Antineoplastic / Chemotherapy Overview

[BLAD] A single intravesical chemotherapy instillation "immediately after a TURBT (within 24 hours) has been shown to reduce the incidence of urothelial cancer recurrence and progression significantly." For advanced disease, "Enfortumab vedotin and pembrolizumab (EV+P) have replaced cisplatin-based treatments as first-line chemotherapy for advanced or metastatic urothelial (bladder) cancer." [RCC] NCI lists targeted drugs (for example sunitinib, cabozantinib, axitinib, pazopanib, everolimus) and immunotherapy (nivolumab, pembrolizumab, ipilimumab, avelumab) for renal cell cancer. Intravesical BCG is immunotherapy with no class page; its label rules are under nursing care.

[GBM] Temozolomide with radiation, then as maintenance (TEMODAR label). Take at the same time each day, consistently with or without food; swallow capsules whole — "TEMODAR capsules should not be opened, chewed, or dissolved." If powder touches skin, "wash the affected area with water immediately." Check ANC and platelets before each cycle; give PCP prophylaxis in the concomitant phase; liver tests on schedule; contraception. [MET] "Chemotherapy is usually not the primary therapy for most patients." No doses here — see the class page.

Systemic therapy by subtype. Endocrine therapy — "indicated in all hormone receptor-positive patients": tamoxifen (benefit shown in premenopausal HR-positive women; most frequent effect hot flashes; boxed warning for uterine cancer, stroke and PE in the risk-reduction setting) or an aromatase inhibitor such as anastrozole (bone loss, cholesterol rise, arthralgia). Anti-HER2 — trastuzumab for HER2-positive tumors > 1 cm (boxed warning: cardiomyopathy, infusion reactions, embryo-fetal and pulmonary toxicity). Chemotherapy for triple-negative tumors > 1 cm and selected HR-positive disease — NCI flags "Cardiotoxicity from anthracyclines" and "Marrow neoplasia" as toxicities of special concern.

The disorder-side logic in one sentence: chemotherapy targets rapidly dividing cells, which is both why it works and why it hurts. "MOST CHEMOTHERAPY DRUGS SHOW ACTIVITY IN RAPIDLY MULTIPLYING CELLS, SO THEY TEND TO AFFECT RAPIDLY MULTIPLYING CELLS, eg, BONE MARROW, GI TRACT, AND HAIR FOLLICLES. Common toxicities… include MYELOSUPPRESSION, NAUSEA, VOMITING, GI SIDE EFFECTS, MUCOSITIS, ALOPECIA, STERILITY, INFERTILITY, AND INFUSION REACTIONS." Why regimens combine agents: "Multitargeted or COMBINATION therapy is SUPERIOR to single-agent therapy in most cancer treatments," and combinations "with DIFFERENT MECHANISMS OF ACTION and NONOVERLAPPING TOXICITIES can be chosen to DECREASE THE RESISTANCE AND TOXICITIES," appearing to "PREVENT THE DEVELOPMENT OF RESISTANT CLONES by promoting cytotoxicity in RESTING AND DIVIDING cells" — the worked curative example being "bleomycin/vinblastine/cisplatin for testicular cancers." Dosing and interactions belong on the assessment list: agents "are generally administered using BODY SURFACE AREA dosing," and "DRUG-DRUG INTERACTIONS ARE EXPECTED" because cytochrome P450 metabolises many of them — bortezomib, docetaxel, etoposide, imatinib, sunitinib, sorafenib and the vinca alkaloids through CYP3A4/5 — so know the "common drugs with strong INDUCERS like PHENOBARBITAL AND PHENYTOIN and INHIBITORS of CYP enzymes like GRAPEFRUIT JUICE." The nadir is a concept first and a number second: the only sourced figure is one agent class’s "neutropenia nadir: 6 to 10 days with recovery in 14 to 21 days" — there is no universal 7-to-14-day rule, and the clinical instruction does not need one, because fever during the nadir is an emergency regardless of the number. Named toxicity signatures worth carrying: high-dose cytarabine — "neurotoxicity and conjunctivitis"; gemcitabine — liver enzyme elevations and interstitial pneumonitis; methotrexate-type agents — myelosuppression, mucositis, hepatotoxicity, nephrotoxicity, cutaneous reactions; 5-fluorouracil — "dose-limiting HAND-FOOT, mucositis, diarrhea," with toxicity in dihydropyrimidine dehydrogenase deficiency treatable by "uridine triacetate"; taxanes — "hypersensitivity reactions, myelosuppression, peripheral neuropathy"; vinca alkaloids — peripheral neuropathy affecting both motor and sensory function; anthracyclines — cumulative cardiotoxicity. And the psychological load is named as part of the class’s burden, requiring "MULTIDISCIPLINARY AND INTERPROFESSIONAL INTERVENTIONS." The class page owns agent-by-agent pharmacology.

[CERV] "Concurrent cisplatin-based chemotherapy with radiation therapy is the standard of care for women who require radiation therapy for treatment of cervical cancer"; carboplatin if cisplatin is not tolerated (e.g., renal disease). Platinum toxicities: myelosuppression incl. febrile neutropenia, nephrotoxicity, neurotoxicity. [OVAR] Platinum-based chemotherapy with debulking surgery; intraperitoneal delivery "directly into the peritoneal cavity"; PARP inhibitors olaparib, rucaparib and niraparib as maintenance for certain recurrent disease; bevacizumab (most severe effects: gastrointestinal perforation, impaired wound healing and hemorrhage). No doses here — see the class page.

Adjuvant chemotherapy by stage — never for everyone. "Adjuvant chemotherapy has no role in stage I colon cancer management." For stage III, "the standard adjuvant chemotherapy for stage III colon cancer is an oxaliplatin-containing regimen (FOLFOX, XELOX, or FLOX) administered for 6 months," started "within 6 to 8 weeks of surgical resection pending the patient’s recovery"; for stage II, NCI: "The potential value of adjuvant chemotherapy for patients with stage II colon cancer is controversial." Metastatic disease: "FOLFOX or FOLFIRI is considered acceptable for first-line treatment of patients with metastatic colorectal cancer," with anti-EGFR or anti-VEGF agents chosen by tumor biomarkers and side, and immunotherapy for MSI-high tumors. Oxaliplatin — dose-limiting neurotoxicity, "acute and reversible cold-triggered sensory neuropathy or chronic dose-limiting cumulative sensory neurotoxicity." Capecitabine — diarrhea, hyperbilirubinemia and hand-foot syndrome. Bevacizumab — "hypertension, bleeding, gastrointestinal perforations, impaired wound healing, and arterial-venous thrombotic events." Cetuximab — diarrhea, magnesium wasting, infusion reaction and ocular-skin toxicity. Irinotecan — a lower starting dose for UGT1A1*28 homozygotes.

[ESO] Locally advanced disease (T3–T4 or node-positive): "neoadjuvant chemoradiotherapy followed by surgery is commonly recommended." Metastatic disease aims at "symptom palliation, improved quality of life, and prolonged survival." Pembrolizumab is listed for selected advanced tumors (StatPearls, citing NCCN). [GAS] "Patient outcomes improve with perioperative chemotherapy." HER2-positive: "trastuzumab with chemotherapy is the standard for HER2-positive cancers." Advanced gastric cancer therapy is palliative — "to alleviate symptoms, enhance quality of life, and modestly extend survival."

[CIS] Cisplatin with radiation — for the larynx, "definitive radiation concurrent with cisplatin chemotherapy remains an option for laryngeal preservation" (StatPearls, citing ASCO). Boxed warnings: cumulative renal toxicity, ototoxicity (tinnitus, high-frequency hearing loss — audiometry before each dose), anaphylactic-like reactions, myelosuppression, nausea and vomiting; pretreatment hydration; never confuse with carboplatin. [CET] Cetuximab — boxed warnings for "serious and fatal infusion reactions" and cardiopulmonary arrest with radiation; monitor magnesium, potassium and calcium; "Limit sun exposure." No doses here — see the class page.

Cytotoxic chemotherapy is the backbone here because leukemia is a systemic marrow disease with no tumour to resect — there is nothing to cut out, so the treatment has to reach every marrow space at once. Regimens are therefore phase-based rather than single-course: in ALL, induction with an anthracycline, vincristine, asparaginase and a corticosteroid, then consolidation/intensification, then maintenance on oral therapy. In AML the standard is the "7+3" regimen — "a 7-day course of cytarabine continuous infusion with a 3-day course of an anthracycline" — for younger fit patients, with hypomethylating agents plus venetoclax for older or unfit patients, and allogeneic stem cell transplantation as "the only established curative therapy." The disorder-specific harm to teach is that the marrow suppression producing the cure is the neutropenia, thrombocytopenia and anemia that dominate nursing care, and that anthracyclines are cardiotoxic, requiring baseline ECG and echocardiography before the first dose.

[NSCLC] Stage I–III treated "with the intent to cure" (surgery, chemotherapy, radiation, combined); stage IV gets systemic therapy chosen by biomarkers — EGFR tyrosine kinase inhibitors (osimertinib, erlotinib, gefitinib, afatinib), ALK inhibitors, or immunotherapy (pembrolizumab or atezolizumab) when PD-L1 is high. Chemotherapy agents include carboplatin, cisplatin, docetaxel, gemcitabine, paclitaxel, pemetrexed and vinorelbine. Bevacizumab "is contraindicated in squamous cell NSCLC due to the risk of severe and often fatal hemoptysis." [SCLC] Limited stage: concurrent platinum-etoposide chemoradiation, then durvalumab; extensive stage: "First-line treatment is with chemo-immunotherapy" (durvalumab or atezolizumab), which is palliative. Cisplatin: "Aggressive prehydration and posthydration protocols are mandatory with cisplatin to prevent nephrotoxicity"; watch magnesium, potassium and calcium, hearing loss, neuropathy; "Cisplatin is highly emetogenic." Checkpoint inhibitors: immune-related adverse events such as pneumonitis, colitis, hypothyroidism; "Hypophysitis and adrenal insufficiency are life-threatening if missed." No doses here — see the class page.

Combination chemotherapy and immunotherapy by type. Early HL: ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) with or without radiation. Advanced HL: "six cycles of N-AVD is now the standard approach." DLBCL: "typically Pola-R-CHP (polatuzumab, rituximab, cyclophosphamide, doxorubicin, and prednisone) or R-CHOP." Rituximab is the anti-CD20 antibody in R-CHOP — boxed warning for fatal infusion reactions, severe mucocutaneous reactions, HBV reactivation and PML. Toxicities to watch: doxorubicin (cardiomyopathy), bleomycin (pneumonitis), vincristine and brentuximab (neuropathy).

Induction by fitness. Fit patients: quadruplet or triplet regimens including bortezomib — D-VRd (daratumumab + bortezomib + lenalidomide + dexamethasone) or VRd; CyBorD is preferred with significant renal dysfunction. Less-fit patients: daratumumab- or isatuximab-based regimens. Lenalidomide — oral; boxed warning for embryo-fetal toxicity, hematologic toxicity and thromboembolism; available only through the Lenalidomide REMS program; lower doses in renal dysfunction. Bortezomib — proteasome inhibitor given subcutaneously or IV; neuropathy, hypotension, low counts ("Monitor complete blood counts regularly throughout treatment"), tumor lysis, cardiac failure and PRES. Alkylators such as melphalan are avoided before stem cell harvest.

[TX] "The two main regimens used are FOLFIRINOX and gemcitabine plus protein-bound paclitaxel." FOLFIRINOX (5-fluorouracil, oxaliplatin, irinotecan) "is extremely toxic, and only fit young patients can withstand it"; older or less fit patients "might be offered gemcitabine and protein-bound paclitaxel." Most possibly resectable patients get chemotherapy before surgery, and "Postoperative chemotherapy improves overall survival." Because palliative regimens have limited efficacy, "all newly diagnosed patients should consider enrolling in clinical trials." Olaparib maintenance can be considered for germline BRCA1/BRCA2 metastatic disease that has responded to first-line platinum-based therapy for more than 4 months. DPYD warning: patients with the DPYD*2A variant who receive fluoropyrimidines (5-FU, capecitabine) "may experience severe, life-threatening toxicities that are sometimes fatal." No doses here — see the class page.

Cytoreduction for high-risk disease or when phlebotomy is not enough. Hydroxyurea — the sources place it differently: StatPearls (2023) calls it "The first-line agent" for cytoreduction in high-risk patients; StatPearls (2026) says it "is usually considered second-line therapy" after phlebotomy (poor venous access, high phlebotomy need, severe thrombocytosis, intractable pruritus). Adverse effects: "cytopenias, oral ulcers, GI upset, peripheral neuropathy, and rare but severe pulmonary toxicity"; NHS: do not take it "if you’re pregnant or trying to become pregnant." Ropeginterferon (Besremi) is indicated for "adults with polycythemia vera"; boxed neuropsychiatric warning; "Can cause fetal harm." On pregnancy the sources differ — NHS says interferon "can be taken in pregnancy," StatPearls says higher-risk pregnant patients "may require the addition of pegylated interferon-α" — but the Besremi label warns it "Can cause fetal harm." Ruxolitinib (Jakafi) — for PV with "an inadequate response or are intolerant of hydroxyurea"; watch counts, infection (including tuberculosis), skin cancer and thrombosis, and do not stop it abruptly — symptoms "may flare."

Testicular cancer is highly chemosensitive — cisplatin-based BEP or EP. Advanced prostate cancer may receive chemotherapy, a PARP inhibitor for BRCA-type mutations, or radium-223 for bone disease. Hormone therapy for prostate cancer (LHRH agonists such as leuprolide, antiandrogens, abiraterone) is described on this page in prose.

Melanoma systemic therapy. Stage III adjuvant options "include nivolumab, pembrolizumab, or dabrafenib/trametinib if BRAF mutated"; advanced melanoma: checkpoint inhibitors (anti-PD-1, anti-CTLA-4, dual), BRAF inhibitors "for patients who test positive for the BRAF V600 pathogenic variant," MEK inhibitors, TIL therapy and T-VEC. Advanced BCC: vismodegib (hedgehog inhibitor) — taste disturbance, muscle cramps, alopecia, and rarely "teratogenicity." Topical 5-fluorouracil and imiquimod for actinic keratoses and superficial lesions — topical 5-FU on sun-damaged skin "prevents additional actinic keratoses and SCC requiring surgery," with local "erythema, irritation, and crusting."

Powerful anti-inflammatory/immunosuppressive hormones. Never stop abruptly after prolonged use — taper.

Block the serotonin (5-HT3) trigger that drives vomiting from chemo, radiation, and surgery. A key risk is ondansetron’s dose-dependent QT prolongation.

Dial down an overactive or transplant-rejecting immune system. The shared price is infection and malignancy — the biologics carry boxed warnings.