Odette Cancer Centre not affected by immunotherapy dose variance issue

Cancer Care Ontario has issued a Safety Bulletin about the delivery of three immunotherapy drugs — Pembrolizumab, Nivolumab and Panitumumab. These drugs are used to treat locally advanced or metastatic cancers. At some hospitals in Ontario, more than the expected amounts of drug remained in the IV tubing, resulting in a variation in intended dose being given to patients.

Sunnybrook’s Odette Cancer Centre is not affected by this issue.

Since the issue was brought to light by Cancer Care Ontario, our team has been reviewing our practices for administering these drugs. Staff who administer these and other medications continually review best practices to ensure safe and quality care for our patients. It is normal to have a small volume of drug left behind in IV tubing.

We recognize this can be concerning for patients and their families.

Please note this issue is affecting some Ontario hospitals. If you’ve received any of these therapies at another hospital, please speak to your physician at your next appointment. For more information please visit cancercareontario.ca

How do you know current patients aren’t affected at Odette?
When leadership at Odette was notified of the issue affecting three high-dose monotherapy drugs at some hospitals, they met with nursing leaders to review our standard flushing practices, and also observed the drugs being administered. This review provided assurance that Odette’s standard practice involves flushing the IV line to ensure minimal drug is left behind in the IV tubing. This standard practice and tubing has been in place at Odette since 2015. Between 2009 and 2015, we used different IV tubing; there was a practice of flushing the line during that time period.

What are you doing to ensure this type of dose discrepancy never happens?
Our staff review best practices and undergo continuing education to make sure we are always providing the best possible care for our patients. Knowing that there has been a variance in how these drugs are delivered in Ontario, we have been meeting with our staff to review practice and ensure a standardized approach.

I noticed some fluid in the IV tube at my appointment. Does that mean I’m affected by dose variance? 
We know news like this can cause worry for patients and families. Please remember that there will always be a small amount of residual fluid left in the IV tubing, even when the line is flushed.

What about other cancer drugs?
The Safety Bulletin issued by Cancer Care Ontario is only with respect to three low volume, high concentration drugs used for targeted therapy: Pembrolizumab, Nivolumab and Panitumumab. Our standard practice is to flush these IV lines to ensure a minimal amount of residual fluid, for these and all drugs low-volume, high concentration drugs administered at the hospital.

Where can I find more information about this?
Please visit cancercareontario.ca for more information about this issue.