Transcript Drugs for Neoplasia

Drugs for Neoplasia
Chapter 37
Cancer in the U.S.
2007 Prevalence: 11.7 Million
Males: 5.36 M; Females: 6.37 M
2008: New Cancer Cases
745,000 Males
692,000 Females
Estimated Deaths
294,000 Males
272,000 Females
American Cancer Society 2011
Pathogenesis
• Neoplasm = new tissue or Tumor
• Carcinoma or Cancer = abnormal,
uncontrolled cell division or tissue growth.
• Oncogenes: genes that cause cancer(?)
(Members of one family develop the same
type of cancer.)
• Damaged tumor suppressor genes?
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Pathogenesis
Viruses are associated with 15% of all cancers:
Herpes Simplex Virus
Epstein-Barr
Cytomegalovirus
Human Papillomavirus (HPV)
HIV & Transplant Medications :
weaken or suppress the immune system
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Environmental Risk Factors
Alcohol
→
Liver Cancer
Asbestos
→
Lung Cancer
Benzene
→
Leukemia
More Risk Factors
• Tobacco → Lung, Head, Neck Cancer
(1/3rd of all Cancer in U.S.)
• X Rays/Radiation → Leukemia
• Sun → Skin Cancer
•
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Cancer Treatment
• Surgery
• Radiation therapy
• Drug therapy (chemotherapy)
– To cure
– To control
– For palliation
– For prophylaxis
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Cancer Treatment
Surgery
– Remove localized, solid Tumor
– Reduce numbers of cancer cells
– When compromising blood flow, breathing, or
causing pain (Palliation).
Radiation
– Localized Tumor, follow up after Surgery, or
palliation for inoperable Cancers
Chemotherapy
• Transported through blood
– Has potential to reach each cancer cell
• Some drugs can cross blood-brain barrier
• Some drugs instilled directly into body cavities
(ex: bladder)
• Often combined with or done after surgery
and radiation to increase chance of cure
(adjuvant therapy).
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Case Study
• Mr. C. is a 57 y.o. male with a history of
duodenal ulcer, Right Total Hip Replacement,
pneumonia, HTN, 20 pack/yrs smoker (10
cigarettes/day X 40 years), and a recent onset
of weakness, loss of appetite, constipation
and fatigue. He was diagnosed with a partial
bowl obstruction due to adenocarcinoma. Mr.
C. just completed a course of Radiation and
has now been admitted to the Cancer Care
Unit status post (s/p) Sigmoid Colectomy.
Admission Orders
• IV Dextrose 5% in Water (D5W) at 125 cc/hr
• IV Fluorouracil (5-FU) 12mg/kg/day X 4 days
• Cyclophosphamide (Cytoxin) 5 mg PO daily X
5, then 3 mg PO weekly
• Morphine PCA 2 mg IV/hr basal rate, 1 mg q 6
min PRN, max 12 mg/hr lock out, for pain
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• Nursing Drug Handbook 2008
Admission Orders
• Ondansetron (Zofran) 4 mg IV 30 minutes
before meals and Q2h PRN N/V
• Sips of water then Clear Liquid diet as
tolerated after passing flatus
• Up with assistance
• Intake and Output
Antineoplastic Drugs
• Several different categories of Chemotherapeutic
Drugs are derived from plants, bacteria and/or
laboratory synthesis. The drugs have diverse actions
against Cancer cells, disrupting DNA or RNA
production, or having toxic action against metabolic
pathways. The result is a slowing or stopping of
growth, and/or killing of the cancer cell.
Antineoplastic Drugs are more effective against
rapidly replicating cells.
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Antimetabolites
Structurally similar to folic acid, purines
and pyrimidines, which are essential for DNA
& RNA synthesis, Antimetabolite Drugs are
analogs to Vitamin B9 and nucleic acids. These
drugs do not function in the same way, rather
they disrupt or slow cancer cell growth or
cause their death. Antimetabolites are usually
prescribed for leukemia's and solid tumors.
wikipedia.org
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Fluorouracil (5-FU)
• Antimetabolite Category (Pyrimadine Analog)
• Action: disrupts and slows cancer cell growth in
the ‘S’ Phase (DNA synthesis) of the Cell Cycle,
causing cell death.
• Adverse Effects
– Common: N/V, stomatitis, anorexia, rash, H/A,
alopecia
– Serious: Bone Marrow suppression, severe N/V/D,
hepato/pulmonary/neurotoxicity, mucositis,
hypersensitivity reactions
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Cyclophosphamide (Cytoxan)
• Alkylating Agent (nitrogen mustard)
• Action: Cytoxan changes or disrupts the shape
of the DNA Double Helix which slows or
interrupts normal cellular division and causes
cellular death.
•
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Cytoxan
• Adverse Effects:
– Common: N/V, anorexia, stomatitis, rash, H/A,
alopecia, fluid retention
– Serious: Bone Marrow suppression, severe N/V/D,
Stevens-Johnson syndrome, hemorrhagic cystitis,
pulmonary toxicity, hypersensitivity reactions ,
nephrotoxicity, sterility. (5% develop acute
nonlymphocytic leukemia 4 or more years later.)
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Cytoxan
Contraindications:
– Hypersensitivity reactions
– Active infections
– Severely suppressed bone marrow
Drug-Drug Interactions: Cytoxan used along with
Immunosuppressant agents increases risk for
infection and neoplasm, bone marrow toxicity if
used with allopurinol.
Nursing Process: Assessment
• Review Health Hx. : physical exam
(current infection?), labs, current
medications, neurological (mood,
sensory impairment).
• Caution: immunosuppressive drugs cause
risk of exacerbation of Herpes Zoster in
patients with Hx of herpes/chicken pox.
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Nursing Diagnosis
Which potential or actual Nursing Diagnosis
do you think would apply to Mr. C.?
Potential/Actual Nursing Diagnosis
• Infection, Risk for, related to
compromised immune system
• Pain, Acute, related to Surgical Incision
• Nutrition, Imbalance, Less than body
requirements 2nd to n/v/d, anorexia from
drug side effects, limited oral intake
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Potential/Actual Nursing Diagnosis
• Skin Integrity, Impaired, related to
extravasation
• Body Image, Disturbed, due to physical
changes as a result of drug side effects
• Activity Intolerance/Fatigue/Risk for
Injury/Falls, related to decreased RBC
production due to drug side effect and/or
poor nutritional intake, and/or muscle
wasting.
•
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Planning: Client Goals &
Expected Outcomes
• The Client will:
– Experience a reduction in tumor mass or
progression of abnormal cell growth
– Maintain WBC’s >4,000, Platelet’s >50,000,
CBC WNL, Absolute Neutrophil Count (ANC)
> 500/mm3
– Demonstrate understanding of drug action by
describing use, side effects & precautions
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Planning: Client Goals &
Expected Outcomes
• Good pain management, tolerate gradual
progression of increasing activity and maintain
ADL’s, quality rest/sleep
• Experience minimal or no adverse drug effects
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Implementation
Interventions/Rationales
Patient & Family Education
Monitor for Hypersensitivity / Adverse
Reactions
-Observe for/Client immediately reports
chest/throat tightness, problem swallowing, facial
swelling, abd pain, H/A, dizziness
Implementation/Education
Protect from Infection: Monitor Labs and VSS
(watch for blood dyscrasias and compromised
immune system)
• Client reports increasing fatigue or cough, sore
throat, fever > 100.4, chills/sweats, freq./painful
urination, rash/blisters
• Avoid crowds/people with infections/cut flowers or
change H2O daily using 1 tsp bleach
• Frequent hand washing, oral hygiene, ongoing
assessment of opportunistic infections
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• Black, J., & Hawks, J., 2009
Implementation
Protect from Infection Cont’ed:
• Adequate nutrition/fluid intake, avoid raw
fruits/vegetables (family prep/clean up, must
cook thoroughly) or
• Take periods of rest between activities, avoid
demanding tasks/avoid activities requiring
mental alertness till drug effects are known
• Institute Protective Isolation if Neutrophil
Count <500/ml
Implementation
• Assess for Pain
– Provide adequate pain relief from surgery or drug
effects
– Instruct patient/family in pain management (pain
scale, when to medicate, reassessment, etc.).
Implementation
• Monitor VSS & Cardiopulmonary status
including EKG changes
– Client reports any respiratory distress or chest,
arm, neck or back pain, edema or activity
intolerance
– Keeps all scheduled medical appointments.
Adverse effects may not appear until 6 months
after treatment (tx).
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Implementation
• Monitor Renal status (I&O, lab values, daily weights).
– Client reports changes in thirst, character and/or quantity
of urine, low back/flank pain, trouble voiding, weight gain
– Observe for blood in urine months after treatments
– Drink 2-3 liters of water, in small portions, 1 day before tx,
and daily for 72 hrs after tx (if no fluid restrictions & pt.
can tolerate)
– Encourage pt. to urinate Q1-2 hrs while awake to help
avoid hemorrhagic cystitis
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• Nursing Drug Handbook 2008
What do you see?
Implementation
• Monitor Gastrointestinal (GI) status & Nutrition,
administer antiemetic 30 minutes before meals
– Client reports anorexia, n/v/d, mouth discomfort
(mucositis).
– Eat small frequent meals, avoid hot, spicy, difficult to
chew and strong odor foods
– Drink plenty of cool liquids
– Examine mouth for irritations/sores, good hygiene,
use soft toothbrush, no toothpicks
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Implementation
Monitor GI and Genitourinary (GU) status
– Monitor for constipation and report change in
bowl habits, increase fiber, fluids and activity as
ordered &/or tolerated
– Report changes in menstruation, sexual function,
vaginal discharge
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Implementation
• Collect Fecal Occult Blood Specimens (FOB)
(Drugs may cause GI bleeding)
Client reports epigastric pain, coffee-ground
emesis, tarry stools or frank bleeding, bruising.
Avoid ASA (aspirin), NSAIDS (nonsteroidal antiinflammatory)
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Implementation
• Monitor Neurological & Sensory Status
– Client to report change in skin color, vision (pain,
halo), hearing (ringing, buzz), gait, mood,
sensations (numbness or tingling) or any dizziness,
vertigo. (Cytoxin can cause ototoxicity.) Encourage
periodic ear and eye exams. Assess transportation
needs and ability to drive, make social service
referral prn.
– Limit exposure to sun, use sunscreen, sun glasses,
long sleeve shirts
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Implementation
• Monitor hair and skin status
– Report any loss of or sloughing of skin or hair,
rash, purple-red blisters, pruritis, acne or boils
– Wear cold gel cap during chemotherapy to help
minimize hair loss
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Implementation
• Monitor Liver Function Tests (LFT’s)
– Report jaundice, abd pain, tenderness, bloating,
change in stool color or consistency
– Keep all lab appointments.
Caution in treating pt.’s with Diabetes Mellitus:
monitor daily blood sugar levels, notify provider of
hypoglycemia (<80 mg/dl)
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Implementation
• Antineoplastic Administration:
Nursing Policy and Procedures
– Safety
– Chemotherapy Certification
– Spill management
– IV pump
– Equipment & drug disposal
Evaluation of Outcomes
• Client exhibits reduction or progression of
Tumor mass
• WBC’s >4,000, Platelet’s >50,000, CBC & ANC
WNL
• Client demonstrates an understanding of drug
actions by accurately describing side effects
and precautions
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Mr. C.
• It is now 2 days post op and Mr. C. has had two
rounds of 5FU and 4 rounds of Cytoxin. His lymph
node pathology report states 12 of 17 nodes
were positive for cancer cells. His pain is well
controlled with the Morphine, however he has
had significant N/V and has not tolerated a clear
liquid diet. The MD has ordered Phenergan
Suppositories 25 mg PR Q6H ATC which has
provided good relief, and has changed the IV to
D5 & 1/2 NS with 20meq/KCl at 125cc/hr.
Mr. C.
• Mr. C.’s lab results show a drop in his WBC’s to
2.2 (pre-op 4.5), Platelets 73,000 (pre-op
138,000) & ANC of 400mm3. What nursing
behaviors would be appropriate?
Mr. C.
• The nurse assesses for infection and bleeding.
After conferring with the MD, the nurse places
Mr. C. on protective isolation. She educates
Mr. C. that he is at greater risk of infection due
to his low white blood cell count and instructs
him to avoid exposure to others who are ill or
infectious. She also advised Mr. C. to be
careful to avoid injury.
Other Antineoplastic Agents
• Antitumor Antibiotics: isolated from
microorganisms or bacteria, are more toxic
than standard antibiotics.
• Action: bind to DNA, disrupting replication
and or causing cell death (similar to Alkylating
Agents) with similar side effects.
Antitumor Antibiotic: Doxorubicin
• Action: a prototype drug, Doxorubicin
(Adriamycin) attaches to DNA and distorts the
helix, preventing normal DNA and RNA
synthesis. It is a broad spectrum antibiotic,
given IV only. Unique method of delivery is via
lipid vesicles, or liposomes, which open in
close proximity of cancer cells, sparing normal
tissue. Very effective against solid tumors.
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Doxorubicin
60-75mg/m2 IV q 3 weeks
• Adverse Effects:
– Common: acute n/v, alopecia, anorexia,
stomatitis, rash, H/A
– Serious: Cardiotoxicity: dysrhythmias and
irreversible heart failure. Bone marrow
suppression, extravasation can cause severe pain
and extensive tissue damage. Severe n/v/d,
mucositis, pulmonary toxicity, hypersensitivity
reactions (including anaphylaxis). Acute
myelogenous leukemia may occur 1-3 years later.
Natural Products Category:
Plant Extracts & Alkaloids
• Prototype Drug: Vincristine (Oncovin)
• Actions and Uses:
Vincristine, a Vinca Alkaloid from the periwinkle
plant, is a cell-cycle-specific agent that prevents
cells from completing mitosis by interrupting the
M-phase of replication, has a broad spectrum of
activity and causes minimal immuno-suppression.
Treats pediatric leukemia's, lymphomas, and solid
tumors.
Vincristine (Oncovin)
1.4mg/m2 IV weekly
• Adverse Effects:
– Common: N/V, alopecia, anorexia, stomatitis, rash,
asthenia
– Serious: Bone marrow suppression, Severe n/v/d,
mucositis; cardio, pulmonary, neuro and
nephrotoxicity; hypersensitivity reactions
(including anaphylaxis).
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• Nurse’s Drug Guide 2009
Hormones & Hormone
Antagonists
• Actions and Uses: Very large doses of
glucocorticoids, progestins, estrogens or
androgens that block essential substances for
the growth of hormone-dependant tumors of
the brest or prostate. As a group, they are the
least toxic of the antineoplastic drugs.
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Tamoxifen (Nolvadex)
• Actions and Uses: Tamoxifen is the prototype
antineoplastic drug in the Hormone
Antagonist (antiestrogen) Class. It is the drug
of choice for treatment of metastatic brest
cancers which have cells that require estrogen
for growth (estrogen receptor positive). Also,
Tamoxifen is given prophylactcally to high-risk
clients to prevent the disease.
Tamoxifen (Nolvadex)
10-20 mg PO daily/BID
• Adverse Effects:
– Common: hot flashes, insomnia, brest
enlargement & pain, H/A, N/D, asthenia,
vaginal discharge, fluid retention
– Serious: hypersensitivity reactions
(including anaphylaxis), thromboembolic
disease, sexual dysfunction, HTN,
increased risk for endometrial CA
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Biologic Response Modifiers &
Immune Therapies
• Action and Uses: This group of drugs
modify and or stimulate the bodies own
immune system to fight the cancer cells.
This class includes Interferons,
Interleukin-2, and Monoclonal
antibodies.
interferon alfa-2 (Intron-A)
• Actions and Uses: This prototype drug is
naturally produced by T cells in response to
viral and biological stimuli. Interferons possess
a generalized action, suppressing cell division,
enhancing phagocytic activity and promoting
cytotoxic action of T lymphocytes. Treats hairy
cell leukemia, Kaposi’s Sarcoma (KS) and
chronic Hepatitis B or C.
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interferon alfa-2 (Intron A)
(leukemia 2-3 million, KS 36 million units daily SubQ/IM)
• Adverse Effects:
–Common: stomatitis anorexia, N/V, ,
alopecia, stomatitis, rash, asthenia,
–Serious: Bone marrow suppression,
severe n/v/d, pulmonary toxicity,
hypersensitivity reactions (including
anaphylaxis)
Monoclonal Antibodies (MABs)
• MAB’s are engineered or synthesized to attack
one specific tumor antigen (protein). Upon
binding to the cancer cell, the cancer cell is
identified by the host as foreign. Rituzamab
and Alemtozumab kill cancer cells via
phagocytosis, compliment fixation, and
apoptosis. Cetuximab and Trastuzumab stop
tumor cell growth by inhibiting growth factor
receptors.
Mr. C.
• 5th day post op Mr. C. is managing clear liquids
in small amounts and remains afebrile. His
WBC’s remain low at 3.9 and his Platelets are
59,000. His incisions are healing, and he has
had a small BM. Upon discharge, he will
continue to receive treatment with 5FU and
Cytoxan at the Out Patient Oncology Unit
(OOU).
Mr. C.
• A Port-a-Cath has been placed to his right
upper chest. The nurse asks him if he is feeling
depressed. She provides support and active
listening as he shares his concerns. The nurse
contacts his brother at his request. As the
nurse leaves the room, Mr. C. smiles and says,
“I’ll be fine.”
Mr. C.
• Mr. & Mrs. C. understand that they are to
watch for fever, increased fatigue and avoid
people with infections. They will call to
arrange appointments with the OOU and also
keep their appointments with the Surgeon
and Oncologist. The Visiting Nurse Association
(VNA) will follow up with twice weekly home
visits and provide referrals to Home Health
Agencies and Care Giver Support Groups as
needed.
Discussion/Reflections
• What QSEN Competencies could be applied to
this scenario?
• What stressors, lines of defense and resistance
and reactions could be involved when
discussing the Neuman Systems Model?
Cancer Vaccines
•
April 2010, FDA approved first cancer treatment vaccine,
sipuleucel-T (Provenge®). It stimulates an immune response for
prostatic acid phosphatase (PAP), an antigen associated with
prostate cancer. Men who had a specific type of metastatic prostate
cancer received Sipuleucel-T demonstrated an added survival of by
about 4 months (19).
• The U.S. Food Drug Administration (FDA) has approved two new
vaccines, Gardasil® and Cervarix®, and that protect against
infection by two types of HPV that cause approximately 70 percent
of all cases of cervical cancer (vaginal, vulvar) worldwide, as well as
anal, penile, and oropharyngeal cancers (10).
• In 1981, The FDA approved the first cancer preventive vaccine that
protects against HBV infection. Chronic HBV infection can lead to
liver cancer. Today, most children in the United States are
vaccinated against HBV shortly after birth (12).
• http://www.cancer.gov
References
Pharmacology for Nurses, A Pathophysiological Approach, 2nd Ed., 2008, 3rd
Edition 2011 Pearson Education, Inc.
American Cancer Society 2011
Nursing Drug Handbook 2008, Lippincott, Williams & Wilkins
Nurse’s Drug Guide 2009, Prentice Hall
http://www.merck.com/mmhe/sec09/ch131/ch131i.html
en.wikipedia.org/wiki/Purine
http://www.cancer.gov Retrieved 10/18/10
Medical-Surgical Nursing: Clinical Management for Positive Outcomes, 8th Ed.
2009, Black, J., Hawks, J. Saunders/Elsevier Inc.