Cancer chemotherapy

1. MANAGEMENT OF
ADVERSE EFFECTS OF
CANCER CHEMOTHERAPY

2. CANCER
An abnormal growth of cells which tend
to proliferate in an uncontrolled way and,
in some cases, to metastasize (spread).

3. CELL CYCLE

4. CLASSIFICATION OF ANTICANCER DRUGS
CELL CYCLE SPECIFIC AGENTS

6. CELL CYCLE NON SPECIFIC AGENTS

8. GENERAL ADVERSE EFFECTS OF ANTICANCER
DRUGS
1. Immediate ADR: Nausea, Vomiting
2. Myelosuppression
3. Mucositis
4. Alopecia
5. Teratogenicity

9. NAUSEA AND VOMITING
• Emesis; nausea- protective reflexes- to get rid of toxic
substances- prevents further ingestion.
• Central emesis center:
• Chemoreceptor trigger zone in area postrema at bottom of 4th
ventricle
• Solitary Tract nucleus.

10. NAUSEA AND VOMITING
• Inputs to emesis center from- vagus nerve, splanchnic
afferents, cerebral cortex, vestibular apparatus.
• Receptors on:
• CTZ- Serotonin (5HT3), Dopamine (D2), Opioids.
• STN- encephalin, histamine, ACh, 5HT3.

12. NAUSEA AND VOMITING
1. Anticipatory- conditioned reflex to sight and smell
2. Acute- within 24hrs of chemotherapy
3. Delayed- more than 24hrs

13. DRUGS CAUSING NAUSEA AND VOMITING
• Highly emetogenic- cisplatin, carmustine, cyclophosphamide,
dacarbazine, mechlorethamine, streptozocin
• Moderate emetogenic- doxorubicin, daunorubicin,
cytarabine, oxaliplatin, carboplatin, ifosfamide

14. DRUGS CAUSING NAUSEA AND VOMITING
• Low emetogenic- Etoposide, 5-FU, gemcitabine, MTX,
pemetrexed, mitomycin, paclitaxel
• Least emetogenic- Vinca alkaloids, cladarabine,
bevacizumab.

16. ANTI-EMETIC AGENTS IN CANCER
CHEMOTHERAPY
• LOW RISK OF EMESIS:
• PRE- CHEMOTHERAPY
• Dexamethasone
• Metoclopramide± diphenhydramine
• Prochlorperazine ± Lorazepam
• POST- CHEMOTHERAPY(delayed emesis)
• None

17. ANTI-EMETIC AGENTS IN CANCER
CHEMOTHERAPY
• MODERATE RISK OF EMESIS
• PRE-CHEMOTHERAPY
• 5HT3 antagonist+ dexamethasone
• 5HT3 antagonist+ dexamethasone+ aprepitant

18. ANTI-EMETIC AGENTS IN CANCER
CHEMOTHERAPY
• POST- CHEMOTHERAPY (delayed emesis)
• Aprepitant (days 2 and 3)
• Dexamethasone or 5 HT3 antagonist (days 2-3 or 4)
• Aprepitant (days 2-3, if used pre-chemo) ±
dexamethasone (days 2-4) ± lorazepam (days 2-4)

19. ANTI-EMETIC AGENTS IN CANCER
CHEMOTHERAPY
• HIGH RISK OF CHEMOTHERAPY
• PRE-CHEMOTHERAPY
• 5HT3 antagonist+ dexamethasone+ aprepitant ± lorazepam

20. ANTI-EMETIC AGENTS IN CANCER
CHEMOTHERAPY
• POST- CHEMOTHERAPY (delayed emesis)
• Dexamethasone+ aprepitant
• Dexamethasone (days 2-4)+ aprepitant (days 2 and 3) ±
lorazepam (days 2-4)

21. MYELOSUPPRESSION
• Chemotherapy induced myelosuppression drugs target
proliferating cells which includes both tumour cells and
hematopoietic cells.

22. MYELOSUPPRESSION
• Manifestations- anemia; thrombocytopenia; neutropenia.
• Often managed with delay/ reduction in dose to allow
hematopoietic activity to recover.
• Results in low relative dose intensity.

23. ANTICANCER DRUGS CAUSING
MYELOSUPPRESSION
• Highest-
• Alkylating agents;
• Antimetabolites;
• Anthracyclines- doxorubicin; daunorubicin
• Lowest-
• Asparginase
• Bleomycin
• Vinca alkaloids
• Hormonal antagonists

24. HEMATOPOIETIC SYSTEM
MYELOID TISSUES
Bone marrow and the cells
derived from it (e.g., red cells,
platelets, granulocytes and
monocytes)
LYMPHOID TISSUES
Thymus, Lymph nodes and
spleen.

25. PLEURIPOTENT HSC
2 MULTIPOTENT PROGENITORS
COMMON LYMPHOID
PROGENITOR CELLS
COMMON MYELOID
PROGENITOR CELLS

26. COMMITTED PROGENITORS
(COLONY FORMING UNITS)
PRECURSORS- MYELOBLASTS,
PROERYTHROBLASTS,
MEGAKARYOBLASTS.
MATURE GRANULOCYTES,
RED CELLS AND PLATELETS.

28. CHEMOTHERAPY INDUCED ANAEMIA
• Recombinant human erythropoietin- epoetin alfa.
• Stimulates proliferation and maturation of committed
erythroid progenitors to increase red cell production.
• 150 units/kg thrice a week or 450-600 units/kg once a week.
• Used when Hb levels fall below 10g/dl.

29. CHEMOTHERAPY INDUCED ANAEMIA
• Erythropoiesis stimulating protein, darbepoetin alfa.
• Genetically modified erythropoietin.
• 4 mutated amino acids with additional carbohydrates side
chains prolongs the circulatory survival of the drug to 24-
26 h.

30. CHEMOTHERAPY INDUCED NEUTROPENIA
• Myeloid growth factors.
• Glycoproteins.
• Stimulate proliferation and differentiation of one or
more myeloid cell lines.
• Enhance the function of mature granulocytes and
monocytes.

31. • Recombinant forms are:
• Granulocyte Colony Stimulating Factor (G-CSF)
• Granulocyte Macrophage Colony Stimulating Factor (GM-CSF)

32. • Recombinant human G-CSF- Filgrastim
• Produced in a bacterial expression.
• Non glycosylated peptide of 175 amino acids.
• Molecular weight 18kDa.

33. • Pegfilgrastim-
• Covalent conjugation product of filgrastim and a form of
polyethylene glycol.
• Lenograstim-
• Glycosylated form of recombinant G-CSF.

34. • Recombinant human GM-CSF- Sargramostim
• Produced in a yeast expression.
• Partially glycosylated peptide of 127 amino acids.
• 3 molecular species with molecular weights of 15,500; 15,800;
19,500.
• These preparations have serum half-lives of 2-7 hours.
• May be administered Intravenously or subcutaneously.

35. CHEMOTHERAPY INDUCED NEUTROPENIA
• Accelerates rate of neutrophil recovery after dose
intensive myelosuppressive chemotherapy.
• Reduces the duration of neutropenia
• Raises the nadir count following a cycle of chemotherapy.

36. Clinical guidelines for the use of G-CSF after cytotoxic
chemotherapy recommend reserving G-CSF for :
• Patients at high risk for febrile neutropenia based on age,
medical history, and disease characteristics.
• Patients receiving dose-intensive chemotherapy regimens
that carry a greater than 40% risk of causing febrile
neutropenia.

37. • Patients with a prior episode of febrile neutropenia after
cytotoxic chemotherapy.
• Patients at high risk for febrile neutropenia.
• Patients who are unlikely to survive an episode of febrile
neutropenia.

38. • Doses:
• G-CSF: 5mcg/kg/d
• GM-CSF: 250mcg/m2/d
• Started within 24-72 hours after completing chemotherapy.
• Completed until absolute neutrophil count is greater than
10,000cells/µl
• Pegfilgrastim is given as a single dose of 6mg.

39. CHEMOTHERAPY INDUCED
THROMBOCYTOPENIA
• Thrombopoietic growth factors- Interleukin 11; Thrombopoietin.
• Interleukin 11-
• Cytokine; Stimulates hematopoiesis, intestinal epithelial cell
growth, osteoclastogenesis; inhibits adipogenesis.
• Enhances megakaryocyte maturation invitro.

40. CHEMOTHERAPY INDUCED
THROMBOCYTOPENIA
• Recombinant human IL-11: Oprelvekin.
• Thrombopoietic response in 5-9 days.
• 25-50 µg/kg per day subcutaneously.
• Used in patients undergoing chemotherapy for nonmyeloid
malignancy with severe thrombocytopenia (platelet count
<20,000/µl)
• Administered till platelet count >1,00,000 µl.

41. CHEMOTHERAPY INDUCED ALOPECIA
• Incidence- 65%
• Most traumatic factor in cancer patient care.
• Negative impact on individual perceptions of appearance,
body image, sexuality and self esteem.

42. DRUGS CAUSING ALOPECIA
• Taxanes; Antimicrotubule inhibitors- >80%
• Topoisomerase inhibitors; Anthracyclines- 60-100%
• Alkylating agents- >60%
• Antimetabolites- 10-50%
• Higher incidence in combination therapy than monotherapy.

43. CHEMOTHERAPY INDUCED ALOPECIA
• Dystrophic anagen effluvium.
• In anagen proliferation of epithelial cells greatest
activity in matrix cells of hair bulb building up hair shaft.
• Chemotherapy abrupt cessation of mitotic activity
weakening of partially keratinized proximal portion of hair
shaft narrowing and breakage.

44. CHEMOTHERAPY INDUCED ALOPECIA
• Begins 1-3 weeks after initiation.
• Scalp- common location
• Hair of beard, eyebrows, eyelashes, axillary and pubic region may
be affected.
• Hair loss is reversible. Occurs after 3-6 months.
• Permanent alopecia- Rx with busulfan and cyclophosphamide.

45. TREATMENT- PHYSICAL PREVENTION
• SCALP TORNIQUES
• Application of bands around head occludes superficial
blood flow to scalp reduces amount of drug delivered to
hair follicles.
• Pressure- 10mmHg more than SBP to 300 mmHg.
• 5-10 min before or at the time of chemotherapy upto 30 min
later.

46. TREATMENT- PHYSICAL PREVENTION
• SCALP COOLING
• Application of cold to scalp using cap (pre-cooled or
exchanges coolant with reservoir)
• 5 min before treatment till an hour later.
• Vasoconstriction reduces blood flow to scalp reduces
amount of drug available for hair follicle.

48. • Practically ineffective if drug administered as continuous
infusion for long time.
• Increases risk of scalp metastasis.
• Hence contraindicated in hematological malignancies and
cutaneous T cell lymphoma.

49. TREATMENT- PHARMACOLOGICAL
PREVENTION
• Minoxidil- a vasodilator
• Prolongs duration of anagen phase.
• Fails to induce significant regrowth of hair in permanent
alopecia caused by busulfan and cyclophosphamide.

50. TREATMENT- PHARMACOLOGICAL
PREVENTION
• Cyclosporine A
• Immunosuppressive immunophilin ligand.
• Use in alopecia side effect of excess hair growth
• Induces anagen and inhibits catagen of hair cycle
promotion of hair growth.

51. MUCOSITIS
• Threatens effectiveness of therapy dose reduction;
increases health care cost; impairs patients quality of life.
• Oral mucositis- a frequent complication of cytoreductive
cancer chemotherapy.
• Associated with pain; in neutropenic pts with cancer risk
factor for sepsis.

52. • Gastrointestinal mucositis injury of rest of alimentary
tract.
• Most prominent in small intestine.
• Followed by esophagus, stomach, large intestine.

60. MANAGEMENT OF ORAL MUCOSITIS
• Oral decontamination- antifungal and antibacterial rinses.
• Topical and systemic pain management-
• Topical- 2% lidocaine; morphine solution.
• Frequent rinsing with NaCl mucosa moist; decreases caking
of secretions; soothes inflamed or ulcerated mucosa.

61. MANAGEMENT OF ORAL MUCOSITIS
• Cryotherapy with ice chips.
• Palifermin- Keratinocyte Growth Factor.
• 60 µg/kg/day for 3 days before and after chemotherapy.
• Control of bleeding:
• Topical thrombin packs.
• Topical antifibrinolytic agents- tranexamic acid.

62. CHEMOTHERAPY AND TERATOGENICITY

69. THANK YOU

70. REFERENCES
• Goodman and Gillman Manual of Pharmacology and therapeutics.
• Katzung- Basic and clinical pharmacology- 12th edition
• Medscape
• Luanpitpong S, Rojanasakul Y. Chemotherapy induced Alopecia. Available
from: http://intechopen.com
• Sonis S, Elting L, Keefe D, Peterson D, Schubert M, Hauer-Jensen M et al.
Perspectives on cancer therapy-induced mucosal injury. Cancer.
2004;100(S9):1995-2025.
• 3. Naidu M, Ramana G, Rani P, Mohan l, Suman A, Roy P. Chemotherapy-
Induced and/or Radiation Therapy-Induced Oral Mucositis-Complicating
the Treatment of Cancer. Neoplasia. 2004;6(5):423-431.