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.