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Clinical Concerns Late and Long-term Physical Effects... Continued from cover In general, different treatment approaches have specific sets of side effects. Surgery Surgery, depending on the site, may cause alterations in function (ie, ostomy, malabsorption, incontinence, or neuropathic injury and pain). Nutritional deficits or chronic pain may occur secondary to surgical interventions. Lymphedema is related to the surgical removal of lymph nodes or disruption of lymphatic circulation. Late-occurring lymphedema can develop within 1 year of treatment or more than 20 years after treatment. Evaluating patients for either upper or lower extremity edema, depending on the surgical site, is important to help identify lymphedema early and prevent further injury to the extremity and minimize the extent of swelling. Chemotherapy Chemotherapy is associated with multiple acute side effects, but extended follow-up research has identified long-term and late effects related to specific classes of drugs. The late effects of anthracyclines on cardiac function have been recognized since the 1970s.1 The long-term risk of developing congestive heart failure and conduction defects related to anthracycline and trastuzumab use are widely recognized. Age, combination therapy, radiation therapy to the chest, and preexisting cardiac disease are known to contribute to the risk.3,4 Bleomycin may cause an acute hypersensitivity reaction and, for some, this may develop into delayed pulmonary fibrosis. Contributing risk factors in-
Denice Economou, RN, MN, CNS, AOCN
Patients who have received chest radiation, such as those with breast cancer, lung cancer, or Hodgkin disease, may also experience radiation-related pneumonitis, which can manifest as early as 1 to 3 months posttreatment or as late as 24 months posttreatment. clude age, concomitant radiation therapy, and cumulative dosing.5 Nitrosoureas have also been associated with pulmonary fibrosis. Patients who have received conditioning regimens for allogeneic or autologous bone marrow transplants are at risk, and the presence of graft-versus-host disease further increases the risk for pulmonary fibrosis. Methotrexate can lead to liver fibrosis and chronic hepatitis and, for those with baseline hepatitis B or C, methotrexate may reactivate viral hepatitis.6 Cisplatin can lead to nephrotoxicity by damaging the proximal tubules, and this can persist long term. Cisplatin toxicity is cumulative, commonly occurring
Table Major System Consequences of Cancer and Its Treatments System Cognitive/sensory
Consequences “Chemobrain” Slower responses Hearing loss Visual changes Neuropathy
Cardiovascular
Cardiomyopathy Effects on pericardium Myocardium Conduction Coronary arteries/valves Pulmonary fibrosis Interstitial lung disease Obstruction
Pulmonary
Gastrointestinal
Malabsorption Anatomic and functional changes Ischemia and fibrosis
Renal
Chronic kidney disease
Endocrine
Hypothyroidism Adrenal insufficiency Diabetes mellitus Hypothalamus Pituitary gland
Adapted from Reference 1.
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September 2010 I VOL 3, NO 6
Marcia Grant, RN, DNSc, FAAN
when doses are greater than 1200 mg/m2. This can lead to chronic kidney disease (CKD). Cyclophosphamide and ifosfamide, both alkylating agents, can also lead to CKD.7 Platinum agents as well as vinca alkaloids are associated with ototoxicity and hearing loss secondary to inner ear damage. Additional side effects secondary to chemotherapy include postchemotherapy rheumatism syndromes and chronic immunosuppression.8 Radiation therapy Radiation side effects correlate to the anatomic areas radiated. Chest radiation for Hodgkin disease or lung cancer, for instance, may lead to pericarditis, pericardial effusion, and interstitial fibrosis. In patients with lung cancer, chest radiation can reduce left ventricular volume and cause perfusion deficits that lead to dyspnea and coronary artery disease (CAD). Patients with other risk factors for CAD, such as hypertension, hyperlipidemia, and a history of smoking, are at higher risk.9 The risk for a fatal myocardial infarction in patients treated with mantel field radiation is 40 times higher than the baseline risk.10 This includes patients with Hodgkin disease as well as those with left breast, esophageal, and lung cancers. Patients who have received chest radiation, such as those with breast cancer, lung cancer, or Hodgkin disease, may also experience radiation-related pneumonitis, which can manifest as early as 1 to 3 months posttreatment or as late as 24 months posttreatment.11 Thoracic radiation may lead to fibrosis of the sinus node, muscular dysfunction, or complete heart block. Pulmonary complications may be short-lived, but as many as 50% of patients who have received thoracic radi-
ation will experience some late-effect pulmonary complications.12 The hope is that newer techniques that minimize radiation exposure of healthy tissues will reduce the risk for these posttreatment complications. Radiation to the gastrointestinal tract causes significant physical side effects. As with surgical interventions, nutritional and functional changes can occur. Because of the increased damage related to rapid cell turnover and the large surface area of mucosa, the gastrointestinal system is particularly vulnerable. Bowel dysfunction, pain, bloating, late complications of fibrosis, and vasculitis can severely affect quality of life.13 There is also the possibility of a second cancer occurring in the radiation field. Head and neck radiation, depending on the site, may cause ototoxicity, balance issues, or chronic nausea.14,15 Conclusion Patients may experience multiple symptoms and side effects related to their cancer and its treatment. It is essential for healthcare providers to recognize the ramifications of the therapies our patients receive and to attempt to be proactive in educating them about side effects and minimizing them whenever possible. Providing the greatest quality of life for our patients, regardless of their quantity of life, is what matters most. ● References 1. Miller KD, Triano LR. Medical issues in cancer survivors—a review. Cancer J. 2008;14:375-387. 2. Rowland JH. What are cancer survivors telling us? Cancer J. 2008;14:361-368. 3. Singal PK, Iliskovic N. Doxorubicin-induced cardiomyopathy. N Engl J Med. 1998;339:900-905. 4. Von Hoff DD, Layard MW, Basa P, et al. Risk factors for doxorubicin-induced congestive heart failure. Ann Intern Med. 1979;91:710-717. 5. Sleijfer S. Bleomycin-induced pneumonitis. Chest. 2001;120:617-624. 6. Rodriguez-Frias EA, Lee WM. Cancer chemotherapy I: hepatocellular injury. Clin Liver Dis. 2007;11:641-662. 7. Tarrass F, Benmensour M, Bayla A. End-stage renal disease following carboplatin chemotherapy for a nasopharyngeal carcinoma. Ren Fail. 2007;29:1049-1051. 8. Warner E, Keshavjee A, Shupak R, Bellini A. Rheumatic symptoms following adjuvant therapy for breast cancer. Am J Clin Oncol. 1997;20:322-326. 9. Hooning MJ, Botma A, Aleman BM, et al. Long-term risk of cardiovascular disease in 10-year survivors of breast cancer. J Natl Cancer Inst. 2007;99:365-375. 10. Hancock SL, Donaldson SS, Hoppe RT. Cardiac disease following treatment of Hodgkin’s disease in children and adolescents. J Clin Oncol. 1993;11:1208-1215. 11. Carver JR, Shapiro CL, Ng A, et al; for the ASCO Cancer Survivorship Expert Panel. American Society of Clinical Oncology clinical evidence review on the ongoing care of adult cancer survivors: cardiac and pulmonary late effects. J Clin Oncol. 2007;25:3991-4008. 12. Adams MJ, Lipshultz SE, Schwartz C, et al. Radiation-associated cardiovascular disease: manifestations and management. Semin Radiat Oncol. 2003;13:346-356. 13. Andreyev HJ. Gastrointestinal problems after pelvic radiotherapy: the past, the present and the future. Clin Oncol (R Coll Radiol). 2007;19:790-799. 14. Gabriele P, Orecchia R, Magnano M, et al. Vestibular apparatus disorders after external radiation therapy for head and neck cancers. Radiother Oncol. 1992;25:25-30. 15. Honore HB, Bentzen SM, Moller K, Grau C. Sensori-neural hearing loss after radiotherapy for nasopharyngeal carcinoma: individualized risk estimation. Radiother Oncol. 2002;65:9-16.
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