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POTENTIAL PROBLEMS
RELATED TO CANCER
TREATMENT
By Catherine M. Handy, Ph.D., RN, AOCN
Oncology Clinical Nurse Specialist
Current Anti-Cancer Approaches
Surgery
Remove known tumor masses
Radiation
Kill rapidly dividing tumor cells,
including tumor cells in adjacent tissues
Chemotherapy
Kill rapidly dividing tumor cells
Hormonal
therapy
Inhibit the growth and survival of
hormone-dependent tumor cells
Targeted
therapy
Specifically inhibit processes
required for tumor cell growth
Surgery
• Surgery is the oldest and the most investigated therapy for
cancer.
• Many different rationales for cancer-related surgeries
– Diagnostic: To obtain tissue necessary for diagnosis and staging
– Curative: To remove entire tumor with adequate margins of normal
tissue
– Preventive or prophylactic: To reduce risk of cancer developing in
high-risk patients
• Esophageal resection for Barrett’s esophagus
• Bilateral mastectomy for BRCA mutations
– Palliative: To treat cancer symptoms, not cure
• Tumor debulking
• Esophageal stent placement
Radiation Therapy: Indications
• Can be the primary treatment
• Used before surgery to shrink tumor
• Used after chemotherapy or surgery to get tumor cells left
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•
•
•
behind
Delivered to high-risk areas to prevent cancer growth
Used to control cancer
Used to manage symptoms or to improve quality of life
Used to treat structural emergencies
Radiation Therapy Side Effects
• General:
• Fatigue
• Skin
• All other toxicities are particular to the organs that were in
the treatment field
• For example, if a patient received radiation therapy for lung cancer
the esophagus, heart, spinal cord and perhaps the thyroid also
received some radiation
Chemotherapy vs. Targeted Therapies
Cytotoxic Chemotherapy
• “Poisonous substances”
that interrupt normal
cellular division in
proliferating cells and are
more effective in cancer
cells due to the rapid
proliferation of tumors
• Dosages generally based
on BSA (Pediatric and
specific agent doses may
differ.)
Biotherapy/Targeted
Therapies
• Designed to interfere with
specific molecules or
signaling pathways
involved in tumor growth
and progression
• Dosed in mg, units, m2
Hormone Side Effects
• Anti-estrogens
• Menopause
• VTE
• Osteopenia/osteoporosis
• Medical castration
agents
• Feminization
Chemotherapy General Side Effects
• Myelosuppression
• GI
• Mucositis
• N/V
• Diarrhea
• Alopecia
• Renal
Monoclonal Antibody Side Effects
• Hypersensitivity reactions: less mouse and more
human = less chance of hypersensitivity
• EGFR
• Skin toxicity
• VEGF
• Vascular toxicity
• CD 20
• lymphopenia
Kinase Inhibitor Side Effects
• Because they are po, uncertain absorption
• Possible interference with metabolism of other drugs and
interaction with enzymes or proteins other than
designated target (e.g. cytochrome P450 enzyme)
PERIPHERAL
NEUROPATHY (PN)
OR
CHEMOTHERAPYINDUCED PERIPHERAL
NEUROPATHY (CIPN)
Definition
• Often thought to refer only to numbness and tingling of
the hands or feet
• PN is a group of neurologic dysfunctions that occur
outside the spine and brain.
• Refers to any part of the body affected by peripheral
nerves
Incidence
In those receiving neurotoxic chemotherapeutic agents,
the incidence of developing PN can range from 10% to
100%.
Risk Factors
Comorbidities:
– Diabetes
– Alcohol overuse
– Metabolic imbalances
– Vitamin B12 deficiency
– Cachexia
– HIV
– Other paraneoplastic syndrome
– Cancer
– Age
– Medications
Pathophysiology
• CIPN is not understood totally.
• Can vary depending on the type of chemotherapy given
• Chemotherapy is believed to damage the sensory axons
first and then cause degeneration and dying of axons and
myelin sheaths.
Pathophysiology
• Axons can regenerate if the offending agent is removed.
• Damage to cell bodies is often not completely reversible.
Characteristics
Sensory CIPN:
– Negative manifestations such as numbness or reduced
sensation
– Positive symptoms/pain sensations such as paresthesia,
dysesthesia, causalgia, and allodynia
– Large sensory nerve damage may result in decreased deep
tendon reflexes and vibratory sense, ataxia, and abnormal
position sense of body parts.
Characteristics
• Motor CIPN and autonomic CIPN are uncommon.
• Motor CIPN is difficult to characterize as it is related to
sensory damage, such as weakness, loss of feeling, or
foot pain.
• Autonomic CIPN can cause nausea, abdominal
fullness or bloating, early satiety, constipation, urinary
issues, and erectile dysfunction.
Associated Chemotherapy
• Vinca alkaloids, taxanes, and platinum analogs
are most commonly implicated—Dose-limiting
CIPN
• Less commonly, high-dose ifosfamide, high-dose
methotrexate, etoposide, procarbazine,
cytarabine, suramin, bortezomib, thalidomide, and
arsenic trioxide
• CIPN may occur during or soon after
chemotherapy administration.
• CIPN may progress with increasing doses or
worsen after some drugs have been discontinued.
Assessment
• Grading tools are available to grade the toxicity.
• Determine the level of functional impairment.
• Focus on evaluating from the patient’s perspective
(subjective data).
Assessment Tools
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•
Semmes-Weinstein filaments for cutaneous touch
Vibration—Nerve conduction
Reflexes
Assessment of temperature
Proprioception—Romberg test for balance
Sharp/dull sensation—Pinprick test
Gait assessment—Walking on heels and toes
Muscle strength—From no contraction to active
movement against full resistance
• Patient-reported symptoms
Medical Management of CIPN
• Accurate assessment is essential!
• Dose adjustment of chemotherapy
• Pharmacologic interventions (effectiveness not yet
established)
– IV or oral calcium/magnesium
– Glutathione
– Supplemental vitamin E
– Amifostine, glutamate, and glutamine
– Xaliproden
Painful CIPN
Agents to decrease dysethetic pain:
• Anticonvulsants
• Tricyclic antidepressants
• Opioids
• Topical agents
Patient Teaching
• Self-report measures
• Identify triggers
• Self-care measures
• Online educational sites
Nursing Considerations
• Complex causes with few treatments
• Goals should consider quality of life.
• Nurses are an integral part of the team to help manage
CIPN, especially with ongoing assessment.
HYPERGLYCEMIA
MALGLYCEMIA
Diabetes Brief Overview
• Characterized by high blood glucose levels
• Also known as diabetes mellitus
• Caused by defects in the body’s ability to produce and/or use
•
•
•
•
insulin
• Hormone needed to convert glucose (sugar, starches) into
energy
• Produced in the pancreas
Glucose buildup in the blood causes diabetic complications.
Types of diabetes: type I, type II, gestational
Approximately 25.8 million people (> 8% of the population) in
the U.S. have diabetes.
Cancer survivors: 8%18% report diabetes or prediabetes.
Potential Impact
• Both diabetes and cancer are prevalent diseases.
• Incidence is increasing globally for both.
• Between 8%18% of patients with cancer have diabetes.
• Diabetes and hypertension often coexist; if so, these two
conditions along with cancer need to be addressed when
planning treatment and surveillance following treatment.
• A link exists between type II diabetes and cancer, most likely
due to sharing similar risk factors.
• Drug interactions and contraindications are a possibility.
• Exacerbation of symptoms related to diabetes may occur
when certain cancer treatments are administered or when
cancer progresses.
Impact Examples for Patients with
Diabetes
• Some cancer treatment regimens include:
– Corticosteroids and other drugs, affecting blood glucose
levels.
– Immunosuppressive agents, increasing the risk of poor
wound healing and infection.
– Agents that result in nausea, vomiting, and diarrhea,
affecting dietary intake and blood glucose levels.
– Agents causing peripheral neuropathy, increasing this
complication of diabetes.
• Kidney function may also be affected by both diseases and
some cancer treatments.
Nursing Care Implications
• Gather thorough health history data, including detailed
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•
•
•
information about conditions and medications. Update at each
visit.
Assess baseline and monitor blood glucose closely before,
during, and following treatment for those regimens potentially
affecting diabetic control.
Assess and manage baseline and ongoing symptoms related
to all conditions.
Assist with collaboration efforts between physicians treating
both diabetes and cancer.
Promote diabetes self-management efforts; enlist assistance
from a diabetes educator and dietitian to assess and plan for
any needed changes in exercise, weight control, and meal
planning.
Steroid Use in Cancer
• Therapeutic:
• As part of Chemotherapeutic regimen for leukemia ,lymphoma,
myeloma
• Treatment of Graft versus host disease (GVHD)
• Therapeutic/Prophylactic:
• Prevention and treatment of chemotherapy induced nausea and
vomiting
Steroid Use in Cancer
• Prophylactic:
• Prevention of hypersensitivity reactions with certain
chemotherapeutic agents such as the taxanes
Steroid Induced Malglycemia
• Malglycemia:
• Hypoglycemia (blood glucose < 70 mg/dl)
• Hyperglycemia (blood glucose of 126 mg/dl or greater
• Glycemic variability (standard deviation of two or more
measurements of 29 mg/dl or greater)
Potential Impact of Malglycemia on
Clinical Outcomes In Hospitalized
Patients
• Increased risk of infection and sepsis
• Increased mortality
• Decreased survival
• Increased length of stay
• Increased Toxicities
Storey, S. & Von Ah, D. (2012) Impact of malglycemia on clinical outcomes in hospitalized patients with cancer: A
review of the literature. Oncology Nursing Forum39(5), 458-465.
Strategies for Glycemic Management in
the Hospitalized Patient
• Diet
• Physical activity
• Medications
• Sulfonylureas
• Metformin
• Thiazolidiones
• Insulin
• Basal-bolus insulin therapy
Malglycemia in the Non-Hospitalized
Cancer Patient
• Not as well studied
• Caused by both therapeutic and prophylactic steroid use
• Similar concerns with potential consequences
• Impaired cellular repair
• Increased clotting
• Increased aggregation of platelets
• Increased inflammation
• Decreased ability to fight infection
• Increased cellular proliferation
• Increased mortality
De Vos-Schmidt, D., & Dilworth, K. (2014). Management strategy for steroid-induced malglycemia
during cancer treatment. Clinical Journal of Oncology Nursing 18(1), 41-44.
Management Strategies
• Send patient to PCP or endocrinologist
• One strategy developed by one oncology nurse and one
diabetes nurse educator:
• All patients given corticosteroids screened with a 2 hr postprandial
blood glucose on day 2 of the first chemotherapy cycle
• Blood glucose <140 mg/dl: no interventions needed
• Blood glucose 140-199 mg/dl: Blood glucose meter and education
on its use and dietary carbohydrate control
De Vos-Schmidt & Dilsworth, 2014
Management Strategies
• Blood glucose > 200 mg/dl:
• Education about glucose monitoring, use of and insulin pen and
dietary carbohydrate control
• Blood glucose monitoring before each meal
• Dietary carbohydrate control
• Sliding scale insulin
•
De-Vos-Schmidt & Dilworth, 2014
HYPERTENSION
The Malignant Cell
• Overexpression of EGFR1
• Cell receives continuous signals to divide.
• Daughter cells do not differentiate; return to cell cycle to
divide again.
• Cell makes VEGF to stimulate angiogenesis.
• Cell is signaled to ignore messages for apoptosis.
Angiogenesis
• Process by which a tumor develops its own blood supply
• Needed for the tumor to exceed 1 mm in diameter
• Triggered by hypoxia, oncogenic signals, and pro-
angiogenic growth factors
• Growth of tumor and rate of spread are related to tumor
vascularity.
Role of VEGF in Angiogenesis
• Binds to receptors on the endothelial cells of nearby blood
vessels
• Sends message to increase production of more
endothelial cells
• Causes endothelial cells to migrate through basement
membrane and toward the tumor
• New blood vessel tube is formed.
Bevacizumab (Avastin)
• Monoclonal antibody against VEGF
• Activity in a variety of tumors including colorectal and
brain
• Toxicity profile:
• GI perforation
• Delayed would healing
• Arterial and venous thrombotic events
• Bleeding/hemorrhage
• Hypertension
Blood Pressure Classification
BP Classification SBP mmHg
DBP mm Hg
Normal
<120
and
<80
Prehypertension
120-139
or
80-90
Stage 1
Hypertension
140-159
or
90-99
Stage 2
Hypertension
≥ 160
or
≥ 100
Management of BP for Adults
BP Classification Lifestyle
Modificatio
n
Initial Drug Therapy
Without Compelling
Indication
Initial Drug
Therapy With
Compelling
Indications
Normal
Encourage
Prehypertension
Yes
No BP drug indicated
Drug(s) for
compelling
indications
Stage 1
hypertension
Yes
Thiazide-type diuretics
for most. May consider
ACEI, ARB, BB, CCB,
or combination
Drug(s) for
compelling
indications
Stage 2
hypertension
Yes
Two-drug combination
for most (usually
thiazide-type diuretic
and ACEI or ARB or BB
or CCB)
Other
antihypertensive
drugs as needed
Hypertension Glossary
• Compelling indications: other comorbid conditions that
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•
•
•
increase risk of heart disease. Treat patients with chronic
kidney disease or diabetes to BP goal of <130/80
ACEI: Angiotension converting enzyme inhibitor
ARB: Angiotension receptor blocker
BB: Beta blocker
CCB: Calcium channel blocker
National Heart, Lung and Blood Institute: The Eighth Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8)
Survivorship: Institute of Medicine Report
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•
•
•
•
•
•
•
Establish survivorship as a distinct phase of care
Implement survivorship care plans
Build bridges between oncology and primary care
Develop and test models of care
Develop and evaluate clinical practice guidelines
Institute quality of survivorship measures
Strengthen professional education
Expand use of psychosocial and community support
services
• Invest in survivorship research
Executive Summary From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, D.C.:
The National Academies Press; 2006.
Pulmonary
Urological
Cardiac
Organ
Toxicities
Reproductive
Due to damaging effects of
drugs or treatment on
organ-specific normal cells
Ocular
Neurological
Renal
Liver
Late Effects
• May appear months to years after treatment has
ended
• Include physical, psychological, and cognitive
– Bones
– Memory
effects
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Organs
Body tissues
Feelings
Moods
Actions
Post-traumatic stress disorder
Thinking
– Learning
– Concentration/attention span
– Math, problem solving, handwriting,
reading, and spelling
– Planning and organizing
– Processing
Fatigue
• Affects almost 100% of patients undergoing cancer
•
•
•
•
treatments
Most common and distressing symptom of cancer
patients
Related to disease, biochemical imbalance,
deconditioning, stress, treatment, quality of rest/sleep,
nutrition, and functional status
Results in altered sleep patterns, depression, anxiety, and
environmental factors
Can be lasting effect for weeks to months to years
Cardiac
• Patients at risk:
• Radiation treatment in which the heart potentially received
radiation:
• Radiation to a mediastinal mass in lymphoma
• Radiation to breast, lung, esophagus
• Early effects are pericarditis, pericardial effusion, tamponade
• Late effects are valvular insufficiency, constrictive pericarditis, MI
Landier, W. & Smith, S. (2011). Late effects of cancer treatment. In C. H. Yarbro, D. Wujcik &
B.H. Gobel (Eds.) Cancer Nursing Principles and Practice Seventh Edition. Sudbury, MA: Jones
and Bartlett Publishers
Cardiac
• Chemotherapy/Targeted therapy:
• **Anthracyclines (“rubicin”)
• High dose cyclophosphamide
• Trastuzumab
• Many agents combined with anthracyclines
• CHF and cardiomyopathy
• 5-Fluoruracil and Capecitabine can cause acute coronary
symptoms
• Monitor EKG, Echo, MUGA
Landier & Smith, 2011
Pulmonary
• Radiation to the lung
• Pneumonitis
• Restrictive/obstructive lung disease
• Chemotherapy
• Bleomycin
• Busulfan
• Nitrosureas (BCNU)
• Pulmonary fibrosis
• Avoid high concentrations of oxygen in patients who have received
these agents
• Monitor PFT, CXR
Landier & Smith, 2011
Neurological
• Peripheral: Persistent peripheral neuropathy, especially
with paclitaxel
• Monitor neuro exam
• Neurocognitive: many after chemotherapy complain of
“chemo brain” and exhibit neurocognitive testing
• Monitor neurocognitive testing
Landier & Smith , 2011
Neurological
• Central Nervous System:
• Neurosurgery
• High doses of radiation to brain
• Can have motor and sensory deficits, seizures, CVA,
leukoencephalopathy
• Auditory: hearing loss with platinum chemotherapy
• Ocular: cataracts and glaucoma with corticosteroids
• Monitor neuro, audiological and visual exam; imaging as
indicated
Landrier & Story , 2011
Reproductive
• In general the alkylating agents can cause infertility in
men and women
• In men, prostate cancer therapy (radiation or surgery) can
cause impotence and incontinence
• Androgen deprivation therapy (medical castration) can
cause hypogonadism
• Monitor FSH, testosterone
Landier & Story, 2011
Reproductive
• In women, pelvic irradiation may cause vaginal stenosis,
uterine vascular insufficiency
• Hormone therapy with tamoxifen, aromatase inhibitors,
lupron may cause early menopause
• Monitor FSH, LH, estradiol
Landrier & Story, 2011
Gastrointestinal
• With surgery or radiation may see adhesions, strictures,
perforations, impaired absorption of nutrients, diarrhea,
fecal incontinence, chronic enterocolitis, anorexia
• May see impaired swallowing after head and neck
irradiation
• Monitor electrolytes, colonoscopy
Landrier & Story , 2011
Liver
• Treatment with antimetabolites or abdominal radiation
can lead to hepatic dysfunction
• Monitor LFTs, imaging as indicated
Landrier & Story, 2011
GU
• After bladder, prostate or spinal surgery may see
incontinence, dysfunctional voiding, neurogenic bladder
• Hemorrhagic cystitis after cyclopohosphamide
• Monitor UA
Landrier & Story , 2011
Renal
• Chemotherapy:
• Platinum agents
• Ifosfamide
• Methotrexate
• Nitrosureas
• Symptoms:
• Glomerular toxicity
• Tubular dysfunction
• Renal insufficiency
• Chronic kidney disease
• Monitor renal function tests, UA
Landrier & Story ,2011
Lymphatic
• Radiation to the lymph node channel or lymph node
dissections can result in lymphedema
Landrier & Story ,2011
Musculoskeletal
• Treatment with corticosteroids, androgen deprivation
therapy, aromatase inhibitors, surgical castration,
oopherectomy may result in osteopenia/osteonecrosis
Landrier & Story , 2011
Dental
• Xerostomia, dental caries and periodontal disease with
radiation
• Osteonecrosis with bisphosphonate therapy
• Dental care as indicated
Landrier & Story, 2011
Hematologic
• Alkylating agents and other chemotheraeutic agents can
cause myelodysplastic syndrome (MDS) and acute
myelogenous leukemia (AML)
• Monitor CBC
Landrier & Story ,2011
Chronic Graft-Versus-Host Disease
• Occurs 324 months after transplant
• May involve skin, liver, eyes, mouth, upper respiratory
tract, and esophagus
• Erythematous skin rash is hallmark manifestation.
• Cyclosporine and corticosteroids
Psychosocial
• Depression
• Anxiety
• PTSD
• Limitations in health care access
• Alterations in body image
• Psychosocial assessment
Landrier & Story ,2011
Institute of Medicine Report
•
•
•
•
•
•
•
•
Establish survivorship as a distinct phase of care
Implement survivorship care plans
Build bridges between oncology and primary care
Develop and test models of care
Develop and evaluate clinical practice guidelines
Institute quality of survivorship measures
Strengthen professional education
Expand use of psychosocial and community support
services
• Invest in survivorship research
Executive Summary From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, D.C.:
The National Academies Press; 2006.
References
American Diabetes Association. (2014). Diabetes basics. Retrieved from
http://www.diabetes.org/diabetes-basics
Edgington, A., & Morgan, M.A. (2010). Looking beyond recurrence: Comorbidities in
cancer survivorship. Clinical Journal of Oncology Nursing, 15, E3E12.
Giovannucci, E., Harlan, D.M., Archer, M.C., Bergenstal, R.M., Gapstur, S.M.,
Habel, L.A., . . . Yee, D. (2010). Diabetes and cancer: Consensus report. Diabetes
Care, 33, 16741685. Retrieved from
http://care.diabetesjournals.org/content/33/7/1674.long
U.S. National Library of Medicine, MedlinePlus. (2014). Diabetes. Retrieved from
http://www.nlm.nih.gov/medlineplus/diabetes.html
U.S. National Library of Medicine, PubMed Health: A.D.A.M. Medical Encyclopedia.
(2014). Diabetes. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002194
Stevens, C., Dinkel, S., & Catanzaro, J. (2011). The complex dual diagnosis of
diabetes and cancer. Clinical Journal of Oncology Nursing, 15(6), 654-658.
References
Biedrzycki, B.A. (2010). Peripheral neuropathy. In C.G. Brown (Ed.), A
guide to oncology symptom management (pp. 405421). Pittsburgh, PA:
Oncology Nursing Society.
De Vos-Schmidt, D. & Dilsworth, K. (2014). Management strategy for
steroid-induced malglycemia during cancer treatment. Clinical Journal of
Oncology Nursing, 18,41-44.
Landrier, W. & Smith, S. (2011). Late effects of cancer treatment. In C.H.
Yarbro, D. Wujcik & B.H. Gobel (Eds.), Cancer Nursing: Principles and
Practice (pp. 1755-1779). Sudbury, MA: Jones and Bartlett Publishers.
National Heart, Lung, and Blood Institute (2014). The Eighth Report of the
Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC 8).
Oncology Nursing Society. (2009). Putting evidence into practice:
Peripheral neuropathy. Retrieved from http://www.ons.org/
Research/PEP/Peripheral
Storey, S. & Von Ah, D. (2012). Impact of malglycemia on clinical outcomes
in hospitalized patients with cancer: A review of the literature. Oncology
Nursing Forum, 39 (5), 458-465.
Wickham, R. (2007). Chemotherapy-induced peripheral neuropathy: A
review and implications for oncology nursing practice. Clinical Journal of
Oncology Nursing, 11, 361376.
References
American Cancer Society. (2012). Cancer facts and figures.
Retrieved from
http://www.cancer.org/Research/CancerFactsFigures/Can
cerFactsFigures/index
Eggert, J. (2010). Cancer biology. In J. Eggert (Ed.),
Cancer basics. Pittsburgh, PA: Oncology Nursing Society.
Van Gerpen, R. (2007). Pathophysiology. In M.E.
Langhorne, J.S. Fulton, & S.E. Otto (Eds.), Oncology
nursing (5th ed., pp. 298308). St. Louis, MO: Mosby.