WHAT IS CANCER?

Large group of malignant diseases with

some or all of the ff characteristics:
a. Abnormal cell proliferation
b. Lack of controlled growth and division
c. Ability to metastasize
 WHAT IS CANCER?

A few diseases that result from faulty or

abnormal genetic expression caused by
changes that have occurred in the DNA.
 WHAT IS CANCER?
• The uncontrolled growth of
cells due to damage to DNA
(mutations) and, ocassionally
due to an inherited
propensity to develop tumors.
 Chemotherapy
• A systemic intervention used in the treatment
of certain disease conditions
• In modern-day use, refers primarily to the use
of cytotoxic agents to treat CANCER.
• CHEMOTHERAPEUTIC AGENTS- Used only
when disease prognosis shows that patient
would benefit from the treatment
The Cell Cycle
• Broadly, most chemotherapeutic drugs work by
impairing mitosis (cell division), effectively
targeting fast-dividing cells.
• In cancer, cells rapidly divide and does not enter
the resting phase because they are
unresponsive to growth-inhibitory signals.
• Only a percentage of the cancer cells are killed
with each course of chemotherapy. Therefore,
repeated doses—or cycles of chemotherapy
must be done.
SITES OF ACTION OF CYTOTOXIC AGENTS

Antibiotics

Antimetabolites

S
(2-6h)
G2
(2-32h) Vinca alkaloids

M Mitotic inhibitors
(0.5-2h)

Taxoids

Alkylating agents

G1
(2-¥h)

G0
 GOALS
• CURE

• CONTROL

• PALLIATION
• Chemotherapy may be used as

1.) Adjuvant therapy

2.) Neoadjuvant therapy
3.) Chemoprevention
4.) Myeloablation
 Classification of Chemotherapy Drugs
CYCLE-SPECIFIC
• Antimetabolites
– interfere with nucleic acid synthesis
– Attack during S phase of cell cycle
• Cytatabine, floxuridine, fluorouracil, hydroxyurea,
methotrexate, thioguanine
• Enzymes
– Useful only for leukemias
• Asparaginase
• Plant Alkaloids
– Cycle-specific to M Phase
– Prevent mitotic spindle formation
• Vinblastine, vincristine
Classification of Chemotherapy Drugs

CYCLE-NONSPECIFIC
• Alkylating Agents
– Disrupt deoxyribonucleic acid (DNA)
• Carboplatin, Cisplatin, Cyclophosphamide,
Ifosfamide, Thiotepa
• Antibiotics
– Bind with DNA to inhibit synthesis of DNA
and RNA
• Bleomycin, doxorubicin, idarubicin,
mitomycin, mitoxantrone
 Classification of Chemotherapy Drugs

CYTOPROTECTIVE AGENTS
– Protect normal tissue by binding with
metabolites of other cytotoxic drugs
• Dexrazoxane
• Mesna
FOLIC ACID ANALOGS
– Antidote for methotrexate toxicity
• Leucovorin
HORMONE AND HORMONE INHIBITORS
– Interfere with binding of normal hormones to
receptor proteins
– Manipulate hormone levels
– After hormone environment
– Usually palliative,not curative
• Androgens, Antiandrogens, Antiestrogens, Estrogens,
Gonadotropin, Progestins
 Other AntiCancer Agents
Novel Agents
• Monoclonal Antibody
– Trastuzumab (Herceptin)
– Rituximab (Mabthera)
– Cetuximab (Erbitux)
• Tyrosine Kinase Inhibitor
– Imatinib (Glivec)
• EGFR Inhibitors
– Erlotinib (Tarceva)
– Gefitinib (Iressa)
• VEGF Inhibitors
– Bevacizumab (Avastin)
 BIOLOGICAL THERAPY
• Consists mostly of the administration of biological
response modifiers
• Also includes the use of immunotherapy
• Biological response modifiers
– Alter the body’s response to therapy
– May cause direct cytotoxicity
• Immunotherapy
– Uses drugs to enhance the body’s ability to destroy
cancer cells
– Seeks to evoke effective immune response to human
tumors by altering the way cells grow, mature, and
respond to cancer cells
– May include the administration of monoclonal antibodies
and immunomodulatory cytokines
 Immunotherapy
• Monoclonal antibodies
– Specifically target tumor cells
– More recent form of biotherapy that manipulates
the body’s natural resources instead of
introducing toxic substances that aren’t selective
and can’t differentiate between normal and
abnormal processes or cells
– Recognizes only a single unique antigen
• Rituximab (Rituxan)
• Trastuzumab (Herceptin)
 Immunotherapy
• Immunomodulary cytokines
– Intracellular messenger proteins (proteins
that deliver messages within cells)
• Colony-stimulating factors
– Erythropoietin (Epogen), Granulocyte colony-
stimulating factor (Neupogen), Granulocyte-
macrophage CSF (Leukine)
• Interferon
• Interleukins
• Tumor Necrosis factor
 Routes of Administration
• Oral Route
• Subcutaneous and
Intramuscular
• IV administration
❖ IV push
❖ IV piggy back (large
volume)
• Direct Introduction
❖ Intrathecal
❖ Intrapleural
❖ Intraperitoneal
❖ Chemoembolization
❖ Ommaya reservoir
Safehandling Chemotherapeutic Agents

• Chemotherapeutic Drugs are hazardous

drugs.
• a hazardous drug is defined as an agent that
presents a danger to healthcare personnel due
to its inherent toxicity.
➢They are carcinogenic
➢They are genotoxic
➢They are teratogenic
➢There is evidence of toxicity at low doses
 PREPARING CHEMOTHERAPEUTIC DRUGS
• GATHERING THE EQUIPMENT
• Before preparing chemotherapeutic drugs, be sure to
gather all the necessary equipment, including:
– Patient’s medication order or record
– Prescribed drugs
– Appropriate diluent (if necessary)
– Medication labels
– Long-sleeped gown
– Chemotherapy gloves
– Face shield or goggles and face mask
– 20G needles
– Hydrophobic filter or dispensing pin
 PREPARING CHEMOTHERAPEUTIC DRUGS
GATHERING THE EQUIPMENT (continuation)
– Syringes with luer-lock fittings and needles of
various sizes
– IV tubing with luer-lock fittings
– 70% alcohol
– Sterile gauze pads
– Plastic bags with “hazardous drug” labels
– Sharps disposal container
– Hazardous waste container
– Chemotherapy spill kit
 PREPARING CHEMOTHERAPEUTIC DRUGS

• ORGANIZING DRUG PREPARATION AREAS

– Prepare chemotherapeutic drugs in well-ventilated
workspace
– Perform all drug admixing or compounding within a Class
II Biological Safety Cabinet or a “vertical” laminar airflow
hood with a HEPA filter, which is vented to the outside
– If a Class II Biological Safety Cabinet isn’t available, it is
recommended to use a special respirator
– Have close access to a sink, alcohol pads, and gauze pads
as well as Chemotherapy hazardous waste containers,
sharps containers, and chemotherapy spill kits
 PREPARING CHEMOTHERAPEUTIC DRUGS
ORGANIZING DRUG PREPARATION AREAS
(cont.)
– Make sure that all hazardous waste containers
are made of punctureproof, shatterproof,
leakproof plastic
– Make sure that yellow biohazard labels are
available for labeling all chemotherapy-
contaminated IV bags, tubings, filters, and
syringes
– Make sure that red sharps containers are
available for disposal of all contaminated sharps
such as needles.
 PREPARING CHEMOTHERAPEUTIC DRUGS
WEAR PROTECTIVE CLOTHING
• Essential protective clothing includes a cuffed gown,
gloves, and a face shield or goggles and a face mask
• Gowns should be disposable, water-resistant, and
lint-free with long sleeves, knitted cuffs, and a
closed front
• Gloves should be disposable, powder-free, and
made of thick latex or thick nonlatex material
• Double gloving is an option when the gloves aren’t
of the best quality
 SAFETY MEASURES
GENERAL MEASURES
• At the local level, most health care facilities
require nurses and pharmacists involved in
the preparation and delivery of
chemotherapeutic drugs and care of the
patient with cancer.
• Take care to protect staff, patients and the
environment from unnecessary exposure to
chemotherapeutic drugs
 SAFETY MEASURES
• Make sure your facility’s protocols for
spills are available in all areas where
chemotherapeutic drugs are handled,
including patient-care areas
• Refrain from eating, drinking, smoking or
applying cosmetics in the drug-preparation
area.
 SAFETY MEASURES
ACCIDENTAL EXPOSURE
• If a chemotherapeutic drug comes in contact
with your skin, wash the area thoroughly with
soap and water to prevent drug absorption
into the skin
• If the drug comes in contact with your eye,
immediately flush the eye with water or
isotonic eyewash for at least 5 minutes, while
holding the eyelid open
• After an accidental exposure, notify your
supervisor immediately
 SAFETY MEASURES
WASTE DISPOSAL
– Place all contaminated needles in the sharps container;
don’t recap needles
– Use only syringes and IV sets that have a luer-lock fitting
– Label all chemotherapeutic drugs with a yellow
biohazard label
– Transport the prepared chemotherapeutic drugs in a
sealable plastic bag that’s prominently labeled with a
yellow chemotherapy biohazard label
– Don’t leave the drug-preparation area while wearing the
protective gear you wore during drug preparation
 SAFETY MEASURES
HANDLING A CHEMOTHERAPY SPILL
• Put on protective garments, if you
aren’t already wearing them
• Isolate the area and contain the
spill with absorbent materials from
a chemotherapy spill kit
• Use the disposable dustpan and
scraper to collect broken glass or
desiccant absorbing powder
 SAFETY MEASURES
HANDLING A CHEMOTHERAPY SPILL (cont’n)
• Carefully place the dustpan, scraper
• and collected spill in a leakproof,
punctureproof, chemotherapy-designated
hazardous waste container
• Prevent aerosolization of the drug at all
times
• Clean the spill area with a detergent or
bleach solution
ADMINISTERING CHEMOTHERAPEUTIC DRUGS
• Gathering the equipment
– Prescribed drugs
– IV access supplies
– Sterile PNSS
– IV syringes and tubings with luer
lock
– Leakproof chemical waste
container
– Chemotherapy gloves
– Chemotherapy spill kit
– Extravasation kit
 ADMINISTERING CHEMOTHERAPEUTIC
DRUGS
Preventing Infiltration
• Use a low-pressure infusion pump to
administer vesicants through a peripheral
vein, to decrease the risk of extravasation
• Use a central venous catheter for continuous
vesicant infusions
 ADMINISTERING CHEMOTHERAPEUTIC
DRUGS
Guidelines in giving vesicants
• Use a distal vein that allows successive
proximal venipunctures
• Avoid using the hand, antecubital space,
damaged areas, or areas with compromised
circulation
• Don’t probe or “fish” for veins
• Place a transparent dressing over the site
 ADMINISTERING CHEMOTHERAPEUTIC
DRUGS
Guidelines in giving vesicants (cont’n)
• Start the push delivery or the infusion
with normal saline solution
• Inspect the site for swelling and erythema
• Tell the patient to report burning,
stinging, pain, pruritus, or temperature
changes near the site
• After drug administration, flush the line
with 20mL of NSS
 ADMINISTERING CHEMOTHERAPEUTIC
DRUGS
Concluding Treatment
• Dispose of all used needles and
contaminated sharps in the orange sharps
container
• Dispose of PPE’s in yellow
chemotherapeutic waste container
• Dispose of unused medications,
considered hazardous waste, according to
your facility’s policy
ADMINISTERING CHEMOTHERAPEUTIC DRUGS

Concluding treatment (cont)

• Wash hands thoroughly
• Document the ff.
– sequence in which the drugs were administered
– site accessed, the gauge and length of the catheter,
and the number of attempts
– name, dose, and route of the administered drugs
– Type and volume of the IV solutions and adverse
reactions and nursing interventions
• According to facility policy, wear protective
clothing when handling body fluids from the
patient for 48 hours after
 MANAGING COMPLICATIONS OF
CHEMOTHERAPY
ALOPECIA
• Hair loss that occurs as chemotherapeutic drugs
destroy the rapidly growing cells of hair follicles
• May be minimal or severe
• Occurs 2-3 weeks after treatment begins
• Almost always temporary
Signs and Symptoms
• Hair loss that may include eyebrows, lashes and body
hair
Nursing Interventions
• Minimize shock and distress by warning the patient of this
possibility
• Discuss with the patient why it occurs
• Describe to the patient how much hair loss to expect
• Emphasize to the patient the need for appropriate head
protection against sunburn
• Inform the patient that new hair may be a different texture or
color
• Give the patient sufficient time to decide whether to order a
wig
• Inform the patient that his scalp will become sore at times due
to follicles swelling
Prevention measures
• For patients with long hair, suggest cutting hair shorter before
treatment because washing and brushing cause more hair loss
ANEMIA
• Occurs as chemo drugs destroy healthy cells and
cancer cells
• RBCs are destroyed and can’t be replaced by the
bone marrow
Signs and symptoms
• Dizziness, fatigue, pallor, and shortness of breath
after minimal exertion
• Low hemoglobin level and hematocrit
• May develop slowly over several courses of
treatment
Nursing Interventions
• Monitor hemoglobin level, hematocrit, RBC count;
report dropping values
• Be prepared to administer a blood transfusion or
erythropoietin
Prevention Measures
• Instruct the patient to take frequent rests, increase
his intake of iron-rich foods, and take a
multivitamin with iron as prescribed
• If the patient has been prescribed a drug such as
epoetin, make sure he understands how to take
the drug and what adverse effects he should watch
for and report
DIARRHEA
• Occurs because the rapidly dividing cells of the intestinal
mucosa are killed
• Complications include weight loss, F&E imbalance, and
malnutrition
Signs and symptoms
• An increase in the volume of stool compared with the
patient’s normal bowel habits
Nursing Interventions
• Assess frequency, color, and consistency of stool
• Encourage fluids, give IV fluids and potassium supplements
as ordered
Prevention measures
• Use dietary adjustments and antidiarrheal meds
• Provide good perianal skin care
EXTRAVASATION
• The inadvertent leakage of a vesicant solution into
the surrounding tissue
Signs and Symptoms
• Initial signs and symptoms may resemble those of
infiltration – blanching, pain, swelling
• Symptoms possibly progressing to blisters; to skin,
muscle, tissue and fat necrosis; and to tissue
sloughing
Blood return is an INCONCLUSIVE test and shouldn’t
be used to determine if IV catheter is correctly
seated in the peripheral vein. To assess peripheral
IV placement, flush the vein with NSS and observe
site for swelling.
Extravasation of Doxorubicin
Nursing Interventions
• Stop the infusion
• Check your facility’s policy to determine if the IV
catheter is to be removed or left in place to infuse
corticosteroids or a specific antidote.
• Notify the physician
• Instill the appropriate antidote according to facility
policy. Usually, you’ll give the antidote for
extravasation either by instilling it through the
existing IV catheter or by using a 1 mL syringe to
inject small amounts subcutaneously in a circle
around the extravasated area
• After the antidote has been given, remove the IV
catheter
Preventive measures
• Verify IV line patency and placement
by flushing with normal saline sol’n
• Remember, “When in doubt, take it
out!”
• Use a transparent, semi-permeable
dressing for inspection of site.
INFILTRATION
• The inadvertent leakage of a nonvesicant solution
or medication into the surrounding tissue
• Infusion-site related
Signs and symptoms
• Blanching
• Change in IV flow rate
• Numbness and tingling in swollen area due to
nerve compression injury leading to compartment
syndrome
• Swelling around IV site (the swollen area will be
cool to touch)
Nursing Interventions
• Remove the IV catheter
• Insert a new IV catheter in a different
location
Prevention Measures
• Check for infiltration before, during, and
after the infusion by flushing the vein with
normal saline solution
LEUKOPENIA
• Reduced leukocytes or WBCs
• Occurs as WBCs and cancer cells are destroyed
by chemo drugs
Signs and Symptoms
• Susceptibility to Infections
• Neutropenia
Nursing Interventions
• Watch for the nadir, the point of lowest blood
cell count
• Be prepared to administer colony-stimulating
factors
• Institute neutropenic precautions
• Teach the patient and caregiver about:
– Good hygiene practices
– Signs and symptoms of infection
– The importance of checking the patient’s temperature
regularly
– How to prepare low-microbe diet
– How to care for vascular access devices
• Instruct the patient to avoid
– Crowds
– People with colds or respiratory infections
– Fresh fruit
– Fresh flowers
– plants
NAUSEA and VOMITING
• Can appear in 3 different patterns
– Anticipatory
– Acute
– Delayed
ANTICIPATORY NAUSEA and VOMITING
Signs and Symptoms
• Nausea and vomiting that’s a learned response from prior
nausea and vomiting after a dose of chemotherapy
• High anxiety levels (acts as a trigger)
Nursing Interventions
• Posttreatment control of nausea and vomiting may prevent
future anticipatory episodes
Prevention measures
• Pretreat the patient with lorazepam (Ativan) at least 1 hr
before arriving for treatment
• Patients with overwhelming anxiety may need IV lorazepam
before chemo is administered
ACUTE NAUSEA and VOMITING
Signs and symptoms
• Nausea and vomiting occurring within the first 24
hours of treatment
Nursing Interventions
• Treat the patient with acute nausea and vomiting
with antiemetic drugs
– Dexamethasone
– Granisetron
– Lorazepam
– Metoclopramide
– Ondansetron
DELAYED NAUSEA and VOMITING
Signs and Symtoms
• Nausea or vomiting starting or continuing beyond
24 hours after chemo has begun
Nursing Interventions
• The administration of serotonin antagoninsts,
corticosteroids, various antihistamines,
benzodiapines, and and metoclopramide is usually
effective in treating patients
Prevention Measures
• Administer antiemetic before chemo begins
• Some patients with delayed nause and vomiting are
treated with an antiemetic for 3 days or longer
STOMATITIS
• Inflammation of the lining of the oral mucosa
• Can spread into the esophagus and pharynx
Signs and Symptoms
• Painful mouth ulcers that range from mild to
severe appearing 3 to 7 days after certain
chemotherapeutic drugs are given
Nursing Interventiosn
• Instruct the patient to perform meticulous oral
hygiene
• Administer topical anesthetic mixtures as
appropriate
• If pain is severe, opioid analgesics may be
prescribed until the ulcers heal
Prevention Measures
• Instruct the patient to suck on ice chips while
receiving certain drugs that cause stomatitis; this
decreases the blood supply to the mouth, thus
decreasing ulcer formation
THROMBOCYTOPENIA
• Reduced blood platelet count
Signs and Symptoms
• Bleeding gums
• Coffee-ground emesis
• Hematuria
• Hypermenorrhea
• Increased bruising
• Petechiae
• Tarry stools
Nursing interventions
• Monitor patient’s platelet count
• Avoid unnecessary IM injections or venipuncture
• If an IM injection or venipuncture is necessary,
apply pressure for at least 5 minutes; apply a
pressure to the site.
• Instruct the patient to
– Avoid cuts and bruises
– Shave with an electric razor
– Avoid blowing his nose
– Stay away from irritants that would trigger sneezing
– Avoid using rectal thermometers
• Instruct the patient to report sudden headaches
(which could indicate potentially fatal intracranial
bleeding)
VEIN FLARE
• Occurs during infusion of an irritant into the vein
Signs and Symptoms
• Bright redness possibly appearing in the vein along with
blotches or hives on the affected arm
• Burning pain or aching along the vein as well as up through
the arm
Nursing Interventions
• If the reaction is severe, injection of an IV steroid may be
required
• If the patient complains of pain or burning during the
infusion:
– Increase the dilution of the infused medication
– Decrease the infusion rate
– Restart the IV in a different vein