As the use of immunotherapeutic

agents increases in single-agent and Immunotherapy

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Administration
multimodality treatment regimens,
oncology nurses face the challenge
of administering and caring for
patients receiving new and unique
agents. Oncology Nursing Society Oncology Nursing Society recommendations
clinical staff and clinical nurses
collaborated to produce a set of Kathleen Wiley, RN, MSN, AOCNS®, Kristine B. LeFebvre, MSN, RN, AOCN®,
recommendations to educate nurses Lisa Wall, PhD, RN, Abigail Baldwin-Medsker, MSN, RN, OCN®, Kim Nguyen, MT(ASCP), CIC,
involved with the monitoring of pa- Lisa Marsh, BSN, MA, RN, CCRP, and Diane Baniewicz, MSN, CRNP
tients receiving immunotherapy on

administration procedures and safe
handling of these agents to ensure
patient and staff safety and to reduce
risk of error. The recommendations
are meant to provide clinical nurses
with a framework on which to build
policies and procedures for adminis-
tering new treatment modalities.
AT A GLANCE
ɔɔ Clinical nurses require fundamen-
tal knowledge of immunotherapy
classes to safely and effectively
care for patients receiving immu-
notherapeutic agents.
ɔɔ Administration of immunother-
apeutic agents should include
safety procedures such as inde-
pendent verification of drugs and
doses prior to administration.
ɔɔ Drug-specific considerations
should be applied when deter-
mining the safe-handling needs
of practices caring for patients
receiving immunotherapy.
KEYWORDS
treatment modalities; drug
therapy; healthcare policies;
safe-handling procedures
DIGITAL OBJECT
IDENTIFIER
10.1188/17.CJON.S2.5-7
A
✔
lthough many unknowns
about immunotherapies
exist, the base of litera-
ture on administration
considerations, antici-
pated side effects, and treatment strate-
gies for immuno-oncology is broadening.
However, little has been published regard-
ing evidence-based administration and
safe-handling procedures. Nurses may be
administering immunotherapeutic agents
possibly for the first time in their practice.
This article presents a summary of recom-
mendations based on Oncology Nursing
Society (ONS) guidelines for practice and
the anecdotal experiences of professionals
at cancer centers with various backgrounds
in immunotherapy administration. ONS
is committed to following trends regard-
ing immunotherapeutic agents to provide
timely recommendations and guidelines
based on the best evidence available to
support institutional policies and proce-
dures and the healthcare professionals ad-
ministering immunotherapy.
Education and Competencies  terleukins, oncolytic viruses, and chime-
ONS’s position on the education of nurs-
es who administer and care for individu-
als receiving chemotherapy and biother-
apy agents is that they hold fundamental
knowledge of the agents being received
by patients, including, but not limited to,
mechanisms of action, pharmacologic and
administration principles, indications for
treatment, expected toxicities and adverse
events, assessment and management rec-
ommendations, and a process to ensure
patient safety (ONS, 2015). The same posi-
tion holds true for immunotherapy agents.
ONS recommends that nurses have a fun-
damental knowledge of the class of im-
munotherapy the patient is receiving, as
well as knowledge of specific agents and
protocols to follow, and apply this knowl-
edge to administration and monitoring
for efficacy and adverse events during the
treatment trajectory. Similar to processes
for defining and maintaining chemother-
apy competence, institutions involved in
immunotherapy administration must de-
termine what educational programs and
competencies will be required of nurses
and healthcare practitioners working with
patients receiving these agents and build
these competencies into existing policies
and procedures.
The importance of a fundamental
knowledge of immunotherapy becomes
critical when considering the highly
unique and life-threatening complica-
tions associated with immunotherapeutic
agents such as checkpoint inhibitors, in-
ric antigen receptor (CAR) T-cell thera-
pies (Maude, Barrett, Teachey, & Grupp,
2014; Tyre & Quan, 2007). In addition,
the immunotherapy-related side effect
of diarrhea is managed very differently
from diarrhea caused by traditional cyto-
toxic chemotherapy. Although it may be
difficult to obtain side effect information
on investigational agents, nurses must be
aware of available drug information, and

CJON.ONS.ORG SUPPLEMENT TO VOLUME 21, NUMBER 2  CLINICAL JOURNAL OF ONCOLOGY NURSING  5

IMMUNOTHERAPY ADMINISTRATION
report any new or unusual side effects in
a timely manner to help build a side effect
profile for immunotherapy agents.
Administration Principles  notherapy treatment plans as they are with
To date, multiple classes of immunothera-
py agents are currently either approved for
clinical use or are deeply vetted in clinical
trials. Routes of administration for immu-
notherapy agents vary from oral agents to
complex, multi-step parenteral and intra-
tumoral administration. Until more is un-
derstood about the long-term effects and
potential risks of these agents, ONS (2015)
recommends treating the administration
of immunotherapeutic agents with the
same level of care and vigilance as other
antineoplastic agents.
The updated American Society of
Clinical Oncology/ONS chemotherapy
administration safety standards (Neuss
et al., 2017) outline domains of practice
to reduce the risk of error in the pre-,
intra-, and post-chemotherapy adminis-
tration periods, which serve as a founda-
tion for evidence-based best practices.
These safety standards may be referenced
when considering policies and proce-
dures surrounding immunotherapy agents.
Applying these standards to immunother-
apy administration ensures that indepen-
dent checks between two professionals
deemed competent in immunotherapy ad-
ministration are verifying and document-
ing critical components of administration
orders, such as patient identifiers, drug
name and dose, route and rate of admin-
istration, and dosing calculation variables
(Neuss et al., 2017).
ONS further outlines recommen-
dations for practice when adminis-
tering chemotherapy and biotherapy
agents via all routes of administration in
Chemotherapy and Biotherapy Guidelines and
Recommendations for Practice (Polovich,
Olsen, & LeFebvre, 2014). ONS recom-
mends that the administration consider-
ations and nursing implications in these
guidelines be applied to the safe handling
and administration of immunotherapy
agents in clinical settings.
6   CLINICAL JOURNAL OF ONCOLOGY NURSING  SUPPLEMENT TO VOLUME 21, NUMBER 2
Nurses must also make note of some
important concepts surrounding immuno-
therapy treatment plans. First, dose reduc-
tions are typically not an option in immu-
chemotherapy regimens. Immunotherapy
doses are either given in full or held com-
pletely (Rubin, 2015). Second, multimo-
dality treatment plans are increasingly
popular in clinical practice and may in-
clude immunotherapy, chemotherapy, ra-
diotherapy, and/or other immuno-oncol-
ogy agents (Drake, 2012). These concepts
support the approach of oncology nurses
having fundamental knowledge of anti-
neoplastic principles in conjunction with,
rather than in isolation of, one another.
Immunotherapy Safe Handling
Safe-handling precautions related to im-
munotherapy are drug-specific. Limited
research is available on the hazardous
"Multiple classes of immunotherapy
agents are currently either approved
for clinical use or are deeply vetted
in clinical trials."
potential of investigational drugs and
those new to the market. Every insti-
tution should have an ongoing process
for drug evaluation through current lit-
erature, product information, and safe-
ty data sheets (National Institute for
Occupational Safety and Health [NIOSH],
2016). According to NIOSH (2016), haz-
ardous drug precautions are indicated
when drugs display traits of carcinogenic-
ity, teratogenicity, genotoxicity, reproduc-
tive toxicity, or organ toxicity at low dos-
es, as well as when a mechanism of action
indicates a hazardous risk. Understanding
the mechanisms of action is essential in
determining potential risks to the patient,
their family and caregivers, and healthcare
providers. Because immunotherapy agents
may pose a risk of biohazard exposure,
nurses should collaborate with infection
control or biologic safety departments to
assist with developing policies and proce-
dures regarding immunotherapy agents.
For example, live-virus cancer vaccines
(oncolytic viruses) are a class of immu-
notherapy requiring isolation procedures
for the duration of a patient’s treatment
or until all his or her lesions are healed.
Soiled dressings must be properly discard-
ed, and personal protective equipment,
including gowns, gloves, and, in some
cases, face or eye protection, is indicated
(McMahon, 2016).
Conclusion 
Immunotherapy promises exciting ad-
vancements in oncology care. Nurses ad-
ministering immunotherapeutic agents
and caring for those receiving treatment
must be knowledgeable about how the
medications work, their side effect pro-
files, and safe-handling and administra-
tion procedures. Safety precautions, such
as independent dose verification and com-
prehensive patient education, can help to
protect patients from harm. Until more
information is available, existing chemo-
therapy safety standards should be applied
to the administration of immunothera-
peutic agents in all settings.
Kathleen Wiley, RN, MSN, AOCNS®, and Kristine
B. LeFebvre, MSN, RN, AOCN®, are oncology
clinical specialists at the Oncology Nursing Society
in Pittsburgh, PA; Lisa Wall, PhD, RN, is a clinical
nurse specialist and Abigail Baldwin-Medsker,
MSN, RN, OCN®, is a nurse leader, both at Memorial
Sloan Kettering Cancer Center in New York, NY; Kim
CJON.ONS.ORG
Nguyen, MT(ASCP), CIC, is an infection preventionist
and Lisa Marsh, BSN, MA, RN, CCRP, is a research
nurse manager, both at the University of Texas MD
Anderson Cancer Center in Houston; and Diane
Baniewicz, MSN, CRNP, is a nurse practitioner at the
Children’s Hospital of Philadelphia in Pennsylvania.
Wiley can be reached at kwiley@ons.org, with copy
to editor at CJONEditor@ons.org. (Submitted January
2017. Accepted February 1, 2017.)
The authors take full responsibility for this content. The
article has been reviewed by independent peer reviewers to
ensure that it is objective and free from bias.
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