Methods of Administering Chemotherapy

Cytotoxic agents can be administered in a variety of ways, including:

a. Oral (by mouth)
b. Topical (on the surface of the skin as a cream or lotion)
c. Intravenous (into a vein or IV)
d. Intramuscularly (into a muscle or IM)
e. Subcutaneous (under the skin or SQ)
f. Intra-arterial (into an artery)
g. Intrathecal (into the central nervous system via the cerebrospinal fluid)
h. Intrapleural (into the chest cavity)
i. Intraperitoneal (into the abdominal cavity)
j. Intravesical (into the bladder)
k. Intralesional (into the tumor)

The term parenteral is used to describe drugs given intravenously, intramuscularly, or subcutaneously. The intravenous route is most often used. Intramuscular and subcutaneous injections are used less often because many drugs can be very irritating or even destroy skin or muscle tissues. Giving cytotoxic drugs via an IV route gets the drugs quickly throughout the body. IV therapy may be given through a vein in the arm or hand or through a vascular access device (VAD), using a catheter implanted into a larger vein in the chest, neck, or arm. VAD’s are used in cancer treatment to give several drugs at the same time, for long-term chemotherapy, for continuous infusion therapy, and to give vesicants (drugs that can destroy tissues if an IV infiltrates.)

There are several types of VAD’s:

a. A PICC (peripherally inserted central catheter) provides continuous access to a peripheral vein in the arm for several weeks or longer.
b. A midline catheter is a VAD that is not inserted as far as a PICC. It may be used for intermediate length therapy when a regular peripheral IV is not advisable or available.
c. A tunneled central venous catheter is a type of VAD with multiple lumens, surgically placed in a large central vein, with a catheter tunneled under the skin.

d. Some patients benefit from an implantable VAD. An implantable device includes a port of plastic, stainless steel, or titanium with a silicone septum attached to a catheter surgically placed under the skin of the chest or arm in a large or central vein. The port can be accessed with a needle when cytotoxic drugs need to be given.

For more information about PICC lines and midline catheters, you can access the course PICC Line Care and Maintenance: An Introduction

Drag your cursor over the picture below to highlight major veins

Intravesical chemotherapy is especially effective for early stage bladder cancer. Each treatment involves the placement of a urinary catheter to give the drug into the bladder. The drug is retained in the bladder for several hours and then drained. Intrapleural and intraperitoneal routes of administering chemotherapy are useful for some people with mesothelioma (cancer that involves the lining of the lung), ovarian cancer that has spread to the peritoneum, and lung or breast cancers that have spread to the pleura. Intraperitoneal chemotherapy is given through a catheter that is specially designed to remove or add large amounts of fluid from or into the peritoneum through an implanted port. Intrathecal chemotherapy is given directly into the cerebrospinal fluid to reach cancer cells in the central nervous system. Most chemotherapy drugs that are given intravenously are unable to cross the blood brain barrier – a special characteristic of the capillary walls of the brain that prevents potentially harmful substances from moving from the bloodstream to the brain and cerebrospinal fluid. Intrathecal chemotherapy may be done via a lumbar puncture or through a special reservoir that is placed into the skull with access to the ventricles, (spaces inside the brain filled with cerebrospinal fluid.)
A drug given via the intrathecal route is given into the cerebrospinal fluid.

Health care professionals who prepare and administer cytotoxic drugs attend classes and must demonstrate their competency before giving drugs to patients. Two major concerns when giving cancer chemotherapy drugs are drug accuracy and the potential for tissue damage from some drugs that are given intravenously. To ensure accuracy, health care professionals giving cytotoxic drugs must review physician orders carefully and compare what is ordered with a formal drug protocol or reference source. Drug doses are usually ordered based on the patient’s body surface area. Using the patient’s weight and height, body surface area can be determined.
Many cytotoxic agents can cause severe tissue damage if an IV needle or catheter delivers the drug into tissues rather than into the bloodstream. The term extravasation is used when a cytotoxic drug infiltrates into local tissues. Some drugs, known as irritants, can cause local cellular damage. Other drugs, referred to as vesicants, can cause severe tissue damage requiring skin grafting. To avoid infiltration with vesicant drugs, the larger veins of the arm are used for IV administration. Drugs that are classified as vesicants include cisplatin, dactinomycin, daunorubicin, doxorubicin, idarubicin , mechlorethamine, mitomycin-C, mitoxantrone, paclitaxel, vinblastine, vincristine, vindesine, vinorelbine, and 5-fluorouracil. In some instances, locally applied antidotes may help minimize the effects of infiltration.
Cytotoxic drugs that are vesicants can cause local tissue destruction.

Exposure to cytotoxic drugs poses a potential health risk to personnel who handle, administer, and dispose of these drugs. Potential routes of exposure include both direct and indirect contact. Examples of direct contact include skin and mucous membrane contact and absorption, inhalation, or ingestion of cytotoxic drugs. Indirect contact can occur through handling body fluids and excreta of clients who have received cytotoxic drugs. Health care personnel involved with preparing, administering, or caring for patients who are receiving cytotoxic drugs are taught to take special precautions to decrease their risk of exposure.