Oncology Part II Radiation Therapy and Chemotherapy Spring, 2010

Overview of Radiation Therapy (XRT)

One of the four major modalities
Chemotherapy, surgery, biological response modifiers

One of the earliest used treatment approaches (1899 for basal cell CA; by 1922 had become a recognized clinical therapy for cancer) Frequency of use in treatment process is 50 60 % Purposeto destroy malignant cells within the treated volume of tissue while minimizing damage to normal tissue Can be used for both local/regional disease, also for palliation

Radiation Therapy
Ionizing Radiation

External Beam Radiation Therapy

Brachytherapy (Sealed sources)

Radiopharmaceutical Therapy

Radiation Physics
Radiation: energy that is emitted & transferred through space. Ionizing radiation: special kind of energy which causes ejection of orbiting electron from an atom when it passes through cells
Electromagnetic waves Particulate radiation

Radiation damages cells

Molecules become agitated Chemical reactions within cells

occur DNA alterations = chromosomal strand breaks Resulting cell death or degeneration

Principles of Radiation Therapy

Factors that influence radiosensitivity Rate of cell division Most radiosensitive are rapidly dividing cells Least radiosensitive are non-dividing or slowly dividing cells Cell cycle phase Most radiosensitive are late G2, mitosis Least radiosensitive are those in late synthesis (S)

Principles of Radiation Therapy

Differentiation Most radiosensitive are poorly differentiated Least radiosensitive are well differentiated Oxygentation Most radiosensitive are well oxygenation Least radiosensitive are hypoxic Tumor size Most radiosensitive are small tumors Least radiosensitive are large tumors

Goals of Radiation
Cure: Localized disease Neoadjuvant therapy Given prior to definitive therapy such as

surgery Adjuvant therapy Preventive treatment to asymptomatic areas after surgery or chemotherapy Prophylaxis prevention treatment to high-risk Sites; (e.g., cranial radiation in small cell lung cancer)

Goals of Radiation
Control: Disease is extensive or recurrent

For example: breast, bladder, brain, ovarian, lung, H&N cancers

Prophylaxis: Prevent spread Kill tumor cells in areas where they are likely to become apparent cranial radiation for lung cancer, spinal for lymphoma Palliation: Symptom control reduce pain from bone mets; treat spinal cord compression, brain metastases; relieve obstruction of the superior vena cava, colon, ureters, trachea; heal fungating lesions

Radiation Terminology
Rad = amt of radiation

absorbed per dose Gray = international measure (1 rad = 1 cGy; 1 Gy=100 rad)
Further definitions and explanation--NCI http://cancer.gov/cancertopics/treatment/ty pes-of-treatment

Methods of Delivery
External beam: source is outside of body, administered by

machines: Linear accelerator: deliver electron energy in precise beam with little radiation scatter Cobalt 60: widely used radioisotope; emit gamma rays; lower dose & percentage depth; half-life of 5.3yrs Cyclotron: neutron beam therapy; high LET energy, but low dose rate Proton beam: small volume tumors, in clinical trials see

this website for general overview of XRT and specific information on proton beam http://www.mdanderson.org/departments/radiation/dindex.cfm?pn

Methods of Delivery, cont.

Internal (Brachytherapy): source is placed into a

body cavity or tumor bed sealed radioactive isotopes (cobalt-60, iridium192, iodine-125, gold-198) in form of tubes, seeds, wires, ribbons, applicators: "afterload" technique unsealed (metabolized or absorbed)

Brachytherapy: Sealed
Internal Delivery
Intracavitary

cesium or radium implant in vagina (cervical or endometrial cancers) Interstitial iridium implants in breast iodine or gold in prostate On the surface strontium for superficial ocular melanoma Intraluminal cesium for esophageal, lung, bile duct

 Brachytherapy approaches

Specialty/novel radiotherapy approaches

Targeting margins of tumor bed-Mammosite http://www.cityofhope.org/radonc/spec_prog

Radioimmunotherapy http://www.cityofhope.org/rit/

Radiopharmaceuticals
Nonsealed colloidal

isotopes Iodine 131 (po) for thyroid cancer Strontium (IV) for metastatic bone lesions Phosphorus 32 (intrapleural) for mesothelioma

Stereotactic radiosurgery
Focused high dose radiation aimed at tumor in brain, 1 treatment Computer shows exact location Tumor treated from different angles with beam of high dose XRT

Intraoperative radiotherapy
Intraoperative radiotherapy
Deliver dose directly to tumor bed Minimize injury to adjacent structure and tissue

Treatment planning
Multidisciplinary consultation Simulation to tailor to volume and

location of tumor bed localization by fluoroscopy, xray, CT immobilization devices, blocks, masks marks on skin to outline field computerized coordination Calculation of total dose, fractionation, number of fields, time schedule

Image from City of Hope website, retrieved Feb 1, 2004

Fractionation
Concept
of balancing dose-time-number of treatments considerations with the effect on a given tumor Based on fundamentals of radiobiology, fractionating (dividing)

The radiation dose spares normal tissue by allowing repair and repopulation between fractions Increases tumor kill by

Common fractionation schemes

allowing for reoxygenation of hypoxic cancer cells Facilitating reassortment of cells into more sensitive phases of cell cycle.

Standard5 equal fractions weekly Hyperfractionationlarger # of smaller doses (2x per day) Hypofractionationsmaller number of larger fractions Accelerated fractionationmultiple daily fractions Split course irradiationlarger daily fractions with planned break in the middle of course

Mieszkalski, Brady, Yaiger, and Class (2001) Clinical Oncology. American Cancer Society

Markings for Radiation Treatments

Radiosensitizers
These are compounds that potentiate effects of XRT by
Increasing susceptibility of cells to XRT damage Decreasing cells ability to repair damage

Agents:
5 FU Taxol Cisplatin CPT II Gemcitatbine oxaliplatin

Radioprotectors
Goal is to
Modify effects of radiation on normal tissue while allowing effects on tumor Decrease incidence and severity of toxicities Enable increased XRT dose to tumor with fewer or same toxicities to normal tissue

Agents
Example is Amifostine (Ethyol) Only agent FDA approved at present

Toxicity prevention
Strategies to reduce toxicity
Multiple fields Small bowel exclusion Surgical techniques to move organs (ovaries)

Chemical approaches
Amifostine (Bruce, 2004)
Reduced SE such as mucositis, xerostomia IV administration prior to daily XRT; evaluation of the subcut route (Bruce, 2004)

Protection of Health Care Professionals

External XRT can be harmful ONLY during time

pt actually being treated use lead-lined gloves & apron Internal XRT: Gamma rays Consider: Time Distance Shielding

Planning Nursing Care to Minimize Exposure: For implants, internal radiation

Objective is to deliver quality care in least amount

of time
Patients are usually Self-care Prepare food tray before entering room Change linens PRN only Wear monitoring device Long-handled forceps, lead lined container available for

possibility of dislodged radiation source Limit visitors Do not care for pt if pregnant or possibly so
DO NOT need to follow these guidelines if patient is receiving

external radiation

Classification of Side Effects

Early (acute):
1 5

During, or about 2 wks into rx Intermediate: Near end of and in 1st few wks after rx Long-term (chronic): months-years post-rx

Common patient problems

Site-specific: e.g.

elimination, diarrhea Potential impaired skin integrity Knowledge deficit Altered protective mechanisms Fatigue

Altered

Nursing management: Patient education

Patient education is crucial to successful management of radiotherapy to
Ensure successful treatment outcomes Minimize side effects Maximize patient comfort

Excellent sources of information regarding patient education:

radiation therapy patient ed
http://cancer.gov/cancertopics/radiationtherapy-and-you

Site-Specific Side Effects

Head/Neck
Mucositis Xerostomia Dental Caries Trismus Esophagitis Pericarditis Pleuritis

Chest Esophagitis
Pneumonitis

Abd/Pelvis N&V
Cystitis Diarrhea Vaginal fibrosis Sterility

Local Side Effects Integumentary

Generally self-limiting Skin: most common SE, though severe

reactions rarely occur

Alopecia: thinning over 2-3 wks,

permanent with doses > 4500 rads

Skin Reactions
Acute
Erythemia Folliculitis Dry desquamation Moist desquamation Hyperpigmentation epilation

Late
Atrophy Fibrosis Telangiectasia Xerosis Hypopigmentation necrosis

Skin Care
Assessment
Visibility of marks Dryness, scaling, broken areas of skin Evidence of infection Location & Character of pain/itching

Notify MD for:
Deterioration in skin integrity at radiation site Rash Pain & itching at radiation site unrelieved by meds. Decreased visibility of radiation markings

 Care of skin

Skin Care

Cleanse irradiated areas gently each day with tepid water & nonalkaline soap Do not remove markings Expose irradiated area to the air as much as possible Do not use tape within the radiated area Maintain room environment at a comfortable temperature Can add oil-free emollients to the bath water (e.g. Aveeno) Use topical medications to control dry skin (alcohol free, water based such as Aquaphor) Avoid lotions that contain heavy metals. May increase skin reactions Use an electric razor instead of wet shaving

Skin Care
Care of skin
Implement mouth care for those patients receiving radiation to the head and neck region. Encourage adequate fluid intake (2-3 liters/day) and well-balanced diet high in protein. Encourage patient to wear non-constricting clothing & 100% cotton material in areas that come into contact

Skin Care
Care of skin
Do not use hot/cold stimuli to radiation site

Patient Education
Instruct in effects of radiation on skin Instruct to avoid:
Use of perfumed lotion, soaps, cosmetics, deodorants, & oilbased products Scratching of radiated area Exposure to sun use sun screen Check with HCP about

Nursing Management : H&N

Avoid irritants Gentle, frequent oral

care Artificial saliva Dental evaluation, fluoride rx TMJ stretching exercises Nutritional interventions

Xerostomia
RT damage to salivary glands Prevention amifostine Management
Pilocarpine (Salagen) Modify diet as needed Take frequent sips of water Humidification Salvia substitute Dental follow-up Fluoride treatment

Trismus
RT tonic contraction of the jaw muscles as a result of fibrosis Management
Physical therapy or speech therapy consult Mouth exercises jaw opening devices
Open mouth as wide as possible 20 times in succession = three times a day Place heels of both hands under jaw, push up with hands while stretching mouth wide open Place middle and index fingers on mandibular teeth & thumb on maxillary pry the mouth open. Hold open as wide as possible for 2 seconds then relax. Do 10 times with each hand, and repeat 4 times a day.

Nursing Management: Chest

Monitor cough-

increase fluids Monitor lab - WBC, ESR Oxygen support Administer steroids

Nursing Management: Abdomen/Pelvis XRT

Prevention of nutritional alterations: Lite foods prior to tx, small frequent

meals, antiemetics High fluid intake, avoid coffee, alcohol, tea Managing elimination alterations Antispasmodics, antidiarrheal meds, low residue diet Management/prevention of sexuality alterations Use of vaginal dilator, continue intercourse Sperm banking

Bone Marrow Effects

Stem cells highly radiosensitive Leukocytes & platelets most affected Increased if previous chemotherapy Largest amt of bone marrow in the ilia,

skull, sternum, vertebrae, metaphyses of long bones Depends on dose and volume treated: >3000 rads, BM replaced by fibrous Limits future chemotherapy options

Nursing Management: BM Effects

Inform pt of

site/dose Monitor counts Avoid exposure to infection S&S, prevention of bleeding

Fatigue
Systemic effect, possibly R/T tumor

breakdown waste products Multifactorial: previous cancer treatment, malnutrition, pain, anemia, frequency of treatments Nursing: encourage rest periods nutritional interventions pt/family education energy conservation

Late Effects of Radiation Therapy

Brain: Cognitive impairment, hearing loss,

cataracts H&N: Hypothyroidism, osteonecrosis of mandible, skin necrosis Chest Wall/Lung: Lung fibrosis, arm edema, esophageal stricture, pericarditis Abdomen/Pelvis: Colon perforation or obstruction, fistulas, bladder fibrosis, leg or scrotal edema, impotency, infertility, vaginal retraction

Chemotherapy

Purpose of Chemotherapy
s

Administer the largest dose possible, to kill the largest number of cancer cells, while inducing reversible and tolerable toxicity in the host. "therapeutic index"

Cell Kill Theory

M G2 G1

Relationship to Cell Cycle

s

Cell cycle specific

drug interrupts cell division at specific points schedule-dependent effective if large no. cells dividing

Cell cycle non-specific

drug acts at any point in the cell cycle dose-dependent

Cancers Highly Sensitive to Chemotherapy

Hodgkin's Disease s ALL s Non-Hodgkin's Lymphoma (children) s Burkitt's Lymphoma s Testicular Cancer s Gestational Trophoblastic Tumors s Wilms tumor s Osteogenic Sarcoma s Rhabdomyosarcoma
s

Cell Kill Fraction

Depends On:
Tumor sensitivity s Tumor growth rate s Tumor size s Vascular supply s Host immunity s Nutrient supply
s

Increased Survival with Adjuvant Chemotherapy

Breast Cancer s AML s SCC Lung s Prostate Cancer s Hairy Cell Leukemia s Chronic Granulocytic Leukemia
s

Combination Therapy
s

Multiple agents Greater cell kill Fewer resistant cell lines

Uses of Chemotherapy
Induction Adjuvant Primary

for advanced disease to local treatment

treatment administration

Local/regional

Preoperative Chemotherapy
s

Rationale
effectiveness

can

be measured
less

extensive local treatment required

Adjuvant Therapy
s

Rationale
microscopic goes

disease

where the cancer

is
decrease

minimum no. of cells needed for metastasis

Primary Treatment
s

Hematological Malignancies Advanced Stage Solid Tumors Palliative Treatment

Routes of Administration
Topical (cutaneous lymphoma) s Oral (alkylating agents, hormones) s Subcu (biological agents) s Intramuscular (Depo leuprolide) s Intravenous
s

Central Venous Tunneled Catheter

Implanted Port

Routes of Administration (continued)

s

Intrathecal (ARAC, methotrexate) Intrapleural (etoposide, IL, INF, platinum) Intraperitoneal (as above, often cisplatin) Intraarterial (5FU, FUDR)

Ommaya Reservoir

MYTHS?
s

All chemo makes you sick, and sicker All chemo is the same All chemo makes your hair fall out Side effects are expected and uncontrollable

SIDE EFFECTS
Kills all cells which are dividing rapidly s Mucous membranes, bone marrow, and hair follicles most acutely affected s Stomatitis, esophagitis, enteritis s Neutropenia s Alopecia s Nausea & vomiting (also chemicallymediated) s Skin changes
s

BONE MARROW SUPPRESSION

s

Proliferating progenitor cells s Risk factors: s Marrow tumor involvement s Prior treatment with radiotherapy, chemo s High negative nitrogen balance s Neutropenia most significant s at nadir (usually day 7-14, recovery day 28) s absolute granulocyte counts < 1,000/mm3 s duration of neutropenia as important as degree

POTENTIAL FOR INFECTION

s

80% arise from endogenous org. s Chemo-induced damage to GI & resp. trac facilitate entry of org. Increased when AGC < 500/mm3 s Fever >100.4 deg. or chills s need immediate antibiotic treatment s multi-agent IV antibiotics s sepsis s Patient/family education s Thorough physical assessment

Low White Blood Cell Counts

Leukopenia < 2000

decreased level of white blood cells predisposing the person to infections

Neutropenia < 500 -1000 Generally defined as immunocompromised when
3

Absolute Neutrophil Count (ANC)

ANC = (% neutrophils + % bands) X WBC 100 Example: patient has following lab work neutrophils = 50%, bands = 8%, WBC = 4000 ANC = 50% + 8% X 4000 100 ANC = (.50 + .08) X 4000 = 2320 Another way to calculate is to convert % straight into a decimal. E.G. 50% = .50, 8% = .08

Interpretation of the ANC

Chemotherapy is frequently held if the WBCs are between 1000-3000/mm3 or if the ANC is below 1500 cells/mm3.

What does the ANC tell? Risk for infection Not significant Minimal Moderate Severe

ANC 1500-2000 ANC 1000-1500 ANC 500-1000 ANC < 500

 Neutropenic patient can not mount an adequate inflammatory response to an infecting organism.

Immunocompromised Patient

Normal signs of infection: heat, swelling, redness, exudate formation

May not be present

Fever - the only indicator of an infection

Progression from localized infection to life-threatening sepsis is so rapid fatality rate is 18% to 40% in the first 48 hours.

Mucous membranes Lungs Skin Venipuncture sites Catheter sites Perineal area Perirectal area

Most Frequent Sites of Infection

Most Common Organisms

Bacteria
E. coli P. aeruginosa K. pneumoniae Staphylococci

Viruses
Herpes virus Varicella-zoster virus Cytomegaloviru s

Fungus
Candida Aspergillus

Assessment: Early Detection of Infection

Potential for systemic infection Skin integrity Patient hx. Factors that compromise immune function ANC Vital signs comprehensive physical exam Patient hx. Recent trauma to skin, Assess for redness, pain, discoloration, swelling. Examine skin folds, wound sites , suspicious lesions

Skin folds PIV/ central lines Peri rectal area

Assessment: Early Detection of Infection

Pulmonary system
Pt Hx. Dysphagia, diminished gag reflex, tobacco use, exposures. Respiratory rate, effort, pattern, and depth of respiration. Use of accessory muscles. Auscultation of chest Recent changes in pulmonary status cough, chest tightness or pain, DOE, SOB

Assessment: Early Detection of Infection

Oral mucosa
Pt hx. Chemotherapy, radiation to head/neck, tobacco, ETOH use, periodontal disease, hydration, nutritional status. Oral cavity - color, moisture, lesions, ulcerations, amount and character of saliva

dysphagia or retrosternal pain

Patients routine for oral hygiene

Assessment: Early Detection of Infection

Rectal mucosa
Pt hx. Diet, sexual practices, medications, chemotherapy, HIV status, change in bowel habits Assessment for erythema, ulceration, hemorrhoids, bleeding Character, frequency of bowel movements

Assessment: Early Detection of Infection

Genitourinary System
Pt Hx. Benign prostatic hypertrophy, HIV status, bladder -toxic chemotherapy, symptom of GU infection (dysurina, urinary frequency, urgency, hematuria, pruritis, vaginal/penile discharge) Exam - genitilia lesions, ulcerations, discharge Characteristics of urine - color, turbidity, odor

Assessment: Early Detection of Infection

Central Nervous System Subtle changes in neurologic function can signify either the onset of an infection or progression of a malignancy. Headache, fever, meningismus, personality changes, focal neurological signs, nuchal rigidity, altered mental status, seizures

Nursing Management: Interventions

Goal of interventions is to prevent or minimize infections. Vital signs including temperature for fever. Prophylactic pulmonary hygiene measures especially for B cell deficiencies Monitor CBC with differential Meticulously clean sources where bacteria live No fresh cut flowers or live plants in room Encourage regular personal hygiene (include oral care) Protect from other persons with infections Assign only healthy HCP to care for patient Avoid injections

POTENTIAL FOR BLEEDING

s

Platelet count < 100,000/mm3 Risk for bleeding high if < 25,000/mm3 Effect of nitrosoureas, some antibiotics (mitomycin C) Patient teaching
s s s s

avoid aspirin prevent constipation D/C use of razors

ORAL TOXICITY
sPain, Alteration in Nutrition s2-3 X more often in hematologic malignancies; 75% BMT patients sDirect effect (cytotoxic) or indirect (related to myelosuppression) sDose-related, common with antimetabolites & some antibiotics sRisk factors: elderly, pre-existing oral disease, local irritants, poor oral hygiene, myelosuppression

ORAL TOXICITY, cont.

s

Begins at nadir, day 7-14; resolves day 21-28 s S&S: dry mucosa, burning sensation, taste alterations, pain, inflammation & ulceration, bleeding s Interventions:
s s s s

pre-chemo dental evaluation oral hygiene nutrition analgesics

ORAL HYGIENE
s

After each meal and at HS at least Lubrication of lips; saliva substitutes

Salt and soda or Normal saline

Topical anesthetics ac & prn

viscous lidocaine, sucralfate suspension

Culture of lesions Soft toothbrush & unwaxed floss if platelet ct ok and no lesions

Nausea and Vomiting

sExperienced

by over 50% of all patients receiving chemotherapy QOL

most feared side effect worsens throughout the treatment can lead to non-compliance

sDecreased
q q q

sPhysiological
q q q

dehydration fluid and electrolyte imbalance esophageal tears

Influencing Factors
sAge sPrevious sSex sCourse sHistory sHistory

emetic control

number of motion sickness heavy alcohol use

Chemotherapy Factors
sEmetic sEmetic sDose sCombination sType

potential pattern

of administration

Pattern of Occurrence
sAcute

within 1-2 hours q resolves in 24 hours

q

sDelayed
q

begins or continues after 24 hours

sAnticipatory

present prior to a course of chemo q operant conditioning q difficult to treat q often persists after chemo d/c'd
q

Pharmacologic Therapy
Based on emetic pathway(s) s Consider emetogenic potential of chemo agents used s Pre-med essential s Around-the Clock dosing s Consider delayed N&V s Combination antiemetic therapy, e.g. sSerotonin inhibitor + Steroid sAnticholinergic + Anxiolytic
s

Non - Drug Therapies

sProgressive sGuided

muscle relaxation

imagery

sHypnosis

sTiming s

of treatment

sAcupuncture

Enteritis
sCells of small intestine most vulnerable sAntimetabolites (ARAC, 5-FU, MTX) & antibiotics (doxorubicin, dactinomycin) s5-FU & leukovorin most toxic sSymptoms due to cellular necrosis or, less likely to infection or antibiotic-associated colitis sRisk factors: XRT to abd/pelvis, AGVH disease, antibiotics, dietary changes sCan progress to denudement of GI lining

Enteritis, con't.
s

S & S: diarrhea, abd cramping, rectal urgency, anal irritation, bloody stools Day 7-14, resolving 3-4 wks Interventions:
low fat, low residue, gluten & lactose-free diets culture for clostridium difficile toxin antidiarrheal drugs once infection R/O q anticholinergics, antispasmodics, antisecretory agents; opiates

Anorexia

Alopecia
Varies according to chemo agent (partial vs. total), anthracyclines, methotrexate, vincristine, cytoxan s Not confined to the scalp s Hair loss often total; comes out by handfuls over 1-2 day period, 2-3 wks after first cycle; reversible 4-6 wks s Patient preparation for loss s Avoid sun, cold; s Hair/scalp care s ** No ice caps
s

Cardiotoxicity
s

Cardiomyopathy: direct damage to myocyte Anthracyclines

incidence of 2 -3 % cumulative doses of 550/m2, less if prior XRT liposomal preparations

Weeks or months post-chemo Irreversible, 60% mortality

Cardiotoxcicity, con't.
s

Taxol:
bradycardia most common Ventricular tachycardia conduction blocks

Interventions:
baseline EKG, echo endomyocardial biopsies continuous infusion of agent early recognition of S & S

Pulmonary Toxicity
s

Irreversible and progressive Interstitial pneumonitis Pulmonary fibrosis Higher in elderly, previous XRT Agents:

Bleomycin: 10% with > 450 units, busulfan, BCNU ARAC, Mitomycin C: capillary leak, pulm. edema

Pulmonary Toxicity, con't.

s

Occurs from a few months to 10 years postchemo Risk factors: previous XRT, pre-existing lung disease, elderly Clinical onset slow (months) S & S: dry cough, mild fever, exertional dyspnea, basilar fine rales

Neuro Toxicity
s

Peripheral Neuropathies

myalgias, areflexia, distal sensory loss, motor weakness, foot drop vincristine, cisplatinum, taxoids dose-related, usually reversible

CNS (can be irreversible)

ifosfamide: blurred vision, CN & motor dysfunctions, incontinence, seizures, coma methotrexate: encephalopathy cisplatinum: ototoxicity HD ARAC (>2gm/m2): cerebellar + peripheral

GU TOXICITY
s Hemorrhagic

cystitis: chemo by-products bind to bladder mucosa, microcapillary irritation & ulceration & S: usually painless hematuria, suprapubic pain Cytoxan (up to 10%) & less often,ifosfamide with ifosfamide from Mesna

sS

s Agents:

s Protection s Long-term

cystitis, bladder fibrosis & contraction, rarely requires cystectomy

GU TOXICITY, cont.
s

Usually occurs days to wks post-chemo Not necessarily dose-related Interventions:

aggressive hydration & diuresis frequent voiding bladder irrigation via 3-way Foley cystoscopy to cauterize bleeders vasopressins to decrease clotting intravescicular administration of agents

Skin Toxicity
s

Erythema, hyperpigmentation, and peeling of soles and palms (hand/foot syndrome)

abates with interruption of drug, decreasing dose

Drying of skin with most agents Most dramatic is erythema, puritis & peeling (with cytokines)

FATIGUE
s

Overwhelming experience Not relieved by rest Causative factors in absence of anemia unknown; most often with cytokines Quality of life Interventions:

energy conservation

Gondal Toxicity
s

Age & dose related Alkylating agents most toxic Men:

damage to spermatocytes, azoospermia,

oligospermia, abnormal motility abnormal semen volume

Women:

destruction of ovarian follicles

Gondal Toxicities, con't.

s

S & S (general): fatigue, anxiety, loss of libido, altered body image S & S (males): impotence S & S (females): hot flashes, irregular menses or amennorhea, dysparunia Interventions:

sperm banking OCPs to protect ovarian follicle

Second Cancers
s

Chemo is carcinogenic Related to alkylating agents Leukemias and non-Hodgkins lymphomas, with poorer prognosis than usual Highest incidence following Hodgkin's disease

Bone Marrow Transplant

Autologous Allogenic Matched unrelated donor

Bone Marrow Transplant

Allogenic Matched unrelated donor

Graft versus host disease skin liver gut