minimizing side effects of chemotherapy
TRANSCRIPT
Minimizing the Side Effects
Of Chemotherapy
Atif Hussein, MD, MMM, FACP
Memorial Cancer Institute
Hollywood, FL
The Cell Cycle
The Cell Cycle
Cancer Cell Characteristics
• Unchecked & Uncontrolled Growth
• Loss of contact inhibition
• Loss of capacity to differentiate
• Increased growth fraction
• Chromosomal Instability
• Capacity to metastasise
• Altered biochemical properties
Chemotherapy Side Effects
• Chemotherapy targets cells which are
dividing rapidly.
• Chemotherapy cannot distinguish
between normal cells and cancer cells
• Healthy Cells which have a high rate of
growth and multiplication include cells of
the bone marrow, hair, GI mucosa and
skin.
Chemotherapy Side effects
• Side effects may be drug specific e.g. anthracyclines and cardiotoxicity, vinca alkaloids and neuropathy/constipation, bleomycin and pulmonary fibrosis
• Severity of side effects varies between drugs.
• Side effects often occur 7-14 days post treatment.
COMMON CONCERNS WITH
CHEMOTHERAPY
• Nausea and Vomiting
• Infection
• Bleeding
• Peripheral neuropathy
• Diarrhea
• Constipation
• Mucositis
• Fatigue
• Fluids
• Nutrition
• Skin care
• Hand-Foot syndrome
• Emotional needs
• Stress
• When to call the
nurse
Side Effects: Gastro-Intestinal
• Nausea & Vomiting
• Diarrhea & constipation
• Loss of appetite
• Taste Changes
• Mucositis
Everyone Worries About Nausea
and Vomiting
• Not everyone experiences nausea.
• Nausea and vomiting can occur before, during
or for several days after receiving treatment.
• Take anti-nausea medication as prescribed.
• Let your nurse or doctor know if you’re unable
to keep medications down, drink fluids, or your
anti-nausea medication doesn’t work.
Nausea and Vomiting:
Patient-specific risk factors
• Higher-risk groups:
– Young
– Female
– High pretreatment expectation of nausea
• Negative risk factor: high alchohol
consumption
Nausea and Vomiting:
Stratification
• High (level 4)
– >90% risk of emesis without treatment
• Moderate (level 3)
– 31-90%
• Low (level 2)
– 10-30%
• Minimal (level 1)
– <10%
Nausea and Vomiting
• Certain classes of drugs are worse than
others
--Cis-Platinum
--Doxorubicin (Adriamycin)
• Which anti-emetic agents should be used
is determined by the emetic potential of
the drug
Nausea and Vomiting:
Serotonin Receptor Inhibitors
• Granisetron (Kytril)
• Ondansetron (Zofran)
• Palonosetron (Aloxi) : Benefit of longer duration of action
• Best used as a “cocktail” with steroid (dexamethasone) and lorazepam
Nausea and Vomiting
Serotonin Receptor Inhibitors:
Common Side Effects
• Headache
• Constipation
– Prevent with use of laxatives and stool
softeners
Nausea and Vomiting:
NK 1 Receptor Inhibitor
• Aprepitant (Emend)
–Used for acute and delayed nausea
in combination with a serotonin
receptor-blocking drug
Nausea and Vomiting:
Dopamine Antagonists
• Phenothiazines
– Prochlorperazine (Compazine)
• Metoclopramide (Reglan)
• Trimethobenzamide (Tigan)
– Limited role except for mildly
emetogenic drugs and may be helpful
in delayed nausea
Delayed Nausea
• Dexamethasone
• Lorazepam (Ativan)
• Dopamine antagonists
– Prochlorperazine (Compazine)
– Trimethobenzamide (Tigan)
Mucositis (Mouth Sores)
• More common with certain drugs:
– 5-fluorouracil (5-FU)
– Methotrexate
– Doxorubicin (Adriamycin)
– Cyclophosphamide (Cytoxan)
Mucositis (Mouth Sores)
• Prevention
– Icing of the mouth during treatment
• Treatment Options
–Gel Clear
–Magic Mouthwash
–Viscous lidocaine
• Example of Grade 4 Mucositis
• Brush your teeth with a soft toothbrush.
• Use mild toothpaste and alcohol-free
mouthwash
• If you have not had regular dental care, see a
dentist before beginning chemotherapy.
• If your mouth feels sore, rinse three or four
times daily with warm salt water solution (one
teaspoon salt in eight ounces water), swish
vigorously, and spit.
Oral Care
Diarrhea
• Diarrhea is having multiple liquid bowel movements in a
24-hour period.
• Your health care provider can suggest a diet
plan to help ease this problem.
• Take an anti-diarrhea medication as
directed.
• Drink fluids.
• Call your provider if your diarrhea is bloody,
lasts more than 24 hours, or you have
symptoms of dehydration, abdominal pain
or fever.
Diarrhea
• Major toxicity of several drugs used to
treat gastrointestinal cancers, for
example, 5-FU and irinotecan
(Camptosar)
• Acute diarrheal reaction to irinotecan
– Atropine at time of treatment
Delayed Diarrhea:
Treatment
• Anti-Motility Drugs
– Loperamide (Imodium)
– Diphenoxylate (Lomotil)
• Octreotide (Sandostatin)
– Somatostatin analogue
– Works to prolong GI transit time
– Subcutaneous administration
Constipation
• Try over-the-counter laxatives, stool
softeners, or fiber.
• Drink plenty of fluids.
• Take daily walks if you can.
• Increase fiber in your diet by eating well-
washed fruits and vegetables, whole
grain breads and cereals.
SKIN TOXICITIES
Hand-Foot Syndrome
• Pain, redness, swelling, and peeling of the
skin of the palms and soles
• Associated with certain agents
– Capecitabine (Xeloda)
– Liposomal doxorubicin (Doxil)
– Infusional 5-FU
– Weekly taxane therapy
Hand-Foot Syndrome:
Treatment Options
• Dose reduction
• Avoid tight-fitting shoes; repetitive rubbing or
prolonged heat to hands and feet
• Emollients
– Eucerin
– Bag Balm
– Can be used effectively with cotton socks and/or
gloves at bedtime
• Chemo can cause skin changes such as
dryness, itching, and sun sensitivity. Nail
condition can also change.
• Keep your skin clean with a mild, moisturizing
soap and moisturize with gentle lotions.
• Protect your skin from injury.
• Avoid direct, intense sun exposure.
• Use sunscreen (minimum 30 SPF) and wear
protective clothing and a hat when outdoors.
Skin Care
Chemotherapy-Induced
Peripheral Neuropathy (CIPN):
Neuropathy
• Painful burning sensation
• Progressive numbness
• Motor weakness
Incidence of Chemotherapy-Induced
Peripheral Neuropathy (CIPN)
• Chemotherapy is prolonging life
• Cancer is becoming a chronic, manageable disease
• Many nurses will encounter those affected by this common side effect
• Estimated to occur in 20% of cancer patients undergoing chemotherapy
What is Chemotherapy-Induced
Peripheral Neuropathy (CIPN)?
• Characterized as injury, inflammation, or degeneration of peripheral nerve fibers
• Can result in loss of motor and sensory nerve function
• CIPN can result when certain chemotherapeutic agents are used to treat cancer
• These agents can be referred to as “neurotoxic”
Sensory nerves
Sensory nerves are responsible for detecting:
• Pain
• Touch
• Temperature
• Position
• Vibration
Pathophysiology (continued)
• Peripheral neuropathy results from damage to the axon, myelin sheath, or cell body
• Pathogenesis of CIPN is not completely understood
• It is known that different sensations arise depending on chemotherapeutic agent administered (Wickham, 2007)
Signs and Symptoms of CIPN
• Symptoms that patients
may experience depend on
length of infusion, dose,
co-morbidities, and the
drug being administered
• Symptoms are divided
into sensory, motor, and
autonomic symptoms,
correlating with which
peripheral nerve is
affected
Neuropathy: Prevention
• Avoidance of cold exposure for 48-72
hours after oxaliplatin therapy
• Amino acid therapy (glutamine)
• Vitamin B6 (pyridoxine)
Neuropathy:
Treatment Options
• Dose reduction
• Gabapentin (Neurontin)
• Amitriptyline (Elavil)
Pharmacologic treatment of CIPN
Glutamine:
• Amino acid, may have neuroprotecive properties
• In studies, those who take it for Taxol- preventive CIPN showed less weakness, loss of vibratory sensation, and toe numbness versus control group
Microsoft Image Clip Art, 2007
Pharmacologic treatment of CIPN
Glutathione:
• May hamper initial accumulation of platinum agents in peripheral nerve cells
• Incidence of neuropathy was greater in placebo than control group
• In some studies, incidences of no CIPN were reported with IV infusion
Opioids:
• Useful for painful CIPN
• Doses can be titrated to effective range for CIPN and pain
Nonpharmacologic Treatment of
Chemotherapy-Induced peripheral
Neuropathy (CIPN)
Acupuncture:
• Shown gait improvement
• Has shown improvement in sensation and balance
• Patients taking pain medication for CIPN ended up decreasing doses
HEMATOLOGICAL SIDE
EFFECTS
Side Effects: Bone Marrow
Neutropenia:
Increased risk of infection.
Anemia:
Tiredness, lethargy & breathlessness
Thrombocytopenia:
Increased risk of bleeding
Red blood cells
Carry nutrients
and oxygen
Neutrophils
A type of
white cell
that fights
infection
Platelets
Helps the
blood to
clot
Chemotherapy can
increase your risk for
infection because it may
lower your white blood cell
count.
Infection
Preventing Infection
• The first defense is
hand washing.
• Patient, patient’s
caregivers, family
members, and
visitors need to wash
hands frequently.
• Carry and use hand
sanitizer when you
leave the house.
• Have a thermometer at home to monitor your
temperature.
• Take your temperature if you feel sick or
unusually hot or cold, and before you call your
provider.
• If you have a fever over 100.5°F, call your health
care provider right away. Do not take Tylenol or
aspirin unless instructed to do so.
• Call for fever, chills, cough, sore throat or burning
with urination
Watching for infection
Preventing Bleeding
• A low platelet count can cause bleeding
• Some chemo drugs can lower platelets
• Use a soft toothbrush.
• Blow your nose gently.
• Avoid injuries that could cause cuts or bruises.
• If you cut yourself, apply gentle but firm pressure to stop the bleeding.
OTHER SIDE EFFECTS
• Fatigue
• Stress
• Tumor Lysis Syndrome
• Body Image
• Dehydration
• Nutrition
• Others
Fatigue: Multifactorial
• Anemia
– Erythropoietin (Procrit)/darbepoetin (Aranesp)
• Depression
– Selective serotonin reuptake inhibitor (SSRI)
• Sleep Disturbance
-- Sleep aid: zolpidem tartrate (Ambien),
eszopiclone (Lunesta)
• Psychostimulants
-- Methylphenidate (Ritalin)
•The most commonly reported side effect
•Take a daily walk or continue your usual
exercise routine, if you can.
•Eat a healthy diet.
•Plan daily activities ahead of time.
•Prioritize your activities to conserve
energy.
•Get plenty of rest.
•Let others help with chores.
Fatigue
Stress
Are you experiencing any of these
symptoms?
•difficulty concentrating
•trouble sleeping
•too much worry
•problems with coping
Supporting your emotional
needs is essential to your
cancer treatment.
Stress
Side Effects:
Body Image
• Hair Loss
• Weight Loss/ Weight Gain
• Long term central venous catheters
• Skin changes (colour, rashes, sensitivity
to sunshine/chlorine, dry)
Dehydration: Fluids
• Keeping hydrated with fluids is important
during chemotherapy treatment.
• Fluids are in water, beverages, and food.
• Keep a bottle of water or juice with you at all
times and sip on it often.
• If you have vomited, try to drink about two
quarts of fluids a day for a few days afterward.
• A good rule of thumb: take in enough fluids to
keep urine light yellow.
Nutrition
• Eat smaller portions more frequently.
• Try milkshakes, smoothies, or
supplements like Ensure for extra
calories if you are losing weight.
• Some chemo causes a metallic taste.
Try using plastic utensils to ease this
effect.
• Some people gain weight during
chemotherapy.
Side Effects:
Other
• Altered Kidney Function
• Changes in hearing (high dose Cisplatin)
• Cardiac Toxicity (Doxorubicin/ Idarubicin)
• Late Effects: Infertility, secondary malignancy, growth retardation.
When should I call the doctor?
• Fever over 100.5°F
• Redness or swelling at IV site
• Uncontrolled vomiting or diarrhea
• Blood in urine or stool or uncontrolled bleeding
• Signs of infection
• Feeling unwell
You should be able to eat, drink, have reasonable bowel and bladder function and feel good enough to get up and around-if not, call.
Key Points:
• Chemotherapy is a major treatment in curing or prolonging survival in cancer patients
• It has a wide range of side effects depending on the drugs given.
• Nurses have a key role to play in caring for a patient receiving chemotherapy
• Safety issues are paramount in administration.
Summary
The potential benefit to the patient of treatment as an
option must always outweigh the toxic effects.
THANK YOU VERY MUCH!!!