Chemotherapy

What are antineoplastic agents?

"chemo therapy"

Different uses of antineoplastic agents in cancer care

neoadjuvant

Adjuvant

what is neoadjuvant therapy?

gives chemo to shrink tumor size then goes in and surgically removes

(pre surgery shrinkage)

what is adjuvant therapy?

pt has had surgery but microscopic cells remain, chemo goes in and kills remaining cancer

(post surgery)

The cell cycle

first growth phase = G1= growth and normal metabolic roles

Synthesis phase = s= DNA replication

Second growth phase = G2= growth and preparation for mitosis

Mitotic phase = prophase, metaphase, anaphase, telophase --> cytokines

one key to advanced life is cell division

cells divide millions of times everyday to sustain life and growth of a single human
(known as the cell cycle)

Principles of chemo: how can a patient become resistant to chemotherapy?

tumor resistance

- drug doses are limited by their side effects
- effectiveness of the drug will depend on the stage of tumor growth

Principles of chemo: Why do patients receive multiple drugs?

Mechanisms of action: multiple chemo drugs that work in different phases of the cell cycle

Patterns of toxicity: know what toxicities can occur and make sure they DON’T OVERLAP

Principles of chemo: What factors are dosing limiting factors?

give chemo to the point where we are getting a good response or toxicities (which ever comes first)

excretion of the drug can a dose limiting factor

previous radiation therapy is a dose limiting factor

Principles of chemo: How chemo drugs are scheduled

Intermittent courses of intense chemotherapy better than continuous drug administration
Maximal doses should be given in short courses

-repeated low doses should be avoided to reduce effectiveness and reduce selective action against malignant cells because normal cells are being induced into cycle

If two drugs cause bone marrow toxicity → reduce toxicity but not giving them at the same time

Effective combinations include drugs that exert their effects in different phases of the cell cycle

Drugs of the same cell cycle phase – many do not have additive effects

Principles of chemo: Limitations/failures to chemotherapy

neoplasms mutate spontaneously toward drug resistance; mutations are present in large tumors rater than small once

- may be due to alterations in cell membranes that inhibit the transport of drug into cell

- the activity of certain enzymes can activate or inactivate drugs

- pt organs- if liver/kidneys aren't working

Steps to safely administer chemotherapy

1. know the pt actual height and weight
2. w/ another nurse calculate the pts body surface area
3. with another nurse check the physicians order to ensure that the doses of chemo ordered are within acceptable guidelines
4. check labs/tests that are pertinent to each drug
5. review the protocol for the drugs to be given and make sure everything is in place for administration of the drugs
(some agencies have chemo consent forms)
6. know the route of administration
7. know the agencies p/p regarding management of an extraversion

ALWAYS CHECK for adequate blood return before staring chemo
- if vesicant agent is ordered and the IV access is peripheral, most institutions state that the drug can only run for 1 hour
- a NURSE must be at the bedside throughout the WHOLE infusion
- if the infusion is longer than a hour, the MD should put in a central line
- BLOOD return is checked after each 2-3 cc's of the infusion (VERY TIME CONSUMING)

NEVER send a pt off the floor with chemo running
if chemo is infusing via a CVC then the blood return is checked every 4 hrs

What personal protective equipment is needed for the nurse when administering chemo

•Gloves - must be latex or nitrile; change every 30minute or when torn. DO NOT wear outside of area, not into other patients room. Two pair used.

•Gown - must be disposable, lint free, non permeable fabric with a closed front & long-sleeved sleeves. Gown cuff on sleeves tucked into gloves. 2nd pair of gloves over the cuff of the sleeves of gown.

•Eye & face mask - if splashes occurs, then wear PR mask or eye goggles or eye shields. Regular eye glasses are not appropriate - can not protect eyes. Surgical masks will not protect either.

How does accidental exposure occur

Transferring drugs using syringes or needles
- opening ampules
- changing Iv bags, bottles, or tubing
- priming IV tubing, clearing air from syringes
- withdrawing needles from vials

handling bodily fluids
- disposing of linens & materials soaked or soiled with bodily fluids of people who received chemo
- clean up of cytotoxic drug spills

3 ways exposure occurs-
Inhalation of drug aerosols or droplets

•Absorption of drug through direct contact with skin or direct contact with eyes

•Ingestion through direct contact with contaminated foods, food containers, or smoking materials.

Acute symptoms of accidental exposure
-Headache
-Nausea
-Dizziness & lightheadedness
-Skin & mucosal irritation
-Rash & hair loss
-Coughing & throat irritation
-Eye irritation

Steps to minimize accidental exposure

•A standard duration of 48 hours is length of time to follow guidelines
-Safe Handling
•Wear latex or nitrile gloves and disposable gown
•When splash or spills likely to occur; wear eye protection
•Flush toilet twice or more to completely wash away body fluids
•Cover toilet with a chux pad if splashing it likely
•Linens - precautions required to limit exposure to linens contaminated with vomitus, urine, feces, or other bodily fluids

Antimetabolites

Cell cycle specific

Action: interfere with the biosynthesis of precursors essential to cellular growth by mimicking folic acid, pyrimidines, & purines, by interfering with the normal synthesis of nucleic acids in one of 2 ways
-by falsely substituting purines, pyrimidines, or folic acid
-by inhibiting critical enzymes involved in nucleic acid or folic acid synthesis

DRUG: Fluorouracil

•Fluorouracil (5-FU) - IV, IA, topical
-Used for gastric, head and neck, breast cancer

side effects
•myelosuppression
•alopecia
•mucositis
•diarrhea
•discoloration of veins

-Note - derivation of drug (FUDR) can be administered intrahepatically and is compatible with heparin

DRUG: Methotrexate

•Methotrexate (MTX) - IV, IM, PO, intrathecal
-Used in rheumatoid arthritis, other inflammatory disorders, Cancer - breast, head & neck, renal, ovarian, bladder, testicular, lymphomas, etc

-Side Effects
•Photosensitivity

•Liver dysfunction
monitor LFT
no alcohol use; use NSAIDs or salicylate products because they can increase toxicity

•mucositis
•Myelosuppression

Vinca alkaloids

•Cell cycle specific

•Action: drugs in this class, in an unknown way, prevents mitosis from occurring and thus stops the cell cycle by disrupting the mitotic spindles crucial to be successful of metaphase.
-Called "mitotic inhibitors"

DRUG: Vincristine (Oncovin)- 2 mg/week maximum

= a Vesicant agent


•Side Effects common to vinca alkaloids

•Myelosuppression

•Nausea & vomiting

•Neurotoxic
-can cause peripheral neuropathies
(Foot drop, paralytic ileus, tingling in hands/feet)

what does it mean when a chemotherapeutic agent is classified as a vesicant agent

Drugs that can result in tissue necrosis or formation of blisters when accidentally infused into tissue surrounding a vein

Taxanes

DRUG: paclitaxel (Taxol)

Side effects:

hypersensitivity reactions
-->premedicate with a steroid, antihistamine, & an H2 blocker

hair loss

Side Effects common to vinca alkaloids

Topoisomerase - 1 inhibitors

Cell Cycle specific

•Action: kill cells when in the S-phase of cell cycle. Inhibit cell replication by inhibiting the enzyme topoisomerase-1.

•Side effects:

-Irinotecan (Camptosar) = severe diarrhea
-->give atropine

Alkylating agent

•Cell cycle nonspecific

•Action: interfere with the chemical structure of the DNA essentials to the reproduction of any cell. Alkylation process occurs where alkyl group attached to nucleic acid instead of a H+.


•Cyclophosphamide (Cytoxan) - PO, IV

-Used for Chronic leukemia, ovarian, breast, HD & NH lymphomas, multiple myeloma

-Side Effects

•**Hemorrhagic cystitis
teach paitent-->
-Must administer early in the day
-Need adequate hydration
-Assess urine for blood
-Void frequently and especially before bedtime

•Sterility
•Nausea and vomiting
•Myelosuppression
•High dose -cardiotoxic

•Cisplatin (Platinol) - IV

•Nephrotoxicity =
-Monitor I & O
-Adequate hydration
-Watch creatinine & BUN
-Mannitol
•Peripheral neuropathy
•Electrolyte imbalance
-Watch Mg++ & K+
-May be administering with these electrolytes in IVF

•Ototoxicity
-High frequency hearing loss - audiogram

Antitumor antibiotic

•Cell cycle nonspecific

•Action: Act by either alkylation process or process called intercalation which involves the insertion of the drug molecule between the 2 strands of DNA to block synthesis.

•Anthracyclines- subgroup of the category - work by intercalation
daunorubicin
doxorubicin (Adriamycin)
idarubicin


-Doxo"**rubicin" (Adriamycin) = Red in color
•Vesicant agent
•Cardiotoxic - must have baseline & periodic ECHO's
•Hair loss


-Bleomycin
•Causes pulmonary toxicity
•Must have baseline PFTs
•Must give test dose with first administration - can cause hypersensitivity /anaphylaxis reaction
•Contraindicated in persons over 70 yr of age


•Side Effects
-Other than Bleomycin , ALL drugs in this class are vesicant agents.
-If giving vesicant agent - must watch closely!!!
-Have a new IV and if administering IVP - check for blood return every 2-3 cc's.
-If infusing via CVC, verify blood return with 2nd RN before starting, then check & document every 4 hours.
-STOP infusion if pain, redness, or infiltration - call MD
-Remember- other chemo's are also vesicants

What are the two classes of anti-estrogen agents

1. tamoxifen (breast cancer
2. raloxifene

What are the two anti-estrogen agents MOA

blocks estrogen receptors

What are the side effects of tamoxifen

- increases uterine cancer risk
- increases blood clot risk
- increased risk of DVT and pulmonary embolism

(some positives)
- reduces breast cancer risk
- lowers LDL cholesterol
- strengthens bones

what are the side effects of aromatase

- high risk for osteoporosis

What actions should the nurse take for a pt with alopecia

•Hair loss - hair will grow back

•inform client that hair loss can be expected approximately 2 weeks after initiation of chemotherapy; may be sudden, gradual, partial, or complete; and can include scalp hair, pubic hair, beard, eyebrows, and eyelashes

•reassure client that hair loss is temporary (regrowth sometimes occurs before cessation of treatment but usually occurs 2-3 months after it)

•inform client that hair regrowth may be a different color, texture, and consistency
•encourage client to cut hair very short to decrease the anxiety related to seeing large quantities of hair fall out
•inform client that he/she can reduce rate of scalp hair loss by:

•brushing hair gently using a soft bristle brush
•shampooing hair only once or twice a week and using a gentle shampoo and lukewarm water

•avoiding use of equipment/products that dry hair (e.g. hot rollers, hair dryers, curling iron, dyes)
•avoiding hair styles that create tension on hair (e.g. ponytails, braids)

•encourage client to wear a wig, scarf, hat, false eyelashes, or makeup if desired to camouflage hair loss

what actions should a nurse take for a pt with neutropenia

•Implement measures to reduce the risk for infection:

•protect client from others with infections and those who have recently been vaccinated (a person may have a subclinical infection after a vaccination)
•use good handwashing technique and encourage client to do the same
•adhere to the appropriate precautions established to prevent transmission of infection to the client (standard precautions, neutropenic precautions)
•maintain a fluid intake of at least 2500 ml/day unless contraindicated
•perform actions to prevent or reduce severity of stomatitis and relieve dryness of the oral mucous membrane
•avoid invasive procedures (e.g. urinary catheterizations, arterial and venous punctures, injections) whenever possible; if such procedures are necessary, perform them using sterile technique
•change equipment, tubings, and solutions used for treatments such as intravenous infusions, respiratory care, irrigations, and enteral feedings according to hospital policy
•initiate measures to prevent constipation (e.g. offer client a daily fiber supplement such as a mixture of bran, applesauce, and prune juice; encourage a minimum fluid intake of 2500 ml/day; encourage increased intake of foods high in fiber; administer laxatives as ordered) in order to prevent damage to the bowel mucosa from hard stool

•avoid unnecessary rectal invasion (e.g. temperature taking, enemas, suppositories, rectal tube) to prevent trauma to rectal mucosa and possible abscess formation
•perform actions to prevent stasis of respiratory secretions (e.g. assist client to turn, cough, and deep breathe; increase activity as tolerated)
•perform actions to prevent urinary retention (e.g. instruct client to void when the urge is first felt, promote relaxation during voiding attempts) in order to prevent urinary stasis
•instruct and assist client to perform good perineal care routinely and after every bowel movement
•administer the following as ordered:
-antimicrobial agents (usually initiated when the neutropenic client becomes febrile or may be administered prophylactically if the neutrophil count is less than 500/mm3)
-colony-stimulating factors (e.g. filgrastim) to stimulate granulocyte production.

What action should a nurse take for a pt with thrombocytopenia

•Implement measures to prevent bleeding:

•avoid giving injections whenever possible; consult physician about prescribing an alternative route for medications ordered to be given intramuscularly or subcutaneously

•when giving injections or performing venous and arterial punctures, use the smallest gauge needle possible
•apply gentle, prolonged pressure to puncture sites after injections, venous and arterial punctures, and diagnostic tests such as bone marrow aspiration

•take B/P only when necessary and avoid overinflating the cuff
•caution client to avoid activities that increase the risk for trauma (e.g. shaving with a straight-edge razor, using stiff bristle toothbrush or dental floss)

•whenever possible, avoid intubations (e.g. nasogastric) and procedures that can cause injury to rectal mucosa (e.g. taking temperatures rectally, inserting a rectal suppository or tube, administering an enema)

•pad side rails if client is confused or restless

•perform actions to reduce the risk for falls (e.g. keep bed in low position with side rails up when client is in bed, avoid unnecessary clutter in room, instruct client to wear slippers/shoes with nonslip soles when ambulating)
•instruct client to avoid blowing nose forcefully or straining to have a bowel movement; consult physician about an order for a decongestant and/or laxative if indicated

•administer the following if ordered:
•platelet-stimulating factor (oprelvekin [Neumega])
•estrogen-progestin preparations to suppress menses
•platelets.

What actions should a nurse take for a pt with anemia

•Balance activity and rest
•Monitor oxygenation
•Erythropoietin
•Blood transfusions

What action should a nurse take for a pt with mucositis

Assessment
Pain control
Dietary
Oral Hygiene

Side effects of interferons

-Flu-like effects: fever, chills, HA, malaise, myalgia, & fatigue
-GI: N/V, diarrhea, anorexia
-CNS: paranoia, dizziness, confusion
-CV: tachycardia
-Hematologic: neutropenia, thrombocytopenia
-Renal: inc. BUN & creatinine
-Pysch: depression, suicidial ideation

Use of supportive care especially erythropoietin and G-CSF; why used? How does the nurse know if they are working?

•G-CSF
- important for cancer pt
Decrease the duration of chemotherapy-induced anemia, neutropenia, and thrombocytopenia

•Allow for higher dosages of chemotherapy

•Decrease bone marrow recovery time after bone marrow transplantation or irradiation

•Stimulate other cells in the immune system to destroy or inhibit the growth of cancer cells, as well as virus- or fungus-infected cells

(pushes granulocytes to mature quicker)

Erythropoietin
- important for kidney pts
- keeps the RBC up to minimize blood transfusions