Cancer Treatment Modalities

Chapter 22

factors that determine what therapy is used

• tumor histology

• staging outcomes

• physiologic status (co-morbid illness) 

• psychologic status 

• personal desires 

multimodality therapy

• many pts. receive 2 or more treatment modalities to achieve cure or long term control

• take advantages of more than one mechanism of action

goals of treatment

• cure

• control

• palliation

cure 

• treatment offered that is expected to have greatest chance of disease eradication 

• ex - surgical excision usually cures basal cell skin cancer 

control

• still find cancer cells

• goal of treatment plan for many cancers that cannot be completely eradicated but are responsive to anticancer therapy 

• followed closely for early signs and symptoms 

palliation

• relief or control of symptoms are the maintenance of a satisfactory quality of life 

• ex - using radiation therapy to reduce the tumor size and relieve subsequent symptoms 

personalized cancer medicine

best thing but only rich can afford it - based on genetics

surgical therapy

treatment of choice for many years was to remove the cancer and as much of the surrounding normal tissue as possible 

prevention

• used to reduce the risk of cancer development 

• ex - genetic mutation of BRCA-1 or BRCA-2 and a strong family history of early onset breast cancer - prophylactic mastectomy 

cure and control principles

• only as much tissue as necessary is removed 

• usual sites of regional spread may be surgical removed 

• ex - radical neck dissection, lumpectomy, mastectomy, pneumonectomy, orchiectomy, thyroidectomy, and bowel resection 

debulking or cytoreductive procedure

only part of it is removed. used if the tumor can not be completely removed

supportive and palliative care

• uses when cure or control is not possible

• ex - placement of central venous access device 

a patient is scheduled for a colon resection for cancer of the colon in the morning. the patient says to you “i don’t think i can handle all of this.” how should you respond? 

“tell me more” 

radiation therapy

• local treatment modality for cancer

• 50% of all pts. with cancer receive radiation 

• causes tissue damage 

effects of radiation

• side effects will all be in that location 

• breaks chemical bonds in DNA 

low energy beam (electrons)

• penetrates short distance

• used to treat superficial skin lesions 

high energy beams (photons)

• penetrates at a greater depth, not reaching full intensity until they reach a certain depth

• optimal for internal target while sparing the skin 

principles of radiation

• typically delivered once a day Monday through Friday or 2 to 8 weeks depending on the desired dose 

• radiation affects only tissue within the treatment field

tumors with high radiosensitivity

• radiation works well

• ovarian dysgerminoma

• testicular seminoma

• hodgkins disease

• non-hodgkins disease

• wilms tumor

• neuroblastoma 

radiation therapy - simulation

• radiation just on the tiny part

• marking stays on 

• the oncologist specifies the dose and volume of area to be treated

• pt put in devices to keep them still

external radiation

• external beam therapy

• most common form of treatment 

• pt is never radioactive 

• pt. is exposed to radiation from a megavoltage treatment machine 

internal radiation

• consists of implantation of radioactive materials directly into the tumor (seed or rod) 

• common for neck, head, gynecologic or prostate

• dose may be high or low

• often used with external radiation

radiopharmaceutical

• unsealed liquid (ex. iodine 131)

• can be used with monoclonal antibodies to directly deliver radiation

nurse must wear what

• a film badge

• measures the amount of radiation exposure

• wear only at work

chemotherapy 

• use of chemicals as a systemic therapy for cancer

• used in the treatment of most solid tumors and hematologic malignancies

• treatment for cure, control, and palliation 

• attacks not only cancer cells but also normal ones

determine response of chemotherapy

• mitotic rate of tumor

• size of tumor

• age of the tumor

• location of tumor

• presence of resistant tumor cells = chemo doesnt work as well

chemotherapy effect on cells

• effective against dividing cells, so cancer escape death by staying in G0 phase (resting phase)

• as tumors get bigger, more cells become inactive and convert to G0 = more cancerous cells in resting phase

cell cycle phase nonspecific 

• alkylating agents

• nitrosoureas

• platinum drugs

cell cycle phase specific

• antimetabolites

• mitotic inhibitors

• topoisomerase inhibitors 

administrating chemotherapy

• only person involved should be trained in handling chemo

• LPN’s cant give chemo 

• prepared under a hood to decrease risk of inhaling particles 

• use gloves, flush twice, don’t prepare food w/ bare hands 

methods of admin for chemo

• iv (most common)

• im

• oral

• subq

• intracavitary

• intrathecal

• intraarterial

• topical 

Iv chemo therapy

• figure out height and weight 

• can cause extravasation 

• CVAD 

• can use peripherally but has to be put directly into the vein - check blood return 

extravasation

• vesicants

• pain is the main symptom

• swelling, redness, and vesicles

• stop the IV and leave it in place

• give antidote 

• after a few days, tissue may ulcerate or become necrotic 

• use cold compress not warm

tunneled catheter

• inserted through the central vein and is tunneled through SQ tissue

• complications include occlusion, sepsis, bleeding, venous thrombosis, infection

• groshong 

peripherally inserted central venous catheters

• short term use

• inserted in the antecubital fossa and advanced to a position with the tip ending in the distal one third of the superior vena cava

• complications include occlusion, phlebitis, infection 

implanted infusion ports

• single or double port

• surgically placed in the desired vein and the other end is connected to the port

• must use a HUBER needle 

• complications include clotting, catheter migration, infection, bleeding, thrombosis, air embolism 

regional chemotherapy administration

given directly onto the tumor

intra-arterial chemotherapy

• delivers the drug via the arterial vessel supplying the tumor

• treatment - osteogenic sarcoma, cancers of the head and neck, bladder, brain, and cervix, melanoma, primary liver cancer, metastatic liver disease

• reduce systemic toxicity 

intraperitoneal chemotherapy

• delivers chemo to the peritoneal cavity for peritoneal metastasis like colorectal and ovarian cancer

• 1-2 liters of fluid in peritoneum

• complications include abd. pain, catheter occlusion, dislodgement, migration, and infection

intrathecal or intraventricular chemotherapy

• cancers that metastasize to the CNS, such as breast, lung, GI, leukemia, and lymphoma

• Ommaya reservoir is used - soft plastic, dome shaped disk with an extension catheter that is surgically implanted

• complications include headache, nausea, vomiting, fever, and nuchal rigidity

intravesical bladder chemotherapy

• chemo into the bladder 

• retained for 1-3 hours

• reduces urinary and sexual dysfunction

• complications include dysuria, urinary frequency, hematuria, bladder spasms

chemo on normal tissue 

• cant distinguish between normal and cancer cells

• may cause fatigue, anorexia, and taste alterations

• acute toxicity - during or right after drug admin.

• delayed effects - N & V, bone marrow suppression

Dosing for chemo

based on height & weight - body surface area

immunotherapy

boosts immunity

monoclonal antibodies

• end in mab 

• binds to specific target cells to destroy them

• SE - fever, chills, n&v, bone marrow suppression, cardiotoxicity, hepatotoxicity, capillary leak syndrome, anaphylaxis 

angiogenesis inhibitor

• bevacizumab (Avastin), pazopanib (voltrient), ramucirumab (cyramza) 

• binds to growth factor and inhibits angiogenesis

• SE - hypertension, colon bleeding, perforation, impaired wound healing, thromboembolism, hemorrhage, anaphylaxis 

cytokines - interferons

• inhibit DNA & protein synthesis 

• mainly injections every day 

• SE - flulike syndrome, fever, chills, myalgias, fatigue

• give to pt. until they cant get out of bed 

cytokines - interleukins

• stimulates immune system to fight cancer

• stimulates T and B cells

• capillary leak syndrome & bone marrow suppression 

capillary leak syndrome

• goes to interstitial space

• SE - hypotension, ascites, crackles in lungs, weight gain, peripheral edema

• change the med 

BCG vaccine

• used to prevent TB but can treat prostate & bladder cancer

• SE - flu like symptoms, nausea, vomiting, and rash 

resistance in therapy

cancer cells can become resistant to targeted therapies. tumor finds a new growth pathway and not longer depends on the target

side effects of immunotherapy and targeted therapy 

• flu like symptoms

• headache, fever, chills, myalgias, fatigue, malaise, weakness, photosensitivity, anorexia, nausea

• acetaminophen before treatment and qe4

• large amounts of fluids 

• tachycardia and orthostatic hypotension

• capillary leak syndrome, renal, hepatic, and CV

• neuro problems - confusion, insomnia, memory loss

corticosteroids

• cortisone, cortef, Medrol, prednisone, Decadron 

• disrupt the cell membrane and inhibits synthesis of protein 

estrogen receptor modular

raloxifene (Evista)

estrogens

• DES, estracace, estrogen 

• interferes with effects of testerone 

hematopoietic growth factor therapy

• support cancer patients through treatment 

• granulocyte macrophage colony stimulating factor - to prevent bone marrow supression 

sargramostim (Leukine)

• indications - myeloid cell recovery after bone marrow transplation 

• SE - n&v, diarrhea, fever, chills, myalgia, headache, fatigue 

Filgratism (neopogen, neulasta, granix, zarxio)

• Granulocytes

• stimulates production of WBC (4,000-11,000) 

• SE - bone pain, n&v 

Epotin (Epogen, Procrit) & Darbepoetin (Aranesp) 

• erythropoietin - RBC - (4.4-6.1) 

• SE - hypertension, thrombosis, headache

• risk of thrombosis if hemoglobin is greater than 12 - stop med 

oprelvekin (Neumega)

• platelet growth factor - (150,000-400,000) 

• indicated for thrombocytopenia 

• SE - fluid retention, peripheral edema, dyspnea, tachycardia, nausea, mouth sore 

hematopoietic stem cell transplant

• allows for very high doses of chemo and radiation 

• normally cures 

• you need a match with someone 

sources of HSCT includes

• bone marrow 

• peripheral blood - more mature cells

• umbilical cord blood 

stem cells from bone marrow

from iliac crest or sometimes from the sternum

peripheral stem cells

outpatient

cord blood stem cells

• rich in hematopoietic stem cells

complications of HSCT

• graft-versus-host disease - attacks organs such as skin, liver, and GI tract

• pancytopenia period - protect from infection

gene therapy

• prevent from developing cancer 

• can use for screening, correct abnormal gene, or for treatment