Anti-neoplastic agents, commonly known as chemotherapy drugs, are a diverse group of medications used to treat cancer. Cancer is characterized by uncontrolled growth and spread of abnormal cells. Chemotherapy works by targeting and killing these rapidly dividing cancer cells, but it also affects normal rapidly dividing cells in the body, leading to various side effects.

Nurses play a critical role in the administration of these powerful drugs, meticulous monitoring for severe side effects, and providing comprehensive supportive care and education to patients and their families throughout the challenging cancer treatment journey.

Principles of Chemotherapy

Chemotherapy is often used in combination with other cancer treatments like surgery, radiation therapy, and immunotherapy. Key principles include:

• Cell Cycle Specificity: Some chemotherapy drugs are effective only during specific phases of the cell cycle (e.g., S-phase, M-phase), while others are non-cell cycle specific, affecting cells in any phase.

• Combination Therapy: Multiple chemotherapy drugs with different mechanisms of action are often used together in a regimen. This approach aims to:

  • Increase the kill rate of cancer cells.

  • Target cancer cells at different stages of the cell cycle.

  • Reduce the likelihood of drug resistance.

  • Minimize toxicity to normal cells by using lower doses of individual drugs.

• Dosing and Scheduling: Chemotherapy is typically given in cycles, with periods of treatment followed by rest periods. This allows normal cells to recover while maximizing the killing of cancer cells. Dosing is often based on body surface area (BSA).

• Adjuvant Therapy: Chemotherapy given after primary treatment (e.g., surgery) to kill any remaining cancer cells and prevent recurrence.

• Neoadjuvant Therapy: Chemotherapy given before primary treatment (e.g., surgery) to shrink tumors and make them easier to remove.

• Palliative Therapy: Chemotherapy given to relieve symptoms and improve quality of life, rather than to cure the cancer.

Major Classes of Anti-neoplastic Agents

Chemotherapy drugs are broadly categorized by their mechanism of action.

1. Alkylating Agents

• Mechanism: Directly damage DNA by adding an alkyl group to DNA bases, preventing DNA replication and leading to cell death. They are non-cell cycle specific.

• (e.g., Cyclophosphamide, Cisplatin, Carboplatin, Busulfan)

• Uses: Broad range of cancers including leukemias, lymphomas, breast, ovarian, lung, and brain cancers.

• Side Effects:

  • Myelosuppression (bone marrow suppression): Leading to neutropenia (risk of infection), thrombocytopenia (risk of bleeding), and anemia.

  • Nausea and vomiting (often severe).

  • Alopecia (hair loss).

  • Cystitis (bladder inflammation – especially with Cyclophosphamide, prevented by hydration and Mesna).

  • Nephrotoxicity (kidney damage – especially with Cisplatin, prevented by hydration).

  • Ototoxicity (hearing damage – Cisplatin).

  • Peripheral neuropathy (Cisplatin).

• Nursing Implications: Monitor CBC closely. Administer antiemetics. Ensure adequate hydration. Monitor kidney function. Educate on infection prevention, bleeding precautions, and hair loss.

2. Antimetabolites

• Mechanism: Mimic essential nutrients needed for DNA and RNA synthesis, thereby interfering with cell division. They are cell cycle specific (S-phase).

• (e.g., Methotrexate, 5-Fluorouracil (5-FU), Cytarabine, Gemcitabine)

• Uses: Leukemias, lymphomas, breast, colorectal, ovarian, and gastrointestinal cancers.

• Side Effects:

  • Myelosuppression.

  • Mucositis (inflammation of the mucous membranes, especially in the mouth and GI tract).

  • Nausea, vomiting, diarrhea.

  • Alopecia.

  • Hepatotoxicity (liver damage).

  • Nephrotoxicity (Methotrexate).

• Nursing Implications: Monitor CBC, liver/kidney function. Administer antiemetics. Provide meticulous oral care for mucositis. Educate on infection/bleeding precautions. Methotrexate requires “leucovorin rescue” to protect normal cells.

3. Antitumor Antibiotics (Cytotoxic Antibiotics)

• Mechanism: Interfere with DNA and RNA synthesis, often by intercalation (inserting into DNA) or by generating free radicals that damage DNA. They are non-cell cycle specific.

• (e.g., Doxorubicin, Daunorubicin, Bleomycin)

• Uses: Leukemias, lymphomas, breast, ovarian, lung, and sarcomas.

• Side Effects:

  • Myelosuppression.

  • Nausea, vomiting, alopecia.

  • Cardiotoxicity (heart damage – especially with Doxorubicin, Daunorubicin). This is dose-limiting.

  • Pulmonary fibrosis (lung scarring – Bleomycin).

  • Red urine (Doxorubicin – harmless).

• Nursing Implications: Monitor cardiac function (ECG, echocardiogram) before and during treatment. Assess for signs of heart failure. Monitor for pulmonary symptoms with Bleomycin. Educate patients about potential heart problems and expected urine discoloration.

4. Mitotic Inhibitors (Vinca Alkaloids and Taxanes)

• Mechanism: Interfere with cell division (mitosis) by targeting microtubules, which are essential for cell structure and chromosome separation. They are cell cycle specific (M-phase).

• Vinca Alkaloids (e.g., Vincristine, Vinblastine):

  • Side Effects: Peripheral neuropathy (common with Vincristine – numbness, tingling, weakness, constipation due to autonomic neuropathy). Myelosuppression (less with Vincristine, more with Vinblastine).

• Taxanes (e.g., Paclitaxel, Docetaxel):

  • Side Effects: Myelosuppression (often severe), peripheral neuropathy, hypersensitivity reactions (often require pre-medication), alopecia, muscle/joint pain.

• Uses: Leukemias, lymphomas, breast, ovarian, lung, and Kaposi’s sarcoma.

• Nursing Implications: Monitor for peripheral neuropathy. Administer pre-medications for taxanes. Monitor CBC. Assess for constipation.

5. Topoisomerase Inhibitors

• Mechanism: Block the action of topoisomerase enzymes, which are crucial for DNA replication and repair, leading to DNA breaks and cell death.

• (e.g., Etoposide, Irinotecan, Topotecan)

• Uses: Lung, ovarian, colorectal, and testicular cancers, leukemias, lymphomas.

• Side Effects: Myelosuppression, nausea, vomiting, diarrhea (often severe and delayed with Irinotecan).

• Nursing Implications: Monitor CBC. Administer antiemetics and antidiarrheals as needed. Monitor for severe diarrhea.

6. Hormonal Therapies

• Mechanism: Block or reduce the production of hormones that fuel certain cancers (e.g., estrogen for breast cancer, testosterone for prostate cancer).

• (e.g., Tamoxifen – anti-estrogen; Leuprolide – GnRH analog; Anastrozole – aromatase inhibitor)

• Uses: Hormone-sensitive breast cancer, prostate cancer.

• Side Effects: Generally less severe than cytotoxic chemotherapy. Can include hot flashes, fatigue, mood changes, sexual dysfunction, bone density changes, increased risk of blood clots (Tamoxifen).

• Nursing Implications: Educate on expected hormonal side effects. Monitor for signs of blood clots.

7. Targeted Therapies

• Mechanism: Specifically target molecular pathways or proteins that are essential for cancer cell growth, survival, or spread, while sparing normal cells more than traditional chemotherapy.

• (e.g., Imatinib – targets BCR-ABL in CML; Trastuzumab – targets HER2 in breast cancer; Bevacizumab – inhibits angiogenesis)

• Uses: Cancers with specific molecular targets (e.g., CML, HER2-positive breast cancer, certain lung cancers).

• Side Effects: Vary widely by drug. Can include rash, diarrhea, hypertension, fluid retention, fatigue, infusion reactions. Generally different and often less severe than traditional chemotherapy, but unique toxicities exist.

• Nursing Implications: Educate on specific side effects. Monitor for infusion reactions. Monitor vital signs and relevant lab tests.

8. Immunotherapy (Immune Checkpoint Inhibitors)

• Mechanism: Block “checkpoint” proteins that cancer cells use to evade the immune system, thereby unleashing the body’s own immune response against cancer.

• (e.g., Pembrolizumab, Nivolumab, Ipilimumab)

• Uses: Melanoma, lung cancer, kidney cancer, bladder cancer, Hodgkin lymphoma, and others.

• Side Effects: Can cause immune-related adverse events (irAEs) where the activated immune system attacks healthy tissues (e.g., colitis, pneumonitis, hepatitis, endocrinopathies, skin rashes). These can be severe.

• Nursing Implications: Monitor for signs of immune-related side effects (often presenting as inflammation in various organs). Educate patients to report any new symptoms immediately. Requires close collaboration with the medical team for management (often with corticosteroids).

Nursing Management of Patients Receiving Anti-neoplastic Agents

Caring for patients on chemotherapy is complex and requires specialized knowledge and meticulous care.

• Safe Handling and Administration:

  • Chemotherapy drugs are hazardous. Nurses must use appropriate personal protective equipment (PPE) (gloves, gowns, eye protection) during preparation and administration.

  • Follow strict protocols for drug preparation, administration (often IV infusion), and disposal.

  • Verify patient identity, drug, dose, route, and time meticulously.

  • Monitor IV access site closely for extravasation (leakage into surrounding tissue), which can cause severe tissue damage.

• Myelosuppression Management:

  • Neutropenia (low white blood cells): Monitor CBC, especially ANC (Absolute Neutrophil Count). Implement neutropenic precautions (hand hygiene, avoiding sick contacts, no fresh flowers/raw foods). Monitor for fever (a medical emergency in neutropenia). Administer colony-stimulating factors (e.g., Filgrastim) as ordered to boost WBC production.

  • Thrombocytopenia (low platelets): Monitor platelet count. Implement bleeding precautions (avoid IM injections, use soft toothbrush, electric razor, avoid aspirin/NSAIDs). Monitor for signs of bleeding (petechiae, bruising, blood in stool/urine, epistaxis). Administer platelet transfusions as ordered.

  • Anemia (low red blood cells): Monitor hemoglobin. Assess for fatigue, pallor, shortness of breath. Administer blood transfusions or ESAs as ordered.

• Nausea and Vomiting Management:

  • Administer prophylactic antiemetics (e.g., Ondansetron, Aprepitant) before chemotherapy.

  • Assess severity and frequency of nausea/vomiting.

  • Provide small, frequent meals, bland foods. Encourage hydration.

• Mucositis Management:

  • Perform frequent oral assessments.

  • Provide meticulous oral hygiene (soft toothbrush, non-irritating mouthwashes).

  • Administer pain relief (topical anesthetics).

  • Avoid irritating foods (spicy, acidic, hot).

• Fatigue Management:

  • Assess and validate fatigue.

  • Encourage balancing rest and activity.

  • Educate on energy conservation techniques.

• Alopecia Management:

  • Educate patients that hair loss is temporary.

  • Discuss coping strategies (wigs, scarves, hats).

• Peripheral Neuropathy Management:

  • Assess for numbness, tingling, pain, weakness.

  • Educate on safety precautions (fall risk, protecting extremities).

  • Administer adjuvant medications (e.g., Gabapentin) as ordered.

• Fluid and Electrolyte Balance:

  • Monitor I&O, hydration status.

  • Monitor electrolytes, especially with nephrotoxic drugs or severe vomiting/diarrhea.

• Nutritional Support:

  • Assess nutritional status.

  • Provide small, frequent, high-calorie, high-protein meals. May require nutritional supplements or enteral/parenteral nutrition.

• Pain Management:

  • Assess pain regularly. Administer analgesics as needed.

• Body Image and Psychosocial Support:

  • Address concerns about body image changes (hair loss, weight changes).

  • Provide emotional support, counseling, and resources (support groups).

• Patient and Family Education:

  • Provide comprehensive education on the chemotherapy regimen, expected side effects, when to report symptoms, infection prevention, bleeding precautions, and self-care strategies.

  • Educate on the importance of adherence to appointments and lab tests.

  • Discuss fertility preservation options if applicable.

  • Provide information on long-term follow-up care.