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Flashcards in Management of Cancer Side Effects Deck (58):

Anti-neoplastic agents
1. Unable to discriminate between what?

2. What cells are susceptible to chemotherapy?

3. Describe the reaction range?

1. Unable to discriminate between neoplastic and normal cells

2. Every cell in each cell cycle is susceptible to effects of chemotherapy

3. Reactions can range from hair loss to life-threatening infections


1. Hair follicle has a ______ ______ index?

2. Assessment? 2

3. Education?

4. Insurance companies will often pay for what?

1. Hair follicle has a high mitotic index

2, Assessment:
-Occurs within 2 weeks after drug administration, is reversible
-Occurs in week 3 of cranial irradiation

3. Education: emotional support

4. Insurance companies will often pay for wigs


1. What can anorexia be caused by relating to cancer? 3
2. Assessment? 3
3. Eduaction? 2
4. Medications that can help? 3

-radiation of bowel or
-disease related

2. Assessment:
-dietary history,
-lab values

3. Education:
-Weekly weights
-Small frequent meals

4. Medications:
-megesterol (Megace),
-dronabinol (Marinol)


1. Related to what? 2
2. Usually chronic. Why? 2
3. Which drugs are the worst for this? (what is the most important)?

4. What specific mechanism does it affect ?

1. Related to
-effect of drugs or
-radiation to cardiac muscle, pericardium

2. Usually chronic:
-cumulative dosing of cardiotoxic drugs, irreversible
-Radiation to large volumes of heart or pericardium

3. Doxorubicin******
-daunorubicin, mitoxantrone, high dose cyclophosphamide, high dose 5FU, and paclitaxel

4. ejection fraction


1. Assessment?
2. Collaborative management? 4
3. Medication?
4. Educate? 4

1. Assessment:
-history of hypertension, smoking, pre-existing cardiac disease

2. Collaborative management:
-MUGA scan,
-exercise and diet modification,
-dose reduction, and

3. dexrazoxone (Zinecard) cardioprotective……prevent free radicals

4. Educate:
-instruct on possible cardiotoxicity,
-s/s of CHF,
-daily weights,
-symptom management at home


1. PP?
2. Assessment? 4
3. Management? 3
4. Educate? 2

1. Pathophysiology: result of neurotoxic effects resulting in decreased peristalsis

2. Assessment:
-patients receiving vinca alkaloids,
-opioid pain management,

3. Management:
-bowel program,
-exercise and diet modifications,
-laxative and stool softener

4. Educate:
-increasing fluids and dietary interventions,
-establish a bowel program


Skin or Cutaneous Responses
1. PP? What is very similar in appearance to a superficial burn?
2. Assessment? 3
3. Educate? 3
4. Management? 2

1. Pathophysiology: Drug-mechanism unknown
-Radiation dermatitis
2. Assessment :
-common reactions include rash,

3. Educate:
-Prepare patients for the potential changes,
-monitor for signs and symptoms of infection,
-avoid heat and vasodilation

4. Management:
-Call the radiation oncologist and discuss skin care or
-call the medical oncologist and discuss medical management


Skin or Cutaneous Responses
1. What is hand-foot syndrome also called?
2. What is it?
3. Most commonly associated with what? 3
4. Might be able to prevent how?

1. Acral erythema
2. Painful palms and soles with erythema, desquamation, and ulceration

3. Most commonly associated with

4. May be able to prevent with holding ice packs during infusion and/or taking pyridoxine


1. PP?
2. Incidence? (especially which drug)
3. Assessment? 3

1. Pathophysiology: GI tract mucosa very sensitive to cytotoxic drugs due to high mitotic index

2. Incidence: occurs in 75% of patients especially those receiving antimetabolites

3. Assessment:
-neutropenic status,
-bowel elimination patterns,


Collaborative management of Dirrhea? 3

Educate? 4

1. Collaborative management:
-IV/fluid support,
-Loperamide, diphenoxylate
-? Use Codeine

2. Educate:
-Low residue diet
-fluid requirements
-Watch for signs and symptoms of dehydration
-Perianal care


________ is the most commonly reported symptom



1. PP? 4
2. Assessment? 3
3. Collaborative management?
4. Educate? 3

1. Pathophysiology:
-changes in sleep patterns,
-psychosocial factors

2. Assessment:
-risk factors,
-acute vs. chronic,
-fatigue level

3. Collaborative management:
-multidisciplinary referrals

4. Educate:
-setting realistic goals,
-energy management,
-causes and factors of fatigue


Hemorrhagic Cystitis
1. PP?
2. Incidence? (which drug most common??) 3
3. Assessment? 5
4. Collaberative management? 2
5. Educate? 3

1. Pathophysiology: bladder mucosal irritation from metabolic by-products of drugs

2. Incidence: regimens with
-high dose methotrexate

3. Assessment:
-urinary frequency,
-previous history of pelvic radiation

4. Collaborative management:
-lab monitors,
-PO/IV hydration with diuretics (to keep the bladder flushed)

5. Educate:
-potential for side effect to occur,
-increase fluid intake,
-frequent urination


1. PP?
2. Assessment? 6
3. Collaberative management? 2
4. Educate?

1. Pathophysiology: direct toxic effect to liver when drugs are being metabolized

2. Assessment:
-ETOH use,
-liver disease,
-medication use,
-jaundice, ascites,

3. Collaborative management:
-monitor labs,
-limit acetaminophen to less than 4000mg/day

4. Educate: avoid alcohol


Hypersensitivity Reactions
1. PP?
2. Assessment?
3. Collaborative management? 6
4. Educate? 2

1. Pathophysiology: antigen/antibody reaction

2. Assessment: clinical manifestations of local or systemic reaction

3. Collaborative management:
-test dose,
-premedication prior to chemo,
-emergency equipment,
-H1 and H2 blockers,

4. Educate:
-potential for allergic reaction,
-signs and symptoms of reactions


1. PP?
2. Incidence? 3 cancers
4. Assessment? 3

1. Pathophysiology: direct effect of drug or radiation on oral mucosa

2. Incidence:
-leukemia and
-just about all head and neck cancer patients

-XEROSTOMIA: dysphagia, plaque formation, pale dry oral mucosa (non-painful)
-Mucositis: Erythema, desquamation, ulceration (very painful)
-Yeast infections: Thrush, oral or esophageal candidiasis


May be able to give prophylactic medication to prevent which symptom?



1. Collaberative management? 4
2. Educate? 3

1. Collaborative management:
-aim is for prevention,
-dental referral,
- “Magic mouthwash” (viscous lidocaine, benadryl, nystatin susp,)
-chlorhexidine (Peridex) rinse

2. Educate:
-frequent oral hygiene,
-use of saline or baking soda rinses QID,
-cryotherapy (suck on ice)


The World Health Organization has proposed a grading scale for mucositis:
Describe grades 0-4

-Grade 0= no change
-Grade 1= soreness
-Grade 2= erythema (redness), ulcers, can eat solids
-Grade 3= ulcers, requires a liquid diet
-Grade 4= severe ulcers prohibiting oral intake


Nausea and Vomiting

(1) stimulation of the vagus nerve by the release of serotonin
(2) stimulation of the chemoreceptor trigger zone (CTZ) in the medulla
(3) stimulation of the true vomiting center (TVC)

Can be anticipatory, acute, or delayed


Incidence of N/V?


alkylating agents highly emetogenic,

females > males,
youth > elderly


Nausea and Vomiting
1. Assessment? 4
2. Collaborative Management? 5
3. Educate? 3

1. Assessment:
-rule out other causes of nausea,
-hydration status,
-weight loss,

2. Collaborative management:
-timely administration of antiemetics,
-fluid support,
-emotional support,
-dietary support,
-telephone f/u if treated as an outpatient

3. Educate:
-patient to notify you if symptoms persist >48 hrs,
-unable to maintain oral intake,
-take antiemetics around the clock for 48-72 hours after receiving chemo


Chemotherapy induced N/V
1. Most effective therapy is what? 2
2. What is the preferred agent?
3. Other agents? 2

1. a 5-HT3 agent plus dexamethasone

2. Palonosetron (Aloxi) is now the preferred agent (Previously Odansetron (Zofran))

3. Other agents
-Lorazepam (BZD)
-Prochlorperazine (Phenothiazine) (Compro)


1. PP? 2
2. Incidence? 2

1. Pathophysiology:
-direct cell damage to the kidney;
-indirect cell damage by metabolites

-associated with cisplatin therapy,
-high dose methotrexate


1. PP? 3
2. Incidence? 2
3. Assessment? 8
4. Management?
5. Educate?

1. Pathophysiology:
-(a) direct effect on the nervous system;
-(b) metabolic encephalopathy;
-(c) intracranial hemorrhage due to coagulopathy or myelosuppression

2. Incidence:
-high dose chemotherapy,
-drugs crossing the blood-brain barrier

3. Assessment:
- tinnitis,
-peripheral neuropathies,
-fine motor losses,
-numbness, tingling,
-gait disturbances,
-changes in mentation,
-urinary retention,

4. Management:
-Avoid extremes in temperature

5. Educate: s/s of neurotoxicity, many symptoms reversible if interventions initiated early


Pulmonary Toxicity
1. PP?
2. Incidence? 3
3. Assessment?
4. Collaberative management? 3
5. Educate? 2

1. Pathophysiology: toxic damage to alveoli resulting in pneumonitis and pulmonary fibrosis

2. Incidence:
-busulfan and

3. Assessment: thorough respiratory assessment

4. Collaborative management:
- pulmonary function tests prior to therapy,
-treat with corticosteroids and
-dc chemo

5. Educate:
-signs and symptoms associated with pulmonary toxicity,
-energy conservation techniques


Sexual and Reproductive Dysfunction
1. PP? 3
2. Assessment? 2
3. Collaborative Management? 2
4. Educate? 2

1. Pathophysiology:
-(a) toxic effects on the gametes;
-(b) physical side effects of chemotherapy;
-(c) can be permanent or temporary

2. Assessment:
-early menopause,

3. Collaborative management:
-sperm banking,

4. Educate:
-implications of treatment on sexuality,
-long-term side effects


1. PP? 3
2. Incidence?6

1. Pathophysiology:
-(a) bone marrow highly sensitive to toxic effects of chemotherapy due to high mitotic index;
-(b) can be dose-limiting and delay treatment;
-(c)anemia, neutropenia thrombocytopenia, pancytopenia

2. Incidence:
-alkylating agents,


1. PP?
2. Assessment? 6
3. Collaberative management? 4
4. Educate? 2

1. Pathophysiology: changes in the erythrocyte-proliferation pathways

2. Assessment:
-concomitant radiation,
-poor nutritional status,
-history of renal or hepatic impairment

3. Collaborative management:
-CBC, RBC transfusions as needed,
-iron supplements,
-oxygen therapy,
-[EPO (Procrit/Epogen) only if absolutely necessary as increased risk of death associated in cancer pts]

4. Educate:
-signs and symptoms of anemia,
-change positions slowly to prevent falls and injury


1. PP?
2. Assessment? 4
3. Collaborative management? 4
4. Educate? 3

1. Pathophysiology: ANC (absolute neutrophil count) of less than 1,500
2. Assessment:
-prior chemotherapy or radiation,
-signs and symptoms of infection

3. Collaborative management:
-neutropenic fever recommendations,
-filgrastim or
-pegfilgrastim [Granulocyte colony-stimultion factor (G-CSF)]

4. Educate:
-signs and symptoms of infection,
-meticulous hygiene,
-daily temps


Any what gets admited to the hospital?



Calculating the ANC: Steps?

1. Obtain the CBC including the differential

2. Add the neutrophils and bands and convert to a percentage

3. Multiply the total WBC x total neutrophil percentage

Example: WBC=1600; neutrophils=48; bands=5; 48+5=53; 53/100=0.53; 1600x0.53=848


1. PP?
2. Assessment? 4
3. Collab. managment? 5
4. Educate?

1. Pathophysiology:
-bone marrow suppression decreases platelet production

2. Assessment:
-bruising, and
-signs and symptoms of intracranial bleed

3. Collaborative management:
-platelet counts
A. less than 50,000 risk of bleeding is present;
B. less than 20,000 high risk for bleeding;
C. less than 10,000 critical risk
D. Platelet transfusion
E. Thrombocytopenic precautions (electric razor, no suppositories or douches, no dental flossing, no injections, etc.)

4. Educate: the signs and symptoms of bleeding to report


Radiation side effects
Long term or high dose exposure (General)
5 (most common)

1. Nausea
2. Vomiting
3. Trouble Swallowing
4. Fatigue***
5. Decrease in platelets and lymphocytes
-Decreased immune function


Radiation side effects
1. Skin? 2
2. Mucous membranes? 3
3. Reproductive organs? 2
4. Bone? 2

1. Skin
-Erythema – desquamation (reversible)
-Hair loss at site

2. Mucous Membranes
-Fibrin plaquing
-Urinary and bladder changes
-Visceral changes (secretory)

3. Reproductive organs
-Irreversible damage to gametes

4. Bone
-Suppress osteoblast activity
-Decrease number of osteocytes


Pain measurement tools: Attention to nonverbal signs of pain is also important?

1. Autonomic changes such as
-tachycardia, and

2. Agitation or confusion in patients with
-organic brain disease

3. Apathy, inactivity, or irritability

4. Refusal to eat

5. Protect the painful part or show facial grimacing


Pain measurement tools : scales?

1. Pain scale
2. McGill Pain Questionnaire
3. Memorial Pain Assessment Card


Pain Management
1. Pain in cancer patients can be caused by direct effects of the tumor such as? 2

2. Caused by complications of treatment? 3

1. Pain in cancer patients can be caused by direct effects of the tumor
-invasion of bone by tumor
-nerve compression

2. Caused complications of treatment
-radiation fibrosis
-chemotherapy-induced neuropathy
-postoperative surgical pain


What is the most common cause of somatic pain in pts with cancer?

Bone metastasis


1. Visceral pain is often associated with?

2. Common causes of visceral pain?

1. often associated with nausea and diaphoresis.

2. pancreatic cancer and metastases in the abdomen


1. Describe Neuropathic pain?

2. Characterized by its relative resistance to what?

3. Neuropathic pain is caused by injury to the nervous system like? 2

1. Prolonged, severe, burning or squeezing

2. Characterized by its relative resistance to opioids, making it the most challenging type of pain to treat

3. Neuropathic pain is caused by injury to the nervous system
-tumor compressing nerves or the spinal cord
-cancer infiltrating the nerves or spinal cord


What is the most common kind of pain?

neuropathic pain


Pain Sites

1. Bone pain
2. Back pain
3. Headache
4. Facial pain
5. Abdominal pain
6. Pelvic pain
7. Post op pain
8. Phantom pain
-More than 1 site


Multiple factors influence the development of cancer pain:

1. Cancer type and site
2. the presence or absence of metastases
3. 85% of those with bone involvement had pain which required analgesic medication compared to only 5 percent of those with leukemia


What were the most frequent causes of pain?

1. Visceral involvement,
2. bone metastases,
3. soft tissue invasion, and
4. nerve/plexus pressure or
5. infiltration


Treatment Goals

1. Diminish pain and associated emotional distress
2. Increase physical, social, vocational, and recreational involvement
3. Optimize health
4. Improve psychological well being
5. Improve coping ability
6. Reduce dependence on health care system


What drugs should you not use during cancer? 2

1. Codeine
2. Meperidine (demerol)


Pain Management
steps? 3

Three Step Approach
The World Health Organization proposed a three-step approach to the pharmacologic treatment of cancer pain

1. Use of pharmacologic agents, including both non-opioid and opioid agents, as well as analgesic adjuvants

2. Physical and nonpharmacologic approaches to managing pain, which focus on treating the cancer or how the patient reacts to cancer pain

3. Neurosurgical and anesthetic interventional procedures which physically or pharmacologically abrogate the nerve conduction pathways for pain.


Three Step Approach
The World Health Organization proposed a three-step approach to the pharmacologic treatment of cancer pain
1. Step 1?
2. Step 2?
3. Step 3?

1. Non-Opioid (tylenol, aspirin. NSAID)

2. Opiod (Tramadol, Hydrocodone) +/- non-opioid +/_ adjuvant

3. Opiod (Morphine, Fentanyl, Oxycodone) +/- non-opioid +/_ adjuvant


Step one
Non-steroidals and Acetaminophen

1. What kind of schedule before initiating opioid analgesics?

2. If adequate pain relief is not achieved, _________ analgesics are often continued in conjunction with opioids, either in fixed dose combinations or separately

1. Around-the-clock

2. nonopioid


Steps two and three
1. Advocate the addition of ________ for moderate and severe cancer pain, with or without an adjuvant analgesic

2. Opioids are widely used because why? 4

3. Opioids can be used for all types of pain, although _____________ pain may be more difficult to treat

1. opioids

-their reliability,
-multiple routes of administration,
-and ease of titration

3. neuropathic


Choice of opioid
1. The first opioid preparation chosen typically has a _______ half-life and is used on an as needed basis, since initial pain is often episodic and predictable?

2. If pain becomes constant, a _________________ (available orally for morphine and oxycodone and transdermally for fentanyl) can be added (Pick one!)

1. short

2. sustained-release preparation


Choice of opioid
1. _______ a synthetic analog of codeine, may have a dual mechanism of action

2. MOA?

1. Tramadol,

2. Inhibits neuronal reuptake of serotonin and norepinephrine, like tricyclic antidepressants

It is not known whether combining typical opioids and tricyclic antidepressants can achieve effects similar to Tramadol


What about other drugs?

Which drugs are rarely adequate when used alone for cancer pain, but are used to provide an opioid-sparing effect, thereby lessening opioid side effects and possibly slowing the development of opioid tolerance?

Role in treating neuropathic pain, which is often difficult to treat with opioids alone

1. Antidepressants,
2. anticonvulsants,
3. local anesthetics


Other drugs
TCA? 4
Anticonvulsants? 3

Tricyclic antidepressants
1. Amitriptyline (Elavil)
2. Nortriptyline (Pamelor)
3. Imipramine (Tofranil)
4. Desipramine (Norpramin)

1. Carbamazepine (Tegratol)
2. Clonazepam (Klonopin)
3. Gabapentin (Neurontin)


MD Anderson protocol
1. Mild to moderate pain?

2. Moderate to severe pain?

3. Tingling & burning pain? 2

4. Pain caused by swelling?

1. Non-opioids: Examples are acetaminophen and NSAIDs, such as aspirin and ibuprofen

2. Opioids: Examples are morphine, hydromorphone, oxycodone, hydrocodone, codeine, fentanyl and methadone

-Antidepressants: Examples are Amitriptyline, Imipramine, Doxepin
-Antiepileptics: Examples include Gabapentin

4. Steroids: Examples are prednisone and dexamethasone


Interventional approaches to the management of cancer pain

1. Nerve blocks
-Celiac plexus block
-Superior hypogastric plexus block
2. Myofascial injections
3. Neuroma injections
4. Spinal cord stimulation
5. Intrathecal and epidural injections


What is biofeedback?

A technique that makes the patient aware of bodily processes normally thought to be involuntary (blood pressure, skin temperature and heart rate). Patients can gain some conscious voluntary control of these processes, which can influence their level of pain.