WHAT IS CANCER?

Large group of malignant diseases with some or all of the ff characteristics: a. Abnormal cell proliferation b. Lack of controlled growth and division c. Ability to metastasize

WHAT IS CANCER?
A few diseases that result from faulty or abnormal genetic expression caused by changes that have occurred in the DNA.

WHAT IS CANCER? The uncontrolled growth of cells due to damage to DNA (mutations) and, ocassionally due to an inherited propensity to develop tumors.

Chemotherapy
A systemic intervention used in the treatment of certain disease conditions In modern-day use, refers primarily to the use of cytotoxic agents to treat CANCER. CHEMOTHERAPEUTIC AGENTS- Used only when disease prognosis shows that patient would benefit from the treatment

The Cell Cycle

 Broadly, most chemotherapeutic drugs work by impairing mitosis (cell division), effectively targeting fast-dividing cells. In cancer, cells rapidly divide and does not enter the resting phase because they are unresponsive to growth-inhibitory signals. Only a percentage of the cancer cells are killed with each course of chemotherapy. Therefore, repeated dosesor cycles of chemotherapy must be done.

SITES OF ACTION OF CYTOTOXIC AGENTS

Antibiotics Antimetabolites S (2-6h)

G2 (2-32h) M (0.5-2h)

Vinca alkaloids

Mitotic inhibitors

Taxoids Alkylating agents

G1 (2-h)

G0

GOALS
CURE CONTROL
PALLIATION

 Chemotherapy may be used as 1.) Adjuvant therapy 2.) Neoadjuvant therapy 3.) Chemoprevention 4.) Myeloablation

Classification of Chemotherapy Drugs

CYCLE-SPECIFIC Antimetabolites
interfere with nucleic acid synthesis Attack during S phase of cell cycle
Cytatabine, floxuridine, fluorouracil, hydroxyurea, methotrexate, thioguanine

Enzymes
Useful only for leukemias
Asparaginase

Plant Alkaloids
Cycle-specific to M Phase Prevent mitotic spindle formation
Vinblastine, vincristine

Classification of Chemotherapy Drugs

CYCLE-NONSPECIFIC Alkylating Agents

Disrupt deoxyribonucleic acid (DNA)
Carboplatin, Cisplatin, Cyclophosphamide, Ifosfamide, Thiotepa

Antibiotics
Bind with DNA to inhibit synthesis of DNA and RNA
Bleomycin, doxorubicin, idarubicin, mitomycin, mitoxantrone

Classification of Chemotherapy Drugs CYTOPROTECTIVE AGENTS

Protect normal tissue by binding with metabolites of other cytotoxic drugs
Dexrazoxane Mesna

FOLIC ACID ANALOGS

Antidote for methotrexate toxicity
Leucovorin

HORMONE AND HORMONE INHIBITORS

Interfere with binding of normal hormones to receptor proteins Manipulate hormone levels After hormone environment Usually palliative,not curative
Androgens, Antiandrogens, Antiestrogens, Estrogens, Gonadotropin, Progestins

Other AntiCancer Agents

Novel Agents Monoclonal Antibody
Trastuzumab (Herceptin) Rituximab (Mabthera) Cetuximab (Erbitux)

Tyrosine Kinase Inhibitor

Imatinib (Glivec)

EGFR Inhibitors
Erlotinib (Tarceva) Gefitinib (Iressa)

VEGF Inhibitors
Bevacizumab (Avastin)

BIOLOGICAL THERAPY
Consists mostly of the administration of biological response modifiers Also includes the use of immunotherapy Biological response modifiers
Alter the bodys response to therapy May cause direct cytotoxicity

Immunotherapy
Uses drugs to enhance the bodys ability to destroy cancer cells Seeks to evoke effective immune response to human tumors by altering the way cells grow, mature, and respond to cancer cells May include the administration of monoclonal antibodies and immunomodulatory cytokines

Immunotherapy
Monoclonal antibodies
Specifically target tumor cells More recent form of biotherapy that manipulates the bodys natural resources instead of introducing toxic substances that arent selective and cant differentiate between normal and abnormal processes or cells Recognizes only a single unique antigen
Rituximab (Rituxan) Trastuzumab (Herceptin)

Immunotherapy
Immunomodulary cytokines
Intracellular messenger proteins (proteins that deliver messages within cells)
Colony-stimulating factors
Erythropoietin (Epogen), Granulocyte colonystimulating factor (Neupogen), Granulocytemacrophage CSF (Leukine)

Interferon Interleukins Tumor Necrosis factor

Routes of Administration
Oral Route Subcutaneous and Intramuscular IV administration IV push IV piggy back (large volume) Direct Introduction Intrathecal Intrapleural Intraperitoneal Chemoembolization Ommaya reservoir

Safehandling Chemotherapeutic Agents

Chemotherapeutic Drugs are hazardous drugs. a hazardous drug is defined as an agent that presents a danger to healthcare personnel due to its inherent toxicity. They are carcinogenic They are genotoxic They are teratogenic There is evidence of toxicity at low doses

PREPARING CHEMOTHERAPEUTIC DRUGS

GATHERING THE EQUIPMENT Before preparing chemotherapeutic drugs, be sure to gather all the necessary equipment, including:
Patients medication order or record Prescribed drugs Appropriate diluent (if necessary) Medication labels Long-sleeped gown Chemotherapy gloves Face shield or goggles and face mask 20G needles Hydrophobic filter or dispensing pin

PREPARING CHEMOTHERAPEUTIC DRUGS

GATHERING THE EQUIPMENT (continuation)
Syringes with luer-lock fittings and needles of various sizes IV tubing with luer-lock fittings 70% alcohol Sterile gauze pads Plastic bags with hazardous drug labels Sharps disposal container Hazardous waste container Chemotherapy spill kit

PREPARING CHEMOTHERAPEUTIC DRUGS

ORGANIZING DRUG PREPARATION AREAS
Prepare chemotherapeutic drugs in well-ventilated workspace Perform all drug admixing or compounding within a Class II Biological Safety Cabinet or a vertical laminar airflow hood with a HEPA filter, which is vented to the outside If a Class II Biological Safety Cabinet isnt available, it is recommended to use a special respirator Have close access to a sink, alcohol pads, and gauze pads as well as Chemotherapy hazardous waste containers, sharps containers, and chemotherapy spill kits

PREPARING CHEMOTHERAPEUTIC DRUGS

ORGANIZING DRUG PREPARATION AREAS (cont.)
Make sure that all hazardous waste containers are made of punctureproof, shatterproof, leakproof plastic Make sure that yellow biohazard labels are available for labeling all chemotherapycontaminated IV bags, tubings, filters, and syringes Make sure that red sharps containers are available for disposal of all contaminated sharps such as needles.

PREPARING CHEMOTHERAPEUTIC DRUGS

WEAR PROTECTIVE CLOTHING Essential protective clothing includes a cuffed gown, gloves, and a face shield or goggles and a face mask Gowns should be disposable, water-resistant, and lint-free with long sleeves, knitted cuffs, and a closed front Gloves should be disposable, powder-free, and made of thick latex or thick nonlatex material Double gloving is an option when the gloves arent of the best quality

SAFETY MEASURES
GENERAL MEASURES At the local level, most health care facilities require nurses and pharmacists involved in the preparation and delivery of chemotherapeutic drugs and care of the patient with cancer. Take care to protect staff, patients and the environment from unnecessary exposure to chemotherapeutic drugs

SAFETY MEASURES
Make sure your facilitys protocols for spills are available in all areas where chemotherapeutic drugs are handled, including patient-care areas Refrain from eating, drinking, smoking or applying cosmetics in the drug-preparation area.

SAFETY MEASURES
ACCIDENTAL EXPOSURE If a chemotherapeutic drug comes in contact with your skin, wash the area thoroughly with soap and water to prevent drug absorption into the skin If the drug comes in contact with your eye, immediately flush the eye with water or isotonic eyewash for at least 5 minutes, while holding the eyelid open After an accidental exposure, notify your supervisor immediately

SAFETY MEASURES
WASTE DISPOSAL
Place all contaminated needles in the sharps container; dont recap needles Use only syringes and IV sets that have a luer-lock fitting Label all chemotherapeutic drugs with a yellow biohazard label Transport the prepared chemotherapeutic drugs in a sealable plastic bag thats prominently labeled with a yellow chemotherapy biohazard label Dont leave the drug-preparation area while wearing the protective gear you wore during drug preparation

SAFETY MEASURES
HANDLING A CHEMOTHERAPY SPILL Put on protective garments, if you arent already wearing them Isolate the area and contain the spill with absorbent materials from a chemotherapy spill kit Use the disposable dustpan and scraper to collect broken glass or desiccant absorbing powder

SAFETY MEASURES
HANDLING A CHEMOTHERAPY SPILL (contn) Carefully place the dustpan, scraper and collected spill in a leakproof, punctureproof, chemotherapy-designated hazardous waste container Prevent aerosolization of the drug at all times Clean the spill area with a detergent or bleach solution

ADMINISTERING CHEMOTHERAPEUTIC DRUGS

Gathering the equipment
Prescribed drugs IV access supplies Sterile PNSS IV syringes and tubings with luer lock Leakproof chemical waste container Chemotherapy gloves Chemotherapy spill kit Extravasation kit

ADMINISTERING CHEMOTHERAPEUTIC DRUGS

Preventing Infiltration Use a low-pressure infusion pump to administer vesicants through a peripheral vein, to decrease the risk of extravasation Use a central venous catheter for continuous vesicant infusions

ADMINISTERING CHEMOTHERAPEUTIC DRUGS

Guidelines in giving vesicants Use a distal vein that allows successive proximal venipunctures Avoid using the hand, antecubital space, damaged areas, or areas with compromised circulation Dont probe or fish for veins Place a transparent dressing over the site

ADMINISTERING CHEMOTHERAPEUTIC DRUGS

Guidelines in giving vesicants (contn) Start the push delivery or the infusion with normal saline solution Inspect the site for swelling and erythema Tell the patient to report burning, stinging, pain, pruritus, or temperature changes near the site After drug administration, flush the line with 20mL of NSS

ADMINISTERING CHEMOTHERAPEUTIC DRUGS

Concluding Treatment Dispose of all used needles and contaminated sharps in the orange sharps container Dispose of PPEs in yellow chemotherapeutic waste container Dispose of unused medications, considered hazardous waste, according to your facilitys policy

ADMINISTERING CHEMOTHERAPEUTIC DRUGS

Concluding treatment (cont) Wash hands thoroughly Document the ff.
sequence in which the drugs were administered site accessed, the gauge and length of the catheter, and the number of attempts name, dose, and route of the administered drugs Type and volume of the IV solutions and adverse reactions and nursing interventions

According to facility policy, wear protective clothing when handling body fluids from the patient for 48 hours after

MANAGING COMPLICATIONS OF CHEMOTHERAPY

ALOPECIA Hair loss that occurs as chemotherapeutic drugs destroy the rapidly growing cells of hair follicles May be minimal or severe Occurs 2-3 weeks after treatment begins Almost always temporary Signs and Symptoms Hair loss that may include eyebrows, lashes and body hair

Nursing Interventions Minimize shock and distress by warning the patient of this possibility Discuss with the patient why it occurs Describe to the patient how much hair loss to expect Emphasize to the patient the need for appropriate head protection against sunburn Inform the patient that new hair may be a different texture or color Give the patient sufficient time to decide whether to order a wig Inform the patient that his scalp will become sore at times due to follicles swelling Prevention measures For patients with long hair, suggest cutting hair shorter before treatment because washing and brushing cause more hair loss

ANEMIA Occurs as chemo drugs destroy healthy cells and cancer cells RBCs are destroyed and cant be replaced by the bone marrow Signs and symptoms Dizziness, fatigue, pallor, and shortness of breath after minimal exertion Low hemoglobin level and hematocrit May develop slowly over several courses of treatment

Nursing Interventions Monitor hemoglobin level, hematocrit, RBC count; report dropping values Be prepared to administer a blood transfusion or erythropoietin Prevention Measures Instruct the patient to take frequent rests, increase his intake of iron-rich foods, and take a multivitamin with iron as prescribed If the patient has been prescribed a drug such as epoetin, make sure he understands how to take the drug and what adverse effects he should watch for and report

DIARRHEA Occurs because the rapidly dividing cells of the intestinal mucosa are killed Complications include weight loss, F&E imbalance, and malnutrition Signs and symptoms An increase in the volume of stool compared with the patients normal bowel habits Nursing Interventions Assess frequency, color, and consistency of stool Encourage fluids, give IV fluids and potassium supplements as ordered Prevention measures Use dietary adjustments and antidiarrheal meds Provide good perianal skin care

EXTRAVASATION The inadvertent leakage of a vesicant solution into the surrounding tissue Signs and Symptoms Initial signs and symptoms may resemble those of infiltration blanching, pain, swelling Symptoms possibly progressing to blisters; to skin, muscle, tissue and fat necrosis; and to tissue sloughing Blood return is an INCONCLUSIVE test and shouldnt be used to determine if IV catheter is correctly seated in the peripheral vein. To assess peripheral IV placement, flush the vein with NSS and observe site for swelling.

Extravasation of Doxorubicin

Nursing Interventions Stop the infusion Check your facilitys policy to determine if the IV catheter is to be removed or left in place to infuse corticosteroids or a specific antidote. Notify the physician Instill the appropriate antidote according to facility policy. Usually, youll give the antidote for extravasation either by instilling it through the existing IV catheter or by using a 1 mL syringe to inject small amounts subcutaneously in a circle around the extravasated area After the antidote has been given, remove the IV catheter

Preventive measures Verify IV line patency and placement by flushing with normal saline soln Remember, When in doubt, take it out! Use a transparent, semi-permeable dressing for inspection of site.

INFILTRATION The inadvertent leakage of a nonvesicant solution or medication into the surrounding tissue Infusion-site related Signs and symptoms Blanching Change in IV flow rate Numbness and tingling in swollen area due to nerve compression injury leading to compartment syndrome Swelling around IV site (the swollen area will be cool to touch)

Nursing Interventions Remove the IV catheter Insert a new IV catheter in a different location Prevention Measures Check for infiltration before, during, and after the infusion by flushing the vein with normal saline solution

LEUKOPENIA Reduced leukocytes or WBCs Occurs as WBCs and cancer cells are destroyed by chemo drugs Signs and Symptoms Susceptibility to Infections Neutropenia Nursing Interventions Watch for the nadir, the point of lowest blood cell count Be prepared to administer colony-stimulating factors Institute neutropenic precautions

 Teach the patient and caregiver about:

Good hygiene practices Signs and symptoms of infection The importance of checking the patients temperature regularly How to prepare low-microbe diet How to care for vascular access devices

Instruct the patient to avoid

Crowds People with colds or respiratory infections Fresh fruit Fresh flowers plants

NAUSEA and VOMITING Can appear in 3 different patterns

Anticipatory Acute Delayed

ANTICIPATORY NAUSEA and VOMITING Signs and Symptoms Nausea and vomiting thats a learned response from prior nausea and vomiting after a dose of chemotherapy High anxiety levels (acts as a trigger) Nursing Interventions Posttreatment control of nausea and vomiting may prevent future anticipatory episodes Prevention measures Pretreat the patient with lorazepam (Ativan) at least 1 hr before arriving for treatment Patients with overwhelming anxiety may need IV lorazepam before chemo is administered

ACUTE NAUSEA and VOMITING Signs and symptoms Nausea and vomiting occurring within the first 24 hours of treatment Nursing Interventions Treat the patient with acute nausea and vomiting with antiemetic drugs
Dexamethasone Granisetron Lorazepam Metoclopramide Ondansetron

DELAYED NAUSEA and VOMITING

Signs and Symtoms Nausea or vomiting starting or continuing beyond 24 hours after chemo has begun Nursing Interventions The administration of serotonin antagoninsts, corticosteroids, various antihistamines, benzodiapines, and and metoclopramide is usually effective in treating patients Prevention Measures Administer antiemetic before chemo begins Some patients with delayed nause and vomiting are treated with an antiemetic for 3 days or longer

STOMATITIS Inflammation of the lining of the oral mucosa Can spread into the esophagus and pharynx Signs and Symptoms Painful mouth ulcers that range from mild to severe appearing 3 to 7 days after certain chemotherapeutic drugs are given

Nursing Interventiosn Instruct the patient to perform meticulous oral hygiene Administer topical anesthetic mixtures as appropriate If pain is severe, opioid analgesics may be prescribed until the ulcers heal Prevention Measures Instruct the patient to suck on ice chips while receiving certain drugs that cause stomatitis; this decreases the blood supply to the mouth, thus decreasing ulcer formation

THROMBOCYTOPENIA Reduced blood platelet count Signs and Symptoms Bleeding gums Coffee-ground emesis Hematuria Hypermenorrhea Increased bruising Petechiae Tarry stools Nursing interventions Monitor patients platelet count Avoid unnecessary IM injections or venipuncture

 If an IM injection or venipuncture is necessary, apply pressure for at least 5 minutes; apply a pressure to the site. Instruct the patient to
Avoid cuts and bruises Shave with an electric razor Avoid blowing his nose Stay away from irritants that would trigger sneezing Avoid using rectal thermometers

Instruct the patient to report sudden headaches (which could indicate potentially fatal intracranial bleeding)

VEIN FLARE Occurs during infusion of an irritant into the vein Signs and Symptoms Bright redness possibly appearing in the vein along with blotches or hives on the affected arm Burning pain or aching along the vein as well as up through the arm Nursing Interventions If the reaction is severe, injection of an IV steroid may be required If the patient complains of pain or burning during the infusion:
Increase the dilution of the infused medication Decrease the infusion rate Restart the IV in a different vein