Long Term Effects of Chemotherapy Tracy Sarin ARNP

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Long Term Effects of Chemotherapy Tracy Sarin, ARNP

Long Term Effects of Chemotherapy Tracy Sarin, ARNP

Definition • Late effects: side effects that occur months to years after treatment •

Definition • Late effects: side effects that occur months to years after treatment • Issues arise from surgery, radiation, and chemotherapy

Who and Why • Multidisciplinary • • • Primary care providers Hematology/oncology Nursing Physical

Who and Why • Multidisciplinary • • • Primary care providers Hematology/oncology Nursing Physical and/or occupational therapy Mental health professional • 2006 IOM report: From Cancer Patient to Cancer Survivor: Lost in Translation

Cancer Statistics • In 2014, nearly 14. 5 million Americans with a history of

Cancer Statistics • In 2014, nearly 14. 5 million Americans with a history of cancer were alive (De. Santis, et al, 2014) Men Prostate (43%) Colorectal (9%) Melanoma (8%) Women Breast (43%) Endometrial (8%) Colorectal (8%) • By 2024, population of cancer survivors will increase to approximately 19 million people (De. Santis, et al, 2014)

Virtually Every System is Affected

Virtually Every System is Affected

Head and Neck • Brain/CNS • • Hearing changes Cognitive impairment Memory issues Peripheral

Head and Neck • Brain/CNS • • Hearing changes Cognitive impairment Memory issues Peripheral neuropathy • Eye • Cataracts • Vision change • Oral health/Dental • Decreased tooth enamel • Osteonecrosis of the jaw

Head and Neck • Offending agents • • • Vinca alkaloids (vincristine) Platinums (carbo,

Head and Neck • Offending agents • • • Vinca alkaloids (vincristine) Platinums (carbo, cis, oxali Taxanes (paclitaxel, docetaxel) Etoposide Cytarabine—high dose Ifosfamide—high dose Methotrexate—high dose Steroids Bisphonates

Cardiovascular • • CHF Hypertension MI DVT • Particularly with hormone treatment • Edema

Cardiovascular • • CHF Hypertension MI DVT • Particularly with hormone treatment • Edema • Hyperlipidemia • Cardiomyopathy • Biggest offenders • Anthracyclines and HER 2 targeted drugs (doxorubicin, daunorubicin, traztuzumab, pertuzumab, etc)

Pulmonary • • Shortness of breath Decreased lung capacity Pulmonary fibrosis Interstitial lung disease

Pulmonary • • Shortness of breath Decreased lung capacity Pulmonary fibrosis Interstitial lung disease • Offending agents • • • Bleomycin (most common)— 10% Carmustine (BCNU) – 20 -30% of those getting high dose therapy Methotrexate – 8% Alkylating agents (cyclophosphamide, busulfan) - <1% ? ? ? Immunotherapy agents (nivolumab, pembrolizumab, ipilimumab)? ? ? ? ---stay tuned

GI/GU • • Digestion Neuropathy in gut Chronic bowel changes Bladder cystitis • Offending

GI/GU • • Digestion Neuropathy in gut Chronic bowel changes Bladder cystitis • Offending chemotherapies • • Vinca alkaloids (vincristine) Cyclophosphamide Ifosfamide Platinums (carboplatin, oxaliplatin, cisplatin)

Endocrine • • • Menopause/ovarian failure Infertility Weight gain Decreased libido Erectile dysfunction Hormone

Endocrine • • • Menopause/ovarian failure Infertility Weight gain Decreased libido Erectile dysfunction Hormone deprivation in men Diabetes Thyroid dysfunction Hot flashes

Endocrine • Treatment causes • • • Busulfan Chlorambucil Cisplatin Cyclophosphamide Nitrogen mustard Tamoxifen

Endocrine • Treatment causes • • • Busulfan Chlorambucil Cisplatin Cyclophosphamide Nitrogen mustard Tamoxifen Aromatase inhibitors (anastarzole, exemestane, letrozole) Bicalutamide Leuprolide Steroids Ipilumumab

Musculoskeletal • • • Osteoporosis Osteopenia Increased risk of fracture Arthralgias Myalgias • Offending

Musculoskeletal • • • Osteoporosis Osteopenia Increased risk of fracture Arthralgias Myalgias • Offending agents • Hormone therapy (aromatase inhibitors) • Steroids • Chemotherapies inducing menopause

Skin • • • Nail changes Dry skin Skin discoloration Sun sensitivity Radiation recall

Skin • • • Nail changes Dry skin Skin discoloration Sun sensitivity Radiation recall • Offenders • • • Taxanes 5 FU Cyclophosphamide Doxorubicin Hydroxyurea BRAF inhibitors used in melanoma

Bone Marrow/Secondary Cancers • Cytopenias • MDS • Secondary cancer 1 -3% of patients

Bone Marrow/Secondary Cancers • Cytopenias • MDS • Secondary cancer 1 -3% of patients develop a new, secondary cancer Rate is higher in pediatric cancer survivors ALL in kids--secondary AML Colorectal cancer--secondary colon/retctal primary or other digestive organs • Lung—secondary lung, head/neck, and GU • Melanoma—additional skin cancers • • • Causative agents: doxorubicin, BCNU, ifosfamide, cytoxan, melphalan, etc.

Emotional • • Depression Anxiety Mood swings Guilt Fear of recurrence Post-traumatic stress disorder

Emotional • • Depression Anxiety Mood swings Guilt Fear of recurrence Post-traumatic stress disorder Gratitude • Financial implications of chemotherapy

FATIGUE • Most common side effect of cancer treatment • Offending agents: ALL chemotherapy/hormone

FATIGUE • Most common side effect of cancer treatment • Offending agents: ALL chemotherapy/hormone therapy/biotherapy/immunotherapy

What to do, what to do • Brain/CNS • • • Hearing changes—audiology referral

What to do, what to do • Brain/CNS • • • Hearing changes—audiology referral Eye issues— ophthalmology referral, cataract surgery Oral/dental— diligent dental care Chemobrain—patience, CBT, neuropsych referral Peripheral neuropathy • Assess for functional impairment • Patience • Medication management: gabapentin, pregabalin, duloxetine, amitriptyline, opioids • PT referral • Neurology referral

Cardiovascular • Monitoring • Check EF during treatment with cardiotoxic drugs • CHF—swelling, SOA

Cardiovascular • Monitoring • Check EF during treatment with cardiotoxic drugs • CHF—swelling, SOA • DVT—doppler if indicated (particularly in those on hormone therapy) • Heart disease/hyperlipidemia

Pulmonary • Surveillance/monitoring • Lung disease—refer to pulmonary or managed by PCP • Immunotherapy—treat

Pulmonary • Surveillance/monitoring • Lung disease—refer to pulmonary or managed by PCP • Immunotherapy—treat with steroids and taper

GI/GU • Digestion • Constipation—fiber/laxatives, GI referral • Diarrhea—loperamide, diphenoxylate with atropine, codeine, cholestyramine,

GI/GU • Digestion • Constipation—fiber/laxatives, GI referral • Diarrhea—loperamide, diphenoxylate with atropine, codeine, cholestyramine, GI referral • Neuropathy—motility agents, GI referral • Bladder cystitis • Urology referral

Endocrine • Proactivity/counseling for fertility issues • AYA program, referral for banking • Women’s

Endocrine • Proactivity/counseling for fertility issues • AYA program, referral for banking • Women’s health issues • Menopause/ovarian failure/dryness/hot flashes • Avoid herbs/supplements and hormone replacement therapy • Lubricants • Assessment of hot flashes • Venlafaxine, gabapentin, clonidine • Weight gain • Exercise, referral to dietitian, support groups • DM/thyroid • PCP or endocrinologist

Musculoskeletal • Bone density testing • Ca++ with vitamin D • Weight bearing exercise

Musculoskeletal • Bone density testing • Ca++ with vitamin D • Weight bearing exercise • Assistive device if needed, SAFETY FIRST • PT referral • Bisphonates

Skin • Emollients • Protection • Avoidance • Sunscreen • Cover • Surveillance by

Skin • Emollients • Protection • Avoidance • Sunscreen • Cover • Surveillance by PCP • Dermatology referral

Cytopenias/Secondary cancers • Investigation • Anemia, thrombocytopenia, leukopenia • BMBX necessary? • Encourage followup

Cytopenias/Secondary cancers • Investigation • Anemia, thrombocytopenia, leukopenia • BMBX necessary? • Encourage followup • Follow screening guidelines

Emotional • Referral • Counseling • Support groups • Medication management • Antidepressants •

Emotional • Referral • Counseling • Support groups • Medication management • Antidepressants • Antianxiety medications • Financial counselor

Fatigue • Exercise • PATIENCE • Treat underlying causes • Anemia • Thyroid conditions

Fatigue • Exercise • PATIENCE • Treat underlying causes • Anemia • Thyroid conditions • Vitamin D deficiency • Energy conservation • Prioritize activities • Dietary modifications

Case Study

Case Study

Conclusion • Population of cancer survivors will only grow • ASSESS, ASSESS • Treat

Conclusion • Population of cancer survivors will only grow • ASSESS, ASSESS • Treat or refer

References • Cancer. Net. (2016). Long-term side effects of cancer treatment. Retrieved August, 2016,

References • Cancer. Net. (2016). Long-term side effects of cancer treatment. Retrieved August, 2016, http: //www. cancer. net/survivorshiplong-term-side-effects-cancer-treatment • De. Santis, C. , Lin, C. , Mariotto, A. , Siegel, R. , et al. (2014). Cancer treatment and survivorship statistics, 2014. CA: A Cancer Journal for Clinicians, 252 -271. • MDAnderson Cancer Center. (2016). Possible side effects of cancer treatment. Retrieved, August, 2016, https: //www. mdanderson. org/patients-family/life-aftercancer/long-term-effects. html • Mayo Clinic. (2016). Cancer survivors: Late effects of cancer treatment. Retrieved August, 2016, http: //www. mayoclinic. org/diseases-conditions/cancer/indepth/cancer-survivor/art-20045524 • Oncology Nursing Society. (2014). Red flags in caring for cancer survivors. Retrieved August, 2016, https: //www. ons. org/sites/default/files/media/Red%20 Flags%20 for%20 Cancer%20 Su rvivors. pdf • Up to Date. (2016). Long term side effects of chemotherapy. Retrieved August, 2016, https: //www. uptodate. com/contents/search? search=long%20 term%20 side%20 effect s%20 of%20 chemotherapy&sp=0&search. Type=PLAIN_TEXT&source=USER_INPUT&se arch. Control=TOP_PULLDOWN&search. Offset=1&auto. Complete=false&language=en& max=10