Table 2.
Adverse effects caused by systemic antineoplastic treatments, and their prevention and management
| Adverse effect | Causative agent | Prevention | Management |
|---|---|---|---|
| Cardiovascular toxicity | Anthracyclines, alkylating agents, taxanes, targeted therapies, monoclonal antibodies | Basal assessment of cardiac function (ECHO, LVEF, ECG); evaluation of cardiovascular risk factors and comorbidities | Withdrawal of cardiotoxic therapy; treatment of cardiac dysfunction; ACE inhibitors or beta-blockers should be considered [10] |
| Cognitive dysfunctionality (chemo-brain, chemo-fog) | Potentially all | Ask patients to report any mental disturbances | No recommendations available |
| CVC-related complications (infections, thrombosis, extravasation) | All drugs administered in intravenous infusions through CVCs | Monitor patients for CVC-related infections; control regular venous flux and functioning of infusion disposables; train health care personnel | Suspension of intravenous infusions; early surgical procedures to manage extravasation; surgical removal of CVCs; antidotes specific to drugs in extravasation |
| Dermatological toxicity (skin, hair and nail modifications) | Potentially all systemic cytotoxic treatments (targeted therapies included) | Risk assessment; patient education. Previous treatments can result in cumulative toxicity | Symptomatic treatment based on the grade, type of therapy, and type of cutaneous reactions |
| Diarrhea or constipation | Antimetabolites, topoisomerase inhibitors, vinca alkaloids, targeted therapies | For diarrhea: fluid intake to prevent dehydration, dietary modifications, nutritional support. For constipation: dietary modifications, fluid intake, physical activity | For diarrhea: antidiarrheal drugs (loperamide), somatostatin analogs if appropriate, probiotics, sulfasalazine. For constipation: laxatives (osmotic or stimulant), opioid antagonists (e.g. methylnaltrexone) for opioid-induced constipation |
| Fatigue | Microtubule agents | Consider concomitant factors (e.g. pain, anxiety) | Suggest behavioral modifications; provide nutritional, physical and psychological support; consider pharmacological and non-pharmacological approaches |
| Febrile neutropenia | Taxanes, anthracyclines, antimetabolites, topoisomerase inhibitors, immunomodulatory drugs | Assess the patient’s risk (MASCC score). Use of antibacterial prophylaxis is usually contraindicated. Prophylaxis with G-CSF is recommended if risk is > 20% or if the patient is elderly or has comorbidities | Follow international guidelines (ASCO-ESMO). Patient education and local hospital policies are fundamental |
| Hormonal impairment, infertility | Cyclophosphamide, taxanes, irinotecan, platinum derivatives | Offer procedures to preserve fertility (e.g. sperm or oocyte banking, shield protection during radiotherapy, ovarian transposition); consider using LH-RH agonists as protection (in women) during chemotherapy | Consider using hormonal replacement therapy and pharmacologic treatment to correct male sexual dysfunction |
| Infections | Immunomodulatory agents, transplantation | Follow international guidelines (ASCO-ESMO) for prophylaxis (bacterial-viral-fungal); use prophylactic drugs (antibacterials or antivirals) correctly to avoid drug resistance | Accurate diagnosis is essential for choosing a treatment. Anti-infective drugs should be administered to the site of infection (e.g. respiratory tract, head-neck, gastrointestinal, skin, CVC) |
| Infusion reactions | Potentially all | Risk assessment (e.g. medical history, allergic disorders); premedication with corticosteroids and antihistamines if indicated | Stop or slow the infusion rate, symptomatic treatment |
| Mucositis | Antimetabolites, methotrexate, cyclophosphamide, platinum derivatives, targeted therapies, taxanes, vinorelbine, 5-fluorouracil | Risk assessment; preventive measures (e.g. oral care, regular dental examinations), nutritional support | Suggest behavioral modifications (avoid alcohol, tobacco, hot foods). Patient education by mean of local hospital guidelines is essential. Use apposite oral solutions to manage symptoms and prevent oral infections [11] |
| Nausea and vomiting | Anthracyclines and cyclophosphamide in combination, platinum derivatives, azacitidine, bendamustine, ifosfamide, irinotecan, trabectedine | In case of chemotherapy of high emetic risk, give a single dose of 5HT3 receptor antagonist, dexamethasone and NK1 receptor antagonist before chemotherapy to prevent acute nausea and vomiting | Follow international (ASCO-ESMO-MASCC) and evidence-based guidelines. Antiemetic drugs (corticosteroids, 5-HT3 and NK1 receptor antagonists, dopamine antagonists, benzodiazepines) must be used in accordance with the emetogenic potential of drugs in the chemotherapy regimen [12] |
| Neuropathic pain | Microtubule agents (taxanes, vinca alkaloids, eribulin), platinum derivatives | Monitor first infusion, premedicate (corticosteroids or antihistamines), and identify high-risk patients. Previous treatments can lead to cumulative toxicity | Stop infusion of chemotherapy; give nonopioids, at discretion, with or without strong opioids, amitriptyline 25–75 mg/day or gabapentin 300–3600 mg/day [13] |
| Palmar-plantar erythrodysesthesia (hand-foot skin reaction) | Anthracyclines, antimetabolites, immunomodulatory therapies and targeted therapies | Monitor the patient’s symptoms and behavioral modifications: avoid skin, hand and feet pressure, sun exposure, hot water, friction | Administer oral pyridoxine (up to 150 mg/day); use skin creams (keratolytics or emollients); discontinue or temporarily suspend therapy |
| Thrombosis | Surgical procedures, non-surgical anticancer treatments | For surgical procedures and implanted accesses, prophylaxis includes low molecular weight heparin, fondaparinux, warfarin | Anticoagulant therapy, low molecular weight heparin, fondaparinux. The use of new anticoagulants in oncology is still under evaluation and is recommended only in select cases |
ASCO-ESMO American Society of Clinical Oncology-European Society for Medical Oncology, CVC central venous catheter, ECHO echocardiography, LVEF left ventricular ejection fraction, ECG electrocardiography, MASCC Multinational Association of Supportive Care in Cancer, G-CSF granulocyte-colony stimulating factor, 5-HT3 serotonin3, NK1 neurokinin1