Complications of chemotherapy

Question 1

Other cells affected

Answer 1

• Hair follicles
• Stem cells
• Mucosal cells

Question 2

Common side-effects of chemotherapy

Answer 2

• Nausea + vomiting
• Diarrhoea
• Mucositis
• Hair loss
• Fatigue
• Immunosuppression (infection)
• Fertility problems

Question 3

Why does N + V occur?

Answer 3

• The body sees medicine as foreign.
• Activates chemoreceptor trigger zone.
• Sets of warning signals in brain and digestive system.
• Activation of vomiting centre.

Question 4

Types of N + V

Answer 4

• Acute
• Delayed
• Anticipatory
• Breakthrough
• Refractory

Question 5

Acute N + V

Answer 5

Occurs during the first 24 hours after chemo

Question 6

Delayed

Answer 6

• Occurs more than 24 hours after chemo
• May continue for up to 6-7 days after.

Question 7

Anticipatory

Answer 7

• N + V that occurs prior to beginning a new cycle of chemo.
• Common after 3-4 cycles after chemo.
• Badly controlled acute or delayed symptoms.
• May be a learned response:
  
  • Following N + V induced on a previous cycle
  • Anxiety response

Question 8

Breakthrough

Answer 8

• Development of N + V despite standard anti-emetic therapy.
• Requires treatment with an additional pharmacological agent.

Question 9

Refractory

Answer 9

• Failed treatment of both standard and rescue medicine.

Question 10

Cisplatin

Answer 10

• Grade 3 N+ V, if no anti-emetic administered.
• N = Inadequate caloric intake, IV fluid, tube feedings, TPN indicated> 24 hours.
• V = 6+ episodes in 24 hours
• Use moderate/high risk regime + APREPITANT

Question 11

Drug regime for Low risk N + V

Answer 11

• E.g. single agent fluorouracil regimes.
• Monotherapy with dopamine antagonist (metoclopramide OR domperidone).
• First dose pre-chemo, then regularly for 5-7 days (or PRN).

Question 12

Moderate/high risk N +V drug regime

Answer 12

e.g. Cis/5FU

Pre-chemo:
- Dexamethasone + 5HT-3 antagonist (ondansetron and granisetron)

Post-chemo:
- Dexamethasone + 5HT-3 antagonist + dopamine antagonist
- 5-7 days after

Question 13

Diarrhoea

Answer 13

• Incidence varies between cyckes
• Loperamide (just in case).

Question 14

Mucositis

Answer 14

• Occurs when cancer treatments breakdown epithelial cells lining the GI tract.
• Early treatment is required to minimise eating/drinking issues.
• Mouthwashes
  
  • Difflam
  • Chlorhexidine
• Good oral hygiene
• Soft-bristled toothbrush
  
  • Avoid cutting gums

Question 15

Hair loss

Answer 15

Extent of hair loss varies between different drugs.
- Scalp cooling (cold-caps)
- Time-consuming and not particularly comfortable.

Question 16

Fatigue

Answer 16

• Results from the stress of chemo or N + V
• Performace status monitored between cycles.
• Poor PS = delay or stop chemo

Question 17

Performace status

Answer 17

0 = no symptoms, average activity level.
1 = symptomatic, can carry out normal daily activities.
2 = Symptomatic, bed less than half the day, some assistance required.
3 = Symptomatic, bed more than half the day.
4 = Bedridden

Question 18

Haematological side-effects

Answer 18

• Myelosuppression
• Thrombocytopenia
• Neutropenia

Question 19

Monitoring for haematological side-effects

Answer 19

• FBC before each cycle - delays/dose reduction if inadequate.
  
  • WCC = 3+
  • Neutrophils = 1-1.5+
  • Platelets = 100+
• Counsel patients to be vigilant and report possible symptoms
• Transfusion if very low Hb (anaemia)

Question 20

Myelosuppression

Answer 20

• Decreased bone marrow activity
• Fewer RBCs, WBCs and platelets.

Question 21

Myelosuppression - management

Answer 21

• Transfusions
• Growth factors
• Time between cycles
• Isolation in sterile environment

Question 22

WBC normal range (x10*9/L)

Answer 22

4-11

Question 23

Platelets normal range (x10*9/L)

Answer 23

150-400

Question 24

Neutrophils normal range (x10*9/L)

Answer 24

2-7.5

Question 25

Tumour lysis syndrome

Answer 25

• Tumour cells release their contents into the bloodstream spontaneously or in response to therapy.
• Associated with aggresive/large haematological cancers (high cell burden)

Question 26

Tumour lysis syndrome - process

Answer 26

• Chemotherapy causes mass cell lysis.
• Uric acid (and electrolytes) released from cells as they break down.
• Deranged U+Es = acute kidney injury.

Question 27

Tumour lysis syndrome - treatment

Answer 27

• Prevention is curcial
• Allopurinol or rasburicase
  
  • Promote excretion of uric acid.

Question 28

Subfertility

Answer 28

• Spermbanking
• IVF

Question 29

Cardiomyopathy

Answer 29

• ECG monitoring
• Cardiac glycosides

Question 30

Hepatotoxicity

Answer 30

Liver function tests (pre and post)

Question 31

Nephrotoxicity / Haemorrhagic cystitis

Answer 31

Hydration and forced diuresis (for ifosfamide and cyclophosphamide)

Question 32

Patient education

Answer 32

• Balnced info on side-effects and benefits of treatment.
• Adress:
  
  • What are the side effects?
  • How likely are they to happen to me?
  • What should I do if they occur?

Question 33

Aims of treatment

Answer 33

• Reduce discomfort
• Reduce morbidity and mortality
• Increase tolerable dose threshold