Download Anticancer therapy education programme

North Trent Cancer Network
North Trent Cancer Network
Anticancer therapy
education
programme
For health care professionals involved in the
care of patients receiving intravenous,
intramuscular, oral and/or subcutaneous
anticancer therapy
Health care professionals who are involved solely in the delivery of oral anticancer
therapy should complete the North Trent oral anticancer therapy training programme.
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Acknowledgements:Authors and contributors
Joyce Burman, Doncaster and Bassetlaw NHS Foundation Trust
Angela Gascoigne, Chesterfield Royal Hospital NHS Foundation Trust
Anita Gill, Barnsley Hospital NHS Foundation Trust
Pauline Pledge, Sheffield Teaching Hospitals NHS Foundation Trust
Anne Pulfrey, Sheffield Teaching Hospitals NHS Foundation Trust
Martin Salt, Sheffield Teaching Hospitals NHS Foundation Trust
Gail Smith, Rotherham General Hospital NHS Foundation Trust
Michel Thompson, Rotherham General Hospital NHS Foundation Trust
Clare Warnock, Sheffield Teaching Hospitals NHS Foundation Trust
Denise Wilkinson, Sheffield Teaching Hospitals NHS Foundation Trust
Grateful thanks are given to all those who have provided their knowledge, expertise and
time to the development of this Education Programme. Particular thanks are given to
Lynda Campbell for her secretarial support in developing this document.
First revision 2008
Clare Warnock, Sheffield Teaching Hospitals NHS Foundation Trust
Second revision 2011
Clare Warnock, Sheffield Teaching Hospitals NHS Foundation Trust
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CONTENTS
INTRODUCTION TO THE EDUCATION PROGRAMME
MODULE 1
HEALTH AND SAFETY ISSUES
Introduction
Responsibilities with respect to Cytotoxic Drugs
Protection of Staff
Primary Route of Exposure
Personal Protection
Protect the Patient
Protect the Environment
Accidental Spillage, Contamination and Exposure to Cytotoxic Material
Cytotoxic Chemotherapy Storage
MODULE 2
HOW ANTICANCER THERAPY WORKS
How anticancer therapy Works
Mode of action of chemotherapy
Biological agents: interferon, monoclonal antibodies
Underpinning principles for anticancer therapy scheduling
Aims of treatment
MODULE 3
PRINCIPLES FOR THE ADMINISTRATION OF ANTICANCER THERAPY
Introduction
The Knowledge and Expertise of the healthcare practitioner
Patient Information and Consent
The role of Protocols in anticancer therapy
The Provision of Supportive Therapy
Assessment of Fitness to Receive Treatment
Checking Procedures
Measures to Prevent and Manage Acute Side Effects
Administration of Intravenous anticancer therapy
Vinca alkaloid administration
Potential venous problems during intravenous administration of anticancer
therapy
Extravasation
Extravasation Risk Factors Relating to Venous Access
Steps for Assessing Patency
Extravasation Risk Factors Relating to Drugs
Extravasation Procedure
Action to be Taken in and Extravasation Occurs
Intramuscular/Subcutaneous Administration of anticancer therapy
Oral anticancer therapy
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MODULE 4
SIDE EFFECTS OF ANTICANCER THERAPY
Anaphylaxis
Nausea and vomiting
Bone marrow depression
Neutropenia
Thrombocytopenia
Anaemia
Alopecia
Altered bowel habit
• Diarrhoea
• Consiptation
Cardiac toxicity
Changes in cognitive function
Central nervous system effects
Fatigue
Fertility
Haemorrhagic cystitis
Hand foot syndrome
Mucositis (oral problems)
Nephrotoxicity
Neurotoxicity (including oxaliplatin pharyngo-laryngo dysesthesia)
Pulmonary toxicity
Skin reactions
Tumour lysis syndrome
MODULE 5
PATIENT ADVICE/INFORMATION
Patient Information and anticancer therapy
Patient Advice
MODULE 6
ANTICANCER THERAPY COMPETENCY ASSESSMENT
Definition of Terms
Summary of Assessment Pathway
Theoretical Assessment for the administration of anticancer therapy
Practical assessments for the administration of anticancer therapy
• Oral assessment
• Intramuscular assessment
• Infusional Assessment
• Bolus (Peripheral) Assessment
• Bolus (CVAD) Assessment
References
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1.
Introduction to the Education Programme
This is the third edition of the North Trent Cancer Network modular competency based
training and assessment programme addressing all aspects of delivering anticancer
therapy. The programme contains all of the elements necessary for health care
practitioners to maintain the highest standard of care to cancer patients receiving
anticancer therapy across the network.
Anticancer therapy is the term used to describe non surgical and non radiotherapy
based cancer treatment. It includes chemotherapy and biological therapies (for example,
monoclonal antibodies). For the purpose of this education programme it does not include
hormone based treatments.
This training programme covers the following methods of delivery of anticancer therapy:
• Intravenous infusion
• Intravenous bolus
• Intramuscular or subcutaneous
• Oral
This programme does not cover the following: • Paediatric anticancer therapy
• Intrathecal chemotherapy. This is a separate procedure with its own rules and
regulations to govern its practice.
Health care professionals who are involved solely in the delivery of oral anticancer
therapy should complete the North Trent oral anticancer therapy training programme.
This has been designed for staff involved in assessing, administering or providing patient
information to patients receiving oral anticancer therapy but who are not involved in
administering intravenous, intramuscular or subcutaneous treatment.
2.
Who the Programme is designed for
The programme has been designed to support all healthcare professionals whose role
may bring them into contact with anticancer therapy. Practitioners must fulfil the
following criteria, agreed by the North Trent Cancer Network:
•
Registered health care practitioners who have at least six months post registration
experience and have completed their local preceptorship programme
Practitioners who have been assessed as competent in anticancer therapy/
chemotherapy administration using the North Trent training programme and have had a
period of non-practice greater than three months (eg career break or secondment) must
be assessed as safe to practice on an individual basis. Further training can be identified
where necessary.
Practitioners transferring from other NHS organisations who have completed a
anticancer therapy/chemotherapy training programme will undertake theoretical and
practical assessment as deemed appropriate by their manager. This must include
• reading the North Trent anticancer therapy education programme and
• a minimum of one practical assessment of competence for each route of
administration they will be carrying out as part of their role.
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3.
Aims of the Programme
This Anticancer therapy Education Programme is aimed at practitioners who administer
and provide care for patients receiving anticancer therapy. The care of patients is
directed towards safe practice and the prevention, early detection and minimisation of
complications. Care is also directed towards the giving of information and support at a
level and pace appropriate to the individual patient.
The core principles that underpin the training programme are that practitioners will: (i)
Understand the dimensions and limitations of their role.
(ii)
Know and understand the principles of safe administration and disposal of
cytotoxic agents.
(iii)
Understand their personal accountability for practice under their appropriate
professional regulations (e.g. the Nursing and Midwifery Council (NMC) Code of
Professional Conduct) with particular emphasis on competence, personal
accountability for practice and consent.
(iv)
Understand where their role involves the administration of anticancer therapy
they must undertake specific training to the role (provided by the employer). The
employee must not be involved in the administration of anticancer therapy until
they are deemed competent to do so.
(v)
Understand that nurses will not be involved in the reconstitution of cytotoxic
drugs.
(vi)
Understand that contact with anticancer therapy can be harmful to the unborn
baby. Employees must let their employer know if they are pregnant and a risk
assessment completed. You must NOT reconstitute or administer anticancer
therapy if pregnant.
Specific to intrathecal chemotherapy
All staff will clearly understand that they must not be involved in the checking or
administration of intrathecal cytotoxic chemotherapy until they have successfully
completed specific intrathecal training requirements.
4.
Learning Outcomes
The expectations are that at the end of the education programme the healthcare
practitioner will be able to: (i)
Give an explanation of the ways in which anticancer therapy works
(ii)
Describe the principles behind the safe administration of anticancer therapy and
the management and care of central and peripheral intravenous pathways
(iii)
Demonstrate knowledge of the anticancer therapy drugs used within the
speciality, their toxicities and the short and long term side effects.
(iv)
Demonstrate knowledge of the equipment available to safely control the
administration of anticancer therapy.
(v)
Demonstrate a knowledge and understanding of issues relating to safe handling
and disposal of cytotoxics including: • COSHH regulations and local arrangements and policies for the safe storage and
disposal of cytotoxic drugs.
• Local policies relating to anticancer therapy and: • Personal protection (protective clothing, safe handling of cytotoxic drugs,
handling of bodily waste).
• Pregnancy.
• Patient safety
• Maintaining a safe environment.
• Managing a cytotoxic spillage
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(vi)
(vii)
Explain how good practice and adherence to policy is paramount in the
prevention of extravasation. The health care practitioner (HCP) will also be able
to describe the principles behind the early detection and management of
extravasation
Demonstrate knowledge and awareness of risk management, risk assessment
and control measures surrounding anticancer therapy including knowledge of
untoward incidents, appropriate action and their Trust’s reporting mechanisms.
Responsibilities with Respect to Cytotoxic Drugs
All staff involved in the administration, checking and storage of anticancer therapy
should be familiar with the policies and procedures governing this practice. All staff have
the following responsibilities: (i)
(ii)
(iii)
(iv)
strict adherence to the local procedures for checking anticancer therapy prior to
administration including confirming that the prescription is safe and appropriate
correct use of storage facilities required for anticancer therapy including correct
temperature storage.
consistent use of correct administration techniques and protocols. This includes
ensuring all supportive therapy including pre-medication, anti-emetics and
hydration fluids have been administered and the correct use of appropriate giving
sets (including an in-line filter where applicable).
maintaining a safe environment before, during and after administration. This
includes assessing any risks to safe administration and the taking of appropriate
action when there are compromising risk management issues involved in
administering anticancer therapy identified.
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MODULE 1
HEALTH AND SAFETY ISSUES
(Please also refer to your local Health and Safety Policy)
Introduction
All staff have the responsibility to work within national and local policies e.g. Health and
Safety at Work Act, Control of Substances Hazardous to Health (COSHH) and their local
Health and Safety Policy. Maintaining a safe environment before, during and after
administration is an essential component of safe practice. All HCP’s involved in
anticancer therapy administration must assess any risks to safe administration on an
ongoing basis. They must take appropriate action when compromising risk management
issues are identified.
Anticancer therapy will only be given in designated areas which are identified locally.
Hazards to health have been identified for staff preparing and administering cytotoxic
drugs as they have been identified as mutagenic, teratrogenic and carcinogenic
(Dougherty and Lister 2008). This means they can potentially harm fertility, cause foetal
damage and cause cancer. Because of these risks the Health and Safety Executive
introduced guidelines governing the use of cytotoxic chemotherapy within the regulations
called ‘Control of Substances Hazardous to Health’ (COSHH). The aim of a policy for
handling and administering cytotoxics drugs is to prevent exposure or reduce it to a
minimum.
Protection of Staff
There is a large body of evidence to suggest that healthcare personnel need to be
adequately protected to ensure they are not exposed to potentially harmful substances
when involved in the preparation and administration of cytotoxic drugs. Measures must
be taken to reduce exposure
Primary Routes of Exposure
There are three routes of exposure to anticancer therapy: (i)
(ii)
(iii)
Absorption through the skin.
Inhalation.
Ingestion (administering treatment and then eating something without washing
your hands would be one way in which this could occur).
Exposure to anticancer therapy is most likely to occur during drug preparation and
administration but there are other times when staff can be exposed. For example, some
anticancer therapy drugs can be excreted in the patients bodily fluids for up to 7 days
post administration. Staff will be exposed to this when handling and disposing of body
waste. It is important to wear gloves and aprons when handling body fluids/waste and
pay careful attention to hand washing techniques (Tadman and Roberts 2007).
Patients and relatives need to be informed about this risk of exposure from body fluids
before they go home so that anyone coming into contact with the patient’s body fluids
wears gloves and washes their hands afterwards. Patients should also be aware that
anticancer therapy may be present in seminal fluid and vaginal secretions so a barrier
method of contraception should be used if the patient has sexual intercourse in the week
following treatment (Foster 2002). Patients on a continuous course of oral chemotherapy
should use a barrier method of contraception for the duration of their treatment.
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As a result of studies performed on nurses, pharmacists and pharmacy technicians, a
number of safety measures have been introduced to protect personnel handling
anticancer therapy drugs.
Preparation and/or reconstitution of cytotoxic drugs can only be carried out by pharmacy
staff in a specially equipped area; no other staff should undertake this task. There are
specific procedures and protocols for pharmacy staff to adhere to within their
departments to ensure their protection. There are a few exceptions where a drug has a
very short expiry once reconstituted which make it logistically very difficult for pharmacy
to prepare e.g. each formulation of asparaginase. Where this is the case policies and
procedures must be in place and followed to ensure this is achieved safely.
Warning: under no circumstances may staff who are pregnant or who suspect they may
be pregnant be involved with: Administering cytotoxic drugs.
Cleaning up a cytotoxic spillage.
Handling cytotoxic patient waste.
•
•
•
Personal Protection
A number of regulatory requirements have been set to protect healthcare personnel who
prepare or administer cytotoxic drugs. Disposable gloves, a plastic apron and eye
protection must be worn when directly dealing with cytotoxic drugs to protect skin and
clothing. Gloves and plastic aprons should always be worn when dealing with patient’s
waste which can be disposed of following the standard waste management procedures
(Allwood, Stanley and Wright 2002).
The most important method of protection is common sense and good technique.
•
•
•
Gloves – Disposable gloves must always be worn when handling anticancer therapy.
Aprons – Should be made of plastic or low permeability material.
Goggles – See local policy.
Protect the Patient
Care must be taken to prevent accidental spillage of the cytotoxic agents onto the
patient’s clothing and skin. This can be achieved by using a plastic covered pillow and/or
a plastic backed dressing sheet placed under the patients arm or line when
administering the treatment.
Protect the Environment
Care should be taken to prevent contamination of the area in which the drugs are being
administered. A hard plastic tray with a raised edge must be used for transportation and
containment of the drugs.
Luer lock syringes must be used for all bolus anticancer therapy.
Accidental Spillage, Contamination and Exposure to Cytotoxic Material
All accidental spillages, contamination and exposure to cytotoxic drugs involving
ingestion, inhalation or contamination of the skin, must be dealt with immediately and
first aid measures must be administered as soon as possible.
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Cytotoxic drug Spillage
Refer to North Trent spillage policy. A spillage kit must be available in areas where
anticancer therapy is being administered.
Skin Contamination
Immediately wash the area with copious amounts of soap and water
Eye Contamination
Immediately irrigate the eye with a sterile eyewash solution (or water, if eyewash
solution is not available), as some cytotoxic drugs may cause corneal ulceration. The
affected eye must be examined by a medical practitioner experienced in carrying out
ophthalmic assessment.
Clothing Contamination
Immediately change clothing and treat as contaminated linen.
All staff have the responsibility to report accidents, untoward incidents and near
misses using their Trust’s incident reporting system.
Cytotoxic Waste Disposal
Anticancer therapy must be disposed of safely to minimise the potential of contamination
to all groups of staff involved in waste management. Anticancer therapy is disposed of
separately from other waste. Refer to local policies for specific waste management
procedures.
Risk assessments
The health care practitioner involved in administering anticancer therapy must maintain a
safe environment before, during and after administration. Where they feel there are
compromising risk management issues involved in administering cytotoxics (eg visitors),
s/he must take action to reduce that risk to an acceptable level before proceeding
further. Where the risk issue cannot be resolved, s/he must inform the nurse in charge,
physician and pharmacy of the problem. An incident form must be completed, and
concise documentation made within the nursing record where appropriate.
Storage
Anticancer therapy must be stored as directed by the Pharmacy Department, ensuring
that COSHH regulations are complied with. Items that have not been stored correctly
may become quickly unusable, and may not be available out of normal working hours.
This may compromise the patient’s treatment by causing unnecessary interruption.
Correct storage will also prevent expensive wastage of drugs.
As soon as treatment arrives from pharmacy the correct storage method must be
identified on the pharmacy label. Where refrigeration is required, it should be stored in
designated temperature monitored fridges in the clinical area. Once reconstituted
anticancer therapy has a relatively short time in which it can be used. Attention should
be paid to the expiry dates, particularly where there is more than one bag or syringe of
the same drug.
Anticancer therapy should not be administered directly after removal from the
refrigerator to prevent venous spasm and vein pain.
Each item of treatment will be contained is a sealed plastic bag. These bags should not
be opened until the drug has been checked and is about to be administered.
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MODULE 2
HOW ANTICANCER THERAPY WORKS
How Cytotoxic Chemotherapy Works
The Cell Cycle
The cell cycle is the process by which cells divide and reproduce. The cell cycle has five
stages: • Go - resting phase. During this stage the cell will be fulfilling its normal function and
will not be reproducing.
• G1 - growth phase where the cell prepares enzymes for synthesis required in the S
phase
• S - synthesis phase where DNA replication occurs
• G2 – further growth and preparation for mitosis. During this phase the cell contains
both its original, and its replicated DNA.
• M – mitosis – cellular division during which the cell physically becomes two cells.
In health, cellular division is a carefully regulated process in which cell division is
triggered by the death of a cell. The genes that are responsible for regulating cell
division are called oncogenes and tumour suppressor genes. Oncogenes produce
proteins such as growth factors which drive cellular division; tumour suppressor genes
block growth signals and act as the brakes to cellular division.
In a cancer cell, mutations in these genes alter the control of cellular division. Oncogene
mutation leads to too much, or the wrong type, of growth protein being produced while
tumour suppressor gene mutation leads to a reduction in the ability to halt cell division.
Either or both of these changes can lead to uncontrolled and frequent cell replication.
Chemotherapy, works by disrupting the process of cell division. It is often more effective
on cells which are dividing so it has a greater effect on cancer cells which divide more
frequently than healthy cells. The rate of cell division in cancer cells is influenced by a
number of factors including:
The doubling time
The rate of growth of a cancer is described as the doubling time – i.e. the amount of time
it takes for a cancer to double in size. This can vary from hours to months. The doubling
time is influenced by the characteristics of the parent cell (the cell which gave rise to the
cancer). For example, the doubling time of a teratoma - average three weeks, is faster
than that of a colorectal cancer - average three months (Tadman and Roberts 2007).
Cancers which have a faster doubling time are more likely to have cells which are
actively dividing. This can make them more susceptible to the action of chemotherapy.
The degree of differentiation
The degree of differentiation describes how closely the cancer cell resembles a mature
functioning cell. A well differentiated cell has a close resemblance to a mature cell, while
an undifferentiated cell bears little resemblance. The degree of differentiation is referred
to as the grade of a cancer. Less differentiated cells will have fewer similarities to a
mature cell; they tend to divide more frequently and are more likely to metastasise.
These are termed high grade cancers.
The size of the cancer
Cancer growths which are smaller in size tend to have a faster growth rate and are more
likely to have replicating cells
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Mode of action of chemotherapy
Chemotherapy drugs can be classified by their mode of action. Some chemotherapy
drugs work at particular points in the cell cycle – these drugs are called cell cycle phase
specific. For example:
• aspariginase acts on cells in G1 phase, when enzmes are being synthesised in
preparation for the S phase of the cell cycle
• 5-flurourcil (5-FU) and methotrexate act in the S phase when the cell is replicating its
chromosomes
• bleomycin and etoposide act on cells in the G2 phase
• vinblastine acts in the M phase when cells divide.
Other chemotherapy agents are non cell cycle phase specific and can work at any point
in the cell cycle, including the resting phase, G0, when the cell is not dividing
Chemotherapy drugs have different modes of action. Examples are as follows:
Alkylating Agents (e.g. cyclophosphamide, cisplatin, melphalan)
These work by causing abnormal formation of the “new” DNA during mitosis ensuring
that the DNA strands are not able to separate.
Antibiotics (e.g. doxorubicin, epirubicin)
These work by interfering with the production of DNA and prevent the DNA strands
separating.
Antimetabolites (e.g. methotrexate, gemcitibine)
These work by “imitating” normally existing metabolites which are required for successful
cell division. Antimetabolites are taken up by the cell during the resting phase, and they
then prevent the cell from continuing in the cell cycle. They are cell cycle specific.
Mitotic inhibitors (e.g. vinca alkaloids, taxanes)
Vinca alkaloids: act by blocking cell division (mitosis) and are therefore cell cycle specific
to the M phase. taxanes: prevent mitosis by binding to microtubules
Log kill
One term which is used to describe an underlying principle of how chemotherapy works
is log kill. The log kill is a measure of the cells killed as a percentage of the total
number/size of the tumour. The aim of chemotherapy is to reduce the number of cells to
a level where the body’s immune response can take over and destroy the remaining
cancer cells. This is why treatment often continues even when the tumour is no longer
visible on scan. Beyond a certain size the tumour is too small to see but there is always
the risk that some cells may still be present.
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How biological therapies work
Biological therapies aim to produce an anti-cancer effect either by activating the patient’s
immune system or by administering natural substances present in the immune system
as treatments (Tadman and Roberts 2007).
Immunotherapy
Interferon is produced by the immune system in response to viral infections. Interferon
as a cancer treatment acts on a cancer by
• Interfering with tumour cell growth
• Affecting the expression of oncogenes
• Making tumour cells more vulnerable to being killed by the immune system
• Reducing the amount of blood vessels around a tumour (Tadman and Roberts
2007)
Interferon is used most often in the treatment of leukaemia, lymphoma and renal call
carcinoma.
Monoclonal antibodies
Monoclonal antibodies are designed to bind specifically to cell surface molecules or
protein markers expressed by a cancer cell. The monoclonal antibody recognises the
specific protein markers and locks onto them. They then have several modes of actions
including:
• Blocking/inhibiting the growth signal pathways
• Recruiting the bodies immune system to attack and kill the cancer cell
• Inducing cell lysis (the death of a cell due to break down of the cell membrane)
Monoclonal antibodies have different modes of action for example:
Herceptin
The human epidermal growth factor-2 (HER2) plays a role in the regulation of normal
breast growth and development. However, in some breast cancers HER2 is overexpressed leading to unregulated cell growth. Herceptin is a targeted therapy for HER-2
over-expressing cancers. It binds to the HER2 receptor site and inhibits the effects of the
growth factor (Cooke 2000).
Rituximab
Rituximab has been designed to bind to a molecule called CD20, a cell surface protein
expressed in around 93 percent of patients with B cell lymphoma. Once it is attached to
the CD20 molecule, rituximab attracts other immune cells to the protein and these
induce apoptosis (cell death) in the cancerous cell (Feltham 2008).
Bevacizumab (Avastin®)
Cancer growths need to develop their own blood supply to be able to grow and survive.
This process is called angiogenesis. Bevacizumab is a monoclonal antibody targeted
against vascular endothelial growth factor (VEGF), which plays a key role in the process
by which tumours develop their own blood supply. Bevacizumab is an anti-angiogenic
treatment which binds to VEGF to inhibit the development of the blood supply to the
cancer (Blowers and Hall 2009).
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Tyrosine kinase inhibitors (TKI’s)
Growth factor receptors known as the erbB or HER receptors are found on several
different types of cancer cells. These receptors play a role on the normal processes of
cell growth and development. However in some cancers these growth receptors are
over-expressed leading to unregulated cell growth. One of the ways in which these
growth receptors function is through the activation of a protein inside the cell called a
tyrosine kinase enzyme. This protein can cause the cancer cell to grow.
Drugs have been developed to inhibit the activation of this enzyme which may then stop
the cell dividing. These drugs are called tyrosine kinase inhibitors (TKI’s). Examples of
TKI’s include Erlotinib/Tarceva®, Sunitinib/Sutent®, Imatinib/Glivec® and lapatinib.
Underpinning principles for anticancer therapy
The aim of anticancer therapy is to maximise the destruction of the cancer cells while
minimising the damage to the normal cells. Two approaches which are used to achieve
this are:
1) administering combinations of anticancer therapy drugs and
2) administering anticancer therapy drugs in cycles (Souhami and Tobias 2005).
Combinations of drugs
Anticancer therapy regimens frequently include the administration of more than one type
of drug. For example, R-CHOP involves the administration of the following drugs:
rituximab, doxorubicin, vincristine and cyclophosphamide. High dose steroids –
prednisolone - are given as part of this regimen. The principles that underpin this
practice are as follows:
The different modes of action of each of the drugs can be used to combined and
greater effect.
o This effect can be achieved at lower and safer doses than if only one drug
was being given
As cancer growths are often comprised of different types of cell with varying
sensitivities to different drugs, giving drugs with different modes of action increases
cell kill
Combining drugs that have different side effects allows an increased destruction of
the cancer cells with a reduction in the overall incidence and severity of side effects
o Each of the drugs that are given within the regimen should have different side
effect profiles as much as possible
Scheduling of anticancer therapy in cycles
In a course of anticancer therapy there are planned intervals between the administration
of each dose and/or cycle of treatment. The principles that underpin this practice
are as follows:
each time treatment is given only a proportion of the cancer cells are killed. The
number of cells killed increases with the number of cycles given.
some chemotherapy agents work at specific points in the cell cycle. The intervals
increase the chance of cells being in this phase when the treatment is given
the intervals allow for the recovery of healthy cells. Cancer cells are poor at cell
repair while normal healthy cells can repair sub-lethal damage
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When combining and scheduling anticancer therapy the following factors are considered:
The intervals between doses are a balance between the time required to allow
normal cells to recover while minimising the opportunities for the cancer to continue
to grow
The intervals allowed often reflect the recovery time required for a particular drug.
For example, carboplatin is often given four weekly to provide enough time of the
bone marrow to recover
The aims of treatment
Drug regimen selection will take into consideration the intentions of treatment, for
example curative or palliative.
Curative
The aim of curative treatment is to eradicate all measurable disease. It is given when
there is a good potential for cure – for example the cancer is very sensitive to anticancer
therapy (e.g. lymphoma, teratoma) or the cancer is being treated at an early stage.
Curative treatment is more likely to be intensive and may involve administering drugs
with a high side effect toxicity profile. Efforts are made to reduce delays in the treatment
schedule and avoid dose reductions where possible as this can impact on the potential
outcomes of treatment.
Palliative
The aim of palliative treatment is to extend survival, alleviate symptoms and improve
quality of life. Palliative treatment should carefully balance the potential long and short
term benefits that could be gained from treatment against the potential distress
associated with side effects and the impact of treatment on quality of life.
Adjuvant
Anticancer therapy is frequently given alongside other cancer treatments such as
radiotherapy and/or surgery. The term used to describe this is adjuvant treatment.
Anticancer therapy can also be given before another cancer treatment with the aim of
reducing the size of the cancer growth to increase the potential effectiveness of surgery
or radiotherapy. When given before another treatment the term used is neoadjuvant.
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MODULE 3
PRINCIPLES FOR THE ADMINISTRATION OF ANTICANCER THERAPY
Introduction
It is expected that all staff will perform informal risk assessments as part of their roles in
relation to anticancer therapy. Staff should act appropriately in addressing any identified
area of concern to prevent any untoward incident. Where wider issues are identified in
relation to cytotoxic treatment as part of an informal risk assessment, a formal risk
assessment should be implemented as soon as possible.
Key principles govern the administration of anticancer therapy all routes. These relate to:
The knowledge and expertise of the staff administering treatment.
Patient information and consent.
The role of protocols and calculation of doses.
Providing appropriate supportive treatments (eg anti-emetics, hydration fluids).
Assessment of whether the patient is fit to receive treatment.
Checking procedures.
The prevention and management of acute side effects.
(RCN 2010, Dougherty and Lister 2008).
The Knowledge and Expertise of the HCP
Staff involved in the administration of chemotherapy should have received appropriate
education and training in order to gain the knowledge and skills required. This involves
developing a good understanding of the following aspects of care: The health and safety issues associated with handling, administering and disposing
of cytotoxic material (see Module1).
The key components of patient care including:
• Consent, patient information, education and support
Knowledge of the drug: Drug properties (vesicant or non vesicant), appropriate method of
administration, short and long term side effects and potential adverse reactions
•
Common regimens and protocols including:
• Dose calculations, supportive treatments, rate and route of delivery and the
range of appropriate doses.
Competence in the techniques required for delivering chemotherapy.
• For example, IV drug administration, infusion equipment competence,
cannulation skills, CVAD skills
• Where possible these competencies should be gained in the administration
of less toxic substances before learning to use them in the administration of
chemotherapy
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Patient Information and Consent
Consent
Before receiving anticancer therapy the patient needs to provide informed consent.
Written consent is required before treatment is commenced and every time the regimen
is changed. It is also important to determine whether or not the patient is willing to
proceed prior to each treatment.
Informed consent goes beyond the patient signing their name on a form. Davies (2003)
states that “it is the outcome of a process of communication between the health
professional and the patient over the nature of their treatment alongside a discussion of
the possible risks and benefits of treatment”. The patient should be fully informed of the
details of treatment; specifically when, where and how it will be given, possible side
effects, how to prevent and manage them and how to contact the treatment centre for
advice and support. Patients should also be provided with written information (see
module 5 for further details on patient information).
Fertility
Some anticancer therapies have an impact on fertility and can cause infertility at
standard or high doses. Other agents can have an effect on fertility but the actual effect
depends on a range of factors including age, individual susceptibility and the patients
level of fertility prior to commencing treatment (Davies 2003, Knobf 2006, Royal College
of Physicians 2007, Thaler-DeMers 2006).
Male patients receiving treatment that could effect fertility should be offered the
opportunity of sperm banking. For female patients it is possible to store fertilised ova.
However, this can be difficult to achieve as it can take a few months for this process
resulting in treatment delays. It is vital to check that these issues have been discussed
with the patient prior to administering treatment.
Women can remain fertile during treatment even if their menstrual cycle becomes
disrupted or stops and they should be advised to use effective contraception during and
after treatment. It has been proposed that effective contraceptive precautions should be
recommended in all males and females once treatment is commenced and for at least
one year after it is completed (Royal College of Physicians 2007).
The Role of Protocols in anticancer therapy
Anticancer therapy administration is governed by the use of protocols. Protocols set out
the number of days over which a regimen is given, when specific drugs are to be given,
the dose of each drug and any supportive treatments. There are many different
protocols used in haematology and oncology and it is important that you have a good
understanding of the protocols commonly used in your clinical area. You should also
have easy access to information on any treatment protocols that you are using.
Scheduling of Drug Administration
The protocol identifies the number of days over which a regimen is given (referred to as
a cycle) and when specific drugs are to be given within the cycle. The number of days in
a cycle varies between protocols, for example, some protocols may have a 28 day cycle
others a 21 day cycle. The following is an example of drug schedule within a protocol.
The Gemcitabine/Carboplatin lung protocol is a 21 day regimen. Patients receive
Gemcitabine on days 1 and 8 and Carboplatin on day 1. They then have a break for the
rest of the cycle. Twenty-two days after starting cycle 1 they begin day 1 of cycle 2.
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Calculation of Dose
Treatment protocols also determine the dose of the drugs to be given to each patient as
the dose is often dependant on the patient’s body surface area (BSA).
This approach to calculating doses of anticancer therapy plays a role in maintaining the
therapeutic ratio; the dose that balances maximum cancer cell kill with safe or
manageable levels of side effects/toxicities. Giving too little can reduce the potential
benefit from treatment in terms of cure/survival, giving too much can cause severe side
effects that the patient may not be able to tolerate. An accurate measurement of BSA is
an essential component of safe anticancer therapy administration. As a patient
progresses through their treatment their BSA will need to be reviewed prior to each cycle
as significant weight loss or gain require a change in the doses prescribed.
The unit of measurement for BSA is metres squared (M2) and it is calculated from the
patient’s height and weight. Once the BSA is known the dose of each drug is calculated
by multiplying the protocol dose by the BSA. For example, according to the protocol a
dose of chemotherapy is 50mg per M2 the patient has a BSA of 1.8 M2. The dose is
calculated (50 X 1.8 = 90 mg) so this patient would receive 90 mg of the drug.
The Provision of Supportive Therapy
Treatment protocols also stipulate the administration of other drugs that are given to
minimise or prevent side effects. Examples are contained in table one.
Table 1: Examples of supportive therapies for specific anticancer therapies
Name of
supportive therapy
When it is given
0.9% Normal Saline
infusion
1 – 2 litres
Before and after
Cisplatin.
Folinic acid
Twenty four hours Counteracts the action of Methotrexate and
after
reduces severity/incidence of mucositis and
Methotrexate
bone marrow suppression.
administration
Ifosfamide produces a metabolite called
IV infusion with
acrolein that can damage the urothelium
Ifosphamide.
(lining of the urinary tract). This can cause
haemorrhagic cystitis. Mesna reacts with
acrolein to prevent this damage
.
Mesna
Chlorphenarimine,
Paracetamol,
Steroids
Cisplatin is renal toxic. IV fluids are given to
promote diuresis during and post Cisplatin
administration to ensure the drug passes
rapidly through the renal system.
Prior to
Rituximab
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To reduce the severity and incidence of
hypersensitivity reactions
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Appropriate antiemetics are also identified in the protocol. Many agents cause nausea
and vomiting, but the degree of severity, referred to as the ematogenic potential, varies.
Those drugs that have medium to high ematogenic potential eg Cisplatin and
Doxorubicin have antiemetics, such as Graniestron and Dexamethasone, prescribed as
part of the protocol for the regimen. Patients who are receiving treatment with a lower
ematogenic potential have “as required” antiemetics prescribed. Where regular
antiemetics are prescribed it is important to ensure they are administered while the
patient is in hospital and/or the patient is advised how and when to take them once they
have been discharged home.
Assessment of Fitness to Receive Treatment
The patient’s physical, psychological, emotional and social needs will be assessed prior
to the commencement of each course of treatment. Appropriate referrals will be made as
a result of this assessment.
Prior to receiving anticancer therapy a number of tests will be carried out to identify
whether it is safe for the patient to receive a particular treatment. The tests required are
usually identified in the protocol. Some tests are carried out to ensure the patient is able
to tolerate the potential toxicity of the drug. Examples include: •
•
•
Renal function tests before giving drugs that are renal toxic eg Cisplatin
Blood pressure checks prior to monoclonal antibodies associated with hypertension
(e.g. bevacisumab, sunitinib)
Cardiac investigations prior to giving cardiotoxic drugs eg Doxorubicin, herceptin
(Mallinson 2003).
Other tests are carried out to ensure that the patient is fit enough to receive treatment.
Blood tests of renal and liver function and full blood count are routinely carried out when
a patient is receiving chemotherapy, usually prior to each course. These include:
Blood Chemistry (U&E’s) and Liver Function (LFT’s)
Many anticancer therapy agents are activated in the liver and/or excreted via the
kidneys. Assessing renal and liver function provides an indication of whether the patient
will be able to effectively metabolise and excrete the drugs being given.
Full Blood Count (FBC)
Bone marrow depression is a potential side effect of many anticancer therapy agents
(see page 41). To minimise the risk of infection, sepsis and/or bleeding the patient’s
white cell, platelet and haemoglobin counts need to be above a certain level before
treatment can be given. Before the first dose of anticancer therapy the FBC can be
taken one to two weeks earlier, but once the patient has started a course of treatment it
should be checked 1 to 2 days before the next treatment is given, unless stipulated
otherwise. This is to ensure that the FBC is adequate as counts can change over a few
days depending on where the patient is in the treatment cycle. The low point usually
occurs 5 to 10 days after administration (see page 38).
There may be exceptions to this depending on factors such as diagnosis or
regimen and this should be checked against the local protocols.
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Checking Procedures
Prior to the administration of anticancer therapy the environment must be checked, this
should include the availability of: • Cytotoxic spillage kit.
• Anaphylaxis kit.
• Eye Contamination Kit.
• Extravasation kit.
• Cytotoxic waste disposal.
• Resuscitation equipment.
As with all drug administration it is essential that procedures are in place to ensure that
the right treatment is given to the right patient at the right time. However, this is
particularly important with anticancer therapy as it presents special dangers because
• many agents have a narrow therapeutic index and are toxic even at therapeutic
dosages,
• anticancer therapy regimens are highly complex and
• the timing of administration of particular drugs is dependant on the protocol that the
patient is receiving
(Schwappach 2010).
Checking procedures to minimise the potential for errors are set out clearly in local
anticancer therapy administration procedures. It is vital to ensure that the correct drug is
given to the correct patient at the correct time. Prior to administering treatment the
practitioner should check the following: The Patient
• Understands their treatment including the side effects, measures they could take to
minimise or prevent them and the actions to take if they occur.
• Has provided informed consent and feels prepared and supported.
• Has been assessed by the appropriate health care practitioner (HCP) as being fit to
receive the treatment.
• Has had the tests specified by the protocol carried out (including FBC and other
appropriate tests) and these have been assessed as satisfactory by an appropriate
health care professional.
The Prescription
The practitioner should check that the prescription:
• Is clear, unambiguous, accurate and appropriate for that patient that day.
• Clearly identifies the route of administration that is appropriate for the protocol.
• Includes all concurrent medication or fluids that are part of the protocol
(NMC Standards for medicines management 2008, Dougherty and Lister 2008)
The practitioner will ensure the correct drug is given to the correct patient at the correct
time. This involves checking the following against the prescription with a second
registered nurse; drug name, dose, diluent (type and volume), expiry date, date and time
for administration, route of administration, duration and/or rate of infusion. The
prescription must have been signed by the doctor and have been verified by a
pharmacist.
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The identity of the patient must also be checked by the same two registered nurses. This
should take place next to the patient and include checking the patients name, patient
identification number and date of birth. Shulmeister (2008) identifies a wide range of
possible factors which can increase the risk of patient misidentification including:
• mispronouncing the patients name,
• referring to patients by their first name only,
• passively checking the patients name rather than asking them to state it,
• not using wristbands,
• taking shortcuts in checking such as checking the patients identification at the initial
drug administration but not as subsequent administrations,
• using face recognition based on a belief that you know your patients.
Efforts must be made to minimise the potential of these factors to occur by using correct
checking procedures. In particular the patient must be involved in this check whenever
this is possible by being asked to state their name and date of birth. Where this is not
possible (for example language or communication barriers) extra caution and additional
actions may be required to ensure patient safety.
Evidence from survey studies shows that patients frequently observe, report, and
intercept errors. For example, patients recognize that incorrect drugs or incorrect doses
of the correct drug are being given or that devices such as infusion pumps have
malfunctioned. As patients are the only individuals present during every treatment and
consultation, they are a valuable resource for safe delivery of anticancer therapy
(Schwappach 2010). They should not be relied on to detect errors but involving the
patient in their care and listening to their concerns, along with safe checking procedures
and administration systems, can help to reduce the potential for mistakes.
Assessment of drug interactions
Many anticancer therapy agents can interact with other medications, herbal products
and supplements, either prescribed or purchased over the counter. In some cases
medicines may need dose adjustment or additional monitoring in order to continue
treatment; others are contraindicated. Some groups of medications are more likely to
interact with anticancer therapy than others, for example
• Warfarin, Low molecular weight heparins e.g. Dalteparin, Aspirin, Non Steroidal AntiInflammatory, and many herbal products can affect platelet counts
• Antacids, Ranitidine and Proton Pump Inhibitors e.g. Lansoprazole, Omeprazole,
may affect the absorption of oral treatments.
• Anti-epileptic medications, HIV medications, Claithromycin/Erythromycin, Rifampicin,
Antifungals and St John’s Wort commonly affect metabolism of drugs by the liver.
• Any medications with a narrow therapeutic window (i.e. small increase in dose
causes big increase in toxicity) should also be considered e.g. Digoxin, Warfarin,
Phenytoin, Theophylline, Lithium.
This is not an exhaustive list, if the patient is taking any of these products, or you have
any concerns the full drug history should be ascertained and interactions checked by
pharmacy.
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Measures to Prevent and Manage Acute Side Effects
Acute side effects are those that can occur while treatment is being administered.
Examples of acute side effects include: (i)
(ii)
(iii)
(iv)
(v)
Cholinergic reactions associated with Irinotecan
Hypersensitivity reactions associated with Taxol
Fevers and chills associated with Bleomycin
Central nervous system effects associated with Ifosphamide
Haemorrhagic cystitis associated with Ifosphamide
When administering anticancer therapy it is essential to be aware of any potential
adverse reactions that can occur during administration of particular drugs. Anaphylaxis is
a potential acute side effect that can occur during administration regardless of the route
of administration. The signs, symptoms and management of anaphylaxis are described
on page 36.
Some monoclonal antibodies, including herceptin and rituximab are associated with an
increased incidence of hypersensitivity reactions. Patients need to be closely monitored
for signs of hypersensitivity reactions during administration of these drugs.
Premedication to reduce the incidence and severity of these reactions are given before
they are administered.
Rituximab is given according to a protocol which outlines the rate of administration. The
rate of administration varies according to the number of treatments the patient has
received and the patient’s reaction to rituximab. For example, the first time a patient is
given rituximab the infusion is given at a relatively slow rate. If the patient does not have
a hypersensitivity reaction while this dose of rituximab is being given it can be given at a
faster rate on subsequent infusions. The rate of administration for each cycle is clearly
set out in the rituximab protocol which must be followed. Pre-medication is given before
rituxmab to reduce any hypersensitivity reactions. The pre-medication is set out in the
rituximab protocol and includes: chlorphenarimine, paracetmol and steroids
Having discussed the principles that underpin the administration of all anticancer
therapies, the next section identifies some of the key issues relating to particular routes.
Methods of administration of Intravenous anticancer therapy
Cytotoxic drugs can be administered intravenously by bolus injection or continuous
infusion via peripheral cannula or central venous access device (CVAD). The potential
benefits and hazards of these approaches are as follows: Bolus Injection
Bolus injection allows for continual assessment of the integrity of the vein and early
detection of infiltration/extravasation. However, it can increase the risk of vein irritation
due to the constant contact of the drug with the vein. This can cause pain at the insertion
site and lead to difficulties with distinguishing between venous spasm and extravasation.
Bolus Injection via a Side Arm of a Free Flowing Infusion
Bolus via a side arm assists with dilution of potentially irritant drugs and aids rapid
circulation away from the insertion site. It also allows for continual assessment of vein
integrity and the early detection of extravasation. This method is recommended for the
administration of bolus vesicant drugs. However, small veins/cannula can lead to a slow
rate of infusion and the drug can come back up the giving set.
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Infusional administration
Infusional administration allows increased dilution of the drug reducing chemical irritation
at the site. However, blood return cannot be assessed frequently and the longer the
infusion, the greater the possibility of needle dislodgement. Extravasation may be
difficult to detect until a large volume has infiltrated so whenever possible this method
should not used for vesicants (Dougherty 2008).
Infusion based anticancer therapy can be given as: • Intermittent.
• Continuous.
• Ambulatory continuous infusion. This is given via a central line access and allows
patients to receive treatment at home.
The method chosen for administration will depend on a combination of factors including
the drug, dose and treatment schedule/timing.
A small number of anticancer therapy agents require administration via specially
designed giving sets. For example taxol needs to be given through a taxol giving set
which has an in line filter. Other agents may require light sensitive infusion sets.
Vinka alkaloid administration
Vinca alkaloid drugs include vincristine, vinblastine, vinorelbine and vindesine. All Vinca
alkaloid chemotherapy is dispensed in 50 ml mini-bags. This practice aims to reduce the
possibility of accidental intrathecal administration of vinca alkaloid drugs.
Vinca alkaloid chemotherapy agents are vesicants (see page 27). In most cases
vesicant agents are given as a bolus drug at the side arm of an infusion to enable close
observation of the vein during administration. The same high levels of assessment and
observation are required when administering vinca alkaloid drugs as a bagged infusion.
During the infusion of vinca alkaloids the practitioner must remain with the patient
observing the vein and ensuring the anticancer therapy is being administered safely.
Steps must be taken to ensure the vein is patent prior to, and during, the administration
of the vinca alkaloid. Prior to commencing vinca alkaloid administration an infusion of
sodium chloride 0.9% should be run as a free flow infusion. During infusion the nurse will
assess that the cannula/CVAD is patent and safe to use. The cannula/CVAD should not
be used if any of the following signs of infiltration/ extravasation are present:
•
•
•
Pain, redness, swelling or blistering near the cannula site.
Indurations, swelling or leakage from the cannula site
Absence of free flow during administration of an infusion
(Hadaway 2007, Saureland 2006, Dougherty 2008)
If patency has been established and no problems are experienced the vinca alkaloid
drug should be given as a free flow infusion at the prescribed rate (usually 5- 10
minutes). Following administration of the vinca alkaloid the line should be flushed with a
sodium chloride 0.9% infusion as prescribed.
The table overleaf presents the potential local effects which can occur in the vein and
surrounding tissue with anticancer therapy administration. It is essential that the nurse
administering intravenous treatment has a good understanding of these complications
and the actions they can take if they occur.
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Potential problems that can occur with the vein and surrounding tissues with
anticancer therapy administration (Dougherty 2008, Sauerland 2006, Wells 2008).
Symptom
Explanation
Cold sensation along
the vein.
Often related to the difference between the temperature of the drug
and the temperature of the patient.
Local allergic reaction
(flare response).
Red streak, blotching or hive like erythema from the insertion site
along the vein caused by a venous inflammatory response. There
may also be itching at the site. Symptoms usually subside within 30
minutes with or without treatment.
Chemical phlebitis.
Caused by the repeated administration of irritant drugs. Early signs
include pain, oedema, redness and sensation of warmth. Can make
it difficult to find veins future for cannulation.
Discolouration of the
veins.
Later side effect. Mechanism unknown, usually disappears 2 – 3
months after treatment and causes no other adverse effects.
Incidence highest with particular drugs eg 5 FU and Vinblastine.
Vessel irritation.
An irritant is an agent that can cause aching, tightness and phlebitis
along the injection site or along the vein with or without an
inflammatory reaction. Presenting symptoms include aching and
tightness at the site and erythema or dark discoloration along vessel.
Venous spasm.
Sudden involuntary contraction of a vein resulting in temporary
stopping of the flow of blood through the vein caused by a cold
infusion or irritation by the drug being infused. Presenting symptoms
include pain and cramping above the infusion site.
Action: Consider the likely cause. If it could be the speed of infusion
– continue at a slower administration rate. If it could be from
chemical irritation – dilute the drug being given further if possible
and/or run at a slower rate
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Extravasation
Extravasation is the inadvertent administration of a vesicant drug or solution from a vein
into the surrounding healthy tissue (Sauerland 2006). The majority of anticancer therapy
agents are capable of causing irritation and damage to the vein and surrounding tissue if
they are accidentally administered outside of the vein. However, some agents are also
vesicants. A vesicant is a drug that causes formation of blisters with subsequent tissue
necrosis which requires treatment to limit tissue damage (Dougherty 2008).
The potential consequences of extravasation with vesicant drugs include:
• progressive tissue damage,
• functional and sensory impairment due to damage to vital structures such as
tendons, ligaments and nerves
• surgical intervention such as skin grating and debridement if tissue damage is severe
• psychological distress
• litigation from the patient
(EONS 2007, Hadaway 2007)
Preventing extravasation is an essential component of the care of patients during the
administration of intravenous therapy and a range of measures can be taken to minimise
the potential for extravasation. These include factors relating to venous access and
factors relating to the drug being administered.
Extravasation Risk Factors Relating to Venous Access
Cannulation Technique
The skill level of the person performing cannulation is a key risk factor for the occurrence
of extravasation (EONS 2007). When cannulation is problematic assistance should be
sought from an experienced cannulator. It is recommended that help should be sought
after two failed attempts at cannulation. Measures to aid cannulation in difficult veins
and promote vasodilation may be useful eg heat pads (dependant on local policy).
Cannulation Site
The size and quality of blood vessels is an important factor to consider in preventing
extravasation. Cancer patients often have poor venous access due to multiple episodes
of venepuncture/cannulation and an increased occurrence of damaged veins from
previous treatment administrations. This can make vein choice difficult (Wells 2008).
Arms with occluded venous or lymphatic drainage (eg lymphoedema, SVCO) should not
be used. In patients with breast cancer the arm of the unaffected side should be used for
cannulation whenever possible. There is a risk of poor lymphatic and venous circulation
in the arm on the affected side, particularly, if the patient has had surgery and axillary
node clearance. If there are problems with venous access on the unaffected side advice
should be sought from the Consultant before using the other arm.
Pathological vascular conditions can also give rise to physical problems with
cannulation, for example, Raynauds disease, diabetes, radiation damage. These
conditions can lead to poor venous access and a decreased sensation of pain reducing
the patient’s awareness of problems at the cannula site during treatment administration.
Steroid therapy may suppress the inflammatory response reducing the visible signs of
extravasation.
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The degree of harm that can occur following extravasation can be influenced by the
location of the cannula. Large diameter veins of the mid-forearm are preferred for drug
administration as there would be less functional impairment if extravasation damage
occurred. Veins over vital nerves or tendons or those at sites of flexion should be
avoided due to the potential impact of damage on nerve and joint function. In particular,
veins in the antecubital fossa should not be used as the large amount of subcutaneous
tissue in the area can make early detection of extravasation difficult (EONS 2007).
The aim of cannulation for the administration of anticancer therapy is to use the optimal
vein ie a palpable vein which will adequately take the cannula being used and allow the
necessary venous access for the drug being given. Vein selection should be based on
this assessment. For this reason a large palpable vein on the hand may be preferable if
there is poor venous access on the mid-forearm (Dougherty 2008). Other factors which
need to be considered are the length of time the cannula needs to be in place and the
degree of supervision which the cannula will receive during administration.
Cannulation below (distal) to an earlier attempted cannulation, or venepuncture site can
lead to leakage of the anticancer therapy through the previous puncture sites and should
be avoided (EONS 2007).
Choice of Intravenous Device
Short and flexible peripheral catheters with a small gauge are recommended as they: • Are less likely to puncture the posterior wall of a small vein.
• Cause less pain on insertion.
• Increase the blood flow around the needle, increasing the dilution of the drug.
• Reduce the risk of mechanical phlebitis.
• Are less likely to lead to scar tissue formation.
(Hadaway 2007, Dougherty 2008)
Central venous access devices (eg Hickman/PICC lines) are preferred if cannulation is
likely to be difficult or the patient is going to receive a course of irritant drugs, as there is
less chance of displacement from the vein (EONS 2007). However, the chance of
extravasation is NOT eliminated with central venous access devices and extravasation
into the chest wall, neck and thoracic cavity can cause significant tissue damage.
Causes of extravasation with a central venous access device include dislodgement of
the catheter, thrombosis at the tip causing back tracking, and catheter fracture caused
by “pinch off syndrome”. If the CVAD was inserted into the subclavian vein and changing
the patient’s position relieves the obstruction, suspect pinch-off syndrome. Obtain a
chest x ray to assess for catheter compression. Be sure to inform the radiology
department about the reason for the test so they can position the patient correctly. As
this complication is associated with a risk of line fracture and extravasation the CVAD
should not be used if this is confirmed.
The cannula or CVAD and infusion giving set must be secured appropriately to reduce
the risk of dislodgement and irritation of the vein (Hadaway 2007).
Administration techniques
Vein patency assessment prior to, and during, administration is essential to prevent
extravasation. When possible chemotherapy should be given through a newly sited
cannula as the quality of venous access can deteriorate the longer a cannula remains in
place. Extra care must be taken if a previously sited cannula is to be used. If there is
ANY doubt as to the patency of a cannula before or during chemotherapy administration
it must be re-sited (EONS 2007).
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Steps for Assessing Patency
Peripheral Intravenous Cannula
• Remove any bandaging and check the dressing over the cannula is intact.
• Check the cannula entry site is free from inflammation, swelling, redness, leakage.
• Check patency by observing the cannula site in use. If an IV infusion is in progress
observe the cannula while this is being given, otherwise flush with 0.9% Sodium
Chloride.
• Check that: - No resistance is felt during injection/there are no interruptions to free flow.
- No leakage or swelling occurs around the cannula site.
- There is good blood return.
- The patient does not experience discomfort or change in sensation at the cannula site.
If any problems occur consider re-siting the cannula.
Hickman/PICC Lines
• Check the exit site is free from inflammation, redness and/or swelling
• Assess whether the line has moved: - Does the line seem longer?
- Is the Dacron cuff on a Hickman line visible?
- Does the patient report a difference in the length of the line?
- Is the length of the PICC line different from the PICC insertion details?
• Check patency by observing the CVAD in use. If an IV infusion is in progress
observe the CVAD while this is being given, or flush with 0.9% Sodium Chloride.
Check that: - No resistance is felt during injection/there are no interruptions to free flow.
- No leakage or swelling occurs around the CVAD site.
- There is good blood return.
- The patient does not experience discomfort or any changes in sensation at the CVAD
site, in the chest/neck/ear or arm
Assess the extremity, chest and neck for signs of venous thrombosis
If any of these problems are observed do not proceed with drug administration,
refer to the doctor/ experienced central line practitioner. Problems may indicate that
the line is incorrectly positioned, it may have become dislodged or migrated, it may be
partially or completely blocked. Further investigation is required to ensure the CVAD can
be used safely. This may include radiology investigations to confirm line tip location or
actions to manage partial line blockage. For further information see North Trent Central
Venous Access Device policy
If fluid can be infused easily but blood return is absent this can indicate persistent
withdrawal occlusion, commonly caused by the formation of a fibrin sheaf over the tip of
the lumen. This has the potential to occlude the catheter causing leakage of fluid around
the CVAD site leading to infiltration/extravasation. Patency must be ascertained
before using the CVAD, particularly prior to giving vesicant or irritant drugs. Refer
to the Flowchart for the Management Persistent Withdrawal Occlusion (PWO) (see North
Trent CVAD policy).
Implanted ports are associated with an increased risk of extravasation/infiltration than
other CVAD’s. When accessing a port use a non coring needle of the proper size and
length. Inspect for fluid leakage and oedema and other signs of needle dislodgement. Do
not use unless you are confident the ports has been accessed correctly and is patent.
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Extravasation Risk Factors Relating to Drugs
Knowledge of the Vesicant Potential of a Drug
Prior to administering anticancer therapy it is essential to know the potential damage that
can be caused by the particular drug being given if extravasation should occur and the
correct course of action that should be taken. Some agents bind to the DNA of
surrounding tissue and can be present months after the extravasation has occurred,
consequently, tissue destruction can occur over time. Following vesicant extravasation
tissue damage may not occur immediately and visual inspection at the time is not
enough to determine the potential for, or extent of, damage. Follow up after the event to
assess damage is essential.
Amount of vesicant infiltrated
Continuous visual inspection of the site plays an important role in the early detection of
extravasation and should be employed when a vesicant is being given. Early detection
is more difficult during a continuous infusion of treatment and regular and frequent
inspection of the cannula site should take place.
Patient involvement
Patients play a vital role in preventing and minimising extravasation. The role of the
patient in alerting staff to potential problems is crucial and patients need to be informed
of the signs of potential problems (eg pain, change in sensation, redness, swelling) and
be encouraged to inform the staff immediately if they occur (EONS 2007). Be extra
vigilant in patients with altered sensory function that can reduce awareness of problems
at the cannula site, or those who cannot communicate easily.
Extravasation Procedure
The following describes the actions to be taken following extravasation of cytotoxic
chemotherapy. Not all chemotherapy is vesicant (i.e. can cause severe tissue damage
when given into the surrounding tissue) but most chemotherapy potentially causes
irritation and injury to the tissue and should be treated according to the following
procedure. If tissue damage is suspected then treatment must be initiated quickly.
Objectives
Each practitioner will be able to:
1. Recognise the potential danger of extravasation injuries associated with specific
drugs/solutions which they administer
2. Prevent the complication occurring
3. Recognise the early stages of extravasation
4. Initiate appropriate treatment
Recognition of extravasation from a peripheral cannula
Extravasation should be suspected if any of the following signs are present:
• Pain, redness, swelling or blistering near the cannula site. This should be
distinguishable from a feeling of cold which may occur during the administration of
some drugs/solutions
• Induration (the hardening of a usually soft area of skin), swelling or leakage from the
cannula site
• Absence of blood return
• Resistance on the plunger of the syringe during bolus administration
• Absence of free flow during administration of an infusion
Note: One or more of the above may be present. If extravasation is suspected or
confirmed action must be taken immediately (Hadaway 2007, Dougherty 2008)
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Early firm induration with or without tenderness has been shown to be a reliable sign of
eventual ulceration
• When the full thickness of the skin is damaged the surface may appear very white
and cold with no capillary filling and later may develop a dry, black eschar
• Ulceration is not usually evident until one or two weeks after the injury when the
eschar sloughs to reveal the underlying cavity, ulcers have a typical necrotic
yellowish fibrotic base with a surrounding rim of persistent erythema (National
Extravasation Information Service 2005)
It is important to distinguish extravasation from a flare reaction or venous spasm. A flare
reaction is a local allergic reaction in the vein to the drug being given. The reaction
looks like a nettle rash, and is accompanied by streaking erythema or hives along the
affected vein. It is not usually painful and is not usually associated with swelling or loss
of blood return. The reaction typically tends to subside after 30-60 minutes (Wickman
2006). If the flare reaction is mild you can continue administration at a slower rate and
with increased dilution. If more severe stop administration until the reaction subsides,
then continue at a slow rate.
Venous spasm is caused when the vein is irritated by an intravenous infusion. This is
usually due to the irritant nature of the drug being administered, the cold temperature of
the infusion fluid or too rapid administration of an infusion or bolus injection. Symptoms
of venous spasm include cramp type pain and/or slowing or stopping of the infusion. As
discomfort at the cannulation site or a burning/stinging pain are one of the first
symptoms of extravasation all changes in sensation must be investigated to exclude the
possibility that an extravasation has occurred (Dougherty 2008). If venous spasm has
occurred it can be managed by slowing the infusion rate or diluting the drug further.
Recognition of an extravasation from a Central venous access device
Although extravasation is less likely to occur with a central venous access device than
with a peripheral cannula, it is still possible. To minimise the risk of extravasation, the
line should be checked for patency prior to use. If blood return is absent follow the
Algorithm for Persistent Withdrawal Occlusion (See North Trent Central Venous Access
Device policy). If there is any doubt about line patency seek the advice of a senior
member of medical staff
Extravasation from CVAD’s tend to be more severe than from a cannula, as it is often
more difficult to detect and a greater amount of the drug may have extravasated before
the patient or nurse is aware of the problem.
Signs of central catheter
infiltration/extravasation:
• Aching/discomfort in the shoulder and neck - this symptom is the most common and
should not be overlooked
• Pain or burning of chest wall
• Leakage from catheter exit site
• Swelling of chest wall
• Aching/discomfort in the chest wall
• Fluid leakage at or around exit site and along subcutaneous canal.
Early detection and prompt appropriate action is required to prevent possible
• Skin necrosis
• Scarring around the tendons, nerves and joints
• Secondary infection and abscess formation
• Contracture of affected limbs
• Amputation.
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Managing a suspected extravasation from a CVAD is dependant on clinical
assessment of the symptoms, site of extravasation and the type and volume of drug
involved. An individual risk assessment must be carried out and should include a senior
member of the medical team and an experienced nurse practitioner. If extravasation is
suspected the CVAD must not be used until patency has been verified.
ACTION TO BE TAKEN IF AN EXTRAVASATION OCCURS VIA A PERIPHERAL
CANNULA
1
On suspecting extravasation stop the injection/ infusion immediately.
2
Assess the extent of the extravasation, the drug involved and any help needed.
3
Leave the cannula in place.
4
Explain to the patient what you suspect may have happened and the procedure for
dealing with it.
5
Aspirate any residual drug and blood through the cannula to remove as much of the drug
from the site as possible and minimise tissue damage.
Protective goggles must be worn at this stage.
6
Remove the cannula. Mark round the extravasated area with a pen to provide a baseline
for monitoring the extent of the extravasation. Cover area with sterile gauze
7
Inform doctor if drug involved is group B or C or there are concerns about a group A drug
extravasation.
8
Follow the treatment of extravasation guidelines according to the chemotherapy grouping
pathway. Treatment using an antidote must be prescribed by a doctor prior to
administration unless there is a nurse present who has completed a competency in
administering the specific antidote required under a patient group direction. If the drug is
not covered by the guidelines contact pharmacy for advice.
9
If group B or C or large volume A consider need for referral to the plastic surgery team
10
Provide analgesia as required. Consider use of antihistamine if appropriate.
11
Measure the affected area and document in the patient record. Arrange photographs with
the medical photographer if available if there are any visible signs of an extravasation.
12
Complete the North Trent extravasation reporting form. Complete local incident reporting
form. Ensure copies are sent to the appropriate personnel according to local policy.
13
Complete the Green National Extravasation Reporting Card and submit to Birmingham.
http://www.extravasation.org.uk/greencard
14
Observe the site regularly for erythema, indurations, blistering or necrosis. For inpatients
monitor the site at least daily and document progress/changes in the nursing record.
15
When the patient is discharged home ensure appropriate follow up arrangements are in
place. Provide drug guideline specific written information on the ongoing care of the
affected area. Ask the patient/ carer to observe the site at least daily and contact the
hospital if they notice an increase in discomfort, blistering or peeling of the skin.
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16
Patients with extravasations from Group A drugs should be asked to contact the
ward/department where they were treated if they have any concerns.
If factors suggest that extravasation is more likely to be problematic with a patient in this
group (e.g. large volume of chemotherapy extravasated) arrange for the patient to be
contacted by the ward/dept. where they received treatment within 48 hours after
discharge.
17
Patients with extravasations from Group B or C drugs should be asked to return
for assessment of the effected area within 48 hours following discharge. Follow up care
should be documented on the North Trent extravasation follow up form
After 48 hour further follow-up will be based on the individual assessment. Some
patients may need to be recalled for further review and discussion with the consultant
regarding referral to other health care professionals. Where appropriate liaise with tissue
viability nurse and/or plastic surgeons if indicated.
If there is visible tissue damage, take a photograph of the affected area, and file in the
patients medical notes.
Referral to plastic surgeons following group B, C or large volume A extravasation must be
considered. This is particularly the case if any of the following criteria are present.
•
•
•
•
•
•
Pain or changes in sensation that continue to be present once the immediate
extravasation incident has passed
Lesion greater than 2 centimetres
Functional changes
Blistering
Induration (the hardening of a usually soft area of skin)
Affected area appears white and/or cold with reduced capillary filling (absence of blanching)
However, referral must be considered if there are concerns about the extent or
consequences of any extravasation incident.
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ACTION TO BE TAKEN IF AN EXTRAVASATION OCCURS VIA A CVAD
1
On suspecting extravasation stop the injection/ infusion immediately and investigate
further. An individual risk assessment must be carried out and should include a senior
member of the medical team and an experienced nurse practitioner.
2
On confirmation of extravasation assess the extent of the extravasation, the drug
involved, the volume, the site and any help needed.
3
Leave the CVAD in place at this point.
4
Explain to the patient what you suspect may have happened and the procedure for
dealing with it.
6
If extravasation is confirmed aspirate any residual drug and blood through the CVAD to
remove as much of the drug from the site as possible and minimise tissue damage.
Protective goggles must be worn at this stage.
Follow the treatment of extravasation guidelines according to the chemotherapy grouping
pathway. Treatment using an antidote must be prescribed by a doctor prior to
administration. If the drug is not covered by the guidelines contact pharmacy for advice.
7
Provide analgesia as required. Consider use of antihistamine if appropriate.
8
Measure the affected area and document in medical notes (doctor), and nursing record
(nurse). Arrange photographs if there are any visible signs of an extravasation.
9
Discuss and organise plans for line removal. If Hickman line or port consider seeking
advice from plastic surgeons regarding removal to minimise tissue damage.
All CVADS: A referral to the plastic surgeons should be considered at the earliest
opportunity.
10
Complete the North Trent CVAD extravasation reporting form. Complete incident
reporting form. Ensure copies are sent to the appropriate personnel according to local
policy.
11
Complete the Green National Extravasation Reporting Card and submit to Birmingham.
12
Observe the site regularly for erythema, indurations, blistering or necrosis. For inpatients
monitor the site at least daily and document progress/changes in the nursing record.
13
When the patient is discharged home ensure appropriate follow up arrangements are in
place. Provide the patient with information on the ongoing care of the affected area.
Ask the patient/ carer to observe the site at least daily and contact the hospital if they
notice an increase in discomfort, blistering or peeling of the skin.
14
All Patients with CVAD extravasations should be asked to return
for assessment of the effected area within 48 hours following discharge
After 48 hour further follow-up will be based on the individual assessment. Some
patients may need to be recalled for further review and discussion with the consultant
regarding referral to other health care professionals. Where appropriate liaise with tissue
viability nurse and/or plastic surgeons if indicated.
If there is visible tissue damage, take a photograph of the affected area, and file in the
patients medical notes.
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Documentation of extravasation
Extravasation events must be thoroughly documented and reported. Clear record
keeping will facilitate the patient’s ongoing care. It may also be required in the case of
litigation (Dougherty 2008). The purpose of documentation following extravasation is to:
•
•
•
•
Provide an accurate account of what happened and the action that was taken
Protect the healthcare professionals involved (showing they followed correct
procedures)
Gather information on extravasations, how and when they occurred – for audit
purposes
Highlight any possible deficits in practice which require review
(EONS 2007)
Intramuscular/Subcutaneous Administration of anticancer therapy
Only a few anticancer therapy drugs can be administered via this route as many are too
irritant, can cause tissue damage and/or they cannot be absorbed by this route
(Dougherty and Lister 2008). Prior to intramuscular administration it is important to
check the patient’s platelet count. The count should be above 50 to reduce the risk of
excessive bleeding at the injection site.
The principles of safe practice used for the administration of intravenous anticancer
therapy must be applied when administering intramuscular/subcutaneous agents. For
example, protective equipment should be used and waste must be disposed of as
cytotoxic waste.
Oral anticancer therapy
One of the misconceptions about oral anticancer therapy is that it has less potential side
effects than treatment given by other routes in particular the intravenous route. However,
it is important to note that some oral anticancer therapy drugs have potentially severe
and distressing side effects.
Some oral anticancer therapy drugs have a coating which protects the drug and/or
prevents it from coming into contact with the patients oral mucosa. It is important to
asses the patients ability to swallow the tablet/capsule whole before they take oral
anticancer therapy. If they are unable to do so liaise with the doctors and pharmacy
about appropriate alternatives/action.
Each oral anticancer therapy will have its own instructions for dose and timing of
administration. Some agents need to be taken at particular times in relation to food (e.g.
pre or post meals). Others cannot be taken within a certain time of other medication – for
example, capecitabine must not be taken within 2 hours of antacids. It is important to
confirm that the patient understands this information when they are given their tablets to
take home.
Oral anticancer therapy is often taken by the patient at home. Patient information is an
essential aspect of care as it is vital that the patient understands the importance of
adhering to the administration schedule prescribed.
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It is essential to ensure that the patient understands the following:
how to take the tablets (dose, time, frequency, duration of course)
the medicine has been prescribed for them and should not be given to anyone else
the medicine should be stored in a safe place – particularly out of the reach of
children
what to do if they miss a dose – i.e. they should not try to catch up but should miss
that dose and take the next dose as prescribed
the side effects of treatment and what to do if they experience them
how to obtain further supplies
to return any unused tablets to the hospital pharmacy (Dougherty and Lister 2008)
It is vital that patients on oral anticancer therapy are aware that if they develop side
effects they must contact the treatment centre for advice before they take their next
dose. They must be informed that they should not continue their course of treatment until
they have spoken to a member of the oncology team.
Issues to be considered with administering oral anticancer therapy include: (i)
Always wear gloves when handling oral anticancer therapy and use minimal
handling techniques.
(ii)
Never crush tablets or open capsules as there is a risk of powder being released
that could be inhaled.
Liaise with the doctors/pharmacy if the patient is unable to take a tablet or the
dose prescribed cannot be given by the tablets dispensed.
(iii)
Assess that the patient is able to swallow the medication whole before you give it
to them and ensure they know they should not chew of crush the tablet/capsule.
(iv)
Wash hands after administering tablets.
(v)
Ensure the patient takes the tablet when you give it to them, do not leave it for
them to take “later”.
Administering oral anticancer therapy in the inpatient care setting
A recent National Patient Safety Alert identified specific risks associated with patients
being admitted to hospital who are currently on a course of oral anticancer therapy
(NPSA 2008). These relate to decision making around the continuation of treatment and
potential errors in prescription and administration.
Decisions around continuation of oral anticancer therapy
On admission to hospital patients may be experiencing side effects of their oral
anticancer therapy which requires a cessation of treatment or dose reduction. A decision
must be made by a senior oncology doctor (SpR or above) as to whether the patient
should continue their course of treatment prior to it being prescribed and administered.
To ensure this the doctor prescribing the medication must consult with a senior medical
member of the oncology medical team prior to it being prescribed. The nurse
administering oral anticancer therapy must ensure that the decision to continue with
treatment has been agreed by a senior oncology doctor.
Correct prescribing of oral anticancer therapy
It is essential that the patient receives the correct dose and schedule of oral anticancer
therapy. This information is contained on the chemocare prescription which may not be
available when the patient is admitted. Prior to prescribing the oral anticancer therapy a
copy of the chemocare prescription should be obtained. A copy of the prescription can
be obtained from pharmacy dispensary or it can be printed from chemocare. When oral
anticancer therapy is prescribed on the inpatient drug chart, the nurse must also check
the drug against the chemocare prescription before administration.
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MODULE 4
SIDE EFFECTS OF ANTICANCER THERAPY
Potential Systemic Side Effects
The incidence and severity of the side effects of anticancer therapy are related to the
specific drugs used and the dose being given. This section is a description of some of
the more common side effects, which can occur as a result of anticancer therapy. It is
important to note that patient information and advice on the side effects of treatment
must relate to the specific regimen the patient is receiving.
Side effects can be classified as immediate, short and long term. However, some side
effects do not fit neatly within this time frame – for example bone marrow depression can
occur before 7 days post treatment administration. Similarly, fatigue can occur within
days of treatment administration, but can continue for many weeks or months.
Onset
Time
Side Effect
Immediate
Occurs within thirty minutes
of administration.
Venous pain
Facial/body flushing
Cardiac Arrhythmias
Hypotension
Hypersensitivity reactions
Anaphylaxis
Haemorrhagic cystitis
Abnormal tastes and smells
Short to medium
term
Occurs within hours and up
to seven days of
administration.
Discoloration of urine
Tumour lysis syndrome
Nausea and vomiting
Stomatitis/mucositis
Tumour pain
CNS toxicity
Anorexia
Fatigue
Constipation
Diarrhoea
Taste aberration
Medium to Long
Term.
Occurs later than seven
days and may be
cumulative in nature.
Bone Marrow depression
Alopecia
Hand foot syndrome
Dermatitis
Liver dysfunction
Renal toxicity
Cardiac toxicity
Peripheral neuropathy
Pulmonary fibrosis
Changes in fertility
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Anaphylaxis
Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity
reaction. It is characterised by rapidly developing life-threatening airway and/or breathing
and/or circulation problems usually associated with skin and mucosal changes
(Resuscitation council 2008). Anaphylaxis is a medical emergency - death can occur
within seconds. Anaphylactic reactions can be biphasic in up to 5 % of cases and the
reaction may reoccur between 1 and 72 hours later.
Identifying factors that can lead to an increased risk of occurrence of anaphylaxis is
essential before giving anticancer therapy to a patient. Some patients are at increased
risk of anaphylaxis and it is good practice to assess the patient’s history of allergies and
discuss any increased risk factors with the medical team prior to administering
treatment. Increased risk factors include patients: With a history of asthma, eczema or allergies
Who have had previous reactions to drugs
Who have reacted to the drug currently being given on a previous occasion.
Some anticancer therapy agents are also associated with increased incidence of
anaphylactic or hypersensitivity reaction. These include: monoclonal antibodies,
carboplatin, cisplatin, L-asparaginase and taxanes (Souhami and Tobias 2005). Local
procedures should be in place for early detection and prompt treatment when giving any
drugs associated with an increased risk of hypersensitivity reaction.
Signs and Symptoms of Anaphylaxis
• Itching or strange metallic taste in the mouth.
• Rash or urticara (hives) anywhere on the body
• Facial and generalised flushing
• General feelings of agitation, irritability, a sense of being unwell but the patient finds
it difficult to be specific, light headedness/weakness.
• Swelling of tongue, lips or throat
• Hoarse voice, stridor
• Hypotension
• Tachycardia
• Difficulty in breathing, wheeze
• Abdominal cramps, nausea
• Respiratory collapse/unconsciousness
(Resuscitation Council UK 2008)
Treatment
Should any of the above symptoms develop you should: (i)
(ii)
(iii)
(iv)
(v)
(i)
(ii)
(iii)
Stop administration of drug.
Assess patient for airway, breathing and circulation.
Put out an urgent call for emergency medical help.
Elevate patients legs, start oxygen 10-15/litres/min.
If signs of shock, stridor, wheeze or respiratory distress, give Epinephrine
(Adrenaline) 0.5ml of 1 in 1,000 (1mg/1ml) IM as prescribed.
Change IV giving set and give 0.9% saline quickly (500ml/5minutes) as
prescribed. Do not give colloids in anaphylaxis.
Check vital signs. Repeat Epinephrine after 5 minutes if no improvement.
Patients may also be given Piriton 10mg and Hydrocortisone 200mg IV, IV fluids
and nebulisers eg Salbutamol as prescribed.
(Resuscitation Council UK 2008)
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Nausea and Vomiting
There are three types of nausea and vomiting associated with anticancer therapy: Acute: Starts within minutes to hours of treatment administration and resolves within 24
hours
Delayed: Occurs 16 to 24 hours post treatment and persists for hours to days
Anticipatory: A conditioned response in which the patient experiences nausea
and/or vomiting in anticipation of receiving their treatment. This often occurs when
acute/delayed nausea and vomiting were not well managed at previous administrations
Nausea and vomiting in relation to anticancer therapy is referred to as chemotherapy
induced nausea and vomiting (CINV). It is drug type and dose related and is thought to
involve the actions of the vomiting centre and the chemoreceptor trigger zone in the
brain and the neuro-transmitters dopamine, serotonin and substance P (Tadman and
Roberts 2007). Anti-emetics used in the prevention and treatment of CINV work by
blocking the action of the neurotransmitters. They include serotonin (5HT3) antagonists
such as Granisetron and Ondansetron and dopamine antagonists such as Domperidone.
Aprepitant is a relatively new anti-emetic which works by blocking the receptors in the
vomiting centre (neurokinin 1 receptors) that are activated by substance P. The steroid
Dexamethasone is also widely used in the prevention and treatment of chemotherapy
induced nausea (Miller 2004). Each of these antiemetics works in a different way and
can be used in combinations to prevent or treat CINV.
While different patients react differently to their anticancer therapy there are some risk
factors which increase the potential for nausea and vomiting. These include:
• Younger age (less than 50)
• Female gender
• No/minimal history of alcohol use
• Prior CINV
• History of travel sickness
• Anxiety
The ematogenic potential of specific agents has been identified and anti-emetic
protocols have been established based on the degree of nausea and vomiting likely to
occur with each drug. The table below provides examples of the ematogenic potential of
a range of different agents.
For drugs which are likely to result in moderate to severe nausea and/or vomiting
prophylactic anti-emetics are prescribed. For example, patients receiving Cisplatin are
given IV Dexamethasone and Granisetron prior to receiving their chemotherapy and
regular oral Dexamethasone for the following three days. Aprepitant can also be given
when there is an increased potential for CINV. When it is used in combination with
standard anti-emetic therapy it provides benefit in the acute phase and also the delayed
phase of CINV.
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Examples of the ematogenic potential of different drugs
HIGH RISK (>90%)
Actinomycin D
Carmustine
Cisplatin
High dose Cyclophosphamide
Ifosfamide
Cytarabine
Dacarbazine
MODERATE RISK (30-90%)
Carboplatin
Daunorubicin
Doxorubicin (Adriamycin)
Epirubicin
Idurabicin
Ifosphamide
Melphalan
Oxaliplatin
Vonorelbine
LOW RISK (10- 30 %)
5flourouracil
Aspariginase
Cytarabine
Docetaxel
Etoposide
Fludarabine
Gemcitabine
Paclitaxel
Pemetrexed
The HCP has an essential role to play in managing nausea and vomiting. This includes:
• preventing or minimising symptom occurrence and severity by ensuring the patient
receives appropriate anti-emetics
• assessing the effectiveness of the anti-emetics taken and ensuring they are reviewed
if nausea and vomiting are not controlled
• evaluating the physical, social and psychological impact that the symptom is having
on the patient
Patients may not always report the extent of their CINV as they may feel it is part of the
treatment they have to put up with. They may also be concerned about appearing weak
or their treatment being stopped. It is essential to tell patients before their treatment
commences that CINV can be controlled. When the patient returns for the next treatment
ask them about their symptom severity. If they did experience CINV check that their antiemetic regimen has been reviewed and reassure them that alternative anti-emetic
options are available and CINV can be controlled for most patients.
The assessment of nausea and vomiting should include the use of the common toxicity
grading scores below (Vidal 2011). The aim of symptom control should be to achieve
grade 1 or lower.
Symptom
Grade 1
Grade 2
Grade 3
Grade 4
Nausea
Able to eat
reasonable
intake
Intake
significantly
decreased but
can eat
No Significant
intake
-------
1 episode in 24
hours
2-5 episodes in
24 hours
6-10 episodes
in 24 hours
Vomiting
More than 10
episodes in 24
hours or
parenteral or
enteral support
Patients on oral chemotherapy with nausea and vomiting of grade 3 or 4 or grade
2 for more than 24 hours should be advised NOT to continue their oral anticancer
therapy treatment until they have been assessed by a senior oncology doctor.
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Bone Marrow Depression
Bone marrow depression is a temporary cessation of the bone marrow’s ability to
produce blood cells. This can lead to neutropaenia, thrombocytopenia and anaemia.
Neutropaenia
Neutropaenia is the term used to describe an abnormally low number of circulating
neutrophils (Grundy 2000, Wardley 2000). The neutrophil being the most important
white blood cell needed to combat infection (Wardley 2000). Neutropenia is said to
occur when the circulating netrophil count is less than 1 (Grundy 2000). Neutropaenia is
the most common dose limiting toxicity associated with anticancer therapy. The nadir,
the lowest point of the drop of the white cell count, commonly occurs 7-14 days after
treatment administration. However, it can occur earlier or later than this in the treatment
cycle and should always be considered if a patient presents with symptoms of infection.
The white cell count usually improves by three to four weeks after administration,
enabling further treatment to be given.
All regimens can potentially cause neutropaenia. However, a number of risk factors are
associated with a higher incidence. These include: the type and dose of the drug being
given, previous history of neutropaenia with similar drugs, concurrent radiotherapy to
sites containing bone marrow, older age, poor performance status, poor nutritional status
and co-morbid conditions e.g. COPD, diabetes, cardiovascular disease, liver disease
(Nirenberg 2006a).
Patients with neutropaenia have an increased susceptibility to infection and a reduced
ability to fight it (Coughlan 2008). Complications of neutropaenia include hospitalisation
and reduced treatment efficacy due to delays in treatment and/or dose reductions as
treatment is not usually given while the white cell count is low. The most significant
potential consequence of neutropaenia is death due to infection and sepsis (NCEPOD
2008, Nirenberg 2006a). Patients must be made aware that their ability to fight infection
can be compromised if they develop a low white cell count. They must be advised to
contact the cancer centre if they develop an elevated temperature (37.5oc or above) or
any signs of infection to arrange for admission for a full blood count test and
assessment.
In order to reduce the risk of infection patients should be advised to avoid sources of
infection such as people with colds, sore throats, measles etc and people recently
vaccinated with live vaccines such as MMR and DPT (diphtheria, pertussis, tetanus).
Patients should be advised to avoid dental treatment while they are receiving
chemotherapy due to the risk of introducing infection during dental procedures. If this
treatment is necessary the blood count must be checked before it is carried out.
The nursing care plan for a patient with a low white cell count should include: • Vigilant observation of temperature, pulse, blood pressure, respiratory rate, oxygen
saturations and level of consciousness.
• Careful hand washing by the patient and healthcare staff. This must be stressed to
the patient as well as the hospital staff providing care. (Nirenberg 2006b).
• Maintaining personal and oral hygiene; regular oral assessment and mouth care is
essential due to the risk of opportunistic infections such as candida (Coughlan 2008).
• Careful monitoring and aseptic handling of “at risk” sites such as cannula/central
venous access devices.
• Preventing trauma to the skin and mucous membrane eg avoiding the use of
enemas and suppositories.
• Avoiding actions such as catheterisation, which can potentially introduce infection.
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Neutropenic Sepsis
Patients with a low neutrophil count (below 1.0 x 109/l) are at risk of developing
neutropenic sepsis. In patients with a reduced neutrophil cell count the onset of severe
sepsis may be rapid and severe. It is important to note that the usual signs of infection
may be absent as the immune response is inhibited, in many cases the first and only
sign of infection may be a raised temperature (Coughlan 2008). In severe sepsis or
septic shock the temperature may be low.
The surviving sepsis campaign set out internationally agreed definitions and protocols
for the detection and management of sepsis which provide a firm foundation for caring
for patients with neutropaenic sepsis (Dellinger 2008).
Definitions of sepsis and septic shock
Sepsis
Known or suspected infection with 2 or more of the following symptoms
Temp above 38 or below 36
Pulse more than 90
Respiration rate more than 20
White cell count below 4 x 109/l or above 12 x 109/l
o NB for neutropaenic patients the count would be below 1 x 109/l
Severe sepsis
Symptoms of sepsis PLUS organ dysfunction, low blood pressure or poor perfusion
Indications of organ dysfunction:
Systolic BP less than 90 (or mean BP less than 65)
Altered mental state
O2 saturation levels less than 95%
Urine output less than 0.5 ml/kg/hr
Serum lactate above 2 mmols
INR above 1.5, APPT above 60 seconds
Platelets less than 100 (however, this may be associated with treatment or
underlying disease in chemotherapy patients)
Septic shock
Severe sepsis PLUS hypotension which does not respond adequately to fluid
resuscitation (i.e. the rapid administration of IV fluids)
Other signs: decreased capillary refill, skin mottling, positive fluid balance, metabolic
acidosis (blood pH less than 7.35, bicarbonate less than 20 mmol)
NB It is important to note that patients with neutropaenic sepsis can be critically ill with
minimal symptoms as the clinical signs of septic shock can be subtle. They may NOT
have pyrexia. Observe for pallor, mottled skin, tachycardia, altered mental state, anxiety,
increased respiration rate and hypotension.
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Key factors in the treatment of neutropaenic sepsis
Bloods tests to include:
o Full blood count,
o blood cultures – if the patient has a CVAD both peripheral and CVAD cultures
should be obtained
o urea and electrolytes, lactate, glucose, liver function tests and clotting screen
as appropriate
Administration of intravenous antibiotics as soon as possible. The type of antibiotic
is identified in the neutropaenic sepsis antibiotic protocol.
o if the patient shows signs of severe sepsis or septic shock antibiotics should
be given before the neutrophil count has returned
•
Vigilant monitoring of observations and patient’s condition using the hospital’s Early
Warning Score system
•
Support through the physiological crisis
o Oxygen to achieve saturation levels above 95%
o IV fluids
If BP below 90 (or 40 below the normal BP for the individual patient)
intravenous fluid challenge should be given as prescribed
Monitor urine output
Risk assess with senior medical staff the need for urinary catheterisation
balancing the need for accurate monitoring of urine output against the
risk of infection. This decision should be made by a senior registrar or
consultant
Evaluate potential source of infection –
Take specimens as indicated e.g. sputum, throat swab, urine, stool
Regular medical review
the efficacy of treatment must be reviewed by the medical team on a regular
basis - at least daily
o
the nurse must notify the doctor promptly if they identify any deterioration in
the patients condition, or if they have any concerns about the patients
progress. If required the local escalation policy should be used appropriately
Referral to the critical care medical team for advice and/or transfer should be considered
at the earliest opportunity if the patient develops signs of severe sepsis, particularly if
there has been no response to the fluid challenge or the serum lactate is elevated.
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Thrombocytopaenia
Reduction in platelet count leading to increased risk of bleeding. The normal count in
men and women is 150 – 400 x109/l, (Tadman and Roberts 2007). The drop in platelet
count may occur 7 – 10 days after treatment depending on drug dose. The count at
which it is considered acceptable to give treatment may vary across specialities and the
cancer network.
Patient education is essential so the patient is aware of the need to report early any
signs of a reduced platelet count e.g. bleeding gums, increased bruising,
hypermenorrhea, tarry stools, blood in urine, coffee ground vomit.
Patients should be advised to avoid activity that could cause injury and avoid dental
treatment while they are receiving anticancer therapy. If this treatment is necessary they
need to inform the dentist so checks of the blood count can be made. Advise the patient
to shave using an electric shaver and to use a soft tooth brush when carrying out oral
hygiene. They should also avoid drugs that interfere with platelet function eg aspirin and
alcohol. If they are taking aspirin, as a prescribed drug, this should be discussed with
the doctor.
The patient is at greatly increased risk of bleeding with a count below 20 x109/l. When
platelet counts becomes significantly depleted a platelet transfusion may be required to
prevent or stop bleeding (refer to local guidelines).
Anaemia
Anaemia is the reduction in the red blood cell count below 13.5 (male) or 11.5 (female),
(Hoffbrand & Pettit 1993). Symptoms include tiredness, breathlessness, pallor,
weakness, impaired concentration and cognitive function (Foubert 2006). If the anaemia
is problematic the patient may require a blood transfusion.
Patients receiving adjuvant curative radiotherapy with anticancer therapy are likely to
require blood transfusions if anaemic as the effectiveness of radiotherapy can be
influenced by the presence of oxygen in the cells being treated.
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Other side effects
Alopecia
Alopecia is one of the most distressing and visibly noticeable effects of anticancer
therapy. It can challenge self esteem, threaten body image, act as a constant visible
reminder of their diagnosis and lead to difficulty socialising, a feeling of being
unattractive and relationship difficulties (Power 2008, Roe 2011). The incidence and
severity of alopecia is dependant on the drug and the dose in the treatment regimen,
examples are contained in the table below. Hair loss is often quantified between thinning
and complete baldness, the term alopecia is used to define hair loss over 20% (Roe
2011). Hair loss is not confined to the head and can also include eyelashes, eyebrows,
arms, legs, underarms and pubic areas.
Examples of Drugs that always cause Alopecia
Daunorubicin
Doxorubicin Hydrochloride
Ifosfamide
Paclitaxel
Epirubicin
Docetaxel
Etoposide
Before they commence treatment with a drug that can cause hair loss the patient must
be informed of the potential for hair loss and offered a wig referral. Hair loss often
occurs 10 to 21 days after treatment and may occur suddenly and in large amounts. For
this reason some patients prefer to have their hair cut in a shorter style before it begins
to fall out. Hair loss is temporary and the hair will re-grow gradually after the course of
treatment is completed. Patients should be: •
•
•
•
Informed of the possibility in alteration of colour and texture of the hair when it does
re-grow.
Advised on skin care (protecting the head from sunlight by using a high factor sun
cream) and increased sensitivity to hot and cold temperatures
Advised on hair care: for example, using a soft bristle brush, avoiding perms and
colorants
Informed about other local services that can provide support such as scarf and
headware services
With some regimens scalp cooling may be effective in preventing hair loss. A specially
designed cooling cap is fitted tightly over the patient’s head to ensure maximum contact
with the scalp aided also by applying an overcap. Scalp cooling is used to reduce scalp
temperature causing constriction of blood vessels and thus decreasing the amount of
drug that can pass into hair follicles. It also slows the metabolism rate activity in the
follicles so the cells divide less rapidly and are less vulnerable to the action of
chemotherapy. With scalp cooling there is a potential that the treatment will not reach all
cancer cells that may be in the scalp so it is not appropriate for all patients (Roe 2011).
The procedure used for scalp cooling is dependent on a variety of factors such as the
dosage, plasma half life of the drugs being used and the patient’s ability to tolerate it.
The details for scalp cooling procedures are set out in North Trent protocols.
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Altered Bowel Habits
Anticancer therapy can cause constipation or diarrhoea dependant on the drug given.
Diarrhoea: Many anticancer therapy drugs cause mild to moderate diarrhoea.
Diarrhoea can be a life-threatening complication of treatment. Consequences of
prolonged or severe diarrhoea include dehydration, electrolyte disturbance, renal failure
and hypovolaemic shock. Anticancer therapy induced diarrhoea can increase the
patients susceptibility to infection, and can predispose neutropenic patients to develop
neutopenic sepsis (Benson et al 2004, Cherny 2008).
Assessment
The treatment of anticancer therapy related diarrhoea should be based on an
assessment of the individual patient alongside the grade and duration of diarrhoea.
Other potential causes of diarrhoea must be considered, these include: infection,
medication, constipation/ faecal impaction and bowel obstruction.
The possibility of an infective cause or involvement, including Clostridium difficile (C.diff),
must always be considered in any patient presenting with diarrhoea. An urgent stool
sample must be sent as soon as possible for all patients admitted with diarrhoea.
• Where diarrhoea is more likely to be treatment related appropriate anti-diarrhoeal
medication should be commenced prior to obtaining the stool culture result.
• If it is not an expected side effect or the patients anticancer therapy, or there are
other signs of infection then anti-motility agents such as Loperamide and Codeine
should not be used due to their direct action of slowing down the passage of stool
through the bowel, prolonging mucosal exposure to the toxins. Consultation with
microbiology is essential with these patients.
Assessment criteria
Assessment should include:
• History of onset and duration of diarrhoea
• Number of stools and stool composition (i.e. formed, liquid, presence of blood)
• Consider other causes e.g. risk of sepsis, bowel obstruction, faecal impaction
• Assessment of patient condition e.g. dehydration, electrolyte disturbance, pain
• Medication profile
• Dietary profile (to identify diarrhoeal-enhancing foods)
• Send stool specimen
The severity and grade of diarrhoea should be determined for all patients using the
National Toxicity Criteria as shown in the table below. Interventions should be based on
the assessment of the patient and the toxicity criteria and must follow the management
of chemotherapy related diarrhoea guidelines.
High risk symptoms include: temperature, sepsis, neutropenia, electrolyte
disturbance, nausea and vomiting above grade 2, abdominal pain/cramping, frank blood
in stools, dehydration, haemodynamic instability, diminished performance status.
Patients with grade 3 or 4 diarrhoea (or grade 2 for more than 48 hours) are at risk of
dehydration and will need admitting for symptom management, IV fluids and monitoring
electrolytes. Their nursing care plan must include regular EWS observations (minimum 4
hourly or more frequent as indicated by condition) and fluid balance monitoring. .
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Toxicity Criteria for Treatment Related Diarrhoea (adapted from National Cancer
Institute guidelines)
Grade 1
Grade 2
Grade 3
Grade 4
Patients
without
colostomy
Increase of less than
4 stools a day
compared with pre
treatment
Increase of 4 – 6
stools a day or
nocturnal stools
Increase of 7 or more stools
a day or incontinence, or
symptoms of dehydration,
abdominal cramping
Over 10 episodes a day or
bloody diarrhoea or
symptoms of dehydration
or haemodynamic
instability
Patients with
a colostomy
Mild increase in loose
watery colostomy
output compared with
pre treatment
Moderate increase in
loose watery
colostomy output but
not interfering with
normal activity
Severe increase in loose,
watery colostomy output
interfering with normal
activity, abdominal cramping
Severe increase in loose,
watery colostomy output
and/or symptoms of
dehydration or
haemodynamic instability
Dietary advice for patients with anticancer therapy induced diarrhoea
• Encourage fluid intake, aiming for an oral intake of 3L (approximately
8-12 cups) of clear non-carbonated fluids per day. Patients unable to tolerate
oral fluids, should be admitted for parenteral rehydration.
• Avoid alcohol and drinks with caffeine.
• Eat 5 or 6 small meals rather than 3 large meals a day.
• Reducing intake of high fibre foods e.g. wholemeal bread, high fibre breakfast
cereals (such as All Bran, Bran Flakes, Weetabix) can be helpful for some people.
• Spicy or rich foods can make symptoms of diarrhoea worse in some people.
Diarrhoea relating to Irinotecan chemotherapy
Irinotecan is associated with 2 potential causes of diarrhoea. The first is a cholinergic
reaction which can occur during the administration of the drug or within the first 24
hours. Symptoms include acute abdominal cramps and severe diarrhoea. Prophylactic
S/C Atropine is given immediately before administration and can be given again if the
cholinergic symptoms occur.
Diarrhoea occurring 24 hours after the administration of Irinotecan (referred to as
delayed diarrhoea) is unlikely to be a cholinergic reaction. This diarrhoea can be severe
and requires prompt treatment with the “Irinotecan Loperamide regimen” (see intranet).
If the diarrhoea continues to be severe the patient will need admitting to hospital for fluid
support to prevent dehydration.
Patients on oral chemotherapy with diarrhoea grade 3 or 4 or grade 2 for more
than 24 hours should be advised NOT to continue their oral anticancer therapy
treatment until they have been assessed by a senior oncology doctor.
Constipation: Due to their effects on the autonomic nervous system some drugs can
cause constipation. These include the vinca alkaloids such as Vincristine. Some
antiemetics, including graniestron, can exacerbate the symptoms. Patients must be
given advice on managing constipation as part of the pre-treatment information. Patients
receiving these drugs are at risk of developing paralytic illeus and must be advised to
monitor their bowel actions and contact the treatment centre for advice if their
constipation continues.
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Cardiac toxicity
The most common cardiac toxicities include congestive cardiac failure and
cardiomyopathy. Cardiac effects can be acute. For example, ECG changes and
arrhythmias can occur within hours of treatment administration with high risk drugs such
as doxorubicin, daunorubicin and 5 fluorouracil (Mallinson 2003).
Cardiac effects can also be long term and chronic. Long term cardiac toxicity is most
commonly associated with the use of anthracyclines such as doxorubicin, daunorubicin
or epirubicin. Anthracyclines directly damage the cardiac myocyte cells, resulting in
cellular destruction within the cardiac tissue (Camp-Sorrel 2006). Cardiac changes have
been related to total cumulative doses of anthracyclines. Cumulative drug dose is the
single greatest risk factor; therefore, there are maximum doses of these drugs that can
be given.
Other drugs that can cause cardiac damage include high-dose cyclophosphamide, 5fluorouracil (and capecitabine), paclitaxel (Taxol), ifosfamide, herceptin and lapatanib.
The patient’s cardiac function must be monitored by MUGA scan or echocardiography
prior to the first administration of herceptin or lapatinib and at regular intervals during the
course of treatment.
Hypertension is a side effect associated with the monoclonal antibodies sunitinib and
Bevacizumab. Blood pressure monitoring is required prior to each cycle and more
frequently if hypertension is identified. Medical treatment using anti-hypertensive
medication is required if hypertension develops. In many cases it can be controlled
without discontinuing treatment (Pyle et al 2008)
All patients receiving anticancer therapy associated with cardiac toxicity must be
informed of the risk and the need to contact the treatment centre immediately if they
develop any symptoms. The symptoms include: chest pain, difficulty breathing, cough,
leg or arm oedema or palpitations.
Changes in cognitive function
Changes in cognitive function have been identified as a potential side effect of
chemotherapy. It is sometimes referred to colloquially as “chemo-brain” (Hess and Insel
2007). The symptoms include: impaired memory, reduced ability to plan and problem
solve and forgetfulness. The effects vary between patients, different disease sites and
types of chemotherapy, for example there is a higher incidence in women treated with
chemotherapy for breast cancer than those with ovarian cancer (Hess and Insel 2007).
This is a relatively new area of study so the patterns of incidence and recovery or
decline are not yet known. As this is a subjective symptom it is important to inform
patients that it may occur and encourage them to discuss any concerns they have (Nail
2006).
Central nervous system (CNS) effects
Ifosfamide can cause CNS side effects. Although the mechanism of damage is unclear,
one possibility is that the accumulation of chloracetaldehyde (an ifosfamide metabolite)
directly damages the nervous system (Nielson and Brant 2002). Signs and symptoms
include: lethargy, confusion, somnolence, tonic-clonic spasms, motor unrest, mood
swings, hallucinations, changes in the level of consciousness, coma and (rarely) death
(Nielson and Brant 2002). If any of these symptoms occur drug administration should be
stopped and supportive therapy given to manage symptoms. The symptoms usually
resolve after a few days
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Fatigue
Fatigue has been consistently reported in research studies as one of the most frequently
occurring and most troubling side effects of anticancer therapy. Fatigue relating to
cancer and its treatment has been described as “an unusual, persistent, subjective
sense of tiredness relating to cancer, or cancer treatment that interferes with usual
functioning” (DeJong 2002).
The unique qualities of cancer related fatigue are that it is
• disproportionate to activity or exertion
• not completely relieved by rest
• does not correlate to activity levels
• not relieved by addressing a deficiency such as sleep, food or water
Patients’ experiences of treatment related fatigue have been found to vary according to
the drugs being given and the schedule and method of administration (Miller 2007).
While fatigue is a common problem for patients receiving anticancer therapy there is
evidence to suggest that nurses may underestimate the incidence and severity of this
problem for patients (Parsaie 2000). It is important to acknowledge the impact that this
symptom can have on patients and provide them with information about its potential
occurrence and ways of coping.
Screening is recommended to identify the “7 treatable factors”: pain, emotional distress,
sleep disturbance, anaemia, nutrition issues, de-conditioning or changes in activity levels
and co-morbidities. Other potential factors to exclude include infection and electrolyte
disturbance.
A number of interventions to manage treatment related fatigue have been proposed.
These include: actions such as exercising, balancing activity and rest, prioritizing and
delegating activities, relaxation, diversion and sleep-enhancement techniques (Nijs et al
2008, Barsevik 2008). The effectiveness of each intervention is still being evaluated but
there is increasing evidence to support the positive effects of appropriate level of
exercise (Cramp 2008).
Previously HCP’s have advised fatigued patients to rest. Many patients found this wasn’t
helpful and some reported feeling just as tired after resting. More sleep and rest will not
necessarily be beneficial as decreasing activity could lead to de-conditioning and
decreased activity tolerance. The important thing is to promote good quality sleep and
energy conservation. Appropriate advice on sleep includes
• Maintain a regular sleep-wake schedule, avoid long afternoon naps
• Avoid stimulating substances before bed time
• Have a bedtime routine and keep at least an hour to relax before going to bed
• Minimise night time environmental disruption and remove unpleasant stimuli (e.g.
clocks)
• Avoid lying in bed awake and don’t stay in bed any longer than they intend to sleep
• Go to bed only when sleepy, use the bedroom only for sleep or sexual activity
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Fertility
The impact of anticancer therapy on fertility will depend on a number of factors including:
gender, age and the specific drug(s) and dose(s) of treatment being given. Some
anticancer therapy drugs have little impact on fertility while others cause infertility at
standard doses (Knobf 2006, Thaler-DeMers 2006, Royal College of Physicians 2007).
Male patients receiving anticancer therapy likely to cause infertility should be offered
sperm banking. Sperm can be stored for up to 10 years. For female patients it is
possible to store fertilised ova. However, this can be difficult to achieve as it can result
in treatment delays. Anticancer therapy can also induce an accelerated menopause and
women may need advice for coping with symptoms such as hot flushes and vaginal
dryness (Knobf 2006, Foster 2002, Royal College of Physicians 2007).
Women can remain fertile during anticancer therapy even if their menstrual cycle
becomes disrupted or stops and should be advised to use effective contraception during
treatment. Women are advised to wait 2 years before attempting parenthood – the main
reason for this being that most recurrences occur within 2 years. Men are advised to wait
for 1 year as the mutational risks from damaged sperm are most likely to occur within
this period (Thaler-DeMers 2006, Royal College of Physicians 2007).
Haemorrhagic cystitis
Bleeding from the bladder. This side effect is associated with the drugs Ifosfamide and
Cyclophosphamide (Cocburn and Michell 2002). It is caused by a by-product of the
metabolism of these drugs (Acrolein) which can damage the urinary tract. During
administration of high doses of these drugs the patient’s urine must be tested for the
presence of blood and the doctor informed if blood is detected. Concurrent
administration of Mesna is given to protect the bladder and extra doses of Mesna can be
given if bleeding occurs.
Hand foot syndrome
The other name for this is palmar-plantar erythrodyesthesia. The incidence is increasing
as it is associated with a number of drugs that are being used more widely such as
capecitabine (Innes 2007).
Symptoms include:
Grade 1: Numbness, tingling, painless erythema and swelling
Grade 2: Peeling, painful erythema and swelling, discomfort that affects activities of daily
living
Grade 3: Moist desquamation, ulceration, blistering and severe pain, unable to work or
perform activities of daily living
At grade 2 or above treatment with the drug that caused hand foot syndrome needs to
be halted while the symptom is managed. The dose may need to be modified prior to
being recommenced. Symptom management will depend on the severity of the condition
and can include emollient cream, cooling, analgesia and wound care. It does diminish
within a few days of stopping treatment but if left unmanaged it can progress rapidly so
patient information about this symptom and its management is essential (Innes 2007,
Webster 2007, Harold 2010).
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Mucositis
Oral problems are a common, and often predictable, consequence of anticancer therapy.
They can be caused by the action of the particular agent on the oral mucosa. It can also
be a secondary complication of neutropaenia as the mouth will become susceptible to
infection. Oral mucositis is a dose and treatment limiting toxicity of several anticancer
therapy agents (Harris 2008).
The mouth is important for eating, drinking, speech, communication, taste, and
breathing. Oral health is essential to ensure comfort, maintain nutritional status, protect
against infection and maintain patient well being (Miller 2001). Moderate and severe oral
dysfunction can significantly affect the patient’s quality of life. Consequences include:
pain, difficulty communicating, infection, bleeding, poor nutritional status, taste changes,
low mood, prolonged recovery, disturbed sleep, diminished well being and quality of life
(Cawley 2005)
Engaging the patient in the process of mouthcare can lead to improvements in oral
health and the prevention of oral problems. It is important to teach the patient how to
carry out oral assessment and oral hygiene (Cawley 2005). There must be careful
assessment and monitoring of the oral cavity throughout the course of the
chemotherapy, and encouragement of rigorous oral hygiene (Sieracki 2009).
Oral assessment should be carried out daily in patients with actual or potential oral
health problems (Yaeger 2000, Sieracki 2009). It should include an evaluation of the lips,
oral mucosa, tongue, saliva and teeth. It also includes assessing alterations in voice,
ability to swallow and level of discomfort (Jaroneski 2006). Where available an
appropriate oral assessment tool should be used to structure and document the
examination. Any evidence of oral disease should be reported to the doctor.
Patients need to be informed of the need for good oral hygiene and told how to observe
for signs of oral infection. Routine mouthcare should include brushing the teeth with a
toothbrush and fluoride toothpaste twice daily (in the morning and before going to bed).
Patients should also rinse the mouth with water to remove food debris after each meal. If
patients have dentures they should follow the same routine but remove and clean their
dentures.
Patients who develop mucositis will require regular and frequent mouthcare, pain control
and interventions to ensure their dietary and fluid intake are maintained (Cooley 2002).
Nephrotoxicity
A number of anticancer therapy agents have the potential to cause renal damage.
Patient characteristics can also increase the chances of developing nephrotoxicity. For
example, older patients and those with co-morbidities such as diabetes, hypertension
and heart failure are at increased risk. Careful monitoring of blood chemistry is required
in patients receiving chemotherapy that is nephrotoxic (Coburn and Mitchell 2002).
Cisplatin is particularly nephrotoxic and IV fluids are given before and after Cisplatin
administration to promote a good urine output so the chemotherapy is voided through
the kidneys effectively. Throughout the administration of Cisplatin the patient’s fluid
balance is monitored carefully to ensure the chemotherapy is being excreted effectively.
If the urine output drops below 150 ml per hour during and immediately post
administration, or the patient is in a positive fluid balance after they have received post
hydration, the doctor should be informed so Mannitol, or a diuretic, can be administered.
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Many anticancer therapy agents are excreted via the kidneys, which mean that renal
function needs to be checked prior to treatment administration to prevent overall toxicity.
This is measured by the serum creatinine (or creatinine clearance if the chemotherapy is
particularly nephrotoxic). For agents excreted via the kidneys, dose reduction will be
necessary if renal function is impaired.
Bevacizumab can cause proteinuria which at very high levels can cause Nephrotic
syndrome which is a potentially fatal condition characterized by persistently high levels
of proteinuria. Bevacizumab-associated proteinuria rarely leads to renal dysfunction,
however, patients’ urine protein levels need to be monitored using dipstick urinalysis
prior to each bevacizumab infusion (Blowers 2009).
Neurotoxicity
Peripheral neuropathy is a dose limiting side effect of a number of anticancer therapy
agents including cisplatin, oxaliplatin, paclitaxel (Taxol), etoposide and the vinca
alkaloids eg Vincristine. The symptoms of peripheral neuropathy include pain, tingling,
altered sensation and numbness which usually starts in the toes and/or finger tips. It
then moves closer to the centre of the body (i.e from the fingers to the hands, wrist and
arms and from the toes to the foot, ankle and calf). The symptoms can lead to difficulties
with daily activities and can be painful having a negative impact on quality of life (Smith
2008).
Peripheral neuropathy is usually a cumulative dose related side effect. If it is causing
neurological dysfunction the treatment regimen will be reviewed and the dose of the
causal drug reduced. The symptoms usually improve over time once treatment with the
causal drug has ended but some residual effects may remain. The effects may continue
for months beyond treatment completion.
Oxaliplatin can result in 2 different types of peripheral neuropathy. The first is the
neuropathy described above where the onset occurs following treatment and gradually
improves over six to eight months. The second type is acute neuropathy which occurs
30 to 60 minutes after infusion. Patients can experience dysesthesia of the hands and
feet, jaw tightening and a sense of difficulty breathing – not accompanied by respiratory
distress (pharyngo-laryngo dysesthesia). This can be a very distressing side effect and
patients must be informed about it prior to treatment so they can take preventative
action. Pharyngo-laryngo dysesthesia is often associated with cold temperatures and
patients should be advised to avoid cold drinks or food while they are having their
treatment and to wear gloves and scarves when going into the cold (Armstrong 2005).
Pulmonary toxicity
Long term lung damage such as lung fibrosis can be induced by a number of
chemotherapy agents. These drugs include: high dose bleomycin, cytarabine, high-dose
cyclophosphamide, carmustine (BiCNU), mitomycin-C, busulfan, methotrexate,
procarbazine, docetaxel (Taxotere) and gemcitabine (Camp-Sorrell 2006).
High dose bleomycin is associated with pulmonary toxicity. Patients who have received
extensive treatment with bleomycin may be at risk of developing respiratory failure if a
general anaesthetic is given with high oxygen concentrations. Patients should be made
aware of this and asked to inform health care professionals when this is appropriate.
Patients who have received drugs associated with pulmonary toxicity should be advised
to inform medical staff if they develop any respiratory problems or changes in the future.
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Skin reactions
A number of anticancer therapies can cause skin reactions and rashes. They are a
relatively common side effect of a group of treatments called dual epidermal growth
factor receptor (EGFR) inhibitors and tyrosine kinase inhibitors. Treatment with EGFR
inhibitors has been associated with skin, hair and nail toxicities which are thought to be
related to EGFR inhibition in the Epidermis (Camburn 2009). Erlotinib (tarceva) and
laptanib are examples of this group of drugs.
Skin reactions can be marked and very visible as they can appear on the face and trunk
which can be very distressing for some patients. Patients are advised to use an
emollient moisturiser on commencing treatment to manage dry skin reactions. Treatment
that can be used on more severe reactions include antibiotics if infection is present, anti
histamines if the skin is itchy and topical steroid cream if eczema is present. Refer to the
EGFR skin reaction guidelines. Acne treatments are NOT recommended as the cause
of the skin reaction is different and they will have little effect. If the rash is persistent and
severe, referral to dermatology should be considered.
Tumour Lysis Syndrome
Tumour lysis syndrome (TLS) is an oncology emergency. It is a serious and potentially
life-threatening complication of cancer therapy. It occurs when cancer treatments cause
the destruction (or lysis) of a large number of rapidly dividing cancer cells, overwhelming
the body’s ability to excrete the end products of cell death (Cantril 2004). As cells die
they release potassium, phosphorous and nucleic acids into the systemic circulation. If
the volume released exceeds the body’s ability to metabolise and excrete them it can
cause electrolyte imbalances such as hyperkalaemia, hyperuricamia and
hyperphosphataemia. These place the patient at risk of renal failure and cardiac
abnormalities including ventricular tachycardia and cardiac arrest.
Based on the presence of certain risk factors, patients can be placed into low,
intermediate, or high-risk categories for developing tumour lysis syndrome (HeldWarmkessel 2010).
• High-risk: bulky disease with a high sensitivity to chemotherapy e.g. Burkitt lymphoma,
lymphoblastic lymphoma, T-cell acute lymphoblastic leukaemia or B-cell acute
lymphoblastic leukemia.
• Intermediate risk: diffuse large-cell lymphoma or another type of rapidly growing
cancer.
• Low-risk: indolent (slow-growing) lymphoma or another slowly proliferating cancer
Tumour lysis syndrome usually starts within 24 - 48 hours of treatment commencing but
it can occur up to 5-7 days after the start of chemotherapy (Tadman and Roberts 2005).
Signs and symptoms of tumour lysis syndrome
The early signs of TLS may not be readily apparent and may be detected by abnormal
blood chemistry results (Cantrill 2004). The signs and symptoms of TLS include:
High potassium, phosphate and urea blood chemistry levels
decreased urine output, flank pain,
hypertension, tachycardia, ECG changes, caridac arrhythmia,
nausea and vomiting, diarrhoea, abdominal colic,
muscle weakness, muscle cramps, twitching, confusion, delirium
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The practitioner should observe the patient for these symptoms and seek medical review
if any occur. In patients where there is a risk of tumour lysis syndrome blood chemistry
tests must be carried out and checked frequently and nurses play a vital role in
confirming that this has happened.
Patients at high risk of developing TLS are often prescribed allopurinol as prophylaxis
before commencing their chemotherapy. Intravenous fluids are also often given to
optimise urinary output before, during and after chemotherapy administration. The
patients urine output and fluid balance must be monitored carefully to ensure a good
diuresis has been achieved (100 -150 mls/hour) and to detect any decrease in urine
output.
Other side effects of anticancer therapy include: •
Anorexia,
•
Taste changes,
•
Reactivation of Radiotherapy sites eg Epirubicin and Doxorubicin.
•
Occular irritation.
•
Aching joints and muscles eg Paclitaxel.
•
Nail discolouration and ridges eg Bleomycin, lapatinib.
•
Tumour site pain.
•
Coloured urine (e.g. epirubicin, doxorubicin, itozantrone).
•
Increased risk of bleeding, not related to low platelets (e.g. Bevacizumab)
•
Veno–occlusive disease of the liver (VOD). VOD, is partial or total occlusion of
the small blood vessels within the liver usually due to haemorrhage and/or
thrombus, sometimes leading to irreparable damage to the liver and is a serious
and potentially fatal complication of chemotherapy/radiotherapy.
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MODULE 5
PATIENT ADVICE/INFORMATION
Patient Information and anticancer therapy
Providing clear information in relation to anticancer therapy treatment and side effects is
an important aspect of patient care. Ensuring the patient has given informed consent to
their treatment is essential before administering anticancer therapy.
Patients need to be aware of the side effects of treatment so they can detect problems
early and take action to minimise their severity or seek medical advice when it is
necessary. For example, patients at risk of neutropaenia must know to seek advice if
experiencing symptoms of infection when the white cell count may be low. Similarly
patients receiving treatment that can cause diarrhoea must know how to take their antidiarrhoeal medication and also to contact the hospital if they have prolonged diarrhoea
due to the risk of dehydration and electrolyte imbalance.
Positive outcomes of patient information include: Helping patients gain a sense of control over their illness and treatment
Increasing compliance with treatment
Reducing the severity and incidence of side effects by providing advice on symptom
management and supportive medicines
Enabling a partnership relationship between patients and health care professionals
Reducing the uncertainty patients feel about their illness and treatment
Satisfying the need for information seeking, which for some is an important coping
mechanism
Enabling people to predict and plan their future
(Brennan 2004, Moore 2007).
Providing patient information can be challenging. Patients can feel overwhelmed by the
amount of information they have been given, particularly as some will be complex
medical information that may be unfamiliar to them (Leydon 2000). Patients also vary in
their preferences for the amount, type and timing of information that they require
(Brennan 2004, Cox 2006). Needs and preferences for information will vary between
patients. There is some treatment related information that the patient must be given,
and understand to ensure they are safe once discharged. For example, knowing when
and how to contact the hospital for advice is essential information particularly in relation
to life-threatening or debilitating side effects.
The practitioner should, at all times, act in the best interest of the patient adopting the
patient advocate role. Where they feel there may be issues with regard to lack of informed
consent, s/he must ensure that this issue is fully resolved prior to anticancer therapy
administration.
If there is clearly a lack of understanding, the practitioner should give both written and
verbal information at the patient’s level of understanding. If the practitioner still feels that
the patient does not possess sufficient level of understanding and/or is not happy to
proceed with treatment this must be brought immediately to the attention of the physician
caring for that patient and the nurse in charge of the ward/department. Clear
documentation in the patient records must accompany such issues.
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As part of the patient education process the healthcare practitioner should assess the
patient’s and family’s readiness to learn, level of literacy, information-seeking, and
avoidance behaviours. Timing of information must be appropriate, for example, providing
detailed information about the treatment regimen on the day the patient has been given
their diagnosis is inappropriate. If possible the patient should be accompanied by a
family member of friend to support them (Moore 2007). It is important to try and schedule
enough time for patient information to ensure that key points can be reinforced and the
patient has enough time to ask questions. If possible, education should take place in a
private area and written information should be provided alongside verbal information
(Moore 2007).
Key patient advice includes the following:
•
•
•
•
How the medication works
How to take their medication (oral anticancer therapy and/or supportive medicines)
Expected side effects and actions that can be taken to prevent them or minimise
their severity
Who to contact for advice and to report symptoms of concern
Ensure the patient understands that they should monitor their temperature and contact
the appropriate department if it is 37.5o c or above, or if they develop any other signs of
infection.
Due to the possibility of low platelet counts, advise patients to report any signs of
bleeding or bruising. Aspirin and non-steroidal anti-inflammatory drugs should be
avoided (unless already taking for a previous medical condition) as there is a risk of
bleeding with these drugs, which will be enhanced by myelosuppression caused by
chemotherapy.
Preparations containing paracetamol can be used for pain control, but ensure the patient
is aware that these will reduce their temperature if pyrexial. They should not take
paracetamol to control a raised temperature as this can mask symptoms of infection.
If nausea or vomiting or diarrhoea is severe or prolonged they must contact the
appropriate department as they may be at risk of dehydration.
If the patient has mucositis and is unable to maintain their fluid or nutrition intake, or the
pain from this symptom is not controlled by oral analgesia they should contact the
appropriate department as they may need to be admitted for analgesia and nutritional
support.
The above are basic instructions to give to the patient undergoing anticancer therapy
and apply to many regimens. However, each agent and/or regimen is associated with its
own specific side effects. This information is contained on the drug and regimen specific
patient information leaflets which must be given to the patient and explained to them
prior to commencing their treatment.
A number of helpful websites and support groups are available and patients
should be encouraged to access this information where this is appropriate
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MODULE 6
ANTICANCER THERAPY EDUCATION PROGRAMME COMPETENCY
ASSESSMENT
Definition of Terms
Trainer: The practitioner who delivers the training locally.
Assessor: A HCP with two years experience in anticancer therapy administration,
has been nominated by their line manager and has relevant post basic education in
Haematology/oncology with a teaching and assessing qualification.
Supervisor: A nurse who has been assessed as competent in the administration of
anticancer therapy and can act as a witness to observe and supervise practice by a
trainee
Trainee: A person undertaking the programme.
Staff who are to administer anticancer therapy, must have satisfactorily completed the
North Trent Anticancer Therapy Education Programme. Nursing staff should participate
in local teaching sessions in order to gain the theoretical knowledge that will underpin
practice. The criteria for participation in training and assessment for nursing staff are as
follows: (i)
Must be a registered nurse/practitioner.
(ii)
Must have completed the local induction programme.
(iii)
Newly qualified staff must have completed a period of preceptorship including the
formal drug assessment.
The practitioner must also have been assessed as competent in the requisite associated
skills for the route of administration. For example,
• Intravenous medicines administration for nurses being trained in intravenous
anticancer therapy administration
• Central venous access devices for nurses being trained in administration via a CVAD
• Any medical equipment devices being used to administer treatment
There are three components to developing competence in the administration of
anticancer therapy: (i)
Theoretical training and assessment.
(ii)
Supervised practice.
(iii)
Formal practical assessment
These components are described below. The process of supervised practice and
practical assessment needs to be completed for each mode/route of administration.
Training Sessions
The training sessions will provide nursing staff with the essential theoretical knowledge
required to underpin practice. The sessions will be based on the content of the North
Trent anticancer therapy education programme. The content of the study day/s/sessions
will provide the practitioner with a comprehensive knowledge base required for them to
make informed judgments and decisions around anticancer therapy.
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Following the study session the practitioner must complete the theory assessment. The
expectation is that a minimum score of 100% is a pass. Any less than the minimum
score will constitute a fail and the fractioned will be expected to retake the theory
assessment. When a maximum of three attempts has been undertaken the practitioner
will be referred to their line manager and an action plan formulated.
Supervised Practice
The trainee will have a period of practical training, where they will observe anticancer
therapy being administered and then progress to delivering anticancer therapy under
supervision. Supervised practice will be documented in the form of a progress diary with
sections for both supervisor and trainee to record the session. At an agreed point when
both supervisor and trainee are agreed that sufficient progress has been made the
trainee will undertake two assessments against the competency statements as outlined
in the structured clinical assessment.
A trainee can administer anticancer therapy under supervision before completion of the
theoretical assessment. However, the theoretical assessment must be completed
before undertaking the first Observed Structured Clinical Evaluation (OSCE). Both
theoretical and practical assessments need to be completed in order to pass the
competency training. The entire process should be completed within a period of six
months for each mode of administration; however, the pathways can run concurrently.
Objectives
At the end of the period of supervised practice the nurse will be able to: (i)
Consistently show the ability to safely administer anticancer therapy via the route
being assessed and demonstrate an ability to apply theory to practice.
(ii) Provide fully documented evidence completed by both trainee and supervisor to
support their progress.
(iii) Demonstrate a level of confidence and competence consistent with proceeding to
formal assessment.
Formal assessment
Formal assessment is carried out by a designated assessor against the competency
statements in the assessment criteria, and should only take place at a point when the: (i)
Trainee and supervisor agree a sufficient and consistent level of confidence and
competence has been attained for that particular route of administration
(ii) Trainee has completed two assessments against the competency statements, as
outlined in the structured clinical evaluation (OSCE) with the supervisor.
Objectives
At the end of the formal assessments the practitioner will be able to: (i)
Safely administer anticancer therapy as specified within the competency
statements.
(ii) Demonstrate successful completion of all of the competency statements and have
attained a standard consistent with being deemed a competent practitioner.
Competence
On successful completion of the above criteria, the trainee will be deemed competent.
In order to formalise and record this, both supervisor and trainee should complete (in
full) the record of competency, which requires both signatures. The supervisor must
ensure that a copy of this is given to the line manager and be retained for Trust/Hospital
records in the trainee’s personal file. The trainee should also keep a copy of the
document for their professional portfolio.
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The trainee has the responsibility for maintaining competence through regular practice
and update of knowledge. Where there are any concerns with regard to competence,
either on the part of the trainee or on the part of the Trust, this must be addressed in full
through retraining and where appropriate re-assessment. All concerns regarding
competency must be addressed and documented before the nurse is allowed to practice
unsupervised.
Guidelines for Supervisor/Assessor
Supervisors and Assessors must be competent to practice the indicated skill.
The minimum number of supervised practices of the skill is indicated on the assessment
sheet, which must be completed and signed by each supervisor. If the trainee is unable
to practice the skill and demonstrate understanding to the required standard of
assessment, one further assessment may be undertaken. On successful completion of
the programme and the supervised practice, the practitioner will return a copy of the
assessment sheet to their immediate line manager.
Non-Achievement of Competence
Non-achievement of competence will result in the trainee receiving immediate accurate
and detailed feedback from the assessor; all of which will be documented. An action
plan will then be devised outlining further development needs and strategies for
achieving this. Further periods of supervised practice, support and guidance will be
given prior to the trainee retaking the assessment.
Trainees failing to achieve competence on their third assessment will be deemed
unsuccessful of extending their scope of professional practice and should be discussed
formally through the staff development review process. This would ensure that a fair
and reasonable programme of support, which enabled sufficient opportunity for the
trainee to progress, was provided and followed.
Annual Update of Competence
Competence for each route of anticancer therapy administration must be maintained and
will be evaluated annually through the annual appraisal process. This will be achieved
by: (i)
Reading the NT Anticancer Therapy Education Programme and signing to
indicate that this has been completed.
(ii)
Demonstrating that you are actively working within the area of practice for: Intravenous administration
You should demonstrate that you are administering anticancer therapy on a regular and
frequent basis i.e. continuous practice with a break of no longer than three months.
If not administering anticancer therapy on a regular basis, or you have had a break in
practice of three months or longer, you should identify a plan of action with your
manager. This must include undertaking a minimum of one OSCE per route of
administration prior to administering IV anticancer therapy unsupervised.
Oral, IM and SC competence does not need to be reassessed practically following a
break in practice unless the manager or staff member feels this is required. However,
staff administering anticancer therapy via these routes must read the North Trent
anticancer therapy education programme and demonstrate that they have the required
level of knowledge for safe practice.
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Summary of anticancer therapy Administration Assessment Pathway
There are three components to developing competence in the administration of
anticancer therapy: (i) Theoretical training and assessment.
(ii) Supervised practice.
(iii) Formal practical assessment
The pathway must be followed for each route/ method of administration.
The training session and theory package only needs to be attended/completed on one
occasion as it covers all routes/ methods of administration.
A trainee can administer anticancer therapy under supervision before completion of the
theoretical exercise. However, both theoretical and practical sessions need to be
completed in order to pass the competency training.
Attend the theoretical study session
Complete and pass theory assessment
Practice administration of anticancer therapy under
supervision. Keep a record of supervised practice in progress
diary.
When both supervisor and trainee are agreed that
sufficient progress has been made complete 2
administrations of chemotherapy using the Objective
Structured Consultation Exercise (OSCE)
Complete final assessment by administering anticancer therapy using the
OSCE. This must be carried out with a designated assessor
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NORTH TRENT CANCER NETWORK
THEORETICAL ASSESSMENT FOR THE
ADMINISTRATION OF ANTICANCER THERAPY
1. (a) What are the three primary routes of exposure to anticancer therapy?
(i)
(ii)
(iii)
(b) Identify three ways you could minimise the risk of exposure when handling
anticancer therapy
(i)
(ii)
(iii)
2.
(a) What action would you take in the event of eye contamination?
(b) What action would you take in the event of skin contamination?
3.
(a) Why should you accurately measure a patient’s height and weight before
chemotherapy is prescribed?
(b) A patient is receiving Doxorubicin at 60 mg per m2 and the patient has a
BSA of 1.8. What dose should be prescribed?
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4. At which points in a patient’s anticancer therapy regimen must you check that written
consent has been obtained before administering chemotherapy?
5. Which types/location of vein should be avoided for intravenous anticancer therapy
administration – indicate reasons for your answer
6. Why are short, flexible, small gauge catheters preferred for cannulation in patients
receiving anticancer therapy?
7. When administering IV anticancer therapy which drug should be given first?
8.
(a)
Irritant
(b)
Vesicant
List three things you would look for when you carry out a cannula check
(a)
(b)
(c)
9. (a) What is a flare reaction?
(b) What are the symptoms of a flare reaction?
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10. (a) What are the causes of venous spasm?
(b) What action would you take if venous spasm occurs?
11. What is an extravasation?
12. List four possible signs of extravasation
(a)
(b)
(c)
(d)
13. Identify two measures you can take to prevent extravasation or minimise the amount
of drug infiltration if extravasation should occur.
(a)
(b)
14. (a) List the signs of anaphylaxis
(b) What action would you take if a patient developed these symptoms while receiving
anticancer therapy?
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15. (a) What is tumour lysis syndrome?
(b) list 5 symptoms of tumour lysis syndrome
16. Why does rituximab have its own administration rate protocol?
17 What investigations does a patient require prior to commencing Herceptin and at
regular intervals while they are receiving their course of treatment?
18. What antiemetic(s) would you give to a patient who is receiving anticancer therapy
that has a high risk of causing nausea and vomiting? (according to local policy)
19. There is a chemotherapy spillage during administration, what action would you take?
20. Where do you dispose of chemotherapy?
21. List two health and safety issues you would consider when administering oral
Anticancer therapy
(a)
(b)
22. List two health and safety issues you would consider when administering anticancer
therapy by the IM route
(a)
(b)
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23. (a) List two examples of anticancer therapy related events that would be identified as
an adverse incident
(i)
(ii)
(b) What documentation would you complete following any adverse incident?
24. a) What are the potential risks associated with neutropenia?
(b) What information would you make sure a patient understood in relation to the risks
associated with neutropenia before they were discharged?
25. a) What are the potential risks associated with thrombocytopenia?
(b) What information would you make sure a patient understood in relation to the risks
associated with thrombocytopenia before they were discharged?
26. A patient on oral capecitabine contacts you to say that they have had profuse
diarrhoea for 3 days and are feeling weak and dizzy.
(a) they are due their next dose of oral capecitabine and ask you if they should take it what advice would you give them in relation to this?
(b) What other action would you advise them to take?
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27. What advice about contraception should you give to patients on anticancer therapy?
28. What considerations should be taken before administering Taxol?
(a) relating to supportive medicines
(b) relating to the infusion giving set
29. A patient is admitted who has been on oral anticancer therapy at home. The junior
doctor has prescribed it on the drug kardex. What does a nurse need to check before
administering the drug?
a)
b)
30. What are the usual side effects of the following drugs: (a) Doxorubicin
(b) Vincristine
(c) Methotrexate
(d) Capecitabine
(e) Herceptin
(f) Cisplatin
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NORTH TRENT CANCER NETWORK
RECORD OF COMPETENCY FOR THE THEORETICAL ASSESSMENT
FOR THE ADMINISTRATION OF ANTICANCER THERAPY
Supervised Statement
The trainee has completed the theoretical exercise and answered all questions correctly.
Signature of Assessor: ……………………………………………..
Print Name: …………………………………………………………
Date: ………………………………………
Signature of Practitioner: ………………………………………………………
Print Name: …………………………………………………………
Date: ……………………………………………..
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NORTH TRENT CANCER NETWORK
ANTICANCER THERAPY ADMINISTRATION PROGRESS DIARY
ORAL ANTICANCER THERAPY ADMINISTRATION
Date
Drug administered
Supervisee
Description/Self
Assessment
Signature
Supervisors
Assessment and
Comments
Signature
Date
Drug administered
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Supervisee
Description/Self
Assessment
October 2011
Signature
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Supervisors
Assessment and
Comments
Signature
NORTH TRENT CANCER NETWORK
OBJECTIVE STRUCTURED CONSULTATION EXERCISE FOR ADMINISTRATION OF
ORAL ANTICANCER THERAPY
Trainees Name: -
st
1
Assessment
1
2
3.
4
5
6
Greet and accurately identify patient. Explains
procedure to the patient. Ensures patient
receives adequate verbal/written information
specific to the drug/s and their side effects
Gains patient’s verbal consent to treatment
and ensures written consent is documented
within the patient’s records. Assesses the
patients psychological and emotional state
and responds appropriately
Assesses the patients ability to take oral
treatment – i.e. there are no physical reasons
why they can’t take the tablet/capsule in an
oral form
Prepares appropriate equipment
demonstrating awareness of safe handling
and protective measures.
Checks environment to ensure everything is
prepared for treatment
Assesses the patient’s fitness for treatment.
Reviews history since last attendance if
appropriate. Demonstrates knowledge of
appropriate laboratory results and BSA
Makes the necessary checks to ensure the
correct drug is administered to the correct
patient at the correct time.
These checks include: Name of patient
Date of Birth
Patient identification number
Height, weight documented and correct BSA
calculated
Required blood tests documented as
indicated by drug protocol
Date and time the drugs are to be
administered
Recognises the name of the drug to be
administered
Checks the expiry date
The signature of the prescriber is documented
Checks the details of the patient with the
prescription chart
nd
2
Assessment
rd
3
Assessment
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
st
1
Assessment
7
8
9
10
Dispenses medication safely according to the
local procedures. Ensures the patient takes
the oral treatment.
Monitors patient for signs of adverse side
effects to drugs. Demonstrates knowledge of
what actions are required should these occur.
Document all aspects of the procedure fully
and signs the prescription sheets.
Checks the patient/carer understands the
information and advice they have already
been given and respond to any requests for
information.
Ensure the patient has all medication to take
home and understands how to handle/ store
them. Confirm the details of the next
appointment and prior tests/ investigations as
appropriate.
Comments: -
nd
2
Assessment
rd
3
Assessment
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Signature
Signature
Signature
Print name
Print name
Print name
Date
Date
Date
12
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NORTH TRENT CANCER NETWORK
RECORD OF COMPETENCY FOR THE ADMINISTRATION OF
ORAL ANTICANCER THERAPY
Supervised Statement
The trainee has completed a minimum of three supervised session of administering oral
anticancer therapy. The trainee has completed a formal assessment with the designated
assessor.
Signature of Assessor/Trainer: ……………………………………………..
Print Name: …………………………………………………………
Date: ………………………………………
Practitioner Statement
I have successfully completed the minimum of three supervised practice sessions,
administering oral anticancer therapy. I have completed a formal assessment with the
designated assessor.
I now feel confident and competent in this specific area of drug administration and am
happy to continue as an independent practitioner. I fully understand my responsibilities
in terms of working within the specific Trust and local cytotoxic anticancer therapy
guidelines and maintaining competence. I fully understand the principles of safe practice
and the need to work within the guidelines for practice set out by my professional body
(e.g. the Nursing and Midwifery Council Guidelines for Practice)
Signature of Practitioner: ………………………………………………………
Print Name: …………………………………………………………
Date: ……………………………………………..
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6.6
NORTH TRENT CANCER NETWORK
ANTICANCER THERAPY ADMINISTRATION PROGRESS DIARY
INTRAMUSCULAR/SUBCUTANEOUS ANTICANCER THERAPY ADMINISTRATION
Date
Drug administered
Supervisee
Description/Self
Assessment
Signature
Supervisors
Assessment and
Comments
Signature
Date
Drug administered
North Trent anticancer therapy education programme
V3
Supervisee
Description/Self
Assessment
October 2011
Signature
Page 76 of 97
Supervisors
Assessment and
Comments
Signature
NORTH TRENT CANCER NETWORK
OBJECTIVE STRUCTURED CONSULTATION EXERCISE FOR ADMINISTRATION OF
INTRAMUSCULAR/SUBCUTANEOUS ANTICANCER THERAPY
Trainees Name: -
st
1
Assessment
1
2
3
4
5
6
7
Greet and accurately identify patient. Explains
procedure to the patient. Ensures patient
receives adequate verbal/written information
specific to the drug/s and their side effects
Gains patient’s verbal consent to treatment
and ensures written consent is documented
within the patient’s records. Assesses the
patients psychological and emotional state
and responds appropriately
Prepares appropriate equipment
demonstrating awareness of safe handling
and protective measures.
Checks environment to ensure everything is
prepared for treatment
Assesses the patient’s fitness for treatment.
Reviews history since last attendance.
Demonstrates knowledge of appropriate
laboratory results and reassesses BSA
Makes the necessary checks to ensure the
correct drug is administered to the correct
patient at the correct time.
These checks include: Name of patient
Date of Birth
Patient identification number
Height, weight documented and correct BSA
calculated
Required blood tests documented as indicated
by drug protocol
Date and time the drugs are to be
administered
Recognises the name of the drug to be
administered and knows it is
suitable for
intravenous use
Checks the expiry date
The signature of the prescriber is documented
Checks the details of the patient with the
chemotherapy chart and designated checker
Positions patient correctly for the procedure
ensuring their comfort, privacy and dignity.
Identifies appropriate site for injection.
Administers medication safely
nd
2
Assessment
rd
3
Assessment
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
st
1
Assessment
8
9
10
11
12
Monitors patient for signs of adverse side
effects to drugs or procedure. Demonstrates
knowledge of what actions are required should
these occur.
Documents all aspects of the procedure fully
documented and sign the prescription sheets.
Checks the patient patient/carer understands
the information and advice they have already
been given and respond to any requests for
information.
Ensure the patient has all medication to take
home and understands how to handle/ store
them. Confirm the details of the next
appointment and prior tests/ investigations as
appropriate.
Documents all aspects of the procedure fully
and signs the prescription sheets.
nd
2
Assessment
rd
3
Assessment
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Signature
Signature
Signature
Print name
Print name
Print name
Date
Date
Date
Comments: -
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NORTH TRENT CANCER NETWORK
RECORD OF COMPETENCY FOR THE ADMINISTRATION OF
INTRAMUSCULAR/SUBCUTANEOUS ANTICANCER THERAPY
Supervised Statement
The trainee has completed a minimum of three supervised session of administering
intramuscular/subcutaneous anticancer therapy. The trainee has completed a formal
assessment with the designated assessor.
Signature of Assessor/Trainer: ……………………………………………..
Print Name: …………………………………………………………
Date: ………………………………………
Practitioner Statement
I have successfully completed the minimum of three supervised practice sessions,
administering intramuscular/subcutaneous anticancer therapy. I have completed a
formal assessment with the designated assessor.
I now feel confident and competent in this specific area of drug administration and am
happy to continue as an independent practitioner. I fully understand my responsibilities
in terms of working within the specific Trust and local cytotoxic anticancer therapy
guidelines and maintaining competence. I fully understand the principles of safe practice
and the need to work within the guidelines for practice set out by my professional body
(e.g. the Nursing and Midwifery Council Guidelines for Practice)
Signature of Practitioner: ………………………………………………………
Print Name: …………………………………………………………
Date: ……………………………………………..
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NORTH TRENT CANCER NETWORK
ANTICANCER THERAPY ADMINISTRATION PROGRESS DIARY
INFUSIONAL ANTICANCER THERAPY ADMINISTRATION
Date
Drug administered
Supervisee
Description/Self
Assessment
Signature
Supervisors
Assessment and
Comments
Signature
Date
Drug administered
North Trent anticancer therapy education programme
V3
Supervisee
Description/Self
Assessment
October 2011
Signature
Page 82 of 97
Supervisors
Assessment and
Comments
Signature
NORTH TRENT CANCER NETWORK
OBJECTIVE STRUCTURED CONSULTATION EXERCISE FOR ADMINISTRATION OF
INFUSIONAL ANTICANCER THERAPY
Trainees Name: -
st
1
Assessment
1
2
3
4
5
Greet and accurately identify patient. Explains
procedure to the patient. Ensures patient
receives adequate verbal/written information
specific to the drug/s and their side effects
Gains patient’s verbal consent to treatment
and ensures written consent is documented
within the patient’s records. Assesses the
patients psychological and emotional state
and responds appropriately
Prepares appropriate equipment
demonstrating awareness of safe handling
and protective measures.
Checks environment to ensure everything is
prepared for treatment
Assesses the patient’s fitness for treatment.
Reviews history since last attendance.
Demonstrates knowledge of appropriate
laboratory results and reassesses BSA
Makes the necessary checks to ensure the
correct drug is administered to the correct
patient at the correct time.
These checks include: Name of patient
Date of Birth
Patient identification number
Height, weight documented and correct BSA
calculated
Required blood tests documented as
indicated by drug protocol
Date and time the drugs are to be
administered
Recognises the name of the drug to be
administered and knows it is suitable for
intravenous use
Checks the expiry date
The signature of the prescriber is documented
Checks the details of the patient with the
chemotherapy chart and designated checker
6
Positions patient correctly for the procedure
ensuring their comfort, privacy and dignity.
Checks the patient has suitable venous
access and once cannula sited ensures that a
flash withdrawal of blood can be made if
appropriate.
nd
2
Assessment
rd
3
Assessment
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
st
1
Assessment
7
8
9
10
11
12
13
Administers medication safely, assessing
cannula site regularly. Gives drugs via the
prescribed route at the prescribed rate in the
appropriate order according to local
guidelines. During administration monitors
infusion rate and adjusts if required.
Monitors patient for signs of adverse side
effects to drugs or extravasation.
Demonstrates knowledge of what actions are
required should these occur.
Removes the cannula or disconnects from
venous access device on completion of
treatment according to hospital guidelines.
Document all aspects of the procedure fully
documented and sign the prescription sheets.
Checks the patient patient/carer understands
the information and advice they have already
been given and respond to any requests for
information.
Ensure the patient has all medication to take
home and understands how to handle/ store
them. Confirm the details of the next
appointment and prior tests/ investigations as
appropriate.
Documents all aspects of the procedure fully
and signs the prescription sheets.
Comments
North Trent anticancer therapy education programme
V3
nd
2
Assessment
rd
3
Assessment
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Signature
Signature
Signature
Print name
Print name
Print name
Date
Date
Date
October 2011
Page 84 of 97
NORTH TRENT CANCER NETWORK
RECORD OF COMPETENCY FOR THE ADMINISTRATION OF
INFUSIONAL ANTICANCER THERAPY
Supervised Statement
The trainee has completed a minimum of three supervised session of administering
infusional chemotherapy. The trainee has completed a formal assessment with the
designated assessor.
Signature of Assessor/Trainer: ……………………………………………..
Print Name: …………………………………………………………
Date: ………………………………………
Practitioner Statement
I have successfully completed the minimum of three supervised practice sessions,
administering infusional anticancer therapy. I have completed a formal assessment with
the designated assessor.
I now feel confident and competent in this specific area of drug administration and am
happy to continue as an independent practitioner. I fully understand my responsibilities
in terms of working within the specific Trust and local cytotoxic anticancer therapy
guidelines and maintaining competence. I fully understand the principles of safe practice
and the need to work within the guidelines for practice set out by my professional body
(e.g. the Nursing and Midwifery Council)
Signature of Practitioner: ………………………………………………………
Print Name: …………………………………………………………
Date: ……………………………………………..
North Trent anticancer therapy education programme
V3
October 2011
Page 85 of 97
North Trent anticancer therapy education programme
V3
October 2011
Page 86 of 97
6.8
NORTH TRENT CANCER NETWORK
ANTICANCER THERAPY ADMINISTRATION PROGRESS DIARY
BOLUS ANTICANCER THERAPY (PERIPHERAL CANNULA) ADMINISTRATION
Date
Drug administered
Supervisee
Description/Self
Assessment
Signature
Supervisors
Assessment and
Comments
Signature
Date
Drug administered
North Trent anticancer therapy education programme
V3
Supervisee
Description/Self
Assessment
October 2011
Signature
Page 88 of 97
Supervisors
Assessment and
Comments
Signature
NORTH TRENT CANCER NETWORK
OBJECTIVE STRUCTURED CONSULTATION EXERCISE FOR ADMINISTRATION OF
BOLUS (PERIPHERAL) ANTICANCER THERAPY
Trainees Name:
1
2
3
4
5
6
Greet and accurately identify patient. Explains
procedure to the patient. Ensures patient
receives adequate verbal/written information
specific to the drug/s and their side effects
Gains patient’s verbal consent to treatment
and ensures written consent is documented
within the patient’s records. Assesses the
patients psychological and emotional state
and responds appropriately
Prepares appropriate equipment
demonstrating awareness of safe handling
and protective measures. Selects appropriate
method of administration (eg down a side arm
of an infusion, directly to cannula etc).
Checks environment to ensure everything is
prepared for treatment
Assesses the patient’s fitness for treatment.
Reviews history since last attendance.
Demonstrates knowledge of appropriate
laboratory results and reassesses BSA
Makes the necessary checks to ensure the
correct drug is administered to the correct
patient at the correct time.
These checks include: Name of patient
Date of Birth
Patient identification number
Height, weight documented and correct BSA
calculated
Required blood tests documented as
indicated by drug protocol
Date and time the drugs are to be
administered
Recognises the name of the drug to be
administered and knows it is suitable for
intravenous use
Checks the expiry date
The signature of the prescriber is documented
Checks the details of the patient with the
chemotherapy chart and designated checker
Positions patient correctly for the procedure
ensuring their comfort, privacy and dignity.
Checks the patient has suitable venous
access and once cannula sited ensures that a
flash withdrawal of blood can be made if
appropriate.
st
1
Assessment
Yes
nd
2
Assessment
Yes
rd
3
Assessment
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
st
1
Assessment
7
8
9
10
11
12
Administers medicaiton safely, assessing
cannula site regularly.
Gives drugs via the prescribed route at the
prescribed rate in the appropriate order
according to local guidelines. During
administration monitors infusion rate and
adjusts if required.
Monitors patient for signs of adverse side
effects to drugs or extravasation.
Demonstrates knowledge of what actions are
required should these occur.
Removes the cannula or disconnects from
venous access device on completion of
treatment according to hospital guidelines.
Document all aspects of the procedure fully
documented and sign the prescription sheets.
Checks the patient patient/carer understands
the information and advice they have already
been given and respond to any requests for
information.
Ensure the patient has all medication to take
home and understands how to handle/ store
them. Confirm the details of the next
appointment and prior tests/ investigations as
appropriate.
nd
2
Assessment
rd
3
Assessment
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Signature
Signature
Signature
Print name
Print name
Print name
Date
Date
Date
Comments: -
North Trent anticancer therapy education programme
V3
October 2011
Page 90 of 97
NORTH TRENT CANCER NETWORK
RECORD OF COMPETENCY FOR THE ADMINISTRATION OF
BOLUS (PERIPHERAL) ANTICANCER THERAPY
Supervised Statement
The trainee has completed a minimum of three supervised session of administering
bolus (peripheral) anticancer therapy. The trainee has completed a formal assessment
with the designated assessor.
Signature of Assessor/Trainer: ……………………………………………..
Print Name: …………………………………………………………
Date: ………………………………………
Practitioner Statement
I have successfully completed the minimum of three supervised practice sessions,
administering bolus (peripheral) anticancer therapy. I have completed a formal
assessment with the designated assessor.
I now feel confident and competent in this specific area of drug administration and am
happy to continue as an independent practitioner. I fully understand my responsibilities
in terms of working within the specific Trust and local cytotoxic anticancer therapy
guidelines and maintaining competence. I fully understand the principles of safe practice
and the need to work within the guidelines for practice set out by my professional body
(e.g. the Nursing and Midwifery Council)
Signature of Practitioner: ………………………………………………………
Print Name: …………………………………………………………
Date: ………………………………………
North Trent anticancer therapy education programme
V3
October 2011
Page 91 of 97
REFERENCES
Albanell J and Baselga J (2000) Systemic Therapy. Emergencies Seminars in
Oncology 27(3) 347-361
Allwood M, Stanley A (2002) The Cytotoxics Handbook 4th Edition Radcliffe Medical
Press
Armstrong T, Almadrones L, Gilbert M (2005) Chemotherapy induced peripheral
neuropathy. Oncology Nursing forum 32(2) 305-311
Barsevick A e al (2008) Management of cancer related fatigue Clinical Journal of
Oncology Nursing 12(5) 21-25
Benson et al (2004) Recommended guidelines for the treatment of cancer treatment
induced diarrhoea: American Society of Clinical Oncology. Journal of Clinical
Oncology 22 (14) 2918-2926
Blowers E, Hall K (2009) Managing adverse events in the use of bevacizumab and
chemotherapy. British Journal of Nursing, 18, (6) 424-428
Camburn T (2009) A practical approach to managing the side effects of lapatinib
Cancer Nursing Practice 8 (10) 21-27
Camp-Sorrel (2006) Cardio-respiratory effects in cancer survivors. Cancer Nursing
29 (2) supp. 55-59
Cantril C and Haylock P (2004) Tumour lysis syndrome. American Journal of Nursing
104 (4) 49-52
Cherney (2008) Evaluation and management of treatment related diarrhoea in
patients with advanced cancer: a review Journal of Pain and Symptom Management
36 (4) 413-423
Coburn S and Mitchell S (2002) Acute renal failure: oncology nursing update.
American Journal of Nursing vol 102, supp. 6-12
Cooley,C (2002) Oral Health: Basic or Essential Care?. Cancer Nursing Practice
1(3)33-39
Cooke T (2000) What is HER2? European Journal of Oncology Nursing 4. supp.1 2-9
Coughlan M, Healy C (2008) Nursing care, education and support for patients with
neutropaenia. Nursing Standard 22 (46) 35-41
Cox A, Jenkins V, Catt S, Langridge C, Fallowfield L (2006) Information needs and
experiences: an audit of UK cancer patients. European Journal of Oncology Nursing
Vol.10 263-272
Cramp F, Daniel J (2008) Exercise for the management of cancer-related fatigue in
adults Cochrane Database of Systematic Reviews. Issue 2
Davies C (2003) The impact of cancer treatment on male fertility. Cancer Nursing
Practice 2 (4) 25-31
North Trent anticancer therapy education programme
V3
October 2011
Page 93 of 97
Dellinger P et al (2008) Surviving sepsis campaign: international guidelines for the
management of severe sepsis and septic shock. Critical Care Medicine, 36 (1)
296-327.
DeJong N, Courtens A, Abu-Saad H, Schouten H (2002) Fatigue in Patients with
Breast Cancer Receiving Adjuvant Chemotherapy: A Review of the Literature.
Cancer Nursing 25(4) 283-297
DeNijs E, Ros W, Grijpdonk M (2008) Nursing interventions for fatigue during the
treatment for cancer. Cancer Nursing 31 (3) 191- 206
Dougherty and Lister (2008) Royal Marsden Manual Clinical Nursing Procedures
Blackwell London
Dougherty (2008). ‘IV therapy: recognising the difference between infiltration and
extravasation British Journal of Nursing 17 (14) 896-901
European Oncology Nursing Society (2007) Extravasation guidelines
Feltham A (2008) Send in the clones. Cancer Nursing practice 7 (3) 19- 22
Foster R (2002) Fertility Issues in Patients with Cancer. Cancer Nursing Practice 1(1)
26-30
Foubert J (2006) Cancer related anaemia and fatigue: assessment and treatment.
Nursing standard 20 (36) 50-57
Grundy M (2000) Nursing in Hematology Oncology. Baillere Tindall London
Hadaway L (2007). ‘Infiltration and extravasation’. American Journal of Nursing 107
(8) 64-72
Harold K (2010) Effective management of adverse effects while on oral
chemotherapy: implications for nursing practice European Journal of cancer care 19,
12-20
Harris D et al (2008) Putting evidence into practice. Evidence based interventions for
the management of oral mucositis. Clinical Journal of Oncology Nursing 12 (1)
141 – 152
Hess L and Insel K (2007) Chemotherapy related change in cognitive function: a
conceptual model. Oncology Nursing forum 34 (5) 981 -994
Innes G (2007) Hand-foot syndrome: exploring the provision of information for
patients. Cancer nursing practice 6 (3) 29-33
Jaroneski L (2006) The importance of assessment rating scales for chemotherapy
induced oral mucositis. Oncology Nursing Forum 33 (6) 1085 – 1090
Knobf T (2006) Reproductive and hormonal sequelae of chemotherapy in women
Cancer nursing 29, 66-71
Mallinson J (2003) Cardiotoxicity Associated with Doxorubicin. Effects on the Heart of
using Anthracyclines as Chemotherapy Agents. Cancer Nursing Practice Nov 2 (9)
30-34
North Trent anticancer therapy education programme
V3
October 2011
Page 94 of 97
Miller M and Kearney N (2001) Oral care for patients with cancer: A review of the
literature Cancer Nursing 24(4) 241- 254
Miller M and Kearney N (2004) Chemotherapy related nausea and vomiting – past
reflections, present practice and future management European Journal of cancer
care 13, 71-81
Miller M et al (2007) Patterns of fatigue during a course of chemotherapy European
Journal of Oncology Nursing 11, 125–132
Moore S (2007) Facilitating oral chemotherapy treatment and compliance through
patient/family–focused education Cancer Nursing 30 (2) 112 -121
Nail L (2006) Cognitive changes in cancer survivors Cancer Nursing 106 (3)
Supplement. 48-53
National Chemotherapy Advisory group (2009) Chemotherapy services in England:
Ensuring quality and safety NCAG, London
National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) (2008)
For better or worse? A review of the care of patients who died within 30 days of
receiving anti-cancer therapy, NCEPOD, London
National Extravasation Service (2005) www.extravasation.org.uk last accessed July
2011
Nielsen E and Brant J (2002) Chemotherapy induced toxicity: assessment and
interventions for patients at risk American Journal of Nursing Vol. 102, 16-19
Nirenmerg A, Bush A, Davis A, Friese C, Gillespe T, Rice R (2006a) Neutropaenic
state of the knowledge part 1 Oncology Nursing Forum 33 (6) 1193 - 1201
Nirenmerg A, Bush A, Davis A, Friese C, Gillespe T, Rice R (2006b) Neutropaenic
state of the knowledge part 2 Oncology Nursing Forum 33 (6) 1202 - 1208
The National Patient Safety Agency (2008) Rapid Response Report Risks of
incorrect dosing of oral anti-cancer medicines Reference: NPSA/2008/RRR001 issued on 22 January 2008
Nursing and Midwifery Council (NMC) Code of Professional Conduct May 2008
Nursing and Midwifery Council (NMC) Standards for medicines management 2008
North Trent Cancer Network Guidelines for the Recognition and Treatment of
Neutropaenic Sepsis 2011
Oakley C et al (2010) Safe practice and nursing care of patients receiving oral
anticancer medicines: a position statement from UKONS. Ecancer 4, 177
Parsaie F, Golchin M, Asvadi (2000) A Comparison of Nurse and Patient Perceptions
of Chemotherapy Treatment Stressors; Cancer Nursing 23(5) 371-374
North Trent anticancer therapy education programme
V3
October 2011
Page 95 of 97
Power S and Condon C (2008) Chemotherapy induced alopecia: a
phenomenological study Cancer Nursing Practice 7 (7) 44 - 47
Pyle L, Beirne D, Bird J, Hoggarth L, Jamieson C, Lane L (2008) Managing the side
effects of sunitinib: a guide to empowering the patient Cancer nursing practice 7 (4)
42-46
Resuscitation Council UK (2008) Emergency Medical Treatment of Anaphylactic
Reactions: Resuscitation council UK www.resus.org.uk
Roe H (2011) Chemotherapy-induced alopecia: advice and support for hair loss
British Journal of Nursing 20 (10) S4-11
Royal College of Nursing (2010) Standards for Intravenous Therapy; Royal College
of Nursing Publications
Royal College of Physicians, The Royal College of Radiologists, Royal College of
Obstetricians and Gynaecologists (2007) The effects of cancer treatment on
reproductive functions: Guidance on management. Report of a Working Party.
London: RCP
Saureland C, Engelking C, Wickham R, Corbi D (2006). ‘Vesicant extravasation part
1: mechanisms, pathogenesis and nursing care to reduce risk’, Oncology Nursing
Forum
Sieracki R., Voelz L., Johannik, T., Kopaczewski, D., Hubert K (2009) Development
and implementation of an oral care protocol Clinical Journal of Oncology Nursing 13
(6)718-722
Schulmeister L (2008) Patient misidentification in oncology care. Clinical Journal of
Oncology Nursing 12 (3) 495-498
Schwappach D., Hochreutener M. and Wernli M. (2010) Oncology Nurses’
Perceptions About Involving Patients in the Prevention of Chemotherapy
Administration Errors. Oncology Nursing Forum 37(2) 84-91
Skills for Health Chemotherapy Workforce Competence Framework (2005)
Smith E, Beck S, Cohen J (2008) The total neuropathy score: a tool for measuring
chemotherapy induced peripheral neuropathy Oncology Nursing Forum 35 (1)
96-102
Souhami R and Tobias J (2005) Cancer and its management 5th Edition Blackwell
publications
Tadman M and Roberts D (2007) Oxford handbook of cancer nursing Oxford
University Press
Thaler-Demers (2006) Endocrine and fertility effects in male cancer survivors Cancer
Nursing 29, 66-71
Vidal C (2011) Chemotherapy induced nausea and vomiting: A European perspective
British Journal of Nursing 20 (10) s22-28
North Trent anticancer therapy education programme
V3
October 2011
Page 96 of 97
Webster et al (2007) Palmar plantar erythodysesthesia (PPE): a literature review with
comment on experience in a cancer centre European Journal of Oncology Nursing
11 (3) 238-245
Wells S (2008) Venous access in oncology and haematology patients Nursing
Standard 22 (52) 39 – 46
Wickham R, Engelking C, Saureland C, Corbi D (2006). ‘Vesicant extravasation part
2: evidence based management and continuing controversies’, Oncology Nursing
Forum 33 (6) 1143-1147
Yeager, K et al (2000) Implementation of an Oral Care Standard for Leukaemia and
Transplantation Patients Cancer Nursing 23(1) 40-47
North Trent anticancer therapy education programme
V3
October 2011
Page 97 of 97