Cancer in Relation To Pharmacy - Career

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An open learning programme for pharmacists
and pharmacy technicians
Cancer: in relation to
pharmacy practice
Educational solutions for the NHS pharmacy workforce
DLP 147
Copyright Controller HMSO 2009
Educational solutions for the NHS pharmacy workforce
Copyright controller HMSO 2009
An open learning programme for pharmacists
and pharmacy technicians
Cancer: in relation to
pharmacy practice
ii
Acknowledgements
Lead writers
Geoff Saunders, consultant pharmacist, Christie Hospital, Manchester
Jane Saunders, PCT pharmacist and community pharmacist
Joe Quinn, teacher practitioner, University of Bradford
Louise Sutton, Macmillan haemato-oncology palliative care pharmacist, Stepping Hill
NettyWood, lead pharmacist, Essex Cancer Network
CPPE programme developers
Kuljit Thiaray, CPPE tutor
Matthew Shaw, deputy director
Project team
Paula Higginson, senior pharmacist, learning development, CPPE
Hazel Hughes, community pharmacist, Alliance Boots
Harlene Kithoray, CPPE tutor
Jane Lambe, community pharmacist, Co-op
Anna McNicholas, oncology pharmacist, Christie Hospital
Aamer Naeem, director, Innov8 Creative Solutions Ltd.
Jane Saunders, PCT pharmacist and community pharmacist
Louise Sutton, Macmillan haemato-oncology palliative care pharmacist, Stepping Hill
JeanThurman, locum community pharmacist
Reviewer
This learning programme was piloted nationally by the following pharmacists and
pharmacy technicians: Antonio Cabrera, Naina Chotai, Helen Hill, Hazel Hughes,
Harlene Kithoray, Catherine Mellings, Anne Noott, Burham Zavery.
CPPE reviewer
Paula Higginson, senior pharmacist, learning development
Thanks
We would like to thank Geoff Saunders, NettyWood and their colleagues at the
British Oncology Pharmacy Association (BOPA) for their help and guidance in
producing this open learning programme.
Production
Outset Publishing Ltd, East Sussex
Published in August 2009 by the Centre for Pharmacy Postgraduate Education,
School of Pharmacy and Pharmaceutical Sciences, University of Manchester,
Oxford Road, Manchester M13 9PT
http://www.cppe.ac.uk
Printed on FSC paper stocks using vegetable based inks.
The paper mill and printer have ISO 14001 accreditation.
TT-COC-002529
Contents
About CPPE open learning programmes vii
About this learning programme x
Supporting you, your practice and the NHS xiv
Section 1 Cancer in context 1
1.1 The structure of cancer services 3
1.2 The healthcare teams involved in cancer care 5
The cancer multidisciplinary team 5
The role of the pharmacy team 6
The role of the nursing team 7
Other professionals involved in cancer care 8
Groups who provide support to the multidisciplinary team 9
1.3 National guidance 10
1.4 An introduction to the disease 10
Staging 10
1.5 Lung cancer 11
Background 11
Incidence and mortality 12
Presentation 12
Staging 13
1.6 Breast cancer 13
Background 13
Presentation 14
Staging 15
1.7 Colorectal cancer 15
Background 15
Presentation 15
Staging 15
1.8 Prostate cancer 16
Background 16
Presentation 16
Staging 17
1.9 Skin cancer 17
Background 17
Presentation 18
Staging 18
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C O N T E N T S
1.10 Cervical cancer 18
Background 18
Presentation 19
Staging 19
1.11 The impact of cancer 19
Exercises 1, 5, 6, 7, 11
Practice points 4, 9, 10, 12, 17
Summary and intended outcomes 20
Suggested answers 21
References and further reading 23
Section 2 Preventing and detecting cancer 24
2.1 Risk factors for developing cancer 24
Lifestyle 24
Genetics 26
2.2 Warning signs and symptoms in the pharmacy 28
2.3 Screening and testing 28
Genetic testing 28
Screening 29
Exercises 24, 28
Case studies 30, 32, 34
Practice points 26, 27, 29, 32, 36
References 41
Section 3 Principles of treatment 42
3.1 Aims of treatment 44
3.2 Options for treatment 46
3.3 Principles of chemotherapy 47
Combination therapy 47
Clinical trials 48
3.4 Classes of anticancer drugs 49
Alkylating agents 49
Antimetabolites 49
Mitotic inhibitors 49
Cytotoxic antibiotics 49
Topoisomerase inhibitors 50
Other agents 50
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C O N T E N T S
3.5 Giving chemotherapy 51
Routes of administration 51
Administration 51
Prescribing 52
Preparation 52
Extravasation 53
3.6 Treatment monitoring 53
Case study 55
Practice points 42, 43, 46, 49, 51, 53, 57
Section 4 Responding to symptoms of disease and treatment 61
4.1 Management of side-effects of treatment 62
4.2 Infection 64
Treatment of infections 65
4.3 Nausea and vomiting 66
4.4 Gastrointestinal disturbances 69
4.5 Mucositis 70
4.6 Alopecia 70
4.7 Hand and foot syndrome (palmar plantar) 71
4.8 Tumour lysis syndrome 71
4.9 Hypersensitivity reactions 71
4.10 Managing drug interactions 71
4.11 Vitamins 72
4.12 Complementary and alternative therapies 72
Interactions with complementary and alternative therapies 73
4.13 Safe management of symptoms 73
Enhancing pharmaceutical care 73
Exercises 61, 64, 65
Case studies 63
Practice points 65, 66, 68, 69, 72, 73, 74
References 77
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C O N T E N T S
Section 5 Supporting patients and carers 78
5.1 Communication 78
5.2 Information 81
5.3 Involving and supporting patients 83
Information sources 83
Involving the patient 83
Supporting the patient 83
5.4 Cancer survivors 84
Exercises 79, 80, 84, 85
Case study 86
Practice point 81, 82, 84, 85
Appendices
Appendix 1 Information and resources 94
Appendix 2 BOPA Competency framework for specialist 97
oncology pharmacists
Index 105
List of tables and figures
Tables
Table 1 Risk factors for breast cancer 14
Table 2 Examples of common chemotherapy regimes 48
Table 3 WHO response criteria 54
Table 4 Emetogenic potential of selected cytotoxic agents 68
and their management
Figures
Figure 1 Advice on a method for breast examination 31
Figure 2 The cell cycle 47
Figure 3 Antiemetics and their site of action 67
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About CPPE open learning programmes
About CPPE
The Centre for Pharmacy Postgraduate Education (CPPE) is funded by the
Department of Health to provide continuing education for practising pharmacists
and pharmacy technicians providing NHS services in England. We are part of the
Workforce Academy, within the School of Pharmacy and Pharmaceutical Sciences,
which is part of the Faculty for Medical and Human Sciences.
CPPE offers a wide range of learning opportunities for the pharmacy workforce.
Our full learning portfolio is available on the internet at: http://www.cppe.ac.uk
Themes
We have allocated themes to all our learning programmes. There are 28 themes in
total and they allow you to navigate easily through our full learning portfolio. Each
theme has been assigned a different colour, and this is used to identify the theme in
the annual prospectus, in CPPE news&events, on our website, and on the covers of
all the learning programmes.
This learning programme is part of the Cancer and immunology theme. You will
find additional learning programmes within this theme in our prospectus and on
our website.
This programme can be downloaded in PDF format from our website:
http://www.cppe.ac.uk
We recognise that people have different learning needs and not every CPPE
learning programme is suitable for every pharmacist or pharmacy technician.
Some of our programmes contain core learning, while others deliver more
complex learning that is only required to support certain roles. So we have created
three categories of learning CPPE 1 2 3 and allocated each programme to an
appropriate category.
The categories are:
Core learning (limited expectation of prior knowledge)
Application of knowledge (assumes prior learning)
Supporting specialisms (CPPE may not be the provider and will
signpost you to other appropriate learning providers).
This is a learning programme.
Continuing professional development
You can use this learning programme to support your continuing professional
development (CPD). Consider what your learning needs are in this area. You may
find it useful to work with the information and activities here in a way that is
compatible with the Royal Pharmaceutical Society of Great Britains approach to
continuing professional development (http://www.rpsgb.org.uk/registrationand
support/continuingprofessionaldevelopment) because you will be able to relate
it to your personal circumstances more closely. Use your CPD record sheets or go
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A B O U T C P P E O P E N L E A R N I N G P R O G R A M M E S
to: http://www.uptodate.org.uk/home/welcome.shtml to plan and record the
actions you have taken.
Activities
Exercises
We include exercises throughout this programme as a form of self-assessment. Use
them to test your knowledge and understanding of key learning points.
Practice points
Practice points are an opportunity for you to consider your practical approach to
the effective care of patients or the provision of a service. They are discrete
activities designed to help you to identify good practice, to think through the steps
required to implement new practice, and to consider the specific needs of your
local population. Practice points are not essential learning; you must make your
own decision about whether to do them, and how long to spend on them.
The practice points in this programme have been designed to help you and your
team to make links between the learning and your daily practice and to co-ordinate
with other healthcare professionals.
Case studies
Case studies are based on actual or simulated events and are a way of
helping you to interpret protocols, deal with uncertainties and weigh up
the balance of judgments needed to arrive at a conclusion. Case studies
are designed to prepare you for similar or related cases that you may face in your
own practice.
Reflective questions
We have included reflective questions in this programme to give you an
opportunity to reflect on what you already know, or on what you have read so far,
to reinforce and extend your learning. Thinking about these questions will help
you to meet the objectives of the programme.
Linking CPPE to CPD
To help you see how our learning programme can support your CPD, look out for
this icon.
Assessment
You can complete your learning of this programme by working through the associated
assessment. This is available for you to complete and submit online through the
CPPE website: http://www.cppe.ac.uk. If you are not successful, we offer
automatic feedback after you have completed each section. We have designed the
feedback to let you know the broad area where we think you would benefit from
further learning before attempting the assessment again.
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A B O U T C P P E O P E N L E A R N I N G P R O G R A M M E S
References and further reading
References for all the books, articles, reports and websites mentioned in the text,
together with a list of further reading to support your learning, can be found at the
end of the programme. References are indicated in the text by a superscript
number (like this
3
).
Programme guardians
CPPE has adopted a quality assurance process called programme guardians.
A programme guardian is a recognised expert in an area relevant to the content of
a learning programme who will review the programme every six months. Any
corrections, additions, deletions or further supporting materials that are needed
will be posted as an update to the programme on the CPPE website. We
recommend that you refer to these updates if you are using this (or any other)
learning programme significantly after its initial publication date. A full list of
programme guardians is available on our website. You can email your comments
about this programme to them at: info@cppe.ac.uk
Brand names and trademarks
CPPE acknowledges the following brand names and registered trademarks which
are mentioned throughout the programme: Adcortyl in Orabase
, Bonjela
,
Colpermin
, Creon
, Gelclair
, NovoRapid
, Oramorph
, Ensure Plus
, Xeloda
External websites
CPPE is not responsible for the content of any non-CPPE websites mentioned in
this programme or for the accuracy of any information to be found there. The fact
that a website or organisation is mentioned in the programme does not mean that
CPPE either approves of it or endorses it.
Disclaimer
CPPE recognises that local interpretation of national guidance may differ from the
examples used in this learning programme and you are advised to check with your
own relevant local guidelines. You are also advised to use this programme with
other established reference sources. If you are reading this programme significantly
after the date of initial publication you should refer to current published evidence.
CPPE does not accept responsibility for any errors or omissions.
Feedback
We hope you find this learning programme useful for your practice. Please help us
to assess its value and effectiveness by completing the online feedback form
available on our website: http://www.cppe.ac.uk via the My CPPE tab. Simply
scroll down to find the learning programme title and click on the Tell us what you
think icon. CPPE may email you a reminder to do this. You can also email us direct
if you think your comments are urgent using the email address:
feedback@cppe.ac.uk
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About this learning programme
Welcome to the CPPE open learning programme on Cancer: in relation to
pharmacy practice, which we have designed as a key element of the Cancer and
immunology theme. The aim of this programme is to give you an overview of the
most common cancers and show how the pharmacy team can help to identify and
manage them, and help to support people living with the disease.
By the time you have worked through this programme you will have extended your
knowledge about the most common cancers in the UK and improved your
confidence in dealing with this area of patient care. Your approach and
understanding should enable you to deal sensitively and effectively with people
living with cancer, and their carers.
The study time will depend on you, but we estimate that the reading and activities
will take a total of 8-10 hours.
Target audience
This programme is aimed at pharmacists and pharmacy technicians working in
any area of practice. Some sections may appear more relevant to a sector other
than the one youre working in, but we encourage you to reflect on the best way
you can apply that learning to your own sector of practice.
Learning style adopted in this programme
The programme is split into five sections:
G cancer in context
G preventing and detecting cancer
G principles of treatment
G responding to symptoms of disease and treatment
G supporting patients and carers.
This programme contains enough information to provide you with an overview of
cancer and its management. However, in order to boost your understanding of the
subject we suggest that you do some further reading. We have included a list of the
references that we have used at the end of each section, many of which you may
find helpful. In addition, we recommend that you read the immunology chapter
in any anatomy and physiology textbook.
We also recommend that you visit websites set up by patient groups. Some of these
organisations have local branches. If there is one in your area then why not get in
touch with them? We have provided relevant references and web addresses where
appropriate throughout this programme, as well as information about useful
resources (see Appendix 1).
We have also included activities which ask you to plan your response to a
particular situation. These are to encourage you to reflect on your current
knowledge and understanding of the subject area, and to plan what you might say
in certain circumstances.
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Learning objectives RPSGB competences KSF dimensions
Pharmacists Pharmacy
technicians
Demonstrate an understanding of the public G1, G3, G10 TG2, TG4, TG9 Personal and people development
health agenda by explaining the role of Level 1 and 2
prevention, screening and risk reduction in
Health, safety and security Level 1
relation to your practice.
Health and well-being HWB6 Level 2
Describe the background and presentation of G1, G3 TG2, TG4 Personal and people development
the six most common cancers in the UK. Levels 1 and 2
Analyse your role in the management of G1, G3, G7 TG2, TG4, TG6 Personal and people development
cancers with particular reference to appropriate Levels 1 and 2
therapy, management of side-effects and
Communication Level 3
palliative care.
Health and well-being HWB7 Level 3
Provide appropriate advice on alternative G1, G3, G7 TG4, TG7 Personal and people development
methods of disease management. Level 1 and 2
Health and well-being HWB7 Level 2 and
HWB10 Level 3
Develop your approach to supporting people G2, G3, G8 TG1, TG2, TG7 Communication Level 3
living with cancer and their carers.
Service improvement Levels 1 and 2
Information and knowledge Levels 1 and 2
Undertake a mapping exercise of local G2, G3, G8 TG1, TG2, TG7 Communication Level 3
colleagues and networks to support patients.
Evaluate your personal practice against your G2, G3, G8 TG1, TG2, TG7 Communication Level 3
own service objectives.
A B O U T T H I S L E A R N I N G P R O G R A M M E
Learning objectives
CPPE has linked all its learning programmes to the Royal Pharmaceutical Society
of Great Britains competences for pharmacists and pharmacy technicians. This
will make it easier for you to connect your professional practice to your learning
needs and learning activities. We have selected only the competences for general
pharmacists and pharmacy technicians, but we are aware that others exist.
We have also linked the learning to the dimensions of the NHS Knowledge and
Skills framework (KSF).
The competences and dimensions relevant to this programme are:
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Working through this programme
We would advise you to work flexibly with the materials to suit your own style of
learning. There is no right or wrong approach, but remember that the aim of your
hard work is to enable you to feel confident to meet the challenges facing you. Bear
this in mind as you work through the programme it will help you to decide if
your approach to study is working.
We have designed the programme for self-study, but as you progress through the
sections it will be essential for you to talk through some of the issues with your
staff and colleagues.
Online resources
Some of the references in this programme are to material which is only available
online, and we assume that you have access to a computer connected to the
internet. If you do not wish to retype all the web addresses into your browser you
may find it helpful to download this programme from the CPPE website as a PDF
document containing live web links. Log on to: http://www.cppe.ac.uk
Where we think it will be helpful we have provided the URL to take you directly to
an article or specific part of a website. However, we are also aware that web links
can change (eg, the Department of Health links) so in some cases we have
provided the URL for the organisations home page only. If you have difficulty
accessing any web links, please go to the organisations home page and use
appropriate key words to search for the relevant item.
Note on NICE guidance: To find any of the NICE guidelines or technology
appraisals mentioned in this programme visit the NICE website at:
http://www.nice.org.uk On their home page, under Search NICE guidance, enter
the relevant topic and click Search.
Note on articles: If you have difficulty locating an article on the internet, search
via: http://www.google.co.uk by typing in the title, author, date and name of the
journal. It can also be helpful if you add in, at the end of the search criteria, the
website where you think the information may be, eg, dh.gov.uk
Supporting the British Oncology Pharmacy Association
competency framework
The British Oncology Pharmacy Association (BOPA) has developed a competency
framework to support the development and practice of pharmacy professionals
working in this specialised field. When we developed this programme, we worked
with our colleagues from the BOPA to include content, activities and assessment in
this programme that you could use to demonstrate that you are progressing
through this framework.
If you complete all of the learning and the activities in this programme then you
will be able to meet many of the competences in the foundation level of this
framework. However, you will need to undertake additional learning activities to
meet the following competences:
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Calculation of chemotherapy doses including body surface area
determination
G Able to perform dose calculations using weight or BSA
G Able to use locally available BSA calculators (adult and paediatric)
G Able to use calculation of carboplatin dosing using Calvert equation
G Awareness of dose banding, capping and rounding doses
Procedures for safe handling of chemotherapy
G Knowledge of basic safe handling procedures for pharmacy and chemotherapy
nursing staff including spillage, disposal of chemotherapeutic waste
G Demonstrates basic understanding of occupational hazards of exposure to
chemotherapy drugs and waste
G Understands causes of exposure to chemotherapy
G Able to describe precautions when extemporaneously preparing or
manufacturing oral formulations of chemotherapy (eg, for paediatrics or clinical
trial materials)
Documentation of systemic treatment orders and delivery
G Documentation of pharmaceutical care activities and outcomes, including those
specific to oncology
For more information on the BOPA competency framework, visit their website at:
http://www.bopawebsite.org and to look at the detailed competency framework
visit:
http://www.bopawebsite.org/tiki-page.php?pageName=Position+Statements
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Supporting you, your practice
and the NHS
When devising this programme we paid special attention to how it would
contribute both to your own professional development and to the overall
improvement of NHS services. We have illustrated some of these benefits in the
diagram below (you will find more detail as you progress through the
programme).
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You,
your practice
and this learning
programme
Primary care pharmacy
This programme will help
provide the context for cancer
care as an increasing number
of patients choose home
management.
Community pharmacy
Working through the
programme will help to focus
your development and
learning to support people
living with cancer and
their carers.
Pharmacy technicians
The programme provides a
broad introduction to the
topic of cancer care and a
framework for ongoing
development.
Specialists in
cancer services
The programme can act as an
aide memoire and tool to
help you as you support the
development of others.
Secondary care pharmacy
This programme provides a
framework to support your
professional development in
cancer care.

Section 1
Cancer in context
Objectives
On completion of this section you should be able to:
I describe your own developmental needs for your role in cancer care
I explain about the different cancer services and the roles and
responsibilities of the healthcare professionals involved in cancer
care
I discuss the national framework relating to cancer care with
particular reference to NICE guidance
I state the epidemiology of cancer, listing the common signs and
symptoms of the six most common cancers in the UK
I describe the background and presentation of the six most common
cancers in the UK.
This section considers cancer at a personal, local and national level. We highlight
the main policy developments that have been put in place to ensure the provision
of high quality cancer services nationwide. Then we move on to look at the
statistics relating to the common cancers in the UK, describe how they present and
how they are staged.
As with any learning programme, your key challenge is to reflect on how you
would like to change and improve your practice as a result of what you have learnt.
xercise 1 Cancer what does it mean to you?
It seems like almost everyone has been affected by cancer on a personal or social
level, whether through family members, or at work. Before you start to work
through this programme, take the time now to write down what cancer means to
you. Try to include as much detail as possible you may want to use a mind map
approach, a table, bullet points or prose.
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S E C T I O N 1
Reflection on practice
Now that you have thought through the wide range of factors that you associate
with cancer, look back through your notes. What are your learning needs in
relation to these factors? Which of your learning needs do you want to develop
first?
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C A N C E R I N C O N T E X T
Planning point
You may find it helpful to think of the areas that you find more challenging, or
aspects of cancer care that make you feel uncomfortable; this can often suggest a
learning need.
List below the personal development needs that you have just identified.
You will have an opportunity to return to this exercise at the end of the
programme to evaluate your learning.
1.1 The structure of cancer services
The Calman-Hine report
1
was published in 1995 as a direct result of the concerns
of government (expressed in twoWhite Papers) and interested organisations and
individuals over the provision of cancer services. The report recommended, among
other things, that:
G all patients should have access to uniformly high-quality care
G services should be patient focused
G there was a need for public and professional education about cancer.
In response to the reports recommendations, cancer care in the UK is now
provided through cancer networks, developed to ensure that all patients have
access to specialised care. The report also introduced the concept of cancer
units, often found in district general hospitals, where the more common cancers
are treated, and cancer centres, which provide additional expertise in common
cancers, and also manage rarer cancers after referral from cancer units.
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In response to the reports
recommendations, cancer care
in the UK is now provided
through cancer networks,
developed to ensure that all
patients have access to
specialised care.
S E C T I O N 1
Cancer networks consist of an overall management board, who oversee the work of
several different groups. Each group consists of a range of healthcare professionals
from different hospitals. Some groups are specific to a type of cancer (site-specific
groups), for example, lung cancer; while some groups provide support for all
appropriate patients in the network (cross-cutting groups), for example,
palliative care. Each network has a research element, as well as a user group, a
user being either an ex-patient, a patient, carer, or family member. The user group
is an important part of the cancer network, helping to ensure that the provision
and development of cancer services are patient centred.
Practice point Information toolkit
Visit: http://www.cancer.nhs.uk and locate the website of your local cancer
network.
G What groups are there?
G What other resources can you find?
G Which of these are relevant to you?
G How will you use them?
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Screening Health education
Secondary healthcare Diagnosis Staging
Treatment Follow-up
Primary healthcare, eg, GP
1.2 The healthcare teams involved in cancer care
xercise 2 A cancer care pathway
The chart below outlines the areas of healthcare that are involved at each step of
the cancer care pathway. Complete the chart by adding the titles of the key
oncology team members to each of the boxes below.
Note: You may want to consider end of life care as well.
The cancer multidisciplinary team
There are many different healthcare professionals involved in the care of the
cancer patient, from the initial GP referral through to the hospice.
Each cancer network has input from cancer centre specialists to ensure all patients
get access to appropriately specialised care. Multidisciplinary team meetings
enable specialists, for example, radiologists, surgeons, oncologists, and the patients
GP, to discuss patients who have been newly diagnosed with cancer, and agree a
management plan.
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Multidisciplinary team
meetings enable specialists, for
example, radiologists,
surgeons, oncologists, and the
patients GP, to discuss patients
who have been newly
diagnosed with cancer, and
agree a management plan.
S E C T I O N 1 6
xercise 3 The multidisciplinary oncology team
Use the table below to briefly describe the roles of each member of the oncology
team.
Clinical oncologists
Medical oncologists
Haemato-oncologists
Surgeons
Palliative care
consultants
Associate specialists
in clinical oncology
The role of the pharmacy team
Each cancer centre or unit will have a designated lead pharmacist, who has overall
responsibility for the preparation of chemotherapy. There will often be several
specialist pharmacists, especially at large centres, who will be involved in the
pharmaceutical care of cancer patients. Their duties range from giving
pharmaceutical advice to other healthcare professionals, through to designing
protocols and prescribing complex medications, such as chemotherapy regimes.
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There will often be several
specialist pharmacists,
especially at large centres,
who will be involved in the
pharmaceutical care of
cancer patients.
Cancer pharmacist: specialises in cancer care working within the
multidisciplinary team to ensure correct dosing, monitoring, and management of
side-effects and/or interactions. Cancer pharmacists are a source of advice to the
cancer team and the pharmacy department.
Aseptics pharmacy technician: specialises in aseptics they measure and dispense
chemotherapy in isolators/laminar flow cabinets.
Lead principal aseptics pharmacy technician/pharmacist: oversees aseptics
production, ensuring accurate procedures and the availability of detailed
worksheets for dispensing, and managing the unit; they also ensure all staff follow
good manufacturing practice.
Cancer network pharmacist: leads and supports the strategic direction of
chemotherapy-based cancer care within the cancer network; there is normally only
one in each cancer network.
The role of the nursing team
Specialist nurses are the backbone of the secondary care service and are often
responsible for co-ordinating cancer care. Each cancer centre or unit will have a
lead nurse with responsibility for that hospital. In addition, there will usually be
nurses who specialise in specific areas of cancer care, for example, breast, bowel or
palliative care. Any cancer unit giving chemotherapy, will be supported by a team
of nurses trained in this area, and often they will also be trained in patient
assessment.
xercise 4 Oncology nurses
Briefly describe the role of each of the nurses in the oncology team.
Nurse Role
Clinical nurse
specialists
Chemotherapy nurse
Radiotherapy sister
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Any cancer unit giving
chemotherapy, will be
supported by a team of nurses
trained in this area, and often
they will also be trained in
patient assessment.
S E C T I O N 1 8
Cancer research
nurse
Cancer network
nurse
Palliative care nurse
Other professionals involved in cancer care include:
Oncology specialist dietitian who provides specialised nutritional care to patients
living with cancer; both in the treatment or palliative care setting. They work in
hospitals, hospices, and in the community and are an important part of the
multidisciplinary team.
Occupational therapist who works to increase patient safety and facilitate
independence in activities of daily living (such as dressing, bathing, feeding, and
grooming) by increasing patient strength, educating the patient and/or carer, and
arranging for additional equipment as necessary to support these everyday
activities.
Physiotherapist who works with patients to improve their strength and functional
mobility (such as, walking, getting in and out of bed, climbing stairs) and to give
appropriate advice to the family/caregiver. A physiotherapist would assess any
equipment needs and make recommendations regarding appropriate mobility aids.
Speech therapist who provides a variety of services for cancer patients, focusing
on their communication needs, as well as any difficulty they may have with
swallowing. The speech therapist provides pre- and post-operative advice, and
assesses the patients ability to swallow and any problems they may have with their
speech, and then provides appropriate resources as required.
Each multidisciplinary team also has a co-ordinator who organises the teams
meetings for specific tumour groups. The co-ordinator is responsible for ensuring
all relevant information is available for the meeting, such as patients notes,
X-rays, CT scans.
A U G U S T 2 0 0 9
Groups who provide support to the multidisciplinary team include:
Citizens advice bureau (CAB)
The CAB can provide advice to patients about any benefits, grants or other
assistance they may be entitled to.
Social care
Social care professionals organise a variety of services for patients who are ill and
being cared for at home, ranging from home help and meals-on-wheels, through to
financial support. Funding for these services is often an issue, but various referral
forms exist for terminally-ill patients to ensure quicker access to services. This can
be very important to patients, as many will express a wish to die at home, which
will often only be possible with extra support.
Social workers are responsible for assessing what practical and social help the
patient, or their carer, needs. They also organise and co-ordinate help from a
variety of sources.
Complementary therapists
Complementary therapy can be an important aid for patients dealing with cancer,
and there are a wide variety of complementary therapies available, such as
aromatherapy and massage. Some hospices offer complementary therapies, and
many hospices have day-care facilities where patients can attend for the day and
receive complementary therapy, in addition to participating in other activities, such
as art groups.
Practice point
Find out which complementary therapies are available to cancer patients
in your area.Try contacting your local hospice, or look on their website.
Community nurses
This broad category incorporates district nurses, who will deliver practical care,
such as changing dressings, and palliative care. It also includes specialist
community nurses, particularly in palliative care, who provide clinical and
educational support to fellow professionals, and support and counselling to
patients and carers. Some specialist community nurses are charitably-funded, such
as Macmillan nurses and Marie Curie nurses.
Volunteers
Volunteers help out in many different areas, from hospital visits to sitting with
dying patients. Usually volunteers are organised through charities, and are often
based at the local hospice.
9
A U G U S T 2 0 0 9
Complementary therapy can be
an important aid for patients
dealing with cancer, and there
are a wide variety of
complementary therapies
available, such as
aromatherapy and massage.
S E C T I O N 1
1.3 National guidance
One result of the Calman-Hine report was the publication of guidelines relating to
different cancers, starting with breast cancer in 1996.
2
The responsibility for these
guidelines was taken over by the National Institute for Health and Clinical
Excellence (NICE) in 1999. Their guidance covers screening programmes and
diagnosis of cancer, as well as the treatment of cancer. This programme will refer
to NICE guidance, wherever appropriate.
Practice point
Look at the NICE website (http://www.nice.org.uk) Find the NICE
guidance for cancer services and if possible print a copy of the summary
document for one or two of the cancers you wish to know more about.
1.4 An introduction to the disease
Cancer is a highly emotive word. To many people, cancer means a terrible death
sentence. As a disease, cancer covers a broad spectrum of different conditions.
There are over two hundred different types of cancer, ranging from those with
cure rates of nearly 100 percent, to those which usually result in death. Cancer is a
common disease, affecting around one in three people in their lifetime. It is among
the leading cause of death, being responsible for around one in four deaths in the
UK. In addition to those affected by the disease, cancer also has an impact on
family and friends; most adults will have the experience of someone close to them
having cancer.
Cancer is defined as the disordered, abnormal, uncontrolled growth of cells. It
originates in a particular organ or tissue type, and can spread locally or can spread
to other sites in the body. The other sites are termed metastases, and a cancer
spread in this way is termed metastatic.
Cancerous changes can occur in almost any type of cell in the body, with some
types being more common than others. The four most common cancers in the UK
are lung, breast, colorectal and prostate; although the incidence of each of these
varies between men and women. Also of importance, from a public health point of
view, are malignant melanoma and cervical cancer. We will look at each of these
cancers individually in the following sections.
Although cancer can spread to other organs, we always talk of the cancer in terms
of the organ of origin, as the malignant cells from a particular organ will have
unique characteristics. These can affect which treatments work, and how the
cancer is likely to progress. For example, a breast cancer that has spread to the
lungs or bones is still referred to as breast cancer, and the treatments used will be
breast cancer treatments.
Staging
Initial assessment of the cancer will usually involve taking a scan or X-rays of the
tumour to determine the extent of the cancer. The cancer can then be staged. The
10
A U G U S T 2 0 0 9
Although cancer can spread
to other organs, we always
talk of the cancer in terms of
the organ of origin, as the
malignant cells from a
particular organ will have
unique characteristics.
system of staging used depends on the cancer, but the TNM system is commonly
used. In this system, the T expresses tumour size, and is described as 1 to 4; the N
determines the extent of the lymph node involvement, and is expressed as 0 to 3;
and the M refers to the presence of metastases, with 0 meaning no metastases and
1 indicating the presence of metastases.
For individual cancers, the TNM system is then often converted to a different
staging system, often expressed as 0 to IV, depending on the extent of the disease.
Some cancers, for example, prostate and colorectal cancer use different systems of
staging (see later in this section).
xercise 5
What percentage of all cancer deaths do you think are attributable to lung,
colorectal and breast cancer?
HINT: You can find information about this on the Cancer Research website
(http://www.cancerresearchuk.org/); just click on news and resources,
then cancer stats, then UK cancer incidence then the most common cancers.
Note: We have taken much of the information in this section about different
cancers from the Cancer Research UK website
(http://www.cancerresearchuk.org). The cancer statistics provided in the
remainder of Section 1 are based on information from Cancer Research UK
relating to UK data for 2005. When we developed this programme the statistics
were being updated to 2006 and we anticipate that these will now be available
on the website. It is worth checking for the most recent information.
1.5 Lung cancer
Background
Lung cancer can be divided into three main types, based on histology:
mesothelioma, small-cell lung cancer (SCLC) and non-small-cell lung cancer
(NSCLC). Generally, the SCLC variant has a better initial response to treatment,
but returns rapidly, and is often associated with a worse outcome. Around 90
percent of lung cancer is associated with smoking.
3
Lung cancer was rare up until
E
11
A U G U S T 2 0 0 9
For individual cancers,
the TNM system is then often
converted to a different staging
system, often expressed as
0 to IV, depending on the
extent of the disease.
S E C T I O N 1
the early years of the twentieth century, when the impact of the wider availability
of mass-produced, cheap cigarettes was felt. Other possible causes of lung cancer
include asbestos exposure and radon gas exposure.
Incidence and mortality
Lung cancer is the second most common cancer in men and the third most
common in women. There were 38,598 cases of lung cancer registered in 2005,
with 80 percent occurring in patients over the age of 60.
3
However, the incidence
is currently dropping in men, but is stable in women.
3
Overall, one year after diagnosis, around 25 percent of patients will still be alive,
and the five-year survival rate is seven percent, but much depends on the stage the
cancer had reached when diagnosed earlier diagnosis leads to improved survival.
Presentation
The classic presentation involves some or all of the following symptoms:
G haemoptysis
G cough
G dyspnoea
G chest discomfort
G recurrent / persistent chest infections.
Non-specific symptoms may also be present, such as weight loss, anorexia and/or
fatigue.
Practice point
Consider the symptoms of lung cancer.Why do you think many patients do
not present until the disease is advanced? Jot down the steps that you could
take to improve this.
12
A U G U S T 2 0 0 9
Planning point
Which of these can you commit to?
With larger, locally-advanced tumours, further symptoms may be present,
including:
G superior vena cava obstruction:
G facial swelling
G dilated veins on the upper chest, shoulders, arms
G hoarseness
G oesophageal symptoms:
G dysphagia
G pleural effusions.
A minority of patients may present with paraneoplastic syndrome, especially
patients with SCLC. Features of this include raised calcium levels, syndrome of
inappropriate diuretic hormone secretion (SIADH) and potentially increased
blood clotting (hypercoaguability).
Initial investigation for a suspected lung cancer is sputum cytology, to detect the
presence of malignant cells in the sputum. In addition, a chest X-ray will usually
reveal a mass. A positive result on both of these is usually followed up by a
bronchoscopy; a long, flexible camera passed into the lungs. Ideally a biopsy of any
mass found will be taken, to determine the histology of the cancer.
Staging
The extent of the cancer is usually expressed as stage IA to IV. Stage I tumours are
small, and can often be treated surgically, with a good survival rate. Stage IV
tumours show metastatic spread, and can only be controlled. Unfortunately, many
patients do not present until they have advanced disease.
1.6 Breast cancer
Background
Breast cancers are differentiated into special types or no special type, based on
histological appearance. An important histological investigation for breast cancer is
to determine the estrogen-receptor (ER) status and the HER2-receptor status, as
these can influence treatment options.
13
A U G U S T 2 0 0 9
Initial investigation for a
suspected lung cancer is
sputum cytology, to detect the
presence of malignant cells in
the sputum.
S E C T I O N 1 14
The main risk factor for breast cancer is increasing age; however, it has been
shown that a first pregnancy after 32 years of age, no pregnancy, late menopause
and early menarche can affect the chance of developing breast cancer. There are
several other risk factors, as shown inTable 1.
TABLE 1 Risk factors for breast cancer
Risk factor
Increasing age Greatest risk
Family history
Geographical location
Non-cancerous breast disease (atypical ductal hyperplasia)
Exposure to radiation
First birth at 32 years or more
No pregnancy
Obesity
Late age of menopause
Early age of first period Lower risk
Source: adapted from Spence RAJ, Johnston PG. Oncology. Oxford: Oxford University Press, 2001.
Breast cancer is the most common cancer in women (45,500 new cases diagnosed
in 2005). Male breast cancer is rare, but not unknown (300 cases in 2005
3
). The
incidence of breast cancer has been steadily rising for the past 25 years. However,
it is worth noting that cure rates have also risen. Around 60 percent of cases occur
in patients over 60.
In 2009, the quoted five-year survival rate is 80 percent, although this depends on
age and the staging of the cancer at initial diagnosis. Those diagnosed at stage I
have a five-year survival rate of nearly 88 percent, compared with around
10 percent in patients diagnosed at stage IV. The best five-year survival is shown in
patients between 50 and 69; younger and older patients tend to do worse.
Presentation
Breast cancer usually presents with the patient finding one of the following:
G a lump in their breast
G breast pain
G discharge from the nipple.
Although any one of these needs further investigation, by themselves they dont
necessarily mean that the woman has cancer.
There are rarely any other symptoms of breast cancer, unless the disease is
advanced. If it is advanced the patient may report symptoms from the metastases
A U G U S T 2 0 0 9
The incidence of breast cancer
has been steadily rising for the
past 25 years. However, it is
worth noting that cure rates
have also risen.
(eg, abdominal pain from liver metastases). Investigation will involve a biopsy of
the suspected tumour. Usually this is a fine-needle aspiration, which can produce a
result within 30 minutes. This result can be definitive, but in some cases a larger
core biopsy, or even an open biopsy, involving surgery, may be needed.
Staging
Breast cancer is staged as between 0 and IV, with 0 being a locally-confined
tumour (often described as a carcinoma in situ) and IV being metastatic disease.
1.7 Colorectal cancer
Background
Colorectal cancer refers to tumours of the large bowel, including the rectum.
Generally colorectal cancers are of the same type -adenocarcinoma.
The main risk factors for colorectal cancer are a family history of colorectal cancer,
dietary factors and other colorectal disease (such as ulcerative colitis).
Colorectal cancer is the third most common cancer in men and the second most
common in women, with 36,500 cases in 2005. Around 75 percent of new cases
occur in patients over 65 years of age.
3
The incidence of colorectal cancer has
remained steady for the past 10 years, although the cure rate has improved.
Five-year survival is around 52 percent. As with other cancers this varies with age
and the stage of the disease. Dukes stage A at diagnosis gives a five-year survival
rate of 83 percent, but this drops to just three percent for those with stage D
disease.
Presentation
Colorectal cancer typically presents with abdominal pain, a change in bowel habit,
rectal bleeding or iron-deficiency anaemia. A minority of patients will present with
bowel obstruction, particularly those where the left side of the bowel is affected.
Patients will often have a palpable mass present.
Screening for colorectal cancer can be done using a faecal occult blood test, to
detect the presence of blood in the stool. This will not usually be due to cancer, as
other conditions such as polyps can cause this; however, it is a valuable method to
identify patients who require further investigation.
Staging
Traditionally colorectal cancer has been staged based on the Dukes system, with A
being a locally-confined tumour and D being metastatic spread. The system has
been modified over time, and may be amended to the TNM system for staging.
15
A U G U S T 2 0 0 9
The incidence of colorectal
cancer has remained steady for
the past 10 years, although the
cure rate has improved.
Screening for colorectal cancer
can be done using a faecal
occult blood test, to detect the
presence of blood in the stool.
S E C T I O N 1
1.8 Prostate cancer
Background
The prostate gland is found only in men, located just below the bladder and next
to the rectum. Prostate cancers are usually adenocarcinomas.
Risk factors for prostate cancer include diet, environmental factors and genetic
background, such as family history and ethnicity. Prostate cancer is more common
in men from a Black Caribbean, Black African and mixed race background. Indian
and Pakistani men have a greater risk than Caucasian men; men from a Chinese or
Bangladeshi background are less at risk. However, the main risk factor is increasing
age.
Prostate cancer is the most common cancer in men, with 34,000 cases in 2005.
3
The disease has increased steadily in incidence but not in mortality; probably due
to improved screening procedures and methods. Around 60 percent of cases occur
in patients over 70, and it is extremely rare in the under-50s.
The five-year survival rate is currently around 70 percent. It has been found that
around 80 percent of 80-year-old men have evidence of malignant changes in the
prostate at autopsy, without any obvious disease. A diagnosis of prostate cancer in
an older patient doesnt need to be considered a death sentence if not treated. Men
are found to have prostate cancer at post-mortem without it being the cause of
death. On some occasions there is a real challenge in deciding whether to treat
prostate cancer or not as the effects of treatment may be worse than the cancer itself.
Presentation
Initial symptoms of prostate cancer are:
G hesitancy in passing urine
G increased frequency
G increased urgency
G having to get up in the night to urinate.
However, these symptoms are the same as those of non-cancerous enlargement of
the prostate. Consequently, many cancers are found by chance, following an
operation to reduce the size of the gland. Symptoms of more advanced disease
include:
G impotence
G incontinence
G localised pain
G bone pain can also occur if metastases are present.
Initial investigation would usually involve the doctor feeling the prostate gland
manually, via the rectum. Biopsies of the prostate are usually taken. More accurate
staging of the disease is carried out by transrectal ultrasound. Prostate specific
antigen (PSA) is usually measured, however this tends to be more useful in
monitoring the disease than diagnosing it.
16
A U G U S T 2 0 0 9
Prostate cancer has increased
steadily in incidence but not in
mortality; probably due to
improved screening procedures
and methods.
During initial investigation for
prostate cancer, specific
antigen (PSA) is usually
measured, however this tends
to be more useful in
monitoring the disease than
diagnosing it.
Screening programmes for prostate cancer using PSA levels are controversial, as a
significant minority of men with cancer will have a normal PSA, while some with
an elevated PSA will not have cancer and may undergo biopsy for no reason.
Clinical trials are presently being carried out to determine if there is any value in a
screening programme.
Staging
Prostate cancer is usually staged using the Gleason score, ranging from two being
the least aggressive cancer to 10 being the most aggressive.
Practice point: Plan your response
A regular patient has just found out that his father is undergoing tests, to
rule out prostate cancer. He is angry and upset as he was not allowed time
off work to attend the appointments with his father. His father, due to stress
and anxiety, has been unable to retain any of the information provided by
the hospital. He simply wants to know, if it is identified as cancer does it
mean that his father will be terminally ill?
How would you respond?
1.9 Skin cancer
Background
Skin cancers can be divided into two main types melanoma and non-melanoma.
The non-melanoma cancers are the most common cancer in the UK, but are
usually disregarded in league tables as they are so easily treated. In this section we
will just look at melanoma.
A melanoma is a cancer of the melanocytes, skin cells designed to protect the
body from excessive ultra-violet (UV) light. These cells darken on exposure to UV
light, giving rise to the characteristic sun-tan. The main risk factors for melanoma
are skin type and exposure to UV light, particularly at a young age. The fairer a
persons skin and the more easily it burns in the sun, the greater the risk of
melanoma. A family history of melanoma also increases the risk of developing the
disease.
Malignant melanoma accounted for 9,500 registered cases in 2005,
3
32 percent of
these in patients under the age of 50. It is rapidly increasing in incidence, and is
now the most common cancer in patients in the 15-34 age group.
17
A U G U S T 2 0 0 9
The main risk factors for
melanoma are skin type and
exposure to UV light,
particularly at a young age.
A family history of melanoma
also increases the risk of
developing the disease.
S E C T I O N 1
The five-year survival rate is currently 78 percent in men and 91 percent in
women. Improved survival is linked with a thinner tumour on diagnosis, which is
linked with earlier presentation.
Presentation
Melanoma presents as a dark raised lesion on the skin, usually on the trunk in
males and the lower extremities in females. Symptoms are rare with early stage
disease, and diagnosis is based on examination, using the ABCD criteria:
A Asymmetry of shape
B Border notching (irregular border)
C Colour darkening
D Diameter enlargement (usually around 7-9 mm)
A biopsy would be taken of any suspicious lesion, to confirm the presence of
cancerous changes.
There are no screening programmes for melanoma at present, but there are public
education initiatives to encourage awareness about sun protection.
Staging
Melanoma is staged from 1A to IV, depending on the thickness of the tumour and
any local or metastatic spread.
1.10 Cervical cancer
Background
Cervical cancer can consist of a wide range of different histological presentations,
from squamous cell carcinoma (about 66 percent) to more unusual variants.
The cause of cervical cancer appears to be infection with certain types of human
papillomavirus (HPV). Research has shown that the risk of developing cervical
cancer is linked to the length of exposure to the virus. According to CancerHelp UK
(http://www.cancerhelp.org.uk) groups at increased risk include women with an
early age of first intercourse (16 years or less) and cigarette smokers.
Recently the development of a vaccine against HPV has raised hopes of drastically
reducing or eradicating cervical cancer.
Invasive cervical cancer affected 2,803 patients in the UK in 2005, occurring in an
even spread in women over the age of 25.
3
The incidence of cervical cancer is
decreasing, which probably represents the impact of screening programmes.
Worldwide however, cervical cancer is the second most common cancer, with
80 percent of cases occurring in developing nations.
The five-year survival rate in the UK is around 68 percent, affected very much by
age at diagnosis. In the 15-39 age group the five-year survival rate is 83 percent,
while this drops to 22 percent in the 80-99 age group.
4
18
A U G U S T 2 0 0 9
There are no screening
programmes for melanoma at
present, but there are public
education initiatives to
encourage awareness about
sun protection.
The cause of cervical cancer
appears to be infection with
certain types of human
papillomavirus. Research has
shown that the risk of
developing cervical cancer is
linked to the length of exposure
to the virus.
Presentation
Early-stage disease is usually asymptomatic, and detected on a cervical smear.
Symptoms of later stage disease can include:
G vaginal bleeding
G foul smelling vaginal discharge
G pain (occasionally backache).
Investigation consists of colposcopy (viewing of the cervix and vagina through a
magnifying instrument), usually followed by a biopsy of any visible lesions.
Staging
It is staged from 0 (carcinoma in situ) through to IVB (tumour with distant
metastases).
1.11 The impact of cancer
Being diagnosed with cancer is a major psychological shock. Most people will not
understand the difference between the types or stages of cancer, and therefore
assume that a diagnosis of cancer is a death sentence. Cancer will also have an
impact on the family and friends of the patient.
Cancer patients may require extra care; they may have symptoms caused by the
disease itself, or by the treatment given. There is also the anxiety of waiting for
results, to see if the disease has worsened or improved. As you work through the
rest of this programme try to reflect on the patients perspective as well as your
own. Symptoms you may consider unimportant may be devastating to the patient,
and the burden of repeated hospital attendances and financial worries can be
draining. Contrastingly, things that you think are essential may not seem relevant
to your patients.
Any plans for giving or monitoring cancer treatments need to focus on the patient
as an individual. Remember we are never treating a type of cancer, we are treating
a patient with a type of cancer.
19
A U G U S T 2 0 0 9
As you work through the rest of
this programme try to reflect
on the patients perspective as
well as your own.
Remember we are never
treating a type of cancer, we
are treating a patient with a
type of cancer.
Learning objective Well can you?
Describe your own developmental needs for your
role in cancer care.
Explain about the different cancer services and the
roles and responsibilities of the healthcare
professionals involved in cancer care.
Discuss the national framework relating to cancer
care with particular reference to NICE guidance.
State the epidemiology of cancer, listing the
common signs and symptoms of the six most
common cancers in the UK.
Describe the background and presentation of the
six most common cancers in the UK.
S E C T I O N 1 20
Summary
In this section you have considered what you need to learn about cancer and
started to plan how you will do this. We have discussed how cancer services are
organised, looked at some of the organisations involved in cancer and highlighted
six of the most common cancers.
Intended outcomes
Having worked through this section you should be able to:
A U G U S T 2 0 0 9
Suggested answers
Exercise 3 The multidisciplinary oncology team (page 6)
Clinical oncologists have undergone specialist training in the provision of
radiotherapy and chemotherapy and are members of the Royal College of
Radiologists (oncology section). They provide non-surgical, (ie, radiotherapy and
chemotherapy) advice.
Medical oncologists have undergone specialist training in the management of
malignancies using chemotherapy and are members of the Royal College of
Physicians. They provide chemotherapy advice.
Haemato-oncologists have undergone specialist training in haematology and the
management of haematological malignancies and are members of both the Royal
College of Physicians and Royal College of Pathologists. They provide medical advice.
Surgeons provide the multidisciplinary team with surgical advice on the
management of the cancer patient and are members of the Royal College of
Surgeons.
Palliative care consultants have had specialist training in palliative care (the
holistic care of patients with advanced progressive illness) and are members of the
Royal College of Physicians.
Associate specialists in clinical oncology support consultants, and supervise junior
doctors and medical students during their oncology postings.
Exercise 4 Oncology nurses (page 7)
The clinical nurse specialist specialises in one tumour area (such as lymphoma or
lung cancer) and acts as a key worker linking the patient with the multidisciplinary
team throughout the whole patient pathway. They are a resource for patients,
relatives, and colleagues, to ensure that the cancer patient is given the highest
standard of care possible.
The chemotherapy nurse administers the chemotherapy to the patient. They also
provide a point of advice for patients during treatment.
The radiotherapy sister uses their specialist knowledge and skills in the
identification, assessment, and management of radiotherapy-induced side-effects.
They provide emotional and psychological support and symptom control for patients
during a course of radiotherapy or chemo/radiation. In some hospitals they will also
provide support after treatment in nurse-led clinics.
The cancer research nurse specialises in cancer clinical trials, carrying out all
essential trial activities, from setting up the trial to advising the multidisciplinary
team on treatment protocols.
The cancer network nurse leads the strategic direction of cancer care within the
network; there is normally only one per cancer network.
The palliative care nurse specialises in the palliative care of patients, including non-
cancer patients and is part of the palliative care team.
A
A
21
A U G U S T 2 0 0 9
S E C T I O N 1 22
Exercise 5 (page 11)
What percentage of all cancer deaths do you think are attributable to lung,
colorectal and breast cancer?
In 2005 in the UK, one in four (24 percent) of all cancer deaths were from lung
cancer. Colorectal cancer was the second most common cause of cancer death
(10 percent) and breast cancer was the third most common cause of cancer death in
all persons (8 percent).
3
A
A U G U S T 2 0 0 9
References
1. Calman K, Hine D. A policy framework for commissioning cancer services. London:
Department of Health, 1995.
2. Department of Health. Improving outcomes in breast cancer. London: DH, 1996.
Updated version only now available NICE (2002) Guidance on cancer services:
improving outcomes in breast cancer Manual update. Available online at:
http://www.nice.org
3. Cancer Research UK, CancerStats. Available only online at:
http://info.cancerresearchuk.org/cancerstats/ (accessed 10 August 2009).
Further reading
Ballinger AB, Anggiansah C. Colorectal cancer. British Medical Journal, 2007; 335:
715-8.
Damber J, Aus G. Prostate cancer. Lancet, 2008; 371: 1710-21.
Department of Health. The NHS cancer plan: a plan for investment, a plan for
reform. London: Department of Health, 2000. Available online at:
http://www.dh.gov.uk
Department of Health. The cancer reform strategy. London: Department of Health,
2007. Available online at: http://www.dh.gov.uk
Office for National Statistics. Mortality statistics: cause. England &Wales, 2006. vol.
DH2 No.32. London: TSO, 2006. Available online at:
http://www.statistics.gov.uk/StatBase/Product.asp?vlnk=618
General Register Office for Scotland. Scotlands Population 2006 The Registrar
Generals annual review of demographic trends. Edinburgh, GROS, 2006.
Available online at: http://www.gro-scotland.gov.uk/statistics/publications-
and-data/annual-report-publications/rgs-annual-review-2006/index.html
Northern Ireland Cancer Registry. Cancer mortality in Northern Ireland.
Online statistics available at:
http://www.qub.ac.uk/research-centres/nicr/Data/OnlineStatistics/
#d.en.26094
Spence RAJ, Johnston PG. Oncology. Oxford: Oxford University Press, 2001.
Thompson JF, Scoyler RA, Kefford RF. Cutaneous melanoma. Lancet, 2005; 365:
687-701.
Veronesi U, Boyle P, Goldhirsch A, Orecchia R, Viale G. Breast cancer. Lancet,
2005; 365: 1727-41.
23
A U G U S T 2 0 0 9
Section 2
Preventing and detecting cancer
Objectives
I explain the role of the pharmacy team in advising people on
approaches they can take to reduce their personal risk of developing
cancer
I recognise common signs and symptoms that customers may present
with in the pharmacy
I describe the most commonly-used screening methods
I identify the points at which referral should be made to an
appropriate healthcare professional
I raise awareness of risk factors and the steps that can be taken by the
wider population in avoiding these.
Cancer is a prominent health issue. Many people are concerned about developing
the disease. Cancer may therefore become a topic of discussion between yourself
and patients. These discussions give you a valuable opportunity to provide
reassurance and information about the various ways that people can reduce their
risk of cancer or ensure early detection.
2.1 Risk factors for developing cancer
Lifestyle
There are several ways that people can adapt their lifestyle to reduce the risk of
developing certain cancers. Pharmacists and the pharmacy support team are well
placed to raise awareness of these lifestyle issues and to help their customers make
changes which may lower their risks of developing the disease.
xercise 6
Complete the table over the page, outlining the reason why you think the lifestyle
may be considered to be a risk factor for developing cancer, and then suggest what
you can do to help customers reduce these risks. We have completed the first line
as an example.
E
24
A U G U S T 2 0 0 9
Pharmacists and the pharmacy
support team are well placed
to raise awareness of lifestyle
issues and to help their
customers make changes
which may lower their risks
of developing the disease.
P R E V E N T I N G A N D D E T E C T I N G C A N C E R
Having worked through this exercise you may feel there are areas where you need
to know more. Reflect on your learning needs and visit the CPPE website
(http://www.cppe.ac.uk) for details of relevant open learning programmes
including: Stop smoking, Nutrition,Weight management, and Sexual health: testing and
treating.
25
A U G U S T 2 0 0 9
Lifestyle factor Why is it a risk factor for What can you do in the
developing cancer? pharmacy?
Smoking Cigarette smoking is responsible for at Pharmacists are able to advise on
least one third of all cancer deaths in the nicotine replacement therapies and
UK. This includes not only lung cancers, in some cases supply these free of charge
but also cancers of the mouth, larynx, under a patient group direction.
oesophagus, pancreas, cervix and bladder.
Sunbathing
Diet
Being overweight
Occupational factors
Drugs
Infectious agents
S E C T I O N 2
Genetics
As well as these modifiable risk factors, people may be concerned that they are at
an increased risk of developing cancer because of their genes. Research is
underway to clarify the links between genetics and cancer and also to see if future
treatments can be tailored specifically to individuals.
1
You may find it useful to
scan through current newspapers and magazines to see what messages your
customers are getting about genetics, cancer risk and therapies.
A patient is concerned that they may be at risk of developing cancer, as a
family member has recently been diagnosed.
What factors do you need to take into account?
Inheritable cancers are relatively rare, so it is important to reassure patients when
they are concerned. When considering genetic risk, three generations of family
should be considered rather than just immediate family. The patient needs to list all
the well relatives, as well as those that have been affected by cancer.
Reflective question: Knowledge check
Write down an example of a first degree relative and a second degree relative.
26
A U G U S T 2 0 0 9
Research is underway to clarify
the links between genetics and
cancer and also to see if future
treatments can be tailored
specifically to individuals.
Which genes increase the risk of developing cancer?
A number of genes have been identified that increase the risk of the patient
developing cancer. These genes are thought to be responsible for approximately
five to ten percent of the most common cancers, such as breast and colorectal.
2
These genes are called high penetrance genes as they commonly cause clinical
manifestations. Examples are BRCA1 and BRCA2. There are also low penetrance
genes that are less likely to cause such manifestations. Examples include CHEK2
and PALB2.
3
The remaining 90-95 percent of cancers are thought to occur due to
a combination of weak genetic factors and non-genetic factors.
The genes implicated in causing cancer are mutated human genes. They would
normally be involved in cellular functions within the cell cycle. The mutation
results in disruption to the normal processes and an increased risk of the cells
becoming cancerous.
These high risk genes are associated with causing cancers in specific organs by
increasing the risk of the cells becoming cancerous; they do not put the patient at
greater risk of developing cancer in general. Some patients in possession of these
genes will live healthy lives. For example, the BRCA1 and BRCA2 genes are
responsible for less than 10 percent of all breast cancers. However, patients with
these genes will have a higher risk of developing breast or ovarian cancer compared
with patients without the genes. The average risk for developing breast cancer for a
woman is 11 percent, and for women who carry these genes it is 85 percent.
4
There are several other genetic syndromes. However, the main features that may
suggest inherited cancer susceptibility in a family and necessitate a referral to the
GP include:
G several close (first or second degree) relatives with the same cancer, an
associated cancer (eg, breast or ovary) or a rare cancer (eg, retinoblastoma)
G multiple cancers in paired organs (eg, bilateral breast and ovarian cancer)
G multiple tumours in different organ systems in one individual
G diagnosis at an early age (eg, colon cancer in the 20s and breast cancer before
the age of 40).
Practice point
Where might you research further for information about genetic cancer
links? Identify at least two websites that you could use.
27
A U G U S T 2 0 0 9
Patients with the BRCA1 and
BRCA2 genes will have a higher
risk of developing breast or
ovarian cancer compared with
patients without the genes.
S E C T I O N 2
2.2 Warning signs and symptoms in the pharmacy
Many cancers can be successfully treated if detected early enough. It is therefore
important to encourage people to see their GP if they have any symptoms that
could indicate cancer. Because there are so many types of cancer affecting
different organs in the body, a variety of signs and symptoms can develop, so
anything unusual for that particular patient should be reported as soon as possible.
xercise 7
List the symptoms that you think might potentially indicate cancer and require
further investigation and state which cancers they may be related to.
Turn to the end of the section for suggested answers.
2.3 Screening and testing
Genetic testing
Genetic testing is controversial. If someone is considering genetic testing they will
need in-depth counselling, with plenty of time for reflection both before and after
the genetic testing, to allow them to reach a well-informed opinion. This type of
testing is effectively a two-stage process. The first step is to identify the faulty gene
in the family. The second step is to offer testing to individuals in the family once
the gene has been identified. It is only carried out by recognised laboratories and is
backed up by formal counselling and support.
A negative result could engender false hope and a positive result could create
enormous anxiety. In the case of breast cancer there is presently insufficient
information available on which to base a decision should the incriminating genes
be detected.
A
E
28
A U G U S T 2 0 0 9
It is important to encourage
people to see their GP if they
have any symptoms that could
indicate cancer.
If someone is considering
genetic testing they will need
in-depth counselling, with
plenty of time for reflection
both before and after the
genetic testing, to allow them
to reach a well-informed
opinion.
A positive result may also lead to the decision to undergo prophylactic mastectomy
or oophorectomy, in the hope that it will save life. Information on the benefits of
such surgery is limited. A Cochrane database review found that although
prophylactic mastectomy reduced the incidence of and death from breast cancer,
there was insufficient evidence that it improved survival. Women who chose to
follow this route were satisfied with their decision, but were less satisfied with the
cosmetic result and their body image.
5
Genetic testing is available at most specialist cancer centres and patients would
usually be referred by their GP or specialist consultant. Initially the geneticist will
look at the patients family tree in detail. They will then decide if genetic testing is
appropriate and which family members should be tested.
Screening
Screening does not reduce the risk of developing cancer, but for some cancers it
may help with early detection and hence improve the therapeutic outcome and
increase survival. Screening should be distinguished from diagnosis. The aim of
screening is to look for the presence or absence of a disorder in an otherwise
healthy person, while diagnosis involves identifying a disease or condition in a
patient who has existing signs and symptoms. Moreover, screening often involves
just one or two tests, while diagnosis can often involve a wide range of questions
and examinations.
Practice points
G Visit the CancerHelp website: http://www.cancerhelp.org.uk/ (select
bowel cancer, thendiagnosing, thentests). Familiarise yourself with
the tests; you may wish to repeat this exercise for other cancers.
G Visit the Department of Health website:
http://www.cancerscreening.nhs.uk/index.html and view the
information provided on the national screening programmes.
The value of screening for particular cancers depends on several factors:
G how well tests distinguish between those individuals with cancer and those
without
G to what extent any diagnosed malignancy causes clinical problems
G what the beneficial and harmful effects of the treatment are on the patients
quality of life.
Screening is only of value if the patient can be offered effective treatment. Unlike
diagnosis, screening for cancer is still in its infancy, with tests currently available
for breast, cervical and bowel cancers. However, not all the tests are highly
sensitive. For example, prostate specific antigen does not necessarily screen for
prostate cancer. For more information about specificity and sensitivity have a look
at the CPPE open learning programme, Screening populations, monitoring people,
examining patients, and in particular Booklet 2.
29
A U G U S T 2 0 0 9
A Cochrane database review
found that although
prophylactic mastectomy
reduced the incidence of and
death from breast cancer,
there was insufficient evidence
that it improved survival.
Unlike diagnosis, screening
for cancer is still in its infancy,
with tests currently available
for breast, cervical and
bowel cancers.
S E C T I O N 2
Lung cancer screening
There is currently no evidence that screening is effective in reducing the risk of
lung cancer mortality.
Vera Butlin
Vera Butlin is 76 years old and has been a smoker (more than 40 a
day) for most of her life. Vera would like some advice on her cough,
aches and pains. She says that she has had a cough for years but
recently it is much worse and keeps her awake all night.
What advice would you offer her?
Breast cancer screening
What is the difference between breast awareness and breast self-examination?
Breast self-examination is important (see Figure 1 below), but breast awareness is
considered to be even more important.
6, 7
This means being familiar with how the
breasts feel and look, as well as the changes that occur each month. Putting too
much emphasis on feeling for lumps means that other changes may be missed.
Such changes include:
G skin texture
G colour
G appearance of the nipple
G discharge from the nipple.
A
1
30
A U G U S T 2 0 0 9
Breast self-examination is
important, but breast
awareness is considered to be
even more important.
FIGURE 1 Advice on a method for breast examination
G Stand in front of a mirror and look for any unusual difference between the breasts.
G Look at each breast separately looking for any dimpling or puckering of the breast tissue or
any changes in skin texture or colour.
G Repeat this visual check with the hands above the head.
G Put hands firmly on hips and look at breasts from every angle. Lean forward and notice the
shape of the breasts.
G Feel for any changes. Raise the left arm. Use three or four fingers of the right hand to explore
the left breast. Press gently but firmly across the whole area of the breast, nipple and arm pit.
Check the area between the breasts and the area up to the collar bone. Repeat to check the
right breast.
G If any changes are noticed, see your doctor.
This process will probably take 10 to 15 minutes.
Have a look at the Be breast aware leaflet from the Department of Health, available
online at:
http://www.cancerscreening.nhs.uk/breastscreen/breastawareness.html
Mammography
A mammogram is an X-ray photograph of each breast, which can detect lumps or
abnormal cells in breast tissue at a very early stage. Mammography screening
offers a good chance of reducing mortality from breast cancer. It is best to advise
women that it can be uncomfortable, as the procedure involves compressing the
breast between two plates.
As part of the UK national screening programme, women aged 50-70 years are
advised to attend for mammography every three years. Women under the age of
50 years are not offered routine screening as this test is not as effective in pre-
menopausal women. This is because the density of breast tissue makes it harder to
detect abnormalities, as well as the fact that the incidence of the disease in this age
group is lower. However, women under 50 years who have received hormone
replacement therapy for over 10 years should be encouraged to attend for
screening.
8
31
A U G U S T 2 0 0 9
Women under the age of
50 years are not offered
routine screening as this test
is not as effective in
pre-menopausal women.
S E C T I O N 2
A 19-year-old university student calls you on the phone for some advice.
She has recently found a lump in her left breast. Apart from this her health
is good and there is no family history of breast cancer. She has been to her
GP who has referred her to the local hospital.This morning her
appointment has come through the post but she is confused as she has
been asked to go for an ultrasound, not a mammogram.
Colorectal cancer screening
Colorectal cancer screening aims to detect bowel cancer at an early stage (in
people with no symptoms) when treatment is more likely to be effective. Bowel
screening can also detect polyps. These are not cancers, but may develop into
cancers over time. They can be easily removed and so the risk of bowel cancer
developing is reduced. The NHS bowel cancer screening programme is now being
rolled out nationally and aims to achieve nationwide coverage by the end of 2009.
The screening process involves a simple test kit, which can be done by the patient
at home, checking for faecal occult blood (FOB).
Abnormalities in the bowel, such as polyps or early malignancies, often bleed; the
amount of blood may be so small that it cannot be seen in the bowel movements.
This test can detect tiny amounts of blood if they are present. The test is not
diagnostic and an abnormal result indicates that the person needs to be referred to
a screening centre which provides endoscopy services and specialist nurse clinics.
8
Screening is recommended every two years for all men and women aged 60 to 69
years. People over the age of 70 may request a screening kit by calling their GP
when the programme is in their area.
Joe Harris
Joe Harris is a 32-year-old man of Afro-Caribbean origin who has
recently married and changed his job. He asks you for advice on
irritable bowel syndrome (IBS). On questioning, Joe tells you that
about three months ago when out on a picnic with his wife Janet he
developed a pain down his right side. The pain disappeared after a
couple of days and he had no other symptoms. He did not go to his doctor.
For the last couple of weeks, however, the same pain has come back, on and
off, his appetite has not been as good as normal, he has occasionally been
constipated and today he has had a couple of bouts of diarrhoea. He tells
2
32
A U G U S T 2 0 0 9
The NHS bowel cancer
screening programme is now
being rolled out nationally and
aims to achieve nationwide
coverage by the end of 2009.
Screening is recommended
every two years for all men and
women aged 60 to 69 years.
you his bowels have never been troublesome before. What would you
recommend?
Prostate cancer screening
Although screening for other forms of cancer has been proven to reduce mortality,
this is not the case for prostate cancer. Early detection of prostate cancer does not
always have an impact on the treatment plan or survival of the patient.
8, 9
There are recognised methods of testing for prostate cancer:
G digital rectal examination (DRE)
G transrectal ultrasound (TRUS)
G measurement of levels of serum prostate specific antigen (PSA).
Sometimes combinations of these tests are used. For example, depending on age, a
raised PSA (greater than 4 ng/mL) appears to be a more sensitive test than DRE
or TRUS. However, raised PSA levels also occur in benign prostatic hyperplasia
(BPH) and prostatitis, and only one-third of men with abnormally high PSA levels
will subsequently be shown to have cancer. PSA screening is often followed up
with transrectal needle biopsy (TRNB). This test can be uncomfortable and may
lead to infection and occasionally to bleeding. Thirty percent of men may have
some bleeding in the urine or semen, or see blood in their bowel motions, for up to
three weeks afterwards.
For early prostate cancer there are currently no reliable evaluations of the effect of
treatments on mortality. There is no evidence that it is beneficial and treatment can
result in major complications, such as incontinence or impotence. Screening may
find early cancer, thus raising expectations of treatment. As currently the treatment
is likely to do more harm than the disease, there is no strong argument for the
benefit of routine screening.
A
33
A U G U S T 2 0 0 9
For early prostate cancer there
are currently no reliable
evaluations of the effect of
treatments on mortality. There
is no evidence that it is
beneficial and treatment can
result in major complications,
such as incontinence or
impotence.
S E C T I O N 2
Brian
Brian is 55 years old. He comes to ask you for advice as he is
worried about the number of times (usually twice) he has to get up
in the night to pass urine. After reading an article on mens health
in a magazine he fears he may have cancer.
What would you say to him?
Skin cancer screening
Skin cancer is not routinely screened for in the UK. It is suggested that individuals
should screen themselves regularly and any abnormalities or changes on the skin
that persist for more than four weeks should be referred to the GP. Likewise, any
existing moles or skin changes which are increasing in size should be referred.
Hannah
Hannah is 29 years old, she works in the travel agency next door and
has asked to speak to you. She takes regular holidays abroad and
ardently applies sun cream while on her holidays. She explains that
she tops up her tan by routinely visiting the tanning salon. She
wants you to confirm that using a tanning bed will not increase her
risk of skin cancer.
What would you say to her?
4
A
3
34
A U G U S T 2 0 0 9
Cervical screening
Women between the ages of 25 and 64 should be invited automatically for smears.
Age Frequency of screening
10
25 First invitation
25- 49 Every three years
50- 64 Every five years
Over 65 Only if not screened since age 50 or on having an abnormal test result
Cervical screening is not required for women under 25 as the incidence of cervical
cancer in this age group is rare. Up until this age the cervix is still developing; the
cells are likely still to be changing so the test is not able to differentiate between
normal cell changes and cancerous cell changes, which means that there is a risk of
false positives, causing unnecessary alarm.
When in the menstrual cycle would you advise a patient to make an appointment
for a smear test?
A smear can be done at either a GP surgery or family planning clinic. A smear
cannot be done during menstruation, so women should be advised to make
appointments to have smears at mid-cycle (approximately 14 days after their last
period started).
The first stage in cervical screening involves taking a sample using liquid-based
cytology (LBC). A speculum is inserted into the vagina to hold it open, then a
sample of cells is taken from the cervix using a swab. The swab is placed in a vial
of liquid and sent away for analysis. The test itself takes a few minutes and is
uncomfortable rather than painful; the results are usually obtained in two to four
weeks.
A
35
A U G U S T 2 0 0 9
Cervical cancer is not required
for women under 25 as the
incidence of cervical cancer in
this age group is rare.
S E C T I O N 2
Women may occasionally be called back for a further smear, which can cause
anxiety. A recall can often simply mean that the previous sample was not sufficient
or that some slight changes have been found. A cervical smear can detect pre-
cancerous as well as cancerous changes, so women with slight changes will usually
be sent for a colposcopy, in which an instrument similar to a magnifying glass is
used to look more closely at the changes in the cervix.
8
A patient has read a newspaper article which says that using the
contraceptive pill causes cancer. She asks you for advice.
There is some evidence to suggest that long-term use of the combined and
progesterone-only contraceptive pill is associated with a small increased risk of
developing cervical cancer. Discontinuing the pill will decrease this risk, with the
risk returning to normal levels within 10 years.
8
The human papilloma virus vaccine was introduced in 2008. This vaccine is given
to all girls in the UK, aged 12-13. Girls over the age of 18 are not offered the
vaccine as once women are sexually active they are at risk of having the virus
already. It may be many years before the vaccine has an effect on the incidence of
cervical cancer, so women are still advised to attend for routine cervical screening.
8
Summary
Cancer is a major public health issue, but many cases are preventable by modifying
lifestyle factors and having appropriate regular screening. Working within a
pharmacy you will see people who are fit, as well as those who are sick. You can do
much to inform people about risk factors, advise them on healthy lifestyle choices
and encourage them to go for screening. You can make appropriate referrals by
being aware of the range of symptoms which could indicate cancer and need
further investigation.
It is important to listen to patients worries about diagnosis and treatments. Many
patients are afraid to seek help from their GP as they fear the worst diagnosis. You
can offer reassurance on the symptoms and stress that, if it is cancer, a quicker
diagnosis and treatment results in a better outcome.
36
A U G U S T 2 0 0 9
There is some evidence to
suggest that long-term use
of the combined and
progesterone-only
contraceptive pill is associated
with a small increased risk of
developing cervical cancer.
Explain the role of the pharmacy team in advising
people on approaches they can take to reduce their
personal risk of developing cancer.
Recognise common signs and symptoms that
customers may present with in the pharmacy.
Describe the most commonly-used screening
methods.
Identify the points at which referral should be
made to an appropriate healthcare professional.
Raise awareness of risk factors and the steps that
can be taken by the wider population in avoiding
these.
Intended outcomes
37
A U G U S T 2 0 0 9
Lifestyle factor Why is it a risk factor for What can you do in the
developing cancer? pharmacy?
Smoking Cigarette smoking is responsible for at Pharmacists are able to advise on
least one third of all cancer deaths in the nicotine replacement therapies and
UK. This includes not only lung cancers, in some cases supply these free of charge
but also cancers of the mouth, larynx, under a patient group direction.
oesophagus, pancreas, cervix and bladder.
Sunbathing The use of sun beds and sunbathing without Advise on healthy exposure to sunlight.
protective creams is well known to increase Stock appropriate high factor sun protection
the risk of developing skin and lip cancers products.
(basal cell, squamous cell and melanoma).
Diet One third of all cancer deaths have been Advise on healthy diets.
attributed to dietary components. Possible Encourage people to avoid excessive alcohol
protective factors include fruit and intake.
vegetables, fibre, calcium. Possible risk
factors include fat, red meat, charcoal grilled
food, salt and high alcohol intake.
Being overweight Being overweight or obese increases the risk Pharmacists can advise on weight loss.
of cancers of the breast, endometrium and There are supervised diet plans available in
bowel. some community pharmacies. Cholesterol
lowering and use of statins can also be
recommended by pharmacists.
Occupational factors Asbestos (lung cancer) Pharmacists should refer concerned
Ionising radiation (breast, thyroid and
patients to their GP.
lung cancer and leukaemia)
Polycyclic hydrocarbons released from
burning fossil fuel (bladder, lung and skin
cancer)
Arsenic (skin and lung cancer)
Drugs Estrogens have been implicated in cancers Pharmacists are able to advise on the risks
of the breast and endometrium. Some of different medicines.
cytotoxics such as the alkylating agents and
etoposide have been linked with the
development of secondary acute myeloid
leukaemia (AML).
Infectious agents Several viruses have been implicated in Pharmacists are able to advise patients on
cancers. These include the papilloma virus protecting their health and should refer
(cervical cancer), the Epstein Barr virus concerned patients to their GP.
(Burkitts lymphoma) and HIV (Kaposis Pharmacists can provide safe sex advice
sarcoma). Helicobacter pylori is known to and recommend that people have the
be a causative agent in gastric cancer. HPV vaccine.
S E C T I O N 2
Suggested answers
A
38
A U G U S T 2 0 0 9
List the symptoms that you think might potentially indicate cancer and require
further investigation.
The following are examples of the types of changes which should be taken seriously,
particularly if they persist for more than a couple of weeks:
G a lump anywhere in the body
G a sore that does not heal
G a change in a skin mole
G difficulty in swallowing
G persistent indigestion
G persistent pain (particularly pain that has a non-obvious cause)
G change in bowel habit
G change in urinary frequency and/or persistent pain on passing urine
G unexplained loss of appetite
G unexplained weight loss
G persistent cough or hoarseness and/or coughing blood
G any blood in the urine or stools
G any abnormal vaginal bleeding
G visual disturbance
G temporary loss of consciousness
G unexplained bleeding or bruising.
Case study 1 Vera Butlin (page 30)
What advice would you offer her?
You should recommend that Mrs Butlin sees her GP.
Case study 2 Joe Harris (page 32)
What would you recommend?
Joe may have irritable bowel syndrome (IBS), but his history is not straightforward.
He has not had bowel problems before and he does not describe his pain as
abdominal or stomach pain. As Joe has had some changes in his life the symptoms
could be due to stress, but there is insufficient information on which to make a
diagnosis of IBS. Referral is the most appropriate action.
A
A
A
39
A U G U S T 2 0 0 9
S E C T I O N 2
Case study 3 Brian (page 34)
What would you say to him?
Frequent urination, particularly at night, is a common problem in middle-aged and
elderly men. It may be associated with difficulty or delay in initiating urination and
variability and reduced forcefulness of the urinary stream and post-void dribbling.
Pain may occur if infection is present. Acute retention of urine, or retention with
overflow incontinence may also occur. Brians symptoms are probably caused by
benign prostatic hyperplasia and you should advise him to see his GP.
Case study 4 Hannah (page 34)
What would you say to her?
Research from Cancer Research UK shows that people who use sunbeds under the
age of 35 can increase their risk of developing a melanoma by 75 percent.
11
In some cases it is believed that the intensity of the UV rays of a sunbed can be up to
10 to 15 times stronger than the midday sun.
11
You should explain that sunbed tanning is no safer than holiday sun tanning.
A
A
40
A U G U S T 2 0 0 9
References
1. Cancer Research UK website: http://www.cancerresearchuk.org
2. Eeles RA et al. Genetic predisposition to cancer, 2nd edition, Arnold, 2004.
3. National Institute for Health and Clinical Excellence. Clinical guideline CG41:
Familial breast cancer: the classification and care of women at risk of familial breast
cancer in primary, secondary and tertiary care. London: DH, October 2006.
4. Wooster R, Webster B. Breast and ovarian cancer, New England Journal of
Medicine 2003; 348:2339-47.
5. Lostumbo L, Carbine NE, Wallace J, Ezzo J, Dickersin K. Prophylactic
mastectomy for the prevention of breast cancer. Cochrane Database of
Systematic Reviews 2004, Issue 4. Art. No.: CD002748. DOI:
10.1002/14651858.CD002748.pub2
6. Morrison A S. Is self examination effective in screening for breast cancer?
Journal of the National Cancer Institute 1991; 83:226-7.
7. Newcomb P A, Weiss N S, Storer B E et al. Breast self-examination in relation
to the occurrence of advanced breast cancer. Journal of the National Cancer
Institute 1991; 83:260-5.
8. NHS Cancer screening programmes website:
http://www.cancerscreening.nhs.uk/
9. CancerHelp website: http://www.cancerhelp.org.uk/
10. NHS Cervical cancer screening programme. Available online at:
http://www.cancerscreening.nhs.uk/cervical/
11. Cancer Research UK. News and resources: SunSmart microsite. Available only
online at: http://info.cancerresearchuk.org/healthyliving/sunsmart/
advice-and-prevention/sunbeds/
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A U G U S T 2 0 0 9
Section 3
Principles of treatment
Objectives
I analyse your role in the management of cancers with particular
reference to appropriate therapy, management of side-effects and
palliative care
I identify the core drug treatments and therapies available
I describe the palliative care approaches to managing people with
cancer
I develop a personal action plan, outlining your role in supporting the
management of people living with cancer.
It can take from days to weeks for a patient to have their diagnosis of cancer
confirmed. A variety of procedures are involved, not only to confirm the presence
of cancer, but also to see how advanced it is and if it has spread to other parts of
the body. Tests may include blood tests, CT and MRI scans, endoscopy,
ultrasound and lumbar puncture. Waiting for results can be a very distressing time
for the patient, so it is important to listen to their concerns and answer any
questions they might have.
Once the patient is diagnosed with cancer, and the extent and type of cancer has
been fully identified, the most appropriate treatment is decided upon. Usually, the
patients case is discussed at a multidisciplinary team meeting, consisting of a
variety of medical and surgical specialists, often from different cancer units.
In this section we look at the treatment options available and, more specifically, at
some of the more commonly-used chemotherapy and drug regimes.
Practice point
Your role in the management of cancer
List the three cancers that you see most often in your practice.
Complete a column in the table overleaf for each of the different types of
cancer you are currently managing in your practice.
42
A U G U S T 2 0 0 9
Waiting for results can be a
very distressing time for the
patient, so it is important to
listen to their concerns and
answer any questions they
might have.
P R I N C I P L E S O F T R E AT M E N T
One of your regular patients attends the pharmacy. She explains that her
partner is undergoing a series of tests to determine if he has cancer. She is
distraught that her partner must wait two or three weeks for a second
appointment with a hospital consultant.This next appointment will reveal
the results of the latest tests.
43
A U G U S T 2 0 0 9
What do you see
in your practice?
What treatments
have you supplied?
Were these related
to treatment or
co-morbidity?
Do you see the
patient, the carer
or both equally?
What side-effects
have you seen?
Could these be
managed with
drug treatment?
If so, what?
What palliative
care products have
you supplied?
What do you need
to develop to
improve your
service?
S E C T I O N 3 44
List the names of five cancer treatment drugs.
Make a note of what you consider to be the most important side-effects of these
drugs.
Drug Side-effects
3.1 Aims of treatment
It is important that the desired outcome of treatment is clear and especially
important to explain this to the patient, so that they can give informed consent to
treatment.
There are three approaches to treatment: curative, adjuvant and palliative.
Curative: Curative treatment aims for the complete cure of the disease. For solid
tumours this will rarely be possible with chemotherapy alone, but a
local treatment of chemotherapy in addition to surgery will often be
used. With haematological cancers a cure is possible with
chemotherapy alone, though radiotherapy may be used as well.
A U G U S T 2 0 0 9
Adjuvant: The literal meaning of adjuvant is in addition to. In this context it
describes a treatment given to prevent return of the cancer, following
local treatment (ie, surgery or radiotherapy to the specific tumour area
or site). Usually this will be chemotherapy, but occasionally it may be
radiotherapy after surgery.
Note: Neoadjuvant treatment is when a tumour is too large to be easily
removed. In this circumstance chemotherapy is given before surgery, to
reduce the size of the tumour and facilitate surgical removal.
Palliative: Palliative treatment aims to control the cancer, and hopefully prolong
life and reduce symptoms.
Note: Palliative treatment should not be confused with palliative care,
with the latter referring to symptom control and quality of life, as
opposed to treatment of the disease.
Throughout cancer treatment the patient should be offered supportive care. This
includes counselling, help with social problems, advice on financial or work issues
and control of symptoms, either of the cancer or of the treatment. Palliative care
services can be involved in this, and not just while the patient is dying. It is a
common myth that palliative care is only appropriate at the end of life, when in
fact it can be very useful to have specialised input early on in the course of the
disease.
The GP, district nurse, home care team or social worker can arrange for a cancer
patient to have respite care in a hospice, hospital, residential home or private
nursing home for a short while. Respite care can also be arranged in the patients
home if they prefer.
It is usual for a cancer patient to go into hospital or a hospice for a period of time
so that their symptoms can be monitored. Hospices specialise in the control of
pain and other symptoms and once stabilised the patient may then return to their
home.
If palliative care is a learning need for you, why not order the CPPE open learning
programme on this topic?
What are the three main options for the treatment of cancer?
45
A U G U S T 2 0 0 9
It is a common myth that
palliative care is only
appropriate at the end of life,
when in fact it can be very
useful to have specialised
input early on in the course
of the disease.
S E C T I O N 3 46
3.2 Options for treatment
The three main approaches to treatment are surgery, radiotherapy and
chemotherapy. Treatment of a cancer can involve multiple options, such as surgery
to remove the cancer, followed by radiotherapy or chemotherapy to prevent local
recurrence.
Surgery: The surgical removal of the tumour is normally intended to
achieve a cure of the disease, although it can occasionally be
used to improve symptoms. Traditionally, surgery has involved
the removal of large areas of tissue, as well as the tumour for
example, complete mastectomy. This is termed radical surgery.
Conservative surgery is now becoming increasingly common, to
try to preserve as much function and appearance as possible. An
example would be a lumpectomy for breast cancer, involving the
removal of the tumour and a section of tissue around the
tumour, but preserving most of the breast.
Radiotherapy: Radiotherapy, or radiation therapy, uses ionising radiation to
damage cancer cells. Normal cells will also be damaged, but will
repair themselves faster than cancer cells. The radiation is given
in multiple small doses, with a time interval between doses to
allow the healing of normal cells. The aim of radiotherapy can be
to destroy the tumour, or it can be to reduce the tumour in size
to improve quality of life for the patient.
Chemotherapy: Cytotoxic chemotherapy works by killing cells, with actively
dividing cells being most affected. Cytotoxic agents are used
because cancers consist mainly of dividing cells, so the
chemotherapy should preferentially target the tumour. However,
other parts of the body are also affected, leading to significant
side-effects. Newer agents have been developed to target specific
features of cancerous cells, hopefully leading to more focused,
and therefore safer, treatment.
The wife of a local business man, who has recently been diagnosed with
bowel cancer, asks to speak to you. She is concerned as the doctors have
told her it is malignant. Her husband has been scheduled to have surgery
within the coming days. She wants your opinion on whether it is a drastic
measure to have surgery, as she has heard of chemotherapy and new drugs
being mentioned in the media all of the time.
A U G U S T 2 0 0 9
Cytotoxic antibiotics
Antimetabolites
S
(2-6h)
G
2
(2-32h)
M
(0.5-2h)
Alkylating
agents
G
0
Mitotic inhibitors
Taxoids
Vinca
alkaloids
Source: adapted with kind permission of Netty Wood, British Oncology Pharmacy Association
P R I N C I P L E S O F T R E AT M E N T 47
3.3 Principles of chemotherapy
Cytotoxic chemotherapy works by targeting dividing cells. A variable proportion of
tumour cells will be dividing at any time, varying between 20 percent to 90 percent
of cells, depending on the tumour type. To understand how different cytotoxic
agents work we need to understand what happens in dividing cells. Cell division
can be split into several stages, together making what is termed the cell cycle. The
G
1
-phase is the longest, and is when the synthesis of proteins occurs. The S-phase
is when DNA synthesis occurs. The G
2
-phase is another growth phase, where the
cell starts to divide. This is followed by mitotic division in the M-phase. Cells can
also go from G
1
into G
0
phase, which is a rest phase. This process is summarised
in Figure 2.
FIGURE 2 The cell cycle
Combination therapy
Chemotherapy agents are commonly given in combination, although some are
used alone. Combinations of drugs are called regimes, and are commonly given
acronyms depending on the combination. For example, in the treatment of
stomach cancer, epirubicin, cisplatin and capecitabine are given together, in a
regime known as ECX (the X is from the trade name of capecitabine, Xeloda).
There are many different regimes, some of the more common are listed inTable 2.
A U G U S T 2 0 0 9
S E C T I O N 3
TABLE 2 Examples of common chemotherapy regimes
Tumour Regime Drugs
Breast (adjuvant) EC Epirubicin
Cyclophosphamide
CMF Cyclophosphamide
Methotrexate
5-fluorouracil
Lung (adjuvant or palliative) Cis-gem Gemcitabine
Cisplatin
Bowel Modified de Gramont Folinic acid
5-fluorouracil (bolus dose)
5-fluorouracil (infusion)
XELOX Oxaliplatin
Capecitabine
FOLFOX Oxaliplatin
Folinic acid
5-fluorouracil (bolus dose)
5-fluorouracil (infusion)
The advantage of combination therapy is that by giving agents with different
mechanisms of action, tumour cells are less likely to be resistant. If the agents are
chosen carefully, they can have additive effects, making their overall effectiveness
greater than the sum of the individual agents. Ideally, agents should act in different
stages of the cell cycle.
In choosing drugs to use in combination it is important to consider potential side-
effects, as using two agents that cause the same side-effects will result in increased
toxicity for the patient.
Clinical trials
New cancer therapies are rarely tested against placebos; instead they are usually
tested against the best available treatment currently used. Sometimes new regimes
will be designed to give improved survival or better control of cancer symptoms.
Sometimes they will be designed to be less toxic than existing regimes, and so be
better tolerated by patients. Clinical trial endpoints can vary depending on the
cancer being looked at. For example, adjuvant treatment trials will often look at
five-year survival rates (ie, how many patients are alive five years after treatment).
In contrast, a palliative trial might look at time to disease progression, that is, how
long after treatment until the cancer grows.
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A U G U S T 2 0 0 9
In choosing drugs to use in
combination it is important to
consider potential side-effects,
as using two agents that cause
the same side-effects will result
in increased toxicity for the
patient.
Practice point
Find out which trials your local cancer unit participates in. Have a look at
the protocol for one of them, specifically the pharmacy section.What is the
role of the pharmacy staff?What extra documentation is required?Who is
involved in a trial and what is their role?
3.4 Classes of anticancer drugs
Alkylating agents
Alkylating agents form bonds with DNA, causing abnormal cross-linkages between
DNA strands. They are not phase specific, in that they can affect dividing cells in
any stage of the cell cycle. There are several different classes of alkylating agents,
differing in the chemical groups they bond to on the DNA strands.
Commonly-used alkylating agents include the nitrogen mustards, such as
chlorambucil and cyclophosphamide; and the platinum compounds, such as
cisplatin and oxaliplatin.
Antimetabolites
Antimetabolites are similar to naturally-occurring substances used by the cell in the
manufacture of DNA. They work by inhibiting enzymes involved in the synthesis
of DNA. Due to this mode of action, they are most effective against cells in the
S-phase of the cell cycle, so they work best against rapidly-dividing cells.
Common examples of antimetabolites include folate antagonists, such as
methotrexate; and pyrimidine analogues, such as 5-fluorouracil and capecitabine.
Mitotic inhibitors
Mitotic inhibitors affect the assembly of structures in the cell called microtubules,
which are a part of the mitotic division of the cell. The class known as the vinca
alkaloids, which includes vincristine, bind to microtubules at the start of M-phase,
causing the disassembly of the microtubule formation, thus preventing mitosis.
The class known as the taxanes, including docetaxol and paclitaxel, act by
stabilising the microtubule formation, therefore locking cells in M-phase and
preventing division.
Cytotoxic antibiotics
These drugs act by several different mechanisms, most notably by intercalating
with DNA. (Intercalating is when the drug molecule inserts itself into the structure
of the DNA molecule, deforming the DNA molecule and breaking DNA strands.)
These agents work best during the earlier stages of the cell cycle, ie, stages G
1
through to G
2
.
The two classes of cytotoxic antibiotics are bleomycin, and the anthracyclines,
such as epirubicin.
49
A U G U S T 2 0 0 9
S E C T I O N 3
Topoisomerase inhibitors
There are two topoisomerase enzymes (I and II) involved in DNA replication.
Etoposide acts by stabilising the complex formed by DNA and topoisomerase II,
which results in the cell being unable to make DNA, stopping it in the G
1
phase.
Camptothecin analogues, such as irinotecan and topotecan, act by inhibiting
topoisomerase I and so prevent the replication of DNA.
Other agents
The agents that we have included below are not considered cytotoxics, but are
used in a similar manner in cancer treatment, and some require similar precautions
for handling and administration, so we will consider them alongside the more
conventional agents.
Biological agents monoclonal antibodies
Monoclonal antibodies act by targeting specific receptors (antigens) expressed by
tumour cells. Common examples include rituximab, used in haematological
cancers, trastuzumab, used in certain breast cancers and cetuximab (awaiting
NICE guidance), used in bowel cancer.
Molecularly-targeted therapies
These agents are designed to interfere with molecular pathways specific to tumour
cells. Common examples include imatinib, used in chronic myelogenous leukaemia
(CML) and erlotinib, used in non-small cell lung cancer.
Hormonal agents
In some breast cancers growth is stimulated by estrogens and in prostate cancer
growth is stimulated by androgens, such as testosterone. Therefore, alteration of
the bodys hormone levels can be used as a method of controlling these tumours.
In breast cancer expressing estrogen receptors, anti-estrogens can be used. The
most widely known is tamoxifen, which blocks estrogen receptors directly. This is
used both as an adjuvant therapy to prevent recurrence of the cancer, and as
palliative therapy in advanced breast cancer. The aromatase inhibitors, such as
anastrazole, work by reducing the production of estrogen within the tumour cell,
and are now first-line treatment in certain groups of patients. Another treatment
used is luteinising hormone releasing hormone (LHRH) analogues, which work by
down-regulating the pituitary gland, reducing the production of estrogen. An
example of these is goserelin.
In prostate cancer one treatment option is to reduce circulating testosterone levels.
This can be done using estrogens, such as diethylstilbestrol, or by removal of the
testes (orchidectomy). Another option is to use an androgen blocker, such as
bicalutamide. As in breast cancer, LHRH analogues are sometimes used, as down-
regulation of the pituitary gland will reduce testosterone production.
Adjuvant agents
There are several medicines which can be given alongside chemotherapy, either to
prevent side-effects or to enhance effectiveness.
When folinic acid and 5-fluorouracil are used together in metastatic colorectal
cancer, the response rate improves, compared to that with 5-fluorouracil alone.
50
A U G U S T 2 0 0 9
Tamoxifen is used both as an
adjuvant therapy to prevent
recurrence of the cancer, and
as palliative therapy in
advanced breast cancer.
Folinic acid is also used in high-dose methotrexate therapy (folinic acid rescue), or
in methotrexate overdose, as it acts as an antidote to methotrexate. Folinic acid is a
product of the folate cycle reaction inhibited by methotrexate; by giving folinic
acid we can bypass this inhibition.
Mesna is used with some cyclophosphamide or ifosfamide-containing regimes.
Some of the metabolites of cyclophosphamide and ifosfamide can cause bladder
toxicity. Mesna reacts with these metabolites, neutralising them and preventing
toxicity.
3.5 Giving chemotherapy
Routes of administration
Intravenous chemotherapy is the route that most people think of when
chemotherapy is mentioned. The drugs are administered into a vein either by quick
injection (bolus) or by an infusion. It is usually given on an outpatient basis,
though occasionally inpatient stay may be required for certain complex regimes.
Oral chemotherapy is becoming increasingly common, as it is often more
convenient for patients. It should be remembered that oral chemotherapy can be as
potent as intravenous therapy, so you should never assume a treatment is safer or
less toxic just because it comes in tablet form.
Intrathecal chemotherapy is administered into the intrathecal space of the spinal
column. Some chemotherapy agents, when administered in error by this route,
resulted in the death of the patient involved. This route now has additional
restrictions on the staff who can be involved. The administration of intrathecal
chemotherapy is under strict guidance from the Department of Health.
Practice point
Look at the requirements for giving intrathecal chemotherapy.The relevant
documents can be found on the Department of Health website:
( http://www.dh.gov.uk/ and search for intrathecal chemotherapy).
Other routes of administration include by insertion into the bladder (intravesical),
and by infusion into the pleural lining of the lungs (intrapleural).
Administration
Injectable chemotherapy is always given in a specialised setting by appropriately
trained chemotherapy nurses. These nurses monitor and assess the patient,
including checking blood test results. This ensures that the patient is fit to receive
chemotherapy, and is not suffering excessive toxicity. Oral chemotherapy may be
dispensed and taken at home, depending on the agent being used.
Most chemotherapy agents are fairly stable once compounded, although some
have an expiry time as short as six hours (and azicytidine has an expiry time of
just 45 minutes). It is important that patient attendance is carefully co-ordinated
51
A U G U S T 2 0 0 9
Oral chemotherapy is
becoming increasingly
common, as it is often more
convenient for patients.
The administration of
intrathecal chemotherapy is
under strict guidance from the
Department of Health.
Injectable chemotherapy is
always given in a specialised
setting by appropriately trained
chemotherapy nurses.
S E C T I O N 3
with the ability of pharmacy to make the medications, as in addition to problems
with expiry, storage requirements can be an issue. Chemotherapy should not be
kept anywhere except on a specialised unit or in the pharmacy.
Prescribing
Chemotherapy doses are usually calculated on body surface area (m
2
). This is
considered more accurate than dosing by weight, as obese patients will tend to be
overdosed if dosed on actual weight, but underdosed if dosed on ideal body
weight.
Calculating chemotherapy doses
Body surface area (BSA) is calculated according to the Dubois formula:
BSA (m
2
) = 0.007184 (patient height (cm))
0.725
x (patient weight (kg))
0.425
From: http://www.bnf.org.uk an electronic calculator is available on the website. Usually the actual
BSA is used, though some centres use a maximum of 2.0 for dosing (known as dose capping).
A chemotherapy protocol will list the dose per m
2
(or, rarely, per kg); for example, an epirubicin and
cyclophosphamide regime might be:
Epirubicin 90 mg/m
2
on Day 1
Cyclophosphamide 600 mg/m
2
on Day 1
This will be repeated at regular intervals, dependent on the regime. The above example is given every
21 days for a total of four cycles.
Some chemotherapy is dosed according to specific calculations, for example, the Calvert formula used
in carboplatin dosing:
1
Dose (mg) = AUC (mg/mL.min) x (GFR + 25) (mL/min)
(GFR = glomerular filtration rate, usually estimated from serum creatinine using the Cockcroft and Gault
equation).
Other patient parameters must be taken into account. For example, impaired
kidney and/or liver function may require dose reductions, depending on the
chemotherapy agent used. The North London guidelines are endorsed by the
British Oncology Pharmacy Association (BOPA) for their members. Visit their
website at: http://www.bopawebsite.org for more information.
Chemotherapy is mostly prescribed by specialist doctors, though in some centres
specialist non-medical prescribers may prescribe chemotherapy. The doctors
involved in prescribing should at least be at registrar level.
Preparation
Parenteral chemotherapy is prepared in a specialist environment almost always a
pharmacy aseptic suite that allows operator protection. The chemotherapy
prescriptions are checked first by a specialised pharmacist, who has knowledge of
the regimes used. The products will then be prepared by a specially trained
pharmacy technician. Chemotherapy should never be made on the ward because
52
A U G U S T 2 0 0 9
Chemotherapy is mostly
prescribed by specialist
doctors, though in some
centres specialist non-medical
prescribers may prescribe
chemotherapy.
of the risk of operator exposure. Several chemotherapy agents can cause cancer
themselves, in addition to being harmful in pregnancy and causing other adverse
effects. When parenteral preparations are being prepared, there is the risk of a
small amount being released into the local atmosphere. The aseptic unit used will
be designed both to prevent the operator coming into contact with this, and to
remove it quickly from the environment. In addition, the operator will wear
protective clothing, partly to prevent contamination of the product and also to
protect themselves. Similar precautions are applied when making extemporaneous
oral products; however solid dosage forms only require the wearing of gloves. All
cytotoxic waste must be disposed of separately and correctly.
Extravasation
Extravasation is where a parenteral fluid goes into the subcutaneous tissue instead
of the vein. This is an injury resulting from the leakage of chemotherapy from the
veins or by inadvertent administration into the subcutaneous or subdermal tissue.
This can be potentially very serious with some chemotherapy agents, requiring
urgent treatment, plastic surgery and skin grafts. Acidic or alkaline preparations
are most likely to cause this. The anthracycline class of chemotherapy is
particularly associated with this type of injury. Precautions should be taken to
avoid extravasation: injectable chemotherapy should always be given through an
appropriate line or cannula and be administered by qualified and trained staff.
Attention should be paid to the administration instructions from the
manufacturers.
Extravasation can occur during the infusion or a couple of hours post treatment.
Any patient reporting pain or burning at the site of injection should always be
referred immediately back to the specialist centre, as management of extravasation
requires specialist advice.
Most cancer networks have guidelines on the treatment of extravasation, with an
emergency kit always available wherever chemotherapy is administered.
Practice point
Look at your local cancer networks extravasation policy.
Find the website at http://www.cancer.nhs.uk/networks.htm
Note: If you have difficulty locating the information, then search via:
http://www.google.co.uk by typing incancer network as your search
criteria.
3.6 Treatment monitoring
The effectiveness or otherwise of treatment can be monitored in several different
ways, depending on the cancer. Some cancers express substances that can be
measured in the blood, called tumour markers. These can be peptides, antigens,
hormones or a variety of biological chemicals. They are not always useful in
diagnosing a cancer, as the levels can be raised by other factors such as infection.
However, these markers can be extremely useful when assessing if treatment is
53
A U G U S T 2 0 0 9
Several chemotherapy agents
can cause cancer themselves,
in addition to being harmful in
pregnancy and causing other
adverse effects.
Extravasation is where a
parenteral fluid goes into the
subcutaneous tissue instead
of the vein.
Any patient reporting pain or
burning at the site of injection
should always be referred
immediately back to the
specialist centre, as
management of extravasation
requires specialist advice.
S E C T I O N 3
effective, as rising markers suggest the cancer is growing or spreading, while falling
markers suggest treatment response. The most well-known tumour marker is
probably prostate specific antigen (PSA), expressed in prostate cancer.
Other methods of monitoring disease response include various imaging techniques
(most notably CT-scanning), which can be repeated during the course of
treatment to measure response to chemotherapy. There are different systems used
for reporting the response to treatment, as well as differences in how the response
is reported, depending on the type of cancer. A commonly-used system from the
World Health Organization is summarised inTable 3.
TABLE 3 WHO response criteria
Objective response Definition
Complete response (CR) Disappearance of all known lesions, confirmed by two observations
at least four weeks apart.
Partial response (PR) 50 percent reduction in the total size of all lesions and no new
lesions, confirmed by two observations at least four weeks apart.
No change Neither PR nor PD
Progressive disease (PD) 25 percent increase in the total size of all lesions, or the appearance
of new lesions.
Source: Miller AB, Hoogstraten B, Staquet M, Winkler A, 1981
2
In addition to measuring how the disease is responding, it is essential to consider
the patient. The patients symptoms and quality of life must be considered
throughout treatment, and chemotherapy stopped or reduced as appropriate. It is
important that each time a patient receives chemotherapy, the healthcare
professional involved asks them about any problems they had with the previous
cycle, and records this. In this way the team can build a complete picture of how
the patient is managing with chemotherapy.
Depending on the agents used, specific patient monitoring may be required. For
example, some agents can cause kidney damage (especially platinum compounds),
so creatinine must be measured. If a patient is having intolerable side-effects, for
example, episodes of neutropenia or severe nausea and vomiting, the dose of
chemotherapy can be reduced. Dosage reductions vary, but are usually around
20 percent.
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A U G U S T 2 0 0 9
It is important that each time
a patient receives
chemotherapy, the healthcare
professional involved asks
them about any problems they
had with the previous cycle,
and records this.
Mr Adams
Mr Adams, a 55-year-old male, attends your pharmacy requesting a
laxative. On questioning, he reveals that he has had alternating
diarrhoea and constipation, and recently developed rectal bleeding.
He also reports feeling washed out generally.
1. What are the possible causes of Mr Adams symptoms? What would you
advise?
Mr Adams re-attends some months later. He tells you that he was
diagnosed with rectal cancer, and has had an operation. He is currently on
chemotherapy tablets. He now reports diarrhoea, and would like advice on
possible over-the-counter preparations.
2. What is the likely objective of treating Mr Adams with chemotherapy?
3. What chemotherapy is he likely to be on?
4. Is an over-the-counter preparation appropriate?
5
55
A U G U S T 2 0 0 9
S E C T I O N 3
Mr Adams is re-admitted to hospital some months after finishing his
chemotherapy, with recurrence of his original symptoms. A CT scan
confirms disease recurrence. It is decided to start him on oxaliplatin
chemotherapy. The protocol is:
Day 1: Oxaliplatin 85 mg/m
2
Folinic acid 350 mg
5-Flurouracil 400 mg/m
2
(bolus)
5-Flurouracil 2400 mg/m
2
(46-hour infusion)
His weight is 65 kg and height 1.76 m.
5. Calculate the doses to be given.
6. Why is folinic acid given in this regime?
7. What are the side-effects of oxaliplatin?
A
56
A U G U S T 2 0 0 9
Many cytotoxic medicines have specific side-effects; for example, cisplatin can
cause kidney damage. The patient must be well hydrated so the dose is given with
additional intravenous fluids, and the patients kidney function monitored. The
taxols can cause severe allergic reactions, so patients are usually premedicated with
steroids and antihistamines. Several cytotoxics can cause damage to the nerves in
the hands and feet, termed peripheral neuropathy. Examples here include platinum
compounds, especially oxaliplatin, and the vinca alkaloids.
Side-effects will be considered in greater detail in the following section.
Practice point
Think back to the beginning of this section (see page 43).What did you
decide you needed to do to improve your services? How could you achieve
this?
Develop your own action plan now outlining what you intend to do to
support the medicines management of any of your patients living with
cancer.
Note: Remember that BOPA have developed a competency framework for
pharmacists working in cancer services.You may find it helpful to look at
this when planning what you could do (see Appendix 2).Weve developed
this learning programme to help you demonstrate that you can meet many
of these competencies.
57
A U G U S T 2 0 0 9
Several cytotoxics can cause
damage to the nerves in the
hands and feet, termed
peripheral neuropathy.
S E C T I O N 3
Summary
In this section we have looked at the aims of cancer treatment and considered how
anticancer agents work. Some forms of cancers are treatable and in this section we
have detailed the different types of treatment currently available. It is especially
important to explain the available options to the patient, so that they can give
informed consent to the selected treatment. It is important that the desired
outcome of treatment is clear, and that this aim is transparent for the patient
and/or their carer.
Intended outcomes
58
A U G U S T 2 0 0 9
Analyse your role in the management of cancers
with particular reference to appropriate therapy,
management of side-effects and palliative care.
Identify the core drug treatments and therapies
available.
Describe the palliative care approaches to
managing people with cancer.
Develop a personal action plan, outlining your role
in supporting the management of people living
with cancer.
Suggested answers
Case study 5 Mr Adams (page 55)
1. What are the possible causes of Mr Adams symptoms? What would you
advise?
There are several possible causes for Mr Adams symptoms, for example,
inflammatory bowel disease, polyps; one possibility is colorectal cancer, especially
considering his age. He needs to see his GP as soon as possible, who will probably
refer him for endoscopic investigations.
2. What is the likely objective of treating Mr Adams with chemotherapy?
Chemotherapy would be used as adjuvant treatment, to prevent the recurrence of
disease.
3. What chemotherapy is he likely to be on?
Capecitabine is commonly used as an adjuvant treatment in colorectal cancer, and is
an oral preparation; note the potential for interactions.
4. Is an over-the-counter preparation appropriate?
No. The patient needs to contact his chemotherapy service, who should have
provided details of a 24-hour helpline. Depending on how severe the diarrhoea is, he
may be advised to use loperamide, but this is a decision which needs specialist input,
as chemotherapy-induced diarrhoea can be fatal.
5. Calculate the doses to be given.
Body Surface Area (BSA) (Dubois formula*) = 1.80 m
2
*Body Surface area (m
2
) = 0.007184 (height in cm)
0.725
x (weight in kg)
0.425
Oxaliplatin dose = 1.8 x 85 = 153 mg (would usually round up to 155 mg in practice,
as 5 mg/mL preparation.)
Folinic acid = 350 mg (set dose not dependent on BSA)
5-FU bolus = 1.8 x 400 = 720 mg (realistically 725 mg, as 25 mg/mL preparation)
5-FU infusion = 1.8 x 2400 = 4320 mg (realistically 4325 mg, as above)
6. Why is folinic acid given in this regime?
By supplementing the available intracellular folate, folinic acid prolongs the effect of
5-FU, increasing the anti-tumour activity.
7. What are the side-effects of oxaliplatin?
Have a look at the summary of product characteristics and patient information
leaflet (PIL) on http://www.emc.medicines.org.uk Side-effects include nausea,
vomiting, diarrhoea and blood dyscrasias. What do you think of the way that this is
worded in the PIL?
A
59
A U G U S T 2 0 0 9
S E C T I O N 3
1. Calvert AH, Newell DR, Gumbrell LA, OReilly S, Burnell M, Boxcall FE,
Siddik ZH, Judson IR, Gore ME, Wiltshaw E. Carboplatin dosage: prospective
evaluation of a simple formula based on renal function. Journal of Clinical
Oncology,1989; 7: 1748-1756.
2. Miller AB, Hoogstraten B, Staquet M, Winkler A (1981) Reporting results of
cancer treatment. Cancer 47: 207-214.
Further reading
Alwood M et al. Managing complications of chemotherapy, part 1, chapter 6. The
cytotoxics handbook. 4th edition. Oxford, Radcliffe Medical Press, 2002.
Lind MJ. Principles of cytotoxic chemotherapy. Medicine, 2004; 32(3) 20-29.
Parmar MKB. Adjuvant treatment of cancer. Medicine, 2004; 32(3) 33-35.
Spence RAJ, Johnston PG. Oncology. Oxford: Oxford University Press, 2001.
Walker R and Edwards C. Clinical pharmacy and therapeutics. 3rd edition. London:
Churchill Livingstone, 2003.
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Section 4
Responding to symptoms of disease
and treatment
Objectives
I differentiate between symptoms that can be managed in a non-
specialist setting and those that should be referred on to specialists
I make recommendations for the management and treatment of
symptoms of disease
I recognise interactions between chemotherapy and other medicines
I provide advice on the use of alternative therapies.
All patients with cancer will suffer symptoms caused either by the disease itself or
by treatment. A great deal of the pharmaceutical care of cancer patients occurs in
specialist hospitals, but there is much that you can do at ward and community level
to provide the care and support that cancer patients need.
It is important for the pharmacy team to have a basic knowledge of the
chemotherapy agents currently in use and an awareness of the side-effects that
they can commonly cause. With the increase in the number of oral chemotherapy
agents being used, more patients are managing their treatment at home. As a result
patients may be admitted to non-specialist hospital wards while on treatment, or
may seek advice from community pharmacies while still living at home.
The pharmacy team have an important role to play in helping patients to take their
medicines correctly. Treatment regimes for cancer can be complex and may
change from cycle to cycle. This factor, in addition to the incidence of side-effects
associated with these types of drugs, can lead to poor patient compliance. Patients
need reassurance and clear information on how to take their chemotherapy, as well
as support and advice about how to help prevent unwanted side-effects.
xercise 8
How should the following chemotherapy agents be taken? What are their most
common side-effects?
1. Capecitabine
E
61
A U G U S T 2 0 0 9
With the increase in the
number of oral chemotherapy
agents being used, more
patients are managing their
treatment at home. As a result
patients may be admitted to
non-specialist hospital wards
while on treatment, or may
seek advice from community
pharmacies while still living
at home.
S E C T I O N 4
2. Imatinib
3. Erlotinib
4. Sorafenib
Why not try this exercise for agents such as sunitinib and lenolidomide as well or
other agents you have encountered in your practice.
4.1 Management of side-effects of treatment
Toxicity resulting from treatment is assessed following each cycle of chemotherapy.
By encouraging patients to keep a diary or record of their symptoms on a daily
basis and by taking regular blood tests, the effects of treatment can be monitored
and may result in therapy being changed for subsequent cycles. Changes may
involve using a different antiemetic, a different dose of the chemotherapy agent, or
changing the treatment altogether.
You can monitor any potential for toxic side-effects and help with compliance by
making sure that patients understand any symptoms they may experience and how
best to minimise them. This will help to ensure that the patient continues with
therapy, enhancing any potential for cure.
A
62
A U G U S T 2 0 0 9
By encouraging patients to
keep a diary or record of their
symptoms on a daily basis and
by taking regular blood tests,
the effects of treatment can be
monitored and may result in
therapy being changed for
subsequent cycles.
R E S P O N D I N G T O S Y M P T O M S O F D I S E A S E A N D T R E AT M E N T
Amanda
Amanda is due to start chemotherapy for colorectal cancer next
week. She attends the day unit for a new patient talk. Her regime
consists of: oxaliplatin, folinic acid and 5-fluorouracil.
Try to identify what side-effects she could experience. Use the BNF
and summaries of product characteristics to help you.
Elly
Elly is a cancer patient. Her treatment regime consists of three
cycles of: 5-fluorouracil, epirubicin and cyclophosphamide;
followed by three cycles of Taxotere.
Try to identify what side-effects she could experience. Use the BNF
and summaries of product characteristics to help you.
7
A
A
6
63
A U G U S T 2 0 0 9
S E C T I O N 4
4.2 Infection
Infections can be a problem as they not only put the patient at risk, but they also
result in delays to treatment.
As pharmacists it is important to realise the importance of monitoring for any
adverse effects of chemotherapy, as patients are likely to seek advice from the
pharmacy team on how best to manage the situation.
The bone marrow consists of rapidly dividing cells, the target for chemotherapy.
Nearly all cytotoxic chemotherapy will cause bone marrow suppression
(myelosuppression) to some extent. This in turn increases the risk of infection, so
you need to watch for any relevant signs and symptoms. Patients on chemotherapy
are given a thermometer and advised to take their temperature regularly and if they
have an increased temperature or any other symptoms of infection they need to be
referred to their specialist centre for advice. Patients are also advised to carry alert
cards that carry emergency contact numbers for them to phone in the event of
infection, both during the working day and out of hours. You can check with a
patient to see that they have an alert card and if not contact the oncology team.
Referral to the right place will ensure that the patient receives the most effective
treatment rapidly.
Myelosuppression also leads to anaemia, low neutrophil counts (neutropenia) and
low platelet counts (thrombocytopenia).
Febrile neutropenia the presence of a fever in a patient with neutropenia is
considered a medical emergency requiring urgent admission to hospital. Once
admitted the patient will be treated with intravenous fluids and, in the case of
sepsis, broad-spectrum intravenous antibiotics. In severe or complex cases
granulocyte colony stimulating factors (GCSF) are used. These stimulate the
production of neutrophils by the bone marrow.
xercise 9
What do you consider to be the main signs and symptoms of infection?
Patients should also report any signs of bruising or bleeding (possible
thrombocytopenia), and excessive tiredness or breathlessness (possible anaemia).
Different chemotherapy drugs are associated with causing sepsis due to
neutropenia to different degrees. Prophylactic antibiotics and in some cases
granulocyte colony stimulating factor (GCSF) are given with chemotherapy that
has a high risk of causing sepsis with neutropenia, and on future cycles for patients
who have had an infection.
A
E
64
A U G U S T 2 0 0 9
Patients on chemotherapy are
given a thermometer and
advised to take their
temperature regularly and if
they have an increased
temperature or any other
symptoms of infection they
need to be referred to their
specialist centre for advice.
xercise 10
Using all the resources available to you, find an antibiotic regime used in
neutropenic sepsis. What are the indications for using GCSF?
Treatment of infections
Patients who develop infections while on chemotherapy are treated according to
guidelines from the specialist hospital where they receive their chemotherapy. This
usually involves treatment with broad spectrum intravenous antibiotics for 48 hours,
followed by oral antibiotics to complete the course. If the patients neutrophil count
is too low they may also receive treatment with GCSF on a daily basis, usually until
their neutrophil count returns to above a locally or regionally agreed threshold.
Practice point
Find out what neutrophil threshold is used in your local area.
xercise 11
a) What different types of GCSF are available and how are they given?
b) Find out which ones are used in your local area and why.
A
E
A
E
65
A U G U S T 2 0 0 9
S E C T I O N 4
A patient wants information on how to reduce their risk of infection while
they are on chemotherapy.
Patients can be advised to reduce their risk of infection by:
G trying to avoid crowded places and people with infectious illness (without
becoming hermits)
G being careful to avoid injury, eg, wearing thick gloves when gardening
G take care with personal hygiene and always wash hands thoroughly before
preparing food
G avoiding animal excreta, eg, avoiding cat trays and bird cages
G covering cuts immediately; more pressure than normal may be required to stop
bleeding
G resting when tired and avoiding organising busy periods on the day of treatment
and for a couple of days after.
4.3 Nausea and vomiting
In the past, chemotherapy treatment has been associated with causing nausea and
vomiting and this is often the side-effect that patients are most worried about.
However, as newer cytotoxic agents and antiemetics are developed this situation is
improving. Figure 3 shows the sites of action for a range of antiemetics that are
used in practice.
Nausea and vomiting is caused by the chemotherapy drugs affecting the
chemoreceptor trigger zone in the brain. Different drugs have different emetogenic
potential, with some patients being more susceptible than others to drug-induced
nausea and vomiting.
People affected most commonly include patients under 50 years old, women,
anxious patients and those who experience motion sickness. Susceptibility also
increases with repeated exposure to the drug. Occasionally some patients may start
to anticipate vomiting, particularly after several treatments, which can be a major
problem.
66
A U G U S T 2 0 0 9
Different drugs have different
emetogenic potential, with
some patients being more
susceptible than others to
drug-induced nausea and
vomiting.
R E S P O N D I N G T O S Y M P T O M S O F D I S E A S E A N D T R E AT M E N T 67
A U G U S T 2 0 0 9
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S E C T I O N 4
However, not all chemotherapy regimes will cause nausea and vomiting, much
depends on the emetogenic potential of a drug. Prophylactic antiemetics are given
before and after chemotherapy, depending on the emetogenic potential of the
regime. In combination chemotherapy, the emetogenic potential of the regime is
based on the highest risk drug in the regime. Guidelines vary from centre to
centre, and consideration needs to be given to an individual patients
circumstances. The American Society of Clinical Oncology published suggested
guidelines in 2006;
1
these are summarised inTable 4.
Even those regimes that have a high emetogenic potential can often be given
without problems, as modern antiemetic agents such as the 5-HT
3
receptor
antagonists (eg, ondansetron) which are more capable of preventing and
controlling nausea and vomiting can be given alongside them.
In addition, patients would usually be supplied with as required antiemetics. If a
patient does experience nausea and vomiting on their current treatment, then the
recommended antiemetics to be given should be from the next higher risk
category.
Practice point
Find out what your local guidelines are for the prevention and
management of emesis in chemotherapy regimes.
68
A U G U S T 2 0 0 9
Category Examples of drugs Recommended treatment Recommended treatment
(Frequency of (Day 1: pre-chemotherapy) (Days 2 and 3)
symptoms without
treatment)
High risk (90% +) Cisplatin, cyclophosphamide 5-HT3 antagonist Dexamethasone + aprepitant
(greater than 1.5 g/m
2
) (eg, ondansetron)+
dexamethasone + aprepitant
Moderate risk (30-90%) Carboplatin, oxaliplatin, 5-HT3 antagonist Dexamethasone (+ aprepitant)*
cyclophosphamide, epirubicin, (eg, ondansetron)+ dexamethasone
methotrexate (+ aprepitant)*
(greater than 250 mg/m
2
)
Intermediate risk (10-30%) Etoposide, 5-fluorouracil, Dexamethasone None
capecitabine, paclitaxel,
methotrexate (50-250 mg/m
2
)
Low risk (less than 10%) Vinca alkaloids, oral chlorambucil, None None
oral melphalan
Source: adapted from Kris MG et al, 2006
1
*Anthracycline/cyclophosphamide combination only
TABLE 4 Emetogenic potential of selected cytotoxic agents and their management
Prophylactic antiemetics are
given before and after
chemotherapy, depending on
the emetogenic potential of
the regime.
Practice point
Think about how you might feel if you were to be given chemotherapy.
Would you want to have preventive antiemetics, or would you be content to
manage the symptoms if and when they occurred?
How could you help patients understand the options that are available to
them?
There are three main presentations of nausea and vomiting:
Acute: Developing within 24 hours of the administration of chemotherapy.
Giving appropriate antiemetics before chemotherapy can prevent
this. The choice of antiemetics depends on the regime being used
and its emetic potential. Each area has its own guidelines. Common
agents used are the 5HT
3
antagonists, metoclopramide,
dexamethasone and cyclizine.
Delayed: Developing more than 24 hours after administration of
chemotherapy, and lasting for several days. This is most commonly
associated with cisplatin. Dexamethasone (occasionally given with
aprepitant), metoclopramide, or cyclizine can prevent or reduce this.
Anticipatory: Developing before chemotherapy is administered. This is a
psychological reaction to chemotherapy. The best way to prevent
anticipatory nausea and vomiting is to ensure that the patient has a
nausea-free first course of chemotherapy, by giving appropriate
antiemetics. Should this fail a benzodiazepine, such as lorazepam,
may be helpful because it has sedative and anxiolytic effects. Pre-
medication with a benzodiazepine can be used and given the night
before, or on the morning of treatment.
4.4 Gastrointestinal disturbances
Gastrointestinal disturbances depend on several factors:
G the disease itself (eg, patients with colorectal cancers are more likely to
experience problems)
G the chemotherapy used (eg, capecitabine and irinotecan-containing regimes can
cause severe diarrhoea possibly leading to considerable fluid loss,
haemodynamic collapse and death)
G the supportive agents used (eg, 5HT
3
antagonists can cause constipation).
It is important to note that all patients react differently to chemotherapy and all
chemotherapy can cause either diarrhoea or constipation. Patients who develop
gastrointestinal disturbances while on chemotherapy should be treated according
to the guidelines at the specialist hospital where they receive their chemotherapy. If
a patient does present with diarrhoea, then initial treatment may be with
loperamide, but in all cases the patient should contact their advice service for help,
as intravenous fluids are often required.
69
A U G U S T 2 0 0 9
Patients who develop
gastrointestinal disturbances
while on chemotherapy should
be treated according to the
guidelines at the specialist
hospital where they receive
their chemotherapy.
S E C T I O N 4
4.5 Mucositis
Mucositis can occur with many chemotherapy agents, and is especially concerning
if combined with neutropenia, as the inflamed lining of the mouth can be an
entrance route for bacteria. It can also significantly affect a patients quality of life.
Some cytotoxics such as 5-fluorouracil, methotrexate and the anthracyclines cause
a sore mouth and sometimes small ulcers. If this is going to happen it usually
occurs about five to ten days after treatment and will normally clear up within
three to four days. In addition, radiotherapy to the head and neck region can cause
a sore mouth.
Patients should pay particular attention to oral hygiene by:
G cleaning the mouth and teeth very gently each morning and evening and after
every meal with a soft toothbrush
G removing and cleaning dentures every morning, evening and after every meal
G using a lip balm to keep lips moist
G eating soft foods
G drinking at least three pints of fluid daily.
Therapy is often prophylactic, with the use of chlorhexidine mouthwash and
nystatin. When patients are started on chemotherapy they should be supplied with
an antibacterial mouthwash such as chlorhexidine, and advised to use it regularly
throughout treatment; it is much easier to prevent mucositis than it is to treat it
once it has started.
Common treatments for sore mouth include benzydamine mouthwash/spray,
Bonjela, paracetamol mucilage and Adcortyl in Orabase.
Coating agents are particularly useful when mucositis is very bad; the contents of
the sachet are mixed with a small amount of water and swilled round the mouth. It
coats the inside of the mouth and helps to soothe the area.
It is important to check that the mucositis is not infected with candida or bacteria,
as this may need more specific treatment, such as nystatin, fluconazole or
antibiotics to help it clear. If left untreated it can cause more serious systemic
infection. Severe mucositis caused by treatment with methotrexate may be
improved by treatment with folinic acid rescue.
4.6 Alopecia
Alopecia is a side-effect of many chemotherapy agents. Strategies to prevent this,
such as scalp-cooling to minimise the exposure of hair follicles to chemotherapy,
may be considered check to see what your local trust policy advises. In addition
to hair loss, some cytotoxics can also cause skin changes, such as dryness and
change of colour. Patients can be advised to:
G consider having their hair cut before chemotherapy starts
G use gentle shampoos and conditioners, avoiding perms and hair colourings
G use a soft brush to brush hair
G avoid the use of hairdryers, curlers and curling tongs and gently rub hair dry
70
A U G U S T 2 0 0 9
When patients are started on
chemotherapy they should be
supplied with an antibacterial
mouthwash such as
chlorhexidine, and advised to
use it regularly throughout
treatment; it is much easier to
prevent mucositis than it is to
treat it once it has started.
G consider a wig early on if the likelihood of losing the hair is great, so that it can
be made to match the natural hair colour
G use moisturiser cream or lotion if the skin on the scalp becomes dry
G wear a high factor sun block on the scalp if going out in the sun to prevent
sunburn.
Most hospitals will have a wig-making service available and hair does grow back
after treatment.
4.7 Hand and foot syndrome (palmar plantar)
This symptom only occurs with particular drugs, such as capecitabine. The patient
will initially develop bright red hands and feet, the skin appears dry but is not
painful. As it progresses the skin will become increasingly dry and cracked and
painful to touch. In its severest state the patient will be unable to wear shoes or
socks or touch anything with their hands. To prevent this from occurring, patients
on regimes that can cause this will be advised to regularly moisturise these areas.
Dose reductions will be required for patients that develop pain.
4.8 Tumour lysis syndrome
Tumour lysis syndrome occurs as a result of massive cell breakdown of a tumour
which is particularly sensitive to chemotherapy. It can also result in further
problems such as hyperkalaemia, hyperphosphataemia, hyperuricaemia and
hypocalcaemia. This can put the patient at risk of developing arrhythmias and
renal dysfunction and so urgent treatment is required.
Hyperuricaemia may be prevented by ensuring patients are well hydrated and by
giving allopurinol at the initiation of the chemotherapy cycle when the patient is
most at risk.
4.9 Hypersensitivity reactions
Some chemotherapy agents may cause hypersensitivity-type reactions requiring
therapy. For example, with docetaxel, patients are advised to take dexamethasone
for 24 hours prior to each treatment. Close monitoring of the patient is necessary
during each treatment. Signs of reaction include flushing, a change in blood
pressure and the patient feeling generally unwell.
4.10 Managing drug interactions
When treating cancer patients who are on chemotherapy it is important to clarify
which chemotherapy they are being given, as well as which, if any, additional
medicines they are taking. This information will help to eliminate any risk of drug
interactions.
Many chemotherapy agents have an impact on the cytochrome P450 system so
particular attention is essential.
71
A U G U S T 2 0 0 9
To prevent palmar plantar from
occurring, patients on regimes
that can cause this will be
advised to regularly moisturise
these areas.
When treating cancer patients
who are on chemotherapy it
is important to clarify which
chemotherapy they are being
given, as well as which, if any,
additional medicines they
are taking.
S E C T I O N 4
For example, patients on platinum-based chemotherapy should not be given the
antibiotic gentamicin. Due to the increased risk of bleeding, patients on warfarin
who are starting on chemotherapy should be changed, with some trusts using
treatment dose low molecular weight heparin for the duration of their treatment.
Chemotherapy can affect the electrolyte balance and so patients on diuretics will
need close monitoring of their renal function. A good medication history also
reduces the risk of duplicating treatment.
Practice point
There is some debate over the right way to manage patients receiving
chemotherapy who are on warfarin.What is your trusts policy?
4.11 Vitamins
Patients with cancer are often keen to do anything they can to help themselves and
may seek advice from pharmacists on what supplements they can take. Due to the
lack of information in this area it is very hard to know what can safely be
recommended. Researchers at Columbia University suggest that high dose
vitamins, specifically vitamin C, may lessen the effects of the chemotherapy
treatment.
2
It is best to advise patients to try and maintain a healthy diet where
possible and if they want to take supplements to contact their specialist centre for
advice.
4.12 Complementary and alternative therapies
Cancer patients try to fight cancer in any way they can, and sometimes this can
lead them to try complementary and alternative therapies. However, it is important
to note that sometimes these therapies can interact not only with the patients
medicines or chemotherapy, but also with the disease itself.
Therapies which may be considered include:
G massage
G reflexology
G yoga
G aromatherapy
G acupuncture
G herbal remedies
G homeopathy
G alternative diets for treating cancer.
72
A U G U S T 2 0 0 9
Chemotherapy can affect the
electrolyte balance and so
patients on diuretics will need
close monitoring of their renal
function.
Practice point
For each of these alternative therapies, consider what your personal
opinion is and how you would help people to make an informed choice.
Interactions with complementary and alternative medicines
One of the challenges with recommending or advising on the use of herbal and
other complementary medicines is understanding whether they are likely to
interact with the conventional chemotherapy agents that a patient is taking.
If you are asked about complex interactions with herbal medicines, the most
appropriate course of action is probably to get in touch with your local medicines
information centre you can find their number in the front of your BNF.
If the query is more simple, then a useful first resource would be, Herbal medicines
(Barnes J et al). This has monographs for individual herbal preparations and then a
series of appendices which list conventional medicines and cross-references to
groups of herbal products that may potentially interact. This reference is also
available online at: http://www.medicinescomplete.com
You may also wish to consider subscribing to the natural medicines database
http://www.naturaldatabase.com which is a comprehensive website database.
Alternatively you may find that your question has already been answered if you
look at relevant UK medicines information (UKmi) questions and answers using:
http://www.nelm.nhs.uk
Practice point
What do you need to consider when someone asks you about a
complementary or alternative therapy?
4.13 Safe management of symptoms
Most patients taking chemotherapy will experience symptoms from their treatment
at some point during the treatment course. Some of these symptoms can be
managed safely at home with the correct advice, others must be referred back to
the specialist centre. Recognising symptoms that should be referred back is not
always easy, so it is always best to be overly cautious. Ring the specialist centre and
ask their advice, it is better for the patients treatment to be adjusted due to side-
effects than for it to be stopped altogether due to the ill health of the patient.
Enhancing pharmaceutical care
Being available as a source of information and advice is a very important role for
pharmacists and pharmacy technicians, especially as more oral chemotherapy
agents become available.
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A U G U S T 2 0 0 9
If you are asked about complex
interactions with herbal
medicines, the most
appropriate course of action is
probably to get in touch with
your local medicines
information centre you can
find their number in the front
of your BNF.
Recognising symptoms that
should be referred back is not
always easy, so it is always best
to be overly cautious.
S E C T I O N 4
Saira, the wife of a patient who has been diagnosed with prostate cancer,
wishes to speak to you. She is feeling guilty for being tired of caring for her
husband, and wishes to find out how she can arrange some respite care for
him. In addition, she is concerned as she believes that her husband may
now be suffering from depression on top of everything else.
Planning point
Having worked through this section you may feel you would like to know more
about:
G local cancer care both primary and secondary-provision for cancer patients
G who the appropriate professionals are locally and which are the best sources of
help in the community and in hospital
G the availability of appropriate information leaflets
G drug information sources relevant to medication use in this patient group.
If any of these are relevant to you, build these into your personal development
plan.
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A U G U S T 2 0 0 9
Differentiate between symptoms that can be
managed in a non-specialist setting and those that
should be referred on to specialists.
Make recommendations for the management and
treatment of symptoms of disease.
Recognise interactions between chemotherapy and
other medicines.
Provide advice on the use of alternative therapies.
R E S P O N D I N G T O S Y M P T O M S O F D I S E A S E A N D T R E AT M E N T 75
Summary
In this section we have detailed some of the side-effects that cancer patients may
suffer, both from chemotherapy and from other treatment regimes. We have also
discussed alternative therapies and ways of relieving the side-effects. It is
important that patients are told in advance of any possible side-effects so that they
report any symptoms as soon as possible.
Intended outcomes
A U G U S T 2 0 0 9
S E C T I O N 4
Suggested answers
Capecitabine: dose depends on type of cancer being treated, 1250 mg/m
2
twice
daily for 14 days followed by a seven-day break is a common regime used. The most
common side-effects are diarrhoea, hand and foot syndrome and nausea and vomiting.
Imatinib: dose depends on the type of cancer being treated. Usual dose is
400- 800 mg daily taken continuously. The main side-effects are abdominal pain,
appetite changes, constipation, diarrhoea and flatulence.
Erlotinib: dose depends on the cancer being treated, 100-150 mg daily taken
continuously. The most common side-effects are diarrhoea, abdominal pain,
dyspepsia, flatulence and anorexia.
Sorafenib: dose is 400 mg twice daily taken continuously. The most common side-
effects are diarrhoea, constipation, dyspepsia, dysphasia and anorexia.
What do you consider to be the main signs and symptoms of infection?
Symptoms would typically include a high temperature with redness and swelling at
any infected site.
Using all the resources available to you, find an antibiotic regime used in
neutropenic sepsis. What are the indications for using GCSF?
Youll need to refer to your own protocol for this, either from the cancer network or
your local centre.
a) What different types of GCSF are available, how are they given?
In March 2009 there were three different types of GCSF available; filgrastim,
lenograstim and pegfilgrastim.
Filgrastim is unglycosylated and is given as a daily dose of 300 or 480 micrograms
daily.
Lenograstim is glycosylated and given as a daily dose of 263 micrograms daily.
Pegfilgrastim is pegylated to give it a longer duration of action. Pegfilgrastim is given
as a one off dose of 6 mg.
The choice depends on the duration of treatment required and cost and you should
refer to local policies.
A
A
A
A
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A U G U S T 2 0 0 9
b) Find out which ones are used in your local area and why.
Youll need to refer to your own protocol for this, either from the cancer network or
your local centre.
Case study 6 Amanda (page 63)
Oxaliplatin can cause gastrointestinal disturbances, sensory peripheral neuropathy
and myelosuppression. Folinic acid can cause hypersensitivity reactions.
5FU can cause local irritation at the injection site, myelosuppression and mucositis.
Case study 7 Elly (page 63)
5FU can cause local irritation at the injection site, myelosuppression and mucositis.
Epirubicin can cause cardiotoxicity, myelosuppression and extravasation can cause
severe tissue necrosis. Cyclophosphamide can cause anorexia, cardiotoxicity and
interstitial pulmonary fibrosis. Taxotere can cause fluid retention, hypersensitivity
reactions and myelosuppression.
References
1. Kris MG, Hesketh PJ, Somerfield MR, Feyer P, Clark-Snow R et al. (2006)
American Society of Clinical Oncology Guideline for Antiemetics in Oncology:
Update 2006. Journal of Clinical Oncology, 24:2932-2947.
2. Cancer Research UK. News archive. Available only online at:
http://info.cancerresearchuk.org/news/archive/newsarchive/2008/october/
18811218
A
A
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A U G U S T 2 0 0 9
Section 5
Supporting patients and carers
Objectives
I outline the key issues to consider when communicating with cancer
patients, their families and carers
I develop your approach to supporting people living with cancer and
their carers
I describe your personal concerns and the barriers that may impact
on your ability to discuss cancer
I start developing a portfolio of printed resources that you can use to
support discussions
I design an approach that you will introduce to your pharmacy to
raise your profile for people living with cancer.
There are many people involved in the care of a cancer patient and this diverse
team needs to be able to communicate effectively not only with each other, but also
with the patient, their carers and relatives. This section describes the different
support available to patients, as well as healthcare staff dealing with patients with
cancer.
5.1 Communication
When faced with a cancer diagnosis, patients often experience significant
emotional distress and feelings of uncertainty about their future. Patients have to
deal with a significant amount of complex information and often have to make
difficult, life-altering or threatening treatment decisions. Effective communication
with the patient and their carers is essential for first-class patient care.
Cancer patients need a great deal of care and support, including emotional,
practical, and financial. The complexities of cancer treatment, side-effects of
treatment, and the emotional strain of the disease, mean that patients may benefit
greatly from increased pharmaceutical care. The majority of pharmaceutical care
currently occurs in the secondary or tertiary setting, however the shift of care for
the cancer patient is moving towards the primary setting, and community
pharmacists will find that they become increasingly involved with the treatment of
cancer and the side-effects of chemotherapy.
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A U G U S T 2 0 0 9
Effective communication
with the patient and their
carers is essential for first-class
patient care.
Community pharmacists will
find that they become
increasingly involved with the
treatment of cancer and the
side-effects of chemotherapy.
S U P P O R T I N G PAT I E N T S A N D C A R E R S
xercise 12
Return to Exercise 1 at the start of Section 1 (see page 1).
We asked you to consider how you felt about cancer. How can you use this to
improve your approach to supporting people living with cancer either as
patients or carers?
Key issues to consider when communicating with cancer patients and their
carers
G Confirm the identity of any person with the patient; do not presume their
relationship. Check whether they are a carer, relative, health professional or
someone else and think about the importance of confidentiality.
G Confirm the information needs of the patient/carer.
G How much information does the patient want/need about their treatment or
condition?
G Have they done any research on their treatment/condition?
G Are they an expert patient?
G Confirm the format of the information required
G Do they need information in a different language?
G Can they read?
G Consider all forms of communication, such as paper, electronic, spoken,
video, etc.
G Always provide clear, jargon-free explanations. Check that they understand
what you have told them.
G Actively listen to the patient/carer.
G Consider what your body language is conveying? Does it suggest
understanding, empathy and support?
G Consider what their body language is conveying?
G Do they understand the conversation?
G Do they have a question?
G Are they nervous or scared?
G Confirm their understanding of what you have said, especially if you have given
complex directions.
G Be as honest and open as possible: patients/carers sense when health
professionals are avoiding an area.
G Build a partnership with the patient/carer during their treatment, and help them
to make informed decisions. The concordant approach is key for successful
cancer treatment.
E
79
A U G U S T 2 0 0 9
S E C T I O N 5
G Consider confidential or sensitive issues surrounding cancer and treatment.
G Patients may be devastated they have lost their hair, or may not want people
to know they have cancer.
G Always talk to the patient in an area where they will feel comfortable to
discuss embarrassing side-effects.
Key issues to consider when communicating with other healthcare
professionals who are caring for the cancer patient
G Consider what your role is in the care of cancer patients. This may range from
detecting side-effects of treatment to dispensing chemotherapy.
G Do other professionals know how you can help with the care of a cancer
patient? Do you know your colleagues role in the care of a cancer patient?
G Consider how you could build a partnership with other oncology professionals
in your area.
G Consider how you would give other professionals involved with the care of the
patient the information they require. For example, a patient may be under the
care of the local hospital, a tertiary hospital several miles away, a hospice and/or
a GP, all requiring up-to-date information on the patient.
xercise 13
Write down three ways that you have helped a cancer patient recently.
xercise 14
Suggest five possible barriers that may impact on your ability to discuss cancer
with a patient.
A
A
E
E
80
A U G U S T 2 0 0 9
Practice point
Think about your answer to Exercise 14 and consider how would you deal
with these barriers in your professional role.
Key issues to consider when communicating with caregivers who are based
in the home, other institutions or the community:
G Consider where the caregiver is based.
G Is the caregiver in the home?
G Is it a relative?
G Do they live with or visit the patient?
G Is the caregiver employed in a nursing home?
G Is the caregiver a district nurse or carer?
G How often do they visit the patient at home?
G Is the information you are giving being documented? How can you check this?
G Is the information shared with the patients GP?
G Do you have the patients permission to communicate with the caregiver?
Consider how you would gain this permission if you do not have it yet.
Confidentiality is a key issue in healthcare. It is important never to assume that the
patient wants their relative to know their diagnosis. Patient information should
never be given out on the telephone and only relatives or caregivers that have
permission should be allowed to discuss the patients healthcare needs. Remember
that the patient has the right to full confidentiality, and to have their wishes
regarding sharing of information explicitly followed.
5.2 Information
When talking with patients or carers about treatments, and the side-effects of
treatments, it is useful to have printed information sources available. It is
important to consider the information source when assessing literature, as some
will have a stronger evidence base than others.
Practice point: Information toolkit
Evaluate the support leaflets that you have available.What steps do you
need to take to provide the right information for your patients?
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A U G U S T 2 0 0 9
Remember that the patient has
the right to full confidentiality,
and to have their wishes
regarding sharing of
information explicitly followed.
S E C T I O N 5
Examples of information sources that would be of benefit to you may include:
G Summary of product characteristics of relevant chemotherapy agents, available
online at: http://www.emc.medicines.org.uk
G Department of Health and the NICE websites
G Local cancer network/local hospital treatment guidelines for
mucositis/diarrhoea/nausea and vomiting, etc
G Palliative care formulary
G Diagrams to describe to the patient how the treatment works
G Numbers/contact names/referral process for relevant healthcare professionals
G Medicines information department in your local hospital
G Cancer network websites (these are of varying usefulness)
G Local specialist cancer pharmacist
G Natural medicines database website: http://www.naturaldatabase.com
G Local health promotion unit
One of your customers explains that his 56-year-old wife has recently been
diagnosed with breast cancer and he would like your thoughts on the use
of unlicensed medicines to treat his wife. He has watched a documentary
on television about the state of the art treatments available in the United
States.
Practice point
Find out who the specialist cancer pharmacist is in your local hospital and
how to contact them. Find out if they have any local guidelines to share
with you, or where you may find such information.
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A U G U S T 2 0 0 9
5.3 Involving and supporting patients
As well as written information regarding their treatment, patients will appreciate
support and advice and the chance to be involved in their treatment decisions.
Information sources
Examples of information sources that would be of benefit to the patient and/or
carer may include:
G Patient information leaflets of relevant chemotherapy agents
G Cancerbackup leaflets, available online at: http://www.cancerbackup.org.uk
G Tumour site-specific charities websites
G Cancer Research UK website: http://www.cancerresearchuk.org
G Macmillan Cancer Support website: http://www.macmillan.org.uk
Involving the patient
Informed consent needs to be obtained before treatment and you need to consider
how much the patient wishes to be involved in treatment decisions. For example, a
young female having adjuvant chemotherapy for breast cancer may not wish to
take steroids as they will increase her weight, but may prefer to feel a little
nauseous and manage on different antiemetics.
Advice that you can offer patients includes:
G how and when to take their medicines especially if they are on regular
medicines from their GP
G where to store their medicines (both chemotherapy agents and supportive
medicines)
G how to take their chemotherapy tablets (non-touch technique, washing hands, etc)
If the patient or caregiver are likely to surf the web for information then you can
suggest useful websites that can provide helpful information.
Supporting the patient
The key worker is the patients main point of contact regarding any queries in the
hospital. If a key worker is not assigned to the patient, then the chemotherapy
nurse specialists are usually the point of contact for queries.
Make sure that patients know who to contact with any queries, or in case of an
emergency.
Think about the other types of support that a patient may need, and who can
provide it, for example,
G emotional support may be obtained from local and national support groups and
cancer nurse specialists
G financial support is available from Macmillan nurses, social services and the
Citizens Advice Bureau.
Patients may need written information in a format that they can understand such
as: larger characters, Braille or other languages; information may also be available
in DVD and CD format.
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A U G U S T 2 0 0 9
Informed consent needs to be
obtained before treatment and
you need to consider how
much the patient wishes to be
involved in treatment decisions.
S E C T I O N 5 84
A terminally ill cancer patient has regular medicines delivered to their
home using your prescription collection service.They have asked your
delivery driver to bring some information or leaflets on the benefits that
they are able to apply for; one of their neighbours told them that they
should be entitled to some.
5.4 Cancer survivors
A cancer survivor is someone who is living with cancer, or who has previously had
a diagnosis of cancer. Some have active disease, some are living with the
consequences of their disease, and others can truly be said to be living beyond
their cancer.
xercise 15
There are many ways that the pharmacy team can help a cancer survivor. Jot down
your thoughts about how you could help a cancer survivor in the following areas.
Prevention
Screening
Symptom recognition
E
A U G U S T 2 0 0 9
S U P P O R T I N G PAT I E N T S A N D C A R E R S 85
Diagnosis
Treatment
Follow-up
Financial
xercise 16
Choose one area from Exercise 15 where you plan to increase your support to
cancer survivors. How will you raise your profile to the people who would most
benefit from this service?
A
E
A U G U S T 2 0 0 9
S E C T I O N 5
Mr Costa
Mr Costa is a 55-year-old non-smoking mechanic; he comes to the
pharmacy complaining of abdominal cramps and pain. He has
recently become constipated, a condition which he has never
suffered from before. There have been no changes to his medication.
He suffers from ischaemic heart disease and type 2 diabetes. He has
no known allergies.
Drug history
Aspirin 75 mg daily
ISMN 60 mg daily
Simvastatin 40 mg at night
Ramipril 10 mg daily
Metformin 500 mg three times daily
Insulin glargine 40 IU, in the evening
Insulin NovoRapid six to eight IU, at mealtimes
a) What questions would you ask Mr Costa?
After referral to his GP Mr Costa returns to the pharmacy with a
prescription for co-dydramol, Colpermin, ranitidine and lactulose. He has
also been referred for various investigations: ultrasound scan, flexible
sigmoidoscopy, barium enema and a gastroscopy. He is concerned about all
the different investigations and their purpose.
b) Plan your response.
8
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A U G U S T 2 0 0 9
Mr Costa returns a month later. All his scans are clear but he is still in pain
and his weight is decreasing. His painkiller has been changed to co-codamol
30/500 mg two four times daily, with metoclopramide. He has now been
referred for a CT scan.
c) Write your advice down here (using the words you would use for the
patient).
Mr Costa has been diagnosed with inoperable pancreatic cancer. He is
about to commence palliative gemcitabine chemotherapy. He presents with
a prescription for Creon and co-danthramer.
d) Write your advice to him here (using the words you would use for the
patient).
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A U G U S T 2 0 0 9
S E C T I O N 5
Mr Costa, presents with a prescription for lorazepam. He is getting very
agitated during his chemotherapy sessions and cannot sleep the night
before.
e) Write your advice down here.
Mr Costa returns to the pharmacy. His pain is no longer controlled by the
co-codamol 30/500 mg, and he has been given a prescription for Oramorph
10 mg/5 mL, 5 mL when required. He returns three days later with a
prescription for oxycodone MR 10 mg twice daily, plus oxycodone 5 mg
capsules when required for breakthrough pain. He has also been given a
prescription for Ensure Plus.
f) Why do you think these were prescribed?
A
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A U G U S T 2 0 0 9
Outline the key issues to consider when
communicating with cancer patients, their families
and their carers.
Develop your approach to supporting people living
with cancer and their carers.
Describe your personal concerns and the barriers
that may impact on your ability to discuss cancer.
Start developing a portfolio of printed resources
that you can use to support discussions.
Design an approach that you will introduce to your
pharmacy to raise your profile for people living with
cancer.
S U P P O R T I N G PAT I E N T S A N D C A R E R S 89
Summary
The care of the cancer patient is complex and involves a number of diverse people
across all healthcare sectors. Communication is essential and effective delivery of
cancer treatment requires the careful provision of care by a team who
communicate well.
1
Intended outcomes
A U G U S T 2 0 0 9
S E C T I O N 5 90
Suggested answers
Write three ways that you have helped a cancer patient recently.
The advice and support you have given may include:
G explained how to take their anti-sickness medicines
G provided/wrote a printed list of drugs and frequency so that patient/carer could
tick off when taken
G referred a patient to the treatment hospital when they presented in the pharmacy
unwell after recent chemotherapy (if the patient had neutropenic sepsis, you may
have saved their life)
G helped with the management of mucositis and mouth ulcers to improve the
patients quality of life
G given advice to patients about the side-effects of a chemotherapy agent, such as
capecitabine.
Suggest five possible barriers which may impact on your ability to discuss
cancer with a patient.
Suggested areas
G Own experiences of cancer; this may be good or bad
G Own experiences of death
G Language barriers
G Lack of experience
G Time restraints
G Not knowing that the person has cancer, ie, poor communication with other
healthcare providers
G Lack of privacy
G Previous poor experience or interaction with the patient
G Lack of knowledge surrounding the disease type, so you may not feel confident to
approach patient/carer in case they ask questions
G Unable to cope with emotional distress, ie, if the patient is distressed
A
A
A U G U S T 2 0 0 9
Jot down your thoughts about how you could help a cancer survivor in the
following areas.
Prevention Health promotion
Advice to patients on healthy living
Smoking cessation
HPV vaccine
Screening Inclusion on bowel cancer screening programme
Responding to warning/danger symptoms
Leaflets or information on symptoms
Symptom Knowledge on common side-effects of chemotherapy agents
recognition
Good patient medical history-taking
Signposting the patient to further care as necessary
Diagnosis Emotional support
Listening to the patient/carer
Treatment Advice about treatment related side-effects
Advice about how to take chemotherapy
Advice about safety of chemotherapy in the home
Advice about managing drug interactions/herbal interactions
Follow-up Ensure treatment related side-effects have resolved
Ensure regular medicines are continued where relevant
Financial Informing patient of Macmillan support
Information on benefits they may be entitled to or signposted to
Citizen Advice Bureau for advice
How will you raise your profile to the people who would most benefit from this
service?
Some areas where we thought you might engage with this include:
G working with the cancer hospital multidisciplinary team/cancer network to bring
cancer treatment safely into the primary sector where possible
G increasing knowledge of common side-effects of chemotherapy agents and
symptoms and supporting the patient in their use of antiemetics and other
supportive therapies
G dispensing oral chemotherapy
G issuing pre-payment certificates to cancer patients where relevant (note, at
present cancer patients have to pay for their medicines and are not exempt as yet)
A
A
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A U G U S T 2 0 0 9
S E C T I O N 5
G managing drugs/herbal/OTC interactions with chemotherapy/supportive
medicines/disease together with local specialist cancer pharmacists
G effective communication with the local cancer multidisciplinary team, possibly
through the local specialist cancer pharmacist
G signposting to specialist support where appropriate.
Case study 9 Mr Costa (page 86)
a) What questions would you ask Mr Costa?
G How long have you had the symptoms?
G Have you noticed any weight loss?
G Are you breathless or often tired (could suggest anaemia)?
G Have you had any difficulty swallowing?
G Have you noticed any blood in your stools?
Any patients with ALARM symptoms should be referred immediately.
b) Plan your response.
Heres some information that we got from the Patient UK website. If youre not
familiar with the website yet, then take a look and see whether you could use it to
help your patients or to suggest to them as a resource.
Ultrasound scan
An ultrasound scan is a painless test that uses sound waves to create images of
organs and structures inside your body. It is a very commonly-used test and as it uses
sound waves and not radiation, it is thought to be harmless.
Flexible sigmoidoscopy
This procedure allows your doctor to look inside the rectum and lower part of your
bowel using a narrow, flexible, tube-like telescope called a sigmoidoscope.
Barium enema
A barium enema is an X-ray test to obtain pictures of your colon (the last part of the
gut, sometimes called the large intestine or large bowel).
c) Write your advice down here.
CT scan
This takes pictures of the body and uses a computer to put them together.
A CT scanner uses X-rays and is a painless procedure. A series of X-rays are taken of
your body at slightly different angles, to produce very detailed pictures of the inside
of your body. The pictures produced by CT scans are called tomograms and they
provide doctors with information to help them reach a diagnosis about a variety of
conditions.
We anticipate youd recommend that he takes his pain relief medication regularly, it
works better if not taken on an ad hoc basis.
A
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A U G U S T 2 0 0 9
d) Write your advice to him here.
Take your Creon either with food or just before or just after. You can swallow the
capsules whole or mix them with your food or liquids. If you do decide to mix them
then avoid very hot food or liquid as this will stop the medicine working. Once youve
mixed it do not keep the food for more than one hour.
Take ranitidine approximately one hour before taking Creon. Creon is inactivated by
gastric acid and the ranitidine helps to lower the amount of acid that you have in
your stomach.
You would probably want to ask the doctor to consider a different laxative. Stimulant
laxatives can cause stomach cramps and so may not be suitable for this patient. A
softening agent or an osmotic laxative may be more appropriate.
e) Write your advice down here.
Take the lorazepam the night before to help you sleep. It is short acting so you could
also take it before your chemotherapy session.
Its also a good idea to try to distract yourself. Take something with you to occupy
yourself such as a book, crossword or Sudoku.
You could also suggest that Mr Costa asks the nurse leading the session to book his
treatment at a time to avoid busy periods when he is unlikely to have to wait, ie, first
thing in the morning.
f) Why do you think these were prescribed?
Side-effects of morphine can include sedation, hallucinations, nausea and vomiting,
constipation, itchiness.
Oxycodone is an alternative to morphine with fewer side-effects in some patients.
Mr Costa has probably been given Ensure Plus to help him achieve a good calorie
intake when hes not eating, owing to the pain. Ensure is more palatable if taken
from the fridge. Neutral Ensure can be mixed with food.
References
1. Department of Health. Chemotherapy services in England: a report from the
National Chemotherapy Advisory Group, draft for consultation.
London: DH, 12 November 2008. Available online at: http://www.dh.gov.uk
Further reading
Department of Health. National Cancer Survivorship Initiative newsletter.
Available online at: http://www.dh.gov.uk
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