NLE Oncology Nursing — Cancer Treatment Modalities and Nursing CareStudy Notes

Chemotherapy uses cytotoxic (cell-killing) drugs delivered systemically through the bloodstream to reach cancer cells throughout the body. Because these drugs target rapidly dividing cells, they destroy not only cancer cells but also normal cells that divide quickly. Understanding the cell cycle and drug classification helps you anticipate and manage side effects. **What Makes Chemotherapy Systemic**: Unlike surgery (local) or radiation (local to field), chemotherapy circulates systemically and reaches all parts of the body. This is its greatest strength—it can treat metastatic disease—but also the source of widespread side effects. **Cell-Cycle Specificity**: - **Cell-Cycle-Specific Drugs**: Act during a particular phase of the cell cycle and are most effective against actively dividing cells. Examples include antimetabolites (methotrexate, fluorouracil) acting in S phase and plant alkaloids (vincristine, vinblastine) acting in M phase. These are often given as divided or continuous doses to catch cells in the vulnerable phase. - **Cell-Cycle-Nonspecific Drugs**: Act in any phase, including resting cells. Examples include alkylating agents (cyclophosphamide, nitrogen mustard) and antitumor antibiotics (doxorubicin, daunorubicin). These are typically given as single bolus doses. **The Three Tissue Types Most Affected by Chemotherapy**: 1. **Bone Marrow** (hematopoietic tissue) – produces blood cells; damage causes myelosuppression 2. **Gastrointestinal Mucosa** – causes nausea, vomiting, diarrhea, constipation, stomatitis 3. **Hair Follicles** – causes alopecia (hair loss) These three tissues are among the fastest dividing in the body, explaining why they are hit hardest by chemotherapy. Nurses must anticipate and manage the side effects that arise from this damage.

**Myelosuppression** is the suppression of bone marrow function, resulting in decreased production of all three blood cell lines (red cells, white cells, platelets). It is the **dose-limiting toxicity** of most chemotherapy—meaning it is often the factor that prevents giving higher doses, because severe myelosuppression is life-threatening. **The Three Components of Myelosuppression**: 1. **Neutropenia** (Low Neutrophils) - Neutrophils are the primary defense against bacterial infection - Risk of serious infection increases dramatically when absolute neutrophil count (ANC) falls below 1,000/mm³ - When ANC falls below 500/mm³, the risk of **life-threatening infection** is severe; strict neutropenic precautions are mandatory - Neutropenic patients cannot mount a normal inflammatory response, so they may not develop fever, pus, or localized signs of infection even when experiencing overwhelming sepsis 2. **Thrombocytopenia** (Low Platelets) - Platelets are essential for hemostasis (blood clotting) - Risk of spontaneous bleeding increases when platelet count falls below 50,000/mm³ - Bleeding may be obvious (nosebleeds, heavy menses) or occult (GI bleeding, intracranial hemorrhage) 3. **Anemia** (Low Red Blood Cells) - Results in decreased oxygen-carrying capacity - Causes fatigue, dyspnea, dizziness, and reduced exercise tolerance - May require transfusion or erythropoietin-stimulating agents (though these carry their own risks) **The Nadir: The Point of Greatest Danger** The **nadir** is the lowest point of blood cell counts after a chemotherapy dose, typically occurring **7 to 14 days** after administration, though it varies by drug. This is when the patient is at greatest risk for infection (due to neutropenia) and bleeding (due to thrombocytopenia). Counts are monitored closely during this period, and the next scheduled chemotherapy dose may be delayed if counts have not recovered to a safe level. As a nurse, you must: - Obtain CBC results before and after chemotherapy and during the expected nadir period - Alert the provider immediately if counts fall below critical thresholds - Implement precautions based on ANC and platelet levels - Educate the patient about what the nadir is and why precautions matter **Neutropenic Precautions: A Hierarchy Based on ANC** | ANC Level | Risk Level | Precautions | |-----------|-----------|-------------| | >1,500/mm³ | Normal | None needed | | 1,000–1,500/mm³ | Moderate increase in infection risk | Standard precautions; educate on signs of infection | | 500–1,000/mm³ | HIGH risk | Strict neutropenic precautions | | <500/mm³ | SEVERE; medical emergency risk | Maximal protection; consider protective isolation | **Strict Neutropenic Precautions (ANC <1,000, especially <500)**: 1. **Hand Hygiene**: Meticulous handwashing before all care and at key moments (before eating, after using the bathroom, after coughing/sneezing). Alcohol-based sanitizers are acceptable when soap and water unavailable. 2. **Private Room**: Place the patient in a private room to minimize exposure to pathogens from other patients and healthcare workers. 3. **Visitor Restrictions**: Limit the number of visitors; exclude anyone with signs of infection (cough, cold, fever, diarrhea). Ask visitors to wash hands upon entry. 4. **Avoid Fresh Flowers and Standing Water**: Both harbor bacteria (Pseudomonas, Aspergillus). Plants are also prohibited. 5. **Low-Bacteria Diet** (Strict Neutropenic Diet): - NO raw fruits and vegetables (risk of bacterial contamination) - NO undercooked or raw meats, eggs, or seafood - NO unpasteurized dairy or soft cheeses - NO nuts, seeds, or foods from bulk bins - Cook all food thoroughly; eat warm foods (do not reheat) - This diet is maintained until ANC recovers to >1,000 6. **Minimize Invasive Procedures**: Avoid central lines, urinary catheters, and other invasive devices unless essential. If unavoidable, maintain strict asepsis. 7. **Monitor Temperature Closely**: Take temperature regularly (often every 4 hours or more frequently if patient unwell). Fever in a neutropenic patient is an oncologic emergency (discussed later). 8. **Prophylactic Antibiotics**: Some centers use prophylactic antibiotics (e.g., trimethoprim-sulfamethoxazole) during severe neutropenia, though this is controversial. **Supporting Neutrophil Recovery: Growth Factors** Granulocyte colony-stimulating factors (G-CSFs), such as **filgrastim** (Neupogen) and **pegfilgrastim** (Neulasta), stimulate the bone marrow to produce more neutrophils and can shorten the duration of neutropenia, reducing the risk and severity of infection. These are often given prophylactically or after chemotherapy in patients at high risk, and are standard of care in the Philippines for high-risk situations.

Beyond myelosuppression, chemotherapy causes a constellation of side effects that significantly impact quality of life and adherence. Understanding each and implementing evidence-based nursing care is essential. **1. NAUSEA AND VOMITING (N/V)** Nausea and vomiting are among the most distressing and common side effects, affecting 70–90% of chemotherapy patients. They are driven by: - Direct irritation of the GI mucosa by the drug - Chemotherapy-induced emesis (CIE) via chemoreceptor trigger zone activation - Anticipatory nausea (develops before chemotherapy, due to prior experiences) **Nursing Interventions**: - **Prophylactic Antiemetics**: Give antiemetics BEFORE chemotherapy, not after nausea develops. Standard agents include: - **5-HT3 Antagonists**: ondansetron (Zofran), granisetron (Kytril) – block serotonin receptors; highly effective for acute nausea - **Substance-P/Neurokinin-1 Antagonists**: aprepitant (Emend) – effective for delayed N/V; often given with 5-HT3 antagonist and corticosteroid - **Corticosteroids**: dexamethasone – enhances other antiemetics; often used in combination - **Continue antiemetics around the clock** for at least 2–3 days after chemotherapy, not just on the day of treatment - **Dietary management**: Offer small, frequent, bland meals; avoid hot, spicy, greasy foods; cold foods are often better tolerated - **Hydration**: Monitor intake and output; IV hydration may be needed if vomiting is severe - **Electrolyte monitoring**: Persistent vomiting can cause hypokalemia, hyponatremia, and metabolic alkalosis - **Complementary approaches**: Ginger, acupressure, relaxation, and distraction may help - **Avoid triggers**: Unpleasant smells, sights, and anticipatory anxiety worsen nausea **2. ALOPECIA (HAIR LOSS)** Alopecia is temporary and REVERSIBLE, but it is profoundly distressing because hair is visible and central to body image and self-esteem. **Facts about Chemo-Induced Alopecia**: - Occurs because hair follicles are fast-dividing cells vulnerable to chemotherapy - Typically begins 2–3 weeks after chemotherapy - Hair usually regrows 3–6 months after treatment ends - Sometimes regrowth has a different texture or color (may be curlier or darker) - Affects not only scalp hair but eyebrows, eyelashes, and body hair **Nursing Interventions**: - **Prepare the patient BEFORE hair loss occurs**: Discuss alopecia as a likely side effect, emphasizing that it is temporary - **Suggest alternatives**: Wigs (often covered by insurance; refer to wig services), scarves, turbans, hats, or the option to go bald - **Scalp cooling** (if available): Cold caps or scalp-cooling systems can reduce hair loss by up to 50% by decreasing blood flow to hair follicles during chemotherapy - **Hair care before chemotherapy**: Trim hair short; use mild shampoo; avoid harsh treatments - **Support body image**: Listen without judgment; acknowledge the distress; connect patients to support groups and counseling - **Eyebrow and eyelash loss**: Advise patients they can draw on eyebrows; eyelash loss can be managed with false lashes if desired **3. STOMATITIS AND MUCOSITIS** Stomatitis (inflammation of the oral mucosa) and mucositis (inflammation of any mucous membrane) are painful and can severely impair eating and drinking, risking malnutrition and dehydration. **Pathophysiology**: Chemotherapy damages the rapidly dividing cells of the GI mucosa, particularly the mouth. This typically appears 5–10 days after chemotherapy. **Nursing Interventions**: - **Frequent oral care**: Use a soft toothbrush (or foam swabs if teeth too sensitive); brush after meals and at bedtime - **Rinses**: Saline rinses (warm salt water) or bland rinses (water + baking soda); 4–6 times daily - **AVOID alcohol-based mouthwashes**: Alcohol is irritating and drying - **Topical anesthetics**: Viscous lidocaine (swish and spit, not swallow) or benzocaine spray before eating to reduce pain - **Dietary modifications**: - Soft, bland foods (yogurt, applesauce, mashed potatoes, soup) - Lukewarm or cool foods (avoid hot, which irritates) - AVOID acidic (citrus, tomato), spicy, crunchy, or hard foods - Drink with a straw to bypass oral pain - **Hydration**: Encourage fluids; IV hydration if unable to drink adequately - **Antifungal agents**: If oral candidiasis develops (white patches, pain), prescribe nystatin (swish and swallow) or fluconazole - **Pain management**: Acetaminophen, topical anesthetics, or prescribed analgesics as needed - **Monitor for infection**: Oral mucosa is a portal of entry for bacteria; inspect daily **4. FATIGUE** Cancer-related fatigue is the MOST COMMONLY REPORTED symptom of chemotherapy and is often underestimated by healthcare providers. It is different from normal tiredness: patients report profound exhaustion that does not improve with rest. **Causes**: Anemia, metabolic effects of chemotherapy, emotional stress, sleep disruption, pain, depression **Nursing Interventions**: - **Validate the symptom**: Acknowledge that fatigue is real and significant; it is not 'all in the head' - **Energy conservation**: Teach prioritization of activities; rest before important activities; break tasks into smaller steps - **Schedule rest periods**: Recommend short naps (20–30 minutes) rather than prolonged sleep - **Nutrition and hydration**: Adequate protein, calories, and fluids support energy levels - **Gentle exercise**: Walking, stretching, or yoga can improve energy and mood, even in small doses - **Manage anemia**: Monitor hemoglobin; transfuse if necessary or consider erythropoietin agents - **Sleep hygiene**: Maintain a regular sleep schedule; minimize daytime napping if it disrupts nighttime sleep - **Treat depression**: Fatigue and depression are often intertwined; address with counseling or medication - **Realistic expectations**: Help the patient and family understand that fatigue during treatment is expected and will improve post-treatment **5. DIARRHEA AND CONSTIPATION** Chemotherapy damages the GI mucosa and affects intestinal motility, causing either diarrhea or constipation (sometimes alternating in the same patient). **Diarrhea**: - Results from damage to the intestinal mucosa - Caused by drugs such as 5-fluorouracil, irinotecan - Interventions: Antidiarrheals (loperamide, diphenoxylate); clear liquids; bland diet; hydration; monitor electrolytes **Constipation**: - Common with vinca alkaloids (vincristine, vinblastine) which slow GI motility - Also caused by opioid pain medications, antiemetics, and dehydration - Interventions: Stool softeners (docusate), laxatives (senna, polyethylene glycol), increased fiber and fluids, physical activity - IMPORTANT: **Always prescribe a bowel regimen prophylactically with vincristine**; never give vincristine without a stool softener or laxative order **Vinca Alkaloid-Specific Toxicities**: Beyond constipation, vincristine and vinblastine cause **peripheral neuropathy**—nerve damage manifesting as numbness, tingling, or weakness in the hands and feet. This can be dose-limiting. Assess baseline neurological status and monitor for progression.

**Extravasation** is the unintended leakage of chemotherapy (or other irritant intravenous medication) from the vein into the surrounding subcutaneous tissue. When the leaking drug is **vesicant** (tissue-damaging), extravasation causes severe chemical burns leading to tissue necrosis, scarring, and sometimes permanent loss of function or cosmetic disfigurement. This is a NURSING EMERGENCY requiring immediate action. **Vesicant Chemotherapy Agents** (Most Damaging If Extravasated): - **Doxorubicin** (Adriamycin) – antitumor antibiotic; red color; notorious for severe necrosis - **Vincristine** (Oncovin) – plant alkaloid; causes severe tissue damage - **Cisplatin** – alkylating agent - **Mechlorethamine** – alkylating agent - Many others **Irritant Drugs** (Cause irritation but less severe damage than vesicants): - 5-Fluorouracil, paclitaxel, docetaxel, and others **Non-vesicant Drugs** (Safe even if extravasated): - Bleomycin, carboplatin, etoposide, fluorouracil (when given by central line), and others **Prevention: Your Primary Role as a Nurse** 1. **Verify IV Access Before and During Infusion**: - Check for good blood return from the IV (flashback of blood into tubing) - Assess the insertion site for swelling, redness, coolness, or complaints of pain/burning - Do NOT assume the IV is patent just because it was working earlier; check repeatedly, especially with vesicants - Ask the patient immediately if they feel burning, pain, stinging, or unusual sensations at the IV site 2. **Use Central Lines When Possible**: - For known vesicants or patients requiring repeated chemotherapy, a central venous catheter (CVC) such as a PICC line, port, or tunneled catheter is PREFERRED - Vesicants are safest infused through a CVC because the tip lies in the superior vena cava, a large-diameter vessel, where extravasation is unlikely - Peripheral lines (standard IV) are acceptable for non-vesicants or irritants, but are riskier for vesicants 3. **Secure the IV Carefully**: - Use stabilization devices; tape securely - Use an armboard or splint if needed to prevent movement/flexion at the insertion site - Avoid areas of flexion (antecubital fossa, wrist) if possible; use forearm or hand 4. **Use Appropriate Infusion Techniques**: - Administer vesicants slowly (at least 2–3 minutes for a bolus) to allow early detection of problems - Push vesicants slowly by syringe if using peripheral IV; do NOT infuse rapidly - Run the IV pump slowly; do not use rapid infusions **Recognition of Extravasation: Signs and Symptoms** Early recognition is critical; every minute counts. Signs include: - **Patient report of burning, stinging, or pain at the IV site** (often the EARLIEST sign) - **Lack of blood return** (backflash diminishes or disappears) - **Swelling or edema** at or around the IV site - **Erythema (redness)** in the area - **Coolness or pallor** of the area (compared to other side) - **Leaking from the IV site** (you may see fluid or notice the bandage is wet) - **Resistance to infusion** (fluid is difficult to push, or pump pressure increases) **EMERGENCY ACTION: STOP, ASPIRATE, NOTIFY, TREAT, DOCUMENT** If you suspect extravasation, act IMMEDIATELY: 1. **STOP the infusion immediately** – do not continue pushing the chemotherapy into tissue 2. **Do NOT remove the IV needle immediately** – leave it in place (this is counterintuitive but important) 3. **Aspirate any residual drug from the IV** using a syringe: attach a syringe to the IV, gently aspirate back to remove as much drug as possible from the tissue 4. **Remove the IV after aspiration** and apply a sterile dressing 5. **Notify the provider IMMEDIATELY** and the pharmacist (who can advise on antidotes) 6. **Apply appropriate compresses** (varies by agent): - **COLD compresses**: Most vesicants benefit from cold (constricts vessels, limits spread, reduces pain). Apply ice pack (wrapped in cloth, NOT directly on skin) for 15–20 minutes, 4 times daily for 24–48 hours - **WARM compresses**: Some agents (like vinca alkaloids) benefit from heat (promotes vasodilation and local blood flow). The provider will specify 7. **Elevate the extremity** above heart level 8. **Give antidotes if available**: Some vesicants have specific antidotes (e.g., sodium thiosulfate for mechlorethamine; dexrazoxane for doxorubicin). The provider and pharmacist will guide this 9. **Pain management**: Offer analgesics as prescribed 10. **Photograph the site** (with patient consent) for documentation and follow-up comparison 11. **Document thoroughly**: Time extravasation occurred, drug infused, volume extravasated, location, symptoms, actions taken, patient response, provider notification, and any antidotes given 12. **Follow-up care**: The site must be monitored closely for tissue necrosis. Some extravasations require surgical intervention (debridement, skin grafting) if necrosis develops **Patient Education About Extravasation Risk** Teach the patient: - 'Tell me immediately if you feel burning, stinging, or pain at your IV site. Do not wait.' - 'I will check your IV frequently to make sure it is working properly.' - 'Central lines are safer for strong chemotherapy because the tube goes to a big vein in your chest, not a small vein in your arm.'

Chemotherapy drugs are **hazardous substances**—they are mutagenic (damage DNA), teratogenic (cause birth defects), and carcinogenic (cause cancer). Prolonged exposure can harm healthcare workers, patients' families, and the environment. Safe handling is a professional and ethical responsibility codified in Philippine workplace safety regulations and nursing standards. **Why Safe Handling Matters**: - Nurses and other healthcare workers exposed to chemotherapy over careers have been shown to have increased risks of cancer, reproductive toxicity, and genetic damage - Pregnant nurses who handle chemotherapy face risk of miscarriage and fetal malformations - Contamination of the environment affects the broader community **Personal Protective Equipment (PPE) and Preparation**: 1. **Chemotherapy-Rated Gloves**: - Use double gloves (inner and outer) when handling chemotherapy - Nitrile gloves are standard; latex provides some protection but is less preferred - Nonlatex gloves offer better protection for some agents - Check the gloves for holes or tears before donning - Change gloves if they become contaminated, torn, or after handling each drug 2. **Gown**: - Wear a disposable, fluid-resistant chemotherapy gown - A regular lab coat is NOT sufficient - Gowns protect skin and clothing from spills and splashes 3. **Eye Protection**: - Wear safety glasses or goggles to protect eyes from splashes - Goggles are preferred over glasses because they provide side protection 4. **Respiratory Protection** (If Needed): - Generally not needed for IV administration - May be required during preparation of oral or inhaled chemotherapy 5. **Apron** (Optional): - A plastic apron over the gown provides additional protection **Drug Preparation Safety**: 1. **Biological Safety Cabinet**: - All chemotherapy drug preparation MUST occur in a **biologic safety cabinet (BSC)**, also called a Class II or Class III hood - A BSC is a ventilated cabinet with a HEPA filter that removes aerosolized drug particles and protects both the worker and the environment - Drug preparation at the patient bedside or in an open area is NEVER acceptable - The BSC should be certified annually 2. **Technique for Preparation**: - Work within the BSC; do not lean across or work outside the hood - Use aseptic (sterile) technique to prevent contamination - Use alcohol pads and gauze to minimize aerosolization - Never recap needles; use needleless systems when possible - If a needle must be used, recap using a one-handed scoop technique **Special Considerations for Pregnant Nurses**: - **Pregnant nurses MUST NOT handle chemotherapy** during pregnancy due to teratogenic risk - **Pregnant nurses MUST NOT care for patients with internal radioactive implants** (brachytherapy) due to radiation exposure - Pregnant nurses should inform their manager to allow reassignment to non-chemotherapy and non-radiation patient care during pregnancy - This is both a professional standard and often a legal requirement **Patient Body Fluid Precautions**: - Chemotherapy drugs are excreted in body fluids (urine, feces, vomit, saliva, sweat) for **approximately 48 hours** after chemotherapy administration - These fluids are hazardous and must be handled with special precautions - **Precautions**: - Wear gloves and gown when handling patient body fluids - Double-flush toilets after patient use (or use special chemotherapy toilet liners) - Double-bag soiled linens and mark as hazardous - Properly dispose of incontinence pads and similar items - Teach patients to flush twice after urinating/defecating for 48 hours post-chemotherapy - Teach patients to wash hands after bathroom use - In home settings, caregivers use gloves when handling soiled items **Disposal of Chemotherapy Waste**: 1. **Cytotoxic/Hazardous Waste Containers**: - All chemotherapy-contaminated materials MUST be placed in designated **cytotoxic or hazardous waste containers** - These are usually yellow, labeled with a biohazard symbol - Regular trash is NOT acceptable - Items include: unused chemotherapy vials, syringes, needles, tubing, gloves, gowns, gauze, alcohol pads 2. **Sharps**: - Chemotherapy needles and sharps go into a **chemotherapy sharps container**, separate from regular sharps containers 3. **Unused/Expired Chemotherapy**: - Unused or expired chemotherapy drugs must be returned to the pharmacy for proper disposal by a hazardous waste company - Never dispose of chemotherapy in regular trash or sink **Spill Management**: 1. **Small Spills** (e.g., less than 5 mL or 5 g): - Evacuate the area; post a warning sign - Put on appropriate PPE (double gloves, gown, eye protection) - Contain the spill using absorbent material (paper towels, absorbent pads) - Clean the area with soap and water, then with an appropriate disinfectant (e.g., 70% ethanol) - Place all contaminated materials in a cytotoxic waste container - If skin contact occurs, wash with copious water; if eye contact, flush with water and notify first aid 2. **Large Spills** (e.g., greater than 5 mL or 5 g): - Evacuate the area; call for help - Do not attempt to clean alone - Use a chemotherapy spill kit (available in most institutions) containing absorbent material, gloves, gowns, and a hazardous waste container - Follow institutional protocol; may require specialized hazmat cleanup - Document the spill: what spilled, where, when, who was exposed, actions taken **Exposure Incidents**: If you are exposed to chemotherapy (skin contact, eye contact, needle stick): - Wash the affected area immediately with copious water for at least 5 minutes - For eye exposure, flush with water for 15 minutes and seek medical attention - Report the incident to your manager and occupational health - Document in the incident report - Seek medical evaluation; baseline labs may be recommended - In the Philippines, such incidents must also be reported to the Department of Labor (if serious) per workplace safety regulations **Institutional and Professional Standards**: - The **Philippine Nurses Association (PNA)** and **Professional Regulation Commission (PRC) Board of Nursing** recognize safe chemotherapy handling as a core nursing competency - Many institutions have **chemotherapy safety committees** that oversee protocols, training, and incident reporting - **Annual competency assessments** of nurses handling chemotherapy are standard and required by most accrediting bodies - **Documentation** of chemotherapy handling education in your employee file is important for medicolegal protection

Radiation therapy uses high-energy ionizing radiation (X-rays, gamma rays, electron beams, protons) to damage the DNA of cancer cells, causing them to die. Unlike chemotherapy, which is SYSTEMIC, radiation is a **LOCAL** treatment—it targets a specific area of the body. Side effects are therefore confined to the irradiated field. **How Radiation Works**: - Ionizing radiation damages the DNA double helix, preventing cells from dividing and leading to cell death - Cancer cells are generally more sensitive to radiation because they divide rapidly and often have defective DNA repair mechanisms - Normal cells within the field are also damaged, but are more capable of repair than cancer cells - The goal is to maximize cancer cell kill while minimizing normal tissue damage (the therapeutic ratio) **Two Main Types of Radiation Therapy** **1. EXTERNAL BEAM RADIATION (Teletherapy)** A linear accelerator (LINAC) machine outside the body delivers radiation to a targeted field. The patient receives multiple fractionated doses (typically daily for 5–8 weeks) to allow normal tissue to repair between treatments. **Key Point About External Radiation**: **The patient is NOT radioactive and poses NO radiation risk to others. Family members, children, and healthcare workers are safe.** Radiation is delivered, then the machine turns off; the patient does not carry radiation home. **Simulation and Planning**: - Before treatment begins, a **simulation appointment** is conducted to map the exact area to be irradiated - The radiation oncologist and physicist design the treatment plan to deliver the prescribed dose to the tumor while minimizing dose to normal tissues - **Skin markings** (small permanent or semi-permanent tattoos, or washable marks) are placed on the patient's skin to mark the field boundaries and ensure precise targeting each day - A CT or MRI scan is obtained and used for treatment planning **Treatment Course**: - The patient lies still on the treatment table while the LINAC rotates around the body, delivering radiation from multiple angles - Each treatment takes 15–30 minutes - Treatments are typically given 5 days a week (Monday–Friday) for 2–8 weeks, depending on the cancer and protocol - Treatment is painless; the patient feels and sees nothing during radiation delivery **Common Sites and Typical Courses**: - Breast cancer: 6 weeks (5 days/week) after surgery - Head and neck cancer: 6–7 weeks (high dose to tumor) - Prostate cancer: 8 weeks or hypofractionated (fewer, larger doses) over 4 weeks - Lung cancer: 5–8 weeks - Palliative (symptom relief): 1–2 weeks **2. INTERNAL RADIATION (Brachytherapy)** A radioactive source is placed directly inside or next to the tumor, delivering a high dose of radiation locally over a short time. Common types: **Sealed Brachytherapy**: - A sealed radioactive implant (e.g., a seed, wire, or applicator containing cobalt-60, iridium-192, or cesium-137) is surgically placed inside the tumor or body cavity (e.g., cervical cancer, endometrial cancer, prostate cancer) - The implant remains in place for a set duration (hours to days), then is removed under anesthesia - The source is sealed; radiation stays contained within the implant and does not escape into body fluids **Unsealed Brachytherapy**: - Radioactive material in liquid or capsule form (e.g., radioactive iodine-131 for thyroid cancer) is given orally or IV - The material circulates in the body and concentrates in the target tissue (thyroid, bone, etc.) - The source is NOT sealed; it is excreted in body fluids (urine, sweat, saliva) making these fluids radioactive **Key Point About Internal Radiation**: **WHILE THE SOURCE IS IN PLACE OR CIRCULATING, THE PATIENT EMITS RADIATION AND IS A SOURCE OF EXPOSURE TO OTHERS.** This requires special precautions and limits to visitors and caregivers. **Acute Side Effects of Radiation** Side effects depend on the area irradiated and the total dose. They appear weeks into treatment (not immediately) and result from damage to normal tissue in the field: **Skin (Radiodermatitis)**: - Erythema (redness), similar to sunburn - Dry desquamation (dry, flaky skin) - Wet desquamation (blistering, weeping) in severe cases - Itching and discomfort - Usually begins after 1–2 weeks of treatment - Peaks at end of treatment and may worsen for 1–2 weeks after treatment stops - Heals over weeks to months; severe cases may leave hyperpigmentation or atrophy **GI Tract** (if abdomen or pelvis irradiated): - Nausea and vomiting - Diarrhea - Abdominal cramping - Loss of appetite - Rectal irritation (proctitis) if lower pelvis irradiated **Lungs** (if chest irradiated): - Cough - Dyspnea (shortness of breath) - Can progress to pneumonitis (inflammation) or fibrosis (scarring) if high doses **Mouth and Throat** (if head/neck irradiated): - Stomatitis and mucositis (similar to chemotherapy) - Dry mouth (xerostomia) due to salivary gland damage; can be permanent - Taste changes - Difficulty swallowing **Hair Loss** (in the treated field only, not body-wide like chemotherapy): - Hair loss occurs only within the radiation field - For head/neck radiation, scalp hair loss is common - Hair regrows after treatment, like with chemotherapy **Fatigue**: - Common during and after radiation - Results from the body's energy expenditure on healing **Late Effects** (Months to Years Post-Radiation): - Tissue fibrosis (scarring and stiffness) - Reduced range of motion (e.g., shoulder stiffness after breast radiation) - Secondary cancers (increased risk in high-dose areas) - Cognitive changes (if brain irradiated) - Cardiac toxicity (if heart within field) - Infertility or premature menopause (if ovaries irradiated) **Skin Care During External Radiation: A Detailed Nursing Guide** Radiodermatitis is almost universal with external radiation and is the most bothersome acute side effect. Your teaching is crucial. **Skin Care Principles**: 1. **DO NOT WASH OFF THE RADIATION MARKINGS**: - These marks (small tattoos or washable marks) define the treatment field - Removing them means the next day's treatment will not target the correct area, risking miss or overdose - If a mark fades, inform the radiation therapist; they will redraw it 2. **Gentle Cleansing**: - Wash the irradiated area gently with **lukewarm water and mild soap** only - Pat dry gently; do NOT rub - Wash immediately around the area but not harshly over it 3. **AVOID Lotions, Powders, Deodorants, Perfumes** (Unless Prescribed): - Many lotions and powders contain metals (talc, zinc oxide, aluminum) that can absorb radiation and alter the dose, worsening dermatitis - Some products can trap heat and moisture, increasing irritation - Only use products approved by the radiation oncologist (usually plain aloe vera gel or unscented moisturizer if needed) - Deodorants and perfumes are irritating; avoid them on the irradiated area 4. **Protect from Sun, Heat, and Cold**: - **Avoid direct sunlight**: Sun exposure worsens dermatitis and increases risk of skin cancer long-term. Wear protective clothing or sunscreen (SPF 30+) if sun exposure unavoidable, starting 3 months after treatment ends (not during treatment, due to products) - **Avoid extreme heat and cold**: Do not use heating pads, hot water bottles, or ice packs on the area; tepid water only - **Avoid saunas, hot tubs, and hot showers** during treatment 5. **Clothing**: - Wear **soft, cotton clothing** over the irradiated area - Avoid tight bras, waistbands, or snug clothing that might rub the area - Bra straps should not rest on irradiated skin if possible; consider a soft cotton bra or going without during treatment - Avoid synthetic fabrics that trap heat and moisture 6. **Avoid Scratching and Rubbing**: - Dermatitis itches; scratching damages skin and introduces infection risk - Use cool compresses for itching relief, not scratching - Keep nails short - Use unscented moisturizer for itching if approved 7. **Shaving and Hair Removal**: - Use an **electric razor** only (no blade razors); do not shave the irradiated area if possible, because nicks introduce infection risk to compromised skin - If shaving necessary, use an electric razor and gentle technique - Do NOT use depilatory creams (chemical irritation) 8. **Nutrition and Hydration**: - Adequate protein and vitamins support skin healing - Vitamin C and zinc are particularly important for skin repair **Nursing Assessment During Radiation**: At each visit, assess the skin in the irradiated field: - Erythema grade (0 = none, 1 = light, 2 = bright red, 3 = confluent, 4 = blistering/weeping) - Dry vs. wet desquamation - Itching, pain, or other symptoms - Document and report progression to the radiation oncologist - Adjust skin care and symptom management as needed **Treatment of Radiodermatitis**: If dermatitis develops despite prevention: - **Cool compresses**: Wet gauze or hydrogel packs for 15–20 minutes, several times daily - **Soothing products**: Aloe vera gel (refrigerated), plain moisturizers, or barrier creams approved by the radiation oncologist - **Pain management**: Acetaminophen or topical anesthetics if pain is significant - **Topical antibiotics**: If infection develops - **Avoid further irritation**: All preventive measures intensified - **Rarely, break from treatment**: If dermatitis is severe and painful, a brief break (few days) may allow healing before resuming **Patient Teaching Summary for External Radiation**: 'Your skin in the treatment area will get red and irritated, like a bad sunburn. Here's how to protect it: - Do NOT wash off the marks—they are your 'target.' - Wash gently with lukewarm water and mild soap only. - NO lotions, powders, deodorants, or perfumes on the area—they can make it worse. - Protect from sun and heat; wear soft cotton clothing. - Avoid scratching; use cool compresses for itching. - Use an electric razor if you must shave. - Eat well—good nutrition helps healing. - Tell us immediately if blistering develops.'

When a patient has an **internal radioactive source** (brachytherapy implant or unsealed radioactive material), special precautions are essential to protect healthcare workers, visitors, and family members from radiation exposure. These precautions follow the three principles of radiation protection: **Time, Distance, and Shielding**. **THE THREE PRINCIPLES OF RADIATION PROTECTION** **1. TIME (Minimize Time Near the Source)** - Limit the duration of direct care and time spent in the patient's room - Organize care to be efficient: gather supplies before entering, combine multiple care tasks into one visit, minimize conversation - Explain to the patient: 'I will visit you often, but I will keep each visit brief to protect my health. I will call you to check on you between visits.' - Staff assignments should be rotated so no one nurse receives excessive cumulative exposure **2. DISTANCE (Maximize Distance from the Source)** - Maintain maximum safe distance from the radioactive source - Radiation intensity decreases sharply with distance (inverse square law: doubling distance reduces exposure to 1/4) - Care for the patient from the foot of the bed when possible, rather than leaning close - Do not linger at the bedside - Visitors should stand at least 2 meters away (6 feet) from the patient if possible **3. SHIELDING (Use Physical Barriers)** - **Lead shielding** reduces radiation exposure; place lead shields between the source and staff/visitors if possible - A **lead apron** can be worn by staff, though it adds weight and may not be practical for long-term care - The room itself provides some shielding, so caring for the patient through a partially closed door is acceptable if possible **PRECAUTIONS FOR SEALED IMPLANT (E.G., BRACHYTHERAPY CATHETER)** **Room Assignment**: - Place the patient in a **private room** (not a shared room) - Post signs on the door: 'RADIOACTIVE IMPLANT—RESTRICTED ENTRY' with radiation symbol - Only authorized personnel (nurses, physicians, radiation oncologist) enter the room - Housekeeping does NOT enter; you perform basic hygiene and tidy the room **Nursing Staff**: - Assign a **dedicated primary nurse or team** to care for this patient during the implant period, rotating every 8 hours to limit cumulative exposure - All staff caring for the patient must wear a **radiation dosimeter (film badge)** that measures and records their personal radiation dose - Log the time spent in the room by each caregiver; this is tracked for radiation safety records **Visitors**: - **Pregnant women and children MUST NOT visit or enter the room** (developing fetuses and children are more radiosensitive) - **No pregnant staff members should care for the patient** - Adult visitors are limited in number and time: typically 1–2 visitors, brief visits (30 minutes or less), and usually standing at the far end of the room - Educate visitors about the purpose of precautions: 'The implant is treating the cancer; these precautions keep you safe from radiation while visiting.' - Visitors should NOT touch the patient if the implant is external (e.g., vaginal, rectal applicators); if patient must be touched (e.g., hand-holding), keep contact brief and at maximum distance **Critical Equipment at the Bedside**: - **A lead-lined container** ("lead pot") must be kept in the room - **Long forceps** (at least 12 inches) must be kept in the room - **Purpose**: If the implant becomes dislodged (falls out), you must be able to pick it up with forceps, place it immediately in the lead-lined container, and notify the radiation oncologist STAT - **NEVER touch a dislodged radioactive source with bare hands**; this would expose your hand to high radiation - Practice identifying these items daily **Patient Care During Implant**: - **Bed Rest**: Most implants require strict bed rest to prevent displacement; explain this to the patient - **Positioning**: The patient's position may be specified to keep the implant in place (e.g., lying flat, or with a pillow between knees for vagical implants) - **Bowel and Bladder**: Prevent straining; provide stool softeners and adequate fluids; urinary catheter may be in place - **Nutrition**: Soft, bland diet (implants are typically GI cancer or gynecologic cancer, so patients are uncomfortable with solid foods); IV fluids support hydration - **Pain Management**: Offer analgesics; pain is expected and does not indicate harm - **Hygiene**: Provide bed bath and linen changes without disrupting the implant; discuss with radiation oncologist if the implant is removable (some are, some stay in place) - **Psychological Support**: Explain the procedure, reassure about safety, and check on emotional state. Anxiety is common with restricted activity and isolation **Precautions for Unsealed Sources (E.G., RADIOACTIVE IODINE)** Unsealed sources (liquid or capsule form) are absorbed or ingested and circulate in the body, being excreted in urine, sweat, saliva, feces, and other body fluids. These fluids are RADIOACTIVE and require precautions. **Room and Precautions**: - Private room (often with private bathroom) - Radioactive materials precautions sign on door - **Double-flush toilets** after each use (the first flush captures the initial urine; the second flush ensures complete dilution and removal) - Some institutions use special **absorbent pads** in toilets to contain the radioactive material - Linens soiled with body fluids must be handled specially (segregated and allowed to decay before disposal; the facility determines this timeline) - **Gloves and gowns** when handling the patient or soiled items - Pregnant staff and children should NOT enter **Patient Education for Unsealed Sources**: - Explain that body fluids are radioactive; this is expected and not harmful to the patient - 'Use the toilet normally. Flush twice.' - 'Wash your hands after using the bathroom.' - 'If you spill urine or vomit, notify us immediately; we will clean it.' - 'Wash your clothes separately and let them dry before they are laundered with others.' - 'Maintain distance from others (at least 1 meter/3 feet) to limit their exposure.' **Monitoring and Removal of Implants**: - The radiation oncologist determines when the implant has delivered the prescribed dose and when it can be removed - **Afterloading brachytherapy** (where the radioactive source is inserted after the applicator is in place): removal of the source is usually quick (seconds); the applicator can then be removed without contamination - Once the source is removed, precautions can be discontinued immediately; the patient is no longer radioactive and poses no risk - Teach the patient: 'Once I remove the implant, the radiation is gone, and you can have visitors and go home normally.' **Nursing Duties During Brachytherapy**: 1. Maintain a log of time in the room and staff exposure 2. Don radiation dosimeter before each shift 3. Keep lead-lined container and forceps accessible 4. Organize care for efficiency (time principle) 5. Maintain maximum distance during all care (distance principle) 6. Educate visitors on precautions 7. Support patient emotionally during isolation 8. Monitor for implant displacement or dislodgement (daily assessment) 9. Manage pain, bowel/bladder, nutrition, and hygiene 10. Report removal of the source to radiation oncology and discontinue precautions once cleared

**Surgery** is the oldest and remains one of the most effective cancer treatments. It plays multiple roles in cancer management and must be coordinated with other modalities. As a nurse, you provide perioperative care with special attention to the cancer patient's often-compromised physical and psychological status. **ROLES OF SURGICAL ONCOLOGY** 1. **Diagnosis (Biopsy)** - A tissue sample is obtained surgically to confirm cancer and determine histology, grade, and stage - Examples: core needle biopsy, open biopsy, endoscopic biopsy - Biopsy informs all subsequent treatment decisions 2. **Curative Resection** - Complete surgical removal of localized cancer with adequate margins (surrounding normal tissue) - Most effective when cancer is confined to one site and has not spread systemically - Examples: mastectomy for early breast cancer, colectomy for colon cancer, nephrectomy for kidney cancer, prostatectomy for prostate cancer - Goal is complete removal of all visible and microscopic disease 3. **Debulking (Cytoreduction)** - When cancer cannot be completely removed (e.g., advanced ovarian cancer with widespread peritoneal implants), surgery aims to remove as much tumor burden as possible - Remaining cancer is treated with chemotherapy, which works better on smaller tumor volumes - Debulking improves quality of life and extends survival even if cure is not possible 4. **Palliation** - Surgery to relieve symptoms in advanced cancer - Examples: - Bypass surgery to relieve bowel obstruction - Draining ascites (fluid) for patient comfort - Fixing pathologic fractures or spinal cord compression - Removing a bleeding tumor - Palliative resection may prolong survival but primary goal is comfort 5. **Prevention/Prophylaxis** - Removal of high-risk tissue before cancer develops - Examples: prophylactic mastectomy in BRCA1/2 mutation carriers, colectomy in familial adenomatous polyposis - Less common but increasingly important as genetic testing improves 6. **Reconstruction** - Restoring appearance and function after tumor resection - Examples: breast reconstruction after mastectomy, facial reconstruction after head and neck cancer surgery - May be performed immediately (at same surgery) or delayed (months later) - Often done by plastic surgeons; dramatically improves quality of life and body image **PERIOPERATIVE NURSING CARE FOR CANCER PATIENTS** **Preoperative Phase**: - **Comprehensive Assessment**: - Baseline functional status (patient may be weakened by cancer or prior treatments) - Cardiopulmonary status (critical for extended surgeries or elderly patients) - Nutritional status (malnutrition is common in cancer; adequate protein supports wound healing) - Bleeding tendency (some cancers cause coagulopathy; chemotherapy causes thrombocytopenia) - Medication interactions (some chemotherapy drugs interact with anesthetics; NSAIDs and anticoagulants must be held) - **Education**: - Explain the surgery, expected limitations post-op, and role of surgery in overall cancer treatment - Teach deep breathing, leg exercises, and early mobilization (critical post-op) - For extensive surgery or reconstruction, discuss length of recovery and timeline for return to function - Address psychological concerns: many patients fear the surgery will worsen cancer or cause disfigurement - **Staging Assessment**: - Imaging (CT, MRI, PET) confirms extent of disease and surgical feasibility - Labs (CBC, metabolic panel, PT/INR, Type and Cross if bleeding risk) ensure readiness - Cardiac workup if indicated (cancer patients have high cardiac disease burden) **Intraoperative Phase**: - Operating room nurses coordinate with oncologic surgeons - Specimen handling: cancerous tissue must be labeled, preserved correctly, and sent to pathology immediately for analysis - Adequate hemostasis (bleeding control) is critical; cancer surgery often involves extensive tissue planes - Monitoring anesthesia and fluid balance (extensive surgery causes third-space fluid shifts) **Postoperative Phase**: - **Pain Management**: Effective pain control supports early mobilization and healing; use multimodal analgesia (opioids, acetaminophen, NSAIDs if not contraindicated) - **Wound Care**: Inspect for signs of infection, hematoma, or dehiscence; cancer patients are immunocompromised; infection is serious - **Drains and Tubes**: Many cancer surgeries leave surgical drains (Jackson-Pratt, Hemovac) to prevent fluid accumulation; empty, measure, and monitor drainage - **Nutritional Support**: Protein-rich diet supports tissue repair; dietitian consultation is important - **Early Mobilization**: Despite pain, early walking prevents thromboembolism, pneumonia, and deconditioning; use pain medication before activity - **Anticoagulation**: Many patients require DVT prophylaxis (sequential compression devices, low-molecular-weight heparin) because cancer increases thrombotic risk - **Lymphedema Prevention** (if lymph nodes removed): Teach arm/leg care, precautions to avoid infection, and when to report swelling (lymphedema can develop months or years post-op) - **Psychological Support**: Post-operative blues are common; validate fears and connect to support resources - **Planning for Next Treatment**: Surgery is often the first step; coordinate timeline for adjuvant chemotherapy or radiation with the surgical team **SPECIAL CONSIDERATIONS FOR CANCER SURGICAL PATIENTS** 1. **Extended Surgeries**: Some cancer operations take 4–8 hours (extensive debulking, major reconstruction). Nursing must prevent complications of prolonged anesthesia (hypothermia, pressure injuries, nerve compression). 2. **Extensive Blood Loss**: Major cancer surgery can cause significant bleeding, requiring transfusion. Consent for blood products and autologous (own) blood donation should be discussed preoperatively. 3. **Chemotherapy Effects**: Recent chemotherapy may cause low counts (thrombocytopenia, anemia, neutropenia), delaying surgery or requiring special precautions. 4. **Radiation Effects**: Prior radiation may cause tissue fibrosis, poor wound healing, and reduced vascularity; surgeons must account for this. 5. **Distant Metastasis**: Surgery for primary tumor does not treat metastatic disease; patient counseling about prognosis is important. 6. **Body Image and Psychological Impact**: Disfiguring surgeries (amputation, mastectomy, colostomy, laryngectomy) profoundly affect self-esteem and sexuality; early psychological support and peer counseling are essential.

Over the past 10 years, cancer treatment has shifted from broad-based cytotoxic chemotherapy toward therapies that target specific molecules or unleash the immune system. These newer modalities are more selective, often causing fewer side effects than chemotherapy, but they have their own toxicity profiles that nurses must understand. **TARGETED THERAPY: ATTACKING SPECIFIC CANCER MOLECULES** Targeted therapies work by blocking specific molecular pathways or proteins essential for cancer cell survival and growth. They are designed to hit cancer cells while sparing normal cells, though some normal cells expressing the target are affected. **Examples and Mechanisms**: 1. **Monoclonal Antibodies**: - Synthetic antibodies that bind to specific antigens on cancer cells or supportive tissue - **Trastuzumab (Herceptin)**: Binds to HER2 protein on breast cancer cells (HER2-positive tumors); blocks growth signaling - Nursing considerations: Monitor cardiac function (ejection fraction) before and during treatment; trastuzumab can cause cardiomyopathy - Teach patient: 'You will have heart function tests before chemotherapy; heart problems are possible but rare.' - **Rituximab (Rituxan)**: Binds to CD20 on B-cell lymphomas; depletes B cells - Nursing considerations: Infusion reactions common with first dose (fever, chills, rigors); premedicate with acetaminophen, diphenhydramine, and corticosteroid; monitor vital signs closely during infusion - Teach: 'Your first infusion may cause chills and fever; this is expected and will be managed.' 2. **Tyrosine Kinase Inhibitors (TKIs)**: - Small molecules that block intracellular tyrosine kinases, stopping growth signaling - **Imatinib (Gleevec)**: Inhibits BCR-ABL kinase in chronic myeloid leukemia (CML) and c-KIT in gastrointestinal stromal tumors (GISTs) - Nursing considerations: Usually given orally; monitor for cytopenias, GI upset, fluid retention - Many other TKIs are available for various cancers (erlotinib for lung, sorafenib for kidney, etc.) - Nursing considerations: Oral medications allow outpatient management; educate on consistent timing and interaction with foods; monitor for adverse effects **Advantages of Targeted Therapy**: - More selective: hits cancer-specific molecules - Often fewer side effects than chemotherapy (alopecia, severe nausea, myelosuppression less common) - Some can be oral (improved quality of life) - Potential for long-term disease control or remission **Disadvantages**: - Cancer may develop resistance (acquired mutations) - Cost is often very high - Some (e.g., trastuzumab) still require IV infusion - Side effects are drug-specific and sometimes unexpected **IMMUNOTHERAPY: HARNESSING THE IMMUNE SYSTEM** Immunotherapy awakens the patient's own immune system to recognize and destroy cancer cells. Several classes exist: 1. **Interferons and Interleukins**: - **Interferon-alpha**: Activates natural killer cells and enhances antigen presentation; used for melanoma and some lymphomas - **Interleukin-2**: Stimulates T-cell proliferation and activation; used for melanoma and renal cell cancer - **Side effects**: Flu-like symptoms (fever, chills, myalgias), fatigue, nausea; can be dose-limiting - **Nursing care**: Premedicate with acetaminophen before infusion; educate patient that "flu-like" symptoms are expected, temporary, and indicate the immune system is being activated 2. **Immune Checkpoint Inhibitors (ICIs)**: - Cancer cells express PD-L1 and other molecules that trick immune T cells into "standing down" (immune evasion) - ICIs block these "off" signals, reactivating T cells to attack cancer - **Examples**: - **Pembrolizumab** (Keytruda): Anti-PD-1; used for melanoma, lung cancer, others - **Nivolumab** (Opdivo): Anti-PD-1 - **Atezolizumab** (Tecentriq): Anti-PD-L1 - **Side effects**: **Autoimmune and inflammatory**: Can cause colitis, pneumonitis, hepatitis, thyroiditis, glomerulonephritis, myositis—essentially, autoimmunity in any organ - Incidence varies (20–60% of patients experience immune-related adverse events, though many are mild) - Serious events (grade 3–4) occur in 5–15% of patients - Can be fatal if not recognized and treated promptly (e.g., immune-mediated pneumonitis) - **Nursing care**: - Educate the patient on symptoms of autoimmunity: diarrhea/colitis (>4 stools/day, abdominal pain), shortness of breath/cough (pneumonitis), yellowing of skin/eyes (hepatitis), rashes, joint pain, palpitations - '**Report these symptoms immediately—do not wait**,' you must emphasize - Monitor baseline and regular labs: CBC, liver enzymes, thyroid function, creatinine - Treatment of immune-related adverse events: high-dose corticosteroids (dexamethasone, methylprednisolone IV) to suppress the errant immune response - Hold ICI if severe immune-related adverse event develops; may restart at lower dose if toxicity resolves **INFUSION AND HYPERSENSITIVITY REACTIONS** Many targeted agents (especially monoclonal antibodies) and all immunotherapies are given IV. Infusion reactions and hypersensitivity can occur, particularly on first exposure. **Management of Infusion Reactions**: 1. **Premedication**: Before first infusion, give acetaminophen, diphenhydramine, and (for some agents) corticosteroid 2. **Monitoring**: During infusion, monitor vitals closely; slow the infusion rate initially 3. **Recognition of Reaction**: Fever, chills, rigors, flushing, rash, dyspnea, hypotension, chest discomfort 4. **Response**: - **STOP the infusion immediately** - Place patient in recumbent position (Trendelenburg if hypotensive) - Establish IV access if not present; run NS - Call for provider/physician - Prepare emergency equipment (oxygen, epinephrine, airway equipment) - Continue monitoring vitals - **Do NOT restart infusion without provider order** 5. **After Reaction**: - Investigate cause (true allergic vs. inflammatory) - Rechallenge may be possible with slower infusion rate and more aggressive premedication - Some patients tolerate second and subsequent infusions without reaction once tolerance develops **Patient Education for Targeted and Immunotherapy**: - 'These drugs are designed to kill cancer while sparing normal cells, so side effects may be different from chemotherapy.' - 'Some come as pills you take at home; others require infusions in the clinic.' - 'Report new symptoms or changes immediately—some immune therapies can cause autoimmune reactions in any part of your body.' - 'Blood tests are done regularly to catch any problems early.' - 'These are new drugs; we are learning about them alongside you.'