Minimizing the Side Effects

Of Chemotherapy

Atif Hussein, MD, MMM, FACP

Memorial Cancer Institute

Hollywood, FL

The Cell Cycle

The Cell Cycle

Cancer Cell Characteristics

• Unchecked & Uncontrolled Growth

• Loss of contact inhibition

• Loss of capacity to differentiate

• Increased growth fraction

• Chromosomal Instability

• Capacity to metastasise

• Altered biochemical properties

Chemotherapy Side Effects

• Chemotherapy targets cells which are

dividing rapidly.

• Chemotherapy cannot distinguish

between normal cells and cancer cells

• Healthy Cells which have a high rate of

growth and multiplication include cells of

the bone marrow, hair, GI mucosa and

skin.

Chemotherapy Side effects

• Side effects may be drug specific e.g. anthracyclines and cardiotoxicity, vinca alkaloids and neuropathy/constipation, bleomycin and pulmonary fibrosis

• Severity of side effects varies between drugs.

• Side effects often occur 7-14 days post treatment.

COMMON CONCERNS WITH

CHEMOTHERAPY

• Nausea and Vomiting

• Infection

• Bleeding

• Peripheral neuropathy

• Diarrhea

• Constipation

• Mucositis

• Fatigue

• Fluids

• Nutrition

• Skin care

• Hand-Foot syndrome

• Emotional needs

• Stress

• When to call the

nurse

Side Effects: Gastro-Intestinal

• Nausea & Vomiting

• Diarrhea & constipation

• Loss of appetite

• Taste Changes

• Mucositis

Everyone Worries About Nausea

and Vomiting

• Not everyone experiences nausea.

• Nausea and vomiting can occur before, during

or for several days after receiving treatment.

• Take anti-nausea medication as prescribed.

• Let your nurse or doctor know if you’re unable

to keep medications down, drink fluids, or your

anti-nausea medication doesn’t work.

Nausea and Vomiting:

Patient-specific risk factors

• Higher-risk groups:

– Young

– Female

– High pretreatment expectation of nausea

• Negative risk factor: high alchohol

consumption

Nausea and Vomiting:

Stratification

• High (level 4)

– >90% risk of emesis without treatment

• Moderate (level 3)

– 31-90%

• Low (level 2)

– 10-30%

• Minimal (level 1)

– <10%

Nausea and Vomiting

• Certain classes of drugs are worse than

others

--Cis-Platinum

--Doxorubicin (Adriamycin)

• Which anti-emetic agents should be used

is determined by the emetic potential of

the drug

Nausea and Vomiting:

Serotonin Receptor Inhibitors

• Granisetron (Kytril)

• Ondansetron (Zofran)

• Palonosetron (Aloxi) : Benefit of longer duration of action

• Best used as a “cocktail” with steroid (dexamethasone) and lorazepam

Nausea and Vomiting

Serotonin Receptor Inhibitors:

Common Side Effects

• Headache

• Constipation

– Prevent with use of laxatives and stool

softeners

Nausea and Vomiting:

NK 1 Receptor Inhibitor

• Aprepitant (Emend)

–Used for acute and delayed nausea

in combination with a serotonin

receptor-blocking drug

Nausea and Vomiting:

Dopamine Antagonists

• Phenothiazines

– Prochlorperazine (Compazine)

• Metoclopramide (Reglan)

• Trimethobenzamide (Tigan)

– Limited role except for mildly

emetogenic drugs and may be helpful

in delayed nausea

Delayed Nausea

• Dexamethasone

• Lorazepam (Ativan)

• Dopamine antagonists

– Prochlorperazine (Compazine)

– Trimethobenzamide (Tigan)

Mucositis (Mouth Sores)

• More common with certain drugs:

– 5-fluorouracil (5-FU)

– Methotrexate

– Doxorubicin (Adriamycin)

– Cyclophosphamide (Cytoxan)

Mucositis (Mouth Sores)

• Prevention

– Icing of the mouth during treatment

• Treatment Options

–Gel Clear

–Magic Mouthwash

–Viscous lidocaine

• Example of Grade 4 Mucositis

• Brush your teeth with a soft toothbrush.

• Use mild toothpaste and alcohol-free

mouthwash

• If you have not had regular dental care, see a

dentist before beginning chemotherapy.

• If your mouth feels sore, rinse three or four

times daily with warm salt water solution (one

teaspoon salt in eight ounces water), swish

vigorously, and spit.

Oral Care

Diarrhea

• Diarrhea is having multiple liquid bowel movements in a

24-hour period.

• Your health care provider can suggest a diet

plan to help ease this problem.

• Take an anti-diarrhea medication as

directed.

• Drink fluids.

• Call your provider if your diarrhea is bloody,

lasts more than 24 hours, or you have

symptoms of dehydration, abdominal pain

or fever.

Diarrhea

• Major toxicity of several drugs used to

treat gastrointestinal cancers, for

example, 5-FU and irinotecan

(Camptosar)

• Acute diarrheal reaction to irinotecan

– Atropine at time of treatment

Delayed Diarrhea:

Treatment

• Anti-Motility Drugs

– Loperamide (Imodium)

– Diphenoxylate (Lomotil)

• Octreotide (Sandostatin)

– Somatostatin analogue

– Works to prolong GI transit time

– Subcutaneous administration

Constipation

• Try over-the-counter laxatives, stool

softeners, or fiber.

• Drink plenty of fluids.

• Take daily walks if you can.

• Increase fiber in your diet by eating well-

washed fruits and vegetables, whole

grain breads and cereals.

SKIN TOXICITIES

Hand-Foot Syndrome

• Pain, redness, swelling, and peeling of the

skin of the palms and soles

• Associated with certain agents

– Capecitabine (Xeloda)

– Liposomal doxorubicin (Doxil)

– Infusional 5-FU

– Weekly taxane therapy

Hand-Foot Syndrome:

Treatment Options

• Dose reduction

• Avoid tight-fitting shoes; repetitive rubbing or

prolonged heat to hands and feet

• Emollients

– Eucerin

– Bag Balm

– Can be used effectively with cotton socks and/or

gloves at bedtime

• Chemo can cause skin changes such as

dryness, itching, and sun sensitivity. Nail

condition can also change.

• Keep your skin clean with a mild, moisturizing

soap and moisturize with gentle lotions.

• Protect your skin from injury.

• Avoid direct, intense sun exposure.

• Use sunscreen (minimum 30 SPF) and wear

protective clothing and a hat when outdoors.

Skin Care

Chemotherapy-Induced

Peripheral Neuropathy (CIPN):

Neuropathy

• Painful burning sensation

• Progressive numbness

• Motor weakness

Incidence of Chemotherapy-Induced

Peripheral Neuropathy (CIPN)

• Chemotherapy is prolonging life

• Cancer is becoming a chronic, manageable disease

• Many nurses will encounter those affected by this common side effect

• Estimated to occur in 20% of cancer patients undergoing chemotherapy

What is Chemotherapy-Induced

Peripheral Neuropathy (CIPN)?

• Characterized as injury, inflammation, or degeneration of peripheral nerve fibers

• Can result in loss of motor and sensory nerve function

• CIPN can result when certain chemotherapeutic agents are used to treat cancer

• These agents can be referred to as “neurotoxic”

Sensory nerves

Sensory nerves are responsible for detecting:

• Pain

• Touch

• Temperature

• Position

• Vibration

Pathophysiology (continued)

• Peripheral neuropathy results from damage to the axon, myelin sheath, or cell body

• Pathogenesis of CIPN is not completely understood

• It is known that different sensations arise depending on chemotherapeutic agent administered (Wickham, 2007)

Signs and Symptoms of CIPN

• Symptoms that patients

may experience depend on

length of infusion, dose,

co-morbidities, and the

drug being administered

• Symptoms are divided

into sensory, motor, and

autonomic symptoms,

correlating with which

peripheral nerve is

affected

Neuropathy: Prevention

• Avoidance of cold exposure for 48-72

hours after oxaliplatin therapy

• Amino acid therapy (glutamine)

• Vitamin B6 (pyridoxine)

Neuropathy:

Treatment Options

• Dose reduction

• Gabapentin (Neurontin)

• Amitriptyline (Elavil)

Pharmacologic treatment of CIPN

Glutamine:

• Amino acid, may have neuroprotecive properties

• In studies, those who take it for Taxol- preventive CIPN showed less weakness, loss of vibratory sensation, and toe numbness versus control group

Microsoft Image Clip Art, 2007

Pharmacologic treatment of CIPN

Glutathione:

• May hamper initial accumulation of platinum agents in peripheral nerve cells

• Incidence of neuropathy was greater in placebo than control group

• In some studies, incidences of no CIPN were reported with IV infusion

Opioids:

• Useful for painful CIPN

• Doses can be titrated to effective range for CIPN and pain

Nonpharmacologic Treatment of

Chemotherapy-Induced peripheral

Neuropathy (CIPN)

Acupuncture:

• Shown gait improvement

• Has shown improvement in sensation and balance

• Patients taking pain medication for CIPN ended up decreasing doses

HEMATOLOGICAL SIDE

EFFECTS

Side Effects: Bone Marrow

Neutropenia:

Increased risk of infection.

Anemia:

Tiredness, lethargy & breathlessness

Thrombocytopenia:

Increased risk of bleeding

Red blood cells

Carry nutrients

and oxygen

Neutrophils

A type of

white cell

that fights

infection

Platelets

Helps the

blood to

clot

Chemotherapy can

increase your risk for

infection because it may

lower your white blood cell

count.

Infection

Preventing Infection

• The first defense is

hand washing.

• Patient, patient’s

caregivers, family

members, and

visitors need to wash

hands frequently.

• Carry and use hand

sanitizer when you

leave the house.

• Have a thermometer at home to monitor your

temperature.

• Take your temperature if you feel sick or

unusually hot or cold, and before you call your

provider.

• If you have a fever over 100.5°F, call your health

care provider right away. Do not take Tylenol or

aspirin unless instructed to do so.

• Call for fever, chills, cough, sore throat or burning

with urination

Watching for infection

Preventing Bleeding

• A low platelet count can cause bleeding

• Some chemo drugs can lower platelets

• Use a soft toothbrush.

• Blow your nose gently.

• Avoid injuries that could cause cuts or bruises.

• If you cut yourself, apply gentle but firm pressure to stop the bleeding.

OTHER SIDE EFFECTS

• Fatigue

• Stress

• Tumor Lysis Syndrome

• Body Image

• Dehydration

• Nutrition

• Others

Fatigue: Multifactorial

• Anemia

– Erythropoietin (Procrit)/darbepoetin (Aranesp)

• Depression

– Selective serotonin reuptake inhibitor (SSRI)

• Sleep Disturbance

-- Sleep aid: zolpidem tartrate (Ambien),

eszopiclone (Lunesta)

• Psychostimulants

-- Methylphenidate (Ritalin)

•The most commonly reported side effect

•Take a daily walk or continue your usual

exercise routine, if you can.

•Eat a healthy diet.

•Plan daily activities ahead of time.

•Prioritize your activities to conserve

energy.

•Get plenty of rest.

•Let others help with chores.

Fatigue

Stress

Are you experiencing any of these

symptoms?

•difficulty concentrating

•trouble sleeping

•too much worry

•problems with coping

Supporting your emotional

needs is essential to your

cancer treatment.

Stress

Side Effects:

Body Image

• Hair Loss

• Weight Loss/ Weight Gain

• Long term central venous catheters

• Skin changes (colour, rashes, sensitivity

to sunshine/chlorine, dry)

Dehydration: Fluids

• Keeping hydrated with fluids is important

during chemotherapy treatment.

• Fluids are in water, beverages, and food.

• Keep a bottle of water or juice with you at all

times and sip on it often.

• If you have vomited, try to drink about two

quarts of fluids a day for a few days afterward.

• A good rule of thumb: take in enough fluids to

keep urine light yellow.

Nutrition

• Eat smaller portions more frequently.

• Try milkshakes, smoothies, or

supplements like Ensure for extra

calories if you are losing weight.

• Some chemo causes a metallic taste.

Try using plastic utensils to ease this

effect.

• Some people gain weight during

chemotherapy.

Side Effects:

Other

• Altered Kidney Function

• Changes in hearing (high dose Cisplatin)

• Cardiac Toxicity (Doxorubicin/ Idarubicin)

• Late Effects: Infertility, secondary malignancy, growth retardation.

When should I call the doctor?

• Fever over 100.5°F

• Redness or swelling at IV site

• Uncontrolled vomiting or diarrhea

• Blood in urine or stool or uncontrolled bleeding

• Signs of infection

• Feeling unwell

You should be able to eat, drink, have reasonable bowel and bladder function and feel good enough to get up and around-if not, call.

Key Points:

• Chemotherapy is a major treatment in curing or prolonging survival in cancer patients

• It has a wide range of side effects depending on the drugs given.

• Nurses have a key role to play in caring for a patient receiving chemotherapy

• Safety issues are paramount in administration.

Summary

The potential benefit to the patient of treatment as an

option must always outweigh the toxic effects.

THANK YOU VERY MUCH!!!