APHON is pleased to partner with the Children's Oncology Group (COG) again this year to present a special educational track of sessions that focuses on the care of children enrolled on COG clinical trials.
Caring for Children on COG AML protocols: Quick Hits and Nursing Tips (C205)
Acute myeloid leukemia (AML) is the second most common form of leukemia in children, and the intensive therapy used to treat pediatric AML requires expert nursing knowledge. The rate of event-free survival for childhood AML is estimated to be 55%, and intensification of current chemotherapy protocols is not possible because of the treatment’s known toxicity profile, which includes cardiotoxicity and infectious toxicity. The Children’s Oncology Group (COG) is working to improve the survival of pediatric AML patients through advances in risk stratification and new chemotherapy formulations, targeted therapies, and supportive care strategies. In this session, we will review the current COG protocols for children with newly diagnosed AML, AAML1831 (de novo AML), and AAML1531 (Down syndrome AML), through a nursing perspective, with a focus on targeted and investigational agents, supportive care measures, and patient and family education.
Lighting the Way in COG with MATCH: Targeted Therapies in Pediatric CNS Tumors (C211)
Pediatric MATCH (Molecular Analysis for Therapy Choice) is a joint effort between the National Cancer Institute (NCI) and Children’s Oncology Group (COG) matching targeted therapies to specific tumor genomic sequencing in patients with relapsed or refractory solid tumors, non-Hodgkin lymphomas, brain tumors, and histiocytic disorders. Pediatric MATCH uses validated next-generation sequencing targeted assay of more than 4,000 separate mutations across more than 140 genes. The study has 13 subprotocols with each subprotocol focusing on agent classifications. These agent classes include pan-TRK, FGFR, EZH2, MEK, PI3K/mTOR, ALK, BRAF, PARP, CDK4/6, ERK ½, IDH1, Farnesyl Transferase, and RET inhibitors. All of these inhibitors have been found to be important in a variety of pediatric cancers. Many of these classes have been trialed in pediatric central nervous system (CNS) tumors in various settings and have shown to have treatment effects, especially in tumors previously thought to be difficult to treat. Yet, within the pediatric CNS tumor arena, the most studied associated agents to date are vemurafenib (BRAF), palbociclib (CDK4/6), and selumetinib (MEK). The presentation will (1) provide an overview of Pediatric MATCH; (2) review BRAF, CD4/6K, and MEK pathways; and (3) review the agents’ side effects, and associated side-effect management, that nursing plays a key role in monitoring for and treating.
Hot Topics in Pediatric Oncology: Updates from the Children’s Oncology Group (C217)
Improvements in patient care occur when new research findings are moved into practice. The average length of time for this translation, however, is 17 years. Within the past 3 years, the Children’s Oncology Group (COG) has produced 248 publications (about 83 per year). This research productivity is impressive but makes it difficult for anyone person to stay informed. The purpose of this presentation is to assist with the dissemination of COG-related research results by summarizing five recently completed studies with high relevance for nursing practice:
- Article 1: Prevention of infection, specifically central line-associated bloodstream infection (CLABSI) is a top priority for children receiving cancer treatment. Many institutions implemented a practice of daily chlorhexidine gluconate (CHG) baths in children undergoing cancer therapy to prophylactically prevent CLABSI. Zerr et al. (2020) published a randomized controlled trial (177 subjects) exploring the use of daily CHG bathing in a double-blind placebo-controlled trial for childhood cancer patients. The rate of CLABSI in the CHG experimental group was higher than that in the control group (p = .049). This study does not support the use of CHG bathing in children with cancer.
- Article 2: Historically, children treated for standard-risk B-acute lymphoblastic leukemia have received vincristine (VCR) and dexamethasone (DEX) pulses every 4 weeks during maintenance therapy. Side effects from these agents are common. Angiolillo et al. (2021) published results from COG AALL0932, which explored survival outcomes in 2,364 children randomized in a 2 × 2 factorial design to receive VCR/DEX every 12 weeks (vs. every 4 weeks) with a methotrexate (MTX) starting dose of 20/mg/m2 or 40 mg/m2, once weekly during maintenance. Every 4 weeks VCR/DEX pulses and the lower (20/mg/m2) starting dose of MTX maintained excellent outcomes.
- Results from three additional 2021 COG publications will be discussed, along with specific implications for nursing practice related to caring for childhood cancer patients.
Incorporating Children’s Oncology Group Health Links into Clinical Practice (C223)
The care of children with cancer spans diagnosis and treatment, with the goal being survivorship. Approximately 80% of children diagnosed with cancer will survive, and many childhood cancer survivors may experience both physical and psychological late effects secondary to their cancer or its treatment. The term late effects is used when describing complications, disabilities, or adverse outcomes that are the result of the disease process, treatment, or both (Hewitt et al., 2003). The Children’s Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers (COG LTFU) are risk-based, exposure-related, evidence-based clinical practice guidelines intended to increase awareness of potential late effects and to standardize and enhance the follow-up care provided to survivors of pediatric cancer throughout their lifespan. The Nursing Clinical Practice Subcommittee, which worked in parallel with the development of the COG LTFU, developed Health Links, complementary patient health education materials designed specifically to accompany selected sections of the guidelines to provide targeted health information (Landier et al., 2004; Eshelman et al., 2004). What began with 33 Health Link topics in 2004 has now expanded to 43 topics, with many Health Links now available in French, Spanish, and Chinese language. We will share the history of Health Links development along with clinical and practical scenarios to ensure pediatric oncology nurses are aware of this valuable resource and are able to incorporate these patient education resources into daily practice.
Clinical Trials in the Children’s Oncology Group: A Case Study Approach (C229)
Clinical trials are essential in the treatment of pediatric and young adult patients with cancer and have resulted in dramatic improvements in cure rates over the years. Because of clinical trials, we are now better able to understand the biology of different types of cancers affecting children and young adults and determine the best treatment options. Clinical trials would not be possible without nurses, who are fundamental members of the clinical team and are essential for the successful implementation of clinical trials. Nurses at the bedside and in the clinic provide crucial patient care and patient/family education for patients enrolled on Children’s Oncology Group clinical trials and facilitate communication between physicians, clinical research associates, pharmacists, and the clinical team. Nurses also provide vital documentation for clinical trial reporting. However, without a working knowledge of the essential elements of a clinical trial, the nurse cannot fully contribute to the success of the trial. Using a case study approach, this session will provide the opportunity for nurses to gain a better understanding of the importance of clinical trials both to patients and their families, as well as to the advancement of research. We will explore the roles of clinical trial team members (physicians, advanced practice providers, nurses, clinical research associates, and the study team) to understand how team members can best work together to achieve optimal study outcomes. Nurses will also have an opportunity to learn how to identify and grade adverse events, about the importance of accurate documentation, and about the impact of reporting adverse events to the clinical trials study team. Nurses being prepared to work with pediatric and young adult patients enrolled on Children’s Oncology Group clinical trials can contribute to trial success and prove rewarding for the nurse, the clinical team, and the patient and their family.
Treating Smarter, Not Harder: Abandoning Intensification and Replacing with Immunotherapy for Patients with Down Syndrome and B-ALL (C234)
Children with Down syndrome (DS) have a striking predisposition for developing acute leukemia, with a 40-fold increased risk of developing acute lymphoblastic leukemia (ALL) compared to non-DS patients (Wadhwa et al, 2017). Approximately 3% of children with ALL have DS, and these children have inferior outcomes and higher rates of treatment-related mortality (TRM) and are at greater risk of relapse (Buitenkamp et al., 2014). Significant supportive care strategies have been implemented in recent protocols, but TRM rates have remained significantly higher for DS B-ALL patients despite these efforts (Rabin et al., 2015). Children with DS are uniquely sensitive to side effects from chemotherapy, and toxicity in this population led to temporary suspensions of DS treatment arms on previous clinical trials AALL0331 and AALL0232. Therefore, the Children’s Oncology Group (COG) is testing the immunotherapy blinatumomab in children with DS B-ALL with the aim of increasing survival and minimizing toxicity. Blinatumomab has been safely used in children with DS and relapsed B-ALL (von Stackelberg et al., 2016; Wadhwa, Kutny, & Xavier, 2017). COG protocol AALL1731 is a phase three clinical trial investigating the addition of blinatumomab to standard chemotherapy in patients classified as standard risk (SR). Patients with SR DS will be eligible for randomization and high-risk B-ALL and DS (DS-High) patients will have a unique treatment arm that includes three cycles of blinatumomab. AALL1731 has a correlative study aimed at exploring the neurocognitive, functional, and quality of life outcomes in DS-ALL patients. There is an urgent need to understand this impact because patients with preexisting neurodevelopmental conditions have been excluded from neurocognitive studies in childhood cancer. In this session, nurses will learn about the treatment of patients with DS B-ALL on AALL1731, the rationale behind the intensified supportive care measures specific for patients with DS, and the unique impacts of therapy for patients with DS B-ALL.