Chemotherapy and its side effects.

1. Chemotherapy and its side effects. Maria Ronson Lead Chemotherapy Nurse

2. Learning outcomes • How it works on cells terminology. • Understand and learn about side effects of chemotherapy. • Management of side effects.

3. Chemotherapy • Chemotherapy attacks rapidly dividing fast growing cells. • Cancer cells divide much quicker than normal cells. • Some chemotherapy drugs work by damaging part of control centre inside each cell.

4. Cytotoxic Chemotherapy • Cytotoxic literally translated means ‘toxic to cells’. Hence these drugs are those which kill cells. • Chemotherapy - the treatment of disease by the use of chemical substances

5. History • Beginnings of the modern era of chemotherapy traced directly to discovery of nitrogen mustard (chemical warfare agent) as an effective treatment for cancer. • Autopsy observations of people exposed to mustard gas revealed lymphoid and myeloid suppression • Goodman and Gilman reasoned that this agent could be used to treat lymphoma, since lymphoma is a tumour of lymphoid cells. • Treated mice that had lymphoma with chemicals derived from mustard gas. • In collaboration with a thoracic surgeon (Gustav Linskog), they injected a related agent (mustine) into a patient with Non-Hodgkin's lymphoma and observed a dramatic reduction in the patient’s tumour mass. • Cancer drug development has exploded since then into a multi-billion dollar industry

6. Cell cycle

7. Cell cycle • http://www.youtube.com/watch?v=VRhz3DhjG5M

8. Cell cycle • Different drugs attack different stages of cell cycle. • Fast growing cells are found in cancer cells and Hair follicles GI tract Bone marrow

9. Basic Principles of Chemotherapy • Prevents cancer cells from multiplying, invading, metastasising and killing patient. • Affects cell multiplication and tumour growth. • Especially affects cells with a rapid rate of turnover. • Effectively given - marked effect and minimal toxicity.

10. Phase and cell cycle specific • Phase Specific Drugs – Agents that are most active in a specific phase of the cell cycle i.e.. Cytarabine in the S phase. • Cell Cycle Specific Drugs – Agents that are effective whilst cells are actively in cycle but not dependant on the cells being in a particular phase. i.e. Cyclophosphamide. • Cell Cycle Non Specific Drugs – Agents that are effective whether the cancer cells are in cycle or resting. i.e. Carmustine(works when asleep)

11. Types of Chemotherapy Drugs • alkylating agents and related compounds, acting by forming covalent bonds with DNA and thus impeding replication • antimetabolites, blocking or subvert one or more of the metabolic pathways involved in DNA synthesis ( S Phase) • cytotoxic antibiotics, i.e. substances of microbial origin that prevent mammalian cell division ( Mytosis) • plant derivatives (vinca alkaloids, taxanes, campothecins) -most of these specifically affect microtubule function and hence the formation of the mitotic spindle( Block Division of cell and cause cell death

13. Induction therapy – initial treatment. Consolidation therapy – subsequent treatment to destroy cancer cells not caught at induction phase. Maintenance therapy – treatment with lower doses over a longer period of time – used for some lymphomas. Adjuvant therapy - administered after primary therapy e.g.Surgery Neo adjuvant therapy - Given before surgery to reduce tumour size.

14. Conventional Chemotherapy • Chemotherapy may be used conventionally to: • cure patients • prolong survival • palliative care – symptom control

15. Bone marrow • The soft blood-forming tissue that fills the cavities of bones and contains fat and immature and mature blood cells, including white blood cells, red blood cells, and platelets. • Diseases or drugs that affect the bone marrow can affect the total counts of these cells.

16. Images of bone marrow

17. Terminology used • Pancytopenia- low red cells, white cells and platelets. • Thrombocytopenia- low platelets. • Blood nadir – lowest point blood cells will reach.

18. Hair loss • Some chemotherapy’s will cause hair loss

19. Examples of drugs which will cause hair loss • Carrabin, epirubicin, doxarubicin, gemcitabine, vincristine, vinorelbine. • Drugs that don’t include - cisplatin and carboplatin, procarbazine.

20. Holistic remedies • Cold caps (not always appropriate). • Emotional support and psychological support with body image. • Wig voucher. • Look good feel good. • Less styling (baby shampoo, don’t blow dry).

21. Gi Symptoms

22. Nausea and Vomiting • Acute: occurring within 24 hours of chemotherapy. • Delayed: occurring between 24 hours and 5 days after treatment. • Anticipatory: triggered by taste, odour, memories, visions or anxiety related to chemotherapy.

23. Nausea and vomiting cont. .. • Emesis is a defence mechanism in medulla oblongata • Receptors in the brain eg dopamine, d2 receptors, seretoninect control emesis 9 stop you feeling sick) • Chemotherapy causes increase in 5-HT which decreases receptors causing nauseas and vomiting (emetic response).

24. Types of antiemetic's • Dexamethasone - corticosteroids (not fully understood how it works). • Metraclopamide - D2 receptor, works by blocking d2 in brain. • Ondansetron - 5ht3 blocks pathway which causes nausea and vomiting. • Cyclizing - antihistamine, blocks channels in vomiting centre. • Others include domperidone, lorazepam. • All target different receptors in vomiting centre.

25. Assessing anti-emetics/nausea • Assess severity ? • Timing of antiemetic's prior to meals ? • Food diary , diary methods, • Consider iv fluids dietician referrals • Syringe drivers , Natural methods, • Re assess symptoms regularly

26. Protocol on the intranet • Anti-Emetic Protocol for Patients receiving Chemotherapy. http://fcsharepoint/trustdocuments/Documents/HAEM-PROT-002.docx

27. Bowel changes • Chemotherapy can also cause changes in bowel habits such as constipation or diarrhoea as they irritate the lining of the bowel. • Important to rule out infection before ad mistering Loperamide , send sample , stool chart adequate hydration. • Treat constipation as required, monitor fluid balance .

28. Mucositis • Definition of Mucositis - “Oral mucositis is defined as an inflammation of the lining of the oral cavity” (Soady2000). Redness Severe Ulceration Estimated that oral mucositis is a complication in 40% of patients receiving chemotherapy and 75% of those exposed to high dose chemotherapy (Herrstedt 2000).

29. Who Mucositis scale

30. Nursing management Brushing teeth Mouthwashes Paracetamol Difflam Gelclair Lidocaine Opioids • Oral hygiene routine • Cold sore – antiviral • Thrush – antifungal • Ice chips • Treat infections • Neutropenia – GCSF • IV fluids if not drinking • Alternative feeding

31. Bone marrow depression • Neutropenic sepsis • Prompt action essential as life threatening

32. Neutropenic septic patient (Golden hour) • Blood cultures (3 sites) • Antibiotics • Door to needle time • Iv fluids septic screen • Neutropenic sepsis policy on intranet • Direct admission

33. Cytopenias • Anaemia – Top up transfusions. • Thrombocytopenia- Give platelet transfusions. • GCSF, Neulasta . • Electrolyte imbalance, Give potassium, iv fluids, Polyfuser ect …..

34. Tumour lysis • Increase in uric acid, causes renal failure • Risk factors include: • Lymphomas, mainly B-cell • High grade disease • Rapidly proliferating disease • High WCC • Poor renal function • Less common in solid tumours unless bulky • Prevention – Allopurinol, Diuresis, Monitor fluid balance. • Treatment- Rasburicase

35. Fatigue • Fatigue Is a common side effect of chemotherapy , It can be caused by a number of factors which can mean its difficult to treat • In order to treat fatigue have to determine cause which can be difficult…

37. Causes of fatigue • The cancer itself , effect of body eg can release cytokines, damage organs, Body requires more energy due to tumour weakening body. • Electrolyte imbalance. • The chemotherapy's effect on normal cells, e.g. anaemia. • Chronic pain , emotions ( anxiety, depression). • Poor nutrition – cancer changes your ability to process nutrients. • Hormonal changes. • Medications.

38. Managing fatigue • Determine cause and treat it ?. • Gentle exercise. • Resting (don’t over do it). • Diet changes. • Keep a diary. • Allow plenty of time don’t rush.

39. PPE Palmar – Plantar erythrodysesthesia or hand and foot syndrome

40. PPE CONT … Complication of continuous 5FU Therapy (Fluorouracil, oral capcitabine) Crushing of deep capillary's in hands and soles of feet. Presentation -numbness, tingling, swelling, dryness, cracking, oedema, erythema, pain and blistering.

41. Treatment can include, dose adjustment. • Avoid high activity exercise, avoid tight clothing. • Topical treatment such as lanolin. • Analgesia. • Ice Packs. • More research is needed.

42. Peripheral neuropathy related to chemotherapy • Damage to nerves due to chemotherapy. • (CIPN) causes tingling, burning, balance problems, hypersensitivity. • Taxanes, platinum agents and vinca’s can cause this. • Main treatment includes controlling with medication such as gabapentin.

43. Monoclonal antibodies • Immune proteins which can be selected to precisely bind to almost any target, (known as targeted therapies. • “Humanisation” of these antibodies (genetically transforming them to be as similar to a human antibodies as possible) has allowed the creation of a new family of highly effective humanised monoclonal antibodies, (mimic antibodies of body). • Makes cancer cells more visible to immune system attach to different proteins.

44. Monoclonal antibodies

46. Immunotherapy • Immunotherapy, also called biologic therapy, is a type of cancer treatment designed to boost the body's natural defenses to fight the cancer. It uses substances either made by the body or in a laboratory to improve or restore immune system function.

47. Normal breakdown of proteins • VELCADE blocks the proteasome,causing an Imbalance of proteins in the cells • Protein imbalance can lead to cell death

48. . ‘Magic bullet to Cure Cancer

49. Steroids • Have a mild chemotherapy effect , reduce inflammation , reduce immune response , boost appetite and relieve sickness.

50. Summary • Chemotherapy is a complex treatment used in a variety of settings • Should be administered by appropriately trained nurses who are able to provide effective ongoing assessment of patients. • The potential benefit of treatment as an option must always outweigh toxic effects to the patient.