RTT 335 Patient Care in RTT Chemotherapy

History 1950’s to 1960’s: animal experiments with anti cancer drugs Late 1960’s: systemic chemo. Could induce long lasting clinical remissions for choriocarcinoma, lymphoma and Hodgkin’s disease. Started to be used as adjuvant therapy in early stage disease.

1970’s, 1980’s, 1990’s Vinca alkaloids, anthracyclin antibiotics and platinum derivatives Epipodophyllotoxins and taxanes These new drugs led to an abundance of chemotherapy combinations.

Medical oncology The interpretation of the natural history of malignant disease The appropriate application of cancer chemotherapeutic techniques. The diagnosis and management of complications of the disease The coordination of emotional, nutritional and social support.

Cancer chemotherapy First clinical studies were with nitrogen mustard. It was known to have myelosuppressive and lympholytic properties.

Drug classification Antimetabolites Alkylating agents Natural or semisynthetics(antibiotics, plant alkaloids, enzymes, monoclonal antibodies, podophyllum derivitives) Miscellaneous agents Hormones and hormone inhibitors. See handout.

Antimetabolytes Low molecular weight molecules that are mistaken by the cell for normal metabolytes. They either inhibit critical enzymes or become incorporated into the nucleic acid and produce incorrect codes. This results in inhibition of DNA synthesis

Alkylating agents. Are a group of compounds that are capable of forming molecular bonds with nucleic acids and proteins. The final action is on the DNA and results in cross-linking and strand breaks.

Natural products Mitotic inhibitors: vincristine, vinblastin Podophyllum derivitive: arrests cells in the G2 phase Antibiotics: the antitumor antibiotics are a group of antimicrobial compounds. They affect the function and synthesis of nucleic acids. Enzymes:deprives selected malignant cells of an amino acid essential to their survival.

Hormones and hormone inhibitors Androgens alter pituitary functions or directly affect neoplastic cells Corticosteroids: cause lysis of lymphoid tumors Estrogens: suppress testosterone production in males and alter breast cancer cell response to prolactin Progestins act directly at the level of the cell receptor to promote differentiation Estrogen inhibitors compete with estrogen for binding on protein in the cancer cell.

Pharmacological aspect of cancer chemotherapy Absorption Distribution Biotransformation excretion

Absorption Absorption determines the route of administration: oral, intramuscular, intravenous or intrathecal. The rate of absorption affects the concentration achieved which determines the intensity of the exposure of cancer cells to the drug. The pharmacokinetics are important in determining the drug dose.

Distribution The concentration and effectiveness of the drugs can sometimes be enhanced by local or regional instillation into a body cavity or by infusion

Biotransformation The activation of one drug by another

Excretion The excretion patterns are important in determining toxicity. For example, methotrexate is largely excreted by the kidneys and care must be taken not to overdose the kidneys.

Routes and methods of administration. Oral Subcutaneous and intramuscular Intravenous Intraarterial Intrathecal Intraperitoneal Intrapleural

Oral Care must be taken for proper dosage and scheduling. Patients must be educated as they sometimes dismiss oral medication as not important or serious.

Subcutaneous and intramuscular Are reserved for those drugs that do not cause irritation and damage to tissues. Patients may complain of pain at the injection site.

Intravenous IV push: cost effective for those medications that are not harmful to the vein wall. IV sidearm: continuous solution and medication injected in. IV piggyback: medication is infused over a period of time. Continuous drip: medications are added to solution and run at appropriate rate. Can be used at home with portable pumps.

Intraarterial Arterial catheter and medication is given via pump.

Intrathecal Antineoplastic agents are injected directly into the spinal fluid, via lumbar puncture.

Intraperitoneal and intrapleural Insertion of catheter into the peritoneum. Insertion of chest tube.

Venous access devices. Because of the need to repeat venipuncture to administer courses of chemotherapy, another means of venous access needs to be considered. Semipermanent central catheters(chest wall) Implanted venous access port

Safe handling of chemotherapeutic agents. Personnel disposal Patients: side effects

Personnel Must receive training Document exposure to chemo. Agents Agents should be mixed in a class II biological safety cabinet Wear protective barrier garments Gloves Hand washing Do not recap syringes Two pairs of gloves and protective clothing should be worn to clean up spills.

Disposal Hazardous waste EPA recommends incineration in a special hazardous waste incinerator or burial at an EPA approved site.

Patients: side effects and toxicities Acute Extravasation – leaking into tissues Anaphylaxis Nausea and vomiting

Extravasation Can produce tissue necrosis The management depends on the drug being used.

Anaphylaxis A test dose can be given if allergies are common with the drug. epinephrine

Nausea and vomiting Antiemetic drugs Relaxation techniques Education: clear liquid diet, eat foods at room temperature, dry crackers, avoid foods with strong smell, resting during periods of nausea.

Patients: side effects and toxicities Nonacute Hematologic Stomatitis alopecia

Hematologic Anemia Thrombocytopenia leukopenia

Stomatitis Inflammation of oral mucosa Begins as dryness and progress to ulceration Oral care: 1.5% hydrogen peroxide mouth washes, Xylocaine, leave dentures out, narcotics for pain

Alopecia Hair loss Is usually temporary Drugs with the greatest potential for producing hair loss are: doxorubicin, cyclophosphamide and vincristine. Education and preparedness.