CHEMOTHERAPY An Overview Amy Sinacola. Haematology Macmillan Clinical Nurse Specialist

Aims of session Understand Cell Cycle Chemotherapy and the cancer cell Side effects Nursing implications Administration & safety

Definition: Chemotherapy The treatment of cancer using specific chemical agents or drugs that are destructive to malignant cells and tissues. The term comes from two words that mean "chemical" and "treatment." Cytotoxic literally translated means ‘toxic to cells’.

The Cell Cycle The Cell Cycle

Mitosis

Cell Biology: Mitosis A cell in mitosis

Normal Cell Characteristics: Metabolism. Strictly controlled & predictable Maturation & Specialisation. Occurrs before dividing. Strictly controlled. Reproduction = Cell death Contact Inhibition. Mechanism for switching off division when in contact with different cells Recognition. Like cells stay together.

Cancer Cell Characteristics: Unchecked & Uncontrolled Growth Loss of contact inhibition Loss of capacity to differentiate Increased growth fraction Chromosomal Instability Capacity to metastasise Altered biochemical properties

Chemotherapy and Cancer Cells Cell Cycle specific : Most active against cells in a specific phase therefore need prolonged exposure or repeated doses. Cell Cycle Non-specific: Most effective against actively dividing cells but also effective in G0.

Chemotherapy Chemotherapy may be used conventionally to: Cure patients Prolong survival Palliative care symptom control

Chemotherapy Combination Therapy. Prevents resistance. Adjuvant Therapy. Administered after primary therapy e.g.Surgery Neo adjuvant Therapy: Given before surgery to reduce tumour size.

Chemotherapy Over 50 different chemotherapy drugs Administered as an outpatient or inpatient depending on toxicity Modes of administration include: Oral e.g. Methotrexate, Hydroxyurea IV: Canula/Indwelling Central Venous Catheter Sub cut Intracavity e.g pelvic cavity, bladder Intrathecal. Can be fatal if wrong drug administered!

Intrathecal Chemotherapy

Chemotherapy Side Effects Chemotherapy targets cells which are dividing rapidly. Chemotherapy cannot distinguish between normal cells and cancer cells Healthy Cells which have a high rate of growth and multiplication include cells of the bone marrow, hair, GI mucosa and skin.

Chemotherapy Side effects contd… Side effects may be drug specific e.g. anthracyclines and cardiotoxicity, vinca alkaloids and neuropathy/constipation, bleomycin and pulmonary fibrosis Severity of side effects varies between drugs. Side effects often occur 7-14 days post treatment.

Side Effects: Acute Tumour Lysis Syndrome. A Metabolic Emergency. Occurrs due to rapid cell lysis (death) & large amounts of cell metabolites in blood. If untreated can lead to acute renal failure, cardiac arrest and death.

Side Effects: Acute Neutropenic Sepsis: Occurs due to Bone Marrow Failure and poor immune response to infection. Predisposing factors include: Neutropenia Underlying disease Chemotherapy Venous access devices

Neutropenic Sepsis Severe overwhelming infection where inadequate blood flow to the tissues results in cellular dysfunction and, if not reversed, eventual organ failure. Most common micro organism is gram negative Mortality rate 40-90%

Side Effects: Acute Haemorrhage Invading tumours e.g gastric MALT lymphomas Haemorrhagic Cystitis related to high dose Cyclophosphomide Anaphylactic Reaction

Side Effects:Bone Marrow Neutropenia: Increased risk of infection. Anaemia: Tiredness, lethargy & breathlessness Thrombocytopenia: Increased risk of bleeding

Side Effects: Gastro-Intestinal Nausea & Vomiting Diarrhoea & constipation Loss of appetite Taste Changes Mucositis

Side Effects Example of Grade 4 Mucositis

Side Effects: Body Image Hair Loss Weight Loss/ Weight Gain Long term central venous catheters Skin changes (colour, rashes, sensitivity to sunshine/chlorine, dry)

Side Effects: Other Fatigue: Often multi-factorial Peripheral neuropathy Altered Kidney Function Changes in hearing (high dose Cisplatin) Cardiac Toxicity (Doxorubicin/ Idarubicin) Late Effects: Infertility, secondary malignancy, growth retardation.

Case Study 17 year old girl with Hodgkins disease. Has had 3 cycles of chemotherapy treatment and is halfway through the course. She is feeling sick up to 24 hours before coming to hospital for treatment and vomiting up to 48 hours after receiving chemotherapy. She has lost 1 stone in weight in 2 months, she feels tired and is not wanting to have any more treatment.

Case Study 36 year old lady just diagnosed with None Hodgkins Lymphoma. She works part time as a beauty therapist and has 2 small children under the age of 5. She is to receive outpatient chemotherapy of R-CHOP and requires a long term central venous catheter. What would you include in your nursing assessment?

How can nurses help. Information and Education. What to do if unwell. Infection is a big risk! Advice on Symptom Control Timely administration of drugs Regular assessment of side effects and effectiveness of interventions e.g anti emetics, analgesia etc Nutritional assessment and intervention

How can nurses help Psychological Care: Body Image, Diagnosis of life threatening disease, Fear of dying Involve Family members, talking to children about parents diagnosis etc Consider Sexual advice needed Consider financial implications Direct to supportive services in their area eg support groups, complementary therapies etc. Refer to Community Team if support at home needed

Points about Administration: Staff Must be administered by chemotherapy trained nurses only Safe handling is essential. Cytotoxic drugs are carcinogenic, mutagenic and teratogenic. Potential exposure occurs during: preparation, administration and changing lines, handling of body fluids e.g urine, handling of chemo waste products e.g lines, medication bottles, spillage / leakage of chemotherapy. ALWAYS TAKE UNIVERSAL PRECAUTIONS

Key Points: Chemotherapy is a major treatment in curing or prolonging survival in cancer patients It has a wide range of side effects depending on the drugs given. Nurses have a key role to play in caring for a patient receiving chemotherapy Safety issues are paramount in administration.

Summary: The potential benefit to the patient of treatment as an option must always outweigh the toxic effects.