CPHON: Treatments and Side Effects

chemotherapy

medications used to destroy or prevent growth of cancer (rapidly dividing) cells, interferes with the ability to divide/duplicate

cell cycle specific

antimetabolites

plant alkaloids

cell cycle nonspecific

alkylating agents

nitrosoureas

anti-tumor antibiotics

topoisomerase I inhibitor

biologic response modifiers

asparaginase

heavy metals

hormonal agents

antimetabolites

cell cycle specific chemo- interfere with DNA/RNA in S phase

• 5FU

• 6MP

• Gemcitabine

• cytarabine

• fludarabine

• MTX

  Numbers, -abines, MTX

plant derivatives

cell cycle specific chemo- from natural products that blocks ability to divide by stopping enzyme from making reproduction proteins

4 classes:

• Vinca Alkaloids

• Epipodophyllotoxins

• Taxanes

• Camptothecin

Vinca Alkaloids

plant derivative, cell cycle specific chemo- in M phase, major side effect peripheral neuropathy

• VCR

• Vinblastine

• Vindesine

• Vinorelbine

Epipodophyllotoxins

plant derivative, cell cycle specific chemo- in S and G2 phase cause DNA strand breaks

• Etoposide

• Teniposide

Taxanes

plant derivative, cell cycle specific chemo- in M phase, inhibits mitosis

• paciltaxel

• docetaxel

camptothecins

plant derivative, cell cycle specific chemo- in G2 and M phase binds to topoisomerase I and cause damage

• camptotecin

• topotecan

• irinotecan

alkylating agents

nonspecific chemo, damages DNA and works on all cycles, increases risk of leukemias 5-10 years after treatment

• Carboplatin

• Cisplatin

• cyclophosphamide

• Ifosfamide

• Melphalan

• Procarbazine

• Temozolomide

• Thiotepa

  • -in, -ine, -ide, thiotepa, melphalan

nitrosoureas

nonspecific chemo, subset of alkylating agents, slow enzymes that repair DNA

• Carmustine

• Lomustine

antibiotics

nonspecific chemo, made from microorganisms, break or bind DNA

• Bleomycin

• Dactinomycin

• Daunorubicin

• Mitomycin

• Doxarubicin

• Mitoxantrone

  • -cin, mitoxantrone

hormones

nonspecific chemo, enters and modifies transcription, can also be used to prevent nausea/vomiting and allergic reactions

• dexmethasone

• prednisone

miscellaneous agents

nonspecific chemo, does not fit into category

• enzymes (PEG)

• Hydroxyurea

• Procarbazine

biotherapy

nonspecific, function as antineoplastics

• monoclonal antibodies

• cytokines

• tyrosine kinase inhibitors

• vaccines

• gene therapy

• retinoids

• hematopoietic growth factors

monoclonal antibodies

nonspecific biotherapy, lab produced molecules that act as antibiotics and attack cells- seek out proteins on cancer cells

• Rituximab

• Alemtuzumab

• Bevacizumab

Cytokines

nonspecific biotherapy, signals immune system to do its job

• Interferons

• Interleukins

tyrosine kinase inhibitors

nonspecific biotherapy, block enzyme (TK) which stops cancer cells from dividing, targeted therapy/less side effects

• Imatinib

vaccines

nonspecific biotherapy, can be used to treat/prevent cancer

• Gardasil: HPV

• Hep B: liver cancer

• immunotherapy: treat by boosting immune system

gene therapy

nonspecific biotherapy, designed to target specific genes and proteins involved in growth and survival of cancer cells

retinoids

nonspecific biotherapy, facilitate differentiation and suppress proliferation of cancer cells, well tolerated antitumor activity

• All-trans retinoic acid (ATRA)

• Isotretinoin

colony stim factors

responsible for maturation of blood cells, shortens length of myelosuppression

• Epoetin/Darepoetin: RBC production

• oprelvekin: plt production

• sargramostim: granulocyte production

• filgrastim: neutrophil production

• pegfilgrastim: WBC production

vesicants

medications that can cause significant tissue injury

• SLAPP: Stop, leave needle, aspirate, pull needle, provider notify

• Give antidotes

• Ex:

  • Dactinomycin, Daunorubicin, Doxorubicin, Idarubicin, plant alkaloids

radiation

can be used alone for treatment of cancer or in combination with chemotherapy, destroys rapidly dividing cells

side effects: fatigue, myelosuppression, skin changes (hair loss, burn, desquamation), radiation recall (burns- cool cloths)

• late: dose >10gy effects on growth, >30 cause vasculopathies in large brain vessels

external beam radiation

most common form of radiation, high energy beams delivered to tumor

• proton: directly the tumors, minimize damage to surrounding tissue

• conformal: delivers different amounts to different parts of tumor

• image guided: scans/XRs to ensure position

• stereotactic: give in different directions

internal beam radiation (brachytherapy)

type of radiation where radioactive seeds are implanted in body to continuous attack cancer cells

surgery

cancer treatment focused on removing tumor

• biopsy

• primary- complete resection

• debulking- partial resection

• second look- exploratory/further debulk

HSCT (hemopoietic stem cell transplant)

immature cells that give rise to other blood cells, replaces diseased cells with non-cancerous stem cells

• syngeneic- from identical twin

• allogenic- donor, preferred match sib

• auto- self, harvested and preserved

HLA typing (human leukocyte antigen)

used in BMTs to match patients and donors, they are proteins on cell surfaces- major histocompatibility complex that identifies self from non-self

• more match= less risk GVHD

harvest

marrow- process of removing stem cells from donor’s iliac crest

peripheral stem cell- collected through apheresis

donor

to give cells:

• screening history (meds/illness/zika/exclude)

• high risk= tattoos, piercings, IV drug use

• HLA typing

• Dental & Psych Eval

recipient

to receive cells:

• screening/exam/HLA

• organ function/scans

• urine collection/sperm or egg bank/harvest

• central line

• lodging post transplant

matched related

type of Allo BMT

pros: rapid hematopoiretic and immunological reconstitution, less incidence of infection & GVHD

cons: only 30% patient have this (sib)

mismatch related

type of Allo BMT

pros: healthy source of cells, easy donor access and availability

cons: increased risk GVHD and graft failure

MUD

type of Allo BMT

pros: viable alternative for 75% pts

cons: GVHD, locate donor, infection, graft failure, death

cord

type of Allo BMT

pros: decreased incidence of GVHD

cons: limited cells, once transplanted- no more cells can be harvested, increased engraftment time

auto

type of BMT:

pros: faster recovery of cells, no GVHD risk

cons: no graft vs leukemia risk (increased relapse risk), risk of tumor contamination

syngeneic

type of BMT:

pros: GVHD not a risk, no cancer in transplanted cells (best option)

cons: risk of graft vs leukemia effect

conditioning

prep for BMT, includes:

• eradicating tumor cells

• immunosuppress pt to reduce rejection risk

• reduce risk of GVHD

• prepares marrow space for healthy cells

• 1-2 weeks: chemo, radiation, combo

HSCT complications

early: mucositis, sepsis, hemorrhagic cystitis, VOD

• good oral cares, nutrition education, anti-infective prophylaxis

intermediate/late: infection, graft failure, GVHD, pulmonary effects, endocrine dysfunction, secondary cancers, relapse

sepsis

HSCT complication:

risk factors include neutropenia, barrier breakdown, depressed B and T cell function, not in remission at time of transplant

tx: early recognition, VS, cultures and antibiotics in an hour of fever, IV fluids, oxygen

hemorrhagic cystitis

HSCT complication:

diagnosis confirmed by hematuria and symptoms of cystitis

• early onset: due to conditioning tx

• late onset: typically due to viral (BK)

tx: hyperhydration, analgesia, platelets, catherization and irrigation, cystoscopy

VOD (veno-occlusive disease or sinusoidal obstruction syndrome)

HSCT complication:

early, rare but significant, caused by backflow of liver sinusoid glands due to inflammation

tx: prophy- defibrotide, monitoring labs and abdominal distension

GVHD (graft vs host disease)

HSCT complication:

immune response where the donor graft recognizes recipient antigens as foreign and cause inflammatory response, higher risk for HLA disparity

• affects skin/GI/liver and lungs

• dx clinically (rash, cramping/diarrhea, high bili) or bx (skin/GI tract)

• tx aimed at immunosuppression

GVHD grading

1: skin involvement alone

2: skin involvement, gut or liver involvement

3: stage 3 involvement of any organ system (generalized erythroderma, bili greater than 6,1, diarrhea)

4: stage 4 involvement of any organ system ( generalized erythroderma with bullous formation, bili >15, diarrhea and ileus/pain)

HSCT discharge

pt must be/have:

• ANC >500

• afebrile

• off IV antibiotics

• oral meds and intake

• family manage lines

• complications resolved

• follow up adherence

irradiated

blood product treatment that helps autoimmunization

leukocyte reduced

blood product treatment indicated for patients receiving chemo, helps prevent CMV (negative- can cause infection and death in immunosuppressed pts) and autoimmunization

platelets

blood product that helps with clotting, normal value is >100, given when <10

• prophylactically in brain tumors or invasive surgery (>50)

FFP (fresh frozen plasma)

blood product when RBCs removed from whole blood, contains proteins and coag factors (replace in DIC or liver failure)

albumin

blood product used to treat patients with hypovolemia and hypoproteinemia

• use cautiously with patients susceptible to fluid overload

cryoprecipitate

blood product prepared by thawing FFP, replaces fibrinogen and clotting factor deficiencies

• contains factor VIII and XIII, fibrinogen, and von willebrand

thrombosis

blocking of blood vessel by a particle that has broken from blood clot at site of formation

risks: obesity, immobility, autoimmune disorders, dehydration, malignancies, surgery, ARA-C

clotting factors

tx clotting deficiencies (8&9), cross match not required, used for bleed or prophylaxis

apheresis

nonsurgical treatment where component of blood (plasma or RBCs) is removed or replaced, usually monthly exchanges

• indicated for stoke, severe SCD

• iron chelation therapy: deferasirox- exjade or jadenu

phlebotomy

used to treat iron overload from sickle cell disease, polycythemia, and transplant

• removal of % of blood and replace with NS or non-sickled blood

hydroxyurea

antimetabolite chemo, can be used in SCD to reduce frequency of pain crisis and need for blood transfusions, myelosuppression common

heparin

treatment for thrombosis: inactivates thrombin and factor Xa, SQ or IV

• easily reversed

• sx: bleeding, HIT

LMWH (low molecular weight heparin)

treatment for thrombosis: inhibits factor Xa, q12 hour SQ, more predictable than heparin

warfarin (coumadin)

treatment for thrombosis: inhibits synthesis of vit k clotting factors, watch PT and INR (2-3), frequent monitoring

• encourage consistent amounts of vit k foods to not affect dosing

phase I

part of clinical trial:

determines safety or maximum tolerated dose of drug/agent

phase II

part of clinical trial:

determines efficacy of new agent/treatment in treating specific types of cancer

phase III

part of clinical trial:

determines the overall response, survival, and QOL with new treatment plan- is new treatment the same or better than current treatment plan

phase IV

part of clinical trial:

determines long term safety and efficacy of treatment, after approval for use- decrease side effects

informed consent

recommendation of treatment performed in lay terms, alternative options offered, benefits and burdens explained, research purpose and compensation

• decision maker must be able to: understand information, weigh it out in current situation, and communicate their choice