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• To enhance your awareness of the skills required for educating patients about anticancer therapy
• To find advice and resources for delivering effective pre-treatment patient education sessions
• To contribute towards revalidation as part of your 35 hours of CPD (UK readers)
• To contribute towards your professional development and local registration renewal requirements (non-UK readers)
Systemic anticancer therapy (SACT) incorporates all types of therapies used to treat cancer, including cytotoxic therapy (also called chemotherapy), immunotherapy, hormonal therapies and targeted therapies. Nurse-led pre-SACT patient education sessions aim to inform patients about their treatment, including its potential side effects and what they should do if they experience symptoms, to enhance patient safety and to reinforce informed consent. This article discusses the importance of pre-SACT patient education sessions in the context of cytotoxic therapy and details six areas for nurses to consider when planning on delivering such sessions.
Cancer Nursing Practice. doi: 10.7748/cnp.2024.e1875
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Gayle S (2024) Delivering a pre-systemic anticancer therapy patient education session. Cancer Nursing Practice. doi: 10.7748/cnp.2024.e1875
Published online: 30 September 2024
The aim of this article is to enhance nurses’ understanding of the core components of a pre-systemic anticancer therapy (SACT) patient education session to ensure effective delivery. After reading this article and completing the time out activities you should be able to:
• Explain why providing pre-SACT education is a vital aspect of patient care.
• Describe the side effects of cytotoxic medicines and whether the side effects are common to most cytotoxic medicines or specific to particular ones.
• Recognise how SACT-related side effects may affect patients’ lives and what management advice to give them.
• Plan the delivery of a pre-SACT education session incorporating the six areas for consideration detailed in this article.
• Understand how to evaluate your delivery of pre-SACT patient education sessions.
Systemic anticancer therapy (SACT) is a broad term that describes all types of therapies used to treat cancer, including cytotoxic therapy (also called chemotherapy), immunotherapy, hormonal therapies and targeted therapies (UK SACT Board 2024), which may be administered individually or in combination. This article focuses on cytotoxic therapy.
People who receive SACT are at risk of developing potentially life-threatening complications if they do not seek expert advice promptly when they experience symptoms that may be caused by treatment-related side effects (Alessy et al 2021). One of the main reasons why people do not always seek prompt expert advice about such symptoms is a lack of information and understanding regarding SACT-related side effects and the action required (UK Oncology Nursing Society (UKONS) 2023). Furthermore, some people may hesitate to take action due to fear that their treatment may be paused, which would put them at risk of a deterioration in their condition (Olver et al 2018).
Nurse-led pre-SACT patient education sessions aim to inform patients and their families or carers, before treatment starts, about potential treatment-related side effects. They are an opportunity to dispel patients’ misconceptions, address their concerns and reinforce the importance of them seeking prompt expert advice when required. Such sessions also aim to ensure patients and their family or carers understand the diagnosis and the rationale for the selected treatment, thereby reinforcing informed consent. Furthermore, they provide an opportunity for the nurse to find out about the patient’s individual characteristics so that they can help them understand how their lives may be adversely affected by SACT and provide them with tailored management advice (Isaacs et al 2022). Patients usually receive their pre-SACT education session between one week and a few days before treatment starts, depending on the treatment centre.
Nurse-led pre-SACT patient education sessions are usually delivered one-to-one and in person, but they can also be delivered via video link or by telephone. In some areas, sessions are delivered to a group rather than one-to-one, either in person or remotely. A one-to-one session is focused on the individual and tailored to their specific needs, and the patient may feel safe to discuss sensitive issues. A group session can help some patients feel that they are sharing similar experiences with others, which may lay the foundation for peer support.
Nurses planning on delivering a pre-SACT education session must ensure that their knowledge and skills are up to date (Nursing and Midwifery Council (NMC) 2018).
This article discusses six areas for nurses to consider when planning on delivering a pre-SACT patient education session:
• Knowledge.
• Safety.
• Language and information needs.
• Communication techniques.
• Equality, diversity and inclusion.
• Local policy and care quality.
• Patients due to start systemic anticancer therapy (SACT) receive a nurse-led education session aimed at informing them about their treatment
• Patients’ lives can be severely affected by the side effects of SACT and nurses need to provide them with tailored management advice
• During a pre-SACT education session, the nurse explains to the patient how treatment is administered, how it works and what side effects it can have
• At their pre-SACT education session, the patient receives advice on how to self-assess their symptoms and determine what action to take
• A pre-SACT education session also serves to check that the patient understands their diagnosis and treatment, thus reinforcing informed consent
An essential component of a pre-SACT education session is to explain to the patient how treatment is administered, how it works and what its potential side effects are.
Cytotoxic therapy is administered in different ways depending on the medicine type (Box 1).
• Oral – as a tablet
• Topical – applied to the skin
• Subcutaneous – injected under the skin into the subcutaneous fat layer
• Intrapleural – injected between two layers of tissue in the lung
• Intraperitoneal – injected into the space between the peritoneum and the abdominal cavity
• Intravesical – administered via the bladder
• By aerosol – sprayed directly onto the cancer
• Intravenous – injected into a vein
• Intra-arterial – injected into an artery
• Intrathecal – injected into the spinal cord
(Adapted from Macmillan Cancer Support 2021, 2022)
Cytotoxic medicines are commonly administered intravenously and/or orally in an outpatient setting (DeVita et al 2023). Intravenous (IV) cytotoxic therapy is typically administered via a cannula inserted into a vein, often in the hand (Figure 1). It may also be administered via (Cancer Research UK 2024a):
• A peripherally inserted central catheter (PICC) – a thin hollow tube (line) that is inserted into a large vein above the antecubital fossa in the arm and threaded through the vein until its end reaches just above the heart (Figure 2). Treatment is administered via the lumen that protrudes from the arm.
• A portacath – a small chamber (port) that is implanted under the skin of the chest and attached to a thin tube (line) threaded through a vein leading to the heart (Figure 3). To administer treatment, a needle is inserted through the skin into the port.
• A central line – a thin hollow tube that is inserted into a vein in the chest and threaded through the vein until its end reaches just above the heart (Figure 4). Treatment is administered via the lumen which protrudes from the chest.
Some patients may receive their treatment at home via a continuous pressure pump, which is usually attached to a PICC or a portacath. The pump will administer the medicine continuously, generally over a period of 24-46 hours (Cancer Research UK 2024b). Patients receiving SACT at home must be instructed on what they should do and who they should contact if they experience any problems with the pump and/or their PICC or portacath, such as a blockage in the tube (Aranda et al 2012).
Cytotoxic medicines work by interrupting the cell cycle at different stages (Tilsed et al 2022). The cell cycle is an ordered set of events (stages) that occur within a cell as it grows and divides. Cytotoxic medicines destroy cells that are in the process of dividing and damages the genes inside the nucleus (the cell’s ‘control centre’) (Morgan 2003, Cancer Research UK 2024c). For a detailed explanation of the cell cycle in the context of cytotoxic therapy, see Morgan (2003).
Different classes of cytotoxic medicines destroy cancer cells (and healthy cells) in different ways. For example:
• Alkylating agents work by damaging deoxyribonucleic acid (DNA) to prevent cell reproduction (Thirumaran et al 2007). DNA contains, in the form of biological instructions, information required for cell reproduction, growth and survival (Alberts et al 2002).
• Antimicrotubular agents (or mitotic inhibitors) work by preventing cell division.
• Topoisomerase inhibitors I and II affect DNA replication and transcription by interrupting topoisomerase enzyme formation (Bharti and Aggarwal 2018). Transcription is the process of copying a segment of DNA onto ribonucleic acid (RNA). RNA influences how the instructions contained in DNA are interpreted, which determines physiological characteristics (Alberts et al 2002).
Oncologists and non-medical prescribers qualified to prescribe SACT use the patient’s body surface area or body weight to calculate the required medicine dose. The dose may change during the course of therapy according to the patient’s tolerance of the prescribed treatment and the emergence of any side effects. It is important that the nurse explains this to the patient, emphasising that a reduced dose does not necessarily mean substandard treatment and that the dose is calculated to treat the cancer while minimising the risk of side effects (Macmillan Cancer Support 2024a).
Read about the side effects of cytotoxic medicines at:
www.cancerresearchuk.org/about-cancer/treatment/chemotherapy/side-effects/about
Think about a patient you have recently worked with who is being treated with cytotoxic medicines. Which side effects do they experience, if any?
Patients treated with cytotoxic medicines often experience similar side effects regardless of which medicines they take, so there are side effects that are common to most of these medicines (Amjad et al 2023). However, cytotoxic medicines may also have side effects that are specific to each one of them. This is because certain cells in the human body are more sensitive than others to particular cytotoxic medicines and because different cytotoxic medicines affect tissues, organs or body systems in different ways (Tilsed et al 2022). For example, irinotecan hydrochloride targets hair follicle cells, while capecitabine influences enzymic reactions in the digestive system.
It is important that the nurse who delivers the pre-SACT education session is aware of the common and specific side effects of cytotoxic medicines so that they can provide this information to the patient. It is also important to ensure that the patient understands that they may not experience all the known side effects of their medicines and that people’s tolerance of treatment varies.
Examples of side effects common to most cytotoxic medicines are shown in Box 2 and examples of side effects specific to particular cytotoxic medicines are shown in Table 1.
(Adapted from Joint Formulary Committee 2024, Macmillan Cancer Support 2024b)
• Tiredness
• Anaemia
• Bruising
• Bleeding
• Anaphylaxis
• Altered taste
• Reduced appetite
• Gastrointestinal upset
• Constipation
• Diarrhoea
• Nausea
• Vomiting
• Low mood
• Psychological distress
• Impaired memory
• Impaired ability to think clearly
• Infection
• Risk of impaired liver function
• Risk of impaired renal function
• Risk of infertility
(Adapted from Perry 2012)
In your workplace or specialty, which cytotoxic medicines are commonly prescribed to patients? Research the side effects associated with these particular medicines using the resources below:
www.macmillan.org.uk/cancer-information-and-support/treatments-and-drugs
The NMC (2018) professional standards of practice and behaviour require nurses to ensure patients’ records are clear and accurate and that informed consent has been obtained before any action is taken. Before commencing the pre-SACT education session, the nurse should check with the patient that their data – such as their name, date of birth, hospital number and diagnosis – are correct and that they have signed the consent form for their treatment (Reinhard et al 2019).
To reinforce informed consent, the nurse can make sure that the patient has understood the information that was provided to them during the consent process. The consent process will have been undertaken at an earlier stage by a specialist practitioner – such as a clinical nurse specialist, oncologist or pharmacist – and will have included an explanation of the diagnosis, prescribed treatment regimen, rationale for treatment and potential side effects.
It is also important that the nurse clarifies the patient’s allergy status and past medical history, including any previous surgery, since cytotoxic medicines can prompt severe allergic reactions (anaphylaxis) and slow down the rate of wound healing. If the patient has had recent surgery, the nurse should liaise with the oncologist regarding a safe time point at which to start SACT (Deptuła et al 2019).
What is your organisation’s policy on patient self-assessment of symptoms associated with side effects of SACT? Does your organisation have a 24-hour helpline? Does it provide direct access to a clinical nurse specialist? Are patients given a symptom alert card or a cancer treatment alert card?
It is vital that the patient understands how to self-assess symptoms associated with SACT-related side effects and what action they need to take if they experience such symptoms.
The UKONS (2016) Oncology/Haematology 24 Hour Triage Rapid Assessment and Access Toolkit is a symptom-based risk assessment tool widely used to triage patients who may be experiencing side effects of SACT. It was developed for use by staff who operate 24-hour advice lines for patients receiving SACT. The toolkit uses a ‘green, amber, red’ scoring system; patients whose symptoms have all been assessed as ‘green’ need to be given self-care advice; patients with one ‘amber’ symptom will need to be reviewed within 24 hours; patients with two or more ‘amber’ symptoms are escalated to the ‘red’ category; and all patients in the ‘red’ category require urgent assessment (UKONS 2016).
During a pre-SACT education session, the patient is typically given a ‘condensed’ version of the UKONS (2016) toolkit, which may be in the form of a treatment diary, a symptom alert card and/or a written information leaflet. These documents will support the patient to self-assess their symptoms and determine what action to take. If they find that they are in the ‘red’ category, they will need to seek urgent medical advice, either by attending their local emergency department (ED) or by contacting their clinical nurse specialist team. The information given to the patient should include details of who they should contact if they experience treatment-related symptoms. The patient should also be given a cancer treatment alert card containing information about SACT that they can share with any healthcare professional who may become involved in their care, for example if they attend the ED for urgent review (UKONS 2016).
The various documents described above may be developed locally or sourced from organisations such as Macmillan Cancer Support (see ‘Further resources’).
In some healthcare organisations patients have access to a digital platform that supports symptom self-assessment, maintains live records, sends updates to the patient’s oncology team and offers the patient a direct line of communication with their oncology team to assist them in determining what action to take based on their symptoms (NHS England 2024). Some healthcare organisations have a designated acute oncology service that provides a direct route to assessment and intervention if required, thus avoiding patients having to wait in the ED.
It is recommended that healthcare organisations offering SACT have a 24-hour helpline to enable patients to access a clinical nurse specialist who can assess their symptoms and advise on management (UKONS 2023).
The nurse who delivers a pre-SACT patient education sessions needs to know the 24-hour helpline telephone number and details of the local clinical nurse specialist team (Alessy et al 2021) so that they can share these with the patient. The patient should also be made aware of the clinical nurse specialist team’s working hours and given an out-of-hours contact number.
The NMC (2018) requires nurses to ensure patients understand all information they are given. Therefore, where possible, the nurse should ascertain whether there are communication barriers – for example, whether the person understands and speaks English or whether they have specific communication needs – before delivering the pre-SACT patient education session. This will enable the nurse to arrange for an interpreter to be present and/or to source information in an appropriate language or format as needed. This will also help reinforce informed consent, aid the identification of the patient’s holistic support needs and promote patient safety.
To support the effective delivery of a pre-SACT patient education session, the nurse needs to consider their communication techniques. Suboptimal communication can result in the patient misunderstanding information, not adhering to the advice given, not trusting the healthcare professional and experiencing increased anxiety, all of which risks negatively affecting their experience, safety and outcomes (Mustafa et al 2023).
The nurse should avoid jargon, simplify complex medical terminology, use active listening and open-ended questions, and adopt a soft vocal tone and empathic language to signify calmness and compassion (Mohd Salim et al 2023). The nurse can acknowledge the patient’s concerns using phrases that demonstrate empathy (such as ‘That sounds difficult for you’) and discuss these concerns using phrases that demonstrate active listening (such as ‘You mentioned […]. Can you tell me a bit more about that?’). Using open and welcoming body language and facial expressions, facing the patient and maintaining eye contact – if appropriate – is also important in this context (Finn et al 2017).
During the education session, the nurse should attempt to assess the patient’s comprehension and retention of the information given (Kean et al 2016) and consider the need for a mental capacity assessment – for example for patients who have a learning disability, brain injury or dementia. A mental capacity assessment evaluates the person’s ability to make decisions concerning their care (Office of the Public Guardian 2020) and is often completed by the lead oncologist in line with local safeguarding policy.
It is good practice to ensure the patient is accompanied by a family member, friend or carer during the education session to support their understanding of the information and their adherence to the advice given.
Healthcare professionals have a responsibility to provide culturally appropriate care that is sensitive to people’s identity and background (Care Quality Commission (CQC) 2024). The nurse who delivers a pre-SACT patient education session should understand how the patient’s individual characteristics, such as their physical or cognitive ability, gender or ethnicity, can influence their experience of treatment (Piombo et al 2021) and tailor the session to the patient’s individual needs.
It is important that the nurse is aware of beliefs or values that they hold and may inhibit the provision of inclusive care. It has been reported that healthcare professionals do not always discuss sex and intimacy adequately during patient consultations (Gorman et al 2022), possibly because of conservative cultural norms, values and beliefs, embarrassment or lack of confidence (Stead et al 2003). Moreover, Reese et al (2017) reported that patients often under-report issues on sensitive topics such sex and intimacy. The nurse should therefore consider how they might help the patient feel confident to discuss any concerns they may have.
Equitable care requires tailoring education to the needs of the individual (Terui 2017), which involves identifying the patient’s concerns and preferences and what is important to them (CQC 2024). Table 2 provides examples of how patients’ lives might be affected by the side effects of SACT and gives corresponding management advice. The information in the table is based on the author’s clinical experience.
The nurse who delivers a pre-SACT patient education session should ensure that they adhere to their organisation’s local policy. For example, in some organisations, a proforma or checklist is used to guide such sessions (Mueller and Glennon 2007).
It is important that the nurse allocates an uninterrupted time slot (between 45 minutes and an hour) to allow sufficient time for the session and ensures that the patient’s dignity and confidentiality are maintained at all times (NMC 2018, Tariq and Hackert 2022).
To enhance care quality and patient experience, pre-SACT education sessions should be evaluated, for example by engaging in self-reflection and/or group reflection, reviewing NHS National Cancer Patient Experience Survey data, benchmarking against set standards for local practice, or conducting service evaluations and/or clinical audits.
Patients who receive SACT are at risk of potentially life-threatening complications if they do not seek prompt expert advice when they develop symptoms associated with treatment-related side effects. Nurse-led pre-SACT patient education sessions provide an opportunity to inform patients about treatment-related side effects and what action they need to take if they experience symptoms. Such sessions also ensure that the patient understands their diagnosis and the rationale for the selected treatment, thereby reinforcing informed consent.
Nurses who deliver pre-SACT education sessions must ensure their knowledge and skills are up to date and should consider how they can evaluate the sessions they provide to enhance care quality and patient experience.
Undertaking this CPD article can be used as evidence for revalidation, or the equivalent in the country where you work. Now that you have completed it, reflect on your practice in this area and consider writing a reflective account. Guidelines are available at rcni.com/reflective-account
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