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Cancer therapy and side effects Flashcards

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1
Q

Which type of cancers have available screening programmes and who is eligible for them?

A

Cervical cancer
Smear tests are offered every three years to females between the ages of 25-49 and every 5 years to those between the ages of 50-64.

Breast cancer
Mammograms are offered every 3 years to females from 50-71 years.

Bowel cancer
Males and females aged between 60-74 years are sent a home test kit every 2 years to collect feces for testing.

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2
Q

What are some of the patient factors that would help you decide which route and regime of treatment is most appropriate?

A

Age of the patient
Previous treatment
Other conditions or medications they are taking (Diabetes, monitoring blood glucose levels)
Health and fitness status of the patient (Pregnant)
Hepatic and renal conditions
Performance status (0-5), 4 not well enough to be treated, 2 or 3 dose needs to be adjusted
Polypharmacy and drug interactions

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3
Q

What are some of the cancer factors that would help you decide which route and regime of treatment is most appropriate?

A

Location of the tumor (is it operable)
Size of the tumour
Type of tumour (sub-class)
Grading of the tumour (has it metastasized)

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4
Q

What are some of the factors that determine patient specific dosing and examples?

A

Body surface area (mg/m2) classic chemotherapies
Dosing per weight (mg/kg)
Flat dosing (standard dose for all) lot of newer drugs
Dose adjustment according to renal function
Entirely determined by renal function (Carboplatin)

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5
Q

When are you able to have chemotherapy at home?

A
  • If you are prescribed capsules of tablets to take (Tamoxifen for breast cancer, prescribed for 5 or 10 years)

-If your hospital has home-care chemotherapy nurses

-Low dose, continuous (24 hr) chemotherapy that can be given in a pressure pump

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6
Q

How is chemotherapy normally administered in a day centre?

A

If the chemotherapy is to be administrated intravenously.
Can be given via:
Cannula
Central line
PICC (peripherally inserted central catheter)
Portacath or port- (chamber at the end of the central line)

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7
Q

What is a PICC line?

A

Peripherally inserted central catheter, consists of a long, thin, hollow, tube which is inserted into the arm and then to where the tumour is or was, so it is a bit more targeted treatment.

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8
Q

What are some of the issues that can arise with a PICC line?

A

May get an infection
Blood clot can develop
The line can split
Line can become blocked

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9
Q

How are some of the problems associated with a PICC line overcome?

A

After administration of the chemotherapy, the lines are often rinsed with water to ensure the line isn’t blocked and all the drug has been administered.
The line is washed every week or so with a saline rinse to prevent an infection developing
Line is also rinsed with heparin (anti-clotting agent) to prevent a blood clot.

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10
Q

When do you have to stay in hospital with chemotherapy?

A

Doctor wants to monitor you in case of a reaction developing
You require fluids before or after the treatment via a drip
The drug needs to be administered in a slow, controlled way
The drug needs to be administered a number of times a day for a couple of days in a row

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11
Q

Aside from cancer cells, which other cells does chemotherapy drugs target?

A

Chemotherapeutic drugs are non-specific and target cells with a high turnover rate which aside from cancer cells include:
Hair follicles (resulting in hair loss)
Blood cells in the bone marrow (resulting in anaemia, increased bruising and bleeding, more prone to infection)
Reproductive cells (infertility)
Cells in the digestive tract

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12
Q

What does the two week wait refer to in cancer treatment?

A

In the UK, two week wait means that anybody who has presented symptoms that could be indicative of cancer are seen within two weeks by a specialist to be checked over, confirm diagnosis or discharged.

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13
Q

What are some of the scans used to confirm the diagnosis of cancer?

A

Scans including:
MRI
X-ray
PET-scan
Ultrasounds
Bone scan
CT-scans

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14
Q

Aside from scans which additional tests are used to diagnose cancer?

A

Biopsy (piece of abnormal is taken are examined by a pathologist)
Tumour marker tests
Sputum cytology
Blood chemistry tests
Full blood count (white, red and platelets)
Cytogenic analysis (looking for changes in chromosomes)
Immunophenotyping (using antibodies to identify antigens on cell-surface)
Liquid biopsy
Urinalysis (describes the colour of urine, contents in urine)
Urine cytology (looking for traces of cancer cells shed from the urinary tract)

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15
Q

Why is histology so important?

A

Analysing genes to determine the type of cancer present and hence which treatments would be most effective (not reasonable to give hormone therapy to a triple negative breast cancer).
Also good for identifying patients who are at risk of developing certain types of cancer (if they possess the BCR-ABL gene Philadelphia chromosome).

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16
Q

If a patient possesses the BCR-ABL gene which type of cancer are they at risk of getting?

A

Leukemia (95% of patients with chronic myeloid leukaemia possess the gene).

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17
Q

Describe the different stages of cancer?

A

Stage 0- cancer is where it started and hasn’t spread
Stage 1- cancer is small and hasn’t spread
Stage 2- cancer is large but hasn’t spread
Stage 3- cancer is large and may have spread to surrounding tissue or lymph nodes
Stage 4- cancer has spread to at least one other organ (it has metastasized)

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18
Q

Describe the different grades of cancer.

A

Grade 1- cancer cells resemble normal ones and aren’t growing quickly
Grade 2- cancer cells do not look like normal cells and are growing faster than normal cells
Grade 3- cancer cells that look abnormal and may grow or spread more aggressively

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19
Q

What does the T in the TNM grading system stand for?

A

T - size of the tumour (scale is 1-4)
T1- less than 3cm
T2 - more than 3cm
T3 - near the airways
T4- invaded local structures

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20
Q

What does the N in the TNM grading system stand for?

A

N- whether the cancer has spread to lymph nodes or other tissue
N (0)- no spread
N1- nearby lymph nodes
N2- lymph nodes on the same side of the body
N3- spread to lymph nodes across the body, not on the same side

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21
Q

What does the M in the TNM grading system stand for?

A

M1- has not metastasised
M2- it has metastasised

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22
Q

What is the main role of chemotherapy in the treatment of cancer?

A

Can be used pre-operatively to shrink the tumour size before surgery or post-operatively to ‘scoop up’ any remaining cancer cells that were not able to be removed and to prevent the cancer from returning.

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23
Q

What does curative treatment involve?

A

Aimed to cure the cancer and is decided based upon the type of cancer, grading, stages etc.
Normally involves high dose, aggressive chemotherapy. Normally followed up with scans and regularly monitoring afterwards to ensure relapse does not occur.

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24
Q

What is the difference between neoadjuvant and adjuvant?

A

Neoadjuvant- chemo is given before surgery to shrink the tumour
Adjuvant- chemo is given after surgery to scoop up remaining cells(micro metastasises)
These are curative treatments

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25
What does palliative care involve?
When you are not able to cure the cancer, chemo and radiotherapy to reduce symptoms, making the patient comfortable
26
What is concomitant treatment?
Drugs to make cells more sensitive to other types of treatment for example radiotherapy.
27
What is subsequent line therapy?
When a patient is started on one line of therapy and then is switched over to another type due to either the cancer progressing or patient can't tolerate the side effects or risk of sepsis.
28
What are the four systemic therapies?
Oral IV Intramuscular Subcutaneously
29
What are the three regional therapies?
Intrathecal (methotrexate) into the spine Intra-arterial Intra-vesical
30
What is the lifetime limit of anthracyclines and why is it in place?
Lifetime limit is different for each but for example Doxorubicin has a cumulative lifetime limit of 400-500mg/m2 and it has implemented due to the risk of cardiotoxicity of the drugs as they causes damage to the myocardial tissue by reactive free radicals. Total exposure needs to be calculated for each treatment as a percentage of what they are allowed.
31
What kind of supplement reduces platelet count and what is the increased risk with chemo?
Garlic, chemo can target blood cells in the bone marrow and increases the risk of bruising and bleeding even more due to reduced platelet count.
32
What are some of the ways the response to treatment is monitored?
External examination X-rays, CT scans Blood tests for organ function Tumour marker test (PSA rise during prostate cancer indicates progression of the disease)
33
How are the responses defined?
Complete- cured Partial Stable Progression- relapse
34
What are the different types of chemo-therapies and what are their drug targets?
Alkylating agents - two alkylating groups causes cross linking preventing replication and transcription Anthracyclines - stabilises the DNA and topoisomerases 2 which induces apoptosis Antimetabolites-mimic the enzymes needed for the cancer cells to replicate Taxanes- interfere with microtubules which are needed to move structures in mitosis Vinca alkaloids- interfere with the M-phase of mitosis, depolymerize microtubules and destroy mitotic spindles.
35
What are some of the benefits of using combination therapies for chemotherapy?
Different mechanisms, reducing potential for resistance Reduced side effects (in comparison to high doses of one drug) Increased efficacy
36
How does drug resistance of chemotherapies arise?
Decreased drug influx (reduced amount of drug getting into the cell) Increased drug efflux (more drug being pumped out of the cell) Inactivation of apoptotic pathways Altered drug targets (receptor desensitization) Mutation of targets Increased metabolism (drug is broken down quicker)
37
Which type of cancers are hormone therapy an option for?
Certain types of breast cancer or ovarian cancer which are known as estrogen receptor positive or progesterone receptor positive as the cancer cells over-express hormones for these receptors and induce their growth. Prostate, progesterone receptors
38
What are some examples of hormone receptor antagonists?
Tamoxifen (selective estrogen receptor modulator) and enzultamide (nonsteroidal antiandrogen medicine).
39
Are hormone therapies cytotoxic?
No but they are anti-cancer drugs
40
How do monoclonal antibodies work?
Prevent angiogenesis, by inhibiting the vascular endothelial growth factors
41
What are some examples of monoclonal antibodies?
Avastatin
42
Aside from estrogen and progesterone receptor positive, which other protein would you test for in breast cancer?
Assessing with HER 2 protein is over-amplified in the cancer cells. Herceptin is used as a monoclonal antibodies targeting the HER 2 genes (providing the patient is HER 2 positive).
43
How are extremely cytotoxic drugs administered in the treatment of cancer?
They are connected via a chemical linker to a monoclonal antibody, which takes it to the site of tumour. Chemical linker degrades releasing the cytotoxic drug molecule to act locally in addition to the monoclonal antibody.
44
What are immune checkpoint inhibitors?
Immunotherapy drugs called immune checkpoint inhibitors work by blocking checkpoint proteins from binding with their partner proteins. This prevents the “off” signal from being sent, allowing the T cells to kill cancer cells, retraining the immune system.
45
What are some examples of immune checkpoint inhibitors?
PD-1 or its protein partner PD-L1
46
What are some of the benefits of oral treatments?
Increased patient satisfaction Can stay at home Reduce patients in hospital Less invasive
47
What are some of the disadvantages of oral treatments?
As pharmacists we do not know how the patient takes the drug (with food or without, reducing absorption) May have interactions Side effects
48
By what mechanism does Imantinib work?
Imantinib is an example of a tyrosine kinase inhibitor, which is useful in the treatment of cancer. Cancer cells often over-secrete growth factors which enables their uncontrolled replication, and tyrosine kinases are switched on enabling this downstream pathway. By blocking this signal it prevents the downstream replication and growth of cancer cells.
49
What is fluorouracil an example of?
Anti-metabolite used in chemotherapy often in combination with other drugs.
50
Which types of cancer is fluorouracil used?
Breast cancer Anal cancer Colorectal cancer Head and neck cancer Stomach cancer Some skin cancers (given as an ointment)
51
What are some of the risk factors for developing chemotherapy induced nausea and vomiting?
Female Non-smoker Migraines Previous nausea and vomiting in pregnancy Drugs Hypotension Hypoxemia Obesity Type of surgery Opoids in surgery Anesthesia Eating too early post op or delay in gastric emptying
52
What are some of the clinical complications of nausea and vomiting?
Psychological - fear, paranoid Dehydration Loss of appetite leading to weight loss (this is crucial in cancer patients, need to try and keep their weight up and nutrition) Fatigue Disruption to daily life Aspiration pneumonia Oesphagus tears Quality of life reduced Ultimately it can lead to chemotherapy dose reductions, dose delay and discontinuation of treatment.
53
How does chemotherapy induce nausea and vomiting?
Chemotherapy drugs make your body release chemicals that signal between nerves. These are called neurotransmitters and include serotonin. These chemicals stimulate the chemoreceptor trigger zone (CTZ) and the vomiting centre.
54
What are the different types of nausea and vomiting?
Acute- within 24 hours of chemo Delayed- more than 24 hours post chemo Breakthrough- n&v despite prophylaxis Anticipatory- prior to admin of chemo Refractory- CINV despite appropriate measures
55
Which anti-emetics are given for each type of CINV?
Acute - Metoclopramide, Domperidone, 5HT3 Delayed - Dexamethasone, NK1 Breakthrough - 5HT3, NK1 Anticipatory - Lorazepam Refractory - Levomepromazine, NK1, Nabilone (not often used as side effects)
56
When are anti-emetics usually prescribed for chemotherapy?
Normally given as prophylaxis if the chemotherapy drugs prescribed have a high incidence of inducing nausea or vomiting. Or upon meeting with a Pharmacist after each round of chemo, they mention in the cycle they experienced nausea and vomiting they will then be prescribed it.
57
When do the patients take anti-emetics for chemo?
Usually a couple of days prior to a round of chemo and then probably two/three days afterwards.
58
What is mucositis?
Ulcerated gums or sore mouth as a result of chemotherapy.
59
Why does mucositis occur?
Chemotherapy targets cells with a rapid turnover and an example of these including those in the mucosal cells in the mouth and GI tract.
60
How can mucositis be prevented?
Dental check up before commencing chemo Avoid flossing and electric toothbrushes (can aggravate) Use salt water (saline) to cleanse the mouth Avoid spicy and very hot foods Avoid commercial products if contain alcohol Brush regularly
61
How can the pain associated with mucositis be managed?
Local anaesthetic mouthwashes or lozenges ‘Gentle’ mouthwashes Analgesics (paracetamol) Ice
62
What should you prescribe if a mouth infection occurs as a result of chemo?
If it is bacterial, take cultures, begin with empirical antibiotics If it is fungal, systemic fluconazole or nystatin should be used If it is viral, aciclovir
63
Which three chemotherapy agents are the most likely to cause chemo induced diarrhea?
5-fluorouracil Capecitabine Irinotecan
64
What is some of the non-pharmacological advice for chemo-induced diarrhea?
Stay hydrated, 2 1/2 litres of water a day Avoid alcohol, caffeine, milk products, high-fat foods and high-fibre foods. Have small frequent meals
65
When should you contact the hospital for chemo-induced diarrhea?
If you have diarrhea at night If you have diarrhea more than four times a day You have a moderate or severe increase in stoma activity The anti-diarrhoea drugs do not work within 24 hours. Given drip, fluids, electrolytes etc
66
What is the first line treatment for diarrhea?
Loperamide (4mg then 2mg every 2 hours until diarrhoea free for 12 hours)
67
Which antibiotic is used for treatment of diarrhea?
Ciprofloxacin- 250mg twice daily for 7/7 if lasts >24 hours
68
What is defined as delayed diarrhea?
If it occurs after 24 hours of chemo (usually 3-10 days)
69
What are some of the symptoms of anti Cholinergic Syndrome?
Increased sweating Saliva Stomach cramps Diarrhoea
70
What is used in the treatment of cholinergic syndrome?
Subcutaneous atropine (300mcg) or as prophylaxis
71
Which type of chemotherapies cause constipation?
Cisplatin and vinca alkaloids
72
Aside from the chemotherapies what are some other causes of constipation in cancer patients?
Inactivity Anti-emetic induced (Ondasteron) Opiods for pain
73
What are some of the recommendations of managing constipation?
Prevention includes: Fluids High fibre food, fruits and veg Exercise Treatment: Laxatives Review medication
74
What are some of the measures implented to try and reduce hair loss as a result of chemo?
During chemotherapy, patient will normally wear a scalp cooling pack to try and reduce blood flow and hence drug distribution in the head.
75
When does hair loss (alopecia) usually occur and when does it start to grow back?
Although hair loss can be different in all patients and different according to the type of chemo, some may loose nothing, others can lose half etc it usually occurs a couple of weeks after the first round of chemotherapy, the head may become quite sore and it can come out in patches. They hair usually begins to grow back 4-6 weeks after finishing chemo.
76
Describe the consequences of myelosuppression as a result of chemotherapy.
Chemotherapy targets blood cells within the bone marrow due to their high turnover rate. This causes reductions to white and red blood cells and platelets. Reduction of white blood cells: Crucial in the immune response and therefore patients are more prone to infections caused by neutropenia. Neutropenic sepsis is not uncommon in patients undergoing chemotherapy. Reduction of red blood cells: Response for the transport of oxygen around the body, resulting in anemia and fatigue leading to lethargy, dizziness etc. Fatigue can also be result of all lot of energy being used, to respond to the effects of the drugs, disposing of dead cells and building new ones. Reduction of platelets: Platelets contain clotting agents and therefore with a reduction in the bloodstream, there is an increased likelihood of bruising and bleeding, known as thrombocytopenia.
77
What is febrile neutropenia?
It is the presence of a fever in a neutropenic patient and is defined as a temperature > 38C and absolute neutrophil count < 0.5 x 109/l as a result of myelosuppressive chemotherapy.
78
In addition to receiving myelosuppressive chemotherapy what are some of the other risk factors for the development of febrile neutropenia?
Older than 65 Haemological malignacies Elevated bilirubin Elevated liver enzymes Low albumin (>35 g/L) Co-morbidity
79
What are some diagnostic tests to confirm febrile neutropenia?
Full blood count and differential Urinalysis and renal function tests (urea and creatinine) Liver function tests Blood cultures
80
How can febrile neutropenia be prevented (non-pharmacological)?
Good hygiene Avoid crowds and sick people Food safety (no probiotics)
81
How can febrile neutropenia be prevented (pharmacological)?
GCSF Prophylaxis antibiotics Dose reductions of chemo
82
What does GCSF stand for?
Granulocyte colony stimulating factor
83
What is the purpose of GCSF?
It is a type of growth factor (glycoprotein) used to stimulate the bone marrow into producing granulocytes and stem cells and release them into the bloodstream. It also helps survival, proliferation, differentiation, and function of neutrophil precursors and mature neutrophils and therefore is beneficial to patients who as a result of chemotherapy have neutropenia.
84
When and how are GCSFs given?
Normally a home administered sub-cutaneous injection 3-7 days after myelosuppressive chemotherapy.
85
What are some examples of GCSFs?
Lenograstim (Granocyte) Filgrastim (Neupogen, Zarzio, Nivestim, Accofil)
86
What is the criteria for receiving GCSFs?
Chemotherapy with >20% risk of FN Continuing chemotherapy following episode of FN
87
What are the risk factors for developing the complications of febrile neutropenia?
Severe symptoms Hypotensive Chronic Obstructive Pulmonary Disease symptoms Leukaemia treatment Dehydrated > 60 years Inpatient
88
Which antibiotics should be given for low risk neutropenic sepsis?
Ciprofloxacin Co-amoxiclav
89
What are the red flag symptoms of neutropenic sepsis that you should administer high risk response immediately?
Non-blanching, mottled rash Heart rate more than 130bpm Blood pressure systolic below 90 mmHg Temperature more than Not passed urine in the last 18 hours Needs to keep SpO2 above 92% Only responds to voice
90
What is the SEPSIS SIX and how is it used in the primary care of patients?
Any identified red flag symptoms of neutropenic sepsis, requires administration of the sepsis six within an hour of diagnosis. 1. Administer oxygen 2. Take blood cultures 3. Give empirical IV antibiotics 4. Give IV fluids 5. Check serial lactates 6. Measure urine output Follow normal sepsis guidelines, review after 48 hours
91
What antibiotic is usually given for high risk neutropenic sepsis?
Vancomycin/Gentamicin Tazocin Ceftazidime
92
What advice is given to help combat fatigue?
Move around and exercise when you can Limit activities Eat healthfully Drink plenty of fluid
93
What side effects does capecitabine cause?
Causes hand-foot syndrome which involves the painful swelling and erythema of the hands and feet including, numbness, tingling, ulceration and bleeding.
94
How can the dermatological side effects be prevented?
Avoid tight fitting shoes, rubbing, hot water, moisturisers
95
What is the treatment for the dermatological side effects associated with chemotherapy?
Lanolin containing creams
96
Which specific chemotherapies can cause induced dermatological side effects?
EGFR inhibitors including: Cetuximab (antibody to EGFR) and Erlotinib (EGFR specific tyrosine kinase inhibitor)
97
Which treatment is recommended for a mild EGFR induced skin reaction?
Topical antibiotic cream/lotion (clindamycin)
98
Which treatment is recommended for a moderate EGFR induced skin reaction?
Add topical steroid (eg Hydrocortione cream) Add Oral antibiotics (eg doxycycline)
99
Which treatment is recommended for a severe EGFR induced skin reaction?
Dematology referral Dose reduction Consider stopping treatment if all else fails
100
What are some of the side effects of immunotherapy?
Colitis Pneumonitis Hepatitis Endocrinopathies Rash
101
What are some of the long term side effects associated with chemotherapy?
Cardiac Thromboembolic Secondary Cancers Infertility Respiratory
102
What is extravasation?
The unintentional leakage of vesicant fluids or medications from the vein into the surrounding tissue
103
How is extravasation treated?
Either with a cold or warm patch
104
What are some examples of pre-medication used for the treatment of hypersensitivity?
Dexamethasone 20mg po every 6 hours for 4 doses Ranitidine 150mg po every 8 hours for 3 doses. Chlorphenamine 4mg po every 6 hours for 4 doses

Cancer (6 decks)

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