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Toxicity: Myelosuppression
- Bone marrow suppression is common
- look for:
- Neutorpenia
- Anemia
- Thrombocytopenia
- --Usually 12-14 days post administration
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Toxicities: Neutorpenia
- ^risk of nfxn
- v WBC and ANC
- Fever >101.
- --Tx with antibiotics for min of 48hrs.
- --Tx with bone marrow growth factors
- --Greatest risk is native bacteria in foreign places. Worst are gram- which travel through BS-->sepsis. Pt education on sepsis is vital, because otherwise they may not know to call MD or come in.
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How do you calculate ANC?
Total WBC (neutrophil% plus bands)
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Toxicity: Anemia
- Transfuse when Hgb<8, <10 if getting radiation.
- Blood is filtered to remove WBC (WBCs may give pt feeling of general illness like flu)
- Infuse total volume over 3-4hrs.
- Coordinate with radiation Tx.
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Toxicity: Thrombocytopenia
- Apheresed (single donor) transfusion is preferred because multiple donors ^ risk of development of platelet antibodies
- Infuse as rapidly as tolerated (30-60min), but DO NOT PUSH.
- Platelet count <50K is really bad.
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Toxicity: GI
- Stomatitis
- N/V/C/D: if C, start on stool softener stat, because if thrombocytopenic, straining to stool may-->hemorrhage.
- anorexia
- taste distortion
- Past Hx of Type I herpes. If yes-->acyclovir. Always ask about cold sores/genital herpes.
- PCA pump w morphine, esp if mouth sores present. Will get better when WBC returns to normal.
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Toxicity: N/V
- Serotonin-Antagonist agents most helpful
- --Ondansetron (Zofran)
- --Granisetron (Kytril)
- ----No dystonia, hallucinations, sedation
- ----after 5 days, must switch anti emetics to another mechanism of action (Benadryl/Ativan) because serotonin receptors will be saturated and Rx will stop being effective. Will also prolong QT intervals-->TDP at high doses)
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Toxicity: Constipation
- Usually caused by poor intake, but increase due to polypharm
- Sepsis possible from seeding GI flora into blood stream.
- Stool softeners important
- Very common in elderly
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Toxicity: Diarrhea
- Breakdown of GI mucosa
- Eradication of normal flora-->growth of opportunistic flora (C. Diff)
- Tx with abx.
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Toxicity: Renal
- E-lyte wasting
- --Ca+, Phos, Mg++
- v GFR-->v drug excretion
- Always assess fro preexisting renal disease because may Cx some therapies.
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Toxicity: Hepatic
- Abd pain
- Jaundice
- Hepatomegaly
- ^LFT
- Hepatic fibrosis
- *Very common in adults
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Toxicity: Pancreatic
- Pseudo-Diabetes due to v insulin production/secretion
- --Monitor for SnSs of DM, especially if also on steroids.
- Monitor pancreatic enzymes (trypsin, amylase, lipase)
- --Tx by NPO, NG tube, hydration, pain Rx. (Pain will cross midine if pancreas is source. Also, vomiting will not relieve symptoms).
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Toxicity: Coagluation
- v anti-thrombin III levels + poor hydration-->^risk of clots.
- Consumption of clotting factors
- Monitor for DIC, DVTs
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Toxicity: Neurologic
- Paresthesias in fingers and toes (foot drop-->^fall risk)
- Ataxic
- Ptosis
- Diminished DTRs
- Cranial nerve dysfunction
- SZR
- SIADH
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Toxicity: Cardopulmonary
- Cardiomyopathy/CHF
- Abnormal PFTs
- Pulmonary fibrosis
- anaphylaxis
- fluid shifts
- opportunistic nfxn
- --pneumocystis
- --cytomegalovirus
- *Preexisting comorbidities will greatly ^risk of cardiopulmonary complications.
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Toxicity: Reproductive
- amenorrhea
- impaired spermatogenesis (can be permanent if after puberty).
- premature menopause
- contraception
- reproductive alternatives, ie sperm banking?
- After treatment, go find a high-risk oncologist.
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What are some late effects of therapy?
- Cognitive issues, aka "Chemobrain"
- Chronic fatigue
- Endocrine fnxn
- Chronic neuropathy
- Hearing loss
- Bone demineralization can be accelerated by some Rx.
- Cardiopulmonary
- Recurrent malignancies (usually 10-15 years post regression)
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What are some biological and targeted therapies?
- Interferon: inhibits DNA/RNA synthesis
- Angiogenesis inhibitors: Avastin, Thalidomide-->reduce tumor's ability to create own vasculature. Will work on brain tumors because it can enter CSF
- Hormone suppressant therapy
- *adverse effects of biologic agents will generally be flu-like symptoms. More serious will be massive fluid shifts.
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What is precision therapy?
Therapy targeting specific gene mutations.
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What are some of the major emergenies related to cancer
- Cap leak ksyndrom
- Superior vena cava syndrome
- Spinal cord compression
- Sepsis
- Third spacing
- Tumor lysis syndrome
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Hallmarks of cancer cells
- Don't shut off, will not respond to anti-growth signals
- Will evade apoptosis
- Limitless reproductive potential (telomeres lose function)
- Creates own blood supply
- Will invade tissue and potential for metastasis
- Inflammation caused by extrinisc nfxn
- --ASA is also a good prophylaxis for various forms of cancer because chronic inflammation-->^risk cancer.
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