SE of Anti-Neoplastic Agents
Alopecia Anorexia Cardiotoxicity Constipation Skin or Cutaneous Responses Diarrhea Fatigue Hemorrhagic cystitis Hepatotoxicity Hypersensitivity reactions Mucositis/Stomatits/ Esophagitis N/V Nephrotoxicity Neurotoxicity Pulmonary toxicity Sexual & reproductive dysfunction Myelosuppression Anemia Neutropenia Thrombocytopenia
Assessment of Alopecia
Usually within 2 weeks
Reversible
Education with Alopecia
Emotional support
Assessment of Anorexia
Dietary history
Weight
Lab values
Education for Anorexia
Weekly weights
Small frequent meals
Medications for Treatment of Anorexia
Antiemetics
Megesterol (Megace)
Dronabinol (Marinol)
Remeron: Antidepressant
Cardiotoxicity
Related to effect of drugs or radiation to cardiac muscle, pericardium
Chronic Cardiotoxicity
Cumulative dosing of cardiotoxic drugs
Radiation to large volumes of heart or pericardium
Medications that have Cardiotoxicity
Doxorubicin Daunorubicin Mitoxantrone High dose cyclophosphamide High dose 5FU Paclitaxel
Assessment of Cardiotoxicity
History of HTN
Smoking
Pre-existing cardiac disease
Collaborative Management of Cardiotoxicity
MUGA scan Exercise Diet modification Dose reduction EKG Dexrazoxone (Zinecard)
Education for Cardiotoxicity
Inform of possible cardiotoxicity
S/S of CHF
Daily weights
Symptoms management
Pathophysiology of Constipation
Result of neurotoxic effects resulting in decreased peristalsis
Assessment of Constipation
Patients receiving vinca alkaloids
Hypercalcemia
Opioid pain management
Dehydration
Management of Constipation
Bowel program
Exercise
Diet modifications
Laxative & stool softener
Education for Constipation
Increasing fluids
Dietary interventions
Establish a bowel program
Assessment of Skin or Cutaneous Responses
Rash
Photosensitivity
Hypersensitivity
Education for Skin or Cutaneous Responses
Prepare patients for potential changes
Monitor S/S of infection
Avoid heat & vasodilation
Management of Skin or Cutaneous Responses
Call Rad Onc to discuss skin care
Call Med Onc to discus medical management
Acral Erythema (Hand-foot syndrome)
Painful palms & soles with erythema, desquamation, & ulceration
What is Acral Erythema Commonly Associated with what medications
5FU
Capecitabine
Doxirubicin
How to prevent aural erythema?
Holding ice packs during infusion
Taking pyridoxine
Pathophysiology of Diarrhea
GI mucosa very sensitive to cytotoxic drugs due to high mitotic index
Assessment of Diarrhea
Neutropenic status
Bowel elimination patterns
Hydration
Collaborative Management of Diarrhea
IV/fluid support
Loperamide
Diphenoxylate
Education for Diarrhea
Low residue diet
Fluid requirements
Watch for S/S of dehydration
Perianal care
Pathophysiology of Fatigue
Anemia
Changes in sleep patterns
Pain
Psychosocial factors
Assessment of Fatigue
Risk factors
Acute vs. chronic
Fatigue level
Collaborative Management of Fatigue
Multidisciplinary referrals
Education for Fatigue
Setting realistic goals
Energy management
Cause & factors of fatigue
Pathophysiology of Hemorrhagic Cystitis
Bladder mucosal irritation from metabolic by-products of drugs
Medications that Cause Hemorrhagic Cystitis
Cycclophosphamide
Ifosfamide
High dose methotrexate
Assessment of Hemorrhagic Cystitis
Dysuria Urinary frequency Burning Hematuria Previous history of pelvic radiation
Collaborative Management of Hemorrhagic Cystitis
Lab monitors
PO/IV hydration with diuretics
Education for Hemorrhagic Cystitis
Potential for SE to occur
Increase fluid intake
Frequent urination
Pathophysiology Hepatotoxicity
Direct toxic effect to liver when drugs are being metabolized
Assessment of Hepatotoxicity
ETOH use Liver disease Medication use Jaundice Ascites Hepatomegaly pain
Collaborative Management of Hepatotoxicity
Monitor labs
Limit acetaminophen to
Education for Hepatotoxicity
Avoid alcohol
Pathophysiology of Hypersensitivity Reactions
Antigen/antibody reaction
Assessment of Hypersensitivity Reactions
Clinical manifestations of local or systemic reaction
Collaborative Management of Hypersensitivity Reactions
Test dose Premedication prior to chemo Emergency equipment Steroids H1 & H2 blockers Epinephrine
Education for Hypersensitivity Reactions
Potential for allergic reactions
S/S of reactions
Pathophysiology of Mucositis/Stomatitis/ Esophagitis
Direct effect of drug or radiation on oral mucosa
Common Cancers with Mucositis/Stomatitis/ Esophagitis
Leukemia
Lymphoma
H&N Cancers
Assessment of Mucositis/Stomatitis/ Esophagitis
Xerostomia
Mucositis
Yeast Infections
Signs/Symptoms of Xerostomia
Dysphagia
Plaque formation
Pale, dry oral mucosa
NOT PAINFUL
Signs/Symptoms of Mucositis
Erythema
Dequamation
Ulceration
VERY PAINFUL
Signs/Symptoms of Yeast Infections
Thrush
Oral or esophageal candidiasis
Collaborative Management of Mucositis/Stomatitis/ Esophagitis
Aim is prevention, dental referral, “magic mouthwash”, chlorhexidine (Peridex) rinse
Education with Mucositis/Stomatitis/ Esophagitis
Frequent oral hygiene
Use of saline or baking soda rinses QID
Cryotherapy
Grading of Mucositis/Stomatitis
0= no change 1= soreness 2= erythema, ulcers, can eat solids 3= ulcers, liquid diet 4= severe ulcers; no oral intake
Pathophysiology of N/V
Stimulation of vagus nerve by release of serotonin
Stimulation of the chemoreceptor trigger zone in the medulla
Stimulation of the true vomiting center
Epidemiology of N/V in Cancer Patients
Females > Males
Youth > Elderly
Assessment of N/V
Rule out other causes of nausea, hydration status, weight loss, electrolytes
Collaborative Management of N/V
Timely administration of antiemetics Fluid support Emotional support Dietary support Telephone F/U if treated as outpatient
Education for N/V
Patient to notify clinic if symptoms persist >48 hours
Unable to maintain oral intake
Antiemetics around the clock for first 24-72 hours after chemo
Medications for Chemotherapy Induced N/V
Palonosetron (Aloxi)
Odansetron (Zofran)
Lorazepam (BZD)
Prochlorperazine (Phenothiazine)
Pathophysiology of Nephrotoxicity
Direct cell damage to the kidney
Indirect cell damage by metabolites
Common Medications that Lead to Nephrotoxicity
Cisplatin
High dose methotrexate
Assessment of Nephrotoxicity
Age
Renal disease
Nephrotoxic drugs
Lab values
Management of Nephrotoxicity
Adequate IV hydration
Rescue therapy with dialysis
Education for Nephrotoxicity
Adequate fluid intake
Pathophysiology of Neurotoxicity
Direct effect on the nervous system
Metabolic encephalopathy
Intracranial hemorrhage due to coagulopathy or myelosuppression
Reasons for Neurotoxicity
High dose chemotherapy
Drugs crossing the blood-brain barrier
Assessment of Neurotoxicity
Tinnitis Peripheral neuropathies Fine motor loss Numbness Tingling Gait distrubances Changes in mentation Urinary retention Constipation
Management of Neurotoxicity
Avoid extreme temperatures
Education for Neurotoxicity
S/S of neurotoxicity
Many symptoms reversible if interventions initiated early
Pathophysiology of Pulmonary Toxicity
Toxic damage to alveoli resulting in pneumonitis & pulmonary fibrosis
Chemo Therapy with Pulmonary Toxicity
Bleomycin
Busulfan
Radiotherapy
Assessment of Pulmonary Toxicity
Thorough respiratory assessment
Collaborative Management of Pulmonary Toxicity
Pulmonary function tests prior to therapy
Treat with corticosteroids
Discontinue therapy
Education for Pulmonary Toxicity
S/S associated with pulmonary toxicity
Energy conservation techniques
Pathophysiology of Sexual & Reproductive Dysfunction
Toxic effects on the gametes
Physical SE of chemotherapy
Can be permanent or temporary
Assessment of Sexual & Reproductive Dysfunction
Early menopause
Sterility
Collaborative Management of Sexual & Reproductive Dysfunction
Sperm banking
Counseling
Education for Sexual & Reproductive Dysfunction
Implications of treatment of sexuality
Long term effects
Pathophysiology of Myelosuppression
Bone marrow highly sensitive to toxic effects of chemotherapy due to high mitotic index
Can be dose-limiting & delay treatment
Anemia, neutropenia, thrombocytopenia, pancytopenia
Situations for Myelosuppression
Leukemia Taxmen use Alkylating agent use Antimetabolite use Etoposide use Nitrosurea use
Pathophysiology of Anemia
Changes in the erythrocyte-proliferation pathways
Assessment of Anemia
Dyspnea Fatigue Concomitant radiation Poor nutritional status Elderly Hx of renal or hepatic impairment
Collaborative Management of Anemia
CBC
RBC transfusions as needed
Iron supplements
Oxygen therapy
Education of Anemia
S/S of anemia
Change positions slowly to prevent falls & injury
Pathophysiology of Neutropenia
ANC
Assessment of Neutropenia
Age
Malnutrition
Prior chemotherapy or radiation
S/S of infection
Collaborative Management of Neutropenia
CBC Neutropenic fever recommendations Filgrastim Pegfilgrastim
Education for Neutropenia
S/S of infection
Meticulous
Hygiene
Daily temps
Who always gets admitted to the hospital for cancer patients?
Anyone with a fever
Pathophysiology of Thrombocytopenia
Bone marrow suppression decreases lately progression
Assessment of Thrombocytopenia
Petechiae
Bruising
Hemorrhage
S/S of intracranial bleeding
Collaborative Management of Thrombocytopenia
Platelet counts
Platelet transfusion
Thombocytopenic precautions
Thrombocytopenic Precautions
Electric razor
No suppositories or douches
No dental flossing
No injections
Education for Thrombocytopenia Patients
S/S of bleeding to report
Radiation SE
N/V Trouble swallowing Fatigue Decrease in platelets & lymphocytes Erythema Alopecia Fibrin plaquing Urinary & bladder changes Visceral changes Irreversible damage to gametes Sterility Suppress osteoblast activity Decrease number of osteocytes
Skin SE of Radiation
Erythema
Alopecia
Mucous Membranes SE of Radiation
Fibrin plaquing Urinary & bladder changes Visceral changes (secretory)
Reproductive Organ SE of Radiation
Irreversible damage to gametes
Sterility
Bone SE of Radiation
Suppress osteoblast activity
Decrease number of osteocytes
Nonverbal Signs of Pain
HTN Tachycardia Diaphroresis Agitation or confusion Apathy, inactivity, or irritability Refusal to eat Protect painful part Show facial grimacing
Pain Measurement Tools
Pain scale
McGill Pain Questionnaire
Memorial pain assessment card
What type of pain is caused by invasion of bone by the tumor?
Deep, achy, unrelenting pain
What type of pain is caused by nerve compression?
Neuropathic pain
Lightening bolts
Stabbing
Pins & needles
Pain Complications of Treatment
Radiation fibrosis
Chemotherapy-induced neuropathy
Postoperative surgical pain
Types of Pain
Somatic
Visceral
Neuropathic
Define Somatic Pain
Potential or real injury to tissues & is type pain that we treat
Description of Somatic Pain
Tender & localized to site of injury
Constant
Sometimes throbbing or achy
What is the most common cause of somatic pain in patients with cancer?
Bone mets
Define Visceral Pain
Poorly localized & often referred to a distant site which may be tender
Description of Visceral Pain
Less constant than somatic pain
Dull, colicky waves
Causes of Visceral Pain
Activation of pain receptors resulting from infiltration, compression, extension, or stretching of the thoracic, abdominal, or pelvic viscera
Common Causes of Visceral Pain
Pancreatic CA
Mets in the abdomen
Define Neuropathic Pain
Prolonged, severe, burning or squeezing pain
What may accompany neuropathic pain?
S/S of autonomic instability
Cause of Neuropathic Pain
Injury to the nervous system
Pain Sites
Bone pain Back pain Headache Facial pain Abdominal pain Pelvic pain Post-op pain Phantom pain More than 1 site
Factors that Influence the Development of Cancer pain
Cancer type & site
Presence or absence of mets
Most Frequent Causes of Pain
Visceral involvement
Bone metastases
Soft tissue invasion
Nerve/plexus pressure or infiltration
Treatment Goals of Pain
Diminish pain & associated emotional stress
Increase physical, social, vocational, & recreational involvement
Optimize health
Improve psychological well being
Improve coping ability
Reduce dependence on health care system
Pain Management
Use of pharmacologic agents as well as analgesic adjuvants
Physical & nonpharmacologic approaches (treating CA or how patient reacts to pain)
Neurosurgical & anesthetic interventional procedures
Step Wise Approach to Pain Management
Non-opioid + adjuvant
Opioid (hydrocodone) + non-opioid + adjuvant
Opioid (oxycodone) + non-opioid + adjuvant
What medication should you not prescribe in cancer patients?
Codeine
This is due to varying responses to medication
Step 1 in Pain Management
NSAIDS and Acetaminophen
Around the clock dosing
Why are opioids widely used in cancer patients for pain?
Reliability
Safety
Multiple routes of administration
Ease of titration
Choice of Opioids
Short half-life & PRN to start
Sustained release can be added
Which opioid may have a dual MOA?
Tramadol
MOA of Tramadol
Inhibits neuronal re-uptake of serotonin & norepinephrine
What medications can be used to provide an opioid-sparing effect?
Antidepressants
Anticonvulsants
Local anesthetics
TCAs for Pain Management in Cancer Patients
Amitriptyline (Elavil)
Nortriptyline (Pamelor)
Imipramine (Tofranil)
Desipramine (Norpramin)
Anticonvulsants for Pain Management in Cancer Patients
Carbamazepine (Tegratol)
Clonazepam (Klonopin)
Gabapentin (Neurontin)
MD Anderson Protocol for Mild to Moderate Pain
Non-opions
MD Anderson Protocol for Moderate to Severe Pain
Opioids: morphine, hydromorphone, oxycodone, hydrocodone, codeine, fentanyl, & methadone
MD Anderson Protocol for Tingling & Burning Pain
Antidepressants: amitriptyline, imipramine, doxepin
Antiepileptics: gabapentin
MD Anderson Protocol for Pain Caused by Swelling
Prednisone
Dexamethasone
Most Commonly Used Opioids in Management of Cancer Pains
Morphine
Fentanyl
Medications to Avoid in Management of Cancer Pain
Codeine
Meperidine
What can contribute to depression in cancer patients?
Uncontrolled pain
SE of opioids
Fear of pain
Anesthetic Interventional Approaches to Pain Management
Nerve blocks: celiac plexus, superior hypogastric plexus Myofascial injections Neuroma injections Spinal cord stimulation Intrathecal & epidural injections
Complementary & Alternative Pain Management
Biofeedback Breathing & relaxation exercised Distraction Heat or cold Hyponosis Imagery Massage, pressure & vibration Transcutaneous electrical nerve stimulations (TENS) Acupuncture Coenzyme Q10 Self-help & support groups
Define Biofeedback
Technique that makes the patient aware of bodily process normally through to be involuntary and gain conscious control over these processes which can influence level of pain (blood pressure, skin temp, HR)
Breathing & Relaxation Exercises for Pain Management
Focus attention on performing a specific task instead of on pain
Distraction in Pain Management
Method to divert patient’s attention to a more pleasant event, object, or situation
Heat or Cold in Pain Management
Temperature to facilitate pain control with ice or heating pad
Hypnosis in Pain Management
Focused state of consciousness that allows the patient to better process information
Imagery in Pain Management
Soothing, positive mental images that allow the patient to relax
Massage, Pressure, & Vibration in Pain Management
Physical stimulation of muscles or nerves can facilitate relaxation & relieve painful muscle spasms or contractions
Transcutaneous Electrical Nerve Stimulation (TENS) in Pain Management
Mild electric current is applied to the skin at the site of pain