1. Chemotherapy
Cancer Therapy

2. Patient Receiving Chemotherapy

3. Today’s Class: Chapter 16 Pg. 381-386 Goals of chemotherapy
Agents & drug classifications
Methods of administration
Side effects (assessment/management)
Nursing care, management & interventions

4. Chemotherapy Class Objectives:
Discuss the goals of chemotherapy.
Describe the agents used in chemotherapy, including classification, methods of administration and side effects.
Describe the nursing assessment and management of side effects of chemotherapy

5. Chemotherapy
Is the use of drugs (antineoplastic agents) to kill tumor cells by interfering with cellular functions and reproduction.
Systemic treatment rather than a localized therapy such as surgery and radiation therapy.
Also known as Cytotoxic Drugs

6. Goals of Chemotherapy:
1) Cure: tumor or cancer disappears and doesn’t return.
2) Control: stop the cancer from growing and spreading.
3)Palliation: when cure and control are not possible the goal is to relieve symptoms caused by cancer, improve QoL.
Chemotherapy is appropriate when:
Disease is wide spread
The risk of undetectable Dx is high
The tumor can’t be resected & is resistant to radiation
Chemo can be:
Neoadjuvant: shrink a large tumor and lower the stage of the tumor so it can be surgically removed or possibly even cure with subsequent local therapy.
Adjuvant: given to prevent growth of stray cancer cells remaining after surgery or radiation. breast ca)

7. Goals of Chemotherapy
Must be realistic because they will define the meds to be used & aggressiveness of treatment.
The primary focus of chemotherapy is preventing cancer cells from multiplying, invading adjacent tissue or developing metastasis.
Objective of chemo : Destroy all malignant cells without excessive destruction of normal cells
The response a patient has to a chemo treatment may be classified as a cure, complete response, partial response, stable disease or progression.
Usually, cure implies a person is disease free at 5 years.

8. Potential Patient Responses
Complete response (CR)
complete disappearance of the disease. No disease is evident on examination, scans or other tests.
Partial response (PR)
some disease remaining in body, but there has a been a decrease in size or number of the lesions by 30% or more.
Stable disease (SD)
disease has remained virtually unchanged in size and number of lesions. Generally, a less than 50% decrease or a slight increase in size would be described as stable disease.
Progressive disease (PD)
Disease has increased in size or number on treatment.

9. Chemotherapeutic Agents :
Cell Cycle Specific: mostly affect the S phase & some the M phase. Administered in minimal concentrations by continuous dosing routes.
Cell Cycle Non-Specific: affects dividing and resting cells in all phases of the cell cycle. Administered in single bolus injection.
Combination: agents that differ in both cell cycle specificity & their toxicities are combined to maximize tumor cell kill with minimal toxicity.Administered in repeated courses.
Cell cycle specific: drugs exert a specific action when in S and some in M phase of the cell cycle.
Combination chemo: Administered in repeated courses so to minimize immunosuppression effects that might have otherwise occurred. Also long term use of a single drug found that lethal toxicities & results in drug resistance. Ex. 5FU- fluorouracil
Cell Kill hypothesis – only a percentage of cancer cells are killed with each course of chemo so repeated doses - or cycles is used. The length of the cycle is determined by the recovery of the patient’s healthy cells as well as the characteristics of the agents. Myelosuppression is a common dose-limiting toxicity and determines the length of the chemo cycles. It generally takes days for neutrophils to recover after treatment with a myelosuppressive chemotherapy.
Combination chemo: are used to act on the tumor cells by different mechanisms. Administered in repeated courses so to minimize toxicities such as immunosuppression, decrease chance of drug resistance
Combination chemo: administered in repeated doses to minimize immunosuppression effects that otherwise might have occurred. Also long term use of a single dose drug found that lethal toxicities & results in drug resistance. EX 5Fu (fluoracil).

10. Major Chemo Classifications
Cell cycle Non Specific:
Alkyating- alter DNA (nitrogen mustard, busulfan)
Antitumor Antibodies DNA & RNA distort
( Bleomycin)
Hormonal Agents-
bind to receptor sites that promote growth
(Tomoxifen)
Cell Cycle Specific:
Antimetabolites-interfere DNA synthesis, S Phase (5FU, MTX ,folic acid)
Vinca Alkaloids- inhibits spindle formation during mitosis (Vincristine)
Chem classified according to pharmacologic actions & effects on cell cycle.
Antimetabolites: ex 5FU interferes with synthesis of nucleic acids & proteins.
Hormonal Agents-modify growth (Androgens & Antiantrogens) specific mechanism not clear, they modify growth of certain hormone dependent cancers ex estrogen treats some cancers as it provides less favorable environment for growth of cancer cells.

11. Factors to consider when choosing patient’s chemo. treatment
Type of cancer
Stage of Cancer (TNM System)
Patient’s Age
General State of Health
Other health problems (liver, renal )
Types of anticancer treatments in the past
TNM system: tumor size, spread lymph nodes & whether spread to other body organs or not

12. Methods to Administer Chemo:
Oral Intrapleural
Topical Intraperitoneal
IV Intravesical
IM Intralesional SC
Intra-arterial
Intrathecal
Intrathecal- omaya resouvoir.

13. Chemotherapeutic Agents
Chemotherapeutic agents are apt to impair or damage cells in the marrow than other normal cells in the body (myelosuppression).
myelosuppression is the depression of bone marrow function; decreased production of blood cells
Only actively dividing cells in the bone marrow are affected (i.e. stem cells). Cells with shorter life span are more affected (white vs. red blood cell)
The damage to the bone marrow is directly porportional to the drug dosage. Thus, the damage to these tissues is dose limiting. (Monitor CBC regularly)
What would happen if the nurse didn’t know what the acceptable limit was???
Myelosuppression of bone marrow- one of the most common side effects of chemo.
Low count doesn’t occur immediately after chemo cause drugs don’t destroy cells already in the blood stream. Drugs temporarily prevent formation of new blood cells in the marrow.
Myelosuppression decreases the number of WBCs (leukopenia), red blood cells (anemia), and platelets (thrombocytopenia) and increases the risk for infection and bleeding. Depression of these cells is the usual reason for limiting the dose of the chemotherapeutic agents. Monitoring blood cell counts frequently is essential, as is protecting the patient from infection and injury, particularly while the blood cell counts are depressed.

14. Chemotherapeutic Agents
The resulting reduction in the body’s RBC, WBC and platelets limits the next dose of chemotherapy that may be safely given or causes postponement of further drug treatment of cancer until the patient recovers from the toxic effects. (Recovery)
Life span blood cells: WBC approx. 6 hours
Plts approx 10 days
RBC’s approx 120 days
Nadir: the lowest level that blood cells can fall
Post chem WBC & PLTS nadir 7-14days
RBC several weeks.

15. Chemotherapy: Side Effects
Normal Cells Affected:
bone marrow
mouth
stomach
intestine
hair follicles
reproductive system

16. Side Effects of Chemo: RBC Decrease
RBC Decrease : Anemia Fatigue SOB Cold Pale Irritable Dizzy Weakness Tingling
RBC’s- (erythrocytes) female g/L & male g/L
Since RBCs have a life span of 120 days, those at greatest risk are those receiving long chemo regimens > 4 months.

17. Anemia
RBC’s transport oxygen to all parts of the body are produced in the bone marrow.
Sometimes chemo can reduce the bone marrow’s ability to produce these cells, resulting in too few RBC’s to carry oxygen to other body tissues.
Without enough oxygen, other tissues are unable to perform their functions.
Anemia following chemotherapy is usually related to bone marrow suppression but may be multi factorial.(bleeding, iron deficiency)

18. Female g/L & Male g/L

19. Anemia Nursing Interventions
Assist pt. to conserve energy
sit on bedside prior to ambulating
oxygen administered as ordered
small frequent meals nutritional meals
communicate feelings of frustration & anger are normal when fatigued
obtain order to administer blood when hgb.<80
Assessment includes history, physical, lab values (OB, CBC, ferritin, RBCs, Vit B12)
Erythropoietin (works in 50% of cases) & costly

20. Side Effects of Chemo.
Platelets Decrease: bruises petechiae bleeding gums blood urine/stool
Petechiae: small purplish spots on the skin from hemmorrhage.
Petechiae: small purplish spots on the skin from hemorrhage.
Normal platelets: ,000 cells
Platelets have life span of 7-10 days

21. Thrombocytopenia
Platelet count in healthy individual ranges 150, ,000 per micro liter of blood.
Thrombocytopenia occurs when the plt. Count <100,000
b/t 50,000-74,000 the condition is considered moderate.
<50,000 risk bruising and bleeding increases
<20,000 plt. transfussion

22. Symptoms of Thrombocytopenia
Small red or purple spots on the skin
unexplained bruising
blood in stools(black) or emesis (coffee)
usually heavy menstrual bleeding
red to pink urine
Assessment: Hisory (bleeding, meds, black stool, blood flow in women, alcohol consumption), physical ( petechiae, orifices, gums, fainting etc,), lab data (cbc, OB, U/A/ PT, PTT, INR)
Assess, report

23. Nursing Interventions: Thrombocytopenia
Avoid use straight-edged razor
Avoid aspirin & NSAID’s
Avoid IM’s
avoid rectal temps. and suppositories
Use lotions and lubricants on skin & lips
Ensure BM’s soft
Soft toothbrush

24. Nursing Interventions: Thrombocytopenia
Notify/educate for signs of bleeding
Notify physician of hypertension
Apply pressure to injection site, venipuncture, biopsy site for 4-5 minutes post-procedure
Avoid indwelling catheters
May use birth control pill temporarily to prevent/arrest menses
Pts with thrombocytopenia may experience a fatal intracranial or subdural hemorrhage. Any head injury should be taken very seriously.

25. Side effects of Chemo: Neutropenia
Neutropenia: abnormally low WBC’s which increases risk of infection.
WBC decrease therefore increase susceptiability to INFECTIONS
Symptoms:
Fever, sore throat, cough, SOB,Nasal congestion, burning urination, shaking
chills, redness, swelling and warmth of an injury
WBC leukocytes: normal 4,000-11,000 mm3
Neutropenia: abnormally low WBC’s increase risk of infection.
Assess, know significance & report

26. Nursing Interventions: Decreased WBC
good handwashing b/t pts.
monitor v/s (esp.T)
monitor lab values
monitor signs inf.(resp,urinary oral,skin)
maintain good patient hygiene
no mouthwashes (drying)
avoid people with colds
balanced diet

27. Managing Mucositis Through buccal cavity assessment
oral hygiene: soft toothbrush, freq. Rinses, keep moist
no commercial mouthwashes or lemon/glycerine swabs
use saline, club soda or saline & baking soda
meds as chlorhexidine rinses (may discolor teeth)
When chemo and radiation are combined, the incidence and severity are increased
no commercial mouthwashes or lemon/glycerine swabs: alters the cells in buccal cavity causing drying.

28. Radioprotector
Pilocarpine administered orally decreases the chance of mucositis, fungi, infections and ulcers of the mouth.
Cholinergic: causes exocrine glands to release saliva.
Med used to protect buccal cavity cells during chemotherapy therefore decreasing the chance of infections, ulcers & mucositis.

29. Managing Peri-rectal Complications
Scrupluous peri-care
Clean front to back(F)
Sitz baths
Stool softners

30. Alopecia Unavoidable side effect of some chemo which is individual.
The life cycle of the cell that produces a hair shaft is ~ one day.
Rapid rate of cell growth & reproduction makes hair follicles sensitive to effects of chemo.
B/t 7 &14 days post chemo hair thinning & loss begin (not permanent)
hair may grow back a new color or texture
Usually begins 7-10 days after first chemo treatment, begins to grow one to two months after treatment

31. Caring for Scalp & Hair during Chemo
Do not use hair coloring/permanent treatments
Do not use brush type rollers
use mild shampoos
avoid blow drying
use soft brushes
use a sun block with most or all hair loss
to protect scalp from sun use hat, scarf or turban

32. Safe handling of Chemo
Three routes of accidental exposure: 1). Absorption through skin 2). Inhalation ). Ingestion (food, gum)
Cytotoxic Precautions: protective practices whereby all excreta from pt. on chemo. may contain metabolized or cytotoxins. (urine & feces highest concentration)
begin:prior to chemo & end ~ 48hrs. Post completion chemo
Condoms should be used to decrease likelihood of cytotoxic secretions being passed to partner. Should not conceive while partner is on chemo.
Specialized certification is necessary. Strict guidelines.
Cytotoxic drugs are potentially mutagenic (inducing genetic changes in chromosomes); carcinogenic (causing cancer); teratogenic (causing harm to unborn fetus)
On units may give tomoxifen (breast ca po)
Bulsufan
Reminder to double flush toilet

33. Cytotoxic Precautions: Protective Equiptment
Gown: protective, non absorbent, disposable
Gloves: Non-powdered latex made for chemo
Goggles: not regular glasses
Masks: potential risk of droplet (topical chemo)
Cytotoxic Caution Signs: foot of bed
Spill Kits: commercially developed
Sharps Container: needles, IV’s, blades

34. Chemo. Administration Remember:
to always spike chemo. bag at waste level
to water proof tape at all connections
to remove protective equipment prior to leaving pt’s room
know signs & symptoms of side effects chemo
adhere to hospital policies & procedures regarding chemo. Be certified to give chemo
Two RN’s always check chemo

35. Chapter 13 Pain Next Class