McKenna's Pharmacology for Nursing, 2e

217

C H A P T E R 1 4  Antineoplastic agents

CRITICAL THINKING SCENARIO Antineoplastic therapy and breast cancer

THE SITUATION B.P., a 34-year-old woman, is a schoolteacher with two young daughters. She noticed a slightly painful lump under her arm when showering. About 2 weeks later, she found a mass in her right breast. Initial assessment found that she had no other underlying medical problems, had no allergies and took no medications. Her family history was most indicative: many of the women in her family—her mother, two grandmothers, three aunts, two older sisters and one younger sister—died of breast cancer when they were in their early 30s. All data from the initial examination, including an evaluation of the lump in the upper outer quadrant of her breast and the presence of a fixed axillary node, were recorded as baseline data for further drug therapy and treatment. B.P. underwent a radical mastectomy with biopsy report for grade IV infiltrating ductal carcinoma (28 of 35 lymph nodes were positive for tumour) and then radiation therapy. Then she began a 1-year course of doxorubicin, cyclophosphamide and paclitaxel (AC/paclitaxel/sequential). CRITICAL THINKING What are the important implications for B.P.? Think about the outlook for B.P., based on her biopsy results and her family history. What are the effects of high levels of stress on the immune system and the body’s ability to fight cancer? What impact will this disease have on B.P.’s job and her family? Think about the adverse drug effects that can be anticipated. How can good teaching help B.P. to anticipate and cope with these many changes and unpleasant effects? What future concerns should be addressed or at least approached at this point in the treatment of B.P.’s disease? What are the implications for her two daughters? How may a coordinated health team work to help the daughters cope with their mother’s disease, as well as the prospects for their future? DISCUSSION The extent of B.P.’s disease, as evidenced by the biopsy results, does not signify a very hopeful prognosis. In this case, the overall care plan should take into account not only the acute needs related to surgery and drug therapy, but also future needs related to potential debilitation and even the prospect of death. Immediate needs include comfort and teaching measures to help B.P. deal with the mastectomy and recovery from the surgery. She should be given an opportunity to vent her feelings and thoughts in a

protected environment. Effort should be made to help her to organise her life and plans around her radiation therapy and chemotherapy. The adverse effects associated with the antineoplastic agents she will be given should be explained and possible ways to cope should be discussed. These effects include the following: Alopecia . B.P. should be reassured that her hair will grow back, but she will need to cover her head in extremes of temperature. Purchasing a wig before the hair loss begins may be a good alternative to trying to remember later what her hair was like. Nausea and vomiting . These effects will most often occur immediately after the drugs are given. Antiemetics may be ordered, but they are frequently not very effective. Bone marrow suppression . This will make B.P. more susceptible to disease, which could be a problem for a teacher and a mother with young children. Ways to avoid contact and infection, as well as warning signs to report immediately, should be discussed. Mouth sores . Stomatitis and mucositis are common problems. Frequent mouth care is important. The person should be encouraged to maintain fluid intake and nutrition. Because the antineoplastic therapy will be a long-term regimen, it might help to prepare a calendar of drug dates for use in planning other activities and events. All of B.P.’s treatment should be incorporated into a team approach that helps B.P. and her family deal with the impact of this disease and its therapy, as well as with the potential risk to her daughters. B.P.’s daughters are in a very high risk group for this disease, so the importance of frequent examinations as they grow up needs to be stressed. In some areas of the country, healthcare providers are encouraging prophylactic mastectomies for women in this very high risk group. CARE GUIDE FOR B.P.: ANTINEOPLASTIC AGENTS Assessment: History and examination Allergies to any of these drugs, renal or hepatic dysfunction, pregnancy or breastfeeding, bone marrow suppression, or GI ulceration Concurrent use of ketoconazole, diazepam, verapamil, quinidine, dexamethasone, cisplatin, cyclosporine, Local : evaluation of injection site CNS : orientation, affect, reflexes Skin : colour, lesions, texture GI : abdominal, liver evaluation Laboratory tests : FBC with differential; renal and hepatic function tests teniposide, etoposide, vincristine, testosterone or digoxin, which could interact with these drugs