HANDBOOK OF
SYSTEMIC TREA TREATMENT TMENTS S FOR CANCER
8th edition Guidelines for the administration of commonly used anticancer agents and the nursing care of cancer patients
Abbreviations ALP
alkaline phosphatase
IM
intramuscular
ALT ALT
alanine aminotransferase
INR
international normalised ratio
AML
acute myeloid leukaemia
IP
intra-peritoneal
ARDS
acute respiratory distress syndrome
IV
intravenous
LDH
lactate dehydrogenase
LFTs
liver function tests
LLN
lower limit of normal
LVD
left ventricular dysfunction
LVEF
left ventricular ejection fraction
MAO
monoamine oxidase
AST
aspartate aminotransferase
AV
atrioventricular
BB
bundle branch
BMD
bone marrow depression
BP
blood pressure
BCRP
breast cancer resistance protein
MI
myocardial infarction
BUN
blood urea nitrogen
NCI CTCAE
CHF
congestive heart failure
CNS
central nervous system
National Cancer Institute Common Terminology Criteria for Adverse Events
CPK
creatine phosphokinase
NPSA
National Patient Safety Agency
CSF
cerebrospinal fluid
NS
sodium chloride 0.9%
CVA
cerebrovascular accident
P-gp
P-glycoprotein
CVAD
central venous access device
PPE
palmar plantar erythrodysaesthesia syndrome
D5W
dextrose (glucose) 5%
PPI
proton pump inhibitor
dpm
drops per minute
PRES
DRESS
drug rash with eosinophilia eosinophilia and systemic symptoms
posterior reversible encephalopathy syndrome
RTI
respiratory tract infection
SC
subcutaneous
SIADH
syndrome of inappropriate antidiuretic hormone secretion
DS
dextrose 4% + sodium chloride 0.18%
DVT
deep vein thrombosis
EGFR
epidermal growth factor receptor
TEN
toxic epidermal necrolysis
FBC
full blood count
TIA
transient ischaemic attack
GGT
gamma glutamyl transferase
TSH
thyroid-stimulating hormone
GI
gastrointestinal
ULN
upper limit of normal
GORD
gastro-oesophageal reflux disease
UTI
urinary tract infection
GvHD
graft versus host disease
VEGF
vascular endothelial growth factor
IA
intra-arterial
VTE
venous thromboembolism
IBD
inflammatory bowel disease
WBC
white blood cell count
ILD
interstitial lung disease
WFI
water for injection
Abbreviations ALP
alkaline phosphatase
IM
intramuscular
ALT ALT
alanine aminotransferase
INR
international normalised ratio
AML
acute myeloid leukaemia
IP
intra-peritoneal
ARDS
acute respiratory distress syndrome
IV
intravenous
LDH
lactate dehydrogenase
LFTs
liver function tests
LLN
lower limit of normal
LVD
left ventricular dysfunction
LVEF
left ventricular ejection fraction
MAO
monoamine oxidase
AST
aspartate aminotransferase
AV
atrioventricular
BB
bundle branch
BMD
bone marrow depression
BP
blood pressure
BCRP
breast cancer resistance protein
MI
myocardial infarction
BUN
blood urea nitrogen
NCI CTCAE
CHF
congestive heart failure
CNS
central nervous system
National Cancer Institute Common Terminology Criteria for Adverse Events
CPK
creatine phosphokinase
NPSA
National Patient Safety Agency
CSF
cerebrospinal fluid
NS
sodium chloride 0.9%
CVA
cerebrovascular accident
P-gp
P-glycoprotein
CVAD
central venous access device
PPE
palmar plantar erythrodysaesthesia syndrome
D5W
dextrose (glucose) 5%
PPI
proton pump inhibitor
dpm
drops per minute
PRES
DRESS
drug rash with eosinophilia eosinophilia and systemic symptoms
posterior reversible encephalopathy syndrome
RTI
respiratory tract infection
SC
subcutaneous
SIADH
syndrome of inappropriate antidiuretic hormone secretion
DS
dextrose 4% + sodium chloride 0.18%
DVT
deep vein thrombosis
EGFR
epidermal growth factor receptor
TEN
toxic epidermal necrolysis
FBC
full blood count
TIA
transient ischaemic attack
GGT
gamma glutamyl transferase
TSH
thyroid-stimulating hormone
GI
gastrointestinal
ULN
upper limit of normal
GORD
gastro-oesophageal reflux disease
UTI
urinary tract infection
GvHD
graft versus host disease
VEGF
vascular endothelial growth factor
IA
intra-arterial
VTE
venous thromboembolism
IBD
inflammatory bowel disease
WBC
white blood cell count
ILD
interstitial lung disease
WFI
water for injection
CONTENTS Acknowledgments
2
Note from the publisher
3
Preface
4
GENERAL GUIDANCE
Systemic anticancer treatment pathway
5
Suggested 24-hr telephone advice for patients having chemotherapy
9
UKONS oncology/haematology oncology/haematology helpline triage tool
10
Recommendations for your safety and protection protection
12
The management of extravasation
15
Suggested algorithm for the treatment of extravasation
16
Suggested cytotoxic spillage kit
17
References
18
Further resources
19
Nursing implications of drug side effects
20
DRUG MONOGRAPHS
List of drug monographs
30
Drug monographs
31
References References for drug monographs
151
APPENDICES
Appendix 1: Glossary
163
Appendix 2: NCI CTCAE CTCAE v4.0
171
Appendix 3: The cell cycle
174
Appendix 4: Useful formulae
175
Lilly Handbook of Systemic Treatments for Cancer 8th Edition
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ACKNOWLEDGMENTS Lilly Oncology UK and the publisher, Haymarket Medical, would like to acknowledge the following healthcare professionals for their contributions to updating the administration and nursing guidelines and drug monographs for the 8th edition of the handbook.
Authors of the 8th edition (2014) The Royal Marsden NHS Foundation Trust: Lisa Dougherty – nurse consultant, IV therapy and lead chemotherapy nurse Anita McWhirter – pharmacy clinical services manager & the clinical pharmacy team
Greater Midlands Cancer Network: Philippa Jones – Macmillan Network lead chemotherapy nurse
Previous editions We wish to also extend our special thanks to the following past and present members of staff of the Royal Marsden Hospital, London and Surrey: Marilyn Marks and Kerry Jennings for the 1st edition Val Speechley and Tim Root for the 2nd and 3rd editions Lisa Dougherty, Julie Mycroft and Tim Root for the 4th edition Stephen Almond, Judith Earl and Lisa Dougherty for the 6th edition Lisa Dougherty, Lorraine Hyde, Philippa Jones, Caroline Kay, Louise McNamara, Richard Schorstein and Anita McWhirter for the 7th edition
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February 2014
Note from the publisher Welcome to the 8th edition of the Lilly Handbook of Systemic Treatments for Cancer (2014). The intent of this handbook is to assist healthcare professionals in their day-to-day patient management by providing concise information and guidelines for the administration of commonly used pharmacological agents for the treatment of cancer. The contents of this handbook have been developed collaboratively by nurse and pharmacist teams at the Royal Marsden NHS Foundation Trust led by Lisa Dougherty and Anita McWhirter, respectively; in association with the chemotherapy manager and network lead chemotherapy nurse of the Greater Midlands Cancer Network – Philippa Jones, on behalf of Eli Lilly and Company Ltd (“Lilly”) and the publisher, Haymarket Medical. Lilly’s role, as the sponsor of this handbook, has been limited to checking the factual accuracy of information on Lilly products and ensuring compliance with the PMCPA Code of Practice for the Pharmaceutical Industry. Save for the above, and the compilation of the ‘Appendices’ section, the updated contents of the handbook have been developed independently by the authors in collaboration with the publisher. The monographs in this handbook were compiled from manufacturers’ summaries of product characteristics (SPCs) and other established resources. Some of the information presented may reflect local practice and the clinical expertise of the healthcare professionals involved. The monographs of the products contained herein are not intended to be a substitute for the manufacturers’ SPCs. Only adverse events deemed to be of particular relevance are included. The publisher has tried to ensure that the information contained in this handbook is accurate and up-to-date at the time of publication. It is the user’s responsibility to check for any variation in the product SPC subsequently. These can be found at www.medicines.org.uk/emc . It is important not to use copies of the handbook that are out of date or pass on old editions. The practice guidance presented in this handbook is offered as recommendations, and does not diminish the requirement for clinical judgment. Readers are strongly advised to check these recommendations against their local protocols and guidelines and to make their own further enquiries of manufacturers or specialists in relation to particular drugs, treatments or advice. Lilly, the publisher and the authors cannot accept liability for errors or omissions, and disclaim any liability arising out of the use of this handbook in practice.
Haymarket is certified by BSI to environmental standard ISO14001
©2014 Lilly Oncology UK. No part of this publication may be reproduced. Not for resale. Published by Haymarket Medical, Teddington Studios, Broom Road, Teddington TW11 9BE. Printed by Cardiff Printing Company, Llantrisant, South Wales. Date of preparation: February 2014; UKONC00326 Lilly Handbook of Systemic Treatments for Cancer 8th Edition
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Preface The range of systemic anticancer therapies has increased dramatically and within the past year over 20 new therapies have become widely available. For the last edition, a change in the title of the handbook from ‘Cancer Chemotherapy’ to the ‘Handbook of Systemic Treatments for Cancer’, reflected the inclusion of newer agents that are not purely cytotoxic in nature, such as those targeting specific molecular receptors and cell signalling pathways. This handbook is a Lilly initiative to help improve patient care and continues to be used as a definitive reference and guide to practice by nurses, doctors and pharmacists. The 8th edition updates the existing 84 monographs and includes 24 new drugs. Evidence to support the text has been provided, underpinned by the principles in the Cancer Services Manual, the requirement of peer review standards and a comprehensive reference list. Contributions to this updated edition have been from nursing staff that are involved in the assessment of patients and the adminstration of chemotherapy on a daily basis, and pharmacists who are involved in the dispensing and preparation of systemic anticancer therapy, as well as in giving advice to both staff and patients. It is hoped that all healthcare professionals will find this updated guide useful, and that it continues to meet their needs in the clinical setting. Editor Lisa Dougherty Nurse consultant, IV therapy and lead chemotherapy nurse, The Royal Marsden NHS Foundation Trust
Ordering additional copies of the handbook If you would like to order additional copies of the
HANDBOOK OF SYSTEMIC TREATMENTS FOR CANCER or register your interest to receive future editions, please visit
www.lillyoncology.co.uk
4
February 2014
Systemic anticancer treatment pathway A number of national reports and guidelines recommend the implementation of key steps in the systemic anticancer treatment (SACT) pathway to ensure the safe and appropriate delivery of treatment. The pathway presented here has been developed to reflect the recommendations contained in the following documents: 1. For better, for worse? National Confidential Enquiry into Patient Outcome and Death, November 2008. 1 2. Chemotherapy Services in England: Ensuring quality and safety. A report from the National Chemotherapy Advisory Group, 2009. 2 3. Manual for Cancer Services: Chemotherapy Measures (2.0), 2013. 3
Prior to commencing a course of treatment It is recommended that the key actions shown below are taken prior to commencing a course of treatment and it is advisable that there is a procedure in place to check that this happens.
1 Decision to treat, consent and treatment plan1-3 • The decision to initiate the course of SACT should have been made at consultant level unless there are exceptional circumstances. • There should be a completed standardised consent form that includes reason for and intention of treatment, as well as common and serious toxicities which have been discussed with the patient. • Patients should be fully involved in decision-making regarding their care and treatment. Written information should always be provided for the patient and this should be recorded on the consent form. • There should be a treatment plan for each course of SACT detailing: • Diagnosis and staging according to an internationally recognised staging system • Performance status and co-morbidities • Treatment intent • Tests required pre-SACT • Planned number of cycles • Frequency and method of assessment of response to treatment • Any deviation from protocol and reason for this
This treatment plan should be authorised and signed by a consultant oncologist or haemato-oncologist.
2 Physical assessment 1,3 • The results of a comprehensive assessment of the patient’s physical condition and suitability for treatment should be recorded. This will include a record of the patient’s performance status at the time of the decision to treat. • Baseline observations of BP, pulse and respiratory rates should be taken and recorded as per treatment protocol. • Baseline blood tests should be performed including FBC, urea and electrolytes and renal function. • Treatment- or disease-specific investigations, for example specific tumour markers, should be performed. • The results of all pre-treatment investigations should be reviewed prior to treatment administration.
Lilly Handbook of Systemic Treatments for Cancer 8th Edition
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3 The individual assessment by oncology nurses/pharmacists prior to the start of the course of SACT should include1 • Patient and carer information, education, support and advice. • Each patient should be provided with a card containing key information about the treatment and contact details of the 24-hr telephone advice service that is available for patients receiving SACT. • The importance of contacting the telephone advice service, if there are worries about symptoms that may be related to treatment, should be explained clearly.
4 Prescribing and dispensing3 • Prescribing, prescription verification and dispensing of SACT should only be undertaken by appropriately trained staff. • All SACT prescriptions should be checked by an oncology pharmacist who has undergone specialist training, demonstrated appropriate competence and is locally authorised/accredited for the task.
5 Administration of treatment3,4 • Administration should only be undertaken by appropriately trained nurses who have been deemed competent by their employing organisation. • All SACT should be checked by a second nurse prior to administration. • The prescription should be checked against the patient with the following details confirmed: patient identity, allergy status, consent, patient understanding of the SACT they are to receive and their fitness to receive treatment. • The prepared drugs should be checked to ensure they match the prescription for date, dose and patient details, as well as checking the volume, route of administration, diluent, correct method (infusion or bolus injection) and expiry date/time. • The patient should have an appropriate vascular access device (VAD) in situ or one should be inserted by an appropriately trained nurse. • During administration, the nurse should monitor the patient and the VAD site for any side effects and manage them accordingly. • The nurse should wear appropriate personal protective clothing and dispose of all equipment in the appropriate sharps bins or clinical waste bags.
6 Discharge following administration The following checks should be performed prior to allowing the patient to go home: • The patient should have all the supportive drugs they are prescribed and understand the importance of taking them as instructed. • The patient should have an appointment for their next cycle and/or review. • The patient should have a request form for pre-treatment investgations if required. • Reinforce the availability of the 24-hr telephone advice service.
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February 2014
Prior to commencing each cycle of treatment To ensure continued safe and appropriate delivery of SACT, it is vital that the following key actions are taken prior to commencing each cycle of treament and it is advisable that there is a procedure in place to check that this happens.
1 Pre-treatment assessment1-3 The results of an assessment of the patient’s physical condition and suitability for treatment should be recorded, including: Assessment of toxicity Clinicians assessing patients for SACT must perform a full assessment of toxicities that the patient may have experienced at any time since receiving their previous cycle of treatment. This assessment should be recorded in the patient’s treatment record and any significant toxicity experienced by the patient should be discussed with the prescriber prior to treatment administration as there may be a need to modify the treatment plan. The ‘Manual for Cancer Services: Chemotherapy Measures’, recommends the use of the National Cancer Institute’s Common Terminology Criteria for Adverse Events (CTCAE). 3,5 Physical assessment • A review and record of the patient’s performance status with action taken if deterioration is noted. The ‘Manual for Cancer Services: Chemotherapy Measures’ recommends the use of the WHO system for grading of performance status, but the Eastern Co-operative Oncology Group (ECOG) system can also be used.3,6 • Observations and recording of BP, pulse and respiratory rates, temperature and body weight, as indicated • Standard blood tests, including FBC, urea and electrolytes and renal function, should be performed. The results should be within acceptable/agreed treatment parameters. • Treatment- or disease-specific investigations, such as specific tumour markers, must be performed.
The results of all pre-treatment investigations should be reviewed prior to treatment administration.
2 Pre-treatment review • Treatment plan – are there any changes to the plan, for example dose modifications or alterations to supportive medications? Have these changes happened? • Assessment of response – should the patient have had a senior review and necessary investigations to assess response to treatment prior to this cycle? Has this been completed?
3 Patient and carer information, education, support and advice3 • The provision of information, education and support is an ongoing process and the needs and requirements of the patient should be assessed regularly throughout treatment. The assessment and any action arising from it should be recorded in the patient’s medical record. • The importance of contacting the 24-hr telephone advice service, if the patient is worried about symptoms that may be related to their treatment, should be reinforced throughout treatment.
Lilly Handbook of Systemic Treatments for Cancer 8th Edition
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4 Prescribing and dispensing3 • Prescribing, prescription verification and dispensing of SACT should only be undertaken by appropriately trained staff. • All SACT prescriptions should be checked by an oncology pharmacist, who has undergone specialist training, demonstrated their appropriate competence and is locally authorised/ accredited for the task.
5 Administration of treatment3,4 • Administration should only be undertaken by appropriately trained nurses who have been deemed competent by their employing organisation. • All SACT should be checked by a second nurse prior to administration. • The prescription should be checked against the patient to confirm patient identity, allergy status, consent and fitness to receive treatment. • The prepared drugs must be checked to ensure they match the prescription for date, dose and patient details as well as volume, route, diluent, correct method (infusion or bolus injection) and expiry date/time. • The patient should have an appropriate vascular access device (VAD) in situ or one should be inserted by an appropriately trained nurse. • During administration, the nurse should monitor the patient and the VAD site for any side effects and manage them accordingly. • The nurse should wear appropriate personal protective clothing and dispose of all equipment in the appropriate sharps bins or clinical waste bags.
6 Discharge following administration The following checks should be performed prior to allowing the patient to go home: • The patient should have all the supportive drugs they are prescribed and understand the importance of taking them as instructed. • The patient should have an appointment for their next cycle and/or review. • The patient should have a request form for pre-treatment investigations if required.
7 End of treatment3 Following the final cycle of a course of treatment, the patient and their primary care team should be provided with a plan for further care and informed who will take responsibility for its provision.
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February 2014
Suggested 24-hr telephone advice for patients having chemotherapy The ‘Manual for Cancer Services: Chemotherapy Measures’ recommends that cancer networks and acute trusts ensure that patients receiving SACT who may be experiencing side effects or complications related to their treatment have access to 24-hr telephone advice on how to obtain help and treatment. 3 The United Kingdom Oncology Nursing Society (UKONS) central west chemotherapy nurses group has developed a 24-hr triage tool that can be used to risk-assess patients who contact a helpline or present as an emergency.7 UKONS recommend that there be a programme of training and assessment of competency prior to using the tool; however, a brief explanation of the assessment process and a copy of the assessment tool are included in this book for your information. The UKONS 24-hr triage tool is a recognised tool that is a simple, reliable, evidence-based process that grades toxicities according to the significance of presenting symptoms and advises action accordingly. It identifies patients who require: • Referral to acute oncology teams for urgent assessment • Clinical monitoring or review The risk assessment process includes a ‘Red Amber Green’ (RAG) cumulative scoring system to guide decision-making. It is important that the effects of treatment are not underestimated and that the significance of the cumulative effects of a number of lower-level toxicities is recognised.
Risk assessment process It is vitally important that the process is methodical and thorough in order for it to be useful and provide an accurate triage assessment. There are a number of questions to ask and information that will need to be collected to make sure that the correct advice is given. Step 1 The user moves methodically down the triage assessment tool, asking appropriate questions, for example, does the patient have any nausea? If NO, tick green and move on. If YES, use the questions provided to help you grade the problem and tick either amber or red. Step 2 Advice is given and action taken according to the guidelines below: • RED – any toxicity graded here takes priority and assessment should follow immediately. Red triage requires face-to-face consultation and assessment by an appropriately trained and qualified member of the clinical team. This assessment should take place in a suitable area that has access to investigation and treatment facilities. Patients should be asked to attend as soon as possible for assessment. • x2 AMBER – two or more amber toxicities should be escalated to red. Action and assessment should follow immediately. • AMBER – a single amber toxicity should be reviewed/followed up within 24 hrs. This may be a telephone consultation or an urgent review clinic appointment. The caller should be instructed to call back if they continue to have concerns or their condition deteriorates. • GREEN – patients should be given reassurance that the problem at present does not give cause for concern but they should be vigilant and if the situation gets worse or does not improve they should call back immediately. Step 3 A record of the assessment and advice given should be made in the patient’s medical record. Lilly Handbook of Systemic Treatments for Cancer 8th Edition
9
ONCOLOGY/HAEMATOLOGY HELPLINE GRADE TOXICITY
4 0
4
GRADE 1
TRIAGE TOOL
GRADE 2
GRADE 3
4
Fever and receiving cytotoxic chemotherapy or immunocompromised
IF TEMP 37.5°C or ABOVE or BELOW 36°C or GENERALLY UNWELL– URGENT Assessment AND MEDICAL REVIEW– Follow neutropenia pathway ALERT – Pt’s on steroids/analgesics or dehydrated may not present with pyrexia but may still have infection (If in doubt do a count)
Chest pain Onset? What makes it worse? Radiation? Any cardiac history STOP CAPECITABINE or INFUSIONAL SFU
None
Performance Status Has there been a recent change in performance status?
Asymptomatic
l l Symptomatic but completely l ambulant
Symptomatic, <50% in bed during the day
Symptomatic,>50% in bed, but not bed bound
Nausea How many days? What is the patient’s orall intake? Is the patient taking antiemetics as prescribed? Access patients urinary output
None
Able l to eat/drink reasonable l intake Review antiemetics as prescibed
Can eat/drink but intake l decreased significantly Review antiemetics according to llocall policy l
No significant intake Arrange urgent assessment and review
Vomiting How many days/episodes? What is the patient’s orall intake? Does the patient have constipation or diarrhoea? (see specific toxicity) Assess patients urinary output
None
1 episode in 24 hours Review antiemetics as prescibed
2-5 episodeds in 24 hours Review antiemetics according to llocall policy l
6-10 episodes in 24 hours Arrange urgent assessment and review
>10 episodes in 24 hours Arrange urgent assessment and review
Oral/stomatitis How many days? l Is there evidence of mouth ulcers? Is there evidence of infection? l to eat/drink? Are they able Assess patients urinary output
None
Painless l ulcers, l eryth ema, mild l l to eat/drink soreness able Use mouthwash as recommended
Painfull erythema. oedema or l ulcers but can eat/drink Continue to use mouthwash, l drink plenty of fluids. Use ll either as a tablet l or painkillers mouthwash
l Painfull erythema difficulty with eating and drinking Arrange urgent assessment and review
Mucosall necrosis and/or requires parenterall or enterall support Arrange urgent assessment and review
Diarrhoea Consider infection! How many days has this occurred for? How many times in a 24hr period? Does the patient have any abdominall pain/discomfort? l For how long? Has the patient taken any medication? See specific toxicity for pain NB. If taking CAPECITABINE chemotherapy, follow specific pathway
None
Increase to 2-3 bowell movements a day over pre-treatment movements Drink more fluids l Obtain stooll sample ?consider regimen specific antidiarrhoeall
Increase to 4-6 episodes a day or nocturnall movement/ moderate cramping l Drink plenty of fluids l Obtain stooll sample ?obtain regimen specific antidiarrhoeall
Increase to 7-9 episodes a day or incontinence Severe cramping Arrange urgent assessment and review
Increase to >10 episodes a day l bloody l or grossly diarrhoea or need for parenterall support Arrange urgent assessment and review
Constipation l opened? How llong since bowels l What is normal? Doed the patient have any abdominall pain/vomiting? Has the patient taken any medication?
None
l – no bowell movement in Mild l 24 hours last Dietary advice, increase fluid intake, review supportive medication
Moderate – no bowell movement in last l 48 hours If associated with pain/vomiting move to red Review fluid and dietary intake Recommend laxative l
Severe – no bowell movement in llast 72 hours Arrange urgent assessment and review
Paralytic l ileum l >96 hours Arrange urgent assessment and review
Fever NOT receiving chemotherapy
Normall
n/a
>37.5°C - 38°C Check in 1 hr and contact again if stillll pyrexiall – see red
>38-40°C Arrange urgent assessment and review
>40°C Arrange urgent assessment and review
Infection If Pyrexiall see fever toxicity Has the patient taken their temperature? – When? Has the patient experienced any shivering, chills ll or shaking episodes?
None
Generally ll wellll
Generally ll wellll Arrange Review
Severe symptomatic infection Arrange urgent assessment and review
Life threatening sepsis Arrange urgent assessment and review
Palmar - plantar syndrome NB. If taking CAPECITABINE chemotherapy, follow specific pathway
N one
Numbness, tingling, painless l l erythema and swelling ll Advise patient to rest hands and feet. Use emolient cream l
Painfull erythema and swelling ll ? Arrange review–(may require dose reduction or defer treatment). Advise analgesia l
Moist desquamation, ulceration, blistering and l l severe pain Arrange review – (may require dose reduction or defer treatment) Advise analgesia l
Fatigue How many days has this occured for? Any other associated symptoms?
None
Increased fatigue but not altering normall activities l Rest accompanied with intermittent mild l activity
Moderate or causing difficulty l performing some activities ? Arrange review
Severe or loss l of ability l to perform some activities Arrange review
Bedridden or disabling l Arrange urgent assessment and review
Anorexia What was their weight before? What is appetite like? l Any contributory factors e.g. dehydration, diarrhoea, vomiting, mucositus and nausea? – link l to specific toxicity
None
Loss of appetite without alteration l in eating habits Dietary advise
Orall intake altered l without significant weight lloss or malnutrition: l ? Arrange review
Orall intake altered l in association with significant weight loss/malnutrition l l Arrange urgent assessment and review
Life threatening complications l e.g. collapse ll Arrange urgent assessment and review
Dyspnoea/shortness of breath Is it a new symptom? Is dyspnoea worsening? Is there any chest pain?– link l to specific toxicity How llong for? What can the patient do? (? alteration in PS) l CONSIDER SVCO/ANAEMIA/PULMONARY EMBOLISM
None
No new symptoms
Dyspnoea on exertion ? Arrange review
Dyspnoea at normall level l l of activity Willll need urgent assessment and review
Dyspnoea at rest or requiring ventilatory l support Arrange urgent assessment and review
Rash Is it localised l l or generalised? l How llong has it been there? Any signs of infection? Is it itchy? HAEMATOLGY FOLLOW LOCAL GUIDANCE
None
Macular l or papular l eruption or erythema without associated symptoms Localised l rash, otherwise wellll
Macular l or papular l eruption or erythema with Pruritus or other associated symptoms Arrange review
Symptomatic unwellll Arrange urgent assessment and review
Symptomatic unwellll Arrange urgent assessment and review
Neurosensory/motor When did the problem l start? Is it continuous? Is it getting worse? Is it affecting mobility/function l Any constipation or urinary incontinence? Consider Spinall Cord Compression
None
Mild l parasthesia, subjective weakness; no objective findings Monitor and contact immediately l if deteriorates
Mild il or moderate sensory loss, l moderate parasthesia, i mild il weakness with i no loss l of function i Immediate i contact ifi deteriorates i Arrange review i
Severe sensory loss, l parasthesia or weakness that interferes with function Arrange urgent assessment and review
Paralysis l Arrange urgent assessment and review
Bleeding Is it a new problem? l Is it continuous? What amount? Where from? Is the patient on anticoagulants? l HAEMATOLOGY FOLLOW LOCAL POLICY
None
Mild l selfl limited l controlled ll by conservative measures
Gross 1-2 units Urgent assessment to A&E
Gross 3-4 units per episode Urgent assessment to A&E
Massive >4 units per episode Urgent assessment to A&E
Pain Is it a new? Where is it? How long l have you had it? Have you taken any analgesia? l Consider thrombosis? Any swelling/redness? ll
None
Mild l pain Not interfering with function Advise/discuss analgesea l
Has pain Pain or analgesea l interfering with function, but not ADL Arrange review
Severe pain Pain or Analgesia l interfering ADL Arrange urgent assessment and review
Severe pain, disabling! l Arrange urgent assessment and review
Bruising Is it a new problem? Is it local/generalised? l l l l Is there any trauma involved? l
None
Petechia/bruising, llocalised l Arrange review
Moderate Petechia/purpura Generalised bruising l Arrange urgent assessment and review
Generalised petechia/purpura l Arrange urgent assessment and review
Extravasation Any problems immediately l l after administration? When did the problem l start? Is the problem l around the injection site? Has the patient got a centrall venous catheter? Explain l the reaction?
© P. Jones et al/UKONS/GMCN
Advise URGENT A&E for medicall assessment
Non vesicant Review next day
Bed bound
Vesicant Arrange urgent assessment and review
Endorsed by:
10
4 February 2014
Recommendations for your safety and protection The following recommendations concern the safe reconstitution and handling of cytotoxic agents in order to prevent self contamination. Ideally, all drugs will be reconstituted by trained pharmacy staff in a microbiological safety cabinet or isolator. Where a nurse may be required to reconstitute a cytotoxic drug it must be carried out in an isolator that is not on the ward/department or by using a closed reconstitution device. It should only be carried out when absolutely necessary. Local instructions for isolator use should be followed.8,9
The administration of SACT 1 General 1.1 All drugs should be handled with respect, taking great care to avoid spillage.8 1.2 A pre-treatment assessment should be carried out folowing the steps in the pre-treatment pathway (pages 5-8). Drug dosage (according to the protocol) should be checked prior to administration of any SACT.1,3,8,10 1.3 Strict aseptic technique should be observed at each stage of the procedure, for example, when adding any drug to an IV solution or via an administration set/injection cap. 10 2 Routes There are a number of routes for the administration of SACT. 2.1 Oral The term ‘oral anticancer medicine’ refers to drugs with direct antitumour activity, administered via the oral route, including traditional cytotoxic chemotherapy (eg, capecitabine, vinorelbine), smallmolecule treatments (eg, imatinib, erlotinib) and other agents such as thalidomide. 8 2.2 Intravenous This is the administration of cytotoxic drugs via a peripheral or central vein. It is the most commonly used route of administration.8 2.2.1
Vein selection The vein used should be firm, bouncy, straight and, if possible, previously unused. Bruised and inflamed areas should be avoided. Ideally the injection or infusion should be given into a large, easily visible, superficial vein. Any limb with a compromised circulation, for example, as a result of mastectomy, lymphoedema, thrombophlebitis or trauma, should be avoided.11 The antecubital fossa should be avoided, especially when administering vesicant drugs.8,11 In everyone’s interest, it is suggested that a practitioner should have no more than two attempts at device placement and should then seek the advice of a more experienced practitioner.11 Where no suitable veins are available or the patient is to receive regular administration of highly irritant/vesicant infusions, then consideration should be given to the placement of a CVAD.8
2.2.2
Device selection Cannulae (22 or 24g) should be selected following vein assessment, choosing the smallest gauge and shortest length appropriate for the type and length of therapy. The smaller the device, the less trauma to the vein and the better the blood flow around the device. This increases dilution and rapid removal of the irritant and makes chemical phlebitis less likely. However, longer cannulae (22 or 20g) may be necessary to reduce the risk of dislodgment or associated infiltration and extravasation. 8
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2.2.3
Administration (a) Each device must always be tested with NS before injecting SACT, and similarly flushed after administration. If several drugs are to be given, the device should be flushed after each one to prevent possible interactions. This can be accomplished by attaching and detaching a syringe of NS after each drug or by attaching a compatible infusion to the device and using one of the following techniques: 10 (i) A fast-running infusion into which the drug is administered simultaneously via the side arm if the vein can accommodate it or if this method is specified in the literature. This is useful for highly irritant drugs but may not be necessary when administering via a CVAD. (ii) A stop/start flushing technique if the vein is fragile or small and cannot accommodate a large fluid flow. (b) Any drug known to be a vesicant should be given first when multiple drugs are prescribed (but after any pre-medication). It is at this time that the integrity of the vein is greatest and extravasation is least likely. For practical reasons, drugs to be given by infusion, for example, dacarbazine, should be administered last. 8,11 (c) A number of cytotoxic drugs are vesicant and will cause extreme tissue damage if leakage occurs from the vein. Even a very small leak is a serious situation and care must be taken to ensure that all the drug enters the vein. Consequently, drugs should be given slowly and the area around the device observed throughout the administration. 8 The practitioner should regularly assess the comfort of the patient, observe the site for swelling or skin colour changes and check vein patency by checking for blood return. 8 If the nurse has any doubt about the patency of the device and vein then the administration should stop and the site should be checked before continuing. If extravasation is suspected then follow the management of extravasation guidance on page 15. 8,11 (d) Drug solutions that are stored in the refrigerator may cause venospasm and an ‘aching’ sensation along the vein. It is important to distinguish between this and the sharp ‘burning’ sensation which may indicate the extravasation of a vesicant. 8 (e) With repeated injections of some drugs, veins may become very sensitive. The key is either to dilute the drug or increase vasodilation. The following may help: (i) Inject the drug slowly or administer as an infusion. (ii) Make use of frequent NS flushes. (iii) Give the injection via a fast-running NS infusion. (iv) Use the smallest gauge cannula to increase blood flow around the device and ensure more rapid circulation of the drug. (v) Apply a heat pack above the cannula site to increase vasodilation.
2.3 Intrathecal This is the administration of cytotoxic drugs into the CNS via the CSF using a lumbar puncture. 8 SACT administered via this route has the potential to cause great harm and has been associated with the deaths of at least 13 patients since 1985. Since 2001, all Trusts that administer intrathecal SACT have been required to comply with the national guidance on safe administration, most recently updated in 2008. 12,13 Guidance issued by the NPSA means that from 2013, Trusts must now ensure that all spinal (intrathecal) bolus doses and lumbar punctures are performed using syringes, needles and other devices with connectors that cannot connect with intravenous Luer connectors.14,15
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The key requirements of the 2008 guidance include: 12 • Only trained, designated personnel whose names are recorded on the appropriate intrathecal register are authorised to prescribe, dispense, check or administer intrathecal SACT. • All staff involved in the intrathecal SACT process must undertake a formal competency-based induction programme and update annually. • In adults, IV drugs must be administered BEFORE intrathecal drugs are issued (or after IV continuous infusions have been started). • Children receiving intrathecal therapy under general anaesthetic will have their intrathecal treatment first in theatre. IV drugs (excluding vinca alkaloids) may be given later in day care or on the ward, but never in theatre. • Intrathecal chemotherapy should always be administered in a designated area, within normal working hours; out-of-hours administration must only occur in exceptional circumstances. • Checks must be made by medical, nursing and pharmacy staff at relevant stages throughout the prescribing, preparation and administration process. • This guidance predominantly relates to treatment given intrathecally, by lumbar puncture (via spinal injection) but is also relevant to intra-ventricular chemotherapy (via injection into the ventricles of the brain).
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The management of extravasation Extravasation is the leakage of vesicants (any solution or medication that causes the formation of blisters with subsequent tissue necrosis and may be DNA- and non-DNA binding) into local tissue. It requires immediate action if local tissue damage is to be prevented. If any doubt arises about patency of the vein, the injection or infusion should be stopped and recommenced in another vein if necessary, preferably in the other arm. If this is not possible, use of a vein proximal to that already used will prevent leakage from the earlier puncture site.8,16 Extravasation should be suspected if: 8 • the patient complains of a sharp stinging or burning sensation around the cannula site. • swelling or leakage occurs at the site of the cannula. • no flashback of blood is obtained (but absence of this, seen alone, is not necessarily an indication of extravasation). • resistance is felt on the plunger of the syringe during bolus administration. • free flow of fluid is absent if an infusion is in progress. When using a CVAD, blood return must always be established prior to administration. 17 If there is no blood return, the Trust should have a local policy that describes the steps to be taken by the practitioner in order to ascertain that the tip of the CVAD is in the correct position. Prevention is key and nurses should know which patients are at most risk. Clinical practice guidelines on the management of extravasation have been issued by the European Society for Medical Oncology (ESMO) and the European Oncology Nursing Society (EONS); however, guidance may vary according to local policy. 18,19 The policy detailed here is the current policy of the Royal Marsden NHS Foundation Trust. It is included for reference only. All staff who administer SACT should ensure that their Trust or hospital develops its own extravasation policy.
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SUGGESTED ALGORITHM FOR THE TREATMENT OF EXTRAVASATION SUSPECT EXTRAVASATION IF: (a) Patient complains of burning or stinging pain OR (b) There is evidence of swelling, induration, leakage at site OR (c) There is resistance on plunger of syringe or absence of free flow of infusion OR (d) There is no blood return (if found in isolation via a peripheral cannula this should not be regarded as an indication of a non patent vein. However, in the event of no blood return from a CVAD – follow algorithm for persistent withdrawal occlusion)
STOP THE INJECTION / INFUSION WITHDRAW AS MUCH OF THE DRUG AS POSSIBLE (INJECTION ONLY) REMOVE THE PERIPHERAL CANNULA COLLECT THE EXTRAVASATION PACK CONSIDER CONTACTING THE EXTRAVASATION TEAM TO PERFORM FLUSH OUT TECHNIQUE
CATEGORY A DRUGS Vinca alkaloids, paclitaxel Inject 1500 iu hyaluronidase SC around the site Apply a warm pack to aid absorption of hyaluronidase Warm pack to remain in situ for 2-4 hrs
ELEVATE THE LIMB
CATEGORY B DRUGS Dactinomycin, dacarbazine, daunorubicin, doxorubicin, epirubicin, idarubicin, mitomycin C, streptozocin, trabectedin Apply cold pack to cause vasoconstriction for 15-20 mins, 3-4 times a day for at least 24 hrs If extravasation is with any of the following: mitomycin C, doxorubicin, idarubicin, epirubicin, dactinomycin Draw around area of extravasation with indelible pen Put on gloves Apply thin layer of dimethyl sulfoxide topically to the marked area using the small plastic spatula in lid of the bottle Allow it to dry and apply gauze This should be applied within 10-25 mins If extravasation of doxorubicin, idarubicin, epirubicin or daunorubicin occurs (ie, 3.5ml or more peripherally or any volume via a CVAD), then stop cold pack, do not apply dimethyl sulfoxide and contact member of extravasation team to advise on use of dexrazoxane
Apply hydrocortisone cream to reduce local inflammation. Where appropriate apply dimethyl sulfoxide every 2 hrs for 24 hrs and then 6 hourly for up to 7 days
INFORM THE MEDICAL STAFF
Document in duplicate – one copy in patient’s notes and one copy to the nurse consultant IV therapy. Complete a clinical incident form
GIVE PATIENT A PATIENT INFORMATION SHEET
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Suggested cytotoxic spillage kit8
Essential equipment • • • •
Two plastic overshoes Two disposable armlets Two clinical waste bags Two pairs of disposable non-sterile latex or nitrile gloves • Goggles (non-disposable): EN 166-8
• • • • • •
Particulate respirator mask Plastic apron Gown Paper towels Plastic bucket Copy of spillage procedure
1 Act immediately. Assess the level of exposure of any individual and isolate them from the spill. 2 Collect spillage kit. 3 Put on both pairs of gloves, goggles and a gown and then a disposable plastic apron over the gown. If there is visible powder spill, put on a good-quality particulate respirator mask. If spillage is on the floor, put on overshoes.
Procedure 4 Wipe up powder spillage quickly with well dampened paper towels, starting at the outer edge of the spill area and working in a circular motion towards the middle to contain spill and dispose of them as ‘highrisk’ waste. 5 Mop up liquids which have been spilled on a hard surface with paper towels, starting at the outer edge of the spill area and working in a circular motion towards the middle to contain spill and dispose of them as ‘high-risk’ waste. 6 Wash hard surfaces at least twice with copious amounts of cold, soapy water and dry with paper towels. The floor should then be given a routine clean as soon afterwards as possible. If spillage has occurred on a carpet it will require cleaning as soon as possible. If spillage
is on clothing, remove it as soon as possible and treat as ‘soiled linen’. If spillage has penetrated clothing, wash contaminated skin liberally with soap and cold water. If spillage is on bed linen put on gloves and an apron, change it immediately and treat as ‘soiled linen’. If an accident or spillage involving direct skin contact occurs, the area should be washed thoroughly with soapy water as soon as possible. In the event of a cytotoxic splash to the eye, irrigate thoroughly with NS or tap water for at least 15 minutes.
Post-procedure 7 Any accident or spillage by nursing staff involving direct skin contact with a cytotoxic drug must be reported to the occupational health department and manager as soon as possible after the first aid is performed and appropriate documentation completed.
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References 1.
2.
3.
4.
5.
6. 7. 8. 9. 10.
11. 12.
13. 14.
15. 16. 17. 18. 19. 20.
21. 22. 23. 24. 25.
National Confidential Enquiry into Patient Outcome and Death. For better, for worse? A review of the care of patients who died within 30 days of receiving systemic anti-cancer therapy. London, NCEPOD, 2008. Available from: http://www. ncepod.org.uk/2008report3/Downloads/SACT_report.pdf (accessed 14 January 2014). National Chemotherapy Advisory Group. Chemotherapy services in England: Ensuring quality and safety. London, NCAG, 2009. Available from: http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_ consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_104501.pdf (accessed 14 January 2014). National Cancer Peer Review - National Cancer Action Team. National Cancer Peer Review Programme. Manual for Cancer Services: Chemotherapy Measures, v2.0. London, NCAT, 2013. Available from: http://www.cquins.nhs. uk/?menu=resources (accessed 14 January 2014). Nursing and Midwifery Council. Standards for medicines management. London, NMC, 2010. Available from: http://www.nmc-uk.org/Documents/NMC-Publications/NMC-Standards-for-medicines-management.pdf (accessed 14 January 2014). US Department of Health and Human Services, National Institutes of Health, National Cancer Institute. Common Terminology Criteria for Adverse Events (CTCAE) v4.03; June 2010. NIH Publication No.09-5410. Available from: http:// www.eortc.be/services/doc/ctc/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf (accessed accessed 14 January 2014). Oken MM, Creech RH, Tormey DC et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982; 5: 649-55. UK Oncology Nursing Society. Oncology/Haematology 24-hour triage – rapid assessment and access tool. October 2010. Available from: http://www.ukons.org/ (accessed 14 January 2014). Hall K, Hyde L, Schorstein R. Chapter 19. Cytotoxic therapy. In: Dougherty L, Lister S (eds). The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 8th edition. Oxford, Wiley-Blackwell, 2011. Health and Safety Executive. Safe handling of cytotoxic drugs. HSE Information Sheet MISC615. London, HSE, 2003. Available from: http://www.hse.gov.uk/pubns/misc615.pdf (accessed 14 January 2014). Dougherty L. Chapter 10. Intravenous management. In: Brighton D, Woods M (eds). The Royal Marsden Hospital Handbook of Cancer Chemotherapy – a guide for the multidisciplinary team . Edinburgh, Elsevier Churchill Livingstone, 2005. Dougherty L. Chapter 9. Obtaining peripheral venous access. In: Dougherty L, Lamb J (eds). Intravenous Therapy in Nursing Practice. 2nd edition. Oxford, Blackwell, 2008. Department of Health. Health Service Circular. HSC 2008/001 Updated national guidance on the safe administration of intrathecal chemotherapy. London, DH, 2008. Available from: http://webarchive.nationalarchives.gov. uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/ dh_086844.pdf (accessed 14 January 2014). National Patient Safety Agency. Using Vinca Alkaloid Minibags (Adult/Adolescent Units) NPSA/2008/RRR004. London, NPSA, 2008. Available from: http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59890 (accessed 14 January 2014). National Patient Safety Agency. Safer spinal (intrathecal), epidural and regional devices - Part A: update. NPSA/2011/ PSA001. London, NPSA, 2011. Available from: http://www.nrls.npsa.nhs.uk/alerts/?entryid45=94529 (accessed 14 January 2014). National Patient Safety Agency. Safer spinal (intrathecal), epidural and regional devices – Part B. NPSA/2009/PSA004B. London, NPSA, 2009. Available from: http://www.nrls.npsa.nhs.uk/alerts/?entryid45=94529 (accessed 14 January 2014). Dougherty L. IV therapy: recognizing the differences between infiltration and extravasation. Br J Nurs 2008; 17: 896, 898-901. Masoorli S. Extravasation injuries associated with the use of central vascular access devices. JVAD 2003; 8: 21-3. Pérez Fidalgo JA, García Fabregat L, Cervantes A et al; ESMO Guidelines Working Group. Management of chemotherapy extravasation: ESMO-EONS Clinical Practice Guidelines. Ann Oncol 2012; 23 Suppl 7: vii167-73. Dougherty L, Oakley C. Advanced practice in the management of extravasation. Cancer Nursing Practice 2011; 10: 16-22. Polovich M, Whitford JM, Olsen M. Chapter VII. Side Effects of Cancer Therapy. In: Polovich M, Whitford JM, Olsen M (eds). Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. 3rd edition. Pittsburgh, Oncology Nursing Society, 2009. Dolan S. Chapter 21. Anaemia. In: Brighton D, Woods M (eds). The Royal Marsden Hospital Handbook of Cancer Chemotherapy – a guide for the multidisciplinary team. Edinburgh, Elsevier Churchill Livingstone, 2005. Dougherty L. Chapter 23. Alopecia. In: Brighton D, Woods M (eds). The Royal Marsden Hospital Handbook of Cancer Chemotherapy – a guide for the multidisciplinary team. Edinburgh, Elsevier Churchill Livingstone, 2005. Dolan S. Chapter 25. Electrolyte abnormalities. In: Brighton D, Woods M (eds). The Royal Marsden Hospital Handbook of Cancer Chemotherapy – a guide for the multidisciplinary team. Edinburgh, Elsevier Churchill Livingstone, 2005. Wolf L. Chapter 26. Skin and nail changes. In: Brighton D, Woods M (eds). The Royal Marsden Hospital Handbook of Cancer Chemotherapy – a guide for the multidisciplinary team. Edinburgh, Elsevier Churchill Livingstone, 2005. Stephens M. Chapter 29. Pulmonary effects. In: Brighton D, Woods M (eds). The Royal Marsden Hospital Handbook of Cancer Chemotherapy – a guide for the multidisciplinary team. Edinburgh, Elsevier Churchill Livingstone, 2005.
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Further resources •
• • • • • • • • • • • •
British Oncology Pharmacy Association. Position statement on safe practice and the pharmaceutical care of patients receiving oral anti-cancer chemotherapy. London, BOPA, 2004. Available from: http://www.bopawebsite.org/ publications/docs/position-statements (accessed 29 January 2014). Department of Health. Reference guide to consent for examination or treatment, second edition 2009. London, DH, 2009. El-Saghir N, Otrock Z, Mufarrij A et al. Dexrazoxane for anthracycline extravasation and GM-CSF for skin ulceration and wound healing. Lancet Oncol 2004; 5: 320-1. Goodin S. Safe handling of oral chemo agents in community settings. Pharmacy Times 2007 (Sep 1). Available from: http://www.pharmacytimes.com/publications/issue/2007/2007-09/2007-09-6789 (accessed 29 January 2014). Griffin E. Safety considerations and safe handling of oral chemotherapy agents. Clin J Oncol Nurs 2003; 7(6 Suppl): 25-9. Langer SW, Sehested M, Jensen PB. Treatment of anthracycline extravasation with dexrazoxane. Clin Cancer Res 2000; 6: 3680-6. Nursing and Midwifery Council. The code: Standards of conduct, performance and ethics for nurses and midwives. London, NMC, 2008. Rickard CM, Webster J, Wallis MC et al. Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. Lancet 2012; 380: 1066-74. Royal College of Nursing. Standards for infusion therapy. The RCN IV Therapy Forum. 3rd edition. London, RCN, 2010. Schulmeister L. Chapter 18. Antineoplastic therapy. In: Infusion Nurses Society, Alexander M, Corrigan A et al (eds). Infusion Nursing. 3rd Edition. Philadelphia, Saunders Elsevier, 2009. Sewell G, Summerhayes M, Stanley A. Administration of chemotherapy. In: Allwood M, Stanley A, Wright P (eds). The Cytotoxics Handbook. 4th edition. Oxford, Radcliffe Medical Press, 2002. Toft B. External Inquiry into the adverse incident that occurred at Queen’s Medical Centre, Nottingham, 4th January 2001. London, Department of Health, 2001. Vidall C, Roe H, Dougherty L et al. Dexrazoxane: a management option for anthracycline extravasations. Br J Nurs 2013; 22: S6 -12.
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Nursing implications of drug side effects 8,20-25 These are ordered to provide the following: • • • •
Patient education Observations/assessment Monitoring Action
Haematological toxicity 1 Anaemia • encourage good dietary intake, eg, food high in iron such as liver or broccoli/spinach • observations for pallor, dizziness, shortness of breath • regular FBC • blood transfusion – usually packed cells • administer erythropoietin as appropriate 2 Leucopenia • encourage meticulous hand hygiene in staff, patients and carers • teach patient to recognise early signs of infection and report • give chemotherapy alert card to ensure immediate attention at A&E department • prevent exposure to adults or children with known infection • close observation of patient on steroids • take regular swabs and specimens if at risk • regular monitoring of white blood cells • administer prophylactic granulyte colony-stimulating factor (GCSF) • administer antibiotics and GCSF as required • ensure appropriate isolation when WBC very low 3 Thrombocytopenia • warn patient to avoid physical injury • avoid use of razor (use electric) • avoid IM injections • advise use of soft toothbrush • teach patient how to recognise early signs and report • avoid drugs that interfere with platelet function, eg, aspirin, alcohol • observation for bleeding including petechiae, haematuria • regular platelet count • administer platelet transfusion 4 Haemorrhagic tendency • teach patient to watch for signs of bleeding, epistaxis, haematuria, bruising • eliminate other reasons for bleeding, eg, low platelet count 5 Infection/sepsis • explain possibility to patient • give advice about how to prevent infection, recognise signs and symptoms and when to call for advice • give chemotherapy alert card to ensure immediate attention at A&E department • administer antibiotics within 1 hr of assessment • ensure appropriate isolation if required
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Gastrointestinal toxicity 6 Stomatitis • advise patient to avoid extremely hot and cold food, heavy spices and citrus fruits, alcohol and smoking • regular observation of entire mouth using an oral assessment tool where appropriate • check for fungal infections • regular mouth washes, every 2-3 hrs and always after meals • soft diet if severe • administer analgesics and/or antifungals • administer barrier preparation (eg, sucralfate or Gelclair®) for local relief 7 Taste aberration (dysgeusia) (i) At time of treatment • offer strongly flavoured sweets during injection (ii) At other times • provide dietary advice • advise sipping drinks/chewing gum/sweets • concentrate on foods that taste good • sharp tasting drinks may be refreshing 8 Anorexia • encourage meals early in the day as better tolerated • advise patient to try small frequent meals • consider how food is presented • determine dietary habits from nursing history • weigh patient regularly • offer food supplements • provide artificial saliva, if due to dry mouth • refer to dietician 9 Dyspepsia • educate patient • administer medications (PPIs, antacids) as indicated 10 Nausea and vomiting • inform patient of what to expect and when • advise patient to try dry crackers for nausea • suggest patient try distraction, meditation, relaxation, acupressure bands or acupuncture • consider patient preference regarding techniques prior to procedure • administer antiemetics prior to chemotherapy and assess effectiveness • for highly emetogenic drugs ensure appropriate antiemetics administered pre-SACT and then regularly, for at least three days after each course • maintain fluids and observe for electrolyte imbalance 11 Constipation • warn patient of possibility • encourage diet high in fibre • encourage fluids • provide prophylactic laxatives
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12 Diarrhoea • warn patient of possibility • advise a low roughage diet • suggest good perianal hygiene (NB, anal fistulae are more common in immunosuppressed patients) • observe for signs of dehydration and electrolyte imbalance • provide/administer antidiarrhoea agents
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Skin toxicity 13 Venous discolouration • explain possibility to patient • reassure patient it is temporary 14 Venous/injection site pain • administer injection slowly with frequent flushes of NS whenever pain occurs • always distinguish vein pain from extravasation • dilute injection further (if pharmaceutically acceptable) • use local heat to aid vasodilation • suggest CVAD insertion if pain is difficult to tolerate during infusion 15 Nail discolouration and ridging • explain possibility to patient • reassure patient it is temporary 16 Skin pigmentation • explain reason to patient • reassure patient it is temporary • advise against prolonged exposure to bright sunlight 17 Phlebitis (i) Chemical • administer drugs with NS flushes • administer drugs slowly • use large vein with good blood flow • use small gauge needle • apply local heat or glyceryl trinitrate patch to increase vasodilation (ii) Thrombophlebitis • inform patient of possibility and that it is temporary • apply symptomatic relief (heat/cold) • use heparinoid or steroid cream • suggest application of anti-inflammatory cream or gel, eg, ibuprofen 18 Flushing (i) If a local flush along vein in arm at time of administration • advise patient that it is temporary • administer hydrocortisone injection/apply cream (ii) If body flushing at time of injection • reassure patient that it is temporary • slow drug administration 19 Dermatitis/rash • inform patient of possibility • observe for changes or pain (? shingles) • seek dermatology opinion • administer antihistamine IV or orally as required • apply calamine or similar
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20 Palmar plantar erythrodysaesthesia (PPE) • advise patient to protect skin from sun • encourage and apply greasy emollient to ensure skin is kept supple • observe severity and administer pyridoxine • administer antibiotics as prescribed 21 Pruritis • educate patient • offer antihistamines 22 Erythema multiforme/Stevens-Johnson syndrome/toxic epidermal necrolysis (TEN) • discontinue any medication that could be responsible • correct fluid and electrolyte imbalance and nutritional deficits • provide analgesia, physiotherapy and wound dressings • administer antibiotics for secondary infection 23 Alopecia • explain possibility to patient and advise degree of hair loss • provide patient an opportunity to discuss • reassure patient that hair will grow back • order wig before hair loss • encourage patient to cut long hair to prevent the weight pulling on roots • advise on hair care – frequency of washing, use of a neutral pH shampoo, use of brushes and comb • advise against perms and colourants • encourage patient to see own hairdresser for support • use scalp hypothermia where appropriate
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