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Minimizing the Side Effects Of Chemotherapy Atif Hussein, MD, MMM, FACP Memorial Cancer Institute Hollywood, FL The Cell Cycle The Cell Cycle Cancer Cell Characteristics • • • • • • • Unchecked & Uncontrolled Growth Loss of contact inhibition Loss of capacity to differentiate Increased growth fraction Chromosomal Instability Capacity to metastasise Altered biochemical properties Chemotherapy Side Effects • Chemotherapy targets cells which are dividing rapidly. • Chemotherapy cannot distinguish between normal cells and cancer cells • Healthy Cells which have a high rate of growth and multiplication include cells of the bone marrow, hair, GI mucosa and skin. Chemotherapy Side effects • Side effects may be drug specific e.g. anthracyclines and cardiotoxicity, vinca alkaloids and neuropathy/constipation, bleomycin and pulmonary fibrosis • Severity of side effects varies between drugs. • Side effects often occur 7-14 days post treatment. COMMON CONCERNS WITH CHEMOTHERAPY • • • • • • • • • • Nausea and Vomiting Infection Bleeding Peripheral neuropathy Diarrhea Constipation Mucositis Fatigue Fluids Nutrition • Skin care • Hand-Foot syndrome • Emotional needs • Stress • When to call the nurse Side Effects: Gastro-Intestinal • • • • • Nausea & Vomiting Diarrhea & constipation Loss of appetite Taste Changes Mucositis Everyone Worries About Nausea and Vomiting • Not everyone experiences nausea. • Nausea and vomiting can occur before, during or for several days after receiving treatment. • Take anti-nausea medication as prescribed. • Let your nurse or doctor know if you’re unable to keep medications down, drink fluids, or your anti-nausea medication doesn’t work. Nausea and Vomiting: Patient-specific risk factors • Higher-risk groups: – Young – Female – High pretreatment expectation of nausea • Negative risk factor: high alchohol consumption Nausea and Vomiting: Stratification • High (level 4) – >90% risk of emesis without treatment • Moderate (level 3) – 31-90% • Low (level 2) – 10-30% • Minimal (level 1) – <10% Nausea and Vomiting • Certain classes of drugs are worse than others --Cis-Platinum --Doxorubicin (Adriamycin) • Which anti-emetic agents should be used is determined by the emetic potential of the drug Nausea and Vomiting: Serotonin Receptor Inhibitors • Granisetron (Kytril) • Ondansetron (Zofran) • Palonosetron (Aloxi) : Benefit of longer duration of action • Best used as a “cocktail” with steroid (dexamethasone) and lorazepam Nausea and Vomiting Serotonin Receptor Inhibitors: Common Side Effects • Headache • Constipation – Prevent with use of laxatives and stool softeners Nausea and Vomiting: NK 1 Receptor Inhibitor • Aprepitant (Emend) – Used for acute and delayed nausea in combination with a serotonin receptor-blocking drug Nausea and Vomiting: Dopamine Antagonists • Phenothiazines – Prochlorperazine (Compazine) • Metoclopramide (Reglan) • Trimethobenzamide (Tigan) – Limited role except for mildly emetogenic drugs and may be helpful in delayed nausea Delayed Nausea • Dexamethasone • Lorazepam (Ativan) • Dopamine antagonists – Prochlorperazine (Compazine) – Trimethobenzamide (Tigan) Mucositis (Mouth Sores) • More common with certain drugs: – 5-fluorouracil (5-FU) – Methotrexate – Doxorubicin (Adriamycin) – Cyclophosphamide (Cytoxan) Mucositis (Mouth Sores) • Prevention – Icing of the mouth during treatment • Treatment Options – Gel Clear – Magic Mouthwash – Viscous lidocaine • Example of Grade 4 Mucositis 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 – – – – 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 • • • • • • • 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 • • • • Hair Loss Weight Loss/ Weight Gain Long term central venous catheters Skin changes (colour, rashes, sensitivity to sunshine/chlorine, dry) Dehydration: Fluids • Keeping hydrated with fluids is important during chemotherapy treatment. • Fluids are in water, beverages, and food. • Keep a bottle of water or juice with you at all times and sip on it often. • If you have vomited, try to drink about two quarts of fluids a day for a few days afterward. • A good rule of thumb: take in enough fluids to keep urine light yellow. Nutrition • Eat smaller portions more frequently. • Try milkshakes, smoothies, or supplements like Ensure for extra calories if you are losing weight. • Some chemo causes a metallic taste. Try using plastic utensils to ease this effect. • Some people gain weight during chemotherapy. Side Effects: Other • Altered Kidney Function • Changes in hearing (high dose Cisplatin) • Cardiac Toxicity (Doxorubicin/ Idarubicin) • Late Effects: Infertility, secondary malignancy, growth retardation. When should I call the doctor? • • • • Fever over 100.5°F Redness or swelling at IV site Uncontrolled vomiting or diarrhea Blood in urine or stool or uncontrolled bleeding • Signs of infection • Feeling unwell You should be able to eat, drink, have reasonable bowel and bladder function and feel good enough to get up and around-if not, call. Key Points: • Chemotherapy is a major treatment in curing or prolonging survival in cancer patients • It has a wide range of side effects depending on the drugs given. • Nurses have a key role to play in caring for a patient receiving chemotherapy • Safety issues are paramount in administration. Summary The potential benefit to the patient of treatment as an option must always outweigh the toxic effects. THANK YOU VERY MUCH!!!