Complications of

Chemotherapy
• Discuss post-chemotherapy
complications and their management
• Chemotherapy can have wide-
ranging effects on patients
• Human body amazing at what it can
tolerate
What is chemotherapy?
• Treatment with drugs that kill cancer cells
(or make them less active)
• Interfering with tumour cells ability to
grow and proliferate
– Adjuvant chemotherapy ie localized breast
cancer
– Induction chemotherapy ie AML
– Curative chemotherapy ie Diffuse Large B Cell
Lymphoma
– Palliative chemotherapy
Categories of
Chemotherapy
• Antibiotic derived—anthracyclines, bleomycin
• Plant Alkaloids—periwinkle plant--vincristine,
paclitaxel
• Alkylators—cylcophosphamide
• Antimetabolites—interfere with synthesis of
nucleic acids-5FU, Methotrexate
• Epipodophyllotoxins—inhibit topoisomerase 2--
etoposide
• Anti-hormonal—tamoxifen, coritcosteroids
• TYROSINE KINASE INHIBITORS--GLEEVEC
• MONOCLONAL ANTIBODIES—TARGETED therapy
Complications of
Chemotherapy
• SHORT TERM
Fever
Nausea
Infusional reactions
Oral complications
Diarrhea
Anemia
Neuropathy
Alopecia
Rash, Extravasation

Emotional
FEBRILE NEUTROPENIA
On Chemotherapy, 7 to 14 days post
chemo
WBC nadir, NEUTROPHILS are 1st line
of DEFENCE
Temperature great than or equal to
38.3 degrees centigrade
Absolute Neutrophil count (ANC) less
than 1.0
One of the few Oncologic
EMERGENCIES
FEBRILE NEUTROPENIA

• History, Physical
• Focus on possible source of infection
• Respiratory tract, urine, skin, gi tract
• CBC, LFT,CR
• CXR
FEBRILE NEUTROPENIA
• Draw cultures from 2 different sites,
urine C/S
• 50% of cultures positive
– 65% positive cultures are gram positive
organisms
• Broad Spectrum antibiotics
• If well, hemodynamically stable
– CIPRO and CLAVULIN PO and home
FEBRILE NEUTROPENIA

• IF UNWELL

• ADMIT WITH BROAD SPECTRUM IV

ANTIOBIOTICS IE TAZOCIN OR
IMIPENEM OR AMP AND GENT
• WITH NEUPOGEN SUPPORT( 300mcg
sc daily until anc >1.0), IV FLUIDS
ETC.
FEBRILE NEUTROPENIA
• Usually fever lasts less than 48 hours
• If fever longer than 48 hrs, patient needs
IV antibiotics, consider antifungals
• Usually bacterial or viral infections but
fungal infections becoming more of an
issue
• As WBC and ANC recover, patient usually
improves
NB special situation for Acute Leukemics,
PICC lines
FEBRILE NEUTROPENIA

• Clinical consideration and follow-up

very important, especially if patient
discharged home
NAUSEA

• Most chemotherapeutic agents

cause nausea
• Why?
3) systemically as drug makes it’s way
to nausea centre of brain
(chemotherapeutic trigger zone)
4) Sight and smell of drug
 Neuronal pathways involved with
chemotherapy- and radiotherapy-
induced nausea and vomiting

Sensory input (pain, smell, sight) Higher cortical

Memory, fear, anticipation
centres

Chemoreceptor
Chemotherapy Trigger Zone Vomiting Centre
(area prostrema, (medulla)
4th ventricle)
Vomiting Reflex

Chemotherapy Labyrinths
Stomach
Radiotherapy Small intestine Neuronal pathways

Factors which can

cause nausea & vomiting
NAUSEA

• Types of Nausea
– Anticipatory—conditioned reflex to sight
and smell of chemotherapy area
– Acute—within 24hrs and related to
chemotherapeutic agents
– Delayed—more than 24 hrs. post
chemotherapy--specific agents—
cisplatin, cyclophosphamide, adriamycin
NAUSEA

• Worst offenders:
– Cisplatin
– High dose cyclophosphamide
– Doxorubicin, eprirubicin, carboplatin
also have a high incidence of nausea
NAUSEA TREATMENT
Medications:
Prochlorperazine (stemetil)
Metoclopramide (maxeran)
Ondansetron (Zofran)—5HT3 antagonists
Dexamethasone
Lorazepam, Haloperidol
Aprepitant
Drug treatment of chemotherapy- and
radiotherapy-induced nausea and
vomiting
Sensory input (pain, smell, sight) Higher cortical
Memory, fear, anticipation
centres

Histamine antagonists
Muscarinic antagonists Benzodiazepines
Dopamine antagonists
Cannabinoids

Chemoreceptor
Chemotherapy Trigger Zone Vomiting Centre
(area prostrema, (medulla)
4th ventricle)
Vomiting Reflex
5HT3
antagonists

Sphincter modulators

Chemotherapy Labyrinths
Stomach
Radiotherapy Small intestine Neuronal pathways

Factors which can

cause nausea & vomiting
Sites of action of drugs
NAUSEA TREATMENT

• Relaxation
• Varying foods, meals
INFUSIONAL REACTIONS
• Very common with new MONOCLONAL
ANTIBODY agents ie RITUXIMAB
• Infusion of these agents may take several
hours
• Fever, hypotension, asthmatic like
reactions, pain
• Premedicate or treat with Dexamthasone,
Benadryl, Tylenol
• May have to stop infusion temporarily
• If serious, may have to discontinue agent
Oral Complications
• Occurs in approx 40% of patients
receiving chemotherapy
• Very common
• Team approach using nutritionist,
nursing, dentist, pain management
team
• Oral hygiene important-soft tooth
brushes, floss?
• Source of bacteremia
Oral Complications

• loss of taste
– Affects appetite, nutrition
– Which in turn affects healing
– In this situation, we advise patients to
think of eating as a job
– Sometimes, oral complications require
nutrition supplements or alternatives
MUCOSITIS

• Chemotherapy is intended to injure

rapidly dividing cells such as the
MUCOSA
• Presents with mouth sores,
inflammation, sometimes sloughing
of mucosa anywhere in the
GASTROINTESTINAL TRACT, RESP
TRACT …
• Usually occurs in the mouth
MUCOSITIS

• SIMPLE ORAL MUCOSITIS TREATED

WITH MOUTH RINSE
– MAGIC MOUTHWASH
– SALT WATER GARGLES
– TOPICAL ANALGESIA ie Xylocaine
viscous, tantum
– Systemic analgesia
– NYSTATIN
MUCOSITIS

• Upper gi tract
– Heartburn
– Very common
• Antacid, Ranitidine, Pantoloc
MUCOSITIS

• SEVERE MUCOSITIS
– GI TRACT
• DIARRHEA, SLOUGHING OF MUCOSA,
ESOPHAGITIS
• ADMISSION, TNA, BOWEL REST, OTHER
SUPPORTIVE MEASURES
• 5FU ONE OF THE MAIN CULPRITS
DIARRHEA

• VERY COMMON, approx 45%.

USUALLY A FEW DAYS AND SELF-
LIMITING
DIARRHEA

• Risk factors
– Elderly
– Known colitis
– GI tumour
– 5FU, irinotecan
– Concomitant irradiation
DIARRHEA

• Infection—CDIFF or other
• Laxatives, other medications (stool
softeners)
• Of course, usually the chemotherapy
is the culprit.
DIARRHEA
• Usually self-limiting
• Hydration—po, IV if more SERIOUS
• Diet—fluids, BRAT (Bananas, Rice,
Apples, Toast)
• Loperamide (immediately if on
Irinotecan)
– 4mg followed by 2mg Q4H or until
formed stool. Up to 16 mg per day
– Usually rule out CDIFF first
DIARRHEA
• If severe, Ocreotide (Sandostatin)
– Decreases fluid output from bowel
– 100mcg sc TID
– Growth hormone analogue-decreases all
salivary gland secretions

And Antibiotics may be considered espec if CDIFF

positive
oral metronidazole or oral vancomycin
oral CIPRO
ANEMIA

• Bone marrow suppression from

chemotherapeutic agents
• Secondary to malignancy
• Anemia work-up
ANEMIA

• Chemotherapy induced anemia

• Erythropoietin, Aranesp
– Stimulate marrow to produce RBC’s
– Used while on chemotherapy only
– Additional iron: po vs. iv
– Sc injection
ANEMIA
• Adverse effects of Erythropoietin
– Flu-like illness
– Rashes
– Diarrhea
– Headache
– Bone pain
– Liver, kidney
– Vascular event: FOLLOW HEMOGLOBIN
ANEMIA

• Dosage: Eprex 40,000 units sc

qweekly Aranesp: 150mcg sc
qweeklyto 7 days)
NEUROPATHY

• Very common with vincristine,

vinblastine, cisplatin
• Usually temporary.
• Sometimes leads to dose alterations
or stopping of some drugs
NEUROPATHY

• Most commonly, we see numbness

and tingling in fingers and toes
• Can you do up your buttons?
• Is numbness becoming more
proximal?
• May need to alter chemotherapeutic
agents or doses thereof
Emotional effects of
chemotherapy
• Malignant diagnosis can be
overwhelming
• The discussion of treatments and
adverse effects can also be
overwhelming
• Anxiety, depression, fatigue related
to diagnosis and treatments
• LOTS of information regarding
treatments
Emotional effects of
chemotherapy
• “Gaining Control by giving up
control”. Dr. B. Rotella
• daily routine goes upside down
• Changing work routine…missing
work for weeks, months
• Income changes
Emotional effects of
chemotherapy
• “The inability to forget is infinitely
more devastating than the inability
to remember”. Mark Twain
• Hard to forget some of the stressful
times one goes through
• Battle fatigue
Emotional effects of
chemotherapy
• “It always seems impossible until it’s
done”. Nelson Mandela
• Getting through months of
chemotherapy is very, very difficult
• People are amazing though.
• The human condition is to battle
Emotional effects of
chemotherapy
• “Things to do today: Exhale, Inhale,
Exhale”. Buddha
• Just surviving each day step by step
• Team approach: social worker,
supportive care coordinators,
pastoral care, pharmacy
Complications of
Chemotherapy
• Longterm
– Cardiac
– Secondary Malignancies
– Fatigue
– Neuropathy
– Arthropathy
Cardiac Complications

• Adriamycin or other anthracyclines

• 450mg per m2 dose lifetime
• Strong treatment for breast cancer
and hematologic malignancies
• Affects myocardium longterm above
maximum dose
Secondary Malignancies

• Skin cancers
• Breast cancers
• Hematologic Malignancies
Fatigue

• Thorough history, physical exam and

ancillary tests
• Fatigue workshop
Arthropathy

• Post monoclonal antibodies

• Treated in usual fashion with NSAIDs,
prednisone
GLEEVEC
• Oral “chemotherapy” for Chronic Myeloid
Leukemia
• Molecular model of chemotherapeutic
treatments, tyrosine kinase inhibitor
• Philadelphia Chromosome produces
abnormal protein, BCR-ABL
• Gleevec stops the signal of the BCR-ABL
protein, therefore halting Leukemogenesis
• Fluid retention, diarrhea, nausea, fatigue,
abdo pain, muscle cramps, bone pain