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Bendamustine and Rituximab

(BEN-duh-MUS-teen and rih-TUK-sih-mab)

“BR” is used to chronic lymphocytic leukemia (CLL), which starts with certain white blood cells in the bone marrow and then goes into the blood.

“BR” is used to chronic lymphocytic leukemia (CLL), which starts with certain white blood cells in the bone marrow and then goes into the blood.

Page 1 INTRAVENOUS CANCER TREATMENT EDUCATION BENDAMUSTINE AND RITUXIMAB Name of the regimen and cancer drugs Your care team may refer to your treatment as “BR”. “BR” consists of 2 different anti cancer therapies. Bendamustine (BEN duh MUS teen): Bendeka™, Treanda™, Belrapzo™ Rituximab (rih TUK sih mab): Rituxan™, Ruxience™, Truxima™ Common uses “BR” is used to chronic lymphocytic leukemia (CLL), which starts with certain white blood cells in the bone marrow and then goes into the blood. “BR” is used to treat slow growing non Hodgkin lymphomas (NHL), which starts with certain white blood cells in the lymph system. NHL include diffuse large B cell lymphoma (DLBCL), follicular lymphoma (FL), MALT lymphoma, mantle cell lymphoma, nodal and splenic marginal zone lymphoma, Waldenström macroglobulinemia/lymphoplasmacytic lymphoma. BR regimen is mostly commonly used for CLL and NHL but may be used for other treatments. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each “BR” treatment is repeated every 21 or 28 days, depending on the reason your doctor has prescribed it. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug, or drugs, stop working or you have side effects which stop you from continuing treatment. Bendamustine IV given on Days 1 and 2 over 10 60 minutes Rituximab IV given on Day 1 over 90 minutes to several hours Drug DAY 1 2 3 4 5 6 7 8 9 10 ... Cycle 2 Day 1 Bendamustine X X X Rituximab X X BENDAMUSTINE AND RITUXIMAB Page 2 INTRAVENOUS CANCER TREATMENT EDUCATION Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Possible drug interactions BR may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, over thecounter medications, vitamins, and herbal products that you take. Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. Anti nausea medications You will receive medications to prevent nausea just before your chemotherapy. You may also get prescriptions for other medications to take at home, as below: Instructions: Growth Factors Growth factors, like filgrastim, pegfilgrastim, and others, are medications used to treat neutropenia and prevent infections. Neutropenia is a condition where there are lower than normal white blood cells caused by some type of chemotherapy. Growth factors help the bone marrow to make more white blood cells. Medications to prevent side effects You will receive your medications to prevent side effects just before your chemotherapy. You may get prescriptions for other medications to take at home, as below: BENDAMUSTINE AND RITUXIMAB Page 3 INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving BR are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an in fection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symptoms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page BENDAMUSTINE AND RITUXIMAB Page 4 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Continued on the next page BENDAMUSTINE AND RITUXIMAB Page 5 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8 10 (8 ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Fatigue • You may be more tired than usual or have less energy. • Stay as active as possible, but know it is okay to rest as needed. • Try to do some type of moderate activity every day. • Conserve your energy. Plan your activities and do them at a time of day when you feel a bit more energetic. • Follow a healthy diet and stay hydrated. • Accept help from family and friends • Find healthy ways to manage stress, such as meditation, journaling, yoga, and guided imagery • Develop good sleeping habits, limit napping during the day to help you sleep better at night. • Avoid operating heavy machinery if you feel too tired. Contact your care team if you experience extreme fatigue that prevents you from doing your normal daily activities. Continued on the next page BENDAMUSTINE AND RITUXIMAB Page 6 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Diarrhea (loose and/ or urgent bowel movements) Monitor how many bowel movements you have each day. • Drink 8 10 (8 ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland, low fiber foods (such as bananas, applesauce, potatoes, chicken, rice, and toast). • Avoid high fiber foods, such as raw vegetables and fruits and whole grains. • Avoid foods that cause gas, such as broccoli and beans. • Avoid foods with lactose, such as yogurt and milk. • Avoid spicy, fried, and greasy foods. Contact your care team if: • The number of bowel movements you have in a day increases by 4 or more • You feel dizzy or lightheaded Talk with your care team if you believe you have diarrhea. They may recommend an over thecounter medication or prescribe something to help keep it under control. Numbness or tingling in hands and feet. Report changes in your sense of touch, such as a burning feeling, pain on the skin or weakness. BENDAMUSTINE AND RITUXIMAB Page 7 INTRAVENOUS CANCER TREATMENT EDUCATION Rare but serious side effects Infusion reactions: Rituximab can rarely cause an infection reaction. During your treatment, let the nurse know right away if any of these symptoms happen: chills or shaking, dizziness, fever, itchiness or rash, flashing, difficulty breathing, wheezing, sudden back pain, or feeling faint. Tumor Lysis Syndrome: Bendamustine and rituximab can cause tumor lysis syndrome when starting treatment. Your care team may do blood tests to check for this side effect. Infertility: Bendamustine can impact your ability to conceive or father a child. Discuss this with your healthcare provider. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. (INSTITUTIONAL CONTACT INFO) Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started BR, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low flow toilet, close the lid and flush twice to ensure that all waste has been discarded. If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. Wash hands with soap and water after using the toilet for at least 20 seconds. If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. Wash any skin that has been exposed to body waste with soap and water. Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. BENDAMUSTINE AND RITUXIMAB Page 8 INTRAVENOUS CANCER TREATMENT EDUCATION Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving BR. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. Tell your care team if you become pregnant or plan to breastfeed. Additional resources Additional instructions Updated – July 12, 2021 Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy to understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.

Carboplatin and Paclitaxel

(KAR boh pla tin and PA klih TAK sil)

Carboplatin and paclitaxel are most commonly used to treat non-small cell lung cancer or ovarian cancer but may be used for other treatments.

Carboplatin and paclitaxel are most commonly used to treat non-small cell lung cancer or ovarian cancer but may be used for other treatments.

Page 1 CARBOPLATIN AND PACLITAXEL INTRAVENOUS CANCER TREATMENT EDUCATION Name of the regimen and cancer drugs Your care team may refer to your treatment as “Carbo Taxol” or “Taxol Carbo”. The regimen consists of 2 different chemotherapies. Carboplatin (KAR boh pla tin); Paraplatin® Paclitaxel (PA klih TAK sil); Taxol® Common uses Carboplatin and paclitaxel are most commonly used to treat non small cell lung cancer or ovarian cancer but may be used for other treatments. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each carboplatin and paclitaxel treatment is repeated every days. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug, or drugs, stop working or you have side effects which stop you from continuing treatment. Carboplatin: The infusion is given IV over minutes on day(s) on each treatment day. Paclitaxel: The infusion is given minutes on day(s) on each treatment day. Drug DAY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Carboplatin Paclitaxel CARBOPLATIN AND PACLITAXEL INTRAVENOUS CANCER TREATMENT EDUCATION Page 2 Instructions: Growth Factors Growth factors, like filgrastim, pegfilgrastim, and others, are medications used to treat neutropenia and prevent infections. Neutropenia is a condition where there are lower than normal white blood cells caused by some type of chemotherapy. Growth factors help the bone marrow to make more white blood cells. Anti nausea medications and other medications You will receive medications to prevent nausea and other side effects just before your chemotherapy. You may get prescriptions for other medications to take at home, as below: Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Possible drug interactions Carboplatin and paclitaxel may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, over the counter medications, vitamins, and herbal products that you take. Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. CARBOPLATIN AND PACLITAXEL INTRAVENOUS CANCER TREATMENT EDUCATION Page 3 Common Side Effects Common side effects that have been known to happen in patients receiving carboplatin and paclitaxel are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an in fection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symptoms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page CARBOPLATIN AND PACLITAXEL INTRAVENOUS CANCER TREATMENT EDUCATION Page 4 Possible Side Effect Management Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Continued on the next page CARBOPLATIN AND PACLITAXEL INTRAVENOUS CANCER TREATMENT EDUCATION Page 5 Possible Side Effect Management Fatigue • You may be more tired than usual or have less energy. • Stay as active as possible, but know it is okay to rest as needed. • Try to do some type of moderate activity every day. • Conserve your energy. Plan your activities and do them at a time of day when you feel a bit more energetic. • Follow a healthy diet and stay hydrated. • Accept help from family and friends • Find healthy ways to manage stress, such as meditation, journaling, yoga, and guided imagery • Develop good sleeping habits, limit napping during the day to help you sleep better at night. • Avoid operating heavy machinery if you feel too tired. Contact your care team if you experience extreme fatigue that prevents you from doing your normal daily activities. Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8 10 (8 ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Continued on the next page CARBOPLATIN AND PACLITAXEL INTRAVENOUS CANCER TREATMENT EDUCATION Page 6 Possible Side Effect Management Diarrhea (loose and/ or urgent bowel movements) Monitor how many bowel movements you have each day. • Drink 8 10 (8 ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland, low fiber foods (such as bananas, applesauce, potatoes, chicken, rice, and toast). • Avoid high fiber foods, such as raw vegetables and fruits and whole grains. • Avoid foods that cause gas, such as broccoli and beans. • Avoid foods with lactose, such as yogurt and milk. • Avoid spicy, fried, and greasy foods. Contact your care team if: • The number of bowel movements you have in a day increases by 4 or more • You feel dizzy or lightheaded Talk with your care team if you believe you have diarrhea. They may recommend an over thecounter medication or prescribe something to help keep it under control. Mouth irritation or sores Practice good mouth care. • Rinse your mouth after meals and at bedtime, and more frequently if you develop sores in your mouth • Brush your teeth with a soft toothbrush or cotton swab after meals • Use a mild non alcohol mouth rinse at least 4 times a day (after eating and at bedtime). One example is a mixture of 1/8 teaspoon of salt and 1/4 teaspoon of baking soda in 8 ounces of warm (not hot) water • Avoid acidic, hot or spicy foods and beverages, and rough foods that might irritate the mouth • If you have sores in your mouth, avoid using tobacco products, alcohol, and mouthwashes that contain alcohol Call your care team if you experience pain or sores in your mouth or throat. Continued on the next page CARBOPLATIN AND PACLITAXEL INTRAVENOUS CANCER TREATMENT EDUCATION Page 7 Possible Side Effect Management Hair loss (alopecia) • Your hair will likely grow back after treatment is over. • Some people choose to wear scarves, caps, or wigs. A short haircut prior to treatment may help with stress of hair loss. • Partial or complete hair loss is likely, usually 1 2 weeks after start of therapy. This hair loss can be all body hair. • Hair will grow back after treatment is completed, although the color and/or texture may be different • It may take 3 to 6 months after therapy is completed to resume normal hair growth • Be sure to keep your head covered to protect it from the sun during the summer and cold during the winter. • If not covering your scalp during the summer months, be sure to use sunscreen when spending time outdoors. Muscle or joint pain or weakness • Keep a diary of your pain, including when and where the pain happens, what it feels like, and how long it lasts • Stay as active as possible, but know that it is okay to rest as needed, too • Tell your care team if pain limits what you can do If the pain or weakness bothers you, ask your provider what you may use to help with this discomfort. Take only pain medication that has been prescribed or recommended by your care team Taste changes Some people may have a metallic or bitter taste in their mouth. To help with taste changes: • Choose and prepare foods that look and smell good to you • Use plastic spoons, forks, or knives if food tastes like metal • Flavor foods with spices or juices to change taste • Suck on mints or chew gum to mask taste • Brush teeth before and after eating with a soft bristle toothbrush • Avoid smoking Notify your doctor if you are having trouble eating or are losing weight. Numbness or tingling in hands and feet Report changes in your sense of touch, such as a burning feeling, pain on the skin or weakness. Changes in finger and toe nails Paclitaxel can cause changes in your finger and toe nails. You may develop dark or white lines on your nails or your nails may break easier. In rare cases these changes can result in loss of the nail. These changes will grow out over time. You should not use fake fingernails since this can increase nail damage and infection. CARBOPLATIN AND PACLITAXEL INTRAVENOUS CANCER TREATMENT EDUCATION Page 8 Rare but serious side effects Carboplatin and Paclitaxel can rarely cause an infusion or allergic type reaction. During your treatment, let the nurse know right away if any of these symptoms happen: chills or shaking, dizziness, fever, itchiness or rash, flushing, difficulty breathing, wheezing, sudden back pain, or feeling faint. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. (INSTITUTIONAL CONTACT INFO) Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started carboplatin and paclitaxel, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low flow toilet, close the lid and flush twice to ensure that all waste has been discarded. If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. Wash hands with soap and water after using the toilet for at least 20 seconds. If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. Wash any skin that has been exposed to body waste with soap and water. Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. CARBOPLATIN AND PACLITAXEL INTRAVENOUS CANCER TREATMENT EDUCATION Page 9 Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving carboplatin and paclitaxel. Patients of reproductive ability should use highly effective contraception during treatment and after the last dose for at least 6 months. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. Tell your care team if you become pregnant or plan to breastfeed. Additional resources Prescribing information link: Carboplatin: https://www.accessdata.fda.gov/drugsatfda docs/label/2010/020452s005lbl.pdf Paclitaxel: https://www.accessdata.fda.gov/drugsatfda docs/label/2011/020262s049lbl.pdf Updated – July 19, 2021 Additional instructions Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy to understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the IVE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.

Cetuximab

(seh-TUK-sih-mab)

Cetuximab is most commonly used to treat head and neck cancer and for patients that have KRAS wild-type colorectal cancer, but may be used for other treatments.

Cetuximab is most commonly used to treat head and neck cancer and for patients that have KRAS wild-type colorectal cancer, but may be used for other treatments.

Page 1 INTRAVENOUS CANCER TREATMENT EDUCATION CETUXIMAB Name of the regimen and cancer drugs Cetuximab (seh TUK sih mab): Erbitux Common uses Cetuximab is most commonly used to treat head and neck cancer and for patients that have KRAS wild type colorectal cancer, but may be used for other treatments Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each cetuximab treatment is repeated every 7 days. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug stops working or you have side effects which stop you from continuing treatment. Cetuximab IV is given weekly. Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Drug DAY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Cetuximab X X X Possible drug interactions Cetuximab may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, over the counter medications, vitamins, and herbal products that you take. Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. Instructions: Medications to prevent side effects You will receive your medications to prevent side effects just before your chemotherapy. You may get prescriptions for other medications to take at home, as below: CETUXIMAB Page 2 INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving cetuximab are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Rash or itchy skin • Keep your skin moisturized with creams and moisturizing lotions to decrease the risk of rash or itchiness and wear loose fitting clothing. • Avoid using perfumes and cologne as these products may increase rash symptoms. • Avoid being in the heat for long periods of time. • Your provider may recommend an over the counter antihistamine or a topical cream. • Sunlight can make symptoms worse • Avoid sun exposure as much as possible to decrease the risk of sunburn. The highest exposure to UV (ultra violet) radiation occurs between the hours of 10am and 4pm. • Wear long sleeved clothing, with UV protection if possible. • Wear broad brimmed hats. • Apply broad spectrum sunscreen (UVA/UVB) with at least SPF 30 as often as directed on the bottle. • Use lip balm with at least SPF 30 If your rash or itching continues to worsen, contact your care team. Continued on the next page CETUXIMAB Page 3 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Acne like rash A rash that looks like acne may happen on your face, chest, and upper back while taking this medication. • Your doctor may prescribe medication to help prevent or manage the rash • If you do get a rash, keep the area around the rash clean and dry • Check with your care team before using anything to treat it. • Do not use over the counter acne treatments such as benzoyl peroxide or salicylic acid and soaps containing alcohol • Wash with a mild, moisturizing soap. Avoid long, hot baths or showers • After washing, pat skin dry. Avoid vigorous rubbing • Oatmeal baths and unscented moisturizers may help with itching • Sunlight can make symptoms worse: • Avoid sun exposure as much as possible to decrease the risk of sunburn. The highest exposure to UV (ultra violet) radiation occurs between the hours of 10am and 4pm. • Wear long sleeved clothing, with UV protection if possible. • Wear broad brimmed hats. • Apply broad spectrum sunscreen (UVA/UVB) with at least SPF 30 as often as directed on the bottle. • Use lip balm with at least SPF 30 • Avoid tanning beds Fatigue • You may be more tired than usual or have less energy. • Stay as active as possible, but know it is okay to rest as needed. • Try to do some type of moderate activity every day. • Conserve your energy. Plan your activities and do them at a time of day when you feel a bit more energetic. • Follow a healthy diet and stay hydrated. • Accept help from family and friends • Find healthy ways to manage stress, such as meditation, journaling, yoga, and guided imagery • Develop good sleeping habits, limit napping during the day to help you sleep better at night. • Avoid operating heavy machinery if you feel too tired. Contact your care team if you experience extreme fatigue that prevents you from doing your normal daily activities. Continued on the next page CETUXIMAB Page 4 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Nausea or vomiting • You may be more tired than usual or have less energy. • Stay as active as possible, but know it is okay to rest as needed. • Try to do some type of moderate activity every day. • Conserve your energy. Plan your activities and do them at a time of day when you feel a bit more energetic. • Follow a healthy diet and stay hydrated. • Accept help from family and friends • Find healthy ways to manage stress, such as meditation, journaling, yoga, and guided imagery • Develop good sleeping habits, limit napping during the day to help you sleep better at night. • Avoid operating heavy machinery if you feel too tired. Contact your care team if you experience extreme fatigue that prevents you from doing your normal daily activities. Muscle or joint pain or weakness • Keep a diary of your pain, including when and where the pain happens, what it feels like, and how long it lasts • Stay as active as possible, but know that it is okay to rest as needed, too • Tell your care team if pain limits what you can do If the pain or weakness bothers you, ask your provider what you may use to help with this discomfort. Take only pain medication that has been prescribed or recommended by your care team Constipation Keep track of how many bowel movements you have each day. • Drink 8 10 (8 ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake • Stay active and exercise, if possible • Eat foods high in fiber like raw fruits and vegetables Contact your care team if you have not had a bowel movement in 3 or more days Your care team may recommend over the counter medications to help with constipation. A daily stool softener such as docusate (Colace®) and/or laxative such as senna (Senakot®) may be helpful. If these do not help within 48 hours, tell your care team. Continued on the next page CETUXIMAB Page 5 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Numbness or tingling in hands and feet Report changes in your sense of touch, such as a burning feeling, pain on the skin or weakness. Diarrhea (loose and/ or urgent bowel movements) Monitor how many bowel movements you have each day. • Drink 8 10 (8 ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland, low fiber foods (such as bananas, applesauce, potatoes, chicken, rice, and toast). • Avoid high fiber foods, such as raw vegetables and fruits and whole grains. • Avoid foods that cause gas, such as broccoli and beans. • Avoid foods with lactose, such as yogurt and milk. • Avoid spicy, fried, and greasy foods. Contact your care team if: • The number of bowel movements you have in a day increases by 4 or more • You feel dizzy or lightheaded Talk with your care team if you believe you have diarrhea. They may recommend an over thecounter medication or prescribe something to help keep it under control. Changes in electrolyte levels and other laboratory values: Low magnesium levels Low potassium levels Low calcium levels Changes in some lab values may occur and will be monitored by a simple blood test. You may not feel any symptoms if the changes are mild and they usually are not a sign of a serious problem. More severe changes may occur which can be a sign of a serious problem. Notify your care team if you have any of the following: • Shortness of breath • Chest discomfort • Weakness or fatigue • New aches and pains • Headaches • Dizziness • Swelling of your legs or feet • Red or brown colored urine Continued on the next page CETUXIMAB Page 6 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Headache Ask your provider what you may use to help with this discomfort. If your headache is mild, try resting in a dark, quiet room and apply a cool cloth to your forehead. Contact your care team right away if your headache: • Follows a head injury • Is severe, or starts suddenly • Does not go away after 3 days • Is associated with vomiting, visual disturbance, neck stiffness, drowsiness, confusion, made worse by coughing or lowering the head, rash, weakness in an arm or leg, or numbness Infection • Wash your hands often, especially before eating and after using the bathroom • Avoid people with fevers, flu, or other infections • Bathe often to keep good personal hygiene. • Report symptoms of a lung infection like a cough, sneezing, runny nose, fever, and scratchy or sore throat to your provider Mouth irritation or sores Practice good mouth care. • Rinse your mouth after meals and at bedtime, and more frequently if you develop sores in your mouth • Brush your teeth with a soft toothbrush or cotton swab after meals • Use a mild non alcohol mouth rinse at least 4 times a day (after eating and at bedtime). One example is a mixture of 1/8 teaspoon of salt and 1/4 teaspoon of baking soda in 8 ounces of warm (not hot) water • Avoid acidic, hot or spicy foods and beverages, and rough foods that might irritate the mouth • If you have sores in your mouth, avoid using tobacco products, alcohol, and mouthwashes that contain alcohol Call your care team if you experience pain or sores in your mouth or throat. Nail changes • Usually this change starts at the cuticle and may affect the skin around the nail. Nails on fingers and toes may look swollen and reddened, and may grow ridges • Wear gloves when cleaning or doing dishes, or working in the garden • Keep nails trimmed and hands clean • Biting, chewing, or picking at your nails can increase the risk of getting an infection • Talk to your care team if you notice any changes in your nails Cough or shortness of breath A cough that does not produce any mucous or (dry cough) may occur while taking this medication. If you experience any breathing problems or shortness of breath, notify your care team right away. This may be a serious side effect of the medication. CETUXIMAB Page 7 INTRAVENOUS CANCER TREATMENT EDUCATION Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: Infusion reactions: cetuximab can rarely cause an infusion reaction. During your treatment, let the nurse know right away if any of these symptoms happen: chills or shaking, dizziness, fever, itchiness or rash, flushing, difficulty breathing, wheezing, sudden back pain, or feeling faint. Cardiac arrest: cetuximab can cause your heart to stop beating effectively. Seek medical attention right away if you begin feeling chest pain, shortness of breath, weakness, dizziness or light headedness, or heart palpitations. Pulmonary toxicity: Cetuximab may result in serious and fatal lung toxicity. If you start to experience shortness of breath, fatigue, breathlessness, or discomfort/worsening of symptoms while lying on your back, please immediately contact your care team. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. (INSTITUTIONAL CONTACT INFO) Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started cetuximab, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low flow toilet, close the lid and flush twice to ensure that all waste has been discarded. If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. Wash hands with soap and water after using the toilet for at least 20 seconds. If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. Wash any skin that has been exposed to body waste with soap and water. Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. CETUXIMAB Page 8 INTRAVENOUS CANCER TREATMENT EDUCATION Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving cetuximab. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. Tell your care team if you become pregnant or plan to breastfeed. Additional resources Product website: https://www.erbitux.com/ Prescribing information link: https://www.accessdata.fda.gov/drugsatfda docs/label/2019/125084s273lbl.pdf Updated – July 19, 2021 Additional instructions Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy to understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.

Cytarabine and Daunorubicin (7+3)

(sye-TARE-a-been and daw-noe-ROO-bi-sin)

Cytarabine and Daunorubicin are used to treat acute myeloid leukemia (AML), but may be used for other treatments.

ytarabine and Daunorubicin are used to treat acute myeloid leukemia (AML), but may be used for other treatments.

Page 1 INTRAVENOUS CANCER TREATMENT EDUCATION CYTARABINE & DAUNORUBICIN (7+3) Name of the regimen and cancer drugs Your care team may refer to your treatment as 7+3. 7+3 consists of 2 different anti cancer therapies. 7: Cytarabine (sye TARE a been): Cytosar 3: Daunorubicin (daw noe ROO bi sin): Cerubidine Common uses Cytarabine & daunorubicin are used to treat acute myeloid leukemia (AML), but may be used for other treatments. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Cytarabine IV on Days 1 7. Daunorubicin IV on Days 1 3. This treatment is called induction therapy. You will only receive this treatment one time. This regimen is often administered inpatient. Drug DAY 1 2 3 4 5 6 7 Cytarabine X X X X X X X Daunorubicin X X X CYTARABINE & DAUNORUBICIN (7+3) Page 2 INTRAVENOUS CANCER TREATMENT EDUCATION Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Possible drug interactions 7+3 may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, over thecounter medications, vitamins, and herbal products that you take. Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. Infection prevention There is a risk of serious infections during treatment. You may receive medications to prevent infection in the hospital, and may also get prescriptions for medications to take at home for infection prevention, as below: Blood Product Transfusions You may receive blood transfusions while you are getting treatment for your cancer. These products are given to replace blood cells or blood products lost during the course of your cancer treatment. Your physician will decide if transfusions are needed based on certain laboratory results, such as hemoglobin, hematocrit, or platelets. If you have personal or religious beliefs that prohibit the receipt of blood product transfusions, please let your care team know before treatment begins. Instructions: Anti nausea and other medications You will receive medications to prevent nausea just before your cancer treatment. You may also get prescriptions for other medications to take at home, as below: CYTARABINE & DAUNORUBICIN (7+3) Page 3 INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving 7+3 are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an in fection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symptoms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page CYTARABINE & DAUNORUBICIN (7+3) Page 4 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Continued on the next page CYTARABINE & DAUNORUBICIN (7+3) Page 5 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8 10 (8 ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. CYTARABINE & DAUNORUBICIN (7+3) Page 6 INTRAVENOUS CANCER TREATMENT EDUCATION Rare but serious side effects Daunorubicin is a vesicant. If it leaks outside of the IV, it can cause severe damage to your skin. Notify your nurse right away if you feel any pain, aching, burning, itching, swelling, or redness at the site of your IV. Daunorubicin can make your heart work harder to pump blood to the rest of your body. Notify your care team if you experience shortness of breath or chest pain. This regimen may cause tumor lysis syndrome when starting treatment. Your care team may do blood tests to check for this side effect. These medications may be harmful to your kidneys. Speak to your care team to know when you need to have laboratory tests done to monitor your kidneys These medications may be harmful to your liver. Speak to your care team to know when you need to have blood tests done to monitor your liver function. If you get this side effect, your doctor may change your dose or stop treatment for some time. A secondary cancer can rarely occur months or years after treatment. Your care team will check your blood cell counts even after treatment is done to monitor for this side effect. Severe allergic reactions are a rare but serious side effect of cytarabine. Right away seek medical attention if you notice difficulty breathing, swelling of the mouth or tongue, or a serious rash. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. (INSTITUTIONAL CONTACT INFO) CYTARABINE & DAUNORUBICIN (7+3) Page 7 INTRAVENOUS CANCER TREATMENT EDUCATION Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started 7+3, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low flow toilet, close the lid and flush twice to ensure that all waste has been discarded. If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. Wash hands with soap and water after using the toilet for at least 20 seconds. If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. Wash any skin that has been exposed to body waste with soap and water. Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. CYTARABINE & DAUNORUBICIN (7+3) Page 8 INTRAVENOUS CANCER TREATMENT EDUCATION Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving 7+3. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. Tell your care team if you become pregnant or plan to breastfeed. Additional resources Additional instructions Updated – August 30, 2021 Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy to understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.

Docetaxel and Cyclophosphamide (TC)

(DOH-seh-TAK-sil and sye-kloe-FOS-fa-mide)

Docetaxel and Cyclophosphamide (TC) is most commonly used to treat breast cancer that does not have a protein called human epidermal growth factor 2 (HER2), but it may be used for other treatments. (It may be given before or after surgery.)

Docetaxel and Cyclophosphamide (TC) is most commonly used to treat breast cancer that does not have a protein called human epidermal growth factor 2 (HER2), but it may be used for other treatments. (It may be given before or after surgery.)

Page 1 DOCETAXEL AND CYCLOPHOSPHAMIDE (TC) INTRAVENOUS CANCER TREATMENT EDUCATION DOCETAXEL AND CYCLOPHOSPHAMIDE (TC) Name of the regimen and cancer drugs Your care team may refer to your treatment as TC. TC consists of 2 different anti cancer therapies. T: DOCETAXEL (DOH seh TAK sil); Taxotere® C: CYCLOPHOSPHAMIDE (sye kloe FOS fa mide); Cytoxan® Common uses TC is most commonly used to treat breast cancer that does not have a protein called human epidermal growth factor 2 (HER2), but it may be used for other treatments. It may be given before or after surgery. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each TC treatment is repeated every 21 days. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug, or drugs, stop working or you have side effects which stop you from continuing treatment. Each cycle may be repeated 4 times. Docetaxel IV given on Day 1. Cyclophosphamide IV given on Day 1 Growth Factor subcutaneous injection given on Day 2. Drug Cycle 1 Day 1 2 3 4 5 6 7 ... 21 Cycle 2 Day 1 2 Docetaxel X X Cyclophosphamide X X Pegfilgrastim X X Page 2 DOCETAXEL AND CYCLOPHOSPHAMIDE (TC) INTRAVENOUS CANCER TREATMENT EDUCATION Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Possible drug interactions TC may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, over thecounter medications, vitamins, and herbal products that you take. Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. Instructions: Growth Factors Growth factors, like filgrastim, pegfilgrastim, and others, are medications used to treat neutropenia and prevent infections. Neutropenia is a condition where there are lower than normal white blood cells caused by some type of chemotherapy. Growth factors help the bone marrow to make more white blood cells. Anti nausea medication other medications You will receive medications to prevent nausea and other side effects just before your chemotherapy. You may get prescriptions for other medications to take at home, as below: Dexamethasone In addition to anti nausea, dexamethasone is also used to prevent fluid retention (edema) and allergic reactions. You should take this medication regardless of how you feel on the days prescribed. Page 3 DOCETAXEL AND CYCLOPHOSPHAMIDE (TC) INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving TC are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an in fection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symp toms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page Page 4 DOCETAXEL AND CYCLOPHOSPHAMIDE (TC) INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Continued on the next page Page 5 DOCETAXEL AND CYCLOPHOSPHAMIDE (TC) INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Hair loss (alopecia) • Your hair will likely grow back after treatment is over. • Some people choose to wear scarves, caps, or wigs. A short haircut prior to treatment may help with stress of hair loss. • Partial or complete hair loss is likely, usually 1 2 weeks after start of therapy. This hair loss can be all body hair. • Hair will grow back after treatment is completed, although the color and/or texture may be different • It may take 3 to 6 months after therapy is completed to resume normal hair growth • Be sure to keep your head covered to protect it from the sun during the summer and cold during the winter. • If not covering your scalp during the summer months, be sure to use sunscreen when spending time outdoors. Fatigue • You may be more tired than usual or have less energy. • Stay as active as possible, but know it is okay to rest as needed. • Try to do some type of moderate activity every day. • Conserve your energy. Plan your activities and do them at a time of day when you feel a bit more energetic. • Follow a healthy diet and stay hydrated. • Accept help from family and friends • Find healthy ways to manage stress, such as meditation, journaling, yoga, and guided imagery • Develop good sleeping habits, limit napping during the day to help you sleep better at night. • Avoid operating heavy machinery if you feel too tired. Contact your care team if you experience extreme fatigue that prevents you from doing your normal daily activities. Fluid retention or swelling (edema) • Do not stand for long periods of time • Keep your legs elevated when sitting or lying down • Try to not eat salty foods, which can increase swelling • Avoid tight fitting clothing and shoes • Weigh yourself daily • Take any medications as prescribed to decrease fluid retention Contact your care team if you notice: • Swelling in the hands, feet, or legs • You are short of breath • You have gained 5 pounds or more in one week Neuropathy TC may cause numbness, pain, or burning in your hands or feet. Talk to your care team about ways to resolve this side effect. Continued on the next page Page 6 DOCETAXEL AND CYCLOPHOSPHAMIDE (TC) INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Mouth irritation or sores (stomatitis or mucositis) Practice good mouth care. • Rinse your mouth after meals and at bedtime, and more frequently if you develop sores in your mouth • Brush your teeth with a soft toothbrush or cotton swab after meals • Use a mild non alcohol mouth rinse at least 4 times a day (after eating and at bedtime). One example is a mixture of 1/8 teaspoon of salt and 1/4 teaspoon of baking soda in 8 ounces of warm (not hot) water • Avoid acidic, hot or spicy foods and beverages, and rough foods that might irritate the mouth • If you have sores in your mouth, avoid using tobacco products, alcohol, and mouthwashes that contain alcohol Call your care team if you experience pain or sores in your mouth or throat. Rash or itchy skin • Keep your skin moisturized with creams and moisturizing lotions to decrease the risk of rash or itchiness and wear loose fitting clothing. • Avoid using perfumes and cologne as these products may increase rash symptoms. • Avoid being in the heat for long periods of time. • Your provider may recommend an over the counter antihistamine or a topical cream. • Sunlight can make symptoms worse • Avoid sun exposure as much as possible to decrease the risk of sunburn. The highest exposure to UV (ultra violet) radiation occurs between the hours of 10am and 4pm. • Wear long sleeved clothing, with UV protection if possible. • Wear broad brimmed hats. • Apply broad spectrum sunscreen (UVA/UVB) with at least SPF 30 as often as directed on the bottle. • Use lip balm with at least SPF 30 If your rash or itching continues to worsen, contact your care team. Muscle or joint pain or weakness • Keep a diary of your pain, including when and where the pain happens, what it feels like, and how long it lasts • Stay as active as possible, but know that it is okay to rest as needed, too • Tell your care team if pain limits what you can do If the pain or weakness bothers you, ask your provider what you may use to help with this discomfort. Take only pain medication that has been prescribed or recommended by your care team Continued on the next page Page 7 DOCETAXEL AND CYCLOPHOSPHAMIDE (TC) INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8 10 (8 ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Diarrhea (loose and/ or urgent bowel movements) Monitor how many bowel movements you have each day. • Drink 8 10 (8 ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland, low fiber foods (such as bananas, applesauce, potatoes, chicken, rice, and toast). • Avoid high fiber foods, such as raw vegetables and fruits and whole grains. • Avoid foods that cause gas, such as broccoli and beans. • Avoid foods with lactose, such as yogurt and milk. • Avoid spicy, fried, and greasy foods. Contact your care team if: • The number of bowel movements you have in a day increases by 4 or more • You feel dizzy or lightheaded Talk with your care team if you believe you have diarrhea. They may recommend an over thecounter medication or prescribe something to help keep it under control. Nail changes • Nails on fingers and toes may look swollen and reddened and may grow ridges. • Skin/Nail changes: report any rashes, dryness or scaling to care provider, use mild soaps and rinse well, avoid hot water, use alcohol free oil based moisturizers, report any darkening or peeling skin or any changes to the nail. • Usually this change starts at the cuticle and may affect the skin around the nail. • Wear gloves when cleaning or doing dishes, or working in the garden • Keep nails trimmed and hands clean • Biting, chewing, or picking at your nails can increase the risk of getting an infection • Talk to your care team if you notice any changes in your nails Page 8 DOCETAXEL AND CYCLOPHOSPHAMIDE (TC) INTRAVENOUS CANCER TREATMENT EDUCATION Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: Hypersensitivity reactions: Severe allergic reactions are a rare but serious side effect of TC. Seek medical attention right away if you notice difficulty breathing, swelling of the mouth or tongue, or a serious rash. Secondary malignancy: A secondary cancer can rarely occur months or years after treatment. Your care team will check your blood cell counts even after treatment is done to monitor for this side effect. Hemorrhagic cystitis: Cyclophosphamide can cause irritation of the bladder walls, leading to blood in the urine. It can be prevented by drinking plenty of fluids (8 10 eight ounce) glasses per day and emptying bladder frequently, especially before bed. Pulmonary toxicity/pneumonitis: TC can cause lung and breathing problems. Tell your care team right away if you have new or worse cough, shortness or breath, cheat pain, difficulty breathing, or wheezing. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. (INSTITUTIONAL CONTACT INFO) Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started TC, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low flow toilet, close the lid and flush twice to ensure that all waste has been discarded. If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. Wash hands with soap and water after using the toilet for at least 20 seconds. If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. Wash any skin that has been exposed to body waste with soap and water. Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Page 9 DOCETAXEL AND CYCLOPHOSPHAMIDE (TC) INTRAVENOUS CANCER TREATMENT EDUCATION Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving TC. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. Tell your care team if you become pregnant or plan to breastfeed. Additional resources Taxotere® (docetaxel): http://products.sanofi.us/taxotere/Taxotere.pdf Cyclophosphamide (Cytoxan): https://www.accessdata.fda.gov/drugsatfda docs/ label/2013/012141s090,012142s112lbl.pdf Updated – July 22, 2021 Additional instructions Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy to understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.

Docetaxel, Carboplatin, Trastuzumab, and Pertuzumab (TCHP)

(DOH-see-TAK-si, KAR-boh-pla-tin, tras-TU-zoo-mab, and per-TU-zoo-mab)

Docetaxel, Carboplatin, Trastuzumab, and Pertuzumab (TCHP) is most commonly used for treatment of human epidermal growth factor receptor 2 (HER2) overexpressing breast cancer, but may be used for other treatments.

Docetaxel, Carboplatin, Trastuzumab, and Pertuzumab (TCHP) is most commonly used for treatment of human epidermal growth factor receptor 2 (HER2) overexpressing breast cancer, but may be used for other treatments.

Page 1 DOCETAXEL, CARBOPLATIN, TRASTUZUMAB, PERTUZUMAB (TCHP) INTRAVENOUS CANCER TREATMENT EDUCATION DOCETAXEL, CARBOPLATIN, TRASTUZUMAB, PERTUZUMAB (TCHP) Name of the regimen and cancer drugs Your care team may refer to your treatment as TCHP. TCHP consists of 4 different anti cancer therapies. • Docetaxel (DOH see TAK sil): Taxotere® • Carboplatin (KAR boh pla tin); Paraplatin® • Trastuzumab (tras TU zoo mab); Herceptin® • Pertuzumab (per TU zoo mab); Perjeta® Common uses TCHP is most commonly used for treatment of human epidermal growth factor receptor 2 (HER2) overexpressing breast cancer, but may be used for other treatments. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each TCHP treatment is repeated every 21 days. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug, or drugs, stop working or you have side effects which stop you from continuing treatment. Docetaxel IV on Day 1 Carboplatin IV on Day 1 Trastuzumab (5 FU) IV push on Day 1 Pertuzumab IV on Day 1 Drug DAY 1 2 3 4 5 6 7 8 9 ... 21 Cycle 2 Day 1 2 Docetaxel X X Carboplatin X X Trastuzumab X X Pertuzumab X X Growth Factor (ON DAY 2) X X Page 2 DOCETAXEL, CARBOPLATIN, TRASTUZUMAB, PERTUZUMAB (TCHP) INTRAVENOUS CANCER TREATMENT EDUCATION Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Instructions: Growth Factors Growth factors, like filgrastim, pegfilgrastim, and others, are medications used to treat neutropenia and prevent infections. Neutropenia is a condition where there are lower than normal white blood cells caused by some type of chemotherapy. Growth factors help the bone marrow to make more white blood cells. Anti nausea medication other medications You will receive medications to prevent nausea and other side effects just before your chemotherapy. You may get prescriptions for other medications to take at home, as below: Dexamethasone In addition to anti nausea, dexamethasone is also used to prevent fluid retention (edema) and allergic reactions. You should take this medication regardless of how you feel on the days prescribed. Possible drug interactions TCHP may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, overthe counter medications, vitamins, and herbal products that you take. Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. Page 3 DOCETAXEL, CARBOPLATIN, TRASTUZUMAB, PERTUZUMAB (TCHP) INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving TCHP are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an in fection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symp toms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page Page 4 DOCETAXEL, CARBOPLATIN, TRASTUZUMAB, PERTUZUMAB (TCHP) INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Continued on the next page Page 5 DOCETAXEL, CARBOPLATIN, TRASTUZUMAB, PERTUZUMAB (TCHP) INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Diarrhea (loose and/ or urgent bowel movements) Monitor how many bowel movements you have each day. • Drink 8 10 (8 ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland, low fiber foods (such as bananas, applesauce, potatoes, chicken, rice, and toast). • Avoid high fiber foods, such as raw vegetables and fruits and whole grains. • Avoid foods that cause gas, such as broccoli and beans. • Avoid foods with lactose, such as yogurt and milk. • Avoid spicy, fried, and greasy foods. Contact your care team if: • The number of bowel movements you have in a day increases by 4 or more • You feel dizzy or lightheaded Talk with your care team if you believe you have diarrhea. They may recommend an over thecounter medication or prescribe something to help keep it under control. Hair loss (alopecia) • Your hair will likely grow back after treatment is over. • Some people choose to wear scarves, caps, or wigs. A short haircut prior to treatment may help with stress of hair loss. • Partial or complete hair loss is likely, usually 1 2 weeks after start of therapy. This hair loss can be all body hair. • Hair will grow back after treatment is completed, although the color and/or texture may be different • It may take 3 to 6 months after therapy is completed to resume normal hair growth • Be sure to keep your head covered to protect it from the sun during the summer and cold during the winter. • If not covering your scalp during the summer months, be sure to use sunscreen when spending time outdoors. Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8 10 (8 ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Continued on the next page Page 6 DOCETAXEL, CARBOPLATIN, TRASTUZUMAB, PERTUZUMAB (TCHP) INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Fatigue • You may be more tired than usual or have less energy. • Stay as active as possible, but know it is okay to rest as needed. • Try to do some type of moderate activity every day. • Conserve your energy. Plan your activities and do them at a time of day when you feel a bit more energetic. • Follow a healthy diet and stay hydrated. • Accept help from family and friends • Find healthy ways to manage stress, such as meditation, journaling, yoga, and guided imagery • Develop good sleeping habits, limit napping during the day to help you sleep better at night. • Avoid operating heavy machinery if you feel too tired. Contact your care team if you experience extreme fatigue that prevents you from doing your normal daily activities. Mouth irritation or sores (stomatitis or mucositis) Practice good mouth care. • Rinse your mouth after meals and at bedtime, and more frequently if you develop sores in your mouth • Brush your teeth with a soft toothbrush or cotton swab after meals • Use a mild non alcohol mouth rinse at least 4 times a day (after eating and at bedtime). One example is a mixture of 1/8 teaspoon of salt and 1/4 teaspoon of baking soda in 8 ounces of warm (not hot) water • Avoid acidic, hot or spicy foods and beverages, and rough foods that might irritate the mouth • If you have sores in your mouth, avoid using tobacco products, alcohol, and mouthwashes that contain alcohol Call your care team if you experience pain or sores in your mouth or throat. Taste changes Some people may have a metallic or bitter taste in their mouth. To help with taste changes: • Choose and prepare foods that look and smell good to you • Use plastic spoons, forks, or knives if food tastes like metal • Flavor foods with spices or juices to change taste • Suck on mints or chew gum to mask taste • Brush teeth before and after eating with a soft bristle toothbrush • Avoid smoking Notify your doctor if you are having trouble eating or are losing weight Continued on the next page Page 7 DOCETAXEL, CARBOPLATIN, TRASTUZUMAB, PERTUZUMAB (TCHP) INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Rash or itchy skin • Keep your skin moisturized with creams and moisturizing lotions to decrease the risk of rash or itchiness and wear loose fitting clothing. • Avoid using perfumes and cologne as these products may increase rash symptoms. • Avoid being in the heat for long periods of time. • Your provider may recommend an over the counter antihistamine or a topical cream. • Sunlight can make symptoms worse • Avoid sun exposure as much as possible to decrease the risk of sunburn. The highest exposure to UV (ultra violet) radiation occurs between the hours of 10am and 4pm. • Wear long sleeved clothing, with UV protection if possible. • Wear broad brimmed hats. • Apply broad spectrum sunscreen (UVA/UVB) with at least SPF 30 as often as directed on the bottle. • Use lip balm with at least SPF 30 If your rash or itching continues to worsen, contact your care team. Muscle or joint pain or weakness • Keep a diary of your pain, including when and where the pain happens, what it feels like, and how long it lasts • Stay as active as possible, but know that it is okay to rest as needed, too • Tell your care team if pain limits what you can do If the pain or weakness bothers you, ask your provider what you may use to help with this discomfort. Take only pain medication that has been prescribed or recommended by your care team Fluid retention or swelling (edema) • Do not stand for long periods of time • Keep your legs elevated when sitting or lying down • Try to not eat salty foods, which can increase swelling • Avoid tight fitting clothing and shoes • Weigh yourself daily • Take any medications as prescribed to decrease fluid retention Contact your care team if you notice: • Swelling in the hands, feet, or legs • You are short of breath • You have gained 5 pounds or more in one week Continued on the next page Page 8 DOCETAXEL, CARBOPLATIN, TRASTUZUMAB, PERTUZUMAB (TCHP) INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Numbness or tingling in hands and feet Report changes in your sense of touch, such as a burning feeling, pain on the skin or weakness. Changes in liver function Your liver function will be checked every so often by a simple blood test. Contact your care team if you notice any of the following. • Yellowing of the skin or whites of your eyes • Dark or brown urine • Bleeding or bruising Changes in kidney function Your liver function will be checked every so often by a simple blood test. Contact your care team if you notice any of the following. • Decreased amount of urination • Unusual swelling in your legs and feet Changes in electrolyte levels and other laboratory values: Low sodium levels Low magnesium levels Changes in some lab values may occur and will be monitored by a simple blood test. • You may not feel any symptoms if the changes are mild and they usually are not a sign of a serious problem. • More severe changes may occur which can be a sign of a serious problem. Notify your care team if you have any of the following: • Shortness of breath • Chest discomfort • Weakness or fatigue • New aches and pains • Headaches • Dizziness or confusion • Swelling of your legs or feet • Red or brown colored urine Nail changes Usually this change starts at the cuticle and may affect the skin around the nail. • Biting, chewing, or picking at your nails can increase the risk of getting an infection • Talk to your care team if you notice any changes in your nails Page 9 DOCETAXEL, CARBOPLATIN, TRASTUZUMAB, PERTUZUMAB (TCHP) INTRAVENOUS CANCER TREATMENT EDUCATION Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: Cardiomyopathy (heart problems): Trastuzumab and Pertuzumab can make your heart work harder to pump blood to the rest of your body. Notify your care team if you experience shortness of breath or chest pain. Infusion reaction: Docetaxel, Carboplatin, Trastuzumab and Pertuzumab can rarely cause an infusion reaction. During your treatment, let the nurse know right away if any of these symptoms happen: chills or shaking, dizziness, fever, itchiness or rash, flushing, difficulty breathing, wheezing, sudden back pain, or feeling faint. Vesicant extravasation: docetaxel is a vesicant. If it leaks outside of the IV, it can cause severe damage to your skin. Notify your nurse right away if you feel any pain, aching, burning, itching, swelling, or redness at the site of your IV. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. (INSTITUTIONAL CONTACT INFO) Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started TCHP, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low flow toilet, close the lid and flush twice to ensure that all waste has been discarded. If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. Wash hands with soap and water after using the toilet for at least 20 seconds. If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. Wash any skin that has been exposed to body waste with soap and water. Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Page 10 DOCETAXEL, CARBOPLATIN, TRASTUZUMAB, PERTUZUMAB (TCHP) INTRAVENOUS CANCER TREATMENT EDUCATION Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving TCHP. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. Tell your care team if you become pregnant or plan to breastfeed. Additional resources Product website: https://www.herceptin.com/ and https://www.perjeta.com/ Prescribing information link: Trastuzumab (Herceptin): https://www.gene.com/download/pdf/herceptin prescribing.pdf Pertuzumab (Perjeta): https://www.gene.com/download/pdf/perjeta prescribing.pdf Docetaxel (Taxotere): https://www.accessdata.fda.gov/drugsatfda docs/label/2012/201525s002lbl.pdf Carboplatin (Paraplatin): https://www.accessdata.fda.gov/drugsatfda docs/label/2010/020452s005lbl.pdf Updated – July 22, 2021 Additional instructions Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy to understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.

Dose-dense Doxorubicin and Cyclophosphamide (ddAC)

(dok-suh-ROO-buh-si and sye-kloe-FOS-fa-mide)

Dose-dense Doxorubicin and Cyclophosphamide (ddAC) is most commonly used to treat breast cancer but may be used for other treatments.

Dose-dense Doxorubicin and Cyclophosphamide (ddAC) is most commonly used to treat breast cancer but may be used for other treatments.

Page 1 DOXORUBICIN AND CYCLOPHOSPHAMIDE INTRAVENOUS CANCER TREATMENT EDUCATION DOXORUBICIN AND CYCLOPHOSPHAMIDE Name of the regimen and cancer drugs Your care team may refer to your treatment as “ddAC” or “dose dense AC”. AC consists of 2 different chemotherapies A: DOXORUBICIN (dok suh ROO buh sin); Adriamycin ® C: CYCLOPHOSPHAMIDE (sye kloe FOS fa mide); Cytoxan® Common uses ddAC is most commonly used to treat breast cancer but may be used for other treatments. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each ddAC treatment is repeated every 14 days. This is known as one cycle. Your treatment may be given for a number of set cycles, or it will keep going until the drug, or drugs, stop working or you have side effects which stop you from continuing treatment. This regimen is typically continued for a total of 4 cycles. Doxorubicin: Day 1. Doxorubicin is a red colored solution given as an IV Cyclophosphamide: Day 1. The infusion is given IV Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Instructions: Growth Factors Growth factors, like filgrastim, pegfilgrastim, and others, are medications used to treat neutropenia and prevent infections. Neutropenia is a condition where there are lower than normal white blood cells caused by some type of chemotherapy. Growth factors help the bone marrow to make more white blood cells. Anti nausea medications You will receive medications to prevent nausea just before your chemotherapy. You may also get prescriptions for other medications to take at home, as below: Drug DAY 1 2 3 4 5 6 7 8 9 ... 14 Cycle 2 Day 1 Doxorubicin X X Cyclophosphamide X X Pegfilgrastim X Page 2 DOXORUBICIN AND CYCLOPHOSPHAMIDE INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving ddAC are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an in fection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symptoms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page Possible drug interactions ddAC may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, overthe counter medications, vitamins, and herbal products that you take. Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. Grapefruit or grapefruit juice may interact with ddAC. Avoid eating or drinking these during treatment. Page 3 DOXORUBICIN AND CYCLOPHOSPHAMIDE INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Continued on the next page Page 4 DOXORUBICIN AND CYCLOPHOSPHAMIDE INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Change in the color of urine It is normal to have red or orange colored urine for 1 to 2 days after the infusion of doxorubicin. Tell your care team if it does not stop in a few days, or if you see what looks like blood or blood clots in your urine. Fatigue • You may be more tired than usual or have less energy. • Stay as active as possible, but know it is okay to rest as needed. • Try to do some type of moderate activity every day. • Conserve your energy. Plan your activities and do them at a time of day when you feel a bit more energetic. • Follow a healthy diet and stay hydrated. • Accept help from family and friends • Find healthy ways to manage stress, such as meditation, journaling, yoga, and guided imagery • Develop good sleeping habits, limit napping during the day to help you sleep better at night. • Avoid operating heavy machinery if you feel too tired. Contact your care team if you experience extreme fatigue that prevents you from doing your normal daily activities. Hair loss (alopecia) • Your hair will likely grow back after treatment is over. • Some people choose to wear scarves, caps, or wigs. A short haircut prior to treatment may help with stress of hair loss. • Partial or complete hair loss is likely, usually 1 2 weeks after start of therapy. This hair loss can be all body hair. • Hair will grow back after treatment is completed, although the color and/or texture may be different • It may take 3 to 6 months after therapy is completed to resume normal hair growth • Be sure to keep your head covered to protect it from the sun during the summer and cold during the winter. • If not covering your scalp during the summer months, be sure to use sunscreen when spending time outdoors. Continued on the next page Page 5 DOXORUBICIN AND CYCLOPHOSPHAMIDE INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8 10 (8 ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Mouth irritation or sores (stomatitis or mucositis) Practice good mouth care. • Rinse your mouth after meals and at bedtime, and more frequently if you develop sores in your mouth • Brush your teeth with a soft toothbrush or cotton swab after meals • Use a mild non alcohol mouth rinse at least 4 times a day (after eating and at bedtime). One example is a mixture of 1/8 teaspoon of salt and 1/4 teaspoon of baking soda in 8 ounces of warm (not hot) water • Avoid acidic, hot or spicy foods and beverages, and rough foods that might irritate the mouth • If you have sores in your mouth, avoid using tobacco products, alcohol, and mouthwashes that contain alcohol Call your care team if you experience pain or sores in your mouth or throat. Page 6 DOXORUBICIN AND CYCLOPHOSPHAMIDE INTRAVENOUS CANCER TREATMENT EDUCATION Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: Doxorubicin is a vesicant. If it leaks outside of the IV, it can cause severe damage to your skin. Notify your nurse right away if you feel any pain, aching, burning, itching, swelling, or redness at the site of your IV. Doxorubicin may affect your heart’s ability to pump blood. Tell your healthcare provider right away if you experience new or worsening shortness of breath, chest pain, irregular heartbeat, or swelling of your ankles or legs. Cyclophosphamide can cause irritation of the bladder walls, leading to blood in the urine. It can be prevented by drinking plenty of fluids (8 10 eight ounce) glasses per day and emptying bladder frequently, especially before bed. A secondary cancer can rarely occur months or years after treatment. Your care team will check your blood cell counts even after treatment is done to monitor for this side effect. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. (INSTITUTIONAL CONTACT INFO) Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started ddAC, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low flow toilet, close the lid and flush twice to ensure that all waste has been discarded. If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. Wash hands with soap and water after using the toilet for at least 20 seconds. If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. Wash any skin that has been exposed to body waste with soap and water. Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Page 7 DOXORUBICIN AND CYCLOPHOSPHAMIDE INTRAVENOUS CANCER TREATMENT EDUCATION Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving ddAC. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. Tell your care team if you become pregnant or plan to breastfeed. Additional resources Doxorubicin liposomal (Adriamycin): https://www.accessdata.fda.gov/drugsatfda docs/ label/2012/062921s022lbl.pdf Cyclophosphamide (Cytoxan): https://www.accessdata.fda.gov/drugsatfda docs/ label/2013/012141s090,012142s112lbl.pdf Updated – July 19, 2021 Additional instructions Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy to understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.

Doxorubicin Liposomal

(doks-oh-ROO-bi-sin lye-po-SO-mal)

Doxorubicin Liposomal is most commonly used to treat ovarian cancer which has progressed or recurred after treatment with platinum-based chemotherapy but may be used for other treatments.

Doxorubicin Liposomal is most commonly used to treat ovarian cancer which has progressed or recurred after treatment with platinum-based chemotherapy but may be used for other treatments.

Page 1 INTRAVENOUS CANCER TREATMENT EDUCATION DOXORUBICIN LIPOSOMAL Name of the regimen and cancer drugs Doxorubicin liposomal (doks oh ROO bi sin lye po SO mal): Doxil® Common uses Doxorubicin liposomal is most commonly used to treat ovarian cancer which has progressed or recurred after treatment with platinum based chemotherapy but may be used for other treatments. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empies into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each doxorubicin liposomal treatment is repeated every 28 days. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug stops working or you have side effects which stop you from continuing treatment. Doxorubicin liposomal IV given on Day 1 Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Possible drug interactions Doxorubicin liposomal may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, over the counter medications, vitamins, and herbal products that you take. Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. Drug DAY 1 2 3 4 5 6 7 8 9 ... 28 Cycle 2 Day 1 Doxorubicin Liposomal X X Instructions: Anti nausea medications You will receive medications to prevent nausea just before your chemotherapy. You may also get prescriptions for other medications to take at home, as below: DOXORUBICIN LIPOSOMAL Page 2 INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving doxorubicin liposomal are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an in fection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symptoms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page DOXORUBICIN LIPOSOMAL Page 3 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Continued on the next page DOXORUBICIN LIPOSOMAL Page 4 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Pain or discomfort on hands and/or feet. Hand and foot syndrome (HFS) is a skin reaction that appears on the palms of the hands and soles of the feet. It can appear as a rash, peeling skin, or feel like “pins and needles”. Let your care team know right away if you experience this side effect. To prevent HFS, you can: • Keep hands and feet moisturized with a non fragranced moisturizing cream • Urea 10% or 20% cream may be helpful • Avoid exposure to hot water on the hands and feet, in showers, baths or doing dishes • Avoid tight shoes or socks • Avoid excess rubbing on hands and feet unless putting on lotion • Wear gloves when working with your hands Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8 10 (8 ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Mouth irritation or sores (stomatitis or mucositis) Practice good mouth care. • Rinse your mouth after meals and at bedtime, and more frequently if you develop sores in your mouth • Brush your teeth with a soft toothbrush or cotton swab after meals • Use a mild non alcohol mouth rinse at least 4 times a day (after eating and at bedtime). One example is a mixture of 1/8 teaspoon of salt and 1/4 teaspoon of baking soda in 8 ounces of warm (not hot) water • Avoid acidic, hot or spicy foods and beverages, and rough foods that might irritate the mouth • If you have sores in your mouth, avoid using tobacco products, alcohol, and mouthwashes that contain alcohol Call your care team if you experience pain or sores in your mouth or throat. Continued on the next page DOXORUBICIN LIPOSOMAL Page 5 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Fatigue • You may be more tired than usual or have less energy. • Stay as active as possible, but know it is okay to rest as needed. • Try to do some type of moderate activity every day. • Conserve your energy. Plan your activities and do them at a time of day when you feel a bit more energetic. • Follow a healthy diet and stay hydrated. • Accept help from family and friends • Find healthy ways to manage stress, such as meditation, journaling, yoga, and guided imagery • Develop good sleeping habits, limit napping during the day to help you sleep better at night. • Avoid operating heavy machinery if you feel too tired. Contact your care team if you experience extreme fatigue that prevents you from doing your normal daily activities. Rash or itchy skin • Keep your skin moisturized with creams and moisturizing lotions to decrease the risk of rash or itchiness and wear loose fitting clothing. • Avoid using perfumes and cologne as these products may increase rash symptoms. • Avoid being in the heat for long periods of time. • Your provider may recommend an over the counter antihistamine or a topical cream. • Sunlight can make symptoms worse • Avoid sun exposure as much as possible to decrease the risk of sunburn. The highest exposure to UV (ultra violet) radiation occurs between the hours of 10am and 4pm. • Wear long sleeved clothing, with UV protection if possible. • Wear broad brimmed hats. • Apply broad spectrum sunscreen (UVA/UVB) with at least SPF 30 as often as directed on the bottle. • Use lip balm with at least SPF 30 If your rash or itching continues to worsen, contact your care team. Continued on the next page DOXORUBICIN LIPOSOMAL Page 6 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Diarrhea (loose and/ or urgent bowel movements) Monitor how many bowel movements you have each day. • Drink 8 10 (8 ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland, low fiber foods (such as bananas, applesauce, potatoes, chicken, rice, and toast). • Avoid high fiber foods, such as raw vegetables and fruits and whole grains. • Avoid foods that cause gas, such as broccoli and beans. • Avoid foods with lactose, such as yogurt and milk. • Avoid spicy, fried, and greasy foods. Contact your care team if: • The number of bowel movements you have in a day increases by 4 or more • You feel dizzy or lightheaded Talk with your care team if you believe you have diarrhea. They may recommend an over thecounter medication or prescribe something to help keep it under control. Urine discoloration This drug is red in color and it can change the color of your urine • Urine may appear red, brown, orange, or pink from the color of the medication for one to two days after you receive a dose Tell your care provider if your urine is dark red and thicker, which could be a sign of bleeding DOXORUBICIN LIPOSOMAL Page 7 INTRAVENOUS CANCER TREATMENT EDUCATION Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: Cardiomyopathy: doxorubicin liposomal can make your heart work harder to pump blood to the rest of your body. Notify your care team if you experience shortness of breath or chest pain. Vesicant extravasation: doxorubicin liposomal is a vesicant. If it leaks outside of the IV, it can cause severe damage to your skin. Notify your nurse right away if you feel any pain, aching, burning, itching, swelling, or redness at the site of your IV. Secondary malignancy: A secondary cancer can rarely occur months or years after treatment. Your care team will check your blood cell counts even after treatment is done to monitor for this side effect. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. (INSTITUTIONAL CONTACT INFO) Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started doxorubicin liposomal, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low flow toilet, close the lid and flush twice to ensure that all waste has been discarded. If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. Wash hands with soap and water after using the toilet for at least 20 seconds. If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. Wash any skin that has been exposed to body waste with soap and water. Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. DOXORUBICIN LIPOSOMAL Page 8 INTRAVENOUS CANCER TREATMENT EDUCATION Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving doxorubicin liposomal. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. Tell your care team if you become pregnant or plan to breastfeed. Additional resources Updated – July 19, 2021 Additional instructions Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy to understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.

FOLFOX and Bevacizumab

(FOLFOX and be-va-siz’-yoo-mab)

FOLFOX and bevacizumab is most commonly used to treat colon cancer but may be used for other treatments.

FOLFOX and bevacizumab is most commonly used to treat colon cancer but may be used for other treatments.

Page 1 FOLFOX AND BEVACIZUMAB INTRAVENOUS CANCER TREATMENT EDUCATION FOLFOX AND BEVACIZUMAB Name of the regimen and cancer drugs Your care team may refer to your treatment as FOLFOX and bevacizumab. FOLFOX and bevacizumab consists of 4 different anticancer therapies. • Oxaliplatin (ox al” I pla’ tin): Eloxatin • Leucovorin (loo koe vor’ in) • 5FU; Fluorouracil (floor” oh ure’ a sil): Adrucil • Bevacizumab (be va siz’ yoo mab): Avastin, Mvasi, Zirabev Common uses FOLFOX and bevacizumab is most commonly used to treat colon cancer but may be used for other treatments. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Leucovorin IV on Day 1 Oxaliplatin IV on Day 1 Flourouracil (5 FU) IV push on Day 1 Fluorouracil (5 FU) continuous IV infusion over 46 hours beginning on Day 1 and ending on Day 2 Bevacizumab IV on Day 1 Each FOLFOX + bevacizumab treatment is repeated every 14 days. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug, or drugs, stop working or you have side effects which stop you from continuing treatment. Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Drug DAY 1 2 3 4 5 6 7 8 9 10 ... Cycle 2 Day 1 Oxaliplatin X X Leucovorin X X 5FU X X X Bevacizumab X X Instructions: Growth Factors Growth factors, like filgrastim, pegfilgrastim, and others, are medications used to treat neutropenia and prevent infections. Neutropenia is a condition where there are lower than normal white blood cells caused by some type of chemotherapy. Growth factors help the bone marrow to make more white blood cells. Page 2 FOLFOX AND BEVACIZUMAB INTRAVENOUS CANCER TREATMENT EDUCATION Possible drug interactions FOLFOX and bevacizumab may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, over the counter medications, vitamins, and herbal products that you take. Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. Common Side Effects Common side effects that have been known to happen in patients receiving FOLFOX and bevacizumab are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an in fection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symptoms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page Instructions: Anti nausea medications You will receive medications to prevent nausea just before your chemotherapy. You may get prescriptions for other medications to take at home, as below: Page 3 FOLFOX AND BEVACIZUMAB INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8 10 (8 ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Mouth irritation or sores (stomatitis or mucositis) Practice good mouth care. • Rinse your mouth after meals and at bedtime, and more frequently if you develop sores in your mouth • Brush your teeth with a soft toothbrush or cotton swab after meals • Use a mild non alcohol mouth rinse at least 4 times a day (after eating and at bedtime). One example is a mixture of 1/8 teaspoon of salt and 1/4 teaspoon of baking soda in 8 ounces of warm (not hot) water • Avoid acidic, hot or spicy foods and beverages, and rough foods that might irritate the mouth • If you have sores in your mouth, avoid using tobacco products, alcohol, and mouthwashes that contain alcohol Call your care team if you experience pain or sores in your mouth or throat. Continued on the next page Page 4 FOLFOX AND BEVACIZUMAB INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Fatigue • You may be more tired than usual or have less energy. • Stay as active as possible, but know it is okay to rest as needed. • Try to do some type of moderate activity every day. • Conserve your energy. Plan your activities and do them at a time of day when you feel a bit more energetic. • Follow a healthy diet and stay hydrated. • Accept help from family and friends • Find healthy ways to manage stress, such as meditation, journaling, yoga, and guided imagery • Develop good sleeping habits, limit napping during the day to help you sleep better at night. • Avoid operating heavy machinery if you feel too tired. Contact your care team if you experience extreme fatigue that prevents you from doing your normal daily activities. Numbness or tingling in hands and feet Report changes in your sense of touch, such as a burning feeling, pain on the skin or weakness. Diarrhea (loose and/ or urgent bowel movements) Monitor how many bowel movements you have each day. • Drink 8 10 (8 ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland, low fiber foods (such as bananas, applesauce, potatoes, chicken, rice, and toast). • Avoid high fiber foods, such as raw vegetables and fruits and whole grains. • Avoid foods that cause gas, such as broccoli and beans. • Avoid foods with lactose, such as yogurt and milk. • Avoid spicy, fried, and greasy foods. Contact your care team if: • The number of bowel movements you have in a day increases by 4 or more • You feel dizzy or lightheaded Talk with your care team if you believe you have diarrhea. They may recommend an over thecounter medication or prescribe something to help keep it under control. Continued on the next page Page 5 FOLFOX AND BEVACIZUMAB INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Sun sensitivity Your skin will be more sensitive to the sun. • Avoid excess sun exposure to decrease the risk of sunburn • Wear a broad brimmed hat • Apply broad spectrum sunscreen (UVA/UVB) with SPF 30 or higher and use a lip balm with at least SPF 30 • Avoid tanning beds Page 6 FOLFOX AND BEVACIZUMAB INTRAVENOUS CANCER TREATMENT EDUCATION Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: Interstitial Lung Disease: Oxaliplatin may be harmful to your lungs. Inform your care team of any new difficulty breathing, cough, or fever. Your provider may stop treatment with oxaliplatin if your lungs are affected. Hypersensitivity Reactions: Severe allergic reactions are a rare but serious side effect of oxaliplatin. Right away seek medical attention if you notice difficulty breathing, swelling of the mouth or tongue, or a serious rash. Wound Healing Problems: If you need to have a surgical or dental procedure, tell your doctor that you are taking bevacizumab. Bevacizumab may need to be stopped until your wound heals after some types of surgery. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. (INSTITUTIONAL CONTACT INFO) Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started FOLFOX and bevacizumab, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low flow toilet, close the lid and flush twice to ensure that all waste has been discarded. If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. Wash hands with soap and water after using the toilet for at least 20 seconds. If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. Wash any skin that has been exposed to body waste with soap and water. Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Page 7 FOLFOX AND BEVACIZUMAB INTRAVENOUS CANCER TREATMENT EDUCATION Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving FOLFOX and bevacizumab. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. Tell your care team if you become pregnant or plan to breastfeed. Additional resources Oxaliplatin: https://www.accessdata.fda.gov/drugsatfda docs/label/2011/021759s012lbl.pdf Leucovorin: https://www.accessdata.fda.gov/drugsatfda docs/label/2012/040347s010lbl.pdf 5FU: https://www.accessdata.fda.gov/drugsatfda docs/label/2016/012209s040lbl.pdf Updated – July 20, 2021 Additional instructions Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy to understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.

Gemcitabine

(jem-SY-ta-been)

Gemcitabine is most commonly used to treat pancreatic cancer but may be used for other treatments.

Gemcitabine is most commonly used to treat pancreatic cancer but may be used for other treatments.

Page 1 GEMCITABINE INTRAVENOUS CANCER TREATMENT EDUCATION GEMCITABINE Name of the regimen and cancer drugs Gemcitabine (jem SY ta been): Gemzar® (JEM zar) Common uses Gemcitabine is most commonly used to treat pancreatic cancer but may be used for other treatments. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each gemcitabine treatment is repeated every 28 days. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug stops working or you have side effects which stop you from continuing treatment. Gemcitabine is given on Day 1, 8, 15 and then 1 week off Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Instructions: Growth Factors Growth factors, like filgrastim, pegfilgrastim, and others, are medications used to treat neutropenia and prevent infections. Neutropenia is a condition where there are lower than normal white blood cells caused by some type of chemotherapy. Growth factors help the bone marrow to make more white blood cells. Anti nausea medications You will receive medications to prevent nausea and other side effects just before your chemotherapy. You may get prescriptions for other medications to take at home, as below: Drug DAY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 ... Cycle 2 Day 1 Gemcitabine X X X X Page 2 GEMCITABINE INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving gemcitabine are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an in fection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symptoms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page Possible drug interactions Gemcitabine may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, over the counter medications, vitamins, and herbal products that you take. Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. Page 3 GEMCITABINE INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Continued on the next page Page 4 GEMCITABINE INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Fever You may feel hot, cold and shivery, achy or dizzy. This usually starts during the first month of therapy but could happen at any time. • Call your doctor immediately if you have a fever 100.4º F Ask your doctor if you can take medicine to help with the fever. Rash or itchy skin • Keep your skin moisturized with creams and moisturizing lotions to decrease the risk of rash or itchiness and wear loose fitting clothing. • Avoid using perfumes and cologne as these products may increase rash symptoms. • Avoid being in the heat for long periods of time. • Your provider may recommend an over the counter antihistamine or a topical cream. • Sunlight can make symptoms worse • Avoid sun exposure as much as possible to decrease the risk of sunburn. The highest exposure to UV (ultra violet) radiation occurs between the hours of 10am and 4pm. • Wear long sleeved clothing, with UV protection if possible. • Wear broad brimmed hats. • Apply broad spectrum sunscreen (UVA/UVB) with at least SPF 30 as often as directed on the bottle. • Use lip balm with at least SPF 30 If your rash or itching continues to worsen, contact your care team. Changes in liver function Your liver function will be checked every so often by a simple blood test. Contact your care team if you notice any of the following. • Yellowing of the skin or whites of your eyes • Dark or brown urine • Bleeding or bruising Fluid retention or swelling (edema) • Do not stand for long periods of time • Keep your legs elevated when sitting or lying down • Try to not eat salty foods, which can increase swelling • Avoid tight fitting clothing and shoes • Weigh yourself daily • Take any medications as prescribed to decrease fluid retention Contact your care team if you notice: • Swelling in the hands, feet, or legs • You are short of breath • You have gained 5 pounds or more in one week Page 5 GEMCITABINE INTRAVENOUS CANCER TREATMENT EDUCATION Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: This product may result in serious and potentially fatal lung toxicity. When taking gemcitabine, if you start to experience shortness of breath, fatigue, breathlessness, or discomfort/worsening of symptoms while lying on your back, please immediately contact your prescriber. Gemcitabine may be harmful to your liver. Speak to your care team to know when you need to have blood tests done to monitor your liver function. If you get this side effect, your doctor may change your dose or stop treatment for some time. A condition called reversible posterior leukoencephalopathy syndrome can occur while taking gemcitabine. Call your care team right away if you have headaches, seizures, confusion or changes in vision. Gemcitabine may increase your sensitivity to radiation therapy or cause skin rash in places previously treated with radiation. Tell your doctor about your medication and radiation history and let your doctor know if you develop a skin rash. o Hemolytic uremic syndrome can occur in rare cases, when small clots form in the blood vessels from damage or inflammation and block the blood flow to the kidneys, preventing them from working correctly. Call your heatlhcare team if you have bleeding, feel dizzy or short of breath or have swelling and you are not urinating your normal amount. A condition called capillary leak syndrome can occur when fluid moves from the blood vessels out to surrounding tissues. Notify your healthcare provider if you experience excessive thirst and weight gain. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. (INSTITUTIONAL CONTACT INFO) Page 6 GEMCITABINE INTRAVENOUS CANCER TREATMENT EDUCATION Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started gemcitabine, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low flow toilet, close the lid and flush twice to ensure that all waste has been discarded. If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. Wash hands with soap and water after using the toilet for at least 20 seconds. If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. Wash any skin that has been exposed to body waste with soap and water. Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving gemcitabine. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. Tell your care team if you become pregnant or plan to breastfeed. Page 7 GEMCITABINE INTRAVENOUS CANCER TREATMENT EDUCATION Additional resources Updated – July 23, 2021 Additional instructions Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy to understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.

High-Dose Cytarabine (“HiDAC”) and Daunorubicin

(sye-TARE-a-been and daw-noe-ROO-bi-sin)

High-Dose Cytarabine (“HiDAC”) and Daunorubicin is most commonly used to treat acute myeloid leukemia (AML) but may be used for other treatments.

High-Dose Cytarabine (“HiDAC”) and Daunorubicin is most commonly used to treat acute myeloid leukemia (AML) but may be used for other treatments.

INTRAVENOUS CANCER TREATMENT EDUCATION HIGH-DOSE CYTARABINE & DAUNORUBICIN Name of the regimen and cancer drugs Your care team may refer to your treatment as High Dose Cytarabine (“HiDAC”) / Daunorubicin. HiDAC/daunorubicin consists of 2 different anti-cancer therapies. • Cytarabine (sye TARE a been): Cytosar • Daunorubicin (daw noe ROO bi sin): Cerubidine Common uses Your treatment is most commonly used to treat acute myeloid leukemia (AML) but may be used for other treatments. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. This treatment is known as induction and is planned for one cycle. o Cytarabine IV given on Days 1, 3, 5, and 7. o Daunorubicin IV given on Days 1-3. o This treatment regimen typically requires admission to the hospital. Drug DAY 1 2 3 4 5 6 7 Cytarabine X X X X Daunorubicin X X X HIGH-DOSE CYTARABINE & DAUNORUBICIN Page 2 INTRAVENOUS CANCER TREATMENT EDUCATION Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Possible drug interactions o High-dose cytarabine and daunorubicin may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, over-the-counter medications, vitamins, and herbal products that you take. o Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. Infection prevention There is a risk of serious infections during treatment. You may receive medications to prevent infection in the hospital, and may also get prescriptions for medications to take at home for infection prevention, as below: Instructions: Anti-nausea and other medications You will receive medications to prevent nausea and eye problems just before your cancer treatment. You may also get prescriptions for other medications to take at home, as below: HIGH-DOSE CYTARABINE & DAUNORUBICIN Page 3 INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving high-dose cytarabine and daunorubicin are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an in-fection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symptoms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page HIGH-DOSE CYTARABINE & DAUNORUBICIN Page 4 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8-10 (8-ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. HIGH-DOSE CYTARABINE & DAUNORUBICIN Page 5 INTRAVENOUS CANCER TREATMENT EDUCATION Rare but serious side effects o Daunorubicin is a vesicant. If it leaks outside of the IV, it can cause severe damage to your skin. Notify your nurse right away if you feel any pain, aching, burning, itching, swelling, or redness at the site of your IV. o High-dose cytarabine may cause serious neurologic side effects. Let your care team know right away if you have headaches, dizziness, seizures, confusion or changes in vision. Your care team should perform routine neurologic assessments prior to each dose to test for signs of early side effects. o High-dose cytarabine may result in serious and fatal lung toxicity. If you start to experience shortness of breath, fatigue, breathlessness, or discomfort/worsening of symptoms while lying on your back, please immediately let your care team know. o High-dose cytarabine may cause eye pain, blurred vision, tearing, and light sensitivity. You may receive eye treatments to prevent this side effect from occurring. o Daunorubicin and high-dose cytarabine can make your heart work harder to pump blood to the rest of your body. Notify your care team if you experience shortness of breath or chest pain. o This regimen may cause tumor lysis syndrome when starting treatment. Your care team may do blood tests to check for this side effect. o These medications may be harmful to your kidneys. Speak to your care team to know when you need to have laboratory tests done to monitor your kidneys. o These medications may be harmful to your liver. Speak to your care team to know when you need to have blood tests done to monitor your liver function. If you get this side effect, your doctor may change your dose or stop treatment for some time. o A secondary cancer can rarely occur months or years after treatment. Your care team will check your blood cell counts even after treatment is done to monitor for this side effect. o Severe allergic reactions are a rare but serious side effect of cytarabine. Right away seek medical attention if you notice difficulty breathing, swelling of the mouth or tongue, or a serious rash. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. (INSTITUTIONAL CONTACT INFO) HIGH-DOSE CYTARABINE & DAUNORUBICIN Page 6 INTRAVENOUS CANCER TREATMENT EDUCATION Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started high-dose cytarabine and daunorubicin, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. o Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. o Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low-flow toilet, close the lid and flush twice to ensure that all waste has been discarded. o If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. o Wash hands with soap and water after using the toilet for at least 20 seconds. o If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. o If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. o Wash any skin that has been exposed to body waste with soap and water. o Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. o Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. HIGH-DOSE CYTARABINE & DAUNORUBICIN Page 7 INTRAVENOUS CANCER TREATMENT EDUCATION Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving highdose cytarabine and daunorubicin. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. o Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. o Tell your care team if you become pregnant or plan to breastfeed

Nivolumab (14 Day)

(nih-VOL-yoo-mab)

Nivolumab (14 Day) is used to treat many different types of cancer, including melanoma, classical Hodgkin Lymphoma, and lung, head and neck, esophageal, bladder, colorectal, liver, and kidney cancers.

Nivolumab (14 Day) is used to treat many different types of cancer, including melanoma, classical Hodgkin Lymphoma, and lung, head and neck, esophageal, bladder, colorectal, liver, and kidney cancers

Page 1 INTRAVENOUS CANCER TREATMENT EDUCATION NIVOLUMAB Name of the regimen and cancer drugs Nivolumab (nih VOL yoo mab): Opdivo Common uses Nivolumab is used to treat many different types of cancer, including melanoma, classical Hodgkin Lymphoma, and lung, head and neck, esophageal, bladder, colorectal, liver, and kidney cancers. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each nivolumab treatment is repeated every 14 days. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug stops working or you have side effects which stop you from continuing treatment. Nivolumab IV given on Day 1 Possible drug interactions Nivolumab may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, over the counter medications, vitamins, and herbal products that you take. Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. Drug DAY 1 2 3 4 5 6 7 8 9 ... 14 Cycle 2 Day 1 Nivolumab X X NIVOLUMAB Page 2 INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving nivolumab are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Fatigue • You may be more tired than usual or have less energy. • Stay as active as possible, but know it is okay to rest as needed. • Try to do some type of moderate activity every day. • Conserve your energy. Plan your activities and do them at a time of day when you feel a bit more energetic. • Follow a healthy diet and stay hydrated. • Accept help from family and friends • Find healthy ways to manage stress, such as meditation, journaling, yoga, and guided imagery • Develop good sleeping habits, limit napping during the day to help you sleep better at night. • Avoid operating heavy machinery if you feel too tired. Contact your care team if you experience extreme fatigue that prevents you from doing your normal daily activities. Continued on the next page NIVOLUMAB Page 3 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Muscle or joint pain or weakness or muscle spasms • Keep a diary of your pain or spasms, including when and where the pain happens, what it feels like, and how long it lasts • Stay as active as possible, but know that it is okay to rest as needed, too • Tell your care team if pain or spasms limit what you can do If the pain, weakness, or spasms bothers you, ask your provider what you may use to help with this discomfort. Take only pain medication that has been prescribed or recommended by your care team Rash or itchy skin • Keep your skin moisturized with creams and moisturizing lotions to decrease the risk of rash or itchiness and wear loose fitting clothing. • Avoid using perfumes and cologne as these products may increase rash symptoms. • Avoid being in the heat for long periods of time. • Your provider may recommend an over the counter antihistamine or a topical cream. • Sunlight can make symptoms worse • Avoid sun exposure as much as possible to decrease the risk of sunburn. The highest exposure to UV (ultra violet) radiation occurs between the hours of 10am and 4pm. • Wear long sleeved clothing, with UV protection if possible. • Wear broad brimmed hats. • Apply broad spectrum sunscreen (UVA/UVB) with at least SPF 30 as often as directed on the bottle. • Use lip balm with at least SPF 30 If your rash or itching continues to worsen, contact your care team. Diarrhea (loose and/ or urgent bowel movements) Monitor how many bowel movements you have each day. • Drink 8 10 (8 ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland, low fiber foods (such as bananas, applesauce, potatoes, chicken, rice, and toast). • Avoid high fiber foods, such as raw vegetables and fruits and whole grains. • Avoid foods that cause gas, such as broccoli and beans. • Avoid foods with lactose, such as yogurt and milk. • Avoid spicy, fried, and greasy foods. Contact your care team if: • The number of bowel movements you have in a day increases by 4 or more • You feel dizzy or lightheaded Talk with your care team if you believe you have diarrhea. They may recommend an over thecounter medication or prescribe something to help keep it under control. Continued on the next page NIVOLUMAB Page 4 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8 10 (8 ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Cough or shortness of breath A cough that does not produce any mucous or (dry cough) may occur while taking this medication. If you experience any breathing problems or shortness of breath, notify your care team right away. This may be a serious side effect of the medication. Lung (respiratory tract) infection • Wash your hands often, especially before eating and after using the bathroom • Avoid people with fevers, flu, or other infections • Bathe often to keep good personal hygiene. • Report symptoms of a lung infection like a cough, sneezing, runny nose, fever, and scratchy or sore throat to your provider Changes in liver function Your liver function will be checked every so often by a simple blood test. Contact your care team if you notice any of the following. • Yellowing of the skin or whites of your eyes • Dark or brown urine • Bleeding or bruising Changes in kidney function Your liver function will be checked every so often by a simple blood test. Contact your care team if you notice any of the following. • Decreased amount of urination • Unusual swelling in your legs and feet Continued on the next page NIVOLUMAB Page 5 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Changes in electrolyte levels and other laboratory values: High blood glucose Low sodium levels High lipase levels Changes in some lab values may occur and will be monitored by a simple blood test. • You may not feel any symptoms if the changes are mild and they usually are not a sign of a serious problem. • More severe changes may occur which can be a sign of a serious problem. Notify your care team if you have any of the following: • Shortness of breath • Chest discomfort • Weakness or fatigue • New aches and pains • Headaches • Dizziness or confusion • Stomach pain • Swelling of your legs or feet • Red or brown colored urine • Urinating more often than usual • Diarrhea Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: Nivolumab can alter your hormone levels. Symptoms may include weight and mood changes, headaches, fatigue. Contact your doctor if you are experiencing any of these symptoms. Nivolumab may cause a severe skin reaction resulting in flu like symptoms and painful rashes that can spread and blister. Your healthcare professional may withhold or permanently discontinue medication depending on the severity. Your treatment may cause inflammation in your colon. If symptoms of diarrhea or severe abdominal pain are present, please contact your health care team right away. Your health care team may have to prescribe corticosteroids in order to decrease the inflammation. Nivolumab can cause lung and breathing problems. Tell your care team right away if you have new or worse cough, shortness of breath, chest pain, or difficulty breathing or wheezing. Nivolumab can rarely cause an infusion reaction. During your treatment, let the nurse know right away if any of these symptoms happen: chills or shaking, dizziness, fever, itchiness or rash, flushing, difficulty breathing, wheezing, sudden back pain, or feeling faint. Nivolumab can cause severe reactions in people who receive a stem cell transplant before or after treatment. If you have received a stem cell transplant, talk with your care team about these risks before starting treatment. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. (INSTITUTIONAL CONTACT INFO) NIVOLUMAB Page 6 INTRAVENOUS CANCER TREATMENT EDUCATION Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started nivolumab, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low flow toilet, close the lid and flush twice to ensure that all waste has been discarded. If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. Wash hands with soap and water after using the toilet for at least 20 seconds. If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. Wash any skin that has been exposed to body waste with soap and water. Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving nivolumab. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. Tell your care team if you become pregnant or plan to breastfeed. NIVOLUMAB Page 7 INTRAVENOUS CANCER TREATMENT EDUCATION Additional resources Product website: www.opdivo.com Prescribing information link: https://packageinserts.bms.com/pi/pi opdivo.pdf Product resources: https://www.opdivo.com/patient caregiver support/patient resources Updated – July 20, 2021 Additional instructions Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy to understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.

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