About the audience…

OCN Review Course • When will you take the exam? – Now anytime- 3 months post the sign up • Is anyone in the group, just contemplating taking the test? Chris Rimkus RN, MSN, AOCN • Anyone in here to get CEU’s? • The goal of the OCN test is to validate that you are a well rounded oncology nurse

Plan for the day Disclosures • Goal of this course is to do snapshot review • I am on a couple speakers bureaus, but this – For those taking it soon- validate what you know will not impact anything I teach today – For those considering, shows what you need to – Onyx/Amgen focus on – Genentech • I will question you to see what you know and maybe show you where you need to focus attention • It is possible for me to discuss some off • Stay on track!! label information – This may take some work for me/you • There will be a lot of info and to be efficient – With an open question/answer, sometimes time with your time, it is likely the breaks are not gets away enough for appropriate adult learning • Get through all material theory • Get done ON TIME!!!!!!!!!!!!

ONCC.ORG

1 ONS.ORG

Resources to use

• ONCC Website – 50 free questions- OCN – Other- do as many as you can • Core Curriculum- outdated but still recommended by those who take the test • ONS standards of professional practice • ONCC practice tests • Guidelines for practice from ONS • Other textbooks

Do as many of the free tests as Do both versions of OCN, CBCN, you can!!! BMTCN, AOCNS

2 Books I Know… These books are still relevant… These are new editions this year

$65-80 $55.86- Amazon $35.46- Amazon

$90.26- Amazon $56.05- Amazon

More Books- Not Blueprint last updated 2013: Based on role delineation study conducted 2012 sure of?? • Health promotion/Screening/early detect 6% of test • Treatment Modalities 16% of test • Scientific basis including research 9% of test • Symptom management 22% of test – Including sexuality $39.99- Amazon • Psychosocial dimensions of care 8% of test • Palliative care/End of life 11% of test • Survivorship 8% of test • Oncologic Emergencies 12% of test • Professional Performance 8% of test

Check out the position papers in Which of the following about oncology nursing certification is true?

• It validates an RN’s qualifications and knowledge for practice in a specific clinical area • It is a way to guarantee to the public that an RN is able to practice independently • It is granted by an agency of the federal government • It confirms that clinical competency has been attained Oncology Nursing Society. (n.d.). Oncology Nursing Society positions. Retrieved from http://www.ons.org/publications/positions

3 Health promotion/screening and early detection/scientific basis Cancer Incidence

• Health Promotion; screening, early detection----- 6% – Epidemiology (e.g., at-risk populations including A. • 1,685,210(1,658,370) people will be cultures; socioeconomic status; age; occupations) diagnosed with cancer in 2016 – Prevention (e.g., high risk behaviors; preventive health • 595,690(589,430) will die in 2016 practices) • Overall male/female distribution? • Scientific Basis for Practice including Research—9% • List the top cancer incidences – Carcinogenesis. Immunology. • List diseases that are more common in men than – Genetics Common metastatic sites. women (non gender driven) – Specific cancers (pathophysiology, diagnostic measures, prognosis) – Classification (tumors, staging, grading). • List diseases more common in women than men – Research protocols and clinical trials

http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-031941.pdf

What do these terms mean? • Plasia: this suffix means “formation” – anaplasia – dysplasia – hyperplasia • Carcinoma • Sarcoma • Germ Cell Normal genes that regulate cell growth and repair – Mutations allow proliferation • Carcinoma in situ The proto-oncogene can become an oncogene by a relatively small Copyright© 1995 by the modification of its original function Oncology Nursing Society • What is the difference between malignant and All Rights Reserved benign?

4 Terminology (con’t) Name those targets

• Adenocarcinoma • Squamous cells • Differentiation EGFR • Metastasis • Angiogenesis • Apoptosis

Dendritic Cells Antigen Presenting Cells Checkpoint inhibitors Can be used for vaccine therapy T Cells Cytotoxic Immunity

Parts of the immune system that can fight cancer- used in melanoma and Graft vs. disease or host B Cells Humoral Immunity

Used in MAB formation

(86)A patient asks a nurse, “How can you claim cancer is not contagious when you keep saying that viruses cause it?” The nurse’s response should be Epidemiological Indicators based on knowledge that:

• Incidence: The number of cancers that • There is no reliable information that viruses cause develop in a population during a defined cancer in humans period (eg., one year) ACS data • The viruses that may causes cancer are not • Prevalence: The actual number of cancers communicable that exist in a defined population at a given • the virus theory of cancer causation has been time #/100,000 people… superseded by the oncogene theory • Mortality: The number of people who die • Viruses can initiate cancer but cell transformation requires additional factors of a particular cancer during a defined period

5 Data Bases and Organizations Cancer Prevention- Can we that Monitor Cancer prevent cancer

• NCI: National Cancer Institute • 188,000 of the 595,000 deaths caused by • ACS: American Cancer Society smoking • The Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute gathers cancer • 20% of all cancers r/t obesity, poor diet, incidence data from 11 geographic areas, covering inactivity and alcohol excess approximately 14% of the U.S. population. These population-based data of long duration (1973–present) are a unique and important resource in monitoring stage- related survival.

Give examples of the following:

Which of the following statements about bladder cancer is true?

• Primary Prevention: • Secondary Prevention: What type of prevention •The age-adjusted rate in African-American men is almost twice that of white men. • Tertiary Prevention: is the HPV vaccine? What ethical theory is •Bladder cancer is one of the most common forms of cancer in the United States. being enacted when approving the injection •Only 10% of bladder cancer is localized at the time of diagnosis. that gives the greatest good for the most people? Util •The incidence is four times greater in men than in women.

A nurse involved in smoking cessation programs is participating in what type of prevention activity? Researchers estimate that if everything known about cancer Answers prevention were applied, which of the following would likely be true? •Secondary

Answers

•Tertiary •Cancer would be eradicated. •Few cancers would be affected. •Childhood cancer incidence rates would decrease •Indirect dramatically. •Approximately two thirds of cancers would not occur. •Primary

6 Cancer Risk Terms Risk Terms

• Relative risk= probability of getting cancer • Attributable risk= the amount of disease in based on the risks a population that could be avoided by – 20 yr women's study reducing or eliminating risks • Absolute risk= cancer incidence or – if no children ever started smoking, we could decrease lung cancer by???%) mortality – Hazard ratio/odds ratio • Cumulative risk= the total amount of risk of developing a disease over time – 1 in 4 men will develop prostate cancer in their life – 1 in 8 women will develop breast cancer

Develop an education plan for Education process the following • Pt/family- ensure 6th grade reading level • Community • For kids to prevent them from starting to – What education program would you smoke develop to try to impact cancer – What age should you start? incidences – How should you make the plan? • Staff • You just went to a conference and need • A program to increase African American to do an inservice “to give back since access to Mammograms your travel was paid for” – Give me a few objectives for the program – What would you do to ensure the staff got something out of it? – How would you target this audience to get buy in?

Which of the following actions must Which of the following statements about transformed (cancerous) cells is true? be performed first when developing Answers an educational program? •Cancer cells exhibit minimal changes in cell surface antigens. •Cancer cells nuclei are smaller than that of a normal cell. •Cancer cells exhibit alterations in growth such as loss of cell-cycle A. Formulate criteria for evaluation control and reduced apoptosis. B. Select educational methods •Cancer cells have contact inhibition.

C. Assess learning needs Rationale: D. Determine educational objectives

Cancer cells differ from normal cells in many ways. General properties of transformed cells include cytological changes such as increased size of the nucleus and increased nuclear-to-cytoplasmic ratio; altered cell growth due to loss of cell-cycle control and reduced apoptosis; changes in the cell membrane such as the expression of new surface antigens and cell surface glycoproteins, and loss of contact inhibition (i.e., the ability to stop growing when the cell comes in contact with another cell).

7 Carcinogenesis is a process in which cancer results from: One mechanism for overexpression of oncogenes is amplification, when the number of copies of a gene increases. Answers A new therapy for breast cancer, trastuzumab, blocks the •changes in the cell's protein structure that result in malignant transformation. overexpression of which gene? •multiple genetic alterations that occur over several months through three stages: initiation, promotion, and progression. •multiple genetic alterations that occur over several years through three stages: Answers initiation, promotion, and progression. •multiple genetic alterations that simultaneously occur in several target cells. •EGFR •P53 •RAS Rationale: Carcinogenesis is a process involving genetic alterations resulting in malignant transformation and involving •HER/2NEU exposure of cellular DNA to carcinogens. Carcinogenesis is believed to occur in three stages: initation, promotion and progression. The time frame for carcinogenesis is years versus months, and occurs in a single initiated cell that undergoes clonal expansion. Protein structure alterations are not involved in carcinogenesis. Cancer cells are often unable to perform designated functions and usually form at an uncontrolled rate

Carcinogenesis Questions you should know • Lifestyle – smoking: lung, esophagus, head and neck, • Which cancers are genetically derived? kidney, cervix, pancreas (there was a recent publication • Which cancers are hereditary? that identified 15 different cancers that smoking has impact on) • Which cancers are caused by smoking? – Alcohol- esophageal, liver, pharyngeal, gastric, colon & breast • Which cancer are caused by poor diet? cancers – Diet-20-40% all cancer deaths; obesity 20% of deaths; strongest link • Which cancers are caused by alcohol? is for colon/rectal- also strongly associated with recurrence of breast cancer • Which cancers are caused by viruses? – Gastric reflux- gastric, esophageal • Which drugs are a cancer risk for patients? • Occupational • The answers are on the next slides in your – chemicals: blood cancer (chemical warfare, bladder and packet (hidden)- FYI kidney(factory workers) cancer, lung (asbestos), nursing (chemo)?

Carcinogenesis (con’t) Specific Gene mutations/Family • Environment syndromes Known – sun/tanning beds: Melanoma • BRCA 1 and 2: Breast, ovarian – Radon- lung cancer – Radiation from the earth/getting scans/ electromagnetic fields: • Her 2: Breast, Ovarian, GI • Viral • HNPCC (lynch syndrome): GI, liver, upper – HBV/ HCV: Hepatoma – HPV: Cervical Cancer, rectal and oral cancers urinary, brain, skin, ovary, endometrial – EBV: Burkitt’s Lymphoma • FAP (APC gene): Colon, desmoid tumors – HIV: Lymphoma, Kaposi’s sarcoma • Dysplastic Devi: Melanoma • Iatrogenic – Immune Suppression: Multiple types of cancer • von hippel landau: cancer in fluid filled sacs – Hormone replacement- breast throughout the body and hemangiomas – Radiation and chemotherapy- blood cancer, bone cancer, lymphoma • Others …

8 Information You Should know Screening for Cancer • PAP smears About Screening – yearly starting at age 18/21 or have been sexually active- may go to q • When should a women get her first PAP Smear? 3 yrs if last 3 have been normal • When should a man get screened for prostate • Mammogram – yearly after age 40 cancer AND what is the screening? – monthly SBE age 20, CBE every 3 yrs age 20-39 then yearly • What is the screening recommended for colon • Colon Cancer Screening cancer AND at what age? – > 50 FOBT yearly and with flex sig every 5 yrs – Colonoscopy q 10yrs • What is the screening for ovarian cancer? • Prostate • What is the screening for lung cancer? – Men >50 PSA annually • Physical exam • What type of prevention is all of this? – age 20-39 and asymptomatic check up q 3 yrs • The screening recommendations is on the next – >40 yearly exam slide

Of the classes of chemotherapy, which class has the strongest potential for Blueprint carcinogenic activity

• Alkylating agents • Treatment Modalities 16% of test Know drugs in – Surgery • Antibiotics each class as they – Blood and marrow transplant • Antimetabolites may ask you the class of drug – Radiation therapy • Plant Alkaloids instead of – Chemotherapy specific drug – Targeted therapies – Biotherapy

Diagnosis of Cancer • Breast Cancer What stage – How is the disease diagnosed? and what tx for this stage? What stage and tx for this – What are the tumor markers? stage? What stage – What treatment modalities are used? and what tx • What chemo regimens might be used? for this stage? Resources for breast • Name tumor markers for: cancer: Y-Me; – Testicular cancer Koman; National When – Liver cancer Breast Ca Coalition; would you Living beyond do this? – Colon Cancer Breast Ca; young – Ovarian Cancer survivor coalition – Lymphocytic cancers – Pancreatic cancer What stage is this cancer?

9 A diagnosis of invasive breast Prior to consenting to a modified radical mastectomy, a patient seeks information about breast reconstruction. In counseling the patient, the cancer implies that the tumor; nurse should be aware that: Answers • Is greater than 1cm •surgery on the contralateral breast may be necessary to achieve symmetry. •reconstruction is contraindicated in women with multicentric breast disease. • Involves at least two regional lymph nodes •a woman should be free of disease for 2 years before having reconstructive surgery. • Has penetrated and grown into adjacent •reconstruction is rarely covered by medical insurance because it is viewed as cosmetic. tissue • Has metastasized Rationale: Reduction or augmentation mammoplasty may be needed to achieve symmetry. Reconstruction can be performed at any time, including at the time of mastectomy. However, reconstruction may not be advised in all patients. For What would histology be used for? example, a patient with a significant comorbidity may not be a candidate for reconstruction due to increased intraoperative or postoperative risk. Heavy smokers may be advised to quit smoking prior to reconstuctive surgery because smoking reduces blood flow to the reconstructed breast. Breast reconstruction is considered rehabilitative surgery and is covered by most insurance companies.

A patient has undergone a modified radical mastectomy. The most appropriate arm Lymphedema exercise for her to perform on the first day • Difference in circumference of affected limb of after surgery would be; greater than 1.5cm compared with unaffected limb and related to impaired lymphatic flow • Causes What is the • Pendulum swings of the arm – Diseases with invasion into lymphatics sentinel • lymphoma lymph node • Full range-of-motion swings of the arm • breast cancer • Overhead arm raises • Melanoma • Others • Forearm flexes – Scarring from radiation therapy – Metastatic disease impinging lymph flow • Prevention of/treatment for…

During counseling, a patient with breast cancer asks the A 76 year old female is to begin chemotherapy for nurse, “Now that I have finished my chemotherapy, how breast cancer. Which of the following would provide long do I have to wait to become pregnant?” the most accurate measurement of protein status? The best answer is?

• Serum creatinine • “No delay is necessary, since pregnancy • Serum albumin will not change your prognosis” • Urine protein • “You will not be able to get pregnant due to • Serum prealbumin the chemotherapy effects.”

• Prealbumin (not to be confused with albumin) is an important marker for assessing • “You should wait at least a year before protein deficiency. Prealbumin is produced in the liver, but is not affected by liver function unless function is extremely impaired. Biochemically, prealbumin has the becoming pregnant” function of transporting thyroid hormone. In addition, prealbumin also binds to retinol- binding protein (RBP), the main transport protein for free vitamin A. • “Are you aware that pregnancy increases • In adults, prealbumin screening has been useful in assessing protein status in AIDS- or your risk of recurrence?” cancer-related cachexia, as well as nutritional status in nursing home residents.

10 A patient has resectable lung cancer. The Lung Cancer tumor is 6cm. Lymph node dissection was done revealing hilar nodes involved. Pet scan shows disease in the lung, carinal and • Two major different classifications mediastinal lymph nodes. – Difference between the two – Common metastatic sites • T2N2M0 What • Symptoms seen in lung cancer and it’s • T3N2M1 treatments

treatment • T4N0M0 are used in lung cancer? • T4N3M1 Chemo Resources: Lungevity; used? American lung association

Lung cancer is more difficult to treat/cure than other cancers for this reason Dyspnea Disease related? • Because of the complex anatomy of the lung Treatment related? • Because there is no early detection for lung cancer Assessment of… • Because it is more malignant and aggressive than other cancers Testing associated with? • There are no effective treatments for lung cancer. Treatment of terminal dyspnea

A patient with bladder cancer has just had a complete cystectomy with creation of a continent ileal reservoir. Diseases/Treatment/Side effects Discharge instructions should focus primarily on: • Bladder cancer – Treatment used? • The catheterization technique – Common metastatic sites – Immediate side effects from treatment vs. late? • the external-pouch application

• Prostate Cancer Resources: Man to • fluid-restriction guidelines man; Malecare – Treatments used? Son asks when he should get screening • anticipation of bowel incontinence – Common metastatic site – Immediate side effects of the treatment vs. late?

11 A patient is scheduled for brachytherapy. When Afterload machine for prostate cancer asked what this means, the nurse’s best response to Usually 3 the patient would be that brachytherapy involves the; treatments over 2 days A technique in which an unloaded applicator or needle is placed within a patient at the time of an operative procedure • Placement of a radioactive source in or near and subsequently loaded with a radioactive source. The the tumor site loading is done under controlled conditions in which • Use of a split course of external-beam health care personnel are protected against radiation irradiation aimed at the tumor site exposure. • Instillation of a radioactive substance for

A radiotherapy technique in which an applicator, such as an acrylic purposes of palliation mold of an area to be irradiated, is placed in or on the patient and then loaded from a safe source with a high-activity radioisotope. The • Use of both irradiation and chemotherapy applicator contains grooves for the insertion of nylon tubes into which for inaccessible tumors the radioactive material can be introduced. Remote afterloading is used in the treatment of head, neck, vaginal, and cervical, prostate tumors.

Question Disease/Treatment/Symptoms Following radical prostatectomy for prostate cancer, which of • Ovarian cancer the following is most important during the initial – Treatment used? postoperative period? – Common sites of metastatic disease Answers – Side effects from treatment •Initiating sexual counseling with the patient and significant other

•Applying warm compresses to prevent bladder spasms

•Encouraging Kegel exercises to strengthen perineal Resources: NOCC; muscles Clearity foundation, Gilda’s Club; SGO •Monitoring the type and amount of urine output

Reproductive System American Cancer Society Online • Sexuality Sexuality Resource Resource for patients – Issues with intimacy – Issues of sexual function Sexuality books from ACS • male • female – menopausal changes (lack of estrogen) • Fertility – Note age and situation of person – Offer resources prior to treatment • Recommend the ACS booklets

12 (65)Which of the following therapies is Cancer Treatment associated with increased vascular • Melanoma permeability? – Treatment used? – Common sites of spread – Side effects to the treatment? • IL-2 • GCSF Mohs procedure  is microscopically controlled surgery used to treat common types of skin cancer. It is one of the many • Interferon alfa methods of obtaining complete margin control during removal of a skin cancer (ccpdma - complete • Levamisole circumferential peripheral and deep margin assessment using frozen section histology. • Cervical Cancer – Treatment used? – Immediate Side effects to treatment vs. Late?

The 2 most difficult to manage side effects of interferon therapy are; Lymphoma

• 2 different types • Fatigue and diarrhea – Treatment used? • Flulike syndrome and headache – Common sites of spread • Fatigue and central nervous system (CNS) – Immediate Side effects vs. Late? •HD has itching 1 year after alterations completion of tx •Early stage supraclav LN, ed on side • Skin reactions and flulike syndromes effects of rad (fertility?)

Leukemia/lymphoma society

What do you do if the Disease/Treatment/Symptoms chemotherapy extravasates? • 23 year old with Hodgkin Lymphoma – What treatment would you expect? • Name vesicants – First cycle of ABVD and has a peripheral IV, – Treatment for anthracyclines has a red streak up the vein after the first 10ml – Treatment for vinca alkaloids of doxorubicin- what is this and what do you • How is it recommended that Vincristine be do? given based on a national patient safety – How likely would this patient be infertile standard? – Which cell cycle phase is least responsive to – You need to make a policy, what organizations chemotherapy help guide your practice? – What if this patient relapses?

13 Your patient getting StatementDon't on the Scope and Standards of Oncology Nursing Practice doxorubicin/bleomycin/vinblastine/dacarbazine. Which of the following results would necessitate a change in the proposed regimen?

• An LDH of 135 • A multiple gated acquisition of 30% • A CA 125 of 35 • A Hct of 34%

Your patient is 14 weeks pregnant and in for chemotherapy, what would you expect for her chemotherapy plan? Diseases/Treatment/ Symptoms

• Give full dose as she is past the first trimester. • Colon Cancer • Decrease the dose as full dose would be – Treatments used? dangerous to the unborn child – Sites of metastasis – Symptoms from treatment • She should not get chemotherapy as it is unethical and you should refer this case to the • Rectal Cancer ethics council – Treatments used – Sites of metastasis • Suggest a therapeutic abortion to save the – Symptoms seen mother’s life then proceed with planned chemotherapy

Your patient had rectal cancer and had a Individuals undergoing pelvic radiotherapy for lower anterior resection, what post op rectal cancer might experience which of the education would you expect? following secondary side effects?

• Care of the colostomy • Hypokalemia • Discussion of the need to monitor bowel • Hypocalcemia movements • Hyperphosphatemia • Hypermagnesemia

• What other treatment for GI cancers might – APR- abdominal peritoneal repair cause this? • always has a permanent colostomy • What MAB(s) used for colorectal cancer – LAR- lower anterior resection depletes magnesium? • Doesn’t always have a colostomy

14 A patient with an ileostomy has minimal fecal output and states that he has been nauseated. He has also • Issues with oral medications? noticed occasional forceful liquid spurts into his Shouldn’t all have • How do you educate patient on treatment access to the meds appliance. These symptoms are most likely due to: plan and ensure adherence? they need? • Safe handling issues with oral drugs? What ethical principle is this • Gas describing? Just • diarrhea

Name oral • obstruction chemotherapy Your patient has medicare for colon and only, what does this mean? • constipation rectal cancer What is the difference between medicare and Medicaid?

Disease/Treatment/symptoms Nutrition • Enteral Nutrition • Head and neck cancer – Complications seen – Treatments used? • Parenteral Nutrition – Symptoms from disease – Complications seen – Common sites of metastasis – Symptoms from treatment • Refeeding syndrome- what is this??

(134) A pt is receiving enteral nutrition therapy. The home-care nurse can most easily determine whether the Anorexia/Cachexia pt’s caloric and fluid needs are being met by assessing: • Causes – Cytokines from cancer and cancer treatment – Real physiologic mechanism • Serial weights – Results in poor outcomes • intake and output • How do we measure • weekly serum glucose levels – Protein stores • abdominal girth measurements – Weight – Patient/family report • Treatment (marinol, dexamethasone, megestrol)

15 Mucositis and Xerostomia Ms. J is receiving amifostine and cisplatin(CDDP) for treatment of her head and neck cancer. Amifostine is

• Mucositis- What is this?? • An alkylating chemotherapy agent – Causes? • A chemoprotective agent – Treatment? • Adjuvant chemotherapy • An alternative/complementary therapy • Xerostomia- What is this? – Causes What two electrolytes are depleted with cisplatin (CDDP)? – Treatment

The immediate educational priority for the A patient being treated for head and neck cancer has client who has had a total laryngectomy is developed severe dysphagia and is aspirating while eating. The nurse should first:

• A referral for speech therapy • Consult with the speech therapist to assess and • A referral to a counselor to help with teach swallowing techniques emotional adaptation • Appropriate nutritional instruction that • consult the surgeon about placement of a addresses adequate wound healing and the gastrostomy tube functional impact on the client’s ability to swallow • obtain an order to begin total parenteral nutrition • Appropriate safety measures for life with a stoma • monitor daily weight and intake

Which of the following conditions is likely to cause long-term alterations in a patient’s sense of taste after radiation therapy for a tumor of the neck? Question

A patient undergoes a total laryngectomy for a diagnosis of • Severe mucositis laryngeal cancer. Postoperative nursing interventions will Who include: should we Answers • decreased saliva production call in to help us? •providing humidification by a tracheostomy collar. • proliferation of taste buds •preventing aspiration once oral intake is resumed.

•teaching the patient sterile technique for tracheostomy care. • suppression of tumor by-products

•insisting that the patient perform self-care activities independently.

16 Issues with External Beam Diseases/Treatment/Symptoms Radiation

• Pancreatic Cancer

– Treatments used Define the terms used in – Common sites of metastasis Rad/Onc •Simulation – Symptoms seen •Trismus- treatment? •Vaginal stenosis- treatment •Oophoplexi- why done? •Fraction Resources: PanCan

Pancreatic cancer patient in for hook up of At what dose of radiation will there likely be 5FU and gets concurrent chemo/radiation irreversible damage to healthy tissue (i.e. hair; gonads)?

What is causing this? • 4000mg • 4000cGy Should he continue with • 4Gy treatment? • 3500milicuri What ethical principle is this? • NMF

Types of radiation therapy and sources of radiation used Your patient now has liver mets- • External Beam – IMRT is short for Intensity Modulated Radiation Therapy. The intensity of the radiation in IMRT can be what can be done?? changed during treatment to spare more adjoining normal tissue than is spared during conventional radiation therapy. Because of this an increased dose of radiation can be delivered to the tumor using IMRT. Intensity modulated radiation therapy is a type of conformal radiation, which shapes radiation beams to closely approximate the shape of the tumor. Radiofrequency ablation • IGRT ishe process of frequent two and three-dimensional imaging, during a course of radiation treatment,  RFA is performed to treat tumors in lung liver, kidney, bone and (rarely) in other body used to direct radiation therapy utilizing the imaging coordinates of the actual radiation treatment plan.[2] The organs. Once the diagnosis of tumor is confirmed, a needle-like RFA probe is placed patient is localized in the treatment room in the same position as planned from the reference imaging dataset. An inside the tumor. The radiofrequency waves passing through the probe increase the example of Three-dimensional (3D) IGRT would include localization of a cone-beam computed tomography temperature within tumor tissue that results in destruction of the tumor. Generally RFA is (CBCT) dataset with the planning computed tomography (CT) dataset from planning. used to treat patients with small tumors that started within the organ mets • Internal (implants) Cryosurgery •Cryosurgery is a technique for freezing and killing abnormal cells. It is used to treat some Afterloading is the placement of the brachytherapy source kinds of cancer and some precancerous or noncancerous conditions, and can be used both • Brachytherapy - inside the body and on the skin The Remote Afterloader automatically places the radioactive source at predetermined Cryosurgery is an alternative to surgery for liver cancer that has not spread, for cancer that positions within the applicator and stores the source between treatments. has spread to the liver from another site, for prostate cancer confined to the prostate gland, for a precancerous condition of the cervix, and for cancerous and noncancerous tumors of • Gamma Knife the bone . Use liquid nitrogen or argon gas Cryosurgery may have fewer side effects than other types of treatments, and is less • Cyberknife expensive and requires shorter recovery times . The technique is still under study, and its long-term effectiveness is not known • Fractionation

17 Repeated paracentesis for malignant ascites can lead to : GI Dysmotility

• Severe protein depletion • Constipation – What drugs/treatments /conditions cause • decreased risk of infection constipation? – What is the treatment for constipation? • fluid overload • Diarrhea – What drugs/treatments/conditions cause • cardiogenic shock diarrhea? – What is the treatment for diarrhea

Mr. Jones is a 48 year old with esophageal cancer who presents for carboplatin/paclitaxel that is Nausea and Vomiting being given concurrent with radiation. He sits • Emetic Pathways down in the chair and starts throwing up. – Vagal afferents - chemical change in upper GI tract • What could be the cause of the vomiting? – Pharyngeal afferents (glossopharyngeal nerve) - excessive – There are at least 5 different reasons coughing resulting in gagging or emesis • What antiemetics would you expect to be a part of this – Midbrain afferent - increased ICP chemo regimen? – Vestibular system - inner ear leads to motion sickness – What other premeds would you expect? – Chemoreceptor trigger zone (CTZ) - near fourth ventricle of brain • You give palonosetron prior to treatment – Cerebral Cortex (memory center) – 2 hours later he starts feeling very nauseated, what would – Neurotransmitters you offer based on your knowledge of emetogenic pathways? • dopamine – What might you suggest be added to his next treatment given • 5HT3 NK1 that he is feeling really sick with each treatment? • Prostaglandin Other – Bowel obstruction

The physician orders prochlorperazine and droperidol to be given together before chemotherapy. The nurses More diseases and treatments primary concern should be whether:

• These medications should also be given following • A patient with Leukemia chemotherapy – List difference between leukemias • Both medications should be administered, due to – Diagnosed by? concerns about extrapyramidal symptoms – Is treated with? • Cardiac monitoring should be initiated because – The side effects to treatment are? these medications can interact to cause • Name common treatment modalities for arrhythmias multiple myeloma • The cost of the drugs would indicate use of a single agent such as ondansetron – What are some of the complications associated with multiple myeloma?

18 You draw a CBC and note the following: Mr. J completed treatment for B-cell NHL 3 wks ago WBC- 1.8 with 43% neutrophils; H/H 8.5/25; with ibritumomab tiuxetan. He presents to the clinic Plt 22,000 today with complaints of increasing fatigue, dyspnea • What education would you give this patient on exertion, and increasing bruising. regarding his WBC and platelets? His current symptoms are likely related to: – What growth factors can be given and timing • Tumor lysis syndrome • Other than the effects of chemo, what are other causes for anemia in patients with cancer? • Pulmonary embolism – Recent patient with breast cancer only on herceptin • Disease progression every 3 weeks who is also a vegetarian. Hgb • Myelosuppressive effects of therapy dropping from 10-8.3. – What could be the cause? – Treatments? Hidden slides with more info

Thrombocytopenia Management of Anemia • Platelet count < 100,000 • Patient education • Approximately 15% of circulating platelets are consumed – energy conservation in normal daily intravascular coagulation – adequate nutrition • Certain medications can alter platelet function (ASA, • iron, B-12 and folate rich foods Ibuprofen, NSAIDS) • Prevent anemia or progression of anemia • Thrombocytopenia is more common with – administer growth factor – higher intensive regimens • Procrit – excessive pretreatment • Epogen • Increased risk of bleeding with procedures when platelets • Aranesp are < 50,000 – monitor for response • Risk of spontaneous bleeding increases when platelet count 10,000-20,000 • may need to increase dose • may need to add iron supplementation

Special Situations with the (45) A patient has a fever of 102, 7 days after receiving 200mg cisplatin, 80mg methotrexate, and 8mg vinblastine. The patient’s lab Neutropenic Patient results are as follows: WBC-1000; Plt-50K; Neutrophils 15%; Hb 10.3; Hct 31.2%; BUN- 45; creatinine- 2.8 • Common pathogens/antimicrobials The nurse should anticipate an order for which of the following – Bacterial: staph, e-coli, strep, klebsiella medication’s – Viral: Herpes, CMV – Fungal: candida, aspergillus • Interferon alfa • Evidenced based preventive measures – strict handwashing • Monoclonal antibodies – Vaccinations • Granulocyte colony stimulating factor – Antibiotics • Erythropoietin – Growth factors

19 You have a patient who is admitted and has a paper explaining that they had received Tositumomab, Iodine 131 as an outpatient Radiopharmaceuticals

• What does this mean? • Who you gonna call? • Used for lymphoma • Y90 (ibritumomab tiuxetan) • What are the risks? • I131 (Tositumomab, Iodine I 131) • Side effects? • Used for pain control • Strontium 89, samarium 153 • Side effects?

Treatment for compression Changes in mental status in a pt with fractures multiple myeloma most likely are an initial sign of What diseases are at risk for compression fracture? • Renal insufficiency Kyphoplasty- balloon/cement • Hypercalcemia Vertebroplasty- cement • Hypocalcemia • Septic Shock

Which two are sources of A bit of info about BMT/SCT Hematopoetic Stem Cells?

• What is an autologous transplant? • Brain tissue • Diseases treated • Umbillical cord A person who has been What is an allogeneic transplant? exposed to radiation and now has bone marrow Diseases treated VOD(Veno occlusive • Aborted fetus disease)/SOS(sinusoidal failure- needs a stem What is GVHD(Graft vs. Host Disease)? obstructive syndrome) • Bone marrow cell transplant Leukoencephalopathy Acute- less than 3 months(90-100 days) • What drugs might What ethical principle Chronic beyond 90-100 days cause this? assures that we do what is needed for this What is the major side effect to BMT? patient? Ben

20 Your patient is 90 days post allogeneic stem cell transplant and is complaining of itching in the eyes, Target organs of acute GVHD are what is the best explanation for this symptom?

• Skin, liver GI tract • Acute GVHD • vagina, heart, spleen • Herpes, varcella Zoster • skin, pancreas, brain • Cataracts from the TBI • GI tract, eyes, mouth • Chronic GVHD

The purpose of the conditioning regimen in CAM= Complementary and/or the hematopoietic stem cell transplantation(HSCT) process is to: Alternative Therapy • Complementary therapy is? • Prevent GVHD – Examples for: • Hot flashes • Eradicate malignant cells and prevent graft • Nausea rejection • Peripheral neuropathy • Reduce the adverse effects of HSCT • Immune regeneration • Mobilize HSCT cells from the bone marrow • Depression to the peripheral blood – Issues/concerns? • Alternative therapy is? – Examples? – Issues/concerns?

A client undergoing hormonal therapy with tamoxifen calls and A pt with anticipatory nausea cannot tolerate inquires whether the oncologist would recommend any specific lorazepam. The complimentary therapy that you nutritional or dietary supplements. The nurse would be most concerned if the client stated: suggest might be helpful is:

• “My husband is on a big soy kick and wants us to give up • Massage meat and eat tofu instead?” • “My neighbor says she swears by high-dose vitamin C to • Music therapy prevent colds and suggested I try it this winter.” • St Johns Wort • “I read a magazine article about eating fruits and vegetables from various color families and wasn’t sure if • Relaxation therapy what it said was true.” • “My mother-in-law has a book on macrobiotics and thought I might like to read it.”

21 Define the treatment terms… • Patient with a large lung lesion wrapped Terms continued around the aorta receives carboplatin/paclitaxel q3wk x 4 followed by • A patient with breast cancer gets lung resection doxorubicin/cyclophosphamide/docitaxel • Patient with melanoma who has surgical then gets irradiation after the completion. resection of the tumor on scalp followed by – Why is the radiation after the treatment? interferon IV/SQ • Cyclophosphamide/Doxorubicin given • Head and neck cancer patient who receives every 2 weeks instead of every 3 weeks as cisplatin/cetuximab with radiation is typical. – What is the role of chemotherapy here?

Phases of Clinical Trials Phase Primary Goals Characteristics Phases of Clinical Trials I Establish MTD & Relapsed/ refractory dosing schedule disease • A randomized trial of cyclophosphamide/doxorubicin Evaluate toxicity Small # of patients (CA)vs. CA + Paclitaxel Determine Dose-escalating cohorts pharmacokinetics Pharmacokinetics – What phase is this? II Determine efficacy Groups of patients • A dose escalation trial of CO4471 Evaluate toxicity Measurable disease to – What phase is this? assess response rates III Establish efficacy by Randomization • A trial of the use of CCI 7701 plus gemcitabine in assessing survival between experimental Obtain QOL data tx & standard tx &/or unresectable pancreatic cancer. control group – What phase is this? Large # of patients IV Expand “off-label” use Postmarketing trials of Further assess toxicity commerically available data drugs

As a member of the ethics committee, the nurse applies the principle of autonomy when recommending a Research course of action based on a desire to:

• What is the nurses role in research? • One of the NP’s in your practice contacts • Respect the self-command of the patient you and asks you if they should come over and teach the nurses how to draw labs • Act in the best interest of the patient because they keep “messing up the PTT’s” • Do no harm to the patient when drawing them from a CVC. – Given what you know about the evidence for • Give what is due to the patient this issue, what would your response be? – If you were concerned about the staff practice, how could you ensure that the staff was actually following the practice?

22 A cognitively impaired client who is unable to Oncologic Emergencies participate in his/her medical decision making can rely on appropriate medical care by having a 12% of test

Emergent conditions related to cancer or the treatment of cancer • Legal will • Disseminated Intravascular • Sepsis • Insurance policy Coagulation • Pulmonary Embolism • Durable power of attorney and advance • Tumor Lysis Syndrome • Anaphylaxis • Typhilitis directive • Hypercalcemia of Malignancy • Fulminant Hepatic • Syndrome of Inappropriate Failure • Organ and tissue donation Antidiuretic Hormone • Spinal cord Compression • Pathologic fractures • Superior Vena Cava Syndrome • Extravasation • Cardiac Tamponade • Others

Oncologic emergencies can happen at any time during Your patient with AML has the following lab values; the course of an Oncologic diagnosis WBC=86,000, H/H= 8.6/25.1, Plt=22,000, Cr=1.8, As nurses, our overall goals is to: Na=132, K=4.8, Phos=7.2, LDH=954, Uric Acid= 9.5 Based on this information, what medication would you expect to be given prior to chemotherapy? • Prevent, reverse or minimize life- threatening complication • Ondansetron • Identify patients at risk and assess each • Allopurinol interaction • Dexamethasone • Educate patients and family members • Rasburicase regarding risk and how/when to manage the complications • Follow the physicians orders only

Allopurinol and Rasburicase Etiology of TLS Patients at risk?

23 Ms. Jones has breast cancer. She has been lethargic, Which of the following is an electrolyte complaining of abdominal pain and bloating. Labs were abnormality associated with TLS? drawn: Creat=1.7, calcium= 12.1. What would the initial treatment be to correct this disorder?

• Hypokalemia • Alendronate • Hypercalcemia • 1 liter of NS What lab affects calcium What labs level in the blood • Hyperuricemia might be • Zoledronic acid chemistry? included in • Hypophosphatemia TLS labs? • Gallium Nitrate

• What does this patient likely have? Why? – What other treatment is available?

In a patient with bone metastases, which of A person at risk for developing hypercalcemia the following symptoms should alert the should be encouraged to maintain mobility nurse to the presence of hypercalcemia? because weight-bearing movement

• Muscle Cramps • Increases resorption of calcium • Edema • Stimulates osteoclastic activity • Dyspnea • Increases urine acidity • Polyuria • Results in osteoblastic activity*

Hypercalcemia What is this?

• Patients at risk? – Metabolic disorder that, in cancer, results from bone resorption (is the process by which osteoclasts break down bone and release the minerals, resulting • Signs and Symptoms in a transfer of calcium from bone – bradycardia fluid to the blood) • tumors may produce PTH-rP – lethargy, confusion • osteolytic prostaglandins of – arrhythmias the E series – nausea/ vomiting/ • associated with the existence constipation of osteoclast -activating – fatigue, weakness, factors apathy

24 A patient receiving treatment for lymphoma reports experiencing numbness and tingling in the feet, Spinal Cord Compression weakness when ambulating and dribbling of the urine. The nurse should suspect: • Definition/ Pathophysiology – Tumor invasion compressing cord • Development of diabetes mellitus – Vertebral collapse pinching off spinal cord • Peripheral neuropathy • Development of spinal cord compression • What diseases put patients at risk for spinal cord compression? • Production of ectopic hormone

Signs and Symptoms of Cord Interventions: Cord Compression Compression • Pain • What is the immediate treatment for spinal • Motor defects cord compression? – weakness, heaviness, stiffness in extremities – ataxia – loss of coordination/ gait changes • What other treatments are needed? – paralysis • Sensory defects – decreased sensation • What other disciplines could be of – paresthesias assistance in the treatment of spinal cord – numbness, tingling compression? – bowel and bladder dysfunction – sexual dysfunction

Syndrome of Inappropriate Antidiuretic Hormone SIADH

• Definition/ Pathophysiology – Paraneoplastic syndrome in which the tumor ectopically produces vasopressin – Will exhibit SxS of fluid retention, inability to excrete urine, and dilutional hyponatremia • Disease(s) most likely to cause SIADH?

25 SIADH Treatment of SIADH

• Signs and symptoms of the disease (SxS of hyponatremia) • What treatment would you expect for – Nausea, anorexia someone with SIADH? – Fatigue, weakness – Altered mental status (confusion) – Muscle cramps • Lab Values seen – decreased sodium – decreased serum osmolality – increased urine sodium – increased urine osmolality

(40)A pt with lymphoma was treated with CVP. The patient has had increased shortness of breath and a cough during the past 2 weeks. Her face looks somewhat puffy, and she says that her Superior Vena Cava Syndrome blouses are too tight around the neck. • Definition / Pathophysiology The most likely explanation of these symptoms is: – An obstruction of the blood flow returning to the heart from the head, neck, upper thorax and upper extremities – Any obstruction of SVC leads to venous congestion, reduced cardiac output, edema of surrounding • Tumor lysis syndrome structures and hypoxia • Diseases at risk for developing SVC? • Lymphangitic pulmonary disease • Treatment-related cardiotoxicity • Superior vena cava syndrome

Interventions for SVC syndrome Which of the following blood test results are evident in patients with DIC?

• What is the biggest risk for this syndrome to • Increased partial thromboplastin time and become an emergency vs. the body increased hemoglobin level compensating? • Increased partial prothrombin and increased prothrombin times • What is the treatment for SVC syndrome? • Decreased platelet count and decreased prothrombin time • Decreased fibrinogen and decreased fibrin split products levels

26 Disseminated Intravascular Pt’s at highest risk of DIC are those Coagulation diagnosed with: • NHL • When you think of DIC, what is the first • Astrocytoma symptom you would expect the patient to be doing? • Renal cell carcinoma • Acute Promyelocytic leukemia

• What labs would you expect to see elevated? • What labs would you expect to see decreased?

DIC (Con’) DIC (Con’t) • Assessment • Medical interventions – Identify those at risk – Treat the underlying disease – Specific labs – Heparin • D-Dimer > 500mcg/L- caused by the formation and breakdown of – Aminocaproic acid clots – Replacement of blood and clotting factors • FDP > 40mcg/ml- caused by fibrinolysis • FFP • PT prolonged >12.5 seconds- caused by increase of fibrin split products consumption of vitamin K-dependant factors • Platelets • PTT prolonged > 30 sec- caused by consumption of clotting factors • PRBC • Plt decreased due to platelet consumption • Cryoprecipitate • H/H decreased due to bleeding – Nursing actions • Fibrinogen decreased < 150mg/dl due to consumption and • Vital signs and temperature fibrinogenolysis • Monitor for bleeding/ clotting/ bruising- abnormal and • Antithrombin III decreased < 80% due to consumption of clotting uncontrollable factors

Complications of Blood Your patient has an A WBC count of 1.2 and 20% neutrophils. She is somewhat Component Therapy lethargic and has a blood pressure of

Patient just 88/50, her heart rate is 119 • Allergic reactions completed 1 unit Formula on next hidden slide • Transfusion associated lung injury Plt and 2 units of • Is she neutropenic? PRBC’s. Is • Hemolytic reactions shaking and cold – When does neutropenia occur post chemo? • Bacterial contamination and has – What is the term describing this time frame? shortness of • What could be going on? • Volume overload breath What could be • What should be done? • Hypothermia going on? • Air embolism • What are the risks? • Transmission of viruses • What are the labs/procedures needing to be done?

27 Formula for calculating ANC The most common cause of sepsis is:

1. Segs + Bands x WBC = ANC • Fungi 100 • Viruses • Gm-positive bacteria 2. (% bands + % segs) x WBC= ANC • Gm-negative bacteria

**Need to remember that WBC is in MM(3) , so need to move decimal point to the right 3 positions (WBC= 3.0= 3000)

Mr. Smith is receiving his 8th cycle of FOLFOX. You What is the single most important risk started the oxaliplatin 15 minutes ago and now the patient factor for the development of sepsis starts turning red and itching all over. What should you do? • Fever • Slow the infusion, as this is a side effect if • Diabetes Remember no the drug is run too fast. pus in NTP • Inadequate nutritional intake • Give a dose of diphenhydramine as he is • Duration of granulocytopenia having an histamine release from the drug • Stop the infusion and treat the symptoms prior to resuming the infusion • Do nothing as this is a minor reaction and will pass.

Hypersensitivity Reactions Cardiac Tamponade

• List drugs at risk for HSR What might cause cardiac tamponade? • List risk factors that place a patient at risk for HSR • What drugs do we use to treat the reactions? • Which drugs have a recommended test dose? • Which drugs have recommended premedication? • What is desensitization?

28 Which of the following statements about What testing would you expect for cardiac tamponade are accurate? someone who has tamponade?

• Results from pericardial effusion • EKG • Most commonly due to lung cancer • Troponin • Can be acute onset or develop over time • CXR • Retrosternal chest pain is a symptom • ECHO • All of the above • All of the above

• What treatment would you expect?

Which statement is not true regarding Cardiac Toxicity malignant pleural effusion: • Drugs that cause cardiac toxicity? • May be an initial sign of cancer – Max cummulative dose of doxorubicin – Cardioprotective agent used • An accumulation of fluid in the pericardial space • Hyper/hypotension – MAB causing hypertension • May be a sign of advanced disease • Radiation to the chest wall • Happens in about 50% of all cancer patients sometime in the course of their disease – Monitoring post chest wall- risks to vessels • Other reasons for cardiac complications?

A nurse is providing discharge instructions to a pt who Which of the following statements has developed deep vein thrombosis in the left leg regarding pulmonary emboli is false? following radical hysterectomy. The pt takes warfarin sodium. Which of the following pt outcomes would indicate a need for additional teaching? • May be due to air, fat, as well as a clot • Using an electric razor for shaving her legs • One of the most difficult diagnoses to make • Eating a diet low in fiber • CXR is not generally diagnostic • Avoiding eating a diet high in green leafy • Is often preceded by hypoxia leading to vegetables increased anxiety or change in mental status • Avoiding crossing her legs while sitting

29 When infusing chemotherapy agents through a CVC, you should verify a blood return

• Before the infusion • Before, during and after the administration • At the completion of the infusion • It is not necessary to very blood return because this is a central line

Quality of life Palliative Care

• Easily interpretable, so be careful! Curative Focus: Disease-Specific • End of life/palliation Treatment • Survivorship Palliative Focus: Comfort/Supportive Bereavement Treatments Support

Alopecia Sleep Disorder • Which treatments cause alopecia? • What is the timing for the alopecia to occur? • List reasons for poor sleep in cancer • When will it likely come back? patients • You have a 76 year old male with NHL who will be receiving RCHOP. He wonders about hair loss. • What are some interventions that have – Do you think he will care about hair loss? evidence related to poor sleep in cancer – How will you discuss this with him to decrease his concerns patients about hair loss? – He asks you if there is treatment/prevention for the hair loss. He asks you about a cold cap he read something about. • Refer to ACS for financial assistance with wigs and for Look Good, Feel Better

30 Causes of Cancer Related Fatigue

• Cancer Neurotoxicity • Treatment • Central – Surgery Chemotherapy – Reasons for? – Radiation Biologics – Drugs to cause? • Anemia – Assessment/treatment? • Dehydration • How long does • Peripheral • Affective disorders fatigue last? • What are evidenced – stress – Reasons for? based treatments – anxiety – Drug classes that cause you would suggest – depression to prevent/treat • Specific drugs • Nutritional deficits fatigue – Assessment/treatments • Uncontrolled symptoms Hidden slides

Interventions for Peripheral Peripheral Neuropathy Neuropathy • Assessment • What are the drugs that typically cause – Terms that identify the pain as peripheral neuropathy vs – What other comorbidities add to the risk somatic or visceral pain • Injury, inflammation or degeneration of the – Stocking drug distribution peripheral nerve fibers • Treatment – Sensory nerves- touch pain, temperature, • Antiepileptic (gabapentin/pregabalin) position and vibration • Antidepressant (duloxetine, amitryptiline – Motor nerves-voluntary movement, muscle • Non medication (TENS, PT/OT, capsaisin topical, tone and coordination alpha lipoic acid- herbal) – Autonomic nerves-involuntary movement

Pt is receiving 3mg/hr IV Morphine for her pancreatic cancer pain. After 3 days, she is Pain Management scheduled to go home. You know that 30mg po is equal to 10mg IV morphine. • List the many reasons patients with cancer have pain? The most appropriate discharge rx would be. – Reasons for acute cancer pain – Reasons for chronic cancer pain • 30mg Q 12 • How do we treat pain? – Patient has widely metastatic bone pain associated with prostate cancer • 60mg Q 12 – Patient on fentanyl patch MS contin 100mg TID and MSIR 30mg Q 2-3 • 100mg Q 12 hours for their rectal pain associated with metastatic rectal cancer. Still ranking pain 10/10 • 120mg Q 12 – Patient with multiple myeloma who has low back pain associated with compression fracture – Patient is a known drug abuser and alcoholic who has • Should she get some breakthrough metastatic pancreatic cancer and ranking abdominal pain medication? What should it be/dose? 10/10

31 Which of the following methods of naloxone A 51 year old with metastatic disease from colon administration is preferred for a patient who has cancer has a new prescription for MS Contin. What been receiving opioids on a long-term basis and who potential side effect also needs to receive begins to experience respiratory depression? prophylactic attention at this time? • Single IV bolus • Nausea and vomiting • Single subcutaneous injection • Respiratory depression • Continuous subcutaneous infusion • Skin rash • IV titration • Constipation

A nurse mistakenly administers a long-acting Depression/Distress morphine tablet instead of the prescribed long-acting oxycodone. What is the nurse’s next step? • Risk Factors – Advanced disease and poor prognosis – Advanced Age A. Continue to monitor the patient closely for the next 8hrs Distress thermometer – Previous mental health B. Hold all further medications for the patient. – Medications C. Notify the patient and physician of the error. – Unrelieved symptoms D. Call the risk management department to guide • Treatment documentation. – Supportive interventions • Active listening • Support groups – Psychotherapy – Psychopharmacology

Symptoms at the End of Life Medications at End of Life

• Some already discussed are similar to those • Opioids: combined with sedative, given experienced during treatment IVCI, subcu CI, rectal – Pain, constipation, fatigue • Delirium: Haldol • Others • Sedatives: Lorazepam, haloperidol, alprazolam, diazepam • Dyspnea: morphine • Moist respirations: anticholinergics • Myoclonus: benzodiazepines

32 An inappropriate coping Which of the following is an essential mechanism/symptom during the first component of hospice care? month of grieving would be: • There is provision for disease treatment • The patient/family is the primary unit of care • Crying • The care team includes nurse only • Angry outbursts • Care is completed when the patient dies • Substance abuse

Hospice focuses on the person rather than the disease. Hospice addresses not only the medical, but also the • Poor appetite emotional, psychological, and spiritual needs of the patient and loved ones. Hospice emphasizes quality rather than length of life. Hospice neither hastens nor postpones death. The goal is to make each remaining day as rich and positive as possible. Hospice uses a team of professionals and trained volunteers to provide support, education and counseling for the important persons in the life of the dying individual. Hospice supports both the patient and the patient's family. Since serious illness impacts everyone in the family, hospice considers the family's needs, too. "Family" is whoever a person says his or her family is—whether they are related or not. Hospice supplements care given by friends and family so that those with terminal illness can live at home— wherever home may be.

Hospice offers grief support to surviving families and friends as well as the entire community

Survivorship Issues • Survivor Care Plans • Long term physical effects to cancer treatment • Long term emotional effects of cancer • Insurability • Employment • National coalition for cancer survivorship

– toolbox http://www.livestrong.org/Get-Help/Learn-About-Cancer/Cancer-Support- – survivor day Topics/Practical-Effects-of-Cancer/Cancer-Survivorship-After-Treatment

Late Effects of Therapy/Survivorship issues • Brain tumor patients • Hodgkin Disease • Head and neck cancer • Testicular cancer • Breast Cancer • ALL • Cervical cancer

33 (127)A young adult who received prophylactic cranial Late Effects of irradiation and intrathecal methotrexate 5 years previously is now at risk for which of the following side Therapy/Survivorship issues effects?

Brain: Cognitive impairment, hearing loss, cataracts H&N: Hypothyroidism, osteonecrosis of • Cerebral vascular accident mandible, dental caries, skin necrosis • Memory deficits Chest Wall/Lung: Lung fibrosis, arm edema, • Persistent headaches esophageal stricture, pericarditis, CAD Abdomen/Pelvis: Colon perforation or • Dental abnormalities obstruction, fistulas, bladder fibrosis, leg or scrotal edema, impotency, infertility, cystitis, vaginal retraction

Survivors in the extended or intermediate stage of survival are; Quality of life

• Finished completely with all medical treatments • In remission or receiving maintenance Review Questions!!!! therapy • Considered “cured” of their disease • Undergoing initial therapy

A patient receiving dexamethasone during A nurse who works with a client from a different therapy for multiple myeloma is at risk for? cultural background can promote communication in the therapeutic relationship by;

• Insomnia • Explaining cultural differences to the client • Anorexia • Minimizing cultural differences • Pruritis • Incorporating a knowledge of cultural • Decreased mobility patterns • Maintaining eye contact

34 (18) A patient with breast cancer is to undergo adjuvant A male patient with lung cancer is scheduled to chemotherapy with cyclophosphamide, doxorubicin, and 5FU. Which of the following statements about hair loss receive 50Gy of radiation to the chest area and is should be incorporated in the teaching plan? concerned about chest hair loss. The nurse’s response would be: • “Hair loss only occurs when the head is • This drug combination will result in minimal hair loss irradiated” • Use of minoxidil 2% solution applied topically prior to • With this low dose of 50Gy, hair loss will each chemotherapy treatment will reduce the risk of hair be temporary, if it occurs at all.” loss • The look good feel better program will supply wigs free of • “Hair loss may be permanent with radiation charge over 40Gy.” • Complete nearly complete hair loss should be anticipated following the initial chemotherapy treatment • “Hair loss only occurs when you receive chemotherapy in combination with radiation”

(8) A woman experiencing alopecia due to (23) A patient receiving high doses of an opioid to chemotherapy would best be referred to which of control pain related to metastatic cancer is prescribed the following programs? dextroamphetamine, most likely to:

• Reach to recovery • Increase appetite and food intake • increase bowel motility and improve elimination • Y-Me • decrease secretions and improve breathing ability • decrease sedation and enhance pain relief • Look good, feel better

• I can cope

(33) Initial nursing assessment of a patient who A patient who had a surgical resection for adenocarinoma reports “feeling low” during chemo treatments of the lung 2 years ago reports smoking two packs of should include: cigarettes daily. A routine check up reveals recurrent disease. The first nursing priority will most likely be to: • A discussion of the patient’s childhood support systems • Provide emotional support because the • a referral to a psychologist for a metal-status discovery of recurrence is extremely examination stressful • reviewing the projected treatment and follow-up • Provide physical support because rapid plan physical deterioration is expected • asking the patient about symptom control and • Provide information about palliative care possible sleep disturbances • Encourage the patient to stop smoking since that is now more important than ever.

35 A patient experiences shaking chills during the Which of the following are not signs and administration of amphotericin B. Which of the following medications will most likely be recommended? symptoms of malignant cerebral edema?

• Lorazepam • Meperidine • Headache, nausea and vomiting • Diphenhydramine • Personality changes • Acetaminophen • Speaking in tongues • Visual disturbances

What can cause increase intracranial pressure in patients with cancer?

Which of the following statements about the preparation of antineoplastic Rationale for safe handling agents is true?

• Local reactions • Sterile technique is not required in the preparation of IV – skin and/ or eye contamination NIOSH antineoplastics because of their lethal effect on tumor cells. OSHA • Carcinogenicity • Intravenous antineoplastics are best prepared and ONS – ability to cause cancer dispensed by the same procedures as any other IV ASHP admixture. • Mutagenicity • Only specially trained physicians, nurses, and pharmacists – ability to cause change in DNA should prepare antineoplastics for administration. • Teratogenicity • In reconstituting antineoplastics, positive pressure must be – causes effect on unborn children used to inject the diluent into the vial. • Long term risks

(54) Which of the following national organizations was created to assist parents and families of children Resources for patients with cancer and adult survivors of childhood cancer? • There definitely will be questions about what resources you would refer your • Make Today Count patients to… • Road to Recovery – Komen • I Can Cope – Fertile hope • Candlelighters Childhood Cancer Foundation – Candlelighters Childhood Cancer Foundation – ACS – Leukemia/lymphoma – Cancer support networks (used to be called Wellness communities)

36 Which of the following is a voluntary public service organization that would be most likely to provide Other Professional Performance transportation for a person with cancer who needs Issues to know daily radiation treatments? • Legal issues – Nursing errors (lack of documentation/medication errors) • American Automobile Association – You don’t have a blood return from your CVC and the doctor tells you “it is OK to give the chemo as I am writing the order for such • American Red Cross and take liability for this” – You give cisplatin- there was no hydration ordered- the patient • National Hospice Organization goes into renal failure. • American Cancer Society • Ethical issues – List some typical ethical issues you deal with regarding patient care – Know the terms on the next two slides (hidden) All of the • Patient advocacy definitions of the – National coalition for cancer survivorship ethical principals – American’s with Disability Act are on the following slides- Know them!!

• Paternalism: Decisions made by others based on their own interpretation of what is best for that person Know the definitions of the terms – Knowing “what is in the person’s best interest” – Therapeutic privilege • Beneficence: Duty to benefit – Professional responsibility • Nonmaleficence: Duty to prevent or remove harm – Legal rights – Situations: • Justice: Fairness • Genetic testing – Distribution of burdens & benefits based on the least • Treatment withdrawal/DNR advantaged in society • Investigational treatments • Undert reatment of pain – Issues: • Autonomy: Personal freedom • Allocation of resources • Universality – Free action • Publicity – Authenticity • Finality – Effective deliberation – Moral reflection • Veracity: Obligation to tell the truth – Issues: – Issues: • Treatment decisions, Right to refuse – Informed consent • Informed consent – Breaking bad news

A patient who has just completed treatment for cancer wants to return to her job in the aerospace industry. Her employer tells her that she cannot have her job back (130) Which of the following is an indirect, rather because she has had cancer. Her employer's action is than a direct, cost of cancer care? violating which of the following? • The Federal Rehabilitation Act of 1973 • Child care • The National Cancer Act of 1971 • Home care • Current American Cancer Society • Medication guidelines • Surgical supplies • Occupational Safety and Health Administration (OSHA) guidelines

37 Joint Commission accreditation is important to hospitals primarily because: • Influential physicians practice only in Joint commission accredited facilities • It is a requirement for reimbursement for services from most third party payors • It designates a hospital as a comprehensive cancer center • It guarantees quality nursing care to healthcare consumers

Other Last Minute Strategies Last month study tips • TEST QUESTIONS!!!!!!!!!!!!!! – ONS • Go back and review your notes • Online review course – Look at the blueprint and see the sections and – “bundles” on demand – $279- member where you may need more review (so you don’t • Free tests on the ONCC website- do the ones we have to review all) discussed!!! • Questions, questions, questions • Online tests for purchase – Do as many as you can out of the core curriculum since that is the most likely source/style of tests (you may be surprised, but some questions actually come out of that book)

Test Taking Tips Test Taking Tips • During the test • Reduce anxiety – Listen to the proctor – make a list of what to bring to the test- have out – Look for words such as most, first, initially, the night before immediately, usually – Good rest/eat prior – Try turning each multiple choice option into a true false statement then mark “T” or “F” after each option • Don’t cram the night before – When weighing options, look for those that embody – Arrive early good nursing judgement and that enhances • Make a dry run to the center to ensure you know communication, respect and acceptance of pt’s feelings where you are going and how much time it takes – Do not change an answer • Check out parking – Pace yourself – Don’t drink too much fluid/caffeine prior – Stay calm

38 Facts about the test Scoring of the Test… • Total Oncology Certified Nurses= more than 32,000 • Stats for passing: What score do I need to pass the test? ONCC tests are scored using a scaled score. A scaled score is not a percentage score; it is a transformation of a raw score (number of items answered correctly) into a different unit of measurement. Two well-known tests administered in the United States that report scores as scaled scores are the • 165 questions ACT and SAT. A scaled score of 55 is the passing score for all ONCC tests. – 145 count The 55 equates to different raw scores on various forms on the test depending – 20 new/being tested on the difficulty of the form. For more information on passing scores, please • 3 hours visit http://oncc.org/TakeTest/TestInformation/Scores. – 10 minute tutorial – 2hr 45min test – 5 minute exit survey • Multiple choice – Passing score based on how many correct

Take note of your score! You are Going to Make it!! The areas you didn’t do as well on will be areas you will need to have more ed on for • You will get a recert preliminary score before leaving the test center :) • Reward yourself for a job well done!

Renewal in 4 years The end is here!!

• Evaluations • CEU’s • Good Luck!!

• Email me any suggestions for future classes, ??, that you passed.

[email protected]

39 References References

• Brant, J.M., & Wickham, R.S. (Eds.). (2004). Statement on the scope • Gullate, M. (Ed.). (2007). Clinical guide to antineoplastic therapy: A and standards of oncology nursing practice. Pittsburgh, PA: Oncology chemotherapy handbook (2nd ed.). Pittsburgh, PA: Oncology Nursing Society. Nursing Society. • Ignatavicius, D., & Workman, M.L. (Eds.). (2010). Medical-surgical nursing: • Bruner, D.W., Haas, M., & Gosselin-Acomb, T. (Eds.). (2005). Patient-centered collaborative care (6th ed.). St. Louis: MO: Saunders/Elsevier. Manual for radiation oncology nursing practice and education (3rd ed.). Pittsburgh, PA: Oncology Nursing Society. • Itano, J., & Taoka, K. (Eds.). (2005). Core curriculum for oncology nursing (4th ed.). St. Louis, MO: Elsevier Saunders. • Carroll-Johnson, R.M., Gorman, L.M., & Bush, N.J. (Eds.). (2006). • Jennings-Dozier, K., & Mahon, S. (Eds.). (2002). Cancer prevention, Psychosocial nursing care along the cancer continuum (2nd ed.). detection, and control: A nursing perspective. Pittsburgh, PA: Oncology Pittsburgh, PA: Oncology Nursing Society. Nursing Society. • Deglin, J.H., & Vallerand, A.H. (2009). Davis’s drug guide for nurses • Kuebler, K., & Esper, P. (Eds.). (2008). Palliative practices from A–Z for the (11th ed.). Philadelphia: F.A. Davis. bedside clinician (2nd ed.). Pittsburgh, PA: Oncology Nursing Society. • Ezzone, S. (Ed.). (2004). Hematopoietic stem cell transplantation: A • Langhorne, M., Fulton, J., & Otto, S.E. (Eds.). (2007). Oncology nursing (5th manual for nursing practice. Pittsburgh, PA: Oncology Nursing ed.). Philadelphia: Mosby. Society. • Newton, S., Hickey, M., & Marrs, J. (2009). Mosby’s Oncology Nursing Advisor (2nd ed.). St. Louis, MO: Mosby.

References Supplemental

• American Cancer Society. (2009). Cancer facts and figures for African • Polovich, M., Whitford, J.M., & Olsen, M. (Eds.). (2009). Americans 2009–2010. Atlanta, GA: Author. Retrieved August 5, 2009, from Chemotherapy and biotherapy guidelines and recommendations for http://www.cancer.org/downloads/STT/cffaa_2009-2010.pdf practice (3rd ed.). Pittsburgh, PA: Oncology Nursing Society. • American Cancer Society. (2008). Cancer facts and figures for • Yarbro, C.H., Frogge, M.H., & Goodman, M. (2004). Cancer symptom Hispanics/Latinos 2006–2008. Atlanta, GA: Author. Retrieved August 5, management (3rd ed.). Sudbury, MA: Jones and Bartlett. 2009, from http://www.cancer.org/downloads/STT/CAFF2006HispPWSecured.pdf • Yarbro, C.H., Goodman, M., & Frogge, M.H. (Eds.). (2005). Cancer • American Cancer Society. (2009). Cancer facts and figures 2009. Atlanta, nursing: Principles and practice (6th ed.). Sudbury, MA: Jones and GA: Author. Retrieved August 5, 2009, from Bartlett http://www.cancer.org/downloads/STT/500809web.pdf • Barton-Burke, M., & Wilkes, G.M. (2006). Cancer therapies. Sudbury, MA: Jones & Bartlett. • Blecher, C.S. (Ed.). (2003). Standards of oncology education: Patient/significant other and public (3rd ed.). Pittsburgh, PA: Oncology Nursing Society.

Reading List Readings

• Camp-Sorrell, D. (Ed.). (2004). Access device guidelines: • Jacobs, L.A. (Ed.). (2003). Standards of oncology Recommendations for nursing practice and education (2nd ed.). Pittsburgh, PA: Oncology Nursing Society. nursing education: Generalist and advanced • Cope, D., & Reb, A. (Eds.). (2006). An evidence-based approach to practice levels (3rd ed.). Pittsburgh, PA: Oncology the treatment and care of the older adult with cancer. Pittsburgh, PA: Nursing Society. Oncology Nursing Society. • Eaton, L.H., & Tipton, J.M. (Eds.). (2009). Putting evidence into • Oncology Nursing Society. ONS Positions. practice: Improving oncology patient outcomes. Pittsburgh, PA: Retrieved July 14, 2009, from Oncology Nursing Society. http://www.ons.org/publications/positions. • Gullate, M. (2005). Nursing management: principles and practices. Pittsburgh, PA: Oncology Nursing Society. • Polovich, M. (Ed.). (2003). Safe handling of hazardous drugs. Pittsburgh, PA: Oncology Nursing Society.

40 MEDICATIONS Important information Class of Drug OTHER NAME Alpha order about the drug NabAlbumin bound Peripheral neuropathy, milky Abraxane Plant Alkyloid Paclitaxel appearance Actinomycin Antitumor Antibiotic Dactinomycin, Cosmegen Adriamycin Antitumor Antibiotic Doxorubicin Heart, vesicant, anthracycline Monoclonal Ado-trastuzumab Kadcyla Her 2 inhibitor Antibody Afinitor mTOR inhibitor Everolimus Aldesleukin Biologic Therapy IL-2, Interleukin-2 Capillary leak Severe lyphodepletion need Monoclonal Alemtuzumab CamPath 1H prophylactic antibiotics. Antibody HSR* Folic acid, Vit B12 replacement Alimta Antimetabolite Pemetrexed Dex for fluid retention. Alkeran Alkylating Agent Melphalan, L-Pam High dose, severe mucositis Amifostine Not Chemo Ethyol Hypotension, N/V, Not Chemo High dose-cerebellar toxicity and ARA-C Antimetabolite Cytosar, cytarabine ocular Aranesp Growth Factor Darbopoietin alfa Renal toxicity Used for hypercalcemia and to Aredia Bisphosphonate Pamidronate prevent bone loss, osteonecrosis of the jaw Nucleoside Arranon Nelarabine metabolite inhibitor Arsenic Trioxide Trisenox Prolonged QTc, correct K and mg Allergic reaction Asparginase Elspar, L-Asparginase Coagulopathies Pancreatitis All Trans Retinoic Pulmonary syndrome that requires Vesenoid, Tretinoin Acid (ATRA) dex High Bp, headaches Avastin Antiangiogenesis Bevacizumab Poor wound healing, GI perforation In SQ form- skin reaction (2 Azacytidine or 5- Hypomethylating Vidaza shots), can be given IV or SQ, Azacytidine Agent don’t hold dose for low bld ct Delayed pulmonary toxicity BCNU Nitrosourea Carmustine Mixed in alcohol Bendamustine Alkylating Agent Treanda HSR* Bevacizumab Antiangiogenesis Avastin

Revised 10-1-2013 1 MEDICATIONS Important information Class of Drug OTHER NAME Alpha order about the drug Secondary MDS/AML Severe myelosuppression Congrugated Need to take something to protect Bexxar Monoclonal Tostumomab I131 the thyroid (SSKI, Lugols solution Antibody or potassium iodide) Special precautions for radiation exposure to staff/family Pulmonary toxicity Bleomycin Antitumor Antibiotic Blenoxane Fevers HSR* Monoclonal Peripheral neuropathy, Brentuximab Antibiotic myelosuppression, HSR Peripheral neuropathy, Bortezomib Proteosome Inhibitor Velcade reactivation of viral infection. Busulfan Alkylating Agent Myleran Seizures in high dose Busulfex Alkylating Agent Busulfan injection Cabazitaxel Plant Alkaloid Jevtana CamPath 1H Biologic Alemtuzumab Immune suppression Diarrhea - immodium and Camptosar Camptothecans Irinotecan, CPT-11 cholinergic- atropine Hand foot syndrome Capecitabine Antimetabolite Xeloda Prolonged INR AUC dosing Carboplatin Alkylator like (nm) Paraplatin Delayed HSR* (8-10th dose) Carmustine Nitrosourea BCNU CCNU Nitrosourea Lomustine Monoclonal HSR*, acne like rash Cetuximab Erbitux Antibody K-ras mutation doesn’t respond Chlorambucil Alkylating Agent Leukeran Renal (check BUN/Cr) Alkylator like Cisplatin Platinol N/V; peripheral neuropathy- (platinum) ototoxicity. Also called CDDP Cladrabine Leustatin, 2CDA Dactinomycin, Cosmegen Actinomycin Cystitis- mesna sometimes used especially in high dose Cyclophosphamide Alkylating Agent Cytoxan Void often Secondary malignancies Cytarabine ARA-C, ctyarabine Cytoxan Alkylating Agent Cyclophosphamide

Revised 10-1-2013 2 MEDICATIONS Important information Class of Drug OTHER NAME Alpha order about the drug Burning during peripheral Dacarbazine DTIC infusion You will likely give this with a Dacogen Decitabine low ANC/Plt because is used to treat MDS Dactinomycin Actinomycin, Cosmegen Denileukin diftitox Ontak Darbepoietin alfa Aranesp Tyrosine kinase Dasatinib Sprycel Pleural effusion inhibitor Daunomycin Antitumor Antibiotic Daunorubicin Heart, anthracycline Daunorubicin Antitumor Antibiotic Daunomycin Decitabine Dacogen Tearing, nail changes, fluid Docetaxel Plant Alkaloid Taxotere retention (give dex); peripheral neuropathy Doxil Antitumor Antibiotic Liposomal Doxorubicin Hand foot rash; HSR* Doxorubicin Antitumor Antibiotic Adriamycin DTIC Dacarbazine Eculizumab Soliris Cardiac toxicity Ellence Antitumor Antibiotic Epirubicin Vesicant, anthracycline Alkylator like Cold dysesthesia Eloxatin Oxaliplatin (platinum) HSR* later doses Elspar Asparginase Epirubicin Antitumor Antibiotic Ellence Erythropoetin alfa Procrit Erbitux Monoclonal antibody Cetuximab Rash Tyrosine kinase Erlotinib Tarceva Pulmonary (interstitial lung inhibitor disease) Low blood pressure Ethyol Amifostine Nausea/vomiting Etoposide VP-16 Everolimus mTOT inhibitor Afinitor Ice to prevent mucositis 5-FU Antimetabolite Fluorouracil Diarrhea

Revised 10-1-2013 3 MEDICATIONS Important information Class of Drug OTHER NAME Alpha order about the drug Coronary vasospasms

Floxuridine FUDR Fludara Antimetabolite Fludarabine Fluorouracil Antimetabolite 5-FU FUDR Floxuridine Bone pain Can be used to mob stem cells G-CSF - Filgrastim Growth factor Neupogen To be taken 24 hours after chemo – daily dosage Gemcitabine Antimetabolite Gemzar Gemzar Antimetabolite Gemcitabine Fever; pulmonary Tyrosine kinase Gleevec Imatanib inhibitor WBC growth factor, also stimulates macrophages so has GM-CSF Leukine, sagramostim some antifungal protection Can be used to mob stem cells For Her2+ breast cancer, Cardiac Herceptin Monoclonal antibody Trastuzumab toxicity; HSR* Hexalen Hycamtin Topotecan Hydrea Hydroxyruea Oral, also used for sickle cells Hydroxyurea Hydrea Idamycin Antitumor antibiotic Idarubicin Cardiac/vesicant, anthracycline Cystitis- mesna always IFEX Alkylating Agent Ifosfamide Neurologic (coma, hallucinations) Ifosfamide Alkylating Agent IFEX Imatinib Gleevec Flu like symptoms, fatigue Interferon alpha Roferon depression. Interleukin-2 Aldesleukin, proleukin Irinotecan Camptosar (CPT-11) Ixabepilone Ixempra Peripheral neuropathy Ixempra Ixabepilone Jevtana Cabazitaxel

Revised 10-1-2013 4 MEDICATIONS Important information Class of Drug OTHER NAME Alpha order about the drug Monoclonal Kadcyla Ado-trastuzumab Antibody To rebuild mucosa to prevent Kepivance Keratinocyte growth Palifermin mucositis L-Asparginase Elspar, Asparginase Lapatinib TKI Tykerb Prolonged QTc Teratatogenic, increased risk of Lenalidomide Immunomodulator Revlimid blood clots Synergistic with 5FU and a rescue Leucovorin Not Chemo Folinic Acid for high dose methotrexate, Not Chemo Leukeran Chlorambucil Leustatin Cladrabine, 2CDA Lomustine CCNU Matulane Procarbazine Nitrogen Mustard, Mechlorethamine Infertility, vesicant Mustargen Melphalan Alkeran Mercaptopurine 6MP Binds to metabolite of Mesna Mesnex ifosphamide and cyclophosphamide High dose renal toxic and need Methotrexate leucovorin rescue Mithramycin Plicamycin Mitomycin C Mitomycin intrabladder Mitoxantrone Novantrone Abd cramping Mozobil CXCR4 inhibitor Plerixafor Used to mobilize stem cells for BMT Nab Paclitaxel Abraxane Vesicant, give through side arm of Navelbine Vinorelbine running IV Nelarabine Arranon Peglylated filgrastim, Neulasta Growth factor 24 hours after chemo 1 shot only GCSF Neumega Oprelvekin Platelet growth factor

Revised 10-1-2013 5 MEDICATIONS Important information Class of Drug OTHER NAME Alpha order about the drug Neupogen Growth factor G-CSF - Filgrastim Multikinase Nexavar Sorafenib Rash, long eyelashes inhibitor Nilotinib TKI Tasigna Mustargen, Nitrogen Mustard Sterility Mechlorethamine Monoclonal antibody Nivolumab Opdivo Immune mediated effects (PD1 inhibitor) Nplate Romiplostim For ITP to improve platelets Novantrone Mitoxantrone Cardiac, blue Ontak Denileukin diftitox Peripheral neuropathy Oncovin Plant alkaloid Vincristine Cap at 2mg Jaw pain Monoclonal Opdivo Nivolumab Antibody Oprelvlekin Neumega Oxaliplatin Eloxatin HSR*; premed with H1,H2 and Paclitaxel Taxol dex Peripheral neuropathy Palifermin Kepivance Osteonecrosis of the jaw, elevated Pamidronate bisphophonate Aredia creatinine Panitumumab EGFR antagonist Vectibix Magnesium depletion Paraplatin Carboplatin Peglylated GCSF Neulasta Pemetrexed Antimetabolite Alimta Monoclonal Pembrolimumab Kaytruda Immune mediated effects (colitis) Antibody Pentostatin Perjeta Monoclonal antibody Pertuzumab Her 2 blocker Platinol Cisplatin Plerixafor Mozobil Plicamycin Mithramycin

Revised 10-1-2013 6 MEDICATIONS Important information Class of Drug OTHER NAME Alpha order about the drug Procarbazine Matulane Procrit Erythropoietin Alfa Provenge Sipuleucel-T Collect stem cells to make this Revlimid Lenalidomide HSR* Rituxan MAB Rituximab Reactivation of Hep Roferon Interferon Alfa Flu-like symptoms Romiplostim Nplate Sipuleucel-T Provenge Mercaptopurine, 6-MP Oral Purinethol Soliris MAB Eculizumab Sorafenib Multikinase inhibitor Nexavar Rash Sprycel Dasatinib Streptozocin Zanosar Sunitinib Multikinase inhibitor Sutent Rash Sutent Sunitib Rash Tarceva Erlotinib Tasigna Nilotinib Taxol Paclitaxel Taxotere Docetaxel Immune suppression – need to be Temodar Temozolamide on septra Temozolamide Temodar Temsirolimus Torisel Fixed dosing Peripheral neuropathy; Thalidomide Thalomid constipation; STEPS (for reproductive issues) Thioguanine 6-TG Thiotepa Thioplex Topotecan Hycamtin Torisel Temsirolimus

Revised 10-1-2013 7 MEDICATIONS Important information Class of Drug OTHER NAME Alpha order about the drug Trastuzumab Herceptin Treanda Bendamustine Vesenoid, All Trans Tretinoin Retinoic Acid (ATRA) Trisenox Arsenic Trioxide Tykerb Lepatinib Vectibix Panitumumab Myelosuppressive Velban Vinblastine Peripheral neuropathy Velcade Bortezomib Verinostat Zolinza Vesenoid ATRA, Tretinoin 5-Azycitabine or Vidaza Azycitabine Vinblastine Plant alkaloid Velban Peripheral neuropathy Non myelosuppressive Vincristine Oncovin Peripheral neuropathy Vinorelbine Navelbine VP-16 Etoposide Xeloda Capecitabine Y90 Ibritumomab Zevalin Same as Bexxar tiuxetan Zolinza Verinostat Used for breast cancer now to prevent bone mets Zometa bisphosphonate Zolodrenic acid Renal toxic, osteonecrosis of the jaw

*HSR = hypersensitivity reaction

Revised 10-1-2013 8

Supportive Care Drugs

MEDICATIONS OTHER Important information about the drug Alpha order NAME SSRI; Side Effects drowsiness, insomnia, nausea, weight changes, frequent urination, decreased sex drive, anorgasmia, dry mouth,[15] increased sweating, trembling, diarrhea, excessive yawning, and fatigue Citalopram Celexa SSRI discontinuation syndrome: has been reported when treatment is stopped. Tapering off citalopram therapy, as opposed to abrupt discontinuation, is recommended in order to diminish the occurrence and severity of discontinuation symptoms. Seretonin-norepinepherine reuptake inhibitor Used for peripheral neuropathy as well as antidepression Duloxetine Cymbalta Side effects: dry mouth and sexual dysfunction (can also have discontinuation syndrome) Used for nausea as well as to increase gastric motility Metoclopramide Reglan Side effects include diarrhea, dystonic reactions Used for peripheral neuropathy Gabapentin Neurontin Side effects: dizziness, drowsiness, and peripheral edema (swelling of extremities)[ Used most commonly for peripheral neuropathy Side Effects: dizziness, blurry vision, weight gain, sleepiness, Pregabalin Lyrica trouble concentrating, swelling of your hands and feet, dry mouth, and feeling “high” Used for peripheral neuropathy and to help with depression Side Effects: Blurred vision; change in sexual desire or ability; Amitriptyline Elavil constipation; diarrhea; dizziness; drowsiness; dry mouth; headache; loss of appetite; nausea; tiredness; trouble sleeping; weakness Antidepressant Mirtazapine Remeron Side Effects: somnolence, increase weight gain, increased appetite, dizziness.

Venlafaxine Effexor Used for hot flashes, PN and depression

Xgeva Denusumab To prevent skeletal fractures; low calcium is a risk

Revised 10-1-2013 9