Addressing Knowledge Gaps in Management of Tumor Lysis Syndrome

Recently, i3 Health provided a continuing medical education/nursing continuing professional development/continuing pharmacy education (CME/NCPD/CPE)–approved activity, Best Practices in the Management of Tumor Lysis Syndrome Associated With Emerging Cancer Therapies, during which clinicians’ knowledge gaps were challenged and knowledge gains were achieved.

Tumor lysis syndrome (TLS) is a rare, potentially life-threatening oncologic emergency typically associated with chemotherapy-induced tumor cell death in which potassium, phosphate, and nucleic acids are released into the bloodstream. This release of intracellular materials results in severe metabolic abnormalities such as hyperuricemia and hyperphosphatemia. TLS is an oncologic emergency that can lead to morbidity and mortality associated with kidney injury, heart failure, fluid retention, and neuromuscular and gastrointestinal effects associated with metabolic abnormalities. TLS may also lead to delays and reductions in chemotherapy dosing and alter the selection of cytotoxic agents. The most effective management strategy is prevention; however, despite appropriate prophylactic measures, approximately 3% to 5% of high-risk patients receiving chemotherapy are affected. It is vital that clinicians understand and practice optimal preventive measures, management strategies, and treatment options for their patients.

To address the knowledge gaps experienced by medical staff regarding optimal management of TLS, the activity was made available on i3 Health’s website from October 1, 2021, until September 30, 2022. This activity was led by two professionals in the field: Matthew Davids, MD, MMSc, an Associate Professor of Medicine at Harvard Medical School, and Amy Goodrich, RN, BSN, MSN, CRNP-AC, a Research Associate at Johns Hopkins University School of Medicine. Support was provided through educational funding from Sanofi Genzyme.

A total of 1,589 learners participated in this activity, with 1,421 completing it for credit. Most participants were registered nurses (90%), followed by nurse practitioners, advanced practice nurses, physicians, pharmacists, physician assistants, clinical nurse specialists, and those who chose “other” as their profession. Among those who participated, the average number of patients with TLS seen per month was eight, and the average number of years in practice was 15.

The baseline data collected revealed knowledge gaps in the following areas: assessing the risk for TLS associated with emerging therapies for hematologic malignancies, developing evidence-based management plans to optimize prevention, recognition, and treatment of TLS in patients with hematologic malignancies, and applying monitoring strategies to ensure adequate control of uric acid levels in patients diagnosed with TLS.

Participants were given a matching pretest and posttest at the beginning and end of the activity, respectively. The pretest assessment revealed that 73% of participants were successful in identifying mild chronic kidney disease as the comorbidity that would increase the risk of TLS during venetoclax treatment for a patient recently diagnosed with chronic lymphocytic leukemia; 75% were successful in recognizing the high risk of TLS associated with combination chemotherapy with R-EPOCH (rituximab/etoposide/prednisone/vincristine sulfate/cyclophosphamide/doxorubicin) for a patient with Burkitt lymphoma and high-risk features; 39% were successful in identifying oral plus intravenous infusion hydration and rasburicase as the appropriate TLS prophylaxis for a patient with diffuse large B-cell lymphoma; 47% were successful in understanding the need to check uric acid levels every four to six hours for 48 hours after chemotherapy for patients at high risk for TLS; and only 28% were successful in identifying the use of oral non-calcium phosphate binders to manage hyperphosphatemia in a patient with clinical TLS.

The posttest assessment revealed significant knowledge gains for each learning outcome: 25% more learners (98%) were successful in identifying patient-related risk factors for TLS; 23% more (98%) were successful when determining risk classification for TLS; 49% more (88%) successfully identified prophylaxis appropriate for a patient at high risk for TLS; 45% more (92%) were successful in understanding the proper monitoring for a patient at high risk for TLS; and 50% more (78%) were successful in understanding the management of established clinical TLS.

Upon completion of the activity, 95% of learners reported feeling more confident in treating their patients with TLS, and 95% felt that the material presented would be used to improve the outcomes of their patients.

The data revealed by the posttest assessment affirm the effectiveness of online educational content pertaining to optimal management and treatment strategies for TLS. Based on these data, i3 Health has determined that the multidisciplinary team may benefit from CME/NCPD/CPE activities that provide TLS education on identifying patients at risk for TLS, emerging research regarding the prevention, recognition, and treatment of TLS, and best practices for managing patients with established TLS to improve outcomes.


i3 Health (2022). Best practices in the management of tumor lysis syndrome associated with emerging cancer therapies: activity outcomes report. Data on file. 

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