Chemotherapy and its side effects.

Transcription

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 hjg5m

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

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

12 Alkylating agents Anti-metabolites Antibiotics Mitotic inhibitors Carmustine Cytarabine Bleomycin Etoposide Cyclophosphamid e Methotrexate Daunorubicin Vinblastine Cisplatin Fluorouracil Doxorubicin Vincristine

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. ts/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 (Soady 2000). 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 Oral hygiene routine Cold sore antiviral Thrush antifungal Ice chips Treat infections Neutropenia GCSF IV fluids if not drinking Alternative feeding Brushing teeth Mouthwashes Paracetamol Difflam Gelclair Lidocaine Opioids

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

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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

45 Antibody Brand Name Date approved Target Indication Alemtuzumab Campath 2001 Cd52 CLL Brentuximab Adcetris 2011 Cd30 Anaplastic large cell lymphoma, HL Gemtuzumab Mylotarg 2000 Cd33 AML Ofatumumab Arzerra 2009 Cd 20 CLL, NHL Rituximab Mabthera 1997 Cd20 NHL

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.

51 Wish list for a Drug! What do we WANT in a drug? High Efficacy Low Toxicity Good Biological Availability Reasonable Half-Life Facile Route of Administration REASONABLE PRICE!!!!!!

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