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LUNG CANCER Lung Cancer What is lung cancer? Lung cancer is a malignant tumor of the lungs. Originates in the tissues of the lungs. Lung cancer is the leading cause of cancer deaths. Who does it affect? Lung cancer mainly affects smokers; males more than females. African Americans are 40% more likely to have lung cancer. Why? The main cause of lung cancer is smoking and exposure to environmental carcinogens. What types of lung cancer are there? The lungs are made up of several kinds of cells that perform different functions. The type of lung cancer depends on which type of cell the cancer has infected, there are at least 12 different types. Pathophysiology of Lung Cancer Lung cancer arises from a single transformed epithelial cell in the tracheobronchial airways. A carcinogen (i.e. cigarette smoke, environmental agents) binds to a cell’s DNA and damages it. The damaging of the cell results in cellular changes, abnormal cell growth and eventually a malignant cell. Pathophysiology of Lung Cancer As the damaged DNA is passed on to the daughter cells, the DNA undergoes further changes and becomes unstable. Due to the accumulation of genetic changes, the pulmonary epithelium undergoes malignant transformation from normal epithelium to eventually invasive carcinoma. Pathophysiology of Lung Cancer How Smoking Affects the Lungs Normal Respiratory Epithelium change when put under stress – smoking Dysplasia First abnormality observed is dysplasia Smokers cough develops Metaplasia Secondly, metaplasia occurs All steps still reversible Anaplasia Lastly anaplasia occurs and is irreversible when lung cancer develops 2 Main Types of Lung Cancer Small Cell 15-20% Starts in the cells of the bronchi, bronchioles, aveoli, or supporting tissues of the lung Grows quickly and metastasizes in other parts of the body (generally the liver and brain) Most aggressive of the two main types and has the worst prognosis Cells look like oats when viewed under a microscope. It will sometimes be called oat cell carcinoma or cancer. 2 Types: Limited Extensive Non-small Cell 75-80% Grows more slowly 3 Types: Squamous cell carcinoma Large cell carcinoma Adenocarcinoma: including bronchioalveolar carcinoma Stage Limited Tumor is small and confined to the chest including mediastinum and supraclavicular lymph nodes. There is no pleural effusion (fluid around the lung). Extensive Tumor is wide-spread and cannot be confined to the chest Recurrent If small cell lung cancer recurs, the prognosis is very poor regardless of stage or treatment Signs and Symptoms Diagnostic Tests Treatment Survival Rate New or changing cough Hemoptysis Recurrent lung infections Hoarseness S.O.B. Increased sputum Weight loss Swelling of face or arms Fatigue Difficult to DX. Only 1/3 of patients with small cell are identified early on Blood tests: chemistry profile; examination of sputum or fluid from chest for presence of malignant cells Imaging: chest x-ray; CT scan, MRI; spiral CT scanning has been developed to identify early stage lung cancer in at risk populations Biopsy: of mediastimum, lymph nodes, chest lining Microscopy: once cells are collected, pathologists can use this to accurately diagnose small cell lung cancer Combination chemotherapy: multiple drugs are much more effective than single-agent Radiation therapy: given at the same time as chemotherapy, this may improve survival rate Surgery: A small % of patients with very early stage disease may benefit 2 year: 20% Same as above If tumor has metastasized: Severe headaches Double vision Weight loss Pain in bones chest, abdomen or neck The above exams plus those to evaluate presence of metastases Scans: CT of abdomen; MRI or CT of brain; PET scans of mediastinum; bone scan Endoscopy/biopsy: fiber-optic bronchoscopy with brushings or biopsy; biopsy of bone, lymph nodes or liver Combination chemotherapy: Different combinations may be more effective than others Radiation therapy: this may help relieve symptoms or with metastatic disease (brain, bone) but it is not necessary to the chest 2 year: 5% Any of the above plus others The above Palliative therapy: Pain relief and orthopedic aids Investigational drugs/ clinical trials 2-3 months Non-Small Cell Lung Cancer Stages Staging for non-small cell lung cancers, called the TNM system, takes into account… T: nature of primary tumor ie. lung N: lymph node involvement M: evidence of metastases Stage I - Confined to one lung Has not spread to the adjacent lymph nodes or outside the chest. Stage II - Located in one lung - May involve lymph nodes on the same side of the chest Does not include lymph nodes in the mediastinum or outside the chest. - Stage IIIA: - - Cancer is a single tumor or mass that is not invading any adjacent organ Involves one or more lymph nodes away from the tumor but not outside the chest. Stage IIIB - Cancer has spread to more than one area in the chest Not outside the chest. Stage IV - Cancer has metastasized to different sites in the body May include the liver, brain or other organs. Recurrent/Relapsed: - Cancer has progressed or returned Following initial treatment Types of Lung Resections For non-small cell lung cancer Lobectomy Single lobe of lung is removed Bilobectomy 2 lobes of the lung are removed Sleeve Resection Cancerous lobe(s) is removed and a segment of the main bronchus is resected Pneumonectomy Removal of entire lung Segmentectomy A segment of the lung is removed Wedge Resection Removal of a small, pie shaped area of the segment Chest Wall Resection removal of cancerous lung tissue for cancers that have invaded the chest wall. Signs and Symptoms Symptoms that suggest lung cancer include: Dyspnea (shortness of breath) Hemoptysis (coughing up blood) most often rules out a pneumonia Chronic cough or change in regular coughing pattern Wheezing Chest pain or pain in the abdomen Cachexia (weight loss b/c the tumor deprives the body of essential nutrients causing normal tissues to starve), fatigue and loss of appetite Dysphonia (hoarse voice) Clubbing of the fingernails (uncommon) Difficulty swallowing (ataxia) Monday Morning in the Emergency Department Patty Nelson, a 56 year old woman presents with a 12-week history of cough with hemoptysis, progressive SOB, dyspnea, and a 20 lb weight loss. Patty appears disheveled and smells of cigarettes. Her husband Jeff says that she has had trouble breathing for at least 3 months. Relieving her severe respiratory distress is our primary concern. Her vitals are as follows: T – 37.4, P – 114, R – 32, BP – 134/88, O2 – 87% on RA An IV was initiated with NS @ 125ml/hr. Patty was given Ventolin 2.5 mg via nebulizer and Atrovent 400mcg via nebulizer to bronchodilate. O2 is administered via nasal cannula @ 4L/min. She was also given Decadron 10mg IV to decrease swelling and inflammation in her chest. Once her SOB and dyspnea were controlled Patty stated she had chest pain and rated her pain as 2/10. Once Patty was able to properly intake oxygen a further assessment was conducted... ER Continued…. Patty is a retired cashier at Sears and her husband Jeff of 33 years, is a retired City worker. They have three grown children who live out of town. Patty informs us that she has visited her family physician several times in the past six months for what was first suspected to be a recurring common cold, and was later treated as a pneumonia. The suspected pneumonia was unresponsive to treatment with antibiotics. The physician is suspicious of her presenting signs and symptoms and orders a CXR, CT scan of the chest and abdomen, and blood work. Patty’s physical assessment reveals: Normal heart sounds Wheezing in the lungs with decreased air entry to lower lobes Respirations are rapid, labored, and shallow with mild accessory muscle use CMS is adequate with PPP, and delayed capillary refill Soft abdomen with bowel sounds x4, passing flatus, last BM this am As suspected the CXR revealed a mass in the lung located in the lower left lobe. The CT scan provided a view of the thorax showing swelling in the mediastinal lymph nodes. The physician diagnosed Patty with lung cancer. To determine the type of lung cancer present the physician ordered the following tests to provide a more accurate diagnosis: Fiberoptic Bronchoscopy for Biopsy: Provides a detailed study of the tracheobronchial tree and allows for biopsies of suspicious areas A biopsy is necessary to make a definitive diagnosis of cancer cells: tissues are removed from the body and checked under a microscope, if they are cancerous they may be studied further to see how fast they are growing Tissue sample taken to diagnose or rule out disease Mediastinoscopy Used to obtain biopsy samples from lymph nodes in the mediastinum MRI To rule out brain metastases Chemistries: For renal, bone, and liver abnormalities CXR shows pulmonary density, a solitary peripheral nodules, atelectasis, and infection CT Scan of chest and abdomen: to assess disease extent identifies small nodules not visualized on the CXR and also to examines areas of the thoracic cage not clearly visible on CXR Sputum for cytology Sent for culture in the lab Mediastinoscopy is a procedure in which a lighted instrument (mediastinoscope) is inserted through a neck incision to visually examine the structures in the top of the chest cavity and take tissue samples. This procedure can be used to biopsy lymph nodes surrounding the airway to help diagnose or see how far a particular disease has spread. Sputum Cytology Sputum sample obtained by coughing deeply and expelling the material that comes from the lungs into a sterile medium. A positive culture may identify diseaseproducing organisms that may help rule out respiratory conditions Rarely used to diagnose lung cancer; it is used as a screening tool CXR and CT Results Patty’s Diagnosis Small Cell Lung Cancer Extensive Stage (left lobe and mediastinal lymph nodes) Diagnosis Small Cell Lung Cancer (SCLC) Small cell carcinoma is called oat cell cancer Is a fast growing type of lung cancer Very early metastasis 10% patient are alive at 2 years Each Pt’s Tx Is Unique Treating lung cancer depends on: The cancer's specific cell type How far it has spread in the body The patient's performance status. Measures pts general wellbeing and overall strength. Used to determine whether they can receive chemotherapy, whether dose adjustment is necessary, and as a measure for the required intensity of palliative care. Patty’s cancer team will consist of: Doctors: Hematologists Oncologists Pathologists Radiation Oncologists Radiologists Surgeons Nurses Physicists Radiation Therapists Social Workers Occupational Therapists Psychiatrists Respiratory Therapists Treatment Patty is not a good surgical candidate b/c her cancer is in the extensive stage. Chemotherapy will be the first choice of tx A PICC line is inserted so that Patty can begin chemotherapy. She is started on 6 cycles of Etoposide and Cisplatin. Patty is given 10mg IV Decadron and 75mg IV Maxeran 30 min prior to chemotherapy. After chemo, Patty is prescribed Maxeran q2h prn for two doses, then 75mg q3h prn for three doses. The Meds so Far… Atrovent (Ipratropium) bronchodilator, anticholinergic Maintenance of airway and control of bronchospasm Inhibits contraction of bronchial smooth muscle Assess respiratory status Ventolin (Albuterol) bronchodilator, adrenergic Prevents reversible airway obstruction and controls acute bronchospasm Relaxes smooth muscle of the airway May cause nervousness, restlessness, tremor, chest pain Assess lung sounds, pulse, BP, Decadron (Dexamethasone) corticosteroid Used for a wide variety of chronic diseases May cause HYPT, ecchymoses, euphoria Assess respiratory status, lung sounds, Maxeran (Metoclopramide) antiemetic Prevention of chemotherapy induced emesis Blocks dopamine receptors, causing CNS depress May cause drowsiness, extrapyramidal reactions, restlessness Assess N&V, bowel sounds, abd distention If distonic reactions occur administer 50mg IM diphenhydramine Morphine opioid analgesic Binds to opiate receptors in CNS to decrease pain May cause confusion, sedation, hypotension, constipation, respiratory depression Assess type, location, and intensity of pain Narcan is the antidote for respiratory depression: Dilute 0.4mg ampule in 10ml NS and administer 0.5ml IV push every 2 minutes Hyrdomorphone (Dilaudid) opioid analgesic May cause confusion, sedation, constipation, hypotension Assess type, location, and intensity of pain Narcan is the antidote Oxycodone (Oxy IR) opioid analgesic Same as above PCA Pumps: Allow the patient to administer their own pain medication when needed Think “pain prevention” rather than sporadic pain control PCAs allow the patient to receive adequate pain control with less medication Check q1h x 2h, q2h x 12h, q4h x 5 days, then q8h Chemotherapy The use of cytotoxic drugs to treat cancer Systemic: drugs circulate and kill cancer cells Combination chemotherapy is administering more than one drug at a time More effective Reduce side effects Prevent resistance A chemotherapy cycle: Period of treatment followed by a resting period with no treatment Length and timing of the cycle depends on the combination of drugs used After drug administration there is 3-4 week rest period to allow body to recover Usually given for 4-6 cycles What is Chemotherapy Use of chemicals to alter tumor growth patterns and cell reproduction and treat metastases Can be used as an adjunct to surgery or radiation therapy. Non-selective therefore both cancer and normal cells are affected. Targets RNA and/ or DNA in cells to prevent mitosis and/or induce apoptosis (self-death). Act on cells that are dividing and cells in interphase. Chemo Side Effects Early side effects cause changes to rapidly dividing cells such as: Hair loss Erythema and other skin changes Bone marrow causing reduced WBC, RBC, platelets, HgB Mouth sores N&V, diarrhea Changes in reproductive organs i.e. menopause Phlebitis Headaches Anorexia Burning on urination, blood in urine Numbness to extremities, generalized weakness Hearing problems i.e. tinnitus Late side effects can cause problems after treatment and can last for long periods of time Fatigue Bone marrow suppression Organ injury: heart, kidney, lung Infertility Renal failure Renal Failure CrCL (ml/sec) REDUCE BY ANCILLARY SUPPORTIVE TREATMENTS 0.2-0.8 Etoposide by 25%, cisplatin by 50% Oral or IV hydration is encouraged Antiemetic Regimen DRUG ADMINISTRATION GUIDELINES CISPLATIN < 0.2 Etoposide by 50% and OMIT cisplatin Check serum creatinine prior to cisplatin May be given together with 50mL of mannitol 20% and 100mL 0.9% NaCl Infuse IV rate of 1mg/minute Monitor input and output Extravasation potential: irritant ETOPOSIDE Baseline blood pressure and every 15-30 minutes during infusion Infuse IV over 60 minutes EXTRAVASATION POTENTIAL: IRRITANT DURATION OF CHEMOTHERAPY VISIT Approximately 3 hours RECOMMENDED CLINICAL MONITORING CBC before treatment Oral examination for stomatitis Baseline and routine renal function tests Baseline and periodic liver function test Monitor hearing and neurologic toxicities DRUG COSTS (PER 1.7 m2 BSA) Approximate chemotherapy cost $102.00 per cycle Treatment Results Patty has been discharged and visits her family physician for a follow up appointment. She has a complete response to chemotherapy on CXR and CT scan of the thorax and abdomen as evidence by a reduction in the size of the tumor. Her cancer seems to be under control at the present time. Symptoms of Metastases Headache Weakness, numbness, or paralysis Dizziness Partial loss of Vision Bone or joint pain Abdominal pain upon probing Unexplained weight loss Loss of appetite Unexplained fever Jaundice SOB, caused by fluid in the chest Cardiac symptoms, including irregular pulse and difficutly breathing Swelling of the face, arms, and neck, possibly, with visible vein distention on the skin of the chest caused by superior vena cava syndrome (pressure of a tumor on the large chest (SVC) 6 Months Later… Patty returns to the ER with c/o persistent headaches, severe SOB, dyspnea, and hemoptysis. She is also experiencing pain in her muscles and joints. On assessment the physician notices mild yellowing of the skin and sclera and some swelling in her neck and left arm. Patty is referred for X ray and CT scan of her head, chest, and abdomen. X ray shows that the original mass in her lungs has grown and CT scan reveals multiple brain and liver metastases. CT of Brain Right sided brain metastasis Palliative Care Goal: Relieve suffering and improve quality of living and dying when disease can not be cured. It is important for people to live out their days with meaning and as little distress as possible. It may complement and enhance disease modifying therapy or it may become the total focus of care. Embraces life and regards death as a normal process. Neither speeds up death nor delays it. Provides relief from pain and other distressing symptoms. Integrates the psychological and spiritual aspects of care. Offers a support system to help patients live as well as possible until death. Offers a support system to help families cope with their loved one's death and to help them cope afterward with their own bereavement. Palliative Cont…. What is Palliative Radiation Therapy and Chemotherapy? When cure is not possible, both radiation therapy and chemotherapy can help to relieve the symptoms and to improve the quality of life. These treatments are used to shrink a tumor, or to slow down it's spread, so that while you may be living with an incurable cancer, you can still continue to live well. Patty is admitted due to the severity of the metastases. Due to the recurrent nature of her cancer she has a poor prognosis, she is treated palliatively with decadron and radiation therapy to help relieve her cough, dyspnea, chest pain, hemoptysis, and joint and muscle pain. Radiation The treatment of cancer using high energy x-rays, gamma rays, and electrons. Radiation targets rapidly dividing cells Side Effects: Fatigue Hair loss to treated area Erythema Radiation Therapy Interrupts cellular growth More than ½ of patients with cancer will receive a form of radiation at some point It is most often used when a tumor cannot be removed surgically or when local metastases is present Sometimes used prophylactically to prevent leukemic infiltration to the brain or spinal cord Used palliatively to relieve symptoms of metastases 2 Types of Ionizing Radiation Electromagnetic Rays: Radiation breaks the strands of the DNA helix which leads to cellular death Particle Rays: Lead to tissue disruption Cells that divide frequently are more sensitive to radiation therapy ( ie. Bone marrow, lymphatic tissue, epithelium of GI tract etc.) Tumors that are well oxygenated have more successful rates with radiation treatment Chemotherapy creates a more sensitive tumor Radiation Delivery Methods There are 2 forms of Radiation Therapy; External Radiation: Rays are delivered from outside of the body, and are calculated by the size and depth of the tumor Internal Radiation: Radioisotope device is implanted by many routes (needles, seeds, beads or catheters into body cavities) Radiation improves Patty’s quality of life by relieving some of the complications associated with her cancer. Patty is experiencing constant pain during this stage of her illness. The following tool is used to assess the severity of her pain and which medications will best relieve her pain. Factors Contributing to Decreased Intake of Nutrients Effects of Cancer Treatment Reduced Oral Intake Anorexia N&V Altered Perceptions of Taste and Smell Local Effects of Tumor Odynophagia, Dysphagia Malabsorption Early Satiety Psychosocial Factors Depression, Anxiety Food Aversion Surgery Altered mastication and swallowing Postgastrectomy syndromes Pancreatic Insufficiency Anastomotic stricture Chemotherapy N&V Altered Perceptions of taste and smell Stomatitis, mucositis Diarrhea Radiation Odynophagia, Dysphagia Xerostomia, mucositis Strictures and Fistulas Cachexia A syndrome that includes anorexia, early satiety, weight loss, anemia, asthenia, taste alterations, and altered metabolism. Most severe for of malnutrition associated with cancer. Causes 80% of deaths associated with cancer. Pt experiences weight loss despite normal food and fluid intake. Pts with cancer have a high BMR, due to energy demands of the tumor. Pt’s may end up on TPN. Purpose To provide nutrition for a) pts who can not eat or drink b) pts who can not absorb what they eat or drink c) pts who can not intake enough calories to gain weight, gain energy, or heal tissues It may be given to people who are unable to absorb nutrients through the intestinal tract because of vomiting that won't stop, severe diarrhea, or intestinal disease. It may also be given to those undergoing high-dose chemotherapy or radiation and bone marrow transplantation. A form of nutrition that is delivered into a vein. TPN does not use the digestive system. TPN Solutions Amino Acid Solution 4.25% Dextrose 10% or 25% 10% can be delivered via peripheral or central route, and 25 % is delivered via central route only Lipids 10% or 20% Different additives such as Trace Elements Vitamins Zinc, Magnesium A,D,K Electrolytes Sodium, Potassium Pt Care Plan Routine TPN blood work CBG’s QID Strict I & O TPR QID and once during the night (notify MRP if T is >38.5) BP Q shift Give Vit K 10 mg IM weekly Treatment Pt. wt. as per protocol Central midline drsg changes IV line changes Perpipheral IV site changes (Q 96 hours or as per protocol) TPN Cont… A fluid balance record, diabetic record and graphic records are kept for TPN pts as well as A TPN record in their chart which includes the following Date & Time of Hanging Sol’ns Type of Sol’n and Volume Rate ordered Initials Date and Time Sol’n Finished Date and Time of Line changes (amino, lipid) Date and Time of all other IV line changes IV site drsg change ( RN Note) As Patty’s condition continues to deteriorate, Patty’s family realizes that the end is near. The nurse must now take on added responsibilities with family care as they become the primary patient (in some ways). Care for the Family When all treatment options have been exhausted, the nurse must continue to care for the family. The nurse can ensure that the family has begun to plan ahead in organizing the patients’ personal affairs. The nurse can remind the family to remember to care for themselves: Adequate rest and nutrition. Signs of Death & Dying Pt becomes less social, sleeps for long periods of time, and is difficult to rouse: Nursing Intervention Allow quality rest time Reassure patient that it is alright to sleep Plan to spend time with the patient when they are most awake Speak in a calm, natural way; never assume that the patient can not hear Pt shows a decrease in eating habits: Nursing Intervention Offer small servings of light food and fluids, ice chips, popsicles Remind patient to swallow, as they may forget Promote comfort by keeping the mouth and lips moist Signs of Death & Dying The patient may Become confused/disoriented Nursing Intervetion Speak calmly and clearly, explain what you are doing as you provide care Remind the patient of time, place, and who is in the room Keep a soft light on The patient may become restless Nursing Intervention Offer music, light massage, medication, or other comfort measures They may lose control of bladder and bowels Nursing Intervention Keep the person clean and comfortable Have Changes in breathing: Irregular rate, may stop for 5-30 seconds followed by a deep breath; periods of rapid, shallow, panting breathing; wet sounding breathing Nursing Intervention Raise the head of the bed, or place patient on their side Signs of Death & Dying Patient may: Have an irregular pulse or heartbeat Decreased circulation: Skin may feel cool or moist, become pale, swollen, or blue, but the patient will not be feeling cold Be unresponsive to voice and touch (withdrawal); sleeping with eyes open This is the preparation for release, the beginning of letting go: Hearing remains to the end, speak in a calm, natural way Identify yourself when you speak Hold the persons’ hand Give permission to let go When Death Has Occurred The person will be entirely unresponsive Breathing will stop Pulse stops Eyes will be open or closed, with a stare in a fixed direction Jaw will relax Loss of bladder or bowel control may occur Notify Physician if not already Care After Death 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Apply Gloves Remove all tubing ie. Indwelling catheters Reinsert dentures if applicable Position patient according to agency policy Elevate head of bed or place small pillow under their head Close eyes Wash any soiled body parts Place an absorbent pad under the buttocks Change dressing with a clean one Put Patient in a clean gown Brush and comb hair Cover body with sheet exposing only the head (only if family wants to see them) Place into body bag and label body Call a porter Care of the Dead Body The following forms must be completed 1. 2. 3. 4. Medical certificate of death ( must be filled out by a nurse and signed by a physician)or (coroner) Warrant to bury the body of a deceased person (filled out by the nurse and signed by the coroner) Consent for autopsy ( for all deaths can be completed by a nurse or physician) Release of liability and responsibility, removal of bodily remains (c by nurse, signed by family) Patty’s body and personal effects have been taken care of and the family are about to go home. Patty’s husband, Jeff, turns to you as he is leaving and asks, “How will I cope? Patty did everything for me. I can’t even read.”