SEMINARSIN
Oncology Nursing
Vol III, No 2
Nursing’s Role in Chemotherapy
Julena Lind and Nancy Jo Bush
ACH DAY in the United States,thousandsof
E nurses are involved in the administration of
chemotherapy. This is a relatively new phenome-
non. Just two decadesago, those patients who re-
ceived chemotherapywere likely to have it admin-
istered by their physician. As chemotherapy
became a more prevalent treatment modality,
nurses assumed a greater role in the actual drug
delivery. Today nursesnot only teach other nurses
the specialized techniques of chemotherapy ad-
ministration, but they have also developed formal
guidelines and standardsto ensure safe and com-
petent care for cancer patients receiving chemo-
therapeutic agents. This issue of Seminars in
Oncology Nursing looks at chemotherapy admin-
istration from a nursing perspective. The follow-
ing articles represent today’s state of the art ap-
proach to the delivery of chemotherapy. By way
of introduction, this article provides an overview
on the historical development of chemotherapy,
standard intravenous delivery, and current direc-
tions in chemotherapy administration.
HISTORICAL DEVELOPMENT OF CHEMOTHERAPY
It was not until the early 1940sthat the modem
era of chemotherapy began with the introduction
of the polyfunctional alkylating agents.’ By the
1960s complete classes of cytotoxic drugs were
available. The 1970s brought two very important
new drugs, adriamycin and cisplatinum, into the
realm of standard cancer therapy.2-4Today thou-
sandsof compounds have been tested and numer-
ous combinations of drug have been investigated.
Clinical Trials
As these new drug compoundsbeganto demon-
strate an effectivenessin treating cancers,the need
to have a coordinated systemof identifying, devel-
Seminars in Oncology Nursing, Vol 3, No 2 (May), 1987:
May 1987
Administration
oping, and evaluating them becameobvious. The
National Cancer Institute (NCI) began a program
in 19555to systematically evaluate the usefulness
of drugs with identifiable antitumor activity. Since
that time the NC1 has been conducting experi-
ments designed to answer therapeutic questions
which range from: the most appropriate drug to
use for a given tumor; to adequatedosageconsid-
erations; to toxic side effects of a new compound;
to the efficacy of one agentover another. The NC1
investigational studies have been categorized as
phase I, II, and III clinical trials.
A comprehensive description of clinical trials
and the associatednursing roles are describedelse-
where.6*7
Delivery Approaches
Although most chemotherapy has been given
intravenously, either by continuous drip or bolus
injection (IV push), other methods of regional de-
livery have been attempted since the early 1950s.
The advantageof regional drug delivery is the ad-
ministration of higher drug concentrations to the
tumor while minimizing systemic toxicity. *
Since the 1950smany investigational trials have
looked at chemotherapy delivered intra-arterial-
l~,~-” intracavitarily,12-15intrathecally,16*17and by
regional perfusion. 18,i9 Current technology has
created innovative devices to facilitate drug deliv-
ery to specific regional areas. In this issue, four
From the Centerfor Health Information, Education and Re-
search at California Medical Center, Los Angeles and the Val-
ley Presbyterian Medical Center, Van Nuys, CA.
Address reprint requests to Julena Lind, RN, MN, 320 W IS
St, Los Angeles, CA 90015.
0 1987 by Grune & Stratton, Inc.
0749-2081187/0302-0001$05.00/0
pp 83-86 83
84
articles are devoted to alternate delivery ap-
proaches. Hoff addresses intraperitoneal chemo-
therapy administration, while Hagle, Simon, and
Mioduszewski and Zarbo discuss implantable de-
vices for chemotherapy, central venous and right
atria1 catheters, and ambulatory infusion pumps,
respectively.
Nursing’s Evolving Role
The involvement by nurses in chemotherapy ad-
ministration is very difficult to document before
1960. One cancer nursing author recollects that
the first chemotherapy administered in the 1950s
was given exclusively by physicians using a very
precise technique. She states, “for a nurse to ad-
minister chemotherapy at that time would have
been unthinkable. ’ ‘20
Nursing journals began to reflect the role of
nursing in chemotherapy during the early
1960~.~‘-~~ The first cancer nursing textbook,
written in 1967, included a few pages on “nursing
care of the patient receiving chemotherapy,” but
did not discuss administration concepts.24 The
1970s brought a dramatic increase in the numbers
of nursing articles related to chemotherapy.25-28
Today three different nursing journals are devoted
exclusively to cancer nursing with some discus-
sion of chemotherapy in nearly every issue.
Since the 1960s nurses have developed very
explicit steps for the intravenous administration of
chemotherapy. These guidelines include drug
preparation, patient preparation, venipuncture site
selection, administration technique, and safe han-
dling procedures. For a detailed review, the reader
is referred to a 1984 Oncology Nursing Society
publication.29
Today the use of complex combination drug
regimens demands more than simple memory in
the intricate preparation of many different chemo-
therapeutic agents. Several good references are
available and should be made a standard part of an
oncology unit or clinic. 30-33
The techniques of administration have remained
relatively consistent. The first journal article to
fully describe standard administration technique is
as useful today as it was in 1980.34 Two of the
many valuable points emphasized in that article
are worth noting here: controlling the nausea and
vomiting associated with chemotherapy and the
risks of extravasation. Administration of anti-
emetics prior to chemotherapy can be as important
LIND AND BUSH
to the patient and family as the administration of
the cytotoxic drugs themselves. A good review of
antiemetic therapy currently in use in cancer has
been provided in the literature.35-38 For nursing,
extravasation is perhaps one of the most trouble-
some risks of chemotherapy administration. In this
issue, Montrose gives a comprehensive descrip-
tion of the prevention and treatment of extra-
vasation. Specific guidelines for intravenous
chemotherapy are listed elsewhere in the liteta-
ture 29.34.39.40
Nursing’s role in chemotherapy has evolved
enough to create subspecialties within a specialty.
Meeske and Ruccione in this issue give an excel-
lent overview of chemotherapy administration in
children. Hubbard provides an in-depth view of
nursing’s historical past and challenging future in
regards to chemotherapy.
CURRENT DIRECTIONS
Drug Delivery
There are emerging therapies that may be effec-
tive in both the local delivery and cell-targeted
delivery of drugs. 41 Cell-targeted drug delivery
includes drug carriers, such as proteins and lipo-
somes, and the use of monoclonal antibodies.
Hubbard’s article in this issue references recent
research in monoclonal antibodies. These new
techniques of chemotherapy delivery will increase
the ability to target the drug directly to the tumor,
simultaneously increasing tumor cell kill and de-
creasing toxicity.42
Chemotherapy timing may be another important
variable in the toxicity of therapy and response of
tumor cells. 43 Timing differs from chemotherapy
scheduling and refers to the time of day in which
drugs are administered. Current studies based on
data from animals and humans demonstrate circa-
dian rhythms and diurnal variations in DNA syn-
thesis, B and T lymphocyte production, and natu-
ral killer cell activity. 43 If the circadian rhythms,
the diurnal and seasonal variations of tumor cells
and the host were known, then the drugs could be
administered at a time when they would be most
effective.
Nursing’s Role
A major current concern of oncology nurses is
the safe administration of chemotherapy. This in-
volves both safe handling of antineoplastic agents
and proficiency in intravenous technique. Miller,
NURSING’S ROLE IN CHEMOTHERAPY
in this issue, provides an extensive review of cur-
rent research in the safe handling of cytotoxic
drugs.
Proficiency in technique implies in-depth
knowledge of cancer care. Education in this area
should include: pathophysiology of cancer, phar-
macology of antineoplastic agents, treatment side
effects, and mechanisms of drug delivery.44
Health care settings must provide theoretical back-
ground as well as adequate clinical experience in
standard chemotherapy administration technique.
This should be demonstrated and evaluated under
the supervision of an experienced nurse preceptor.
Policies regarding management of drug extravasa-
tion, safe handling and disposal of wastes, and in-
travenous technique must be available within the
agency.
In 1986 the Oncology Nursing Society adminis-
tered the first certification exam to test entry level
competencies into the specialty of oncology nurs-
ing. In the future, the certification process might
be expanded to include recognition of additional
expertise in an oncology subspecialty, eg, chemo-
therapy. 45 Chemotherapy competency courses
must be implemented in the hospital and in home
health agencies to ensure safe practice and ac-
countability for nurses who are administering and
monitoring chemotherapeutic agents.46f47
In addition to standard intravenous chemothera-
py administration. intracavity therapy and man-
agement of arterial lines and implantable pumps
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Economic Ir@ences
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of Seminars in Oncology Nursing makes reference
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py administration.
Admonitions to provide high quality nursing
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care settings. The looming nursing shortage adds
yet another economic factor to the challenge of
providing safe, competent chemotherapy adminis-
tration
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nursing’s role in chemotherapy administration can
be one of challenge and reward. We hope that this
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administration is stimulating, educational, and
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ticulately described, nurses are the key to the che-
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