
of recurrence; helpful for planning future 2. Surgery (Lester, 2018)
treatment options a) Surgery is a precise local treatment. It may be
f) The tumor, node, metastasis (TNM) staging sys- robotic assisted (Doyle-Lindrud, 2015).
tem is maintained by the American Joint Com- b) Surgery may remove all or a portion of the pri-
mittee on Cancer and the Union for International mary tumor, lymph nodes, and adjacent tis-
Cancer Control. It is the most commonly used sues.
anatomic staging system and is based on specific c) It can be used to obtain specimens for cytopa-
criteria. It is combined with a staging number thology.
(0–IV) and sometimes with substage classifica- d) Surgery may be the only treatment a patient
tions (e.g., IIa, IIb). In general, stage I confers a requires.
more favorable prognosis than stage IV (Ameri- e) It may be preceded by (neoadjuvant) or followed
can College of Surgeons, n.d.; Amin et al., 2017; by (adjuvant) modalities, such as chemotherapy,
Vogel, 2018; see Figure 4-1). immunotherapy, or radiation therapy.
g) Hematologic malignancies, malignant mel- f) Surgery may be used in the palliative setting to
anoma, brain cancers, and other cancers are alleviate or lessen intolerable symptoms.
staged according to different systems (Amer- 3. Radiation therapy (Behrend, 2018; Gosselin, 2018)
ican Brain Tumor Association, n.d.; Leukemia a) Radiation therapy is a local treatment in which
and Lymphoma Society, n.d.-a, n.d.-b; Multi- energy is precisely aimed at a specific target.
ple Myeloma Research Foundation, 2021; Vogel, b) It may be planned before surgery to decrease
2018). tumor burden (neoadjuvant) or after surgery
(1) The Ann Arbor staging system is used to (adjuvant) to prevent recurrence of the primary
stage Hodgkin lymphoma. tumor.
34 Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

FIGURE 4-1. Tumor, Node, Metastasis (TNM) Staging

T = tumor size N = nodal involvement M = metastasis
• TX = not assessed • NX = not assessed • MX = not assessed
• Tis = in situ cancer • N0 = no lymph nodes involved • M0 = no metastasis
• T0 = no primary tumor found • N1, N2, N3 based on the number/location • M1 = metastasis
• T1, T2, T3, T4 based on the tumor size/ of lymph nodes involved
extent • Nmi = micrometastasis in the node
• N(i−) = isolated tumor cells in the node

A patient’s TNM stage may also have one or more letters at the beginning. These letters indicate when staging occurred.
• cTNM or TNM: No letter or a “c” indicates a clinical staging.
• pTNM: A “p” indicates a pathologic staging.
• ycTNM: A “yc” indicates a clinical staging following systemic or radiation therapy.
• ypTNM: A “yp” indicates a pathologic staging following systemic or radiation therapy.
• rTNM: An “r” indicates staging following a recurrence of cancer.
• aTNM: An “a” is used for staging cancer that was found during an autopsy.

Note. Based on information from American College of Surgeons, n.d.; Amin et al., 2017.

c) This therapy is more effective for some diseases inhibitors, and luteinizing hormone–releasing
than others. hormone antagonists and agonists.
d) Multiple treatment delivery methods exist, 6. Immunotherapies and gene therapies (Bayer et al.,
including various external beam treatments, ste- 2017; Lea, 2018; Martin, 2017; Muehlbauer et al.,
reotactic radiosurgery, image-guided CyberKnife® 2018; Vioral, 2018; see Chapter 10)
radiosurgery, brachytherapy, and sealed and a) Immunotherapies and gene therapies are systemic
unsealed radionuclide therapy. treatments that use the patient’s immune system
e) It is often given in combination with other anti- through various pathophysiologic mechanisms.
neoplastic therapies and termed chemoradiation b) They may be synthetic (e.g., chimeric antigen
or radioimmunotherapy, depending on the clas- receptor T cells), biologically derived (e.g., mono-
sification of the concurrent treatment. clonal antibodies), or nonpathogenic or patho-
4. Chemotherapy is the most traditional systemic can- genic virus (requiring modification for use).
cer therapy (Dowling et al., 2017; see Chapter 6). c) Examples include chimeric antigen receptor
a) Chemotherapy is most commonly administered T-cell therapies, checkpoint inhibitors, monoclo-
as a systemic treatment. nal antibodies, cancer vaccines, immunomodula-
b) It may be used locally for instillations (e.g., blad- tors, cytokines, and oncolytic viruses.
der, peritoneum) or as a topical therapy. d) These therapies cause significant cytokine release
c) Chemotherapy may be used as a single agent or, syndrome, hypersensitivity reactions, and other
more commonly, in combination. unique side effects because of the immune
d) It may be dose limiting from cytotoxic effects on response to the drug.
healthy tissues. e) This is a rapidly developing class of treatment
e) This therapy disrupts the cell cycle at different options.
points, triggering cellular death. f) Gene therapies typically correct defective genes
f) It is used in high doses for hematopoietic stem by inserting a healthy gene into the nuclei of
cell transplantation. abnormal cells to repair, replace, or alter its func-
g) Examples include alkylating agents, antimetabolites, tion through viral vectors.
antitumor antibiotics, nitrosoureas, and plant alka- g) Biosimilars are biologic products similar to, but
loids (e.g., taxanes, vinca alkaloids, camptothecins). not the same as, the reference drug they mimic.
5. Hormone therapy (Tortorice, 2018; see Chapter 7) (1) Biosimilar drugs have no clinically meaning-
a) Hormone therapy is a systemic treatment, often ful differences from the reference product.
combined with other antineoplastic agents. It can (2) They are not generic forms of a refer-
be oral or injectable. ence drug (which are chemically iden-
b) It has various mechanisms of action and unique tical to the reference drug) instead they
side effect profiles. are chemically similar, and structural and
c) Examples include corticosteroids, androgens, chemical changes should not affect effi-
antiandrogens, selective estrogen receptor mod- cacy (U.S. Food and Drug Administra-
ulators, estrogen receptor antagonists, aromatase tion [U.S. FDA], 2021b).
 Chapter 4. Overview of Cancer and Cancer Treatment 35

(3) Biosimilars are produced through an been identified to select appropriate targeted
abbreviated manufacturing process and therapy.
are expected to be an affordable alterna- d) Targeted agents include tyrosine kinase inhib-
tive to some therapy agents. itors, anaplastic lymphoma kinase inhibitors,
7. Targeted therapies (Devita et al., 2020; Wilkes, 2018; cyclin-dependent kinase inhibitors, and epider-
see Chapter 8) mal growth factor receptor inhibitors. Many other
a) Targeted therapies are treatments that act on key targets exist, and most of these agents are oral.
altered oncogenes or tumor suppressor genes (see e) Unlike traditional chemotherapy, which disrupts
Table 4-5). cellular division in healthy and cancer cells, tar-
b) Key oncogenes encode for protein kinases, are geted agents affect only altered cancer cells, min-
involved in signaling pathways, are sensitive to imizing toxicity in nonmalignant cells (Wilkes,
pharmacologic inhibition, and are actionable 2018).
therapy targets. 8. High-dose chemotherapy with hematopoietic stem
c) Genomic alterations have become highly sensi- cell transplantation
tive, and specific biomarkers for disease detec- a) High-dose chemotherapy, with or without radi-
tion, monitoring, and treatment selection have ation, is administered with the intention of bone

TABLE 4-4. History of Cancer Treatments

Period Events

Pre-20th In the 1500s, heavy metals were used systemically to treat cancers; however, their effectiveness was limited, and
century their toxicity was significant (Burchenal, 1977).
Prior to 1890, surgical treatment or cauterization of tumors was the most common therapeutic option (Falzone et al.,
2018).
In the 1890s, William Coley developed and explored Coley toxins, the first nonspecific immunostimulants used to
treat cancer.
In 1899, Marie and Pierre Curie proposed using radiation to treat cancer (Falzone et al., 2018).

1930–1940 The use of nitrogen mustard gas as a chemical weapon in World War I and the accidental use of this banned weapon
in World War II led to the discovery of the first DNA alkylating agent, as its toxic effect led to bone marrow and white
blood cell suppression. This discovery led to the use of chemotherapy to treat hematologic and solid tumors (Falzone
et al., 2018). Alkylating agents became recognized as a successful treatment for lymphoma (Gilman & Philips, 1946).
Folic acid antagonists, later called methotrexate, were found to be effective against pediatric acute lymphoblastic
leukemia (Farber et al., 1948).
Congress passed the National Cancer Act in 1937, establishing the National Cancer Institute.

1950s Research dedicated to nonhematologic cancers began with actinomycin-D in pediatric solid tumors (Falzone et al., 2018).
The Children’s Cancer Group (now part of the merged Children’s Oncology Group) was formed as the first coopera-
tive group dedicated to finding effective treatments for pediatric cancer.
Metastatic choriocarcinoma was the first metastatic disease cured by treatment with methotrexate in 1956.
The first bone marrow transplant was performed in 1956.

1960–1970 Combined therapeutic protocols using several chemotherapy drugs with different mechanisms of action became the
standard in clinical practice (Falzone et al., 2018).
The Philadelphia chromosome was discovered in the cells of chronic myeloid leukemia. This genetic abnormality is
a fusion gene called BCR-ABL1, which continuously promotes cancer growth. This marked the beginning of the
search for targeted therapies against this abnormal cancer cell behavior.
Mechlorethamine, vincristine, procarbazine, and prednisone (MOPP), the first combination chemotherapy, were used
and found to be curative against Hodgkin lymphoma (Noonan, 2007).
Chemotherapy was used with surgery and radiation, beginning combination treatment for cancer.
The development of hybridoma technology began leading to the discovery of monoclonal antibodies.
Tamoxifen is synthesized in 1962 and first used in 1969.

1970s The National Cancer Act of 1971 provided funding for cancer research.
Adjuvant chemotherapy became a standard cancer treatment (Bonadonna et al., 1995; Fisher et al., 1986).
The discovery of the human leukocyte antigen histocompatibility system expanded the use of and survival from
bone marrow transplantation (Perry & Linch, 1996).
The TP53 gene, the most commonly altered gene in human cancer, was discovered in 1979, beginning the search for
the genetic basis of cancer.

(Continued on next page)

36 Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

TABLE 4-4. History of Cancer Treatments (Continued)

Period Events

1980s Community clinical oncology programs were developed in 1983 to contribute to National Cancer Institute chemo-
therapy clinical trials.
Focus turned to symptom management to alleviate dose-limiting toxicities related to neutropenia, nausea and vomit-
ing, and cardiotoxicity.
Scientists investigated recombinant DNA technology, leading to treatments involving interferon alpha and erythro-
poietin. This marked the beginning of biotechnical advancements in cancer treatment (Devita et al., 2020).
High-dose chemotherapy was used for myeloablation prior to bone marrow and stem cell transplantation (Perry &
Linch, 1996).

1990s New classifications of drugs (e.g., taxanes) were developed; paclitaxel was found to be effective against ovarian and
breast cancers (Rowinsky et al., 1992).
Biotechnical advancements continued with approvals of granulocyte–colony-stimulating factor and granulocyte
macrophage–colony-stimulating factor, interleukin-2, interleukin-11, and the first cancer-directed monoclonal anti-
bodies rituximab and trastuzumab.
The approval and widespread use of ondansetron for the prevention of chemotherapy-induced nausea and vomit-
ing had an enormous impact on symptom management, improved quality of life for chemotherapy patients, and
allowed for the greater development of outpatient treatment protocols (Perez, 1995).
Based on the studies by Mary-Claire King, the first tumor suppressor and breast cancer susceptibility gene, BRCA1,
was sequenced in 1994. BRCA2 was discovered the following year. These breakthroughs confirmed the genetic
basis of some cancers (Gnarra et al., 1995; Hoskins et al., 1995; Miki et al., 1994).
Aromatase inhibitors were approved for breast cancer treatment. This marked a step forward for hormone therapy.

2000s The U.S. Food and Drug Administration approved imatinib to treat chronic myeloid leukemia, the first targeted treat-
ment that disrupts the action of the altered BCR-ABL gene (Falzone et al., 2018).
The Human Genome Project was completed, meeting the goal of mapping and understanding of all the genes of
human beings (Devita et al., 2020).
Radioimmunotherapy was developed to deliver radioactivity directly to select tumor cells, avoiding damage to
healthy tissue (e.g., ibritumomab tiuxetan, tositumomab, iodine-131).
The U.S. Food and Drug Administration approved the following:
• Bevacizumab is the first approved antiangiogenic agent for cancer (American Society of Clinical Oncology, n.d.-a).
• Aprepitant, a neurokinin-1 antagonist, is used in combination with other antiemetic drugs to prevent
chemotherapy-induced nausea and vomiting.
• A prophylactic vaccine prevents human papillomavirus infections that cause cervical cancer (American Society of
Clinical Oncology, n.d.-a).
• Targeted therapies were developed to affect epidermal growth factor receptors in lung cancer (gefitinib and erlo-
tinib) and colon cancer (cetuximab and panitumumab) (American Society of Clinical Oncology, n.d.-a).

2010– In 2010, the Patient Protection and Affordable Care Act was signed into law.
present American cancer survivors numbered 13.7 million, the highest total to date (American Society of Clinical Oncology,
n.d.-a).
The U.S. Food and Drug Administration approved the following:
• Sipuleucel-T was the first cancer treatment vaccine to use the patient’s dendritic cells in the immune system to
attack cancer cells (Anassi & Ndefo, 2011).
• The immunotherapy drug ipilimumab for unresectable or metastatic melanoma stimulates the body’s immune sys-
tem to attack cancer cells (Bristol-Myers Squibb, 2011; National Cancer Institute, 2015).
• The first antibody–drug conjugate, ado-trastuzumab emtansine (T-DM1), links trastuzumab (the monoclonal anti-
body) with a microtubular inhibitor.
• The first programmed cell death-ligand 1 checkpoint inhibitor, atezolizumab, is used to treat advanced bladder can-
cer (American Society of Clinical Oncology, n.d.-b).
• Chimeric antigen receptor T-cell therapy is used for select patients with B-cell acute lymphoblastic leukemia. It
is the first gene therapy that uses technology to reprogram the patient’s immune system to destroy cancer cells
(Novartis Pharmaceuticals, 2017).
• Bevacizumab-awwb is the first biosimilar approved in the United States to treat cancer (U.S. Food and Drug Admin-
istration, 2017b).
• Larotretinib was the first agent approved to treat a genetic variant, rather than the tumor location, marking the
beginning of tumor agnostic therapies (Raez & Santos, 2018).
• By May 2021, more than 70 U.S. Food and Drug Administration–approved targeted agents were available to treat
solid and hematologic malignancies based on biomarkers detected in the tumor (National Cancer Institute, 2020a).
 Chapter 4. Overview of Cancer and Cancer Treatment 37

marrow ablation, with subsequent rescue using ditional cancer treatments toward genomically
peripheral, bone marrow, or umbilical stem cells. guided care known as precision oncology (Devita
b) Transplants can be autologous, allogeneic, synge- et al., 2020).
neic, or haploidentical. High-dose chemotherapy 2. Traditional cancer treatments are designed to remove
with hematopoietic stem cell transplantation is solid tumors surgically and halt tumor growth
the standard of care for many hematologic malig- through systemic disruption of mitotic division in
nancies (Tortorice, 2018). all cells (through radiation or chemotherapy). This
is accomplished via single or combination therapies
E. Treatment approaches (Haque et al., 2017; Jin et al., 2017; Mokhtari et al.,
1. Chemoprevention uses selected pharmacologic 2017; Tortorice, 2018; Zhang et al., 2017).
agents to prevent cancer in high-risk individuals a) Drug combinations or drug–therapy combina-
(e.g., tamoxifen for women whose personal health tions (e.g., drug plus radiation therapy) provide
history indicates a statistically increased risk for superior efficacy and survival advantage over
developing breast cancer) (Smith et al., 2018). monotherapy in many tumor types and combi-
2. Neoadjuvant therapy uses one or more treatment nation regimens.
modalities before the primary treatment (e.g., che- b) The mechanism by which this occurs is not fully
motherapy before surgery). The goal is to debulk the understood in some cases.
primary tumor before surgery or address microme- c) Hypotheses include that one agent may poten-
tastases (Tajima et al., 2017; Tortorice, 2018). tiate the effect of another or that the combined
3. Adjuvant therapy follows the primary treatment agents or therapies create effects that together are
modality (e.g., chemotherapy or radiation after sur- unique.
gery). The goal is to target minimal disease or micro-
metastases for patients at high risk for recurrence
(Tortorice, 2018). TABLE 4-5. Genomic Alterations Used to Select
4. Conditioning or preparative therapy is the adminis- Treatment
tration of chemotherapy, sometimes with total body
Genomic
irradiation, to eliminate residual disease or ablate Alteration Disease Type With Approved Treatment
the marrow space before receiving a hematopoietic
Oncogene Driver Variants
stem cell transplantation (also referred to as mye-
loablation). ABL1 Chronic myeloid leukemia and acute lym-
a) Myeloablative therapy includes the obliteration phoblastic leukemia
of bone marrow with chemotherapy agents that ALK Lung cancer and melanoma
are typically administered in high doses in prep-
aration for hematopoietic stem cell transplanta- BRAF Melanoma and colorectal and lung cancers
tion. This therapy does not allow for spontane- EGFR Lung cancers
ous marrow recovery because of the lethal doses
of agents used; therefore, it must be followed by ERBB2 (HER2) Breast, colorectal, endometrial, and gas-
tric cancers
transplantation to prevent death (Zack, 2018).
b) Nonmyeloablative therapy is reduced-intensity ESR1 Breast cancers
conditioning using doses that are not lethal to
KRAS Lung and colorectal cancers
bone marrow (Epperla et al., 2017). This type
of transplant is dependent on the graft-versus- MET Lung cancers
tumor effect.
NRAS Lung and colorectal cancers
5. Immunosuppression is the administration of anti-
neoplastic agents at doses sufficient to blunt a NTRK fusions All solid tumors
patient’s immune response. Agents such as meth-
PIK3CA Breast cancers
otrexate are given post-transplantation to prevent
graft-versus-host disease. Select agents are used to ROS1 Lung cancers
treat noncancerous conditions, such as autoimmune Tumor Suppressor Genes
diseases.
ATM Prostate cancers
F. Treatment strategies BRCA1 and Breast, ovarian, pancreatic, and prostate
1. Over the past two decades, unprecedented advance- BRCA2 cancers
ments in molecular biology, genomics, and gene
Note. Based on information from Devita et al., 2020; Wilkes, 2018.
sequencing technology have led to a shift from tra-
38 Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (Second Edition)

(1) Tumor cell populations are heterogeneous; cating patients on maintaining the prescribed
therefore, a combination of agents or ther- dosing schedule are paramount to optimal out-
apies with different mechanisms of action comes (Matikas et al., 2017).
can increase the number of cells killed at e) Dose density and intensity and relative dose
any one time. intensity concepts may not apply to targeted
(2) Combination agents or therapies with dif- therapies, immunotherapies, and hormone thera-
ferent mechanisms of action also reduce pies because of different toxicity profiles.
the possibility of drug resistance, as 4. Genomically guided treatment with molecular or
researcher consensus concludes that many genomic biomarkers
mechanisms of resistance are likely to be a) Detecting protein biomarkers for estrogen and
occurring within a single tumor (Mokh- progesterone receptors through the immunohis-
tari et al., 2017; NCI, 2016). tochemistry staining technique was one of the
(3) Combinations of drugs can be used earliest applications in patient management (Dai
synergistically to access sanctuary sites. et al., 2016).
One drug’s solubility or affinity for spe- (1) The overexpression of estrogen receptors
cific tissues may be different from, but and progesterone receptors in breast can-
complementary to, another particular cer predicts the potential for a clinical
drug’s characteristics (Mokhtari et al., response to hormone therapy.
2017). (2) Estrogen receptor status is also a prog-
(4) Drugs with similar toxicities generally are nostic indicator in that patients with hor-
avoided; however, this is not always pos- mone receptor positivity generally have
sible. Therapy combinations may potenti- a more favorable prognosis (Dai et al.,
ate the toxic effects of either or both ther- 2016).
apies or may be lessened because of differ- b) Tumor-specific genomic alterations in driver
ent targeted mechanisms of action (Mokh- genes, which promote growth and tumor for-
tari et al., 2017). mation, and some tumor suppressor genes are
3. Dosing of cytotoxic chemotherapy predictive biomarkers for response to targeted
a) Treatment cycles are designed to permit recov- agents in the treatment of malignancy (Malone
ery from damage to healthy tissues and organs et al., 2020).
and are based on the known pharmacokinetics (1) DNA sequencing is a laboratory pro-
of agents. Because the average white blood cell cess used to learn the exact order (or
nadir is 10–14 days, many regimens are based sequence) of the four building blocks
on this time frame (Drooger et al., 2016; Tor- that make up DNA and find alterations
torice, 2018). that may cause diseases such as cancer
b) Dose density refers to the drug dose per unit of (NCI, n.d.-c).
time. Higher dose density is achieved by short- (2) The Cancer Genome Atlas was a collab-
ening the intervals between treatments (Lamber- oration between NCI and the National
tini et al., 2017). Reducing the time between che- Human Genome Research Institute that
motherapy cycles may diminish tumor regrowth. resulted in the development of compre-
c) Dose intensity is the amount of drug delivered hensive maps of the key genomic changes
over time. taking place in 33 different types of can-
(1) Dose reduction or delay resulting from cer (NCI, n.d.-a).
chemotherapy side effects, scheduling (3) Specific variants in the tyrosine kinase sig-
conflicts, or any other reason reduces dose naling pathway lead to uncontrolled cell
intensity and may negatively affect patient proliferation and tumor formation.
survival (Matikas et al., 2017). (a) By stimulating the downstream
(2) The prophylactic use of a myeloid growth intracellular signaling process, these
factor has allowed for the administration variants cause accelerated cell prolif-
of dose-dense and dose-intense chemo- eration, extended cell survival, and
therapy regimens that would otherwise increased angiogenesis.
result in unacceptable neutropenia (Mati- (b) Biomarker testing for these variants
kas et al., 2017). can guide the prioritization of ther-
d) Relative dose intensity is calculated by compar- apies specific to these receptors for
ing the received dose to the referenced (standard) patients most likely to benefit from
dose. Proactively managing symptoms and edu- a targeted agent. It can also identify
 Chapter 4. Overview of Cancer and Cancer Treatment 39

those who will not benefit from a tar- for Research and Treatment of Cancer, NCI, and
geted agent. NCI of Canada. These guidelines addressed
(c) Numerous small molecule tyrosine most of the deficiencies in the WHO criteria.
kinase inhibitors have been designed (1) RECIST guidelines recommended the use
to block phosphorylation and sup- of one-dimensional tumor measurements
press tumor growth (Malone et al., (the longest diameter) rather than the
2020; Wilkes, 2018). cross product (Bates & Fojo, 2019).
As of May 2021, more than 70 FDA- (a) Complete response is the complete
approved targeted agents exist to treat disappearance of the disease.
solid and hematologic malignancies based (b) Partial response is a 30% or more sig-
on biomarkers detected in the tumor nificant reduction in the sum of the
(NCI, 2020b; see Chapter 8). longest diameter of the target lesion.
c) Programmed cell death-ligand 1 (PD-L1) protein (c) Stable disease is a change that does
is found on healthy and cancer cells. not meet the criteria for response or
(1) Overexpression of PD-L1 by tumor cells progression.
inactivates the body’s immune activity (d) Progression includes a 20% or
against the cancer cell by binding with the more significant increase in the
programmed cell death protein 1 (PD-1) sum of the longest diameter of tar-
antigen on the T cell. By suppressing the get lesions.
T cell, the cancer cell can evade attack by (2) RECIST 1.1 was developed in 2009 as
the body’s immune system. technology and medicine advanced.
(2) Immunotherapy treatments that target Using the same criteria for response
either PD-L1 or PD-1 block this binding, as RECIST 1.0, it also identified and
keeping PD-L1 from inactivating the T addressed its predecessor’s issues. For
cell and boosting the immune system in example, criteria were updated to include
its response against the cancer cell (Bayer nodal disease (Bates & Fojo, 2019).
et al., 2017). RECIST 1.1 also has known limitations,
(a) PD-1 inhibitors help treat several including the following (Persigehl et al.,
types of cancer, including mela- 2020):
noma, non-small cell lung cancer, (a) The criteria depend solely on ana-
kidney cancer, bladder cancer, head tomic measurements and do not con-
and neck cancer, and Hodgkin lym- sider tumor vascularity or functional
phoma. imaging parameters.
(b) PD-L1 inhibitors have effectively (b) In 2017, iRECIST was published to
treated bladder cancer, non-small include a modified set of response
cell lung cancer, and Merkel cell car- criteria to address therapy response
cinoma (ACS, 2019b). patterns seen with immunotherapy.
(c) Traditional cytotoxic chemother-
G. Measuring response apy often results in the reduction of
1. The earliest measures of determining response date tumor size. However, newer targeted
back to 1976. Since then, many tools and factors have agents that interfere with or inhibit
been considered when measuring response. A gold cell growth and division by inhibit-
standard for all tumor types is not used. ing molecular pathways are consid-
2. Objective tumor response and quantitative measure- ered cytostatic, meaning they block
ment tumor cell proliferation. In contrast,
a) Objective tumor response is assessed through standard chemotherapy agents are
quantitative measurements, such as surgical cytotoxic, meaning they kill tumor
examinations, imaging studies, or serum bio- cells.
markers. (d) Studies of several cancer types, such
b) Baseline measurements recorded at the time of as prostate cancer, mesothelioma,
diagnosis are compared to those recorded after soft tissue sarcoma, and neuroendo-
treatment completion. crine tumors, have also shown that
c) The Response Evaluation Criteria in Solid RECIST 1.1 criteria are inaccurate in
Tumors (RECIST) guidelines were published in reporting response to therapy (San-
2000 by members of the European Organisation drasegaran, 2015).
Random documents with unrelated
content Scribd suggests to you:
Fahrzeuge unwiderbringlich nach Süden reißt. Und wenn uns von
12,700 Inseln erzählt wird, welche im indischen Meere liegen sollen,
so werden wohl die Korallen-Ringe der Lakkediven, d. h. 100,000
Inseln und der Titel des Sultans der Malediven, der sich Herr der
12,000 Inseln nannte, dabei besondere Berücksichtigung gefunden
haben.
Erst im Jahre 1294 kam die bedeutend an Mitgliederzahl
zusammengeschmolzene Gesandschaft nach Persien, denn ein
großer Theil des ursprünglich aus 600 Personen bestehenden
Gefolges war während der Reise gestorben. Auch Argunchan, dem
die Braut bestimmt war, war inzwischen (am 10. März 1291) aus
dem Leben geschieden. Ihm war sein Bruder Kaichatu (Kiacatu) in
der Herrschaft gefolgt; dessen Sohn, Gasan (Casan), trat an die
Stelle seines verstorbenen Ohms und heiratete die Braut. Kaichatu
selbst aber empfing die Poli in fürstlicher Weise und gab ihnen auf
ihrer Weiterreise die umfassendsten Geleitsbriefe mit, so daß sie in
unsicheren Gegenden zuweilen unter dem Schutze von 200
bewaffneten Reitern dem Abendlande zueilten. Von Persien aus
schlugen sie über Bagdad den nördlichen Weg ein über das
armenische Hochland nach Trapezunt und gelangten von da zu Schiff
über Konstantinopel und Negroponte im Jahre 1295, nach 25jähriger
Abwesenheit wieder in ihre Vaterstadt Venedig.
Fassen wir noch einmal die Resultate dieser epochemachenden
Reise zusammen,[40] so war Marco Polo der erste Reisende, welcher
ganz Asien der Länge nach durchzog und die einzelnen Länder
beschrieb. Er sah die Wüsten Persiens und die grünen Hochflächen
und wilden Schluchten Badachschans, die Jade-führenden Flüsse
Ost-Turkistans und die Steppen der Mongolei, die glänzende
Hofhaltung in Cambalu und das Volksgewimmel in China. Er erzählte
von Japan mit seinen goldbedeckten Palästen, von Birma mit seinen
goldenen Pagoden, schildert zuerst die paradiesischen Eilandfluren
der Sundawelt mit ihren aromatischen Gewürzen, das ferne Java und
Sumatra mit seinen vielen Königreichen, mit seinen geschätzten
Erzeugnissen und seinen Menschenfressern; er sah Ceylon mit
seinen heiligen Bergen, besuchte viele Häfen Indiens und lernte
dieses im Abendlande noch immer von Sagen verhüllte Land in
seiner Größe und seinem Reichthum kennen. Er gab zuerst im
Mittelalter einen klaren Bericht von dem christlichen Reiche in
Abessinien und drang mit seinem Blick einerseits bis nach
Madagascar vor, andererseits zog er im Innern Asiens
Erkundigungen über den höchsten Norden, über Sibirien ein, über
das Land der Finsterniß, wo weder Sonne noch Mond noch Sterne
scheinen und ein ewiges Zwielicht herrscht, wo man auf
Hundeschlitten fährt oder auf Renthieren reitet, ein Land, hinter
welchem endlich ein eisiger Ocean sich ausdehnt.
Wissenschaftliche Bildung besaß Polo nicht. Er wundert sich
darüber, daß Sumatra so weit im Süden liegt, daß der Polarstern aus
dem Gesicht verschwindet und die Inseln im Eismeer auf der andern
Seite so weit im hohen Norden sich befinden, daß man den
Polarstern hinter sich läßt. Die Himmelsgegenden, nach denen der
Weg führte, oder wohin Länder ihrer Lage nach angegeben werden,
sind oft falsch bestimmt, seine Wegelängen erscheinen vielfach
übertrieben.
Vor allem aber ist zu beklagen, daß er nicht Chinesisch verstand,
obwohl er so lange im Lande weilte und sogar officiell mit dem Volke
verkehren mußte. Daher die falschen Uebersetzungen und
Erklärungen chinesischer Namen, wie wenn er King-sze als Stadt des
Himmels deutet; daher auch die Verstümmelung der Ortsnamen und
seltsame Schreibweise derselben. Zwar berichtet er über mancherlei
interessante Einrichtungen im Lande, von den wohlgepflegten, mit
Bäumen bepflanzten Heerstraßen, den Posten und Läufern, den zur
Bequemlichkeit der Reisenden an der Straße errichteten Gasthäusern
und der polizeilichen Beaufsichtigung des Fremdenverkehrs in den
großen Städten. Er erwähnt zwar die Einrichtung von
Kornmagazinen, den Gebrauch der Steinkohlen, die weitverbreitete
Anwendung des Papiergeldes; aber andere wesentliche
Eigenthümlichkeiten und Erfindungen bleiben unbeachtet und nach
dieser Richtung erscheint das Werk lückenhaft. Wir vermissen
Mittheilungen über die Magnetnadel, über Pulver, über Bücherdruck,
künstliches Eierausbrüten und Fischerei mit Kormoranen; auch des
Thees geschieht keine Erwähnung. In der neuen Geschichte Asiens
erscheint Polo ungenau. Allein man muß auch erwägen, unter
welchen Verhältnissen sein Buch entstand. Kaum von seiner weiten
Reise zurückgekehrt, nahm er an dem Kriege theil, in welchen
Venedig mit seiner Rivalin verwickelt war, wurde noch im Jahre 1295
in der Seeschlacht bei Corzola, einer der dalmatischen Inseln,
gefangen genommen und nach Genua gebracht, wo er in der
Gefangenschaft einem Genossen, dem Pisaner Rusticiano oder
Rustichello seinen Bericht dictirte. — Trotzdem gehört Marco Polo zu
den geographischen Classikern des Mittelalters.
Ursprünglich war der Bericht, noch nicht in Bücher und Capitel
abgetheilt, in altfranzösischer Sprache niedergeschrieben, wie man
dies aus der grade hier am meisten bewahrten Naivität der
Erzählung mit ihrer stereotypen Redeweise und ihrer Unbehilflichkeit
im Ausdruck, aber auch aus der hier annähernd correctesten
Schreibweise der Eigennamen erkannt hat. Dann wurde das Werk ins
Lateinische, Italienische übersetzt und überarbeitet.
Trotzdem hat sein Bericht nicht plötzlich gewirkt. Seine
Zeitgenossen Dante und Sanudo erwähnen ihn noch nicht; wohl aber
citirt ihn sein persönlicher Freund Pietro di Abano (geb. 1250 in
Abano bei Padua, gest. 1316). Den ersten Einfluß auf die
Ländergemälde verspürt man in der catalanischen Karte von 1375,
wo Vorder-Indien als Halbinsel sich aus den von Ptolemäus
gezogenen engen Schranken loslöst und manche Landschaften
Indiens und Südchinas ganz richtig gezeichnet sind.
 Lith. Kunst-Anst. v. Aug. Kürth, Leipzig
G. Grote’sche Verlagsbuchhandlung, Berlin

CHINESISCHES PAPIERGELD AUS DER MING-DYNASTIE (1368–1645).

Facsimile Reproduction in ¼ der natürl. Größe (Original in Paris).
 ❏
GRÖSSERE BILDANSICHT

Die erste deutsche Uebersetzung erschien 1477 unter dem Titel:

„Das ist der edel Ritter Marcho Polo von Venedig der große
Landfahrer, der uns beschreibt die großen Wunder der Welt, die er
selbr gesehenn hat. Von dem auffgang pis zu dem undergang der
sunnen, dergleychen vor nicht meer gehort seyn. Diß hat gedruckt
Friczs Creüßner zu Nurmberg nach cristi gepurdt 1477.“ Im 15. und
16. Jahrhundert wurde Polo’s Bericht von den Kartographen in
ausgiebiger Weise gebraucht und auch misbraucht, indem man oft in
unkritischer Methode seine Länder und Städte über die Erdräume
vertheilte. Trotzdem bildete es das wichtigste Fundament für die
Kenntniß des östlichen und südlichen Asien, bis seine unbestimmten
Angaben durch bessere, auf mühsamen Landreisen gewonnene
Resultate ersetzt werden konnten. Das schönste von allen
Resultaten, meint Libri,[41] welches dem Einfluß Polo’s zu danken, sei
dieses, daß Columbus durch seine Schilderungen zur Entdeckung der
neuen Welt angeregt worden, und daß er, eifersüchtig auf Polo’s
Ruhm, es für seine Lebensaufgabe gehalten, Zipangu zu erreichen,
von dem der Italiener solche Wunderdinge berichtet habe.
Allein H. Yule (a. a. O. I, 103) bemerkt mit Recht dagegen, daß
Columbus die Berichte Polo’s nur aus zweiter Hand kenne und zwar
aus einem Briefe Toscanelli’s. Polo’s Namen nennt der Entdecker der
neuen Welt nicht. Seine feste Ueberzeugung von der Schmalheit des
westlichen Oceans leitet sich nicht aus der Berechnung der
Entfernungen asiatischer Länderräume nach Polo’s Angaben her,
wonach Ostasien bis weit in den großen Ocean hinein sich
erstrecken müßte, sondern stammt von seinem beliebten
Gewährsmann, dem Cardinal d’Ailly, welcher seinerseits sich wieder
auf Roger Bacon berief.
Ob sich Karten, von Polo’s Hand entworfen, noch länger erhalten,
bleibt zweifelhaft. Doch wird erzählt, daß der Prinz Pedro von
Portugal 1426 von der venetianischen Signoria eine Karte erhielt,
welche entweder ein Original oder eine Copie von einer durch Polo
selbst gefertigten Karte gewesen sein soll.
 5. Die späteren Missionsreisen und Handelszüge.

Polo hatte in Asien eine Reihe von Nachfolgern, namentlich

glaubenseifrige Mönche, welche zwar nicht so umfassende Reisen
wie der venetianische Kaufmann machten, aber doch manche
Ergänzungen seines Berichtes brachten und namentlich dazu
beitrugen, daß noch längere Zeit das Interesse für die östliche Welt
lebhaft erregt blieb.
Der erste unter diesen Missionaren war der Franziskaner
J o h a n n v o n M o n t e c o r v i n o in Süditalien, geb. 1247, gest.
um 1328. Derselbe befand sich zu gleicher Zeit mit den Poli in Asien.
Im Jahre 1289 vom Pabste entsendet, ging er in Begleitung des
Kaufmanns Petrus de Lucalongo nach Persien und weiter nach
Indien, hielt sich dort bei den Thomaschristen längere Zeit auf und
konnte über Land und Leute manches neue erzählen. Seine
Erlebnisse und Beobachtungen sind in einem Briefe niedergelegt,
welchen er von Maabar in Ober-Indien 1292 oder 1293 nach dem
Abendlande sendete. Indien heißt bei ihm Maebar. Die Bewohner der
dekhanischen Halbinsel sind eigentlich nicht schwarz, sondern
olivenfarben und von schöner Gestalt. Ihre tägliche Nahrung besteht
in Reis und Milch; Brot und Wein kennen sie nicht. Unter den
Produkten werden Pfeffer, Ingwer und Bersi (Brasilholz) besonders
erwähnt. Montecorvino ist der erste abendländische Reisende,
welcher Zimmt als ein wichtiges Erzeugniß Ceylons nennt. Auch
kennt er die eigenthümliche Schrift auf Palmblätter. Die
jahreszeitlichen Winde (die Monsune) regeln die Schifffahrt, auch die
Regen sind an bestimmte Zeiten gebunden. Südlich vom indischen
Meere gibt es kein Festland mehr, sondern nur Inseln, und zwar
mehr als 12000,[42] von denen aber ein Theil unbewohnt ist.
Von Indien wandte sich Montecorvino nach China an den Hof
Kublais; diesen Fürsten, den Gönner Polo’s, fand er aber nicht mehr
unter den Lebenden. Kublai starb 1294.
 Von Cambalu aus, wo 1305 eine Kirche gebaut und ein Kloster
gegründet wurde und wo der Franziskaner das Oberhaupt der
christlichen Gemeinde, im Range eines Erzbischofs[43] wurde, schrieb
er noch zwei Briefe in die Heimat, im Januar 1305 und im Februar
1306. Ein dritter Brief, oder eigentlich der Schluß des zweiten
Briefes, ist später von Menentillus von Spoleto mitgetheilt, woraus
man früher die irrthümliche Folgerung zog, daß Menentillus selbst in
China geweilt habe. Montecorvino scheint der erste und auch der
letzte Erzbischof von Cambalu gewesen zu sein.[44]
Zwischen 1316 und 1318 folgte seinen Spuren ein anderer
Ordensbruder O d o r i c h v o n P o r d e n o n e in Friaul. Er nahm
seinen Weg über Konstantinopel, Trapezunt und Armenien nach
Tebris, wo zwischen 1284 und 1291 bereits ein Pisaner Kaufmann,
Jolus oder Ozolus ansässig gewesen war. Ueber Sultanieh und
Kaschan ging er nach Jesd. Auf Kreuz- und Querzügen, abseits von
dem gewöhnlichen Karawanenwege, scheint er an den persischen
Golf gekommen zu sein. Er schildert die beweglichen Sandmassen
der Wüsten im Innern Persiens, rühmt die ausgezeichneten Feigen
und grünen Trauben von Jesd, besuchte die öden Palasttrümmer von
Comerum (wahrscheinlich Persepolis) und ging über Schiras ins
Tigristhal hinab nach Bagdad. Am babylonischen Thurme vorbei
gelangte er ans persische Meer und nach Ormuz, stieg hier zu Schiff
und fuhr auf einem gebrechlichen Fahrzeuge, dessen Planken ohne
Eisennägel nur durch Kokosfäden zusammengenäht waren, ähnlich
wie es Polo und Montecorvino bereits beschrieben hatten, in 28
Tagen nach Tana auf Salsette nördlich von Bombay und von da nach
Malabar (Minibar), wo der beste Pfeffer gedeiht. Dort blühten damals
die Plätze Flandrina (Pandarani), eine jetzt verschwundene Stadt,
nördlich von Kalikut, und Cyngilin, d. i. Kranganor, südlich von
Kalikut, damals der Sitz einer der ältesten Dynastien in Malabar.[45]
Um die Südspitze Vorder-Indiens herum ging die Fahrt weiter nach
Mobar (Koromandel), wo nach der Ansicht Odorichs der Leib des
heiligen Thomas begraben liegt. Auch Ceylon wurde besucht, wo es
Vögel mit 2 Köpfen (Tukan) gibt, und von hier auch Mailapur
(Madras) erreicht. Eine Seereise von 50 Tagen brachte unsern
Glaubensboten an den Nicobaren (Nicoveran) vorbei nach Lamori,
einem Reiche von Sumatra.[46] Wegen der Hitze gehen die
Einwohner nackt, es herrscht bei ihnen Weibergemeinschaft, wie
auch auf der Insel Pagi oder Pagai westlich von Sumatra, und
Landcommunismus, auch sind sie dem Canibalismus ergeben. Das
Gebiet bringt Gold, Kampfer, Aloeholz, Reis und Weizen hervor.
Weiter gegen Süden liegt das Reich Sumoltra. Hier begegnen wir
zum ersten Male unverkennbar dem heutigen Namen der Insel,
welcher von dem Königreiche auf das ganze Eiland übertragen ist.
Nachdem Odorich noch verschiedene Häfen besucht hatte, wandte
er sich nach der reichen Insel Java, welche nach seiner Vorstellung,
eine arge Uebertreibung — gut 3000 Meilen Umfang hat. An
Produkten lieferte diese zweitschönste von allen Inseln Kampfer,
Kubeben, Kardamom- und sogar Muskatnüsse. Mit Gold und Silber
geschmückte Tempel verkündeten die Macht und den Reichthum der
Fürsten. Von hier kehrte Odorich nach dem Norden zurück, berührte
die Südküste Borneos, wie sich aus den von ihm erwähnten
Produkten Sagomehl, Palmwein, Bambus u. s. w. ergibt, besuchte
das Königreich Zampa (Tschampa), wo der König viele gezähmte
Elephanten besitzt, und endete in Kanton, im Lande Manzi
(Südchina), welches auch Ober-Indien genannt wurde, seine
Seereise. Er bezeichnet diesen berühmten Seehafen mit dem Namen
Censcalan.[47] Die Stadt liegt eine Tagereise vom Meere entfernt an
einem großen Flusse und treibt den ausgedehntesten Seehandel.
„Ganz Italien besitzt nicht so viele Schiffe als diese eine Stadt.“ Die
betriebsame, dichte Bevölkerung Chinas und seine zahlreichen
Städte machten einen gewaltigen Eindruck. Odorich greift wohl
etwas zu hoch, wenn er meint, es gäbe in Manzi 2000 Städte,
welche größer als Vicenza oder Traviso seien. Allein eine annähernde
Zahl von Städten besteht nach der Zusammenstellung Yules (Cathay
I, 104) noch jetzt. Von Kanton wandte sich Odorich nach Zayton und
von da nach dem Hafen Fuzo (Futscheu). Die weitere Landreise
führte sodann durch manche Städte und über ein hohes Gebirge, in
welchem zwei verschiedene Menschenrassen hausen, nordwärts zu
einem großen Fluß, in welchem er zuerst die Kormoranfischerei
kennen lernte, und dann nach Cansay, dem Quinsay Polo’s. In Bezug
auf die Größe dieser Weltstadt übertreibt er noch mehr als sein
Vorgänger. Die Stadt liegt in den Lagunen wie Venedig, hat 100
Meilen im Umfange und von den 12 Hauptthoren aus erstrecken sich
die Vorstädte noch meilenweit ins Land hinein.
Von hier gelangte der Franziskaner nach Chilenfu (Nanking), wo
zuerst die Könige von Manzi residirten. Damals hatten die
Umfassungsmauern eine Länge von 40 Meilen,[48] jetzt nur die
Hälfte. Auf dem großen Strome Talay (Ta kjang oder Yang tse kjang)
ging die Fahrt an manchen Städten vorbei zum Schifffahrtscanal, und
über den Hwangho endlich nach Cambalech (Peking), wo Odorich 3
Jahre verweilte und einer der von Montecorvino gegründeten
Kirchen vorstand.
Als neue Beobachtungen des chinesischen Lebens, welche Polo
unerwähnt gelassen, erzählt Odorich, es sei ein Zeichen der
Vornehmen, sich lange Nägel wachsen zu lassen, bei einigen werde
der Daumennagel so lang, daß er rund um die Hand gehe. Bei
Frauen gelte es als Schönheit, sehr kleine Füße zu haben. Daher
pflegten die Mütter den neugeborenen Mädchen die Füße fest zu
umwickeln, daß dieselben nicht wachsen könnten. Auch beschreibt
er zuerst die weißen Hühner mit wollhaarigem Gefieder, welche nur
in China heimisch sind.[49]
Ueber den Weg, welchen Odorich auf seiner Heimreise einschlug,
wissen wir nur soviel, daß er sich von Peking westwärts ins
Binnenland, in das Land Tenduc, welches er für das Reich des
Priesters Johann hielt, begab, vielleicht auch Singanfu besuchte und
über die Hochgebirge nach Tibet und seiner Hauptstadt Lhasa
vordrang. Hier verlieren sich alle Spuren; möglicherweise führte die
Route durch Persien über Tebris wieder zurück. Um 1330 gelangte er
wieder nach Venedig und starb im Januar 1331 in Udine. Auf einem
Theile seiner Wanderung hatte er einen irischen Mönch Jakob zum
Begleiter. Er war der erste Europäer, welcher Tibet sah.
 Hand eines reichen Annamiten.

Auch auf dem nördlichen Handelswege nach Centralasien fanden

sich in der ersten Hälfte des 14. Jahrhunderts eifrige
Glaubensprediger ein, denn der Pabst hatte allen, welche im Dienste
der Kirche sich den Mühen und Gefahren unterzogen, unter den
Tataren das Christenthum zu verbreiten, denselben Ablaß „a poena
et a culpa“ verheißen, wie denen, welche nach Jerusalem pilgerten.
So zog 1338 auch der spanische Franziskaner P a s c a l v o n
V i t t o r i a von Venedig aus, fuhr übers schwarze Meer nach der
Krim (Gazaria) und Asow (Tana) und begab sich dann in Gesellschaft
einiger griechischer Händler zu Wagen nach Sarai (Sarray), wo er,
wahrscheinlich im Ordenskloster der Stadt, über ein Jahr lang
verweilte, dann die Wolga (Tygris) hinab ins Meer von Baku (Vatuk),
d. i. das kaspische Meer gelangte und nach 12 Tagen Saraitschik (d.
h. kleiner Palast) am Uralflusse erreichte. Der Ort liegt gegenwärtig
in Ruinen. Pascal war im Stande, mit den Tataren in ihrer Sprache zu
verkehren, denn er hatte in Sarai die kumanische (chamanische)
Sprache und die uigurische Schrift, welche bis nach China
verstanden wurde, sich angeeignet. Vom Uralflusse verfolgte er,
nachdem sein bisheriger Begleiter Fra Gonsalvo Transtorna
umgekehrt war, seinen Weg allein, ritt zu Kamel durch die turanische
Steppe nach Chiwa (Urganth) und predigte dort in der
Landessprache. Von da aus drang er ins Reich Tschagatai (Imperium
Medium der Abendländer), wurde durch Kriegsunruhen zwar
mehrfach aufgehalten, kam aber doch endlich nach Almalik
(Armalec) der Hauptstadt von Tschagatai, in der Nähe des heutigen
Kuldscha, und verkündigte trotz aller Verfolgung glaubensmuthig die
christliche Lehre. Von hier aus sandte er einen Brief, den einzigen,
nach Europa, in welchem er über seine Reisen berichtete. Leider ist
er, wahrscheinlich schon im nächsten Jahre, 1339 als Märtyrer
gefallen.[50] In demselben Jahre erreichte auch ein Kaufmann,
Wilhelm von Modena, die Stadt Almalik.
Die letzte große Wanderung quer durch Asien führte der
Franziskaner J o h a n n von M a r i g n o l l i, ein geborener
Florentiner (geb. 1290) aus. Auf einen Brief des Großchans, vom Juli
1336, welcher 1338 nach Avignon gelangte, schickte der Pabst
Benedikt XIII. eine Gesandtschaft, aus 32 Personen bestehend, im
December desselben Jahres von Avignon ab. Unter den Sendlingen
befand sich auch Marignolli. Man kam auf dem bekannten Wege
über Konstantinopel und Kaffa im Herbst 1339 nach Sarai, wo man
überwinterte, und schlug dann die Handelsroute über Urgendsch
nach Almalik (Armalec) ein. Hier blieb Marignolli bis 1341 und zog
dann über Komul (Kamil) nach Peking, wo die Gesandtschaft bei
dem Kaan eine Audienz hatte unter Vortragen des Kreuzes und unter
dem Gesange: „Credo in unum deum.“ In Cambalu verweilten sie 3
bis 4 Jahre als Gesandte des Pabstes am kaiserlichen Hofe, dann
ging die Wanderung weiter nach dem Hafen Zayton. Die
Schilderung, welche Marignolli von China entwirft, ist etwas
verworren. So hält er den Hwang ho und den Yang tse kjang für ein
und denselben Strom. Von dem Lande Manzi, d. i. Südchina, welches
früher unter dem Namen India maxima bekannt war, sagt er, es
habe 30,000 große Städte, unter denen Campsay (Quinsay) die
schönste, größte, reichste und wunderbarste sei mit zahlreichen
Prachtgebäuden und Götzentempeln, in denen bisweilen 1000 bis
2000 Mönche wohnten. Zu Ende des Jahres 1347 segelte Marignolli
nach Indien. Unterwegs stattete er auch der Königin von Saba[51]
einen Besuch ab und landete dann an der Küste Malabar in Indien in
der Stadt Columbum (Quilon oder Kollam). Denn hier verkehrten
auch chinesische Handelsschiffe. In Kollam existirte eine Gemeinde
von Thomaschristen. Die Vorsteher derselben bewahrten in Folge
eines alten Privilegiums das Normalgewicht (statera), mit welchem
Pfeffer und andere Spezereien gewogen wurden. Daher nennt
Marignolli sie auch „die Herren des Pfeffers“.[52] Bei dieser Stadt
errichtete er auch eine Marmorsäule mit Kreuz und salbte es mit Oel.
An der Säule befanden sich die Wappen des Pabstes und Marignolli’s
mit indischer und lateinischer Schrift. „Ich weihete es,“ erzählt der
Bote des Pabstes, „und segnete das Denkmal in Gegenwart einer
unendlichen Menschenmenge und wurde auf den Schultern von
Häuptlingen in einem Palankin getragen.“ Von da begab sich
Marignolli nach Ceylon; aber das Paradies, welches nach
Mittheilungen der Eingebornen im Innern liegen sollte, hat er selbst
nicht gesehen. Nach der Ansicht des Johannes Scotus ist das
Paradies auf dem höchsten Punkte der Erde gelegen und reicht bis in
die Mondsphäre hinein. Daher muß das Wasser, welches aus dem
Garten Eden entspringt und die Bäume tränkt, mit starkem Falle
herabstürzen. Die Singhalesen fanden daher auch bei Marignolli
Glauben, wenn sie ihm erzählten, man könne das Rauschen der
Paradiesquelle 40 Meilen weit hören. Auf der höchsten Spitze des
Berges ist noch der Fußstapfen Adams und das Haus zu sehen, das
er selbst gebaut hat.
Auf der Rückkehr von Ceylon nach der Koromandelküste fiel
Marignolli mohammedanischen Seepiraten in die Hände und wurde
aller Werthgegenstände, die er aus dem Osten mitgebracht, beraubt;
aber man schonte seines Lebens und so konnte er über Ormuz,
Bagdad, in dessen Nähe er die Ruinen des Thurmes zu Babel (d. h.
den Mudschelibe) besuchte, über Mossul, wo er die Ruinen von
Ninive gesehen, Haleb und Damaskus nach dem Abendlande
heimkehren und 1353 dem Pabste in Avignon das Antwortschreiben
des Großkaan überreichen.[53]
Die oft wiederholten Handels- und Missionsreisen zu den
Residenzen der tatarischen Großfürsten machen es erklärlich, daß,
lediglich um den praktischen Bedürfnissen der Kaufleute zu genügen,
Beschreibungen des Weges mit Angabe der Entfernung und Kosten
entworfen wurden. Ein solcher R e i s e f ü h r e r ist unter dem Titel
„Libro di divisamenti di Paesi“ von dem Italiener P e g o l o t t i
zusammengestellt, welcher im Dienste der Handelsgesellschaft Bardi
in Florenz zwischen 1315 und 1317 als Factor in Antwerpen und von
1324–27 in Cypern lebte. Daß Pegolotti die Reise nach China selbst
gemacht habe, ist nicht erwiesen und auch nicht wahrscheinlich. Der
damals übliche Weg ging über das schwarze Meer und durch
Südrußland. Unter den allgemeinen Verhaltungsregeln ward als
rathsam empfohlen, daß man sich zunächst einen langen Bart
stehen lasse. Dann nehme man sich in Tana einen Dragoman und
ein paar tüchtige Diener, welche kumanisch verstehen; auch
empfiehlt es sich eine Frau mitzunehmen, welche womöglich
gleichfalls kumanisch spricht. Dann versorge man sich mit Mehl und
Salzfisch, denn Fleisch findet man allenthalben genug. Bewaffneten
Schutz braucht man nicht, da die ganze Straße bis China, Dank der
Fürsorge der tatarischen Herren, sicher ist. Hat man etwa (nach
unserem Geld berechnet) für 240,000 Mark an Waaren, so wird die
ganze Reise etwa 3000 bis 4000 Mark kosten. Ein vierräderiger
Ochsenkarren mit Filzdach trägt eine Last von 10 Centnern, ein
Kamelwagen, zu dem drei Zugthiere gehören, gegen 30 Centner, ein
Pferd zieht etwa 6½ Centner.
Was nun die Entfernung und Stationen betrifft, so rechnet man
auf den Weg von Tana bis Astrachan (Gintarchan) mit Ochsenkarren
25 Tage, von da bis Sarai 1 Tag, von da bis Saraitschik (Saracanco)
am Ural 8 Tage. Von hier kann man zu Land oder zu Wasser weiter
reisen. Auf dem Landwege braucht man bis Organci (Chiva) mit
Kamelkarren 20 Tage, weiter bis Otrar (Oltrare) an einem
Nebenflusse des Syr-Darja südlich der Stadt Turkestan, unter 43° n.
B., wieder 35–40 Tage. Von Saracanco direct nach Otrar kürzt sich
der Weg auf 50 Tage ab. In Otrar nimmt man Packesel und reiset 45
Tage bis Armalec (bei Kuldscha) und 70 Tage bis Kan-tschou
(Camexu). Dann reitet man zu Pferde 45 Tage, bis man an einen
chinesischen Fluß[54] gelangt, auf welchem man nach Cassai
(Quinsay) kommt und von hier in 30 Tagen die ganze Reise bis
Gamalec (Cambalec, Peking) vollendet.
Leider war dieser aufblühende Verkehr mit dem Oriente nicht
mehr von langer Dauer; denn als 1368 in China die mongolische
Dynastie gestürzt worden war und eine einheimische Fürstenfamilie
an die Spitze trat, wurde das Land gesperrt und der Handel völlig
abgebrochen. Nur Indien blieb offen. Und hierher kam im 15.
Jahrhundert noch ein venetianischer Kaufmann N i c o l o d e ’
C o n t i, dessen Erzählung nur durch den seltenen Zufall sich
erhalten hat, daß Conti auf der Heimreise nach Europa auf dem
rothen Meere in die Hände von Piraten gefallen und aus Todesfurcht
den Islam annahm, dann freigelassen, sich in seiner Gewissensangst
um Ablaß an den Pabst Eugen IV. wandte, welcher von 1439–42 sich
in Florenz aufhielt, und dessen Secretär Poggio (Poggius) die
Erlebnisse des Reisenden niederschrieb.[55] Der ganze Bericht macht
den Eindruck der Treue und Zuverlässigkeit, doch mag wohl Poggio
manches auf eigne Hand hinzugefügt haben, so über die Insel
Taprobane. Conti hatte sich in seiner Jugend in Aegypten
aufgehalten, um Handel zu treiben, war dann flüchtig geworden,
weil er das ihm von seinem Vater anvertraute Capital vergeudet
hatte, und war mit einer großen Karawane von 600 Köpfen durch
das steinige Arabien und über Chaldäa an den Euphrat gereist.
Während des Zuges durch die syrische Wüste hatten sie, ähnlich wie
Polo, seltsame Erscheinungen, welche nach Angabe von erfahrenen
Männern, die dergleichen schon früher erlebt hatten, für
Dämonenspuk ausgegeben wurden. Es war, als ob Reiterschwärme
vorübersausten. Man wird bei der Schilderung unwillkürlich an das
bekannte Gedicht von Freiligrath: Das Gesicht des Reisenden
erinnert. Dann kam er nach der Stadt Babilonia am Euphrat, „welche
die heutigen Bewohner Baldachia (Bagdad) nennen“.[56] Dann ging
es den Fluß hinunter nach Basra (Balsera) und übers Meer nach
Ormuz (Ormesia), damals bereits auf der Insel gelegen. Unterwegs
berührte er den Hafen Colchum (bei Diego Ribero 1529 Conga, jetzt
Kongun, südlich von Schiras).
In einem persischen Hafen, den er Calacatia[57] nennt, hielt er
sich längere Zeit auf, um persisch zu lernen. Seine weitere Reise
unternahm er dann in der Tracht eines Persers und fuhr in
Gesellschaft seiner adoptirten Landsleute zu Schiff nach Cambaya
(Cambahita), welches sie nach einer Fahrt von einem Monat
erreichten. Cambaya war damals einer der bedeutendsten
Hafenplätze Indiens. „Wenn die abendländische Welt zum Genuß
hinterindischer und chinesischer Produkte gelangte, so verdankte sie
dies zumeist den unternehmenden Kaufleuten und tüchtigen
Seecapitänen von Cambaya und Kalikut.“[58] Eine Küstenfahrt führte
Conti nach Süden in die Region, welche ausgezeichneten Ingwer
liefert.
MAPAMONDI VOL DIR AYTANT CON YMAGE DEL MONDE DE LES
REGIONS QVE SON SVS LA TERRA E DE DIVERSAS MANERAS DE
GENS QVE EN ELA HABITAN
(Westlicher Teil)

❏
GRÖSSERE BILDANSICHT

(Östlicher Teil)
 Lithogr. Kunst-Anst. v. Aug. Kärth, Leipzig.
G. Grotesche Verlagsbuchhandlung, Berlin.
Catalanische Erdkarte, für König Karl V. von Frankreich 1375 in Mallorca
gezeichnet. (Paris, National-Bibliothek.) Zu Gunsten der Deutlichkeit sind einerseits
die zahlreichen Compasslinien des Originals weggelassen und ist andererseits das
Meer mit einem blauen Ton gedeckt.
❏
GRÖSSERE BILDANSICHT

Mapamondi, das heisst das Bild der Welt und der verschiedenen
Staaten der Welt und der Gegenden, welche auf der Erde sind, der
verschiedenen Arten von Völkern, welche auf derselben wohnen.
(Und besagtes Bild oder Figur ist rund wie ein Spielball und ähnlich
einem Ei, getheilt in vier Elemente. Denn wie das ganze Ei von
aussen von seiner Schale umgeben ist, wie die Schale das Eiweiss,
und dieses den Dotter umgibt, und darauf der Tropfen des Embryo
gebildet ist: so ist diese Welt auf allen Seiten vom Himmel umgeben,
wie von der Eierschale, der Himmel umgibt die reine Luft, wie die
Schale das Eiweiss; die trübe Luft ist umgeben von der reinen Luft,
wie der Dotter vom Eiweiss u. s. w.)

Die Bewohner von Norwegen leben mehr von Fischen und von der Jagd als von
Brot. Diese Gegend ist sehr rauh und kalt und gebirgig, wild und voll von
Gebüschen. Viel Wild gibt’s hier: als Hirsche, weisse Bären und Gerfalken. Es gibt
Hafer, aber nur sehr wenig, wegen der grossen Kälte.
 In Irland gibt es viele merkwürdige Inseln, darunter ist eine kleine, wo die
Menschen nicht sterben; aber wenn sie sehr alt sind, um zu sterben, trägt man sie
von der Insel. Da gibt’s keine Schlange und keine Kröte und keine giftige Spinne;
denn das ganze Land duldet kein giftiges Thier. (Da ist auch ein See und eine
Insel. Noch mehr, es gibt dort Bäume, die tragen Vögel, wie andere Bäume reife
Feigen tragen.) Desgleichen gibt es eine andere Insel in welcher die Frauen nicht
niederkommen; wenn aber die Zeit der Entbindung kommt, schafft man sie, der
Sitte gemäss, von der Insel fort.

Die glückseligen Inseln liegen in dem grossen Meere linker Hand, an der Grenze
des Occidents, aber nicht fern im Meere. (Isidor spricht also in seinem 15. Buche:
 Diese Inseln heissen Fortunatae.) Denn sie sind reich an allen Gütern, Korn,
Früchten, Kräutern, Bäumen und die Einwohner glauben, es sei hier das Paradies,
wegen der milden Sonnenwärme und der Fruchtbarkeit des Bodens. (Isidor sagt
auch) Die Bäume wachsen hier wenigstens 140 Fuss hoch und tragen viele
Früchte und Vögel. Man findet hier Honig und Milch, vorzüglich in der Insel Capria,
die nach der Menge der Ziegen, die es hier gibt, benannt ist. Dann ist hier die
Insel Canaria, benannt nach den grossen und starken Hunden, welche dort sind.
(Plinius, dieser Meister der Geographie, sagt, dass es unter den Fortunaten eine
gibt, wo alle Güter der Welt wachsen, ebenso alle Früchte, ohne dass man sie zu
säen und zu pflanzen braucht. Auf der Höhe der Gebirge sind sehr wohlriechende
Bäume, zu jeder Zeit mit Blättern und Früchten bedeckt. Die Einwohner essen
davon einen Theil des Jahres. Die Bewohner Indiens glauben, dass ihre Seelen
nach dem Tode diese Inseln bewohnen werden und dass sie dort ewig leben
werden von dem Wohlgeruch dieser Früchte. Sie glauben, dass dies ihr Paradies
sei, aber, offen gestanden, es ist dies eine Fabel.)

Das Schiff des Jacob Ferrer ging in See nach dem Goldflusse am Tage des heil.
Laurentius, am 10. August 1346.
Die Orkney-Inseln, in denselben ist 6 Monate Tag, während die Nacht hell ist, und
6 Monate Nacht, während der Tag trübe ist.

Cap Finisterre, das Westcap Afrikas, hier beginnt (Afrika) und endigt in Alexandrien
und Babilonia (Stadt in Aegypten) und umfasst die ganze Küste der Berberei und
reicht (bis Alexandrien) gegen Mittag u. Aethiopien (und Aegypten. Man findet in
diesem Lande viel Elfenbein wegen der Menge von Elephanten, die hier geboren
werden und welche hier an den Strand kommen.)
Welcome to our website – the perfect destination for book lovers and
knowledge seekers. We believe that every book holds a new world,
offering opportunities for learning, discovery, and personal growth.
That’s why we are dedicated to bringing you a diverse collection of
books, ranging from classic literature and specialized publications to
self-development guides and children's books.

More than just a book-buying platform, we strive to be a bridge

connecting you with timeless cultural and intellectual values. With an
elegant, user-friendly interface and a smart search system, you can
quickly find the books that best suit your interests. Additionally,
our special promotions and home delivery services help you save time
and fully enjoy the joy of reading.

Join us on a journey of knowledge exploration, passion nurturing, and

personal growth every day!

ebookbell.com