·         Can cure, control/slow growth, or provide palliative care

·         Cell cycle

o        G1 – RNA and proteins are built

o        S – DNA is made from RNA and proteins (G1)

o        G2 – RNA and protein synth prep for division (doubles self)

o        M – mitosis

o        G0 – dormant or resting, normal cell function (some cells hours, some like neurons for years, some only when injured like liver cells)

·         Drugs either cell-cycle specific or cell cycle non-specific

·         Newer categories of chemo drugs are more specific, only attaching cancer cells, or less damage to health tissues

·         Healthy cells affected are those that rapidly reproduce (bc drugs attack dividing cells) – GI tract, gonads, bone marrow, hair follicles, lymph tissue

·         Given multiple times to allow for recovery of normal cells and kill more malignant

·         about 90% malignant killed at first treatment, then 90% of the remaining and so on, theroretically the remaining can be killed by body

·         Cell kill theory – I think it is that as 90% are killed in series, eventually there are so few that the immune system takes over?  Is the rationale for multiple treatments?

• not fermented like black, just dried, therefore more compounds like polyphenols or flavanoids, are antioxidants
• use cautiously hypertension, cardiac issues, anxiety, insomnia, diabetes (why?) and ulcers.  Avoid during pregnancy. All due to caffeine.
• Maybe prevents cancer bc of antioxidant effect

• only mild side effects
• Lentinan is a derivative
• Boosts immune system and prolongs survival rates of cancer
• also lowers cholesterol

Cell-cycle specific

Cell-cycle non-specific

• Plant Alkaloids
• Vinca Alkaloids
• vinblastine
• vincristine
• vinorelbine
• Taxanes
• docetaxel
• paclitaxel
• Podophyllotoxins
• etoposide
• teniposide (VM-26)
• Camptothecin Analogs
• irinotencan
• topotecan
• Antimetabolites
• capecitabine
• cladribine
• clofarabine
• cytarabine (ara-C)
• fludarabine
• fluorouracil (5-FU)
• femcitabine
• mercaptopurine (6-MP)
• methotrexate (Rheumatrex)
• nelarabine
• pemetrexed
• pentostatin
• thioguanine
• Miscellaneous
• ixabepilone

• Alkylating Drugs
• Nitrogen Mustard Derivitives
• chlorambucil
• cyclophosphamide
• ifosfamide
• mechlorethamine
• melphalan
• Ethyleneimines
• altretamine
• thiotepa
• Alkyl Sulfonate
• busulfan
• Hydrazines
• dacarbazine
• procarbazine
• temozolamide
• Nitrosoureas
• carmustine (BCNU)
• lomustine (CCNU)
• streptozocin
• Platinum-Based
• cisplatin
• oxaliplatin
• carboplatin
• Anti-biotics
• bleomycin
• dactinomycin
• daunorubicin
• doxorubicin
• epirubicin
• idarubicin
• mitomycin
• mitoxantrone
• Miscellaneous
• DNA Inhibitor
• hydroxyurea
• Adrenocortical Inhibitor
• mitotane
• Enzymes
• asparaginase
• pegaspargase
• Antimicrotubule Agents
• estramustine (estradiol and nitrogen mustard)
• Retinoids
• tretinoin
• bexarotene

·         act at specific time of cell division

·         affect bad and good cells

·         used in combo to get all stages of cell division

·         Plant alkaloids

o        vinca

§         interfere with AA production at S phase and formation of microtubules in M phase

o        taxanes

§         M phase microtubules

o        podophyllotoxins

§         S and G2 phases

o        camptothecin analogs

§         DNA synth at S phase

·         Antimetabolites

o        incorporate into cell components during S phase interfering with RNA and DNA synthesis preventing division. 

o        Includes methotrexate (Rheumatrex). 

o        Also used for autoimmune disorders

·         Also used for autoimmune disorders

·         Alkylating Agents

o        The book describes all cell-cycle nonspecific drugs as alkylating, I think.  Except for the antibiotics and miscellaneous

o        make cell more alkaline to damage cells

o        malignant cells more susceptible to alkaline environment than healthy cells

o        Nitrogen Mustard derivatives

§         interfere with DNA crosslinks

o        ethyleneimines

§         interfere with DNA crosslinks

o        platinum based

§         interfere with DNA crosslinks

o        alkyl sulfonate (busulfan)

§         interferes with DNA of granulocytes and used primarily for leukemias

o        hydrazines

§         multiple phases of cell cycle

o        nitrosureas

§         unique in cross of BB barrier, so used for brain tumors

·         Antineoplastic Antibiotics

o        do not fight infection

o        action similar to alkylating drugs

o        interfere with DNA and RNA synth

o        Treats solid tumors, and other types of cancer as well

·         Miscellaneous Antineoplastics

o        mechanism of many not clear

Adverse Reactions to all antineoplastics (chemotherapy)

·         Immediate reactions

o        N/V, often serious, use antiemetics and IV fluids/electrolytes

o        extravasation of IV into surrounding tissues

·         During Therapy Cycles

o        affect rapidly producing normal cells, like bone marrow, hair, GI, reproductive tract

o        Bone marrow suppression with anemia, leucopenia thrombocytopenia

§         this is most common, and may lead to cessation to allow regeneration

o        Stomatitis diarrhea

o        hair loss

o        Some, alkaloids, affect nervous system

§         peripheral tingling caused by tiny capillary leaks in extremities causing skin color change to numbness)

·         Long term (years)

o        organ damage (platinum based) with effects on heart, lungs, neuro

o        gonad damage with fertility issues

o        original treatment can cause a secondary leukemia

General Contraindications Antineoplastics

·         leucopenia

·         thrombocytopenia

·         anemia

·         serious infections

·         serious renal disease

·         pregnancy and lactation

o        most are categories C and D

o        methotrexate is category X

General Precautions Antineoplastics

·         renal/hepatic impairment

·         active infection

·         debilitating illness

·         recent cancer treatment (chemo or radiation)

Interactions Antineoplastics

·         CYTOPROTECTIVE AGENTS are used in conjunction to prevent damage to health cells

o        allopurinol – counters increase of uric acid from rapid tumor cell lysis

o        amifostine – binds  metabolites of cisplatin to protect kidneys and reduces xerostoia

o        dexrazoxane – protects heart with doxorubicin

o        leucovorin (Wellcovorin) – provides folic acid after methotrexate

o        mesna – cinds metabolites of ifosfamide to protect bladder

·         Plant alkaloids with

o        digoxin à decreased digoxin

o        phenytoin à increases risk of seizures

o        oral anticoags à prolonged bleeding

·         Antimetabolites with

o        digoxin à decreases digoxin

o        phenytoin à decreases need for phenytoin

o        NSAIDS à I think the book has a typo…... pg 523

·         Alkylating agents with

o        aminoglycosides à increased risk kidney damage and ototoxicity

o        loop diuretics à increases risk ototoxicity

o        phenytoin à increased risk of seixure

·         Antineoplastic antibiotics with

o        digoxin à decreases digoxin

·         Miscellaneous antineoplastics with

o        insulin or oral hypoglycemics à hyperglycemia

o        oral anticoags à bleeding

o        antidepressants, antihistamines, opiates, sedatives àCNS depression

·         type and location of lesion 

·         stage 

·         general condition and health hx 

·         anxiety/fears about treatment; knowledge of treatment 

·         previous of concurrent treatments 

·         other psychosocial or financial concerns, etc. 

·         before admin, weight (some drugs based on weight) and VSs; some based on body surface in meters squared 

·         CBC, etc done if drug has bone marrow depression 

·         vessel integrity for IV access                                    
Preadmin treatments like IV hydration, antiemetic 

·         Greatly depends on patients condition, response, adverse reactions and lab results 

·         lab tests may include CBC, kidney function; abnormal results may require changing care plan 

·         Monitory labs and inform PCP before next doses of results 

·         Administration has changed from lengthy hospital stays, to outpatient setting by highly skilled in-home nurses and quicker 

·         Antineoplastics are not prescribed by general practitioner, only oncology trained 

·         Per OSHA, antineoplastics must be prepared in a "biologic safety cabinet" BSC to prevent inhilation, exposure 

·         For Skin - gowns and gloves 

·         Ingestion - goggles with face shield 

·         Inhilation - NIOSH approved respirator for cleaning up spills 

at home

examples are  capecitabine (Xeloda) or temozolamide (Temodar) 

·         subcutm (up to 1mL), IM (Z-Track) and IV (various types) 

·         Cisplatin cannot be prepared with aluminum IV equip. bc reacts and loses potency 

·         Only special nurses admin, but other nurses may monitor 

·         PPE necessary 

·         give preadmin treatments when prescribed for best effect

·         observe pt close

·         Observe IV site for extravasation, can lead to necrosis, bad.  Discontinue infusion and notify if discomfort, redness along pathway, or infiltration occurs.

·         Continually update nursing assessments, diagnosis, and care plans as conditions change

·         notify oncologist of all pt changes like general condition, adverse reactions, lab tests

·         provide emotional support

“Imbalanced Nutrition: Less then req” re Admin of Antineoplastics

·         Anorexia from fatigue, or just not hungry; a common occurance with antineoplastics

·         From nausea, taste changes, GI sores

·         N/V common; doc may order Antiemetic like ondansetron (Zofran)

o        Antiemetic may have adv rxn of sedation, which may add to anorexia

·         Track I/O for vomiting pt

o        to prevent handling contam waste, use pts weight to assess for fluid loss and observe for signs of dehydration and electroplyte imbalances

·         To stim appetite, small freq meals when pt can tolerate

o        avoid greasy, fatty

o        remove unpleasant smells, sights, sounds, etc

o        better tolerated are cold, dry and salty foods

o        Provide diversional acdtivities like tv, music, books, relaxation, vidualization

·         Common effect is change in taste

o        proteins especially may taste metallic

o        small freq meals better tolerated, breakfast best tolerated

·         Stress importnatce of nutrition esp. proteins

·         Monitor weight weekly or more and report weight loss

·         If too much weight lost, may need feeding tube or Total Parenteral Nutrition (TPN), not ideal.

·         GI tract cells, including oral, are sensitive to antineoplastics bc divide rapidly; may occur 5-7 days after start chemo, and last 10 days after.  This affects appetite.

o        Stomatitis – inflam of  mouth

o        Oral mucositis – inflame of oral mucous membranes

o        Avoid irritating foods like alcohol, spices, alchohol based mouthwash, toothpaste

o        provide soft or liquid food high in nutrition

o        report white patches in mouth, burning sensations, bleeding

o        Mouth care encouraged to be performed q 4 hours, including rinse with normal saline

o        Avoid lemon/glycerin swabs bc irritate and complicate

“Fatigue, Risk for Injury, Risk for Infection. Myelosupression” re: Admin of Antineoplastics

·         Interfere with bone marrow making new cells = MYELOSUPPRESSION or BONE MARROW SUPPRESSION, can be dangerous

·         leucopenia (WBCs) , thrombocytopenia (thrombocytes), anemia (RBCs)

·         Anemia – fatigue, dizziness, SOB, palpitations

·         Help pt prioritize activities to conserve energy

·         Encourage slowing down and napping

·         NEUTROPENIA – have decreased infection resistance

o        monitor closely for signs of infection

o        can be worse with radiation

·         NURSING ALERT – leucopenia severe with temozolomide (Temodar) along with radiation to brain.  Pt is stared on prophylactic therapy to prevent Pneumocystitis pneumonia (PCP)

·         Instruct to stay away from people

·         Colony stimulating factors may be prescribed for in b/t chemo treatments

·         Low blood counts are a primary reason chemo isdelayed

·         NURSING ALERT – report the following immediately:

o        temp 100.4 or more

o        cough

o        sore throat

o        chills

o        frequent urination

o        WBC less than 2500

·         Thrombocytopenia is platelet count less than 100,000

o        monitor for bleeding and prevent bleeding

o        if injection , apply pressure 3-5 min to prevent hematoma (bleeds into tissue)

o        Inform not to use disp razors, nail trimmers, dental floss, toothbrushes, sharp objects

o        no highly physical activity

o        monitor closely for bruises, lesions, bleeding

·         NURSING ALERT – notify immediately

o        bleeding gums

o        easy bruising

o        petachiae

o        increased menst. bleeding

o        bloody urine

o        coffee-ground emesis

“Disturbed Body Image” re: Admin of Antineoplastics

·         ALOPECIA – doxorubicin and vinblastine assoc with severe hair loss; usually occurs 10-21 days after 1^st cycle, temporary (usually); hair is lost from whole body, not just head

·         Might help with purchasing wig or cap

“Impaired Tissue Integrity” re: Admin of Antineoplastics

·         ERYTHEMA – red, warm and sometimes painful areas on skin

·         Skin is rapid grower, so possible breakdown with treatment

·         Avoid sun, wear protective clothing

·         NURSING ALERT - Some antineoplastics can resensitize old radiation areas = RADIATION RECALL – the old lines of old radiation will appear

·         Some antineoplastics are VESICANTS = cause tissue necrosis if infiltrate or extravasate from blood vessel to soft tissue.

o        this can be severe causing damage, physical deformity, loss of function, tendon dysfunction; may require skin grafting

o        daunorubicin, doxorubicin, vinblastine

·         NURSING ALERT – pts at risk for extravasation are those unable to communicate the pain of it like elderly, debililitated, confused or those with fragile veins

·         If getting a VESICANT, make sure estravasation protocols are signed and there is an extravasation kit near before admin; monitor IV site continuously and check for blood return frequently

·         If vesicant prescribed as infusion, give though central line and cheacked q 1-2 hours

·         Extravasation can occur without warning, or can be detected early with vigilance.

·         NURSING ALERT – signs of extravasation:

o        swelling is most common

o        stinging, burning, pain

o        redness

o        lack of blood return – if only symptom, make sure the IV line is ok (could be that);

·         If extravasation suspected, stop infusion immediately, initiate antidotal procedures and report

Education re: Admin of Oral Antineoplastics

·         Oral meds at home, some should not be handled by others, just pt.  Family members taught how to admin without touching

·         Take Preadmin treatments like antiemetics in timely manner to max effect

·         Some chemo regimens can be confusing, and may cause missing dose, etc; stress importance of staying on dosing schedule as prescribed  Might use calendar, and bring with to apts. Usually only one course is prescribed at a time to avoid possible fatal od

·         Unless otherwise indicated, take on empty stomach with water to enhance absorption

·         Report ANY adv rxns,no matter how small, immediately

·         Some drugs leave body relatively unchanged, men should not use urinals for at least 48 hrs after last dose and double-flushn with lid down

·         No OTCs unless approved,including alcohol

·         Inform all other medical professionals about treatment