Operative techniques used to prevent
SURGERY dissemination of tumor cells into and beyond the
-plays a major role in diagnosing, staging
and treating cancer.
DIAGNOSTIC SURGERY
• Cytologic specimens
-can be obtained from tumors that tend to
shed cells from their surface.
1. Endoscopy – involves direct visualization
of gastrointestinal tract.
2. Bronchoscopy – lungs
3. Laryngoscopy – larynx
4. Colposcopy- cervix and vagina
5. Cystoscopy – bladder
6. Laparoscopy – pelvic or abdominal cavity
• Needle Biopsy
-is a simple method of obtaining tissue
samples.
1. Fine needle aspiration
-tumor cells are withdrawn from the tumor
with a needle and syringe.
-provides individual cells or clumps of cells
for review.
2. Core needle biopsy
-the needle is larger and a core or barrel
of tissue is obtained.
-it allows the pathologist to examine the
cells with their spatial relationships intact.
• Excisional biopsy and Incisional biopsy
-the size of the tumor and purpose of the
biopsy determine if an excisional or
incisional biopsy is performed.
1. Excisional biopsy
-is used for small tumors (2-3 cm) for
which the biopsy also may serve as
treatment if the tissue margins contain no
tumor cells.
- is performed if the entire tumor is
excised for examination.
-also called total type of biopsy.
2. Incisional biopsy
-is performed if the tumor is already large
and only a part of the neoplasm is excised.
-also called subtotal type of biopsy.
3. Stereotactic breast biopsy
-is a radiography-guided method for
localizing and sampling small, nonpalpable
breast lesions that are discovered on
mammography when malignancy is
suspected.
SURGERY AS TREATMENT
-surgery is performed in 55% of clients
with cancer; 40% are treated with surgery alone.
-Radical surgery became the standard of
cancer treatment.
-when surgery is performed with curative
intent, the type of tumor determines the extent of
the excision.
-for slow-growing tumors (squamous cell
carcinoma and adenocarcinoma of the skin), a
wide local excision may be sufficient.
-tumors of the colon and breast that
spread to the regional lymph nodes are removed
with an en bloc excision of the tumor and regional
lymph nodes.
-large tumors (sarcomas) are removed
with radical excicions such as amputations.
operative field:
1. Glove changing
2. Instrument cleaning
3. Wound irrigation with cytotoxic agents
SURGERY FOR RECURRENCE AND
METASTASIS
Excision of metastatic lesions is considered if:
1. No other evidence of disease exists and;
2. The metastatic lesions appeared after a
relatively long disease-free interval.
PALLIATIVE SURGERY
-the use of palliative care is carefully
considered and only if the risk-benefit ratio is
favourable.
Benefits of palliative surgery:
1. Reduce pain by such means as
interrupting nerve pathways or implanting
pain-control pumps
2. Relieve airway obstructions
3. Relieve obstructions in the GI and urinary
tracts
4. Relieve pressure on the brain or spinal
cord
5. Prevent hemorrhage
6. Remove infected and ulcerating tumors
7. Drain abscesses
RECONSTRUCTIVE SURGERY
Major goal: to improve the client’s quality of
life by restoring maximal function and
appearance.
PREVENTIVE SURGERY
-the client at unusually high risk for cancer
may elect to undergo a preventive
(prophylactic) surgical intervention.
-clients with multiple risk factors may consider
preventive surgery.
TREATMENT MODALITIES FOR CANCER
RADIATION THERAPY
- Movement of energy through a space or
medium
- Causes damage or changes to the cells
- Used in high doses to kill cancer cells
- Used as a primary treatment
- Adjunct to other therapies
GOAL:
1. Destruction of cancer tissue
2. Make the treatment easier and shorter
3. Primary treatment
4. Adjuvant
5. Palliative
Radiation used to cure cancer
• Early stage of Hodgkin’s disease
• Testicular seminomas
• Thyroid carcinomas
• Localized cancer of the head and neck
• Cancers of the uterine cervix
• Skin cancer
 Adjuvant Treatment- used either pre-
operatively or post-operatively to aid in the
destruction of cancer cells
PALLIATIVE RADIATION THERAPY
• To relieve symptoms of metastatic disease
• Reduce pain
2 types of Ionizing Radiation
1. Electromagnetic Rays
a. Xrays
b. Gamma rays
2. Particles
a. Electrons
b. Protons
c. Neutrons
d. Alpha particles
TYPES OF RADIATION
1. External Radiation/ Teletherapy
-An external source of radiation in
the form of: gamma rays & x-rays
-Treatment may be administered
once or more times a day
-Number of times depending to the
size of tumor and location
-Client should lie still exactly the
same area is irradiated each
treatment
-Marks made on skin to delineate
area of treatments
- Advantage: Skin sparring effect
3. Internal radiation (Brachytherapy)
-Placed in or near the the tumor or
into the systemic circulation
MAJOR TYPES:
1. Sealed Isotype (placed in the body)
2. Unsealed Radionucliae- systemic
administration genereally given orally, IV,
or into a body cavity
SEALED SOURCE RADIATION
• Interactivity (Cesium-131/ Radium 226)
o 24-72 hours
o Treat cancer of the uterus and cervix
• Interstitial Therapy (Iridium-192, Iodine
125, Cesium 137, Gold-198 or Radium-222)
o Treat prostate and breast cancer
o Used with the use of seeds, catheter,
ribbons and needles
o Implants temporarily (needle, ribbon or
catheter) and permanent (prostatic
seed)
• Unsealed (Radioisoptope/Radionuclide)
o Use colloid suspension that come in
contact with the body tissues
o Source of radiation is given orally or IV
or instilled into a body cavity
SIDE EFFECTS OF RADIATION
• Nausea and Vomiting
• Stomatitis
• Skin Reaction
• Dry Mouth
• Dysgeusia
• Sterility
• Suppression of Immune System
• Depression of Bone marrow
HOW IT WORKS?
Radiosensitivity – relative susceptibility of tissues
to radiation
• Depends on individual cells and tissue
characteristics
Highly radiosensitive Tumor
• Divides rapidly
• Well-vascularized Greatly affected
by Radiation
• High oxygen content
Radiation therapy uses high energy
Ionizing radiation – destroys cells ability to
reproduce by destroying its DNA, delaying mitosis
and Dna repair, and inducing apoptosis (cell
suicide)
Rapidly dividing cells – more vulnerable to
radiation than slowly dividing cells.
Ex. Cancer cells, hair
Normal cells – greater ability than cancer cells to
repair sublethal DNA damage from radiation
Sufficient dose – needed to kill cancer cells while
sparing normal cells from excessive cell death
Oxygen free radicals – formed during ionization
and interacts readily with nearby molecules
causing cellular damage
Chemotherapy
• Systemic chemotherapy is the main
treatment available for disseminated
malignant diseases.
• Progress in chemotherapy resulted in cure
for several tumors.
• Chemotherapy usually require multiple
cycles.
• 50% diagnosed of cancer
Cell Life Cycle
• Gap 0: Resting phase; cell not dividing
• Gap 1 (G1): RNA and enzyme synthesis
• 2 hours to Several Days
• Synthesis (S): DNA is produced
• 8 to 30 hours
• Gap 2 (G2): RNA and mitotic protein
production
• lasts a few hours only
• Mitosis (M): Cell division occurs
• 30 to 90 minutes; cell very vulnerable at
mitosis
Cell Cycle
Classification of cytotoxic drug:
• Cytotoxic agent can be roughly
categorized based on their activity in
relation to the cell cycle.
c y t o t o x i c d r u g
p h a s e n o n p s h p a e s c e i f s i cp . e c i f i c
 • Partial response: is decrease by more
than 50% of malignant tumors or lesions.
Chemotherapy Effect on Cellular Reproduction • Stable disease: no increase in size of any
• Some drugs are Cell-Cycle Specific lesion nor the appearance of any new
 Work in a certain phase of cell growth cycle lesions.
 Work best given continuously or frequently Chemotherapeutic agents:
 Antimetabolites, plant alkaloids,  Alkylating agents:
miscellaneous  Antimetabolites:
  Antitumor antibiotic:
• Some drugs are Cell-Cycle Non-  Plant alkaloids:
Specific  Other agents
 Work in all phases of cell cycle  Hormonal agent:
 Used to treat slow-growing tumors  Immunotherapy:
 Cell kill proportional to amount of drug given Introduction
 Alkylating agents, Antitumor antibiotics,  Classification of Drugs
Nitrosoureas, hormones  Cell-cycle specificity
 Mechanism of Action
Tumor Growth Patterns  Indication
 Tumors grow exponentially at first  Side effects
 As tumors get larger, the growth rate slows Antimetabolites
due to lack of oxygen and nutrients  Cell-cycle specific
 As tumors get very large, many cells are not  Act in S-phase
proliferating, and some have died due to lack  Inhibit enzyme production for DNA
of oxygen and nutrients synthesis
 Chemotherapy kills the same percentage of  Lead to strand breaks or incomplete DNA
cells with each treatment strands
Factors Affecting Response
Cytosine Arabinoside
• Tumor Burden
 Also called Ara-C or Cytarabine
• Combination vs. Single Agent Therapy
 Treatment for Leukemias and
• Hormone Receptor Status
Lymphomas
• Administration Schedule
 Variety of dose schedules/routes
• Dose Category
• Drug Resistance
 Myelosuppression, alopecia (dose
dependant), N&V, mucositis, diarrhea,
• Supportive Therapies
conjunctivitis, acral redness, liver and
kidney dysfunction, neurologic
Single Drug Treatment dysfunction (high dose)
• Less toxicity to normal tissue BUT….  Non-vesicant
• Less toxicity to cancer cells 5-Flurouracil (5-FU)
• Overall lower response rate  Treatment for GI, breast, and ovarian
• There ARE exceptions: cancers
 Fludarabine for CLL  Variety of dose schedules
 Rituxan for NHL  Mucositis and Diarrhea, mild alopecia,
 Targretin for Cutaneous T-cell Lymphoma photosensitivity, darkening and
 Temodar for Glioblastoma sclerosing of veins, skin changes, mild to
no N&V
Combination Therapy  Potentiates radiation therapy--may be
• Most often used given concurrently
• Each drug effective against the cancer  Leucovorin increases toxicity
• Minimally overlapping toxicities  Non-vesicant
• Drugs have different mechanisms of Methotrexate
action  Treatment for lymphomas, leukemias,
• Drugs may maximize the other drug’s ovarian, breast, lung, testicular, cervical,
effect(synergy) and CNS mets
• Decrease possibility of drug resistance  May be given for non-cancer dx
• Increase percent of cells killed at one time  Variety of dose schedules/routes
 Mucositis and diarrhea, N&V, alopecia,
Complication of Chemotherapy: Myelosuppression, photosensitivity, renal
• Every chemotherapeutic will have some toxicity
deleterious side effect on normal tissue.  Given with Leucovorin (rescue)
E.G; Myelosuppression, nausea & vomiting,  Non-vesicant
Stomatitis, and alopecia are the most frequently Fludarabine
observed side effects.  Treatment for CLL
 25 mg/m2 IV for 5 days
Criteria used to describe response are:  Given as 30 minute infusion
• Complete response (complete  Myelosuppression, nausea, slight alopecia,
remission) is the disappearance of all rash, diarrhea
detectable malignant disease. Capecitabine (Xeloda)
  Treatment for breast cancer
 2,500 mg/m2 orally for 14 days on & 7
days off
 Take with food
 Diarrhea, Mucositis, numbness, tingling,
itching of hands and feet (hand and foot
syndrome)
Gemcitabine (Gemzar)
 Treatment for pancreatic, lung, and many
other cancers
 1000mg/m2 IV every week up to 7 weeks
in a row
 Given as a 30 minute infusion--longer
infusions increase toxicity
 Myelosuppression, N&V, fatigue, increased
liver enzymes, alopecia
 Non-vesicant
Vinca Alkaloids
 Cell-cycle Specific
 Act in late G2 phase, M phase, and S
phase
 Block DNA and RNA production, prevent
cell division, inhibit microtubule formation
Vinorelbine (Navelbine)
 Treatment for lung, breast cancer
 30 mg/m2 IV weekly
 VESICANT
 Given IV push over 6 -10 min through side
port of fast running IV (furthest from IV
site), 100 cc flush
 Myelosuppression, Peripheral neuropathy,
N&V, mild alopecia
Vincristine (Oncovin)
• Treatment for leukemia, breast,
lymphoma, SCLC, sarcoma
• 1.4mg/m2 IV weekly
• DOSE NOT TO EXCEED 2 mg
• VESICANT
• Peripheral neuropathy, constipation,
paralytic ileus, jaw pain
• Neuropathy is cumulative
• FATAL IF GIVEN INTRATHECALLY
Vinblastine (Velban)
 Testicular, Head and neck cancer,
Hodgkin’s disease, Kaposi’s sarcoma
 4 - 18 mg/m2 IV weekly
 VESICANT
 Peripheral neuropathy, constipation,
Myelosuppression, mild alopecia, jaw pain
 Less neuropathy than Vincristine
Epipodophyllotoxins
 Cell-cycle specific
 Work in late G2 and S phase
 Interfere with topoisomerase II enzyme
 Stops cell replication in pre-mitotic phase
Etoposide (VP-16)
 Breast, testicular, SCLC, lymphomas
 100 mg/m2/day x 3 days q 28 days
 Non-vesicant
 Myelosuppression, N&V, alopecia,
orthostatic hypotension
 Rapid infusion causes hypotension-given
over 45-60 min
 Must be dilute or will precipitate
Taxanes
 Cell-cycle specific
 Active in G2 and M phase
 Stabilize the microtubule structure
 Cells cannot divide
Paclitaxel (Taxol)
 Breast, ovarian, SCLC
 Given IV over 24hrs, 3 hrs, or 1 hr
 Myelosuppression, alopecia (severe),
peripheral neuropathy, hypersensitivity
rxns, myalgias, severe fatigue
 Pre-meds: Dexamethasone 20 mg po 12 &
6 hrs prior, Pepcid or Tagamet, Benedryl
plus anti-emetic
 Need NON-PVC tubing with 0.2 micron in-
line filter -- NON-PVC bag or bottle
 IRRITANT
 When given with other chemo drugs; give
Taxol first
Docetaxel (Taxotere)
 Breast, NSCLC, head and neck, ovarian
 60 to 100 mg/m2 IV every 3 weeks
 Myelosuppression, myalgias,
hypersensitivity, peripheral neuropathy,
alopecia (severe)
 Pre-med: Dexamethasone 8 mg po bid
starting 1 day prior and continuing 4 days
after
 Non-PVC tubing and bottle (no filter)
Camptothecins
 Cell-cycle specific
 Act in S phase
 Inhibit topoisomerase I
 Causes double-strand DNA changes
Topotecan (Hycamtin)
 Ovarian, salvage therapy
 1.5 mg/m2 IV daily x 5 days q 3 weeks
 Myelosuppression, diarrhea, mild alopecia
Irinotecan (Camptosar)
 Metastatic colon and rectum
 125 mg/m2 IV weekly x 4 weeks
 Diarrhea (severe), Myelosuppression,
alopecia
 Diarrhea MUST be treated -- patients need
to go home with antidiarrheal and know
how to use it
Miscellaneous
• Cell-cycle specific
• Work in a variety of ways
• Inhibit Protein synthesis
• Act in S phase
• Inhibit RNA and DNA synthesis
L-Asparginase (Elspar)
 Leukemia
 1,000 - 6,000 IU/m2 IM
 Hypersensitivity, anaphylaxis, hepatoxicity,
N&V (slight), fever
 ALWAYS give test dose prior to initial dose-
test dose given intradermally
 Also give test dose if pt has not had in more
than 1 week
 IM administration decreases hypersensitivity
reactions
Pegaspargase (Oncaspar)
 Leukemics who are sensitive to Elspar
 2,500 IU/m2 IM every 14 days
 Hepatotoxicity, coagulopathy, may have
some hypersensitivity rxns
 Less hypersensitivity than Elspar - may not
need test dose
 VERY expensive
Hydroxyurea (Hydrea)
  Leukemias, Malignant melanoma, head and
neck cancer, ovarian
 20 - 30 mg/kg PO q day
 Myelosuppression, N&V (mild), mucositis,
constipation or diarrhea
 Dose is adjusted based on blood counts
Alkylating Agents
 Cell-cycle Nonspecific
 Break DNA helix strand
 Interfere with DNA replication
 Cisplatin
 GU cancers, lung, head and neck,
sarcomas, testicular, renal cell, esophageal
 Doses no higher than 100 mg/m2
 Monitor K+, Mg+, Creatinine
 Severe and prolonged N&V,
nephrotoxocity, ototoxicity,
myelosuppression, alopecia (mild)
 Rigorous hydration needed to prevent renal
toxicity
 Irritant
Carboplatin
 Ovarian, testicular, head and neck, lung,
cervical
 Varied dosing; sometimes ordered as AUC
(area under the curve)
 Thrombocytopenia, N&V, hyper-
sensitivity, myelosuppression,
renal/hepatic toxicity
 No need for rigorous pre- or post-hydration
Oxaliplatin
 Second line therapy for metatstatic
colorectal cancer
 Neuropathy starting within hours
exacerbated by exposure to cold
 Acute and chronic neuropathy
 Neutropenia ( w/ 5-FU), Anemia
Thrombocytopenia
 Renally excreted
 Irritant – use central line
Cyclophosphamide (Cytoxan)
 Breast, lung, prostate, ovary, leukemias,
lymphomas, Multiple Myeloma, head and
neck
 Varied dosing schedule/route
 Hemorrhagic cystitis, myelosuppression,
N&V, alopecia, SIADH, nasal burning
 Patient should drink 8 -10 glasses of water
per day
 Ifosfamide (Ifex)
 Lung, testicular, lymphomas, sarcomas
 1.2 gm/m2 IV days 1-5 q 3-4 wks
 ALWAYS given with Mesna
 Hemorrhagic cystitis, N&V, alopecia,
Myelosuppression, neurotoxicity
 Mesna dose should be 20% of the
Ifosfamide dose
Mechlorethamine HCl
(Nitrogen Mustard)
 Leukemias, lymphomas
 6 mg/m2 IV on day 1 and day 8 q 4 weeks
 Myelosuppression, N&V, chills, fever, pain
at IV site
 VESICANT
 Flush with 125 - 150 cc NS
 Stable for only 10 to 15 minutes; use
immediately after mixing
Dacarbazine (DTIC)
 Lymphomas, Sarcoma, Melanoma
 75 - 1500 mg/m2
 Myelosuppression, N&V, alopecia, flu-like
syndrome, renal and liver toxicity,
diarrhea
 VESICANT
Thiotepa
 Bladder, breast, ovarian, lymphomas
 0.3-0.4 mg/kg IV at 1 - 4 wk intervals; 0.6-
0.8 mg/kg for bladder (intracavitary)
administration
 Myelosuppression, rash, fever, N&V
 Monitor renal function if given IV
Anti-tumor Antibiotics
• Cell-cycle Nonspecific
• Bind with DNA
• Inhibit DNA and RNA synthesis
Doxorubicin (Adriamycin)
 Breast, ovary, prostate, stomach, lung,
liver, head and neck, multiple myeloma,
lymphomas, leukemias
 40-75 mg/m2 q 3 weeks
 Myelosuppression, N&V, alopecia,
mucositis, cardiotoxicity, radiation recall,
photosensitivity, red urine
 VESICANT
 May cause flare reaction
Liposomal Doxorubicin (Doxil)
 Refractory ovarian, Kaposi’s sarcoma
 50 mg/m2 IV q 4 weeks
 Myelosuppression, palmar-plantar
erythrodysesthesia, cardiotoxicity,
mucositis, N&V, rash, alopecia
 Start infusion at 1 mg/min and check for
flushing, SOB, facial swelling, hypotension.
If none, give over 30-60 minutes
 Irritant; not vesicant
Bleomycin (Blenoxane)
 Lung, head and neck, cervical, GYN
cancers, GU cancers, lymphomas
 10-20 units/m2 IV, IM, or SQ 1-2 times per
week
 Hypersensitivity, anaphylaxis, alopecia,
photosensitivity, renal/hepatotoxicity,
fever, chills, pulmonary fibrosis
 Test dose of 1-2 units before 1st dose
 Cumulative lifetime dose ~ 400 units due
to risk for pulmonary fibrosis
Mitomycin - C
 GI tumors, breast, lung, head and neck,
esophageal, bladder, multiple myeloma
 20 mg/m2 IV q 6-8 weeks
 Myelosuppression, alopecia, mucositis,
renal / pulmonary toxicity, fatigue
 VESICANT
 Nadir is 4 to 8 weeks
 Brochospasm can occur when given
simultaneously or after Vinca alkaloid
 Extravasation can occur distant from IV site
Mitoxantrone (Novantrone)
 Breast, lymphomas, leukemia (ALL)
 12 - 14 mg/m2 every 21 days
 Myelosuppression, alopecia, cardiotoxicity
 Urine blue-green with 1st post void
 VESICANT
  Rapid infusion causes facial flushing and
Hormonal Therapy hypotension
 Cell-cycle Nonspecific
 Interfere with hormone receptors Monoclonal Antibodies
 Interfere with protein synthesis in all  Cell-cycle Nonspecific
phases of cell cycle  Uses antibody to target specific cells
Glucocorticoids  Bind to markers on cell surface
 Prednisone, dexamethasone, etc.  Induce cell death (apoptosis)
 Breast, lymphomas, multiple myeloma,  Initiate complement system which results
leukemias, CNS tumors or mets in cell phagocytosis
 Various dosing schedules
 Fluid retention, hyperglycemia, GI irritation, Antibodies/Antigens
masks infections, mood swings, moon face,
osteoporosis, perineal burning with rapid How Antibodies Work
infusion

Tamoxifen
 postmenopausal breast cancer
 10 mg tab po BID
 Vaginal bleeding/discharge, hot flashes,
N&V, risk of uterine cancer
 Usually given for 5 years-no evidence for
continued use
 Given as preventative in high-risk women

Progestins
 Depo-Provera ; Megace
 Breast, renal cell
 Depo-Provera: 400-1,000 mg IM q wk;
Megace: 40 - 320 mg/day in divided doses
PO How MoAbs Are Produced
 Fluid retention, headache, vaginal
bleeding/spotting, increased appetite,
thrombophlebitis
 Megace used as appetite stimulant
 Depo-provera used to prevent menses in
thrombocytopenic patients
Leuprolide (Lupron)
 Prostate, breast cancer
 Dose varies with protocol
 Gynecomastia, hot flashes, N&V, headache,
bone pain
 Symptoms may worsen in first few weeks
of therapy.

Goserelin acetate (Zoladex)

 Prostate, breast cancer
 Dose varies with protocol
 Hot flashes, gynecomastia, N&V
 Given as depot injection SQ into abdomen Various Types of MoAbs
(with 14-16 gauge needle) once a month or
every 3 months

Nitrosoureas
 Cell-cycle Nonspecific
 Break DNA helix
 Interfere with DNA replication
 Cross blood-brain barrier

Carmustine (BCNU)
 Lymphomas, CNS tumors, multiple
myeloma, melanoma, BMT
 75-100 mg/m2 IV x 2 days or 200 mg/m2 IV
single dose q 6-8 wks
 N&V, myelosuppression, renal/liver toxicity,
pulmonary fibrosis
 Nadir: 4-6 weeks
 Crosses blood/brain barrier

Rituximab (Rituxan)
 Leukemias, lymphomas, ITP,
Waldenstrom’s macroglobulinemia
 375mg/m2 IV; schedule varies
 Start at 50 mg/hr; increase gradually if no
reaction.
 Infusion-related side effects; fever with
rigors, hypotension, allergic reactions, N&V,
pain
 Pre-med: Tylenol and Benedryl
Ibritumomab (Zevalin)
 Anti-CD 20 antibody bound to Tiuxetan—
which binds to Yittrium 90 or Indium 111
 Dose = 0.4 mCi/kg
 Given in Nuclear Medicine
 Cannot be given if platelets < 100,000
 Dose reductions based on platelet count
Trastuzumab (Herceptin)
 Breast, prostate
 Dose varies with protocol
 Cardiotoxicity, myelosuppression, allergic
reactions, infusion reactions (chills, fever,
headache) common with 1st infusion- give
over 30 min
• When given with other chemo- therapeutic
agents-give first
• MUGA or Echocardiogram before 1st dose
• Pre-med with Tylenol and Benedryl
Gemtuzumab (Mylotarg)
 AML (leukemia)
 Antibody + calicheamicin (antitumor
antibiotic)
 Mylosuppression, longstanding
thrombocytopenia, fatigue, myalgias,
anorexia, chills and fever
 Given over 2 hours x 2 doses 7 days apart
 Pre-med with Tylenol and Benedryl
Alemtuzumab (Campath)
 Chronic Lymphocytic Leukemia
 Failed first line therapy with Fludarabine
 T-cell Leukemia, Mycosis Fungoides, NHL
 Binds to CD-52 → cell lysis
 Severe Myelosuppression
 Start at 3 mg daily over 2 hours
 When no reactions, increase to 10 mg
 Severe infusion related reactions
 Premedicate with Tylenol, Benedryl, and
Hydrocortisone
Biologic Response Modifiers
 Cell-cycle Nonspecific
 Stimulate immune system-primarily
lymphocytes
 Cause release of cytokines
 Not effective as single agents
 Interferons
 Leukemias, lymphomas, multiple
myeloma, melanoma, hepatitis, renal cell,
Kaposi’s sarcoma
 Dose varies depending on formulation and
disease
 Flu-like syndrome, fever, malaise,
anorexia, diarrhea, rash
 Usually self-administered; best taken at
HS
Aldesleukin (IL-2)
 Renal cell, malignant melanoma
 Dose varies depending on protocol
 Toxicity is dose related
 Capillary-leak syndrome, hypotension,
cardiac arrhythmias, pulmonary edema,
mental status changes, rash with pruritis,
diarrhea, lymphocytosis, weight gain,
edema
 Pre-medicate as ordered
Immunoglobulin (IgG)
 ITP, TTP, anemias, leukemias, post BMT
 Dose varies with manufacturer
 Chills, fever, hypotension, dyspnea,
anaphylaxis, urticaria, edema of lips and
tongue
 Monitor vs q 15 min x 4; then q hr
 Start at slow rate and increase q 15-30
min until MAX rate (depends on
manufacturer)
Chemoprotectants
 Not chemotherapy
 Given with chemotherapy protocol to
decrease toxicities
 Side effects vary with drug
 Protect healthy cells but not cancer cells
Mesna (Mesnex)
 Prophylaxis of acrolein-induced
hemorrhagic cystitis
 IV bolus injection equal to 20% Ifex dose
15-30min prior to Ifex and 4 and 8 hours
after Ifex
 May be given concurrently as CI
 Run for 12 hours after Ifex done
 Oral dose
 Diarrhea, headache, nausea, fatigue (all
mild)
Amifostine (Ethyol)
 Reduction of renal toxicity from Cisplatin
administration
 Protects salivary glands from RT
 Hypotension and nausea, lowers Ca++
 Run NS at 500 cc/hr x 2 hrs
 Ondansetron 32 mg IV Dexamethasone 20
mg IV and Ativan 1 mg IV 1 hour prior to
drug
 Give over ~10 minutes approx 30 min.
prior to Cisplatin-pt should be supine
 Stop infusion if systolic BP drops
significantly from baseline
Dexrazoxane (Zinecard)
 Reduces incidence and severity of
cardiomyopathy from Adriamycin
 Slow IV push or fast IV infusion 30 min
prior to Adriamycin
 Not recommended with initiation of
treatment; used after Adriamycin
cumulative dose > 300mg/m2
 May lower response rate
Leucovorin
 Given with Methotrexate to reduce toxicity
to healthy cells
 A form of folic acid
 Taken up preferentially by healthy cells
instead of Methotrexate which is taken up
more by cancer
 For HD Methotrexate, given until
methotrexate level in safe range
 Increases toxicity of 5-FU
5HT3 receptor antagonists
 Ondansetron (Zofran) 32 mg IV or 4 to 8
mg po TID
 Granisetron (Kytril) 10 mcg/kg IV or 2 mg
PO daily
 Dolasetron (Anzemet) 1.8 mg/kg IV or 100
mg po
 Work prophylactically in chemo Rx
 Less useful for delayed N&V
Hypersensitivity
 Antigen-antibody reaction
 May be related to release of vasoactive
substances from cells
 May be related to diluent; not chemo drug
 Localized, generalized, or systemic
Risk Factors
 High risk drugs
o Bleomycin
o L-Asparginase
o Taxol
o Carboplatin
 History of drug allergies
 Failure to administer pre-meds
 Previous exposure (with/without reaction)
Clinical Manifestations
 Rash or hives with/without itching
 Uneasiness, agitation
 Wheezing, SOB
 Periorbital or facial edema
 Hypotension
 Chest tightness
 Abdominal cramping with/without nausea
 Chilling
Nursing Care
 Premedicate as indicated
 Vital signs q 15 min for first hour
 Give test dose, if indicated
 Bleomycin
 L-Aparginase
 Direct observation for initial 15 to 20 min
 Start infusion slowly and gradually
increase
 If rxn occurs, stop IV, run NS, stay with
patient, give supportive care as needed
BIOTHERAPY
− use of agnets to affect a biologic response
− its core is the immune response
− includes agents that change the relationship
between the tumor and the host by altering
the host’s response to the tumor or by
minimizing or preventing pancytopenia
(neutropenia, anemia and
thrombocytopenia), which may delay
scheduled chemotherapy or other treatment.
TYPES:
1. HEMATOPOIETIC GROWTH FACTORS
- glycosylated proteins that
mediatehematopoiesis (formation and
development of blood vessels)
- Stimulate bone marrow recovery
- Named for the major cell lineage they
mediate
a) Granulocyte and macrophage colony-
stimulator (GM_CSF)
- affects both granulocyte and macrophage
lineage
- approved for myeloid (bone marrow)
reconstitution after autologous BMT and
for use in patient experiencing BMT failure
or engraftment delay
- -generally well tolerated
b) Granulocyte colony-stimulating Factor
(G-CSF)
-Filgrastim, Neuropogen
- -affects only granulocyte
- Pegfilgrastim (Neurasta)
- -pegylated form of Filgrastim
- -can be administered once per
chemotreatment cycle rather than as a
daily SC injection
S/E : (GM-CSF and G-CSF)
o Mild to moderate flu-like manifestations
(fever, myalgia, muscular pain), bone pain,
fatigue, headache
o Rash
o Transient increase in liver enzymes
o Thrombocytopenia (decrease plt)
o Bone pain- most common side effect of G-
CSF
o in areas that have large reserves (pelvic,
sternum, long bones)
o may be due to marrow expansion that
occurs from rapid increase in neutrophil pool
that G-CSF causes
c) Erythropoietin (Eoetin alfa (procrit,
epogen))
- treatment secondary to ESRD and
associated with cancer chemotherapy
- S/E: transient flu-like manifestations
(arthralgia, myalgia)
-
d. Oprelvekin (Neumega)
- for chemotherapy-induced thrombocytopenia
- decrease need for platelet transfusion and
allows patient to receive the desired doses of
chemotherapy as scheduled
- S/E:
 - Edema
- Dyspnea
- Tachycardia
- Conjunctival redness
2. BIOLOGIC RESPONSE MODIFIERS (BRMS)
- Change relationship between tumor and
hostby altering host’s biologic response to
the tumor
- -produces immunologic or other biologic
effects
- -augment, modulate, or restore immune
respons
- -may have direct cytotoxic effects
- -other biologic effects: maturation of cells
and interference with a tumor’s ability to
metastasize
- -includes interfereons, interleukins,
monoclonal antibodies,
immunomodulators and tumor necrosis
factor
Rituximab (Rituxan)
treatment of non-Hodgkin’s lymphoma
Trastuzumab (Herceptin) and Paclitaxel
(Taxol)
-used in combination for treatment of HERZ-
positive breast cancer
Trastuzumab is being investigated as a
treatment option in other solid tumors (ovarian,
pancreatic, prostate)
Tositomomab (Bexxar) and Ibritumomab
Tiuxetan (IDEC-Y2B8)
 2 agents currently being investigated,
combine a radioisotope with a monoclonal
antibody (MoAb)
Under BRMs
a. Interferons (IFNs)
- -small proteins that have cellular activity in
3 areas: antiviral, immunomodulatory,
antiproliferativ
- Interferon-alpha
- -FDA approved for hairy cell leukemia in
1986
- -indications: AIDS-associated Kaposis
sarcoma, clinical trials conducted to
determine its use in other hematologic
malignancies (chronic leukemias, multiple
myeloma, cutaneous T cell lymphoma, low
grade non-Hodgkin’s lymphoma)
- -tonicities appear to be dose-related
S/E flu like symptoms (common: fever, chills.
Tachycardia, muscle aches, malaise, fatigue and
headaches)
- Continued use produces tachypphylactic
response (rapidly decrease response after
admin of few doses (such that these
manifestations decrease in intensity over
time
- Premedication with acetaminophen
(Tylenol ) and diphenhydramine (Benadryl)
is helpful in reducing the patient’s disease
comfort
b. Interleukin
- proteins that serve as regulators of the
immune system
- Capable of inducing multiple biologic
activities
- Numerous interleukins have been identified
yet interleukin-2 (IL-2) has received only FDA
approval
- Interleukin-2: derived from T-cells augments
various t-cell activities and enhances the
function of natural killer cells
- Has been successfully used in clients with
renal cell carcinoma and melanoma
-major toxic response with IL-2 therapy are due to
increasd capillary permeability which may
produce:
• HTN
• Ascites
• Pulmonary edema
• Fatigue
• Generalized weight gain
• Generalized edema
• Rash
• Pruritus
• Occasionally skin desquamation
3. MONOCLONAL ANTIBODIES (MOABS)
- -specific antibodies directed against single
antigenic determinants on the cell surface
- -provide high specificity lakcing in other
types of treatment modalities
- -used either diagnostically/ therapeutically
- Diagnostically: early detection of cancer
by identification of surface markers on
tumor cells and as a dlivery agent of
radioisotopes to the tumor site to aid in
tumor visualization
- Therapeuticallly: used to deliver
immunotoxins, such as, ricin,
chemotherapeutic agents and
radioisotopes directly to the tumor site.
4. ANTI-ANGIOGENESIS AGENTS
- Tumors are dependent on angiogenesis for
continued growth and metastasis.
Angiogenesis
- development of blood vessels
- vascularization
- Ability of cancer cells to secrete
substances that stimulate blood vessel
growth
- A tumor cannot grow more than 0.5mm
without blood supply to transport nutrients
to the tumor
- Very tiny tumors can receive oxygen and
nutrients by diffusion
Anti-angiogenesis
- arresting the development of new blood
supplies
- halt the growth of a tumor
- Destruction of single tumor capillary may
be able to kill many cancer cells that rely
on
- that vessel for nutrition.
Benign Tumors - sparsely vascularized and
grow slowly
Malignant tumors- highly vascular and grow
rapidly
* If angiogenesis is inhibited, cancer
progression may be halted/slowed by preventing
metastasis.
Thalidomide (Thalomid)
- used to treat relapsed and refractory
multiple myeloma
- 1st marketed in 1960s in Canada and
Europe as a sedative
- removed from the market
- associated with phocomelia (absence of
limbs) birth defects of children
- anti-angiogenesis limits the normal growth
of limbs in the neonate
- now being exploited to limit tumor growth
and metastasis
- clinical trials of other solid tumors are
likely to yield other therapeutic
applications of this agent.
5. EMERGING TARGETED THERAPIES
- new approaches in cancer therapies-
based on the recognition of the abnormality in
the malignant cell and developing a treatment
that targets the agent.
Imatinib mesylate (Gleevec)
-An orally administered gene-directed
therapy approved by the FDA for the treatment of
Chronic Myelogenous Leukemia (CML)
- Selectively blocks the abnormal BCR-ABL
fusion gene (Philadelphia chromosome) that is
vital to the survival and proliferation of CNL cells
BONE MARROW TRANSPLANT (BMT)
-May be used to counter the toxic effects
the chemotherapy or Radiation Therapy in the
treatment of breast cancer, lymphoma and other
cancers
-BMT allows the client to receive lethal and
potentially more effective doses of chemotherapy
and radiation therapy with regard to
hematopoietic toxicity
- The process that replaces the damaged
marrow and bone with healthy marrow.
TYPES
1.) Autologous BMT
- Uses client’s own bone marrow
- It is harvested before treatment
- The marrow may or may not be
chemically treated to destroy any
cancer cells
- Marrow is removed from the patient
during the remission phase to allow
another course of ablative therapy to
be given if a relapse occurs
- Relapse may be due to
contamination of the harvested
bone marrow by malignant cells or
the failure of pre-transplant
chemotherapy to eradicate
completely the tumor cells from the
body.
2.) Allogeneic BMT
- Involves use of a marrow from a
matching donor
- Most common
- after harvesting, it is then stored
(frozen) to be re-infused after the
chemotherapy or
- radiation therapy to rescue a bone
marrow from the lethal effects of the
treatment
- Carries the highest rate of morbidity
and mortality because the
complications of
- incompatibility such as Graft VS
Host Disease (GVHD)
3.) Syngeneic BMT
- Uses bone marrow from Identical twin
- Perfect Human Leukocyte Antigen
(HLA) match, eliminates risk of
marrow rejection
- incidence of leukemic response is
higher than when a allogenic donor is
used because
- GVHD is considered to have an anti-
leukemic effect.
Histocompatibility
Siblings – 1 in a 4 chance
Unrelated – 1 in a 500 chance
Before Marrow Harvest
-Informed Consent
-Potential Donor Complications (Pain,
Fever, Hematoma)
-Spinal Anesthesia is used because of
potential for significant blood loss
-Newborns- potential donors
- use of their cord blood which is rich of
stem cells
-freeze their newborn’s cord blood for
potential future use, especially if there is a
history of cancer in the family
Marrow Collection
-Obtained in 5-10ml aliquots form the
marrow spaces with the posterior of occasionally
the
anterior iliac crest or sternum
-Numerous skin punches may be required
-Aspiration needle is redirected to various
marrow spaces and being withdrawn
- 500-1000ml of marrow usually is
obtained
-blood is placed in heparinized tissue
culture media and filtered for removal of fat and
bone particles
-marrow can be infused immediately or
frozen in a solution containing dimethyl sulfoxide
-Marrow is administered from a large
blood infusion by a multi-lumen catheter using an
infusion
pump or small volumes may be prefilled
and given by IV push by a physician
ACUTE GVHD
o Staged according to the organ system
affected
o gut, skin, lungs or liver
o Skin manifestations may resolve the
treatment
o systemic may be treated with
immunosuppressive drug therapy
o High doses of methylprednisolone,
antithymocyte globulin, antilymphocyte
globulin,
o cyclosporine and anti-t-cell immunotoxins
CHRONIC GVHD
o Lass acute manifestations, may occur even
if the client has not experienced acute
GVHD
o appears about 100 days after
transplantation
o Affect the liver, Gastro Intestinal system,
oral mucosa, lungs and skin
Diagnostic test
-Confirmed by skin and oral mucosal
biopsy
 Mind-body techniques
Stages of Acute GVHD
1. Maculopapular Rash >25 % of body
surface area
2. Maculopapular Rash 25-50% of body
surface area
3. Generalized erythroderma
4. Descuamation and Bullae
Other Treatment Modalities for Cancer
 Herbs and Cancer
1- Herbs to Reduce Stagnation.
The accumulation (tumor) is attacked with
strong blood breaking and anti-cancer
herbs. Herbs will differ according to the
location of the cancer. Because many
patients receive chemotherapy, and
because toxicity may be a disease factor,
anti-toxic herbs are often added.
2 - Herbs to Strengthen the Immune
System and balance the body.
Reduce excess and supplement
deficiencies. Most important is the body's
immune energy (wei qi) which must be
heightened to help subdue the cancering
process. One or more herbs are also
included to strengthen digestion and
absorption of the cancer medicine.
3 - Herbs to Eliminate the Root
Causes of the Cancer
to prevent recurrence. We must seek to
understand what is the cause, or the
causes
Common: scutallaria
 Acupuncture
• Acupuncture is now officially
recommended for lung cancer patients
experiencing fatigue, dyspnea,
chemotherapy-induced neuropathy, or
to soothe symptoms of pain or nausea
and vomiting.
• What is the theory behind the claim
that acupuncture is useful in treating
cancer?
Acupuncture may cause physical
responses in nerves cells, the pituitary gland,
and parts of the brain. These responses
can cause the body to release proteins,
hormones, and brain chemicals that control
a number of body functions. It is proposed
that, by these actions, acupuncture affects
blood pressure and body temperature, boosts
immune system activity, and causes the
body's natural painkillers, such as
endorphins, to be released.
• Hypnosis
- a state of heightened
awareness coupled with a deep
sense of physical relaxation
while remaining focused on a
single idea or series of related
ideas.
- Through hypnosis, a patient can
visualize their body fighting the
cancer, becoming healthier and
patient can visualize their body
fighting the cancer, becoming
healthier and removing the
invader. They are able to "see"
the chemotherapy drugs doing
their job and help their body
eliminate the toxins from their
system
• Biofeedback
- a very good complimentary
therapy for cancer patients who
are undergoing chemotherapy,
radiation therapy, or surgery.
Biofeedback cannot stop
cancer. It can't cure cancer,
either, but it can provide a
cancer patient
with the ability to reduce his
stress, muscle tension, and pain
• guided visualization
- a widely used technique to help
people focus on the more
positive aspects of life and
therefore improve their health.
 Chelation
• Chelation therapy is a mainstream
treatment used to treat heavy metal
poisoning. However, the term is also
used to promote an alternative therapy
that is supposed to treat heart disease,
cancer, and other conditions. It most
often involves the injection of ethylene
diamine tetraacetic acid (EDTA), a
chemical that binds, or chelates, heavy
metals, including iron, lead, mercury,
cadmium, and zinc.
• By removing the metallic anions from
the blood stream, EDTA helps the cells
to remain healthy and helps the
damaged cells to heal. Research has
shown a decrease in the incidence of
death by cancer after EDTA treatment.
We don't know the mechanism of
action. In some forms of cancer, the
use of EDTA was found to strip the
tumor cells of their protective coat,
allowing other mechanisms (such as
protein digesting enzymes) to destroy
the tumors.
 Ozone oxygen therapy
• Ozone Therapy is a special form
of cancer oxygen used to kill and stunt
the growth of cancer cells.
• These two treatments have similar
principle. The first one is to add a
higher content of oxygen into the
blood so called Hematogenous Oxygen
Therapy (HOT), while the second one
adds ozone. The procedure is to draw
some amount of patient’s blood
(around 80-100 ml.) into a closed
sterile vessel, then mix it up with
oxygen or ozone under the ultra-violet
ray and re-infuse into the body. Such
amount of red blood cells will be
signaled by the UV turning itself to
have higher capacity for oxygen. The
trained red blood cells after being re-
infusion into the body, will signal the
other red cell in the whole body via the
UV light captured to have higher
oxygen capability.
• It has been proved that ozone or
higher level of oxygen enhance cell
respiration. Further more, through
catalytic action, the ozone and extra-
oxygen will develop various
substances which restrain tumor
growth. It also eliminates hypoxic pain
and side effect of chemo and radio
therapy.
 Homeopathy and cancer
• Homeopathy is a sub-system of natural
health care in which extreme dilutions
of substances from nature are used to
stimulate a healing response. The
basic principle of homeopathy is that
substances that elicit a particular
symptom picture in their physical form
(for example onion causing itchy
watery eyes and a runny nose with
discharge that burns) can be used in a
diluted form to stimulate the healing of
the same set of symptoms.
• One of the most frequently.
recommended homeopathic remedies
for cancer is Arsenicum Album.
• Arsenicum Album is a primary remedy
for cancer and is often recommended
for individuals with terminal cancer
that are entering into the death
process. It helps the individual
confront and deal with their fear of
death – feelings of being stuck in
limbo, not knowing what lies ahead,
not knowing what to expect, feeling
terrified of the transition, afraid to let
go of their life. When used
appropriately, it can be a powerful tool
for assisting individuals in coming to
greater peace about the death
process, enabling them to embrace the
transition with greater spiritual
centeredness.
 Therapeutic Touch
• therapeutic touch removes blockages
and stagnant, harmful energy in the
patient's energy fields. The absence of
free flowing energy or the presence of
harmful energy is believed to cause
pain, illness and disease.
 Diet
• Cancer Diet and Nutrition FAQ
• Soy
- Soy and Breast Cancer
- Soy and Prostate Cancer
• Tomato
- Lycopene in Tomatoes and
Prostate Cancer
• Minerals
- Selenium and Prostate Cancer
- Magnesium cuts Colon Cancer
risk: Study
• Co-Q10
- CoQ10 - Benefits of Coenzyme
Q10 in Cancer

• Vitamins
- Canada recommends Vitamin D
pills to reduce Cancer risk
- Vitamin E supplements may
harm head and neck cancer
patients
- Vitamin D may reduce Cancer
risk
- High Levels of Vitamin D lower
Cancer Risk
- Folate from food, not from
supplements, may cut
Pancreatic Cancer
• Spice
- Benefits of Garlic in Cancer
- More Than a Simple Spice:
Fighting Cancer with Curry
• Fruits & Vegetables
- Cancer Fighting Vegetables
- Fruits and Vegetables reduce
Breast Cancer Recurrence
• Beverage
- Health Benefits of Tea
- Alcohol and Cancer
- Tea may protect against
Ovarian Cancer
• Whole Grains
- Whole Grains Guide - Health
Benefits
• Dairy
- Dairy and Calcium linked to
Prostate Cancer
• Flax Seed
- Benefits of Flax Seed
• Miscellaneous
- Antioxidants 101 - What and
Where?
- Will eating Farmed Salmon
cause Cancer?
- Processed Meat and Cancer
- Does Grilling Meats Increase
the Risk of Cancer?
- Cancer and Unintentional
Weight Loss
- Are there any Pills to prevent
Cancer?
- Top 4 Foods That Can Save
Your Prostate
 Reiki
• a Japanese energy-based therapy that
promotes healing and overall wellness.
A trained reiki practitioner uses his or
her hands to transmit energy to the
recipient.
• administered by a specially trained
practitioner, using his or her hands.
Hands are placed above the body and
"life force energy" is transmitted.
• helped with pain management,
relaxation, and side effects of
treatment like nausea and stomach
upset.
• It is important to note that reiki is not
an alternative cancer treatment. It is
not used to cure cancer or in place of
treatment. Reiki is a complementary
therapy, used to ease the emotional
and physical side effects of treatment.
 Naturopathy
• can help to bring relief from the 'body–
racking' side effects and to restore the
individual’s overall health.
• Naturopathy is a complimentary
branch of medicine that makes use of
natural and safe therapies. It upholds
detoxification as the first step towards
recovery from cancer. Naturopathy
recommends 5 natural steps, which
are dealt with in the following sessions.
o Lifestyle change
-If fully / highly toxic, you need to get de-
numbed,as toxicity often leaves people numb
towards their reactions to the world.

- If you are smoking, work on stopping that habit.

-Avoid excessive alcohol /coffee consumption. These

overload your liver

- Ensure enough sleep everyday

- Exercise regularly

o Healthy eating

o Organ repair

o Eliminating toxins

o Restoring detox organ