Cancer Treatment Modalities Overview Mary M. Gullatte, PhD, RN UICC Program Makati Medical Center, Philippines October 29, 2008

(C) M.Gullatte, 2008 Surgery Diagnosis Staging Treatment Surgery Techniques – Electrosurgery – Cryosurgery – Chemosurgery

(C) M.Gullatte, 2008 Chemotherapy Administration – Venous access devices – Care & maintenance of VADs ‘Safe Handling and disposal Drug classifications Caring for patients receiving chemotherapy

(C) M.Gullatte, 2008 Radiation Therapy Principles of Radiation Therapy Types of Radiation Therapy – External beam (stereotactic) – Internal beam (brachytherapy) – Photodynamic therapy Radiosensitizers Total Body Irradiation

(C) M.Gullatte, 2008 Biotherapy Major agents Gene therapy Growth factors

(C) M.Gullatte, 2008 Multimodal Therapy Surgery plus chemotherapy Chemotherapy plus radiation Biotherapy and combinations All modalities

(C) M.Gullatte, 2008 Complimentary and Integrative Therapies Behavioral Nutritional Energy work Cognitive Cultural practices and beliefs Botanicals

(C) M.Gullatte, 2008 Education Patient and Family Education

(C) M.Gullatte, 2008 Community Resources & Support Larger community Patient community

(C) M.Gullatte, 2008 CHEMOTHERAPY Normal vs malignant growth

(C) M.Gullatte, 2008 Mitosis Interphase Prophase Metaphase Anaphase Telophase

(C) M.Gullatte, 2008 Benign and Malignant Cell Characteristics

(C) M.Gullatte, 2008 Benign Encapsulated No metastasis Partially differentiated Slight vascularity

(C) M.Gullatte, 2008 Malignant Rarely encapsulated Poorly differentiated Metastatic Abnormal cells Moderate to marked vascularity

(C) M.Gullatte, 2008 Cancer Cell Morphology Pleomorphism Hyperchromatism Aneuploidy Abnormal chromosomes

(C) M.Gullatte, 2008 Cancer Cell Cycle G o Post mitotic resting phase G 1 Post mitotic/pre-synthesis SSynthesis G 2 Post-synthetic/pre mitotic phase MMitosis

(C) M.Gullatte, 2008

Cancer Cell Growth Gompertz Growth Curve – Growth Factor (GF) – Doubling time (DT)

(C) M.Gullatte, 2008 Cell Cycle Response to Chemotherapy Gº: Resting phase- no replication G¹: RNA and protein synthesis S: DNA synthesis G ² : Second growth period- RNA and protein synthesis M: Actual cell division

(C) M.Gullatte, 2008 Cell Cycle Specific Agents G¹ -Phase Asparaginase Prednisone Ifosfamide S Phase Fluorouracil carboplatin Cytarabine Methotrexate Thioguanine G ² Phase Bleomycin Etoposide Ifosfamide Amsacrine M Phase Vincristine Vinblastine Vinorelbine Vindesine

(C) M.Gullatte, 2008 Cell Cycle Non-Specific Agents Alkylating Agents Busulfan Chlorambucil Cisplatin Cyclophosphamide Carboplatin Antibiotics Daunorubicin Mitomycin Doxorubicin/Adriamycin Mitoxantrone Nitrosoureas Carmustine Streptozocin Lomustine Miscellaneous agents Dacarbazine Procarbazine

(C) M.Gullatte, 2008 Tumor Response Criteria Complete Remission (CR) Partial Remission (PR) Progression (P) Improvement (I) Stable Disease (SD)

(C) M.Gullatte, 2008 Factors Affecting Response Tumor burden Growth fraction Tumor drug resistance

(C) M.Gullatte, 2008 Classification of Chemotherapy/Antineoplastic Agents Alkylating Antimetabolites Antitumor antibiotics Biologics Hormones Plant alkaloids Targeted Therapy

(C) M.Gullatte, 2008 Biologic Response Modifiers Epoetin alpha Filgrastim Interferon alpha Tumor necrosis factor Rituximab

(C) M.Gullatte, 2008 Hormones Hormone sensitive cancers – Breast – Prostate Glucocorticoids – Dexamethasone – Prednisone

(C) M.Gullatte, 2008 Plant Alkaloids Vinca alkaloids – vincristine Taxanes – paclitaxel Phodophyllotoxins – etoposide

(C) M.Gullatte, 2008 Targeted Therapy Ideal Target – Necessary for tumor survival – Normal cells +/- expression of the target – Blocking the target = tunor response – Minimal expression target results in +/- tumor response

(C) M.Gullatte, 2008 Stimulators and Inhibitors of Angiogenesis Stimulators (growth factors) – Basic fibroblast – Epidermal – Placental – Transforming factor-α – Tumor necrosis factor (TNF) – Vascular endothelial gf (VEGF) Inhibitors – Angiostatin – Endpstatin – Interferons α, β, γ – Interleukins 4, 12, 18 – Thrombospondin – Tissue inhibitor of metalloproteinase -1, -2, -3

(C) M.Gullatte, 2008 Vesicant Agents Antitumor antibiotics Alkylating agents Vinca alkaloids

(C) M.Gullatte, 2008 Principles and Standards of Chemotherapy Administration Safe-handling and Disposal guidelines Preparation and administration Routes of Administration Storage and transport Hazardous drug spills Patient and family education

(C) M.Gullatte, 2008 Safe Handling and Disposal Reconstituting (lamina flow hood) Personal Protective Equipment (PPE) Spills (face shield, respirator, gloves, gown) Patient body fluids (urine, emesis) Disposal of empty chemotherapy containers (bags, bottles, IV tubing, vials) Surface decontamination

(C) M.Gullatte, 2008 Preparation and Administration Orders (check protocol, regimens, BSA, labs, vascular access) Pharmacy, Nurse, Physician, Responsibility – Pharm D. (orders, mixing, priming tubing, delivery to unit for nurse) – Nurse (patient education, administration (oral, IV, IP) – Physician or Midlevel (IT, IA) Personal Protective Equipment – gloves, goggles, cuffed gown

(C) M.Gullatte, 2008 Routes of Chemotherapy Administration Oral Intravenous (IV) Intraperitoneal (IP) Intra-arterial (IA) Intrathecal a.k.a., intraventricular (IT)

(C) M.Gullatte, 2008 Storage and Transport Clean area Label area No chemicals above eye level Transport primed solutions to the area securely Prime with drug free fluids Secure clamp Properly label

(C) M.Gullatte, 2008 Hazardous Chemotherapy Spill Emergency code Secure and contain the area Size of spill PPE and Spill kit Disposal

(C) M.Gullatte, 2008 Patient and Family Education Medications Expected side effects Precautions Managing at home When to call the nurse or doctor

(C) M.Gullatte, 2008 Questions?