Post on 11-May-2020
NURSING THE PATIENT HAVING CYTOTOXIC
CHEMOTHERAPY AND RADIOTHERAPY FOR
COLORECTAL CANCER
Catherine Marshall
Colorectal CNS
Weston Park Hospital
AIMS AND OBJECTIVES
To explain how cytotoxic chemotherapy
works to treat bowel cancers.
To describe the types of drugs used in
colo – rectal and anal cancer.
To explain the health and safety issues
around administration.
To explain how radiotherapy works and
it’s uses in rectal and anal cancer.
THE CELL CYCLE
Is an ordered set of events, culminating
in cell growth and division into two
daughter cells.
Normal cells are in interphase, growing
and preparing for cell division.
Cells leave the cycle to G0 phase, to
carry out their basic functions and then
die.
THE CELL CYCLE
CYTOTOXIC CHEMOTHERAPY
It interferes with the cell cycle by damaging the
production of DNA and mitosis.
It is described as either phase specific or cycle
specific. It is therefore more effective if 2 or
more drugs, acting at different phases of the
cell cycle, are given simultaneously.
Is given systemically, via a peripheral cannula,
orally, intramuscularly, intra thecally or via a
central line (Hickman, Portacath or PICC).
RATIONALE OF REGIMES
Although giving more than one drug may produce more side effects and toxicity, using a single agent or a combination of drugs hopes to :-
Damage DNA and stop cell duplication.
Reduce the cancer load, whilst sparing healthy cells.
Enhance the effect with other modalities (surgery/DXR).
SIDE EFFECTS
Cytotoxic chemotherapy does not differentiate
between malignant and normal cells, hence
the side effects.
Cells which are rapidly dividing include hair
follicles, the bone marrow, skin and the lining
of the gastro intestinal tract, so are more
sensitive to chemotherapy but are therefore
more likely to exhibit side effects.
Normal cells can recover if damaged.
BONE MARROW DEPRESSION
Danger time 5 – 10 days post chemotherapy, for most regimes (the nadir). All patients have FBC, U&E, LFTs taken a day or two before the next cycle of chemotherapy to ensure the bone marrow has recovered.
ANAEMIA
Blood transfusion indicated if Hb < 100gm and the patient is symptomatic. Chemotherapy is not normally delayed.
THROMBOCYTOPAENIA
Delay of 1 or 2 weeks to recover if platelets are <100, consider transfusion if the patient is haemorrhaging.
NEUTROPAENIA (<1)
Educate patient and relatives regarding signs and symptoms of sepsis – thermometer purchase. Alert card/GP information.
Contact WPH if pyrexial ≥ 37.5° - review on the emergency assessment unit by nurse practitioner and doctor.
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 IV antibiotics.
STANDARD OPERATING
PROCEDURES
Education programme for all new nursing staff,
with annual updates for all others.
Annual updates on anaphylaxis and
extravasation.
Scrupulous checking prior to administration by
out patient/pharmacy/nursing staff.
Protective clothing (apron, gloves, goggles)
and transport equipment.
Hazardous waste management.
EXTRAVASATION OF CYTOTOXIC
DRUGS
STAFF PROTECTION
INHALATION chemotherapy waste bins
have closed lids. (purple)
INGESTION gloves are worn when
changing bags or handling giving sets.
ABSORPTION gloves, aprons and
goggles are worn.
WHAT’S THE WORRY?
Prolonged or excessive exposure to
cytotoxic chemotherapy is:-
CARCINOGENIC : - induces cancer.
TERATRAGENIC : - damages the ovaries
and testicles at cellular level.
MUTAGENIC : - can harm the unborn
foetus.
ADDITIONAL PATIENT
EDUCATION
Chemotherapy is excreted in all body fluids
and can stay in the system for 48 hours.
Patients are advised not to become pregnant
or inseminate someone for 1 year after
completion. Barrier contraception is advised.
Sperm and egg storage are offered if
appropriate, more straightforward for male
patients than females.
COLO RECTAL DRUGS
NEO - ADJUVANT : - given to make the rectum more radio sensitive and to downstage colon and liver tumours prior to resection and to treat micro metasteses undetectable by scan.
ADJUVANT : - given to reduce recurrence rates after primary resection if staging = pT3-4, +/- lymph node involvement.
PALLIATIVE :- given to improve lifespan, and/or for symptom control.
TRIALS : - previously trialled drugs, giving them at different stages of treatment pathway, when standard regimes have failed.
CAPECTABINE
A number of tablets, which are converted in the body to Fluorouracil, are taken twice daily for 2 weeks, then 1 week without.
It reduces recurrence by 8%- 10% when used after surgery, in the adjuvant setting (8 cycles). 4 or 6 cycles are given in the palliative setting and then the patient is scanned to measure response.
Advantageous for hospital or needle phobic patients, and those desperate to continue working.
After completing the 6 months of adjuvant chemotherapy, the patient has the normal follow up protocol pathway with the surgeon/nurse practitioners.
Given to patients with rectal cancer, at a sub therapeutic dose, having 5 weeks of radiotherapy.
SIDE EFFECTS
Fatigue.
Diarrhoea:- the stoma can bleed and be sore. Patients already having diarrhoea may have less toxicity with the intra venous alternative.
Mucositis :- ranging from the odd blister on the lips, soft/hard palate and tongue to significant dysphagia.
Palmar/plantar syndrome :- loss of dexterity, but no permanent neuropathy.
Angina :- can cause coronary artery spasm, so previous cardiac patients are excluded.
PALMAR PLANTAR SYNDROME
DPD deficiency
Dihydropyrimidine Dehydrogenase is an enzyme which excretes Capecitabine from the liver. A small percentage of patients lack this enzyme and exhibit all the side effects, very severely, after the first cycle. Colitis and diarrhoea is usually the worst presentation and warrants admission to hospital for fluid and nutritional support. It can be fatal.
OXALIPLATIN AND
CAPECITABINE OR 5FU
Oxaliplatin/Capecitabine every 3 weeks or Oxaliplatin/5FU every 2 weeks.
Adjuvant 12 cycles, reduces the recurrence rate by
10% -15%.
Palliative, 4 cycles then scan for response. If stable or good response, the patient is monitored but not given further treatment to 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 peripheral cannula, or 2 hour out patient stay if administered via PICC line, when the Oxaliplatin is administered in WPH, then the Fluorouracil (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 handling
cold 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 5FU
PALLIATIVE ,2ND LINE CHEMOTHERAPY
Given if there’s no response to Oxaliplatin and 5FU/ Capecitabine.
Previous Oxaliplatin based regimen has resulted in neuropathy.
The patient already has neuropathy due to other co morbidities.
If recurrence occurs within 6 months of first line palliative treatment.
SIDE EFFECTS
Immediate or delayed diarrhoea.
Alopecia.
Increased sweating and saliva production
(cholinergic response) for which S/C Atropine
is given as prophylaxis, ½ hour prior to
administration.
Itching and rash.
Nausea and vomiting.
Pronounced bone marrow depression.
Monoclonal Antibodies
Also known as targeted therapy, as the patient
sometimes requires genetic testing of their
original tumour for KRAS and other markers.
They are not DNA destroying drugs, like
cytotoxics, but recognise and lock onto
specific protein receptors and cause an
immune response resulting in cell death or
block growth factors and prevent blood vessel
development to tumours.
Bevacizumab/Aflibercept/Cetuximab
Have to be applied for from the Cancer Drug Fund as they are not recommended as standard treatment in the palliative setting by NICE.
Have to given along with chemotherapy.
Have to be given continuously, with breaks of less than 6 weeks, (funding is withdrawn) until disease progression or patient choice. This is therefore a consideration for patients who want breaks from treatment or who have side effects from the chemotherapy.
Side Effects
Allergic 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 LADDER
MONO
CLONAL
ANTI-
BODIES
OXALIPLATIN OR
IRINOTECAN
FLUOROURACIL
OR
CAPECITABINE
CARCINOMA OF ANUS
SQUAMOUS CARCINOMA; treated with 5 weeks of daily radiotherapy along with Mitomicin C and 5FU chemotherapy on the first and final weeks.
ADENO CARCINOMA; less successful than squamous histology.
Many patients will have a defunctioning colostomy performed prior to treatment for pain relief and to prevent intestinal obstruction, as radiotherapy can cause inflammation of the bowel mucosa.
SUMMERY
Cytotoxic chemotherapy can be used to
treat colo rectal cancer with a curative or
palliative intent.
The potential side effects can have a
temporary or permanent effect on the
quality of life.
It has only a 10 – 15% benefit in the
adjuvant setting.
RADIOTHERAPY
HOW RADIOTHERAPY WORKS
High energy electromagnetic gamma
rays produce ionisation of atoms when
they pass through biological tissue. The
electron is displaced from it’s orbital
path around the nucleus causing
cellular destruction.
( Souhami & Tobias, 2005)
THERAPEUTIC RATIO
The aim of radiotherapy is to optimise the
dose to the tumour, but minimise the
damage to normal tissue. The spectrum
of cellular sensitivity, the arterial blood
supply, the amount of necrotic tissue and
the degree of oxygenation are key for
success. Smokers are strongly advised
to 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, neutropaenia and thrombocytopaenia.
Can be carcinogenic, mutagenic and teratogenic, to patients and staff.
( Faithfull & Wells, 2003
FACTS AND FIGURES
40% of patients with cancer will have radiotherapy, which is generally more curative than chemotherapy treatments, but of these patients, more than half will receive it to palliate symptoms. Sometimes, chemotherapy is given simultaneously, at a sub therapeutic dose to enhance the radiotherapy.
(www.cancerresearchuk.org)
In Weston Park Hospital, an average of 3,800 patients are treated annually, with 55,700 # (a fraction is the term used to describe a single dose of radiotherapy). Only 8% are treated as in patients.
Rectal cancer and radiotherapy
The rectum is the only part of the bowel
that can be irradiated, as it is fixed in the
pelvis and stays in the same position
every day.
The treatment takes about 5 minutes
each day, the patient in exactly the same
position, helped by tattooing the skin.
Long course radiotherapy
28# are given every day, Monday – Friday, when the circumferential resection margin (CRM) is compromised, before planned anterior resection/APER. If there is no cardiac history, Capecitabine is given in a sub therapeutic dose, to radio- sensitise the tumour.
Scans are performed 6-8 weeks post treatment to assess the response, prior to the surgery. The effects of radiotherapy will continue to be seen during this time. Scans are then reviewed at MDT meetings.
Patients find this protracted treatment psychologically difficult to accept and cope with.
Short course radiotherapy
5 # are given the week prior to planned
surgery where the circumferential
resection margin is clear, and offers a
50% less chance of recurrence.
The patient experiences minimal side
effects as the treated bowel is resected
before radiation damage is evident.
PALLIATIVE RADIOTHERAPY
Palliative radiotherapy is given if the
patient is too frail for surgery and for
recurrent inoperable disease.
Usually 5# can be useful to control the
symptoms of tenesmus, pain, and
bleeding, but will not improve diarrhoea,
in fact will be experienced as a side
effect.
PELVIC RADIATION – LINEAR
ACCELERATOR
SIDE EFFECTS
Sore skin over all the pelvic area
Infertility, early menopause, erectile dysfunction
Diarrhoea
Tenesmus
Bleeding
Incontinence
Cystitis like symptoms, frequency and urgency
Vaginal stenosis
Anal cancer
Squamous cell cancers are more radio and
chemotherapy sensitive than
Adenocarcinomas.
If no metasteses are seen on staging scans, 6
weeks of radiotherapy in 28# are given with
Mitomicin C and 5FU chemotherapy, the first
and last weeks of treatment.
Review scans after 6 weeks, at MDT meeting.
If not a complete response, proceed to APER.
ROLE OF THE CNS
The CNS is the passenger on the cancer
patient’s journey, hitching a ride at various
points to make the journey easier.
To provide information on treatment options.
To offer support and advice on managing side
effects and coping.
Financial signposting.
Prepare the patient and family for end of life
issues.