chapter 46, chapter 45 antineoplastics

cytotoxic drug adverse effects

Adverse Effects As with all of the antineoplastic drugs, cytotoxic antibiotics have the undesirable effects of hair loss, nausea and vomiting, and myelosuppression. The emetic potential of the various drugs in this category is given in Box 45-1. Major adverse effects specific to the cytotoxic antibiotics are listed in Table 46-5.

etiology of cancer

Age- and Sex-Related Differences The probability that a neoplastic disease will develop generally increases with advancing age. A number of rare cancers, such as acute lymphocytic leukemia and Wilms tumor, occur predominantly in pediatric patients. With the exception of cancers affecting the reproductive system, few cancers exhibit a sex-related difference in incidence. Lung and urinary cancers are more common in men than in women, but this may have more to do with exogenous factors such as smoking patterns and occupational exposure to environmental toxins than to sex-related characteristics. The incidence of colon, rectal, pancreatic, and skin cancers are comparable in men and women. A number of hematologic cancers have a slight male predominance. Genetic and Ethnic Factors Few cancers have been confirmed to have a hereditary basis (some types of breast, colon, and stomach cancer are exceptions). The understanding of tumor biology has helped guide therapy tremendously. Two such advances are determination of hormone receptor status and identification of specific gene expression in various types of tumor cells. For example, some tumor cells express themselves on their cell membrane surfaces, either estrogen receptors or progesterone receptors, and some tumor cells express specific genes such as the HER2/neu gene. Because these indicators aid in classification of a patient's tumor, they also help in choosing appropriate drug therapy, predicting response to therapy, and anticipating prognosis. Discovery of the BRCA1 and BRCA2 genes has allowed identification of women who are at risk for breast cancer because they have a certain alteration in one of these BRCA genes. Many women with a family history of breast cancer choose to be tested for the presence of a BRCA gene mutation, which has led 713some women to undergo prophylactic breast removal. Tumors with identifiable gene expression patterns can show a familial pattern of inheritance. For example, Burkitt's lymphoma is more common in young African children and children of African descent. Another example of an ethnic predisposition is the high incidence of nasopharyngeal cancer in persons of Chinese descent. Oncogenic Viruses Extensive research has indicated that there are cancer-causing (oncogenic) viruses that can affect most mammalian species. Examples include human papillomavirus, the various cat leukemia viruses, the Rous sarcoma virus in chickens, and the Shope papillomavirus in rabbits. The herpesviruses are common examples of oncogenic viruses. Epstein-Barr virus is a type of herpesvirus. It is most commonly recognized as the cause of infectious mononucleosis (commonly referred to as "mono" or the "kissing disease"). However, it is also associated with the development of Burkitt's lymphoma and nasopharyngeal cancer. Infection with human papillomavirus (often abbreviated as HPV) has been linked to both cervical and anal cancer. Occupational and Environmental Carcinogens A carcinogen is any substance that can cause cancer. In the nucleus of every cell are found molecules of nucleic acids, namely deoxyribonucleic acid (DNA) and ribonucleic acid (RNA). Genes are transcribed into messenger RNA molecules, which in turn are translated into protein molecules necessary for cellular structure and function. This process is discussed further in the section on alkylating drugs in Chapter 46. A mutagen is any substance or physical agent (e.g., radiation) that induces changes in DNA molecules. Mutations often transform normal cells into cancer cells. Thus, mutagenicity is associated with and often (but not always) leads to carcinogenicity. The U.S. Food and Drug Administration (FDA) mandates that carcinogenic studies be performed before any new drug is approved for use. However, no amount of clinical testing can fully reveal all of a drug's possible carcinogenic effects. Carcinogenic effects may not be observed until the drugs are used in the general population. If patterns of carcinogenicity begin to emerge during this period of postmarketing surveillance (or postmarketing studies), the drug may be recalled from the market. Radiation Radiation is a well-known and potent carcinogenic agent. There are two basic types of radiation: (1) ionizing, or high-energy, radiation, and (2) nonionizing, or low-energy, radiation. Both types can be carcinogenic. Ionizing radiation is very potent and can penetrate deeply into the body. It is called ionizing because it causes the formation of ions within living cells. This type of radiation (e.g., that used in radiographic studies) is also used to treat (irradiate) cancerous tumors (e.g., radium implants). Nonionizing radiation is much less potent and cannot penetrate deeply into the body. Ultraviolet light is an example of this type of radiation and is the cause of skin cancer. In contrast to chemotherapy, radiation therapy is considered to be a locoregional and not a systemic cancer treatment. Adverse effects of radiation therapy (e.g., radiation burns; nausea with GI tract irradiation) tend to be more localized to the site of treatment as well. Immunologic Factors The immune system plays an important role in terms of cancer surveillance and the elimination of neoplastic cells. Neoplastic cells are believed to develop in everyone; however, a healthy person's immune system recognizes them as abnormal and eliminates them by means of cell-mediated immunity (cytotoxic T lymphocytes; see Chapter 47). It has also been shown that the incidence of cancer is much higher in immunocompromised individuals.

alkaloid topoisomerase II INHIBITORS

Alkaloid Topoisomerase II Inhibitors Etoposide and teniposide are derivatives of epipodophyllotoxin. They exert their cytotoxic effects by inhibiting the enzyme topoisomerase II, which causes breaks in DNA strands. These drugs work during the late S phase and the G2 phase of the cell cycle. Drug Profiles Selected Mitotic Inhibitors and Etoposide image etoposide Etoposide (VP-16) (generic) is a topoisomerase II inhibitor. Its structure, mechanism of action, and adverse-effect profile are similar to those of teniposide. It is believed to kill cancer cells in the late S phase and the G2 phase of the cell cycle. It is indicated for the treatment of small-cell lung cancer and testicular cancer. It is available in both oral and injectable forms. The oral form is poorly absorbed and has fallen out of favor because it produces significant toxicities without therapeutic benefit. The IV drug is formulated in a hydroalcoholic diluent, which can cause toxicity (hypotension) if administered in too high a concentration. A water-soluble form of the drug (Etopophos) can eliminate these administration issues, but it is very expensive compared with the standard preparation. Indications: Selected Mitotic Inhibitors and Etoposide Drug (Pregnancy Category) Pharmacologic Class Indications Epipodophyllotoxin Derivative image etoposide (Toposar, generics) (D) Topoisomerase II inhibitor Testicular and small-cell lung cancer Taxane image paclitaxel (Taxol, Onxol) (D) Mitotic inhibitor Ovarian, breast, esophageal, bladder, head and neck, cervical cancer; non-small-cell and small-cell lung cancer; Kaposi's sarcoma Vinca Alkaloid image vincristine (Vincasar PFS, generics) (D) Mitotic inhibitor ALL, AML, HL, NHL, rhabdomyosarcoma, neuroblastoma, Wilms tumor, brain tumors, small-cell lung cancer, Kaposi's sarcoma ALL, Acute lymphocytic leukemia; AML, acute myelocytic leukemia; HL, Hodgkin's lymphoma; NHL, non-Hodgkin's lymphoma. image paclitaxel Paclitaxel (Taxol) is a natural mitotic inhibitor that was originally isolated from the bark of the Pacific yew tree. The European yew tree is the source for another mitotic inhibitor known as docetaxel (Taxotere). Paclitaxel is currently approved for the treatment of ovarian cancer, breast cancer, non-small-cell lung cancer, and Kaposi's sarcoma, among other cancers. Paclitaxel is water-insoluble (hydrophobic), and for this reason it is put into a solution containing oil rather than water. The particular oil used is a type of castor oil called Cremophor EL, the same oil with which cyclosporine is formulated. Many patients tolerate it poorly and show hypersensitivity associated with infusion. For this reason, before patients receive paclitaxel they are premedicated with a steroid (dexamethasone), H1 receptor antagonist (diphenhydramine), and H2 receptor antagonist (ranitidine). Paclitaxel is available only in injectable form. There is an albumin-bound form of the drug (Abraxane) that is not associated with severe infusion reactions. image vincristine Vincristine is an alkaloid isolated from the periwinkle plant that is indicated for the treatment of acute lymphocytic leukemia and other cancers. It is available only in injectable form. It is an M phase-specific drug that inhibits mitotic spindle formation. Vincristine is the most significant neurotoxin of the cytotoxic drug class, but it continues to be used in part because of its relative lack of bone marrow suppression. Special care must be taken not to inadvertently give vincristine via the intrathecal route. Several deaths have been reported due to this error. The World Health Organization and the Institute for Safe Medication Practices suggest that vincristine be diluted in 72325 to 50 mL of fluid and never dispensed via a syringe to prevent this lethal error from occurring. A special warning is required for all vincristine products dispensed that states "For Intravenous Use Only—Fatal If Given By Other Routes." (See Safety and Quality Improvement: Preventing Medication Errors below.)

alkalyting drugs adverse effects

Alkylating drugs are capable of causing all of the dose-limiting adverse effects described in Chapter 45. Other adverse effects 736are described in Table 46-2. The relative emetic potential of the various alkylating drugs is given in Box 45-1. The adverse effects of these drugs are important because of their severity, but they can often be prevented or minimized by prophylactic measures. For instance, nephrotoxicity from cisplatin can often be prevented by adequately hydrating the patient with intravenous fluids. *Carboplatin has less nephrotoxicity and neurotoxicity but more bone marrow suppression than cisplatin. Drug extravasation (Box 46-1) occurs when an intravenous catheter punctures the vein and medication leaks (infiltrates) into the surrounding tissues. With cancer chemotherapeutic drugs, in particular doxorubicin (a cytotoxic antibiotic), extravasation can cause severe tissue damage and necrosis (tissue death). Extravasation antidotes for selected drugs are listed in Table 46-3

antimetabolites overview

Antimetabolites A compound that is structurally similar to a normal cellular metabolite is known as an analogue of that metabolite. Analogues may have agonist or antagonist activity. An antagonist analogue is also known as an antimetabolite. 718 Mechanism of Action and Drug Effects Antineoplastic antimetabolites are cell cycle-specific analogues that work by antagonizing the actions of key cellular metabolites. More specifically, antimetabolites inhibit cellular growth by interfering with the synthesis or actions of compounds critical to cellular reproduction: the vitamin folic acid, purines, and pyrimidines. Purines and pyrimidines make up the bases contained in nucleic acid molecules (DNA and RNA). Antimetabolites work via two mechanisms: (1) by falsely substituting for purines, pyrimidines, or folic acid; and (2) by inhibiting critical enzymes involved in the synthesis or function of these compounds. Thus, they ultimately inhibit the synthesis of DNA, RNA, and proteins, all of which are necessary for cell survival. Antimetabolites work primarily in the S phase of the cell cycle, during which DNA synthesis is most active. The available antimetabolites are listed below. Although some chemotherapy drugs have abbreviations, it is best to avoid use of abbreviations as they have been associated with medication errors. Best practice is to put the generic and brand name on the label of the finished product to serve as a double check: Folate antagonists • methotrexate (MTX) • pemetrexed • pralatrexate Purine antagonists • cladribine • fludarabine • mercaptopurine (6-MP) • pentostatin • thioguanine Pyrimidine antagonists • capecitabine • cytarabine (ara-C) • floxuridine fluorouracil (5-FU) • gemcitabine Folic Acid Antagonism The antimetabolite methotrexate is an analogue of folic acid. It inhibits the action of dihydrofolate reductase, an enzyme responsible for converting folic acid to its active form, folate, which is needed for the synthesis of DNA. The result is that DNA is not produced and the cell dies. In practice, the terms folic acid and folate are often used interchangeably. Pemetrexed is the name of a newer folate antagonist with a mechanism of action similar to that of methotrexate. Pralatrexate (Folotyn) is the newest dihydrofolate reductase inhibitor, specifically indicated for T-cell lymphoma. Purine Antagonism The purine bases present in DNA and RNA are adenine and guanine (see the discussion in Chapter 46), and they are required for the synthesis of the purine nucleotides that are incorporated into the nucleic acid molecules. Mercaptopurine and fludarabine are synthetic analogues of adenine, and thioguanine is a synthetic analogue of guanine. Cladribine is a more general purine antagonist, whereas pentostatin inhibits the action of the critical enzyme adenosine deaminase. Cladribine is unique in that it actually lacks cell-cycle specificity relative to other drugs in its class. It is included in this section because of its similar pharmacology and mechanism of action. All of these drugs work by ultimately interrupting the synthesis of both DNA and RNA. Although allopurinol is chemically similar to purines, it does not disrupt DNA synthesis. Instead, it inhibits xanthine oxidase, which reduces serum and/or urinary levels of uric acid. Rasburicase is an enzyme that degrades uric acid to more soluble end products. Uric acid is a common waste product that often accumulates in the blood following lysis of tumor cells, part of a condition known as tumor lysis syndrome (see Adverse Effects). Pyrimidine Antagonism The pyrimidine bases, cytosine and thymine, occur in the structure of DNA molecules, and cytosine and uracil are part of the structure of RNA molecules. These bases are essential for DNA and RNA synthesis. Floxuridine and fluorouracil are synthetic analogues of uracil, and cytarabine is a synthetic analogue of cytosine. Capecitabine is actually a prodrug of fluorouracil and is converted to that drug in the liver and other body tissues. Because of its prodrug form, it can be given orally. Gemcitabine inhibits the action of two essential enzymes, DNA polymerase and ribonucleotide reductase. Overall, these drugs act in a way that is very similar to that of the purine antagonists, incorporating themselves into the metabolic pathway for the synthesis of DNA and RNA and thereby interrupting the synthesis of both of these nucleic acids. Indications Antimetabolite antineoplastic drugs are used for the treatment of a variety of solid tumors and some hematologic cancers. They may also be used in combination chemotherapy regimens to enhance the overall cytotoxic effect. Methotrexate is also used to treat severe cases of psoriasis (a skin condition) as well as rheumatoid arthritis (see Chapter 47). Because some of these drugs are available in both oral and topical preparations, they are sometimes used for low-dose maintenance and palliative (noncurative) cancer therapy. Allopurinol and rasburicase are both indicated for the hyperuricemia associated with tumor lysis syndrome and are usually given in anticipation of this condition during various chemotherapy regimens associated with this syndrome. Allopurinol is also used commonly in oral form to treat gout (see Chapter 44). The commonly used drugs and their common specific therapeutic uses are listed in the table on p. 720. Adverse Effects Like most antineoplastic drugs, antimetabolites can cause hair loss, nausea, vomiting, diarrhea, and myelosuppression. The relative emetic potentials for some of these drugs are listed in Box 45-1. In addition, other major types of toxicity including neurologic, cardiovascular, pulmonary, hepatobiliary, GI, genitourinary, dermatologic, ocular, otic, and metabolic toxicity. Common manifestations of these various toxicities are listed in Table 45-6, roughly in order of increasing severity. Note that a 719single drug may not cause all of the specific symptoms that are listed for each toxicity category, and actual symptoms may vary widely in severity among patients. The most common general symptoms are fever and malaise. Metabolic toxicity also includes tumor lysis syndrome, a common postchemotherapy condition. This syndrome is often associated with induction (initial) chemotherapy for rapidly growing hematologic malignancies. It may include hyperphosphatemia, hyperkalemia, and hypocalcemia. These electrolyte abnormalities are often treated with diuretics such as mannitol, IV calcium supplementation, oral or rectal potassium exchange resin, and oral aluminum hydroxide. Hyperuricemia can lead to nephropathy, and hemodialysis may be required in severe cases of tumor lysis syndrome.A severe, but usually reversible, form of dermatologic toxicity is known as palmar-plantar dysesthesia or paresthesia (also called hand-foot syndrome). It can range from mild symptoms such as painless swelling and erythema to painful blistering of the patient's palms and soles. Other severe, but fortunately uncommon, dermatologic syndromes that can similarly affect the skin in more generalized regions include Stevens-Johnson syndrome and toxic epidermal necrolysis.

antineoplastic enzymes

Antineoplastic Enzymes Two antineoplastic enzymes are commercially available: asparaginase and pegaspargase. A third, Erwinia asparaginase, is available only by special request from the National Cancer Institute for patients who have developed allergic reactions to Escherichia coli-based asparaginase. All three drugs are 724synthesized from cultures of certain bacteria using recombinant DNA technology. Indications The antineoplastic enzymes are currently approved exclusively for the treatment of acute lymphocytic leukemia. Adverse Effects Of particular note for the antineoplastic enzymes is a fairly unique adverse effect of impaired pancreatic function. This can lead to hyperglycemia and severe or fatal pancreatitis. Other types of adverse effects associated with these drugs are dermatologic, hepatic, genitourinary, neurologic, musculoskeletal, GI, and cardiovascular effects. Interactions Commonly reported drug interactions involving the antineoplastic enzymes are summarized in Table 45-11. TABLE 45-11 Selected Antineoplastic Enzymes: Common Drug Interactions Enzyme Interacting Drug Observed and Reported Effects* asparaginase cyclophosphamide, mercaptopurine, vincristine Interference with efficacy or clearance of asparaginase mercaptopurine, methotrexate, prednisone Enhanced liver toxicity of asparaginase methotrexate Reduced antineoplastic effect when given concurrently, but possibly enhanced antineoplastic effect when given 9 to 10 days before or shortly after methotrexate prednisone Hyperglycemia (give asparaginase after prednisone) vincristine Neuropathy (give asparaginase after vincristine) aspirin, NSAIDs, dipyridamole, heparin, warfarin Use with caution due to possible coagulation abnormalities *Note that not all mechanisms for these drug interactions have been clearly identified. NSAIDs, Nonsteroidal antiinflammatory drugs. Drug Profiles image asparaginase Asparaginase (Elspar) is used for the treatment of acute lymphocytic leukemia. Its mechanism of action is slightly different from that of traditional antineoplastic drugs in that it is an enzyme that catalyzes the conversion of the amino acid asparagine to aspartic acid and ammonia. Leukemic cells are then unable to synthesize the asparagine required for the synthesis of DNA and proteins needed for cell survival. The only commercially available asparaginase product in the United States is Elspar. It is derived from the E. coli bacterium, and it is common for patients to develop allergic reactions to it. When this happens, one alternative is to switch to a product synthesized from Erwinia bacteria. This product is not sold commercially in the United States but is available by special request from the National Cancer Institute. Another treatment alternative is to use the commercially available pegaspargase product described in the following drug profile. All antineoplastic enzymes are available only in injectable form. pegaspargase Pegaspargase (Oncaspar) has a mechanism of action, indications, and contraindications similar to those of asparaginase. It is essentially the same enzyme that has been formulated so as to reduce its allergenic potential. This process involves chemical conjugation of the enzyme with units of a relatively inert compound known as monomethoxypolyethylene glycol. Because polyethylene glycol is abbreviated PEG, this process is known as pegylation. It is a process that is increasingly used in formulating various drugs, some of which are described in other chapters (e.g., see Chapter 47). These drugs are recognized by the prefix peg in their generic names. Pegaspargase is usually prescribed for patients who have developed an allergy to asparaginase—a common occurrence, as mentioned earlier, especially with repeated treatment.

nursing intervention part 1

Antineoplastic drugs are some of the most toxic medications given to patients because they cause the death of normal cells along with the death of cancer cells. The high potency of these drugs also places the patient at higher risk for toxicity, serious complications, and adverse effects. The possibility of such adverse effects and toxicities requires skillful nursing care based on cautious and thorough assessment and subsequent critical thinking. General considerations in nursing implementation applicable to most antineoplastic drugs as well as some specific aspects of implementation related to cell cycle-specific drugs are presented in the following paragraphs. In the following paragraphs, the specific adverse effect(s) associated with cell cycle-specific drugs will be discussed and are italicized. Other nursing process information related to cell cycle-nonspecific drugs is presented in Chapter 46. For antineoplastic therapy in general, nursing considerations related to reducing fear and anxiety include establishing a therapeutic relationship beginning with trust and empathy. Approach the patient in a warm, empathic, and supportive manner while projecting confidence in providing nursing care. Provide individualized explanations and teaching about the patient's illness, care, and treatments that are appropriate to the patient's educational level. Collaborate with all members of the health care team. Encourage patients to consider relaxation techniques such as listening to music, performing meditation, or engaging in guided imagery. It may be necessary to call on all potential sources of support, including social services, counseling services, financial assistance services, Meals On Wheels, and religious-spiritual or belief systems with respect to the patient's needs. Appropriate consults may also be necessary with other practitioners such as a licensed clinical social worker, discharge planner, clinical psychiatrist, mental health nurse, nurse practitioner, and oncology nurse specialist, as well as with support groups for the patient, family, and/or significant others. A variety of interventions that may be indicated for the management of stomatitis or excessive oral mucosa dryness and irritation include the following: (1) Instruct the patient to perform oral hygiene before and after eating or as needed to provide cleanliness and comfort. Advise the patient to avoid lemon, glycerin, undiluted peroxide, or alcohol-containing products because they are drying and irritating to the oral mucosa. (2) Recommend use of a soft-bristle toothbrush or soft-tipped toothette or swab with solutions of diluted warm saline. (3) If dentures are worn, encourage the patient to remove and clean them frequently and, if stomatitis is severe, to insert only at mealtimes. (4) Advise using OTC saliva substitutes, keeping the lips moist, and using sugarless candy or gum to stimulate saliva flow. (5) Stress that spicy, acidic, or hot foods; alcohol; and tobacco must be avoided because they are irritants. (6) Oral antifungal suspensions (e.g., nystatin) may be ordered if white patches are noted on the oral mucosa; use analgesic solutions (e.g., lidocaine swish and swallow), as ordered, to help manage discomfort. Other regimens may be prescribed, as needed. Nausea and vomiting occur commonly with antineoplastic drugs. Emetic potential varies depending on the drug and treatment protocol (see earlier discussion and Box 45-1). Educate the patient on measures to enhance comfort during times of nausea and vomiting, including restricting oral intake as ordered; removing noxious odors or sights to avoid stimulating the vomiting center; performing oral hygiene as needed; promoting relaxation through slow, deep breathing; consuming small, frequent meals and eating slowly; and consuming clear liquids and a bland diet. Use of IV fluids may be indicated for hydration purposes if nausea and vomiting are severe. Antiemetics are also a vital part of antineoplastic therapy (see Chapter 52 for more specific drug-related information). Premedication with antiemetics 30 to 60 minutes before administration of the antineoplastic(s) is the preferred treatment protocol to help reduce nausea and vomiting, prevent dehydration and malnutrition, and promote comfort. Combination 729antiemetic drug therapy may be more effective than single-drug therapy. An antiemetic may be given with the chemotherapeutic regimen and prescription medication for at-home use. Ginger ale and ginger-based teas may be helpful. While its exact anti-nausea mechanism is unknown, it is thought that there are chemicals in ginger that influence the nervous system, stomach, and intestines to reduce nausea.

antimetabolite drug interaction

As is true for cancer drugs in general, the administration of one antimetabolite drug with another that causes similar toxicities may result in additive toxicities. Table 45-7 lists some known common examples of drugs that cause interactions with antimetabolites. TABLE 45-7 Selected Antimetabolites: Common Drug Interactions Antimetabolite Interacting Drug Observed and Reported Effects* capecitabine warfarin Altered coagulation test results with potential for fatal bleeding phenytoin Reduced phenytoin clearance and toxicity cytarabine digoxin Reduced absorption likely due to cytarabine-induced damage to intestinal mucosa; elixir form may be better absorbed fluorouracil warfarin Enhanced anticoagulant effects mercaptopurine (6-MP) allopurinol Inhibition of 6-MP metabolism by inhibition of xanthine oxidase enzyme, with possible enhanced 6-MP toxicity; reduce dose to one third to one fourth warfarin 6-MP reported to both enhance and inhibit effects of warfarin Hepatotoxic drugs Increased risk for liver toxicity methotrexate (MTX) Protein-bound drugs and weak organic acids (e.g., salicylates, sulfonamides, sulfonylureas, phenytoin) Possible displacement of MTX from protein-binding sites, enhancing its toxicity Penicillins, NSAIDs Possible reduced renal elimination of MTX with potentially fatal hematologic and GI toxicity Live virus vaccines Viral infection (true for any immunosuppressive drug) folic acid Reduced MTX efficacy (theoretical only) theophylline Reduced theophylline clearance Hepatotoxic drugs Increased risk for liver toxicity pentostatin fludarabine Potentially fatal pulmonary toxicity

nursing process intervention part 1 antineoplastics part 2

Before initiating drug therapy with the cell-cycle-nonspecific drugs, hormonal antineoplastics, and/or miscellaneous drugs, you must be completely knowledgeable about the drug, its use, and impact on all rapidly dividing cells, whether normal or malignant (see Chapters 34, 35, and 45 for additional information). With alkylating drugs, always handle these and all other antineoplastics with caution because of their possible carcinogenic, mutagenic, and teratogenic properties (see Box 46-3). The patient receiving alkylating drugs will more than likely experience problems related to bone marrow suppression, such as anemia, leukopenia, and thrombocytopenia (see Chapter 45 for specific interventions). Most nursing interventions are focused on preventing infection, conserving energy, preventing bleeding and injury, and reducing nausea. Other nursing considerations for these drugs include taking vital signs every 1 to 2 hours or as needed during infusion; increasing fluids; monitoring intake and output; following orders for intravenous therapy for hydration; and monitoring any nausea/vomiting. Contact the prescriber if vomiting is uncontrolled so that appropriate medications can be implemented. Monitor the patient constantly for abnormal peripheral sensations, especially with cisplatin. Report to the prescriber any numbness or tingling of extremities and any ringing or roaring in the ears and/or hearing loss. Encourage the patient experiencing peripheral neuropathies to avoid extremely cold temperatures or the handling of cold objects. Cisplatin is particularly 743nephrotoxic, so closely monitor renal function throughout therapy. Intravenous hydration is often required at a rate of 100 to 200 mL/hr starting before cisplatin administration with a total of 2000 to 3000 mL/day, depending on the dose of cisplatin and if not contraindicated. Do not use aluminum needles or administration sets with many of these drugs because aluminum can degrade their platinum compounds; ensure that the proper infusion equipment is used. Because hemorrhagic cystitis is associated with cyclophosphamide use, make sure the patient's hydration is maintained to minimize this adverse effect. Pulmonary toxicity may occur with some of the alkylating drugs, particularly busulfan; therefore, constantly monitor and be alert to cough, shortness of breath, and abnormal breath sounds. Immediately report these adverse effects to the prescriber. Other drugs in this group may be given by various routes, such as intrapericardial, intratumoral, and intravesical. Be sure you perform appropriate interventions per the manufacturer's guidelines or health care institutional policy. Reconstitute the parenteral formulations for any of these drugs according to the manufacturer's guidelines and suggestions. Not all diluents are compatible. One very important component of nursing care with alkylating drugs and their parenteral administration is monitoring the IV site/infusion continually for signs and symptoms of infiltration. Infiltration could lead to extravasation of the medication into the surrounding tissue. To briefly review, IV infiltration is the leakage of fluids or blood from a dislodged catheter or needle cannula from the intima of the vein and into the surrounding tissue. Signs and symptoms of infiltration include inflammation at or near the insertion site with swollen, taut skin with pain, blanching, and coolness of skin around the IV site; slowed or stopped IV infusion; no backflow of blood into the IV tubing; and/or no blood return obtained. The reason infiltration is of concern with these drugs is that some of them are irritants and others are vesicants with the potential of severe tissue damage. Therefore, if extravasation occurs with some of these drugs, antidotes are required to try and prevent damage from leakage of the drug into the tissue. Specific antidotes for alkylating drugs are presented in Table 46-3. Always follow health care institutional policy when treating extravasation of any medication. With IV infusions of antineoplastics, monitoring of the IV site and infusions is usually more frequent, with many guidelines/policies outlining the standard of care to be hourly assessment with documentation. It is important to note that the vast majority of chemotherapeutic drugs are administered via a central line indwelling catheter device (e.g., Port-A-Cath or MediPort) to minimize the risk for extravasation. Check the device and its patency prior to the drug's administration.

nursing process assessment part 1 antineoplastics part 2

Begin the overall assessment of patients taking any of these drugs with a thorough nursing history, medication profile, and past and present medical history. Assess vital signs and weight/height, as both these parameters may be needed to calculate doses. Document the presence of conditions that represent cautions or contraindications as well as potential drug interactions. Perform a head-to-toe physical assessment with specific 741attention to the following: skin turgor with level of moisture and integrity of the skin and oral mucosa; baseline level of neurologic functioning including motor/sensory intactness, level of consciousness, alertness, deep tendon reflexes, and presence of any abnormal sensations; bowel sounds, bowel patterns, and inquiry into any problems such as diarrhea, constipation, nausea, vomiting, or gastroesophageal reflux; urinary patterns and color, amount, and odor of urine; breath sounds as well as respiratory rate, rhythm, and depth; and heart sounds. Laboratory tests that may be ordered include fluid and electrolyte levels (sodium, potassium, chloride, magnesium, calcium), RBC and WBC counts, hemoglobin, hematocrit, renal and hepatic function tests, and serum protein-albumin levels (see Chapter 45). For patients receiving alkylating drugs, bone marrow suppression (carboplatin), pulmonary fibrosis (busulfan), nephrotoxicity and/or neurotoxicity (more with cisplatin than carboplatin), and hemorrhagic cystitis (cyclophosphamide) may occur; thus, perform an appropriate and thorough nursing assessment (see Assessment in Chapter 45). Be specific, and assess/document deep tendon reflexes and baseline hearing level. Assess results of any baseline pulmonary function testing, and perform a thorough respiratory assessment. High-dose cyclophosphamide may lead to hemorrhagic cystitis; therefore, document baseline urinary patterns and any abnormal symptoms. Note hydration status before administering cyclophosphamide to avoid hemorrhagic cystitis. One of the major adverse effects associated with the use of cytotoxic antibiotics (e.g., bleomycin) is pulmonary fibrosis. A variety of medical testing will be ordered (e.g., radiographs [x-rays], computed tomographic [CT] scans, magnetic resonance imaging [MRI] scans, positron emission tomography [PET] scans, arterial blood gas levels, and partial pressures of CO2 and O2), so assess findings. When dactinomycin or daunorubicin are given intravenously, the drug is generally administered via a central line indwelling catheter device (e.g., Port-A-Cath or MediPort), because if it is given by peripheral intravenous line and extravasation occurs, there is a risk for necrosis with tissue sloughing that may erode through the layers of skin and underlying supportive structures (e.g., muscles, ligaments). See the pharmacology discussion of extravasation as well as Table 46-3 and Box 46-3. In addition, in patients with documented cardiac disease or a history of thoracic irradiation, administer dactinomycin, daunorubicin, and doxorubicin with extreme caution due to cardiovascular toxicity. CT scans and ultrasound studies may be needed before and during treatment to assess cardiac ejection fraction because of the risk for cardiotoxicity, which is often associated with cumulative doses.

cancer overview part 1

Cancer is a broad term encompassing a group of diseases that are characterized by cellular transformation (e.g., by genetic mutation), uncontrolled cellular growth, possible invasion into surrounding tissue, and metastasis to other tissues or organs distant from the original body site. This cellular growth differs from normal cellular growth in that cancerous cells do not possess a growth control mechanism. Lack of cellular differentiation or maturation into specialized, productive cells is also a common characteristic of cancer cells. Figure 45-1 illustrates the multiple steps involved in the development of cancer. Cancerous cells will continue to grow and invade adjacent structures. They may break away from the original tumor mass and travel by means of the blood or lymphatic system to establish a new clone of cancer cells and create a metastatic growth 711elsewhere in the body. A clone is a cell or group of cells that is genetically identical to a given parent cell. For the remainder of this and the next chapter, the term cancer will generally be used to refer to any type of malignant neoplasm.

cancer drug therapy part 1

Cancer is normally treated using one or more of three major medical approaches: surgery, radiation therapy, and chemotherapy. The term chemotherapy refers to the pharmacologic treatment of cancer. Normal cells in the body divide (proliferate) in a controlled and organized fashion, and this growth is regulated by means of various mechanisms. In contrast, cancer cells lack regulatory mechanisms, and they proliferate uncontrollably. Figure 45-4 shows how various combinations of cancer treatment may succeed, or fail, over time. Cancer chemotherapy drugs can be subdivided into two main groups based on where in the cell cycle they have their effects. Antineoplastic drugs that are cytotoxic (cell killing) in any phase of the cycle are called cell cycle-nonspecific drugs. Those drugs that are cytotoxic during a specific cell cycle phase are called cell cycle-specific drugs. These are broad categories that describe the activity of a drug with regard to cell cycle. Individual drugs may have actions that fall into both of these categories. Regardless of the cell cycle characteristics of a drug, it is more effective on rapidly growing tumors. This chapter discusses the cell cycle-specific drugs. Chapter 46 focuses on cell cycle-nonspecific drugs as well as various miscellaneous antineoplastic drugs. The ultimate goal of any anticancer regimen is to kill every neoplastic cell and produce a cure, but this goal is not achieved in most cases. Fortunately, some patients' immune systems may be able to clear the remaining tumor. Factors that affect the chances of cure and the length of patient survival include the cancer stage at time of diagnosis, the type of cancer and its doubling time, the efficacy of the cancer treatment, the development of drug resistance, and the general health of the patient. When total cure is not possible, the primary goal of therapy is to control the growth of the cancer while maintaining the best quality of life for the patient with the least possible level of discomfort and fewest treatment adverse effects. It must be emphasized that cancer care and treatment involve many rapidly evolving medical sciences. Cancer is an intensively researched area, with the ultimate goals being to prevent cancer and to prevent premature death. Chemotherapy medications are often dosed as part of complex, specific treatment protocols that are subject to frequent revision by oncology practitioners and researchers. For these reasons, doses of chemotherapeutic agents are not listed in this textbook. When faced with a chemotherapy drug, one must check the dose against standard chemotherapy textbooks and the specific protocol being utilized. Furthermore, the indications that are listed for each specific drug are the primary FDA-approved indications that are current at the time of this writing. These, too, may change unpredictably with time as a given drug is determined to be more (or less) effective for treating certain types of cancer. Also, in clinical practice, patients are often treated with one or more antineoplastic medications in "off-label" uses; that is, the drug is not currently approved for those particular uses by the FDA. No antineoplastic drug is effective against all types of cancer. Most cancer drugs have a low therapeutic index, which means that a fine line exists between therapeutic and toxic levels. Clinical experience has shown that a combination of drugs is usually more effective than single-drug therapy. Because drug-resistant cells often develop, exposure to multiple drugs with multiple mechanisms and sites of action will destroy more subpopulations of cells. The delayed onset of resistance to a particular antineoplastic drug is one benefit of combination drug therapy. 716To be most effective, drugs used in a combination regimen would ideally possess the following characteristics: • Some efficacy even as single drugs in the treatment of the particular type of cancer • Different mechanisms of action so that the cytotoxic effect is maximized; this includes differences in cell-cycle specificity • No or minimal overlapping toxicities One major drawback to the use of antineoplastic drugs is that nearly all of them cause adverse effects. These toxicities generally stem from the fact that chemotherapy drugs affect rapidly dividing cells—both harmful cancer cells and healthy, normal cells. Three types of rapidly dividing human cells are the cells of hair follicles, GI tract cells, and bone marrow cells. Because most of today's antineoplastic drugs cannot differentiate between cancer cells and healthy cells, the healthy cells are also destroyed, so hair loss, nausea and vomiting, and bone marrow toxicity are the undesirable consequences. Effects on the GI tract and bone marrow are often dose-limiting adverse effects; that is, the patient can no longer tolerate an increase in dosage that may be necessary to adequately treat the cancer and achieve good disease response. Hair follicle cells are rapidly dividing cells. Cancer drugs that affect these cells often cause the adverse effect known as alopecia, or hair loss. Many patients, especially women, choose to wear wigs, hats, or scarves to disguise this adverse effect. Some antineoplastic drugs are more harmful to the epithelial cells of the stomach and intestinal tract, which often leads to diarrhea and mucositis, and may also increase the risk for nausea and vomiting. The likelihood that a given drug will produce vomiting is known as its emetic potential. Anticancer drugs cause nausea and vomiting by stimulating the cells of the chemoreceptor trigger zone. Several antiemetic drugs are used to prevent these symptoms and are described in Chapter 52. Box 45-1 lists the relative emetic potential of selected chemotherapy drugs.

cancer overview part 4

Carcinomas arise from epithelial tissue, which is located throughout the body. This tissue covers or lines all body surfaces, both inside and outside the body. Examples are the skin, the mucosal lining of the entire gastrointestinal (GI) tract, and the lining of the bronchial tree (lungs). Sarcomas are malignant tumors that arise primarily from connective tissues, but some sarcomas are tumors of epithelial cell origin. Connective tissue is the most abundant and widely distributed of all tissues and includes bone, cartilage, muscle, and lymphatic and vascular structures. Its purpose is to support and protect other tissues. 712 Lymphomas are cancers within the lymphatic tissues. Leukemias arise from the bone marrow and are cancers of blood and bone marrow. Leukemias differ from carcinomas and sarcomas in that the cancerous cells do not form solid tumors but are interspersed throughout the lymphatic or circulatory system and interfere with the normal functioning of these systems. For this reason, they are sometimes referred to as circulating tumors, although hematologic malignancy is a more precise term. Lymphomas can be quite bulky and are usually classified as solid tumors. Cancer patients may also experience various groups of symptoms that cannot be directly attributed to the spread of a cancerous tumor. Such symptom complexes are referred to as paraneoplastic syndromes. They are estimated to occur in up to 15% of patients with cancer and may even be the first sign of malignancy. Cachexia (general ill health and malnutrition) is the most common such symptom complex. Examples of other common paraneoplastic syndromes are given in Table 45-3. These syndromes are believed to result from the effects of biologically or immunologically active substances, such as hormones and antibodies, secreted by the tumor cells. Many patients also exhibit more generalized symptoms, such as anorexia, weight loss, fatigue, and fever.

cell cycle specific drug classes

Cell cycle-specific drug classes include antimetabolites, mitotic inhibitors, alkaloid topoisomerase II inhibitors, topoisomerase I inhibitors, and antineoplastic enzymes. These drugs are collectively used to treat a variety of solid and/or circulating tumors, although some drugs have much more specific indications than others.

nursing intervention part 2

Diarrhea is also a common adverse effect of antineoplastic therapy. Perform the following nursing interventions: (1) Advise the patient to avoid or limit oral intake of irritating, spicy, and gas-producing foods; caffeine; high-fiber foods; alcohol; very hot or cold foods or beverages; and lactose-containing foods and beverages. (2) Consult appropriate personnel, as ordered, to help the patient and family plan meals and arrange ways to meet the patient's dietary and bowel elimination needs. (3) Administer opioids (e.g., paregoric) or synthetic opioids (e.g., loperamide, diphenoxylate hydrochloride) as prescribed, for their antidiarrheal properties. Adsorbents-protectants and antisecretory drugs may also help reduce GI upset and diarrhea (see Chapter 51). To address nutritional concerns, the following measures may prove beneficial in improving oral intake and nutritional status: (1) Perform a 24-hour recall of food intake, and report the typical week's diet for the patient. (2) Use antiemetic therapy, pain management, mouth care, and hydration, as ordered, to reduce the adverse effects of therapy and improve appetite. (3) To ease taste alterations, advise the patient to consume mild-tasting foods and to use chicken, turkey, cheese, or Greek yogurt for protein sources as tolerated. (4) Provide plastic rather than metal utensils if the patient complains of a metallic taste. (5) Encourage eating foods that are easy to swallow, such as custards; gelatins; puddings; milkshakes; eggnog; commercially prepared high-protein, high-calorie supplemental shakes; mashed white or sweet potatoes; blended drinks with crushed ice, fruit, and yogurt; nutritional supplement drinks and snacks; frozen popsicles; and lactose-free ice cream. (6) Instruct the patient to avoid sticky or dry foods. (7) Encourage the consumption of small, frequent meals in an environment that is conducive to eating (e.g., free of odors and excess noise). (8) Appetite stimulants such as megestrol acetate or dronabinol may be helpful. (9) Encourage the patient to practice energy conservation, with frequent rest periods before and after meals. Alopecia is a common adverse effect of antineoplastics and is very disturbing regardless of age or gender. Warn the patient and family about the possibility of hair loss, and tell them when it will occur (usually 7 to 10 days after treatment begins but dependent upon the specific drug used) and that it is reversible. Inform the patient that new hair growth is often a different color and/or texture from the hair lost. Provide information about the options of acquiring a wig or hairpiece, or wearing scarves or hats, before the actual hair loss. The American Cancer Society may be a resource for items such as wigs, scarves, and hats. Antineoplastic-induced bone marrow suppression leads to anemias, leukopenia, neutropenia, and thrombocytopenia (see previous discussion and Safety: Laboratory Values Related to Drug Therapy on pp. 726 and 727 in this chapter and Chapter 46). Anemias result in fatigue and loss of energy and are common adverse effects of therapy and the disease process. Anemias may require blood transfusions, peripheral blood stem cell treatment, or treatment with prescribed medications such as iron preparations, folic acid, or erythropoietic growth factors (e.g., epoetin or darbepoetin alfa). These injections may be given at home and may be administered at the first sign of a decrease in RBC counts. Conservation of energy and planning of care is very important in minimizing patient fatigue. Risk for infection from leukopenia or neutropenia and/or immunosuppression is one of the more significant adverse effects that requires close attention. Inform the patient and family and/or caregivers that when WBC counts are low, the patient is at high risk for infection and that defenses remain low until the counts recover. Following Standard Precautions and using good handwashing technique are most important in preventing transmission of infection in the hospital and home settings. Because fever is a principal early sign of infection, take oral or axillary temperature at least every 4 hours during periods in which the patient is at risk. Avoid taking the temperature rectally to minimize tissue trauma, breaks in skin integrity, and thus loss of the first line of defense and increased risk for infection. Encourage the patient to immediately report to the prescriber a temperature elevation of 100.5° F (38.1° C) or higher so that appropriate treatment may be initiated and complications avoided.

antimetabolite drug interaction

Drug Profiles Folate Antagonist image methotrexate Methotrexate is the prototypical antimetabolite of the folate antagonist group and is currently one of only three antineoplastic folate antagonists used clinically. It has proved useful for the treatment of solid tumors such as breast, head and neck, and lung cancers and for the management of acute lymphocytic leukemia and non-Hodgkin's lymphomas. Methotrexate also has immunosuppressive activity, because it can inhibit lymphocyte multiplication. For this reason, it is useful in the treatment of rheumatoid arthritis (see Chapter 47). Its combined immunosuppressant and antiinflammatory properties also make it useful for the treatment of psoriasis. High-dose methotrexate is associated with severe bone marrow suppression and is always given in conjunction with the "rescue" drug leucovorin. Leucovorin is an antidote for folic acid antagonists. The body produces active folic acid via metabolic steps utilizing the enzyme dihydrofolate reductase. Because methotrexate inhibits this enzyme, healthy cells die due to lack of folic acid. By giving leucovorin (which is rapidly converted 720to the active form of folic acid), it provides the body with active folic acid, which prevents death of normal cells. Methotrexate is available in both injectable and oral (tablet) form. A preservative-free injectable formulation is required for intrathecal (into the subarachnoid space) administration, used in the treatment of some cancers. Other folate antagonists are pemetrexed and pralatrexate, which have actions similar to that of methotrexate. However, they are used less commonly than methotrexate because they have limited indications: lung cancer and T cell lymphoma, respectively. Indications: Selected Antimetabolites Drug (Pregnancy Category) Pharmacologic Class Indications capecitabine (Xeloda) (D) Pyrimidine antagonist (analogue) Metastatic colorectal and breast cancer cladribine (Leustatin) (D) Purine antagonist (analogue) Hairy cell leukemia image cytarabine (Cytosar-U) (D) Pyrimidine antagonist (analogue) Leukemias (several varieties), NHL fludarabine (Fludara) (D) Purine antagonist (analogue) Various acute and chronic leukemias, NHL fluorouracil (Adrucil) (D) Pyrimidine antagonist (analogue) Colon, rectal, breast, esophageal, head and neck, cervical, and renal cancer gemcitabine (Gemzar) (D) Pyrimidine antagonist (analogue) Pancreatic, non-small-cell lung, and bladder cancer image methotrexate (Trexall, tablet form; otherwise generic) (X) Folate antagonist (analogue) Acute lymphocytic† leukemia; gestational choriocarcinoma; breast, head and neck, and many other cancers †The term lymphocytic is synonymous in the literature with the term lymphoblastic. NHL, Non-Hodgkin's lymphoma. Purine Antagonists The currently available purine antagonists are cladribine, fludarabine, mercaptopurine, pentostatin, and thioguanine. Mercaptopurine and thioguanine are administered orally, whereas the other three are available only in injectable form. These drugs are used largely in the treatment of leukemia and lymphoma. cladribine Cladribine (Leustatin) is indicated specifically for the treatment of a certain type of leukemia known as hairy cell leukemia, so named because of the appearance of its cancerous cells under the microscope. fludarabine Fludarabine (Fludara), like cladribine, also has a very specific single indication—in this case, chronic lymphocytic leukemia. It is also commonly used in the treatment of follicular lymphoma and as part of salvage therapy in acute myelogenous leukemia. Pyrimidine Antagonists The currently available pyrimidine antagonists are capecitabine, cytarabine, floxuridine, fluorouracil, and gemcitabine. These drugs are used more commonly than the purine antagonists. They are available only in parenteral formulations except 721for capecitabine, which is currently available only in tablet form. capecitabine Capecitabine (Xeloda) is indicated primarily for the treatment of metastatic breast cancer. image cytarabine Cytarabine (ara-C) (Cytosar) is used primarily for the treatment of leukemias (acute myelocytic and lymphocytic leukemia and meningeal leukemia) and non-Hodgkin's lymphomas. It is available only in injectable form and may be given IV, subcutaneously, or intrathecally. It is also now available in a special encapsulated liposomal form for intrathecal use only in treating meningeal leukemia. Cytarabine has a unique set of adverse reactions, called "cytarabine syndrome." Cytarabine syndrome is characterized by fever, muscle and bone pain, maculopapular rash, conjunctivitis, and malaise. It usually occurs 6 to 12 hours following cytarabine administration. The syndrome may be treated or prevented by the use of corticosteroids. fluorouracil Fluorouracil (5-FU) (Efudex, Adrucil) is used in a variety of treatment regimens, including the palliative treatment of cancers of the colon, rectum, stomach, breast, and pancreas. It also is used in the adjuvant setting in the treatment of breast and colorectal cancer. gemcitabine Gemcitabine (Gemzar) is an antineoplastic drug structurally related to cytarabine. Gemcitabine is believed to have antitumor activity superior to that of cytarabine. It is used as first-line therapy for locally advanced or metastatic cancer of the pancreas and for the treatment of non-small-cell lung cancer. Gemcitabine is increasingly used to treat other solid tumors, including breast cancer.

alkalyting drug profiles

Drug Profiles The most widely used alkylating drugs, based on standard treatment protocols, are profiled as follows: 737 image cisplatin Cisplatin (Platinol) is an antineoplastic drug that contains platinum in its chemical structure. It is classified as a probable alkylating drug because it is believed to destroy cancer cells in the same way as the classic alkylating drugs—by forming cross-links with DNA and thereby preventing its replication. It is also considered a bifunctional alkylating drug. Cisplatin is used for the treatment of many solid tumors, such as bladder, lung, testicular, and ovarian tumors. It is available only in injectable form. Medication errors, resulting in deaths, have occurred when cisplatin was confused for carboplatin. The best practice is to use both trade name and generic name when dealing with chemotherapy drugs. image cyclophosphamide Cyclophosphamide (Cytoxan) is a nitrogen mustard derivative that was discovered during the course of research to improve mechlorethamine. It is a polyfunctional alkylating drug and is a prodrug requiring in vivo activation. It is used in the treatment of cancers of the bone and lymph, as well as other solid tumors. Cyclophosphamide is also used in the treatment of leukemias and multiple myeloma, as well as for noncancer-related illnesses such as prophylaxis for rejection of kidney, heart, liver, and bone marrow transplants and severe rheumatoid disorders. It is available in both oral and injectable dosage forms. image mechlorethamine Mechlorethamine (nitrogen mustard) (Mustargen) is the prototypical alkylating drug. It is a nitrogen analogue of sulfur mustard (mustard gas) that was used for chemical warfare in World War I. Mechlorethamine was the first alkylating antineoplastic drug discovered. Although its use has declined with the development of newer and better drugs, it continues to be administered in the treatment of Hodgkin's and non-Hodgkin's lymphoma. Mechlorethamine is a bifunctional alkylating drug capable of forming cross-links between two DNA nucleotides, which interferes with RNA transcription and prevents cell division and protein synthesis. It is available in parenteral form only, for administration intravenously or by an intracavitary route, such as intrapleurally or intraperitoneally. It can also be used topically for treatment of cutaneous T-cell lymphoma.

topoisomerase I inhibitor drug profiles

Drug Profiles irinotecan Irinotecan (Camptosar) is often given with both fluorouracil and leucovorin. It is available only in injectable form. topotecan After initial therapy with other antineoplastics, cancer cells commonly become resistant to their effects. The use of topotecan (Hycamtin) to treat ovarian cancer and small-cell lung cancer has been studied extensively. As noted earlier, it produces therapeutic responses, even in cases in which powerful drugs such as cisplatin and paclitaxel have failed. Topotecan is available only in injectable form. Indications: Selected Topoisomerase I Inhibitors Drug (Pregnancy Category) Pharmacologic Class Indications irinotecan (Camptosar) (D) Synthetic camptothecin Metastatic colorectal cancer, small-cell lung cancer, cervical cancer topotecan (Hycamtin) (D) Semisynthetic camptothecin Ovarian and small-cell lung cancer

nursing process evaluation antineoplastics part 2

Evaluation Focus the evaluation of nursing care upon determining whether goals and outcomes have been met, as well as on monitoring for therapeutic responses and adverse and toxic effects of antineoplastic therapy. Therapeutic responses may manifest as clinical improvement, decrease in tumor size, and decrease in metastatic spread. Evaluation of nursing care with reference to goals and outcomes may reveal improvements related to a decrease in adverse effects; a decrease in the impact of cancer on the patient's well-being; an increase in comfort, nutrition, and hydration; improved energy levels and ability to carry out activities of daily living; and improved quality of life. The goals and outcomes may be revisited to identify more specific parameters to monitor. In addition, certain laboratory studies such as measurement of tumor markers; levels of carcinoembryonic antigens; and red blood cell, white blood cell, and platelet counts may also be used to determine how well the goals and outcomes have been met. As part of the evaluation, prescribers may also order additional x-rays, CT scans, MRIs, tissue analyses, and other studies appropriate to the diagnosis during and after antineoplastic therapy, at time intervals related to anticipated tumor response.

nursing process evaluation antineoplastic

Focus evaluation of nursing care on reviewing whether goals and outcomes are being met as well as monitoring for therapeutic responses and adverse and toxic effects of the antineoplastic therapy. Therapeutic responses may manifest as clinical improvement, decrease in tumor size, and decrease in metastatic spread. Evaluation of nursing care, with reference to goals and outcomes, may reveal improvements related to a decrease in adverse effects and a decrease in the impact of cancer on the patient's well-being. There will be increases in comfort, nutrition, hydration, energy levels, and ability to carry out activities of daily living, and improved quality of life with therapeutic effectiveness. Revisit goals and outcomes to identify more specific areas to monitor. In addition, certain laboratory studies including tumor marker levels such as carcinoembryonic antigens, RBC and WBC counts, and platelet counts may be performed to aid in determining how well the treatment protocol has worked and to monitor adverse effects of bone marrow suppression. Also, if absolute neutrophil count (ANC) drops below 500 cells/mm3, the prescriber may discontinue chemotherapy but then reinitiate when the level is above 1000 cells/mm3 or as institutional policy or prescriber dictates. Other blood counts are considered, too. As part of the evaluation, the prescriber may also order additional radiographs, computed tomographic scans, magnetic resonance images, tissue analyses, or other studies appropriate to the diagnosis both during and after antineoplastic therapy has been completed, at time intervals related to the anticipated tumor response.

vincristine right route is essential

For several years, the Institute for Safe Medication Practices has recommended changes in procedures to ensure that vincristine and other vinca alkaloids are not given intrathecally (via the spinal route) or by any other route. Administering these drugs through the spinal route is almost always fatal, and the death is slow and excruciating. Mistakes occur when the drug is drawn up in a syringe for intravenous administration and then is inadvertently given via the intrathecal route. These errors are preventable. Pharmacies should prepare vincristine in a diluted volume, such as in a 50-mL minibag of normal saline, to deter practitioners from giving the drug intrathecally. Drugs given intrathecally are not normally dispensed in a minibag. The nurse, who may be assisting the health care practitioner with intrathecal procedures, needs to be aware of the potential fatal error that may occur if vincristine is given via the wrong route.

nursing intervention antineoplastic part 3

If needed, and as ordered, administration of colony-stimulating factors may be beneficial. Filgrastim, pegfilgrastim, and sargramostim are examples of drugs given to accelerate WBC recovery during antineoplastic drug therapy. Use these drugs, as ordered, to minimize neutropenia. These medications act on the bone marrow to enhance neutrophil production and help decrease the incidence, severity, and duration of neutropenia. You must administer these drugs within a certain time frame (see Chapter 47). Encourage patients with immune suppression to be aware of their environments and persons to avoid, such as individuals who have recently been vaccinated (who may have a subclinical infection) or who have a cold or flu or other symptoms of an infection. Maintaining a "low-microbe" diet by washing fresh fruits and vegetables and making sure foods are well cooked is also recommended. Educate patients on the importance of performing oral care frequently (see discussion of stomatitis) and to turn, cough, and deep breathe to help prevent stasis of respiratory secretions. Thrombocytopenia is also an adverse effect of antineoplastic therapy and puts the patient at risk for bleeding. Monitor platelet counts, coagulation studies, RBC counts, hemoglobin levels, and hematocrit values, and report any decreases (see Safety: Laboratory Values Related to Drug Therapy on p. 726). Avoid injections if possible, and utilize alternative routes of administration. If injections or venipunctures are absolutely necessary, always use the smallest-gauge needle possible and apply gentle, prolonged pressure to the site afterward. Monitor patients undergoing bone marrow aspiration closely after the procedure for bleeding at the aspiration site. Perform blood pressure 730monitoring as needed. Be efficient and quick and without overinflating the cuff to avoid bruising. Monitor the patient for bleeding from the mouth, gums, and nose. Check for bleeding after toothbrushing, and report excessive bleeding to the prescriber. Inform the patient that antineoplastics may also have a negative impact on the reproductive tract, causing destruction of the germinal epithelium of the testes and damage to the ovaries and to a fetus (teratogenesis). Other problems may include sterility; amenorrhea; premature menopausal symptoms of hot flashes, decreased vaginal secretions, mood changes, or irritability; and decreased libido or sexual dysfunction. Counsel male patients about the risk for sterility, which may be irreversible. Discuss with male patients the option and topic of sperm banking before chemotherapy, if deemed appropriate. Stress that female patients of childbearing age who are sexually active need to protect themselves against pregnancy because of the risk for embryonic death. Encourage contraceptive measures during chemotherapy and for up to 8 weeks after discontinuation of therapy; however, some antineoplastic drugs require use of contraception for up to 2 years after completion of treatment because of the long-term risk for genetic abnormalities. With antimetabolites, always follow the prescriber's orders regarding premedication with antiemetics and/or antianxiety drugs. Follow orders or protocol for the use of other symptom-control medications, as prescribed. GI adverse effects are common with antimetabolites and usually occur on about the fourth day and require preplanning for special pharmacologic interventions (e.g., antiemetics, antispasmodics, analgesics) and nonpharmacologic measures (dietary changes, oral care). Antibiotic therapy may also be ordered prophylactically. See earlier discussion of nursing considerations associated with stomatitis, loss of appetite, diarrhea, nausea, nutrition, hydration, vomiting, and anemias. For further discussion on the handling of antimetabolites and other IV antineoplastic drugs, see Box 46-3. Use extreme caution in handling and administration of cytarabine by the various routes (IV, subcutaneous, or intrathecal). Other major concerns with cytarabine therapy are bone marrow suppression (see earlier discussion) and cytarabine syndrome (see the Assessment section). If high dosages are used, cytarabine may also cause central nervous system, GI, and/or pulmonary toxicity, so closely monitor these systems to ensure patient safety and comfort. For intrathecal administration, the drug may be reconstituted with sodium chloride, or the prescriber may use the patient's spinal fluid. Do not add fluorouracil to any other IV infusions; administer the drug by itself in the appropriate diluent. When an infusion port is not used, do not use IV sites over joints, tendons, or small veins, or in extremities that are edematous. Give IV dosages exactly as ordered, and constantly monitor the IV site, infusion port, and/or infusion solution and equipment. If IV infiltration occurs, follow the protocol for management of infiltration and contact the prescriber. Follow all hospital or infusion protocols without exception because treatment of extravasation is handled differently depending on the specific drug. If extravasation of a vesicant occurs, the drug is usually discontinued immediately; leave the IV cannula in place (for possible use of antidotes through cannula to access affected area), and follow institutional protocol. Antidotes and use of other drugs, as well as use of hot or cold packs, is usually outlined in the protocol for managing extravasation (see Box 46-1). If topical forms of the drug are used, inform the patient that it is important to apply the drug exactly as ordered and to the affected area only. Use gloves or a finger cot to apply the topical dosage form. Gemcitabine, another antimetabolite, is dosed based on absolute granulocyte counts and platelet nadirs and is given if the counts exceed 1500 × 106 cells/L and 100,000 × 106 platelets/L, respectively. Keep IV solutions at room temperature to avoid crystallization, and use within 24 hours. Give infusions as ordered. Antiemetics and antidiarrheals may be needed. Mercaptopurine comes in oral dosage forms; give as ordered. Finally, the antimetabolite methotrexate has numerous toxicities and adverse effects that may be minimized by appropriate medical treatment. For example, there may be orders for boosting the immune status and blood cell counts before aggressive therapy is initiated. Cytoprotective drugs are used. Continue to monitor creatinine clearance, as ordered, to detect any nephrotoxicity. Nutritional status may be enhanced by the intake of foods high in folic acid, including bran, dried beans, nuts, fruits, asparagus, and other fresh vegetables, if tolerated. Consumption of these foods is yet another measure to help minimize the possibility of methotrexate toxicity. If GI upset and/or stomatitis occur, the patient may need to decrease any sources of irritation (e.g., high-fiber food). Methotrexate is usually given orally or IV. Wear gloves when giving the drug. If any of the solution comes in contact with the skin, wash the area immediately and thoroughly with soap and water. (See Box 46-3 for discussion of concerns in the handling and administration of vesicant drugs.) For the mitotic inhibitors, specifically the taxane family of drugs and docetaxel in particular, premedication protocols are usually specified and include administration of oral corticosteroids (e.g., dexamethasone) beginning several days before day 1 of therapy to help decrease the risk for hypersensitivity. Measure vital signs frequently during the infusion, especially in the first hour of the infusion. Closely monitor the patient for the sudden onset of bronchospasm, flushing of the face, and localized skin reactions; these may indicate a hypersensitivity response requiring immediate treatment. Contact the prescriber immediately. These symptoms may occur within just a few minutes of beginning the infusion. In addition, any dyspnea, abdominal distension, crackles in the lungs, or dependent edema during therapy require immediate attention. Cutaneous reactions may also appear during therapy and include rash on the hands and feet; these also need immediate attention and treatment. With paclitaxel, the patient may also be premedicated with diphenhydramine, corticosteroids, and H2 antagonist drugs. Take all measures to minimize tissue trauma (e.g., avoidance of intramuscular injections and rectal temperature taking, if possible) to promote comfort and prevent bleeding and infection. With the topoisomerase I inhibitors, irinotecan and topotecan, monitor blood counts closely with every treatment. A drop in blood counts and/or severe diarrhea may cause a temporary postponement of therapy. Treat any extravasation of the 731solution immediately, and follow protocol. Ensuring that IV sites remain patent is critical to the prevention of tissue damage secondary to extravasation of antineoplastic drugs that are considered to be irritants and/or vesicants. Nausea and vomiting may lead to dehydration and electrolyte disturbances. Advise patients and family members to report these symptoms immediately before negative consequences occur (see previous discussion for specific interventions). IV incompatibilities are numerous for both drugs and are of constant concern. With topotecan, IV extravasation is usually accompanied by a mild local reaction such as erythema or bruising. If these symptoms are noted, they must be managed immediately to avoid further trauma and/or risk for loss of skin integrity (the first line of defense against infection). Headaches and difficulty breathing may be more common with topotecan; therefore, closely and frequently monitor the patient for these symptoms. Handle the enzyme antineoplastics asparaginase and pegaspargase with extreme caution and care. The patient may receive an intradermal test dose of asparaginase before therapy begins or when 1 week or longer has passed between doses. With asparaginase and pegaspargase, if the solution comes in contact with the skin, thoroughly wash or rinse the area with copious amounts of water for a minimum of 15 minutes. During therapy, if there are signs and symptoms of oliguria, anuria (renal failure), or pancreatitis, the drug will most likely be discontinued. The intramuscular route of administration is usually preferred because it carries a lower risk for causing clotting abnormalities, GI disorders, and renal and hepatic toxicity. If solutions are cloudy, do not use them. If more than 2 mL is ordered/required for an intramuscular dosing, use two injections. Pancreatitis is problematic with these drugs and can be serious. Pay close attention to symptoms such as severe abdominal pain with nausea and vomiting. Constantly monitor serum lipase and amylase levels. If any signs or symptoms of pancreatitis occur, the prescriber will usually discontinue the drugs immediately. Use of cytoprotective drugs is briefly discussed in the Pharmacology section earlier in the chapter, with further discussion provided in Chapter 46.

nursing process implementation antineoplastic

Implementation Antineoplastic drugs are some of the most toxic medications given to patients because they cause the death of normal cells along with the death of cancer cells. The high potency of these drugs also places the patient at higher risk for toxicity, serious complications, and adverse effects. The possibility of such adverse effects and toxicities requires skillful nursing care based on cautious and thorough assessment and subsequent critical thinking. General considerations in nursing implementation applicable to most antineoplastic drugs as well as some specific aspects of implementation related to cell cycle-specific drugs are presented in the following paragraphs. In the following paragraphs, the specific adverse effect(s) associated with cell cycle-specific drugs will be discussed and are italicized. Other nursing process information related to cell cycle-nonspecific drugs is presented in Chapter 46. For antineoplastic therapy in general, nursing considerations related to reducing fear and anxiety include establishing a therapeutic relationship beginning with trust and empathy. Approach the patient in a warm, empathic, and supportive manner while projecting confidence in providing nursing care. Provide individualized explanations and teaching about the patient's illness, care, and treatments that are appropriate to the patient's educational level. Collaborate with all members of the health care team. Encourage patients to consider relaxation techniques such as listening to music, performing meditation, or engaging in guided imagery. It may be necessary to call on all potential sources of support, including social services, counseling services, financial assistance services, Meals On Wheels, and religious-spiritual or belief systems with respect to the patient's needs. Appropriate consults may also be necessary with other practitioners such as a licensed clinical social worker, discharge planner, clinical psychiatrist, mental health nurse, nurse practitioner, and oncology nurse specialist, as well as with support groups for the patient, family, and/or significant others. A variety of interventions that may be indicated for the management of stomatitis or excessive oral mucosa dryness and irritation include the following: (1) Instruct the patient to perform oral hygiene before and after eating or as needed to provide cleanliness and comfort. Advise the patient to avoid lemon, glycerin, undiluted peroxide, or alcohol-containing products because they are drying and irritating to the oral mucosa. (2) Recommend use of a soft-bristle toothbrush or soft-tipped toothette or swab with solutions of diluted warm saline. (3) If dentures are worn, encourage the patient to remove and clean them frequently and, if stomatitis is severe, to insert only at mealtimes. (4) Advise using OTC saliva substitutes, keeping the lips moist, and using sugarless candy or gum to stimulate saliva flow. (5) Stress that spicy, acidic, or hot foods; alcohol; and tobacco must be avoided because they are irritants. (6) Oral antifungal suspensions (e.g., nystatin) may be ordered if white patches are noted on the oral mucosa; use analgesic solutions (e.g., lidocaine swish and swallow), as ordered, to help manage discomfort. Other regimens may be prescribed, as needed. Nausea and vomiting occur commonly with antineoplastic drugs. Emetic potential varies depending on the drug and treatment protocol (see earlier discussion and Box 45-1). Educate the patient on measures to enhance comfort during times of nausea and vomiting, including restricting oral intake as ordered; removing noxious odors or sights to avoid stimulating the vomiting center; performing oral hygiene as needed; promoting relaxation through slow, deep breathing; consuming small, frequent meals and eating slowly; and consuming clear liquids and a bland diet. Use of IV fluids may be indicated for hydration purposes if nausea and vomiting are severe. Antiemetics are also a vital part of antineoplastic therapy (see Chapter 52 for more specific drug-related information). Premedication with antiemetics 30 to 60 minutes before administration of the antineoplastic(s) is the preferred treatment protocol to help reduce nausea and vomiting, prevent dehydration and malnutrition, and promote comfort. Combination 729antiemetic drug therapy may be more effective than single-drug therapy. An antiemetic may be given with the chemotherapeutic regimen and prescription medication for at-home use. Ginger ale and ginger-based teas may be helpful. While its exact anti-nausea mechanism is unknown, it is thought that there are chemicals in ginger that influence the nervous system, stomach, and intestines to reduce nausea. Diarrhea is also a common adverse effect of antineoplastic therapy. Perform the following nursing interventions: (1) Advise the patient to avoid or limit oral intake of irritating, spicy, and gas-producing foods; caffeine; high-fiber foods; alcohol; very hot or cold foods or beverages; and lactose-containing foods and beverages. (2) Consult appropriate personnel, as ordered, to help the patient and family plan meals and arrange ways to meet the patient's dietary and bowel elimination needs. (3) Administer opioids (e.g., paregoric) or synthetic opioids (e.g., loperamide, diphenoxylate hydrochloride) as prescribed, for their antidiarrheal properties. Adsorbents-protectants and antisecretory drugs may also help reduce GI upset and diarrhea (see Chapter 51). To address nutritional concerns, the following measures may prove beneficial in improving oral intake and nutritional status: (1) Perform a 24-hour recall of food intake, and report the typical week's diet for the patient. (2) Use antiemetic therapy, pain management, mouth care, and hydration, as ordered, to reduce the adverse effects of therapy and improve appetite. (3) To ease taste alterations, advise the patient to consume mild-tasting foods and to use chicken, turkey, cheese, or Greek yogurt for protein sources as tolerated. (4) Provide plastic rather than metal utensils if the patient complains of a metallic taste. (5) Encourage eating foods that are easy to swallow, such as custards; gelatins; puddings; milkshakes; eggnog; commercially prepared high-protein, high-calorie supplemental shakes; mashed white or sweet potatoes; blended drinks with crushed ice, fruit, and yogurt; nutritional supplement drinks and snacks; frozen popsicles; and lactose-free ice cream. (6) Instruct the patient to avoid sticky or dry foods. (7) Encourage the consumption of small, frequent meals in an environment that is conducive to eating (e.g., free of odors and excess noise). (8) Appetite stimulants such as megestrol acetate or dronabinol may be helpful. (9) Encourage the patient to practice energy conservation, with frequent rest periods before and after meals. Alopecia is a common adverse effect of antineoplastics and is very disturbing regardless of age or gender. Warn the patient and family about the possibility of hair loss, and tell them when it will occur (usually 7 to 10 days after treatment begins but dependent upon the specific drug used) and that it is reversible. Inform the patient that new hair growth is often a different color and/or texture from the hair lost. Provide information about the options of acquiring a wig or hairpiece, or wearing scarves or hats, before the actual hair loss. The American Cancer Society may be a resource for items such as wigs, scarves, and hats. Antineoplastic-induced bone marrow suppression leads to anemias, leukopenia, neutropenia, and thrombocytopenia (see previous discussion and Safety: Laboratory Values Related to Drug Therapy on pp. 726 and 727 in this chapter and Chapter 46). Anemias result in fatigue and loss of energy and are common adverse effects of therapy and the disease process. Anemias may require blood transfusions, peripheral blood stem cell treatment, or treatment with prescribed medications such as iron preparations, folic acid, or erythropoietic growth factors (e.g., epoetin or darbepoetin alfa). These injections may be given at home and may be administered at the first sign of a decrease in RBC counts. Conservation of energy and planning of care is very important in minimizing patient fatigue. Risk for infection from leukopenia or neutropenia and/or immunosuppression is one of the more significant adverse effects that requires close attention. Inform the patient and family and/or caregivers that when WBC counts are low, the patient is at high risk for infection and that defenses remain low until the counts recover. Following Standard Precautions and using good handwashing technique are most important in preventing transmission of infection in the hospital and home settings. Because fever is a principal early sign of infection, take oral or axillary temperature at least every 4 hours during periods in which the patient is at risk. Avoid taking the temperature rectally to minimize tissue trauma, breaks in skin integrity, and thus loss of the first line of defense and increased risk for infection. Encourage the patient to immediately report to the prescriber a temperature elevation of 100.5° F (38.1° C) or higher so that appropriate treatment may be initiated and complications avoided. If needed, and as ordered, administration of colony-stimulating factors may be beneficial. Filgrastim, pegfilgrastim, and sargramostim are examples of drugs given to accelerate WBC recovery during antineoplastic drug therapy. Use these drugs, as ordered, to minimize neutropenia. These medications act on the bone marrow to enhance neutrophil production and help decrease the incidence, severity, and duration of neutropenia. You must administer these drugs within a certain time frame (see Chapter 47). Encourage patients with immune suppression to be aware of their environments and persons to avoid, such as individuals who have recently been vaccinated (who may have a subclinical infection) or who have a cold or flu or other symptoms of an infection. Maintaining a "low-microbe" diet by washing fresh fruits and vegetables and making sure foods are well cooked is also recommended. Educate patients on the importance of performing oral care frequently (see discussion of stomatitis) and to turn, cough, and deep breathe to help prevent stasis of respiratory secretions. Thrombocytopenia is also an adverse effect of antineoplastic therapy and puts the patient at risk for bleeding. Monitor platelet counts, coagulation studies, RBC counts, hemoglobin levels, and hematocrit values, and report any decreases (see Safety: Laboratory Values Related to Drug Therapy on p. 726). Avoid injections if possible, and utilize alternative routes of administration. If injections or venipunctures are absolutely necessary, always use the smallest-gauge needle possible and apply gentle, prolonged pressure to the site afterward. Monitor patients undergoing bone marrow aspiration closely after the procedure for bleeding at the aspiration site. Perform blood pressure 730monitoring as needed. Be efficient and quick and without overinflating the cuff to avoid bruising. Monitor the patient for bleeding from the mouth, gums, and nose. Check for bleeding after toothbrushing, and report excessive bleeding to the prescriber. Inform the patient that antineoplastics may also have a negative impact on the reproductive tract, causing destruction of the germinal epithelium of the testes and damage to the ovaries and to a fetus (teratogenesis). Other problems may include sterility; amenorrhea; premature menopausal symptoms of hot flashes, decreased vaginal secretions, mood changes, or irritability; and decreased libido or sexual dysfunction. Counsel male patients about the risk for sterility, which may be irreversible. Discuss with male patients the option and topic of sperm banking before chemotherapy, if deemed appropriate. Stress that female patients of childbearing age who are sexually active need to protect themselves against pregnancy because of the risk for embryonic death. Encourage contraceptive measures during chemotherapy and for up to 8 weeks after discontinuation of therapy; however, some antineoplastic drugs require use of contraception for up to 2 years after completion of treatment because of the long-term risk for genetic abnormalities. With antimetabolites, always follow the prescriber's orders regarding premedication with antiemetics and/or antianxiety drugs. Follow orders or protocol for the use of other symptom-control medications, as prescribed. GI adverse effects are common with antimetabolites and usually occur on about the fourth day and require preplanning for special pharmacologic interventions (e.g., antiemetics, antispasmodics, analgesics) and nonpharmacologic measures (dietary changes, oral care). Antibiotic therapy may also be ordered prophylactically. See earlier discussion of nursing considerations associated with stomatitis, loss of appetite, diarrhea, nausea, nutrition, hydration, vomiting, and anemias. For further discussion on the handling of antimetabolites and other IV antineoplastic drugs, see Box 46-3. Use extreme caution in handling and administration of cytarabine by the various routes (IV, subcutaneous, or intrathecal). Other major concerns with cytarabine therapy are bone marrow suppression (see earlier discussion) and cytarabine syndrome (see the Assessment section). If high dosages are used, cytarabine may also cause central nervous system, GI, and/or pulmonary toxicity, so closely monitor these systems to ensure patient safety and comfort. For intrathecal administration, the drug may be reconstituted with sodium chloride, or the prescriber may use the patient's spinal fluid. Do not add fluorouracil to any other IV infusions; administer the drug by itself in the appropriate diluent. When an infusion port is not used, do not use IV sites over joints, tendons, or small veins, or in extremities that are edematous. Give IV dosages exactly as ordered, and constantly monitor the IV site, infusion port, and/or infusion solution and equipment. If IV infiltration occurs, follow the protocol for management of infiltration and contact the prescriber. Follow all hospital or infusion protocols without exception because treatment of extravasation is handled differently depending on the specific drug. If extravasation of a vesicant occurs, the drug is usually discontinued immediately; leave the IV cannula in place (for possible use of antidotes through cannula to access affected area), and follow institutional protocol. Antidotes and use of other drugs, as well as use of hot or cold packs, is usually outlined in the protocol for managing extravasation (see Box 46-1). If topical forms of the drug are used, inform the patient that it is important to apply the drug exactly as ordered and to the affected area only. Use gloves or a finger cot to apply the topical dosage form. Gemcitabine, another antimetabolite, is dosed based on absolute granulocyte counts and platelet nadirs and is given if the counts exceed 1500 × 106 cells/L and 100,000 × 106 platelets/L, respectively. Keep IV solutions at room temperature to avoid crystallization, and use within 24 hours. Give infusions as ordered. Antiemetics and antidiarrheals may be needed. Mercaptopurine comes in oral dosage forms; give as ordered. Finally, the antimetabolite methotrexate has numerous toxicities and adverse effects that may be minimized by appropriate medical treatment. For example, there may be orders for boosting the immune status and blood cell counts before aggressive therapy is initiated. Cytoprotective drugs are used. Continue to monitor creatinine clearance, as ordered, to detect any nephrotoxicity. Nutritional status may be enhanced by the intake of foods high in folic acid, including bran, dried beans, nuts, fruits, asparagus, and other fresh vegetables, if tolerated. Consumption of these foods is yet another measure to help minimize the possibility of methotrexate toxicity. If GI upset and/or stomatitis occur, the patient may need to decrease any sources of irritation (e.g., high-fiber food). Methotrexate is usually given orally or IV. Wear gloves when giving the drug. If any of the solution comes in contact with the skin, wash the area immediately and thoroughly with soap and water. (See Box 46-3 for discussion of concerns in the handling and administration of vesicant drugs.) For the mitotic inhibitors, specifically the taxane family of drugs and docetaxel in particular, premedication protocols are usually specified and include administration of oral corticosteroids (e.g., dexamethasone) beginning several days before day 1 of therapy to help decrease the risk for hypersensitivity. Measure vital signs frequently during the infusion, especially in the first hour of the infusion. Closely monitor the patient for the sudden onset of bronchospasm, flushing of the face, and localized skin reactions; these may indicate a hypersensitivity response requiring immediate treatment. Contact the prescriber immediately. These symptoms may occur within just a few minutes of beginning the infusion. In addition, any dyspnea, abdominal distension, crackles in the lungs, or dependent edema during therapy require immediate attention. Cutaneous reactions may also appear during therapy and include rash on the hands and feet; these also need immediate attention and treatment. With paclitaxel, the patient may also be premedicated with diphenhydramine, corticosteroids, and H2 antagonist drugs. Take all measures to minimize tissue trauma (e.g., avoidance of intramuscular injections and rectal temperature taking, if possible) to promote comfort and prevent bleeding and infection. With the topoisomerase I inhibitors, irinotecan and topotecan, monitor blood counts closely with every treatment. A drop in blood counts and/or severe diarrhea may cause a temporary postponement of therapy. Treat any extravasation of the 731solution immediately, and follow protocol. Ensuring that IV sites remain patent is critical to the prevention of tissue damage secondary to extravasation of antineoplastic drugs that are considered to be irritants and/or vesicants. Nausea and vomiting may lead to dehydration and electrolyte disturbances. Advise patients and family members to report these symptoms immediately before negative consequences occur (see previous discussion for specific interventions). IV incompatibilities are numerous for both drugs and are of constant concern. With topotecan, IV extravasation is usually accompanied by a mild local reaction such as erythema or bruising. If these symptoms are noted, they must be managed immediately to avoid further trauma and/or risk for loss of skin integrity (the first line of defense against infection). Headaches and difficulty breathing may be more common with topotecan; therefore, closely and frequently monitor the patient for these symptoms. Handle the enzyme antineoplastics asparaginase and pegaspargase with extreme caution and care. The patient may receive an intradermal test dose of asparaginase before therapy begins or when 1 week or longer has passed between doses. With asparaginase and pegaspargase, if the solution comes in contact with the skin, thoroughly wash or rinse the area with copious amounts of water for a minimum of 15 minutes. During therapy, if there are signs and symptoms of oliguria, anuria (renal failure), or pancreatitis, the drug will most likely be discontinued. The intramuscular route of administration is usually preferred because it carries a lower risk for causing clotting abnormalities, GI disorders, and renal and hepatic toxicity. If solutions are cloudy, do not use them. If more than 2 mL is ordered/required for an intramuscular dosing, use two injections. Pancreatitis is problematic with these drugs and can be serious. Pay close attention to symptoms such as severe abdominal pain with nausea and vomiting. Constantly monitor serum lipase and amylase levels. If any signs or symptoms of pancreatitis occur, the prescriber will usually discontinue the drugs immediately. Use of cytoprotective drugs is briefly discussed in the Pharmacology section earlier in the chapter, with further discussion provided in Chapter 46.

cytotoxic drug indications

Indications Cytotoxic antibiotics are used to treat a variety of solid tumors and some hematologic malignancies as well. Commonly used examples of these drugs and the malignancies they are used to treat are presented in Table 46-4.

cytotoxic drug interactions

Interactions The cytotoxic antibiotics that are used in chemotherapy interact with many drugs. They all tend to produce increased toxicities when used in combination with other chemotherapeutic drugs or with radiation therapy. Some drugs, most notably bleomycin and doxorubicin, have been known to cause serum digoxin levels to increase. Observe patients receiving one of these drugs along with digoxin for signs of digoxin toxicity. Dosage reduction or elimination of digoxin therapy may be indicated (see Chapter 24).

cytotoxic drugs moa and drug effect

Mechanism of Action and Drug Effects Cytotoxic antibiotic antineoplastic drugs are cell-cycle-nonspecific drugs. They interact with DNA through a process called intercalation, in which the drug molecule is inserted between the two strands of a DNA molecule, ultimately blocking DNA synthesis. These drugs inhibit the enzyme topoisomerase II, which leads to DNA strand breaks. Many of these drugs are able to generate free radicals, which also leads to DNA strand breaks and programmed cell death.

cancer overview part 2

Metastasis refers to the spreading of a cancer from the original site of growth (primary lesion) to a new and remote part of the body (secondary or metastatic lesion). The terms malignancy, neoplasm, and tumor are often used as synonyms for cancer. A neoplasm ("new tissue") is a mass of new cells. It is another term for tumor. There are two types of tumors: benign and malignant. A benign tumor is of a uniform size and shape and displays no invasiveness (in terms of infiltrating other tissues) or metastatic properties. The terms nonmalignant and benign suggest that tumors may be harmless, which is true in most cases. However, a benign tumor can be lethal if it grows large enough to mechanically interrupt the normal function of a critical tissue or organ. Malignant neoplasms consist of cancer cells that invade (infiltrate) surrounding tissues and metastasize to other tissues and organs. Some of the various characteristics of benign and malignant neoplasms are listed in Table 45-1.

miscellaneous antineoplastics

Miscellaneous Antineoplastics The miscellaneous antineoplastic drugs are those that, because of their unique structure and mechanism of action, cannot be 739classified into the previously described categories. However, some drugs that are originally classified as miscellaneous drugs are later reclassified as more is learned about their mechanisms of action and other characteristics. Drugs currently in the miscellaneous category include bevacizumab, everolimus, hydroxyurea (which is actually cell-cycle-specific), ipilimumab, imatinib, mitotane, ofatumumab, pazopanib, romidepsin, sorafenib, sunitinib, hormonal drugs, and radioactive and related antineoplastic drugs. Selected miscellaneous drugs are profiled in the following sections. Drug Profiles The various drugs in the miscellaneous category of antineoplastics are used to treat a wide range of neoplasms. Hydroxyurea and imatinib are administered orally. Bevacizumab and mitotane are available only in injectable form. Sipuleucel-T (Provenge) is a new form of treatment for prostate cancer. It is not a chemotherapeutic agent; rather, it is an autologous cellular immunotherapy for the treatment of asymptomatic or minimally symptomatic metastatic hormone-resistant prostate cancer. It uses the patient's own monocytes that are activated and then reinfused into the patient. Infusion-related reactions are common, and patients are to be pretreated with acetaminophen and diphenhydramine. It is restricted to physicians who have undergone extensive training. Certinib (Zykadia) is a new tyrosine kinase inhibitor indicated for ALK-positive lung cancer that is unresponsive to other therapies. It was approved under accelerated approval by the FDA and is considered "breakthrough" therapy. It is administered orally, on an empty stomach, at least 2 hours before or 2 hours after a meal. Serious side effects include bradycardia, severe diarrhea, and nausea and vomiting, and often require dose reduction. Hepatotoxicity, hyperglycemia, QTc prolongation, and life-threatening interstitial lung disease or pneumonitis can also occur. Drug interactions include conivaptan, grapefruit juice, strong CYP3A4 inhibitors, and inducers and drugs that can prolong the QTc interval. bevacizumab Bevacizumab (Avastin) was the first antineoplastic drug in a new category—angiogenesis inhibitors. Angiogenesis is the creation of new blood vessels that supply oxygen and other blood nutrients to growing tissues. In the case of malignant tumors, angiogenesis that occurs within the tumor mass promotes continued tumor growth. Inhibiting this process offers a promising new mechanism for antineoplastic drug action. Bevacizumab is a recombinant "humanized" monoclonal immunoglobulin G1 antibody derived from mouse antibodies. The scientific name for any compound derived from mouse tissue is murine. Humanization refers to the use of recombinant DNA techniques to make animal-derived antibody proteins more genetically similar to those of humans. It works by binding to and inhibiting the biologic activity of human vascular endothelial growth factor (VEGF). VEGF is an endogenous protein that normally promotes angiogenesis in the body. Bevacizumab is available only in injectable form. The only recognized contraindication is severe drug allergy or allergy to other murine products. It is approved for the treatment of metastatic colon cancer, rectal cancer in combination with 5-fluorouracil (see Chapter 45), non-small-cell lung cancer, and malignant glioblastoma. Bevacizumab was approved for treatment of breast cancer; however, the FDA revoked the breast cancer indication in 2011. Adverse reactions include those affecting the cardiovascular system (hypertension or hypotension, deep vein thrombosis), central nervous system (pain, headache, dizziness, asthenia), skin (alopecia, dry skin), metabolism (weight loss, hypokalemia), gastrointestinal (GI) tract (nausea, vomiting, diarrhea, epistaxis, abdominal pain, constipation, GI hemorrhage), kidneys (nephrotoxicity with proteinuria), hematopoietic system (leukopenia), and respiratory tract (infection). More severe effects can occur in any of these systems but are much less common than those listed. Drug interactions reported to date are limited but include potentiation of the cardiotoxic effects of the anthracycline antibiotics such as doxorubicin. hydroxyurea Hydroxyurea (Hydrea, Droxia) is an antimetabolite that interferes with the synthesis of DNA by inhibiting the incorporation of thymidine into DNA. More specifically, it inhibits ribonucleotide reductase, which is involved in conversion of ribonucleotides to deoxyribonucleotides. It works primarily in the S and G1 phases of the cell cycle, which makes it a cell-cycle-specific drug. It is discussed in this chapter because it is included as a miscellaneous drug. Hydroxyurea is used in the treatment of squamous cell carcinoma in concert with radiation to take advantage of its radiosensitizing activity. It is also used in the treatment of various types of leukemia. The drug is available only in oral form. Adverse reactions include edema, drowsiness, headache, rash, hyperuricemia, nausea, vomiting, dysuria, myelosuppression, elevated liver enzyme levels, muscular weakness, peripheral neuropathy, nephrotoxicity, dyspnea, and pulmonary fibrosis. Hydroxyurea interacts with the anti-HIV drugs zidovudine, zalcitabine, and didanosine (see Chapter 40), all of which can have a synergistic effect with hydroxyurea. Concurrent use with fluorouracil increases the risk for neurotoxic symptoms. Because hydroxyurea can reduce the clearance of cytarabine, dosage reduction of cytarabine is recommended when the two are used concurrently. 740 imatinib Imatinib (Gleevec) is the standard of care for the treatment of chronic myeloid leukemia (CML). It works by inhibiting the action of a key enzyme (bcr-abl tyrosine kinase) responsible for causing CML. Although its name sounds similar to those of various monoclonal antibody drugs, imatinib is not a monoclonal antibody but rather a targeted therapy. It is available only in oral form. Common adverse reactions include fatigue, headache, rash, fluid retention, GI and hematologic effects, musculoskeletal pain, cough, and dyspnea. Potential drug interactions are numerous and involve other drugs metabolized by the cytochrome P-450 hepatic enzymes. Examples include amiodarone, verapamil, warfarin, azole antifungals, antidepressants, and antibiotics. A pharmacist may be needed to review the patient's medication regimen and adjust dosages or delete medications accordingly, in collaboration with the patient's prescriber. mitotane Mitotane (Lysodren) is an adrenal cytotoxic drug that is indicated specifically for the treatment of inoperable adrenal corticoid carcinoma. It is available only in oral form. Adverse reactions include CNS depression, rash, nausea, vomiting, muscle weakness, and headache. Reported drug interactions include enhanced CNS depressive effects when taken concurrently with other CNS depressants (e.g., benzodiazepines). Mitotane may also increase the clearance of both warfarin and phenytoin, reducing their effects. The potassium-sparing diuretic spironolactone may negate the effects of mitotane. octreotide Octreotide (Sandostatin) (see Chapter 30) is a unique medication used for the management of a cancer-related condition called carcinoid crisis and treatment of the diarrhea caused by vasoactive intestinal peptide-secreting tumors (VIPomas).

mitotic inhibiotors

Mitotic Inhibitors Mitotic inhibitors include natural products obtained from the periwinkle plant and semisynthetic drugs obtained from the mandrake plant (also known as the "may apple"). The periwinkle plant contains antineoplastic alkaloids. These vinca alkaloids include vinblastine, vincristine, and vinorelbine. Two newer plant-derived drugs are the taxanes. These include paclitaxel, once derived from the bark of the slow-growing Western (Pacific) yew tree, and docetaxel, a semisynthetic taxane produced from the needles of the European yew tree. The current process of isolating the starting material for paclitaxel from the needles has made the drug supply more abundant. Docetaxel is pharmacologically similar to paclitaxel. The newest taxanes are cabazitaxel (Jevtana), which is indicated for prostate cancer, and eribulin (Halaven), which is indicated for breast cancer. Mechanism of Action and Drug Effects Depending on the particular drug, these plant-derived compounds can work in various phases of the cell cycle (late S phase, throughout G2 phase, and M phase), but they all work shortly before or during mitosis and thus retard cell division. Each different subclass inhibits mitosis in a unique way. The vinca alkaloids (vincristine, vinblastine, and vinorelbine) bind to the protein tubulin during the metaphase of mitosis (M phase). This prevents the assembly of key structures called microtubules. This, in turn, results in the dissolution of other important structures known as mitotic spindles. Without these mitotic spindles, cells cannot reproduce properly. This results in inhibition of cell division and cell death. The taxanes (paclitaxel, docetaxel, and cabazitaxel) act in the late G2 phase and M phase of the cell cycle. They work by causing the formation of nonfunctional microtubules, which halts mitosis during metaphase. Indications Mitotic inhibitors are used to treat a variety of solid tumors and some hematologic malignancies. They are often used in combination chemotherapy regimens to enhance the overall cytotoxic effect. Selected drugs and some of their specific therapeutic uses are listed in the Indications table on the next page. Adverse Effects Like many of the antineoplastic drugs, mitotic inhibitor antineoplastic drugs can cause hair loss, nausea and vomiting, and myelosuppression (see Table 45-6). The emetic potential of some of these drugs is given in Box 45-1. Toxicity and Management of Extravasation Most of the mitotic inhibitor antineoplastics are administered IV, and extravasation of these drugs is potentially serious. Specific antidotes and additional measures to be taken for the treatment of extravasation of the mitotic inhibitors are given in Table 45-8. Interactions A variety of drug interactions are possible with most antineoplastic drugs, some more significant than others. A few basic principles apply to all antineoplastic drug classes. Any drug that 722reduces the clearance of an anticancer drug also increases the risk for toxicity, whereas a drug that increases the elimination of an anticancer drug reduces its efficacy. The use of multiple antineoplastic drugs can cause severe neutropenia and infection, due to additive bone marrow suppression. Monitor and treat patients accordingly for hematologic toxicity and infections. Observed drug interactions specific for mitotic inhibitors are summarized in Table 45-9.

cancer drug therapy part 2

Myelosuppression, also known as bone marrow suppression or bone marrow depression, is another unwanted adverse effect of certain antineoplastics. It commonly results from drug- or radiation-induced destruction of rapidly dividing cells in the bone marrow, primarily the cellular precursors of WBCs, red blood cells (RBCs), and platelets. This can also occur due to the disease processes of the cancer itself. Myelosuppression, in turn, leads to leukopenia, anemia, and thrombocytopenia. The cancer patient is often at greater risk for infection because of leukopenia (reduced WBC count) secondary to chemotherapy. Patients often need antibiotics intravenously (IV), either to prevent or to treat bacterial infections. Such patients are referred to as being neutropenic. Drug-induced anemia (reduced RBC count) often leads to hypoxia and fatigue, whereas thrombocytopenia (reduced platelet count) makes the patient more susceptible to bleeding. The lowest level of WBCs in the blood following chemotherapy (or radiation) treatment is called the nadir. The time until the nadir is reached in a given patient may become shorter and the recovery time for the bone marrow may become longer with multiple courses of antineoplastic treatment. The nadir normally occurs roughly 10 to 28 days after dosing, depending on the particular drug or combination of drugs that is used. Anticipation of this nadir based on known cancer drug data can be used to guide the timing of prophylactic (preventive) administration of antibiotics and blood stimulants known as hematopoietic growth factors (see Chapter 47). Extravasation—unintended leakage of a chemotherapy drug (with vesicant potential) into the surrounding tissues outside of the IV line is a serious complication with chemotherapy. Specific treatment of extravasations vary depending on the drug and are listed in various tables and boxes throughout this chapter and Chapter 46 (Tables 45-8 and 46-2 and Boxes 46-1 and 46-2). Because of the often severe toxicity of cancer medications, a current major focus of cancer drug research is the development of targeted drug therapy. Targeted drug therapy utilizes drugs that recognize a specific molecule involved in the growth of cancer cells, while mostly sparing healthy cells. One example of such targeted therapy is the newer class of cancer drugs known as monoclonal antibodies (see Chapter 47). There has been a recent expansion of targeted drug therapy. Tyrosine kinase inhibitors are drugs that impede the development of new blood vessels, tumor growth, and cancer progression. Lenvatinib (Lenvina) and sorafenib (Nexavar) are approved for thyroid cancer. Palbociclib (Ibrance) is approved for used in breast cancer. Ceritinib (Zykadia) is approved for non-small cell lung cancer. All of the tyrosine kinase inhibitors are given orally. Because this is an rapidly expanding category, the reader is referred to www.cancer.gov/cancertopics/treatment/types/targeted-therapies/targeted-therapies-fact-sheet for the latest developments in targeted therapy. Pharmacokinetic data for antineoplastic medications is seldom used to guide dosing. Only a few anticancer drugs benefit from therapeutic drug monitoring. For these reasons, pharmacokinetic data are not included with the drug profiles in this chapter. In spite of their notorious toxicity, given the often fatal outcome of neoplastic diseases, most cancer drugs are rarely considered to be absolutely contraindicated. Even if a patient has a known allergic reaction to an antineoplastic medication, the urgency of treating the patient's cancer necessitates administering the medication and treating any allergic symptoms with premedications such as antihistamines, corticosteroids, and acetaminophen. For these reasons, no specific contraindications are listed for any of the drugs in this chapter. Common relative contraindications for cancer drugs include very low WBC count, ongoing infectious process, severe compromise in nutritional and hydration status, reduced kidney or liver function, or a decline in organ function in any system that may be further affected by the toxic effect of the drug being administered. These are situations in which chemotherapy treatment is commonly delayed until the patient's status improves. In general, most chemotherapy is held when the patient's absolute neutrophil count (ANC) is less than 500 cells/mm3 (severe neutropenia) (see Chapter 46). Dosages are often reduced for older adult patients or others with significantly compromised organ system function, depending on the drugs used. Reduction in fertility is a major concern in postpubertal patients. Cancer also complicates 1 in 1000 pregnancies. All chemotherapy drugs are classified as pregnancy category D. The choice to use chemotherapy in a pregnant woman is based on risk versus benefit. Both radiation and chemotherapy treatments can cause significant permanent fetal harm or death. The greatest risk is during the first trimester. Chemotherapy treatment during the second or third trimester is more likely to improve maternal outcome without significant fetal risk. Prepubertal patients are more resilient and can have normal puberty and fertility after receiving chemotherapy. In the older adult, frailty refers to loss of most of the patient's functional reserve and limited ability to tolerate even minimal physiologic stress (e.g., chemotherapy treatment). More robust older adults are better candidates for cancer treatment, although frail patients often benefit as well, especially in terms of palliative (noncurative) symptom control.

cell growth cycle

Normal cells in the body divide (proliferate) in a controlled and organized fashion, and this growth is regulated by various mechanisms. In contrast, cancer cells lack such regulatory mechanisms and divide uncontrollably. Often the growth of cancer cells is more constant than that of nonmalignant cells. Thus, one important growth index for malignant tumors is the time it takes for the tumor to double in size. This doubling time varies greatly for different types of cancers and is important in determining the prognosis. The time it takes for regrowth to occur depends on the doubling time of the particular cancer. Tumors with shorter doubling times are often difficult to cure due to rapid regrowth. The cell growth characteristics of normal and neoplastic cells are similar. Both types of cells pass through five distinct gap phases: G0, the resting phase, in which the cell is considered out of the cell cycle; G1, the first gap phase; S, the synthesis phase; G2, the second gap phase; and M, the mitosis phase (Figure 45-2). During mitosis, one cell divides into two identical daughter cells. Mitosis is further subdivided into four distinct subphases related to the time periods before and during the alignment and separation of the chromosomes (DNA strands): prophase, metaphase, anaphase, and telophase. A complete cell cycle from one mitosis to the next is called the generation time. It is different for all tumors, ranging from hours to days. The cell growth cycle and the events that occur in the various phases are summarized in Table 45-5. Figure 45-3 shows where in the general phases of the cell cycle the various cell cycle-specific chemotherapeutic drugs show their greatest activity. The growth activity in a mass of tumor cells has an important bearing on the killing power of chemotherapeutic drugs. The percentage of cells undergoing mitosis at any given time is called the growth fraction of the tumor. The actual number of cells that are in the M phase of the cell cycle is called the mitotic index. Chemotherapy is most effective when used in a rapidly dividing or highly proliferative tumor. Hematopoietic stem cells are cells in the bone marrow that have the capacity for self-renewal and repopulation of the different types of blood and bone marrow cells. In the bone marrow, the hematopoietic stem cell divides asynchronously, regenerating itself while producing a cell that will go through a series of cell divisions to produce mature blood cells. Tumors 714in the bone marrow that affect a cell close to the stem cell are unable to mature and are considered poorly differentiated. The level of differentiation within a tumor, whether solid or circulating, becomes especially important in the treatment of neoplasms. This is because more highly differentiated tumors generally have a better therapeutic response (tumor shrinkage) to treatments such as chemotherapy and radiation. In contrast, some cancers, such as leukemia, involve proliferation of immature white blood cells (WBCs) known as blast cells. Cancers with a larger proportion of undifferentiated cells are often less responsive to chemotherapy or radiation. Lack of normal cellular differentiation is known as anaplasia, and such undifferentiated cells are said to be anaplastic cells.

alkalyting drug interactions

Only a few alkylating drugs are capable of causing significant drug interactions. The most important rule for preventing such drug interactions is to avoid administering an alkylating drug with any other drug capable of causing similar toxicities. For example, a major adverse effect of cisplatin is nephrotoxicity. Therefore, if possible, do not administer it with a drug such as an aminoglycoside antibiotic (gentamicin, tobramycin, or amikacin) because of the resulting additive nephrotoxic effects and hence the increased likelihood of renal failure. Mechlorethamine and cyclophosphamide, both of which have significant bone marrow-suppressing effects, are not to be administered with radiation therapy or with other drugs that suppress the bone marrow. In general, you need to work with available pharmacy and oncology staff to proactively anticipate (and avoid, if possible) undesirable drug and treatment interactions.

cancer overview part 3

Over 100 types of cancer affect humans. Various tumor types based on tissue categories include sarcomas, carcinomas, lymphomas, leukemias, and tumors of nervous tissue origin. Examples of these common types of malignant tumors are presented in Table 45-2. It is important to know the tissue of origin, because this determines the type of treatment, the likely response to therapy, and the prognosis.

patient centered teaching antineoplastics part 2

Patient-Centered Care: Patient Teaching • Advise the patient to avoid aspirin, ibuprofen, and products containing these drugs to help prevent excessive bleeding. • Be open with discussion about the risk for alopecia (a complete discussion is presented in Chapter 45) as an adverse effect of many of the antineoplastic drugs. • Encourage the increase of fluids of up to 3000 mL/day, if not contraindicated, to prevent dehydration and further weakening. In the case of cyclophosphamide therapy, adequate hydration is needed to prevent and/or help manage hemorrhagic cystitis. • Constipation may be problematic, so educate the patient about ways to help manage this altered bowel status that may be due to the antineoplastic or due to the narcotics used for pain management. To help avoid constipation, 745increasing fluids and consumption of a balanced diet are important; however, the oncologist often orders either a stool softener or a mild noncramping laxative to prevent the problem. • Diarrhea may also be experienced. Advise the patient to avoid spicy, irritating foods; gas-producing foods; caffeine; high-fiber foods; alcohol; and very hot or cold foods and beverages. Preventive medication, such as synthetic opioids (e.g., loperamide) or adsorbents-protectants, may be prescribed to help prevent or treat excess diarrhea. • Educate the patient about the importance of daily weights and reporting a 2-pound increase in weight over 24 hours or a 5-pound increase in 1 week. • Demonstrate the proper technique for monitoring blood pressure and pulse rate. Encourage the use of a journal to record daily weights, blood pressure readings, and pulse rate. • With cytotoxic antibiotics, emphasize the importance of adhering to a daily heart-healthy regimen of conserving energy, planned activities, and seeking/asking for assistance with care and activities of daily living, as needed, to conserve strength and energy. Educate about the importance of reporting the occurrence of hypotension, bradycardia, chest pain, and/or dyspnea. • The following are helpful online resources for the patient and significant others: www.fda.gov, www.fda.gov/ForHealthProfessionals/default.htm, www.nih.gov, www.healthfinder.gov, www.who.int/en, and www.oncolink.org/index.cfm.

nursing process intervention part 2 antineoplastics part 2

Patients receiving cytotoxic antibiotics such as bleomycin may require more frequent monitoring of pulmonary function. Baseline chest x-rays may be obtained for comparison with subsequent x-rays if pneumonitis occurs. Monitor results of liver and renal function tests throughout therapy with dactinomycin, daunorubicin, doxorubicin, and mitomycin. Heart sounds, daily weights, blood pressure, pulse rate, and monitoring for signs and symptoms of cardiovascular toxicities (e.g., alterations in vital signs, abnormal heart sounds, dyspnea, chest pain) are especially important with doxorubicin, idarubicin, and mitoxantrone. Additionally, if the patient experiences an increase of 2 pounds or more in 24 hours or 5 pounds or more in 1 week, notify the prescriber, as this may reflect fluid retention related to heart failure. Mitomycin is associated with liver, kidney, and lung toxicities. Close monitoring of these systems during treatment is key to patient safety. Use of hormone antagonists in the treatment of various neoplasms is common, particularly with breast and prostate cancer. Associated nursing interventions and patient education for the use of these drugs are discussed in depth in Chapters 34 and 35. Corticosteroid therapy and related nursing considerations are presented in Chapter 33. Hydroxyurea is used sparingly but is a component of some treatment protocols. This drug is given orally. Monitor platelet and leukocyte counts before, during, and after treatment due to the adverse effect of bone marrow suppression. If the platelet count falls below 100,000 platelets/mm3 or leukocyte count falls below 2000 cells/mm3, therapy may need to be temporarily halted until counts rise toward normal values. See the earlier discussion and Chapter 45 about nursing considerations associated with anemia, fatigue, weakness, bleeding tendencies, and infection. Additionally, hyperuricemia may precipitate gout-related symptoms (e.g., painful, swollen joints); report these to the prescriber so that the appropriate medication may be ordered. Often a drug, such as allopurinol, is prescribed to help control the levels of uric acid caused by cell death from the chemotherapy. The use of sipuleucel-T is associated with infusion-related reactions, and those prescribers trained to prescribe/administer the drug will have prescribed a pretreatment protocol with acetaminophen and diphenhydramine. Ceritinib is given orally and must be given on an empty stomach or at least 2 hours before or 2 hours after a meal. Closely monitor cardiac and respiratory status during this treatment due to its side effects (see pharmacology discussion). In addition to the nursing interventions discussed earlier and in Chapter 45, keep epinephrine, antihistamines, and antiinflammatory drugs available in case of an allergic or anaphylactic reaction. Each antineoplastic drug has its own peculiarities and its own set of cautions, contraindications, nursing implementations, and toxicities. Cytoprotective drugs are useful in reducing certain toxicities. For example, use of intravenous amifostine may help to reduce the renal toxicity associated with cisplatin. With the occurrence of hyperuricemia (see Table 45-6 and Box 45-2), intravenous or oral allopurinol may be given to reduce uric acid levels. Other major concerns related to the care of patients receiving chemotherapy are the oncologic emergencies that arise because of damage occurring to rapidly dividing normal cells as well as rapidly dividing cancerous cells. Some of the complications that are potential emergencies include infections, infusion reactions and allergy, stomatitis with severe ulceration, bleeding, metabolic aberrations, severe diarrhea, renal failure, liver failure, and cardiotoxicity, including dysrhythmia or heart failure (Box 46-4).

alkalyting drugs overview

Records of the use of drugs to treat cancer date back several centuries. However, truly successful systemic cancer chemotherapy treatments were not documented until the 1940s. At this time, the first alkylating drugs were developed from mustard gas agents that were used for chemical warfare before and during World War I. The first drug to be developed was mechlorethamine, which is also known as nitrogen mustard. It is the prototypical drug of this class and is still used today for cancer treatment. Since its antineoplastic activity was discovered in the mid-twentieth century, many analogues have been synthesized for use in the treatment of cancer, and they are collectively referred to as nitrogen mustards as well. The alkylating drugs commonly used in clinical practice in the United States today fall into three categories: classic alkylators (the nitrogen mustards); nitrosoureas, which have a different chemical structure than the nitrogen mustards but also work by alkylation; and miscellaneous alkylators, which have a different chemical structure than the nitrogen mustards but are known to work at least partially by alkylation. These drugs are used to treat a wide spectrum of malignancies. The drugs in each category are as follows: Classic alkylators (nitrogen mustards) • chlorambucil • cyclophosphamide • ifosfamide • mechlorethamine • melphalan Nitrosoureas • carmustine • lomustine • streptozocin Miscellaneous alkylators • altretamine • busulfan • carboplatin • cisplatin • dacarbazine • oxaliplatin • procarbazine • temozolomide • thiotepa

patient safety

Sound-Alike Drugs: "Rubicins" The anthracycline chemotherapy drugs have the same sound-alike suffix and are often nicknamed the "rubicins." These drugs include daunorubicin, doxorubicin, epirubicin, idarubicin, and valrubicin. Even though these drugs are in the same class, their use and drug effects are very different. Medication errors have occurred because one "rubicin" has been mistaken for another. It is important to refer to these drugs by both trade name and generic name rather than as a "rubicin."

alkylating drugs moa and drug effect

The alkylating drugs work by preventing cancer cells from reproducing. Specifically, they alter the chemical structure of the cells' deoxyribonucleic acid (DNA). Alkyl groups that are part of the structure of alkylating drugs attach to DNA molecules by forming covalent bonds with the bases. As a result, abnormal chemical bonds form between the adjacent DNA strands, which leads to the formation of defective nucleic acids that are then unable to perform the normal cellular reproductive functions, which leads to cell death. Alkylating drugs can be characterized by the number of alkylation reactions in which they can participate. Bifunctional alkylating drugs have two reactive alkyl groups that are able to alkylate two sites on the DNA molecule. Polyfunctional alkylating drugs can participate in several alkylation reactions. Figure 46-1 shows the location along the DNA double helix where the alkylating drugs work.

cytotoxic antibiotics

The cytotoxic antibiotics consist of natural substances produced by the mold Streptomyces as well as semisynthetic substances in which chemical changes are made in the natural molecule. Cytotoxic antibiotics have bone marrow suppression as a common toxicity. The one exception is bleomycin, which instead causes pulmonary toxicity (pulmonary fibrosis and pneumonitis). Other severe toxicities associated with the use of cytotoxic antibiotics are heart failure (daunorubicin) and in rare cases acute left ventricular failure (doxorubicin). The available cytotoxic antibiotics, categorized according to the specific subclass to which they belong, are as follows: Anthracyclines • daunorubicin • doxorubicin • epirubicin • idarubicin • valrubicin Other cytotoxic antibiotics • bleomycin (which is actually a cell-cycle-specific drug) • dactinomycin • mitomycin • mitoxantrone • plicamycin

cancer drug nomenclature

The more technical term for cancer is malignant neoplasm. Drugs used to treat cancer are therefore known as antineoplastic drugs but are also called cancer drugs, anticancer drugs, and, most commonly, cytotoxic chemotherapy or just chemotherapy. The nomenclature (naming system) of cancer drugs can be somewhat more complex and confusing than that for other drug classes. Cancer treatment is an intensively researched area in health care with many active research protocols. Multiple names are often used for the same drug, depending on its stage of development. Recall from Chapter 2 that medications have a chemical name, a generic name, and a trade name. This section 715introduces yet another name for medications, especially cancer drugs: the investigational or protocol name. A drug's chemical name is used by the chemists who first discover and work with the drug. The generic name is frequently first assigned to a chemical compound after a pharmaceutical manufacturer has determined that it is worthy of continued clinical research. It is often at this point that the chemical compound becomes an investigational drug. The trade name is a marketing name used by the manufacturer of a given drug. During the time before marketing and while a given medication is undergoing clinical research, it is frequently referred to by its protocol name. The protocol name is often a code name that consists of a combination of letters and numbers separated by one or more dashes. The following are two typical examples that illustrate these concepts:

alkalyting drugs indications

The most commonly used alkylating drugs today are effective against a wide spectrum of malignancies, including both solid and hematologic tumors. Common examples of the various types of cancer that different alkylating drugs are used to treat are listed in Table 46-1.

cell cycle non specific drugs

There are currently two broad classes of cell-cycle-nonspecific cancer drugs: alkylating drugs and cytotoxic antibiotics.

topoisomerase I inhibitor

Topoisomerase I Inhibitors Topoisomerase I inhibitors are a relatively new class of chemotherapy drugs. The two drugs currently available in this class are topotecan and irinotecan. Both are semisynthetic analogues of the compound camptothecin, which was originally isolated in the 1960s from Camptotheca acuminata, a Chinese shrub. For this reason, these drugs are also referred to as camptothecins. Mechanism of Action and Drug Effects The camptothecins inhibit proper DNA function in the S phase by binding to the DNA-topoisomerase I complex. This complex normally allows DNA strands to be temporarily cleaved and then reattached in a critical step known as religation. The binding of the camptothecin drugs to this complex retards this religation process, which results in a DNA strand break. Indications The two currently available topoisomerase I inhibitors are used primarily to treat ovarian and colorectal cancer. Topotecan has been shown to be effective even in cases of metastatic ovarian cancer that have failed to respond to platinum-containing regimens (e.g., cisplatin, carboplatin) and paclitaxel. Topotecan is also used to treat small-cell lung cancer. Irinotecan is currently approved for the treatment of metastatic colorectal cancer, small-cell lung cancer, and cervical cancer. Adverse Effects The main adverse effect of topotecan is bone marrow suppression. Other adverse effects are relatively minor compared with those of the other antineoplastic drug classes. These include mild to moderate nausea, vomiting, and diarrhea; headache; rash; muscle weakness; and cough. Irinotecan causes more severe adverse effects than topotecan. In addition to producing similar hematologic adverse effects, it has been associated with severe diarrhea known as cholinergic diarrhea. It is recommended that this condition be treated with atropine unless use of that drug is strongly contraindicated. Delayed diarrhea may occur 2 to 10 days after infusion of irinotecan. This diarrhea can be severe and even life-threatening and must be treated aggressively with loperamide. There is a moderate risk for nausea and vomiting with irinotecan, which requires appropriate supportive care such as IV rehydration and antiemetic drug therapy. Interactions Topotecan has a unique drug interaction involving the granulocyte colony-stimulating factor filgrastim (see Chapter 47). Filgrastim is commonly used to enhance WBC recovery after chemotherapy. When topotecan is given along with filgrastim, myelosuppression has actually been shown to be worsened. It is recommended that filgrastim be administered 24 hours after completion of the topotecan infusion. Laxatives and diuretics are not given with irinotecan, because of the potential to worsen the dehydration resulting from the severe diarrhea that this drug can produce. Severe cardiovascular toxicity, including thrombosis, pulmonary embolism, stroke, and acute fatal myocardial infarction, have been reported when irinotecan is given with fluorouracil and leucovorin. The role of irinotecan in this toxicity syndrome is unclear, because fluorouracil is a well-recognized cause of myocardial ischemia, including myocardial infarction and sudden death. Such drug combinations are given with careful monitoring. Several additional recognized drug interactions occur with irinotecan, which are summarized in Table 45-10.

cytotoxic drugs managment of overdose and toxicity

Toxicity and Management of Overdose Severe cases of cardiomyopathy are associated with large cumulative doses of doxorubicin. Routine monitoring of cardiac ejection fraction, cumulative dose limitations, and the use of cytoprotective drugs such as dexrazoxane can decrease the incidence of this devastating toxicity. Box 46-2 outlines the management of doxorubicin extravasation.

nursing process assessment part 1 antineoplastic

With antineoplastic therapy, perform the following components of a thorough physical assessment: nursing assessment including past and present medical history and family history; medication profile with a listing of allergies and all prescription drugs, over-the-counter (OTC) drugs, herbals, and supplements; height and weight; vital signs; and baseline hearing and vision testing (as ordered). Assess bowel and bladder patterns, neurologic status, heart sounds, heart rhythm, breath sounds, and lung function. Examine the skin and mucosa, giving attention to turgor, hydration, color, and temperature. Note any signs and symptoms of fear and anxiety with attention to complaints of insomnia, irritability, shakiness, restlessness, and/or palpitations. Complete a thorough assessment of cultural, emotional, spiritual, sexual, and financial influences, concerns, and issues. Assess the patient's past and present ability to perform activities of daily living and the patient's mobility status, gait, and balance. Perform a pain assessment using objective methods such as an intensity rating scale (e.g., 0 to 10, where 0 = no pain and 10 = worst pain ever). Note the pattern of pain, focusing on the location, quality, onset, duration, and precipitating or alleviating factors. Document any oral, pharyngeal, esophageal, and/or abdominal pain; painful swallowing; epigastric or gastric pain, especially after eating spicy or acidic foods; achiness in joints or lower extremities; or numbness, tingling, burning sensation, or sharp pain in the extremities. Question the patient about past experiences with pain and about any drug, nondrug, or alternative therapies used as well as any previous successes or failures in pain management. Cultural beliefs and background as they relate to pain are important to assess because the individual's culture may affect how pain is perceived, verbalized, and treated (see Chapter 10). Culture and racial ethnicity also impact a patient's perspective on health, illness, as well as treatment of illnesses (see Chapters 2 and 4). Assess contraindications, cautions, and drug interactions. Thoroughly review and document the findings prior to the use of these drugs. Laboratory tests that are usually ordered, but not limited to, include levels of the following: electrolytes, minerals, vitamins, uric acid, red blood cell and white blood cell count, platelets/clotting and bleeding time, renal function (BUN, creatinine, serum uric acid, urine creatinine clearance), hepatic function (AST, ALT, LDH, bilirubin), and cardiac enzymes (see Safety: Laboratory Values Related to Drug Therapy on the next page). Assays of tumor markers may also be ordered to establish baseline levels and determine the impact of the disease and subsequent therapeutic effectiveness (see Safety: Laboratory Values Related to Drug Therapy on p. 727). For more information about the specific adverse effects associated with the destruction of various populations of normal cells due to chemotherapy, see Box 45-2. Specific areas of assessment related to some of the more common adverse effects of chemotherapy on normal, rapidly dividing cells include the following: • For altered nutritional status and impaired oral mucosa: Assess signs and symptoms of altered nutrition with a focus on weight loss, abnormal serum protein-albumin and blood urea nitrogen (BUN) levels (a negative nitrogen status due to low protein levels would be indicated by a decreasing BUN level), weakness, fatigue, lethargy, poor skin turgor, and pale conjunctiva. Assess oral mucosa for any signs and symptoms of stomatitis, such as pain or burning in the mouth, difficulty swallowing, taste changes, viscous saliva, dryness, cracking, and/or fissures with or without bleeding of the mucosa. • For effects on the GI mucosa: Assess bowel sounds (hyperactive or hypoactive versus normoactive). Assess presence of diarrhea, such as frequent, loose stools (more than three stools per day), urgency, and abdominal cramping. Assess for the presence of blood in the stool as well as consistency, color, odor, and amount. Assess for nausea and vomiting, and determine whether symptoms are acute, delayed, or anticipatory (occurring in future); if vomiting occurs, 726determine the color, amount, consistency, frequency, and odor, and whether blood is present (hematemesis). The severity of nausea and vomiting may be rated using a scale of 1 to 10 (where 10 is the worst symptoms) or using the terms mild, moderate, and severe. • For alopecia: Assess the patient's views, concerns, and emotions about potential hair loss. Assess the patient's need to prepare for hair loss, either by leaving the hair as it is and allowing it to fall out on its own; having the hair cut short; or wearing a scarf, hat, bandana, or hair wrap and/or purchasing a wig before the hair is actually lost. Purchasing a wig prior to chemotherapy will allow for a closer match to a patient's pre-chemotherapy hairstyle.

nursing process assessment part 3 antineoplastic

With cell cycle-specific drugs, document all allergies, cautions, contraindications, and drug interactions. Most antimetabolite drugs do not produce severe emesis (i.e., in fewer than 10% of cases). Pentostatin and some of the pyrimidine analogues have emetic potential, so perform an assessment of baseline GI functioning when giving these drugs. In addition, the folate antagonists are not as likely to cause emesis but may be associated with GI abnormalities, such as ulcers and stomatitis. Because these drugs are generally administered parenterally (IV), assessing peripheral access areas or central venous sites is critical to prevent the risk for damage to surrounding tissue, joints, and 727tendons. Assess IV sites every hour for redness, swelling, heat and pain, as needed, or as per institutional protocol. One specific assessment consideration associated with the use of the antimetabolite cytarabine is monitoring for the occurrence of cytarabine syndrome. This syndrome usually occurs within 6 to 12 hours after drug administration and is characterized by fever, muscle and bone pain, maculopapular rash, conjunctivitis, and malaise. Assessment and quick identification of this syndrome may lead to its prevention and appropriate treatment. In patients receiving mitotic inhibitors (e.g., vinblastine, vincristine) and alkaloid topoisomerase II inhibitors (e.g., etoposide), perform baseline hepatic and renal function tests, as ordered. Serum uric acid levels are usually ordered because these levels rise with increased cell death from cancer and/or its treatment. The increase in uric acid may precipitate or exacerbate gout, which, if diagnosed accurately, may be managed. Other mitotic inhibitors, docetaxel and paclitaxel, are associated with severe neutropenia and a decrease in platelet counts (see Safety: Laboratory Values Related to Drug Therapy on this page as well as in Chapter 47); therefore, CBCs are ordered before, during, and after drug therapy. Constantly assess the patient during and after treatment for severe hypersensitivity reactions characterized by dyspnea, severe hypotension, angioedema, and generalized urticaria. Drops in blood cell counts may even occur before any clinical evidence is present, which is why it is important to monitor these laboratory values. Note baseline neurologic functioning with attention to any confusion as well as changes in level of alertness/consciousness. Assess for the presence of any peripheral neuropathies. Because these drugs have multiple incompatibilities and are irritants (irritating the IV site and vein) or vesicants (causing cell death with extravasation and necrosis with ulcerations), you must become familiar with potential solution and/or drug interactions. Consulting with the prescriber and pharmacist as well as current authoritative resources would be appropriate. Documentation must include initial and frequent follow-up assessments of the IV site. Topoisomerase I inhibitors are associated with hematologic adverse effects; thus, perform baseline WBC counts as ordered. Bone marrow suppression is predictable, noncumulative, reversible, and manageable; therefore, do not give drugs such as topotecan to patients with baseline neutrophil counts of fewer than 1500 cells/mm3. Irinotecan causes more severe adverse effects than topotecan; assess related systems and note the findings. The potential for irinotecan-related cholinergic diarrhea requires continual assessment of the gastrointestinal tract. Diarrhea may appear 2 to 10 days after the irinotecan infusion. If severe forms of diarrhea occur, the patient requires further medical treatment. The diarrhea may even be life-threatening. There is only a moderate risk for nausea and vomiting with irinotecan, which requires immediate and appropriate assessment and care. Drug interactions to assess for include the concurrent administration of topotecan with filgrastim, which results in a worsening of myelosuppression. Do not give laxatives or diuretics with irinotecan due to the potential for severe diarrhea, volume loss, and subsequent dehydration. When given with fluorouracil and leucovorin, severe cardiovascular toxicity (including thrombosis), pulmonary embolism, stroke, and acute fatal myocardial infarction may occur. Perform a cautious and skillful assessment of related systems. See Table 45-10 for more drug interactions. With the use of natural enzyme drugs (e.g., asparaginase, pegaspargase), assess pancreatic function because of the potential for severe or even fatal pancreatitis. Because of this risk for pancreatitis, assess the patient closely for moderate to severe abdominal pain (upper-left quadrant), nausea, vomiting, and hyperglycemia. Serum alkaline phosphatase and WBC counts, if elevated, may indicate possible pancreatitis if also supported by clinical presentation. Additionally, assessment and documentation of dermatologic, hepatic, genitourinary, neurologic, musculoskeletal, GI, and cardiovascular systems is important due to the drug's impact on these systems. Genetic considerations are an additional area of importance in the treatment of cancer with antineoplastics, as well as with all drug therapy. Assess patients for the presence of the following 728characteristics before chemotherapy is initiated: (1) genetic markers for oral cancers, (2) genetic determinants of testosterone or estrogen metabolism, and (3) genetically linked enzyme system abnormalities such as those involving specific cytochrome P-450 enzymes that metabolically convert nicotine to a carcinogenic substance. These genetic factors are very complex; nevertheless, be aware of the possible influence of genetic differences and be forward in your critical thinking on the impact of drug research and genetics. See Chapter 8 for more information on genetics as related to drug therapy and the nursing process.

nursing process assessment part 2 antineoplastics part 2

With use of hormonal antineoplastic drugs, obtain a thorough medical, nursing, and medication history. Many of the drugs included in this category are presented in depth in Chapters 34 and 35, which also discuss aspects of the nursing process related to their use. Assessment associated with the use of estrogen antagonists such as fulvestrant, tamoxifen, raloxifene, and toremifene citrates often begins with a review of the results of any tumor estrogen receptor assays, CT scans, x-rays, and other diagnostic testing. Perform a neurologic assessment (see previous discussion and Chapters 34 and 45) with attention to baseline complaints of any pain, abnormal sensations, or headaches. Note any menopausal symptoms upon assessment because of the possible adverse effect of vasodilation and hot flushes. In addition, these drugs may cause nausea and vomiting, so a thorough GI assessment is beneficial. With the use of androgens (e.g., fluoxymesterone, testosterone), obtain a thorough gynecologic history of the female patient with attention to any menstrual issues or problems because of the adverse effect of menstrual irregularities. It is also important to assess the patient's body image and feelings of self-esteem because of the possible adverse effects of acne, hirsutism, and virilization in female patients as well as gynecomastia in male patients. See Chapter 35 for more information on the side effects of androgens. Bicalutamide, flutamide, and nilutamide are antiandrogens and require thorough assessment of any cardiac diseases due to the potential for peripheral edema. This could exacerbate any preexisting cardiac disorder. Perform a thorough gastrointestinal (GI) and gynecologic assessment because of the possibility for nausea, diarrhea, as well as hot flushes. Documentation of the use of a reliable form of birth control is important because of teratogenic effects. Male sperm production may be affected (see Chapter 45), and a decline in sexual functioning and/or desire may occur because of the antiandrogenic effects. With use of gonadotropin-releasing hormone agonists, such as leuprolide and goserelin, assess the patient for allergies to the drugs. Contraceptive history is important because women who are taking these drugs must use a nonhormonal contraceptive. Often the prescriber will order laboratory tests for serum testosterone and prostatic acid phosphatase levels for male patients before and during therapy; an increase will be noted during 742the initial week of therapy, with levels returning to baseline by 4 weeks. For patients taking antiadrenal drugs (e.g., mitotane), in addition to performing a basic assessment, inquire about any GI disturbances because of the common adverse effects of nausea and vomiting. With the miscellaneous antineoplastic drugs, glucocorticoids and mineralocorticoids may be given to prevent adrenal insufficiency and may also play a part in the therapeutic regimen. An understanding of baseline adrenal functioning through examination of laboratory test results is important to the safe use of these drugs. With the miscellaneous drug hydroxyurea, assessment of liver, renal, neurologic, and pulmonary function with baseline blood cell counts are important due to the adverse reactions associated with this drug. With use of bevacizumab, an angiogenesis inhibitor, assess cardiovascular, central nervous system, GI tract, and renal functioning because of the adverse effects of hypotension or hypertension, headache, pain, dizziness, nausea, vomiting, diarrhea, and nephrotoxicity. Sipuleucel-T (Provenge), a newer drug used with prostate cancer, is not a true chemotherapeutic drug but rather an autologous cellular immunotherapy drug. It is important to understand that sipuleucel-T is associated with infusion reactions, and its use is restricted to those prescribers who have undergone extensive training. With ceritinib, assess baseline cardiovascular status with blood pressure, pulse rate, and EKG findings because it is associated with the side effects of bradycardia and changes in QTc interval. Additionally, assess breath sounds, breathing patterns, and pulmonary function testing results due to adverse effects of life-threatening interstitial lung disease or pneumonitis. Drug interactions to assess for include grapefruit juice, strong CYP3A4 inhibitors/inducers, conivaptan, and any drugs that prolong the QTc interval.

patient centered care teaching antineoplastics

• Educate patients that GI adverse effects and irritation to the oral and GI mucosa may be decreased by avoiding intake of alcohol, tobacco, spicy and high-fiber foods, citrus fruit juices or foods, and foods that are too hot or cold or have a rough texture. • Stress that daily mouth care is needed. Instruct the patient to report mouth sores, pain, or white patches to the prescriber immediately. Headache, fatigue, faintness, shortness of breath (possibly indicative of anemia), bleeding, easy bruising (possibly indicative of a drop in platelet count), sore throat, and fever (possibly indicative of infection) also need to be reported immediately to the appropriate prescriber. Fever and/or chills may be the first sign of an oncoming infection. • Discuss contraception, sperm banking, and other reproductive issues with male patients and women of childbearing age. 732 • Emphasize to the patient receiving antineoplastic drugs which OTC medications to avoid (e.g., aspirin, ibuprofen, and any combination products containing these OTC drugs). • Emphasize pain control measures such as the following: Request and/or self-administer (if at home setting) pain medication prior to the pain becoming severe and uncontrollable. Encourage the use of ranking their pain on a scale of 0 (no pain) to 10 (worst pain ever experienced). • Review and demonstrate, as appropriate, the use of nonpharmacologic measures of pain control such as relaxation, music therapy, pet therapy, biofeedback, massage, therapeutic touch, and diversion. These may also be used in conjunction with drug therapy to enhance comfort. • Measures to assist in the support of the patient's immune system and preventing infection include frequent hand washing, deep breathing exercises, increase in fluids/hydration status, consumption of a well-balanced diet, and avoidance of malls/shopping centers or areas/gatherings with large crowds. Avoiding being around those with symptoms of colds, flu, or other communicable illnesses is also important. • Encourage frequent skin care and enhancement of skin integrity with keeping the skin clean and dry and moisturized. • Review measures/ways for the patient to minimize oral mucosal breakdown and infection, such as frequent mouth care and dental hygiene measures using mild toothpaste, gentle sponge-type toothettes, and non-alcohol-based mouthwash, as well as taking fluids frequently. • Emphasize the importance of a daily regimen for increasing urinary health, such as forcing fluids and consuming fluids that minimize urinary infections (e.g., cranberry juice). • Antineoplastics may cause alopecia (hair loss). Before therapy, provide the patient with the opportunity to discuss options for hair and scalp care. These options may include, but are not limited to, having the hair cut short before treatment; selecting, purchasing, or renting a wig or hairpiece comparable to the patient's existing hair in color, texture, length, and style; or having bandanas, scarves, or hats on hand before the hair is actually lost. Although hair loss is temporary, inform patients that it will occur and that hair will appear differently upon growing back. The American Cancer Society may be a resource for wigs and hairpieces. • The following websites are helpful online resources for the patient and significant others: www.fda.gov, www.cancer.gov, www.nih.gov, www.healthfinder.gov, www.who.int/en/, and www.oncolink.org/index.cfm. • With cytarabine, encourage the patient to increase fluid intake to help decrease the risk for dehydration and/or hyperuricemia. • With fluorouracil and gemcitabine, encourage the patient to perform frequent oral hygiene and to report to the prescriber immediately any bleeding, bruising, chest pain, diarrhea, nausea, vomiting, heart palpitations, infection, or changes in vision. Instruct patients to protect themselves from the sun while taking fluorouracil, including avoiding overexposure to sun or ultraviolet light and using protective clothing, sunscreen, and sunglasses. • With mercaptopurine, educate the patient that alcohol must be avoided to help minimize drug toxicity. • With methotrexate, inform the patient to notify the prescriber if nausea and vomiting are problematic or uncontrollable, or if fever, sore throat, muscle aches and pains, or unusual bleeding occurs. Advise the patient to avoid alcohol, salicylates, nonsteroidal antiinflammatory drugs, and exposure to sunlight or ultraviolet light. Instruct both male and female patients to use contraceptive measures for up to 3 months or longer, if appropriate. • With taxanes, specifically paclitaxel, counsel the patient to report to the prescriber immediately any signs or symptoms of neuropathy (e.g., numbness or tingling of the extremities). • With etoposide and teniposide as with other antineoplastics, if WBC counts are low, caution the patient to avoid individuals who are ill. Additionally, advise the patient to report to the prescriber immediately any easy bleeding, bruising, difficulty breathing, fever, sore throat, or chills. • With asparaginase and pegaspargase, encourage the patient to force fluids and to report any severe nausea or vomiting, bleeding, excessive fatigue, or fever or other signs or symptoms of infection.

nursing process assessment part 2 antineoplastic

• For bone marrow suppression: Assess for signs and symptoms of anemia or a decrease in RBCs, hemoglobin level, and hematocrit (e.g., pallor of the skin, oral mucous membranes, and conjunctiva; fatigue; lethargy; loss of interest in activities; shortness of breath; and inability to concentrate). Assess for signs and symptoms of leukopenia (decrease in WBCs [see Chapter 46] and/or absolute neutrophil count [ANC; normal range is 1500 cells/mm3, with severe neutropenia being less than 500 cells/mm3]), including fever; chills; tachycardia; abnormal breath sounds; productive cough with purulent, green, or rust-colored sputum; change in the color of the urine; lethargy, fatigue; and acute confusion. Assess for signs and symptoms of thrombocytopenia (decrease in thrombocytes [usually less than 100,000] and platelet clotting factors), including indications of unusual bleeding such as petechiae; purpura; ecchymosis; gingival (gum) bleeding; excessive or prolonged bleeding from puncture sites (e.g., intramuscular or IV administration sites or blood draw sites); unusual joint pain; blood in the stool, urine, or vomitus; loss of function in extremities; and a decrease in blood pressure with elevated pulse rate (see Safety: Laboratory Values Related to Drug Therapy above as well as those in Chapters 26 and 27; see also Box 45-2). Always assess for the normal ranges of laboratory values. • For possible sterility, teratogenesis, and damage to ovaries with amenorrhea: In adult male patients, assess baseline reproductive history with attention to sexual functioning, fathering of children, and past and current reproductive or sexual problems or concerns. In female adult patients, in addition to the relevant aspects already mentioned, inquire about fertility, menstrual and childbearing history, and age of onset of menses and menopause, if applicable