Cancer of the Cervix - Pharmacy

Contents

Introduction

There are numerous resources to consult regarding chemotherapy issues. This document aims to collate relevant information needed by the general health care professional in relationship to cytotoxic chemotherapy and its application to gynaecology oncology. By approaching the topic from the patient's point of view, anticipating the most common questions and concerns, it is hoped that the health care professional will gain the specific knowledge required to deal effectively with these issues.

Most people have preconceived ideas about chemotherapy treatment. Often this is derived from historical events or the media and patients may wrongly anticipate severe side effects, which may cause unnecessary anxiety. Alternatively some patients expect that any toxicity can be prevented, as they have read about advancements in cancer chemotherapy and treatment, for example, of nausea. It is therefore important that the health care professional has a basic knowledge of the patient's individual treatment plan to allay their fears as much as possible. This should include:

The common questions patients ask and the answers health care professional can give listed below are only a general guide. It should provide sufficient information to set up effective communication between the patient, their carers and the health professional; empower the patient to have realistic expectations and actively participate in their chemotherapy.

What is Cytotoxic Chemotherapy?

Cytotoxic drugs are cell poisons. They act by preventing the cancer cells from multiplying. The drugs cannot differentiate however between normal and malignant cells but they do most damage to rapidly dividing cells. Thus, in addition to cancer cells they also affect other rapidly dividing tissue like the bone marrow, the lining of the gut, the hair follicles and the gonads. This accounts for much of the side effects expected from chemotherapy. 

Chemotherapy may be: 

Expectations and acceptance of adverse effects will depend upon these settings.

Cytotoxics are most effective when the tumour volume is very small. Therefore, chemotherapy is usually given as "adjuvant" therapy with other treatments like surgery and radiotherapy.

Immediate Effects

Will it Hurt?

Obviously there is always some discomfort involved in administering drugs by injection unless the patient has a 'Hickman' line or similar in-dwelling line in place. Once the cannula has been successfully sited the patient should not experience any distressing discomfort. Specific recommendations on drug reconstitution and administration are included in the production information to minimise irritation to the vein or surrounding tissue. These should be followed carefully. 

If the patient experiences discomfort, this may be related to drug administration. Many cytotoxic drugs are acidic or alkaline in nature and cause irritation to the vein or a sore, bruised sensation in the injection area. This can be painful even though the vein remains intact and there is no extravasation problem. Ice packs may help to reduce this. Various methods can also be used to help promote good venous access such as the use of heat pads and relaxation techniques. The patient should be reassured that subsequent treatments will hopefully be less problematic. 

Drugs may leak from the vein too. This is termed extravasation. Certain cytotoxic drugs (called vesicants) can cause significant damage to surrounding tissue when this occurs, causing pain, swelling and ulceration of various degrees close to the injection site. The patient should be made aware that despite optimal technique, such an occurrence is possible and that they should make the administrator aware of any burning, stinging, pain at the site. Once notified, drug administration should stop and the line checked for adequate blood return, swelling and resistance. Immediate action should be then be taken to prevent tissue damage. Specific instructions for subsequent management of extravasation for the specific drug(s) should be followed according to the hospital's policy.

Some antiemetic drugs given IV may also cause discomfort e.g. dexamethasone can cause perineal "burning" if given too quickly or not diluted enough. Intravenous metoclopramide can also cause a "stinging" sensation.

What's Causing this Unpleasant Taste/Smell?

Some of the chemotherapy bolus injections e.g. fluorouracil and cyclophosphamide can cause the patient to experience an unpleasant metallic taste during the injection. Some patients also complain of a strange smell or choking sensation. Sucking mints or boiled sweets can help to alleviate this. It will also subside if the injection is given more slowly.

Will I Be Sick?

Chemotherapy can cause both vomiting and nausea. Some drugs such as DTIC (dacarbazine), cisplatin, carboplatin can cause immediate symptoms of vomiting (during drug administration), others may cause delayed nausea; e.g. cyclophosphamide. Antimetics should be given prior to, and for a period after chemotherapy administration, with the type of antiemetic and dose adjusted to the individual's needs. The aim is to prevent any symptoms occurring and to prevent complications of dehydration, anorexia and anticipatory nausea.

Antiemetic drugs will target particular symptoms. Anti-5HT3 drugs like ondansetron, dolasetron and tropisetron are particularly effective against the symptoms of vomiting. Dexamethasone and other corticosteroids are effective against delayed nausea and vomiting, while metoclopramide is effective only against nausea. Medication should be taken as prescribed to try and prevent these side effects

Why Can't I Have My Chemotherapy Today?

Before any regime of chemotherapy, the patient usually requires a full blood count check. A minimum platelet and white cell count will be required for safe administration of chemotherapy. Haemoglobin is less important since the patient can be transfused if necessary. With certain drugs that are nephrotoxic such as cisplatin and carboplatin, a check of electrolytes and renal function is also required.

Treatment will be delayed if abnormalities are present or until the counts are within these minimum limits.

Why is My Mouth Sore?

Some of the drug regimes used can cause severe stomatitis. This is caused by damage to the cells producing the membrane of the mouth, leading to inflammation and ulceration. In severe cases, the pain from this may necessitate the use of strong opioid pain killers and can complicate the patients recovery. Prevention is therefore paramount when starting the treatment. 

General preventative measures include:

Some specific chemotherapy drugs may require specific measures e.g. methotrexate- induced stomatitis can be minimised by the use of the "antidote" folinic acid. If there is evidence of ulceration or inflammation then appropriate antifungal treatments may need to be commenced. Benzydamine (Difflam) can help with the local soreness. Local anaesthetics should however be avoided where possible. 

Diet may also need to be adapted to allow ease of swallowing and patients should be advised to avoid acidic, very hot or cold, and spicy foods.

Why is My Urine a Strange Colour?

Some drugs may cause temporary discolouration of the urine: 

Prior to this occurring, patient on drugs likely to cause this effect should be reassured that the discolouration should clear up approximately 24 hours after drug discontinuation. 

Patients receiving doxorubicin (which causes a red tinge) together with cyclophosphamide should ensure that the red colouration is not due to bleeding. Cyclophosphamide can cause haemorrhagic cystitis, which could be masked by the concomitant doxorubicin. If this occurs, the patient should report the adverse event to their doctor as soon as possible. The drug mesna can be used to counteract this problem. In addition, to prevent haemorragic cystitis, the patient should be advised to drink well prior to the cyclophosphamide bolus and to empty his/her bladder frequently to help flush the bladder.

Can I Do Anything to Help My Blood Count Recover?

This is a commonly asked question. Advice is usually to just behave normally, eating good nutritious food, resting when tired etc. There are no specific treatments unless a haematopoietic growth factor is used which stimulates the growth of various blood cells. Commonly used agents are the granulocyte colony stimulating factors (filgrastim or lenograstim) and erythropoietin which stimulates erythropoiesis. Usually, it is not imperative that the patient receives their treatment exactly on cycle, so by delaying therapy it gives their own body a chance to regenerate its own cells again

Can I Have An Alcoholic Drink?

Advice may vary. Generally, patients should be advised to drink in moderation; particularly of stronger alcoholic drinks like spirits, as the liver may already be dealing with the toxic effects of chemotherapy. A "standard drink" per day i.e.:

is usually quite acceptable.

Can I Get Help At Home?

Most people will receive their treatment without needing any home care at all. However some patients receiving continuous infusion chemotherapy or those having subcutaneous injections of biological therapy may need community nursing input or visits to the hospital.

Biological response modifiers may be given together with cytotoxic chemotherapy. The most common drugs used are interferon and granulocyte colony stimulating factors. 

It is usually possible to teach the patient to self inject. If unable to do this themselves and there is no suitable person in the family to help them, then community nurse support may be needed specifically for this. Sometimes this is just required initially until the patient gains confidence to take over the injection.

Any patient with a 'Hickman' line in site who is unable/ unwilling to care for it during treatment cycles may also need community or hospital support.

What Problems May I Have in Between Treatments?

Because cytotoxics are bone marrow suppressive it is of vital importance that the chemotherapy patient understands their vulnerability to infection. This should not be alarmist, but patients should be advised that if they suspect they have acquired an infection, i.e. they feel hot, shivery or have a cough or sore throat, then they should contact their doctor as soon as possible for potential antibiotic cover.

Profound neutropenia may require hospital admission and I.V. antibiotics if they become febrile.

The patient will also be more susceptible to bruising and should avoid:

Patients should be encouraged to maintain good oral hygiene since this will reduce infection risks. Oral candida is very common and should be treated promptly with antifungal agents e.g. nystatin, miconazole or fluconazole.

Taste aberrations and some anorexia are a common feature with chemotherapy and small, frequent meals are usually more tempting.

Depending on the treatment schedule, many people feel well enough to continue with normal activities but reassure your patient that a degree of lethargy and feeling below par is both common and quite variable.

Longer Term Side Effects

Will I Lose My Hair?

One of the most distressing side effects of some of the cytotoxic drugs is alopecia. This may be slight, patchy or total depending on the drug and dose given. If a patient experiences alopecia it usually occurs approximately two weeks to one month after their first treatment. Some patients will have a degree of hair loss following chemotherapy that is unexpected. This may be due to their poor general state, anxiety, post surgery etc. Patients should be reassured that they should find that their hair will often regrow even while they progress with their treatment. 

Drugs causing severe alopecia include:

Will I Be Able to Work?

Many people want to continue with their "normal" lives in between cycles of chemotherapy. Wherever possible the patient should be encouraged to work if they want and are capable of it. Some very physical jobs may be too demanding, as a common complaint following chemotherapy is lethargy and tiredness.

Caution is also needed when a bone marrow suppressive drug is used if the patient works with children or in an environment where the infection risk may be higher than usual. Examples of these drugs include:

Can I Go On a Holiday?

Patients on chemotherapy are immune-suppressed and are at high risk of contracting infections. Such patients should be made aware of the risks of infectious diseases acquired during foreign travel. Generally, patients should be advised to wait for a suitable time after treatment has finished if the wish to go abroad, or may be able to fit in a break between cycles of treatment.

Patients may also need to return home for medical help, earlier than planned. Medical insurance and contingency plans to cover this situation need to be factored in to any travel plans.

Patients with 'Hickman' lines or having treatment involving use of syringe and needle etc. may need a covering letter from their doctor to allow them to take these items in and out of the country.

Will I Be Able to Have Children?

As gynaecological cancers frequently affect women in their reproductive years, the question of a woman's future fertility after chemotherapy or radiotherapy needs to be addressed. 

There are different phases of the reproductive process that may be affected by cancer chemotherapy. These are:

The drug group most commonly associated with reproductive dysfunction are the alkylating agents e.g.:

Sterility may also occur due to radiotherapy or surgery prior or post chemotherapy.

In contrast to this it may be possible to fall pregnant whilst on chemotherapy, and patients may need advice on contraceptive measures to employ during this time. 

In addition, cancer has been estimated to occur in 1 of every 1000 pregnancies. Cancer of the cervix is the most common type of malignancy encountered in pregnancy women, followed by cancers of the breast, vulva, ovary and vagina. Only rarely do tumours spread from mother to foetus, and those that do are usually melanomas. Treatment is complicated by the need not only to treat the mother but also to avoid abortion and minimise foetal damage. In some cases, early delivery is recommended before the commencement of therapy. 

The foetus is most vulnerable to congential abnormalities during organogenesis (week four to week ten of the first trimester). While cytotoxic drugs must therefore be avoided in the first trimester, during the second and third trimesters, both single-agent and combination chemotherapy has been successfully employed in some malignancies where benefit has been assessed as outweighing risk. 

References

Treasure McGuire
BPharm, BSc, GradDipClinPharm.
Conjoint Lecture, School of Pharmacy, University of Queensland
Assistant Director-Pharmacy (Education/ Information), Mater Misericordiae Hospitals

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