Symptom Management and Sharing Bad News

1. SYMPTOM MANAGEMENT OF CHEMOTHERAPY
IMMUNOTHERAPY
AND
BREAKING BAD NEWS
ANA ROSA ESPINOSA, DNP, MBA, RN, OCN®

2. Learning Objectives
At the end of the presentation the learner will be able to:
 Recognize and manage side effects of Chemotherapy
 Recognize and manage toxicities associated with
Immunotherapy and Targeted Therapy
 List the steps to follow when breaking bad news

3. Mucositis: Causes and Toxicity
Levels
 Chemotherapy
Agents
that may cause
Mucositis
 Busulfan ; Capecitabine; cyclophosphamide; doxil;
 5-Fluorouracil
 Mechlorethamine ; liposomal; doxorubicin
 Sign and
Symptoms
 Changes in taste, difficulty and painful swallowing, talking,
eating.
 White patches, discolored lesions, ulcers, or changes in oral
moisture.
 Edema of oral mucosa and tongue, and mucosal ulcerations.
 Change in saliva texture, quantity.
 Cracks, fissures in mucosa.
 Changes in voice quality.

4. Mucositis: Symptoms and
Treatments
 Treatment
focused on
prevention
Topical and systemic pain management:
 2% viscous lidocaine, Magic Mouthwash preparations.
 Ice-chip cryotherapy, palifermin and antiviral medications (depending
on the type of malignancy).
 Frequent gentle brush of teeth with fluoride toothpaste, use of a
toothette is helpful and floss gently.
 Rinse or gargle with a solution of saltwater and baking soda, avoid
mouth rinses that have alcohol.
 Foods that require little or no chewing.
 Avoid acidic, spicy, salty, coarse, and dry foods.

5. Hair Loss
 Chemotherapy-induced hair loss:
 Occurs with an estimated incidence of 65%.
 Includes loss of hair anywhere on the body.
 Negative impact on body image, sexuality, and
self-confidence.
 47% of female patients consider hair loss the most traumatic
aspect of chemotherapy.
 8% would decline chemotherapy due to fears of hair loss.

6. Hair Loss : Causes
 Chemotherapy
agents that causes
hair loss
 Adriamycin- complete hair loss on the head, usually
during the first few weeks of treatment, may also cause
the loss of eyelashes and eyebrows.
 Methotrexate – may or may not cause hair to thin.
 Cytoxan and 5-fluorouracil - minimal hair loss.
 Taxol - complete hair loss, including head, brows, lashes,
pubic area, legs and arms.
 Vinca alkaloids.

7. Hair Loss : Treatment
 Treatment  Newly FDA approved Cold Cap - hats filled with gel chilled
between -15 to - 40 degrees Fahrenheit, worn for 20 to 50
minutes before, during and after treatment.
 Scalp cooling doesn’t work with all chemotherapy drugs
 Shampoos without detergents, menthol, salicylic acid, alcohol,
and perfumes.
 Avoid using permanent waves, bleach, and coloring agents on
hair, as well as vigorous brushing, hot rollers, and hair dryer
use.
 Consider shaving the head, as this may decrease itching and
allow for wig application, if warranted.
 A prescription for “cranial prosthesis” may be required.

8. Chemotherapy Infusion
Reactions
 Drugs associated with reactions: carboplatin; cetuximab; docetaxel; oxaliplatin; paclitaxel;
rituximab and trastuzumab
 Signs and Symptoms of Hypersensitivity Reactions:
 Cardiovascular - chest pain, hypotension, hypertension, tachycardia, bradycardia,
arrhythmia,
 Central nervous system - headache , dizziness, confusion, loss of consciousness.
 Dermatologic – rash, pruritus, urticaria, flushing, local or diffuse erythema, conjunctival
erythema and tearing, angioedema.
 Endocrine - rigors, diaphoresis, fever, generalized feeling of warmth.
 Gastrointestinal - nausea, vomiting, metallic taste, diarrhea, abdominal cramping
Genitourinary - incontinence, uterine cramping or pelvic pain, renal impairment.
 Musculoskeletal - arthralgias, myalgias, fatigue, tumor pain, hypotonia.
 Psychiatric - anxiety, sense of impending doom.
 Treatment: stop infusion, maintain vascular access with normal saline. Assess airway, breathing,
and circulation. Have another staff member ready with emergent equipment and medication. The
decision to restart an infusion will depend on the nature of the reaction and discretion of the
clinician.

9. Myelosuppression: includes anemia, neutropenia and thrombocytopenia and a
significant decrease in the neutrophils, megakaryocytes, and erythrocytes within the
bone marrow.
Nadir: Following cytotoxic therapy, the time or level at which the lowest blood cell count
is reached. The nadir varies with individual agents but usually occurs 7-10 days after
treatment.
 Anemia
Reduction (<12g/dl) in normal
concentration of hemoglobin or
red blood cells in the blood.
 Signs and Symptoms
 Feeling fatigued, short of breath, dizzy or
confused.
 Pale skin and cold extremities, headaches, and
chest pain.
 Treatment
 Transfusion, iron supplements, darbepoetin,
epoetin
Myelosuppression: Anemia

10.  Neutropenia
A low level of neutrophils, a certain
type of white blood cell
ANC of 1000 to 1500 - mild risk of
infection
ANC of 500 to 1000 - moderate risk of
infection
ANC less than 500 - severe risk of
infection
 Signs and Symptoms
 Fever > 100.5 degrees
 Chills
 Sore throat
 Cough
 Shortness of breath
 Burning sensation and blood in the urine
 Lower back pain that could be a kidney infection
 Diarrhea
 Skin rashes
 Redness and swelling at the IV site
 Treatment
 filgrastim, G-CSF
 pegfilgrastim
 sargramostim, GM-CSF
 Antibiotic therapy (for febrile neutropenia)
Myelosuppression: Neutropenia

11.  Thrombocytopenia
Decrease in circulating platelet
count below 100,000/mm3.
 Signs and Symptoms
 Bleeding in the mouth and gums
 Bruising
 Nosebleeds
 Rash (pinpoint red spots called petechia)
 Treatment
 Platelet transfusion
 Patient Education
 Do not cough forcefully or harshly.
 Do not blow your nose too hard.
 Avoid straining too much with bowel movements.
 Do not use rectal thermometers, suppositories or enemas.
 Use an electric razor for shaving.
 Talk to your oncologist before dental work.
 Do not take any medications that affect blood clotting.
 Do not take any non-steroidal, anti-inflammatory medications
(NSAIDs) such as Motrin®, Aleve®, Advil®, etc.
 For headaches or other pain, use acetaminophen.
Myelosuppression:
Thrombocytopenia

12. Peripheral
Neuropathy
Peripheral Neuropathy:
• Over 50% of cancer patients receiving
chemotherapy regimens including:
platinums, vinca alkaloids, and taxanes
experience chemotherapy-induced peripheral
neuropathy (CIPN).
• CIPN is a dose-limiting toxicity that reduces
quality of life and can increase mortality.
There are no FDA-approved drugs to treat CIPN
and behavioral interventions like exercise have
received little research attention.

13. Peripheral
Neuropathy : Symptoms/Treatment
 Symptoms of Peripheral Neuropathy
 Pain, burning or tingling
in fingers, toes hands
and feet .
 Loss of sensation to touch; sensitivity to
temperature extremes.
 Difficulty picking things up or buttoning
clothes.
 Muscle weakness, cramping or pain in hands
and/or feet.
 Constipation.
 Decreased reflexes balance problems
 Treatment
 Anti-seizure medications- gabapentin
(Gralise, Neurontin) and pregabalin
(Lyrica)
 Antidepressants -amitriptyline, doxepin
and nortriptyline (Pamelor) have been
found to help relieve neuropathy.
 Pain relievers as nonsteroidal anti-
inflammatory drugs, duloxetine.
 For more-severe symptoms, recommend
prescription opioids, such as tramadol .

14. Women with Breast Cancer
 Symptoms
 Hot flashes, vaginal infections , dryness, itching
 Decreased sex drive and mood changes.
 Stress, fatigue, and decreased interest in sex
 Body image changes and psychological distress
 Treatment
 Hormonal manipulation/estrogen therapy.
 Antidepressants; psychosocial support.
 Lubricants/moisturizers; Vaginal dilators
 Kegel exercises, relaxation techniques,
Men with Prostate Cancer
 Symptoms
 Reduced ability to achieve an erection or
orgasm
 Aromatase inhibitors also may cause joint
and muscle pain, and an increased risk of
bone thinning
 Psychological distress.
 Treatment
 Oral erotogenic agents: sildenafil, prostaglandin
injections.
 Penile vacuum devices; prostheses.
 Vasodilators; testosterone.
 Referral for psychotherapy, sex therapy, or surgical
treatment if needed
Effects on Sex and Reproduction

15. Immunotherapy
 Immunotherapy is a broad category of cancer
therapies that use the body’s immune system to
fight cancer cells.
 Immunotherapy drugs are designed to alert the
immune system about these mutated cells so it
can locate and destroy them.
They fall in three categories:
 Check point inhibitors
 Cytokines
 Cancer Vaccines

16. Nivolumab Pembrolizumab
Indications:
 Hodgkin
Lymphoma
 Lung Cancer
 Kidney Cancer
Melanoma
 Bladder Cancer
Indications:
 Bladder
Cancer
Indications:
 Melanoma
 Lung Cancer
 Head and Neck
Cancer
 Hodgkin
Lymphoma
Avelumab
Indications:
 Merkel Cell
Carcinoma
Immune Check Point Inhibitors
Ipilimumab
Indications:
 Melanoma
Atelizumab

17.  Immune-mediated
Pneumonitis
Symptoms may include shortness of breath, chest pain, new or
worsened cough.
 Treatment  Monitor patients for signs with radiographic imaging and
symptoms of pneumonitis.
 If a suspicion for pneumonitis is raised based on clinical
or radiological findings:
 Administer corticosteroids for Grade 2 or greater
pneumonitis.
 Withhold PD-inhibitor therapy in patients who develop
moderate (grade 2) pneumonitis
 Permanent discontinuation of the drug for severe
(grade 3) or life-threatening (grade 4) pneumonitis.
 The clinical course can be fulminant and rapidly progress.
Toxicities associated with Check
Point Inhibitors

18.  Immune-
mediated Colitis
 Symptoms: Rapid onset of diarrhea/colitis approximately six
weeks into treatment.
 Treatment  Early diagnosis and treatment of symptoms can decrease the risk
of more severe toxicity.
 Mild to moderate diarrhea –steroids over a prolonged period of
time with a slow taper (30–45 days).
 Severe diarrhea- high dose of intravenous steroids, adding
infliximab if no improvement after 5–7 days.
 Severe toxicity or multiple organ systems involvement
intravenous steroids and/or infliximab should be considered as the
initial treatment.
Toxicities associated with Check
Point Inhibitors

19.  Immune-mediated
Nephritis and Renal
Dysfunction
Symptoms: Renal dysfunction or ≥ Grade 2 increased
creatinine.
 Treatment  Monitor patients for elevated serum creatinine prior to and
periodically during treatment.
 Withhold PD for moderate (Grade 2) or severe (Grade 3)
increased serum creatinine and administer corticosteroids at
a dose of 0.5 to 1 mg/kg/day prednisone equivalents
followed by corticosteroid taper.
 If worsening or no improvement occurs, increase dose of
corticosteroids to 1 to 2 mg/kg/day prednisone equivalents.
 Permanently discontinue PD
Toxicities associated with
Check Point Inhibitors

20. Toxicities associated with
Check Point Inhibitors
 Immune-mediated
Hypothyroidism and
Hyperthyroidism
Symptoms: Thyroid disorders
 Treatment  Monitor thyroid function prior to and periodically during
treatment. Administer hormone-replacement therapy for
hypothyroidism.
 Initiate medical management for control of
hyperthyroidism.
 There are no recommended dose adjustments of PD for
hypothyroidism or hyperthyroidism.

21.  Immune-
mediated Hepatitis
Symptoms: AST and ALT elevations.
 Treatment  Rule out viral or other drug-induced causes of hepatitis.
 If no other etiology, initiate treatment with corticosteroids.
 For prolonged hepatitis may require prolonged or repeated
corticosteroid tapers (a minimum of three weeks and/or additional
immunosuppression.
 Grade 2 hepatic toxicity – AST or ALT >2.5 times the upper limit of
normal (ULN) but ≤5 times the ULN, or total bilirubin >1.5 times the
ULN but ≤3 times the ULN. Withhold nivolumab treatment.
 Grade 3 or greater hepatic toxicity – AST or ALT >5 times the ULN, or
total bilirubin >3 times the ULN. Treatment should be permanently
discontinued.
Toxicities associated with Check
Point Inhibitors

22. Case Presentation : 62 years old Hispanic patient
presented with a diagnosis of Metastatic lung
Adenocarcinoma Stage 4
Initial Chemotherapy Treatment - Carbo, Avastin and Taxol
On February 2nd 2016, PET Scan revealed progression of the cancer to the R lung and the patient was
treated with Cyberknife.
In August of 2016, a PET Scan revealed progression to the Adrenal Glands and the treatment was
changed to nivolumab. Patient was treated with nivolumab from August through November 2016.
In November, the patient developed a high fever and shortness of breath and was diagnosed with
bilateral Pneumonitis. nivolumab treatment was discontinued and the patient was treated with IV
steroids.
Patient recovered and palliative chemotherapy was initiated with Taxotere and Cyramza.
In December of 2016, the patient developed severe bilateral Pneumonia, became critically ill and
was intubated. He was treated with IV steroids and all chemotherapy treatment was discontinued.
Patient survived the severe pneumonia and was discharged home.
The last treatment he received was in November of 2016. Patient has refused further
treatment. Patient’s last PET scan in September 2017 shows no cancer progression.
Case will be discussed in our next tumor board.
This is one of the potential adverse effects of Immunotherapy
However, the patients cancer has not progressed in almost 1 year.

23. Toxicities Associated with EGFR
Inhibitors.
 Cutaneous Toxicity:
 Skin rash associated with epidermal growth factor receptor
inhibitor (EGFRI).
 It is not completely understood, but interference with the
proliferation, differentiation, migration, and attachment of
keratinocytes.
 Is believed to occur with EGFRI therapy resulting in
recruitment of inflammatory cells and injury to cutaneous
tissues.

24. Cutaneous Toxicity Treatment
.
Grade Intervention
0 Prophylaxis treatment
• Sunscreen SPF > 15
• Moisturizing creams
• Tetracycline antibiotics x 6-8 wks + low-potency steroid cream BID
1 Continue medication; current dose
• Hydrocortisone 2.5% cream AND clindamycin 1% gel
2 Continue medication; current dose
• Hydrocortisone 2.5%, desonide, alclometasone 0.05% creams (neck & face)
• Fluoncinonide 0.05% cream (chest & back) AND
• Doxycycline 100 mg OR minocycline 100 mg BID
3 Modify dose
• Same as grade 2 + prednisone 0.5 mg/kg x 7 days
• Isotretinoin 20-30 mg/day x 2 months
4 Interruption or discontinuation of treatment
• IV antibiotics and steroids
• Isotretinoin 20-30 mg/day

25. Breaking Bad News
 Bad news may be defined as “any information
which adversely and seriously affects an
individual's view of his or her future.
 Bad news is always, however, in the “eye of the
beholder,” such that one cannot estimate the
impact of the bad news until one has first
determined the recipient's expectations or
understanding.
 Patient are entitle to accurate information to
assist them in making important quality-of-life
decisions

26. Breaking Bad News
 WHAT ARE THE BARRIERS
TO BREAKING BAD NEWS?
 Anxiety - a burden of responsibility for the news, and fear
of negative evaluation.
 How to be honest with the patient and not destroy their
hope
 Dealing with the patients emotions
 Finding the right time
 Not enough training on disclosing unfavorable
information
 HOW CAN A STRATEGY FOR
BREAKING BAD NEWS HELP
THE CLINICIAN AND THE
PATIENT?
The process of disclosing bad news can be viewed as an
attempt to achieve four essential goals
1. Gathering information to determine the patient's
knowledge, expectations and readiness
2. Provide intelligible information in accordance with the
patient's needs and desires.
3. Reduce the emotional impact
4. Strategize a treatment plan

27. Breaking Bad News
 THE SIX STEPS OF SPIKES
 STEP 1: S—SETTING UP
the Interview
 Arrange for some privacy.
 Involve significant others.
 Sit down.
 Make connection with the patient
 Manage time constraints and interruptions.
 STEP 2: P—ASSESSING THE
PATIENT'S PERCEPTION
Steps 2 and 3 of SPIKES are points in the interview where you
implement the axiom “before you tell, ask.”
 Use open-ended questions to know how the patient
perceives the medical situation
 What is the patient telling you ? Use the information to
tailor the bad news to what the patient understands.
 Is the patient engaging in any variation of illness denial
 Unrealistic expectations of treatment

28. Breaking Bad News
 STEP 3: I—OBTAINING THE
PATIENT'S INVITATION
 Is the patient ready to receive for full information about
their diagnosis, prognosis, or not.
 Patient expressing a desire for information, lessens the
anxiety associated with divulging the bad news
 STEP 4: K—GIVING
KNOWLEDGE AND
INFORMATION TO THE PATIENT
 When the patient senses that bad news is coming, it may
lessen the shock of the bad news disclosure.
 Examples : “Unfortunately I've got some bad news to tell
you.
 Giving medical facts, the one-way part of the physician-
patient dialogue, may be improved by a few simple
guidelines.
 Start at the level of comprehension and vocabulary of
the patient
 Use nontechnical words such as “spread” instead of
Metastasis
 Sample tissue instead of biopsy.
 Avoid excessive bluntness

29. Breaking Bad News
 STEP 5: E—
ADDRESSING THE
PATIENT'S EMOTIONS
WITH EMPATHIC
RESPONSES
 The reaction of bad news is often an expression of shock,
isolation, and grief, from silence to disbelief
 Identify the emotion experienced by the patient by naming it to
oneself.
 Use open questions to query as to what they are thinking or feeling.
 Give the patient a brief period of time to express his or her feelings,
emotion by making a connecting statement.
 I'm sorry…..
 STEP 6: S—STRATEGY
AND SUMMARY
 Patients with clear plan for the future are less anxious and
uncertain.
 Presenting treatment options is not only a legal mandate , but it
will establish the physician regards for their wishes as important.
 Sharing responsibility for decision-making may reduce any sense
of failure on the part of the physician when the treatment is not
successful.
 Checking the patient's misunderstanding of the discussion and a
flexible approach can prevent patients to overestimate the efficacy
or misunderstand the purpose of treatment .

31.  In summary, chemotherapy is often seen more for its side effects than for its life-saving
potential. Fortunately, after years of experience with chemotherapy drugs, nurses, mid level
providers, doctors and patients have found ways to manage common side effects.
 Different drugs cause different side effects. Although specific side effects may be predictable
for certain classes of drugs, each person's experience with chemotherapy is unique.
 It is important to take a good history to address any illnesses that will interfere with
chemotherapy targeted agents.
 Given the potential toxicities of certain chemotherapeutic agents, baseline pre-chemotherapy
blood work provides a basis for monitoring the effects of both the cancer and the
chemotherapy.
 Be aware of all the side effects and address them as soon as possible.
 Involve the multidisciplinary team from day one including: pain management, dietary
services, psychosocial services, prehab, rehab, and social services.

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