Chemotherapy

• Never administer chemo without knowing the following

o Patient height and weight
o Calculate body surface area (BSA) with another nurse
o Check physician’s order to ensure correct doses with another nurse
o Check labs/tests that are pertinent to each drug
o Review protocol
o Chemo consent forms
o Know & check correct route
 IV is used most oftenensure IV or CVC is patent
 Ensure good blood return
o Know protocol r/t extravasation
• Vesicant=any agent capable of causing blistering or tissue necrosis.
• Irritant=any agent causing local inflammation, but does not cause tissue necrosis.
• Extravasation=tissue damage secondary to drug infiltration that occurs because of
one of two reasons
o The drug is absorbed by local cells in the tissue and binds to critical
structures (ex:DNA) causing cell death. The drug is then released from that
cell and moves to surrounding cells.
o The drug doesn’t bind to DNA. Local tissue damage is more readily
neutralized than is damaging to surrounding tissue.
• If a vesicant agent is ordered and the IV is peripheral, most institutions state that
the drug can only run for 1 hour & a nurse must be present for the entire hour.
o Check blood return after every 2 to 3 cc of infusion.
o If infusion is longer than one hour MD should put in a central line.
o If infusion is via CVC, check blood return every 4 hours.
o Patient must stay on the floor if chemo is running.

Safety
1) Exposure
a) Inhalation of drugs aerosols or droplets
b) Absorption of drug through direct contact with skin or direct constant with eyes.
c) Ingestion through direct contact with contaminated food, food containers, or
smoking materials.
2) Symptoms
a) Acute= HA, nausea, dizzy, skin & mucosal irritation, rash and hair loss, coughing
and throat irritation, eye irritation
3) PPE
a) Gloves-latex or nitrile; change every minute
b) Gown-disposable
c) Eyes and face-if splashes may occur, then wear PP make and eye goggles or
shield.
4) Administration
a) Wrap a gauze pad around the connector if cytotoxic agents being delivered
through Y site tubing
b) Plastic-backed absorbent pad placed under all work areas when preparing
cytotoxic drugs
5) Body Fluids/Linens
a) Wear gloves & gowns
b) Eye protection if splashes may occur
c) Flush toilet at least twice
d) Linens- wear gloves and gowns
6) Small spills
a) Clean up ASAP wearing two pairs of gloves (latex, powder-free), gown and face
shield. A respirator mask is word if airborne liquid or powder.
b) Liquids- absorbent gauze pads
c) Solids- wet absorbent gauze pads
d) Puncture-proof container, gauze absorbent pads, and other contaminated
materials should be placed into a cytotoxic drug disposal bag.
e) Spill area should be cleared 3 times using a detergent solution followed by clean
water
f) Large cytotoxic waste bag should be sealed and placed into a second cytotoxic
waste disposal.
g) The outer cytotoxic waste disposal bags sealed and placed in a puncture proof
cytotoxic waste disposal container.
7) Documentation
a) Drug and approximately spilled amount
b) How the spill occurred
c) Spill management procedures followed
d) All persons exposed to spill
e) Notification of proper personnel of the spill

Two Types of Chemotherapeutic Agents

1) Cell-cycle specific which usually works best with multiple doses
2) Cell-cycle nonspecific which is usually dose dependent

Antimetabolites
1) Cell cycle specific
2) Works by mimicking folic acid, pyrimidines and purines or by interfering with the
normal synthesis of nucleic acids in one of two ways
a) Falsely substituting a purine, pyrimidine, or folic acid
b) By inhibiting critical enzymes involved in nucleic acid or folic acid synthesis
• Flurorouracil (5-FU)
• Fludarabine (Fludara)
• Floxuridine (FUDR)
• Capecitabine (Xeloda)
• Cytarabine (ARA-C)
• Methotraxate
• Mercaptopurine (6-MP)
• Thioguanine (TG)

Methotrexate (MTX)
1) Routes are IV, IM, PO, & intrathecal
2) Used for RA, inflammatory disorders, cancer—breast, head & neck, renal, ovarian,
bladder, testicular, lymphoma, etc.
3) Side effects
a) Photosensitivity
b) Liver dysfunction—monitor LFT
i) No alcohol use, NSAID use, or salicylate products
c) Mucositis
d) Myelosupression
4) HIGH dose methotextrate guidelines
a) Leucovorin rescue-administer & monitor levels
i) Monitor serum levels of MTX every 12 to 24 hours
ii) Must remain <5x10-8
b) Acute tumor lyses syndrome=massive release of intracellular components
i) What would you monitor for?
ii) Allopurinol must be started several days before drug therapy begins
iii) Urine pH>7.0
iv) If pH <7.0 give NaHCO3 via IVF and/or PO
v) Bicitra

Fluorouracil (5-FU)
IV, IA, topical
1) used for gastric, head & neck, breast CA
2) side effects
a) Myelosupression
b) Alopecia
c) Mucositis
d) Diarrhea
e) Discoloration of veins (reversible)

*Floxuridine (FUDR) can be administered intrahepatically and is compatible with heparin.

Vinca Alkaloids are cell cycle specific and prevent mitosis from occurring by disrupting
mitotic spindles crucial for metaphase, which is why they are also called mitotic
inhibitors. The specific MOA is unknown.
• Vinblastine (velban)
• Vindristine (oncovin) *2 mg/week max
• Vinorelbine (navelbine)
Side effects include neurotoxicity, which can cause
• peripheral neuropathies—foot drop, paralytic ileus, tingling in hands and feet
• myelosuppression
• N/V

Taxanes
1) Pacitaxel (Taxol)
a) Adverse effects include hypersensitivity, premeditate with steroid, antihistamine,
and an H2 blocker, hair loss
2) Docetaxel (Taxotere)
a) Same side effects as vinca alkaloids

Topoisomerase-1 inhibitors are cell cycle specific

• They work by inhibiting enzyme topoisomerase-1 in the S-phase
• These are the side effects specific for each type of topoisomerase-1 inhibitor
o Irinotecan (camptosar)—severe diarrhea, so give atropine
o Topetecan (hycamptin)—diarrhea
o Etoposide (VP-16)—hypertension, bronchospasm, so watch BP. Given IV or PO.

Alkylating Agents are cell-cycle nonspecific. They alter the chemical structure of the
DNA essential to the reproduction of any cell.
1) Nitrogen mustard
2) Ifosfamide (Iflex)
3) Busulfan (myleran)
4) Thlotepa (thioplex)
5) Carboplatinum (paraplatin)
6) Chlorambucil (leukeran)
7) Cisplatinum (platinol)
8) Cyclophosphamide (cytoxan)

Cyclophosphamide (cytoxan) PO, IV

Used to treat chronic leukemia, ovarian, breast, HDL & LDL, multiple myeloma, etc.
Side effects
1) Sterility
2) N/V
3) Myelosupression
4) In high doses—cardiotoxic
5) Hemorrhagic cystitis
a) Must give early in day, hydrate, assess urine for blood, and void frequently,
especially before bed time

Cisplatinum (platinol) IV
Side Effects
1) Nephrotoxicity
a) Monitor I&O, hydrate, monitor creatinine & BUN, mannitol
2) Peripheral neuropathy
3) Electrolyte imbalance
a) Monitor Mg+2 & K+
4) Ototoxicity—high frequency hearing loss-audiogram
5) Very emetogenic
Nitrosoureas crosses the BBB & can be used to treat brain cancers
• Carmustine (BCNU) PO, IV
• Lomustine (CCNU) PO, IV

Anti-Tumor Antibiotics are cell-cycle nonspecific

Work by the alkylation process of by intercalation
Intercalation=insertion of drug molecule between 2 strands of DNA to block synthesis
• Anthracyclines (subgroup)
o Intercalation
 Daunorubin
 Doxorubicin
  Idarubicin
o Side effects
 Doxorubicin
• Red color, vesicant agent, cardiotoxic (get baseline & periodic
ECHOs), hair loss
• Max accumulative dose= 55mg/m2
 Dexrazoxane—zinecard?
 Bleomycin
• Pulmonary toxicity, baseline PFTs
• Contraindicated in persons >70 y/o
o Other side effects
 Besides bleomycin, all drugs in this class are vesicant agents, so you
must watch closely.
 If IV is new & IVP check for blood return every 2 to 3 ccs
 If CVC verify blood return with 2nd RN before starting and every 4 hours
after
 Stop infusion if pain, redness, or infiltration & call the MD

Miscellaneous Agents
Asparaginase (elspar) IV is a second line defense for acute lymphocytic leukemia.
*must give a test dose each time to assess for hypersensitivity/anaphylaxis reaction
Hydroxyurea (Hydrea) PO is used for certain solid tumors and CML, sickle-cell & AIDS
*bone marrow toxicity occurs in 1 week of starting
Hormones
• Interfere with protein synthesis or receptor blockade
• Changes cell metabolism
• Less toxic than antineoplastic agents
o Corticosteroids
o Estrogens & antiestrogens
o Androgens & antiandrogens
o Progestins
o LHRH antagonist
o Aromatase inhibitors

Antiestrogens
Tamoxifen (Nolvadex)
1) For post menopausal F with breast cancer
2) Approved for prevention
3) SE or complications include hot flashes, increased risk for DVT, & HA

Aromatase Inhibitors
Anastrozole (Armidex)
Aromatase=enzyme that converts adrenal andogens to estrogen
For post menopausal F with breast cancer

Progestins
Palliation for F with endometrial cancer
Megestrol (megale) for management of cachexia in advanced AIDS or cancer
SE= hair follicles, myelosupression, GI mucosa, reproductive organs

Myelosuppression
1) Leukopenia/neutropenia
2) Thrombocytopenia
3) Anemia
What will you monitor in these patients?
What are the interventions/teaching for these patient?
Mucositis
Nursing management
1) Assessment
2) Pain control
3) Dietary
4) Oral hygiene
Alopecia
1) Hair will grow back, but will probably be a different color and texture
2) Do not use scalp hats with ice to reduce alopecia. Any ideas why?
3) Do not bleach or perm hair, no rollers, etc.
4) Use gentle products on hair

Drugs affecting the immune system

Immunomodulating Agents
1) Interferons
2) Interleukins
3) Colony-stimulating factors (CSFs)

Interferon
Action
1) Possess antiviral & antineoplastic effects
2) Enables the immune system to recognize the cancer cells better by directly inhibiting
effects on DNA & protein synthesis and increasing cancer cell Ag on the cell surface.
3) This stops virus replication & prevents penetration into healthy cells.
4) They also enhance the action of other cells in the immune system and stops the
division of other cancer cells.
Uses
1) Treatment of viral infections
a) Rhinovirus, retrovirus, papillovirus, condyloma, hepatitis C
2) Treatment of certain cancers
a) Kaposi sarcoma, multiple myeloma, renal cell carcinoma, bladder cancer
3) Treatment of some autoimmune disease, like multiple sclerosis
Side Effects
1) Flu-like: fever, chills, HA, malaise, myalgia & fatigue
2) GI: N/V, diarrhea, anorexia
3) CNS: paranoia, dizziness, confusion
4) CV: tachycardia
5) Hematologic: neutropenia, thrombocytopenia
6) Renal: increased BUN & creatinine
7) Psych: depression, suicidal thoughts
Nursing
1) Monitor CBC, renal function, VS
2) Treat flu symptoms with Tylenol
3) Teach about fever patterns
4) Be on watch for depression & suicidal thoughts

Interleukins
Action
1) Enhances multiplication of the activated killer T-lymphocytes
2) These T lymphocytes recognize cancer cells as non-self and ignores normal cells
3) It also increases production of B lymphocytes
Uses
1) Renal cell carcinoma
2) Malignant melanoma
3) Colorectal cancer
4) Limited use in HD
Side Effects
1) Capillary leak syndrome causing fluid retention in fluids. The patient with gain 20-30
lbs and appear with edema
2) Fluid retention can lead to CHF, arrhythmias, MI
3) Flu-like symptoms
Nursing
1) Monitor I&O, weight
2) Treat flu symptoms with Tylenol
3) Patient may become hypertensive, with pulmonary edema, due to capillary leak
syndrome, do not treat with diuretics.

Colony Stimulating Factors

Glycoprotine hormones responsible for differentiation, proliferation, maturation &
functional activity of hematopoietic cells
1) Granulocye colony stimulating factor (G-CSF)
a) Filgrastim (Neupogen)
b) Pegfilgrastim (Neulasta)
c) Sargramostim (Leukine) – GM-CSF
2) Erythropoietin
a) Epoetin-alpha (EPO, Procrit)
3) Thrombopoiesis
a) Oprelvekin (Neumega)
Clinical application for hematopoietic growth factors in oncology
1) Decrease chemotherapy-induced myelosuppression
2) Stimulate hematopoiesis in marrow failure
3) Promote cellular differentiation
4) Support peripheral stem cell harvesting
5) Enhance antibiotic therapy
Administration
1) Subcutaneous injection in most cases
2) Must teach patient/ family how to administer
3) Usually given until reach lab parameter set by practitioner
a) WBCs > 3000