Tracy Sarin ARNP Definition Late effects side effects that occur months to years after treatment Issues arise from surgery radiation and chemotherapy Who and Why Multidisciplinary Primary care providers ID: 680925
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Long Term Effects of Chemotherapy
Tracy Sarin, ARNPSlide2
Definition
Late effects: side effects that occur months to years after treatment
Issues arise from surgery, radiation, and chemotherapySlide3
Who and Why
Multidisciplinary
Primary care providers
Hematology/oncology
NursingPhysical and/or occupational therapyMental health professional2006 IOM report: From Cancer Patient to Cancer Survivor: Lost in TranslationSlide4
Cancer Statistics
In 2014, nearly 14.5 million Americans with a history of cancer were alive (DeSantis, et al, 2014)
Men
Women Prostate (43%) Breast (43%) Colorectal (9%) Endometrial (8%) Melanoma (8%) Colorectal (8%)
By 2024, population of cancer survivors will increase to approximately 19 million people (DeSantis, et al, 2014)Slide5
Virtually Every System is AffectedSlide6
Head and Neck
Brain/CNS
Hearing changes
Cognitive impairment
Memory issuesPeripheral neuropathyEyeCataractsVision changeOral health/DentalDecreased tooth enamelOsteonecrosis of the jawSlide7
Head and Neck
Offending agents
Vinca
alkaloids (vincristine)
Platinums (carbo, cis, oxaliTaxanes (paclitaxel, docetaxel)EtoposideCytarabine—high doseIfosfamide—high doseMethotrexate
—high doseSteroidsBisphosphonatesSlide8
Cardiovascular
CHF
Hypertension
MIDVT
Particularly with hormone treatmentEdemaHyperlipidemiaCardiomyopathyBiggest offendersAnthracyclines and HER2 targeted drugs (doxorubicin, daunorubicin, traztuzumab, pertuzumab
, etc)Slide9
Pulmonary
Shortness of breath
Decreased lung capacity
Pulmonary fibrosis
Interstitial lung disease Offending agentsBleomycin (most common)—10%Carmustine (BCNU) – 20-30% of those getting high dose therapyMethotrexate – 8%Alkylating agents (cyclophosphamide, busulfan) - <1%????? Immunotherapy agents (
nivolumab, pembrolizumab, ipilimumab)????????---stay tunedSlide10
GI/GU
Digestion
Neuropathy in gut
Chronic bowel changesBladder cystitis
Offending chemotherapiesVinca alkaloids (vincristine)CyclophosphamideIfosfamidePlatinums (carboplatin, oxaliplatin, cisplatin)Slide11
Endocrine
Menopause/ovarian failure
Infertility
Weight gainDecreased libido
Erectile dysfunctionHormone deprivation in menDiabetesThyroid dysfunctionHot flashesSlide12
Endocrine
Treatment causes
Busulfan
Chlorambucil
CisplatinCyclophosphamideNitrogen mustardTamoxifenAromatase inhibitors (anastarzole, exemestane, letrozole)
BicalutamideLeuprolideSteroidsIpilumumabSlide13
Musculoskeletal
Osteoporosis
Osteopenia
Increased risk of fracture
ArthralgiasMyalgiasOffending agentsHormone therapy (aromatase inhibitors)SteroidsChemotherapies inducing menopauseSlide14
Skin
Nail changes
Dry skin
Skin discoloration
Sun sensitivityRadiation recallOffendersTaxanes5FUCyclophosphamideDoxorubicinHydroxyureaBRAF inhibitors used in melanomaSlide15
Bone Marrow/Secondary Cancers
Cytopenias
MDS
Secondary cancer
1-3% of patients develop a new, secondary cancerRate is higher in pediatric cancer survivorsALL in kids--secondary AMLColorectal cancer--secondary colon/retctal primary or other digestive organsLung—secondary lung, head/neck, and GUMelanoma—additional skin cancersCausative agents:
doxorubicin,BCNU, ifosfamide, cytoxan, melphalan, etc.Slide16
Emotional
Depression
Anxiety
Mood swingsGuilt
Fear of recurrencePost-traumatic stress disorderGratitudeFinancial implications of chemotherapySlide17
FATIGUE
Most common
side effect of cancer treatment
Offending agents: ALL chemotherapy/hormone therapy/biotherapy/immunotherapySlide18
What to do, what to do
Brain/CNS
Hearing changes—audiology referral
Eye issues— ophthalmology referral, cataract surgery
Oral/dental— diligent dental careChemobrain—patience, CBT, neuropsych referralPeripheral neuropathyAssess for functional impairmentPatience Medication management: gabapentin, pregabalin
, duloxetine, amitriptyline, opioidsPT referralNeurology referralSlide19
Cardiovascular
Monitoring
Check EF during treatment with
cardiotoxic
drugsCHF—swelling, SOADVT—doppler if indicated (particularly in those on hormone therapy)Heart disease/hyperlipidemiaSlide20
Pulmonary
Surveillance/monitoring
Lung disease—refer to pulmonary or managed by PCP
Immunotherapy—treat with steroids and taperSlide21
GI/GU
Digestion
Constipation—fiber/laxatives, GI referral
Diarrhea—
loperamide, diphenoxylate with atropine, codeine, cholestyramine, GI referralNeuropathy—motility agents, GI referralBladder cystitisUrology referralSlide22
Endocrine
Proactivity/counseling for fertility issues
AYA program, referral for banking
Women’s health issues
Menopause/ovarian failure/dryness/hot flashesAvoid herbs/supplements and hormone replacement therapyLubricantsAssessment of hot flashesVenlafaxine, gabapentin, clonidineWeight gainExercise, referral to dietitian, support groupsDM/thyroidPCP or endocrinologistSlide23
Musculoskeletal
Bone density testing
Ca++ with vitamin D
Weight bearing exercise
Assistive device if needed, SAFETY FIRSTPT referralBisphosphonatesSlide24
Skin
Emollients
Protection
Avoidance
SunscreenCoverSurveillance by PCPDermatology referralSlide25
Cytopenias/Secondary cancers
Investigation
Anemia, thrombocytopenia, leukopenia
BMBX necessary?
Encourage followupFollow screening guidelinesSlide26
Emotional
Referral
Counseling
Support groups
Medication managementAntidepressantsAntianxiety medicationsFinancialFinancial counselorSlide27
Fatigue
Exercise
PATIENCE
Treat underlying causesAnemia
Thyroid conditionsVitamin D deficiencyEnergy conservationPrioritize activitiesDietary modificationsSlide28
Case StudySlide29
Conclusion
Population of cancer survivors will only grow
ASSESS, ASSESS, ASSESS
Treat or referSlide30
References
Cancer.Net
. (2016). Long-term side effects of cancer treatment. Retrieved August, 2016,
http://www.cancer.net/survivorshiplong-term-side-effects-cancer-treatment
DeSantis, C., Lin, C., Mariotto, A., Siegel, R., et al. (2014). Cancer treatment and survivorship statistics, 2014. CA: A Cancer Journal for Clinicians, 252-271.MDAnderson Cancer Center. (2016). Possible side effects of cancer treatment. Retrieved, August, 2016,
https://www.mdanderson.org/patients-family/life-after-cancer/long-term-effects.htmlMayo Clinic. (2016). Cancer survivors: Late effects of cancer treatment. Retrieved August, 2016, http://www.mayoclinic.org/diseases-conditions/cancer/in-depth/cancer-survivor/art-20045524Oncology Nursing Society. (2014). Red flags in caring for cancer survivors.
Retrieved August, 2016,
https://
www.ons.org/sites/default/files/media/Red%20Flags%20for%20Cancer%20Survivors.pdf
Up to Date. (2016). Long term side effects of chemotherapy.
Retrieved August, 2016,
https://
www.uptodate.com/contents/search?search=long%20term%20side%20effects%20of%20chemotherapy&sp=0&searchType=PLAIN_TEXT&source=USER_INPUT&searchControl=TOP_PULLDOWN&searchOffset=1&autoComplete=false&language=en&max=10