Transcript Pharmacology and the Nursing Process, 4th ed. Lilley/Harrington

Chapter 45
Antineoplastic Drugs Part 1:
Cancer Overview and Cell
Cycle–Specific Drugs
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Cancer
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Cellular transformation
Uncontrolled and rapid cellular growth
Invasion into surrounding tissue
Metastasis to other tissues or organs
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Cancer (cont’d)
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Cancerous cells do not have:
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Growth control mechanisms
Positive physiologic function
Cancer cells either:
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Grow and invade adjacent tissues, or
Break away from original tumor mass and travel by
means of blood or lymphatic system to distant sites
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Cancer (cont’d)
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Primary lesion
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Metastasis
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Uncontrolled cell growth
Secondary lesion, in a new and remote part of the
body
Neoplasm (“new tissue”)
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Original site of growth
Mass of new cells; tumor
Tumor
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Benign
Malignant (cancer)
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Cancer: Tissues of Origin
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Carcinomas
Sarcomas
Lymphomas and leukemias
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Also known as circulating tumors or hematologic
malignancies
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Paraneoplastic Syndromes
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Various group of symptoms that cannot be
directly attributed to the spread of a cancerous
tumor
May be the first sign of malignancy
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Cachexia (most common)
Fatigue, fever, weight loss
Others
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Etiology of Cancer
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Age- and sex-related differences
Genetic factors
Ethnic factors
Oncogenic viruses
Occupational and environmental carcinogens
Radiation
Immunologic factors
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Cell Growth Cycle
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G0: resting phase
G1: first gap phase
S: synthesis phase
G2: second gap phase
M: mitosis phase (cell reproduction)
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Chemotherapy
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Pharmacologic treatment of cancer
Antineoplastic drugs
Divided into two groups based on where in the
cellular life cycle they work
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Cell cycle–nonspecific (CCNS)
Cell cycle–specific (CCS)
Some drugs have characteristics of both
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Cancer Drugs:
Antineoplastic Medications
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Cell cycle–specific drugs
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Drugs that are cytotoxic during a specific cell-cycle
phase
Used to treat a variety of solid and/or circulating
tumors
• Antimetabolites
• Mitotic inhibitors
• Alkaloid topoisomerase II inhibitors
• Topoisomerase I inhibitors
• Antineoplastic enzymes
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Cancer Drugs:
Antineoplastic Medications (cont’d)
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Cell cycle–nonspecific drugs
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Cytotoxic during any cell-cycle stage
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Cancer Drugs:
Antineoplastic Medications (cont’d)
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Miscellaneous cell cycle–specific drugs
Miscellaneous antineoplastics (cell-cycle
specificity unclear)
Hormonal agents
Radioactive antineoplastics
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Chemotherapy (cont’d)
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Drugs have a narrow therapeutic index
Combination of drugs is usually more effective
than single-drug therapy
Drug resistance
Nearly all drugs cause adverse effects
Dose-limiting adverse effects
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Chemotherapy (cont’d)
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Harmful to all rapidly growing cells
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Harmful cancer cells
Healthy, normal human cells
• Hair follicles
• GI tract cells
• Bone marrow cells
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Chemotherapy Terms
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Dose-limiting adverse effects
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Alopecia
Emetic potential
Myelosuppression
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GI tract and bone marrow
Bone marrow suppression (BMS)
Bone marrow depression (BMD)
Nadir
Extravasation
Targeted drug therapy
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Antimetabolites
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Folate (folic acid) antagonists
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Purine antagonists
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methotrexate (MTX), pemetrexed, palatrexate
fludarabine (F-AMP),mercaptopurine (6-MP),
thioguanine (6-TG), cladribine, pentostatin
Pyrimidine antagonists
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fluorouracil (5-FU), cytarabine (ara-C), capecitabine,
floxuridine (FUDR), gemcitabine
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Antimetabolites (cont’d)
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Folic acid antagonism
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Interferes with the use of folic acid
As a result, DNA is not produced, and the cell dies
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Antimetabolites (cont’d)
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Purine antagonism
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Interrupts metabolic pathways of purine nucleotides
Results in interruption of DNA and RNA synthesis
Tumor lysis syndrome
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Antimetabolites (cont’d)
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Pyrimidine antagonism
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Interrupts metabolic pathways of pyrimidine bases
Results in interruption of DNA and RNA synthesis
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Antimetabolites: Indications
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Used in combination with other drugs to treat
various types of cancer, such as solid tumors
and some hematologic cancers
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Acute and chronic lymphocytic leukemias
 Leukemias (several types)
 Colon, rectal, breast, stomach, lung, pancreatic
cancers
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Antimetabolites:
Indications (cont’d)
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Oral and topical forms may be used for low-dose
maintenance and palliative cancer therapy
Often used in combination chemotherapy
regimens
Methotrexate is also used to treat severe cases
of psoriasis and rheumatoid arthritis
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Antimetabolites: Adverse Effects
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Hair loss, nausea and vomiting,
myelosuppression
Neurologic, cardiovascular, pulmonary,
hepatobiliary, GI, genitourinary, dermatologic,
ocular, otic, and metabolic toxicity
Tumor lysis syndrome
Palmar-plantar dysesthesia (also called handfoot syndrome), Stevens-Johnson syndrome,
toxic epidermal necrolysis
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Classroom Response Question
Which condition does the nurse anticipate when
assessing a patient with tumor lysis syndrome?
A. Hyperuricemia
B. Hypophosphatemia
C. Hypokalemia
D. Hypercalcemia
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Classroom Response Question
A patient who is receiving high-dose chemotherapy with
methotrexate is also receiving leucovorin. The purpose of
the leucovorin is to:
A. produce an additive effect with the methotrexate by
increasing its potency against the cancer cells.
B. reduce the incidence of cardiomyopathy caused by the
methotrexate.
C. add its antiinflammatory effects to the treatment
regimen.
D. reduce the bone marrow suppression caused by the
methotrexate.
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Mitotic Inhibitors
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Natural products obtained from the periwinkle
plant
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Vinca alkaloids
Semisynthetic drugs obtained from the
mandrake (mayapple) plant
Drugs obtained from the yew tree
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Mitotic Inhibitors (cont’d)
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Vinca alkaloids (periwinkle)
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vinblastine, vincristine, vinorelbine
Taxanes
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docetaxel (European yew tree: needles)
 paclitaxel (western yew tree: bark)
 cabazitaxel
 eribulin
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Mitotic Inhibitors: Mechanism of
Action
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Can work in various phases of the cell cycle (late
S phase, throughout G2 phase, and M phase)
All work shortly before or during mitosis and thus
retard cell division
Each different subclass inhibits mitosis in a
unique way
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Mitotic Inhibitors: Indications
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Often used in combination therapies
Used to treat a variety of solid tumors and some
hematologic malignancies
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Testicular, small cell lung, breast, ovarian, non–small
cell lung cancers
Kaposi’s sarcoma
Acute leukemia
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Mitotic Inhibitors: Adverse Effects
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Hair loss, nausea and vomiting,
myelosuppression
Liver, kidney, lung toxicities
Convulsions
Extravasation
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Several specific antidotes can be used
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Alkaloid Topoisomerase II Inhibitors
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Derived from mandrake plants
Used to treat small cell lung cancer and
testicular cancer
Not used as much now because of significant
toxicities without therapeutic benefit
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etoposide
teniposide
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Classroom Response Question
The nurse identifies which of the following as the
most significant neurotoxin of the cytotoxic drug
class?
A. paclitaxel (Taxol)
B. docetaxel (Taxotere)
C. vincristine (Vincasar PFS)
D. etoposide (Toposar)
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Topoisomerase 1 Inhibitors
(Camptothecins)
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Derived from camptothecin, a substance taken
from a Chinese shrub
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topotecan (Hycamtin)
irinotecan (CPT-11, Camptosar)
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Topoisomerase 1 Inhibitors
(Camptothecins) (cont’d)
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Cell cycle–specific drugs
Inhibit proper DNA function in the S phase
Prevent DNA relegation
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Topoisomerase 1 Inhibitors
(Camptothecins) (cont’d)
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Indications
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Ovarian and colorectal cancer
Small cell lung cancer
Other tumors
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Topoisomerase 1 Inhibitors
(Camptothecins) (cont’d)
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Adverse effects
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Bone marrow suppression (predictable, reversible,
noncumulative, manageable)
 GI effects (nausea, vomiting, diarrhea)
 Irinotecan causes cholinergic diarrhea (delayed,
occurring 2 to 10 days after dosage)
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Antineoplastic Enzymes
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Synthesized using cultures of bacteria and
recombinant DNA technology
As a result, an enzyme is produced
This enzyme is isolated and purified for clinical
use
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asparaginase (Elspar): used to treat acute
lymphocytic leukemia
pegaspargase (Oncaspar)
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Nursing Implications
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Assess baseline blood counts before
administering antineoplastic drugs
Follow specific administration guidelines for
each antineoplastic drug
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Classroom Response Question
A pregnant woman has been diagnosed with cancer and is
meeting with her oncologist to plan treatment. Which
statement about chemotherapy and pregnancy is true?
A. She will have to wait until the baby is born before
starting chemotherapy.
B. The greatest risk of fetal harm from chemotherapy is
during the third trimester.
C. Chemotherapy treatment during the second or third
trimester poses less risk to the fetus.
D. Chemotherapy is unsafe during pregnancy, but
radiation therapy is safe in low doses.
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Nursing Implications (cont’d)
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Remember that all rapidly dividing cells (both
normal and cancer cells) are affected
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Mucous membranes
 Hair follicles
 Bone marrow component
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Monitor for effects on these tissues or
complications
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Nursing Implications (cont’d)
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Monitor for complications
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GI mucous membranes: stomatitis, altered bowel
function with high risk for poor appetite, nausea,
vomiting, diarrhea, and inflammation and possible
ulcerations of GI mucosa
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Nursing Implications (cont’d)
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Monitor for complications
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Hair follicles: loss of hair (alopecia)
Bone marrow components: dangerously low (lifethreatening) blood cell counts
Monitor for adverse effects specific to the type of
antineoplastic drug given
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Nursing Implications (cont’d)
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Implement measures to monitor for and prevent
infection in patients with neutropenia or
leukopenia
Implement measures to monitor for and prevent
bleeding in patients with thrombocytopenia and
anemia
Keep in mind that anemia may result in severe
fatigue
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Classroom Response Question
The nurse is caring for a patient who received
chemotherapy 24 hours ago. The patient’s white
blood cell count is 4,400 mcL. Which symptom, if
experienced by the patient, should the nurse report
to the prescriber immediately?
A. Fatigue
B. Diarrhea
C. Fever
D. Nausea and vomiting
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Nursing Implications (cont’d)
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Monitor for stomatitis (oral inflammation and
ulcerations), and implement measures to reduce
the effects if it occurs
Anticipate nausea and vomiting, and implement
measures to reduce these effects
Antiemetics often work better if given 30 to 60
minutes before chemotherapy is started
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Nursing Implications (cont’d)
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Women of childbearing age will need to use a
nondrug form of contraception during therapy
In addition to physical measures, keep in mind
the need for emotional support during this time
for both the patient and family
Monitor for therapeutic responses to
antineoplastic therapies and the many possible
adverse effects
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Classroom Response Question
When working with a patient who is neutropenic,
the nurse identifies which as the most effective
measure to prevent the patient from developing an
infection?
A. Administer prophylactic antibiotics
B. Stop administration of the chemotherapeutic
drug
C. Perform hand hygiene
D. Vaccinate the patient to prevent bacterial
infection
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