Roles and Responsibilities of the Multidisciplinary Care Team in Acute Lymphoblastic Leukemia

Acute lymphoblastic leukemia (ALL) management is a lengthy and complex process that spans multiple locations. Over the course of 2 to 3 years, patients undergo treatment for induction, consolidation, maintenance, and possibly hematopoietic cell transplantation.^1-3 Although some aspects of treatment can only be delivered in tertiary care centers or community hospital settings that can deliver high-level, around-the-clock care, patients return home after various points during treatment to receive outpatient care between hospitalizations.^4,5

Management of ALL through the use of multidisciplinary care teams helps patients and their caregivers navigate the complexities of their journeys, beginning with the initial hospitalization. During hospitalization and the transition to outpatient care, nurses serve as trusted sources of support, education, and training.⁴ Pharmacists likewise support inpatients and transitioning patients through education and reconciliation of medications.⁶ Following discharge, responsibilities shift to the outpatient setting, where oncologists and hematologists work with primary care providers and nurse practitioners to ensure that patients receive appropriate follow-up, and information regarding the patient’s progress is shared among team members.¹

In the outpatient setting, successful management requires a multidisciplinary approach to address multiple ongoing care needs, including adherence to medications, ambulatory treatment, and monitoring. Objective medication adherence data can be used by nurses, physicians, pharmacists, and other members of the multidisciplinary care team to target interventions to improving adherence.⁷ Nurses, in particular, may have relationships with patients and caregivers that allow insight into possible barriers to adherence that can be targeted for intervention.⁷ In addition to adherence to medications, patients with ALL may receive ambulatory treatments that require a coordinated multidisciplinary care approach to ensure appropriate and safe delivery of care.

Both chimeric antigen receptor T-cell (CAR-T) therapy and bispecific antibody therapy may be administered in outpatient settings. For patients with ALL receiving CAR-T therapy in outpatient settings, nurses can provide close monitoring and rapid recognition of adverse events, whereas pharmacists can develop protocols and policies to facilitate supportive care.⁸ Patients receiving bispecific antibody therapy such as blinatumomab for ALL are also able to receive treatment in outpatient settings with the help of multidisciplinary care teams. Following a minimum in-hospital infusion period that varies based on treatment cycle, members of the multidisciplinary care team determine whether patient discharge with continued home infusion therapy is appropriate.⁹

Successful home-based administration of blinatumomab results from the coordinated efforts of physicians, nurses, and pharmacists to ensure appropriate therapeutic administration while monitoring for adverse events in coordination with home infusion companies.^9,10 For patients and families who wish to minimize hospitalization time, some portions of ALL management can be provided in the home setting. For patients wishing to complete post-methotrexate supportive care at home, multidisciplinary teams of providers, nurses, and pharmacists can facilitate timely inpatient administration of therapy and laboratory draws to coordinate with home healthcare agency availability and educate caregivers to ensure competency in providing supportive care in the home.¹¹

References

1. Puckett Y, Chan O. Acute lymphocytic leukemia. 2021. In: StatPearls [Internet]. www.ncbi.nlm.nih.gov/books/NBK459149. Accessed December 2, 2021.
2. National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology: acute lymphoblastic leukemia. Version 2.2021. July 19, 2021. www.nccn.org/professionals/physician_gls/pdf/all.pdf. Accessed November 10, 2021.
3. National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology: pediatric acute lymphoblastic leukemia. Version 1.2022. October 1, 2021. www.nccn.org/professionals/physician_gls/pdf/ped_all.pdf. Accessed November 10, 2021.
4. Silva-Rodrigues FM, Bernardo CSG, Alvarenga WA, et al. Transitional care to home in the perspective of parents of children with leukemia. Rev Gaucha Enferm. 2019;40:e20180238.
5. Association of Community Cancer Centers (ACCC). Multidisciplinary acute lymphocytic leukemia care environmental scan. 2019. www.accc-cancer.org/docs/projects/acute-lymphoblastic-leukemia/all-environmental-scan_final.pdf?sfvrsn=30e98431_2. Accessed December 2, 2021.
6. Shank BR, Nguyen PAA, Pherson EC. Transitions of care in patients with cancer. Am J Manag Care. 2017;23(7 Spec No.):SP280-SP284.
7. Wu YP, Stenehjem DD, Linder LA, et al. Adherence to oral medications during maintenance therapy among children and adolescents with acute lymphoblastic leukemia: a medication refill analysis. J Pediatr Oncol Nurs. 2018;35:86-93.
8. Mahadeo KM, Khazal SJ, Abdel-Azim H, et al. Management guidelines for paediatric patients receiving chimeric antigen receptor T cell therapy. Nat Rev Clin Oncol. 2019;16:45-63.
9. Szoch S, Boord C, Duffy A, Patzke C. Addressing administration challenges associated with blinatumomab infusions: a multidisciplinary approach. J Infus Nurs. 2018;41:241-246.
10. Bojilova-Dor L, Pinkney K, Cauff B, et al. Successful outpatient administration of blinatumomab infusion in pediatric patients with acute lymphoblastic leukemia. Poster presented at 2021 ASH Annual Meeting; December 13, 2021; Atlanta, GA.
11. Ranney L, Hooke MC, Robbins K. Letting kids be kids: a quality improvement project to deliver supportive care at home after high-dose methotrexate in pediatric patients with acute lymphoblastic leukemia. J Pediatr Oncol Nurs. 2020;37:212-220.