1. Chemotherapy Training Level 1 Essex Cancer Network October 2012

2. INTRODUCTION

3. Why? Level One training is required for all staff who may come across chemotherapy in their normal job, such as dispensary technicians, assistants and aseptics staff. Level Two training is for all staff involved in prescription verification of SACT prescriptions. Level Three training is for specialist oncology staff, who work within the area of cancer for more than 50% of their time, or are designated as a cancer specialist at their trust.

4. Principles for Level One Training Knowledge Basic background knowledge of cancer Training One hour lunchtime session held each year. Key elements of syllabus Health and safely/ safe handling Relevant protocols/SOPs to trust Labelling Counselling Where to go for further advice Background and principles of chemotherapy Revalidation To be revalidated the individual must attend a yearly update in oncology training session.

5. CANCER

6. 6 Background knowledge of cancer Cancer – Abnormal growth of cells which tend to proliferate in an uncontrolled way and may spread – Derived from Greek word karkinos meaning crab Tumour – Latin word meaning “abnormal swelling” Neoplasm – “new growth” (benign or malignant) Benign – Not cancer – Does not invade surrounding tissue or spread to other parts of the body.

7. 7 Background knowledge of cancer Malignant – Tending to be severe and become progressively worse – Can invade and destroy nearby tissue and that may spread to other parts of the body. – Latin combination of "mal" meaning "bad" and "nascor" meaning "to be born“ – literally means "born to be bad" Oncology – Branch of medicine that deals with cancer, including study of their development, diagnosis, treatment, and prevention Haematology – Branch of medicine that specialises in study & treatment of blood

8. 8 Cancer Treatment Choices Radiotherapy Systemic therapy Surgery Can be used alone or in combination – to enhance local control & attack potential sites of metastases Systemic therapy – Chemotherapy – Hormone therapy – Biological therapy – Experimental chemotherapy

9. CHEMOTHERAPY

10. Principles of chemotherapy “Normal cells obey strict rules. Divide only when told. Die rather than misbehave.” Normal cells have several systems for interrupting the cell cycle if there is a problem These control systems are called “checkpoints” Checkpoints are biological traffic lights telling the cell when it can safely carry on to replicate or when to stop and fix a problem

11. Principles of chemotherapy In cancer cells, some or all of the usual checkpoints fail leading to an over proliferation of abnormal cells The faulty checkpoints make the cell unable to check if the DNA replication was complete, if any mutations needed to be repaired, if the DNA was properly separated between the daughter cells, or many other problems These cells are likely to become cancerous with their multiple genomic problems Whereas normal cells have functioning checkpoints, abnormal cells checkpoints have been lost or disabled

12. 12 Aim of Systemic Chemotherapy Cure – Cancer / Tumour disappears and does not return Control – If cure is not possible, the goal is to control the disease (stop growth & spreading) Palliation – For advanced cancer, where control is unlikely. Drugs used to relieve symptoms  Improve QoL

13. Why in ‘regimens’ Combination chemotherapy is used to try and improve rate and duration of response by combining drugs with different mechanisms of action: – helps to prevent resistance – known to be effective as single agents – different toxicity (toxicities don’t overlap) – try to use drugs with synergistic killing effect – no clinically important drug interactions between the agents

14. Why in courses? Use pulsed intermittent therapy to allow normal cells to recover Normal (bone marrow cells) cells recover quicker from chemotherapy then cancer cells Normal tissues are inevitably damaged by chemotherapy – bone marrow & epithelial lining cells usually recover within 2-3 weeks On this basis, most chemotherapy given at 3 – 4 weekly intervals

15. 15 Time (Weeks) Fraction Cell Survived 360 Bone Marrow Cells Tumour Cells Course of treatment Limit of detection Relapse Pulsed therapy

16. Mucositis Nausea/vomiting Diarrhea Cystitis Sterility Neuropathy Common Side Effects Alopecia Pulmonary fibrosis Cardiotoxicity Local reaction Renal failure Myelosuppression

17. ORAL CHEMOTHERAPY

18. NPSA RRR Risks of incorrect dosing of oral anti-cancer medicines – 22 January 2008 Doctors, nurses, pharmacists and their staff must be made aware that the – Prescribing – Dispensing, and – Administration of oral anti-cancer medicines should be carried out and monitored to the same standard as injected therapy.

19. NPSA RRR Risks of incorrect dosing of oral anti-cancer medicines – 22 January 2008

20. Principles for Safe Dispensing Prescriptions must be screened by an authorised pharmacist All pharmacy staff involved with dispensing oral anticancer agents must have access to full copies of all relevant protocols (trial and non-trial) Dispensary staff must have ready access to specialist oncology pharmacy advice Dispensary staff should work to detailed operational procedures Label directions must be clear and unambiguous – where relevant include treatment period, start and stop dates and an indication of the need for safe handling

21. Principles for Safe Dispensing Patient information leaflets may be supplemented with additional local information For patients with swallowing difficulties, there is a need to seek specialist advice (medicines information or oncology pharmacist) General risk management issues such as handling of wastage from patients, inappropriate storage and risk to others, especially young children should be given

22. HEALTH AND SAFETY

23. Health and safely Chemotherapy is: – Mutagenic induces mutations – Teratogenic disturbs the growth of embryo/foetus – Carcinogenic causes cancer, changes normal cells into cancerous cells

24. Routes of Absorption Inhalation aerosols or evaporation Absorption skin or mucous membranes Ingestion hand to mouth contact

25. Methods of Exposure Direct contact with cytotoxics Spillage Splash Needle-stick Aerosol Picking them up Therefore made up in aseptics in ‘isolators’

27. Oral Chemotherapy Should not be touched by hand Use cytotoxic triangle to count - Do not use medicines counter The tablet/capsule should be placed into a medicine cup or spoon and taken by the patient directly from the container without handling For patients with swallowing difficulties, there is a need to seek specialist advice on crushing tablets or opening capsules (medicines information or oncology pharmacist)

28. NEED TO KNOWs

29. Relevant protocols/SOPs to trust Please list for your trust

30. Labelling Label directions must be clear and unambiguous – where relevant include treatment period, start and stop dates and an indication of the need for safe handling All labels for chemotherapy agents (not TKIs/MABs) must have stated – ‘Cytotoxic – handle with care’

31. Counselling Unless you have had specific training on chemotherapy agents to level 2 or 3, you should not counsel patients about taking their chemotherapy agents. If you need further advise please contact your specialist cancer pharmacist