TABLE 8-4 Frequently Used Chemotherapeutic Agents

DRUG DOSE, ROUTE, AND HOW MAJOR ADVERSE EFFECTS OTHER ADVERSE EFFECTS OR COMMENTS
FREQUENCY SUPPLIED MyelosuppressionThrombocytopeniaRisk for
Nausea and
Vomiting
Alkylators
Cyclophosphamide ▪ 500-1,500 mg/m2 ▪ 25 mg, 50 Marked Mild Moderate ▪ Hemorrhagic cystitis, alopecia
(Cytoxan) I.V. q3-4wk mg tablets ▪ Monitor liver function
▪ 50-100 mg/m2 PO ▪ 100 mg, ▪ Drink 3 qt (3 L) fluids daily
daily for 14 d 200 mg, 500
mg, 1 g, 2 g
vials
Busulfan (Myleran) ▪ 4-8 mg PO, daily ▪ 2 mg Marked Marked Mild ▪ Pulmonary fibrosis, skin pigmentation
tablets
BCNU (Carmustine) ▪ 150-200 mg/m2 ▪ 100 mg Marked delayed Marked Marked ▪ Local pain during infusion, pulmonary fibrosis,
I.V. q6wk vial with 3 crosses blood-brain barrier/irritant
mL alcohol ▪ Requires reconstitution with supplied diluent
diluent
CBCDA (Carboplatin) ▪ 300-500 mg/m2 ▪ 50 mg, 150 Marked Marked Mild ▪ Possible anaphylaxis, thrombocytopenia can
I.V. q4wk mg, 450 mg be severe and prolonged
vials
CCNU (Lomustine ▪ 130 mg/m2 PO ▪ 10 mg, 40 Marked delayed Marked Moderate ▪ Myelosuppression can be cumulative; crosses
CeeNU) q6wk mg, 100 mg blood-brain barrier; take at bedtime on empty
capsules stomach
Chlorambucil ▪ 16 mg/m2/day × 5 ▪ 2 mg Moderate Moderate Mild ▪ Infertility. Leukopenia delayed up to 3 wk
(Leukeran) d q28d or 0.1-0.2 tablet
mg/kg PO daily
▪ Usually 2 mg
maintenance
Cisplatin (Platinol) ▪ 50-120 mg/m2 I.V. ▪ 10 mg, 50 Moderate Moderate Severe ▪ Nephrotoxicity/neurotoxicity, magnesium
q3-4wk mg vial wasting, ototoxicity, anemia. Requires
▪ 20 mg/m2 I.V. antiemetics before and after
daily for 5 d q3-4wk
Dacarbazine (DTIC) ▪ 150 mg/m2 daily ▪ 100 mg, Mild Mild Marked ▪ Flu-like syndrome, alopecia, facial flushing,
I.V. × 5 d q4wk 200 mg, and paresthesia, vesicant
▪ 375 mg/m2 on day 1,000 mg
1 q15d vial
Ifosphamide (IFEX) ▪ 8-12 gm/m2/cycle ▪ 1 g, 2 g, 3 Moderate Moderate Mild ▪ Neurotoxicity, hemorrhagic cystitis, alopecia,
over 3-5 days every g concomitant uroprotection with Mesna
21-28 days
▪ I.V. for 5 d q3w
Mesna ▪ 20 mg/kg 15 min ▪ 200 mg None None None ▪ Not an antineoplastic agent; binds to reactive
before IFEX, vial metabolite of IFEX or Cytoxan without affecting
repeated q3h for 4 antitumor activity
doses
Mechlorethamine ▪ 6 mg/m2 day 1 ▪ 10 mg vialsMarked Marked Severe ▪ Vesicant, stomatitis, alopecia, chemical
hydrochloride and 8 q28d thrombophlebitis
(nitrogen mustard)
Melphalan (L-Pam, ▪ 0.1 mg/kg/day for ▪ 2 mg Moderate Moderate Mild ▪ Leukemia, second malignancies; given on
Alkeran) 2-3 wk up to 6 tablet empty stomach
mg/m2/d × 5 d ▪ 50 mg vial
q6wk
▪ 6 mg orally, daily
for 2-4 wk
Oxaliplatin (Eloxatin) ▪ 85 mg/m2 I.V. ▪ 50 or 100 Mild Mild Mild ▪ Peripheral neuropathy, stomatitis, anaphylaxis
q2wk mg/5 mL
vial
Procarbazine ▪ 2-4 mg/kg daily ▪ 50 mg Moderate Moderate Mild ▪ Sensitive to amines, neurotoxicity, crosses
(Matulane) PO capsule blood-brain barrier
Streptozocin ▪ 500 mg/m2 I.V. ▪ 1 g vial Mild Mild Moderate- ▪ Irritant, renal failure, reactive hypoglycemia
(Zanosar) daily for 5 d q6wk marked due to insulin release, diarrhea
Antibiotics
Bleomycin ▪ 10-20 units/m2 ▪ 15 unit vialRare Rare Mild ▪ Skin reaction, pulmonary fibrosis, fever,
(Blenoxane) I.V., I.M., S.C. allergic reaction, alopecia, s tomatitis
weekly
▪ Total dose not to
 exceed 400 units
▪ 60-120 units in
100 mL normal
saline for
intracavitary
therapy
Dactinomycin ▪ 0.010-0.015 µg/kg ▪ 0.5 mg vial Marked Marked Moderate- ▪ Alopecia, stomatitis, skin rash, hepatic
(Actinomycin D, I.V. for 5 d q3-4wk severe dysfunction, vesicant, radiation recall
Cosmegen)
Daunorubicin ▪ 60 mg/m2 I.V. for ▪ 20 mg vial Marked Marked Moderate- ▪ Cardiomyopathy, alopecia, red urine, radiation
(Cerubidine) 3 d q3-4wk severe recall, vesicant 450-550 mg/m2 total dose with
▪ 480 mg/m2 total mediastinal radiation
I.V. dose
Doxorubicin ▪ 60-75 mg/m2 I.V. ▪ 10 mg, 20 Marked Marked Moderate ▪ Alopecia, cardiomyopathy, radiation recall,
(Adriamycin) q3wk mg, 50 mg red urine, hepatic dysfunction, vesicant
▪ 30 mg/m2 for 3 d vial
q3-4 wk
▪ Total cumulative
dose 550 mg/m2
Doxorubicin ▪ 20-40 mg/m2 q3- ▪ 20 mg/2 Moderate Moderate Moderate ▪ Similar to adriamycin, less cardiotoxic
liposomal (Doxie) 4wk mL vial
Mitomycin ▪ 10-20 mg/m2 I.V. ▪ 5 mg, 20 Marked Marked Moderate ▪ Renal and pulmonary dysfunction, alopecia,
(Mutamycin) q6-8wk mg, 40 mg stomatitis, delayed myelosuppression, vesicant
vial
Mitoxantrone ▪ 12 mg/m2 I.V. day ▪ 2 mg/mL Moderate Mild Mild ▪ Tachycardia, mucositis; use extreme caution in
(Novantrone) 1-3 in 10 mL, preparation of drug
12.5 mL, 15
mL vial
Plant alkaloids
Irinateran ▪ 50-350 mg/m2 ▪ 40 mg/2 Moderate Moderate Moderate ▪ Severe diarrhea that may require delays or
(Camptogar) weekly × 6 mL vial, 100 dose reduction
mg/5 mL
vial
Vinblastine (Velban) ▪ 5 mg/m2 I.V. q1- ▪ 10 mg vial Marked Marked Mild ▪ Elevated uric acid, neurotoxicity, mucositis,
2wk alopecia, vesicant
Vincristine (Oncovin) ▪ 1-2 mg/m2 I.V. ▪ 1 mg/mL Mild Mild Mild ▪ Distal neuropathy, constipation, vesicant
maximum single vial, 2
dose mg/mL vial
▪ 2 mg I.V.
Vindesine (Eldisine) ▪ 2-4 mg/m2 I.V. q1- ▪ 10 mg Moderate Mild Mild ▪ Neurotoxicity — can be cumulative if
2wk ampule administered with other plant alkaloids,
vesicant
Teniposide (Vm-26) ▪ 50-100 mg/m2 I.V. ▪ 10 mg/mL Moderate Mild Mild ▪ Distal neuropathy, can have cumulative
weekly for 4-6wk ampule neurotoxicity if administered with other plant
alkaloids, alopecia, vesicant
Etoposide (VePesid) ▪ 45-75 mg/m2/d 3- ▪ 50 mg Moderate Mild Mild- ▪ Distal neuropathy, alopecia, hypotension can
(VP-16) 5 d q3-5wk capsule, 100 moderate occur after rapid infusion, headache, give over
▪ 125-140 mg/m2 mg/5 mL 30 minutes, irritant
PO 3 times/wk vial
q5wk
Vinorelbine ▪ 30 mg/m2/ I.V. ▪ 10 mg/vial Moderate Moderate Mild ▪ Distal neuropathies, extravasation and
(Navelbine) weekly necrosis; should consider central access
Antimetabolites
Azacytidine (5- ▪ 150 mg/m2 I.V. for ▪ 100 mg Marked Marked Severe ▪ Diarrhea, neurotoxicity, mucositis
azacytidine) 5 d by continuous vial
infusion
▪ 100 mg/m2
continuous I.V.
infusion q12h q7d
Cytarabine (Cytosar, ▪ 50-100 mg in 100 ▪ 100 mg Marked Marked Moderate ▪ Stomatitis, headaches; anorexia, arachnoiditis
ARA-C) mL saline for vial with intrathecal; cerebellar complications with
intrathecal high dose
5-Fluorouracil (5FU, ▪ 300-500 mg/m2 ▪ 500 mg Moderate-marked Mild Mild ▪ Stomatitis, diarrhea, alopecia, vein
Efudex) I.V. weekly or daily ampule discoloration, photosensitivity, nail color
×5 cream, 1%, changes
5%
Capecitabine (Xeloda)▪ 2,500 mg/m2 × 2 ▪ 250 mg & Moderate-marked Mild Moderate- ▪ Diarrhea, hand-foot syndrome, stomatitis
daily in two divided 500 mg high
doses q14d, repeat tablets
 every 21d
Hydroxyurea ▪ 80 mg/kg PO daily ▪ 500 mg Marked Marked Mild ▪ Alopecia, diarrhea, stomatitis; crosses blood-
(Hydrea) tablet brain barrier
6-Mercaptopurine (6- ▪ 70 to 100 ▪ 50 mg Moderate-marked Moderate-marked Mild ▪ Stomatitis, hematoxicity; reduce dose if giving
MP, Purinethol) mg/m2/day tablet allopurinol concurrently
Methotrexate ▪ 2.5-5.0 mg PO ▪ 2.5 mg Moderated- Moderate-marked Mild ▪ Stomatitis, nephrotoxicity, diarrhea, crosses
(Mexate) daily; I.V. or I.M. tablets marked blood-brain barrier; creatinine clearance must
dose varies ▪ 25 mg, 50 be > 60 mL/minute
▪ 25-50 mg/m2; mg injection
intrathecal 5-10
mg/m2 q3-7d
Thioguanine (6-TG, ▪ 2 mg/kg daily PO ▪ 40 mg Moderate Moderate Mild ▪ Cholestasis, stomatitis, diarrhea,
Tabloid) tablet hepatotoxicity
Gemcitabine ▪ 1,000 mg m2/day ▪ 200 mg/10 Moderate Moderate Mild ▪ Fever, alopecia, hematuria, proteinuria,
(Gemzar) I.V. over 30 min mL vial elevated BUN and creatinine
once per week for ▪ 1 g/50 mL
up to 7 wk or until vial
signs of toxicity
Taxanes
Paclitaxel (Taxol) ▪ 175 mg/m2 I.V. ▪ 30 mg vial, Marked Mild Mild ▪ Peripheral neuropathy, myalgias, alopecia,
over 3 h q3wk, or 6 mg/mL fatigue, heart block, arrhythmia; observe closely
60-100 mg/m2 with 5 mL for hypersensitivity reaction; premedicate with
weekly over 1 h Decadron 20 mg I.V., Benadryl 150 mg I.V. and
Zantac 50 mg I.V.; requires non-PVC I.V. tubing
Docetaxel (Taxotere) ▪ 80-100 mg/m2 I.V. ▪ 20 mg vial, Marked Mild Mild ▪ Peripheral neuropathy, edema, alopecia,
over 1 h q3wk, or 80 mg vial fatigue; observe closely for hypersensitivity
40-80 mg/m2 I.V. reaction; premedicate with Decadron 8 mg PO
weekly bid the day before, the day of, and the day after
chemotherapy
Miscellaneous drug
Topotecan ▪ 1.5 mg/m2/d for ▪ 5 mg vial Severe Severe Moderate ▪ Alopecia, diarrhea, headache, fatigue
(Hycamtin) 5d q28d
Temozolamide ▪ 75 mg/m2 daily ▪ 5, 20,100, Marked Marked Marked ▪ Contraindicated in patients with sensitivity to
(Temodar) during radiation, 140, 180, or dacarbazine; must give prophylaxis for
then 150-200 250 mg pneumocystis infection
mg/m2 on days 1-5, capsules
repeat q28d
Ixapebilone (Ixempra)▪ 40 mg/m2 I.V. ▪ 15, 45 mg Moderate Moderate Mild ▪ Peripheral neuropathy, myalgias, arthralgias
every 3 weeks vials

PROCEDURE GUIDELINES 8-1

Administering I.V. Chemotherapy
EQUIPMENT
 Supplies to start I.V. infusion or a running I.V. line
 Alcohol swabs
 Specific antidote for extravasation (if indicated)
 Disposable plastic-backed absorbent liner
 4″ × 4″ gauze pads
 Medication to be administered

PROCEDURE
Nursing Action Rationale
Preparatory phase

1. Patient education. 1.Patient education will prepare the

a. Review treatment goals. patient for adverse effects, thus
increasing tolerance of the drug.

b. Review the treatment plan and adverse eff ects of chemotherapy.

 c. Review strategies to manage adverse effects.

d. Instruct patient on reportable conditions (eg, fever).

2. Before administering chemotherapy, check for the following: 2.This will minimize chemotherapy
administration errors.
a. Order includes any supportive care medications, including premedications, antiemetics, a.Antiemetics are more effective if
hydration, growth factors, or emergency medications. given before administration and on
a regular dosing schedule
thereafter.
b. Review patient's medication history, including over-the-counter medications, for b To reduce or minimize drug
possible interactions. . interactions and toxicities.
c. Orders include all necessary components: name of drug, route, dosing interval, date,
duration of therapy, diluent type and amount, rate of infusion.
d. Compare written orders to drug protocol. If the drug is investigational, verify informed
consent.
e. Check against the written order.

f. Check current laboratory values; complete blood count, differential, platelets, liver f. Drug may be withheld in severe
function tests, and creatinine. Notify the health care provider if values are elevated and neutropenia, thrombocytopenia, or
would preclude infusion of the drug. impaired liver or kidney function.
3. Calculate the dosage according to milligrams per kilogram (mg/kg) or milligrams per meter
squared (mg/m2) by body surface area (BSA).
4. Verify the patient's name and identification.

5. Be aware of agents that cause anaphylactic reaction, such as asparaginase, paclitaxel, and 5.Increased awareness. Have
docetaxel. emergency resuscitation equipment
and drugs available.
Performance phase

1. Insert I.V. (if appropriate). 1.

a. Select venipuncture site free from sclerosis, thrombosis, or scar formation if possible. If a.An optimal I.V. site reduces the risk
the patient has an established I.V., assess the site for erythema, pain, or tenderness. of extravasation.
b. Check for a blood return by aspirating at a Y-site close to the I.V. catheter. Do not pinch b Pinching the catheter tubing may
the catheter tubing. . dislodge a small clot in a nonpatent
I.V.
c. If doubt exists about vein patency or safety of chemotherapy administration, discontinue c.A vesicant is a chemotherapeutic
the administration and treat as an extravasation if a vesicant chemotherapeutic agent agent capable of causing blistering
has been used. of tissues and possible tissue
necrosis if it extravasates. Some
agents are irritants, which cause
pain along the vein wall with or
without inflammation.
d. Monitor for pain; the patient may describe it as localized to severe burning and radiating
along the vein.
e. Examine the site for erythema or swelling
f. If you suspect an extravasation, stop the infusion immediately and follow the procedure f. Tissue necrosis and sloughing may
described below. lead to permanent tissue damage.
2. Administration. 2.
a. Use a disposable, absorbent, plastic-backed pad under the work area. a.To absorb droplets of the drug that
may inadvertently spill.
b. Put on protective gown, gloves, and eyewear if necessary. b Prevent aerosolization/spillage of
. drug.
c. If possible, prime all tubing before adding antineoplastics to the bag. If priming occurs at
the administration site, the I.V. tubing should be primed with a nondrug fluid.
d. Monitor the patient, particularly during the first 15 minutes, for signs of hypersensitivity d Change in mentation or in vital
or anaphylaxis. . signs may indicate hypersensitivity
or anaphylactic reaction.
3. Monitor the I.V. site through the infusion or I.V. push. Use a transparent (not gauze) dressing 3.This allows for direct visualization of
over the I.V. site. I.V. site.
Management of extravasation
1. If an extravasation is suspected, stop the infusion of the chemotherapy.
2. Disconnect the I.V. tubing and attempt to aspirate all residual chemotherapy in the I.V. catheter 2.To prevent further infusion of
using a syringe. chemotherapy agent.
3. Apply warm or cold packs as indicated.
4. Notify the health care provider.
5. If an antidote is available, administer as prescribed. 5.Antidote may prevent tissue necrosis.
a. For subcutaneous administration
i. Gently clean the area around the
extravasation with an alcohol pad.
ii. Inject the antidote subcutaneously in
a circular pattern around the site of
the extravasation using a 25G needle.
One to five injections will be needed,
depending on the volume of
extravasation. Change the needle
with each new injection.
6. Reapply warm or cold compress as indicated, depending on the chemotherapeutic agent that has
been extravasated.
Follow-up phase
1. Document drug dosage, site, and any occurrence of extravasation, including estimated amount 1.To document extent of injury.
of drug.
2. Observe regularly after administration for pain, erythema, induration, and necrosis. 2.If only a small amount of drug
extravasated and frank necrosis does
not occur, phlebitis may still result,
causing pain for several days or
induration at the site that may last for
weeks or months.
3. Monitor for other adverse effects of infusion. 3.
a. Patient may describe sensations of pain or pressure within the vessel, originating near a.Caused by irritation to the vein.
the venipuncture site or extending 3 to 5 inches (7.5 to 12.5 cm) along the vein.
b. Discoloration-red streak following the line of the vein (called a flare reaction) or b Flare reaction common with
darkening of the vein. . doxorubicin (Adriamycin).
Darkening of vein may occur with 5-
fluorouracil (5-FU).
c. Itching, urticaria, muscle cramps, or pressure in the arm. c.Caused by irritation of surrounding
subcutaneous tissue.

TABLE 8-3 American Cancer Society Recommendations for the Early

Detection of Cancer in Average-Risk Asymptomatic People (2008)

CANCER POPULATION TEST OR FREQUENCY

SITE PROCEDURE
Breast Women, age Breast self- Beginning in their early 20s, women
≥ 20 examination (BSE) should be told about the benefits and
limitations of BSE. The importance of
prompt reporting of any new breast
symptoms to a health professional
should be emphasized. Women who
choose to do BSE should receive
instruction and have their technique
reviewed on the occasion of a periodic
health examination. It is acceptable for
women to choose not to do BSE or to do
BSE irregularly.
Clinical breast For women in their 20s and 30s, it is
examination (CBE) recommended that CBE be part of a
periodic health examination, preferably
at least every 3 years. Asymptomatic
women aged 40 years and over should
continue to receive a clinical breast
examination as part of a periodic health
examination, preferably annually.
Mammography Begin annual mammography at age 40.*
Colorectal Men and Fecal occult blood Annual, starting at age 50.
 women, age test (FOBT)† or fecal
≥50 immunochemical
test (FIT), or
Flexible Every 5 years, starting at age 50.
sigmoidoscopy, or
Stool DNA test Interval uncertain, starting at age 50.
CT colonography Every 5 years, starting at age 50.
Double contrast DCBE every 5 years, starting at age 50.
barium enema
(DCBE), or
Colonoscopy Colonoscopy every 10 years, starting at
age 50.
Prostate Men, age ≥ 50Digital rectal The PSA test and the DRE should be
examination (DRE) offered annually, starting at age 50, for
and prostate- men who have a life expectancy of at
specific antigen test least 10 more years.§
(PSA)
Cervix Women, age Pap test Cervical cancer screening should begin
≥ 18 approximately 3 years after a woman
begins having vaginal intercourse, but no
later than age 21. Screening should be
done every year with conventional Pap
tests or every 2 years using liquid-based
Pap tests. At or after age 30, women
who have had three normal test results
in a row may get screened every 2 to 3
years with cervical cytology (either
conventional or liquid-based Pap test)
alone, or every 3 years with an human
papillomavirus DNA test plus cervical
cytology. Women aged ≥70 who have
had three or more normal Pap tests and
no abnormal Pap tests in the last 10
years and women who have had a total
hysterectomy may choose to stop
cervical cancer screening.
Endometrial Women, at At the time of menopause, women at average risk should be
menopause informed about risks and symptoms of endometrial cancer
and strongly encouraged to report any unexpected bleeding
or spotting to their physicians.
Cancer- Men and On the occasion of a periodic health examination, the
related women, age cancer-related checkup should include examination for
checkup ≥20 cancers of the thyroid, testicles, ovaries, lymph nodes, oral
cavity, and skin, as well as health counseling about tobacco,
sun exposure, diet and nutrition, risk factors, sexual
practices, and environmental and occupational exposures.
*
Beginning at age 40, annual clinical breast examination should be performed prior to
mammography.

†
FOBT as it is sometimes done in physicians' offices, with the single stool sample
collected on a fingertip during a digital rectal examination, is not an adequate substitute
for the recommended at-home procedure of collecting two samples from three
consecutive specimens. Toilet-bowl FOBT tests also are not recommended. In
comparison with guaiac-based tests for the detection of occult blood, immunochemical
tests are more patient-friendly, and are likely to be equal or better in sensitivity and
specificity. There is no justification for repeating FOBT in response to an initial positive
finding.

§
Information should be provided to men about the benefits and limitations of testing so
that an informed decision about testing can be made with the clinician's assistance.
From: Lippincott manual of nursing practice