Malignant disease

BEVACIZUMAB (AVASTIN) TOP 2:ANAPHYLAXIS, SPECIFIC S/S TO MED

- risk for anaphylaxis - SE specific to the med

Filgrastim (Neupogen) Top 3

-Aches in hips and femur -check WBC, ANC -take NSAIDs for bone pain

Leucovorin

Antidote for methotrexate toxicity • PO OR IV • TAKE WITH LOTS OF WATER - AT LEAST 3 QUARTS IN 24 HRS! • LEUCOVORIN IS A COMPOUND SIMILAR TO FOLIC ACID • USED IN COMBINATION WITH THE CHEMOTHERAPY DRUGS FLUORURACIL AND METHOTREXATE. • LEUCOVORIN IS NOT A CHEMOTHERAPY DRUG ITSELF • ENHANCES ANTI CANCER EFFECTS (WITH FLUOROURACIL) • LESSENS SIDE EFFECTS (WITH METHOTREXATE).

Safety: neutropenic precautions at home... Yes

Avoid crowds (mall, grocery, movies, planes) Avoid school-aged children Wear mask if going to MD office No vaccinations with live vaccines Check temp daily, call MD> 100 or shaking chills Report painful urination, rash/blisters Avoid gardening, cleaning kitty litter until after nadir

A nurse is caring for a client who receives rituximab to treat non-Hodgkin's leukemia and who asks the nurse how rituximab works. Which of the following should the nurse include? a. blocks hormone receptors b. increases immune response c. binds with specific antigens on tumor cells d. stops DNA replication during cell division

C

How are monoclonal antibodies such as bevacizumab (Avastin) different from other antineoplastic drugs? a. They treat many different types of cancer, both blood and solid tumors. b. They only need to be administered for a short period of time. c. They are highly specific to certain cell types and target specific cancers. d. They have fewer adverse effects than traditional antineoplastic drugs.

C

*NSAIDs side effects Nobody said it was going to be this uncomfortable

Nausea / Vomiting Serious: GI bleeding & ASA toxicity (HA, tinnitus, sweating) Anorexia and abdominal pain Impaired renal system functioning Dyspepsia and heart burn IF NSAIDS FAIL TO TREAT BONE METASTASES PAIN... NEED NARCOTICS NEXT!

Other side effects of chemo: N/V

Nausea/Vommiting -emetic potential of meds -anticipatory n/v -acute onset -delayed onset

Antitumor antibiotic (doxorubicin)

PROTOTYPE DRUG, DOXORUBICIN (ADRIAMYCIN) • "RED DEATH" • ATTACHES TO DNA AND DISTORTS THE HELIX, PREVENTING NORMAL DNA AND RNA SYNTHESIS. • GIVEN IV ONLY - IS A VESICANT. • VERY EFFECTIVE AGAINST SOLID TUMORS.

NATURAL PRODUCTS CATEGORY: PLANT EXTRACTS & ALKALOIDS

PROTOTYPE DRUG: PACLITAXEL (TAXOL) • 1/3 OF PEOPLE HAVE SIDE EFFECTS: • LOW BLOOD COUNTS. • HAIR LOSS. • ARTHRALGIAS AND MYALGIAS • (PAIN IN THE JOINTS AND MUSCLES) • PERIPHERAL NEUROPATHY (NUMBNESS AND TINGLING OF THE HANDS AND FEET)

Tx of s/s of infection

Prompt recognition of s/s -fever -absence of fever but mental status changes -burning on urination -cough Lab work including cultures of blood and urine IV antibiotics asap while awaiting results of cultures Get culture before antibiotics!!!!!

How effective is chemotherapy?

THERE IS A WIDE VARIATION IN SENSITIVITY OF VARIOUS CANCERS HIGH - LYMPHOMA, LEUKEMIA, TESTICULAR INTERMEDIATE - BREAST, COLON, NON-SMALL CELL LUNG CANCER LOW - PROSTATE, GASTRIC, PANCREATIC WHY DOES COMBINATION CHEMOTHERAPY IMPROVE RESPONSES OVER USE OF A SINGLE AGENT??? Combo helps because you can get multiple cell responses and it effects all parts of the cell cycle

Neutropenia

High risk for infection -most potentially lethal complication of cancer treatment Difficulty identifying source of infection Related terms -leukopenia -compromised host -nadir (point in time when they are most sick) -bone marrow suppression Febrile neutropenia is a medical emergency just like an MI

Immunotherapy

use of immune cells, antibodies, or vaccines to treat or prevent disease

Port-a-cath (PAC) accessed

- draw labs through a port - can use for 10-12 years - must get a CXR before use

CLASS: HORMONE AND HORMONE ANTAGONISTS PROTOTYPE DRUG: TAMOXIFENTOP 3

- not chemo -tx and prevent breast cancer - SE similar to menopause bc its blocking hormones

GI interventions

- administer antiemetic 30 mins before meal - assess abdomen and nutrition - encourage pt eat small frequent meals (high carb for n/v and high protein for anorexia) - avoid hot, spicy, difficult to chew and strong odor foods - drink plenty of cool fluids - examine mouth for irritation/sores, good hygiene, use soft toothbrush, no toothpicks - assess mouth discomfort (mucositis)

CLASS: ALKYLATING AGENTS PROTOTYPE DRUGS: CYCLOPHOSPHAMIDE, CISPLATINTOP 3

- alopecia -immune suppresion -n/v

Bone marrow suppression 3 components

1. Low WBC production= neutropenia 2. Low RBC production= anemia (H&H <10/30) - assess for fatigue, SOB, chest pain - treat with epoetin alpha (Epogen) ... Sq injections 3x a week.... HTN, HA, tachycardia, N/V 3. Low platelet production= thrombocytopenia

A nurse is preparing to administer cyclophosphamide IV to a client who has Hodgkin's disease. Which of the following medications should the nurse expect to administer concurrently with the chemotherapy to prevent an adverse effect of cyclophosphamide? a. protectant agent, such as mesna b. opioid, such as morphine c. loop duretic, such as furosemide d. H1 receptor antagonist, such as diphenhydramine

A

Doxorubicin

60-75MG/METER SQUARED (M2) IV Q 3 WEEKS ADVERSE EFFECTS: • COMMON: ACUTE N/V, ALOPECIA, ANOREXIA, STOMATITIS, RASH, H/A • SERIOUS: • 1) CARDIOTOXICITY: DYSRHYTHMIAS AND IRREVERSIBLE HEART FAILURE.!!!! • 2) BONE MARROW SUPPRESSION • 3) EXTRAVASATION CAN CAUSE SEVERE PAIN AND EXTENSIVE TISSUE DAMAGE. • OTHER: SEVERE N/V/D, MUCOSITIS, PULMONARY TOXICITY, HYPERSENSITIVITY REACTIONS (INCLUDING ANAPHYLAXIS). ACUTE MYELOGENOUS LEUKEMIA MAY OCCUR 1-3 YEARS LATER. -it is red so gets confusing bc you aspirate blood and its the same color.. also cardiotoxic

A nurse is caring for a client who has breast cancer and asks why the treatment plan contains a combination therapy of cyclophosphamide, methotrexate and fluorouracil. The response by the nurse should include that combination chemotherapy is used to do which of the following? (Select all that apply) a. decrease medication resistance b. attach cancer cells at different stages of cell growth c. block chemotherapy agent from entering healthy cells d. stimulate immune system e. decrease injury to normal body cells

A, B, E

A 2-year-old patient is receiving vincristine (Oncovin) for Wilms' tumor. Which of the following findings will the nurse monitor to prevent or limit the main adverse effect for this patient? (Select all that apply.) A. Numbness of the hands or feet B. Angina or dysrhythmias C. Constipation D. Diminished reflexes E. Dyspnea and pleuritis

A. Numbness of the hands or feet C. Constipation D. Diminished reflexes The most serious adverse effect of vincristine is nervous system toxicity. Numbness of the feet or hands, constipation related to decreased peristalsis, and diminished reflexes are all signs of neurotoxicity. Options 2 and 5 are incorrect. Cardiac and pulmonary toxicities are not associated with vincristine.

HORMONES & HORMONE ANTAGONISTS

ACTIONS AND USES: • VERY LARGE DOSES OF GLUCOCORTICOIDS, PROGESTINS, ESTROGENS OR ANDROGENS THAT BLOCK ESSENTIAL SUBSTANCES FOR THE GROWTH OF HORMONE-DEPENDANT TUMORS OF THE BREAST OR PROSTATE. • ARE THE LEAST TOXIC OF THE ANTINEOPLASTIC DRUGS.

INTERFERON ALFA-2 (INTRON A)(LEUKEMIA 2-3 MILLION, KAPOSI SARCOMA 36 MILLION UNITS DAILY SUBQ/IM)

ADVERSE EFFECTS: •COMMON: STOMATITIS ANOREXIA, N/V, , ALOPECIA, STOMATITIS, RASH, ASTHENIA, •SERIOUS: BONE MARROW SUPPRESSION, SEVERE N/V/D, PULMONARY TOXICITY, HYPERSENSITIVITY REACTIONS

IMPLEMENT NEUTROPENIC PRECAUTIONS: A NURSING ROLE!

AKA "REVERSE ISOLATION" OR "COMPROMISED HOST PRECAUTIONS" OR "PROTECTIVE ISOLATION" • STANDARD PRECAUTIONS PLUS... • PRIVATE ROOM +/- GOWN & GLOVES • RIGOROUS HANDWASHING • NO HCPS OR VISITORS WITH URI/INFECTION • KEEP THERMOMETER, BP CUFF, & STETHOSCOPE IN THE ROOM • CLEAN PATIENTS ROOM DAILY • MONITOR VS Q 4HRS; NOTE MINOR TEMP ELEVATIONS • AVOID INDWELLING URINARY CATHETERS • KEEP FRESH FLOWERS & POTTED PLANTS OUT OF PT'S ROOM • COOKED FRUITS AND VEGETABLES ONLY • ORAL CARE - NO HARSH MOUTHWASH Designed to protect a patient at high risk for infection Guard your vulnerable patient!

CISPLATIN (PLATINOL)

ALKYLATING AGENT • ACTION: CHANGES OR DISRUPTS THE SHAPE OF THE DNA DOUBLE HELIX WHICH SLOWS OR INTERRUPTS NORMAL CELLULAR DIVISION AND CAUSES CELLULAR DEATH. • ADVERSE EFFECTS: .......COMMON: : N/V!!!!!!!!, ANOREXIA, ALOPECIA ...... SERIOUS: BONE MARROW SUPPRESSION, SEVERE!!!!!!! N/V/D, NEPHROTOXICITY!!!!!!!!!! need 2L a day • (5% DEVELOP ACUTE NONLYMPHOCYTIC LEUKEMIA 4 OR MORE YEARS LATER.)

Top 5 chemo therapy side effects

If you think chemo is bad you are FALSE Fatigue "chemo brain" Alopecia Low blood cell counts!!!! most risky Stomatitis (mouth sores) Eating problems (anorexia, N/V, diarrhea)

CAR-T OR INTERFERONS TOP 3:ANAPHYLAXIS, ACHINESS, SPECIFIC S/S TO MED

Anaphylaxis NSAIDS Achy feeling

CYCLOPHOSPHAMIDE (CYTOXAN)

Antineoplastic agent ALKYLATING AGENT (NITROGEN MUSTARD) • ACTION: CYTOXAN CHANGES OR DISRUPTS THE SHAPE OF THE DNA DOUBLE HELIX WHICH SLOWS OR INTERRUPTS NORMAL CELLULAR DIVISION AND CAUSES CELLULAR DEATH. • ADVERSE EFFECTS: .....COMMON: N/V, ANOREXIA, STOMATITIS, ALOPECIA .....SERIOUS: BONE MARROW SUPPRESSION, SEVERE N/V/D, HEMORRHAGIC CYSTITIS, NEPHROTOXICITY, STERILITY. ....... (5% DEVELOP ACUTE NONLYMPHOCYTIC LEUKEMIA 4 OR MORE YEARS LATER.)

A nurse is teaching a client who has breast cancer about tamoxifen. Which of the following adverse effects of tamoxifen should the nurse discuss with the client? a. irregular heart beat b. abnormal uterine bleeding c. yellow sclera or dark-colored urine d. difficulty swallowing

B

A nurse is caring for a client who is being treated with interferon alfa-2b for malignant melanoma. For which of the following adverse effects should the nurse monitor? (Select all that apply) a. tinnitus b. muscle aches c. peripheral neuropathy d. bone loss e. depression

B, C, E

A patient who is undergoing cancer chemotherapy asks the nurse why she is taking three different chemotherapy drugs. What is the nurse's best response? A. "Your cancer was very advanced and therefore requires more medications." B. "Each drug attacks the cancer cells in a different way, increasing the effectiveness of the therapy." C. "Several drugs are prescribed to find the right drug for your cancer." D. "One drug will cancel out the side effects of the other."

B. "Each drug attacks the cancer cells in a different way, increasing the effectiveness of the therapy. "Effectiveness of chemotherapy is increased by use of multiple drugs from different classes that attack cancer cells at different points in the cell cycle. Thus, lower doses of each individual agent can be used to reduce side effects. A third benefit of combination chemotherapy is reduced incidence of drug resistance. Options 1, 3, and 4 are incorrect. A combination of drugs is given for most cancers regardless of how advanced the cancer is. The multi-drug is not given to find the right drug because many may exert therapeutic effects. The drugs do not "cancel out" each other but work together.

The nurse notes that the patient has reached his nadir. What does this finding signify? A. The patient is receiving the highest dose possible of the chemotherapy. B. The patient is experiencing bone marrow suppression and his blood counts are at their lowest point. C. The patient has peaked on his chemotherapy level and should be going home in a few days. D. The patient is experiencing extreme depression and will be having a psychiatric consult.

B. The patient is experiencing bone marrow suppression and his blood counts are at their lowest point. The nadir is the point of greatest bone marrow suppression, as measured by the lowest neutrophil count. Options 1, 3, and 4 are incorrect. The nadir does not refer to chemotherapy dose, level, or client symptoms.

What is the most effective treatment method for the nausea and vomiting that accompanies many forms of chemotherapy? A. Administer an oral antiemetic when the patient complains of nausea and vomiting. B. Administer an antiemetic by intramuscular injection when the patient complains of nausea and vomiting. C. Administer an antiemetic prior to the antineoplastic medication. D. Encourage additional fluids prior to administering the antineoplastic medication.

C. Administer an antiemetic prior to the antineoplastic medication. For maximum effect, patients should be given an antiemetic prior to the start of treatment. Options 1, 2, and 4 are incorrect. Waiting to give an antiemetic until after the chemotherapy has started may result in a delay in treatment of the nausea and vomiting. IM injections are usually avoided during chemotherapy because of an increased risk of infection. Fluids are encouraged throughout chemotherapy but will not prevent or treat the nausea and vomiting that may occur.

Nursing care of patients undergoing chemotherapy

Collaborative with MD and pharmacist Educate pt and family - drug therapy - SE to report (chills, fever, mouth sores, n/v, D, neuropathy)... report even with no fever - adequate nutrition for n/v or healing of tissues - plan of care to prevent and control s/s - follow-up for labs

A nurse is preparing to administer leucovorin to a client who has cancer and is receiving chemotherapy with methotrexate. Which of the following responses should the nurse use when the client asks why leucovorin is being given? a. "Leucovorin reduces the risk of a transfusion reaction from methotrexate." b. "Leucovorin increases platelet production and prevents bleeding." c. "Leucovorin potentiates the cytotoxic effects of methotrexate." d. "Leucovorin protects healthy cells from methotrexate's toxic effect."

D

Which of the following statements by a patient who is undergoing antineoplastic therapy would be of concern to the nurse? (Select all that apply.) A. "I have attended a meeting of a cancer support group." B. "My husband and I are planning a short trip next week." C. "I am eating six small meals plus two protein shakes a day." D. "I am taking my 15-month-old granddaughter to the pediatrician next week for her baby shots." E. "I am going to go shopping at the mall next week."

D. "I am taking my 15-month-old granddaughter to the pediatrician next week for her baby shots." E. "I am going to go shopping at the mall next week." Patients and family members should avoid receiving live virus vaccinations or exposure to chickenpox. The patient could have an exacerbation or a more pronounced episode of the disease. The patient should not care for the granddaughter if vaccination with live viruses is planned. The patient should also avoid crowds, especially in enclosed spaces when possible, to minimize exposure risk. The nurse should discuss measures to minimize the risk of infections if the patient desires to go shopping. Options 1, 2, and 3 are incorrect. Attending a support group, maintaining normal activities when possible, and eating small, frequent meals with sufficient protein are routine care measures during chemotherapy.

TARGETED THERAPIES: PROTEIN KINASE INHIBITORS

Don't memorize IMATINIB (GLEEVEC) - A TYROSINE-KINASE INHIBITOR USED IN THE TREATMENT OF MULTIPLE CANCERS, MOST NOTABABLY CHRONIC MYELOGENOUS LEUKEMIA (CML). - KILLS CANCER CELLS BY TURNING OFF TYROSINE KINASES. IN ORDER TO SURVIVE, CELLS NEED SIGNALING THROUGH PROTEINS (SIGNAL CASCADE) TO KEEP THEM ALIVE. - BECAUSE TYROSINE KINASE ENZYME EXISTS ONLY IN CANCER CELLS AND NOT IN HEALTHY CELLS, IMATINIB WORKS AS A TARGETED THERAPY—ONLY CANCER CELLS ARE KILLED THROUGH THE DRUG'S ACTION - THE 5 YEAR SURVIVAL RATE WITH CML INCREASED FROM 31% IN 1993 (BEFORE GLEEVEC'S 2001 FDA APPROVAL) TO 59% IN 2009 - FEW SIDE EFFECTS - AVERAGE = $120,000 A YEAR IN 2016

TARGETED THERAPY: MONOCLONAL ANTIBODIES (MAB)

ENGINEERED TO ATTACK ONLY 1 SPECIFIC TYPE OF TUMOR CELL; ONCE MAB BINDS TO ITS TARGET CELL, THE CANCER CELL DIES, OR IS MARKED FOR DESTRUCTION • RITUXIMAB (RITUXAN) - SES: ANAPHYLAXIS, PRURITUS • BEVACIZUMAB (AVASTIN) - BLOCKS ANGIOGENESIS BY INHIBITING VASCULAR ENDOTHELIAL GROWTH FACTOR A (VEGF-A) - USED FOR METASTATIC COLORECTAL, NSCLC, OVARIAN CANCER - SES: LIFE-THREATENING: HEMORRHAGE, GI PERFORATION & WOUND DEHISCENCE, ARTERIAL CLOTS, HYPERTENSIVE

Neutropenia: absolute neutrophil count

Identify the risk for infection by looking at WBC indices and calculation the absolute neutrophil count (ANC) ANC: WBCxneutrophils +bands ANC of <1000= high risk ANC of <500= very high risk for infection -can get an infection from themselves

Treatment of neutropenia

In addition to neutropenic precautions: Medication- biological response modifiers -to stimulate neutrophil production -prototype: filgrastim (Neupogen) SC SE: fever, alopecia, N/V/D, bone pain, HA, rash - discontinue when ANC is increased 10,000.. want is to be 2,000-3,000

Genomics

Match a cancer to the gene and then match a gene to the med.. everyones cancer is different ex. lung cancer is Dif for everyone

Problems and risks with neutropenia

NEUTROPENIC INFECTION IS A PROBLEM!!! • OCCUR IN 50% - 80% OF PATIENTS WITH CANCER • RESULT IN HOSPITALIZATION FOR 60,000 PATIENTS ANNUALLY • 1 IN 14 PATIENTS WILL DIE OF SEPTIC SHOCK IDENTIFY YOUR PATIENT'S RISK FOR INFECTION RISK FACTORS: • AGE >65 YEARS • WOMAN > MEN • LOW BODY MASS INDEX • PRESENCE OF COMORBIDITIES • LABORATORY ABNORMALITIES • POOR NUTRITIONAL STATUS • OPEN WOUND, OR RECENT SURGERY • ADVANCED DISEASE STAGE • BONE MARROW INVOLVEMENT • TYPE OF CANCER (IE, HEMATOLOGIC, LUNG, BREAST, COLORECTAL, OR OVARIAN) • GENOTYPE

Alopecia

Primary prevention: cold cap (makes head cold during chemo bc it causes vasoconstriction and the chemo is running through blood) could chew ice also to prevent mouth sores Secondary Interventions: -avoid washing hair every day -avoid use of hairdryers -cut long hair/shave early -wig (choose early) -head covering Hair is rapidly dividing cells and chemo kills cells

Bone marrow suppression: thrombocytopenia (PLTS < 150,000)

Safety: nurses should institute bleeding precaution - For platelets <50,000 Avoid trauma -touch pt gently, use lift sheet when repo -avoid IM injections and venipunctures ... if necessary, use smallest gauge needle.... apply firm pressure to site for 5-110 minutes -no sharp edge razors- use electric razors -no rectal tamps -no enemas Assess for s/s of bleeding -test all urine and stool for blood -observe IV sites for bleeding Petechiae can occur with thrombocytopenia

Rapid recap

SIDE EFFECTS OF CHEMOTHERAPY (AND RADIATION WHEN TARGETS BONE MARROW) • DOSE DEPENDENT • BONE MARROW SUPPRESSION • 1) DECREASED WBC (NEUTROPENIA OR LEUKOPENIA) • 2) DECREASED ERYTHROCYTES (ANEMIA) • 3) DECREASED PLATELETS (THROMBOCYTOPENIA) NADIR - TIME WHEN BONE MARROW ACTIVITY

ANTIMETABOLITES

STRUCTURALLY SIMILAR TO FOLIC ACID, PURINES AND PYRIMIDINES •ARE ESSENTIAL FOR DNA & RNA SYNTHESIS •DISRUPT OR SLOW CANCER CELL GROWTH OR CAUSE CELL DEATH •OFTEN PRESCRIBED FOR LEUKEMIAS AND SOLID TUMORS.

How is chemotherapy given?

SYSTEMIC CHEMOTHERAPY: IV OR PO. ENTER BLOODSTREAM AND REACH ALL AREAS OF BODY - USED FOR CANCERS THAT HAVE SPREAD (METASTASIZED) REGIONAL CHEMOTHERAPY: INJECTED DIRECTLY INTO/CLOSE TO TUMOR. • INTRAVESICULAR - BLADDER • INTRAVENTRICULAR - BRAIN • INTRAPERITONEAL - OVARIAN CANCER • CONCENTRATES THE DOSE OF CHEMO REACHING THE CANCER CELLS. REDUCES SIDE EFFECTS BY LIMITING THE AMOUNT OF DRUG REACHING THE REST BODY. IN CYCLES - TREATMENT FOLLOWED BY A REST PERIOD TO GIVE THE BODY TIME TO RECOVER. GENERALLY LAST ABOUT 2 TO 4 WEEKS, USUALLY GET AT LEAST SEVERAL CYCLES

Antiemetics

Serotonin antagonists - odansetron (zofran) -BBW for prolonged QT interval Phenothiazides - prochlorperazine (compazine) ... antipsychotic for nausea Benzodiazepines - lorazepam (Ativan) Metochlopromide (reglan) Steroids - decadron

Targeted therapies

TARGETS SPECIFIC GENES OR PROTEINS TO STOP CANCER GROWTH - CAN BLOCK OR TURN OFF THE SIGNALS THAT ARE ALLOWING CANCER CELLS TO DIVIDE - FOUND IN OR ON CANCER CELLS, OR IN CELLS RELATED TO CANCER GROWTH LIKE BLOOD VESSELS • OFTEN USED WITHWITH CHEMO • TWO MAIN TYPES: MONOCLONAL ANTIBODIES OR SMALL MOLECULE DRUGS • DO NOT WORK FOR EVERYONE! - NEED TO TEST THE PATIENT FOR TYPES OF PROTEINS, MUTATIONS OF THE CANCER • RESPONSE TO THESE MEDS CAN BE TEMPORARY - CANCER CELLS CAN MUTATE - CANCER CELLS FIND A NEW PATHWAY TO GROW • SIDE EFFECTS DIFFERENT FROM CHEMO: SKIN, HAIR, EYE PROBLEMS

CAR-T THERAPY (CHIMERIC ANTIGEN RECEPTOR T-CELL THERAPY)

Take blood out, take abcs, use a virus and inject a new antibody to new T cells, making medicine for each person... grow new T cells and then infuse it back into the body and divide with the anticancer so the T cells swarm the tumor and kill is... indication is for blood cancers.. one time infusion cure even if cancer s=comes back the T cells are still there • INDIVIDUALIZED TREATMENT FOR SOME BLOOD CANCERS, 50-60% CURECURE • TAKE SAMPLE OF PT'S BLOOD, MODIFY THOSE T-CELLS IN LAB WITH VIRUSES, GIVE CHEMO TO LOWER IMMUNE SYSTEM, 3 WEEKS LATER INFUSE GENETICALLY MODIFIED T-CELLS BACK TO PT. • SIDE EFFECTS: - CYTOKINE RELEASE SYNDROME COMMON IN 80% OF PTS (FEVER, LOWER BLOOD PRESSURE, AND SHORTNESS OF BREATH). FREQUENT VS, APPLY O2 - NEUROTOXICITY COMMON (FORGETFULNESS, VIOLENT SEIZURES) FREQUENT NEURO ASSESSMENTS, HAVE PT WRITE A SENTENCE. USUALLY REVERSIBLE WITH STEROIDS.

Since the 1990s: Progress by Many Measures

Treatment • New therapies • Imaging, radiation oncology and surgery advances • Precision medicine • Immunotherapy Prevention • Interventions for infection-related cancers • Cancer susceptibility genes • Drug and surgical risk reduction strategies Quality of Life • Better toxicity management • Less intensive therapies • Palliative care integration Survivorship • Growing research area • Late effects identified • Surveillance strategies established

Cell cycle

Use chemo only when cancer has spread because you would just get it removed if it didn't

Safety- precautions for HCPS

WEAR PROTECTIVE CLOTHING WHEN PREPARING, ADMINISTERING, OR DISPOSING OF CHEMO • CHEMO CAN BE ABSORBED THROUGH THE SKIN AND MUCOUS MEMBRANES • OSHA & ONCOLOGY NURSING SOCIETY HAVE PROACTIVE GUIDELINES & PROTECTIVE STANDARDS • SPILL MANAGEMENT • USE AN IV PUMP! • FLUSH TOILET TWICE!

Fighting cancer with the new and the old?

WHAT IS "OLD" IN CANCER TREATMENTS?•CHEMOTHERAPY WHAT IS "NEW" IN CANCER TREATMENTS?•TARGETED THERAPIES AND VACCINATIONS

CAUTION! IV CHEMOTHERAPY ADMINISTRATION

Watch for extravasation- leakage of vesicant drug into surrounding tissue Nursing interventions -chemo certification -port-a-cath preferred -peripheral IV.. ensure good blood return!!!

Other side effects of chemo

Xerostomia- dry oral membranes Stomatitis- emphasize oral care QID -avoid store mouthwashes - use saline rinses 3-4x a day - avoid hard bristle if Thrombocytopenia Constipation/ diarrhea Sexual dysfunction Peripheral neuropathy Depression

CATEGORIES OF ANTINEOPLASTIC AGENTS

• 1) CHEMOTHERAPIES • ALKYLATING AGENTS (CYCLOPHOSPHAMIDE, CISPLATIN) • ANTIMETABOLITES (METHOTREXATE, FLUOROURACIL) • ANTITUMOR ANTIBIOTICS (DOXORUBICIN) • NATURAL/PLANT BASED (PACLITAXEL) - just know there all different types of chemo and they all work different • 2) HORMONE AND HORMONE ANTAGONISTS (TAMOXIFEN) • 3) IMMUNOTHERAPIES (BIOLOGICAL RESPONSE MODIFIERS)

BIOLOGIC RESPONSE MODIFIERS (IMMUNE THERAPIES)

• ACTION AND USES: THIS GROUP OF DRUGS MODIFY AND OR STIMULATE THE BODIES OWN IMMUNE SYSTEM TO FIGHT THE CANCER CELLS. • INCLUDES INTERFERONS, INTERLEUKIN-2, MONOCLONAL ANTIBODIES, T-CELL THERAPY, CANCER VACCINES

TAMOXIFEN (NOLVADEX)

• ACTIONS AND USES: HORMONE ANTAGONIST (ANTIESTROGEN) • TREATS METASTATIC BREAST CANCERS WHICH HAVE CELLS THAT REQUIRE ESTROGEN FOR GROWTH (ESTROGEN RECEPTOR POSITIVE). • ALSO USED PROPHYLACTCALLY TO HIGH-RISK CLIENTS TO PREVENT THE DISEASE. 10-20 MG PO DAILY/BID ADVERSE EFFECTS: • COMMON: HOT FLASHES, INSOMNIA, BREAST ENLARGEMENT & PAIN, H/A, N/D, ASTHENIA, VAGINAL DISCHARGE • SERIOUS: HYPERSENSITIVITY REACTIONS (INCLUDING ANAPHYLAXIS), THROMBOEMBOLIC DISEASE, SEXUAL DYSFUNCTION, HTN, INCREASED RISK FOR ENDOMETRIAL CA

INTERFERON ALFA-2 (INTRON-A)

• ACTIONS AND USES: THIS PROTOTYPE DRUG IS NATURALLY PRODUCED BY T CELLS IN RESPONSE TO VIRAL AND BIOLOGICAL STIMULI. • INTERFERONS POSSESS A GENERALIZED ACTION, SUPPRESSING CELL DIVISION, ENHANCING PHAGOCYTIC ACTIVITY AND PROMOTING CYTOTOXIC ACTION OF T LYMPHOCYTES. • TREATS HAIRY CELL LEUKEMIA, KAPOSI'S SARCOMA (KS) AND CHRONIC HEPATITIS B OR C.

Chemotherapy: Cause of common SE

• AFFECTS RAPIDLY DIVIDING CELLS - BONE MARROW - HAIR FOLLICLES - GI TRACT [MOUTH, ESOPHAGUS, INTESTINES], REPRODUCTIVE • THE NORMAL CELLS MOST LIKELY TO BE DAMAGED BY CHEMO ARE : - BLOOD-FORMING CELLS IN THE BONE MARROW - HAIR FOLLICLES - CELLS IN THE MOUTH, DIGESTIVE TRACT, AND REPRODUCTIVE SYSTEM • SOME CHEMO DRUGS CAN DAMAGE CELLS IN THE HEART, KIDNEYS, BLADDER, LUNGS, AND NERVOUS SYSTEM.

FLUOROURACIL (5-FU)

• ANTIMETABOLITE CATEGORY (PYRIMADINE ANALOG) • ACTION: DISRUPTS AND SLOWS CANCER CELL GROWTH IN THE 'S' PHASE (DNA SYNTHESIS) OF THE CELL CYCLE, CAUSING CELL DEATH. • IV BOLUS • PO SIMILAR DRUG - CAPECITABINE (XELODA) • CREAM USED TO TREAT BASAL CELL SKIN CANCER • ADVERSE EFFECTS .... COMMON: WELL TOLERATED ...... OTHER: MILD N/V/D, STOMATITIS, ANOREXIA, HAND FOOT SYNDROME (RASH, PARATHESIAS), BONE MARROW SUPPRESSION, TUMOR LYSIS SYNDROME ......DRINK FLUIDS & REPORT PEELING RASH

OTHER ANTINEOPLASTIC AGENTS

• ANTITUMOR ANTIBIOTICS: ISOLATED FROM MICROORGANISMS OR BACTERIA, ARE MORE TOXIC THAN STANDARD ANTIBIOTICS. • ACTION: BIND TO DNA, DISRUPTING REPLICATION AND OR CAUSING CELL DEATH (SIMILAR TO ALKYLATING AGENTS) WITH SIMILAR SIDE EFFECTS.

EVALUATION: CARE OUTCOMES?

• CLIENT EXHIBITS REDUCTION OF TUMOR MASS • SOFT FORMED BM Q 1-3 DAYS • WBC'S >4,000, PLATELET'S >50,000• CBC & ANC WNL • CLIENT DEMONSTRATES AN UNDERSTANDING OF DRUG ACTIONS BY ACCURATELY DESCRIBING SIDE EFFECTS TO REPORT AND PRECAUTIONS • STATES PAIN IS WELL CONTROLLED

When is chemotherapy used?

• DEPENDING ON THE TYPE OF CANCER AND THE STAGE • NEOADJUVANT THERAPY - BEFORE SURGERY (SOMETIMES ALONG WITH RADIATION THERAPY) TO TRY TO SHRINK A TUMOR. • ADJUVANT THERAPY - AFTER SURGERY (SOMETIMES ALONG WITH RADIATION THERAPY) TO TRY TO KILL ANY CANCER CELLS THAT MIGHT HAVE BEEN LEFT BEHIND. • CONCURRENT THERAPY - ALONG WITH RADIATION THERAPY - FOR SOME CANCERS THAT CAN'T BE REMOVED BY SURGERY • AS THE MAIN TREATMENT (SOMETIMES ALONG WITH RADIATION THERAPY) FOR MORE ADVANCED CANCERS OR FOR SOME PEOPLE WHO AREN'T HEALTHY ENOUGH FOR SURGERY. • CHEMO IS OFTEN NOT RECOMMENDED FOR PATIENTS IN POOR HEALTH, BUT ADVANCED AGE BY ITSELF IS NOT A BARRIER TO GETTING CHEMO.

PROPHYLACTIC MEDS FOR NEUTROPENIA: FOR WHOM?

• FOR PATIENTS WHO ARE EXPECTED TO HAVE PROLONGED, SEVERE NEUTROPENIA • WITH WHAT? • PROPHYLACTIC ANTIBIOTICS—ESPECIALLY FLUOROQUINOLONES—AND ANTIFUNGALS - ESPECIALLY IMPORTANT FOR PATIENTS UNDERGOING TRANSPLANT AND PATIENTS USING STEROIDS LONG-TERM. • COLONY-STIMULATING FACTORS REDUCE THE RISK FOR FEBRILE NEUTROPENIA AND HOSPITALIZATIONS AND ARE BEST GIVEN PROPHYLACTICALLY, NOT REACTIVELY.

Cancer

• REPRESENTS > 200 DIFFERENT DISEASES • BEGINS LIFE AS A NORMAL CELL WHICH IS ALTERED AND PROLIFERATES UNCONTROLLABLY • CAN INVADE AND TAKE OVER THE FUNCTION OF ORGANS &/OR CAUSE LIFE-THREATENING COMPLICATIONS • (E.G. spinal cord compression)

Cancer vaccines

• THE U.S. FOOD DRUG ADMINISTRATION (FDA) HAS APPROVED TWO VACCINES, GARDASIL® AND CERVARIX®, AND THAT PROTECT AGAINST INFECTION BY TWO TYPES OF HPV THAT CAUSE APPROXIMATELY 70 PERCENT OF ALL CASES OF CERVICAL CANCER (VAGINAL, VULVAR) WORLDWIDE, AS WELL AS ANAL, PENILE, AND OROPHARYNGEAL CANCERS (10). • IN 1981, THE FDA APPROVED THE FIRST CANCER PREVENTIVE VACCINE THAT PROTECTS AGAINST HBV INFECTION. CHRONIC HBV INFECTION CAN LEAD TO LIVER CANCER. TODAY, MOST CHILDREN IN THE UNITED STATES ARE VACCINATED AGAINST HBV SHORTLY AFTER BIRTH (12). • APRIL 2010, FDA APPROVED FIRST CANCER TREATMENT VACCINE, SIPULEUCEL-T (PROVENGE®). IT STIMULATES AN IMMUNE RESPONSE FOR PROSTATIC ACID PHOSPHATASE (PAP), AN ANTIGEN ASSOCIATED WITH PROSTATE CANCER. MEN WHO HAD A SPECIFIC TYPE OF METASTATIC PROSTATE CANCER RECEIVED SIPULEUCEL-T DEMONSTRATED AN ADDED SURVIVAL OF BY ABOUT 4 MONTHS (19

MONOCLONAL ANTIBODIES (MABS).. all end in MAB and matched to the host, they all work differently

• THEY ARE MATCHED TO THE HOST - LIKE ANTIBODY-ANTIGEN • MAB'S ARE ENGINEERED OR SYNTHESIZED TO ATTACK ONE SPECIFIC TUMOR ANTIGEN (PROTEIN). • IMAGINE THESE WORK LIKE PUTTING A CHILDPROOF PLASTIC PLUG INTO THE WALL SOCKET - THEY "FIT IN" AND MAKE IT "UNUSABLE"

Classic cancer medication chemotherapy

• TRANSPORTED THROUGH BLOOD • HAS POTENTIAL TO REACH EACH CANCER CELL • CANCER IS A DISEASE "AT THE CELLULAR LEVEL"!!!!! • OFTEN COMBINED WITH SURGERY AND/OR RADIATION TO INCREASE CHANCE OF CURE (ADJUVANT THERAPY) • DIFFERENT CHEMO MEDS WORK AT DIFFERENT PARTS OF THE CELL CYCLE

Biological therapy

•INTERLEUKINS/INTERFERONS - • SES: FEVER, MYALGIAS, FATIGUE (FLU-LIKE) • WHAT PRN MEDICATIONS MIGHT BE HELPFUL FOR THE RN TO OFFER??? • INDICATED IN: MALIGNANT MELANOMA, HAIRY CELL LEUKEMIA, RENAL CELL CA, CUTANEOUS T-CELL LYMPHOMA