minimizing side effects of chemotherapy
TRANSCRIPT
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Minimizing the Side Effects
Of Chemotherapy
Atif Hussein, MD, MMM, FACP
Memorial Cancer Institute
Hollywood, FL
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The Cell Cycle
The Cell Cycle
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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
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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.
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Chemotherapy Side effects
• 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.
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COMMON CONCERNS WITH
CHEMOTHERAPY
• Nausea and Vomiting
• Infection
• Bleeding
• Peripheral neuropathy
• Diarrhea
• Constipation
• Mucositis
• Fatigue
• Fluids
• Nutrition
• Skin care
• Hand-Foot syndrome
• Emotional needs
• Stress
• When to call the
nurse
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Side Effects: Gastro-Intestinal
• Nausea & Vomiting
• Diarrhea & constipation
• Loss of appetite
• Taste Changes
• Mucositis
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Everyone Worries About Nausea
and Vomiting
• Not everyone experiences nausea.
• Nausea and vomiting can occur before, during
or for several days after receiving treatment.
• Take anti-nausea medication as prescribed.
• Let your nurse or doctor know if you’re unable
to keep medications down, drink fluids, or your
anti-nausea medication doesn’t work.
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Nausea and Vomiting:
Patient-specific risk factors
• Higher-risk groups:
– Young
– Female
– High pretreatment expectation of nausea
• Negative risk factor: high alchohol
consumption
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Nausea and Vomiting:
Stratification
• High (level 4)
– >90% risk of emesis without treatment
• Moderate (level 3)
– 31-90%
• Low (level 2)
– 10-30%
• Minimal (level 1)
– <10%
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Nausea and Vomiting
• Certain classes of drugs are worse than
others
--Cis-Platinum
--Doxorubicin (Adriamycin)
• Which anti-emetic agents should be used
is determined by the emetic potential of
the drug
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Nausea and Vomiting:
Serotonin Receptor Inhibitors
• Granisetron (Kytril)
• Ondansetron (Zofran)
• Palonosetron (Aloxi) : Benefit of longer duration of action
• Best used as a “cocktail” with steroid (dexamethasone) and lorazepam
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Nausea and Vomiting
Serotonin Receptor Inhibitors:
Common Side Effects
• Headache
• Constipation
– Prevent with use of laxatives and stool
softeners
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Nausea and Vomiting:
NK 1 Receptor Inhibitor
• Aprepitant (Emend)
–Used for acute and delayed nausea
in combination with a serotonin
receptor-blocking drug
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Nausea and Vomiting:
Dopamine Antagonists
• Phenothiazines
– Prochlorperazine (Compazine)
• Metoclopramide (Reglan)
• Trimethobenzamide (Tigan)
– Limited role except for mildly
emetogenic drugs and may be helpful
in delayed nausea
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Delayed Nausea
• Dexamethasone
• Lorazepam (Ativan)
• Dopamine antagonists
– Prochlorperazine (Compazine)
– Trimethobenzamide (Tigan)
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Mucositis (Mouth Sores)
• More common with certain drugs:
– 5-fluorouracil (5-FU)
– Methotrexate
– Doxorubicin (Adriamycin)
– Cyclophosphamide (Cytoxan)
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Mucositis (Mouth Sores)
• Prevention
– Icing of the mouth during treatment
• Treatment Options
–Gel Clear
–Magic Mouthwash
–Viscous lidocaine
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• Example of Grade 4 Mucositis
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• Brush your teeth with a soft toothbrush.
• Use mild toothpaste and alcohol-free
mouthwash
• If you have not had regular dental care, see a
dentist before beginning chemotherapy.
• If your mouth feels sore, rinse three or four
times daily with warm salt water solution (one
teaspoon salt in eight ounces water), swish
vigorously, and spit.
Oral Care
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Diarrhea
• Diarrhea is having multiple liquid bowel movements in a
24-hour period.
• Your health care provider can suggest a diet
plan to help ease this problem.
• Take an anti-diarrhea medication as
directed.
• Drink fluids.
• Call your provider if your diarrhea is bloody,
lasts more than 24 hours, or you have
symptoms of dehydration, abdominal pain
or fever.
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Diarrhea
• Major toxicity of several drugs used to
treat gastrointestinal cancers, for
example, 5-FU and irinotecan
(Camptosar)
• Acute diarrheal reaction to irinotecan
– Atropine at time of treatment
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Delayed Diarrhea:
Treatment
• Anti-Motility Drugs
– Loperamide (Imodium)
– Diphenoxylate (Lomotil)
• Octreotide (Sandostatin)
– Somatostatin analogue
– Works to prolong GI transit time
– Subcutaneous administration
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Constipation
• Try over-the-counter laxatives, stool
softeners, or fiber.
• Drink plenty of fluids.
• Take daily walks if you can.
• Increase fiber in your diet by eating well-
washed fruits and vegetables, whole
grain breads and cereals.
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SKIN TOXICITIES
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Hand-Foot Syndrome
• Pain, redness, swelling, and peeling of the
skin of the palms and soles
• Associated with certain agents
– Capecitabine (Xeloda)
– Liposomal doxorubicin (Doxil)
– Infusional 5-FU
– Weekly taxane therapy
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Hand-Foot Syndrome:
Treatment Options
• Dose reduction
• Avoid tight-fitting shoes; repetitive rubbing or
prolonged heat to hands and feet
• Emollients
– Eucerin
– Bag Balm
– Can be used effectively with cotton socks and/or
gloves at bedtime
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• Chemo can cause skin changes such as
dryness, itching, and sun sensitivity. Nail
condition can also change.
• Keep your skin clean with a mild, moisturizing
soap and moisturize with gentle lotions.
• Protect your skin from injury.
• Avoid direct, intense sun exposure.
• Use sunscreen (minimum 30 SPF) and wear
protective clothing and a hat when outdoors.
Skin Care
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Chemotherapy-Induced
Peripheral Neuropathy (CIPN):
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Neuropathy
• Painful burning sensation
• Progressive numbness
• Motor weakness
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Incidence of Chemotherapy-Induced
Peripheral Neuropathy (CIPN)
• Chemotherapy is prolonging life
• Cancer is becoming a chronic, manageable disease
• Many nurses will encounter those affected by this common side effect
• Estimated to occur in 20% of cancer patients undergoing chemotherapy
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What is Chemotherapy-Induced
Peripheral Neuropathy (CIPN)?
• Characterized as injury, inflammation, or degeneration of peripheral nerve fibers
• Can result in loss of motor and sensory nerve function
• CIPN can result when certain chemotherapeutic agents are used to treat cancer
• These agents can be referred to as “neurotoxic”
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Sensory nerves
Sensory nerves are responsible for detecting:
• Pain
• Touch
• Temperature
• Position
• Vibration
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Pathophysiology (continued)
• Peripheral neuropathy results from damage to the axon, myelin sheath, or cell body
• Pathogenesis of CIPN is not completely understood
• It is known that different sensations arise depending on chemotherapeutic agent administered (Wickham, 2007)
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Signs and Symptoms of CIPN
• Symptoms that patients
may experience depend on
length of infusion, dose,
co-morbidities, and the
drug being administered
• Symptoms are divided
into sensory, motor, and
autonomic symptoms,
correlating with which
peripheral nerve is
affected
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Neuropathy: Prevention
• Avoidance of cold exposure for 48-72
hours after oxaliplatin therapy
• Amino acid therapy (glutamine)
• Vitamin B6 (pyridoxine)
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Neuropathy:
Treatment Options
• Dose reduction
• Gabapentin (Neurontin)
• Amitriptyline (Elavil)
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Pharmacologic treatment of CIPN
Glutamine:
• Amino acid, may have neuroprotecive properties
• In studies, those who take it for Taxol- preventive CIPN showed less weakness, loss of vibratory sensation, and toe numbness versus control group
Microsoft Image Clip Art, 2007
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Pharmacologic treatment of CIPN
Glutathione:
• May hamper initial accumulation of platinum agents in peripheral nerve cells
• Incidence of neuropathy was greater in placebo than control group
• In some studies, incidences of no CIPN were reported with IV infusion
Opioids:
• Useful for painful CIPN
• Doses can be titrated to effective range for CIPN and pain
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Nonpharmacologic Treatment of
Chemotherapy-Induced peripheral
Neuropathy (CIPN)
Acupuncture:
• Shown gait improvement
• Has shown improvement in sensation and balance
• Patients taking pain medication for CIPN ended up decreasing doses
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HEMATOLOGICAL SIDE
EFFECTS
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Side Effects: Bone Marrow
Neutropenia:
Increased risk of infection.
Anemia:
Tiredness, lethargy & breathlessness
Thrombocytopenia:
Increased risk of bleeding
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Red blood cells
Carry nutrients
and oxygen
Neutrophils
A type of
white cell
that fights
infection
Platelets
Helps the
blood to
clot
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Chemotherapy can
increase your risk for
infection because it may
lower your white blood cell
count.
Infection
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Preventing Infection
• The first defense is
hand washing.
• Patient, patient’s
caregivers, family
members, and
visitors need to wash
hands frequently.
• Carry and use hand
sanitizer when you
leave the house.
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• Have a thermometer at home to monitor your
temperature.
• Take your temperature if you feel sick or
unusually hot or cold, and before you call your
provider.
• If you have a fever over 100.5°F, call your health
care provider right away. Do not take Tylenol or
aspirin unless instructed to do so.
• Call for fever, chills, cough, sore throat or burning
with urination
Watching for infection
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Preventing Bleeding
• A low platelet count can cause bleeding
• Some chemo drugs can lower platelets
• Use a soft toothbrush.
• Blow your nose gently.
• Avoid injuries that could cause cuts or bruises.
• If you cut yourself, apply gentle but firm pressure to stop the bleeding.
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OTHER SIDE EFFECTS
• Fatigue
• Stress
• Tumor Lysis Syndrome
• Body Image
• Dehydration
• Nutrition
• Others
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Fatigue: Multifactorial
• Anemia
– Erythropoietin (Procrit)/darbepoetin (Aranesp)
• Depression
– Selective serotonin reuptake inhibitor (SSRI)
• Sleep Disturbance
-- Sleep aid: zolpidem tartrate (Ambien),
eszopiclone (Lunesta)
• Psychostimulants
-- Methylphenidate (Ritalin)
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•The most commonly reported side effect
•Take a daily walk or continue your usual
exercise routine, if you can.
•Eat a healthy diet.
•Plan daily activities ahead of time.
•Prioritize your activities to conserve
energy.
•Get plenty of rest.
•Let others help with chores.
Fatigue
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Stress
Are you experiencing any of these
symptoms?
•difficulty concentrating
•trouble sleeping
•too much worry
•problems with coping
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Supporting your emotional
needs is essential to your
cancer treatment.
Stress
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Side Effects:
Body Image
• Hair Loss
• Weight Loss/ Weight Gain
• Long term central venous catheters
• Skin changes (colour, rashes, sensitivity
to sunshine/chlorine, dry)
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Dehydration: Fluids
• Keeping hydrated with fluids is important
during chemotherapy treatment.
• Fluids are in water, beverages, and food.
• Keep a bottle of water or juice with you at all
times and sip on it often.
• If you have vomited, try to drink about two
quarts of fluids a day for a few days afterward.
• A good rule of thumb: take in enough fluids to
keep urine light yellow.
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Nutrition
• Eat smaller portions more frequently.
• Try milkshakes, smoothies, or
supplements like Ensure for extra
calories if you are losing weight.
• Some chemo causes a metallic taste.
Try using plastic utensils to ease this
effect.
• Some people gain weight during
chemotherapy.
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Side Effects:
Other
• Altered Kidney Function
• Changes in hearing (high dose Cisplatin)
• Cardiac Toxicity (Doxorubicin/ Idarubicin)
• Late Effects: Infertility, secondary malignancy, growth retardation.
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When should I call the doctor?
• Fever over 100.5°F
• Redness or swelling at IV site
• Uncontrolled vomiting or diarrhea
• Blood in urine or stool or uncontrolled bleeding
• Signs of infection
• Feeling unwell
You should be able to eat, drink, have reasonable bowel and bladder function and feel good enough to get up and around-if not, call.
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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.
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Summary
The potential benefit to the patient of treatment as an
option must always outweigh the toxic effects.
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THANK YOU VERY MUCH!!!