Chapter 45: Antineoplastic Drugs Part 1: Cancer overview and cell cylce- specific drugs

Question 1

Extravasation

Answer 1

The leakage of any intravenously or intraarterially
administered medication into the tissue space surrounding
the vein or artery. Such an event can cause serious tissue
injury, especially with antineoplastic drugs. (p. 729)

Question 2

Nadir

Answer 2

Lowest point in any fluctuating value over time; for
example, the lowest white blood cell count measured after
the count has been depressed by chemotherapy. (p. 729)

Question 3

Sarcomas

Answer 3

Malignant neoplasms of the connective tissues arising
in bone, fibrous, fatty, muscular, synovial, vascular, or
neural tissue, often first presenting as painless swellings.
(p. 724)

Question 4

Tumor lysis syndrome

Answer 4

A common metabolic complication of
chemotherapy for rapidly growing tumors. It is characterized
by the presence of excessive cellular waste products and
electrolytes, including uric acid, phosphate, and potassium,
and by reduced serum calcium levels. (p. 731)

Question 5

Carcinomas

Answer 5

arise from epithelial tissue, which is located
throughout the body. This tissue covers or lines all body surfaces,
both inside and outside the body. Examples are the skin,
the mucosal lining of the entire gastrointestinal (GI) tract, and
the lining of the bronchial tree (lungs). The purpose of these
epithelial tissues is to protect the body’s vital organs

Question 6

sarcomas

Answer 6

are malignant tumors that arise primarily from
connective tissues, but some sarcomas are tumors of epithelial
cell origin. Connective tissue is the most abundant and widely
distributed of all tissues and includes bone, cartilage, muscle,
and lymphatic and vascular structures. Its purpose is to support
and protect other tissues.

Question 7

Lymphomas

Answer 7

are cancers within the lymphatic tissues.
Lymphomas
can be quite bulky and are usually classified as solid tumors.

Question 8

Leukemias

Answer 8

arise from the bone marrow and are cancers of blood
and bone marrow. Leukemias differ from carcinomas and sarcomas
in that the cancerous cells do not form solid tumors but
are interspersed throughout the lymphatic or circulatory system
and interfere with the normal functioning of these systems this reason, they are sometimes referred to as circulating tumors,
although hematologic malignancy is a more precise term.

Question 9

Cachexia

Answer 9

(general ill health and malnutrition)

Question 10

Radiation is a well-known and potent carcinogenic agent. There
are two basic types of radiation:

Answer 10

(1) ionizing, or high-energy,

radiation, and (2) nonionizing, or low-energy, radiation

Question 11

ionizing because

Answer 11

it causes the formation of ions within living cells. This type of
radiation (e.g., that used in radiographic studies) is also used
to treat (irradiate) cancerous tumors (e.g., radium implants).

Question 12

Nonionizing radiation is much less potent and cannot penetrate
deeply into the body.

Answer 12

Ultraviolet light is an example of this

type of radiation and is the cause of skin cancer

Question 13

Adverse effects of

radiation therapy

Answer 13

(e.g., radiation burns; nausea with GI tract
irradiation) tend to be more localized to the site of treatment
as well.

Question 14

Neoplastic cells are believed to develop in everyone;

Answer 14

however, a healthy person’s immune system recognizes them
as abnormal and eliminates them by means of cell-mediated
immunity (cytotoxic T lymphocytes;

Question 15

• Causative factors that have been identified include

Answer 15

include age-related and sex-related characteristics; genetic and ethnic factors; oncogenic viruses; environmental and occupational factors; radiation; and immunologic factors.

Question 16

o Epstein-Barr virus is a

Answer 16

a type of herpesvirus commonly recognized as the cause of infectious mononucleosis. It is also associated with the development of Burkitt’s lymphoma and nasopharyngeal cancer

Question 17

• The percentage of cells undergoing mitosis at any given time

Answer 17

is called the growth fraction of the tumor. The number of cells in the M phase of the cell cycle is called the mitotic index. Chemotherapy is most effective when used in a rapidly dividing or highly proliferative tumor.

Question 18

• Factors that affect the chances of cure and the length of patient survival include

Answer 18

the cancer stage at time of diagnosis, the type of cancer and its doubling time, the efficacy of the cancer treatment, the development of drug resistance, and the general health of the patient.

Question 19

• Most chemotherapy is withheld when the patient’s

Answer 19

absolute neutrophil count (ANC) is less than 500 cells/mm3 (severe neutropenia).

Question 20

• Antimetabolite antineoplastic drugs are used for the treatment

Answer 20

of a variety of solid tumors and some hematologic cancers; they may also be used in combination chemotherapy

are cell cycle–specific analogues that work by antagonizing the actions of key cellular metabolites

Question 21

• Allopurinol and rasburicase are both indicated

Answer 21

for the hyperuricemia associated with tumor lysis syndrome and are usually given in anticipation of this condition during various chemotherapy regimens associated with this syndrome.

Question 22

• Mitotic inhibitors include

Answer 22

natural products from plants and semisynthetic drugs from plants. Depending on the particular drug, these plant-derived compounds can work in various phases of the cell cycle (late S phase, throughout G2 phase, and M phase), but they all work shortly before or during mitosis and thus retard cell division.

Question 23

• Vincristine and other vinca alkaloids are not given intrathecally

Answer 23

Administering these drugs through the spinal route is almost always fatal, and the death is slow and excruciating.

Question 24

antineoplastic enzymes is a fairly unique adverse effect

Answer 24

impaired pancreatic function. This can lead to hyperglycemia and severe or fatal pancreatitis.

Question 25

• Complete an assessment of

Answer 25

cultural, emotional, spiritual, sexual, and financial influences, concerns, and issues.

Question 26

• One specific assessment consideration associated with the use of the antimetabolite cytarabine is monitoring for the

Answer 26

occurrence of cytarabine syndrome. This usually occurs within 6 to 12 hours after drug administration and is characterized by fever, muscle and bone pain, maculopapular rash, conjunctivitis, and malaise.

Question 27

• In patients receiving mitotic inhibitors (e.g., vinblastine, vincristine) and alkaloid topoisomerase II inhibitors (e.g., etoposide)

Answer 27

• In patients receiving mitotic inhibitors (e.g., vinblastine, vincristine) and alkaloid topoisomerase II inhibitors (e.g., etoposide)

Question 28

• Assess individuals for the following characteristics before chemotherapy

Answer 28

(1) genetic markers for oral cancers, (2) genetic determinants of testosterone or estrogen metabolism, and (3) genetically linked enzyme system abnormalities such as those involving specific cytochrome P-450 enzymes that metabolically convert nicotine to a carcinogenic substance

Question 29

• GI adverse effects usually occur

Answer 29

on about the fourth day, which may require preplanning for special pharmacologic interventions (e.g., antiemetics, antispasmodics, analgesics) and nonpharmacologic measures (dietary changes, oral care).

Question 30

(teratogenesis)

Answer 30

antineoplastics may also have a negative impact on the reproductive tract, causing destruction of the germinal epithelium of the testes and damage to the ovaries and to a fetus

Question 31

G0: Resting phase

Answer 31

Most normal human cells exist predominantly in this phase. Cancer cells in this phase are not susceptible to the toxic effects of cell cycle–specific drugs.

Question 32

G1: First gap phase or | postmitotic phase

Answer 32

Enzymes necessary for DNA synthesis are | produced

Question 33

S: DNA synthesis phase

Answer 33

DNA synthesis takes place, from DNA strand separation to replication of each strand to create duplicate DNA molecules

Question 34

G2: Second gap phase or | premitotic phase

Answer 34

RNA and specialized proteins are made

Question 35

M: Mitosis phase

Answer 35

Divided into four subphases: prophase, metaphase, anaphase, and telophase; cell divides (reproduces) into two daughter cells

Question 36

Chemotherapy is most effective

Answer 36

when used in a rapidly | dividing or highly proliferative tumor.

Question 37

No antineoplastic drug is effective against all types of cancer. Most cancer drugs have a low therapeutic index, which means

Answer 37

that a fine line exists between therapeutic and toxic levels. Clinical experience has shown that a combination of drugs is usually more effective than single-drug therapy

Question 38

To be most effective, however, the drugs used in such a combination regimen would ideally possess the following characteristics:

Answer 38

• Some efficacy even as single drugs in the treatment of the particular type of cancer • Different mechanisms of action so that the cytotoxic effect is maximized; this includes differences in cell cycle specificity • No or minimal overlapping toxicities

Question 39

chemotherapy drugs affect rapidly dividing cells—both harmful cancer cells and healthy, normal cells.

Answer 39

Three types of rapidly dividing human cells are | the cells of hair follicles, GI tract cells, and bone marrow cells

Question 40

Myelosuppression

Answer 40

bone marrow suppression or bone marrow depression, is another unwanted adverse effect of certain antineoplastics. It commonly results from drug- or radiation-induced destruction of certain rapidly dividing cells in the bone marrow, primarily the cellular precursors of WBCs, red blood cells (RBCs), and platelets

Question 41

nadir... occurs roughly 10 to 28 days | after dosing

Answer 41

``` The lowest level of WBCs in the blood following chemotherapy (or radiation) treatment is called ```

Question 42

Anticipation | of this nadir based on known cancer drug data

Answer 42

can be used to guide the timing of prophylactic (preventative) administration of antibiotics and blood stimulants known as hematopoietic growth factors

Question 43

Targeted drug therapy utilizes drugs that recognize a specific molecule involved in the growth of cancer cells, while mostly sparing healthy cells

Answer 43

One example of such targeted therapy is the newer class of cancer drugs known as monoclonal antibodies

Question 44

Common relative contraindications for cancer drugs include

Answer 44

weakened status of the patient as manifested by indicators such as very low WBC count, ongoing infectious process, severe compromise in nutritional and hydration status, reduced kidney or liver function, or a decline in organ function in any system that may be further affected by the toxic effect of the drug being administered

Question 45

Cell cycle–specific drug classes include collectively used to treat a variety of solid and/or circulating tumors, although some drugs have much more specific indications than others.

Answer 45

antimetabolites, mitotic inhibitors, alkaloid topoisomerase II inhibitors, topoisomerase I inhibitors, and antineoplastic enzymes

Question 46

antagonist analogue

Answer 46

also known as an antimetabolite

Question 47

antimetabolites inhibit cellular growth by interfering with the synthesis or actions of compounds critical to cellular reproduction:

Answer 47

the vitamin folic acid, purines, and pyrimidines. Purines and pyrimidines make up the bases contained in nucleic acid molecules (DNA and RNA).

Question 48

Antimetabolites work via two mechanisms: primarily during S phase

Answer 48

(1) by falsely substituting for purines, pyrimidines, or folic acid; and (2) by inhibiting critical enzymes involved in the synthesis or function of these compounds. Thus, they ultimately inhibit the synthesis of DNA, RNA, and proteins, all of which are necessary for cell survival

Question 49

Folate antagonists

Answer 49

* methotrexate (MTX) * pemetrexed * pralatrexate

Question 50

Purine antagonists

Answer 50

* cladribine * fludarabine (F-AMP) * mercaptopurine (6-MP) * pentostatin * thioguanine (6-TG)

Question 51

Pyrimidine antagonists

Answer 51

* capecitabine * cytarabine (ara-C) * floxuridine (FUDR) * fluorouracil (5-FU) * gemcitabine

Question 52

allopurinol is chemically similar to purines, it | does not disrupt DNA synthesis. Instead

Answer 52

it inhibits xanthine oxidase, which reduces serum and/or urinary levels of uric acid.

Question 53

pyrimidine bases

Answer 53

cytosine and thymine, occur in the structure of DNA molecules, and cytosine and uracil are part of the structure of RNA molecules

Question 54

Floxuridine and fluorouracil

Answer 54

are synthetic analogues of uracil, and cytarabine is a synthetic analogue of cytosine. Capecitabine is actually a prodrug of fluorouracil and is converted to that drug in the liver and other body tissues

Question 55

Hyperuricemia can lead to

Answer 55

nephropathy, and hemodialysis | may be required in severe cases of tumor lysis syndrome

Question 56

A severe, but usually reversible, form of dermatologic toxicity is known as palmar-plantar dysesthesia or paresthesia (also called hand-foot syndrome).

Answer 56

range from mild symptoms such as painless swelling and erythema to painful blistering of the patient’s palms and soles.

Question 57

Killing of normal cells of the GI mucous membranes may result in adverse effects such as

Answer 57

altered nutritional status, stomatitis with inflammation and/or ulceration of the oral mucosa throughout the GI tract, altered bowel function, poor appetite, nausea, vomiting (often intractable and requiring aggressive antiemetic treatment), and diarrhea

Question 58

Killing of normal cells in the bone marrow results in

Answer 58

dangerously low (lifethreatening) blood cell counts. Because of the negative impact on these normal cells, the nurse must carefully assess the patient’s WBCs levels ( leukocytes, neutrophils, and band neutrophils), RBC counts, hemoglobin level, hematocrit, and platelet counts (see the Safety: Laboratory Values Related to Drug Therapy box). In addition, monitoring of the patient’s absolute neutrophil count (ANC) is needed (ANC = % of neutrophils + % bands × WBC). Monitoring ANC values allows the nurse and other health care providers to identify the nadir—the time of the lowest count when the patient is most vulnerable. An ANC of 500 cells/mm3 or lower indicates high risk for infection

Question 59

Killing of the normal cells of hair follicles leads to

Answer 59

alopecia (loss of hair).

Question 60

Killing of germinal epithelial cells (also rapidly dividing) leads to

Answer 60

sterility (irreversible) in males, damage to the ovaries with subsequent amenorrhea in females, and teratogenic effects with possible fetal death in pregnant women.

Question 61

• For altered nutritional status and impaired oral mucosa:

Answer 61

Assess signs and symptoms of altered nutrition with a focus on weight loss, abnormal serum protein-albumin and blood urea nitrogen (BUN) levels (a negative nitrogen status due to low protein levels would be indicated by a decreasing BUN level), weakness, fatigue, lethargy, poor skin turgor, and pale conjunctiva. Assess oral mucosa for any signs and symptoms of stomatitis, such as pain or burning in the mouth, difficulty swallowing, taste changes, viscous saliva, dryness, cracking, and/or fissures with or without bleeding of the mucosa.

Question 62

For effects on the GI mucosa:

Answer 62

Assess bowel sounds (hyperactive or hypoactive versus normoactive). Assess for signs and symptoms of diarrhea, such as frequent, loose stools (more than three stools per day), urgency, and abdominal cramping. Obtain information about the presence of blood in the stool as well as consistency, color, odor, and amount. Assess for nausea and vomiting and determine whether symptoms are acute, delayed, or anticipatory; if vomiting occurs, determine the color, amount, consistency, frequency, and odor, and whether blood is present. The severity of nausea and vomiting may be rated using a scale of 1 to 10 (where 10 is the worst symptoms) or using the terms mild, moderate, and severe

Question 63

For alopecia

Answer 63

Assess the patient’s views, concerns, and emotions about potential hair loss. Assess the patient’s need to prepare for hair loss, either by leaving the hair as it is and allowing it to fall out on its own; having the hair cut short; or wearing a scarf, hat, bandana, or hair wrap and/or purchasing a wig before the hair is actually lost. Purchasing a wig prior to chemotherapy will allow for a closer match to a patient’s pre-chemotherapy hairstyle.

Question 64

For bone marrow suppression:

Answer 64

Assess for signs and symptoms of anemia or the decrease in RBCs, hemoglobin level, and hematocrit (e.g., pallor of the skin, oral mucous membranes, and conjunctiva; fatigue; lethargy; loss of interest in activities; shortness of breath; and inability to concentrate). Assess for signs and symptoms of leukopenia (decrease in WBCs [see Chapter 46] and/or absolute neutrophil count [ANC; normal range is 1500 cells/mm3, with severe neutropenia being less than 500 cells/mm3]), including fever; chills; tachycardia; abnormal breath sounds; productive cough with purulent, green, or rust-colored sputum; change in the color of the urine; lethargy, fatigue; and/or acute confusion. Assess for signs and symptoms of thrombocytopenia (decrease in thrombocytes [usually less than 100,000] and platelet clotting factors), including indications of unusual bleeding such as petechiae; purpura; ecchymosis; gingival (gum) bleeding; excessive or prolonged bleeding from puncture sites (e.g., intramuscular or IV administration sites or blood draw sites); unusual joint pain; blood in the stool, urine, or vomitus; and a decrease in blood pressure with elevated pulse rate (see the Safety: Laboratory Values Related to Drug Therapy box in this chapter as well as Chapters 26 and 27; see also Box 45-2). Always assess for the normal ranges of laboratory values.

Question 65

For possible sterility, teratogenesis, damage to ovaries | with amenorrhea:

Answer 65

In adult male patients, assess baseline reproductive history with attention to sexual functioning, fathering of children, and/or past or current reproductive or sexual problems or concerns. In female adult patients, in addition to the relevant aspects already mentioned, inquire about fertility, menstrual and childbearing history, and age of onset of menses and menopause, if applicable

Question 66

One specific assessment consideration associated with the use of the antimetabolite cytarabine is monitoring for the occurrence of

Answer 66

cytarabine syndrome. This syndrome usually occurs within 6 to 12 hours after drug administration and is characterized by fever, muscle and bone pain, maculopapular rash, conjunctivitis, and malaise. Assessment and quick identification of this syndrome can lead to its prevention and appropriate treatmen

Question 67

In patients receiving mitotic inhibitors (e.g., vinblastine, vincristine) and alkaloid topoisomerase II inhibitors (e.g., etoposide),

Answer 67

perform baseline hepatic and renal function tests, as ordered. Serum uric acid levels are usually ordered because these levels rise with increased cell death from cancer and/or its treatment

Question 68

With the use of natural enzyme drugs (e.g., asparaginase, | pegaspargase),

Answer 68

assess pancreatic function because of the potential | for severe or even fatal pancreatitis

Question 69

Assess individuals for the presence of | the following characteristics before chemotherapy is initiated:

Answer 69

(1) genetic markers for oral cancers, (2) genetic determinants of testosterone or estrogen metabolism, and (3) genetically linked enzyme system abnormalities such as those involving specific cytochrome P-450 enzymes that metabolically convert nicotine to a carcinogenic substance

Question 70

NURSING DIAGNOSES pg741

Answer 70

1. Diarrhea related to the adverse effects of antineoplastic drugs 2. Acute pain related to the disease process and drug-induced joint pain, stomatitis, GI distress, and other discomforts associated with antineoplastic cell cycle–specific therapy 3. Risk for infection related to drug-induced bone marrow suppression with possible leukopenia and neutropenia

Question 71

OUTCOME CRITERIA | 1. Patient states measures to minimize diarrhea.

Answer 71

• Patient states foods and beverages to avoid such as hot, spicy foods and beverages; alcohol; foods high in fiber; gaseous foods such as cruciferous vegetables; and raw seafood. • Patient takes antidiarrheal medication, as instructed and if indicated, to avoid dehydration and electrolyte loss.

Question 72

To address nutritional concerns, the following measures may | prove beneficial in improving oral intake and nutritional status:

Answer 72

(1) Perform a 24-hour recall of food intake, and report the typical week’s diet for the patient. (2) Use antiemetic therapy, pain management, mouth care, and hydration, as ordered, to reduce the adverse effects of therapy and improve appetite. (3) To ease taste alterations, advise the patient to consume mild-tasting foods and to use chicken, turkey cheese, or greek yogurt for protein sources as tolerated. (4) Provide plastic rather than metal utensils if the patient complains of a metallic taste. (5) Encourage eating foods that are easy to swallow, such as custards; gelatins; puddings; milkshakes; eggnog; commercially prepared high-protein, high-calorie supplemental shakes; mashed white or sweet potatoes; blended drinks with crushed ice, fruit, and yogurt; nutritional supplement drinks and snacks; frozen popsicles; and lactose-free ice cream. (6) Instruct the patient to avoid sticky or dry foods. (7) Encourage the consumption of small, frequent meals in an environment that is conducive to eating (e.g., free of odors and excess noise). (8) Appetite stimulants such as megestrol acetate or dronabinol may be helpful. (9) Encourage the patient to practice energy conservation, with frequent rest periods before and after meals.

Question 73

administration of colony-stimulating factors may be beneficial. Filgrastim, pegfilgrastim, and sargramostim are examples of drugs

Answer 73

given to accelerate | WBC recovery during antineoplastic drug therapy

Question 74

Nutritional status may be enhanced | by the intake of foods

Answer 74

high in folic acid, including bran, dried | beans, nuts, fruits, asparagus, and other fresh vegetables, if tolerated.