Management of Pain in Cancer Patients

Causes of Cancer Pains

Bone Destruction
Obstruction of an organ
Compression of a peripheral nerve
Infiltration and distension of tissue
Inflammation and necrosis
Psychological factors such as fear and anxiety

Treatment Modalities

Analgesic Therapies for Cancer Pains

Therapy Examples
Primary Therapy  Chemotherapy
 Radiotherapy
 Hormone therapy
 Immunotherapy
 Surgery
 Antibiotics
Systemic  Non-opioid analgesics
Analgesic  Opioids
Pharmacotherap  Adjuvant analgesics
y

Anesthetic  Intraspinal opioids/local anesthetic

Techniques  Chemical rhizotomy (interruption of a nerve root by the use of glycerol)
 Somatic neurolysis (destruction or dissolution of nerve tissue)
 Sympathetic blockade (blocking of the effect of a hormone or neurotransmitter
at a cell-surface receptor by a pharmacologic antagonist)
Neurosurgical  Rhizotomy (Surgical resection/interruption of nerve root)
Techniques  Cordotomy (cutting of spinal cord fibers)
 Cingulotomy (producing lesions in the tissue of the cingulate gyrus of the
frontal lobe)
 Pituitary ablation (removal of or a part of pituitary gland)
Physiatric  Orthoses (orthopedic appliances or apparatus used to support, align, prevent,
Techniques or correct deformities or to improve function of movable parts of the body.)
 Physical therapy
Psychological  Relaxation training
Techniques  Distraction techniques
Neurostimulatory  Transcutaneous electrical nerve stimulation (electronic stimulation to block
Techniques transmission of pain information to the brain.)

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  Acupuncture (inserting thin needles into the body at specific points to relieve
pain)
The WHO 3-Steps Analgesic Ladder: Guide for Pain Management
WHO recommends the following treatment of cancer pain according to the pain scale perceived
by the patient.

If pain occurs, there should be prompt oral administration of drugs in the following order:
nonopioids (aspirin and paracetamol); then, as necessary, mild opioids (codeine); then strong opioids
such as morphine, until the patient is free of pain. To calm fears and anxiety, additional drugs –
“adjuvants” – should be used. To maintain freedom from pain, drugs should be given “by the clock”,
that is every 3-6 hours, rather than “on demand” This three-step approach of administering the right
drug in the right dose at the right time is inexpensive and 80-90% effective. Surgical intervention on
appropriate nerves may provide further pain relief if drugs are not wholly effective.

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General Nursing Management for Cancer Pain
1. Asses the severity of pain; pain is what the client describes or says that it is
2. Collaborate with other members of the health care team to develop a pain management
program.
3. Administer oral preparation if possible and if they provide adequate relief of pain; the
transdermal route may also be prescribed.
4. Mild to moderate pain may be treated with salicylates, acetaminophen and NSAIDS.
5. Severe pain is treated with opioids such as codeine sulfate, morphine sulfate, methadone,
hydromorphone hydrochloride. Neuropathic pain is treated with a variety of anticonvulsant and
anti-depressants, as well as opioids.
6. Subcutaneous injections and continuous IV administration of opioids provide rapid control .
7. Monitor vital signs and for side effects of medications.
8. Monitor for effectiveness of medications
9. Provide non-pharmacological techniques to relieve pain, such as relaxation, guided imagery,
biofeedback, massage and heat and cold application
10. Do not under medicate a cancer patient who is in pain.

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 Chemotherapy
Chemotherapy, in its most general sense, refers to treatment
of disease by chemicals that kill cells, specifically those of micro-
organisms or cancer. In popular usage, it will usually refer to
antineoplastic drugs used to treat cancer or the combination of these
drugs into a standardized treatment regimen.

In its non-oncological use, the term may also refer to

antibiotics (antibacterial chemotherapy). In that sense, the first
modern chemotherapeutic agent was Paul Ehrlich's arsphenamine,
an arsenic compound discovered in 1909 and used to treat syphilis.
This was later followed by sulfonamides discovered by Domagk and
penicillin discovered by Alexander Fleming.

Other uses of cytostatic chemotherapy agents (including the

ones mentioned below) are the treatment of autoimmune diseases
such as multiple sclerosis and rheumatoid arthritis and the
suppression of transplant rejections

Objectives:

 To destroy all malignant tumor cells without excessive destruction of normal cells
 To control tumor growth if cure is no longer possible
 Used as adjuvant therapy

Contraindications:

 Infection. The anti-tumor drugs are immunosuppresives

 Recent surgery. The drugs may retard healing process
 Impaired renal / hepatic function. The drugs are nephrotoxic & hepatotoxic
 Recent Radiation Therapy. Also immunisuppresive
 Pregnancy. The drugs may cause congenital defects
 Bone Marrow Depression. The drugs may aggravate the condition. The WBC level must be
within normal limits.

AntiNeoplastic Medications

 Kills or inhibit the reproduction of neoplastic cells

 Normal cells are also affected
 Cell cycle phase specific medications
o Affects cells only during a certain phase of the reproductive
cycle
 Cell cycle phase non-specific medications
o Affects cells in any phase of the reproductive cycle

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  Can use combination medications or with other
treatment modalities

Routes of Administration

1. Oral -capsule, tablet, or liquid

2. I.V. push (bolus) or infusion over a specified
time period
3. Intramuscular
4. Intrathecal/ intraventricular given by injection
via an Ommaya reservoir or by lumbar puncture
(Figures 1 and 2)
5. Intra-arterial (Figure 3)
6. Intracavitary such as peritoneal cavity (Fig. 5)
7. Intravesical into uterus or bladder (Fig. 4)
Figure 1 Intraventricular Administration via
8. Topical Ommaya Reservoir

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 Figure 2 Intraarterial route

Figure 3 Intrathecal and Intraventricula route

Figure 4 Intravesical into Bladder


Dosage is based on surface area
(mg/m2) in both adults and
children.

 Most
chemotherapeutic agents have
dose-limiting toxicities that require
nursing interventions
Chemotherapy predictably
affects normal, rapidly growing

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 cells (eg, bone marrow; GI tract lining, hair follicles). It is imperative that these toxicities be
recognized early on by the nurse.

Figure 5 Intracavitary (Peritoneal Cavity)

Nursing Process: Side Effects of Chemotherapy

Adverse effects of chemotherapy are graded on a scale of 0 to 4, with 0 being normal and 4
indicating life-threatening. Scoring of adverse effects will determine if a delay in therapy is necessary,
dose modification is necessary, or cessation of therapy must occur.

A. Alopecia
1. Most chemotherapeutic agents cause some degree of alopecia. This is dependent on the
drug dose, half-life of drug, and duration of therapy.

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 2. Usually begins 2 weeks after administration of chemotherapy. Regrowth takes about 3
to 5 months.
3. The use of scalp hypothermia and tourniquets is highly controversial.

B. Anorexia
1. Chemotherapy changes the reproduction of taste buds.
2. Absent or altered taste can lead to a decreased food intake.
3. Concurrent renal or hepatic disease can increase anorexia.

C. Fatigue
1. The cause of fatigue is generally unknown but can be related to anemia, weight loss,
altered sleep patterns, and coping.

D. Nausea and Vomiting

1. Caused by the stimulation of the vagus nerve by serotonin released by cells in the upper
GI tract.
2. Incidence depends upon the particular chemotherapeutic agent and dosage.
3. Patterns of nausea and vomiting:
a. Anticipatory conditioned response from repeated association between therapy and
vomiting.
b. Acute occurs 0 to 24 hours after chemotherapy administration.
c. Delayed can occur 1 to 4 days after chemotherapy administration.

E. Mucositis
1. Caused by the destruction of the oral mucosa, causing an inflammatory response.
2. Initially presents as a burning sensation with no changes in the mucosa and progresses
to significant breakdown, erythema, and pain of the oral mucosa.
3. Consistent oral hygiene is important to avoid infection.

F. Anemia
1. Caused by suppression of the stem cell or interference with cell proliferation pathways.
2. May require red blood cell transfusion or injection of erythropoietin or darbepoetin.

G. Neutropenia
1. Defined as an absolute neutrophil count (ANC) of 1,500/mm 3 or less.
2. Risk of infection is greatest with an ANC less than 500/mm 3.
3. Caused by suppression of the stem cell.

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 4. Usually occurs 7 to 14 days after administration of chemotherapy.
5. Can be prolonged.
6. Patients should be taught to avoid infection through proper hand washing, avoiding
those with illness, proper hygiene.
7. Patients need to be monitored and treated promptly for fever or other signs of
infection.

H. Thrombocytopenia
1. Caused by suppression of megakaryocytes.
2. Incidence depends on the agent being used.
3. Risk of bleeding is present when platelet count falls below 50,000/mm 3.
4. Risk is high when count falls below 20,000/mm 3.
5. Risk is critical when count falls below 10,000/mm 3.
6. Patient should be taught to avoid injury, eg, no razors, avoid vaginal douches and rectal
suppositories, and avoid dental floss during the period of thrombocytopenia.
7. May require platelet transfusions if count drops below 20,000/mm 3.

I. Hypersensitivity Reactions
1. Nearly all of the available chemotherapeutic agents can produce hypersensitivity
reactions (HSRs) in at least an occasional patient, and some cause reactions in 5% or more
of patients receiving the drug. There are several agents (L-asparaginase, paclitaxel,
docetaxel, teniposide, and doxil) for which HSRs are frequent enough to be a major form of
treatment-limiting toxicity.
2. The mechanism is unknown for most of the chemotherapeutic agents in use.
3. Signs and symptoms include hives, pruritus, back pain, shortness of breath,
hypotension, and anaphylaxis.
4. All unexpected drug reactions should be reported to the manufacturer.

 Nursing Assessment

A. Integumentary System
1. Inspect for pain, swelling with inflammation or phlebitis, necrosis, or ulceration.
2. Inspect for skin rash, characteristics, whether pruritus, general or local.
3. Assess areas of erythema and associated tenderness or pruritus. Instruct patient to
avoid irritation to skin, sun exposure, or irritating soaps.

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 4. Assess changes in skin pigmentation.
5. Note reports of photosensitivity, tearing of the eyes.
6. Assess condition of gums, teeth, buccal mucosa, and tongue.
a. Determine whether any taste changes have occurred.
b. Check for evidence of stomatitis, erythematous areas, ulceration, infection, or pain on
swallowing.
c. Determine whether the patient has any complaints of pain or burning of the oral
mucosa or on swallowing.

B. GI System
1. Assess for frequency, timing of onset, duration, and severity of nausea and vomiting
episodes before and after chemotherapy.
a. Usually occurs from 1 to 24 hours after chemotherapy but may be delayed.
Anticipatory vomiting may occur after first course of therapy. Can be initiated by
various cues, including thoughts, smell, or even sight of the medical personnel.
2. Observe for alterations in hydration, electrolyte balance.
3. Assess for diarrhea or constipation.
a. Ascertain any changes in bowel patterns.
b. Discuss the consistency of stools.
c. Consider the frequency and duration of diarrhea (the number of stools each day for
the number of days).
d. Evaluate dietary changes or use of medications such as opioids or 5-HT3 blockers that
have had an impact on diarrhea or constipation.
4. Assess for anorexia.
a. Discuss taste changes and changes in food preferences.
b. Ask about daily food intake and normal eating patterns.
5. Assess for jaundice, right upper quadrant abdominal pain, changes in the stool or urine,
and elevated liver function tests that indicate hepatotoxicity.
6. Monitor liver function tests and total bilirubin.

C. Hematopoietic System
1. Assess for neutropenia ANC less than 500/mm 3.
a. Assess for any signs of infection (pulmonary, integumentary, central nervous system,
GI, and urinary).
b. Auscultate lungs for adventitious breath sounds.
c. Assess for productive cough or shortness of breath.
d. Assess for urinary frequency, urgency, pain, or odor.

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 e. Monitor for elevation of temperature above 101° F, chills.
2. Assess for thrombocytopenia platelet count less than 50,000/mm 3 (mild risk of
bleeding); less than 20,000/mm3 (high risk of bleeding).
a. Assess skin and oral mucous membranes for petechiae, bruises on extremities.
b. Assess for signs of bleeding (including nose, urinary, rectal, or hemoptysis).
c. Assess for blood in stools, urine, or emesis.
d. Assess for signs and symptoms of intracranial bleeding if platelet count is less than
20,000/mm3; monitor for changes in level of responsiveness, vital signs, and pupillary
reaction.
3. Assess for anemia.
a. Assess skin color, turgor, and capillary refill.
b. Ascertain whether patient has experienced dyspnea on exertion, fatigue, weakness,
palpitations, or vertigo. Advise rest periods as needed.

D. Respiratory and Cardiovascular Systems

1. Assess lung sounds.
2. Assess for pulmonary fibrosis, evidenced by a dry, nonproductive cough with increasing
dyspnea. Patients at risk include those over age 60, smokers, those receiving or having had
pulmonary radiation, those receiving cumulative dose of bleomycin (Blenoxane), or those
with any preexisting lung disease.
3. Assess for signs and symptoms of heart failure or irregular apical or radial pulses.
4. Verify baseline cardiac studies (eg, electrocardiogram, multiple-gated acquisition
scan/ejection fraction) before administering doxorubicin (Adriamycin) or high-dose
cyclophosphamide (Cytoxan).

E. Neuromuscular System
1. Determine whether patient is having difficulty with fine motor activities, such as zipping
pants, tying shoes, or buttoning a shirt.
2. Determine the presence of paresthesia (tingling, numbness) of fingers or toes.
3. Evaluate deep tendon reflexes.
4. Evaluate patient for weakness, ataxia, or slapping gait.
5. Determine impact on activities of daily living and discuss changes.
6. Discuss symptoms of urinary retention or constipation.
7. Assess for ringing in ears or decreased hearing acuity.

F. Genitourinary System
1. Monitor urine output.
2. Assess for urinary frequency, urgency, or hesitancy.

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 3. Evaluate changes in odor, color, or clarity of urine sample.
4. Assess for hematuria, oliguria, or anuria.
5. Monitor BUN and creatinine.

 Nursing Diagnoses

A. Risk for Infection related to neutropenia

B. Risk for Injury related to bleeding from thrombocytopenia
C. Fatigue related to anemia
D. Imbalanced Nutrition: Less Than Body Requirements related to adverse effects of therapy
E. Ineffective protection and risk for hypersensitivity reaction related to chemotherapy
F. Impaired Oral Mucous Membranes related to stomatitis
G. Disturbed Body Image related to alopecia and weight loss

 Nursing Interventions

A. Preventing Infection
1. Monitor vital signs every 4 hours; report occurrence of fever greater than 101 ° F (38.3 ° C) and
chills.
2. Provide patient education.
a. Instruct patient to report signs and symptoms of infection:
i. Fever greater than 101 ° F and/or chills
ii. Mouth lesions, swelling, or redness
iii. Redness, pain, or tenderness at rectum
iv. Change in bowel habits
v. Areas of redness, swelling, induration, or pain on skin surface
vi. Pain or burning when urinating or odor from urine
vii. Cough or shortness of breath
b. Reinforce good personal hygiene habits (routine bathing [preferably a shower], clean
hair, nails, and mouth care).
c. Avoid contact with people who have a transmissible illness.
d. Encourage deep breathing and coughing to decrease pulmonary stasis.
3. Avoid performing invasive procedures rectal temperatures, enemas, or insertion of indwelling
urinary catheters.
4. Monitor white blood cell count (WBC) and differential.
5. Be aware that hematologic nadirs (lowest level) generally occur within 7 to 14 days after drug
administration. Length of myelosuppression depends on specific drug. Institution of further
therapy usually depends on an adequate WBC and ANC.

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 6. Calculate ANC to determine the number of neutrophils capable of fighting an infection by:
7. Interpretation: 105 of the 700 WBCs are neutrophils and capable of fighting an infection
(indicates severe neutropenia).
8. Administer prophylactic antibiotics as prescribed (if WBC is less than 500).
9. Administer growth factors as prescribed. Neupogen 5 mcg/kg S.C. starting 24 hours after
chemotherapy for 10 days for neutropenia prophylaxis or Neulasta 6 mg S.C. for one dose 24
hours after chemotherapy. Should also be administered with subsequent courses of
chemotherapy to hasten neutrophil maturity.

B. Preventing Bleeding
1. Avoid invasive procedures when platelet count is less than 50,000/mm 3, including I.M.
injections, suppositories, enemas, and insertion of indwelling urinary catheters.
2. Apply pressure on injection sites for 5 minutes.
3. Monitor platelet count; administer platelets as prescribed.
4. Monitor and test all urine, stools, and emesis for blood.
5. Provide patient education.
6. Instruct patient to avoid straight-edge razors, nail clippers, vaginal or rectal suppositories.
7. Avoid intercourse when platelet count is less than 50,000/mm 3.
8. Encourage patient to blow nose gently.
9. Avoid dental work or other invasive procedures while thrombocytopenic.
10. Avoid the use of NSAIDs, aspirin, and aspirin-containing products.

C. Minimizing Fatigue
1. Monitor blood counts (hemoglobin and hematocrit).
2. Administer blood products as prescribed.
3. Administer growth factors as prescribed. Erythropoetin 150 U/kg S.C. 3 × per week.
4. Provide patient education and counseling
a. Information about fatigue
b. Reassurance that treatment-related fatigue does not mean your cancer is worse
c. Why fatigue and shortness of breath may occur
d. Suggestions for ways to cope with fatigue
i. Energy conservation
ii. Caution the patient about physical overexertion; encourage rest frequently and
warn patient to expect a tired feeling
iii. Plan frequent rest periods between daily activities; take naps that do not
interrupt nighttime sleep
iv. Set priorities and delegate tasks to others
e. Stress management

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 f. Explain that blood transfusions, if given, are a part of therapy and not necessarily an
indication of a setback
g. Observe skin color
h. Monitor nutritional status

D. Promoting Nutrition
1. Administer antiemetics before chemotherapy and on a routine schedule (not as needed).
2. Be aware that certain antiemetic combinations are more effective than single agents.
a. A 5-HT3 inhibitor, such as ondansetron (Zofran), granisetron (Kytril), dolasetron
(Anzemet), in combination with dexamethasone (Decadron)
b. Corticosteroids in combination with metoclopramide (Reglan)
3. For highly emetogenic chemotherapy regimens:
a. Premedicate with a 5-HT3 inhibitor and dexamethasone.
b. Include an as-needed antiemetic such as metoclopramide, prochlorperazine
(Compazine), dexamethasone, or lorazepam (Ativan).
4. For moderately emetogenic regimens:
a. Premedicate with either prochlorperazine or dexamethasone with metoclopramide plus
diphenhydramine (Benadryl).
b. Include an as-needed antiemetic, such as prochlorperazine or lorazepam.
c. Failures may receive a 5-HT3 inhibitor.
5. For low emetogenic regimens consider oral prochlorperazine.
6. Extrapyramidal reactions occur frequently in patients under age 30 and over age 65. Treat
dystonic reactions with diphenhydramine; treat restlessness with lorazepam.
7. If delayed nausea and vomiting begin 8 hours after acute prophylactic antiemetic therapy and
continue for 24 to 36 hours, administer agents such as metoclopramide with dexamethasone
plus diphenhydramine, prochlorperazine, or lorazepam.
8. Consider alternative measures for relief of anticipatory nausea, such as relaxation therapy,
imagery, and distraction.
9. Encourage small, frequent meals appealing to patient preferences.
10. Encourage patient to eat a diet high in calories and proteins. Provide a high-protein
supplement as needed.
11. Discourage smoking and alcoholic beverages, which may irritate mucous membranes.
12. Encourage fluid intake to prevent constipation.
13. Monitor intake and output, including emesis.
14. Consult dietitian about patient's food preferences, intolerances, and individual dietary
interventions.
15. Recognize that the patient may have alterations in taste perception, such as a keener taste of
bitterness and loss of ability to detect sweet tastes.

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E. Minimizing Stomatitis
1. Report signs of infection erythematous areas, white patches, ulcers.
2. Encourage good oral hygiene.
a. Soft nylon bristled toothbrush, brush 2 to 3 times daily, rinse frequently
b. Floss once daily
3. Encourage the use of oral agents to promote cleansing, debridement, and comfort.
Mouthwashes with more than 25% alcohol should be avoided.
4. Assess the need for antifungal, antibacterial, or antiviral therapy (each infection has a different
appearance).
5. Administer local oral therapy such as combinations with viscous lidocaine (Xylocaine) for
symptomatic control and maintenance of calorie intake.

F. Preventing and Managing Hypersensitivity Reactions

1. Be alert for signs of allergic reactions such as pruritus, urticaria, and difficulty breathing, as
well as back pain. Situation may worsen suddenly to hypotension and anaphylaxis.
2. Stop the medication or infusion immediately, notify the health care provider, and monitor
the patient closely. Treatment is supportive and dependent on type of reaction and its
severity.
a. Do not administer the agent again if there was a severe reaction resulting in significant
hypotension.
b. Premedicate the patient with antihistamine or corticosteroid as directed if there is a
history of moderate reaction.

G. Strengthening Coping for Altered Body Image

1. Reassure patient that hair will usually grow back; however, it may grow back a different
texture or different color.
2. Suggest wearing a turban, wig, or headscarf, preferably purchased before hair loss
occurs. Many insurance companies will pay for a wig with a prescription.
3. Encourage patient to stay on therapeutic program.
4. Be honest with the patient.

H. Patient Education and Health Maintenance

1. Make sure that patient uses good hygiene, knows symptoms of infection to report, and
avoids crowds and people with infection while neutropenic.
2. Advise patient to avoid using a razor blade to shave, contact sports, manipulation of
sharp articles, use of hard bristle toothbrush, and passage of hard stool to prevent
bleeding while thrombocytopenic.

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 3. Advise women to report symptoms of vaginal infection due to opportunistic fungal or
viral infection.
4. Encourage patient participation in plan for chemotherapy and to set realistic goals for
work and activities.
5. Assure patient that changes in menses, libido, and sexual function are usually temporary
during therapy.

 Evaluation: Expected Outcomes

1. Afebrile, no signs of infection

2. No bruising or bleeding noted; stool and urine heme test negative
3. Denies shortness of breath or severe fatigue
4. Tolerates small, frequent meals following antiemetic
5. No oral lesions or pain on swallowing
6. No urticaria, shortness of breath, or change in vital signs
7. Wears turban, expresses feelings about body image

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Table 1 Classification of drugs Used in Chemotherapy
Classification Cell Cycle Mechanism of Side effects Examples
Specificity Action
ALKYLATING AGENTS Cell cycle non- Alter DNA Bone marrow Busulfan (Busulfex, Myleran),Carboplatin
specific synthesis by suppression, (Paraplatin), chlorambucil (leukeran),
misreading DNA vomiting, nausea, cisplatin (Platinol-AQ), Cyclophosphamide
code, initiating cystitis, (Cytoxan), Decarbazine, Hemaxemethylene
breaks in the (cyclophossphamide or altretamine (Hexalen), Ifosfamide (Ifex),
DNA molecules, , Ifosfamide), Melphalan (alkeran), Nitrogen Mustard
cross-linking DNA stomatitis, alopecia, (Mustargen), Oxaliplatin (Eloxatin), Thiotepa
strands. gonadal (Thioplex)
suppression, renal
toxicity (cisplatin)
NITROSOUREAS Cell cycle non- Similar to Delayed and Carmustine (Gliadel), Lomustine (CeeNU) ,
Specific Alkylating agents; cumulative Semustine(MeCCNU), Streptozocin(Zanosar)
cross the blood- myelosuppression, ,
brain barrier especially
thrombocytopenia;
nausea and vomiting

TOPOISOMERASE I Cell cycle Induce breaks in Bone marrow Irinotecan ( Camptosar),

INHIBITORS specific (S- the DNA strands duppression, Topotecan (Hycamtin)
Phase) by binding to nausea, vomiting,
enzyme diarrhea,
topoisomerase I, hepatotoxicity
preventing cells
from dividing

ANTIMETABOLITES Cell cycle Interfere with the nausea, vomiting , 5-Azacytadine, Capecitabine (Xeloda),
specific (S biosynthesis of diarrhea, bone marrow Cytarabine, Edatrexate fludarabine, 5-
Phase) metabolites or suppression, proctitis, Fluouracil, 6-Mercapturine(Purinethol)

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 nucleic acid stomatitis ,renal toxicity Methotrexate, penostatine (Nipent)
necessary for the (methotrexate),
synthesis of RNA hepatotoxicity,
and DNA
ANTI-TUMOR ANTIBIOTICS Cell cycle non- Interfere DNA Bone Marrow Bleomycin Sulfate(Blenoxane) Daunorubicin
specific synthesis by depression, gonadal (DaunoXome) Doxorubicin(Adriamycin)
binding DNA, Suppression, vesication , Plicamycin(Mithracin)
prevent RNA nausea, vomiting ,
synthesis alopecia, anorexia,
cardiac toxicity

MITOTIC SPINDLE POISONS

 Plant alkaloids Cell cycle Arrest metaphase Bone marrow suppression

specific (M by inhibiting (mild with
Phase) mitotic tubular VCR),Neuropathies (VCR), Vincristine Sulfate(Oncovin), Etoposide
formation stomatitis ( Toposar), Teniposide(Vamon), Vinblastine
(spindle); inhibit (Velban), Vindesine (Eldesine), Vinorelbine
DNA and protein (Navelbine)
synthesis

 Taxenes
Cell cycle Arrest metaphase
specific (M by inhibiting Bradycardia, Paclitaxel (Taxol), Docetaxel (Taxotere)
Phase) tubulin hypersensitivity, bone
depolymerization marrow suppression,
alopecia, neuropathies
HORMONAL AGENTS Cell cycle non- Binds to hormone Hypercalcemia, jaundice, Androgens and anti-androgens, estrogens
specific receptor site that Increased appetite, and antiestrogens, progestins and
alters cellular masculinization, atiprogestins, aromatase inhibitors,
growth; block femininization, sodium luteinizing hormone-releassing hormone
binding of and fluid retention, analogues, steroids

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 estrogens to nausea, vomiting, hot
receptor sites flashes, vaginal estrogen
(antiestrogens); dryness
inhibit RNA
synthesis;
suppress
aromatase of
p450 sytem
which decreases
level
Miscellaneous Agent Varies Unknown or too Anorexia, nausea, Asparginase (Elspar), Procarbazine
complex to vomiting, bone marrow (Matulane)
classify suppression,
hepatotoxicity,
hypotension,
anaphylaxis, altered
glucose metabolism

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Safety Measures in Handling Chemotherapy

A. Personal Safety to Minimize Exposure via Inhalation

1. Chemotherapeutic agents should be prepared in a class II biologic safety cabinet
(vertical laminar flow hood).
2. Vent vials with filter needle to equalize the internal pressure or use negative-pressure
techniques.
3. Wrap gauze or alcohol pads around the neck of ampules when opening to decrease
droplet contamination.
4. Wrap gauze or alcohol pads around injection sites when removing syringes or needles
from I.V. injection ports.
5. Do not dispose of materials by clipping needles or removing needles from syringes.
6. Use puncture- and leak-proof containers for non-capped, non-clipped needles.

B. Personal Safety to Minimize Exposure via Skin Contact

1. Wear nitrile examination gloves at all times when preparing or working with
chemotherapeutic agents.
2. Wash hands before putting on and after removing gloves.
3. Change gloves after each use, tear, puncture, or medication spill or after every 60
minutes of wear.
4. Wear a long-sleeve, nonabsorbent gown with elastic at the wrists and back closure.
5. Eye and face shields should be worn if splashes are likely to occur.
6. Use syringes and I.V. tubing with Luer locks (which have a locking device to hold needle
firmly in place).
7. Label all syringes and I.V. tubing containing chemotherapeutic agents as hazardous
material.
8. Place an absorbent pad directly under the injection site to absorb any accidental
spillage.
9. If any contact with the skin occurs, immediately wash the area thoroughly with soap and
water.
10. If contact is made with the eye, immediately flush the eye with water and seek medical
attention.
11. Spill kits should be available in all areas where chemotherapy is stored, prepared, and
administered.

C. Personal Safety to Minimize Exposure via Ingestion

1. Do not eat, drink, chew gum, or smoke while preparing or handling chemotherapy.
2. Keep all food and drink away from preparation area.

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 3. Wash hands before and after handling chemotherapy.
4. Avoid hand-to-mouth or hand-to-eye contact while handling chemotherapeutic agents
or body fluids of the person receiving chemotherapy.

D. Safe Disposal of Antineoplastic Agents, Body Fluids, and Excreta

1. Discard gloves and gown into a leak-proof container, which should be marked as
contaminated or hazardous waste.
2. Use puncture- and leak-proof containers for needles and other sharp or breakable
objects.
3. Linens contaminated with chemotherapy or excreta from patients who have received
chemotherapy within 48 hours should be contained in specially marked hazardous waste
bags.
4. Wear non-sterile nitrile gloves for disposing of body excreta and handling soiled linens
within 48 hours of chemotherapy administration.
5. In the home, wear gloves when handling bed linens or clothing contaminated with
chemotherapy or patient excreta within 48 hours of chemotherapy administration. Place
linens in a separate, washable pillow case. Wash separately in hot water and regular
detergent.

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