Common Chemotherapeutic agents &
Management of side effects
Glory Joseph, RN, ARNP, AOCNP
Oncology Nurse Practitioner
VA M...
Objectives
• Discuss common chemotherapeutic agents for the
treatment of lung, colon and head and neck cancer
• Discuss co...
2009 Estimated US Cancer Cases*
Men
766,130
Women
713,220
• Prostate 25%
• Lung & bronchus 15%
• Colon & rectum 10%
• Urin...
Overview
• Incidence: 2009 estimates
- Male: prostate, lung, colon
- Female: breast, lung, colon
• Mortality: 2009 estimat...
Case study
• Mr. Smith is a 53 year old white male who presented to the
NP clinic with increased cough, wheezing and SOB.
...
Diagnostic tests
• Chest x-ray revealed a 2.1cm nodule RUL
• CT of chest: pulmonary nodule 17 x 14mm in the RUL
• CT guide...
Lung cancer: Epidemiology
• Most common cause of cancer related death
• Accounts for 30% and 26% of all cancer deaths in m...
Risk Factors
• Smoking
• Radiation therapy
• Environmental toxins
• Pulmonary fibrosis
• Genetic factor
• Dietary factors
Case study cont’d……
• Mr. Smith underwent RUL resection. It was recommended
that he receive 6 weeks of post-operative conc...
Classification of chemotherapeutic
agents
• Alkylating agents: cyclophosphamide, ifosfamide,
chlorambucil, cisplatin,carbo...
Conventional chemotherapy
• Combination regimens:
-carboplatin/paclitaxel
-cisplatin/docetaxel
-carboplatin/docetaxel
-cis...
Carboplatin
• Side effects:
-thrombocytopenia, neutropenia, nausea, vomiting
-It exhibits much less renal toxicity than do...
Cisplatin
• Side effects:
-severe nephrotoxicity, severe acute and delayed nausea,
vomiting, myelosuppression, ototoxicity...
Paclitaxel (taxol)
• Side effects:
-myelosuppression, alopecia,
peripheral neurotoxicity, myalgia, fatigue, mucositis,
dia...
Case study contd….
• Mr. Smith’s CT scans were repeated 6 weeks after completion of
treatment. CT of chest was negative. H...
Colon cancer:Epidemiology
• Incidence: 2009 estimates
- 106,100 cases of colon
- 40,870 cases of rectal
- 3rd
most common ...
Risk Factors
• Aging
• Medical conditions
-Hx of polyps,
inflammatory
bowel disease
• Life style
-high fat/low fiber, obes...
Case study cont’d……
• Mr. Smith was recommended 6 months of adjuvant
chemotherapy
• Chemotherapy orders included:
• 5FU/ o...
Classification of
chemotherapeutic agents
• Alkylating agents: cyclophosphamide, ifosfamide,
chlorambucil, cisplatin,carbo...
Classification of
chemotherapeutic agents
• Antimetabolites: 5-Fluorouracil (5 FU), gemcitabine,
methotrexate, hydroxyurea...
Fluorouracil (5FU) IV/
capecitabine po
• Side effects:
-myelosuppression, nausea, anorexia, vomiting, diarrhea
-Mucositis,...
Oxaliplatin
• Side effects:
- Neurotoxicity, fatigue, fever, pain, headache, insomnia,
peripheral neuropathy, n/v/d, myelo...
Irinotecan
• Side effects:
- diarrhea, myelosuppression, alopecia
- can cause early (can occur within 24 hours of
administ...
Neurotoxicity
• Neurotoxicity Assessment Tool
• INSTRUCTIONS FOR PATIENTS
• Circling one number per line, please indicate ...
Case study contd…..
• Mr. Smith successfully completed 6 months of adjuvant
chemotherapy. His CT of chest, abdomen, pelvis...
Head and neck cancer:
Epidemiology
• Incidence: 2009 estimates
- 35,720 cases of oral cavity
- rates twice as high in men ...
Risk factors
UV Light Exposure Tobacco
Prior radiation Alcohol Abuse Genetic pre-disposition
Occupational Exposure
Treatment
• Surgery
• Radiation therapy: ensure that radiation fields don’t
overlap
• Postoperative radiation with or with...
Targeted therapies
• Monoclonal antibodies:
-cetuximab, panitumumab
-attacks the extracellular domain of EGFR
(epidermal g...
Common side effects of
chemotherapy
• Myelosuppression
• Mucositis
• Nausea/vomiting
• Fatigue
• Neurotoxicity
• Ototoxici...
GI mucosal side effects
• Nausea and vomiting:
- one of the most common, most debilitating side effects of
cancer therapy
...
GI mucosal side effects
• Incidence & severity of N/V is affected by:
- Specific agents
- Dose
- Schedule & route of admin...
GI mucosal side effects
• Anticipatory nausea and/ or vomiting
- Incidence: occur in 25% of patients
- Risk factors: young...
GI mucosal side effects
• Delayed nausea and vomiting
- Due to the ongoing effect of chemo on CNS and GI
system
- High ris...
GI mucosal side effects
Diarrhea
• Chemotherapy-induced diarrhea is most commonly
described with
- 5-fluorouracil [5-FU], ...
GI mucosal side effects
Assessments:
• Obtain history of onset and duration of diarrhea
• Describe number of stools and st...
GI mucosal side effects
• Pharmacologic intervention (diarrhea)
• Loperamide and Diphenoxylate and atropine (Lomotil)
• Us...
Cutaneous Reactions: targeted
therapies
• Not much data on long term effects
• Severity of the skin reaction correlates wi...
EGFR Grade 3 Rash
Targeted therapies
• Dermatological issues:
-follicular rash on face, chest, upper back, paronychial
inflammation
-Super i...
Oncology patients………….
Challenges are Tough to
those who never face them
But Easy to those who Accept
them
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  • . It is estimated that about 1.5 million new cases of cancer will be diagnosed in 2009. Cancers of the prostate and breast will be the most frequently diagnosed cancers in men and women, respectively, followed by lung and colorectal cancers in both men and in women.
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    1. 1. Common Chemotherapeutic agents & Management of side effects Glory Joseph, RN, ARNP, AOCNP Oncology Nurse Practitioner VA Medical Center OKC, OK
    2. 2. Objectives • Discuss common chemotherapeutic agents for the treatment of lung, colon and head and neck cancer • Discuss common side effects of the chemotherapeutic agents used in the treatment of above cancers • Discuss management strategies related to each case study
    3. 3. 2009 Estimated US Cancer Cases* Men 766,130 Women 713,220 • Prostate 25% • Lung & bronchus 15% • Colon & rectum 10% • Urinary bladder 7% • Melanoma of skin 5% • Non-Hodgkin 5% lymphoma • Kidney & renal pelvis5% • Leukemia 3% • Oral cavity 3% • Pancreas 3% • All Other Sites 19% 27% Breast 14% Lung & bronchus 10% Colon & rectum 6% Uterine corpus 4% Non-Hodgkin lymphoma 4% Melanoma of skin 4% Thyroid 3% Kidney & renal pelvis 3% Ovary 3% Pancreas 22% All Other Sites
    4. 4. Overview • Incidence: 2009 estimates - Male: prostate, lung, colon - Female: breast, lung, colon • Mortality: 2009 estimates - Male: lung, prostate, colon - Female: lung, breast, colon
    5. 5. Case study • Mr. Smith is a 53 year old white male who presented to the NP clinic with increased cough, wheezing and SOB. Denies fever, chills, chest pain, nausea or vomiting. • Subjective data: duration of cough, occupational hx, smoking hx: 2-3ppd x 30yrs • Objective data: Insp & exp wheezes, use of accessory muscles, tachypnea, pulse ox 89%
    6. 6. Diagnostic tests • Chest x-ray revealed a 2.1cm nodule RUL • CT of chest: pulmonary nodule 17 x 14mm in the RUL • CT guided biopsy: stage-III non- small cell lung cancer (NSCLC)
    7. 7. Lung cancer: Epidemiology • Most common cause of cancer related death • Accounts for 30% and 26% of all cancer deaths in men and women • NSCLC –most common histologic type
    8. 8. Risk Factors • Smoking • Radiation therapy • Environmental toxins • Pulmonary fibrosis • Genetic factor • Dietary factors
    9. 9. Case study cont’d…… • Mr. Smith underwent RUL resection. It was recommended that he receive 6 weeks of post-operative concurrent chemotherapy and radiation. • His chemotherapy included carboplatin/ paclitaxel weekly x 6 weeks concurrently with radiation.
    10. 10. Classification of chemotherapeutic agents • Alkylating agents: cyclophosphamide, ifosfamide, chlorambucil, cisplatin,carboplatin, oxaliplatin, busulfan • Microtubule targeting drugs: Vincristine,vinblastine, vinorelbine, docetaxel,paclitaxel, estramustine
    11. 11. Conventional chemotherapy • Combination regimens: -carboplatin/paclitaxel -cisplatin/docetaxel -carboplatin/docetaxel -cisplatin/vinorelbine
    12. 12. Carboplatin • Side effects: -thrombocytopenia, neutropenia, nausea, vomiting -It exhibits much less renal toxicity than does cisplatin -more myelosuppression than cisplatin
    13. 13. Cisplatin • Side effects: -severe nephrotoxicity, severe acute and delayed nausea, vomiting, myelosuppression, ototoxicity, hypomagnesemia -peripheral neuropathy - neurotoxicity: risk increased if treated with cisplatin in past, risk increases with total dose
    14. 14. Paclitaxel (taxol) • Side effects: -myelosuppression, alopecia, peripheral neurotoxicity, myalgia, fatigue, mucositis, diarrhea, facial flushing -consider dose reduction for severe sensory neuropathy
    15. 15. Case study contd…. • Mr. Smith’s CT scans were repeated 6 weeks after completion of treatment. CT of chest was negative. He was followed subsequently with CT scans q 3months for next 2 years, and were negative. • On one of his routine visits to his NP, he reports to her that he has noticed some blood on the toilet paper for last one month. He suspects that his hemorrhoids have been acting up again. Mr. Smith has anemia, & has never had a colonoscopy. His NP insists that he undergo a colonoscopy. • Colonoscopy revealed a 6cm villous adenoma in the ascending colon. Mr. Smith underwent surgery and was found to have stage-III colon cancer.
    16. 16. Colon cancer:Epidemiology • Incidence: 2009 estimates - 106,100 cases of colon - 40,870 cases of rectal - 3rd most common in male & female • Mortality: 2009 estimates - 49,920 deaths
    17. 17. Risk Factors • Aging • Medical conditions -Hx of polyps, inflammatory bowel disease • Life style -high fat/low fiber, obesity, smoking • Family history
    18. 18. Case study cont’d…… • Mr. Smith was recommended 6 months of adjuvant chemotherapy • Chemotherapy orders included: • 5FU/ oxaliplatin • issue of neuropathy assessed with the choice of oxaliplatin
    19. 19. Classification of chemotherapeutic agents • Alkylating agents: cyclophosphamide, ifosfamide, chlorambucil, cisplatin,carboplatin, oxaliplatin, busulfan • Microtubule targeting drugs: Vincristine,vinblastine, vinorelbine, docetaxel,paclitaxel, estramustine
    20. 20. Classification of chemotherapeutic agents • Antimetabolites: 5-Fluorouracil (5 FU), gemcitabine, methotrexate, hydroxyurea • Topisomerase inhibitor:Topotecan, irinotecan, etoposide • Antitumor antibiotics: Doxorubicin, daunorubicin, bleomycin, idarubicin, mitoxantrone, epirubicin
    21. 21. Fluorouracil (5FU) IV/ capecitabine po • Side effects: -myelosuppression, nausea, anorexia, vomiting, diarrhea -Mucositis, alopecia, ocular toxicities -cerebellar toxicity, hand and foot syndrome -Photosensitivity, cardiac toxicity (rare)
    22. 22. Oxaliplatin • Side effects: - Neurotoxicity, fatigue, fever, pain, headache, insomnia, peripheral neuropathy, n/v/d, myelosuppression -Sensitivity to cold temperatures (patients should avoid consuming cold drinks and foods, breathing cold air)
    23. 23. Irinotecan • Side effects: - diarrhea, myelosuppression, alopecia - can cause early (can occur within 24 hours of administration) and late diarrhea - diarrhea occurs in ~50% of patients
    24. 24. Neurotoxicity • Neurotoxicity Assessment Tool • INSTRUCTIONS FOR PATIENTS • Circling one number per line, please indicate how true each statement has been for you during the past seven days using the following scale. • 0=not at all 1=a little bit 2=somewhat 3=quite a bit 4=very much • I have numbness or tingling in my hands. 0 1 2 3 4 • I have numbness or tingling in my feet 0 1 2 3 4 • I have discomfort in my hands 0 1 2 3 4 • I have discomfort in my feet. 0 1 2 3 4 • I have joint pain or muscle cramps 0 1 2 3 4 • I feel weak all over 0 1 2 3 4 • I have trouble hearing 0 1 2 3 4 • I get a ringing or buzzing in my ears 0 1 2 3 4 • I have trouble buttoning buttons 0 1 2 3 4 • I have trouble feeling the shape of small • Objects when they are in my hand 0 1 2 3 4 • I have trouble walking 0 1 2 3 4
    25. 25. Case study contd….. • Mr. Smith successfully completed 6 months of adjuvant chemotherapy. His CT of chest, abdomen, pelvis after the completion of treatments was negative for any metastatic disease. • After being cancer free for 6 months, he presents with a non healing ulcer over at the left side of his tongue. Biopsy of the site showed that it was a malignant lesion. He underwent surgery, followed by chemo+/ radiation treatments.
    26. 26. Head and neck cancer: Epidemiology • Incidence: 2009 estimates - 35,720 cases of oral cavity - rates twice as high in men than women • Mortality: 2009 estimates - 7,600 deaths from oral cavity & pharynx cancer
    27. 27. Risk factors UV Light Exposure Tobacco Prior radiation Alcohol Abuse Genetic pre-disposition Occupational Exposure
    28. 28. Treatment • Surgery • Radiation therapy: ensure that radiation fields don’t overlap • Postoperative radiation with or without concurrent chemotherapy -Cisplatin, cisplatin/paclitaxel -cisplatin/5FU, cetuximab
    29. 29. Targeted therapies • Monoclonal antibodies: -cetuximab, panitumumab -attacks the extracellular domain of EGFR (epidermal growth factor receptor) • Small molecule therapies: -imatinib, sorafenib, sunitinib -inhibit various tyrosine kinase pathways
    30. 30. Common side effects of chemotherapy • Myelosuppression • Mucositis • Nausea/vomiting • Fatigue • Neurotoxicity • Ototoxicity • Skin rash
    31. 31. GI mucosal side effects • Nausea and vomiting: - one of the most common, most debilitating side effects of cancer therapy - can lead to dehydration, metabolic imbalances - can result in need to discontinue potentially beneficial curative cancer treatment
    32. 32. GI mucosal side effects • Incidence & severity of N/V is affected by: - Specific agents - Dose - Schedule & route of administration - Individual patient variability (age, sex, prior chemo, alcohol use)
    33. 33. GI mucosal side effects • Anticipatory nausea and/ or vomiting - Incidence: occur in 25% of patients - Risk factors: young or middle aged, hx of motion sickness • Acute nausea and vomiting - Incidence: determined by the emetogenicity of specific agent - Risk factors: Gender, age, alcohol use, poor performance status
    34. 34. GI mucosal side effects • Delayed nausea and vomiting - Due to the ongoing effect of chemo on CNS and GI system - High risk patients: Corticosteroid + metoclopromide +5HT3 antagonist - 5HT3receptor antagonists: granisetron, ondansetron, anzemet, aloxi
    35. 35. GI mucosal side effects Diarrhea • Chemotherapy-induced diarrhea is most commonly described with - 5-fluorouracil [5-FU], capecitabine and irinotecan - Irinotecan: early onset during or within several hours of infusion
    36. 36. GI mucosal side effects Assessments: • Obtain history of onset and duration of diarrhea • Describe number of stools and stool composition (watery, blood in stool) • Assess patient for fever, dizziness, abdominal pain/cramping, or weakness • Medication profile
    37. 37. GI mucosal side effects • Pharmacologic intervention (diarrhea) • Loperamide and Diphenoxylate and atropine (Lomotil) • Usual dose of loperamide is initial 4mg dose followed by 2mg q 4 h. • Aggressive regimen for irinotecan induced diarrhea: - Loperamide 4 mg initially, then 2 mg every two hours until diarrhea-free for 12 hours
    38. 38. Cutaneous Reactions: targeted therapies • Not much data on long term effects • Severity of the skin reaction correlates with the positive benefit EGFR grade 2 Rash
    39. 39. EGFR Grade 3 Rash
    40. 40. Targeted therapies • Dermatological issues: -follicular rash on face, chest, upper back, paronychial inflammation -Super infection: yellow, brown crusting • Treatment: -topical antibiotic: 1% clindamycin, erythromycin -systemic antibiotic: minocycline, doxycycline, tetracycline -Avoid sun, use of sun block
    41. 41. Oncology patients…………. Challenges are Tough to those who never face them But Easy to those who Accept them Author unknown
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