NURSING THE PATIENT HAVING CYTOTOXIC CHEMOTHERAPY

NURSING THE PATIENT HAVING CYTOTOXICCHEMOTHERAPY AND RADIOTHERAPY FORCOLORECTAL CANCERCatherine MarshallColorectal CNSWeston Park Hospital

AIMS AND OBJECTIVESTo explain how cytotoxic chemotherapyworks to treat bowel cancers. To describe the types of drugs used incolo – rectal and anal cancer. To explain the health and safety issuesaround administration. To explain how radiotherapy works andit’s uses in rectal and anal cancer.

THE CELL CYCLEIs an ordered set of events, culminatingin cell growth and division into twodaughter cells. Normal cells are in interphase, growingand preparing for cell division. Cells leave the cycle to G0 phase, tocarry out their basic functions and thendie.

THE CELL CYCLE

CYTOTOXIC CHEMOTHERAPY It interferes with the cell cycle by damaging theproduction of DNA and mitosis. It is described as either phase specific or cyclespecific. It is therefore more effective if 2 ormore drugs, acting at different phases of thecell cycle, are given simultaneously. Is given systemically, via a peripheral cannula,orally, intramuscularly, intra thecally or via acentral line (Hickman, Portacath or PICC).

RATIONALE OF REGIMESAlthough giving more than one drug mayproduce more side effects and toxicity,using a single agent or a combination ofdrugs hopes to : Damage DNA and stop cell duplication. Reduce the cancer load, whilst sparinghealthy cells. Enhance the effect with other modalities(surgery/DXR).

SIDE EFFECTSCytotoxic chemotherapy does not differentiatebetween malignant and normal cells, hencethe side effects.Cells which are rapidly dividing include hairfollicles, the bone marrow, skin and the liningof the gastro intestinal tract, so are moresensitive to chemotherapy but are thereforemore likely to exhibit side effects.Normal cells can recover if damaged.

BONE MARROW DEPRESSIONDanger time 5 – 10 days post chemotherapy, for most regimes (thenadir). All patients have FBC, U&E, LFTs taken a day or twobefore the next cycle of chemotherapy to ensure the bonemarrow has recovered.ANAEMIABlood transfusion indicated if Hb 100gm and the patient issymptomatic. Chemotherapy is not normally delayed. THROMBOCYTOPAENIADelay of 1 or 2 weeks to recover if platelets are 100, considertransfusion if the patient is haemorrhaging.

NEUTROPAENIA ( 1) Educate patient and relatives regarding signs andsymptoms of sepsis – thermometer purchase. Alertcard/GP information. Contact WPH if pyrexial 37.5 - review on theemergency assessment unit by nurse practitioner anddoctor. Micro bacterial diet. Stringent mouth care. Defer dental treatment. Defer chemotherapy 1 or 2 weeks. GCSF if persistent. Neutropaenic sepsis can be fatal. Support with IVantibiotics.

STANDARD OPERATINGPROCEDURES Education programme for all new nursing staff,with annual updates for all others.Annual updates on anaphylaxis andextravasation.Scrupulous checking prior to administration byout patient/pharmacy/nursing staff.Protective clothing (apron, gloves, goggles)and transport equipment.Hazardous waste management.

EXTRAVASATION OF CYTOTOXICDRUGS

STAFF PROTECTION INHALATION chemotherapy waste binshave closed lids. (purple) INGESTION gloves are worn whenchanging bags or handling giving sets. ABSORPTION gloves, aprons andgoggles are worn.

WHAT’S THE WORRY?Prolonged or excessive exposure tocytotoxic chemotherapy is:CARCINOGENIC : - induces cancer.TERATRAGENIC : - damages the ovariesand testicles at cellular level.MUTAGENIC : - can harm the unbornfoetus.

ADDITIONAL PATIENTEDUCATION Chemotherapy is excreted in all body fluidsand can stay in the system for 48 hours. Patients are advised not to become pregnantor inseminate someone for 1 year aftercompletion. Barrier contraception is advised. Sperm and egg storage are offered ifappropriate, more straightforward for malepatients than females.

COLO RECTAL DRUGS NEO - ADJUVANT : - given to make the rectum moreradio sensitive and to downstage colon and livertumours prior to resection and to treat micrometasteses undetectable by scan.ADJUVANT : - given to reduce recurrence rates afterprimary resection if staging pT3-4, /- lymph nodeinvolvement.PALLIATIVE :- given to improve lifespan, and/or forsymptom control.TRIALS : - previously trialled drugs, giving them atdifferent stages of treatment pathway, when standardregimes have failed.

CAPECTABINEA number of tablets, which are converted in the body to Fluorouracil, aretaken twice daily for 2 weeks, then 1 week without.It reduces recurrence by 8%- 10% when used after surgery, in the adjuvantsetting (8 cycles). 4 or 6 cycles are given in the palliative setting and thenthe patient is scanned to measure response.Advantageous for hospital or needle phobic patients, and those desperate tocontinue working.After completing the 6 months of adjuvant chemotherapy, the patient has thenormal follow up protocol pathway with the surgeon/nurse practitioners.Given to patients with rectal cancer, at a sub therapeutic dose, having 5weeks of radiotherapy.

SIDE EFFECTS Fatigue.Diarrhoea:- the stoma can bleed and be sore.Patients already having diarrhoea may haveless toxicity with the intra venous alternative. Mucositis :- ranging from the odd blister on thelips, soft/hard palate and tongue to significantdysphagia. Palmar/plantar syndrome :- loss of dexterity,but no permanent neuropathy. Angina :- can cause coronary artery spasm, soprevious cardiac patients are excluded.

PALMAR PLANTAR SYNDROME

DPD deficiencyDihydropyrimidine Dehydrogenase is anenzyme which excretes Capecitabinefrom the liver. A small percentage ofpatients lack this enzyme and exhibit allthe side effects, very severely, after thefirst cycle. Colitis and diarrhoea isusually the worst presentation andwarrants admission to hospital for fluidand nutritional support. It can be fatal.

OXALIPLATIN ANDCAPECITABINE OR 5FUOxaliplatin/Capecitabine every 3 weeks or Oxaliplatin/5FU every 2weeks.Adjuvant 12 cycles, reduces the recurrence rate by10% -15%.Palliative, 4 cycles then scan for response. If stable or goodresponse, the patient is monitored but not given further treatmentto allow recovery from side effects and to improve quality of life,until further disease progression.Can involve a 3 day/2 night stay in hospital with a peripheralcannula, or 2 hour out patient stay if administered via PICC line,when the Oxaliplatin is administered in WPH, then theFluorouracil (5FU) is given over 2 days at home via an infusor.

PICC LINE IN SITU

SIDE EFFECTS OF OXALIPLATIN Parasthesia of the jaw, hands and feet,particularly in cold weather, when handlingcold objects or eating/drinking cold foodstuffs(can be a permanent feature).Nausea and vomiting.Fatigue.Allergic reaction.Extravasation necrosis.

5FU infusor attached to PICC line

IRINOTECAN AND 5FUPALLIATIVE ,2ND LINE CHEMOTHERAPYGiven if there’s no response to Oxaliplatinand 5FU/ Capecitabine. Previous Oxaliplatin based regimen hasresulted in neuropathy. The patient already has neuropathy due toother co morbidities. If recurrence occurs within 6 months of firstline palliative treatment.

SIDE EFFECTS Immediate or delayed diarrhoea.Alopecia.Increased sweating and saliva production(cholinergic response) for which S/C Atropineis given as prophylaxis, ½ hour prior toadministration.Itching and rash.Nausea and vomiting.Pronounced bone marrow depression.

Monoclonal AntibodiesAlso known as targeted therapy, as the patientsometimes requires genetic testing of theiroriginal tumour for KRAS and other markers.They are not DNA destroying drugs, likecytotoxics, but recognise and lock ontospecific protein receptors and cause animmune response resulting in cell death orblock growth factors and prevent blood vesseldevelopment to tumours.

Bevacizumab/Aflibercept/Cetuximab Have to be applied for from the Cancer Drug Fund asthey are not recommended as standard treatment inthe palliative setting by NICE. Have to given along with chemotherapy. Have to be given continuously, with breaks of lessthan 6 weeks, (funding is withdrawn) until diseaseprogression or patient choice. This is therefore aconsideration for patients who want breaks fromtreatment or who have side effects from thechemotherapy.

Side EffectsAllergic reaction at the time of infusion. Bleeding/ clotting. Perforations of gastro-intestinal tract. Fistula formation. Delayed wound healing. Hypertension. Protein loss from kidneys.

THE CHEMOTHERAPY LADDERMONOCLONALANTIBODIESOXALIPLATIN ORIRINOTECANFLUOROURACILORCAPECITABINE

CARCINOMA OF ANUSSQUAMOUS CARCINOMA; treated with 5 weeks of dailyradiotherapy along with Mitomicin C and 5FUchemotherapy on the first and final weeks.ADENO CARCINOMA; less successful than squamoushistology.Many patients will have a defunctioning colostomyperformed prior to treatment for pain relief and toprevent intestinal obstruction, as radiotherapy cancause inflammation of the bowel mucosa.

SUMMERYCytotoxic chemotherapy can be used totreat colo rectal cancer with a curative orpalliative intent. The potential side effects can have atemporary or permanent effect on thequality of life. It has only a 10 – 15% benefit in theadjuvant setting.

RADIOTHERAPY

HOW RADIOTHERAPY WORKSHigh energy electromagnetic gammarays produce ionisation of atoms whenthey pass through biological tissue. Theelectron is displaced from it’s orbitalpath around the nucleus causingcellular destruction.( Souhami & Tobias, 2005)

THERAPEUTIC RATIOThe aim of radiotherapy is to optimise thedose to the tumour, but minimise thedamage to normal tissue. The spectrumof cellular sensitivity, the arterial bloodsupply, the amount of necrotic tissue andthe degree of oxygenation are key forsuccess. Smokers are strongly advisedto give up during treatment.

TISSUE SENSITIVITY Highly sensitive:- bone marrow, gonads.Moderately:- nerve cells, skin, the eye, kidney,gut. Poorly:- bone, muscle, connective tissue.The heart and liver are never irradiated.Radiotherapy can lead to anaemia, neutropaeniaand thrombocytopaenia.Can be carcinogenic, mutagenic andteratogenic, to patients and staff.( Faithfull & Wells, 2003

FACTS AND FIGURES40% of patients with cancer will have radiotherapy, whichis generally more curative than chemotherapytreatments, but of these patients, more than half willreceive it to palliate symptoms. Sometimes,chemotherapy is given simultaneously, at a subtherapeutic dose to enhance the radiotherapy.(www.cancerresearchuk.org)In Weston Park Hospital, an average of 3,800 patientsare treated annually, with 55,700 # (a fraction is theterm used to describe a single dose of radiotherapy).Only 8% are treated as in patients.

Rectal cancer and radiotherapyThe rectum is the only part of the bowelthat can be irradiated, as it is fixed in thepelvis and stays in the same positionevery day. The treatment takes about 5 minuteseach day, the patient in exactly the sameposition, helped by tattooing the skin.

Long course radiotherapy28# are given every day, Monday – Friday, when thecircumferential resection margin (CRM) iscompromised, before planned anteriorresection/APER. If there is no cardiac history,Capecitabine is given in a sub therapeutic dose, toradio- sensitise the tumour. Scans are performed 6-8 weeks post treatment toassess the response, prior to the surgery. The effectsof radiotherapy will continue to be seen during thistime. Scans are then reviewed at MDT meetings. Patients find this protracted treatment psychologicallydifficult to accept and cope with.

Short course radiotherapy5 # are given the week prior to plannedsurgery where the circumferentialresection margin is clear, and offers a50% less chance of recurrence. The patient experiences minimal sideeffects as the treated bowel is resectedbefore radiation damage is evident.

PALLIATIVE RADIOTHERAPYPalliative radiotherapy is given if thepatient is too frail for surgery and forrecurrent inoperable disease. Usually 5# can be useful to control thesymptoms of tenesmus, pain, andbleeding, but will not improve diarrhoea,in fact will be experienced as a sideeffect.

PELVIC RADIATION – LINEARACCELERATOR