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Bleomycin has approval for adult use in treating squamous cell cancer of head and neck regions, Hodgkin's lymphoma, testicular carcinoma. It is also used as a sclerosing agent for malignant pleural effusions. Off-label use includes treatment of germ cell tumors and pediatric Hodgkin's lymphoma. Bleomycin is in the cytotoxic chemotherapy class of medications. This activity describes the indications, action, and contraindications for bleomycin as a valuable agent in treating various malignant cancers. This activity will highlight the mechanism of action, adverse event profile, and other key factors (e.g., off-label uses, dosing, pharmacodynamics, pharmacokinetics, monitoring, relevant interactions) pertinent for members of the interprofessional team in the treatment of patients with various cancers. Objectives: Describe the pathophysiology of bleomycin toxicity. Review the risk factors for developing bleomycin pulmonary toxicity. Summarize appropriate monitoring of bleomycin therapy. Outline some interprofessional team strategies for improving care coordination and communication when administering bleomycin. Access free multiple choice questions on this topic.

Since early clinical trials in the 1960s, bleomycin pulmonary toxicity (BPT) has been a recognized adverse effect of this drug. Recent studies have described BPT rates of approximately 10% in patients taking bleomycin, with 14% of these BPT cases proving fatal. For this reason, careful monitoring for toxicities accompanied by bleomycin levels is essential. As previously described, BPT can include a serious condition known as pulmonary fibrosis. Risk factors for BPT include cumulative dose, raised creatinine, advanced age, supplemental oxygen, and reduced glomerular filtration rate. While many cases of BPT are irreversible or fatal, evidence suggests that in some surviving patients, pulmonary parameters can improve to baseline in approximately two years. Although there are no well-established therapies for reversing BPT, studies involving alternative formulations of the drug have shown promise. Numerous studies have also demonstrated that bleomycin can sometimes be substituted for less toxic chemotherapy and immunotherapy agents as a part of a multi-drug regimen, producing similar outcomes. This approach is especially useful for patients with multiple BPT risk factors and patients whose low-grade disease does not merit the risk of BPT. [11] In addition to substituting less toxic drugs for bleomycin in chemotherapy regimens, efforts to reduce the risk of pulmonary damage have also included the investigation of lipophilic bleomycin analogs, such as liblomycin. These investigations have not yielded promising results in animal models. [13] Thus, it remains to be seen as to whether the role of bleomycin will continue to diminish in the setting of chemotherapeutic treatment regimens.

Due to its low therapeutic index and high toxicity, the administration of bleomycin should only be performed in dedicated treatment centers under expert supervision with an interprofessional team. Improper management of patients at high risk for adverse effects, including those with pulmonary and renal dysfunction, can lead to avoidable instances of drug-related harm and death. For these reasons, regular interprofessional communication involving online charting tools, verbal confirmation of prescribed dosages and infusion rates, and regular patient monitoring must take place. Clinicians, pharmacists, and nursing staff should be knowledgeable regarding individual patient histories and risk factors; whenever possible, these interprofessional team members should have specialty oncology training. Notably, patients with previous bleomycin treatment are predisposed to developing rapid pulmonary deterioration due to the sensitization of pulmonary tissue to oxygen. As with other chemotherapy agents, close monitoring of patients' symptoms during treatment with bleomycin is necessary. Monitoring measures include pulmonary function tests, regular lab value assessment, and periodic chest radiographs. [14] [Level 1]