drugs associated with cancer therapies

8/2/2019 Drugs Associated With CANCER THERAPIES

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Drugs associated with CANCER THERAPIES

OVERVIEW of Antineoplastic Agents

Drugs used to control or kill cancer cells are known as antineoplastic agents.

Also referred to as chemotherapy agents or anticancer drugs.

Because single-agent therapy is unsuccessful in attaining long-term remissions, more than one

agent is used. Also, single-agent therapy produces cell lines resistant to further drug therapies.

Agents of different classes are combined to maximize eachs mode of action. This combining

categories leads to synergistic and additive qualities as well as varied toxicities.

Classes:

1. alkylating agents

2. antimetabolites

3. antitumor antibiotics

4. plant or Vinca alkaloids

5. Other antineoplastic agents

Other antineoplastic agents

Miscellaneous Agents have a mechanism of action that is different from other classifications or is

not fully understood. These agents are cell nonspecific. They also produce major toxicities to

hematopoeitic system and anaphylaxis. Include Aminoglutethimide (Elipten), L- asparaginase

(Elspar), Mitoxantrrone (Novantrone), and procarbazine hydrochloride(Matulane).

Investigational Agents are those currently undergoing clinical trials and are not yet approved by the

Food and Drug Administration. These agents include new drugs and previously approved drugs

whose original approval is now being administered in a different manner, combination or disease.

Some cancer clients choose treatment with an investigational agent or protocol.

Action:

Antineoplastic agents destroy cells in their growth phase. They may be Cell cycle specific or

nonspecific.

Cell cycle specific produce cytotoxic effects in a particular phase of the cells reproductive cycle

(G1-M) and are effective in tumors with rapidly dividing cells.

Cell cycle non specific agents are effective in any phase of the cell cycle (including Go-resting

phase and are most effective against slow growing tumors.

anticancer drugs:


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Cell cycle= growth and division

Cell cycle

18_01_cel l_cycle . jpg


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Effects of chemotherapeutic drugs on cell cycle

As applied:

Cell cycle specific drugs (CCS) or phase specific :

Antimetabolites: Methotrexate, 6-Mercaptopurine

Antibiotic: Bleomycin

Taxane: Paclitaxel

Epipodophyllotoxins: Etoposide, Teniposide

Vinca alkaloids: Vinblastine, Vincristine

Act mainly on dividing cells

Most effective in hematologic and solid tumors with high growth fraction


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Cell cycle non-specific (CCNS) or phase non specific drugs:

Alkylating agents: Cyclophosphamide, Busulfan, Mechlorethamine, Melphalan.

Anticancer antibiotics: Doxorubicin, Daunorubicin, Mitomycin, Actinomycin D.

Camptothecins: Topotecan, Irinotecan

Metal complexes: Cisplatin, Carboplatin

CCNS drugs act on dividing as well as resting cells

Effective in low growth fraction as well as high growth fraction solid tumors

Characteristics of Cancer Cells

The problem:

Cancer cells divide rapidly (cell cycle is accelerated)

They are immortal

Cell-cell communication is altered

uncontrolled proliferation

invasiveness

Ability to metastasize

The Goal of Cancer Treatments

Curative

Total irradication of cancer cells

Curable cancers include testicular tumors, Wills tumor

Palliative

Alleviation of symptoms

Avoidance of life-threatening toxicity

Increased survival and improved quality of life

Adjuvant therapy

Attempt to eradicate microscopic cancer after surgery

e.g. breast cancer & colorectal cancer

Six Established Rx Modalities


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1. Surgery

2. Radiotherapy

3. Chemotherapy

4. Endocrine therapy

5. Immunotherapy

6. Biological therapy

What is a neoplasm?

Cells with an abnormal growth pattern

Either benign or malignant

Any overgrowth of tissue can form a tumor

Benign neoplasm

Composed of cells that look like the tissue of origin

Usually encapsulated

Grow slowly and by expansion

Do not recur or metastasize

Do not destroy tissue generally

Do not cause systemic symptoms or death generally

Malignant neoplasm

Composed of undifferentiated (or immature) cells.

Little resembles the tissue of origin

Grows rapidly

Expands at periphery and invades and destroys surrounding tissue

Recurs and metastasizes to other parts of the body

Spreads by way of lymph and blood to distant parts of the body

Causes systemic signs and symptoms

Ultimately, it can cause death

What makes a cancer able to metastasize?


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Can be spread by blood/lymph system

This helps us predict what organs will be metastasized

Spread by direct contact organ to organ

Iatrogenic spread: surgical seeding or invasive procedure moving cells from one site to another

Oncogenes and Proto-oncogenes

Genes capable of triggering cancerous conditions

Normally suppressed

Can be triggered by invading viruses or other carcinogens

Proto-oncogenes: benign forms of oncogenes necessary of normal function

Fragile and easily damaged and mutated

Immune response

Immune response failure

When the immune system is compromised it fails to.

Suppress oncogenes

Kill off the cancerous cells that normally form within the body

Normal cell cycle becomes deranged

Damage occurs to the DNA and proteins inside the cell

Immunological defects

If the immunological system is not working:

The body is more susceptible to invasion by foreign agents, cancer included

People with immunological disorders are at higher risk for developing certain kinds of

malignant disorders

Persons with AIDS

Persons receiving immunosuppressive therapy for neoplastic or non-neoplastic

disorders

Biological Carcinogens

Viruses

HIV, HBV, papilloma viruses, HTLV


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Genetics

The etiology of cancer is unknown

It is generally assumed that genetic factors are involved

Chemical Carcinogens

Drugs and hormones

Chemotherapeutic drugs

Recreational drugs

DES, estrogen, cortisone, anabolic steroids

Diet

Alcohol

Carcinogens

Chemical agents:

Industrial wastes, pesticides, cigarette smoke, asbestos, phenol

Natural body substances in body: bile acids

Food additives: sodium saccharine, nitrites

Physical agents

Radiation (both solar and ionizing), and radon, nuclear radiation

Risk factors for cancer

Non-controllable

Heredity, age, gender, and poverty

Controllable

Stress, diet, occupation, infection, tobacco use, alcohol use, use of recreational drugs,

obesity, and sun exposure

Types of malignant neoplasms

Solid cancers (Tumors)

Carcinoma: arises in epithelial cells

Sarcoma: arises in connective tissue, muscle, or bone


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Hematological cancers

Leukemia: arises in blood

Myeloma: arises in bone marrow

Lymphoma: arises in lymph tissue

Clinical staging for surgery

Reveals the extent of cancer spread

By sampling regional and distant lymph nodes

By sampling and viewing other organs for tumors

(an example: is the removal of axillary lymph nodes during surgery for breast cancer)

Grading and staging

Once cancer diagnosis is made, the tumor is graded and staged

Grading: evaluates the amount of differentiation of the cancer cells

Grade 1 (the least malignant) to grade 4 (the most malignant)

Grade 1 is the most differentiated and Grade 4 is the least differentiated

Staging: refers to the relative tumor size and extent of the disease

A tumor in situ is stage 0, while a stage 4 indicates widespread metastasis

TNM Staging of Cancer

Based on the following:

(T) relative tumor size

(N) presence and extent of lymph node involvement

(M) distant metastases

Signs and Symptoms of Cancer

C(change in bowel or bladder habits)

A (a sore that doesnt heal)

U(Unusual bleeding or discharge)

T (thickening or lump in tissue)

I (indigestion or difficulty swallowing)


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O (obvious change in wart or mole)

N(nagging cough or hoarseness)

U Unexplained anemia

S sudden unexplained weight loss

Collaborative Management

Most treatments for cancer will require collaboration with multiple health care providers (HCPs)

Collaborative, outcome driven planning is essential to provide the best care with the least negative

impact upon the client and family

Diagnosis of Cancer

Can only be made with a biopsy

Types of biopsys:

Needle biopsy

Incisional biopsy

Excisional biopsy

Diagnostic studies

Radiological testing

X-rays

CTs

Ultrasounds

MRIs

Can only locate and visualize a mass or tumor, cannot make the determination of

malignancy

Diagnostic studies

Direct visualization

Sigmoidoscopy

Cystoscopy

Endoscopy

Bronchoscopy


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Exploratory surgery

Laboratory tests

Tumor markers

Oncofetal antigens

Hormones

Tissue specific proteins

Isoenzymes

Biopsy

The only way to be certain of malignancy

The visualization of changed cells microscopically

Other blood tests

Leukemias are generally suspected when there is a blood smear that contains immature forms of

leukocytes, which is often combined with low blood counts

Surgical Interventions

Was once the only treatment available

Still is used in diagnosis and staging of more than 90% of all tumors and as primary treatment in

more than 60% of tumors

May be:

Curative (complete removal)

Palliative (decreases symptoms)

Adjunctive (debulking tumor so that radiation and chemo can work)

reconstructive

Radiation Therapy

Treatment of choice for some tumors

Can be used to:

Kill tumor cells to cure cancer

Reduce the size of a tumor

Decrease pain


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Relieve an obstruction

Reduce chance of metastasis, if just beginning

How it works

Radiation provides lethal injury to the DNA of the cell

It affects rapidly growing cells, like tumor cells

It also affects normal cells that are growing rapidly

The goal is to achieve maximum tumor control with minimum damage to normal tissue

External Radiation

Source of radiation comes from a machine which emits a relatively uniform dosage of radiation to

all tissues selected for radiation.

Internal radiation

Brachytherapy

Implant (wires, tubes, capsules, rods, etc) placed by a surgeon or oncologist. Usually is

temporary

Can be ingested or injected into the clients blood stream or a body cavity

Is a risk to those who are in contact with the patient. The radiation is transmitted outside

the body

Brachytherapy safety considerations

Maintain the greatest possible distance from the patient

Spend the minimum amount of time with the patient

Use lead gloves and aprons as a shield when possible

Keep pregnant people away

Avoid direct contact with radioisotope containers

Brachytherapy safety considerations

People working with these people a lot must wear a radiation monitor badge to track exposure level

to radiation

Patients should be in a private room with a private bathroom

Dispose of bodily wastes according to facility policy

Handle linens according to facility policy


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Chemotherapy

The use of cytotoxic medications and chemicals to

Cure some cancers

Decrease tumor size (as an adjunct to surgery or radiation therapies)

Prevent or treat suspected metastases

How chemo works

It disrupts the cell cycle in various phases by interrupting cell metabolism and replication

It interferes with the ability of the cell to synthesize needed enzymes and chemicals

It is generally given in specific combinations of drugs to affect malignant cells at their most

vulnerable times

Types of Chemo drugs

Alkylating agents

Antimetabolics

Cytotoxic antibiotics

Plant alkaloids (two types)

Vinca alkaloids

Etopsodes

Hormone and hormone antagonists

Miscellaneous drugs

Preparation and administration

Some medications are oral or IM, but many are given IV. Very irritating, if infiltrated, stop infusion

immediately.

Most states require special certification and education to administer chemo drugs.

These drugs are potentially carcinogenic and corrosive. Follow policies regarding spills.

Safety for the nurse

Wear gloves, mask and gown for administration and work in a quiet area in a methodical manner

Spills can be very hazardous

Follow special spill policies and procedures


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Special equipment for spills available

Nurses should be aware of drugs being given and how to handle client body wastes.

Toxicity

Watch for bone marrow suppression

Watch for infection

Watch for organ toxicity(GI tract, liver, cardiac, pulmonary, urinary, neurological)

Watch for anaphylaxis

Nausea and vomiting

Give antiemetics 30-45 minutes prior to treatments

Give antiemetics on a round the clock schedule if N/V is severe

Use relaxation, therapeutic touch, diversion with music, etc..

Avoid foods, smells, etcthat induce nausea

General Nursing Diagnosis

Anxiety/powerlessness

Body image disturbance

Anticipatory grieving

Risk for infection/injury

Altered nutrition

Pain

fatigue

Impaired tissue integrity

Caregiver role strain

Ineffective individual/family coping

Altered role

Fluid volume disturbance

And many more

Immunotherapy


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Biologic response modifiers

Designed to enhance the clients own immune response

Can consist of the administration of interleukin or interferon

Other kinds of immunotherapy are monoclonal antibodies and hematopoietic growth factors

Bone marrow and stem cell transplantation

Most commonly used for leukemia's, now also for some solid mass tumors, such as breast cancers

Stem cell transplantation

Harvesting from pheresis

Cord blood stem cells

Unproven methods of cancer treatment

Chemicals and drugs

Nutrition

Occult techniques

Mechanical devices

Supportive care

Divine healing

Psychologic Stressors

Death sentence

Guilt

Anger

Fear

Powerlessness

Body image disturbance

Sexual dysfunction concerns

Infection

Tumor itself may cause fistula between two incompatible organs (e.g. bowel and bladder)

Tumor may erode through to the surface causing an open lesion


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Tumor may destroy the tissues that feed it and then become necrotic causing septicemia

Immune system impairment

Pain

One of the most serious concerns of clients and families because of the reputation of being difficultto control

Causes of cancer pain

Due to direct tumor involvement

Due to the treatments

Due to a cause not related to the cancer or the therapy

Nursing Care of the Client with Cancer

Effects of Cancer

1. Disturbed or loss of physiologic functioning, from pressure or obstruction

a. Anoxia and necrosis of organs

b. Loss of function: bowel or bladder obstruction

c. Increased intracranial pressure

d. Interrupted vascular/venous blockage

e. Ascites

f. Disturbed liver functioning

2. Hematologic Alterations: Impaired function of blood cells

a. Abnormal wbcs: impaired immunity

b. Diminished rbcs and platelets: anemia and clotting disorders

3. Infections: fistula development and tumors may become necrotic; erode skin surface

4. Hemorrhage: tumor erosion, bleeding, severe anemia

5. Anorexia-Cachexia Syndrome: wasting away of client

a. Unexplained rapid weight loss, anorexia with altered smell and taste

b. Catabolic state: use of bodys tissues and muscle proteins to support cancer cell growth

6. Paraneoplastic Syndromes: ectopic sites with excess hormone production


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a. Parathyroid hormone (hypercalcemia)

b. Ectopic secretion of insulin (hypoglycemia)

c. Antidiuretic hormone (ADH: fluid retention)

d. Adrenocorticotropic hormone (ACTH)

7. Pain: major concern of clients and families associated with cancer

a. Types of cancer pain

1. Acute: symptom that led to diagnosis

2. Chronic: may be related to treatment or to progression of disease

b. Causes of pain

1. Direct tumor involvement including metastatic pain

2. Nerve compression

3. Involvement of visceral organs

8. Physical Stress: body tries to respond and destroy neoplasm

a. Fatigue

b. Weight loss

c. Anemia

d. Dehydration

e. Electrolyte imbalances

9. Psychological Stress

a. Cancer equals death sentence

b. Guilt from poor health habits

c. Fear of pain, suffering, death

d. Stigmatized

Collaborative Care

A. Diagnostic Tests: used to diagnose cancer

1. Determine location of cancer


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a. Xrays

b. Computed tomography

c. Ultrasounds

d. Magnetic resonance imaging

e. Nuclear imaging

f. Angiography

2. Diagnosis of cellular type of can be done through tissue samples from biopsies, shedded cells (e.g.

Papanicolaou smear) washings

a. Cytologic Examination: tissue examined under microscope

b. Identification System of Tumors: Classification Grading -- Staging

1. Classification: according to the tissue or cell of origin, e.g. sarcoma, from supportive

2. Grading:

a. Evaluates degree of differentiation and rate of growth

b. Grade 1 (least aggressive) to Grade 4 (most aggressive)

3. Staging

a. Relative tumor size and extent of disease

b. TNM (Tumor size; Nodes: lymph node involvement; Metastases)

3. Tumor markers: specific proteins which indicate malignancy

a. PSA (Prostatic-specific antigen): prostate cancer

b. CEA (Carcinoembryonic antigen): colon cancer

c. Alkaline Phosphatase: bone metastasis

4 Direct Visualization

a. Sigmoidoscopy

b. Cystoscopy

c. Endoscopy

d. Bronchoscopy

e. Exploratory surgery; lymph node biopsies to determine metastases


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Other non-specific tests

a. CBC, Differential

b. Electrolytes

c. Blood Chemistries: (liver enzymes: alanine aminotransferase (ALT); aspartateaminotransferase (AST) lactic dehydrogenase (LDH)

Treatment Goals: depending on type and stage of cancer

A. Cure

1. Recover from specific cancer with treatment

2. Alert for reoccurrence

3. May involve rehabilitation with physical and occupational therapy

4. Three Seasons of survival

a. Diagnosis/treatment

b. Extended survival: treatment completed and watchful waiting

c. Permanent survival: risk of recurrence is small

B. Control: of symptoms and progression of cancer

1. Continued surveillance

2. Treatment when indicated (e.g. some bladder cancer, prostate cancer)

C. Palliation of symptoms: may involve terminal care if clients cancer is not responding to treatment

Treatment Options (depend on type of cancer) alone or with combination

A. Chemotherapy

1. Chemotherapy

a. Includes phase-specific and non-phase specific drugs for specific cancer types

b. Often combinations of drugs in specific protocols over varying time periods

c. Cell-kill hypothesis: with each cell cycle a percentage of cancerous cells are killed but

some remain; repeating chemo kills more cells until those left can be handled by bodys immune

system

2. Classes of Chemotherapy Drugs

a. Alkylating agents


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1. Action: create defects in tumor DNA

2. Examples: Nitrogen Mustard, Cisplatin

b. Antimetabolites

1. Action: specific for S phase

2. Examples: Methotrexate; 5 fluorouracil

3. Toxic Effects: nausea, vomiting, stomatitis, diarrhea, alopecia, leukopenia

c. Antitumor Antibiotics

1. Action: non-phase specific; interfere with DNA

2. Examples: Actinomycin D, Bleomycin

3. Toxic Effect: damage to cardiac muscle

d. Miotic inhibitors

1. Action: Prevent cell division during M phase

2. Examples: Vincristine, Vinblastine

3. Toxic Effects: affects neurotransmission, alopecia, bone marrow depression

e. Hormones

1. Action: stage specific G1

2. Example: Corticosteroids

f. Hormone Antagonist

1. Action: block hormones on hormone-binding tumors (breast, prostate, endometrium; cause

tumor regression

2. Examples: Tamoxifen (breast); Flutamide (prostate)

3. Toxic Effects: altered secondary sex characteristics

Effects of Chemotherapy

a. Tissues (fast growing) frequently affected

b. Examples: mucous membranes, hair cells, bone marrow, specific organs with specific

agents, reproductive organs (all fetal toxic, impair ability to reproduce)

4. Administration of chemotherapeutic agents

a. Trained and certified personnel, according to established guidelines


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b. Preparation

1. Protect personnel from toxic effects

2. Extreme care for correct dosage; double check with physician orders, pharmacists

preparation

c. Proper management clients excretement

d. Routes

1. Oral

2. Body cavity (intraperitoneal or intrapleural)

3. Intravenous

a. Use of vascular access devices because of threat of extravasation (leakage into tissues) and long-

term therapy

b. Types of vascular access devices

1. PICC lines (peripherally inserted central catheters)

2. Tunnelled catheters (Hickman, Groshong)

3. Surgically implanted ports (accessed with 90o angle needle)

Nursing care of clients receiving chemotherapy

1. Assess and manage

a. Toxic effects of drugs (report to physician)

b. Side effects of drugs: manage nausea and vomiting, inflammation and ulceration of

mucous membranes, hair loss, anorexia, nausea and vomiting with specific nursing and medical

interventions

2. Monitor lab results (drugs withheld if blood counts seriously low); blood and blood product

administration

3. Assess for dehydration, oncologic emergencies

4. Teach regarding fatigue, immunosuppression precautions

5. Provide emotional and spiritual support to clients and families

B. Surgery

1. Diagnosis, staging, and sometimes treatment of cancer

2. Involves removal of body part, organ, sometimes with altered functioning (e.g. colostomy)

3. Debulking (decrease size of) tumors in advanced cases


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4. Reconstruction and rehabilitation (e.g. breast implant post mastectomy)

5. Psychological support to deal with surgery as well as cancer diagnosis

C. Radiation Therapy

1. Treatment of choice for some tumors to kill or reduce tumor, relieve pain or obstruction

2. Delivery

a. Teletherapy (external): radiation delivered in uniform dose to tumor

b. Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is

placed in tumor or next to it

c. Combination

3. Goals

a. Maximum tumor control with minimal damage to normal tissues

b. Caregivers must protect selves by using shields, distancing and limiting time with client,

following safety protocols

4. Treatment Schedules

a. Planned according to radiosensitivity of tumor, tolerance of client

b. Monitor blood cell counts

5. Side Effects

a. Skin (external radiation): blanching, erythema, sloughing

b. Ulcerated mucous membranes: pain, lack of saliva

c. Gastrointestinal: nausea and vomiting, diarrhea, bleeding, sometimes fistula formation

d. Radiation pneumonia

D. Biotherapy

1. Modification of biologic processes that result in malignancies; based on immune

surveillance hypothesis

2. Used for hematological malignancies, renal and melanoma

3. Monoclonal antibodies (inoculate animal with tumor antigen and retrieve antibodies against

tumor for human)

E. Photodynamic Therapy

1. Client giving photosensitizing compound which concentrates in malignant tissue


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2. Later given laser treatment to destroy tumor

F. Bone Marrow Transplantation and Peripheral Blood Stem Cell Transplantation

1. Stimulation of nonfunctioning marrow or replace bone marrow

2. Common treatment for leukemias

G. Pain Control

1. Includes pain directly from cancer, treatment, or unrelated

2. Necessary for continuing function or comfort in terminally ill clients

3. Goal is maximum relief with minimal side effects

4. Multiple combinations of analgesics (narcotic and non-narcotic) and adjuvants such as

steroids or antidepressants; includes around the clock (ATC) schedule with additional medications

for break-through pain

5. Multiple routes of medications

6. May involve injections of anesthetics into nerve, surgical severing of nerves radiation

7. May need to progress to stronger pain medications as pain increases and client develops

tolerance to pain medication

Nursing Diagnoses for Clients with Cancer

A. Anxiety

1. Therapeutic interactions with client and family; community resources such as AmericanCancer Society, I Can Cope

2. Availability of community resources for terminally ill (Hospice care in-patient, home care)

B. Disturbed Body Image

1. Includes loss of body parts (e.g. amputations); appearance changes (skin, hair); altered

functions (e.g. colostomy); cachexic appearance, loss of energy, ability to be productive

2. Fear of rejection, stigma

C. Anticipatory Grieving

1. Facing death and making preparations for death: will be consideration

2. Offer realistic hope that cancer treatment may be successful

D. Risk for Infection

E. Risk for Injury


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1. Organ obstruction

2. Pathological fractures

F. Altered Nutrition: less than body requirements

1. Consultation with dietician, lab evaluation of nutritional status

2. Managing problems with eating: anorexia, nausea and vomiting

3. May involve use of parenteral nutrition

G. Impaired Tissue Integrity

1. Oral, pharyngeal, esophageal tissues (due to chemotherapy, bleeding due to low platelet counts,

fungal infections such as thrush)

2. Teach inspection, frequent oral hygiene, specific non-irritating products, thrush control

Oncologic Emergencies

A. Pericaridal Effusion and Neoplastic Cardiac Tamponade

1. Concern: compression of heart by fluid in pericardial sac, compromised cardiac output

2. Treatment: pericardiocentesis

B. Superior Vena Cava Syndrome

1. Concern: obstruction of venous system with increased venous pressure and stasis; facial

and neck edema with slow progression to respiration distress

2. Treatment: respiratory support; decrease tumor size with radiation or chemotherapy

C. Sepsis and Septic Shock

1. Concern: Early recognition of infection

2. Treatment: prompt

D.Spinal Cord Compression

1. Concern: pressure from expanding tumor can cause irreversible paraplegia; back pain

initial symptom with progressive paresthesia and leg pain and weakness

2. Treatment: early detection and radiation or surgical decompression

E. Obstructive Uropathy

1. Concern: blockage of urine flow; undiagnosed can result in renal failure

2. Treatment: restore urine flow


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F. Hypercalcemia

1. Concern: high calcium from ectopic parathyroid hormone or metastases

2. Behaviors: fatigue, muscle weakness, polyuria, constipation progressing to coma, seizures

3. Treatment: restore fluids with intravenous saline; loop diuretics; more definitive treatments

G. Hyperuricemia

1. Concern: occurs with rapid necrosis of tumor cells as with chemotherapy; can result in

renal damage and failure

2. Prevention and treatment with fluids and Alopurinol (Zyloprim)

H. SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion)

1. Concern: ectopic ADH production from tumor leads to excessive hyponatremia

2. Treatment: restore sodium level

Chemotherapy is the use of chemicals to treat disease. Paul Erlich, considered to be the father of

chemotherapy, coined this word to describe a specific chemical utilized in the treatment of parasites. Today

the term chemotherapywhile technically describing drug therapy for any disease , is most frequently used

in reference to the treatment of cancer. The simple definition of chemotherapy, although accurate , fails to

encompass its multifaceted nature which is as complex as the disease it attempts to treat.

Just as the word cancer represents many different types of malignant disease, the word chemotherapy

represents many different types of chemotherapeutic agents. The drugs used in cancer treatment vary in

their chemical structure , biological side effects and toxicities. Some are effective in treating one specific

types of cancer while others are utilized in the treatment of wide variety of malignancies. The methods of

administration also vary according to the chemotherapeutic and new techniques for safer and moreeffective administration.

The process of learning about chemotherapy is indeed a challenge. Nursing management of the patient

receiving chemotherapy requires knowledge about the treatment , skill in assessment, technical expertise,

ability and desire to support the client physically and emotionally. The reward in meeting this is to be able to

provide the care this clients need in order to survive their disease and its treatment and hopefully to go on

with their lives with as few physical and emotional scars as possible.

Nursing care begins with a thorough understanding of the patients condition; goal of therapy , drug dose,

route, schedule, administration principles; and potential side effects. Additional nursing management

includes monitoring responses to the therapy, reassessing and documenting signs and symptoms, and

communicating pertinent information to other members of the health care team.

Chemotherapy is the use of cytotoxic drugs in the treatment of cancer. It is one of the four modalities-

surgery, radiation therapy, chemotherapy and biotherapy- that provide cure, control, or palliation.

Chemotherapy is systemic as opposed to localized therapy such as surgery & radiation therapy.

There are four ways chemotherapy may be used:

1. Adjuvant therapy- A course of chemotherapy used in conjunction with another treatment modality.

2. Neoadjuvant chemotherapy- Administration of chemotherapy to shrink the tumor prior to surgical


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removal of the tumor.

3. Primary therapy- The treatment of patients with localized cancer for which there is an alternative

but less than completely effective treatment.

4. Induction chemotherapy- The drug therapy is given as the primary treatment for patients with

cancer for which no alternative treatment exists.

5. Combination chemotherapy- Administration of two or more chemotherapeutic agents in the

treatment of cancer, allowing each medication to enhance the action of the other or act synergistically with

it. e.g. MOPP regimen for Hodgkins disease.

ROLE OF A NURSE

Prior to chemotherapy administration

1 Review- The chemotherapy drugs prescription which should have

-Name of anti-neoplastic agent.

-Dosage

-Route of administration

-Date and time that each agent to be administered.

2. Accurately identify the client

3.Medications to be administered in conjunction with the chemotherapy e.g antiemetics, sedatives etc.

4.. Assess the clients condition including

- Most recent report of blood counts including hemoglobin ,hematocrit, white blood cells and platelets.

-Presence of any complicating condition which could contraindicate chemotherapeutic agent

administration i.e. infection, severe stomatitis , decreased deep tendon reflexes, or bleeding .

-Physical status

-Level of anxiety

-Psychological status.

5. Prepare for potential complications

Review the policy and have medication and supplies available for immediate intervention the event of

extravasation.

Review the procedure and have medication available for possible anaphylaxis

6.Assure accurate preparation of the agent

-Accuracy of dosage calculation

-Expiry date of the drug to be checked

-Procedure for correct reconstitution and

-Recommended procedures for administration

7.Assess patients understanding of the chemotherapeutic agents and administration procedures.

II. Calculation of drug dosage

It is calculated based on body surface area.

III. Drug reconstitution/Preparation- Pharmacy staff should reconstitute all drugs pre-prime the

intravenous tubing under a class II biologic safety cabinet(BSC). In certain conditions nurses may be

required to reconstitute medications. When preparing and reconstituting safe handling guidelines to be

followed.

-All chemotherapeutic drug should be prepared according to package insert in class II BSC.

-Aseptic technique should be followed.

-Personal protective equipment includes disposable surgical gloves, long sleeves gown and elastic or knit


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cuffs.

-Protective eye goggles if no BSC

-To minimize exposure

-Wash hands before and after drug handling.

-Limit access to drug preparation area

-Keep labeled drug spill kit near preparation area.

-Apply gloves before drug handling.

-Open drug vials/ ampoules away from body.

-Place absorbent pad on work surface.

-Wrap alcohol wipe around neck of ampoule before opening.

-Cover tip of needle with sterilize gauge when expelling air from syringe.

-Label all chemotherapeutic drugs.

Clean up any spill immediately

IV. Drug administration

1. Route-

i)Oral - Emphasize the importance of compliance by the patient with prescribed schedule.Drugs with

emetic potential should be taken with meals.

Assure that chemotherapeutic agents are stored as directed by the manufacturer(refrigerate, avoid

exposure to direct light,etc).

ii) Intramuscular and subcutaenous Chemotherapeutic agents that can be administered I/M or

subcutaneously are few in number. Non-vesicants like L-asperaginase, bleomycin, cyclophosphamide,

methotraxate. Cyta arabine,and some hormonal agents are given I/M & /Or subcutaneously.

Use the smallest gauge needle possible for the viscosity of the medication.

-Change the needle after withdrawing the agent from a vial or ampoule.

-Select a site with adequate muscle and/or SC tissue.

iii) Intravenous It is the most common method of administration of cancer chemotherapy. May be given

through central venous catheters or peripheral access. Absorption is more reliable. This route is required

for administration of vesicants and it also reduces the need of repeated injection. Because the I/V provides

direct access to the circulatory system, the potential for infection and life threatening sepsis is a serious

complication of I/V chemotherapy.

The following guidelines to be kept in mind:

-Inspect the solution, container and tubing for signs of contamination including particles, discoloration,

cloudiness, and cracks or tears in bottle or bag

-Aseptic technique to be followed

-Prepare medicines according to manufacturers directions

-Select a suitable vein

-Large veins on the forearm are the preferred site.

-Use distal veins first, and choose a vein above areas of flexion.

-For non-vesicant drugs, use the distal veins of the hands (metacarpal veins): then the veins of the

forearms(basilic and cephalic veins)For vesicants, use only the veins of the forearms. Avoid using the

metacarpal and radial areas.

-Avoid the antecubital fossa and the wrist because an extravasation in these areas can destroy

nerves and tendons, resulting in loss of function.

-Peripheral sites should be changed daily before administration of vesicants


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-Avoid the use of small lumen veins to prevent damage due to friction and the decreased ability to dilute

acidic drugs and solutions. Select the shortest catheter with the smallest gauge appropriate for the type and

duration of the infusion (21g to 25g for I/V medications and 19 g for blood products).

Avoid a vein which has been used for venous access within the past 24 hrs to prevent leakage from a prior

puncture site.

Prevent trauma and infection at the insertion site.-Apply a small amount of iodine based antiseptic ointment over the insertion site & cover the area

with sterile gauze.

Intravenous Chemotherapy Via Central Vein Infusion (Hickman Catheter)

A Hickman catheter is a flexible polymeric silicon rubber catheter which is threaded through the cephalic

vein and into the superior vena cava or through the venacava and into the right atrium of the heart.

Placement in a large vein permits the use of a catheter large enough for infusion of chemotherapy, hyper

osmolar fluids for nutrition purposes, blood products and other needed intravenous fluids.

The silicon rubber material of catheter is chemically inert to prevent decomposition and it is anti-

thrombogenic

A felt cuff near the exit site anchors the catheter on the patients chest and acts as an anatomic barrier toprevent entry of infection causing agents.

It is either single lumen or double-lumen.

IV) Intra-arterial

V)Intra-peritoneal

VI)Intrathecal- Infusion of medication can be given through an Ommaya reservoir, implantable pump

and /or usually through lumbar puncture.

a)Wear protective equipment (gloves, gown and eyewear).

b)Inform the patient that chemotherapeutic drugs are harmful to normal cells and that protective

measures used by personnel minimize their exposure to these drugs.

c)Administer drugs in a safe and unhurried environment.

d)Place a plastic backed absorbent pad under the tubing during administration to catch any leakage.

Do not dispose of any supplies or unused drugs in patient care areas.

V. Documentation

Record

-chemotherapeutic drugs, dose, route ,and time

-Premedications, postmedications, prehydration and other infusions and supplies used for chemotherapy

regimen.

-Any complaints by the patient of discomfort and symptoms experienced before, during, and after

chemotherapeutic infusion.

VI. Disposal of supplies and unused drugs

a)Do not clip or recap needles or break syringes.

b)Place all supplies used intact in a leak proof ,puncture proof, appropriate labeled

container.

c)Place all unused drugs in containers in a leak proof, puncture proof, appropriately labeled

container.

d)Dispose of containers filled with chemotherapeutic supplies and unused

drugs in accordance with regulations of hazardous wastes.


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VII. Management of chemotherapeutic spills

Chemotherapy spills should be cleaned up immediately by properly protected personnel trained in the

appropriate procedure. A spill should be identified with a warning sign so that other person will not be

contaminated.

Supplies RequiredChemotherapy spill kit contains

Respirator mask for air borne powder spills

Plastic safety glasses or goggles

Heavy duty rubber gloves

Absorbent pads to contain liquid spills

Absorbent towels for clean up after spills

Small scoop to collect glass fragments

Two large waste disposal bags

Protective disposable gown

Containers of detergent solution and clear tap water for post spill clean up.

Puncture proof and leak proof container approved for chemotherapy waste disposal

Approved, specially labeled, impervious laundry bag.

Spill on hard surface

Restrict area of spill

Obtain drug spill kit

Put on protective gown, gloves, goggles

Open waste disposal bags

Place absorbent pads gently on the spill; be careful not to touch spill.

Spill on hard surface



Put on protective gown, gloves, goggles

Open waste disposal bags

Place absorbent pads gently on the spill; be careful not to touch spill.

Place absorbent pad in waste bag

Cleanse surface with absorbent towels using detergent solution and wipe clean with clean tap water.

Place all contaminated materials in the bag.

Wash hands thoroughly with soap and water.

Spill on personnel or patient



Immediately remove contaminated protective garments or linen

Wash affected skin area with soap and water

If eye exposure-immediately flood the affected eye with water for at least 5 mts; obtain medical attention

promptly

Notify the physician if drug spills on patient.

Documentation- Document the spill.


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VIII. Staff Education

All personnel involved in the care should receive an orientation to chemo. Drugs including their known risk ,

relevant techniques and procedures for handling, the proper use of protective equipment and materials, spill

procedures, and medical policies covering personnel handling chemo. agents.

Personnel handling blood, vomitus, or excreta from patients who have received chemotherapy should wear

disposable gloves and gowns to be appropriately discarded after use.

IX. Extravasation management

Extravasation is the accidental infiltration of vesicant or irritant chemotherapeutic drugs from the vein into

the surrounding tissues at the I/V site. A vesicant is an agent that can produce a blister and /or tissue

destruction. An irritant is an agent that is capable of producing venous pain at the site of and along the vein

with or without an inflammatory reaction. Injuries that may occur as a result of extravasation include

sloughing of tissue , infection, pain ,and loss of mobility of an extremity.

1.Prevention of extravasation

Nursing responsibilities for the prevention of extravasation include the following

Knowledge of drug s with vesicant potential

Skill in drug administration

Identification of risk factors e.g. multiple vene punctures

Anticipation of extravasation and knowledge of management protocol

New venepuncture site daily if peripheral access is used

Central venous access for 24 hrs vesicants infusion

Administration of drug in a quiet, unhurried environment

Testing vein patency without using chemotherapeutic agents

Providing adequate drug dilution

Careful observation of access site and extremity throughout the procedure

Ensuring blood return from I/V site before, during, and after vesicant drug infusion.

Educating patients regarding symptoms of drug infiltration , e.g. pain, burning, stinging sensation at I/V site.

2.Extravasation management at peripheral site-According to agency policy and approved antidote should

be readily available.

The following procedure should be initiated-

Stop the drug

Leave the needle or catheter in place

Aspirate any residual drug and blood in the I/V tubing, needle or catheter, and suspected infiltration site

Instill the I/V antidote

Remove the needle

If unable to aspirate the residual drug from the IV tubing , remove needle or catheter

Inject the antidote sub-cutaneously clockwise into the infiltrated site using 25 gauge needle; change the

needle with each new injection

Avoid applying pressure to the suspected infiltration site

Apply topical ointment if ordered

Cover lightly with an occlusive sterile dressing

Apply cold or warm compresses as indicated

Elevate the extremity

Observe regularly for pain, erythema, induration, and necrosis


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Documentation of extravasation management.

All nursing personnel should be alert and prepared for the possible complication of anaphylaxis.

X. Nursing Management of common side effects of Chemotherapeutic drugs.

.Nausea & Vomiting

Nausea is the conscious recognition of the subconscious excitation of an area of the medulla closelyassociated with or part of the vomiting center. Nausea may cause the desire to vomit & it often precedes or

accompanies vomiting.

Avoid eating/drinking for 1-2 hrs prior to and after chemotherapy administration

Eat frequent, small meals. Avoid greasy & fatty foods and very sweet foods & candies.

Avoid unpleasant sights, odors & testes

Follow a clear liquid diet

If vomiting is severe inform the physician.

Consider diversionary activities

Sip liquids slowly or suck ice cubes and avoid drinking a large volume of water if vomiting is present

Administer antiemetics to prevent or minimize nausea. Patient may require routine antiemetics for 3-5 daysfollowing some protocols.

Monitor fluid and electrolyte status.

Provide frequent, systemic mouth care.

Bone marrow Depression This can lead to

-Anaemia

-Bleeding due to thrombocytopenia

-Infection due to leukopenia

Nursing Actions

Administer packed RBC according to the physician orders.

Monitor hematocrit and haemoglobin especially during drug nadir

Maintain the integrity of the skin

Avoid activities with the greatest potential for physical injury

Use an electric razor when shaving

Avoid the use of tourniquets

Eat a soft, bland diet, avoid foods that are thermally, mechanically and chemically irritating.

Maintain the integrity of the mucous membranes of G I tract

Promote hydrate to avoid constipation

Avoid enemas, harsh laxatives & the use of rectal thermometers.

Take steroids with an antacid or milk.

Avoid sources of infection

Maintain good personal hygiene.Prevent trauma to skin & mucous membranes

Report s/s of infection to physician

Monitor counts

Avoid invasive procedures, no

Raise the arm while pressure is applied after removal of a needle or catheter


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Alopecia

Explain hair loss is temporary, and hair will grow when drug is stopped.

Use a mild, protein based shampoo, hair conditioner every 4-7 days

Minimize the use of an electric dyer.

Avoid excessive brushing and combing of the air. Combing with a wide tooth comb is preferred.

Select wig, cap, scarf or turban before hair loss occurs.

Keep head covered in summer to prevent sunburn and in winter to prevent heat loss.

Fatigue - Assess for possible causes chronic pain, stress, depression and in-sufficient rest or

nutritional intake.

-Conserve energy & rest when tired

-Plan for gradual accommodation of activities.

-Monitor dietary & fluid intake daily. Drink 3000 ml of fluid daily, unless contra-indicated, in order to avoid

the accumulation of cellular waste products.

Anorexia

Freshen up before meals

Avoid drinking fluids with meals to prevent feeling of fullness

High protein diet

Monitor and record weight weekly. Report weight loss

Stomatitis (Oral)

-Symptoms occur 5-7 days after chemotherapy & persist upto 10 days

-Continue brushing regularly with soft tooth brush

-Use non irritant mouthwash

-Avoid irritants to the mouth

-Maintain good nutritional intake, eat soft or liquid foods high in protein

Follow prescribed medication schedule e.g. drug for oral candidiasis.

-Report physician if symptom persists

-Increase the frequency of oral hygiene every 2 hrs

-Glycerin & lemon juice should never be used to clear mouth or teeth as it cause the tissues to become

dry& irritated.

Diarrhoea - Some clients experience diarrhoea during and after treatment with chemotherapy.

Nursing Action

Monitor number, frequency and consistency of diarrhoea stools.

Avoid eating high roughage, greasy and spicy food alcoholic beverages, tobacco and caffeine products

Avoid using milk products

Eat low residue diet high in protein and calories

Include food high in potassium if fatigue is present like bananas, baked potatoes.

Drink 3000 ml of fluid each day.Eat small frequent meals ; eat slowly and chew all food thoroughly

Clean metal area after each bowel movement.

Administer anti-diarrhoeal agents as prescribed.

Depression

Assess for changes in mood and affect.

Set small goals that are achievable daily


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Participate e.g. music, reading, outings

Share feelings

Reassurance

Cystitis-

Is an inflammation of the bladder, which is usually caused by an infection. Sterile cystitis not induced by

infection. Sterile cystitis not induced by infection, can be a side effect of radiation therapy or due tocyclophosphamide (endoxan) administration. The metabolites of cyclophosphamide are excreted by the

kidneys in the urine

Nursing Actions

Fluid intake at least 3000 ml daily

Empty Bladder as soon as the urge to void is experienced.

Empty bladder at least every 2-4 hrs.

Urinate at bed time to avoid prolonged exposure of the bladder wall to the effects of cytoxan while sleeping.

Take oral cytoxan early in the morning to decrease the drug concentration in the bladder during the night

Report increasing symptoms of frequency bleeding burning on urination, pain fever and chills promptly to

physicianFollowing comfort measures can be adopted if cystitis is present

-Ensure dilute urine by increasing the fluid intake

Avoid foods & beverages that may cause irritation to the bladder alcohol, coffee, strong tea, Carbonated

beverages etc.

Outpatient Chemotherapy Delivery

Aggressive, complex and sophisticated cancer therapies are currently being in ambulatory & home care

settings. This shift is provision of services from the Hospital setting is a result o cost-containment efforts,

advanced technology, competition & increased competence of nurses.

Conclusion Chemotherapy offers patients with cancer a great deal of hope for a cure or a means of

control cancer for a long period of time. Hope and optimism are vital ingredients in care plan.

-Virgie-

drugs associated with cancer therapies

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