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Friday, May 16, 2008

Giving chemotherapy

How chemotherapy drugs are given

Chemotherapy may be given in different ways, depending on the type of cancer you have and the chemotherapy drugs used.

  • Most often chemotherapy is given by injection into a vein (intravenously). This is known as intravenous chemotherapy.
  • Some drugs are given as tablets or capsules (oral chemotherapy).
  • Some are injected into a muscle (intramuscular injection).
  • Others may be injected just under the skin (subcutaneous injection).

Drugs given in the above ways are absorbed into the blood and carried around the body so they can reach all the cancer cells.

  • For some types of cancer, chemotherapy may be injected into the fluid around the spine. This is known as intrathecal chemotherapy.
  • Sometimes the chemotherapy may be injected into particular body cavities such as the pelvic cavity or bladder: this is known as intracavity chemotherapy.

Drugs given in this way tend to stay in the area in which they are given and do not affect cells in other parts of the body.

  • Chemotherapy creams may be used for some cancers of the skin: they only affect the cells in the area of skin to which the cream is applied.

Sometimes, two or more types of chemotherapy may be used together; for example, intravenous and oral chemotherapy.

Intravenous chemotherapy

There are four ways of giving chemotherapy drugs directly into the vein. These are through a:

  • Cannula – a small tube inserted into a vein in your arm or the back of your hand.
  • Central line – a thin, flexible tube inserted through the skin of the chest into a vein near the heart.
  • PICC line (a peripherally inserted central catheter) – a thin flexible tube passed into a vein in the bend or upper part of the arm and threaded through until the end of the tube lies in a vein near the heart.
  • Implantable port (also called a portacath) – a thin, soft plastic tube that is put into a vein. It has an opening (port) just under the skin on your chest or arm.

Cannula

The nurse or doctor will put a short, thin tube (cannula) into a vein in the back of your hand or your forearm. You may find this a bit uncomfortable or painful, but it should not take long and the pain soon wears off. If you find it painful to have the cannula put in, an anaesthetic cream can be used on the skin to numb the area beforehand. The cream takes 10–20 minutes to work.

Once the cannula has been put in, it will be taped securely to keep it in place. A clear bag of fluid (a drip) is then attached to the cannula by a tube. Some chemotherapy drugs are given by injection into a rubber bung in the tubing of the drip. This can take from a few minutes to about 20 minutes.


Chemotherapy being given through a cannula
Chemotherapy being given through a cannula

Some drugs will be given directly in the drip bag (by infusion). This can take from 20 minutes to several hours, or sometimes days. If you feel any discomfort or notice a change in sensation, redness or swelling around the area of the cannula (or along your arm) while the drug is being given, let your nurse or doctor know immediately.

Central lines (tunnelled central venous catheters)

A central line is a long, thin plastic tube put into a vein in your chest. Hickman®* or Groshong®* lines are common types. The doctor or chemotherapy nurse will explain the procedure to you. You will be given a general or local anaesthetic before the central line is put in.

Once it is in place, the central line is either stitched or taped firmly to your chest to prevent it being pulled out of the vein.

There is a small ‘cuff’ around the line which can be felt just under the skin. The cuff holds the line safely in place. A central line can stay in the vein for many months and means that you do not have to have cannulas put in when you have your intravenous chemotherapy. Blood can also be taken from it for testing. You will be able to bathe or shower; although you should prevent water from getting to the area where the tube enters the skin – a plastic dressing can be used for this. Before you go home, make sure you are confident about looking after your central line. If you have any problems, contact the staff in the chemotherapy clinic or on the ward for advice.


A central line
A central line

Possible problems with central lines Two potential problems with central lines are blockage and infection. Once or twice a week the line has to be flushed with saline (salt water), or heparin – a drug which prevents clotting. The nurses on the ward can teach you how to do this, or can arrange for a district nurse to visit your home and do it for you. Your doctor may also prescribe a low dose of warfarin, a drug to help prevent blood clots forming and blocking your line.

If you notice any swelling in your arm or neck, contact the hospital staff as your line may be blocked. If you notice any reddening, darkening or soreness of the skin around the central line, or if you have a high temperature, let your doctor know, as it could be a sign that you have an infection in the line. If this happens you will need to have antibiotics through the line to clear the infection.

Most hospitals consider a temperature above 38ºC (100.5ºF) to be high, but some hospitals use a lower or higher temperature. The doctors and nurses at your hospital will tell you which temperature they use.

Removing your central line When you no longer need the central line, it will be taken out. A doctor or nurse will do this for you, usually in the outpatients department. Your chest will be cleaned with antiseptic, and the line will be gently but firmly pulled until it loosens and comes free. This does not usually take more than a few minutes, but can be uncomfortable. Sometimes a small cut in the skin is needed so that the cuff can be loosened. This is done under a local anaesthetic. A dressing will be put over the area where the line has been removed, and you will be asked to remain lying down until it is certain that there is no bleeding.

PICC lines

Your doctor may suggest that you have a long, thin tube put into a vein in the crook of your arm. This is called a peripherally inserted central venous catheter (PICC). Your doctor or chemotherapy nurse will explain the procedure to you. You will be given a local anaesthetic before the line is put in.

Once it is in place, the PICC line is taped firmly to your arm to prevent it being pulled out of the vein. It can stay in the vein for many months. As with the central line, it means that you do not have to have cannulas put in when you have your intravenous chemotherapy. Blood can also be taken through the line for testing.


The tube is threaded through the vein until the end is near to your heart
The tube is threaded through the vein until the end is near to your heart

The end of the tube comes out just below the crook of your elbow
The end of the tube comes out just below the crook of your elbow

You will be able to bend your arm, bathe and shower, although you should avoid getting water on the area around the tube − a plastic dressing can be used for this. Before you go home, make sure that you are confident about looking after your line. A district nurse can flush your line and change the dressing, or a friend or relative can be taught to do this for you. If you have any problems, contact the staff in the chemotherapy clinic or on the ward for advice.

The possible problems are the same as for central lines: blockage and infection.

Implantable ports (portacaths)

An implantable port is a thin, soft plastic tube that is put into a vein and ends in an opening (port) just under the skin on your chest or arm. The port has a thin rubber disc through which special needles can be passed to give medicines into the vein or take blood.


An implantable port

The tube is a long, thin hollow tube known as a catheter and the port is a disc about 2.5 to 4 cm in diameter. The catheter is usually inserted (tunnelled) under the skin of your chest. The tip of the catheter lies in a large vein just above your heart and the other end connects with the port which sits under the skin on your upper chest. A small bump can be seen and felt underneath the skin, but nothing shows on the outside of your body.

The possible problems are the same as for central lines: blockage and infection.

Infusion pumps

Infusion pumps may be used to give some types of chemotherapy. There are various types of portable pump. These give a controlled amount of chemotherapy into the bloodstream over a period of time (from a few days to a few weeks). The pump is connected to a central line or a PICC line. This means that you can go home with the pump and so you need fewer visits to hospital. The pumps are small enough to fit into a pocket and can be carried in a bag or belt holster.

The chemotherapy drugs are prepared at the hospital. You, and perhaps a family member or friend, will be taught how to look after the pump. Some pumps are battery-operated and care has to be taken not to get them wet when you are washing. Your nurses or pharmacy staff will give you full instructions and should also tell you who to contact if you have any problems or questions. Some pumps are disposable and are operated by a balloon mechanism or spring control.

Extravasation

Drugs given intravenously can occasionally leak into the tissues. This is called extravasation. It usually happens when a cannula dislodges and so is not positioned in the vein correctly. It very rarely happens with a central line.

If you notice any swelling, pain, stinging or redness when you are having your chemotherapy treatment, or after you get home, it is important to contact the hospital straight away. Some chemotherapy drugs can damage the tissues, so the sooner any extravasation is dealt with, the better.

Oral chemotherapy

You may be given chemotherapy tablets or capsules to take at home as all or part of your treatment. You will be told when to take them and will be given other instructions such as whether or not to take them with food. If you cannot take your medicines for any reason you should contact your doctor immediately for advice.

The drugs that you have been given by the hospital make up a complete course of treatment, and it is important to take them exactly as they have been prescribed. Always read the labels on the boxes before you leave the hospital – if the instructions are unclear, ask your nurse, doctor or pharmacist.

If you need to have further supplies of the chemotherapy or other medicines, it is important to get these from your hospital specialist and not from your GP or local pharmacist.

Oral chemotherapy can cause side effects and it is important to be aware of these when taking your medicine.

Intramuscular injection

Some chemotherapy drugs are given by injection into a muscle. The doctor or nurse will explain the procedure to you. The drug is injected into the muscle of the leg or buttock. You may feel some pain or discomfort for a short time.

Subcutaneous injection

Some drugs can be given by injection just under the skin. A very fine needle is used and this may be uncomfortable for a short time.

Intrathecal chemotherapy

In some conditions such as leukaemia or lymphoma (cancer which starts in the lymph system) cancer cells can pass into the fluid which surrounds the brain and spinal cord. This fluid is called cerebrospinal fluid. To prevent this from happening, or to treat it if it occurs, chemotherapy may be given into the cerebrospinal fluid. For this treatment you will usually need to lie on your side with your legs drawn up. The doctor will then use local anaesthetic to numb an area of skin over your spine. A needle is inserted into the space between two of the spinal bones and into the cerebrospinal fluid and the chemotherapy is injected. This procedure is called a lumbar puncture.

It takes from 15 to 30 minutes and you may need to lie flat afterwards for a few hours. It is important to drink plenty of fluids to reduce the chance of getting a headache. If you get a headache, it may last for a few hours. Painkillers can be given to help. Chemotherapy given in this way does not usually cause any other side effects.

Intracavity chemotherapy

To give chemotherapy drugs in this way, a tube is inserted into the affected body cavity, for example the bladder (intravesical treatment) or the abdominal area (intraperitoneal treatment). The chemotherapy is put in through the tube. It may then be drained out again after a set period of time. Drugs given in this way may cause some irritation or inflammation in the area they are given, but they do not tend to cause side effects in other parts of the body.

Chemotherapy creams

Chemotherapy creams are used for some types of skin cancer. They are put onto the affected area of skin in a thin layer and may need to be used regularly for a few weeks. They may cause some soreness or irritation of the skin in the affected area but do not cause side effects in other parts of the body. While you are using chemotherapy creams you may need to wear a dressing over the affected area of skin.

Via: http://www.cancerbackup.org.uk

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