Drugs associated with CANCER THERAPIES OVERVIEW of Antineoplastic Agents Drugs used to control or kill cancer cells are

e known as antineoplastic agents. Also referred to as chemotherapy agents or anticancer drugs. Because single-agent therapy is unsuccessful in attaining long-term remissions, more than one agent is used. Also, single-agent therapy produces cell lines resistant to further drug therapies. Agents of different classes are combined to maximize eachs mode of action. This combining categories leads to synergistic and additive qualities as well as varied toxicities. Classes: 1. alkylating agents 2. antimetabolites 3. antitumor antibiotics 4. plant or Vinca alkaloids 5. Other antineoplastic agents Other antineoplastic agents Miscellaneous Agents have a mechanism of action that is different from other classifications or is not fully understood. These agents are cell nonspecific. They also produce major toxicities to hematopoeitic system and anaphylaxis. Include Aminoglutethimide (Elipten), L- asparaginase (Elspar), Mitoxantrrone (Novantrone), and procarbazine hydrochloride(Matulane). Investigational Agents are those currently undergoing clinical trials and are not yet approved by the Food and Drug Administration. These agents include new drugs and previously approved drugs whose original approval is now being administered in a different manner, combination or disease. Some cancer clients choose treatment with an investigational agent or protocol. Action: Antineoplastic agents destroy cells in their growth phase. They may be Cell cycle specific or nonspecific. Cell cycle specific produce cytotoxic effects in a particular phase of the cells reproductive cycle (G1-M) and are effective in tumors with rapidly dividing cells. Cell cycle non specific agents are effective in any phase of the cell cycle (including Go-resting phase and are most effective against slow growing tumors. anticancer drugs:

Cell cycle= growth and division

1 8_01_ cell_cy cle.jpg

Cell cycle

Effects of chemotherapeutic drugs on cell cycle

As applied:

Cell cycle specific drugs (CCS) or phase specific: Antimetabolites: Methotrexate, 6-Mercaptopurine Antibiotic: Bleomycin Taxane: Paclitaxel Epipodophyllotoxins: Etoposide, Teniposide Vinca alkaloids: Vinblastine, Vincristine Act mainly on dividing cells
Most effective in hematologic and solid tumors with high growth fraction

 Cell cycle non-specific (CCNS) or phase non specific drugs:

Alkylating agents: Cyclophosphamide, Busulfan, Mechlorethamine, Melphalan. Anticancer antibiotics: Doxorubicin, Daunorubicin, Mitomycin, Actinomycin D. Camptothecins: Topotecan, Irinotecan Metal complexes: Cisplatin, Carboplatin
CCNS drugs act on dividing as well as resting cells Effective in low growth fraction as well as high growth fraction solid tumors Characteristics of Cancer Cells The problem: Cancer cells divide rapidly (cell cycle is accelerated) They are immortal Cell-cell communication is altered uncontrolled proliferation invasiveness

Ability to metastasize The Goal of Cancer Treatments Curative Total irradication of cancer cells Curable cancers include testicular tumors, Wills tumor Palliative Alleviation of symptoms Avoidance of life-threatening toxicity Increased survival and improved quality of life Adjuvant therapy Attempt to eradicate microscopic cancer after surgery e.g. breast cancer & colorectal cancer Six Established Rx Modalities

1. Surgery 2. Radiotherapy 3. Chemotherapy 4. Endocrine therapy 5. Immunotherapy 6. Biological therapy What is a neoplasm? Cells with an abnormal growth pattern Either benign or malignant Any overgrowth of tissue can form a tumor Benign neoplasm Composed of cells that look like the tissue of origin Usually encapsulated Grow slowly and by expansion Do not recur or metastasize Do not destroy tissue generally Do not cause systemic symptoms or death generally Malignant neoplasm Composed of undifferentiated (or immature) cells. Little resembles the tissue of origin Grows rapidly Expands at periphery and invades and destroys surrounding tissue Recurs and metastasizes to other parts of the body Spreads by way of lymph and blood to distant parts of the body Causes systemic signs and symptoms Ultimately, it can cause death What makes a cancer able to metastasize?

 Can be spread by blood/lymph system This helps us predict what organs will be metastasized Spread by direct contact organ to organ Iatrogenic spread: surgical seeding or invasive procedure moving cells from one site to another Oncogenes and Proto-oncogenes Genes capable of triggering cancerous conditions Normally suppressed Can be triggered by invading viruses or other carcinogens Proto-oncogenes: benign forms of oncogenes necessary of normal function Fragile and easily damaged and mutated Immune response Immune response failure When the immune system is compromised it fails to. Immunological defects If the immunological system is not working: The body is more susceptible to invasion by foreign agents, cancer included People with immunological disorders are at higher risk for developing certain kinds of malignant disorders Persons with AIDS Persons receiving immunosuppressive therapy for neoplastic or non-neoplastic disorders Suppress oncogenes Kill off the cancerous cells that normally form within the body Normal cell cycle becomes deranged Damage occurs to the DNA and proteins inside the cell

Biological Carcinogens Viruses HIV, HBV, papilloma viruses, HTLV

 Genetics The etiology of cancer is unknown It is generally assumed that genetic factors are involved Chemical Carcinogens Drugs and hormones Chemotherapeutic drugs Recreational drugs DES, estrogen, cortisone, anabolic steroids Diet Alcohol Carcinogens Chemical agents: Industrial wastes, pesticides, cigarette smoke, asbestos, phenol Natural body substances in body: bile acids Food additives: sodium saccharine, nitrites Physical agents Radiation (both solar and ionizing), and radon, nuclear radiation Risk factors for cancer Non-controllable Heredity, age, gender, and poverty Controllable Stress, diet, occupation, infection, tobacco use, alcohol use, use of recreational drugs, obesity, and sun exposure Types of malignant neoplasms Solid cancers (Tumors) Carcinoma: arises in epithelial cells Sarcoma: arises in connective tissue, muscle, or bone

 Hematological cancers Leukemia: arises in blood Myeloma: arises in bone marrow Lymphoma: arises in lymph tissue Clinical staging for surgery Reveals the extent of cancer spread By sampling regional and distant lymph nodes By sampling and viewing other organs for tumors (an example: is the removal of axillary lymph nodes during surgery for breast cancer) Grading and staging Once cancer diagnosis is made, the tumor is graded and staged Grading: evaluates the amount of differentiation of the cancer cells Grade 1 (the least malignant) to grade 4 (the most malignant) Grade 1 is the most differentiated and Grade 4 is the least differentiated

Staging: refers to the relative tumor size and extent of the disease A tumor in situ is stage 0, while a stage 4 indicates widespread metastasis TNM Staging of Cancer Based on the following: (T) relative tumor size (N) presence and extent of lymph node involvement (M) distant metastases Signs and Symptoms of Cancer

C (change in bowel or bladder habits) A (a sore that doesnt heal) U (Unusual bleeding or discharge) T (thickening or lump in tissue) I (indigestion or difficulty swallowing)

 O (obvious change in wart or mole) N (nagging cough or hoarseness)

U Unexplained anemia S sudden unexplained weight loss Collaborative Management Most treatments for cancer will require collaboration with multiple health care providers (HCPs) Collaborative, outcome driven planning is essential to provide the best care with the least negative impact upon the client and family Diagnosis of Cancer Can only be made with a biopsy Types of biopsys: Needle biopsy Incisional biopsy Excisional biopsy Diagnostic studies Radiological testing X-rays CTs Ultrasounds MRIs Can only locate and visualize a mass or tumor, cannot make the determination of malignancy Diagnostic studies Direct visualization Sigmoidoscopy Cystoscopy Endoscopy Bronchoscopy

 Exploratory surgery Laboratory tests Tumor markers Oncofetal antigens Hormones Tissue specific proteins Isoenzymes Biopsy The only way to be certain of malignancy The visualization of changed cells microscopically Other blood tests Leukemias are generally suspected when there is a blood smear that contains immature forms of leukocytes, which is often combined with low blood counts Surgical Interventions Was once the only treatment available Still is used in diagnosis and staging of more than 90% of all tumors and as primary treatment in more than 60% of tumors May be: Curative (complete removal) Palliative (decreases symptoms) Adjunctive (debulking tumor so that radiation and chemo can work) reconstructive Radiation Therapy Treatment of choice for some tumors Can be used to: Kill tumor cells to cure cancer Reduce the size of a tumor Decrease pain

 Relieve an obstruction Reduce chance of metastasis, if just beginning How it works Radiation provides lethal injury to the DNA of the cell It affects rapidly growing cells, like tumor cells It also affects normal cells that are growing rapidly The goal is to achieve maximum tumor control with minimum damage to normal tissue External Radiation Source of radiation comes from a machine which emits a relatively uniform dosage of radiation to all tissues selected for radiation. Internal radiation Brachytherapy Implant (wires, tubes, capsules, rods, etc) placed by a surgeon or oncologist. Usually is temporary Can be ingested or injected into the clients blood stream or a body cavity Is a risk to those who are in contact with the patient. The radiation is transmitted outside the body Brachytherapy safety considerations Maintain the greatest possible distance from the patient Spend the minimum amount of time with the patient Use lead gloves and aprons as a shield when possible Keep pregnant people away Avoid direct contact with radioisotope containers Brachytherapy safety considerations People working with these people a lot must wear a radiation monitor badge to track exposure level to radiation Patients should be in a private room with a private bathroom Dispose of bodily wastes according to facility policy Handle linens according to facility policy

Chemotherapy The use of cytotoxic medications and chemicals to Cure some cancers Decrease tumor size (as an adjunct to surgery or radiation therapies) Prevent or treat suspected metastases How chemo works It disrupts the cell cycle in various phases by interrupting cell metabolism and replication It interferes with the ability of the cell to synthesize needed enzymes and chemicals It is generally given in specific combinations of drugs to affect malignant cells at their most vulnerable times Types of Chemo drugs Alkylating agents Antimetabolics Cytotoxic antibiotics Plant alkaloids (two types) Vinca alkaloids Etopsodes Hormone and hormone antagonists Miscellaneous drugs Preparation and administration Some medications are oral or IM, but many are given IV. Very irritating, if infiltrated, stop infusion immediately. Most states require special certification and education to administer chemo drugs. These drugs are potentially carcinogenic and corrosive. Follow policies regarding spills. Safety for the nurse Wear gloves, mask and gown for administration and work in a quiet area in a methodical manner Spills can be very hazardous Follow special spill policies and procedures

 Special equipment for spills available Nurses should be aware of drugs being given and how to handle client body wastes. Toxicity Watch for bone marrow suppression Watch for infection Watch for organ toxicity(GI tract, liver, cardiac, pulmonary, urinary, neurological) Watch for anaphylaxis Nausea and vomiting Give antiemetics 30-45 minutes prior to treatments Give antiemetics on a round the clock schedule if N/V is severe Use relaxation, therapeutic touch, diversion with music, etc.. Avoid foods, smells, etcthat induce nausea General Nursing Diagnosis Anxiety/powerlessness Body image disturbance Anticipatory grieving Risk for infection/injury Altered nutrition Pain fatigue Impaired tissue integrity Caregiver role strain Ineffective individual/family coping Altered role Fluid volume disturbance And many more Immunotherapy

 Biologic response modifiers Designed to enhance the clients own immune response Can consist of the administration of interleukin or interferon Other kinds of immunotherapy are monoclonal antibodies and hematopoietic growth factors Bone marrow and stem cell transplantation Most commonly used for leukemia's, now also for some solid mass tumors, such as breast cancers Stem cell transplantation Harvesting from pheresis Cord blood stem cells Unproven methods of cancer treatment Chemicals and drugs Nutrition Occult techniques Mechanical devices Supportive care Divine healing Psychologic Stressors Death sentence Guilt Anger Fear Powerlessness Body image disturbance Sexual dysfunction concerns Infection Tumor itself may cause fistula between two incompatible organs (e.g. bowel and bladder) Tumor may erode through to the surface causing an open lesion

 Tumor may destroy the tissues that feed it and then become necrotic causing septicemia Immune system impairment Pain One of the most serious concerns of clients and families because of the reputation of being difficult to control Causes of cancer pain Due to direct tumor involvement Due to the treatments Due to a cause not related to the cancer or the therapy Nursing Care of the Client with Cancer Effects of Cancer 1. Disturbed or loss of physiologic functioning, from pressure or obstruction a. b. c. d. e. Anoxia and necrosis of organs Loss of function: bowel or bladder obstruction Increased intracranial pressure Interrupted vascular/venous blockage Ascites Disturbed liver functioning

f.
2.

Hematologic Alterations: Impaired function of blood cells a. b. Abnormal wbcs: impaired immunity Diminished rbcs and platelets: anemia and clotting disorders

3. 4. 5.

Infections: fistula development and tumors may become necrotic; erode skin surface Hemorrhage: tumor erosion, bleeding, severe anemia Anorexia-Cachexia Syndrome: wasting away of client a. b. Unexplained rapid weight loss, anorexia with altered smell and taste Catabolic state: use of bodys tissues and muscle proteins to support cancer cell growth

6.

Paraneoplastic Syndromes: ectopic sites with excess hormone production

 a. b. c. d.

Parathyroid hormone (hypercalcemia) Ectopic secretion of insulin (hypoglycemia) Antidiuretic hormone (ADH: fluid retention) Adrenocorticotropic hormone (ACTH)

7. Pain: major concern of clients and families associated with cancer a. Types of cancer pain 1. 2. b. Acute: symptom that led to diagnosis Chronic: may be related to treatment or to progression of disease

Causes of pain 1. 2. 3. Direct tumor involvement including metastatic pain Nerve compression Involvement of visceral organs

8.

Physical Stress: body tries to respond and destroy neoplasm a. b. c. d. e. Fatigue Weight loss Anemia Dehydration Electrolyte imbalances

9.

Psychological Stress a. b. c. d. Cancer equals death sentence Guilt from poor health habits Fear of pain, suffering, death Stigmatized

Collaborative Care A. 1. Diagnostic Tests: used to diagnose cancer Determine location of cancer

 a. b. c. d. e. f.

Xrays Computed tomography Ultrasounds Magnetic resonance imaging Nuclear imaging Angiography

2. Diagnosis of cellular type of can be done through tissue samples from biopsies, shedded cells (e.g. Papanicolaou smear) washings a. b. 1. 2. Cytologic Examination: tissue examined under microscope Identification System of Tumors: Classification Grading -- Staging

Classification: according to the tissue or cell of origin, e.g. sarcoma, from supportive Grading: a. b. Evaluates degree of differentiation and rate of growth Grade 1 (least aggressive) to Grade 4 (most aggressive)

3.

Staging a. Relative tumor size and extent of disease TNM (Tumor size; Nodes: lymph node involvement; Metastases)

b.
3.

Tumor markers: specific proteins which indicate malignancy a. b. c. PSA (Prostatic-specific antigen): prostate cancer CEA (Carcinoembryonic antigen): colon cancer Alkaline Phosphatase: bone metastasis

Direct Visualization a. b. c. d. e. Sigmoidoscopy Cystoscopy Endoscopy Bronchoscopy Exploratory surgery; lymph node biopsies to determine metastases

Other non-specific tests a. b. CBC, Differential Electrolytes

c. Blood Chemistries: (liver enzymes: alanine aminotransferase (ALT); aspartate aminotransferase (AST) lactic dehydrogenase (LDH) Treatment Goals: depending on type and stage of cancer A. Cure 1. 2. 3. 4. a. b. c. B. Recover from specific cancer with treatment Alert for reoccurrence May involve rehabilitation with physical and occupational therapy Three Seasons of survival Diagnosis/treatment Extended survival: treatment completed and watchful waiting Permanent survival: risk of recurrence is small

Control: of symptoms and progression of cancer 1. 2. Continued surveillance Treatment when indicated (e.g. some bladder cancer, prostate cancer)

C.

Palliation of symptoms: may involve terminal care if clients cancer is not responding to treatment

Treatment Options (depend on type of cancer) alone or with combination A. Chemotherapy 1. a. b. Chemotherapy Includes phase-specific and non-phase specific drugs for specific cancer types Often combinations of drugs in specific protocols over varying time periods

c. Cell-kill hypothesis: with each cell cycle a percentage of cancerous cells are killed but some remain; repeating chemo kills more cells until those left can be handled by bodys immune system 2. a. Classes of Chemotherapy Drugs Alkylating agents

 1. 2. b.

Action: create defects in tumor DNA Examples: Nitrogen Mustard, Cisplatin

Antimetabolites 1. 2. 3. Action: specific for S phase Examples: Methotrexate; 5 fluorouracil Toxic Effects: nausea, vomiting, stomatitis, diarrhea, alopecia, leukopenia

c.

Antitumor Antibiotics 1. 2. 3. Action: non-phase specific; interfere with DNA Examples: Actinomycin D, Bleomycin Toxic Effect: damage to cardiac muscle

d.

Miotic inhibitors 1. 2. 3. Action: Prevent cell division during M phase Examples: Vincristine, Vinblastine Toxic Effects: affects neurotransmission, alopecia, bone marrow depression

e.

Hormones 1. 2. Action: stage specific G1 Example: Corticosteroids

f.

Hormone Antagonist 1. Action: block hormones on hormone-binding tumors (breast, prostate, endometrium; cause tumor regression 2. 3. Examples: Tamoxifen (breast); Flutamide (prostate) Toxic Effects: altered secondary sex characteristics

Effects of Chemotherapy a. Tissues (fast growing) frequently affected

b. Examples: mucous membranes, hair cells, bone marrow, specific organs with specific agents, reproductive organs (all fetal toxic, impair ability to reproduce) 4. a. Administration of chemotherapeutic agents Trained and certified personnel, according to established guidelines

b.

Preparation 1. Protect personnel from toxic effects

2. Extreme care for correct dosage; double check with physician orders, pharmacists preparation c. d. Proper management clients excretement Routes 1. 2. 3. Oral Body cavity (intraperitoneal or intrapleural) Intravenous

a. Use of vascular access devices because of threat of extravasation (leakage into tissues) and longterm therapy b. Types of vascular access devices 1. 2. 3. PICC lines (peripherally inserted central catheters) Tunnelled catheters (Hickman, Groshong) Surgically implanted ports (accessed with 90o angle needle)

Nursing care of clients receiving chemotherapy 1. Assess and manage a. Toxic effects of drugs (report to physician)

b. Side effects of drugs: manage nausea and vomiting, inflammation and ulceration of mucous membranes, hair loss, anorexia, nausea and vomiting with specific nursing and medical interventions 2. Monitor lab results (drugs withheld if blood counts seriously low); blood and blood product administration 3. 4. 5. B. Assess for dehydration, oncologic emergencies Teach regarding fatigue, immunosuppression precautions Provide emotional and spiritual support to clients and families Surgery 1. 2. 3. Diagnosis, staging, and sometimes treatment of cancer Involves removal of body part, organ, sometimes with altered functioning (e.g. colostomy) Debulking (decrease size of) tumors in advanced cases

 4. 5. C. 1. 2.

Reconstruction and rehabilitation (e.g. breast implant post mastectomy) Psychological support to deal with surgery as well as cancer diagnosis

Radiation Therapy Treatment of choice for some tumors to kill or reduce tumor, relieve pain or obstruction Delivery a. Teletherapy (external): radiation delivered in uniform dose to tumor

b. Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is placed in tumor or next to it c. 3. Goals a. Maximum tumor control with minimal damage to normal tissues Combination

b. Caregivers must protect selves by using shields, distancing and limiting time with client, following safety protocols 4. Treatment Schedules a. b. 5. Planned according to radiosensitivity of tumor, tolerance of client Monitor blood cell counts

Side Effects a. b. c. d. Skin (external radiation): blanching, erythema, sloughing Ulcerated mucous membranes: pain, lack of saliva Gastrointestinal: nausea and vomiting, diarrhea, bleeding, sometimes fistula formation Radiation pneumonia

D.

Biotherapy 1. Modification of biologic processes that result in malignancies; based on immune surveillance hypothesis 2. Used for hematological malignancies, renal and melanoma

3. Monoclonal antibodies (inoculate animal with tumor antigen and retrieve antibodies against tumor for human) E. Photodynamic Therapy 1. Client giving photosensitizing compound which concentrates in malignant tissue

 2. F.

Later given laser treatment to destroy tumor

Bone Marrow Transplantation and Peripheral Blood Stem Cell Transplantation 1. Stimulation of nonfunctioning marrow or replace bone marrow 2. Common treatment for leukemias

G.

Pain Control 1. 2. 3. Includes pain directly from cancer, treatment, or unrelated Necessary for continuing function or comfort in terminally ill clients Goal is maximum relief with minimal side effects

4. Multiple combinations of analgesics (narcotic and non-narcotic) and adjuvants such as steroids or antidepressants; includes around the clock (ATC) schedule with additional medications for break-through pain 5. 6. Multiple routes of medications May involve injections of anesthetics into nerve, surgical severing of nerves radiation

7. May need to progress to stronger pain medications as pain increases and client develops tolerance to pain medication Nursing Diagnoses for Clients with Cancer A. Anxiety 1. Therapeutic interactions with client and family; community resources such as American Cancer Society, I Can Cope 2. B. Availability of community resources for terminally ill (Hospice care in-patient, home care)

Disturbed Body Image 1. Includes loss of body parts (e.g. amputations); appearance changes (skin, hair); altered functions (e.g. colostomy); cachexic appearance, loss of energy, ability to be productive 2. Fear of rejection, stigma

C.

Anticipatory Grieving 1. 2. Facing death and making preparations for death: will be consideration Offer realistic hope that cancer treatment may be successful

D. Risk for Infection E. Risk for Injury

 1. 2. F.

Organ obstruction Pathological fractures

Altered Nutrition: less than body requirements 1. 2. 3. Consultation with dietician, lab evaluation of nutritional status Managing problems with eating: anorexia, nausea and vomiting May involve use of parenteral nutrition

G.

Impaired Tissue Integrity 1. Oral, pharyngeal, esophageal tissues (due to chemotherapy, bleeding due to low platelet counts, fungal infections such as thrush) 2. Teach inspection, frequent oral hygiene, specific non-irritating products, thrush control

Oncologic Emergencies A. Pericaridal Effusion and Neoplastic Cardiac Tamponade 1. 2. B. Concern: compression of heart by fluid in pericardial sac, compromised cardiac output Treatment: pericardiocentesis

Superior Vena Cava Syndrome 1. Concern: obstruction of venous system with increased venous pressure and stasis; facial and neck edema with slow progression to respiration distress 2. Treatment: respiratory support; decrease tumor size with radiation or chemotherapy

C.

Sepsis and Septic Shock 1. 2. Concern: Early recognition of infection Treatment: prompt

D.Spinal Cord Compression 1. Concern: pressure from expanding tumor can cause irreversible paraplegia; back pain initial symptom with progressive paresthesia and leg pain and weakness 2. E. Treatment: early detection and radiation or surgical decompression

Obstructive Uropathy 1. 2. Concern: blockage of urine flow; undiagnosed can result in renal failure Treatment: restore urine flow

F.

Hypercalcemia 1. 2. 3. Concern: high calcium from ectopic parathyroid hormone or metastases Behaviors: fatigue, muscle weakness, polyuria, constipation progressing to coma, seizures Treatment: restore fluids with intravenous saline; loop diuretics; more definitive treatments

G.

Hyperuricemia 1. Concern: occurs with rapid necrosis of tumor cells as with chemotherapy; can result in renal damage and failure 2. Prevention and treatment with fluids and Alopurinol (Zyloprim)

H.

SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion) 1. 2. Concern: ectopic ADH production from tumor leads to excessive hyponatremia Treatment: restore sodium level

Chemotherapy is the use of chemicals to treat disease. Paul Erlich, considered to be the father of chemotherapy, coined this word to describe a specific chemical utilized in the treatment of parasites. Today the term chemotherapy while technically describing drug therapy for any disease , is most frequently used in reference to the treatment of cancer. The simple definition of chemotherapy, although accurate , fails to encompass its multifaceted nature which is as complex as the disease it attempts to treat. Just as the word cancer represents many different types of malignant disease, the word chemotherapy represents many different types of chemotherapeutic agents. The drugs used in cancer treatment vary in their chemical structure , biological side effects and toxicities. Some are effective in treating one specific types of cancer while others are utilized in the treatment of wide variety of malignancies. The methods of administration also vary according to the chemotherapeutic and new techniques for safer and more effective administration. The process of learning about chemotherapy is indeed a challenge. Nursing management of the patient receiving chemotherapy requires knowledge about the treatment , skill in assessment, technical expertise, ability and desire to support the client physically and emotionally. The reward in meeting this is to be able to provide the care this clients need in order to survive their disease and its treatment and hopefully to go on with their lives with as few physical and emotional scars as possible. Nursing care begins with a thorough understanding of the patients condition; goal of therapy , drug dose, route, schedule, administration principles; and potential side effects. Additional nursing management includes monitoring responses to the therapy, reassessing and documenting signs and symptoms, and communicating pertinent information to other members of the health care team. Chemotherapy is the use of cytotoxic drugs in the treatment of cancer. It is one of the four modalitiessurgery, radiation therapy, chemotherapy and biotherapy- that provide cure, control, or palliation. Chemotherapy is systemic as opposed to localized therapy such as surgery & radiation therapy. There are four ways chemotherapy may be used: 1. Adjuvant therapy- A course of chemotherapy used in conjunction with another treatment modality. 2. Neoadjuvant chemotherapy- Administration of chemotherapy to shrink the tumor prior to surgical

removal of the tumor. 3. Primary therapy- The treatment of patients with localized cancer for which there is an alternative but less than completely effective treatment. 4. Induction chemotherapy- The drug therapy is given as the primary treatment for patients with cancer for which no alternative treatment exists. 5. Combination chemotherapy- Administration of two or more chemotherapeutic agents in the treatment of cancer, allowing each medication to enhance the action of the other or act synergistically with it. e.g. MOPP regimen for Hodgkins disease. ROLE OF A NURSE Prior to chemotherapy administration 1 Review- The chemotherapy drugs prescription which should have -Name of anti-neoplastic agent. -Dosage -Route of administration -Date and time that each agent to be administered. 2. Accurately identify the client 3.Medications to be administered in conjunction with the chemotherapy e.g antiemetics, sedatives etc. 4.. Assess the clients condition including - Most recent report of blood counts including hemoglobin ,hematocrit, white blood cells and platelets. -Presence of any complicating condition which could contraindicate chemotherapeutic agent administration i.e. infection, severe stomatitis , decreased deep tendon reflexes, or bleeding . -Physical status -Level of anxiety -Psychological status. 5. Prepare for potential complications Review the policy and have medication and supplies available for immediate intervention the event of extravasation. Review the procedure and have medication available for possible anaphylaxis 6.Assure accurate preparation of the agent -Accuracy of dosage calculation -Expiry date of the drug to be checked -Procedure for correct reconstitution and -Recommended procedures for administration 7.Assess patients understanding of the chemotherapeutic agents and administration procedures. II. Calculation of drug dosage

It is calculated based on body surface area. III. Drug reconstitution/Preparation- Pharmacy staff should reconstitute all drugs pre-prime the intravenous tubing under a class II biologic safety cabinet(BSC). In certain conditions nurses may be required to reconstitute medications. When preparing and reconstituting safe handling guidelines to be followed. -All chemotherapeutic drug should be prepared according to package insert in class II BSC. -Aseptic technique should be followed. -Personal protective equipment includes disposable surgical gloves, long sleeves gown and elastic or knit

cuffs. -Protective eye goggles if no BSC -To minimize exposure -Wash hands before and after drug handling. -Limit access to drug preparation area

-Keep labeled drug spill kit near preparation area. -Apply gloves before drug handling. -Open drug vials/ ampoules away from body. -Place absorbent pad on work surface. -Wrap alcohol wipe around neck of ampoule before opening. -Cover tip of needle with sterilize gauge when expelling air from syringe. -Label all chemotherapeutic drugs. Clean up any spill immediately IV. Drug administration 1. Routei)Oral - Emphasize the importance of compliance by the patient with prescribed schedule.Drugs with emetic potential should be taken with meals. Assure that chemotherapeutic agents are stored as directed by the manufacturer(refrigerate, avoid exposure to direct light,etc). ii) Intramuscular and subcutaenous Chemotherapeutic agents that can be administered I/M or subcutaneously are few in number. Non-vesicants like L-asperaginase, bleomycin, cyclophosphamide, methotraxate. Cyta arabine,and some hormonal agents are given I/M & /Or subcutaneously. Use the smallest gauge needle possible for the viscosity of the medication. -Change the needle after withdrawing the agent from a vial or ampoule. -Select a site with adequate muscle and/or SC tissue. iii) Intravenous It is the most common method of administration of cancer chemotherapy. May be given through central venous catheters or peripheral access. Absorption is more reliable. This route is required for administration of vesicants and it also reduces the need of repeated injection. Because the I/V provides direct access to the circulatory system, the potential for infection and life threatening sepsis is a serious complication of I/V chemotherapy. The following guidelines to be kept in mind: -Inspect the solution, container and tubing for signs of contamination including particles, discoloration, cloudiness, and cracks or tears in bottle or bag -Aseptic technique to be followed -Prepare medicines according to manufacturers directions -Select a suitable vein -Large veins on the forearm are the preferred site. -Use distal veins first, and choose a vein above areas of flexion. -For non-vesicant drugs, use the distal veins of the hands (metacarpal veins): then the veins of the forearms(basilic and cephalic veins) For vesicants, use only the veins of the forearms. Avoid using the metacarpal and radial areas. -Avoid the antecubital fossa and the wrist because an extravasation in these areas can destroy nerves and tendons, resulting in loss of function. -Peripheral sites should be changed daily before administration of vesicants

-Avoid the use of small lumen veins to prevent damage due to friction and the decreased ability to dilute acidic drugs and solutions. Select the shortest catheter with the smallest gauge appropriate for the type and duration of the infusion (21g to 25g for I/V medications and 19 g for blood products). Avoid a vein which has been used for venous access within the past 24 hrs to prevent leakage from a prior puncture site. Prevent trauma and infection at the insertion site. -Apply a small amount of iodine based antiseptic ointment over the insertion site & cover the area with sterile gauze. Intravenous Chemotherapy Via Central Vein Infusion (Hickman Catheter) A Hickman catheter is a flexible polymeric silicon rubber catheter which is threaded through the cephalic vein and into the superior vena cava or through the venacava and into the right atrium of the heart. Placement in a large vein permits the use of a catheter large enough for infusion of chemotherapy, hyper osmolar fluids for nutrition purposes, blood products and other needed intravenous fluids. The silicon rubber material of catheter is chemically inert to prevent decomposition and it is antithrombogenic A felt cuff near the exit site anchors the catheter on the patients chest and acts as an anatomic barrier to prevent entry of infection causing agents. It is either single lumen or double-lumen. IV) Intra-arterial V)Intra-peritoneal VI)Intrathecal- Infusion of medication can be given through an Ommaya reservoir, implantable pump and /or usually through lumbar puncture. a)Wear protective equipment (gloves, gown and eyewear). b)Inform the patient that chemotherapeutic drugs are harmful to normal cells and that protective measures used by personnel minimize their exposure to these drugs. c)Administer drugs in a safe and unhurried environment. d)Place a plastic backed absorbent pad under the tubing during administration to catch any leakage. Do not dispose of any supplies or unused drugs in patient care areas. V. Documentation Record -chemotherapeutic drugs, dose, route ,and time -Premedications, postmedications, prehydration and other infusions and supplies used for chemotherapy regimen. -Any complaints by the patient of discomfort and symptoms experienced before, during, and after chemotherapeutic infusion. VI. Disposal of supplies and unused drugs a)Do not clip or recap needles or break syringes. b)Place all supplies used intact in a leak proof ,puncture proof, appropriate labeled container. c)Place all unused drugs in containers in a leak proof, puncture proof, appropriately labeled container. d)Dispose of containers filled with chemotherapeutic supplies and unused drugs in accordance with regulations of hazardous wastes.

VII.

Management of chemotherapeutic spills

Chemotherapy spills should be cleaned up immediately by properly protected personnel trained in the appropriate procedure. A spill should be identified with a warning sign so that other person will not be contaminated. Supplies Required Chemotherapy spill kit contains Respirator mask for air borne powder spills Plastic safety glasses or goggles Heavy duty rubber gloves Absorbent pads to contain liquid spills Absorbent towels for clean up after spills Small scoop to collect glass fragments Two large waste disposal bags

Protective disposable gown Containers of detergent solution and clear tap water for post spill clean up. Puncture proof and leak proof container approved for chemotherapy waste disposal Approved, specially labeled, impervious laundry bag. Spill on hard surface Restrict area of spill Obtain drug spill kit Put on protective gown, gloves, goggles Open waste disposal bags Place absorbent pads gently on the spill; be careful not to touch spill. Spill on hard surface Restrict area of spill Obtain drug spill kit Put on protective gown, gloves, goggles Open waste disposal bags Place absorbent pads gently on the spill; be careful not to touch spill. Place absorbent pad in waste bag Cleanse surface with absorbent towels using detergent solution and wipe clean with clean tap water. Place all contaminated materials in the bag. Wash hands thoroughly with soap and water. Spill on personnel or patient Restrict area of spill Obtain drug spill kit Immediately remove contaminated protective garments or linen Wash affected skin area with soap and water If eye exposure-immediately flood the affected eye with water for at least 5 mts; obtain medical attention promptly Notify the physician if drug spills on patient. Documentation- Document the spill.

VIII. Staff Education All personnel involved in the care should receive an orientation to chemo. Drugs including their known risk , relevant techniques and procedures for handling, the proper use of protective equipment and materials, spill procedures, and medical policies covering personnel handling chemo. agents. Personnel handling blood, vomitus, or excreta from patients who have received chemotherapy should wear disposable gloves and gowns to be appropriately discarded after use. IX. Extravasation management Extravasation is the accidental infiltration of vesicant or irritant chemotherapeutic drugs from the vein into the surrounding tissues at the I/V site. A vesicant is an agent that can produce a blister and /or tissue destruction. An irritant is an agent that is capable of producing venous pain at the site of and along the vein with or without an inflammatory reaction. Injuries that may occur as a result of extravasation include sloughing of tissue , infection, pain ,and loss of mobility of an extremity. 1.Prevention of extravasation Nursing responsibilities for the prevention of extravasation include the following Knowledge of drug s with vesicant potential Skill in drug administration Identification of risk factors e.g. multiple vene punctures Anticipation of extravasation and knowledge of management protocol New venepuncture site daily if peripheral access is used Central venous access for 24 hrs vesicants infusion Administration of drug in a quiet, unhurried environment Testing vein patency without using chemotherapeutic agents Providing adequate drug dilution Careful observation of access site and extremity throughout the procedure Ensuring blood return from I/V site before, during, and after vesicant drug infusion. Educating patients regarding symptoms of drug infiltration , e.g. pain, burning, stinging sensation at I/V site. 2.Extravasation management at peripheral site-According to agency policy and approved antidote should be readily available. The following procedure should be initiatedStop the drug Leave the needle or catheter in place Aspirate any residual drug and blood in the I/V tubing, needle or catheter, and suspected infiltration site Instill the I/V antidote Remove the needle If unable to aspirate the residual drug from the IV tubing , remove needle or catheter Inject the antidote sub-cutaneously clockwise into the infiltrated site using 25 gauge needle; change the needle with each new injection Avoid applying pressure to the suspected infiltration site Apply topical ointment if ordered Cover lightly with an occlusive sterile dressing Apply cold or warm compresses as indicated Elevate the extremity Observe regularly for pain, erythema, induration, and necrosis

Documentation of extravasation management. All nursing personnel should be alert and prepared for the possible complication of anaphylaxis. X. Nursing Management of common side effects of Chemotherapeutic drugs.

.Nausea & Vomiting Nausea is the conscious recognition of the subconscious excitation of an area of the medulla closely associated with or part of the vomiting center. Nausea may cause the desire to vomit & it often precedes or accompanies vomiting. Avoid eating/drinking for 1-2 hrs prior to and after chemotherapy administration Eat frequent, small meals. Avoid greasy & fatty foods and very sweet foods & candies. Avoid unpleasant sights, odors & testes Follow a clear liquid diet If vomiting is severe inform the physician. Consider diversionary activities Sip liquids slowly or suck ice cubes and avoid drinking a large volume of water if vomiting is present Administer antiemetics to prevent or minimize nausea. Patient may require routine antiemetics for 3-5 days following some protocols. Monitor fluid and electrolyte status. Provide frequent, systemic mouth care. Bone marrow Depression This can lead to -Anaemia -Bleeding due to thrombocytopenia -Infection due to leukopenia Nursing Actions Administer packed RBC according to the physician orders. Monitor hematocrit and haemoglobin especially during drug nadir Maintain the integrity of the skin Avoid activities with the greatest potential for physical injury Use an electric razor when shaving Avoid the use of tourniquets Eat a soft, bland diet, avoid foods that are thermally, mechanically and chemically irritating. Maintain the integrity of the mucous membranes of G I tract Promote hydrate to avoid constipation Avoid enemas, harsh laxatives & the use of rectal thermometers. Take steroids with an antacid or milk. Avoid sources of infection Maintain good personal hygiene. Prevent trauma to skin & mucous membranes Report s/s of infection to physician Monitor counts Avoid invasive procedures, no Raise the arm while pressure is applied after removal of a needle or catheter

Alopecia Explain hair loss is temporary, and hair will grow when drug is stopped. Use a mild, protein based shampoo, hair conditioner every 4-7 days Minimize the use of an electric dyer. Avoid excessive brushing and combing of the air. Combing with a wide tooth comb is preferred. Select wig, cap, scarf or turban before hair loss occurs. Keep head covered in summer to prevent sunburn and in winter to prevent heat loss. Fatigue Assess for possible causes chronic pain, stress, depression and in-sufficient rest or nutritional intake. -Conserve energy & rest when tired -Plan for gradual accommodation of activities. -Monitor dietary & fluid intake daily. Drink 3000 ml of fluid daily, unless contra-indicated, in order to avoid the accumulation of cellular waste products. Anorexia Freshen up before meals Avoid drinking fluids with meals to prevent feeling of fullness High protein diet Monitor and record weight weekly. Report weight loss Stomatitis (Oral) -Symptoms occur 5-7 days after chemotherapy & persist upto 10 days -Continue brushing regularly with soft tooth brush -Use non irritant mouthwash -Avoid irritants to the mouth -Maintain good nutritional intake, eat soft or liquid foods high in protein Follow prescribed medication schedule e.g. drug for oral candidiasis. -Report physician if symptom persists -Increase the frequency of oral hygiene every 2 hrs -Glycerin & lemon juice should never be used to clear mouth or teeth as it cause the tissues to become dry& irritated. Diarrhoea - Some clients experience diarrhoea during and after treatment with chemotherapy. Nursing Action Monitor number, frequency and consistency of diarrhoea stools. Avoid eating high roughage, greasy and spicy food alcoholic beverages, tobacco and caffeine products Avoid using milk products Eat low residue diet high in protein and calories Include food high in potassium if fatigue is present like bananas, baked potatoes. Drink 3000 ml of fluid each day. Eat small frequent meals ; eat slowly and chew all food thoroughly Clean metal area after each bowel movement. Administer anti-diarrhoeal agents as prescribed. Depression Assess for changes in mood and affect. Set small goals that are achievable daily

Participate e.g. music, reading, outings Share feelings Reassurance CystitisIs an inflammation of the bladder, which is usually caused by an infection. Sterile cystitis not induced by infection. Sterile cystitis not induced by infection, can be a side effect of radiation therapy or due to cyclophosphamide (endoxan) administration. The metabolites of cyclophosphamide are excreted by the kidneys in the urine Nursing Actions Fluid intake at least 3000 ml daily Empty Bladder as soon as the urge to void is experienced. Empty bladder at least every 2-4 hrs. Urinate at bed time to avoid prolonged exposure of the bladder wall to the effects of cytoxan while sleeping. Take oral cytoxan early in the morning to decrease the drug concentration in the bladder during the night Report increasing symptoms of frequency bleeding burning on urination, pain fever and chills promptly to physician Following comfort measures can be adopted if cystitis is present -Ensure dilute urine by increasing the fluid intake Avoid foods & beverages that may cause irritation to the bladder alcohol, coffee, strong tea, Carbonated beverages etc. Outpatient Chemotherapy Delivery Aggressive, complex and sophisticated cancer therapies are currently being in ambulatory & home care settings. This shift is provision of services from the Hospital setting is a result o cost-containment efforts, advanced technology, competition & increased competence of nurses. Conclusion Chemotherapy offers patients with cancer a great deal of hope for a cure or a means of control cancer for a long period of time. Hope and optimism are vital ingredients in care plan.

-Virgie-