Chemotherapy, checkpoint inhibitors and oral cancer drugs
Systemic therapy covers chemotherapy, targeted drugs, immunotherapy, hormonal agents and the cancer drugs patients take at home. The 2026 outline put chemotherapy, biotherapy and immunotherapy on one line and named localized and oral therapy, and this page follows it item by item.
Which drug is a vesicant that requires checking blood return before and during peripheral administration?
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Cyclophosphamide is not a vesicant; its key toxicities are marrow suppression and bladder injury.
Gemcitabine is at most a mild irritant and is not classed as a vesicant.
Vinorelbine is a vinca alkaloid vesicant; blood return is confirmed before and during the short infusion because leakage can cause tissue necrosis.
Carboplatin is not a vesicant; extravasation causes little tissue injury.
Systemic therapy
Before each dose of high-dose cytarabine, which assessment is most important for the nurse to perform?
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High-dose cytarabine can cause cerebellar toxicity, especially in older patients or with poor kidney function; ataxia, nystagmus, or slurred speech means the dose is held.
Ejection fraction is monitored with anthracyclines and trastuzumab.
Urine alkalinization is checked before high-dose methotrexate, not cytarabine.
Hearing checks belong with cisplatin, not cytarabine.
Systemic therapy
A patient with multiple myeloma will start bortezomib. Which strategy is known to reduce bortezomib-induced peripheral neuropathy?
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Bortezomib is given as an injection or IV push; slowing it does not lower nerve damage.
Vitamin B6 has not been shown to prevent chemotherapy neuropathy.
Cryotherapy has been studied for taxane neuropathy, not for bortezomib, which is given as a quick injection.
The subcutaneous route gives the same response with markedly less neuropathy than IV, and it is now the standard route.
Systemic therapy
Compared with fully human antibodies, chimeric monoclonal antibodies whose names end in -ximab, such as rituximab and cetuximab, carry a higher risk of:
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QT prolongation is linked to some small-molecule kinase inhibitors and arsenic, not to antibody structure.
Chimeric antibodies keep mouse-derived regions that the immune system can recognize, so infusion reactions are more frequent than with fully human (-umab) agents.
Neuropathy comes from tubulin-binding and platinum drugs, not antibody structure.
Thyroid problems follow checkpoint inhibitors and some kinase inhibitors, not chimeric antibodies.
Systemic therapy
A patient starting abemaciclib for breast cancer should be taught to manage its most common early adverse effect with:
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Fluoride protects teeth after head and neck radiation; it is not used for abemaciclib.
Scalp cooling reduces alopecia from cytotoxic drugs; abemaciclib causes little hair loss.
Diarrhea is the most frequent early effect of abemaciclib, usually in the first weeks; loperamide is started at the first loose stool along with fluids.
Stockings help edema or clot prevention, which is not abemaciclib's main early problem.
Systemic therapy
A patient with ROS1-rearranged lung adenocarcinoma is starting crizotinib. The nurse teaches that a common, usually mild, side effect is:
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Hematuria is not a crizotinib effect; it would suggest a urinary tract problem.
High-frequency hearing loss is typical of cisplatin.
Hand-foot reactions are linked to capecitabine and multikinase inhibitors.
Visual changes such as flashes, trails, or blur occur in most patients, start early, and are usually mild; caution with night driving is taught.
Systemic therapy
After CAR T-cell therapy, a patient has persistent fever, worsening cytopenias, a very high ferritin, and rising liver enzymes as CRS resolves. The nurse anticipates evaluation for:
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ICANS is defined by neurologic signs, which this patient does not have.
Iron overload raises ferritin slowly over many transfusions and does not cause fever or acute liver injury.
Fever, cytopenias, extreme ferritin, and liver injury after CRS suggest immune effector cell-associated HLH-like syndrome, which needs prompt workup and treatment.
Engraftment syndrome follows stem cell transplant as counts recover, not worsening cytopenias after CAR T-cells.
Systemic therapy
After CAR T-cell infusion, which finding is usually the first sign of cytokine release syndrome?
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Hypoxia marks grade 2 or higher CRS, after fever has appeared.
Fever is required for the ASTCT diagnosis of CRS and is usually the first sign; hypotension and hypoxia define higher grades.
Hypotension appears as CRS worsens and raises the grade; it rarely comes before fever.
Neurologic changes point to ICANS, which is graded separately from CRS.
Systemic therapy
A patient with grade 3 cytokine release syndrome is receiving tocilizumab. During and after the infusion, which monitoring is most important to add?
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Cardiac monitoring follows clinical signs, but it is not the added check that tocilizumab specifically calls for.
Fluid balance matters in CRS but does not detect the neurotoxicity that may follow tocilizumab.
Grade 3 CRS needs much closer vital sign monitoring than every 4 hours.
Tocilizumab does not reach the brain well and can raise IL-6 levels there, so ICANS can appear or worsen after it; frequent ICE checks catch this early.
Systemic therapy
Three days after CAR T-cell therapy, a patient is febrile and hypotensive. Which nursing action reflects best practice?
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Withholding CRS treatment lets hypotension and organ injury progress if CRS is the cause.
CRS and infection look alike in a neutropenic patient, so cultures are drawn and empiric antibiotics given while CRS is treated.
Treating only CRS risks missing a bloodstream infection that kills quickly in a neutropenic patient.
Waiting for neurotoxicity delays treatment of both CRS and possible sepsis.
Systemic therapy
On day 3 of high-dose interleukin-2 for melanoma, a patient has hypotension, tachycardia, oliguria, generalized edema, and a 3-kg weight gain. Which complication is most likely?
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High-dose IL-2 predictably makes capillaries leak, shifting fluid into tissues; hypotension, low urine output, edema, and weight gain follow.
Anaphylaxis comes within minutes of exposure with urticaria or bronchospasm, not on day 3 with weight gain.
Sepsis can cause hypotension, but it does not explain rapid generalized edema and weight gain on schedule with IL-2.
An embolism causes sudden dyspnea and chest pain, not generalized edema.
Systemic therapy
What should a patient on checkpoint-inhibitor therapy be taught to do when seeking care elsewhere?
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Immune-related effects often start mild, and an outside clinician who does not know about the drug can miss early colitis, hepatitis, or endocrine problems.
Outside and emergency clinicians often cannot see the oncology record; the patient carries the information with them.
A card naming the drug tells emergency and outside clinicians to consider immune-related effects, which can appear months after the last dose.
Steroids are used for confirmed immune-related effects after assessment; asking for them for any symptom skips evaluation and adds harm.
Systemic therapy
A patient is going home after intravesical BCG for bladder cancer. Which instruction is correct?
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Mild burning and frequency are common; fever, chills, or symptoms lasting more than a few days are reported.
BCG is a live bacterium, so for 6 hours after treatment the patient sits to void and adds bleach to the toilet for about 15 minutes before flushing.
The drug is held for about 2 hours; holding urine much longer is not needed.
Fluids are limited before and during the dwell so urine does not dilute the drug.
Systemic therapy
A patient with severe hand deformities from rheumatoid arthritis cannot open the child-resistant bottle of her oral anticancer drug. The nurse should:
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Relying on others exposes them to a hazardous drug and fails whenever they are away.
Daily visits are a heavy, costly answer to a problem a different cap solves.
Crushing a hazardous oral agent releases dust and may change how the drug is absorbed.
Patients may ask for non-child-resistant closures, which keeps the drug in its original labeled container while solving the access problem.
Systemic therapy
A home health nurse watches a caregiver measure an incorrect dose of oral chemotherapy and struggle to transfer the patient safely. The nurse's best initial action is to:
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Dosing errors with a hazardous drug and unsafe transfers mean the current plan is not safe; the nurse assesses the situation and adds help, such as therapy, aides, or prefilled doses.
Teaching alone assumes the caregiver can manage; the errors show the load may already be too much.
A meeting may help later, but it does not address the safety problem in front of the nurse today.
Documenting without acting leaves the patient exposed to the next wrong dose or fall.
Systemic therapy
Which hormonal agent is most appropriate for a postmenopausal woman with hormone receptor-positive early breast cancer, and which toxicity should the nurse monitor?
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Endometrial cancer risk belongs to tamoxifen, which stimulates the uterine lining.
Aromatase inhibitors are preferred after menopause and lower estrogen further, which speeds bone loss; a baseline DXA scan and bone health measures follow.
Cold-triggered neuropathy is an oxaliplatin effect.
Pulmonary fibrosis is linked to bleomycin and some other cytotoxics, not tamoxifen.
Systemic therapy
A patient with hormone receptor-positive metastatic breast cancer is starting fulvestrant, a SERD. Which administration technique is correct?
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Fulvestrant is an oily intramuscular injection and is never given IV.
An abdominal implant describes goserelin, a GnRH agonist.
The 500-mg dose is given as two 5-mL intramuscular injections, one in each buttock, each over 1 to 2 minutes, with care near the sciatic nerve.
The deltoid cannot take 10 mL, and fast injection of the oily solution causes pain.
Systemic therapy
A man starting leuprolide for prostate cancer reports worsening bone pain in the first week. How should the nurse respond?
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A GnRH agonist first raises testosterone for 1 to 3 weeks, which can briefly worsen bone pain; new weakness or trouble urinating is reported at once.
Early pain after starting leuprolide is expected flare, not proof of progression.
Bone pain is not an allergy symptom; allergy causes rash, swelling, or breathing problems.
Stopping the drug loses testosterone suppression; the flare passes as levels fall.
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This page covers items D to G of Treatment Modalities (20% of the exam): systemic, localized, targeted and oral therapy. Immune-related adverse events, item O of Oncologic Emergencies, are summarized here too. Surgery, radiation and transplant, items A to C, are on radiation, surgery and transplant.
Cytotoxic drugs are grouped by where they act in the cell cycle. Cell cycle–specific drugs kill cells in one phase and are often given as a continuous infusion or in repeated doses. Cell cycle–nonspecific drugs act in any phase, and their effect grows with the dose.
Alkylating agents (cyclophosphamide, ifosfamide, bendamustine, melphalan) and platinum drugs (cisplatin, carboplatin, oxaliplatin) are nonspecific. Ifosfamide and high-dose cyclophosphamide are given with mesna and hydration to protect the bladder; cisplatin is hard on the kidneys and the ears; oxaliplatin causes an acute neuropathy set off by cold.
Antimetabolites (methotrexate, fluorouracil, capecitabine, cytarabine, gemcitabine) act in S phase. High-dose methotrexate requires leucovorin rescue; capecitabine causes hand-foot syndrome.
Anthracyclines (doxorubicin, daunorubicin, epirubicin, idarubicin) carry a cumulative, dose-related risk to the heart, so ejection fraction is measured before and during treatment. Doxorubicin turns urine red for a day or two.
Plant alkaloids: vinca alkaloids (vincristine, vinblastine) and taxanes (paclitaxel, docetaxel) act in M phase and cause neuropathy, and vincristine is fatal if given intrathecally. The topoisomerase inhibitors (etoposide, irinotecan, topotecan) act in S and G2; irinotecan causes an early cholinergic diarrhea and a later diarrhea managed with loperamide.
Antitumor antibiotics other than the anthracyclines: bleomycin and mitomycin.
Nadir by class. The nitrosoureas (carmustine, lomustine) are the classic late-nadir drugs, with counts lowest around 4 to 6 weeks after a dose; vincristine and bleomycin suppress the marrow very little. Low counts themselves are on neutropenia and myelosuppression.
Targeted drugs and the stems that name them
Targeted drugs act on a molecule the cancer depends on, so many need a biomarker result first (EGFR, ALK, HER2, BRAF and others). That ties this item to genomic testing on cancer biology and staging.
The generic name usually carries the class in its stem:
-nib: small-molecule kinase inhibitors, mostly oral (imatinib, osimertinib, ibrutinib). Many interact with drugs and foods that change CYP3A4 activity, grapefruit included.
-mab: monoclonal antibodies, given IV or subcutaneously (trastuzumab, bevacizumab, pembrolizumab). The syllable before -mab marks the source: -xi- chimeric, -zu- humanized, -u- fully human. The WHO's new monoclonal antibody naming scheme (2021) has since replaced -mab for new antibodies, so the rule fits most drugs in use now but not every newer one.
Antibody-drug conjugates join an antibody to a cytotoxic payload, and the name gets a second word for the payload: trastuzumab deruxtecan, enfortumab vedotin, sacituzumab govitecan. The Enhertu (trastuzumab deruxtecan) prescribing information (2026) puts interstitial lung disease and pneumonitis in its boxed warning.
-parib: PARP inhibitors (olaparib, niraparib), used in BRCA-associated and other cancers.
-ciclib: CDK4/6 inhibitors (palbociclib, ribociclib, abemaciclib) for hormone receptor–positive breast cancer.
Immune checkpoint inhibitors and irAEs
Immune checkpoint inhibitors take a brake off T cells instead of attacking the tumor directly:
Because the freed T cells can attack any organ, the toxicities are immune-related adverse events (irAEs): rash and itching, colitis, hepatitis, pneumonitis, inflammation of the thyroid or pituitary, type 1 diabetes, and rarer myocarditis, nephritis and neurologic syndromes. CTLA-4 plus PD-1 combinations cause more of them than either drug alone. Most appear in the first months of treatment, but they can begin after the last dose, so new symptoms months later still count. Endocrine damage is often permanent and is managed with hormone replacement. Grading uses CTCAE v6.0 (2025), and the ASCO guideline on immune-related adverse events (2021) ties each grade to continuing, holding or stopping the drug and to corticosteroids. Organ-by-organ grading is a topic for later.
CAR T cells, bispecifics, CRS and ICANS
CAR T-cell therapy reprograms the patient's own T cells to recognize a target on cancer cells: CD19 in B-cell lymphomas and leukemias, BCMA in myeloma. Bispecific antibodies redirect the T cells the patient already has, with no cell manufacturing: teclistamab, elranatamab and talquetamab in myeloma; epcoritamab, glofitamab and mosunetuzumab in lymphoma; tarlatamab in small cell lung cancer. They begin with step-up doses so that cytokine release builds gradually. Collection, manufacturing and infusion of cell products belong to transplant and cellular therapy nursing, the field of the TCTCN exam.
Cytokine release syndrome (CRS): a fever of 38 °C or more is required. Grade 1 is fever alone; grade 2 adds low blood pressure that does not need vasopressors, or hypoxia managed with low-flow oxygen; grade 3 needs one vasopressor or high-flow oxygen; grade 4 needs more than one vasopressor or positive-pressure ventilation. In the ASCO guideline on CAR T-cell toxicities (2021), tocilizumab is the first drug for CRS, with corticosteroids added at higher grades.
Immune effector cell–associated neurotoxicity syndrome (ICANS): graded by an encephalopathy score, level of consciousness, seizures, motor weakness and cerebral edema. It can come with CRS, after it or on its own, and corticosteroids, not tocilizumab, are its treatment.
Hormonal, oral and localized therapy
Hormonal therapy
Breast cancer: tamoxifen, the aromatase inhibitors (anastrozole, letrozole, exemestane), and the estrogen receptor degraders, injected fulvestrant and oral elacestrant.
Prostate cancer: androgen deprivation with a GnRH agonist (leuprolide, goserelin) or antagonist (degarelix, relugolix), often combined with an androgen receptor inhibitor (enzalutamide, apalutamide, darolutamide) or with abiraterone. Abiraterone is taken with prednisone to offset mineralocorticoid excess: high blood pressure, low potassium and fluid retention.
Oral therapy
Oral anticancer drugs move giving, monitoring and safe handling into the patient's home. The ASCO–ONS antineoplastic therapy administration safety standards (2024) apply to them as they do to infusions: a complete order, a check of dose and schedule, and teaching before the first dose that covers how to take the drug, what to do about a missed dose, storage and handling, side effects and whom to call. The MASCC Oral Agent Teaching Tool (MOATT, 2016) is one structured guide for that conversation. Adherence is checked at every visit, because skipped doses, double doses and quietly stopped drugs are all documented problems with oral therapy, and so are cost and specialty pharmacy delays that hold up the first fill. Ask about every other medicine and supplement, over-the-counter products and grapefruit included, since many oral targeted drugs share metabolic pathways with them.
Localized therapy
The 2026 outline names intrathecal and intravesical therapy. Intrathecal drugs reach the cerebrospinal fluid by lumbar puncture or through an Ommaya reservoir; only drugs made for that route are used (methotrexate, cytarabine), and the patient is watched for headache, fever, neck stiffness and neurologic change. Intravesical drugs are instilled into the bladder through a catheter and held there for a set time: BCG, a live bacterial product with handling rules of its own, and chemotherapy such as mitomycin or gemcitabine.
Mix-ups across drug families
CRS, ICANS or an infusion reaction? An infusion reaction happens while the drug runs or shortly after. CRS follows T-cell activation, typically days after CAR T cells or around the first step-up doses of a bispecific. ICANS is the neurologic picture and can arrive with CRS, after it or alone.
"Biotherapy" as one thing. Monoclonal antibodies, checkpoint inhibitors, CAR T cells and bispecifics differ in how they are given and what they cause, and the drug name in the stem tells you which family you are in.
Oral means low risk. Oral targeted and cytotoxic drugs are hazardous drugs that need the same dose checks, handling precautions and toxicity monitoring as an infusion.
Both take a brake off T cells. CTLA-4 inhibitors (ipilimumab, tremelimumab) act early, when T cells are first activated in lymph nodes; PD-1 and PD-L1 inhibitors act later, in tissues and the tumor. CTLA-4 blockade, alone or with PD-1 blockade, causes more immune-related adverse events.
Are oral chemotherapy pills hazardous drugs?
Many are on the NIOSH List of Hazardous Drugs in Healthcare Settings (2024). Patients and caregivers are taught not to crush or split them unless told to, to wash their hands after handling them, and to store them apart from other household medicines.
Which OCN domain covers chemotherapy?
Treatment Modalities, items III.D to III.G of the 2026 outline. Administration safety also draws on Domains II and V, covered on safe chemotherapy administration.
Domain IV · Symptom Management and Supportive Care25%
06Neutropenia and myelosuppressionAbsolute neutrophil count, neutropenic precautions, febrile neutropenia and the first hour of sepsis, growth factors, bleeding precautions, anemia and transfusion.
07Symptom management and supportive careNausea and vomiting, bowel changes, mucositis, neuropathy, fatigue, skin and hair changes, lymphedema and ostomies, nutrition and weight loss, pain, and complementary therapies.
04Safe chemotherapy administration and handlingOrder checks and independent double checks, dose and body surface area, hazardous drug handling and spills, protective equipment, infusion reactions, and first steps when a vesicant leaks.
05Radiation, surgery and transplantSurgical and procedural care, radiation principles and safety (time, distance, shielding; sealed and unsealed sources), common site effects, and an overview of autologous and allogeneic transplant.
Domain V · Oncologic Emergencies16%
08Oncologic emergencies: structural and treatment-relatedSuperior vena cava syndrome, spinal cord compression, cardiac tamponade, raised intracranial pressure, obstructions and pneumonitis, with a map of all sixteen Domain V emergencies.
09Tumor lysis syndrome and metabolic emergenciesTumor lysis syndrome, SIADH, hypercalcemia of malignancy, DIC and venous thromboembolism: who is at risk, the labs, and what the nurse does first.
Domain II · Oncology Nursing Practice15%
02Cancer biology, staging and practice standardsCarcinogenesis and immunology, genetic versus genomic testing, TNM staging and grading, performance status scales, clinical trial basics, ethics, advocacy and compassion fatigue.
Domain I · Care Continuum14%
01Care continuum: prevention, screening and survivorshipRisk factors, screening and prevention, navigation, survivorship care plans and late effects, advance care planning, and end-of-life and hospice care at the level the OCN exam tests.
Domain VI · Psychosocial Dimensions of Care10%
10Psychosocial care in oncologyDistress screening, coping, body image, sexuality and fertility, learning needs, cultural and spiritual care, caregiver strain, crises, and the cost of cancer care.