Chemotherapy Training Level 1

Chemotherapy TrainingLevel 1

Essex Cancer NetworkOctober 2012

INTRODUCTION

Why?

Level One training is required for all staff who may come across chemotherapy in their normal job, such as dispensary technicians, assistants and aseptics staff.

Level Two training is for all staff involved in prescription verification of SACT prescriptions.

Level Three training is for specialist oncology staff, who work within the area of cancer for more than 50% of their time, or are designated as a cancer specialist at their trust.

Principles for Level One Training

Knowledge •Basic background knowledge of cancerTraining •One hour lunchtime session held each year. Key elements of syllabus•Health and safely/ safe handling•Relevant protocols/SOPs to trust•Labelling•Counselling•Where to go for further advice•Background and principles of chemotherapyRevalidation •To be revalidated the individual must attend a yearly update in oncology training session.

CANCER

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Background knowledge of cancer

• Cancer– Abnormal growth of cells which tend to proliferate in an

uncontrolled way and may spread – Derived from Greek word karkinos meaning crab

• Tumour– Latin word meaning “abnormal swelling”

• Neoplasm– “new growth” (benign or malignant)

• Benign– Not cancer– Does not invade surrounding tissue or spread to other parts

of the body.

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Background knowledge of cancer

• Malignant– Tending to be severe and become progressively worse– Can invade and destroy nearby tissue and that may spread to

other parts of the body. – Latin combination of "mal" meaning "bad" and "nascor"

meaning "to be born“ – literally means "born to be bad" • Oncology

– Branch of medicine that deals with cancer, including study of their development, diagnosis, treatment, and prevention

• Haematology– Branch of medicine that specialises in study & treatment of

blood

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Cancer Treatment Choices

• Can be used alone or in combination – to enhance local control & attack potential sites of metastases

• Systemic therapy– Chemotherapy– Hormone therapy– Biological therapy– Experimental chemotherapy

CHEMOTHERAPY

Principles of chemotherapy

“Normal cells obey strict rules.Divide only when told.

Die rather than misbehave.”• Normal cells have several systems for

interrupting the cell cycle if there is a problem• These control systems are called

“checkpoints”• Checkpoints are biological traffic lights telling

the cell when it can safely carry on to replicate or when to stop and fix a problem

Principles of chemotherapy

• In cancer cells, some or all of the usual checkpoints fail leading to an over proliferation of abnormal cells

• The faulty checkpoints make the cell unable to check if the DNA replication was complete, if any mutations needed to be repaired, if the DNA was properly separated between the daughter cells, or many other problems

• These cells are likely to become cancerous with their multiple genomic problems

Whereas normal cells have functioning checkpoints, abnormal cells checkpoints have

been lost or disabled

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Aim of Systemic Chemotherapy

• Cure– Cancer / Tumour disappears and does not return

• Control– If cure is not possible, the goal is to control the disease (stop

growth & spreading)

• Palliation– For advanced cancer, where control is unlikely. Drugs used to

relieve symptoms Improve QoL

Why in ‘regimens’

• Combination chemotherapy is used to try and improve rate and duration of response by combining drugs with different mechanisms of action:– helps to prevent resistance– known to be effective as single agents– different toxicity (toxicities don’t overlap)– try to use drugs with synergistic killing effect– no clinically important drug interactions between the

agents

Why in courses?

• Use pulsed intermittent therapy to allow normal cells to recover

• Normal (bone marrow cells) cells recover quicker from chemotherapy then cancer cells

• Normal tissues are inevitably damaged by chemotherapy – bone marrow & epithelial lining cells usually recover within 2-3 weeks

• On this basis, most chemotherapy given at 3 – 4 weekly intervals

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Time (Weeks)

Frac

tion

Cell

Surv

ived

3 60

Bone Marrow Cells

Tumour CellsCourse of treatment

Limit of detection

Relapse

Pulsed therapy

Mucositis

Nausea/vomiting

Diarrhea

Cystitis

Sterility

Neuropathy

Common Side Effects

Alopecia

Pulmonary fibrosis

Cardiotoxicity

Local reaction

Renal failure

Myelosuppression

ORAL CHEMOTHERAPY

NPSA RRR Risks of incorrect dosing of oral

anti-cancer medicines – 22 January 2008• Doctors, nurses, pharmacists and their staff

must be made aware that the – Prescribing– Dispensing, and– Administration

of oral anti-cancer medicines should be carried out and monitored to the same standard as injected therapy.

NPSA RRR Risks of incorrect dosing of oral

anti-cancer medicines – 22 January 2008

Oral anti-cancer medicine - incidents by type of medication error

51%

9%

17%

23%Wrong dose, strength,frequency, quantity

Wrong drug / medicine

Omitted medicine

Other

Principles for Safe Dispensing

• Prescriptions must be screened by an authorised pharmacist

• All pharmacy staff involved with dispensing oral anticancer agents must have access to full copies of all relevant protocols (trial and non-trial)

• Dispensary staff must have ready access to specialist oncology pharmacy advice

• Dispensary staff should work to detailed operational procedures

• Label directions must be clear and unambiguous – where relevant include treatment period, start and stop dates and an indication of the need for safe handling

Principles for Safe Dispensing

• Patient information leaflets may be supplemented with additional local information

• For patients with swallowing difficulties, there is a need to seek specialist advice (medicines information or oncology pharmacist)

• General risk management issues such as handling of wastage from patients, inappropriate storage and risk to others, especially young children should be given

HEALTH AND SAFETY

Health and safely

Chemotherapy is:– Mutagenic

• induces mutations

– Teratogenic• disturbs the growth of embryo/foetus

– Carcinogenic • causes cancer, changes normal cells into cancerous

cells

Routes of Absorption

• Inhalationaerosols or evaporation

• Absorptionskin or mucous membranes

• Ingestion

hand to mouth contact

Methods of Exposure

• Direct contact with cytotoxicsSpillageSplashNeedle-stickAerosol Picking them up

Therefore made up in aseptics in ‘isolators’

Oral Chemotherapy

• Should not be touched by hand• Use cytotoxic triangle to count - Do not use

medicines counter• The tablet/capsule should be placed into a

medicine cup or spoon and taken by the patient directly from the container without handling

• For patients with swallowing difficulties, there is a need to seek specialist advice on crushing tablets or opening capsules (medicines information or oncology pharmacist)

NEED TO KNOWs

Relevant protocols/SOPs to trust

• Please list for your trust

Labelling

• Label directions must be clear and unambiguous – where relevant include treatment period, start and stop dates and an indication of the need for safe handling

• All labels for chemotherapy agents (not TKIs/MABs) must have stated – ‘Cytotoxic – handle with care’

Counselling

• Unless you have had specific training on chemotherapy agents to level 2 or 3, you should not counsel patients about taking their chemotherapy agents.

• If you need further advise please contact your specialist cancer pharmacist