Transcript Long Term Effects of Chemotherapy

Long Term Effects of
Chemotherapy
Tracy Sarin, ARNP
Definition
• Late effects: side effects that occur months to years after
treatment
• Issues arise from surgery, radiation, and chemotherapy
Who and Why
• Multidisciplinary
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Primary care providers
Hematology/oncology
Nursing
Physical and/or occupational therapy
Mental health professional
• 2006 IOM report: From Cancer Patient
to Cancer Survivor: Lost in Translation
Cancer Statistics
• In 2014, nearly 14.5 million Americans with a history of cancer
were alive (DeSantis, et al, 2014)
Men
Prostate (43%)
Colorectal (9%)
Melanoma (8%)
Women
Breast (43%)
Endometrial (8%)
Colorectal (8%)
• By 2024, population of cancer survivors will increase to
approximately 19 million people (DeSantis, et al, 2014)
Virtually Every System is
Affected
Head and Neck
• Brain/CNS
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Hearing changes
Cognitive impairment
Memory issues
Peripheral neuropathy
• Eye
• Cataracts
• Vision change
• Oral health/Dental
• Decreased tooth enamel
• Osteonecrosis of the jaw
Head and Neck
• Offending agents
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Vinca alkaloids (vincristine)
Platinums (carbo, cis, oxali
Taxanes (paclitaxel, docetaxel)
Etoposide
Cytarabine—high dose
Ifosfamide—high dose
Methotrexate—high dose
Steroids
Bisphosphonates
Cardiovascular
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CHF
Hypertension
MI
DVT
• Particularly with hormone treatment
• Edema
• Hyperlipidemia
• Cardiomyopathy
• Biggest offenders
• Anthracyclines and HER2 targeted drugs (doxorubicin,
daunorubicin, traztuzumab, pertuzumab, etc)
Pulmonary
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Shortness of breath
Decreased lung capacity
Pulmonary fibrosis
Interstitial lung disease
• Offending agents
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Bleomycin (most common)—10%
Carmustine (BCNU) – 20-30% of those getting high dose therapy
Methotrexate – 8%
Alkylating agents (cyclophosphamide, busulfan) - <1%
????? Immunotherapy agents (nivolumab, pembrolizumab,
ipilimumab)????????---stay tuned
GI/GU
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Digestion
Neuropathy in gut
Chronic bowel changes
Bladder cystitis
• Offending chemotherapies
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Vinca alkaloids (vincristine)
Cyclophosphamide
Ifosfamide
Platinums (carboplatin, oxaliplatin, cisplatin)
Endocrine
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Menopause/ovarian failure
Infertility
Weight gain
Decreased libido
Erectile dysfunction
Hormone deprivation in men
Diabetes
Thyroid dysfunction
Hot flashes
Endocrine
• Treatment causes
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Busulfan
Chlorambucil
Cisplatin
Cyclophosphamide
Nitrogen mustard
Tamoxifen
Aromatase inhibitors (anastarzole, exemestane, letrozole)
Bicalutamide
Leuprolide
Steroids
Ipilumumab
Musculoskeletal
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Osteoporosis
Osteopenia
Increased risk of fracture
Arthralgias
Myalgias
• Offending agents
• Hormone therapy (aromatase inhibitors)
• Steroids
• Chemotherapies inducing menopause
Skin
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Nail changes
Dry skin
Skin discoloration
Sun sensitivity
Radiation recall
• Offenders
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Taxanes
5FU
Cyclophosphamide
Doxorubicin
Hydroxyurea
BRAF inhibitors used in melanoma
Bone Marrow/Secondary
Cancers
• Cytopenias
• MDS
• Secondary cancer
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1-3% of patients develop a new, secondary cancer
Rate is higher in pediatric cancer survivors
ALL in kids--secondary AML
Colorectal cancer--secondary colon/retctal primary or other
digestive organs
• Lung—secondary lung, head/neck, and GU
• Melanoma—additional skin cancers
• Causative agents: doxorubicin,BCNU,
ifosfamide, cytoxan, melphalan, etc.
Emotional
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Depression
Anxiety
Mood swings
Guilt
Fear of recurrence
Post-traumatic stress disorder
Gratitude
• Financial implications of chemotherapy
FATIGUE
• Most common side effect of cancer treatment
• Offending agents: ALL chemotherapy/hormone
therapy/biotherapy/immunotherapy
What to do, what to do
• Brain/CNS
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Hearing changes—audiology referral
Eye issues— ophthalmology referral, cataract surgery
Oral/dental— diligent dental care
Chemobrain—patience, CBT, neuropsych referral
Peripheral neuropathy
• Assess for functional impairment
• Patience
• Medication management: gabapentin, pregabalin,
duloxetine, amitriptyline, opioids
• PT referral
• Neurology referral
Cardiovascular
• Monitoring
• Check EF during treatment with cardiotoxic drugs
• CHF—swelling, SOA
• DVT—doppler if indicated (particularly in those on hormone
therapy)
• Heart disease/hyperlipidemia
Pulmonary
• Surveillance/monitoring
• Lung disease—refer to pulmonary or managed by PCP
• Immunotherapy—treat with steroids and taper
GI/GU
• Digestion
• Constipation—fiber/laxatives, GI referral
• Diarrhea—loperamide, diphenoxylate with atropine, codeine,
cholestyramine, GI referral
• Neuropathy—motility agents, GI referral
• Bladder cystitis
• Urology referral
Endocrine
• Proactivity/counseling for fertility issues
• AYA program, referral for banking
• Women’s health issues
• Menopause/ovarian failure/dryness/hot flashes
• Avoid herbs/supplements and hormone replacement therapy
• Lubricants
• Assessment of hot flashes
• Venlafaxine, gabapentin, clonidine
• Weight gain
• Exercise, referral to dietitian, support groups
• DM/thyroid
• PCP or endocrinologist
Musculoskeletal
• Bone density testing
• Ca++ with vitamin D
• Weight bearing exercise
• Assistive device if needed, SAFETY FIRST
• PT referral
• Bisphosphonates
Skin
• Emollients
• Protection
• Avoidance
• Sunscreen
• Cover
• Surveillance by PCP
• Dermatology referral
Cytopenias/Secondary cancers
• Investigation
• Anemia, thrombocytopenia, leukopenia
• BMBX necessary?
• Encourage followup
• Follow screening guidelines
Emotional
• Referral
• Counseling
• Support groups
• Medication management
• Antidepressants
• Antianxiety medications
• Financial
• Financial counselor
Fatigue
• Exercise
• PATIENCE
• Treat underlying causes
• Anemia
• Thyroid conditions
• Vitamin D deficiency
• Energy conservation
• Prioritize activities
• Dietary modifications
Case Study
Conclusion
• Population of cancer survivors will only grow
• ASSESS, ASSESS, ASSESS
• Treat or refer
References
• Cancer.Net. (2016). Long-term side effects of cancer treatment. Retrieved August,
2016, http://www.cancer.net/survivorshiplong-term-side-effects-cancer-treatment
• DeSantis, C., Lin, C., Mariotto, A., Siegel, R., et al. (2014). Cancer treatment and
survivorship statistics, 2014. CA: A Cancer Journal for Clinicians, 252-271.
• MDAnderson Cancer Center. (2016). Possible side effects of cancer treatment.
Retrieved, August, 2016, https://www.mdanderson.org/patients-family/life-aftercancer/long-term-effects.html
• Mayo Clinic. (2016). Cancer survivors: Late effects of cancer treatment. Retrieved
August, 2016, http://www.mayoclinic.org/diseases-conditions/cancer/indepth/cancer-survivor/art-20045524
• Oncology Nursing Society. (2014). Red flags in caring for cancer survivors. Retrieved
August, 2016,
https://www.ons.org/sites/default/files/media/Red%20Flags%20for%20Cancer%20Su
rvivors.pdf
• Up to Date. (2016). Long term side effects of chemotherapy. Retrieved August,
2016,
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