Download Minimizing side effects of chemotherapy

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