2. side effects and toxicities of chemotherapy

Side Effects and Toxicities of

Chemotherapy

Continuing Education

Nausea and vomiting:o Nausea and vomiting are two of the most common side

effects of chemotherapy.o Vomiting is a reflex controlled in the emetic center of

the brain stem.o Uncontrolled nausea and vomiting can lead to fluid and

electrolyte imbalance, impaired nutrition, nonadherence to treatment, and a reduced quality of life.

Nausea and vomiting can be prevented in 70% - 80% of patients with the use if antiemetics (drugs that relieve the signs and symptoms of nausea and vomiting).

Side Effects and Toxicities of Chemotherapy


There are three patterns of emesis associated with chemo administration:1. Acute emesis occurs in the first 24 hours and is

the most severe.2. Delayed emesis begins 18-24 hours after

treatment and may continue for several days.3. Anticipatory emesis is a response that is triggered

by chemo-associated sights, smells, visual, thoughts and anxiety.

Antiemetic guidelines have been developed by the American Society of Clinical Oncology (ASCO). The Multinational Association of Supportive Care in Cancer (MASCC), and the National Cancer Comprehensive Network (NCCN).o Acute chemo-induced N&V are prevented and

treated with serotonin receptor antagonists, dexamethasone, and aprepitant.

o Delayed N&V are treated with dexamethasone and aprepitant.

o Anticipatory N&V are treated with cognitive therapy and benzodiazapines.


Classes of Antiemetics: Serotonin receptor antagonists are the most

effective agents to prevent acute N&V. o They are administered immediately before

chemotherapy and continued for a few days.o There are a number of these agents available:• Anzemet (dolasetron)• Kytril (granisteron)• Zofran (ondansetron)• Aloxil (palonestron)

o The major side effects of these drugs are headache, diarrhea, fatigue, fever, and drowsiness



Neurokinin-1-Receptor Antagonists:o These block the NK-1 receptor, which is found in the

vomiting and vestibular center of the brain.o The only drugs in this class currently available.

1. Emend for injection (fosaprepitant dimeglumine)2. Emend oral (aprepitant)

o When combined with a serotonin receptor antagonist and dexamethasone therapy, they have added efficacy in both acute and delayed N&V.


Corticosteroidso Dexamethasone is the most commonly used

antiemetic corticosteroid. o Corticosteroids are important in the prevention of

delayed N&V.o Common S/E with short term use include insomnia,

gastric irritation, and transient hyperglycemia.


Dopamine receptor antagonists include..o Reglan (metoclopramide)o Compazine (prochlorperazine)o Phenergan (promethazine)o Haldol (haloperidol)o Efficacy is low when these agents are used alone, they

are sometimes used in conjunction with other antiemetics for breakthrough emesis.

Benzodiazepineso Benzodiazepines can reduce anxiety some patients

experience before and during chemotherapy.o They are not antiemetics but are used in conjunction

with antiemetics.


Nonpharmacological Measures to control Nausea & Vomiting:o There are several nursing measures that may help reduce N&V.o Patients should avoid eating or drinking 1-2 hours after chemo treatments. o Many patients find that foods at room temperature taste better and do not

have as strong of an odor as hot foods.o Dry toast or crackers in the morning may help the patient’s nausea.o Clear liquids and herbal tea provide fluids to prevent dehydration.o Sport drinks also provide electrolytes. o Liquids should be sipped slowly.o Some tart foods such as sour hard candy, dill pickles or lemons may be

helpful for some patients.o Foods such as fried fatty foods or foods with a strong odor should be

avoided. o Soft, relaxing music; low lights and quiet atmosphere may be helpful. Some

patients do well with diversions such as card games, movies or crafts. o Some patients respond well to acupressure, acupuncture, behavior

modification, yoga, massage therapy, hypnosis, and guided imagery.


Myelosuppressiono Myelosuppression is the most common dose-

limiting factor in chemotherapy administration.o Myelosuppression consists of neutropenia,

thrombocytopenia, and anemia.

Neutropenia o Patients with neutropenia have an unusually low

number of neutrophils. Neutrophils attack bacteria and other organisms when they invade your body. Neutropenia predisposes the patient to infection.


Thrombocytopeniao Normal platelet count ranges between 150,000 and 400,000.

Thrombocytopenia occurs when a patient has a low platelet count. The risk of bleeding increases when the count is below 100,000.

Anemia o A patient is considered anemic if the Hgb level is < 8 g/dL. Anemic patients

may be symptomatic or present with headache, dizziness, lightheadedness, SOB, fatigue, pallor, hypothermia, and pale nail beds and conjunctiva.

Fatigueo Cancer related fatigue is the most common side effect of cancer and its

treatment.o Exercise may reduce the intensity of fatigue and the distress associated

with its occurrence.o Treatment of anemia may also be helpful.

Anorexia and Taste Alterations:o Anorexia and taste alterations are common among patients

receiving chemotherapy.o Dysgeusia, a condition in which the gustatory sense is impaired.

Foods taste entirely different and in some circumstances even unpleasant.

o Some patients experience a metallic or bitter taste, or no taste at all.

o Advise the patient that gum or hard candy can help between meals.o Instruct the patient to brush teeth frequently to relieve unpleasant

tastes.o Rinsing the mouth with non irritating mouthwash is often refreshing.o Cold foods or foods served at room temp are usually tolerated

better than hot foods, cold fruits and cheeses are often a better alternative than a hot meal. Small more frequent meals may be tolerated better than three large meals.

o Hard, dry food can cause discomfort and be difficult to swallow as compared to soft meals.

o Commercial mouthwashes, smoking, and alcohol are irritating to the mucous membranes and should be avoided.



Nursing suggestions to help patients cope with taste alterations:o Provide oral hygiene before meals.o Avoid strong cooking odors, such as cabbage and broccoli.o Arrange food attractively.o Eat in pleasant, relaxed environment. o Use pleasant odors, such as cloves.o Avoid noxious odors, such as fish.o Enhance food flavors with herbs, spices, or marinade.o Serve cold foods rather than hot foods.o Eat frequent, small meals.o Administer antiemetics before meals.o Drink high energy shakes.o Serve food on glass dishes and use plastic silverware.

Constipationo Constipation is the difficult, and sometimes painful, passage of

hard, dry stool. It can vary from mild discomfort to the development of a paralytic ileus.

o There are many causes including Chemotherapy, anxiety, depression, opioids, muscle relaxants, hypercalcemia, immobility, dehydration, dietary deficiencies, and tumor involvement.

o Patients at risk for constipation should be instructed to increase their dietary intake of fresh fruits, vegetables, and fiber. The patient should has at least 2 to 3 liters of fluid daily unless otherwise contraindicated.

o Cheese, eggs, chocolate, candy, and foods known to be constipating should be avoided.

o Physical activity and exercise stimulate peristalsis, patients should be encouraged to remain as active as possible.

o Patients should be instructed to respond to the urge to defecate and not wait.


Diarrheao Diarrhea is the abnormal passage of five or more loose or

watery stools in a 24 hour period, often it is accompanied by abdominal cramping.

o Patients with 6 or more diarrhea stools a day are at risk for dehydration and electrolyte imbalance.

o Instruct the patient to increase their intake of constipating foods such as cheese and eggs.

o Foods high in pectin, bulk, and fiber help slow peristalsis. Fluid replacement prevents dehydration.

o Avoid spicy foods, which irritate the GI tract.o Advise patients that fatty or greasy foods stimulate the colon.o Raw fruits and vegetables, nuts, caffeine, seeds, popcorn,

and alcohol should be avoided.


Diarrhea (cont’d)o Intake and output should be accurately

recorded.o Potassium is one of the major electrolytes lost;

therefore fluids and foods high in potassium should be used.

o Pharmacological intervention should be started as soon as possible to avoid complications.

o In cases of severe diarrhea, IV fluid replacement and anti motility agents (such as loperamide , diphenoxylate, or octreotide) may be indicated.


Alopeciao Although hair loss is temporary, alopecia may adversely

affect self image. o Rapidly dividing cells, including the hair follicles, are

affected by chemotherapy.o Hair loss may be thinning, partial, or complete, and may

involve the scalp, eyebrows, and eyelashes.o Hair loss may begin in 7-10 days after treatment, but

sometimes begins even before treatment is completed.o Regrowth usually occurs 3-6 months after the last

treatment.o Care of the scalp should be the same as that for any

area of exposed skin.


Stomatitis and Mucositiso The mucous membranes of the GI tract, especially those of the

mouth, can become red, irritated, and inflamed.o Stomatitis can range from a mild irritation to full blown sores,

with difficulty swallowing. o Chemo related stomatitis usually begins 5-7 days after

treatment and lasts about 10 days.o Educate patient on good oral hygiene.o A soft toothbrush should be used, particular when mouth is

tender.o Advise patients to remove their dentures at night and as much

as possible during the day.o Instruct patients to eat soft foods with a smooth consistency.

Cold foods may be soothing to irritated membranes.o Applying lip balm deeps the lips moist and promotes comfort

and healing.o Ice chips have been used effectively to prevent or reduce

mucositis in patients receiving 5FU.


Cardiotoxicityo Cardiotoxic chemo agents include the anthracyclines, doxorubicin

and daunorubicin, mitoxantrone, paclitaxel, and, in high doses, cyclophosphamide.

o The anthracyclines can damage the myocytes, weakening the cardiac muscle. This results in decreased cardiac output, with progression to congestive heart failure.

o A patient is usually asymptomatic until s/s of CHF appear. Patients c/o SOB, especially on exertion, and a nonproductive cough.

o The physical exam shows neck vein distention, tachycardia, gallop rhythm, and edema.

o A drop in the baseline ejection fraction signals a decrease in left ventricular function. At this point one must weigh the risk of cardiac damage against a meaningful tumor response.

o Frequent monitoring of the EKG helps to identify early sign of impending toxicity.


Neurotoxicityo Neurotoxicity may affect the central nervous system or

the peripheral nervous system.o CNS toxicity includes encephalopathy, seizures,

cerebellar dysfunction, mental status changes, opthalmic toxicity, and ototoxicity.

o Peripheral toxicity causes axonal degeneration or demyelination involving sensory and motor dysfunction.

o Paclitaxel, cisplatin, carboplatin, and the vinca alkaloids are the agents most likely to cause neurotoxicity.

o Peripheral neuropathy usually does not occur until after five or more treatments.

o As the toxicity increases, the patient complains of muscle pain, weakness, and disturbances in depth perception, particularly with ambulation.


Neurotoxicity- cont’d:o Patients need to be cautioned about loose rugs, steps, and articles lying

on the floor that may cause the patient to trip.o Because there is a decrease in sensation, the patient needs to use

caution when using hot water, heating pads, electric blankets, hot stoves, and radiators.

o Exposure to cold is also a concern. Patients should dress warm and use protection against the cold on their hands and feet.

o Paralytic ileus and constipation are also concerns of this patient population.

o Symptoms can manifest within 2 days, and especially in patients receiving vinca alkaloids.

o The patient should be observed for abdominal distention and active bowel sounds. Fresh fruits and vegetables, fiber, and fluids should be added to the diet. Constipation may be compounded in the patient who is also receiving narcotics. Stool softeners may be helpful


Renal Toxicity:o Chemotherapeutic agents that may cause renal toxicity

are cisplatin, carmustine, streptozocin, methotrexate, mytomycin-cm and, to a lesser degree, carboplatin. Concurrent administration of amphotericin, aminoglycoside antibiotics, and vitamin c potentiates nephrotoxcity.

o BUN and creatinine levels need to be obtained prior to administration of the nephrotoxic agents.

o Vigorous hydration is often administered before nephrotoxic agents. Mannitol and Lasix may also be given to promote diuresis.


Pulmonary Toxicityo A few chemotherapy agents can damage the

endothelial cells of the lung. Bleomycin at dosages exceeding 400 units and carmustin in total doses of 1500mg/m2 predispose patients to pneumonitis and interstitial fibrosis. Toxicity can be increase with concurrent use of cyclophosphamide. Other agents include mitomycin and methotrexate.

o The patient usually presents with dyspnea, a nonproductive cough, fatigue, and fever. Lung sounds produce inspiratory bibasilar rales.

o Elderly patients and patients with a smoking history, or a pulmonary condition appear to be at greater risk for pulmonary toxicity.


Sexual and Reproductive Malfunctiono Chemo adversely affects gonadal function. Preservation of

fertility is an active area of research.o In males, chemo reduces the sperm count and temporary

or permanent infertility may result.o Chemo suppresses ovarian function in women. Within 6

months of receiving chemo, women may experience amenorrhea or changes in their menstrual cycle.

o Many women experience s/s of a medical menopause, including hot flashes, irritability, insomnia, and vaginal dryness.

o Gametes or embryos may be frozen before chemotherapy. o There is also interest in protecting the ovaries by using a

gonadotropin-releasing hormone analogs during chemotherapy.
