How chemotherapy drugs are given
- How it is given
- Consent
- Pros & cons
- Where it is given
- Treatment planning
- Clinical trials
- After treatment
Why chemotherapy is given in different ways
Chemotherapy may be given in different ways, depending on the type of cancer you have and the chemotherapy drugs used:
- Most often it is given by injection into a vein (intravenously). This is known as intravenous chemotherapy.
- Some drugs are given as tablets or capsules (orally).
- 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 crook 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 uncomfortable or a little painful but it should not take long and the pain soon wears off. Once the cannula has been put in, it will be taped securely to keep it in place.
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.
The chemotherapy can then be given through the cannula. Usually a drip is attached to the cannula and some 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. Some chemotherapy drugs are diluted in a drip bag and the drip is attached to the cannula. 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 cathers)
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.
*Hickman and Groschong are registered trademarks of CR Bard inc or an affiliate.
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. It 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 this line 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. There are very few restrictions to everyday life. 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.
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 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 this for you.
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.
PICC lines
Your doctor may ask you to 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. 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. There are very few restrictions to everyday life. 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 needles can be passed to give medicines into the vein or take blood.
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. The port shows as a small bump underneath the skin which can be felt, 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. Some pumps are disposable after use and are operated by a balloon mechanism or spring control.
If you have any problems or questions when you get home, contact the nurses or doctor at the chemotherapy clinic or ward.
Chemotherapy tablets or capsules
You may be given tablets or capsules to take at home as all or part of your treatment. Tablets or capsules are known as oral chemotherapy. 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.
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. This may be painful or uncomfortable, but only lasts 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.
Intracavity chemotherapy
To give chemotherapy drugs in this way, a tube is inserted into the affected body cavity, for example the bladder. The chemotherapy is flushed 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 to which they are given, but they do not tend to cause side effects in other parts of the body.
Intrathecal injection (into the fluid around the spinal cord)
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. The fluid is known as cerebrospinal fluid or CSF. To prevent this from happening, or to treat it if it occurs, chemotherapy may be given into the CSF. To do this 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 CSF. The chemotherapy is injected into the CSF through the needle.
This procedure 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.
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.
Giving consent for chemotherapy treatment
Before you have any chemotherapy your doctor will explain the aims of the treatment to you and you will usually be asked to sign a form saying that you give your permission (consent) for the hospital staff to give you the chemotherapy. No medical treatment can be given without your consent, and before you are asked to sign the form you should have been given full information about:
- the type and extent of the treatment you are advised to have
- the advantages and disadvantages of the treatment
- any possible other treatments that may be available
- any significant risks or side effects of the treatment (both short and long term)
- what the treatment aims to achieve.
If you do not understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments are complex, so it is not unusual for people to need repeated explanations.
It can be helpful to have a friend or relative with you when the treatment is explained, to help you remember the discussion more fully. You may also find it useful to write down a list of questions before you go for your appointment.
Patients often feel that the hospital staff are too busy to answer their questions, but it is important for you to be aware of how the treatment is likely to affect you and the staff should be willing to make time for you to ask questions.
You can always ask for more time to decide about the treatment, if you feel that you can't make a decision when it is first explained to you. You are also free to choose not to have the treatment, and the staff can explain what may happen if you do not have it. If you decide against having treatment, tell a doctor, or the nurse in charge, so that they can record your decision in your medical notes. You do not have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.
The benefits and disadvantages of chemotherapy
Many people are frightened of having chemotherapy, because of the side effects that can occur. However, side effects can often be well controlled with medicines.
Some people ask what would happen if they did not have the treatment. Treatment can be given for different reasons and the potential benefits will vary depending upon the individual situation. In people with early cancer, surgery is often done with the aim of curing the cancer and chemotherapy may be given to reduce the risks of the cancer coming back. It is helpful to discuss with your cancer specialist how much the chemotherapy may reduce the chance of the cancer coming back in your particular situation.
If the cancer is at a more advanced stage the aim of treatment may be to control the cancer. This can lead to a reduction in symptoms, a better quality of life and possibly prolong life. However, for some people the treatment will have no effect upon the cancer and they will get the side effects without any of the benefit. If you choose not to have treatment in this situation, you can still be given supportive (palliative) care, with medicines to control any symptoms.
The decision about whether to have chemotherapy treatment can be a difficult one and you may need to discuss it in detail with your doctor. The nurses at Cancerbackup can also discuss the benefits and disadvantages with you.
Where chemotherapy treatment is given
Chemotherapy units are very specialised and not all hospitals have them, so you may need to travel for treatment. Chemotherapy drugs are usually prepared in a special area of the hospital pharmacy. All the drugs are carefully checked by the pharmacy staff to ensure that they are the right ones for you. Chemotherapy tablets, capsules or creams can be given to you to take home.
Most intravenous chemotherapy drugs can be given to you as a day patient at the hospital. This may take from half an hour to a few hours. However, some treatments, such as having chemotherapy into the abdominal cavity, will mean a short stay in hospital – perhaps overnight or for a couple of days. For some chemotherapy treatments – for example, high-dose chemotherapy – you will need to stay in hospital longer, perhaps for a few weeks. Your doctor or nurse will explain exactly what your treatment will involve before it starts.
If you are having chemotherapy by intramuscular injection, subcutaneous injection, intrathecal injection, or intracavity injection into the bladder, it is usually given in the outpatients department or the chemotherapy day unit at the hospital. It may be given on certain wards within the hospital.
Sometimes, specialist chemotherapy nurses can visit you at home to give intravenous chemotherapy. This sort of service is only available in some parts of the UK and with some types of chemotherapy treatment. You can ask your doctor whether it is possible to have your treatment at home.
Points to remember when having chemotherapy at home
- Chemotherapy tablets, capsules or injections may need to be stored in a particular way, such as in the fridge. Always follow the instructions given by your pharmacist.
- It is important not to touch some chemotherapy drugs with your fingers.
- All drugs must be stored out of the reach of children as they could cause serious harm if taken by accident.
- If you are having intravenous chemotherapy by pump and you notice any leakage of the drug from the pump or tube it is essential to let the nurse or doctor at the hospital know immediately.
- If you feel unwell at any time phone the nurse or doctor at the hospital for advice.
Planning your chemotherapy treatment
Your doctor will consider several factors when planning your treatment. The most important of these are:
- the type of cancer you have
- where in the body the cancer is
- how far it has spread (if at all)
- your general health.
How often you have your treatment and how long the whole course of treatment takes will depend on:
- the type of cancer you have
- the particular chemotherapy drugs you are having
- how well the cancer responds to the drugs
- any side effects the drugs may cause.
Before starting chemotherapy, you will have your height and weight checked. This helps the doctor to work out the right dose of chemotherapy for you.
Intravenous chemotherapy is usually given as several sessions of treatment, unless you are having continuous treatment by infusion pump. Depending on the drug, or drugs, each treatment can last from a few hours to a few days. Each treatment is generally followed by a rest period of a few weeks to allow your body to recover from any side effects and to allow the number of cells in your blood to go back to normal. The treatment and the rest period are known as a cycle of treatment. The number of cycles you have will depend on how well your cancer is responding to the chemotherapy.
It may take several months to have all the chemotherapy to treat your cancer. When chemotherapy is given by an infusion pump it can be given continuously over a time varying from several days to several weeks.
Some people having tablets or capsules (oral chemotherapy) take the chemotherapy daily for several weeks or months, before they have a rest period.
Before you are given your chemotherapy, you will normally have blood tests and see the doctor or specialist chemotherapy nurse. This will take some time. Your GP, practice nurse or the staff at a hospital close to your home can take your blood a day or two before your treatment, so that you do not have to wait as long on the day of your treatment. If your blood is taken at your GP surgery, or at another hospital, the results will be sent to the hospital where you are having your treatment. Sometimes you may need to have x-rays or scans.
All chemotherapy drugs are prepared in a special way and you may have to wait while the hospital pharmacy department gets them ready. To help pass the time, it can be helpful to take a book, personal stereo, iPod, newspaper, crosswords or perhaps some letters to write.
Your doctor or chemotherapy nurse will explain your treatment plan. If you have any questions, don't be afraid to ask. It often helps to make a list of questions and to take a close relative or friend with you to remind you of things you want to know but may easily forget.
Changes in the treatment plan
Your doctors will use blood tests and sometimes urine tests to monitor the effect that the chemotherapy is having on your body.
If you have a tumour that can be seen on a scan or felt by the doctor, the hospital staff will regularly check the effects of the chemotherapy, and any other treatment you are having, on the cancer. The results from your blood tests and any scans or x-rays show how much the cancer is responding to the treatment.
Depending on the results of the tests, your treatment plan may sometimes need to be changed. There can be many reasons for this and, if this is necessary, your doctor will tell you why your treatment plan needs to be changed. It may be because the drugs you are having are starting to cause damage to particular parts of the body, such as the bone marrow, kidneys, liver or nerves in the hands or feet. Sometimes it can be because the chemotherapy is not shrinking the cancer enough, and changing to different drugs may be more effective.
Sometimes, your treatment may need to be delayed because the chemotherapy drugs are stopping your bone marrow from working properly. Delaying the chemotherapy gives your bone marrow a chance to recover before the next session of drugs is given.
If there is a special occasion that you would like to attend, or you want to go on holiday, it may be possible to arrange the timing of your treatment to fit in with this. Your doctor can tell you whether this is possible.
Research - clinical trials for chemotherapy treatments
You may be asked to have your chemotherapy as part of a treatment research trial. Cancer research trials are carried out to try to find new and better treatments for cancer. Trials that are carried out on patients are known as clinical trials.
Clinical trials may be carried out to:
- Test new treatments, such as new chemotherapy drugs, gene therapy or cancer vaccines.
- Look at new combinations of existing treatments, or change the way they are given, in order to make them more effective or to reduce side effects.
- Compare the effectiveness of drugs used for symptom control.
- See which treatments are the most cost-effective.
- Find out how cancer treatments work.
Trials are the only reliable way to find out if a different operation, type of chemotherapy, radiotherapy, or other treatment is better than what is already available.
Taking part in a trial
There can be many benefits in taking part in a trial. Trials help to improve knowledge about cancer and the development of new treatments. You will also be carefully monitored during and after the study. Usually, several hospitals around the country take part in these trials.
The process of clinical trials is described in more detail in a separate section on cancer research trials.
Blood and tumour samples
Many blood samples and bone marrow or tumour biopsies may be taken to find out what is wrong with you. Most of these are needed to make the right diagnosis. You may be asked for your permission to use some of you samples for research into cancer. Some samples may be frozen and stored for future use, when new research techniques become available.
The research may be carried out at the hospital where you are treated, or it may be at another hospital. This type of research takes a long time, so you are unlikely to hear the results. The samples will, however, be used to increase knowledge about the causes of cancer and its treatment. This research will, hopefully, improve the outlook for future patients.
After your chemotherapy has finished
After your chemotherapy has finished, you will have regular check-ups and possibly scans or x-rays. These will probably continue for several years. If you have any problems, or notice any new symptoms inbetween these times, let your doctor know as soon as possible. Many people find that they get very anxious for a while before the appointments. This is natural and it may help to get support from family, friends or an organisation.
Sometimes the hardest time to cope with is when treatment is finished and you, and everyone else, see this as the time to get back to normal. Recovery time varies, and no one can say for sure how long you should take to get over the side effects, the tiredness and the emotional effects. The end of the visits to hospital for treatment can leave you feeling alone and neglected. Many people find that they feel very low and emotional at this time, when they had expected to be able to put the cancer and the treatment behind them. This may be the time when you need most support. Support is available to you if you would like it.
For people whose treatment is over apart from regular check-ups, the section on adjusting to life after cancer gives useful advice on how to keep healthy and adjust to life after cancer.
