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Course: Oncology Nursing�Topic: Antineoplastic Agents in Cancer Treatment Part 1

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Module Goals

Learners will be able to:

Describe the classification of antineoplastic agents.
Explain the role of antineoplastic agents in the treatment and palliation of cancer.
Describe factors influencing the selection of antineoplastic agents for cancer.
Compare the methods for administering antineoplastic agents.
Describe the principles of safe handling of antineoplastic agents.

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Classification of Antineoplastic Agents

Most antineoplastic agents are classified according to their structure or cell cycle activity. These are:

Cell cycle phase specific agents:

Act on the cells in specific phase
Most effective against tumors that have a large proportion of cells actively moving through the cell cycle and cycling at a fast rate

Cell cycle phase nonspecific agents:

Affect cells in all phases of the cell cycle
Resting cells (phase G0) are as vulnerable as dividing cells to the cytotoxic effects of these so called nonspecific agents
Most effective drugs against slow-growing tumors

Edcan Cancer Australia, 2021

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Classification of Antineoplastic Agents

Edcan Cancer Australia, 2021

Antineoplastic agents are traditionally divided by their origin or mechanism of action.

The main groups include:

Alkylating and alkylating-like agents
Antimetabolites
Antitumor antibiotics
Plant alkaloids
Miscellaneous agents
Hormonal agents

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Classification of Antineoplastic Agents

Alkylating and alkylating-like agents:

(Cyclophosphamide, Ifosfamide, Chlorambucil, Busulfan, Melphalan)

Interfere with DNA replication.
Effective against rapidly dividing cells.
Active against cells (G0) and used to debulk tumors, causing resting cells to be recruited into active division and those cells are vulnerable to the cell cycle-specific agents.
Active against lymphomas, Hodgkin's disease, breast cancer, and multiple myeloma.
Side Effects: higher risk of developing secondary malignancies.

EdCan Cancer Australia, 2021

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Classification of Antineoplastic Agents

Antimetabolites:

(Methotrexate, 5-Fluorouracil and Cytosine Arabinoside)

Interfere with DNA and RNA synthesis as false metabolites by blocking essential enzymes.
Effective for cell cycle phase specific for S phase.

(Synthesis Phase: The phase of the cell cycle in which DNA is replicated)

Used against rapidly cycling cell populations and are consequently more effective against fast-growing tumors.
Side Effects: Toxicities in the haematopoietic and gastrointestinal systems.

Edcan cancer Australia, 2021

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Classification of Antineoplastic Agents

Antitumor Antibiotics:

(Bleomycin, Daunorubicin, and Doxorubicin)

Also called Anthracyclines
Interfere with RNA and DNA synthesis
Most are cell cycle non-specific
Side Effects:

Toxicities of haematopoietic, gastrointestinal, cardiac and reproductive systems.
Cardiac toxicity may be manifested as acute changes in the electrocardiograph (ECG) and arrhythmias.

Edcan cancer Australia,2021

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Classification of Antineoplastic Agents

Plant alkaloids:

Bind to microtubule proteins during metaphase causing mitotic arrest (cell cannot divide and dies).
Three subgroups:

the vinca alkaloids e.g. vincristine and vinblastine.
the epipodophyllotoxins e.g. etoposide and teniposide.
the taxanes e.g. paclitaxel and docetaxel.

Side Effects: Hypersensitivity toxicities occur in the haematopoietic, integumentary, neurologic and reproductive systems.

Edcan cancer Australia, 2021

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Classification of Antineoplastic Agents

Miscellaneous agents: (e.g asparaginase and hydroxyurea)

Differ from the major classes of cytotoxic agents.
Side effects:Major toxicities in the haematopoietic and gastrointestinal

Hormonal agents: (alter the internal/extracellular environment)

Classifications of hormonal agents-

Adrenocorticoids, eg. prednisone
Androgens, eg. testosterone propionate
Oestrogens, eg. diethylstilbestrol
Selective oestrogen receptor modulators, eg. tamoxifen citrate
Selective aromatase inhibitors, eg. anastrozole
Progesterones, eg. megestrol acetate
Anti testosterone , eg. flutamid

Edcan cancer Australia,2021

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Critical Thinking Question

Which of the following drugs are alkylating antineoplastic drugs? (Select all that apply)

Cyclophosphamide,
Ifosfamide,
Methotrexate
Busulfan

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Role of Antineoplastic Agents

Edcan cancer Australia,2021

Antineoplastic agents alone or in combination uses:

Chemoprevention: To prevent or suppress carcinogenesis in people highly susceptible to certain cancers.
Cure: All cancer cells destroyed.
Control: Prevent or slow the growth of a tumor to prolong survival.
Palliation: Management of symptoms.

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Role of Antineoplastic Agents

Terms used to describe the role of antineoplastic agents in cancer control:

Induction: initial therapy administered with the aim of achieving significant cytoreduction, and ideally, complete remission of disease.
Consolidation/intensification: administered following induction to prolong freedom from disease and overall survival.
Adjuvant treatment: antineoplastic agents used in conjunction with another treatment modality i.e. biotherapy, radiation therapy or surgery, and aimed at treating micro-metastases.

Edcan cancer Australia,2021

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Role of Antineoplastic Agents

Neoadjuvant treatment: use of antineoplastic agents to reduce the size of a tumor before definitive treatment.
Maintenance therapy: prolonged, low-dose therapy administered to extend the duration of remission and achieve cure.
Primary therapy: antineoplastic agents administered as the definitive therapy.
Myeloablative therapy: prepares individuals for haematopoietic stem cell transplantation.
Salvage therapy: agents given after failure of other treatments to control disease or provide palliation.

Edcan cancer Australia,2021

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Critical Thinking Question

Miss Alina has a known case of Acute Basal Cell Carcinoma and she being treated with antineoplastic agents with combination of radiation therapy.

Which of the following term is used to describe her treatment case ?

Induction
Adjuvant treatment
Neoadjuvant treatment
Salvage therapy

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Factors Influencing Selection of Antineoplastic Agents

Edcan cancer Australia,2021

The key issues to consider when planning delivery of antineoplastic agents:

Tumor characteristics
Individual characteristics
Single agent therapy
Combination therapy

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Factors Influencing Selection of Antineoplastic Agents

Tumor characteristics:

Tumor burden: the larger the tumor, the greater the likelihood of the development of metastases
Tumor growth rate: the more rapidly growing the cancer, the more responsive its cells are to cytotoxic therapy
Tumor cell heterogeneity: increases the risk for the development of resistance.
Tumor location
Hormone receptor status
Blood supply to the tumor

Edcan cancer Australia,2021

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Factors Influencing Selection of Antineoplastic Agents

Individual characteristics:

Performance status: those with a better status may have a smaller tumor burden, and better ability to tolerate and respond to cytotoxic therapy
Reduced immunity and weight loss decreases the individual's tolerance to treatment effects.
Circadian rhythm: may affect drug absorption, metabolism, distribution and elimination

E.g. administering Fluorouracil in the evening may assist in reducing toxicities as the cells of the gastrointestinal system and the bone marrow are most actively dividing during the first half of the day

Edcan cancer Australia,2021

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Factors Influencing Selection of Antineoplastic Agents

Single agent therapy:

Often used the early phase of cancer chemotherapy.
Some of these disadvantages:

Poor success at achieving long-term remissions.
Development of resistance to further drug therapy.
Severe or lethal toxicities when given in doses adequate to eradicate the tumor.

Edcan cancer Australia,2021

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Factors Influencing Selection of Antineoplastic Agents

Combination therapy:

Has primarily replaced single-agent therapy in the medical management.

Combinations of agents have been associated with:

Less likelihood of resistance,
Increased fractional cell kill
Improved response rates

Principles for selection of agents within combination therapy include:

All drugs used should be of proven value.
Agents should have different modes of cytotoxic action.
If possible, the dose-limiting toxicities of the chosen agents should be different.

Edcan cancer Australia,2021

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Critical Thinking Question

Dr. Alex is a oncologist in a International Hospital of Chicago. He wants to start treatment with a antineoplastic agent in for patients who have malignant cancers in his clinic. What are the things Dr. Alex will consider in tumor characteristics before starting the treatment? (Select all that apply)

Tumor burden
Tumor growth rate
Tumor cell heterogeneity
Tumor location

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Method for Administering Antineoplastic Agents

Edcan cancer Australia,2021

Routes for administration of antineoplastic agents:

Intravenous

Peripheral venous access
Central venous access
Percutaneous lines
Peripherally inserted central catheters (PICC)
Implantable devices (Port-a-caths)
Tunnelled venous access devices (Hickman catheter)

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Method for Administering Antineoplastic Agents

Oral:

Advantages: Enables shorter treatment time, greater independence of the individual, and improved tolerability
Disadvantages: May not be monitored as intensively, risk of noncompliance, possibility of under or over-dosing, and inconsistency of absorption from the gastrointestinal tract

Intrathecal/intraventricular:

Agents are administered directly into the cerebrospinal fluid, usually as prophylaxis in leukaemia or lymphoma.

Edcan cancer Australia,2021

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Method for Administering Antineoplastic Agents

Intraperitoneal:

Direct administration into the peritoneal cavity.
Allows ovarian or colorectal cancers to be 'bathed' in high concentrations of antineoplastic agents.

Intrapleural

Direct administration into the pleural cavity.
Allows treatment of malignant effusions, which may be associated with lung, breast, prostate, gastrointestinal and ovarian cancer

Edcan cancer Australia,2021

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Method for Administering Antineoplastic Agents

Edcan cancer Australia,2021

Intravesical

Administration of agents directly into the bladder to treat superficial cancer of the bladder

Topical

Commonly prepared as ointments, and usually used to treat sun cancers

Subcutaneous and intramuscular

Uncommonly, agents may be administered by these routes.

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Critical Thinking Question

Miss Rai has malignant breast cancer and she is placed on oral antineoplastic treatment. What could be some disadvantages for oral route of antineoplastic agents? (Select all that apply)

Risk of noncompliance,
Possibility of under or over-dosing
Inconsistency of absorption from the gastrointestinal tract
May not be monitor intensively

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Safe Handling of Antineoplastic Agents

Many antineoplastic agents are proven to be carcinogenic, mutagenic and teratogenic, are classified as hazardous substances
Exposure to antineoplastic agents poses a potential health risk to staff who:

Prepare, handle, or administer the drugs
Care for individuals following administration
Dispose of these drugs or related waste

Direct exposure to antineoplastic agents can occur during administration or handling, and involves inhalation, ingestion or absorption

Edcan cancer Australia,2021

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Methods Preventing Exposure to Antineoplastic Agents

Drug Preparation:

Drug vials should be considered potentially contaminated upon arrival
PPE should be worn by all staff involved with unpacking drug vials
Use a Class IIB2 BSC or Isolator (glove box)
Use a closed system transfer device
Use proper PPE (disposable chemotherapy-resistant gown, chemotherapy-resistant gloves, and face protection)
Prime secondary sets with neutral solution before spiking tubings under BSC
Clean inside of BSC using sodium hypochlorite

Eisenberg, 2009

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Methods Preventing Exposure to Antineoplastic Agents

Drug administration and disposal

Prepare drugs in a low traffic area
Use secondary sets for IVPB chemotherapy whenever possible
Use a closed system transfer device on end of tubing and syringe to prevent leakage
Use proper PPE
Use Luer-Lock tubings and syringes
Avoid touching outside of bags without wearing gloves
Avoid eating or drinking in areas where hazardous drugs are prepared and administered
Dispose of waste in proper leakproof containers that have a sealable lid

(Eisenberg, 2009)

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Critical Thinking Question

RN Rama is a nurse in an oncology ward. She has to prepare a antineoplastic drugs for a child who is a known case of Acute Lymphocytic Leukemia (ALL). What ways she could get exposed to the hazardous effects of the antineoplastic drugs? (Select all that apply)

inhalation
ingestion
absorption
exhalation

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References

Australian Government Cancer Australia(2021).Classification of antineoplastic agents.EdCaN - learning resources for nurses. Retrieved from:https://www.edcan.org.au/edcan-learning-resources/supporting-resources/antineoplastic-agents/classification

Australian Government Cancer Australia(2021).The role of antineoplastic therapy in cancer control.EdCaN - learning resources for nurses. Retrieved from:https://www.edcan.org.au/edcan-learning-resources/supporting-resources/antineoplastic-agents/role-of-antineoplastics

Australian Government Cancer Australia(2021).Factors influencing agent selection and administration.EdCaN - learning resources for nurses. Retrieved from:https://www.edcan.org.au/edcan-learning-resources/supporting-resources/antineoplastic-agents/agent-selection-and-administration

Contact info: info@nursesinternational.org

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References

Australian Government Cancer Australia(2021).Route of Administration.EdCaN - learning resources for nurses. Retrieved from:https://www.edcan.org.au/edcan-learning-resources/supporting-resources/antineoplastic-agents/administration-principles/administration-routes

Australian Government Cancer Australia (2021). Safe Handling. EdCaN - learning resources for nurses. Retrieved from:https://www.edcan.org.au/edcan-learning-resources/supporting-resources/antineoplastic-agents/administration-principles/safe-handling

Eisenberg, S. (2009). Safe Handling and Administration of Antineoplastic Chemotherapy. The Art and Science of Infusion Nursing. V. 32.1 Retrieved from:https://www.nursingcenter.com/wkhlrp/Handlers/articleContent.pdf?key=pdf_00129804-200901000-00005

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