Chemotherapy Biotherapy Certification Resources - ✔nccn.org cancer.org LESSON 1: Cell cycle - ✔g1- increase in size s- dna replicated g2- cell enlarge and ready to divide m phase- 2 hours mitosis - ✔4 stages, prophase, metaphase, anaphase, telophase -chemo targets certain points in the process apoptosis - ✔programmed cell death hematopoiesis - ✔formation of blood cells & how cells differentiate -myeloid: pre cells mature into RBCs, platelets and WBCs -lymphoid: pre cells- mature into WBCS Principles of Biotherapy: p51-95 immunology - ✔-defense against foreign organisms, homeostasis (destroy aged cells), surveillance immune responses - ✔innate: primary line of defense, non specific, no memory adaptive: secondary line of defence with specific memry cytokines - ✔-effect growth and differentiation of WBC -interferons, tumor necrosis factors, growth factos and interleukins -small protein molecules released by cells throughout body providing comunication between cells of the immune system -regular antiboddy production and function of b cells vaccines for cancer prevention - ✔-hep B prevents hepatitis and hepatocellular carcinoma -hpv vaccine filgrastim aka neupogen - ✔SC or IV to derease infection in patients with neutropenic fever associated with myelosuppressive anticancer treatments for nonmyeloid malignancies tbo-filgramstim/ pegfilgrastim - ✔reduce duration of neutroenia in patients with non myeloid malignancies
palifermin - ✔IV to dec incidence of oral mucositis in patients with hem malignanies before BMT sargramostim - ✔aka leukine - patients with AML following chemo to shorten neutrophil recovery and reduce incidence of infection IFN gamma - ✔reduce frequency and severity o infections related to granulomatous disease aldeleukin - ✔treat renal cell carcinoma and metastatic melanoma oprevelkin - ✔prevent severe thrombocytopenia and refuce need for platelet transfusions in patients with nonmyeloid malig plerixafor - ✔with filgrastim to mobilize hematopoeitc stem cells for collection from peripheral blood of patients sipuleucel - ✔castrate resistant prostate cancer rituximab - ✔rituxan- treatment of relapsed or refractory low grade follicular b cell NHL_ first line traetment in combo with chemo in patients with response -can treat severe rheumatoid arthritis -can have severe reactions (hypotension, urticaria, angiodema, hypoxia, rigors, dyspnea, chills, fever, nausea, rash, renal tox) -premed with tylenol and benadryl -slow infusion to resolve some side effects, side effects reduce with each infusion immune system - ✔1st line: skin , ucous membrane, gut flora second line: phagocytes: 3rd line antibodies, t and b cells malignant tumor (cancer) - ✔cell strcuture different from parent tissue, cell division uncontrolled, loosely adherent, invade neighboring tissue, establish blood vessels Approaches to treatment - ✔cure: prolonged absence of disease control: no further growth and palliation : comfort neoadjuvant - ✔therapy in the first step to shrink a tumor before the main treatment) surgery is given -chemo, radiation, hormone therapy adjuvant - ✔therapy given afer primary treatment to lower risk of cancer coming back -chemo, radiation, hormone, targeted and biologic therapy
myeloblation - ✔obliteration of bone marrow with chemo in prep for blood stem cell or bone marrow trasnplant to destroy blood forming cells in the marrow and reduce tumor burden - destroy immune system so it cannot attack donated cells after transplant nonmyeloblative - ✔not as intense, chemo doses are not as intense LESSON 2: Alkylating Agents - ✔-cytoxan -ifosframide -bendamustine platinum based chemo - ✔consideration on age, kidney function, and concurrent use of radiation. both can cause nausea, vomiting, hearting loss, kidney function damage, electrlyte disturb. CBC chem panel and mag checked -cisplatin: admin over longer period of time. nausea can last over a week -carboplatin- risk with age >65, harder on kidney function. over shorter period of time, nausea within first 24 hours. neuro tox cyclophasmide - ✔hair loss 10-14 days post treatment -can be given peripherally -hemmorhagic cystitis - hydration is key, high dose may need bladder protection -easier to give than iphosphamide iphosphamide - ✔neuro changes can occur- personality changes can occur, neuro checks before central line only -need a bladder protective agent 100% of the time nitrosureas - ✔cross blood brain barrier - can treat brain tumors. alkylating agents -pulmonary monitoring Lesson 3: Antimetabolites - ✔-azacitidine -capacitabine -fluorouracil -cytarabine -decitabine -methotrexate inhibit DNA and RNA synthesis - can cause myelosuppression, GI toxicities, phospotsensitiivty, hand foot syndrome, vigorous I V hydration to prevent tumor lysis 5 fluorouracil (5 FU) - ✔-IV oral topic and opthalmic formalation -can cause hyperpigmentation, increased mucositis, photosensitivity, diarrhea -capcytobine is the oral form - needs to be taken 2x day, hand foot syndrome can occur
-INR monitoring methotrexate - ✔antimetabolite, cell cycle specific to S phase -cleared in kidneys - effects: hepatotox, renal tox, mucositis, nausea, myelosuppression, pneumonitis, photosensitivity, neurotoxicity, infertility -yellow in color. renal function, hydrate 2-3L/ day, no alcohol use, sun exposrue, folic acid, avoid effusions azacitidine - ✔for treatment of myelodysplastic syndrome: group of cancers in which immature blood cells do not mature (SOB and fatigue are markers) Lesson 4 A cautionary tale about routes - ✔intrathecal chemo- injects chemo directly into the subarachnoid space so it reaches the CNA -leukemia and lymphoma spreading to CNS since most chemo does not cross blood brain barrier intrathecal chemo - ✔ONLY methotrexate and cytarabine can be given IT -IT hydrocorisone given at same time to reduce inflammation vincristine - ✔dilute in 20mL minibag and infuse over short time- IVP not reommended vinblastine -dilute in 25-50 ns Lesson 5 Antitumor Antibiotics - ✔-anthracyclines: interfere with enzymes for DNA to replicate, work phases of the cell cycle lifetime dose limites because they are cardiotoxic -daunorubicin, doxorubicin, epirubicin, idarubicin nonanthracycline: actinomycin, mitomycin, bleomycin doxorubicin - ✔vesicant extravasation possible- must eval cardiac funciton, ongoing cardiac monitoring, hypersensitivity risk -nausea/ vomiting, mucositis, diarrhea, myelosupression, hepatic impairment, secondary cancer -cardiac: SOB< skipped beats, weight gain -myelosuppress: oral temp daily, report >100.5 GI: nausea vomiting diarrhea, inspect mucosa neuro: numbness/ tingling, burning GU: change in color of urine dexrazoxane - ✔cardiac protectant given before bleomycin - ✔antitumor antibiotic - lifetime dose warning
-can cause hypersensitivity, skin reaction -report SOB< skin issues, protect from sun Lesson 6 symptoms that can be dose limiting - ✔chemo induced nausea and vomiting -lead to dehydration, dec functional status, increased costs and withdrawal from treatment -70% patient will experience. RISK Factors: younger, history of low alcohol consumption, female, morning/ motion sickness HEC: highly emetogenic - carmustine, cisplatin, cyclophosphamide, daarbazine, mechlorethamine, streptozocin CINV - ✔chemo infuced nausea vomiting- vomiting center is central area responsible for CINV -patient are at risk for 2-3 days after last dose of cheom Antiemetics - ✔serotonin antagonists -dolasetron, granisetron, ondansetron, palonosetron neurokinin antagonists- aprepitant, fosaprepitant steroids: dexamethasone Cutaneous Side effects of chemo - ✔5FU and capecitabine has been noted to cause the worst skin resactions -hand foot syndrome -palmar plantar erythrodysesthesia - painful- flaking swelling blisters and sores avoid hot water, impacton feet and rubbing myelosuppression - ✔suppression of bone marroe, red blood and platelets NADIR: point at which blood cell counts are at the lowest after treatemtn. usually 7-1 days after cyce neutrophils heavily affected platelets follow erythrocyte loss appears later NEUTROPENIA: risk of infection. fever >100.2 sign of infect ANC reliable method to dtermine risk - 4,500-10,000 is normal WBC. ANC <1000 risk of infeciton THROMBOCYTOPENIA: injury or loss of stem cell - suppression of platelets. petechiae, bruise, headache, hypotension, prolonged bleeding ANEMIA: presents later dyspnea, fatigue, dizziness, headache -treatment: iron supp, bleed correction, transfusion, oxygen
Neutropenia - ✔know when to expect the nadir 7-10 days after treatment. up to 6 weeks with some treatment -ANC: reliable method to determine infcetion risk polys + bands x WBC /100 fever >100.4 sign of infection GI Toxicities - ✔diarrhea, constipation induced by chemo is common - can cause fecal impaction mucositis- can occur from the mouth to the anus stomatitis- inflam of mouth xerostomia- dryness of the mouth Acute Infusion Reactions - ✔hypersensitivity- uniphasic- immediate biphasic- 1-72 hours later anapylaxis- acute, severe inflammatory response that is sudden and systemic dyspnea, hypotension and loss of conscious GIVE benadryl or hydrocortisone, close vitals, STOP, maintain airway, resuscitation meds Type 1 reactions - ✔pruritus, restless, agitation, impending doom, fever, flushing, chills, urticaria, edema, rash, nausea, dyspnea, wheeze, hypotension, beonchospasm Type IV reaction - ✔cell mediated, delated. pneumonitis, mucositis, granuloma, GVH Lesson 7 safety issues: cumulative dose - ✔cumulative dosing can result in neurotox and nephrotox, alkylating, myelotox, hepatotox, cardio tox, pulmonary and GI tox Lesson 8: safety issues: extravasation and vesicant admin - ✔leak of antineoplastic meds from the vessel in which it is being administered into the surrounding tissue - non DNA binding remain in local area, DNA binding lead to tissue destruction -cytotoxic drugs are classified as irritants and vesicant - irritants cause inflammation, burning or pain . vesicants can cause local blisters and xtensive damage to the tissues NO PIVs in hand, wrist or AC - dont place below a recent venipuncture site CHECK for blood return: 3ML of blood in 3 seconds. larger syringe diameter exerts less pressure on walls of catheter NO BLOOD RETURN NO USE
IV access selection - ✔determine dration of treatment- for peripheral access, small gauge plastic cannula is more suitable. alternative IV site from one arm to the other to preserve the veins -CVADs - cool compress for 24-48 hours then warm compress, hydrocorisone cream, elevate, pat dont rub, pain meds. check area for skin color canges, pain PORT: should get a blood return venous irritation - ✔low pH, blood return may be present lesson 9: plant alkaloids - ✔-etoposide, docetaxel, paclitaxel, vinblastine, vinorelbine vinca alkaloids given IV and should never be given intrathecal Paclitaxel: shoud be stored in glass - through in line filter Cabazitaxel: use in line filter Nap paclitaxel: premeds not required extravasation of plant alkaloids - ✔topotecan and etoposside- irritants -vinorelbine and irinotecan: irritants with vesicant properites: discoloration of sin, rash, phlebitis, urticaria, blistering, skin sloughing lesson 10: biotherapy - ✔treatment that uses substances made from living organisms to treat disease - stim or suppress the immune system to help fight cancer, infection and diseases. some attack specific cancer cells which keep them from growing targeted therapy: uses drugs or other substances to identify and attack cancer cells GOALS: disease cure, improve response or increase disease survival, control or stabilize disease, mtainain or enhance live CATEGORIES: cytokines, monoclonal antibodies (conjugated and unconjugated), small molecule inhibitors, antibody durg conjugates, vaccines Biotherapy terms - ✔receptor: molecule in surgace that binds to a specific substance causing effect in that ell -monomer- molecule that can join with others to form a larger structure called a polymer -ligand: forms a complex with another to exert a biological effect -ligand binding: attaches to receptor site and activates that receptor -dimerization: signals -kinase: adds chemicals to other molecules, causing other molecules to becomes active or inactive -phosphorylation: activation of a chemical process to initiate signaling
-signaling pathways: group of molecules that work together to control a cell function Targeted Therapies - ✔extracellular: target receptors on the outside of the cell -intracellular: target and interfere with processes inside the cell attack many different targets - block angiogensis, block signals in or outside of the body, deliver toxic substances to the cell, stimulate the body's immune system Include: hormone therapies, signal transduction inhibitors, apoptosis inducers, angiogenesis inhibitors, immunotherapies HORMONE THERAPY: adds, blocks, or removes hormones from the body to help slow the growth of cancer cellls SIGNAL TRANSDUCTION INHIBITOR: block signal transduction MONOCLONAL ANTIDOES: end in mab- rituximab, panitumab SMALL MOLECULES - ✔located in the cell because these agents enter more easily -get into the cell, interfere with the internal components and disrupt the function, causing cell death tyroisine kinase inhibitors: end in tinib: oral agents. be aware of adherence and interactions -erlotinib, sunitinib, ponatinib, imatinib, dasatinib, ibrutinib kinase inhibitors: oral agents hedgehog pathway inhibitors: controls cell division of adult stem cells and cell differentiation. oral agents. be aware of adherence and interactions IMMUNOTHERAPIES - ✔trigger immune system to destroy cancer cells- make cell visible for immune system to destroy -others help boost the immune systems ability to fight cancer. include: monoclonal, immune checkpoint inhibitors, cancer vaccines, non specific immunotherapies, adoptive cell therapy, oncolytic virus therapy monoclonal antibodies - ✔man made versions of immune system proteins, used to treat cancer because they are designed to attack a part of a cancer cell nonspecific immunotherapies - ✔use proteins taht normally help regulare immune system to enhance the bodies immune response -cytokines: interleukins -interferons
adoptive cell therapy - ✔help immune system fight diseases such as cancer and infections lesson 11: safety issues, safe handling is about YOU too - ✔carcinogens- a lot of cancer treatment drugs risks of occupational exposure - ✔routes of absorption- dermal, mucous membranes, inadvertent ingestions, inhalation, injection -air samples, floors, drug vials, prep areas, skin under gloves hierarchy of controls - ✔anticipating, recognizing, evaluating and controlling workplace conditions that may cause injury or illness -industrial hygiene uses the principle of hierarchy of controls when determining how to control a workplace hazard drug administration - ✔always remove first set of gloves before touching pump -connect secondary tubing to allow for flushing of tubing -place pad under work area, gauze around syringe connections for IVP, pad nder work area when attaching needles for SQ oral: gloves, directly into a med cup double ID name, DOB, date of admin, name, route, total dose and total volume, date and time prepared/ expired apply gloves, gown, and then re glove over cuffs postadministration precautions - ✔-excreted in urine, breast milk, stool vomit, sweat, semen and vaginal secretions, saliva, other bodily fluids for 48 hrs (some drugs up to 5 days) HANDLING body fluids of patients who have recieved chemo: gown and double glove, face shield if splash at home: wear gown with back closure, double glove, double wash apart from laundry, detergent management of spills - ✔chemo spill kit- sign warning others, use PPE, chemo gown, respirator/ goggles, double glove- use absorbant pads and out in spill bag, use neutralizing solution and wipe, then wipe with water, remove PPE -place bag in chemo waste contrainer lesson 12: changing gears, administration of chemo and biotherapy - ✔nurses responsibility: is vascular access device intended for appropriate use? will they adhere?
is the plan appropriate? additional referrals? is drug vesicant? is tracking in place for lifetime dose limit? assess patients readiess to learn, health literacy, preferred method of learning, barriers to learning is this the right treatment plan? goal of treatment? venous access? side effects to addres before? Administration considerations - ✔routes: oral- convenient, decreased time in hospital, expensive, and difficulty with adherence, inconsistent adborption- food drug interactions nursing: verify dose, PPE, no crushing (pharmacist must do so if NG) SQ: ease, well tolerated, inconsistent absorption, increased fat could increase risk of misplacement. pain/ bleed/ bruising IM: rapid absorption, can cause nerve damage, tissue necrosis, PPE, insert at 90 deg angle, avoid massage intraperitoneal: catheter or IP port. directly into peritoneal cav, infection risk, abdominal pressure, bleeding, diarrhea, per, infection, anaphylaxis intrathecal: CNS malignancies,methotrexate and cytarabine - surgical procedure, lumbar puncture is invasive intrapleural intravesicular: bladder cancer intra aterial IV - continuous or push (through fre flowing IV, attach at injection port, aspirate for blood, slowly admin at a rate of 1-2ml/min -vesicant chemo admin: remain with patient through entire infusion if giving through PIV, limit to IV push or short infusion less than 30-60, no PIV for continuous. verify blood return every 2-5 mL for IVP, 5-10 min during short infusion central venous catheters - blood return before during and after symptoms of extravasation - ✔swelling, loss of blood return, report of pain or burning. discontinue at first sign Pretreatment care - ✔patient education - explain diagnosis and treatment, empower participation, identify sympt to report, promote coping skills
VERIFICATION: checking that prescribed doses are WNL, appropriate time intervals between treatments, route, volume and rate are clearly stated, review labs, ensure questions addressed *verbal and phone chemo not allowed -printed drug reference, current evidence based guideleine, step by step checklist for HIGH DOSE: risk of cardiac toxicit, neuro checks with high dose cytarabine (risk of cerebellar toxicity) high methotrexate given with leucovorin, myeloblation Pre Administration - ✔- online national comprehensive cancer network guidelines is most accurate source of info for evidence based practice guidelines -need 2 nurses to verify dose calc -ONS chemo safety standards requries reference to method of dose calc Recommendations to Prevent Errors - ✔-lack of method followed consistently, lab values, wrong prep methods, wrong sequence/ dose or route, schedule or timing, omissions, wrong rate or IV pump misprogram, wrong patient Vascular access devices - ✔PIV, midline, PICC, nontunneled central catheter, tunneled central catheter, implanted port, temp apheresis or hemodialysis, tunneled apheresis IV considerations - ✔no IV pump with PIV< stay with patient, less than 30-60 min infusions, blood return every 205 mL for IVP, 5-10 for short infusions dosing- metric system: mg, mg/kg, AUC and mg/m2 weight based: based on body weight - weight on day of delivery is crucial BSA dosing: m2 AUC: area under the curbe- carboplatin, drug concentration in the blood over a period of time, renal function part of calc special considerations: older adults and young kids, poor nutrition, obese, prior radiation or chemo, comorbid conditions, myelosuppression lesson 13: introducting bisimilars - ✔Biosimilars: group of medicine products developed to mimic other drugs used for different indications -biological product: vaccines, monoclonal antibodies, gene therapies, cellular therapies, blood and blood product -they have no meaningful difference that alter efficacy or safety from reference prod biologic product is biosimilar to reference prod and can be expected to produce the same clinical results
benefit: cost- far less expensive to produce than trade drug and reduce cancer care cost most expensive antineoplastics: bevacizumab, rituxin, trastuzumab neupogen first biosimilar nursing indication for biosimilar - ✔know if it is being used - confer with pharmacist to determine if available -build safety profile -know interchangeable policy side effects not always the same lesson 14: legal and ethical issues related to cancer - ✔nurse is the last safeguard between appropriate accurate and safe dosing. legal issues: med erros, unintended cytotoxic drug exposure, poor handling, spill, inadvertent exposure to the patient document: calls to different agencies to find assistance for home therapy, meeting with home health nurse for prep, call to patient to notify that WBC low, location of PIV< conco with onc about DNR status, discussion with wife about birthday party pretreatment assessment - ✔patient history, diagnosis, MH/PSH, allergies, med review, symptoms, distress (need for social workers, counselors, religion), pain, fatigue -height, weight, labs, diagnostic test (cardiac EF, etc), cancer during pregnancy, practices that promote safety, treatment plan, confirm order: 2 patient ID< date of admin, diagnosis, regimen, duration of treatmnet, cycle, criteria, allergies, dose calc, drug dose, route/ rate, length of infusion, supportive care Patient PREP: inform, verbally review plan, provide a detailed explanation to the patient, family and caregiver, confirm name and ID< baseline vitals PREP: PPE, infusion pump, ensure product match full name, ID, date of admin, generic name, route of admin, total dose,volume, date and time CHEMO ADMIN: confirm plan with patient - ✔PPE double check 2 patient IDs, drug name, dose, volume, rate, route, cycle, two signatures, rate setting, consent -proper route, monitor patient immediate comp, document drug, patient ed and follow up ETHICS - ✔end of life, right to refuse or refuse consent, whether its truly infromed, conflicts, treatment of plan, patient advocacy challenge, confidentiality, scientific integrity, standards of practice, boundaries, issues related to investigational research lesson 15: putting it all together - ✔-patient education and care coordination -treatment planning -preparation and administration
Patient Education and care coordination - ✔-enables active participation, provides explanation of disease and treatment, enables verbalization of understanding of treatment goals, improves quality of life, decrease costs, increase satisfaction -education: name, rationale, side effects, meds to treat side effects, how to contact physician, testing - DOCUMENT RCHOP (rituxin, cyclophsos, doxorubicin, vincristine, prednisone ) -cause neutropeniadec in WBC that help fight infection. hand hygeine and stay away fro sick Rituxin - ✔can cause serious reaction usually in first dose- monitor closely for issues: report SOB, feeling of throat closing, chest pain, itching, watching heart, blood pressure, confusion/ agitation cyclophosphamide - ✔can cause hemmorhagic cystitis- irritation and inflammation of bladder that can lead to bleeding. watching for blood in urine, drink extra fluids, pee a lot and pee before bed Doxorubicin - ✔chemo that can damage the heart with a lot of it- monitor cumulative dose- in a lifetime. limit to this amount. MUGA scan to eval heart. before recieving drug. vesicant- irritating and damage skin and tissues id leaks, watch IV and skin close vincristine - ✔cause constipation and neuropathy- notify. prednisone - ✔steroid to reduce inflammation and lower immune response. used as part of many different chemo regimens. side effects that can cause high blood sugar, increased agitation or irritability, insomnia Common questions - ✔multiple drugs because cancer cells grow by going through cell cycle and dividing into more cells- different drugs work in different stages - this helps decrease possibility of drug resistance when cancer becomes smart and is less effected by meds mononucal antibodies: agents that come from humans or mouse or both- they search out proteins on the cels surface. NK cells destroy the tumor like mABS- mABS ma cause harm to cells that are marked whereas chemo attacks all cells -this is why chemo has effects on normal cells like hair follicles, oral,GI mucosa, blood cells etc -adjuvant therapy: given following treatment to target minimal residual disease use barrier methods following 48 hours of cehmo NADIR: time when neutrophil count is the lowerst- varies by drug but is usually 7-10 days folowing treatment
Treatment planning - ✔-social history could be barrier - risk of distress if no support , cats in home risk with handling is neutropenic -history of asthma could be concerning -use NCCN guidelines, research studies, protocols and chemoregimen to evaluate drug, dose and schedule