Medications Affecting the Immune System: Chemotherapy Agents

Cancer Detection and Prevention Strategies

• Lifestyle and Preventative Measures

  • Smoking cessation: Crucial step in reducing cancer risk.

  • Health Screenings:

    • Pap smear: Recommended every $3$ years to detect cervical cancer.

    • Mammograms: Recommended yearly for women after the age of $40$.

    • Colonoscopy: Recommended starting at age $50$.

  • Immunizations: Administration of the HPV vaccine to prevent specific virus-linked cancers.

  • Dietary Habits: Adoption of a low-fat diet rich in fresh fruits and vegetables.

  • Weight Management: Maintaining a healthy body weight.

  • Stress Management: Employing techniques to decrease overall stress levels.

  • Sun Safety: Protecting the skin from UV exposure and performing regular skin checks.

• CAUTION: Seven Warning Signs of Cancer

  • C: Change in bowel or bladder habits.

  • A: A sore that does not heal.

  • U: Unusual bleeding or discharge.

  • T: Thickening or a lump in the breast or elsewhere.

  • I: Indigestion or difficulty swallowing.

  • O: Obvious change in a wart or mole.

  • N: Nagging cough or hoarseness.

Overview and Goals of Chemotherapy

• Defining Cancer and Treatment Objectives

  • Cancer treatment involves staging (determining location and extent of invasion) and grading (microscopic examination of cell appearance compared to parent cells).

  • Primary goals of chemotherapy:

    • Achieve a cure: Complete eradication of malignant cells.

    • Control growth: Managing the spread of the disease.

    • Provide palliation: Comfort-focused care to relieve symptoms and improve quality of life in advanced stages when a cure is not achievable.

    • Increase survival rates and times.

  • General Goal: Maximize therapeutic effects while simultaneously reducing toxic effects to the patient.

• Mechanisms of Action

  • Chemotherapy is cytotoxic, meaning it is toxic to cells.

  • Administration occurs at repeated intervals until the drug and the client’s own immune system can destroy all malignant cells.

  • Targeting the Cell Cycle: Drugs act during the reproductive cycle of a cell.

  • Effectiveness: Most active against rapidly dividing cells. This includes malignant cells as well as certain healthy tissues such as:

    • Bone marrow cells

    • Gastrointestinal (GI) cells

    • Hair follicles

    • Gonadal cells (reproductive cells)

  • Drug selection depends specifically on the type of cancer being treated.

Classifications of Chemotherapy Treatment

• Induction Therapy: High-dose therapy intended to force the client into remission.

• Consolidation Therapy: Administered after induction to increase the rate of cure or prolong the duration of survival.

• Intensification Therapy: High-dose therapy utilized during remission to increase the cure rate or prolong the remission period.

• Adjuvant Therapy: Used to destroy or reduce the spread of cancer specifically after a primary treatment like surgery or radiation therapy.

• Palliative Therapy: Focused on controlling symptoms and providing comfort when a cure is not possible.

Administration Routes and Combination Therapy

• Routes of Administration

  • Oral route.

  • Intravenous (IV) route:

    • Angiocatheter.

    • PICC line (Peripherally Inserted Central Catheter).

    • Non-tunneled catheters.

    • Tunneled catheters and Port-a-cath.

    • Note: Many clients utilize a central line or Mediport for treatment.

  • Subcutaneous routes.

  • Intraventricular/Intrathecal route: Often utilizing an Ommaya reservoir.

  • Intra-arterial routes.

  • Intraperitoneal route.

  • Intravesicular route.

  • Intrapleural route.

• Combination Therapy

  • Definition: Combining $2$ or more chemotherapy agents for treatment.

  • Rationale for Combination:

    • Different drugs act on different phases of the cell cycle.

    • To decrease the development of drug resistance.

    • To increase the effectiveness of the drug for achieving remission or cure.

    • To reduce toxic effects on normal, healthy cells.

Specific Chemotherapy Medications

• Doxorubicin (Adriamycin, Rubex)

  • Classification: Antitumor antineoplastic.

  • Mechanism of Action: Binds to DNA and inhibits both DNA and RNA synthesis, leading to the death of rapidly dividing cells.

  • Adverse Effects:

    • GI upset.

    • Alopecia (hair loss).

    • Cardiac toxicity.

    • Bone marrow suppression (Anemia, Neutropenia, Thrombocytopenia).

  • Nursing Interventions/Education:

    • Administer antiemetics for GI symptoms.

    • Monitor for signs of infection.

    • Continuously monitor cardiac function.

    • Monitor CBC (Complete Blood Count).

• Vincristine

  • Classification: Natural Product.

  • Mechanism of Action: Stops cell division by driving mitosis during the M-phase (Cell cycle-specific action).

  • Adverse Effects:

    • Peripheral neuropathy (numbness/tingling).

    • GI upset.

    • Alopecia.

    • Phlebitis at the IV site.

  • Nursing Interventions/Education:

    • Monitor closely for signs of neuropathy.

    • Administer antiemetics as needed.

    • Monitor the IV site for signs of irritation or leakage.

• Cyclophosphamide (Cytoxan)

  • Classification: Alkylating agent.

  • Mechanism of Action: Inhibits protein synthesis by interfering with DNA and RNA synthesis.

  • Note: It is a cytotoxic agent often provided in capsules ($25\,mg$) or vials ($500\,mg$) for injection. Wear gloves when handling.

  • Adverse Effects:

    • Bone marrow suppression (Leukopenia, Anemia, Thrombocytopenia).

    • GI upset.

    • Alopecia.

    • Hemorrhagic cystitis (inflammation of the bladder leading to bleeding).

  • Nursing Interventions/Education:

    • Monitor for signs of infection.

    • Increase fluid intake to $2-3\,liters$ per day.

    • Monitor for blood in the urine.

    • Watch CBC for low platelet counts.

    • Provide antiemetics for nausea.

• Leuprolide (Luprodex)

  • Classification: Hormone antagonist.

  • Mechanism of Action: Decreases levels of testosterone used by the testes.

  • Adverse Effects:

    • Hot flashes.

    • Gynecomastia (enlarged breast tissue).

    • Bone loss.

    • Decreased libido.

  • Nursing Interventions/Education:

    • Increase intake of Calcium and Vitamin D.

    • Regularly check bone density.

    • Monitor PSA (Prostate-Specific Antigen) and testosterone levels during therapy.

• Tamoxifen

  • Classification: Hormone antagonist.

  • Mechanism of Action: Competes with estrogen for binding sites in the breast, stopping the growth of estrogen-dependent cancer.

  • Adverse Effects:

    • Hot flashes.

    • GI upset.

    • Increased risk for Pulmonary Embolism (PE).

    • Hypercalcemia (high calcium levels).

    • Increased risk for endometrial cancer.

  • Nursing Interventions/Education:

    • Monitor platelet counts.

    • Provide antiemetics for nausea.

    • Monitor calcium levels.

    • Monitor vital signs.

• Interferon Alfa-2B

  • Classification: Biologic response modifier.

  • Indications: Used for cancers and viral infections (such as Hepatitis).

  • Mechanism of Action: These proteins increase the patient’s immune response to tumors and viruses while decreasing cancer cell production; essentially boosts the patient's immune response.

  • Adverse Effects:

    • Flu-like symptoms (fever, lethargy, muscle aches, chills).

    • Bone marrow suppression.

    • Alopecia.

    • GI upset.

    • Cardiotoxicity.

    • Neurotoxicity.

    • Possible psychiatric disorders.

  • Nursing Interventions/Education:

    • Monitor vital signs.

    • Provide adequate rest periods.

    • Monitor for infection.

    • Provide antiemetics.

    • Assess Central Nervous System (CNS) and cardiac function.

    • Assess mental status.

• Methotrexate

  • Classification: Antimetabolite.

  • Indications: Rheumatoid arthritis, psoriasis, and certain cancers.

  • Mechanism of Action: Inhibits folic acid metabolism, which inhibits cell reproduction, leading to the death of rapidly replicating cells (also acts as an immunosuppressant).

  • Adverse Effects:

    • Increased risk of infection.

    • Hepatotoxicity (liver damage).

    • Bone marrow suppression.

    • GI upset.

  • Nursing Interventions/Education:

    • Avoid fresh fruits, vegetables, and flowers (potential infection sources).

    • Avoid sick individuals.

    • Monitor CBC and liver enzymes.

    • Provide antiemetics for nausea.

    • Notify MD of any signs of infection.

General Adverse Effects and Complications

• Reasoning for Side Effects: Most adverse effects stem from the damage of rapidly dividing healthy cells.

• Myelosuppression (Bone Marrow Suppression):

  • Red Blood Cells (RBCs):

    • Function: Carry oxygen. Life span: $120\,days$.

    • Normal levels: Men ($13-16\,g/dL$), Women ($12-15\,g/dL$).

    • Issues: Anemia and fatigue; monitor Hemoglobin and Hematocrit.

  • White Blood Cells (WBCs):

    • Function: Fight infection.

  • Platelets:

    • Function: Help blood to clot. Life span: $7-10\,days$.

    • Thrombocytopenia: Defined as < 100,000\,cells.

    • Risk for spontaneous bleeding: Defined as < 20,000\,cells.

  • Nadir: Period $7-14\,days$ after chemo administration when blood cell counts are at their absolute lowest.

• GI Discomfort: Nausea, vomiting, diarrhea, and constipation.

• Integumentary and Mucosal: Alopecia (hair loss) and Mucositis/stomatitis (sores/ulcers in the mouth).

• Organ Toxicity:

  • Renal damage: Associated with increased uric acid.

  • Liver damage: Including fibrosis.

  • Lung and Cardiac toxicity.

  • Peripheral neuropathy: Numbness and tingling.

  • Hearing loss or tinnitus.

• Reproductive Toxicity: Most agents are Pregnancy Category D or X.

Nursing Management and Patient Care

• Assessment Strategies

  • Understand the client's diagnosis and specific goals of care.

  • Provide holistic care addressing physical and emotional needs.

  • Obtain a baseline physical and emotional assessment.

  • Check for allergies and an accurate drug history.

  • Mandatory Lab Data Monitoring:

    • CBC (Complete Blood Count).

    • Liver enzymes.

    • Renal function (BUN, creatinine).

    • CXR (Chest X-ray), EKG, and Pulmonary function tests.

• Interventions for Myelosuppression

  • To Increase WBCs: Administer Filgrastim (Neupogen).

  • To Increase RBCs: Administer Packed Red Blood Cell transfusion or Epoetin alpha (Procrit, Epogen).

  • To Increase Platelets: Platelet transfusion.

  • Patient Advice: Avoid NSAIDs (e.g., Aspirin, Ibuprofen) which can alter platelet function.

• Interventions for Common Symptoms

  • Fatigue and Nausea/Vomiting: The most common side effects.

  • Antiemetic Medications (Nausea/Vomiting prevention):

    • Ondansetron (Zofran).

    • Prochlorperazine (Compazine).

    • Lorazepam (Ativan).

    • Metoclopramide (Reglan).

    • Dexamethasone (Decadron): A steroid used to increase the effectiveness of other anti-nausea drugs.

  • Protocol: Premedicate patients before chemotherapy treatment starts.

• General Nursing Education and Precautions

  • Oral Care: Provide frequent oral care with a soft toothbrush; avoid mouthwash containing alcohol.

  • Hydration: Encourage fluid intake of $2-3\,L/day$.

  • Pregnancy/Fertility: Advise females against becoming pregnant during and for $6\,months$ after treatment. Note potential fertility impairment.

  • Infection Control: Avoid large crowds or ill persons. Educate on Neutropenic Precautions.

  • Organ Monitoring: Monitor BUN/creatinine (kidney), liver enzymes/jaundice (liver), breath sounds/SOB (lung), EKG/chest pain (cardiac).

Safe Administration and Disposal

• Safety Protocols

  • Use specific chemotherapy gloves during administration.

  • Flush the toilet twice after use by the patient.

  • Dispose of all materials as hazardous waste using special precautions.

  • Familiarize yourself with the procedure for chemotherapy spills (Spill kit).

  • Do not administer these medications if you are pregnant.

• Vesicants

  • Certain chemotherapy agents are vesicants, meaning they cause extravasation (tissue damage) if they leak outside of the vein.

Questions & Discussion

• Case Study Question: You are caring for a $48\,y/o$ male receiving aggressive chemotherapy. He complains of mouth sores (stomatitis) and a fever. What would you recommend for this client?

• Answer Guidelines: Based on the material, interventions should include:

  • Assessing for infection due to the fever (Neutropenic precautions).

  • Providing soft toothbrushes and avoiding alcohol-based mouthwash for stomatitis.

  • Checking WBC counts (CBC) as he may be at his nadir ($7-14\,days$ post-chemo).

  • Providing non-acidic foods and frequent oral hygiene.