1 PowerPoint Slides English Text Mandarin Chinese Translation Supportive Management of Treatment-related Effects VideoTranscript Professional Oncology Education Supportive Management of Treatment-related Effects Time: 21:26 21:26 Cynthia Abarado, DNP, RN, GNP-BC Advanced Practice Nurse Genitourinary Medical Oncology The University of Texas MD Anderson Cancer Center MD Anderson Cynthia Abarado, DNP, RN, GNP-BC Supportive Management of Supportive Management of Supportive Management of Supportive Management of Treatment Treatment Treatment Treatment- - -related Effects related Effects related Effects related Effects Supportive Management of Supportive Management of Treatment Treatment - - related Effects related Effects Cynthia Abarado, DNP, RN, GNP-BC Advanced Practice Nurse Genitourinary Medical Oncology Hello, my name is Cynthia Abarado. I am an Advanced Practice Nurse at the Department of Genitourinary Medical Oncology here at The University of Texas MD Anderson Cancer Center in Houston, Texas. I am going to talk to you about supportive management of treatment-related effects. Cynthia Abarado MD Anderson
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PowerPoint Slides English Text Mandarin Chinese Translation
Supportive Management of Treatment-related Effects VideoTranscript
治疗相关作用的支持性管理 视频文本
Professional Oncology Education Supportive Management of Treatment-related Effects Time: 21:26
专业人员肿瘤教学讲座 治疗相关作用的支持性管理 时间: 21:26
Cynthia Abarado, DNP, RN, GNP-BC Advanced Practice Nurse Genitourinary Medical Oncology The University of Texas MD Anderson Cancer Center
德克萨斯大学 MD Anderson 癌症中心 生殖泌尿系统肿瘤医学科 高级专科护士
Cynthia Abarado, DNP, RN, GNP-BC
Supportive Management of Supportive Management of Supportive Management of Supportive Management of
TreatmentTreatment--related Effects related Effects
Cynthia Abarado, DNP, RN, GNP-BC
Advanced Practice Nurse
Genitourinary Medical Oncology
Hello, my name is Cynthia Abarado. I am an Advanced Practice Nurse at the Department of Genitourinary Medical Oncology here at The University of Texas MD Anderson Cancer Center in Houston, Texas. I am going to talk to you about supportive management of treatment-related effects.
你好,我叫 Cynthia Abarado。我是德克萨斯州休士顿德克萨斯大学 MD Anderson 癌症中心生殖泌尿系统肿瘤科的高级专科护士。我将向大家介绍治疗相关作用的支持性管理。
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Supportive Management of Supportive Management of Supportive Management of Supportive Management of
• Recognize signs and symptoms of these conditions
• Identify management options to minimize
these effects
Objectives of this presentation are as follows: to identify common treatment-related effects, recognize signs and symptoms of these conditions, and identify management options to minimize these effects.
Anemia is one of the most common cancer treatment-related effects. Anemia is defined as a hemoglobin less than 11 g/dl. Some causes of anemia [are] related to blood loss, hemolysis, suppression of erythropoiesis and erythropoietin products by inflammatory cytokines, chemotherapy, radiation, nutritional deficiencies, as well as renal impairment.
Some of the manifestations of anemia are fatigue, dizziness, vertigo, depression, impaired cognitive function, anorexia, nausea, pallor, low skin temperature.
贫血的部分表现包括疲乏、头晕眼花、眩晕、抑郁、认知能力受损、厌食、恶心、脸色苍白、皮肤温度过低。
Supportive Management of Supportive Management of Supportive Management of Supportive Management of
Impaired T-cell and macrophage function, exertional dyspnea, tachycardia, palpitations, increased pulse pressure, risk of life-threatening cardiac failure, as well as menstrual problems and loss of libido.
T 细胞和巨噬细胞的功能受损、运动性呼吸困难、心动过速、心悸、脉搏压力增加、危及生命的心力衰竭的风险、以及月经失调和丧失性欲。
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Supportive Management of Supportive Management of Supportive Management of Supportive Management of
Some of the laboratory assessment of anemia include measurements of hemoglobin, which is the amount of oxygen capacity of the peripheral blood; hematocrit, which is the space or volume occupied by the red cells in relation to the blood volume; MCV or mean corpuscular volume, which is the average volume or size of a single RBC in a given blood sample.
• RDW – (red cell distribution width) an automated
calculation of variation in size, which provides
homogeneity (normal RDW) or heterogeneity (high
RDW)
Other measurements are MCH, or the mean corpuscular hemoglobin or the average weight of hemoglobin in each RBC; the MCHC, which is the average hemoglobin concentration or color of the red blood cell; RDW, which is an automated calculation of variation in size providing the homogeneity or heterogeneity of the red cell distribution width.
Some other assessments for different types of anemias include measurement of the reticulocyte count, ferritin, transferrin, serum iron, Coombs test, serum B12, and folate levels.
• Interruption or modification based on hemoglobin
levels of patients; reports increased mortality and
thrombotic vascular events
• Adverse reactions including pure red cell aplasia,
pulmonary embolism, DVT and edema
Some of the strategies in treatment of anemia include parenteral iron administration, blood transfusion, as well as administration of the erythropoiesis-stimulating factors. Indications for the erythropoiesis-stimulating factors have side effects and these include: interruption or modification based on hemoglobin levels of patients, reports [of] increased mortality, and thrombotic vascular events. So patients have to be monitored for a risk of pulmonary embolism, DVT, and edema.
How does anemia affect an individual? It can affect the patient’s quality of life. It has significant effects on therapeutic outcomes. It has also an impact on the patient’s physical functioning and performance status, as well as psychosocial effects. It affects the prognosis and overall survival as well.
– Normal range 2,500 - 6,000 per cubic millimeter of blood (primary white cell)
– ANC < 2,000 = neutropenia
– ANC < 500 places a patient at severe risk for infection
– Nadir
• Time when WBCs are at their lowest point
• Typically 10 to 14 days after chemotherapy
• Recovery may take 3 to 4 weeks
The other cancer treatment-related effect is neutropenia. It is diagnosed by absolute neutrophil count. Absolute neutrophil count of less than 2,000 is neutropenia. The patient’s normal range of the ANC is around 2,500-6,000/mm
3 of blood or primary
white cell. ANC of less than 500 places a patient at severe risk for infection. Nadir is the time when the white cell counts are at their lowest point. Typically, it occurs at around 10 to 14 days after chemotherapy and requires 3 to 4 weeks for recovery.
– Redness, pain, or swelling around a wound or sore
If the patient is neutropenic, he is at risk for developing infection. And some of the signs and symptoms of infection are temperature of greater than 38
°C or 100.4°F, chills, sweating, sore throat,
mouth ulcers, diarrhea, burning sensation during urination, or redness, pain, or swelling around a wound or sore.
• Prophylactic use of growth factors, when indicated:
pegfilgrastim, filgrastim
• Good hand-washing technique
• Early detection and treatment of infection
• Follow treatment guidelines to reduce mortality
NCCN GuidelinesTM, 2007, www.nccn.org
How do we manage neutropenia? After chemotherapy, a prophylactic use of growth factors
when indicated, such as Neupogen or Neulasta, is recommended. The best prevention for infection is a good hand washing technique. Also early detection and treatment of infection can have positive outcome and prevent sepsis or infection. The NCCN Guidelines
TM recommend following
treatment guidelines to reduce mortality in the management of neutropenia.
Other treatment-related side effects are very significant in the nutritional effects of chemotherapy and nutrition and some of these are manifested as in weight loss, fatigue, nausea, vomiting, taste alterations, oral mucositis, constipation (only in chemotherapy though because radiation would have more of a diarrhea side effect), xerostomia, and anorexia.
Specifically surgery can also cause weight loss, fatigue, nausea, vomiting, diarrhea, and loss of appetite. Immunotherapy again can cause weight loss, fatigue, oral mucositis, diarrhea, as well as anorexia.
The most devastating treatment-related side effect, in terms of the digestive tract, is a development of oral mucositis, which is the most common complication associated with chemotherapy. Around 40% of individuals on chemotherapy develop mucositis, 80% of individuals receiving bone marrow transplant and 100% of individuals receiving head and neck radiation would develop oral mucositis.
So, what is mucositis? It is a mucosal injury characterized by ulceration in the oral esophageal and gastrointestinal mucosa. Some of the effects from mucositis are related to pain, dysphagia, diarrhea, dehydration and also it poses as the greatest risk for bacteremia and sepsis.
1) Initiation: DNA and non-DNA damage, direct cellular
injury to basal epithelial cells, generation of reactive
oxygen species
2) Primary damage response: Damage in genes is
followed by upregulation of genes, which results in
the production of a range of destructive proteins and
molecules such as the proinflammatory cytokines
that lead to apoptosis and tissue injury
Scully C et al. Oral Dis 2006 12(3):229
How does oral mucositis develop? There are several phases that occur. And with the introduction of the chemotherapy and radiation the first stage is the initiation where DNA and non-DNA damage direct cellular injury to basal epithelial cells and generation of reactive oxygen species occur. A second phase is the primary damage response. Damage in the genes is followed by upregulation of genes, which results in the production of a range of destructive proteins and molecules such as the proinflammatory cytokines that lead to tissue injury.
口腔黏膜炎是如何发生的呢?口腔黏膜炎的发生分成几个阶段。随着开始使用化疗和放疗,首先是起始期发生的 DNA 和非 DNA 损伤,基底上皮细胞的直接细胞损伤以及产生活性氧。第二阶段是原发性损伤应答。基因受损之后会发生基因上调,产生一系列破坏性蛋白和分子,例如促炎性细胞因子,导致组织损伤。
Supportive Management of Supportive Management of Supportive Management of Supportive Management of
3) Signal amplification: Substances from the damage
response phase provide a positive feedback loop that
drives the destructive process forward
4) Ulceration: The oral epithelium breaks down and
ulcerates. Infections may occur at this stage as it
frequently corresponds with neutropenia and an
increase in gram-negative organisms
5) Healing: biologically dynamic phase with signaling
from the submucosal extracellular matrix, stimulating
the migration, differentiation, and proliferation of the
healing epithelium Scully C et al. Oral Dis 2006 12(3):229
The third phase is a signal amplification, where substances from the damage response phase provide a positive feedback loop that drives the destructive process forward resulting to ulceration. The oral epithelium breaks down and ulcerates. At this point, infection can occur at any stage of this phase, frequently corresponding to the stage of neutropenia, and mostly it is associated with an increase in gram-negative organisms. The fifth phase is the healing phase, which is the biologically dynamic phase with signaling from the submucosal extracellular matrix stimulating the migration, differentiation, and proliferation of the healing epithelium.
Phases of MucositisPhases of MucositisPhases of MucositisPhases of Mucositis
Adapted from Sonis ST. Nat Rev Cancer 2004 4(4):227
This is just a summary or an illustration of the different phases of mucositis. Phase 1 which is the DNA initiation, and then phase 2 is the signaling, phase 3 is the amplification of the response, and phase 4 is the ulceration, and phase 5 is the healing stage.
The incidence of oral mucositis in cancer patients with grade 3 to 4 is very significant. Among patients receiving radiation for head and neck, the incidence is 85 to 100%. Among patients receiving small or stem cell transplantation, it affects 75 to 100%, and for solid tumor with myelosuppression, 5 to 40%.
What are the effects of oral mucositis on nutrition? It can cause malnutrition. It can cause a lot of dietary decrease because of the taste changes, dry mouth, and pain. It can also cause weight loss and dehydration.
The NCCN or --- correction, the National Cancer Institute Toxicity Criteria classifies toxicity into 0 to 4. Zero, none, 1 is the erythema of the mucosa, 2 is the patchy ulcerations or pseudomembranes, 3 is the confluent ulcerations of pseudomembranes with bleeding and minor trauma, and 4 is the tissue necrosis, significant spontaneous bleeding, which can have life-threatening consequences.
Assessment of the oral mucosa is very important when managing mucositis. Examination should involve examination or assessment of the buccal mucosa, soft and hard palate, the dorsum and border of the tongue as well as the floor of the tongue, assessed for erythema, ulcerations, pseudomembranes, bleeding, ability to eat, pain, and difficulty in swallowing.
How do we manage mucositis? A proactive prevention program is the best treatment. Oral care with salt and soda mouthwashes is recommended. Also, avoidance of caffeine, alcohol and tobacco, avoidance of food that could irritate the mouth as well as promotion of good oral hygiene are some of the strategies.
For oral care again good oral hygiene is recommended. Some have used cryotherapy and the Multinational Association of Supportive Care has an oral care protocol which can be referred to.
– 80% of individuals receiving bone marrow transplant
– 100% of individuals receiving head and neck radiation
Oral mucositis again is the most common complication associated with chemotherapy. Again, it affects 40% of individuals on chemotherapy, 80% with those with bone marrow transplant, and 100% with head and neck radiation.
Now, we will go to the taste alterations related to oral mucositis. Taste alterations affect 35 to 70% of cancer patients. And the major types of taste alterations include hypogeusia, or reduction in taste sensitivity, ageusia, which is an absence of taste sensation, and dysgeusia, which is the distortion of normal taste.
So, what are the causes of taste alterations? It has damaged taste buds. Dry mouth can lead to taste alterations, again oral mucosa infection as well as dental problems. Taste alterations can also be caused by chemotherapy side effects, often described by patients as peculiar metallic taste.
So, what are some of the strategies for improving or --- improving patient’s outcome for taste alterations? The recommendations are to serve cold foods, serve tart or sour foods, also use plastic utensils instead of metallic to prevent metallic taste, that is. Recommend rinsing with salt and soda mouthwashes before eating and recommending frozen fruits.
The other major cancer treatment-related side effects involve cancer-induced nausea and vomiting. This affects 70 to 80% of all cancer patients receiving chemotherapy and 10 to 44% experience anticipatory nausea and/or vomiting.
Incidence of CINVIncidence of CINVIncidence of CINVIncidence of CINV
Grunberg SM et al. Cancer. 2004 100(10):2261
This is one of the --- illustration or a graph that shows a study result where the practitioner prediction of cancer-induced nausea and vomiting is measured against actual experiences of the patient. As you can see, the dark orange here has really significant --- significant incidence of patients having actual experiences after a chemotherapy administration.
center (located in the medulla) from the chemoreceptor
trigger zone (CTZ), pharynx and gastrointestinal (GI)
tract (via vagal afferent fibers), and cerebral cortex
• Efferent impulses are sent from the vomiting
center to the salivation center, abdominal muscles,
respiratory center, and cranial nerves
So, what is the cause of cancer-induced nausea and vomiting? The pathophysiology of emesis is interesting. And it is theorized as triggered by the afferent impulses to the vomiting center located in the medulla from the chemoreceptor trigger zone, pharynx, and gastrointestinal tract via the vagal afferent fibers of cerebral cortex. The efferent impulses are sent from the vomiting center to the salivation center, abdominal muscles, inspiratory center, and cranial nerves.
Pathophysiology of CINVPathophysiology of CINVPathophysiology of CINVPathophysiology of CINV
• The CTZ, vomiting center, and GI tract have
many neurotransmitter receptors. Activation of
these receptors by chemotherapeutic agents or their
metabolites may be responsible for chemotherapy-
induced emesis.
• Principal neuroreceptors involved
– Serotonin (5-hydroxytryptamine [5-HT3])
– Dopamine receptors
– Others include acetylcholine, corticosteroid, histamine,
cannabinoid, opiate, and neurokinin-1 (NK-1) receptors
The CTZ/vomiting center and GI tract have many neurotransmitter receptors and these are activated by chemotherapeutic agents or their metabolites. And they are responsible for the chemotherapy-induced emesis. Some of the principle neuroreceptors include serotonin, the dopamine receptors, and also acetylcholine, corticosteroid, histamine, cannabinoid, opiate, and neurokinin receptors.
• Acute onset – occurs few minutes to several hours
after drug administration and commonly resolves
within 24 hours
• Delayed onset – develops 24 hours after
chemotherapy administration
• Anticipatory nausea or vomiting – occurs before
patients receive their next chemotherapy
There are different types of emesis. These are classified into acute onset, which occurs [a] few moments to several hours after drug administration and commonly resolves within 24 hours. There is emesis related --- or described having delayed onset, which develops 24 hours after chemotherapy administration, and then anticipatory nausea and vomiting, which occurs before patients even receive their next chemotherapy.
Another classification is a breakthrough emesis, which is vomiting that occurs despite prophylactic treatment or rescue medication. And then a refractory emesis refers to emesis that occurs during subsequent treatment cycles when antiemetic prophylaxis have failed in earlier cycles.
• The risk of emesis and nausea for persons receiving chemotherapy of high and moderate emetic risk lasts for at least 4 days
• Patients need to be protected throughout the full period of risk
NCCN™ Guidelines, 2007, www.nccn.org
What are some of the important principles on emesis control? Again, prevention of nausea and vomiting is the goal. So, the risk of emesis and nausea for persons receiving chemotherapy of high and moderate emetic risk lasts for at least four days. Patients need to be protected throughout the full period of risk.
• Consider the toxicity of the specific antiemetic(s)
• Choice of antiemetic(s) used should be based
on the emetic risk of the therapy as well as
patient factors
NCCN™ Guidelines, 2007, www.nccn.org
Some other principles involve oral and IV antiemetic formulations --- have equivalent efficacy, so we have to consider that. Use the lowest fully efficacious dose of antiemetics prior to chemotherapy or radiation therapy. Consider the toxicity of specific antiemetics and choice of antiemetic or antiemetics should be used based on the emetic risk of the therapy as well as patient factors.
There are some other causes of emesis that could aggravate or increase nausea and vomiting related to cancer treatment-related effects. Some of these factors are partial or complete bowel obstruction; vestibular dysfunction; brain metastases; some electrolyte imbalances, such as hypercalcemia, hyperglycemia, and hyponatremia; uremia; concomitant drug treatments including opiates; gastroparesis; and anxiety
• Anemia, neutropenia, mucositis and nausea/vomiting
are common side-effects of anti-cancer treatments
• Patients with symptoms of these conditions need
prompt evaluation and treatment
• Various supportive care measures are available to
review symptoms and reduce complications of
treatment-related effects
So, to summarize, we just discussed some of the common side effects of anti-cancer treatments including anemia, neutropenia, mucositis, and nausea and vomiting. Patients with symptoms of these conditions need prompt evaluation and treatment to prevent complications. There are various supportive care measures available and it is important to review symptoms and reduce complications of these problems. So, this is the end of my presentation and I would like to thank you very much for your attention. We would appreciate any feedback as to how this program has helped you in any way. So, again thank you very much and send us your e-mail regarding your feedbacks.