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Ary Harryanto Reksodiputro

Division of Hematology Medical Oncology
Department of Interna Medicine
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Cancer
• It is basically a disease of cells characterized
by the shift in the control mechanism that
govern cell proliferation and differentiation.

Special Characteristics of Cancer Cells

•Uncontrolled Proliferation
•Dedifferentiation and loss of function
•Invasiveness (Spreading)
•Metastasis (spread of cancer from its primary site to other places in the bo
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Management of Cancer

• Surgical
• Radiation
• Chemotherapy

• The neoplastic cell burden is initially

reduced either by surgery and /or
radiation followed by chemotherapy or
combination therapy.
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Chemotherapy

Types of Therapis:
• Adjuvant: Additional treatment after the primary
treatment to lower the risk that the cancer will come
back.

• Neo-Adjuvant therapy :Treatment as a first step to

shrink a tumor before the main treatment.

• Concurrent therapy: When two or more therapies

are given together, such as chemotherapy and
radiation.
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Chemotherapy
• It is the treatment of disease by chemicals
especially by killing micro-organisms or
cancerous cells.

• In popular usage, it refers to antineoplastic

drugs used to treat cancer or the
combination of these drugs into a regimen.
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Principles of cancer chemotherapy
1. Goal of treatment:

• The ultimate goal of chemotherapy is cure.

i.e. long term disease free survival.

• If cure is not attainable, then the goal

becomes pallitation i.e. alleviation of
symptoms and avoidance of life-threatening
toxicity.

•
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Principles of cancer chemotherapy

2. Indications for treatment:

• Chemotherapy is indicated when neoplasms are

disseminated (Spread over a large area)and are not
cured by surgery.

• Chemotherapy is also used as a supplimental

treatment to attack micrometastasis following
surgery and radiation treatment.
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Principles of cancer chemotherapy

3. Tumor susceptibility and growth cycle:

• Rapidly dividing cells are generally more

sensitive to anti cancer drugs. therefore the
fraction of tumor cells that are in replicative
stage of their cycle are most susceptible.

• Non proliferating cells (those are in Go phase)

usually survive the toxic effects of many of
these agents.
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Principles of cancer chemotherapy

4. Cell cycle specificity of drugs:

• The normal and tumor cells differ in the number of

cells that are in various stages of the cycle.
• Chemotherapeutic agents that are effective only
against replicating cells are called cell cycle specific
(CCS) drugs.
• Others are said to be cell cycle non specific (CCNS)
drugs.
• The non specific drugs have more toxicity in
cycling cells and are useful against tumors that have
low percentage of replicating cells.
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Principles of cancer chemotherapy

5. Tumor growth rate:

• The growth rate of most solid tumors in vivo is

initially rapid, but growth rate decreases as tumor
size increases. Because of unavailability of nutrients
and oxygen.
• By reducing the tumor burden through surgery or
radiation promotes the remaining cells growth into
active proliferation and increases their susceptibility
to chemotherapeutic agents.
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Principles of cancer chemotherapy

6. Treatment regimens and scheduling:
•Drugs are administered on the bases of body surface
area.
•Destruction of cancer cell by chemotherapeutic agent
follows first order kinetics , i.e. given dose destroys
constant fraction of cells.(Log kill)
•Combine drug therapy is more successful than single
drug treatment.
•In combine therapy the drugs must have different
toxicities, Mechanism of action.
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Side Effects
Bone marrow suppression
• Anemia – body does not have enough healthy red
blood cells
• Neutropenia – failure of the bone marrow to make
enough white blood cells
• Thrombocytopenia – low platelets in the blood

• Effects on GIT
• Vomiting
• Stomatitis – inflammation of mucous linings
• Dysphagia – difficulty swallowing
• Constipation
• Diarrhea
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Side Effects

• Effects on skin:
• Skin dryness
• Sunburn

• Effects on reproductive system:

• Decrease sperm count
• Decrease menstruation
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Common Side Effects

Alopecia
Mucositis

Pulmonary fibrosis
Nausea/vomiting
Cardiotoxicity
Diarrhea
Local reaction
Cystitis
Renal failure
Sterility
Myelosuppression
Neuropathy
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ONCOLOGY
Principles of chemotherapy
Side effects of chemotherapy
Alopecia
Mucositis

Pulmonary fibrosis
Nausea/vomiting
Cardiotoxicity
Diarrhea

Cystitis Local reaction

Sterility Renal failure

Myalgia
Myelosuppression
Neuropathy
Phlebitis
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Potential side effects

• Bone marrow suppression
• Nausea & vomiting
• Diarrhea
• Constipation
• Hair loss
• Fatigue
• Mouth sores
• Reproductive/hormonal changes
• Sensory changes
• Thinking, memory & attention
changes  
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ONCOLOGY
Principles of chemotherapy
Aim of combination therapy

INCREASED EFFICACY

ACTIVITY SAFETY

Different mechanisms of action Compatible side effects

Different mechanisms of resistance
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Bone marrow suppression

• Blood cells of the bone marrow:
Red blood cells – carry oxygen to body’s cells
White blood cells –fight infection
Platelets – form blood clots/scabs

• Blood cell levels may decrease following

chemotherapy
• Expected to return to normal by the start of
next treatment
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Checking blood cells

• Blood cells must return to a “safe” level prior
to each treatment
• Blood tests are done 1 to 4 days prior to
treatment
• **Check appointment card & lab requisition**

• Blood test results may affect treatment

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Low white blood cells

(neutropenia)

• White cells are your infection fighting cells

• May be lowered for a short time after your

chemo treatment
• Your body will be less able to fight infection

• It is important to recognize the signs and

symptoms of an infection

What are some signs of infection?

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How you can prevent infection

• Wash your hands - frequently with soap &
water
• Avoid people with infections
• Wash your hands
• Check with your oncologist before having
any invasive procedures (e.g. dental or
surgical procedure)
• Avoid skin cuts and nicks
• Wash your hands
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Skin changes

• Skin is body’s first line of defense against

bacteria
Signs and symptoms:
• Redness
• rash / acne
• Itching
• peeling
• Dryness
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Do I come to the clinic if I have an

infection?
Call the Cancer Centre FIRST!
• If you have an infection (flu) or
• If you have been exposed to an infectious
illness such as chicken pox or shingles

Friends and family with infections

should stay at home until they
have recovered
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Low platelets
(thrombocytopenia)

Platelet cells are responsible for making clots

• May be lowered for a short time after your
chemo treatment
• Your ability to form a clot will be lowered

• It is important to recognize the signs and

symptoms of low platelets

What are some signs of low platelets?

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How to manage low platelets

• use soft tooth brush

• continue regular oral hygiene, caution with

flossing
• blow nose gently

• avoid ibuprofen(Advil) & aspirin(ASA),

unless ordered by Doctor
• avoid high risk activities - BE CAREFUL
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Signs & symptoms of low red blood

cells

• Low energy / fatigue

• Shortness of breath

• Chest tightness / chest pain

• Pale appearance

*Report any signs and symptoms*

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How to manage fatigue

• Do regular light exercise
• Balance physical and social activities with rest
• Listen to your body and rest when needed
• Stick to a regular sleep pattern
• Eat a well balanced diet
• Drink plenty of fluids
• Allow friends and family to help you
Talk to your cancer care team if concerned
about fatigue

Resource: Your Bank to Energy Savings “Helping

People with Cancer Handle Fatigue”
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Nausea and Vomiting

• Nausea = an unpleasant, queasy

feeling or feeling sick to your
stomach
• Vomiting = throwing up

Not all people receiving chemotherapy

experience nausea and vomiting
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Medications to prevent
nausea & vomiting
• Physician will give you a prescription to help
prevent nausea and vomiting
• Fill your prescriptions at your community
pharmacy
• Bring the medications with you
 Unless advised, do not take these pills prior to
coming to your Chemo appointment.

If cost is a concern:
Patient & Family Counseling can assist
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How to manage
nausea and vomiting
• Stay well hydrated - 8 cups of fluid
• Eat frequent, small, light meals (esp. on treatment day)

• Keep your mouth clean: brush at least twice daily

Avoid:
• Hot, spicy, greasy foods
• Heavy meals immediately after treatment
• Strong odors
Resource: “Food Choices to Help Control Nausea”
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Constipation
• When you are not having bowel movements as
often as you used to
Caused by:
• Some chemotherapy drugs
• Some anti-nausea drugs
• Most pain medications
• Reduced fluid or fiber intake
• Stress
• Lack of exercise
Resource: “Suggestions for Dealing with Constipation”
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How to manage constipation

• It is normal to have a bowel movement at least
every 2-3 days (even when little food is eaten)
How to prevent:
• Increase your fluid intake – 8 glasses/day

• Warm fluids

• Increase your fiber intake

• Be as physically active as possible

If you have not had a bowel movement in 3 days

please talk to your cancer care team
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Diarrhea
• When your bowel movements are more
frequent or more watery than normal
• Can be serious if not managed

Some causes:
• chemotherapy drugs

• Antibiotics

• bowel surgery

• radiation to the pelvis

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How to manage diarrhea

• If prescribed by your oncologist – use your anti-diarrhea
medications as instructed
• Eat small/frequent meals

• Choose foods with less fiber

Avoid:
• foods that may aggravate diarrhea

• spicy/greasy foods

Resources: “Food ideas to help manage Diarrhea” &

“Dietary fiber content of common foods”
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Dehydration
• Dehydration can be a result of untreated diarrhea

• can be dangerous if not prevented/managed

How to prevent/manage:
• drink 8 to 10 glasses

• Use “anti-diarrhea” medications - as instructed by

your health care team
• When you feel better, eat foods high in calories and protein

Diarrhea lasting more than 24 hours - contact your

cancer care team
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How to manage skin changes

• wash skin often
• warm water and gentle soap
• moisturizers – alcohol/fragrance free
• lanolin based lip balms and creams
• protect against sun exposure (clothing or SPF
30)
• protective eye wear and hats
• electric razor
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Mouth sores
• Occur within a few days after treatment
• On the tongue, gums, sides of the mouth,
lips and throat
Signs and symptoms:
• Pain
• Bleeding gums
• Difficulty chewing and swallowing
• Can lead to an infection
*Report any signs and symptoms*
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How to manage mouth sores

• Inspect mouth regularly
• Practice good oral hygiene
• Rinse 3 to 4 times/day - baking soda in warm
water
• Use a soft toothbrush
• Avoid mouthwash with alcohol
• Make sure dentures fit well
• Avoid extreme hot or cold; spicy foods

Resource: “Food Ideas to Try with Mouth Sores”

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How to manage skin changes

• wash skin often
• warm water and gentle soap
• moisturizers – alcohol/fragrance free
• lanolin based lip balms and creams
• protect against sun exposure (clothing or SPF
30)
• protective eye wear and hats
• electric razor
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Taste changes
• Foods may not taste the same
• Described as “metallic” or “cardboard” taste
• Can affect your appetite
• Use of sweet and salty flavorings - can help
• Changes are temporary

Resource:
“Coping with Taste Changes” and “Food Ideas to
Cope with Taste and Smell Changes”
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Why do we mention to “drink plenty

of fluids”?
• Water and fluids are vital to health

Staying hydrated helps with:

• Nausea
• Dry mouth
• Diarrhea or Constipation
• Fatigue
• Dry skin
• Easier to start your IV
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Tips for treatment day

• length of treatments can vary
• wear comfortable clothing (sleeves that roll up)
• No fragrance – due to sensitivities to smell (this also
applies to support people accompanying you to your
appointments)
• eat a light meal before and after treatment
• take your regular medications

Transportation:
• arrange a ride to and from your appointment

Parking:
• BCCA please bring money for the parking meter
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Patient and Family Counselling

Services
• Support and counselling are a vital part of coping
• Individuals, couples and families
• Support groups and programs
• Information and referral to community services
• Assistance and information about practical and financial
concerns

Resources:
http://www.bccancer.bc.ca/PPI/copingwithcancer/default.h
tm
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 Kemoterapi sitostatika INTRA VENA yang
berpotensi menyebabkan muntah
(EMETOGENIK) pada pasien kanker
“High emetic risk” “Moderate emetic “ Low emetic risk” “ Minimal emetic
risk” risk”

> 90 % frekuensi 30 - 90 % 10 – 30 % < 10 % frekuensi

emesis frekuensi emesis frekuensi emesis emesis

Contoh: Contoh: Contoh: Contoh:

1.Kombinasi 1.Carboplatin 1.Doksorubisin 1. Bleomisin
adriamisin & 2.Oxaliplatin liposomal 2. Asparaginase
cyclopohospha 3.Doksorubisin 2.Eribulin 3. Fludarabine
mide (AC) < 60 mg/m2 3.Docetaxel 4. Dll
2.Cisplatin 4. Daunorubisin 4.Gemcitabine
3.Doksorubisin/ 5. Irinotecan 5.Dll
Adriamisin (Campto)
≥ 60 mg /mm2 6. Dll
4. Dll

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 Obat obat anti emesis PREVENSI untuk
kemoterapi yang diberikan INTRA VENA
“High emetic “Moderate “Low “Minimal
risk” emetic risk” emetic risk” emetic risk”
1. Neurokinin 1.Serotonin (5-HT3) 1. Dexamehason
antagonist: 1. Tidak perlu anti
(NK1) antagonist: emesis
e.g. Ondansetron, atau
Eg. Aprepitant
palonosetron
2. Metoclopramide

atau
2.Serotonin (5- 2. Steroid:
HT3) antagonist: Dexamethason 3. Prochlorperazine
e.g. Ondansetron, oral / injection
atau
palonosetron
atau 4.Serotonin (5-HT3)
antagonist:
3. Neurokinin e.g. Ondansetron,
3. Steroid: (NK1) palonosetron
Dexamethason antagonist:
oral / injection Eg. Aprepitant
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Obat obat anti emesis untuk kemoterapi yang
diberikan ORAL

Serotonin 5-HT3 antagonist:

Risiko emesis
Ondanstron, granisetron, dll)
tinggi & moderat

Risiko emesis
rendah & Nausea &
minimal Metoclopramide, atau Prochlorperazine,49atau
vomitus Haloperidol, atau Onfanstron fll
Pengobatan “BREAKTROUGH” (masih muntah walau
telah diberi obat anti muntah) pada chemotherapy
induced nausea / vomitus

Olanzapine, lorazepam,
Cannabinoid, dll

Metoclopramide, atau Prochlorperazine, atau

Haloperidol, atau Onfanstron fll

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Take home messages

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