Malignant Disease

Question 1

What are the guidelines for the safe handling on cytotoxic drugs?

Answer 1

Trained personnel should reconstitute cytotoxics. Reconstitution should be carried out in designated areas. Protective clothing should be worn (gloves, aprons, eye protection). Pregnant staff should avoid exposure and women of child-bearing age should be made aware of the reproductive risk. Use local procedures for dealing with spillages and safe disposal of waste material. Staff exposure to cytotoxics should be monitored.

Question 2

What are the ‘safe system’ requirements for the use and dispensing of cytotoxic drugs?

Answer 2

Cytotoxic drugs for the treatment of cancer should be given as part of a wider pathway of care coordinated by a multidisciplinary team. Cytotoxic drugs should be prescribed, dispensed and administered only in the context of a written protocol or treatment plan. Injectable cytotoxics should only be dispensed if they are prepared for administration. Oral cytotoxic medicines should be dispensed with clear directions for use.

Question 3

What standards should be followed to ensure the risk of incorrect dosing of cytotoxics is minimised?

Answer 3

Non-specialists should have access to written protocols and treatment plans, and guidance on the monitoring and treatment of toxicity. Staff dispensing oral cytotoxics should confirm that the prescribed dose is appropriate for the patient. Patients should have written information that includes details of intended oral anti-cancer regimen, the treatment plan, and arrangements for monitoring, taken from the original protocol from the initiating hospital.

Question 4

How are doses of drugs used in malignant disease usually calculated?

Answer 4

Using body surface area or body weight. Dose adjustment is common after considering neutrophil count, renal and hepatic function, history of previous adverse effects. Doses may also differ if the drugs are used alone or in combination. Prescriptions should not be repeated unless under the instruction of a specialist.

Question 5

When do many of the side effects of cytotoxic drugs often present?

Answer 5

Not on the day of administration, but days or weeks later.

Question 6

Is the hair loss associated with the use of cytotoxic drugs reversible?

Answer 6

Yes.

Question 7

What is tumour lysis syndrome? What can it lead to?

Answer 7

When large amounts of tumour cells are killed off (lysed) at the same time, their contents are released into the blood stream. Features include hyperkalaemia, hyperuricaemia, hyperphosphatemia with hypocalcaemia. Renal damage and arrhythmias can follow.

Question 8

Hyperuricaemia, which may already be seen in cancer, can be exacerbated by the use of chemo and is associated with acute renal failure. What can be used for treatment or prophylaxis?

Answer 8

Allopurinol, febuxostat, rasburicase.

Question 9

If allopurinol is given alongside mercaptopurine or azathioprine, what changes to therapy should be made?

Answer 9

Doses should be reduced to reduce the risk of bone marrow suppression.

Question 10

Which anti-cancer therapies are mildly emetogenic?

Answer 10

Fluorouracil, etoposide, methotrexate (less than 100mg/m2), vinca alkaloids, abdominal radiotherapy.

Question 11

Which anti-cancer treatments are moderately emetogenic?

Answer 11

Taxanes, doxorubicin, intermediate and low doses of cyclophosphamide, mitoxantrone, high dose methotrexate (greater than 100mg/m2).

Question 12

Which anti-cancer treatments are highly emetogenic?

Answer 12

Cisplatin, dacarbazine, high dose cyclophosphamide.

Question 13

Which drugs are used for the prevention of chemotherapy induced nausea and vomiting?

Answer 13

Dexamethasone, lorazepam, metoclopramide.

Question 14

All cytotoxic drugs except which one’s cause bone-marrow suppression?

Answer 14

Vincristine and bleomycin.

Question 15

How long after administration of cytotoxic drugs is bone marrow suppression seen?

Answer 15

Seven to ten days.

Question 16

When a patient is receiving cytotoxic drugs, how frequently should they have their bloods monitored?

Answer 16

Before treatment, doses should be reduced or therapy delayed if bone marrow has not recovered.

Question 17

Neutropenic sepsis is a potential side effect of the use of cytotoxic drugs, what symptoms should one be aware of?

Answer 17

Fever, flu-like symptoms, uncontrolled bleeding or bruising, diarrhoea, uncontrolled vomiting, severe mouth ulcers. Pt should go to A&E ASAP and not take paracetamol without advice.

Question 18

What is extravasation and how can its incidence be reduced?

Answer 18

Severe permanent local tissue necrosis. Can be reduced by trained staff administering IV cytotoxic drugs.

Question 19

With which cytotoxic drugs is oral mucositis most common?

Answer 19

Fluorouracil, methotrexate, the anthracyclines.

Question 20

Mucositis is self-limiting but with poor oral hygiene it can be the focus of a bloodborne infection. How can this be reduced?

Answer 20

By promoting good oral hygiene.

Question 21

Which cytotoxic drugs are associated with a risk of life threatening cardiotoxic side effects?

Answer 21

Anthracyclines.

Question 22

What drug is licensed for the prevention of anthracycline induced cardiotoxicity?

Answer 22

Dexrazoxane, an iron chelator.

Question 23

What is a common manifestation of urethral toxicity seen with cytotoxic drugs?

Answer 23

Haemorrhagic cystitis. Mesna is useful in preventing toxicity.

Question 24

How is methotrexate induced mucositis and myelosuppression counteracted?

Answer 24

By use of folic/folinic acid.

Question 25

Most cytotoxic drugs are teratogenic, during which period is this most marked? What precaution should be taken before starting therapy?

Answer 25

The first trimester. Pregnancy should be excluded before therapy.

Question 26

What are the dose-limiting side effects of all vinca alkaloids?

Answer 26

Neurotoxicity and myelosuppression.

Question 27

Give some examples of vinca alkaloid cytotoxic drugs.

Answer 27

Vinblastine, vincristine, vindesine, vinflunine, vinorelbine.

Question 28

What may happen if vinblastine, vincristine, vindesine, vinflunine or vinorelbine is administered intrathecally?

Answer 28

Severe neurotoxicity which is often fatal.

Question 29

What are the warning signs of methotrexate toxicity?

Answer 29

Gastro-intestinal toxicity (inflamed mouth or throat), liver toxicity, blood disorders (bone marrow suppression), pulmonary toxicity (pneumonitis), pregnancy or BF.

Question 30

What monitoring is required when patients are on methotrexate?

Answer 30

FBC, renal function, liver function.

Question 31

An increased plasma concentration of methotrexate and increased risk of hepatotoxicity it seen when methotrexate is given with which drug?

Answer 31

Acretin (avoid).

Question 32

An increased risk of toxicity is seen when methotrexate is given with which drugs?

Answer 32

NSAIDs & penicillins (reduced excretion), ciprofloxacin, doxycycline, tetracycline, ciclosporin, PPIs, leflunomide.

Question 33

An increased risk of haematological toxicity is seen when methotrexate is given with which drugs?

Answer 33

Trimethoprim or co-trimoxazole.

Question 34

There is an increased risk of which female reproductive system side effects when they on tamoxifen?

Answer 34

Hyperplasia, polyps, cancer, uterine tremor.

Question 35

Which symptoms of endometrial changes should patients on tamoxifen report urgently?

Answer 35

Abnormal vaginal bleeding, menstrual irregularities, vaginal discharge, pelvic pain or pressure.

Question 36

There is a risk of thromboembolism associated with tamoxifen use, particularly during and immediately after major surgery or periods of immobility. What symptoms should be reported?

Answer 36

Sudden breathlessness and any pain in the calf of one leg.