Pharmacology for Nurses: A
Pathophysiologic Approach
Sixth Edition
Chapter 38
Drugs for Neoplasia
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Learning Outcomes (1 of 2)
38.1 Compare and contrast differences between normal cells and
cancer cells.
38.2 Identify factors associated with an increased risk of cancer.
38.3 Describe lifestyle factors associated with a reduced risk of
acquiring cancer.
38.4 Identify the three primary therapies for cancer.
38.5 Explain the significance of growth fraction and the cell cycle to the
success of chemotherapy.
38.6 Describe the nurse’s role in the pharmacologic management of
cancer.
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Learning Outcomes (2 of 2)
38.7 Explain how combination therapy and special dosing protocols
increase the effectiveness of chemotherapy.
38.8 Describe the general adverse effects of chemotherapeutic drugs.
38.9 For each of the drug classes listed in Drugs at a Glance, know
representative drugs, and explain their mechanism of drug action,
primary actions, and important adverse effects.
38.10 Categorize anticancer drugs based on their classification and
mechanism of action.
38.11 Use the nursing process to care for patients receiving
pharmacotherapy for cancer.
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Cancer (Carcinoma)
• Characterized by rapid, uncontrolled cell division
• Cells lose normal functions and invade normal tissues
• Metastasis: cancer cells travel to another location
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Tumor (Neoplasm)
• Named for tissue where it originates
– Suffix – oma, as in lymphoma
• May be solid masses or disseminated in blood
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Table 38.1 Classification and Naming
of Tumors
Name
Description
Examples
Benign tumor
Slow growing; does not metastasize and
rarely requires drug treatment
Adenoma, papilloma and lipoma,
osteoma, meningioma
Carcinoma
Cancer of epithelial tissue; most common
type of malignant neoplasm; grows rapidly
and metastasizes
Malignant melanoma, squamous cell
carcinoma, renal cancer,
adenocarcinoma, hepatocellular
carcinoma
Glioma
Cancer of glial (interstitial) cells in the central
nervous system
Telangiectatic glioma, brainstem
glioma
Leukemia
Cancer of the blood-forming cells in bone
marrow; may be acute or chronic
Myelocytic leukemia, lymphocytic
leukemia
Lymphoma
Cancer of lymphoid tissue
Hodgkin disease, lymphoblastic
lymphoma
Malignant
tumor
Grows rapidly, becomes resistant to
treatment, and results in death if untreated
Malignant melanoma
Sarcoma
Cancer of connective tissue; grows
extremely rapidly and metastasizes early in
the progression of the disease
Osteogenic sarcoma, fibrosarcoma,
Kaposi sarcoma, angiosarcoma
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Figure 38.1
Invasion and metastasis by cancer cells
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Causes of Cancer (1 of 3)
• Some known carcinogens
• Chemical
– Tobacco (responsible for one third of all cancers)
– Asbestos (lung cancer)
– Benzene (leukemia)
• Physical
– X-rays (leukemia)
– Ultraviolet (UV) light from sun (skin cancer)
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Causes of Cancer (2 of 3)
• Biological
– Viruses (associated with 15% of all cancers)
▪ Examples: herpes simplex viruses, Epstein–Barr,
papillomavirus, cytomegalovirus
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Causes of Cancer (3 of 3)
– Factors that suppress immune system
▪ HIV
▪ Drugs given after transplants
– Oncogenes (genetic predisposition)
– Damage to tumor suppressor gene
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Environmental and Lifestyle
Factors (1 of 2)
• Many associated with higher risk of cancer
• Encourage patients to adopt healthy lifestyle habits
– Eliminate use of and exposure to tobacco
– Limit alcohol use
– Eat healthy diet (low in fat, high in fruits and
vegetables)
– Choose most foods from plant sources
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Environmental and Lifestyle
Factors (2 of 2)
• Exercise regularly; keep weight normal
• Use protection from sun
• Self-examine body monthly for abnormal lumps and skin
lesions
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Lifestyle Factors Regarding Prevention
and Diagnosis
• Get periodic screenings
– Mammogram
– Prostate exam
– Fecal occult blood test
– Colonoscopy
– Pap test and pelvic exam
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Treatment of Cancer
• Drug therapy (chemotherapy)
– To cure
– For palliation
– For prophylaxis
• Surgery
• Radiation therapy
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Chemotherapy
• Transported through blood
– Has potential to reach each cancer cell
• Some drugs can cross blood–brain barrier
• Some drugs distilled directly into body cavities (e.g.,
bladder)
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Surgery
• Performed to remove tumor
– When localized
– When pressing on nerves, airways, or other vital
tissues
• Surgery sometimes not an option
– If tumors affect blood cells
– If surgery would not extend lifespan or improve quality
of life
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Radiation
• Can destroy tumor cells
• Ionizing radiation aimed directly at tumor
• May follow surgery
• Used as palliation for inoperable cancers
– Shrinks size of tumor
– Relieves pain, difficulty breathing or swallowing
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Adjuvant Chemotherapy
• Often combined with or done after surgery and radiation
to increase chance of cure
• May be given as chemoprophylaxis to prevent cancer in
high-risk patients
– Tamoxifen to prevent recurrent breast cancer
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Growth Fraction (1 of 2)
• Measure of how many cells are undergoing mitosis
– Ratio of replicating cells to resting cells
• Major factor in determining success of chemotherapy
• Chemotherapy most effective against rapidly dividing cells
• High growth fraction = many replicating cells
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Growth Fraction (2 of 2)
• Solid tumors have low growth fraction; thus less sensitive
to chemotherapy
• Leukemias and lymphomas have high growth fraction;
thus chemotherapy more effective
• Hair follicles, bone marrow, gastrointestinal tissue have
high growth factor—this explains many adverse effects
(e.g., hair loss)
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Cell Cycle
• Cell cycle
– G0 phase: resting stage
– G1 phase: synthesizes material needed to duplicate
DNA
– S phase: Duplicates DNA
– G2 phase: Premitotic phase
– M phase: Mitosis occurs
– Cell returns to G0 phase
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Figure 38.2
Antineoplastic drugs and the cell cycle
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Achieving Total Cure
• Total cure = every malignant cell removed or killed
– Even one cell could reproduce
– Immune system eliminates very small number of
cancer cells
• Important to diagnose cancer early
– Treat with surgery, radiation, chemotherapy
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Figure 38.3
Cell kill and chemotherapy
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Multiple-Drug Strategy
• Multiple drugs from different classes
– Affect different stages in cell cycle
– Use different mechanisms of action to increase cell kill
• Combinations allow for lower doses
– Reduce toxicity
– Slow development of resistance
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Dosing Schedules (1 of 2)
• Specific dosing protocols
– Depend on type of tumor, stage of disease, overall
condition of patient
– May be given as single dose or several doses
– May be given within days or after several weeks
▪ Gives normal cells chance to recover
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Dosing Schedules (2 of 2)
• Sometimes optimal dose must be delayed
– Lets patient recover from drug toxicities
– Example: in bone marrow depression
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Serious Toxicity Limits Therapy (1 of 3)
• Difficult to kill cancer cells without killing normal cells
• Adverse effects of therapy:
– Alopecia
– Mucositis (painful ulcerations, GI bleeding, diarrhea)
– Nausea and vomiting
▪ Drugs with high emetic potential pretreated with
antiemetics (Zofran, Compazine, Reglan, Ativan)
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Serious Toxicity Limits Therapy (2 of 3)
• Adverse effects of therapy:
– Bone marrow depression (anemia, leukopenia,
thrombocytopenia)
▪ Treated with bone-marrow transplantation, platelet
infusions, or growth factors
– If neutropenia occurs (less than 1500 cells/mL),
infection risk grows
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Serious Toxicity Limits Therapy (3 of 3)
• Vesicants
– Can cause tissue injury if extravasation occurs
– Know emergency treatment before giving vesicants IV
• Long-term consequences
– Possible infertility
– Increased risk for secondary tumors
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Antineoplastics (1 of 3)
• Alkylating agents
– Form bonds with DNA, prevent cell division
• Antimetabolites
– Resemble building blocks of cells
– Disrupt metabolism of nucleic acid
• Antitumor antibiotics
– Antibiotics that can kill some cancer cells
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Antineoplastics (2 of 3)
• Natural products
– From plants, prevent division of cancer cells
• Hormones and hormone agents
– Slow growth of hormone-dependent tumors
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Antineoplastics (3 of 3)
• Biologic response modifiers and monoclonal antibodies
– Enhance body's ability to remove cancer cells
• Miscellaneous drugs
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Alkylating Agents (1 of 3)
• Broad spectrum of activity
• Act by changing structure of DNA in cancer cells
• Use is limited—can cause significant bone marrow
suppression
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Alkylating Agents (2 of 3)
• Prototype drug: cyclophosphamide (Cytoxan)
• Mechanism of action: attaches to DNA and disrupts
replication
• Primary use: to treat wide variety of cancers, including
Hodgkin disease, lymphoma, multiple myeloma, breast
cancer, ovarian cancer
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Alkylating Agents (3 of 3)
• Adverse effects: immunosuppressant effects,
thrombocytopenia
– Nausea, vomiting, anorexia, diarrhea
– Alopecia, hemorrhagic cystitis
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Prototype Drug: Cyclophosphamide
(Cytoxan) (1 of 5)
Therapeutic Class: Antineoplastic
Pharmacologic Class: Alkylating agent; nitrogen mustard
Actions and Uses
Cyclophosphamide is a nitrogen mustard frequently prescribed to fight a wide
variety of cancers, including Hodgkin disease, lymphoma, multiple myeloma,
breast cancer, and ovarian cancer. Cyclophosphamide acts by attaching to DNA
and disrupting replication, particularly in rapidly dividing cells. It is one of only a
few anticancer drugs that are well absorbed when given orally (PO).
Cyclophosphamide is a powerful immunosuppressant. While this is considered
an adverse effect during cancer chemotherapy, the drug is used to intentionally
cause immunosuppression for the prophylaxis of organ transplant rejection and
to treat severe rheumatoid arthritis and systemic lupus erythematosus (SLE).
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Prototype Drug: Cyclophosphamide
(Cytoxan) (2 of 5)
Administration Alerts
• Dilute prior to IV administration.
• Monitor platelet count prior to IM administration; if low,
hold dose.
• To avoid GI upset, take with meals or divide doses.
• Pregnancy category C.
Pharmacokinetics (PO)
Onset
Peak
Duration
1–2 h
1–2 h
Unknown
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Prototype Drug: Cyclophosphamide
(Cytoxan) (3 of 5)
Adverse Effects
Bone marrow suppression is a potentially life-threatening adverse reaction that
occurs during days 9–14 of therapy; the patient is at dangerous risk for severe
infection and sepsis during this period. Thrombocytopenia is common, though
less severe than with many other alkylating agents. Nausea, vomiting, anorexia,
and diarrhea are frequently experienced. Cyclophosphamide causes reversible
alopecia, although the hair may regrow with a different color or texture. Several
metabolites of cyclophosphamide may cause hemorrhagic cystitis if the urine
becomes concentrated; patients should be advised to maintain high fluid intake
during therapy. The drug may cause permanent sterility in some patients. Unlike
other nitrogen mustards, cyclophosphamide exhibits little neurotoxicity.
Contraindications: Cyclophosphamide is contraindicated in patients with
hypersensitivity to the drug and for those who have active infections or severely
suppressed bone marrow.
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Prototype Drug: Cyclophosphamide
(Cytoxan) (4 of 5)
Interactions
Drug–Drug: Immunosuppressant drugs used concurrently with
cyclophosphamide will increase the risk of infections and further
development of neoplasms. There is an increased chance of
bone marrow toxicity if cyclophosphamide is used concurrently
with allopurinol. There is an increased risk of bleeding if given
with anticoagulants.
If used concurrently with digoxin, decreased serum levels of
digoxin occur. Use with insulin may lead to hypoglycemia.
Phenobarbital, phenytoin, or glucocorticoids used concurrently
may lead to an increased rate of cyclophosphamide metabolism
by the liver. Use with hydrochlorothiazide increases the toxicity
of the cyclophosphamide.
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Prototype Drug: Cyclophosphamide
(Cytoxan) (5 of 5)
Lab Tests: Serum uric acid levels may increase. Blood cell
counts will diminish due to bone marrow suppression.
Positive reactions to Candida, mumps, and tuberculin skin
tests are suppressed. Pap smears may give false positives.
Herbal/Food: St. John’s wort may increase the toxic effects
of cyclophosphamide.
Treatment of Overdose: There is no specific treatment for
overdose.
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Role of the Nurse: Alkylating Agents (1 of 3)
• Discontinue if RBC, WBC, and platelet counts fall
• Use caution with hepatic or renal impairment, recent
steroid therapy, leukopenia, or thrombocytopenia
• Hydrate patients with IV or oral fluids before starting
chemotherapy
• Advise patients to avoid crowds and those with respiratory
infections
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Role of the Nurse: Alkylating Agents (2 of 3)
• Be alert to possible development of blood dyscrasias
• Monitor nutritional intake
• Assess for nausea and vomiting
– Be prepared to administer antiemetic drugs
• Offer ice chips or ice pops to relieve mouth pain
• Assess skin integrity
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Role of the Nurse: Alkylating Agents (3 of 3)
• Monitor for signs of hearing loss
• Inform patients of potential adverse impact on fertility
• Alkylating agents range from pregnancy category C to X
• Maintain strict medical asepsis
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Antimetabolites (1 of 3)
• Act by disrupting critical pathways in cancer cells
– Example: folate metabolism or DNA synthesis
• Three types of antimetabolites:
– Folic acid analogs
– Purine analogs
– Pyrimidine analogs
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Antimetabolites (2 of 3)
• Prototype drug: methotrexate (Rheumatrex, Trexall)
• Mechanism of action: blocks synthesis of folic acid
(vitamin B9) to inhibit replication
• Primary use: to treat choriocarcinoma, osteogenic
sarcoma, leukemias, head and neck cancers, breast
carcinoma, lung carcinoma
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Antimetabolites (3 of 3)
• Adverse effects:
– Fatal bone marrow toxicity at high doses
– Hemorrhage and bruising, low platelet counts
– Nausea, vomiting, anorexia
– Gastrointestinal ulceration, intestinal bleeding
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Prototype Drug: Methotrexate
(MTX, Rheumatrex, Trexall) (1 of 5)
Therapeutic Class: Antineoplastic
Pharmacologic Class: Antimetabolite, folic acid analog
Actions and Uses
Methotrexate is a widely prescribed antimetabolite available by the oral, parenteral, and
intrathecal routes. By blocking the synthesis of folic acid, methotrexate inhibits replication,
particularly in rapidly dividing cells. It is prescribed alone or in combination with other drugs
for choriocarcinoma, osteogenic sarcoma, leukemias, head and neck cancers, breast
carcinoma, and lung carcinoma. Its primary use as an antineoplastic agent is in
combination therapy to maintain induced remissions in those individuals who have had
surgical resection or amputation for a primary tumor.
In addition to its role as an antimetabolite, methotrexate has powerful immunosuppressant
properties. While immunosuppression is considered an adverse effect in patients with
cancer, this action of methotrexate can be used to advantage in treating patients with
severe rheumatoid arthritis, ulcerative colitis, and psoriasis.
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Prototype Drug: Methotrexate
(MTX, Rheumatrex, Trexall) (2 of 5)
Administration Alerts
• Avoid skin exposure to the drug.
• Avoid inhaling drug particles.
• Dilute prior to IV administration.
• Pregnancy category X.
Pharmacokinetics
Onset
Peak
Duration
1–4 h PO; 0.5–2 h IM/IV
1–2 h
Unknown
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Prototype Drug: Methotrexate
(MTX, Rheumatrex, Trexall) (3 of 5)
Adverse Effects
Methotrexate has many adverse effects, some of which can be life-threatening.
Nausea and vomiting are severe at high doses.
Black Box Warning: Methotrexate carries multiple black box warnings.
Methotrexate combined with nonsteroidal anti-inflammatory drugs (NSAIDs) may
cause severe and sometimes fatal myelosuppression, which is the primary doselimiting toxicity of this drug. The drug is hepatotoxic and may cause liver cirrhosis
with prolonged use. Ulcerative stomatitis and diarrhea require suspension of
therapy because they may lead to hemorrhagic enteritis and death from intestinal
perforation. Potentially fatal opportunistic infections, including Pneumocystis
pneumonia, may occur during therapy. Pulmonary toxicity may result in acute or
chronic interstitial pneumonitis at any dose level. Severe, sometimes fatal,
dermatologic reactions such as toxic epidermal necrolysis and Stevens–Johnson
syndrome (SJS) have been reported. Low doses of methotrexate have been
associated with the development of malignant lymphomas. High doses can cause
acute kidney injury (AKI).
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Prototype Drug: Methotrexate
(MTX, Rheumatrex, Trexall) (4 of 5)
Contraindications: The use of methotrexate as an antineoplastic is
contraindicated in thrombocytopenia, anemia, leukopenia, concurrent
administration of hepatotoxic drugs and hematopoietic suppressants.
Methotrexate is teratogenic and is contraindicated in pregnant women.
Immunosuppressed patients or those with blood dyscrasias should not receive
methotrexate. Use with alcohol may increase the hepatotoxicity of methotrexate.
Interactions
Drug–Drug: Bone marrow suppressants, such as chemotherapy agents or
radiation therapy, may cause increased effects; the patient will require a lower
dose of methotrexate. Concurrent use with NSAIDs (including aspirin) may lead
to severe methotrexate toxicity. Concurrent administration with live oral vaccines
may result in decreased antibody response and increased adverse reactions to
the vaccine.
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Prototype Drug: Methotrexate
(MTX, Rheumatrex, Trexall) (5 of 5)
Lab Tests: Serum uric acid levels may increase. Blood cell
counts will diminish due to bone marrow suppression.
Herbal/Food: Food delays the oral absorption of methotrexate.
Echinacea may increase the risk of hepatotoxicity. More than 180
mg per day of caffeine (3 to 4 cups of coffee) may decrease the
effectiveness of methotrexate when taken for arthritis.
Treatment of Overdose: Leucovorin is sometimes administered
with methotrexate to “rescue” normal cells or to protect against
severe bone marrow damage. It is most effective if administered
as soon as possible after the overdose is discovered. In addition,
the urine may be alkalinized to protect the kidneys from
methotrexate toxicity.
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Role of the Nurse: Antimetabolites (1 of 2)
• Contraindicated in pregnancy; hepatic, cardiac, and renal
insufficiency; myelosuppression; and blood dyscrasias
• Avoid pregnancy for at least 6 months after therapy with
category X drug
• Adverse effects common to other antineoplastics may
occur
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Role of the Nurse: Antimetabolites (2 of 2)
• Monitor for photosensitivity and idiosyncratic pneumonitis
• Teach patients to use good oral hygiene and encourage
mouth rinses
• Monitor IV site frequently for extravasation
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Antitumor Antibiotics (1 of 2)
• Act by inhibiting cell growth through cytotoxicity
– Actions similar to alkylating agents
• Narrow spectrum of clinical activity
• Cardiotoxicity is major limiting factor
– May occur within minutes or years later
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Antitumor Antibiotics (2 of 2)
• Adverse effects: cardiotoxicity, dysrhythmias
– Irreversible heart failure, lower blood cell counts
– Nausea, vomiting
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Prototype Drug Doxorubicin
(Adriamycin) (1 of 5)
Therapeutic Class: Antineoplastic
Pharmacologic Class: Antitumor antibiotic
Actions and Uses
Doxorubicin attaches to DNA, distorting its double helical structure and preventing normal
DNA and RNA synthesis. It is administered only by IV infusion. Doxorubicin is a broadspectrum cytotoxic antibiotic, prescribed for solid tumors of the bone, GI tract, thyroid, lung,
breast, ovary, and bladder, and for various leukemias and lymphomas. It is structurally
similar to daunorubicin. Doxorubicin is considered to be one of the most effective single
drugs against solid tumors.
Doxorubicin liposomal (Doxil, Evacet) is a form of the drug incorporated into liposomes,
closed, spherical molecules that encase the drug. The liposomal vesicle is designed to
open and release the antitumor antibiotic when it reaches a cancer cell. The goal is to
deliver a higher concentration of drug to the cancer cells, thus sparing normal cells. An
additional advantage is that doxorubicin liposomal has a half-life of 50 to 60 hours, which is
about twice that of regular doxorubicin. Doxorubicin liposomal is approved for use in
patients with Kaposi sarcoma, refractory ovarian tumors, and relapsed multiple myeloma.
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Prototype Drug Doxorubicin
(Adriamycin) (2 of 5)
Administration Alerts
• Extravasation can cause severe pain and extensive tissue damage. Skin
contact or extravasation should be treated immediately with local ice packs to
reduce absorption of the drug.
• For infants and children, verify concentration and rate of IV infusion with the
healthcare provider.
• Avoid skin contact with the drug. If exposure occurs, wash thoroughly with
soap and water.
• Pregnancy category D.
Pharmacokinetics
Onset
Peak
Duration
Rapid
30 min–2 h
Up to 30–40 h
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Prototype Drug Doxorubicin
(Adriamycin) (3 of 5)
Adverse Effects
Doxorubicin has many adverse effects, some of which are serious. The most
serious dose-limiting adverse effect of doxorubicin is cardiotoxicity. Like many
anticancer drugs, doxorubicin may profoundly lower blood cell counts. Acute
nausea and vomiting are common and often require antiemetic therapy.
Complete, though reversible, hair loss occurs in most patients.
Black Box Warning: Severe myelosuppression may occur, which is the major
dose-limiting toxicity with doxorubicin. It may manifest as thrombocytopenia,
leukopenia, and anemia. Doxorubicin exhibits significant cardiotoxicity, which
may be either acute or chronic. Cardiac adverse effects can be life-threatening
and may include sinus tachycardia, bradycardia, delayed heart failure, acute left
ventricular failure, and myocarditis. Heart failure may occur months or years
after the termination of chemotherapy. Acute, infusion-related reactions may
occur, including anaphylaxis. Severe local necrosis may result if extravasation
occurs. Secondary malignancies, especially acute myelogenous leukemia, may
occur 1 to 3 years following therapy.
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Prototype Drug Doxorubicin
(Adriamycin) (4 of 5)
Contraindications: Contraindications include pregnancy, severe
hepatic impairment, lactation, myelosuppression, thrombocytopenia,
preexisting cardiac disease, obstructive jaundice, or previous treatment
with complete cumulative doses of doxorubicin or daunorubicin.
Interactions
Drug–Drug: Use with phenytoin may lead to increased plasma
clearance of doxorubicin and decreased effectiveness. Use with
phenytoin may lead to decreased phenytoin level and possible seizure
activity. Hepatotoxicity may occur if mercaptopurine is taken
concurrently. Use with verapamil may increase serum doxorubicin
levels, leading to doxorubicin toxicity.
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Prototype Drug Doxorubicin
(Adriamycin) (5 of 5)
Lab Tests: Serum uric acid and aspartate aminotransferase
(AST) levels may increase. Blood cell counts will diminish
due to bone marrow suppression.
Herbal/Food: Green tea may enhance the antitumor activity
of doxorubicin. St. John’s wort may decrease the
effectiveness of doxorubicin.
Treatment of Overdose: The primary result of doxorubicin
overdosage is immunosuppression. Treatment includes
prophylactic antimicrobials, platelet transfusions,
symptomatic treatment of mucositis, and possibly
hemopoietic growth factor (G-CSF, GM-CSF).
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Role of the Nurse: Antitumor
Antibiotics (1 of 2)
• Assess cardiac status—obtain baseline ECG
• Assess for pregnancy and lactation
• Monitor for same cytotoxic effects as other antineoplastics
• Risk of hypersensitivity reactions exists as with other
antibiotics
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Role of the Nurse: Antitumor
Antibiotics (2 of 2)
• Changes in rectal mucosa contraindicate suppositories or
rectal temperatures
• Wear protective clothing (gloves, mask, and apron) when
preparing drug
• Monitor IV site because doxorubicin is a severe vesicant
• Give drug through large-bore, quickly running IV; monitor
for extravasation
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Natural Products (1 of 4)
• Plant extracts
– Structural variety but common effect
– Kill cancer cells by preventing cell division
– Called mitotic inhibitors
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Natural Products (2 of 4)
• Prototype drug: vincristine (Oncovin)
• Mechanism of action: cell cycle–specific (M-phase)
agent that kills cancer cells by preventing their ability to
complete mitosis
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Natural Products (3 of 4)
• Primary use: treatment of Hodgkin and non-Hodgkin
lymphomas
– Leukemias, Kaposi sarcoma, Wilms tumor
– Bladder carcinoma, breast carcinoma
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Natural Products (4 of 4)
• Adverse effects: nervous system toxicity, numbness and
tingling in limbs
– Muscular weakness, loss of neural reflexes, pain
– Paralytic ileus, constipation, alopecia
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Mitotic Inhibitors
• Vinca alkaloids
• Taxanes
• Topoisomerase inhibitors
• Camptothecins
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Prototype Drug: Vincristine
(Oncovin) (1 of 4)
Therapeutic Class: Antineoplastic
Pharmacologic Class: Vinca alkaloid, mitotic inhibitor, natural product
Actions and Uses
Vincristine is specific for the M-phase of the cell cycle, where it kills cancer cells by
preventing their ability to complete mitosis. It exerts this action by inhibiting
microtubule formation in the mitotic spindle. Although vincristine must be given IV,
its major advantage is that it causes minimal immunosuppression. It has a wider
spectrum of clinical activity than vinblastine and is usually prescribed in
combination with other antineoplastics for the treatment of Hodgkin and nonHodgkin lymphomas, leukemias, Kaposi sarcoma, Wilms tumor, bladder
carcinoma, and breast carcinoma. A newer form of vincristine (Marqibo) is
encased in a liposomal carrier and is approved for acute lymphoblastic leukemia
that has failed to respond to other therapies.
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Prototype Drug: Vincristine
(Oncovin) (2 of 4)
Administration Alerts
• Extravasation may result in serious tissue damage. Stop the injection
immediately if extravasation occurs, apply local heat, and inject
hyaluronidase as ordered. Observe the site for sloughing.
• Avoid eye contact, which can cause severe irritation and corneal
changes.
• Pregnancy category D.
Pharmacokinetics
Onset
Peak
Duration
15–20 min
Unknown
7 days
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Prototype Drug: Vincristine
(Oncovin) (3 of 4)
Adverse Effects
The most serious dose-limiting adverse effects of vincristine relate to nervous
system toxicity. Children are particularly susceptible. Symptoms include
numbness and tingling in the limbs, muscular weakness, loss of neural
reflexes, and pain. Severe constipation is common and paralytic ileus may
occur in young children. Reversible alopecia occurs in most patients.
Black Box Warning: Myelosuppression may be severe and predispose to
opportunistic infections. Extravasation can cause intense pain, inflammation,
and tissue necrosis. If extravasation occurs, treatment with warm compresses
and hyaluronidase is recommended; cold compresses will significantly
increase the toxicity of vinca alkaloids.
Contraindications: Contraindications to the use of vincristine include
obstructive jaundice, men and women of childbearing age, active infection,
adynamic ileus, radiation of the liver, infants, pregnancy, and lactation.
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Prototype Drug: Vincristine
(Oncovin) (4 of 4)
Interactions
Drug–Drug: Asparaginase used concurrently with or before vincristine may
cause increased neurotoxicity secondary to decreased hepatic clearance of
vincristine. Doxorubicin or prednisone may increase bone marrow toxicity.
Calcium channel blockers may increase vincristine accumulation in cells.
Concurrent use with digoxin may decrease digoxin levels. When vincristine is
given with methotrexate, the patient may need lower doses of methotrexate.
Vincristine may decrease serum phenytoin levels, leading to increased seizure
activity.
Lab Tests: Serum uric acid levels may increase.
Herbal/Food: Unknown
Treatment of Overdose: Overdose with vincristine may cause life-threatening
symptoms or death. Symptoms are extensions of the drug’s adverse effects.
Supportive treatment may include administration of leucovorin.
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Role of the Nurse: Natural
Products (1 of 2)
• Assess allergy to plants or flowers, including herbs or
foods
• Vincristine (Oncovin) may produce acute bronchospasm
and skin rashes
• Inquire if women are pregnant or breastfeeding
• Monitor for same cytotoxic effects as other antineoplastics
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Role of the Nurse: Natural
Products (2 of 2)
• Emphasize need to establish nutritional plan to combat
constipation
– High fluid and fiber intake
• Monitor blood pressure
• Observe patients for symptoms such as headache,
dizziness, or syncope
• May produce severe mental depression; assess possibility
of suicidal ideation
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Hormones and Hormone
Antagonists (1 of 3)
• Antineoplastic drugs slow growth of reproductive-related
tumors
– Breast, prostate, uterine
• Less cytotoxic than other antineoplastics
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Hormones and Hormone
Antagonists (2 of 3)
• Prototype drug: tamoxifen
• Mechanism of action: blocks estrogen receptors on
breast cancer cells
• Primary use: patients with breast cancer
– Also given to high-risk patients to prevent disease
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Hormones and Hormone
Antagonists (3 of 3)
• Adverse effects: nausea and vomiting
– Association with increased risk of endometrial cancer
and thromboembolic disease
– Hot flashes, fluid retention, vaginal discharges
common
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Prototype Drug: Tamoxifen (1 of 4)
Therapeutic Class: Antineoplastic
Pharmacologic Class: Estrogen receptor blocker
Actions and Uses
Tamoxifen is an oral antiestrogen that is a preferred drug for treating metastatic breast
cancer. It is effective against breast tumor cells that require estrogen for their growth (ERpositive cells). It has no effect on ER-negative cancers. Whereas tamoxifen blocks
estrogen receptors on breast cancer cells, it actually activates estrogen receptors in other
parts of the body, resulting in typical estrogen-like effects such as reduced low-density
lipoprotein (LDL) levels and increased mineral density of bone. Tamoxifen is approved for
the palliative treatment of advanced, metastatic, ER-positive breast cancer in men and
postmenopausal women.
Tamoxifen and raloxifene are the only antineoplastics approved for prophylaxis of breast
cancer in women who have a high risk of developing the disease. Tamoxifen is also
approved as adjunctive therapy in women following mastectomy to decrease the potential
for cancer in the opposite breast.
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Prototype Drug: Tamoxifen (2 of 4)
Administration Alerts
• Give with food or fluids to decrease GI irritation.
• Do not crush or chew drug.
• Avoid antacids for 1–2 h following PO dosage of
tamoxifen.
• Pregnancy category D.
Pharmacokinetics
Onset
Peak
Duration
Unknown
5h
5–7 days
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Prototype Drug: Tamoxifen (3 of 4)
Adverse Effects
Nausea and vomiting are common adverse effects of tamoxifen. Hot flashes,
fluid retention, and vaginal discharges are relatively common. Tamoxifen
causes initial “tumor flare,” an idiosyncratic increase in tumor size, but this is
an expected therapeutic event. Hypertension and edema occur in about 10%
of patients taking the drug.
Black Box Warning: The most serious problem associated with tamoxifen
use is the increased risk of uterine cancer. The benefits of tamoxifen
outweigh the risks in women who are taking tamoxifen to treat breast cancer.
The benefit versus risk is not as clear in women who are taking tamoxifen to
prevent breast cancer. There is also a slightly increased risk of
thromboembolic disease, including stroke, pulmonary embolism, and deep
vein thrombosis with the use of tamoxifen. The risk of a thromboembolic
event is believed to be about the same as for oral contraceptives.
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Prototype Drug: Tamoxifen (4 of 4)
Contraindications: Contraindications to the use of tamoxifen include
anticoagulant therapy, preexisting endometrial hyperplasia, history of
thromboembolic disease, pregnancy, and lactation. Precautions should be
observed in patients with blood disorders, visual disturbances, cataracts,
hypercalcemia, and hypercholesterolemia.
Interactions
Drug–Drug: Anticoagulants taken concurrently with tamoxifen may increase the
risk of bleeding. Concurrent use with cytotoxic drugs may increase the risk of
thromboembolism. Estrogens will decrease the effectiveness of tamoxifen.
Lab Tests: Serum calcium levels may increase.
Herbal/Food: Unknown
Treatment of Overdose: Seizures, neurotoxicity, and dysrhythmias may occur
with overdose. The patient is treated symptomatically.
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Role of the Nurse: Hormones and
Hormone Antagonists (1 of 2)
• Assess for pregnancy and breastfeeding
• Hormones other than tamoxifen (Nolvadex) may be
palliative rather than curative
– Important that patient and family understand this
limitation
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Role of the Nurse: Hormones and
Hormone Antagonists (2 of 2)
• Development of cross-gender secondary sexual
characteristics
– Common, yet distressing, side effects of sex-hormone
therapy
• Fertility sometimes affected
• Discuss these effects frankly with patient; offer support
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Biologic Response Modifiers
• Stimulate or assist patient's immune system to rid itself of
cancer cells
– Less toxic than other classes of antineoplastics
– Includes interferons, interleukins, monoclonal
antibodies
– Given concurrently with other neoplastics to limit
immunosuppressive effects
• Inhibit enzyme tyrosine kinase in tumor cells
– Imatinib (Gleevec) and sorafenib (Nexavar)
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Role of the Nurse: Miscellaneous
Antineoplastics
• Asparaginase deprives cancer cells of essential amino
acid
• Mitotane (Lysodren) is similar to insecticide DDT
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Nursing Practice Application:
Pharmacotherapy for Cancer (1 of 11)
Assessment
Baseline assessment prior to administration:
• Obtain a complete health history and drug history, including allergies, specific reactions
to drugs, current prescription and over-the counter (OTC) drugs, herbal preparations,
and alcohol use. Be alert to possible drug interactions.
• Assess signs and symptoms of current infections and for history of herpes zoster or
chickenpox.
• Obtain an immunization history, especially recent vaccinations with live vaccines,
particularly varicella.
• Evaluate appropriate laboratory findings (e.g., complete blood count [CBC], platelet
count, urinalysis, liver and kidney function studies, uric acid, electrolytes, glucose).
• Assess findings from other diagnostic tests specific to the planned type of antineoplastic
therapy (e.g., audiology, cardiac testing, electrocardiography [ECG], electromyography
[EMG]).
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Nursing Practice Application:
Pharmacotherapy for Cancer (2 of 11)
Assessment
• Obtain baseline weight and vital signs. Assess the level of fatigue and the
presence of pain. Assess DTRs.
Assessment throughout administration:
• Assess for desired therapeutic effects (e.g., indicators of treatment success or
palliation such as slowed growth in solid tumors, organ/body-specific MRI/CT
scan demonstrates diminished tumor load without metastasis, able to attend to
normal ADLs, absence of signs of concurrent infections).
• Continue frequent monitoring of laboratory work (e.g., CBC, absolute neutrophil
count [ANC], platelet count, urinalysis, liver and kidney function studies, uric
acid, electrolytes, glucose). (ANC [equals] total WBC count multiplied by the
total percentage of neutrophils [segs plus bands].)
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Nursing Practice Application:
Pharmacotherapy for Cancer (3 of 11)
Assessment
• Continue to monitor findings from diagnostic tests specific to the planned type of
antineoplastic therapy (e.g., audiology, cardiac testing, ECG, EMG).
• Assess for the presence of nausea or pain.
• Assess DTRs and ECG as specific to the type of antineoplastic drugs given.
• Continue daily weights and report any weight gain or loss of more than 1 kg (2lb)
in 24 hours.
• Assess for adverse effects: nausea, vomiting, anorexia, abdominal cramping,
diarrhea, constipation, fever, fatigue, dizziness, dysrhythmias, angina, dyspnea,
muscle or joint pain, paresthesias, diminished or absent DTRs, hypotension,
hyperglycemia, bruising, and bleeding. Immediately report a fever exceeding
parameters established by the provider, severe diarrhea, jaundice, decreased
urine output or hematuria, excessive bruising or bleeding, respiratory distress,
and dysrhythmias or angina.
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Nursing Practice Application:
Pharmacotherapy for Cancer (4 of 11)
Implementation
Interventions and (Rationales)
Patient-Centered Care
Ensuring therapeutic effects:
Ensuring therapeutic effects:
•
•
Continue assessments as described earlier for
therapeutic effects. (Antineoplastic drugs do not have
immediately observable results and results will be
measured over time. These drugs have many
potential adverse effects.)
Provide explanations for all testing and treatments
used; general information on the expected course of
chemotherapy and required home care and frequency
for follow-up appointments; and information on how to
reach the oncology team, especially during off hours.
Minimizing adverse effects:
Minimizing adverse effects:
•
•
Continue to monitor vital signs. Report increasing
temperature that exceeds parameters (e.g., three
temperatures over 38ºC (100.5ºF) or any temperature
over 38.3º C (101ºF) to the oncology provider. Avoid
taking rectal temperatures. (Increasing fever, even
low-grade temperatures may be sign of infection. GI
endothelial cells are affected by chemotherapy, and
rectal mucosa may be damaged if rectal temperatures
are used.)
•
Teach the patient to take temperature every 4 hours if
symptoms indicate a need, including instructions on
when to call the oncology team if parameters are
exceeded.
Instruct the patient that antipyretics are not to be used
unless explicitly approved by the oncology provider.
(Antipyretics may mask the symptoms of an infection,
allowing rapid dissemination of the infection.)
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Nursing Practice Application:
Pharmacotherapy for Cancer (5 of 11)
Interventions and (Rationales)
Patient-Centered Care
•
Continue to monitor frequent laboratory work:
CBC, ANC, platelet count, liver and kidney
function tests, electrolytes, glucose, and
urinalysis. (Bone marrow suppression with
resulting blood dyscrasias is an expected
adverse effect and will be monitored by ANC,
CBC, and platelet counts.)
•
Continue to monitor nutritional and fluid intake.
(Nausea and vomiting are common adverse
effects and usually require antiemetic therapy
to manage. Collaboration: Dietary
consultation may be required to maintain
optimal nutrition.)
•
•
•
•
•
Teach the patient of the need for frequent laboratory work.
Have the patient alert laboratory personnel of chemotherapy
use.
If peripheral veins are used for phlebotomy, scrupulous
cleansing of the site prior to needle stick and prolonged
pressure may be required. If a central line access is used,
scrupulous cleansing of the port is required.
Provide antiemetic therapy during administration of drugs with
high and moderate emetic potential. If the patient has had
previous treatment with the chemotherapy regimen, assess the
extent of nausea and vomiting and which antiemetics had the
most success in preventing nausea.
Encourage increased fluid intake, up to 2 L per day, taken in
frequent small amounts, and small, high-calorie, nutrient-dense
meals rather than large, infrequent meals. Nutritional
supplements may help boost caloric intake.
Encourage frequent oral hygiene: rinse mouth, especially after
eating; use lip balm; and avoid alcohol-based mouthwash,
which can be drying to the mucosa.
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Nursing Practice Application:
Pharmacotherapy for Cancer (6 of 11)
Interventions and (Rationales)
Patient-Centered Care
•
Protect the patient from infection (e.g., wash
hands frequently before patient care; maintaining
scrupulous infection control measures for all IV
lines or venous punctures). (Immunosuppression
places patients at high risk for infection.
Prophylactic therapy with antifungal and
antibacterial mouth rinses, and protective isolation
may be required.)
•
Teach the patient, family, and caregiver infection control
measures as follows:
– Avoid crowded indoor places.
– Avoid people with known infections or young children
who have a higher risk of having an infection.
– Cook food thoroughly, allowing the caregiver to prepare
raw foods prior to cooking them and to clean up; the
patient should not consume raw fruits or vegetables.
– Report any fever and symptoms of infection such as
wounds with redness or drainage, increasing cough,
increasing fatigue, white patches on oral mucous
membranes, white and itchy vaginal discharge, or itchy
blister-like vesicles on the skin.
•
Monitor DTRs, neurologic status, and level of
consciousness. (Alkylating agents, such as
cyclophosphamide, and natural product
antineoplastics, such as vincristine, have
neurologic adverse effects. Changes may occur in
DTRs that are not noticeable to the patient in
early stages but may affect dexterity or
steadiness when walking. Lifespan: Be
particularly cautious with older adults who are at
increased risk for falls. Monitor infants and
children for growth or developmental delays.)
•
Teach the patient to be cautious when walking or performing
manual tasks requiring extra dexterity. Promptly report any
significant difficulty with dexterity or clumsiness when carrying
out ADLs or when walking.
Encourage the increased intake of fluids and moderate fiber in
the diet if constipation is an effect related to decreased
peristalsis. Drug therapy may be required if constipation is
severe to prevent straining during defecation.
•
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Nursing Practice Application:
Pharmacotherapy for Cancer (7 of 11)
Interventions and (Rationales)
Patient-Centered Care
•
Monitor cardiovascular status, including ECG, heart
and breath sounds, presence of edema, and angina or
chest-wall pain. (Alkylating agents such as
cyclophosphamide, antitumor antibodies such as
doxorubicin, natural product antineoplastics such as
vincristine, and hormone and hormone antagonists
such as tamoxifen have cardiovascular adverse
effects such as pericarditis and effects on the cardiac
conduction system.)
•
Teach the patient about the need for frequent
monitoring of cardiac status. Immediately report any
chest-wall pain, angina, palpitations, dyspnea, lung
congestion, or dizziness.
•
Monitor respiratory status, including breath sounds
and pulmonary function tests. (Alkylating agents such
as cyclophosphamide, antimetabolites such as
methotrexate, antitumor antibodies such as
doxorubicin, natural product antineoplastics such as
vincristine, and biologic response modifiers such as
interferon alpha-2 have respiratory adverse effects
such as interstitial pneumonitis.)
•
Teach the patient about the need for frequent
monitoring of respiratory status. Immediately report
any chest pain, dyspnea, lung congestion, or
dizziness.
Teach the patient pulmonary hygiene measures such
as increasing fluid intake to moisten respiratory tract,
avoiding crowded indoor places and people with
known respiratory disease, and avoiding use of room
or body sprays, which may irritate the respiratory tract.
•
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Nursing Practice Application:
Pharmacotherapy for Cancer (8 of 11)
Interventions and (Rationales)
Patient-Centered Care
•
•
Monitor liver and kidney status. (Antineoplastic
drugs may cause significant hepatic and renal
toxicity. Alkylating agents such as
cyclophosphamide may cause hemorrhagic
cystitis. Diverse Patients: Because some
antineoplastics [e.g., tamoxifen, vincristine] are
metabolized through the CYP450 system,
monitor ethnically diverse patients frequently to
ensure optimal therapeutic effects and
minimize adverse effects. Lifespan: Age
related physiological differences may place
older adults at greater-risk for hepatotoxicity or
nephrotoxicity.)
•
Teach the patient to immediately report any
nausea, vomiting, yellowing of the skin or
sclera, abdominal pain, light or clay-colored
stools, diminished urine output, darkening of
urine, suprapubic pain, or blood in the urine.
Advise the patient to increase fluid intake to 2
to 3 L per day.
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Nursing Practice Application:
Pharmacotherapy for Cancer (9 of 11)
Interventions and (Rationales)
Patient-Centered Care
•
Monitor for dermatologic toxicity. (Alkylating agents
such as cyclophosphamide may cause significant skin
reactions, including SJS.)
•
Teach the patient to immediately report any unusual
changes to the skin, rashes, or sunburn-like
appearance promptly. Report any purplish-red,
blistering rash, or peeling skin.
•
Monitor for mucositis. (Antineoplastic drugs may cause
significant mucositis related to effects on rapidly
dividing GI endothelial cells.)
•
Teach the patient to inspect the mouth at least once
daily and to maintain regular dental exams; maintain
good oral hygiene and rinse the mouth with plain
water or solution after eating; use antibacterial and
antifungal mouth rinses and not to rinse the mouth
with water after using; and avoid excessively hot or
cold foods.
Teach the patient to avoid high-roughage foods,
spicy foods, carbonated and acidic beverages,
alcohol, and caffeine. If diarrhea is severe, drug
therapy may be required. Immediately report any
excessive diarrhea, especially if it contains mucus or
blood.
•
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Nursing Practice Application:
Pharmacotherapy for Cancer (10 of 11)
Interventions and (Rationales)
Patient-Centered Care
•
Monitor for hypersensitivity and allergic reactions.
(Antineoplastic drugs may cause significant
hypersensitivity and allergic responses, including
anaphylaxis. Because reactions may not always be
predictable, caution and frequent monitoring are
essential to ensure prompt treatment.)
•
Teach the patient to immediately report any itching,
rashes, or swelling, particularly of the face, tongue, or
lips; urticaria; flushing; dizziness; syncope; wheezing;
throat tightness; or difficulty breathing.
•
Be aware of agency-specific policies and procedures
related to antineoplastic administration, spill
management, and required coursework before
working with or giving chemotherapy. All IV infusions
will be given via monitored pump. IV push drugs may
use a push–pull technique. All spills will be managed
via Occupational Safety and Health Administration (O
HSA) and agency protocols. Larger spills may require
hazmat intervention. (Intensive education programs
are required prior to administering vesicants and other
chemotherapy drugs. Protection of nurses, pharmacy
personnel, and others involved in the preparation and
administration of chemotherapy is essential.)
•
Provide the patient and caregiver with education and
support when giving chemotherapy.
Instruct the patient or caregiver on the specific
procedures of handling and administering any drugs
that are to be used in the home. Gloves will be
required when working with oral solutions. Specific
instructions should be obtained from the oncology
provider or pharmacist if a spill occurs at home.
•
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Nursing Practice Application:
Pharmacotherapy for Cancer (11 of 11)
Interventions and (Rationales)
Patient-Centered Care
Patient understanding of drug therapy:
Patient understanding of drug therapy:
•
•
Use opportunities during administration of medications
and during assessments to provide patient education.
(Using time during nursing care helps to optimize and
reinforce key teaching areas.)
The patient or caregiver should be able to state the
reason for the drug; appropriate dose and scheduling;
what adverse effects to observe for and when to
report; and the anticipated length of medication
therapy.
Patient self-administration of drug therapy:
Patient self-administration of drug therapy:
•
•
When administering medications, instruct the patient
or caregiver in proper self-administration techniques
followed by teach-back as needed. (Proper
administration will increase the effectiveness of the
drugs.)
Provide explicit instructions for the patient or caregiver
on the routine to follow for any antineoplastic drugs
used at home. Encourage the use of calendars for
recording drugs and doses used; and provide
information on handling a liquid spill and on proper
disposal of any unused drug. (Consult local
pharmacies because many will accept unused drugs
for proper disposal. Chemotherapy should never be
flushed down the toilet, poured in a drain, or thrown
away in the trash.)
See Tables 38.2 through 38.8 for lists of drugs to which these nursing actions apply.
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