Overview

Antineoplastic agents kill rapidly dividing cells — cancer cells, but also bone marrow precursors, GI mucosa, and hair follicles, which drives the predictable toxicity profile. Beyond shared myelosuppression, individual agents carry signature organ toxicities: anthracyclines damage the heart, platinums damage the kidneys and hearing, vinca alkaloids and taxanes damage nerves, and alkylating agents damage the bladder and mucosa. Many agents are vesicants that cause severe tissue necrosis on extravasation. The drugs are also hazardous to the nurse, requiring strict safe-handling precautions. The nurse matches the right monitoring and the right protectant agent to each drug's toxicity.

Myelosuppression Nadir

nadir 7-14 days post-dose Hallmark

lowest blood-count point; highest-risk window

calculate absolute neutrophil count

ANC = (% neutrophils + % bands) × WBC; a normal WBC can still hide neutropenia

neutropeniaANC < 1,000/mm³

severe neutropeniaANC < 500/mm³

high infection risk

monitor platelet count

thrombocytopenia peaks near nadir → bleeding risk

absent inflammatory signs

no redness/swelling/pus — fever may be the only sign of infection

neutropenic precautions

private room, strict hand hygiene, no raw fruits/vegetables, no fresh flowers, no rectal temps/suppositories, no IM injections

Cardiotoxicity

doxorubicin Hallmark

anthracycline; cumulative, dose-dependent cardiotoxicity

lifetime cumulative dose limit550 mg/m²

450 mg/m² with prior chest radiation

baseline and serial ejection fraction

echocardiogram or MUGA scan

hold for EF declineHoldEF < 50% or ≥10% drop

notify provider

dexrazoxane

cardioprotectant given before doxorubicin; cannot reverse established damage

rising NT-proBNP

signals emerging heart failure

red-orange urine is expected

from doxorubicin — not hematuria; teach before first dose

Nephro Ototoxicity

cisplatin Hallmark

platinum agent; nephrotoxic and ototoxic, both dose-related and often irreversible

aggressive IV normal saline pre-hydration

primary prevention of nephrotoxicity; 1-2 L before infusion

maintain urine output≥ 100 mL/hr

during and after infusion

check BUN and creatinine each cycle

trend across cycles; hold if creatinine clearance falls below threshold

monitor magnesium and potassium

renal tubular wasting; hypomagnesemia is commonly tested

baseline and serial audiometry

high-frequency hearing loss + tinnitus, often permanent

carboplatin is less nephro/ototoxic

but more myelosuppressive — not interchangeable with cisplatin

Neurotoxicity

EarlyProgresses →

peripheral neuropathy first

numbness, tingling, loss of DTRs starting in fingers and toes

Late / Severe

autonomic neuropathy follows

constipation → paralytic ileus, urinary retention, orthostatic hypotension

Other findings

vincristine Hallmark

vinca alkaloid; neurotoxicity is dose-limiting, not myelosuppression

start prophylactic bowel regimen

stool softeners + stimulant laxatives at treatment start, not after constipation develops

IV only — never intrathecal

intrathecal vincristine is universally fatal

max single adult dose2 mg

caps neurotoxicity

taxane coasting phenomenon

paclitaxel neuropathy can worsen for weeks-months after treatment ends; may be permanent

Cystitis Mucositis

cyclophosphamide Hallmark

alkylating agent; metabolite acrolein damages bladder mucosa → hemorrhagic cystitis

mesna

uroprotectant; binds acrolein in the bladder; given with/before cyclophosphamide, not after hematuria appears

aggressive hydration

~3 L/day to dilute acrolein

void every 1-2 hours

holding urine concentrates acrolein

mucositis

prominent with cyclophosphamide and methotrexate; painful oral ulceration, dysphagia, infection risk

saline or sodium bicarbonate rinses

soft toothbrush; never alcohol-based or hydrogen-peroxide mouthwash

cryotherapy with ice chips

during short infusions; vasoconstricts oral mucosa, reduces drug delivery

Protectant Pairs

mesna protects the bladder

acrolein from cyclophosphamide

dexrazoxane protects the heart

doxorubicin free-radical damage

hydration protects the kidneys

cisplatin nephrotoxicity

Safe Handling

double chemotherapy-rated gloves

ASTM D6978-tested; standard exam gloves are permeable

closed-front disposable chemo gown

eye protection and respirator when aerosolizing

prepare in a vertical biological safety cabinet

protects the preparer; a horizontal hood blows contaminants toward you

use a closed-system transfer device

prevents drug escape during administration

yellow chemotherapy waste container

not red biohazard; all contaminated materials incl. primed tubing

body fluids hazardous 48 hours

wear chemo-rated gloves for urine/stool/emesis/linens

clean spills inward to outward

use a chemo spill kit; restrict access first; only trained staff

pregnant nurses must not handle chemotherapy Hallmark

Patient Teaching

take your temperature when feeling unwell

call the provider immediately at ≥100.4°F (38°C)

do not take acetaminophen for fever at home

it masks neutropenic fever; report instead

avoid raw and undercooked foods

low-microbial diet near nadir; includes raw fruits and vegetables

avoid fresh flowers and standing water

do not change the cat litter box

Toxoplasma risk — delegate

report numbness or tingling

peripheral neuropathy from neurotoxic agents

report new constipation

autonomic neuropathy from vincristine

report ringing or muffled hearing

cisplatin ototoxicity

red-orange urine after doxorubicin is normal

weigh daily and report new shortness of breath

anthracycline heart failure

void every 1-2 hours during cyclophosphamide

use a soft toothbrush and bland rinses

mucositis care

Report Nowescalate immediately

neutropenic fever Hallmark≥ 100.4°F / 38°C

medical emergency — treat as sepsis; blood cultures + broad-spectrum antibiotics; classic signs may be absent

vesicant extravasation

burning/swelling/blanching or loss of blood return — stop infusion, aspirate residual drug through the catheter; doxorubicin/vincristine are vesicants

new or absent blood return during infusion

vesicant extravasation trigger — activate protocol

frank hematuria

hemorrhagic cystitis from cyclophosphamide — report pink-tinged urine immediately, not next shift

EF below 50% or ≥10% drop from baselineEF < 50%

anthracycline cardiotoxicity — hold doxorubicin

new dysrhythmia on doxorubicin

acute cardiotoxicity

rising creatinine with new tinnitus

cisplatin nephro/ototoxicity — hold and notify

absent bowel sounds with distension

vincristine paralytic ileus — surgical emergency risk

uncontrolled bleeding or petechiae

thrombocytopenia at nadir

Clinical Pearl

Match the protectant to the poison: acrolein→mesna (bladder), doxorubicin→dexrazoxane (heart), cisplatin→hydration (kidneys). And in a neutropenic client, no pus or redness doesn't mean no infection — fever alone is the fire alarm, so treat it like sepsis.