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Oncology > Management of Cancer SE > Flashcards

Management of Cancer SE Flashcards

1
Q

Why do anti-neoplastic drugs (chemo) cause such tremendous SEs?

A
  • unable to discriminate b/t neoplastic and normal cells:
    every cell in each cell cycle is susceptible to effects of chemo
  • rxns can range from hair loss to life threatening infections
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2
Q

Why does alopecia occur? When does it occur? What is a soln for this?

A
  • hair follicle has a high mitotic index
  • assessment:
    occurs w/in 2 weeks after drug admin, is reversible
  • occurs in week 3 of cranial irradiation
  • education: emotional support
  • insurance companies will often pay for wigs
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3
Q

Why does anorexia occur? Assessment? Education for pt? Tx?

A
  • occurs b/c: chemo, radiation of bowel or disease related
  • assessment: dietary hx, wt, lab values
  • education:
    weekly wts
    small frequent meals
    Tx:
    antiemetics, megesterol (megace), dronabinol (marinol)
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4
Q

What causes cardiotoxicity? What meds cause this?

A
  • related to effect of durgs or radiation to cardiac muscle, pericardium
  • usually chronic:
    cumulative dosing of cardiotoxic drugs, irreversible
  • radiation to large volumes of heart or pericardium
  • doxorubicin** (MC cause), daunorubicin, mitoxantrone, high dose cyclophosphamide, high dose 5FU, and paclitaxel
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5
Q

What should be a part of the assessment for cardiotoicity? Tx? Education?

A
  • assessment: hx of HTN, smoking, pre-existing cardiac disesae
  • Collaborative management: MUGA scan, exercise and diet modification, dose reduction, and EKG
    tx: dexrazoxone (Zinecard): cardioprotective (prevents free radicals)
  • educate: instruct on possible cardiotoxicity, s/s of CHF, daily wts, sx management at home
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6
Q 
Constipation:
Pathophys,
Assessment,
Management,
Education?
A
  • patho: result of neurotoxic effects resultingin decreased peristalsis
  • assessment: pts receiving vinca alkaloids, hypercalcemia, opioid pain management, dehydration
  • Management: bowel program, exercise, and diet modifications, laxative and stool softener
  • educate: increasing fluids and dietary interventions, est. a bowel program
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7
Q

Pathophys of skin or cutaneous responses?

A
  • PP: drug-mechanism unknown, radiation dermatitis is very similar in appearance to superficial burn
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8
Q

Assessment, education and management of skin or cutaneous responses?

A
  • assessment: common rxns include rash, photosensitivity, hypersensitivity
  • educate: prepare pts for the potential changes, monito for signs and sxs of infection, avoid heat and vasodilation
  • management: call the radiation oncologist and discuss skin care or call medical oncologist and discuss medical management
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9
Q

What is acral erythema? Most commonly assoc with what drugs?

How may it be prevented?

A
  • AKA hand foot syndrome
  • painful palms and soles with erythema, desquamation, and ulceration
  • MC assoc with 5FU, capecitabine, doxirubicin
  • may be able to prevent with holding ice packs during infusion and/or taking pyridoxine
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10
Q

Diarrhea:

PP, incidence and assessment?

A
  • PP: GI tract mucosa very sensitive to cytotoxic drugs due to high mitotic index
  • incidence: occurs in 75% of pts especially those receiving antimetabolites
  • assessment: neutropenic status, bowel elimination patterns, hydration
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11
Q

Collaborative management and education for diarrhea?

A
  • collaborative management:
    IV/fluid support, loperamide, diphenoxylate, codeine
  • education:
    low residue diet, fluid requirements, watch for signs and sxs of dehydration, perianal care
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12
Q

What is the most commonly reported sx that manifests with cancer and cancer tx?
PP, assessment, collaborative management, education?

A
  • fatigue
  • PP: anemia, changes in sleep patterns, pain, psychosocial factors
  • assessment: RFs, acute vs chronic, fatigue level
  • collaborative management: multidisciplinary referrals
  • educate: setting realistic goals, energy management, causes and factors of fatigue
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13
Q

Hemorrhagic cystitis:

PP, what drugs cause this?

A
  • PP: bladder mucosal irritation from metabolic by-products of drugs
  • incidence: regimens with cyclophosphamide, ifosfamide, high dose methotrexate
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14
Q

hemorrhagic cystitis:

Assessment, collaborative management and education?

A
  • Assessment: dysuria, urinary frequency, burning, hematuria, previous hx of pelvic radiation
  • collaborative management: lab monitors, PO/IV hydration with diuretics (to keep bladder flushed)
  • educate: potential for SE to occur, increase fluid intake, frequent urination
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15
Q 
Hepatoxicity -
PP
assessment
management
education?
A
  • PP: direct toxic effect to liver when drugs are being metabolized
  • assessment: ETOH use, liver disease, med use, jaundice, ascites, hepatomegaly, pain
  • management: monitor labs, limit acetaminophen to less than 4000mg/day
  • education: avoid alcohol
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16
Q 
Hypersensitivity rxns:
PP
assessment
management
education?
A
  • PP: ag/ab rxn
  • assessment: clinical manifestations of local or systemic rxn
  • management: test dose, premedication prior to chemo, emergency equipment, steroids, H1 and H2 blockers, epi
  • education: potential for allergic rxn, signs and sxs of rxns
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17
Q 
Mucositis/stomatitis/esophagitis:
PP
incidence
assessment
management
education?
A
  • PP: direct effect of drug or radiation on oral mucosa
  • incidence: leukemia and lymphoma, just about all head and neck cancer pts
  • assessment:
    -xerostomia: dyphagia, plaque formation, pale dry oral mucosa (non-painful)
    -mucositis: erythema, desquamation, ulceration (super painful) - may be able to give prophylactic med to prevent
    -yeast infections: thrust, oral or esophageal candidiasis
  • management:
    aim is for prevention, dental referral, magic mouthwash (viscous lidocaine, benadryl, mystatin sup), chlorhexidine (peridex) rinse
  • education: frequent oral hygiene, use of saline or baking soda rinses QID, cryotherapy (suck on ice)
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18
Q

PP and incidence of nausea and vomiting?

A
  • PP:
    1 -stimulation of vagus nerve by release of serotonin
    2 -stimulation of chemoreceptor trigger zone (CTZ) in the medulla
    3 -stimulation of the truve vomiting center (TVC): can be anticipatory, acute or delayed
  • incidence:
    alkylating agents highly emetogenic, females affected more, youth affected more
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19
Q

Nausea and vomiting:
assessment
management
education?

A
  • assessment: rule out other causes of nausea, hydration status, wt loss, electrolyes
  • management: timely admin of antiemetics (zofran), fluid support, emotional support, dietary supprot, telephone f/u if tx as an outpt
  • education: pt to notify you if sxs persist longer than 48 hrs, unable to maintain oral intake, take antiemetics around clock for 48-72 hours after receiving chemo
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20
Q

Most effective tx for chemo induced N/V?

A
  • 5-HT3 agent + dexamethasone
  • Palonosetron (Aloxi) is now preferred agent (prev. was odansetron (zofran)
  • other agents:
    lorazepam
    prochlorperazine (phenothiazine)
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21
Q

Nephrotoxicity:

PP and incidence?

A
  • PP: direct cell damage to kidney, indirect cell damage by metabolites
  • incidence: assoc with cisplatin therapy, and high dose methotrexate
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22
Q 
Neurotoxicity:
PP
incidence
assessment
management
education?
A
  • PP: a) direct effect on nervous system
    b) metabolic encephalopathy
    c) intracranial hemorrhage due to coagulopathy or myelosuppression
  • incidence: high dose chemo, drugs crossing BBB
  • assessment: tinnitis, peripheral neuropathies, fine motor losses, numbness, tingling, gait disturbances, changes in mentation, urinary retention, constipation
  • management: avoid extremes in temp
  • educate: s/s of neurotoxicity, many sxs are reversible if interventions are initiated early
23
Q 
Pulmonary toxicity:
PP
incidence
assessment
management
education?
A
  • PP: toxic damage to alveoli resulting in pneumonitis and pulmonary fibrosis
  • incidence: bleomycin, busulfan, radiotherapy
  • assessment: thorough respiratory assessment
  • management: pulm fxn tests prior to therapy, tx with corticosteroids and d/c chemo
  • educate: signs and sxs assoc with pulm toxicity, energy conservation techniques
24
Q 
Sexual reproduction:
PP
assessment
management
education?
A
  • PP: a) toxic effects on the gametes b) physical side effects of chemo c) can be permanent or temporary
  • assessment: early menopause, sterility
  • management: sperm banking, counseling
  • education: implications of tx on sexuality, long term SEs
25
Q

Myelosuppression:
PP
incidence ?

A
  • PP:
    a) bone marrow highly sensitive to toxic effects of chemo due to high mitotic index
    b) can be dose-limiting and delay tx
    c) anemia, neutropenia, thrombocytopenia, pancytopenia
  • incidence:
    leukemia, taxanes, alkylating agents, antimetabolites, etoposide, nitrosureas
26
Q 
Anemia:
PP
assessment
management
education?
A
  • PP: changes in erythrocyte proliferation pathways (can be caused by chemo or cancer)
  • assessment: dyspnea, fatigue, concomitant radiation, poor nutritional status, elderly, hx of renal or hepatic impairment
  • management: CBC, RBC transfusions as needed, Fe supplements, O2 therapy, (EPO), only if absolutely necessary as increasd risk of death assoc with cancer pts
  • education: signs and sxs of anemia, change positions slowly to prevent falls and injury
27
Q 
Neutropenia:
PP
assessmnet
management
education?
A
  • PP: ANC of less or equal to 1500
  • assessment: age, malnutriton, prior chemo or radiation, signs and sxs of infection
  • management: CBC, neutropenic fever recommendations, filgrastim or pegfilgrastim
  • education: s/s of infection, meticulous hygiene, daily temps
  • ** any FEVER gets admitted to the hospital
28
Q 
Thrombocytopenia:
PP
assessment
management
education?
A
  • PP: bone marrow suppression decreases platelet production
  • assessment: petechiae, bruising, and hemorrhage, signs and sxs of intracranial bleed
  • management:
    platelet cts: below 50,000 - risk of bleeding is present, less than 20,000 is high risk for bleeding, less than 10,000 is critical risk
    platelet transfusion
    thrombocytopenic precautions (electric razor, no supps or douches, no dental flossing, no injections)
  • education: the signs and sxs of bleeding to report
29
Q

Long term or high dose exposure side effects of radiation?

A
  • Fatigue*** (MC SE of rad)
  • N/V
  • trouble swallowing
  • decrease in platelets and lymphocytes: decreased immune fxn
30
Q

Radiation SEs - skin?

A
  • erythema - desquamation (reversible)

- hair loss at site

31
Q

Radiation SEs - mucous membranes?

A
  • fibrin plaquing
  • urinary and bladder changes
  • visceral changes (secretory)
32
Q

Radiation SEs -Reproductive organs?

A
  • irreversible damage to gametes

- sterility

33
Q

Radiation SEs - bone?

A
  • suppress osteoblast activity

- decrease number of osteocytes

34
Q

What nonverbal signs of pain should you watch for in cancer pts?

A
  • autonomic changes such as HTN, tachycardia, diaphoresis
  • agitation or confusion in pts with organic brain disease
  • apathy, inactivity, or irritability
  • refusal to eat
  • protect the painful part or show facial grimacing
35
Q

Causes of pain in cancer pts?

A
  • can be caused by direct effects of the tumor: invasion of the bone by the tumor or nerve compression (paresthesias)
  • caused by complications of tx:
    radiation fibrosis
    chemo-induced neuropathy
    postop surgical pain
    (can have somatic, visceral or neuropathic pain)
36
Q

What is somatic pain?

MC cause of somatic pain in cancer pts?

A
  • potential or real injury to tissue and is typical pain that we experience
  • pain is tender and localized to the site of injury
  • constant and sometimes throbbing or aching
  • everyday examples include pain asoc with cutaneous burn or an arthritic jt
  • **bone mets is MC cause of somatic pain in cancer pts
37
Q

What is visceral pain? Common causes?

A
  • poorly localized and often referred to a distant site which may be tender
  • it may be less constant than somatic pain, occurring in dull, colicky waves. Unlike somatic pain, it is often assoc with nausea and diaphoresis
  • visceral pain is caused by activation of pain receptors resulting from infiltration, compression, extension, or stretching of the thoracic, abdominal, or pelvic viscera
  • Common causes: pancreatic cancer and mets to abdomen
38
Q

What is neuropathic pain? How is it characterized? Caused by what?

A
  • prolonged, severe, burning or stabbing
  • MC type of pain
  • constant but may be interrupted by paroxysms of dramatically increased pain
  • sxs and signs of autonomic instability (ex: tachycardia, sweating) may accompany neuropathic pain
  • characterized by its relative resistance to opioids, making it most challenging type of pain to tx

neuropathic pain is caused by injury to nervous system:

  • tumor compressing nerves or spinal cord
  • cancer infiltrating the nerves or spinal cord
39
Q

Sites of common pain?

A
  • bone pain
  • back pain
  • HA
  • facial pain
  • abdominal pain
  • pelvic pain
  • post op pain
  • phantom pain
  • more than 1 site
40
Q

What fraction of met cancer has cancer assoc pain?

A
  • 2/3
  • prevalence of moderate or severe pain increases during late phases of malignancy
  • terminal pts: approximately 80% had significant pain assoc with their disease
41
Q

What factors influence the development of cancer pain?

A
  • cancer type and site
  • presence or absence of mets
  • 85% of those with bone involvement had pain which reqd analgesic med compared to only 5% of those with leukemia
  • visceral involvement, bone mets, soft tissue invasion, and nerve/plexus pressure or infiltration were most frequent causes of pain
  • Bone pain - is the most severe pain
42
Q

Tx goals - of cancer pain?

A
  • diminish pain and assoc emotional distress
  • increase physical, social, vocational, and recreational involvement
  • optimize health
  • improve psychological well being
  • improve coping ability
  • reduce dependence on health care system
43
Q

How is pain management best controlled?

A
  • pain tx is best accomplished with antitumor therapy whenever possible
  • radiation, chemo, and palliative surgery should be applied in appropriate cases to debulk or shrink the tumor
  • efforts should be directed towards providing sx relief as soon as pain presents:
    effective pain relief w/o intolerable SEs is occasionally difficult to obtain with the use of conventional analgesics, even with escalating doses of opioids
    in these circumstances, consultation with a specialist in pain management may be necessary
44
Q

Pain management approach - what are the options?

A
  • 1: use of pharm agents, including both non-opioid and opioid agents, as well as analgesic adjuvanats
  • 2: physical and nonpharm approaches to managing pain, which focus on tx cancer and how the pt reacts to cancer pain
  • 3: neurosurgical and anesthetic interventional procedures which physically or phramacologically abrogate the nerve conduction pathways for pain
45
Q

The WHO 3 step approach to pharm tx of cancer pain?

A
  • step 1: non-steroidals and acetaminophen - around the clock schedule b/f initiating opioid analgesics. If adequate pain relief itsn’t acheived, non-opioid analgesics are often cont. in conjunction with opioids
  • step 2: advocate the addition of opioids for moderate and severe cancer pain, w/ or w/o adjuvant analgesic, opioids are used b/c of reliability, safety, multiple routes of admin., and ease of titration (still hard to tx neuropathic pain).
  • step 3: if in severe pain and opioid isn’t working - use a stronger one - morphine
46
Q

How should you choose your opioid for pain tx?

A
  • 1st opioid prep chosen typically has a short half-life and is used on an as needed basis, since initial pain is often episodic and predictable
  • if pain becomes constant, a sustained release prep (available orally for morphine and oxycodone and transdermally for fentanyl) can be added
  • usually tramadol first choice, morphine is a good option too esp for mod-severe pain - quick acting
47
Q

MOA of tramadol?

A
  • synthetic analog of codeine, may have dual MOA
  • inhibits neuronal reuptake of serotonin and NE, like TCAs
  • not known whether combining typical opioids and TCAs can achieve effects similar to tramadol
48
Q

What role do antidepressants, anticonvulsants, and local anesthetics play in cancer pain tx?

A
  • rarely adequate when used alone but are used to provide an opioid sparing effect, thereby lessening opioid side effects and possibly slowing the development of opioid tolerance
  • role in tx neuropathic pain, which is often difficult to tx with opioids alone
49
Q

What TCAs and anticonvulsants are used in cancer pain?

A
  • TCAs:
    Amitriptyline
    Nortriptyline
    Imipramine
  • Anticonvulsants:
    carbamazepine
    clonazepam
    gabapentin (**neuro pain)
50
Q

WHat is the MD Anderson protocol?

A
  • Tx dependent on pain
  • mild to moderate pain:
    non-opioids - acetaminophen and NSAIDs
  • mod. to severe pain: opioids (morphine, hydromorphone, oxycodone, hydrocodone, fentanyl)
  • tingling and burning pain: antidepressants - Amitriptyline, imipramine, doxepin, anti epileptics - Gabapentin
  • pain caused by swelling: steroids (prednisone and dexamethasone - ex intracranial tumor)
51
Q

Cause of depression in patients suffering with cancer pain?

A
  • uncontrolled pain, adverse effects of opioids, and fear of pain can contribute to depression
  • may precipitate suicidal thoughts or requests for aid in dying
52
Q

What are interventional approaches to managing cancer pain?

A

anesthetic:

  • nerve blocks: celiac plexus block, superior hypgastric plexus block
  • myofascial injections
  • neuroma injections
  • spinal cord stimulation
  • intrathecal and epidural injections
53
Q

Complementary and alt. pain management?

A
  • biofeedback: makes pt aware of bodily processes that are thought to be involuntary (BP, skin temp, HR), pts can gain some conscious control of these processes - influence their level of pain
  • breathing and relaxation exercises: yoga
  • distraction: method used to divert the pt’s attention to a more pleasant event, object or situation
  • heat or cold: using temp to facilitate pain control with ice or heating pad
  • hypnosis
  • imagery
  • massage
  • TENS
  • acupuncture, self-help, support groups

Oncology (11 decks)

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