Copyright © 2017, Elsevier Inc. All rights reserved.

Cancer (Cont.) Cancerous cells do not have: Growth control mechanisms Positive physiologic function Cancer cells either: Grow and invade adjacent tissues, or Break away from original tumor mass and travel by means of blood or lymphatic system to distant sites Copyright © 2017, Elsevier Inc. All rights reserved.

Cancer (Cont.) Primary lesion Original site of growth Metastasis Uncontrolled cell growth Secondary lesion, in a new and remote part of the body Neoplasm (“new tissue”) Mass of new cells; tumor Tumor Benign Malignant (cancer) Copyright © 2017, Elsevier Inc. All rights reserved.

Schematic Model of Multistep Carcinogenesis
Copyright © 2017, Elsevier Inc. All rights reserved.

Benign and Malignant Tumors

Cancer: Tissues of Origin
Carcinomas Sarcomas Lymphomas and leukemias Also known as circulating tumors or hematologic malignancies Copyright © 2017, Elsevier Inc. All rights reserved.

Paraneoplastic Syndromes
Various group of symptoms that cannot be directly attributed to the spread of a cancerous tumor May be the first sign of malignancy Cachexia (most common) Fatigue, fever, weight loss Others Copyright © 2017, Elsevier Inc. All rights reserved.

Etiology of Cancer Age- and sex-related differences Genetic factors Ethnic factors Oncogenic viruses Occupational and environmental carcinogens Radiation Immunologic factors Copyright © 2017, Elsevier Inc. All rights reserved.

Cancer Drug Nomenclature
Malignant neoplasm: more technical term for cancer Antineoplastic drugs: drugs used to treat cancer Also called cancer drugs, anticancer drugs, cytotoxic chemotherapy, or just chemotherapy Copyright © 2017, Elsevier Inc. All rights reserved.

Chemotherapy Pharmacologic treatment of cancer Antineoplastic drugs Divided into two groups based on where in the cellular life cycle they work Cell cycle–nonspecific (CCNS) Cell cycle–specific (CCS) Some drugs have characteristics of both. Copyright © 2017, Elsevier Inc. All rights reserved.

General Phase of the Cell Cycle

Cancer Drugs: Antineoplastic Medications
CCS drugs Drugs that are cytotoxic during a specific cell-cycle phase Used to treat a variety of solid or circulating tumors Antimetabolites Mitotic inhibitors Alkaloid topoisomerase II inhibitors Topoisomerase I inhibitors Antineoplastic enzymes Copyright © 2017, Elsevier Inc. All rights reserved.

Cancer Drugs: Antineoplastic Medications (Cont.)
CCNS drugs Cytotoxic during any cell-cycle stage Miscellaneous CCS drugs Miscellaneous antineoplastics (cell-cycle specificity unclear) Hormonal agents Radioactive antineoplastics Copyright © 2017, Elsevier Inc. All rights reserved.

Chemotherapy (Cont.) Drugs have a narrow therapeutic index. Combination of drugs is usually more effective than single-drug therapy. Drug resistance Nearly all drugs cause adverse effects. Dose-limiting adverse effects Copyright © 2017, Elsevier Inc. All rights reserved.

Relationship Between Tumor Cell Burden and Phases of Cancer Treatment

Chemotherapy (Cont.) Harmful to all rapidly growing cells Harmful cancer cells Healthy, normal human cells Hair follicles Gastrointestinal (GI) tract cells Bone marrow cells Copyright © 2017, Elsevier Inc. All rights reserved.

Chemotherapy Terms Dose-limiting adverse effects GI tract and bone marrow Alopecia Emetic potential Myelosuppression Bone marrow suppression (BMS) Bone marrow depression Nadir Extravasation Targeted drug therapy Copyright © 2017, Elsevier Inc. All rights reserved.

Chemotherapy: Special Considerations
Toxicities Contraindications Pregnancy Prepubertal Older adults Copyright © 2017, Elsevier Inc. All rights reserved.

Antimetabolites CCS analogues that work by antagonizing the actions of key cellular metabolites. Antimetabolites work primarily in the S phase of the cell cycle, when DNA synthesis is most active. Copyright © 2017, Elsevier Inc. All rights reserved.

Antimetabolites (Cont.)
Folate (folic acid) antagonists methotrexate (MTX), pemetrexed, pralatrexate Purine antagonists fludarabine (F-AMP), mercaptopurine (6-MP), thioguanine (6-TG), cladribine, pentostatin Pyrimidine antagonists fluorouracil (5-FU), cytarabine (ara-C), capecitabine, floxuridine (FUDR), gemcitabine Copyright © 2017, Elsevier Inc. All rights reserved.

Antimetabolites: Indications
Used in combination with other drugs to treat various types of cancer, such as solid tumors and some hematologic cancers Acute and chronic lymphocytic leukemias Leukemias (several types) Colon, rectal, breast, stomach, lung, pancreatic cancers Copyright © 2017, Elsevier Inc. All rights reserved.

Antimetabolites: Indications (Cont.)
Oral and topical forms may be used for low-dose maintenance and palliative cancer therapy. Often used in combination chemotherapy regimens Methotrexate is also used to treat severe cases of psoriasis and rheumatoid arthritis. Copyright © 2017, Elsevier Inc. All rights reserved.

Antimetabolites: Adverse Effects
Hair loss, nausea and vomiting, myelosuppression Neurologic, cardiovascular, pulmonary, hepatobiliary, GI, genitourinary, dermatologic, ocular, otic, and metabolic toxicity Tumor lysis syndrome Palmar-plantar dysesthesia (also called hand-foot syndrome), Stevens-Johnson syndrome, toxic epidermal necrolysis Copyright © 2017, Elsevier Inc. All rights reserved.

Audience Response System Question
Which condition does the nurse anticipate when assessing a patient with tumor lysis syndrome? Hyperuricemia Hypophosphatemia Hypokalemia Hypercalcemia Correct answer: A Rationale: Manifestations of tumor lysis syndrome include hyperphosphatemia, hyperkalemia, and hypocalcemia. These electrolyte abnormalities are often treated with diuretics such as mannitol, intravenous calcium supplementation, oral or rectal potassium exchange resin, and oral aluminum hydroxide. Hyperuricemia can lead to nephropathy, and hemodialysis may be required in severe cases of tumor lysis syndrome. Copyright © 2017, Elsevier Inc. All rights reserved.

A patient who is receiving high-dose chemotherapy with methotrexate is also receiving leucovorin. The purpose of the leucovorin is to: produce an additive effect with the methotrexate by increasing its potency against the cancer cells. reduce the incidence of cardiomyopathy caused by the methotrexate. add its antiinflammatory effects to the treatment regimen. reduce the BMS caused by the methotrexate. Correct answer: D Rationale: Leucovorin “rescue” is prescribed to reduce the BMS that is associated with high-dose methotrexate therapy. Copyright © 2017, Elsevier Inc. All rights reserved.

Mitotic Inhibitors Natural products obtained from the periwinkle plant Vinca alkaloids: vinblastine, vincristine, and vinorelbine Taxanes: paclitaxel, docetaxel, cabazitaxel (Jevtana), and eribulin (Halaven) Copyright © 2017, Elsevier Inc. All rights reserved.

Mitotic Inhibitors: Mechanism of Action
Can work in various phases of the cell cycle (late S phase, throughout G2 phase, and M phase) All work shortly before or during mitosis and thus retard cell division. Each different subclass inhibits mitosis in a unique way. Copyright © 2017, Elsevier Inc. All rights reserved.

Mitotic Inhibitors: Indications
Often used in combination therapies Used to treat a variety of solid tumors and some hematologic malignancies Testicular, small cell lung, breast, ovarian, non–small cell lung cancers Kaposi’s sarcoma Acute leukemia Copyright © 2017, Elsevier Inc. All rights reserved.

Mitotic Inhibitors: Adverse Effects
Hair loss, nausea and vomiting, myelosuppression Liver, kidney, lung toxicities Convulsions Extravasation Several specific antidotes can be used. Copyright © 2017, Elsevier Inc. All rights reserved.

Alkaloid Topoisomerase II Inhibitors
Used to treat small cell lung cancer and testicular cancer Not used as much now because of significant toxicities without therapeutic benefit Copyright © 2017, Elsevier Inc. All rights reserved.

The nurse identifies which of the following as the most significant neurotoxin of the cytotoxic drug class? paclitaxel (Taxol) docetaxel (Taxotere) vincristine (Vincasar PFS) etoposide (Toposar) Correct answer: C Rationale: Vincristine is the most significant neurotoxin of the cytotoxic drug class, but it continues to be used in part because of its relative lack of BMS. Special care must be taken not to inadvertently give vincristine via the intrathecal route. Several deaths have been reported because of this error. Copyright © 2017, Elsevier Inc. All rights reserved.

Topoisomerase 1 Inhibitors (Camptothecins)
Used primarily to treat ovarian and colorectal cancer Derived from camptothecin, a substance taken from a Chinese shrub topotecan (Hycamtin) irinotecan (CPT-11, Camptosar) Copyright © 2017, Elsevier Inc. All rights reserved.

Adverse effects Topotecan: BMS, mild to moderate nausea, vomiting, and diarrhea; headache; rash; muscle weakness; and cough Irinotecan: causes more severe adverse effects than topotecan (hematologic adverse effects, cholinergic diarrhea, moderate risk of nausea and vomiting) Copyright © 2017, Elsevier Inc. All rights reserved.

Antineoplastic Enzymes
Synthesized using cultures of bacteria and recombinant DNA technology As a result, an enzyme is produced. This enzyme is isolated and purified for clinical use. asparaginase (Elspar): used to treat acute lymphocytic leukemia pegaspargase (Oncaspar) Erwinia asparaginase: available only by special request from the National Cancer Institute for patients who have developed allergic reactions to Escherichia coli–based asparaginase Copyright © 2017, Elsevier Inc. All rights reserved.

Antineoplastic Enzymes (Cont.)
Indication: treatment of acute lymphocytic leukemia Adverse effects: impaired pancreatic function, which can lead to hyperglycemia and severe or fatal pancreatitis, dermatologic, hepatic, genitourinary, neurologic, musculoskeletal, GI, and cardiovascular effects Copyright © 2017, Elsevier Inc. All rights reserved.

Nursing Implications Assess baseline blood counts before administering antineoplastic drugs. Follow specific administration guidelines for each antineoplastic drug. Copyright © 2017, Elsevier Inc. All rights reserved.

A pregnant woman has been diagnosed with cancer and is meeting with her oncologist to plan treatment. Which statement about chemotherapy and pregnancy is true? She will have to wait until the baby is born before starting chemotherapy. The greatest risk of fetal harm from chemotherapy is during the third trimester. Chemotherapy treatment during the second or third trimester poses less risk to the fetus. Chemotherapy is unsafe during pregnancy, but radiation therapy is safe in low doses. Correct answer: C Rationale: Both radiation and chemotherapy treatments can cause significant permanent fetal harm or death. The greatest risk is during the first trimester. Chemotherapy treatment during the second or third trimester is more likely to improve maternal outcome without significant fetal risk. However, radiation treatment poses great risk to the fetus throughout pregnancy and should be reserved for the postpartum period if possible. Prepubertal patients are more resilient, however, and can have normal puberty and fertility. Copyright © 2017, Elsevier Inc. All rights reserved.

Nursing Implications (Cont.)
Remember that all rapidly dividing cells (both normal and cancer cells) are affected. Mucous membranes Hair follicles Bone marrow component Monitor for effects on these tissues or complications. Copyright © 2017, Elsevier Inc. All rights reserved.

Monitor for complications. GI mucous membranes: stomatitis, altered bowel function with high risk for poor appetite, nausea, vomiting, diarrhea, and inflammation and possible ulcerations of GI mucosa Copyright © 2017, Elsevier Inc. All rights reserved.

Monitor for complications. Hair follicles: loss of hair (alopecia) Bone marrow components: dangerously low (life-threatening) blood cell counts Monitor for adverse effects specific to the type of antineoplastic drug given. Copyright © 2017, Elsevier Inc. All rights reserved.

Implement measures to monitor for and prevent infection in patients with neutropenia or leukopenia. Implement measures to monitor for and prevent bleeding in patients with thrombocytopenia and anemia. Keep in mind that anemia may result in severe fatigue. Copyright © 2017, Elsevier Inc. All rights reserved.

The nurse is caring for a patient who received chemotherapy 24 hours ago. The patient’s white blood cell count is 4,400 mcL. Which symptom, if experienced by the patient, should the nurse report to the prescriber immediately? Fatigue Diarrhea Fever Nausea and vomiting Correct answer: C Rationale: Fever is the principal early sign of infection, especially in those with a low white blood cell count. The presence of a fever is of utmost concern and should be reported immediately. A normal white blood cell count is 4500 to 10,000 mcL. Copyright © 2017, Elsevier Inc. All rights reserved.

Monitor for stomatitis (oral inflammation and ulcerations) and implement measures to reduce the effects if it occurs. Anticipate nausea and vomiting and implement measures to reduce these effects. Antiemetics often work better if given 30 to 60 minutes before chemotherapy is started. Copyright © 2017, Elsevier Inc. All rights reserved.

Women of childbearing age will need to use a nondrug form of contraception during therapy. In addition to physical measures, keep in mind the need for emotional support during this time for both the patient and family. Monitor for therapeutic responses to antineoplastic therapies and the many possible adverse effects. Copyright © 2017, Elsevier Inc. All rights reserved.

When working with a patient who is neutropenic, the nurse identifies which as the most effective measure to prevent the patient from developing an infection? Administer prophylactic antibiotics. Stop administration of the chemotherapeutic drug. Perform hand hygiene. Vaccinate the patient to prevent bacterial infection. Correct answer: C Rationale: Risk of infection from leukopenia or neutropenia or immunosuppression is one of the more significant adverse effects that requires close attention. Following Standard Precautions and using good handwashing technique are most important in preventing transmission of infection in the hospital and home settings. Copyright © 2017, Elsevier Inc. All rights reserved.

Copyright © 2017, Elsevier Inc. All rights reserved.

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