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Common Chemotherapeutic agents & Management of side effects

Glory Joseph, RN, ARNP, AOCNPOncology Nurse Practitioner

VA Medical CenterOKC, OK

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

2009 Estimated US Cancer Cases*

Men766,130

Women713,220

• Prostate 25%

• Lung & bronchus 15%

• Colon & rectum 10%

• Urinary bladder 7%

• Melanoma of skin 5%

• Non-Hodgkin 5% lymphoma

• Kidney & renal pelvis 5%

• 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

Overview

• Incidence: 2009 estimates

- Male: prostate, lung, colon

- Female: breast, lung, colon

• Mortality: 2009 estimates

- Male: lung, prostate, colon

- Female: lung, breast, colon

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%

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)

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

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 concurrent chemotherapy and radiation.

• His chemotherapy included carboplatin/ paclitaxel weekly x 6 weeks concurrently with radiation.

Classification of chemotherapeutic agents

• Alkylating agents: cyclophosphamide, ifosfamide, chlorambucil, cisplatin,carboplatin, oxaliplatin, busulfan

• Microtubule targeting drugs: Vincristine,vinblastine, vinorelbine, docetaxel,paclitaxel, estramustine

Conventional chemotherapy

• Combination regimens: -carboplatin/paclitaxel-cisplatin/docetaxel-carboplatin/docetaxel-cisplatin/vinorelbine

Carboplatin

• Side effects:

-thrombocytopenia, neutropenia, nausea, vomiting

-It exhibits much less renal toxicity than does cisplatin

-more myelosuppression than cisplatin

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

Paclitaxel (taxol)

• Side effects:

-myelosuppression, alopecia,

peripheral neurotoxicity, myalgia, fatigue, mucositis,

diarrhea, facial flushing

-consider dose reduction for severe sensory

neuropathy

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.

Colon cancer:Epidemiology


- 106,100 cases of colon

- 40,870 cases of rectal

- 3rd most common in male & female


- 49,920 deaths

Risk Factors

• Aging• Medical conditions -Hx of polyps,

inflammatory bowel disease

• Life style -high fat/low fiber, obesity, smoking• Family history

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


• Alkylating agents: cyclophosphamide, ifosfamide, chlorambucil, cisplatin,carboplatin, oxaliplatin, busulfan

• Microtubule targeting drugs: Vincristine,vinblastine, vinorelbine, docetaxel,paclitaxel, estramustine


• Antimetabolites: 5-Fluorouracil (5 FU), gemcitabine, methotrexate, hydroxyurea

• Topisomerase inhibitor:Topotecan, irinotecan, etoposide

• Antitumor antibiotics: Doxorubicin, daunorubicin, bleomycin, idarubicin, mitoxantrone, epirubicin

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)

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)

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

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

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.

Head and neck cancer: Epidemiology


- 35,720 cases of oral cavity

- rates twice as high in men than women


- 7,600 deaths from oral cavity

& pharynx cancer

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 without concurrent chemotherapy

-Cisplatin, cisplatin/paclitaxel

-cisplatin/5FU, cetuximab

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

Common side effects of chemotherapy

• Myelosuppression• Mucositis• Nausea/vomiting• Fatigue• Neurotoxicity• Ototoxicity• Skin rash

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


• Incidence & severity of N/V is affected by:

- Specific agents

- Dose

- Schedule & route of administration- Individual patient variability (age, sex, prior chemo,

alcohol use)


• 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


• 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


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


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


• 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

Cutaneous Reactions: targeted therapies

• Not much data on long term effects • Severity of the skin reaction correlates with the positive

benefitEGFR grade 2 Rash

EGFR Grade 3 Rash

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

Oncology patients………….

Challenges are Tough to those who never face them But Easy to those who Accept them

Author unknown

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