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December 2013, Supplement to Volume 17, Number
6
Article
Clinical Updates in Blood and Marrow Transplantation in Multiple
Myeloma
Beth Faiman,
MSN, APRN-BC, AOCN®, Teresa Miceli, RN, BSN, OCN®,
Kimberly Noonan, RN, ANP-BC, and Kathryn Lilleby, RN
The process of hematopoietic stem cell
transplantation (HSCT) is well defined, yet debate remains surrounding the role
and timing of HSCT in patients with multiple myeloma (MM). Since the 1980s,
survival advances have been made with the use of newer agents by recognizing
the role of transplantation, identifying the anticipated side effects at each
phase, and improving supportive care strategies. Data support transplantation
as part of the treatment strategy, but the optimal induction regimen and timing
of transplantation have yet to be defined. The general consensus is that
eligible patients should undergo autologous HSCT at some point in the treatment
spectrum, preferably earlier rather than later in the disease. Allogeneic
transplantation is only recommended in the context of a clinical trial and in
patients with high-risk disease. The transplantation process can be overwhelming
for patients and caregivers. Nurses play a key role in improving outcomes by
caring for patients and families throughout the transplantation experience and,
therefore, need to be knowledgeable about the process. This article is intended
to expand discussion on the role of nurses in assisting patients and families
undergoing transplantation to include an overview of the acute care phase of
the transplantation process.
The process of transplantation can be conceptualized
through several phases (see Figure 1). Each phase
carries with it distinct considerations and management strategies to optimize
the overall process. Years of clinical research and experience have provided
knowledge of when challenges, side effects, and appropriate interventions can
occur. Thus, an experienced transplantation team can anticipate patient needs
during the acute phase. Long-term side effects and complications can occur and
require the attention of community-based practitioners, as well. This article will
cover considerations within each phase, with a focus on autologous
hematopoietic stem cell transplantation (AHSCT) and should be used in
conjunction with the Miceli et al. (2013) article in
this supplement to get a broad picture of the transplantation experience.
Allogeneic transplantation, which should only be considered in the context of a
clinical trial, is highlighted in the “Special Interest”
sidebar on page 35.
Phase 0: Induction
or Initial Treatment
Following a confirmed diagnosis of symptomatic
multiple myeloma (MM), the patient begins induction chemotherapy. The goals of
induction therapy are to induce a tumor response and decrease symptoms by
reducing disease burden (Giralt, 2012). Response to
therapy is classified based on the reduction of myeloma protein from baseline.
A complete response is the best surrogate marker for progression-free survival
(Chanan-Khan & Giralt,
2010). A complete response occurs when patients achieve negative immunofixation of the serum and urine, experience the
disappearance of any soft tissue plasmacytomas, and
reduce the number of plasma cells present in the bone marrow to 5% or less (Durie et al., 2006). Improved response rates can be seen
with the newer therapies, such as lenalidomide, bortezomib, and carfilzomib,
followed by AHSCT (Jakubowiak et al., 2012;
Richardson et al., 2010; Rosiñol et al., 2012).
To date, the optimal timing of transplantation
cannot be defined. Considerations include patient performance status, organ
function, response to therapy, financial limitations,
and the overall treatment plan. Participation in a well-designed clinical trial
also should be considered to help identify the best induction therapy,
transplantation timing, and maintenance therapy for each MM subgroup. When
considering transplantation as part of the treatment plan, using stem
cell–sparing induction regimens, which are less damaging to the hematopoietic
stem cells (HSCs), is important. Some antimyeloma
therapies (e.g., alkylating agents) can damage stem cells and negatively impact
the ability to collect adequate amounts of peripheral blood HSCs for
transplantation. In particular, the prolonged use of melphalan
should be avoided in patients eligible for transplantation (Cavo
et al., 2011; Giralt et al., 2009). Possible pretransplantation combinations for induction therapy are
outlined in Miceli et al. (2013) and will not be
discussed here.
Phase 1: Collection
Process
A key component of the transplantation process is
the acquisition of pluripotent HSCs. The sources of HSCs for transplantation
are autologous (self-donation), syngeneic (identical sibling), and allogeneic
(related or unrelated donation). As mentioned earlier, HSCs can be retrieved
from the bone marrow, cord blood, or peripheral blood (Antin
& Yolin Raley, 2009).
Peripheral blood has become the most-used source for HSC collection (Pasquini & Wang, 2011). CD34+ cells are progenitor
cells with the capacity to differentiate and repopulate myeloid and lymphoid
cell lines following bone marrow ablation after high-dose chemotherapy. They
are measured in cells per deciliter (cells/dl) to the power of 106
(million) based on recipient weight (i.e., collection yield of 3.2 x 106
CD34+ cells/kg recipient weight) (DisPersio, Stadtmauer, et al., 2009). Use of CD34+ cells has resulted
in reduced transfusion needs and a shorter engraftment period following
transplantation. Therefore, this has become the preferred source of progenitor
cells (versus bone marrow) (Williams, Zimmerman, Grad, & Mick, 1993) and
will be discussed in the current article.
Mobilization
The process of stimulating the bone marrow to
release HSCs into the peripheral blood is called mobilization. Methods to
mobilize HSCs from the bone marrow into the peripheral blood include the use of
cytokine growth factors, such as granulocyte–colony-stimulating factor (G-CSF)
(e.g., filgrastim), alone or in combination with
chemotherapy or the CXCR4-binding agent plerixafor.
For some patients, the use of G-CSF alone may mobilize adequate HSCs (Giralt et al., 2009). The approach may be effective for
patients younger than 65 years who have not received melphalan
or prolonged use of lenalidomide (Giralt
et al., 2009). Key side effects of cytokine growth factors include
leukocytosis, bone pain, myalgias, and flu-like
symptoms. In addition, some patients may develop a low-grade fever (Amgen Inc.,
2013).
For others, chemotherapy may be added to assist with
the mobilization process and used as an additional treatment option prior to
transplantation, particularly if optimal response has not been achieved.
Although several different chemotherapies are eligible for use during the HSC
mobilization process, including etoposide and
paclitaxel, cyclophosphamide is used most frequently (Giralt
et al., 2009). Common side effects related to high doses of cyclophosphamide
include nausea, alopecia, and myelosuppression. At
the doses used for mobilization, patients rarely will experience mucositis or hemorrhagic cystitis. However, patients are
encouraged to drink plenty of fluids to reduce the risk of bladder toxicity
(Rodriguez, 2010). They also must report to the nurse or provider a fever
greater than 38.3°C (101°F) or a
persistent fever of 38°C (100.4°F) when at blood count nadir (white
blood count less than 100 mcl) (Palumbo et al., 2012). Nadir
from cyclophosphamide, when used in combination with G-CSF for the purpose of
HSC mobilization, is predictable and typically of short duration (8–12 days) (Giralt et al., 2009).
The newest approach to stem cell mobilization is the
use of plerixafor with G-CSF. Plerixafor
is a bicyclam molecule that binds to the CXCR4
receptor site, the stem cell honing site in the bone marrow stroma.
Plerixafor temporarily blocks the SDF-1a signaling
pathway necessary to bind CD34+ cells to the bone marrow, promoting circulation
of the CD34+ cells into the peripheral blood. Plerixafor
in combination with G-CSF was approved by the U.S. Food and Drug Administration
in December 2008 for stem cell mobilization in autologous donors with non-Hodgkin
lymphoma and MM (DiPersio, Uy,
Yasothan, & Kirkpatrick, 2009; Flomenberg et al., 2005; National Cancer Institute, 2013).
Side effects associated with plerixafor include
leukocytosis, thrombocytopenia, diarrhea, nausea, erythema at the injection
site, and fatigue (Genzyme Corporation, 2010).
The combination of plerixafor
and G-CSF has been shown to be more effective at mobilizing HSCs than G-CSF
alone (DiPersio, Stadtmauer,
et al., 2009). Using G-CSF in conjunction with plerixafor results in higher success rates for mobilizing
more stem cells while undergoing fewer apheresis procedures. As a
result, more patients achieve the minimum and target amounts of stem cells
needed for transplantation. Use of plerixafor also
has significantly reduced the number of mobilization failures. Even patients
who previously failed to effectively mobilize HSCs have been successful with
the use of plerixafor, allowing more patients to
proceed to transplantation (Calandra et al., 2008; Gopal et al., 2012).
The cost of two common HSC mobilization approaches
has been compared in the literature (Gertz, Wolf, Micallef, & Gastineau, 2010; Micallef
et al., 2013). Investigators at Memorial Sloan-Kettering Cancer Center in New
York, NY, and the Mayo Clinic in Rochester, MN, performed a retrospective
analysis of all patients with MM treated from November 2008 to March 2011 who
received cyclophosphamide plus G-CSF or plerixafor
plus G-CSF as the first-line mobilization regimen. Plerixafor
was more cost effective than the more widely used cyclophosphamide. Plerixafor plus G-CSF costs less than cyclophosphamide plus
G-CSF because plerixafor requires fewer days of
apheresis (Adel et al., 2011). Another reason for lower cost is that patients
who use plerixafor are less likely to require hospitalization
because of infections. Despite the cost of the medication, the notable benefits
for successful mobilization make it a cost-effective option, particularly for
patients at risk for mobilization failure (Gertz et
al., 2010; Micallef et al., 2013).
The combined mobilization regimen of G-CSF and plerixafor should begin four days prior to planned harvest. G-CSF is given at a dose of
10 mcg/kg daily, by subcutaneous injection, beginning on day –4. The
recommended dose of plerixafor is 0.24 mg/kg given by
subcutaneous injection about 11 hours prior to each planned apheresis session,
beginning on day –1. The dose of plerixafor should
not exceed 40 mg per day, and should be adjusted for creatinine
clearance less than 50 ml per minute (Genzyme Corporation, 2010). One study
suggested that the administration of plerixafor 17
hours prior to collection, rather than 11 hours, was as effective and more
convenient for patients and nurses (Harvey et al., 2011).
Collection
The goal of collection is to procure a sufficient
number of HSCs for reconstitution of hematopoietic function after high-dose
chemotherapy (HDC) is administered to eradicate the MM. Cells are collected via
apheresis using a large bore catheter in a process that separates blood
components and selects specific cells for use. Although the ideal stem cell
collection goal is greater than 3 x 106 CD34+ cells/kg of recipient
weight, 2 x 106 CD34+ cells/kg of recipient weight offers a minimum
goal when HSC yield is low. Greater cell counts allow for faster recovery of
hematopoiesis. Some patients may want to store additional cells for a future
transplantation (Gertz et al., 2010; Giralt et al., 2009).
Once collected, the cells are cryopreserved in a
medium of dimethyl sulfoxide (DMSO) to prevent cell
breakdown, and may be stored for an indefinite period of time (Antin & Yolin Raley, 2009; Gertz et al., 2010).
Stem cell collection can occur days, months, or even years prior to HDC, but
typically occurs early in the diagnosis to ensure adequate collections before
patients are exposed to extended chemotherapy (Antin
& Yolin Raley, 2009; Gertz et al., 2010).
Phase 2:
Pre-Engraftment
The decision to proceed directly to HDC and AHSCT is
individualized based on many patient-specific factors (see Figure 2). It may follow the mobilization and
collection phase for early transplantation, or may be postponed until a later
date at the time of relapse (Kumar, 2009). If chemotherapy is used for stem
cell mobilization, some centers may delay HDC to allow recovery and avoid the
added risk of marrow toxicity.
The amount of time to undergo Phase 2
(pre-engraftment) typically is measured in weeks. The process includes three
components: conditioning, stem cell infusion, and supportive therapy through
engraftment (Antin & Yolin
Raley, 2009). During this time, the recipient may be
an inpatient at the transplantation center for three to four weeks, requiring
geographic relocation if the transplantation center is not near the patient’s
home. Some centers perform the AHSCT process in the outpatient department,
which requires a trained caregiver (Kurtin, Lilleby, & Spong, 2013) and
daily clinic visits to monitor side effects.
Conditioning
The therapy used prior to HSCT is referred to as conditioning.
The term refers to the process of getting the bone marrow in condition to
receive new cells. In patients with MM, high-dose melphalan
(HDM) is the chemotherapy agent of choice (Bensinger,
2009). Total body irradiation is no longer routinely used as part of the
conditioning regimen because of increased toxicity without survival benefit
(Moreau et al., 2002). The standard dose of high-dose melphalan
is 200 mg/m2 via infusion. Dose reductions are made if patients have
impaired renal function, advanced age, or comorbid conditions. A 24-hour rest
period often is planned after high-dose melphalan and
before HSC infusion to avoid the risk of cytotoxicity on newly infused HSC (Talamo et al., 2012).
Stem
Cell Infusion
At this stage of the process, the previously
cryopreserved HSCs are systematically thawed and infused into the patient via a
central venous catheter. The day of infusion is commonly referred to as “Day
0.” The actual infusion can take an hour or longer, depending on the number of
frozen bags of stem cell product to administer. The patient will have a
distinctive odor after the infusion because of the DMSO preservative, which is
most noticeable with respiration and voiding. The odor has been described as
similar to creamed corn or garlic, and gradually diminishes in two or three
days. Patients also can taste the DMSO. Various studies have been conducted to
attempt to decrease this unpleasant effect. Some patients have sucked on an
orange or lemon during the infusion to decrease the taste of the DMSO (Potter,
Eisenberg, Cain, & Berry, 2011). Other activities that are part of the
infusion, such as hydration and frequent vital sign monitoring, will result in
a day-long procedure (Antin & Yolin
Raley, 2009).
Supportive
Therapy
Although pretransplantation
testing is designed to preclude patients with baseline renal, liver, cardiac,
and pulmonary dysfunction from transplantation, end-organ complications may
occur during the pre-engraftment phase of the transplantation process (Laffan & Biedrzycki, 2006; Pallera & Schwartzberg, 2004). HDM and AHSCT are
associated with expected side effects such as alopecia, gastrointestinal (GI)
toxicities, and bone marrow ablation. The side effects of HDM are not present
at the time of chemotherapy infusion, but are delayed as rapidly dividing cells
are damaged from the effects of HDC. Complications of end-organ toxicity and
life-threatening side effects may cause mortality not related to relapsed
disease (Sorror, 2010), such as infectious issues and
pulmonary complications. Anticipated side effects and other pre-engraftment
complications are discussed in the following sections. An overview of common
side effects associated with MM therapies and post-transplantation symptoms
also can be found in Tables 1 and 2 on pages 17 and 19 in Miceli
et al. (2013).
Alopecia: Psychosocial support and counseling
regarding hair loss is important for men and women (Hesketh
et al., 2004). Use of a wig or head gear may be comforting as well as
functional to provide safety and warmth. The expense of a wig may be covered by
insurance if ordered as a hair prosthetic.
Gastrointestinal toxicities: GI toxicity may include
mucositis, esophagitis, nausea, vomiting, and
diarrhea. Antiemetic therapy, hydration, and pain medication often are needed
for management (Antin & Yolin
Raley, 2009; Rodriguez, 2010). Patients experiencing
GI toxicities may develop weight loss, anorexia, dehydration, and infection (Pallera & Schwartzberg, 2004; Rodriguez, 2010). Mucositis is a common side effect of HDM. A study compared
sucking on ice chips versus swishing saline prior to and for two hours
following the melphalan infusion to reduce the
severity and duration of mucositis by decreasing the
circulation of the chemotherapy through the oral tissues. The findings were
significant in that the incidence of grade 3–4 mucositis
was only 14% in the ice chip group compared to 74% in the saline group (Lilleby et al., 2006). Although the results support the use
of ice chips to decrease oral mucositis during melphalan infusion, not all centers currently use this
practice.
GI toxicities can be multifactorial, and all aspects
of the symptoms should be considered. For example, a transplantation recipient
may report pain from oral mucositis. The intervention
may consist of oral care and pain management. Medication used to control pain
potentially could cause nausea and constipation, creating a clinical challenge
for the nursing staff caring for the patient. The goal of supportive care is
not only to alleviate symptoms, but also to prevent additional GI problems such
as ileus, anorexia, and infection (Cooke, Grant, & Gemmill,
2012). Inability to maintain oral intake because of GI toxicity may require the
patient to be admitted to the hospital for closer monitoring and medication
administration. Supportive care guidelines vary with each transplantation
center (see Table 1).
Myelosuppression:
When bone marrow ablation occurs, patients experience profound pancytopenia for
about 10–14 days. Anemia and thrombocytopenia are managed by transfusion
support based on laboratory parameters and patient symptoms. Transplantation
recipients receiving HDC will develop severe neutropenia and are at risk for
infection and sepsis. Infection risk is based on the type of transplantation,
source of hematopoietic cells, underlying disease, disease status, conditioning
regimen, prior infections, and environmental exposure to micro-organisms (Bevans et al., 2009). Antibiotics for bacteria, viruses,
and fungi are used prophylactically when the absolute neutrophil count is less than 500 cells/dl, as well as therapeutically for febrile
neutropenia or occult infection (Subramanian, 2011). Common sources of
infection include central line infections, GI infections such as Clostridium
difficile (C. diff), and skin infections.
However, enteric organisms (Escherichia coli) and opportunistic
infections such as Pneumocystis jiroveci also
are common during this time (Pallera &
Schwartzberg, 2004). Figure 3 lists infectious
organisms commonly seen in transplantation recipients during the
pre-engraftment period. Many transplantation centers attempt to minimize
infection by recommending a low-pathogen environment. Most centers use a Laminair flow filtration system to provide such an
environment (Solomon et al., 2010).
Renal dysfunction: Renal failure can occur at any
time throughout the spectrum of the AHSCT process. When renal problems occur
before stem cell engraftment, the cause can be multifactorial. The source of
the problem often is linked to nephrotoxic medication such as antibiotics, antihypertensives, chemotherapy, or antifungal agents.
Acute renal failure from tubular necrosis may develop. Dehydration from
diarrhea, nausea and vomiting, or anorexia also could cause impaired renal
function. Other causes of renal problems in the early phase of transplantation
include sepsis or relapsed MM (Pallera &
Schwartzberg, 2004).
Pulmonary complications: Pulmonary complications are
estimated to occur in 30%–60% of hematopoietic transplantation recipients.
Certain chemotherapy agents can cause pulmonary complications in the early
phase of transplantation. Pre-engraftment pulmonary complications include
pulmonary edema, bronchiolitis obliterans, and
pneumonia (Blombery et al., 2011). Common organisms
causing pneumonia are listed in Table 3
of Miceli et al. (2013) on page 20 of this
supplement.
Diffuse alveolar hemorrhage (DAH) is characterized
by multilobular culture-negative lung injury. An
estimated 5% of all HSCT recipients develop DAH, with an estimated mortality
rate of 30%–60%. Presenting symptoms include acute shortness of breath,
hemoptysis, fever, chest pain, and cough. Risk factors include older age, total
body irradiation, severe mucositis, renal
insufficiency, and white blood cell recovery. The definitive diagnosis of DAH
is made by identifying bloody return on bronchoalveolar
lavage. Early diagnosis is imperative, and treatment consists of
corticosteroids and supportive care (Lara & Schwartz, 2010; Pallera & Schwartzberg, 2004).
The pre-engraftment phase of transplantation clearly
represents many clinical challenges for oncology nurses, including infection,
GI toxicities, myelosuppression, and renal and
pulmonary complications. Recognition of these problems and appropriate
intervention will potentially prevent significant harm to patients with MM
during this phase of the transplantation process.
Phase 3:
Engraftment
The time it takes for HSCs to migrate from the
peripheral blood to the bone marrow and begin to grow is called blood count
recovery or engraftment. Engraftment is established when the absolute neutrophil
count is greater than 500 cells/dl for three consecutive days or greater than
1,000 cells/dl for one day, and platelets remain greater than 20,000 cells/dl,
independent of platelet transfusions for at least seven days (DiPersio, Stadtmauer, et al., 2009).
About three weeks (days +17 to +25) following infusion of HSCs, most acute
toxicities, including myelosuppression related to the
HDC, have resolved (Russell et al., 2013). Once the patient has no evidence of
infection, has demonstrated engraftment, and establishes the ability to
maintain oral hydration and nutrition, arrangements can be made for discharge (Pallera & Schwartzberg, 2004).
Phase 4:
Post-Transplantation
As discussed in Miceli et
al. (2013), the definition of post-transplantation has become less clear as
more patients are being managed as outpatients during the acute phase of their
transplantation course. For purposes of this discussion, post-transplantation
refers to the time when patients leave the inpatient transplantation center and
return to their home community. Additional discussion regarding the
post-transplantation phase is included in Miceli et
al (2013).
Phase 5: Late
Effects
Advances in the science of HSCT, as well as advances
in supportive care, have improved long-term survival of transplantation
recipients. Survivors, however, are at risk for developing late complications
secondary to pre-, peri-, and post-transplantation
exposures. Those complications may lead to significant morbidity, mortality,
and impaired quality of life (Majhail & Rizzo,
2013).
Long-term complications of AHSCT can be extensive and complicated. Every organ is potentially
affected, and long-term follow-up guidelines are in place for screening and
prevention of long-term transplantation complications. Some of the late
complications include infection, as well as respiratory, ocular, oral, hepatic,
renal, skeletal, neurologic, cardiac, and vascular complications (Majhail & Rizzo, 2013). Secondary primary malignancies
also are a late complication for transplantation recipients (Thomas et al.,
2012). Risk factors associated with the development of secondary malignancies
include total body irradiation, primary disease, male gender, and pretransplantation therapy. Although many late
complications are associated with allogeneic recipients, such as chronic
graft-versus-host disease (cGVHD), autologous
recipients are at risk for late complications as well (Majhail
& Rizzo, 2013) (see Table 2).
Even long after the transplantation has taken place,
the risk of infection in the patient is estimated to be 20 times higher than
reported in the general population (Savani, Griffith,
Jagasia, & Lee, 2011). Common bacterial
infections include pneumococcal, streptococcal, and hemophilus
organisms. Common viral infections include cytomegalovirus and reactivation of
varicella zoster. Hepatitis B or C also can occur (Savani
et al., 2011). Please refer to Miceli et al. (2013)
of this supplement for more information and guidelines for treatment of
infection.
Cardiovascular disease is another late complication
of transplantation. Dyslipidemia, hypertension, diabetes, and kidney disease
are associated with cardiovascular complications. The incidence of
cardiovascular disease increases after transplantation and is thought to be
related to GVHD, use of immunosuppressant agents, and the cumulative effects of
chemotherapy. Other cardiovascular complications include cardiomyopathies,
arrhythmias, or valvular dysfunction (Majhail et al., 2012; Savani et
al., 2011).
Although guidelines are in place to monitor for
long-term complications, barriers exist to implementing the guidelines
(Burkhart, Wade, & Lesperance, 2013). Insurance
coverage and insufficient reimbursement for screening appear to be major
barriers. Lack of awareness and inadequate communication about the guidelines
are other reasons for guideline nonadherence.
Implications for
Nursing Practice
The role of HSCT in patients with MM is complex from
the selection process to side effects and long-term management. Nurses play a
critical role in the care of patients with MM because the nurse will anticipate
and manage side effects and provide education and support to patients and
caregivers. An enhanced understanding of the process is necessary to meet the
needs of patients and caregivers.
Conclusion
HSCT remains an important treatment option for
patients with MM. Eligibility is based on many factors and should be determined
by the transplantation provider. Overall, the procedure is well tolerated in
the autologous setting, with a low mortality rate in patients with MM (Kumar,
2009). Treatment-related mortality is much greater in the allogeneic setting;
therefore, it is only recommended in the context of a clinical trial with a
focus on individuals with high-risk disease characteristics. The goal of
transplantation is to reinforce the response achieved by induction therapy and
improve progression-free survival and overall survival. Acute and manageable
side effects are an expected part of the transplantation process, with an
anticipated period of post-transplantation recovery. Survivors of HSCT are at
risk for developing complications for the remainder of their lives. Nurses must
have adequate information to identify potential problems and implement
strategies to manage the care of patients experiencing transplantation-related
complications, both short- and long-term. Knowledge of the expected side
effects and nursing interventions at each phase of the transplantation process
will help patients and caregivers through this challenging process, improve
outcomes, and enhance quality of life.
The authors gratefully acknowledge Brian G.M. Durie, MD, Robert A. Kyle, MD, and Diane P. Moran, RN, MA, EdM, senior vice president of strategic planning at the
International Myeloma Foundation, for their critical review of the manuscript.
Implications for
Practice
Ø
Consider all factors when determining patient
eligibility for transplantation.
Ø
Gain knowledge of supportive care strategies
within each phase, including special considerations for allogeneic recipients,
to increase the well-being and survival of patients.
Ø
Anticipate short- and long-term side effects
with prompt identification and intervention, when appropriate.
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Beth
Faiman, MSN, APRN-BC, AOCN®, is a nurse
practitioner in the Taussig Cancer Center at the
Cleveland Clinic in Ohio; Teresa Miceli, RN, BSN, OCN®,
is a bone marrow transplantation nurse coordinator and assistant professor of
nursing in the College of Medicine in the William von Liebig Transplant Center
at the Mayo Clinic in Rochester, MN; Kimberly Noonan, RN, ANP-BC, is an adult
nurse practitioner at the Dana-Farber Cancer Institute in Boston, MA; and Kathryn
Lilleby, RN, is a clinical research nurse at the Fred
Hutchinson Cancer Research Center in Seattle, WA. The authors received
editorial support from Alita Anderson, MD, with Eubio Medical Communications, in preparation of this
article supported by Sanofi Oncology. The authors are
fully responsible for content and editorial decisions about this article. The
content of this article has been reviewed by independent peer reviewers to
ensure that it is balanced, objective, and free from commercial bias. No financial
relationships relevant to the content of this article have been disclosed by
the authors, independent peer reviewers, or editorial staff. Mention of
specific products and opinions related to those products do not indicate or
imply endorsement by the Clinical Journal of Oncology Nursing or the Oncology
Nursing Society. Faiman can be reached at faimanb@ccf.org, with copy to editor at CJONEditor@ons.org. (Submitted July 2013.
Revision submitted August 2013. Accepted for publication
September 12, 2013.)
http://dx.doi.org/10.1188/13.CJON.S2.33-41
