9/24/2017. Treatment Modalities. Treatment Modalities 16% 2017 OCN Test Blueprint Content Areas. New 2018 OCN Test Blueprint

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1 2017 OCN Test Blueprint Content Areas Treatment Modalities Juanita Madison, MN, RN, AOCN, AOCNS Oncology Clinical Nurse Specialist Swedish Cancer Institute September, 2017 Content Area Health Promotion, Screening & Early Detection Scientific Basis for Practice (including Research) Percentage of 2014 Test # of Scored Questions* 6% 9 9% 13 Treatment Modalities 16% 23 Symptom Management 22% 32 Psychosocial Dimensions of Care 8% 12 Oncologic Emergencies 12% 17 Survivorship 8% 12 Palliative & End of Life Care 11% 16 Professional Performance 8% 12 *To determine the number of scored items from each subject area, multiple the percentage by 145. New 2018 OCN Test Blueprint Treatment Modalities 16% Surgery Blood and marrow transplant Radiation therapy Chemotherapy Targeted Therapies Biotherapy Content Area Sub-Content Areas 2018 Test% Care Continuum Health Promotion & Disease Prevention Screening & Early Detection Navigation, Advanced Care Planning Epidemiology Survivorship Treatment-related Considerations End-of-Live Care Oncology Nursing Practice Treatment Modalities Scientific Basis Site-Specific Cancer Considerations Scope, Standards, & Related Issues Standards of Professional Performance Surgery; Blood and Marrow Transplant; Radiation Therapy; Chemotherapy; Biotherapy; Immunotherapy; Targeted Therapy; Vascular Access Symptom Management & Palliative Care 23% 19% 17% 19% Oncologic Emergencies 12% Psychosicial Dimensions of Care 10% 2018 OCN Test Blueprint, accessed August 26,

2 Study Resources Itamo, J.K. (Ed), Core Curriculum for Oncology Nursing, 5 th Ed. Elsevier, St. Louis. Treatment Modalities Part 3 Surgical Treatment Blood and Marrow Transplantation Radiation Therapy Chemotherapy Targeted Therapies and Biotherapy Support Therapies & Procedures Study Resources Eggert, J. (Ed), Cancer Basics, 2 nd Ed., ONS, Pittsburg. Section II: Treatment Options Surgery Radiation Therapy Precision Medicine, Biologics, & Targeted Therapies Hormone Therapies Clinical Trials Complementary & Alternative Medicine 5 6 Study Resources Polovich, Olsen, & Lefebvre (eds), Chemotherapy and Biotherapy Guidelines and Recommendations for Practice, 4 th Edition ONS, Pittsburgh, PA. Online Resources Oncology Nursing Society Online Courses OCN Certification Review Bundle $ for ONS members, $ for non-members CE credits Four courses (may be purchased individually) + Practice Tests Prevention, Detection, and the Science of Cancer Treatment and Symptom Management Quality of Life Issues Professional Practice Oncology Nurse OCN Practice Test (only available with purchase of review bundle) 7 accessed August 26,

3 Blood and Marrow Transplant Study Hints for BMT Content: Important to Know.. Vocabulary & definitions of HSCT Autologous vs Allogeneic vs Syngeneic Sources of stem cells for transplant Peripheral blood stem cells vs bone marrow vs umbilical cord blood Mini transplant vs myeloablative transplant Graft versus host disease (GVHD) Hepatic Sinusoidal Syndrome Formerly known as Veno-Occlussive Disease (VOD) Process of BMT Steps of HSCT make good exam questions Many questions will overlap with other content areas (psychosocial, symptom management, etc) SO DON T WORRY ABOUT THIS SECTION TOO MUCH! Acronym BMT HSCT PSCT HPCT SCT PBSCT What s In A Name? Meaning Bone marrow transplantation Or Blood and marrow transplant Hematopoietic stem cell transplantation Peripheral stem cell transplantation Hematopoietic progenitor cell transplantation Stem cell transplantation Peripheral blood stem cell transplantation What are Hematopoietic Stem Cells? Unspecialized cells that can differentiate into specialized cells Turn into different blood cells when activated by environmental cues 11 Gregory, S.J. (2017). Hematopoietic Stem Cell Transplant. In Cancer Basics, 2 nd Ed. Eggert, J. (Ed). ONS, Pittsburgh, PA (pgs ). Shapiro, T.W. (2016). Nursing Implications of Blood and Marrow Transplantation. In Core Curriculum for Oncology Nursing, 5 th Ed. Itano, J.K. (Ed). ONS, Pittsburgh, PA (pgs ). 12 3

4 Hematopoietic Stem Cell Transplant (HSCT) HSCT is the infusion of healthy stem cells in someone whose stem cells are diseased or have been destroyed. In patients with cancer, HSCT allows the administration of high doses of chemotherapy and/or radiation therapy to destroy the cancer cells. 13 Gregory, S.J. (2017). Hematopoietic Stem Cell Transplant. In Cancer Basics, 2 nd Ed. Eggert, J. (Ed). ONS, Pittsburgh, PA (pgs ). Shapiro, T.W. (2016). Nursing Implications of Blood and Marrow Transplantation. In Core Curriculum for Oncology Nursing, 5 th Ed. Itano, J.K. (Ed). ONS, Pittsburgh, PA (pgs ). 14 Diseases Treated With Blood or Marrow Transplant Malignant Diseases: Acute and Chronic Leukemia Hodgkin's Lymphoma and Non-Hodgkin's lymphoma Myelodysplastic Syndromes Multiple Myeloma Selected solid tumors Neuroblastoma Sarcoma Germ cell tumors Breast cancer Ovarian cancer Melanoma Lung cancer Non-malignant diseases: Hematologic Disorders: Aplastic Anemia Fanconi s Anemia Sickle Cell Disease Thalassemia Congenital Immunodeficiencies SCID Wiskott Aldrich Syndrome Genetic Diseases Hurler s Syndrome Guacher Disease Autoimmune Diseases Multiple Sclerosis HSCT Donor Types Autologous Patient s own hematopoietic stem cells used Cells obtained ( harvested ) prior to transplant, stored frozen Perfect tissue type match Syngeneic Stem cells obtained from genetically identical twin Perfect tissue type match Allogeneic Stem cells obtained from person other than patient or identical twin Related or Unrelated Donor Related Donors: Sibling (most common), parent, child, other relative Unrelated Donor: Volunteer donor with similar genetic background (tissue typing) May be tissue typed identical or partially matched Gregory, S.J. (2017). Hematopoietic Stem Cell Transplant. In Cancer Basics, 2 nd Ed. Eggert, J. (Ed). ONS, Pittsburgh, PA (pgs ). 16 4

5 HSCT Donor Types Donor Type Benefit Risk Most Common Diseases Treated Sources of Hematopoietic Stem Cells Bone Marrow (harvest) Autologous Allogeneic Minimal risk of GVHD No disease contamination Graft-versus-tumor (GVT) effect High potential for relapse High potential for GVHD (immunosuppression required) MM NHL HD AML ALL MDS NHL Peripheral Blood Syngeneic Immunosuppression not needed No GVT effect Potential to transmit genetic diseases Umbilical Cord 18 Engraftment Post HSCT Engraftment: Return of hematopoietic function Stem Cell Source Bone marrow Peripheral blood stem cells Umbilical cord blood Time to Engraftment days days 28+ days Gregory, S.J. (2017). Hematopoietic Stem Cell Transplant. In Cancer Basics, 2 nd Ed. Eggert, J. (Ed). ONS, Pittsburgh, PA (pgs ). Shapiro, T.W. (2016). Nursing Implications of Blood and Marrow Transplantation. In Core Curriculum for Oncology Nursing, 5 th Ed. Itano, J.K. (Ed). ONS, Pittsburgh, PA (pgs ). 19 Autologous Stem Cell Transplant Pre-Transplant Transplantation Post- Transplantation Key Components Induction therapy Pre-transplant evaluation Determine eligibility for transplant Determination of insurance coverage Initial patient and caregiver education Mobilization & stem cell collection Conditioning therapy ( Preparative therapy ) Stem Cell Reinfusion (Day 0) Pre-engraftment aplasia Engraftment Post-engraftment Post-transplant monitoring Long-term follow-up 5

6 Mobilization Mobilization: a technique used to increase the number of circulating hematopoietic stem cells from the bone marrow into the blood stream G-CSF + plerixafor High Dose Chemotherapy + G-CSF + plerixafor Stem Cell Collection: Apheresis Apheresis From Greek take away Typically performed as an outpatient Requires large bore central venous access Autologous Stem Cell Transplant Conditioning Pre-Transplant Transplantation Key Components Induction therapy Pre-transplant evaluation Determine eligibility for transplant Determination of insurance coverage Initial patient and caregiver education Mobilization & stem cell collection Conditioning therapy ( Preparative therapy ) Stem Cell Reinfusion (Day 0) Pre-engraftment aplasia Engraftment Conditioning: The preparative regimen used to treat the underlying disease prior to hematopoietic stem cell transplant Chemotherapy + Total Body Irradiation Post- Transplantation Post-engraftment Post-transplant monitoring Long-term follow-up 24 6

7 Sample Transplant Schedule Melphalan Conditioning Therapy Sun Mon Tues Wed Thurs Fri Sat Day -4 Day -3 Day -2 Melphalan 200 mg/m 2 Day -1 Rest Day Day 0 Stem Cell Reinfusion Day +1 Day +2 Day +3 Day +4 Day +5 Day +6 Day +7 Day +8 Day +9 Sample Transplant Schedule BEAM Conditioning Therapy Sun Mon Tues Wed Thurs Fri Sat Day -7 Carmustine 300 mg/m 2 Day -6 Cytarabine 200 mg/m 2 + Etoposide 200 mg/m 2 Cytarabine 200 mg/m 2 Day -5 Cytarabine 200 mg/m 2 + Etoposide 200 mg/m 2 Cytarabine 200 mg/m 2 Day +10 Day +11 Day +12 Day +13 Day +14 Day +15 Day +16 Day -4 Cytarabine 200 mg/m 2 + Etoposide 200 mg/m 2 Day -3 Cytarabine 200 mg/m 2 + Etoposide 200 mg/m 2 Day -2 Melphalan 140 mg/m 2 Day -1 Rest Day Day 0 Stem Cell Reinfusion Day 1 Day 2 25 Cytarabine 200 mg/m 2 Cytarabine 200 mg/m 2 26 Stem Cell Reinfusion: Day 0 Autologous Stem Cell Reinfusion Cryopreserved stem cells were preserved with dimethyl sulfoxide (DMSO) Side effects of reinfusion related to DMSO: Hemolysis Garlic taste & smell Infusion reactions Nausea/vomiting Bradycardia 27 7

8 Pre-Engraftment Aplasia Engraftment Post HSCT Engraftment: Return of hematopoietic function Patient supported through period of marrow aplasia Preventative measures to prevent infection Blood product support Monitor for complications Hepatitic Sinusoidal obstructive syndrome (formerly known as veno-occlusive disease or VOD) Stem Cell Source Bone marrow Peripheral blood stem cells Umbilical cord blood Time to Engraftment days days 28+ days 29 Gregory, S.J. (2017). Hematopoietic Stem Cell Transplant. In Cancer Basics, 2 nd Ed. Eggert, J. (Ed). ONS, Pittsburgh, PA (pgs ). Shapiro, T.W. (2016). Nursing Implications of Blood and Marrow Transplantation. In Core Curriculum for Oncology Nursing, 5 th Ed. Itano, J.K. (Ed). ONS, Pittsburgh, PA (pgs ). 30 Autologous Stem Cell Transplant Pre-Transplant Transplantation Post- Transplantation Key Components Induction therapy Pre-transplant evaluation Determine eligibility for transplant Determination of insurance coverage Initial patient and caregiver education Mobilization & stem cell collection Conditioning therapy ( Preparative therapy ) Stem Cell Reinfusion (Day 0) Pre-engraftment aplasia Engraftment Post-engraftment Post-transplant monitoring Long-term follow-up HSCT Donor Types Autologous Patient s own hematopoietic stem cells used Cells obtained ( harvested ) prior to transplant, stored frozen Perfect tissue type match Syngeneic Stem cells obtained from genetically identical twin Perfect tissue type match Allogeneic Stem cells obtained from person other than patient or identical twin Related or Unrelated Donor Related Donors: Sibling (most common), parent, child, other relative Unrelated Donor: Volunteer donor with similar genetic background (tissue typing) May be tissue typed identical or partially matched Shapiro, T.W. (2016). Nursing Implications of Blood and Marrow Transplantation. In Core Curriculum for Oncology Nursing, 5 th Ed. Itano, J.K. (Ed). ONS, Pittsburgh, PA (pgs ). 32 8

9 Allogeneic Stem Cell Transplant Pre-Transplant Transplantation Post- Transplantation Key Components Patient diagnosed +/- treatment Pre-transplant evaluation Determine eligibility for transplant HLA type siblings/search donor registries Determination of insurance coverage Initial patient and caregiver education Conditioning therapy ( Preparative therapy ) Day 0: Harvest Cells from Donor & Stem Cell Reinfusion Pre-engraftment aplasia Engraftment Post-engraftment Post-transplant monitoring Long-term follow-up Human Leukocyte Antigen (HLA) Tissue Typing HLA system is used to determine best possible stem cell source for transplantation HLA is a protein or marker found on most cells in the body, including white blood cells The immune system uses HLA markers to recognize self versus non-self Half of HLA antigens inherited from the mother and half from the father Ten HLA antigens (markers) are used in HLA typing for allogeneic transplant recipients Shapiro, T.W. (2016). Nursing Implications of Blood and Marrow Transplantation. In Core Curriculum for Oncology Nursing, 5 th Ed. Itano, J.K. (Ed). ONS, Pittsburgh, PA (pgs ). 34 Example of HLA Typing HLA Typing Preferred situation for transplant is a ten-out-often (10/10) antigen, HLA-match The best transplant outcome happens when a patient s HLA and the donor s HLA closely match Partially matched family members or matched unrelated donors from a volunteer pool may also be used as donors 35 Shapiro, T.W. (2016). Nursing Implications of Blood and Marrow Transplantation. In Core Curriculum for Oncology Nursing, 5 th Ed. Itano, J.K. (Ed). ONS, Pittsburgh, PA (pgs ). 36 9

10 Allogeneic Stem Cell Transplant Allogeneic Transplant Types Pre-Transplant Transplantation Post- Transplantation Key Components Patient diagnosed +/- treatment Pre-transplant evaluation Determine eligibility for transplant HLA type siblings/search donor registries Determination of insurance coverage Initial patient and caregiver education Conditioning therapy ( Preparative therapy ) Day 0: Harvest Cells from Donor & Stem Cell Reinfusion Pre-engraftment aplasia Engraftment Post-engraftment Post-transplant monitoring Long-term follow-up Myeloablative Conditioning regimen that completely ablates the bone marrow reserve in the patient Also called standard transplant Nonmyeloablative Also called mini-transplant or reduced-intensity transplant Lower doses of conditioning therapy Enough to cause immunosuppression but not enough to completely ablate the marrow This type of transplant allows the graft-versus-tumor effect to cure the cancer Shapiro, T.W. (2016). Nursing Implications of Blood and Marrow Transplantation. In Core Curriculum for Oncology Nursing, 5 th Ed. Itano, J.K. (Ed). ONS, Pittsburgh, PA (pgs ). Sources of Hematopoietic Stem Cells Bone Marrow (harvest) Peripheral Blood Umbilical Cord 39 Day 0: Allogeneic Stem Cell Infusion Fresh allogeneic stem cells Peripheral Blood Stem Cells or Bone Marrow Administered like a RBC transfusion Larger volume for bone marrow than stem cell Typical bone marrow volume: ml/kg bone marrow + heparinized saline Cryopreserved if umbilical cord blood cells 10

11 Pre-Engraftment Aplasia Engraftment Post HSCT Engraftment: Return of hematopoietic function Patient supported through period of marrow aplasia Preventative measures to prevent infection Blood product support Monitor for complications Hepatitic Sinusoidal obstructive syndrome (formerly known as veno-occlusive disease or VOD) Stem Cell Source Bone marrow Peripheral blood stem cells Umbilical cord blood Time to Engraftment days days 28+ days 41 Gregory, S.J. (2017). Hematopoietic Stem Cell Transplant. In Cancer Basics, 2 nd Ed. Eggert, J. (Ed). ONS, Pittsburgh, PA (pgs ). Shapiro, T.W. (2016). Nursing Implications of Blood and Marrow Transplantation. In Core Curriculum for Oncology Nursing, 5 th Ed. Itano, J.K. (Ed). ONS, Pittsburgh, PA (pgs ). 42 Unique Complications of HSCT Hepatic Sinusoidal Obstruction Syndrome (HSOS) Previously called veno-occlussive disease or VOD Graft-Verus-Host-Disease (GVHD) Allogeneic transplants ONLY Hepatic Sinusoidal Obstruction Syndrome (HSOS) Previously called veno-occlussive disease or VOD Damage to small sinusoids of the liver from pretransplant conditioning regimen Occurs in 5% - 54% of patients Most common in allogeneic transplant from matched unrelated donors Signs & symptoms: Increased LFT s, weight gain, abdominal pain, jaundice Gregory, S.J. (2017). Hematopoietic Stem Cell Transplant. In Cancer Basics, 2 nd Ed. Eggert, J. (Ed). ONS, Pittsburgh, PA (pgs ). Shapiro, T.W. (2016). Nursing Implications of Blood and Marrow Transplantation. In Core Curriculum for Oncology Nursing, 5 th Ed. Itano, J.K. (Ed). ONS, Pittsburgh, PA (pgs ). 11

12 Graft versus Host Disease (GVHD) Donor T-lymphocytes (the graft) recognize the antigens and cells in the transplant recipient (the host) as foreign and mount an immunologic attack Occurs in 30-60% of all allogeneic transplant recipients Risk increased with HLA mismatched transplants Prevention Highest degree of histocompatibility from donor as possible (best HLA match possible) Prophylactic immunosuppression Methotrexate, cyclosporin, mycophenolate, mofetil, or tacrolimus (alone or in combination) Clinical Features of Acute GVHD Skin (most common) Maculopapular rash, often beginning with palmar/plantar surfaces & extending to face, abdomen, & trunk Sunburned appearance to desquamation and loss of skin integrity Liver Elevated alkaline phosphatase and bilirubin RUQ pain, hepatomegaly, and jaundice to ascites Gut Profuse, watery diarrhea with anorexia, nausea & vomiting Diarrhea with intestinal bleeding and crampy abdominal pain to ileus Treatment of Acute GVHD Primary Therapy Prednisone 1-2 mg/kg/day followed by taper after response (may be given as IV methylprednisone) Additional Therapy (immunosuppression) Tacrolimus ATG Etanercept Denileukin Diffitox Pentostatin Sirolimus PUVA (skin) or ECP (skin, liver, gut) Chronic Graft-Versus-Host Disease (GVHD) Syndrome caused by donor immune competent T cells recognizing and mounting an immune response against host cells Resembles autoimmune or collagen vascular disorder Oral symptoms, skin, nails, scalp & body hair, eyes, genitalia, GI tract, liver, lung, muscles/facia/joints, hematopoietic/immune system 12

13 Allogeneic Stem Cell Transplant Pre-Transplant Transplantation Key Components Patient diagnosed +/- treatment Pre-transplant evaluation Determine eligibility for transplant HLA type siblings/search donor registries Determination of insurance coverage Initial patient and caregiver education Conditioning therapy ( Preparative therapy ) Day 0: Harvest Cells from Donor & Stem Cell Reinfusion Pre-engraftment aplasia Engraftment Exam Question Example An allogeneic HSCT is one in which donor cells are derived from: A. An HLA-matched donor B. The client s own marrow C. The client s twin D. A cadaver Post- Transplantation Post-engraftment Post-transplant monitoring Long-term follow-up Exam Question Examples The purpose of the mobilization regimen in the hematopoietic stem cell transplantation process is to: A. Prevent graft-versus-host disease (GVHD) B. Eradicate malignant cells and prevent graft rejection C. Reduce the adverse effects of HSCT D. Mobilize hematopoietic stem cells from the bone marrow to the peripheral blood. Exam Question Examples Which patient is most likely to experience graft-versus-host disease? a. 35-year old who received an autologous hematopoietic stem cell transplant b. 60-year old who received an allogeneic transplant from an unrelated donor c. 20-year old who received a tandem autologous transplant d. 45-year old who received a syngeneic hematopoietic stem cell transplant 13

14 Radiation Therapy Radiation Therapy Overview Use of ionizing radiation as part of cancer treatment to control malignant cells Biologic effects of ionizing radiation: Cellular Target most important target is DNA Direct effect on cell: DNA damage (single-strand and double-strand breaks, formation of crosslinks) Indirect effect on cell: Causes ionization of water which creates free radicals that damage DNA Biologic Response is affected by level of DNA damage Well oxygenated tumors show greater response Sensitivity of cell to radiation 54 Principles of Radiation Therapy (RT) Radiosensitivity of Cells Course of RT planned to deliver dose high enough to destroy the tumor but not to exceed tolerance of normal tissue in radiation field Side effects of RT generally result of radiation effect on normal tissue Cells vary in sensitivity to radiation In general, rapidly dividing cells (normal cells and cancer cells), are most sensitive. Examples: epithelial cells, bone marrow, lymphoid tissue Nondividing or slowly dividing cells are generally less radiosensitive Examples: muscle cells, neurons Shaftic, A.M. (2017). Radiation Therapy. In Cancer Basics, 2 nd Ed. Eggert, J. (Ed). ONS, Pittsburgh, PA. (pgs ). Russel, M.L. (2016). Nursing Implications of Radiation Therapy. In Core Curriculum for Oncology Nursing, 5 th Ed. Itano, J.K. (Ed). ONS, Pittsburgh, PA (pgs ). 55 Shaftic, A.M. (2017). Radiation Therapy. In Cancer Basics, 2 nd Ed. Eggert, J. (Ed). ONS, Pittsburgh, PA. (pgs ). Russel, M.L. (2016). Nursing Implications of Radiation Therapy. In Core Curriculum for Oncology Nursing, 5 th Ed. Itano, J.K. (Ed). ONS, Pittsburgh, PA (pgs )

15 Side Effects of Radiation Therapy Early side effects: Occur during RT or immediately after and generally heal after RT course Usually exhibited first by rapidly proliferating tissues (e.g., GI mucosa, bone marrow, skin) Late side effects: Occur months to years after RT and are permanent Slow proliferating tissues develop injury slowly (e.g., CNS, kidney, cartilage, bone) Russel, M.L. (2016). Nursing Implications of Radiation Therapy. In Core Curriculum for Oncology Nursing, 5 th Ed. Itano, J.K. (Ed). ONS, Pittsburgh, PA (pgs ). 57 Tissue Response to Radiation Therapy (RT) Acute- Responding Tissues Early side effects occur during or immediately after RT Generally heal after the RT course Usually exhibited by tissues with rapidly proliferating cells (e.g., GI mucosa, bone marrow, and skin) Sub-Acute Few (if any) early side effects Responding Damage occurs weeks to months after RT Tissues Tissues with slower proliferating cells (e.g. lung, liver, kidney, heart, spinal cord, brain) Late- Responding Tissues Late effects occur months to years after RT and are permanent Slowing proliferating cells develop injury slowly (e.g. CNS, peripheral nervous system, kidney, cartilage, bone) 58 Methods of Delivery Teletherapy (External Beam) External beam Precise dose delivered from outside the body Delivered by treatment machines: linear accelerator, cobalt-60 sources Brachytherapy Radiation delivered from sealed radioactive sources implanted in body Placed temporarily or permanently: adjacent to tumor (intracavitary or surface application) into the tumor or into a lumen (interstitial application) Into a lumen (intraluminal) Systemic Treatment Systemic administration of a radioactive preparation that selectively targets tissue Teletherapy/ External Beam Radiation Therapy (EBRT) Most common type of radiation therapy Most often delivered in the form of photon beams (either x-rays or gamma rays) Photon is the basic unit of light and other forms of electromagnetic radation Can be thought of as a bundle of energy The amount of energy in photon can vary (e.g. gamma rays have the highest energy, followed by x-rays) Many types of Teletherapy delivered using machine called linear accelerator (also called LINAC) LINAC uses electricity to form a stream of fast-moving subatomic particles Creates high-energy radiation Russel, M.L. (2016). Nursing Implications of Radiation Therapy. In Core Curriculum for Oncology Nursing, 5 th Ed. Itano, J.K. (Ed). ONS, Pittsburgh, PA (pgs )

16 Teletherapy Treatment Process Patient consultation with Radiation Oncologist Simulation X-ray examinations (scans) to simulate treatment volume Facilitates decisions for treatment fields CT or MRI used for tumor localization to plan fields Immobilization devices Treatment marks placed on skin Treatment planning Patient Education Treatment Weekly management evaluation OTV : On-Treatment Visit: Radiation Oncologist & Radiation Nurse evaluate status & side effects Long-term follow-up Russel, M.L. (2016). Nursing Implications of Radiation Therapy. In Core Curriculum for Oncology Nursing, 5 th Ed. Itano, J.K. (Ed). ONS, Pittsburgh, PA (pgs ). Brachytherapy Placement of sealed radioactive isotope, temporarily or permanently, into: Tissue (interstitial) Into hollow body cavity (intracavitary) On surface of the body Rationale: Delivery of high dose radiation to tumor site over continuous period Minimizes radiation dose to adjacent tissue Increased local control, decreased long-term side effects Russel, M.L. (2016). Nursing Implications of Radiation Therapy. In Core Curriculum for Oncology Nursing, 5 th Ed. Itano, J.K. (Ed). ONS, Pittsburgh, PA (pgs ). Unsealed Sources (Radiopharmaceutical Therapy) Radioactive materials administered IV, orally, or into body cavity Systemic administration of a radioactive preparation that selectively targets tissue Delivers to target tissue causing little or no damage to adjacent tissue Short duration of radioactivity within the body Uses: Hyperthyroidism: Iodine 131 I 131) Metastatic bony lesions: Strontium chloride Sr 89 Non-Hodgkin Lymphoma: Ibritumomab tiuextan( Zevalin), CD-20 monoclonal antibody conjugated with yttrium-90 Brachytherapy (Sealed Sources) Radiation delivered from radiation sources (radioactive materials) placed inside or on the body Radioactive isotopes sealed in tiny pellets or seeds Seeds placed in patients using delivery devices (needles, catheters, or other type of carrier). As the isotopes decay naturally, they give off radiation that damages nearby cancer cells Placement can be temporary or permanent Types of Brachytherapy Interstitial brachytherapy Intracavitary brachytherapy 64 16

17 Radiation Safety Safety Practices Depend On Radioisotope Characteristics Regulations regarding radiation exposure Federal requisite safety standards Maximal permissible dose limits State regulations & guidelines Institutional guidelines Energy of isotope Half-life of isotope Time required for half of the atoms of a given quantity of radioactive material to decay Important in unsealed sources of Radiation Therapy Types of Radioactive Particles Alpha particles (large particles, shallow penetration) Beta particles (deeper penetration when injected or ingested, body provides adequate shielding) Gamma particles (wide range of energy & penetration, lead shielding) Monitoring Radiation Exposure Personal monitoring devices Film badge or ring badge Pocket dosimeter Patient or in-room monitoring devices Geiger counter Ionization chamber monitor 17

18 Radiation Safety Personnel Radiation Safety Principles Radiation safety officer Radiation control committee Radioisotope authorized user personnel Minimize TIME of exposure to radiation Maximize DISTANCE from exposure Use appropriate SHIELDING between radiation source and exposed person Russel, M.L. (2016). Nursing Implications of Radiation Therapy. In Core Curriculum for Oncology Nursing, 5 th Ed. Itano, J.K. (Ed). ONS, Pittsburgh, PA (pgs ). 70 Side Effects of Radiation Therapy Great table in Core Curriculum for Oncology Nursing on Side Effects of Radiation Therapy & Nursing Implications (pages ) 71 Skin Side Effects of Radiation Therapy Potential Early Effects Potential Intermediate or Late Effects Erythema Fibrosis Pigmentation Atrophy Dry desquamation Telangiectasis Moist desquamation Altered pigmentation Alopecia Slow healing of trauma Carcinogenesis Nursing Considerations Early effects: Non-moist reaction: wash with mild soap and water and use calendula or hyaluronic-based cream. Use only electric razor, per institutional guidelines Moist desquamation: Wash with mild cleanser and use hydrocolloid or Silver leaf dressing Observe for increased reaction in skin folds Observe for increased expected reactions if patient has had chemotherapy that enhances skin reaction Early and later effects: Protect skin from chemical, mechanical, thermal irritants and injury and from sun 18

19 Exam Question Examples Exam Question Examples A patient is scheduled for brachytherapy. When asked what this means, the nurse s best response to the patient would be that brachytherapy involves the: Which of the following statements best describes the radiobiology of treatment with ionizing radiation? a. Placement of a radioactive source in or near the tumor site b. Use of a split course of external-beam irradiation aimed at the tumor site c. Instillation of a radioactive substance for purposes of palliation d. Use of both irradiation and chemotherapy for inaccessible tumors a. Ionizing radiation injures cellular DNA of both normal & cancer tissues b. Only normal cells can repair damage to DNA c. Altered DNA always produces hereditary changes d. Cells that are lethally damaged by ionizing radiation die within an hour of the radiation dose Exam Question Examples Another name for external-beam radiation therapy is: a. Teletherapy b. Brachytherapy c. Radioimmunotherapy d. Sealed source therapy Exam Question Examples One of the primary goals of dose fractionation is to: a. Redistribute cell age within the cell cycle, making normal cells less radiosensitive b. Allow tumor cells to repopulate, making them more vulnerable to the late consequences that occur if new growth was inhibited c. Deliver a dose sufficient to prevent tumor cells from being repaired while allowing normal cells to recover before the next dose is given d. Provide time between treatments for normal cells to reoxygenate, thus making them less radiosensitive 19

20 Exam Question Examples Complications and side effects of radiotherapy for esophageal cancer include all of the following except: Chemotherapy a. Esophageal stricture b. Radiation pneumonitis c. Skin reaction d. Nausea and vomiting Resources for Studying Chemotherapy, Biotherapy & Targeted Therapies Chemotherapy & Biotherapy Guidelines and Recommendations for Practice, 3 rd Ed. Excellent tables reviewing biotherapy, targeted agents ONS Online Resources ( Chemotherapy/Biotherapy Fundamentals of Administration (9.10 Contact hours) ONS members: $99, Non-ONS Members: $139 ONS/ONCC Chemotherapy/Biotherapy Certificate Course (15 Contact hurs) ONS Members: $199, Non-ONS Members $279 ONS Online Resources: Cancer Therapies Resource Page ce-resources/cancertherapies Comprehensive listing of available Cancer Therapy resources 80 20

21 Goals of Cancer Therapy Prevention Cure Control Palliation Treatment Approaches Adjuvant Therapy Therapy given after the primary treatment modality such as surgery Example: adjuvant chemotherapy following lumpectomy for breast cancer Rationale & goal of adjuvant therapy: Reduce risk of recurrence by eliminating small sites of disease or microscopic disease (micrometastases) Neoadjuvant Therapy Use of one or more treatment modalities prior to the primary treatment (i.e. chemotherapy prior to surgery) Rational for neoadjuvant therapy: Decrease tumor size for surgical removal (shrink tumor prior to removal) Evaluate effectiveness of chemotherapy (before surgery) Wilkes (2009). In Holmes Gobel, B. Triest-Robertson, S. & Vogel, W. (Eds). Advanced Oncology Nursing Certification: Review and Resource Manual (pp ). ONS, Pittsburg, PA.; Polovich, M. et al (Eds) (2009). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 3rd ed., ONS, Pittsburg, PA. Levine, A. (2010). Chemotherapy. In Eggert, J (Ed). Cancer Basics, pp Oncology Nursing Society, Pittsburgh, PA; Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed., pp. 1-16, ONS, Pittsburg, PA. Cell Life Cycle G-0 Resting (cells not committed to cell division) G-1 RNA & protein synthesis (enzymes produced necessary for DNA synthesis) S (Synthesis) DNA synthesis G-2 RNA, protein synthesis M (Mitosis) Cellular division Action of Antineoplastic Drugs Alter cellular activity during one or more phases of cell cycle Affects both normal & malignant cells 21

22 Pharmacologic Classifications Cell Cycle Specific Agents Cell Cycle Non-specific Alkylating agents Nitrosureas Antitumor antibiotics Cell Cycle Specific Antimetabolites Plant Alkaloids (Mitotic inhibitors) Vinca alkaloids Taxanes Epipodophylotoxins Camptotecins Exerts effect only in specific phases of cell cycle Most effective against rapidly proliferating (cycling) cells Cell kill dependent on schedule (duration & timing rather than dose) Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pp ), ONS, Pittsburg, PA. Cell Cycle Non-Specific Agents Affect cells in all phases cell cycle (including G 0 ) Both proliferating & nonproliferating cells killed Cell kill dependent on total dose rather than schedule Combined with cell cycle-specific agents of Cell Cycle Cell Cycle Nonspecific Common Chemotherapy Agents Class Alkylating Agents Nitrosureas Antitumor Antibiotics Common Agents Generic (Brand) Names Bendamustine (Treanda, Bendeka) Cyclophosphamide (Cytoxan) Dacarbazine (DTIC) Ifosfamide (Ifex) Cisplatin (Platinol) Carboplatin (Paraplatin) Oxaliplatin (Eloxatin) Melphalan (Alkeran) Carmustine (BiCNU) Lomustine (CeeNu) Streptozocin (Zanosar) Bleomycin (Blenoxane) Dactinomycin (Cosmegen) Mitomycin (Mutamycin) Mitozantrone (Novantrone) Anthracycline Antitumor Antibiotics Daunorubicin (Daunomycin) Daunorubicin liposomal (DanoXome) Doxorubicin (Adriamycin) Doxorubicin liposomal (Doxil) Epirubicin (Ellence) Idarubicin (Idamycin) Hematopoietic GI Reproductive Integumentary Hematopoietic (delayed) GI Hematopoietic GI Reproductive Integumentary Common Toxicities Hemorrhagic cystitis (ifosfamide, cyclophosphamide) Secondary malignancy Neurologic Hypersensitivity Cardiac Pulmonary (bleomycin) Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pp ), ONS, Pittsburg, PA. 22

23 Alkylating Agents Alkylating Agents Toxicities Cell cycle non-specific Break DNA helix, interferes with DNA replication Examples of alkylating agents Bendamustine Cyclophosphamide Ifosfamide Cisplatin Carboplatin Oxaliplatin Melphalan Hematopoietic Myelosuppression GI Nausea/vomiting Reproductive Azoospermia, amenorrhea Integumentary Alopecia Many agents are vesicants or irritants Carcinogenic Secondary malignancies Hemorrhagic cystitis Ifosfamide, cyclophosphamide Neuropathy Cisplatin analogs Hypersensitivity Carboplatin (after 6-7 doses), oxaliplatin Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pgs ), ONS, Pittsburg, PA. ; Olsen, M. (2017). Chemotherapy. In Cancer Basics, 2 nd Edition, Eggert, J. (Ed) (pgs ). Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pgs ), ONS, Pittsburg, PA. ; Olsen, M. (2017). Chemotherapy. In Cancer Basics, 2 nd Edition, Eggert, J. (Ed) (pgs ). Mesna Uroprotective Agent Binds to acrolein (liver metabolite of ifosphamide & cyclophosphamide) Prevents hemorrhagic cystitis Administered with: Ifosphamide High-dose Cyclophosphamide (e.g. hematopoietic stem cell transplant) May be administered oral or IV Usually administered in divided doses every four hours, up to 24 hours after last dose of chemotherapy Nitrosureas Cell cycle non-specific Breaks DNA helix, interferes with DNA replication Cross blood-brain barrier Examples of Nitrosureas: Carmustine (BiCNU) Lomustine (CeeNU) Streptozocin (Zanosar) Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed, ONS, Pittsburg, PA 91 Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pgs ), ONS, Pittsburg, PA. ; Olsen, M. (2017). Chemotherapy. In Cancer Basics, 2 nd Edition, Eggert, J. (Ed) (pgs ). 23

24 Nitrosureas Toxicities Hematopoietic Delayed myelosuppression Nadir 4-6 weeks after therapy starts GI Severe nausea/vomiting Antitumor Antibiotics Cell cycle non-specific (most agents) Binds with DNA, inhibits DNA & RNA synthesis Examples of antitumor antibiotics Bleomycin (Blenoxane) Dactinomycin (Cosmegen) Mitomycin (Mutamycin) Mitoxantrone (Novantrone) Anthracycline Antitumor antibiotics Daunuorubicin (Daunomycin) Daunorubicin liposomal Doxorubicin (Adriamycin) Doxorubicin liposomal (Doxil) Epirubicin (Ellence) Idarubicin (Idamycin) Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pgs ), ONS, Pittsburg, PA. ; Olsen, M. (2017). Chemotherapy. In Cancer Basics, 2 nd Edition, Eggert, J. (Ed) (pgs ). Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pp ), ONS, Pittsburg, PA. Antitumor Antibiotics Toxicities Hematopoietic Myelosuppression (all drugs except Bleomycin) GI Nausea/vomiting Stomatitis, mucositis Reproductive Gonadal suppression Integumentary Alopecia Vesicants (except Bleomycin, and some liposomal anthracyclines) Cardiotoxicity Anthracyclines (dose dependent) Pulmonary fibrosis Bleomycin Bleomycin Daunorubicin Cumulative Dose Limits Antitumor Antibiotics Antitumor Antibiotic Cumulative Dose Limit 400 Units 550 mg/m 2 without cardiac risks; 400 mg/m 2 in adults receiving chest irradiation Doxorubicin 550 mg/m 2 (450 mg/m 2 if prior chest irradiation or concomitant cyclophosphamide administration) Epirubicin 900 mg/m 2 Idarubicin > 150 mg/m 2 associated with decreased ejection fraction Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pp ), ONS, Pittsburg, PA. 96 Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pp ), ONS, Pittsburg, PA. 24

25 Dexroazoxane (Zinecard) Cardioprotectant Iron-chelating agent, prevents formation of free radicals Administered IV during or prior to administration of doxorubicin Indicated in patients who have received > 300 mg/m 2 cumulative dose of doxorubicin of Cell Cycle Cell Cycle Nonspecific Common Chemotherapy Agents Class Alkylating Agents Nitrosureas Antitumor Antibiotics Common Agents Generic (Brand) Names Bendamustine (Treanda, Bendeka) Cyclophosphamide (Cytoxan) Dacarbazine (DTIC) Ifosfamide (Ifex) Cisplatin (Platinol) Carboplatin (Paraplatin) Oxaliplatin (Eloxatin) Melphalan (Alkeran) Carmustine (BiCNU) Lomustine (CeeNu) Streptozocin (Zanosar) Bleomycin (Blenoxane) Dactinomycin (Cosmegen) Mitomycin (Mutamycin) Mitozantrone (Novantrone) Anthracycline Antitumor Antibiotics Daunorubicin (Daunomycin) Daunorubicin liposomal (DanoXome) Doxorubicin (Adriamycin) Doxorubicin liposomal (Doxil) Epirubicin (Ellence) Idarubicin (Idamycin) Hematopoietic GI Reproductive Integumentary Hematopoietic (delayed) GI Hematopoietic GI Reproductive Integumentary Common Toxicities Hemorrhagic cystitis (ifosfamide, cyclophosphamide) Secondary malignancy Neurologic Hypersensitivity Cardiac Pulmonary (bleomycin) Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (p. 284), ONS, Pittsburg, PA. 97 Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pp ), ONS, Pittsburg, PA. Pharmacologic Classifications Cell Cycle Non-specific Antimetabolites Plant Alkaloids (Mitotic inhibitors) Vinca alkaloids Taxanes Epipodophylotoxins (also Topoisomerase inibitors) Camptothecins (Topoisomerase inhibitors) of Cell Cycle Cell Cycle Specific Common Chemotherapy Agents Class Antimetabolites Vinca Alkaloids Epipodophylotoxins Taxanes Camptothecins Common Agents Generic (Brand) Names Azacitidine (Vidaza) Capecitabine (Xeloda) Cladribine (Leustatin) Clofarabine (Clolar) Cytarabine (Ara-C) Fluorouracil (5FU) Methotrexate (Mexate) Premetrexed (Alimta) Gemcitabine (Gemzar) Vinblastine (Velban) Vincristine (Oncovin) Vinorelbine Etoposide (VP-16, VePesid) Teniposide (VM-26, Vumon) Cabazitaxel (Jevtana) Docetaxel (Taxotere) Paclitaxel (Taxol) Paclitaxel protein-bound particles (Abraxane) Irinotecan (Camptosar) Topetecan (Hycamtin) Hematopoietic GI Integumentary Hematopoietic GI Integumentary Hematopoietic GI Reproductive Integumentary Hematopoietic GI Integumentary Hematopoietic GI Integumentary Common Toxicities Ocular Neurologic Cardiac Pulmonary Neurologic Hypersensitivity Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pp ), ONS, Pittsburg, PA. 25

26 Antimetabolites Cell cycle specific (S ) Mimics & incorrectly substitutes for metabolites (nutrients) needed for cellular function (e.g. folate) Antimetabolite examples Methotrexate Antimetabolites 5FU Azacitabine (Vidaza) Capecitabine (Xeloda) Cladribine (Leustatin) Clofarabine (Clolar) Cytarabine (Ara-C) Floxuridine (FUDR) Fludarabine (Fludara) Fluorouracil (5-FU) Gemcitabine (Gemzar) Methotrexate Pemetrexed Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pp ), ONS, Pittsburg, PA. Antimetabolite Toxicities Plant Alkaloids Hematopoietic Myelosuppression GI Nausea, vomiting Mucositis/stomatitis Diarrhea Integumentary Capecitibine: Hand/foot syndrome (palmarplantar erythrodysesthesia) 5FU: photosensitivity Ocular toxicity Cytarabine (Ara-C) highdose: keratitis 5FU: photosensitivity Vinca alkaloids Taxanes Epipodophylotoxins Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pp ), ONS, Pittsburg, PA. 26

27 Acts in late G2 & M phase Prevents formation of mitotic spindle (prevents cell mitosis) Examples of Vinca Alkaloids Vinblastine Vincristine Vinorelbine Vinca Alkaloids Vinca Alkaloid Toxicities Hematopoietic Myelosuppression (except vincristine) GI Nausea/vomiting (except vincristine) Integumentary All are vesicants Alopecia Neurotoxicity Sensory-motor peripheral neuropathy Constipation (autonomic neuropathy) Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pp ), ONS, Pittsburg, PA. Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pp ), ONS, Pittsburg, PA. Epipodophyllotoxins Epipodophyllotoxin Toxicities Interferes with topoisomerase II enzyme reaction Induce irreversible blockade of cells in premitotic phases of cell cycle (late G2 & S phases) Examples of Epipodophyllotoxins: Etoposide (VP-16, VePesid) Teniposide (VM-26, Vumon) Myelosuppression GI Nausea/vomiting Mucositis (high-dose etoposide) Diarrhea (high-dose etoposide) Cardiovascular Hypotension if infused too rapidly (etoposide) Wilkes (2009). In Holmes Gobel, B. Triest-Robertson, S. & Vogel, W. (Eds). Advanced Oncology Nursing Certification: Review and Resource Manual (pp ). ONS, Pittsburg, PA.; Polovich, M. et al (Eds) (2009). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 3rd ed (pp ), ONS, Pittsburg, PA. 27

28 Taxanes Taxane Toxicities Inhibits cell division in G2 & M phase Promotes early microtubule assembly and prevents disassembling, arresting mitosis Examples of Taxanes: Cabazitaxel (Jevtana) Docetaxel (Taxotere) Paclitaxel (Taxol) Paclitaxel Protein-bound particles (Abraxane) Hematopoietic Myelosuppression GI Nausea/vomiting Integumentary Alopecia Vesicant potential (paclitaxel) Irritant (docetaxel) Neurologic Sensory-motor peripheral neuropathy Arthralgia & myalgias Hypersensitivity reactions Paclitaxel & docetaxel Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pp ), ONS, Pittsburg, PA. Camptothecins Cell cycle phase specific Acts in S phase; inhibit topoisomerase I; cause doublestrand DNA changes Examples of Camptotecans Irinotecan (Camptosar) Topetecan (Hycamtin) Camptothecin Toxicities Hematopoietic: Myelosuppression GI: Early diarrhea Cholinergic reversed with atropine Late diarrhea Motility Integumentary: Alopecia Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pp ), ONS, Pittsburg, PA. 28

29 of Cell Cycle Cell Cycle Specific Common Chemotherapy Agents Class Antimetabolites Vinca Alkaloids Epipodophylotoxins Taxanes Camptothecins Common Agents Generic (Brand) Names Azacitidine (Vidaza) Capecitabine (Xeloda) Cladribine (Leustatin) Clofarabine (Clolar) Cytarabine (Ara-C) Fluorouracil (5FU) Methotrexate (Mexate) Premetrexed (Alimta) Gemcitabine (Gemzar) Vinblastine (Velban) Vincristine (Oncovin) Vinorelbine Etoposide (VP-16, VePesid) Teniposide (VM-26, Vumon) Cabazitaxel (Jevtana) Docetaxel (Taxotere) Paclitaxel (Taxol) Paclitaxel protein-bound particles (Abraxane) Irinotecan (Camptosar) Topetecan (Hycamtin) Hematopoietic GI Integumentary Hematopoietic GI Integumentary Hematopoietic GI Reproductive Integumentary Hematopoietic GI Integumentary Hematopoietic GI Integumentary Common Toxicities Ocular Neurologic Cardiac Pulmonary Neurologic Hypersensitivity Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pp ), ONS, Pittsburg, PA. Hormonal Agents Classification Uses Side effects Glucocorticosteroids Dexamethasone Antiemetic Prevention of cerebral edema with brain tumors Management of severe pain associated with brain metastases, spinal cord compression and bone pain Prevention of hypersensitivity reactions Cancer treatment i.e. multiple myeloma Hypercorticism (Cushing's syndrome), hyperthyroidism, hyperglycemia, and aggravation of diabetes mellitus in susceptible patients, gastrointestinal side effects, dermatologic effects, neurologic effects, mental disturbances Chu & DeVita, 2014 Hormone Therapy for Breast Classification Drug Mechanism of Action Common / Cancer potential side effects Selective Estrogen Receptor Modulators Estrogen receptor antagonist Aromatase Inhibitors (not for use in premenopausal women) Tamoxifen (Nolvadex ) Fulvestrant (Faslodex ) Letrozole (Femara ), Anastrozole (Arimidex ) & Exemestane (Aromasin ) Blocks estrogen receptors in breast cells Blocks & eliminates estrogen receptors Blocks enzyme aromatase in fat tissue that makes small amounts of estrogen, not effective in stopping ovarian production of estrogen. Menopausal symptoms, potential for blood clots & endometrial cancer Weakness, mild n&v, hot flashes, back and joint pain, flu-like symptoms Muscle and joint pain, bone thinning, menopausal symptoms Chu & DeVita, 2014 Hormone Therapy for Prostate Classification Drug Mechanism of Cancer Action Luteinizing hormonereleasing hormone agonists (LHRH) Non-steroidal anti-androgen agents Leuprolide depot (Leupron) Goserelin implant (Zoladex ) Flutamide (Eulexin) Bicalutamide (Casodex) Nilutamide (Nilandron) Causes decreased secretion of LH and FSH from the pituitary resulting in castration levels of testosterone Binds to androgen receptors and inhibits androgen uptake Common / potential side effects Hot flashes, decreased libido, impotence, gynecomastia, tumor flare, discomfort at injection site Hot flashes, decreased libido, impotence, gynecomastia, visual disturbances, potential for interstitial pneumonitis Chu & DeVita,

30 Verification of Dose Calculation Hazardous Drug Safe Handling Requires complete prescriber order Height, weigh, BSA or AUC, & total calculated dose Two chemotherapy-competent individuals (nurse and/or pharmacist), in addition to prescriber, independently double-check dosage calculations Drugs defined as hazardous if they exhibit one or more of the following characteristics: a. Carcinogenicity b. Tetratogenicity or developmental toxicity c. Reproductive toxicity d. Organ toxicity at low doses e. Genotoxicity Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pp ), ONS, Pittsburg, PA. Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (pp ), ONS, Pittsburg, PA. Principles of Safe Handling Personal protective equipment Preparation in biologic safety cabinet with vertical laminar airflow Label as hazardous drugs Safe techniques during storage, transport, administration Personal Protective Equipment Gloves: 2 pair, meet testing standards for hazardous drugs Gown: disposable, long sleeve, tight cuffs, back closure Eye & face protection: worn whenever splashing possible Respirators: NIOSH approved, worn for cleanup of HD spills

31 Central Venous Catheters For all chemotherapy administration: Verify catheter placement and function by x-ray or fluoroscopic dye study prior to initial use Check for blood return by aspiration DO NOT administer cytotoxic agents in the absence of blood return If no blood return: Attempt to flush with normal saline, and gently pull back Reposition patient Ask patient to cough, and take a deep breath Obtain order for declotting procedure, and follow institutional policy Use x-ray or dye study to conform proper placement and to rule out catheter malfunction or migration in absence of blood return Peripheral Venous Access Avoid ventral surface of wrist Use nondominant arm whenever possible Avoid areas of flexion Avoid using lower extremities Avoid using arms of patients who have had axillary lymph node dissection Avoid using an established IV site that is more than 24 hours old, whenever possible Use smallest catheter possible Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (p ), ONS, Pittsburg, PA 121 Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (p ), ONS, Pittsburg, PA 122 Vesicant Chemotherapy IV Administration Via peripheral IV site Avoid using IV pump or syringe pump to minimize pressure on the vein Remain with the patient during the entire infusion Limit administration to no longer than minutes Verify blood return: IV push: every 2-5 ml IV Minibag: every 5 10 minutes during short infusion Via central venous catheter Monitor IV site & verify blood return before, during, & after per institutional policy Exam Question Examples Which of the following chemotherapy medications is a vesicant? a. Topotecan b. Dacarbazine c. Melphalan d. Doxorubicin Polovich, M. et al (Eds) (2014). Chemotherapy & Biotherapy Guidelines & Recommendations for Practice, 4 th ed (p. 127), ONS, Pittsburg, PA

32 Exam Question Examples Exam Question Examples Prior to the fourth dose of high-dose cisplatin, a patient reports that he has trouble manipulating his silverware and toothbrush. The nurse s best initial response is to: a. Reassure the patient that these problems are temporary side effects of chemotherapy b. Document the findings and report them to the physician c. Instruct the patient to seek assistance with meals and oral hygiene d. Arrange for an occupational therapy consultation A nursing assistant obtained a height that is two inches less than the information on the physician s order form. What action does the nurse administering chemotherapy take? a. Measure and verify height b. Call the physician with the new height c. Proceed with the order as written d. Validate the order with the pharmacist Exam Question Examples Which of the following chemotherapy agents is least likely to cause constipation? a. Vinorelbine b. Vincristine c. Vinblastine d. Carmustine Biotherapy & Targeted Therapies 32

33 Definitions Biotherapy: Treatment to boost or restore the ability of the immune system to fight cancer, infections, and other diseases (NCI, 2014). Also used to lessen certain side effects that may be caused by cancer treatments Targeted Therapy: Therapies that moderate, control, and/or kill cancer cells by targeting intracellular pathways used by cancer cells to grow, divide, and spread through the body (Lapka & Franson, 2010). Biotherapy & Targeted Therapy Cytokines Monoclonal Antibodies Small Molecule Inhibitors Vaccines 130 Cytokines Class of proteins secreted by immune cells Messengers of the immune system Released by cells throughout the body Provide communication between cells of immune system Activated by a stimulus & induce responses by binding to specific receptors Cytokines in cancer treatment Colony Stimulating Factors (Growth Factors) Interferons Interleukins Colony Stimulating Factors: Hematopoietic Growth Factors Category Erythropoiesis-stimulating agents (ESA s) Granulocyte-Colony- Stimulating Factor (G-CSF) Granulocyte Macrophage- Colony-Stimulating Factor (GM-CSF) Agents Epoetin alfa (Procrit ) Darbepoetin (Aranesp ) Filgrastim (Neupogen ) Filgrastim-SNDZ (Zarxio ) Tbo-filgrastim (Granix ) Pegfilgrastim (Neulasta ) Sargramostim (Leukine ) 33

34 Erythropoietic-Stimulating Agents (ESA s) Mechanism of action: Stimulates erythropoiesis via same mechanism as endogenous erythropoietin (EPO) Indications: Chemotherapy-induced anemia Anemia due to chronic kidney disease in patients on dialysis and not on dialysis Agents Epoetin alfa (Procrit ) Darbepoetin (Aranesp ) Erythropoietic-Stimulating Agents (ESA s) Route of administration: Subcutaneous & IV Side effects: Risk of tumor progression or shortened overall survival Hypertension Risk of death, stroke, thrombosis, and serious cardiovascular events is increased if hemoglobin >11g/dl when administered Erythropoietic-Stimulating Agents: Nursing Implications Not indicated when cure is anticipated outcome of treatment Ensure adequate iron stores in patients prior to and during use Do not shake vials or syringes containing drug Granulocyte-Colony-Stimulating Factors (G-CSF) Mechanisms of action: Regulates production of neutrophils in bone marrow Side effects of drug class: Most common: Bone pain Allergic reactions, splenic rupture, ARDS, may induce sickle-cell crisis in patients with sickle-cell disease Nursing considerations for drug class: Store in refrigerator, do not freeze Do not shake vials or syringes containing drug Bone pain may require analgesics such as acetaminophen or NSAIDS 34

35 Granulocyte-Colony-Stimulating Factors (G-CSF) Filgrastim (Neupogen ) Tbo-filgrastim (Granix ) Filgrastim-SNDZ (Zarxio ) Pegfilgrastim (Neulasta ) Interferons Actions: Antiviral (inhibit viral replication) Antiproliferative (prevent proliferation of tumor cells) Immunomodulatory (modulate immune response of host) Examples: Interferon alfa-2a Interferon alfa-2b Side Effects: Fever, chills, headache, N/V, diarrhea, fatigue, depression, anorexia, confusion, myelosuppression, injection site erythema Interleukins Stimulate activation of immune cells (T and B cells, NK cells, LAK cells, tumor-infiltrating lymphocytes). Examples: Aldesleukin (IL-2, Proleukin ) Oprelvekin (IL-11, Neumega ) Side Effects: Fever, chills, headache, N/V, diarrhea, myelosuppression, cardiac changes, capillary leak syndrome Targeted Therapies Therapies that moderate, control, and/or kill cancer cells by targeting intracellular pathways used by cancer cells to grow, divide, and spread through the body. Two types Monoclonal antibodies Small molecular inhibitors Novel new agents Oral therapies 35

36 Two Main Types of Targeted Therapies Monoclonal Antibodies Prevents signal transduction by binding outside cell (extracellular). Small Molecule Inhibitors Crosses cell membrane, prevents signal transduction by blocking intracellular portion of the receptor. Types of Monoclonal Antibodies Types Murine Chimeric Humanized Human Suffix -momab -ximab -zumab -umab Agents Ibritumomab Cetuximab Rituximab Bevacizumab Pertuzumab Trastuzumab Ipilimumab National Cancer Institute, Adapted from Brekke & Sandlie, Monoclonal Antibodies Mechanism of action: Bind to specific molecular targets, most commonly membrane-bound receptors This inhibits binding of growth factors to their cell surface receptors Shuts off downstream signaling that stimulates tumor growth May also stimulates immune system to kill targeted cell Administration & handling: Because they are large protein molecules, they need to be administered parenterally Store in refrigerator, do not shake or freeze Monoclonal Antibodies Naked Monoclonal Antibody Antitumor activity solely from antibody binding to target receptor on cell Conjugated Monoclonal Antibody Antibodies physically attached to antitumor agents Antitumor agents may be chemotherapy, radioactive isotope, toxins, or other biologic agents

37 Monoclonal Antibodies Side effects Can cause cytokine release storm Related to release of cytokines such as Interleukin-2 (IL-2), Interferon (IFN) & Tumor Necrosis Factor (TNF) from the targeted cells and other recruited immune cells, such as lymphocytes Nursing Considerations Symptoms usually appear within a few minutes to minutes Clinical management: Stop infusion, and observe the patient until symptoms resolve (usually 30 minutes) After symptoms resolve, resume infusion at slower rate (50%) and titrate rate slowly Monitor vital signs closely (e.g. Q 15 minutes for 1 hour or as condition indicates) Wilkes, 2011; Polovich, M., Olsen, M. & LeFebvre, K., Examples of Monoclonal Antibodies MAB Type Target Disease Indications Rituximab (Rituxan ) Trastuzumab (Herceptin ) Cetuximab (Erbitux ) Ipilimumab (Yervoy ) Chimeric CD20 Non-Hodgkin s Lymphoma (NHL) Chronic Lymphocytic Leukemia (CLL) Rheumatoid Arthritis (RA) Wegener granulomatosis or microscopic polyangitis Humanized HER 2 HER2 + Breast Cancer Chimeric Fully Human EGFR (HER 1) CTLA-4 Metastatic colorectal cancer Squamous cell carcinoma of head and neck Unresectable or metastatic melanoma Examples of Monoclonal Antibodies MAB Type Target Disease Indications Pertuzumab (Perjeta ) Adotrastuzumab emtansine (Kadcyla ) Ibritumomab tiuxetan (Zevalin ) Humanized HER2 HER2 + Metastatic Breast Cancer Humanized HER2 HER2+ metastatic breast cancer Mouse (Murine) CD20 B-cell non-hodgkin s lymphoma Small Molecule Inhibitors Small enough to cross the cell membrane Bind inside the cell preventing cellular instructions to specific pathways May be administered orally National Cancer Institute,

38 Method of Action: Monoclonal Antibodies vs Small Molecule Inhibitors Examples of Small Molecule Inhibitors Agent Target Indication Erlotinib (Tarceva ) EGFR inhibitor Non-Small Cell Lung Cancer (NSCLC) Pancreatic cancer Imatinib mesylate (Gleevec ) BCR-ABL tyrosine kinase Dasatinib (Sprycel ) Multikinase inhibitor Ph+ CML Ph+ ALL Lapatinib(Tykerb ) Tyrosine kinase inhibitor of EGFR and HER2 Ph+ CML Ph+ ALL GIST MDS/MPD ASM, HES, CEL, DFSP Breast cancer Examples of Small Molecule Inhibitors Angiogenesis Agent Target Indication Sorafenib (Nexavar ) Multikinase inhibitor Hepatocellular carcinoma (HCC) Advanced renal cell carcinoma (RCC) Thyroid carcinoma Sunitinib (Sutent ) Multikinase inhibitor Gastrointestinal stromal tumor (GIST) Advanced renal cell carcinoma (RCC) Pancreatic neuroendocrine tumors (pnet) Vandetanib (Caprelsa ) Multikinase inhibitor Medullary thyroid cancer 38

39 Antiangiogenesis Agents Action: Target the neovasculature of tumors to halt their growth, prevent tumor invasion, and preclude metastatic spread. Examples: Bevacizumab (Avastin ) Thalidomide (Thalomid ) Lenalidomide (Revlimid ) Exam Question Examples A patient with terminal cancer is treated for persistent anemia using darbepoetin alfa. The patient understands the risks associated with the treatment by stating, I understand : a. While taking, my anemia may improve and my disease may progress b. The risks are limited to those with a large tumor burden c. Once the anemia has improved the risks will lessen d. The risk for infection and bleeding double with each injection Exam Question Examples Surgery in Cancer Therapy Which of the following therapies is targeted toward the epidermal growth factor receptor? A. Bortezomib B. Bevacizumab C. Cetuximab D. Gemtuzumab 39