Download REIMBURSEMENT ISSUES

Chapter 17
Care of the Patient with Cancer
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Slide 1
Oncology
• Branch of medicine that deals with the study of
tumors
• Oncology nursing is the care of people with cancer
• 1 of 2 men will have cancer
• 1 of 3 women will have cancer
• Second leading cause of death in the United States
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Slide 2
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Slide 3
Oncology
• Cancer is not one disease, but a group of diseases
characterized by the uncontrolled growth and spread
of abnormal cells
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Slide 4
Oncology
• Lung cancer is the leading cause of cancerrelated death in both men and women
breast and prostate have higher occurrence
but have a better cure rate and because of
early detection and treatment
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Slide 5
Oncology – Gerontologic
Considerations
• The incidence of cancer increases with aging due to
decrease in immune system function and changes in
deoxyribonucleic acid (DNA) –molecule that
encodes genetic function
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Slide 6
Development, Prevention, and
Detection of Cancer
• Carcinogenesis (translation- cell alteration)
• The process by which normal cells are transformed
into cancer cells
• Various factors are possible origins of cancer
Normal cell
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Slide 7
Development, Prevention, and
Detection of Cancer

Carcinogens
• Substances known to increase the risk
for the development of cancer
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Slide 8
Development, Prevention, and
Detection of Cancer
• Risk factors
• Smoking
 87% of people who develop lung cancer are
smokers
• Dietary habits
 Colon, rectum, and breast cancer
 High fat, low fiber
 Obesity
• Exposure to radiation
 Ultraviolet rays factor in the development of basal &
squamous cell skin cancers & melanoma
 Effects from radiation from medical imaging (Xrays)
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Slide 9
Development, Prevention, and
Detection of Cancer
Risk factors (continued)
• Exposure to environmental carcinogens
 Fumes from rubber/chlorine or dust from cotton,
asbestos, and coal are examples
• Smokeless tobacco
 Increases the risk of cancer of the mouth,
larynx, pharynx, and esophagus
• Frequent, heavy consumption of alcohol
 May result in oral cancer and cancer of the
larynx, throat, esophagus, and liver
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Slide 10
Hereditary Cancers
• About 90% of cancers are NOT inherited
• Genetic susceptibility

Incidence of breast cancer is higher in women with a
family history of this disease
 Incidence of lung cancer is high in smokers with a
family history of this disease
 Incidence of leukemia is greater in an identical twin
 Neuroblastoma occurs with increased frequency
among siblings (malignant cancer cells form in nerve
tissue of adrenal gland, neck, chest or spinal cord)
 Colon cancer is more likely to occur in women who
have a history of breast cancer
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Slide 11
Hereditary Cancers
• Cancer risk assessment and cancer
genetic counseling
 First step toward identifying
hereditary cancer predisposition
 Provides education, health
promotion, informed consent, and
support
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Slide 12
Heredity Cancers
• Genetic testing is a type of medical test that
identifies changes in chromosomes, genes, or
proteins. The results of a genetic test can confirm
or rule out a suspected genetic condition or help
determine a person's chance of developing or
passing on a genetic disorder.
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Slide 13
Cancer Prevention and Early
Detection
• Planned periodic examination and recognition of
•
•
•
•
•
cancer’s warning signs
Colorectal tests – starting at age 50
Prostate cancer detection – age 50
Pelvic examination with Papanicolaou (Pap) smear
for women - yearly
Breast cancer detection (self-examinations) –
mammogram every 2 years if over 50 years old
Skin examinations- every year at 40 years old
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Slide 14
Cancer Prevention and Early
Detection
• Lung cancer – No screening found to be effective
• Lung cancer is usually found on an X-ray exam but
often there are no symptoms
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Slide 15
Pathophysiology of Cancer
• Cell mechanisms and growth

Normal cells
• When cells are destroyed, cells of the same
type reproduce until the correct number
have been replenished
 Cancer cells
• Instead of limiting their growth to meet
specific needs, they continue to reproduce
in a disorderly and unrestricted manner
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Slide 16
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Slide 17
Pathophysiology of Cancer
• Cell mechanisms and growth (continued)

Neoplasm
• Uncontrolled or abnormal growth of cells
• Benign: Not recurrent or progressive;
nonmalignant
• Malignant: Growing worse and resisting
treatment; cancerous growths; tumors
 Metastasis
• Tumor cells spread to distant parts of the
body
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Slide 18
Pathophysiology of Cancer
• Description, grading, and staging of tumors

Classified according to original site of primary
tumor
 Description
• Carcinoma: Malignant tumors composed of
epithelial cells (skin, glands, mucous memb);
tend to metastasize
• Sarcoma: Malignant tumor of connective
tissues, such as bone, muscle, fat
• Lymphomas/leukemias-hemapoietic system
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Slide 19
Pathophysiology of Cancer
• Tumors are classified as grade 1 to grade 4
(degree of malignancy) dysplasia (abnormal
growth)
 Grade 1: Mild dysplasia—cells only
slightly different from normal cells
 Grade 2: Moderate dysplasia—
moderately well differentiated
 Grade 3: Severe dysplasia—poorly
differentiated
 Grade 4: Anaplasia—cells difficult to
determine
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Slide 20
Pathophysiology of Cancer

Staging
• Tumor, nodes, metastasis (TNM) staging system
for cancer is used to indicate tumor size, spread to
lymph nodes, and extent of metastasis
 Stage 0: Cancer in situ
 Stage I: Tumor limited to the tissue of origin
 Stage II: Limited local spread
 Stage III: Extensive local and regional spread
 Stage IV: Metastasis (spreading from primary to
secondary sites)
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Slide 21
Staging of Cancer
• Metastasis – spread
• 1. direct spread of tumor cells by
diffusion
• 2. circulation by way of blood and
lymphatic channels
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Slide 22
Diagnosis of Cancer
• Incisional biopsy – removal of a portion of
tissue
• Excisional biopsy – removal of the complete
lesion for example – dissection of peripheral
lymph nodes
• Needle aspiration – fluid or tissue aspirated
by needle (breast, thyroid)
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Slide 23
Types of Biopsy
Types of biopsy.
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Slide 24
Diagnosis of Cancer
• Endoscopy – upper GI
• Colonoscopy – entire colon
• Diagnostic imaging

Bone scanning (areas of concentration)
 Tomography (different depths, multiple photos)
 Computed tomography (CT) Bone, GI, urinary, lung brain
 Radioisotope studies (concentration of isotope indicates tumor)
 Ultrasound testing
 Magnetic resonance imaging (no radiation; uses
radiofrequency energy waves emitted by magnetic coils)
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Slide 25
Diagnosis of Cancer
• Laboratory tests





Serum alkaline phosphatase (> in bone/liver
mets)
Serum calcitonin (> in thyroid Ca)
Carcinoembryonic antigen (CEA) (> colorectal
Ca; could indicate recurrence or mets in some
other Ca)
PSA (prostate) and CA-125 (ovarian Ca)
Stool examination for blood
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Slide 26
Cancer Therapies
• Surgery




Preventive
Diagnostic
Curative
Palliative
• Reconstruction
• Relieve pain, obstruction, etc.
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Slide 27
Cancer Therapies
• Radiation therapy – used to cure/control
cancer spread to lymph nodes or to treat
tumors that cannot be removed
 External radiation therapy
o Markings or tattoos – area on the
body is marked
o Avoid creams, lotions, powders,
sunlight, heat, cold
 Internal radiation therapy
o Sealed and unsealed
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Slide 28
Internal Radiation Therapy
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Slide 29
External Radiation Therapy
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Slide 30
Cancer Therapies
• Chemotherapy- drugs used to reduce size or slow
growth of the metastatic cancer

Side effects
• Leukopenia ( decrease WBCs -observe/protect against infection)
• Anemia (low platelets w/ low hemoglobin…monitor for cardiac
decompensation)
• Thrombocytopenia (low platelets -monitor for bleeding)
• Alopecia (hair loss -scalp protection, emotional support)
• Stomatitis (antifungals, magic mouthwash, antibiotics
inflammation of oral mucosa - Lidocaine)
• Nausea, vomiting, and diarrhea (antiemetics, antidiarrheals
also use Ativan to induce calming state)
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Slide 31
Cancer Therapies
Side effects of Chemotherapy
Tumor lysis syndrome (patient with high tumor
burdens likely candidate)


Intracellular contents rapidly released into bloodstream; high
levels K+, phosphate, uric acid, hypocalcemia
High risk for renal failure and cardiac malfunction
o S/S : abnormal lab values, potassium, calcium, uric acid,
creatinine, blood urea, nitrogen and urine PH
o Prophylactic measure taken prior – hydration, medications,
diuretics, cardiac monitoring
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Slide 32
Cancer Therapies
• Chemotherapy Administration –

Oral, intramuscular, IV or topical route

Vesicant drugs are given only by the IV route into a
large vein. These drugs cause blistering of tissue that
eventually will lead to necrosis if they infiltrate out of
the blood vessel and into soft tissue. (Adriamycin,
Doxil)
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Slide 33
Cancer therapy - Chemotherapy
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Slide 34
Cancer Therapies
• Biotherapy


Treatments with agents derived from biological
sources or affecting biological responses using the
immune system
Three major mechanisms of biological response
modifiers (BRMs)
1. Increases, restores, or modifies the host defenses
against the tumor (Neupogen, Epogen)
2. Toxic to tumors
3. Modifies the tumor biology (interferons, gamma)
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Slide 35
Cancer Therapies - Biotherapy
• In the mid-1980s, encouraging results were seen in
the use of interferon to treat a rare blood disorder
called hairy-cell leukemia. The FDA has approved
interferon for this disease, as well as chronic
myelogenous leukemia, AIDS-related Kaposi's
sarcoma, and genital warts.
• Handled properly, immunotherapy could indeed
stimulate the body's defenses.
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Slide 36
Cancer Therapies
• Bone marrow transplantation

•
Process of replacing diseased or damaged
bone marrow with normally functioning bone
marrow
 High risk of sepsis and multisystem failure
Peripheral stem cell transplantation
 Alternative to bone marrow transplant
 This procedure is based on the fact that
peripheral or circulating stem cells are
capable of repopulating the bone marrow
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Slide 37
Advanced Cancer
• Pain management

Opioids
• Morphine, hydromorphone (Dilaudid), fentanyl,
methadone
• Sustained-release morphine

MS Contin, Roxanol SR
• Administration



IV drips, intrathecally, orally and epidurally
Avoid peaks and valleys
Manage side effects
• Patient self-control

Distraction, massage, relaxation, biofeedback, hypnosis,
and imagery
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Slide 38
Advanced Cancer
• Pain management (continued)

Patients should not be subjected to severe suffering
from potentially controllable pain
 May require care for “breakthrough” pain
 Fear of addiction should not be a factor when
considering pain relief for the terminally ill
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Slide 39
Advanced Cancer
• Nutritional therapy

Problems
•
•
•
•
•
•
•
Malnutrition
Anorexia/cachexia
Altered taste sensation
Nausea/vomiting
Diarrhea
Stomatitis
Mucositis
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Slide 40
Advanced Cancer
• Communication and psychological support

Factors that may determine how the patient copes
•
•
•
•
•
•
•
•
•
Ability to cope with stressful events in the past
Availability of significant others
Ability to express feelings and concerns
Age at the time of diagnosis
Extent of disease
Disruption of body image
Presence of symptoms
Past experience with cancer
Attitude associated with cancer
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Slide 41
Advanced Cancer
• Terminal prognosis

Most patients with advanced cancer know they are
dying
 Honesty and openness are the best approaches
 Spiritual activities may provide mental and emotional
strength
 Social worker assists the patient and family in
planning for home care
 Hospice services can be arranged—efforts are
directed toward relief from pain and other problems
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Slide 42
Chapter 14
Antineoplastic Medications
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43
Overview




Neoplasms-abnormal growth or tumor
Metastasis-rapid cell growth into other areas
Malignancy-cancerous growth
Chemotherapeutic agents-agents used to
treat cancerous or malignant diseases.
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44
Antineoplastic Medications
Action and Uses
 Alkylating agents interfere with cell
division
– Attach physically to DNA in tumor cell to prevent
from functioning normally
– Occurs in cancerous and healthy cells
– Anemia, high risk infection, N/V, diarrhea
 Antibiotic preparations not used as
antiinfectives
– Very specific cancers
– Interfere with DNA and RNA synthesis thus killing
cancer cells
– All administered IV or into body cavity using
catheter
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45
Antineoplastic Medications
 Antimetabolites affect cell metabolism
– Interfere with metabolic functions of cells
– Mimic building blocks of cancer cells but cause cell
destruction/death
 Action of male and female hormones on cancer
unclear
– Hormone antagonists (Tamoxifen, estrogen)
– Slow tumor growth
 Mitotic inhibitors interfere with cell division
– Plant extracts that cause cell division to stop
 Biologic response inhibitors
– Stimulate body’s immune system to stop cancer
 Miscellaneous
– Prevent anemia, stimulate platelet production, stimulate
WBC production
– Clinical trials
Antineoplastic Medications
(cont.)
Adverse Reactions
 Dose-dependent
 GI: nausea, vomiting, diarrhea, and anorexia
 Bone marrow depression
 System-specific toxicity
– Renal, hepatic, ototoxicity, ocular effects
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47
Antineoplastic Medications
(cont.)
Drug Interactions
 Drug-specific: consult manufacturer’s
guidelines
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48
Williams' Basic Nutrition &
Diet Therapy
14th Edition
Chapter 23
Nutrition Support in Cancer and
HIV/AIDS
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rights reserved.
49
Lesson 23.1: Nutrition Support in
Cancer


Environmental agents, genetic factors, and
weaknesses in the body’s immune system can
contribute to the development of cancer.
The strength of the body’s immune system relates to
its overall nutritional status.
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50
Process of Cancer Development
(p. 471)

The nature of cancer



Multiple forms: highly variable nature
Second leading cause of death in United States
Cancer designates a malignant tumor neoplasm
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51
The Cancer Cell (p. 472)



Orderly process of cell division is disrupted by
mutation
Cancer is normal cell growth that has gone
wrong
Tumors identified by:



Primary site of origin
Stage of tumor size and metastasis
Grade: level of aggressiveness
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52
The Body’s Defense System
(p. 473)

Two types of lymphocytes (defensive immune
system cells)





T cells
B cells
T cells activate phagocytes
Phagocytes destroy invaders and antigens
B cells produce antibodies, which kill antigens
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53
The Body’s Defense System
(cont’d) (p. 473)
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54
Relation of Nutrition to Immunity
and Healing (p. 473)

Immunity



Balanced nutrition maintains immune system
Malnutrition reduces capacity of immune system
via atrophy of organs and tissues involve in
immunity
Nutrition vital in combatting sustained attacks of
diseases (e.g., cancer)
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55
Relation of Nutrition to Immunity
and Healing (cont’d) (p. 473)

Healing



Strong tissue is fundamental to immune system
Tissue building and healing requires optimal
nutrition
Vigorous MNT speeds recovery after surgery for
cancer
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56
Nutrition Complications of Cancer
Treatment (p. 474)

Three major forms of therapy used to treat
cancer



Surgery
Radiation
Chemotherapy
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57
Surgery (p. 474)


All surgery requires nutrition support for the healing
process
General condition of cancer patients often is
weakened by the disease process
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58
Radiation (p. 474)




Involves high-energy radiographs targeted on the
cancer site
Often kills surrounding healthy cells as well as
cancerous cells
Nutrition problems driven by site and intensity of
radiation treatment
Sense of taste may be affected, prompting efforts to
enhance food appearance and aroma
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59
Radiation (p. 474)
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60
Chemotherapy (p. 474)


Highly toxic drugs administered via the
bloodstream to kill cancer cells
Normal, healthy cells also affected



Bone marrow
Gastrointestinal
Hair loss
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61
Drug-Nutrient Interactions
(p. 475)



Use of monoamine oxidase inhibitors (pretreatment
antidepressant drugs) requires tyramine-restricted
diet
Antineoplastic drugs have drug-nutrient interactions
Some patients use herbs to prevent or treat cancer,
can have food-drug interactions
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62
Medical Nutrition Therapy in the
Patient with Cancer (p. 475)

General systemic effects of cancer




Anorexia, loss of appetite
Increased metabolism
Negative nitrogen balance
Specific effects related to cancer

Depending on location and nature of tumor
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63
Basic Objectives of Nutrition Plan
(p. 477)

Nutrition screening and assessment


Primary responsibility of clinical dietitian
Other members of health care team may take part
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64
Basic Objectives of Nutrition Plan
(cont’d) (p. 477)

Nutrition intervention




Prevent weight loss
Maintain lean body mass
Prevent unintentional weight gain
Identify and manage treatment-related side effects
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65
Prevention of Catabolism
(p. 477)


MNT to meet increased metabolic demands
of disease process
Medications used to:

Increase appetite
 Reduce nausea
 Prevent protein degradation
 Increase caloric intake
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66
Relief of Symptoms (p. 477)





Stress management
Pain management
Relaxation techniques
Psychological support
Physical activities
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67
Nutrition Monitoring and
Evaluation (p. 478)



Dietitian develops customized MNT plan for patient
Plan is evaluated regularly with patient and family
Plan adjusted as needed
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68
Medical Nutrition Therapy
(p. 478)




Energy: cancer places great metabolic demands
Protein: essential amino acids and nitrogen for
rebuilding
Vitamins and minerals: at least to DRI standards
Fluid: to replace losses, remove waste products,
meet drug needs
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69
Nutrition Management (p. 479)

Enteral: oral diet with supplementation



Preferred route
Adjust to maximize palatability
Maximize energy and nutrient density
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70
Enteral: Oral Diet with
Supplementation (p. 479)

Loss of appetite



Major issue with cancer
Can lead to cachexia
Requires vigorous program of eating that does not
depend on appetite
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71
Enteral: Oral Diet with
Supplementation (cont’d) (p. 482)

Oral complications




Ensure basic mouth care
Frequent small snacks rather than traditional
meals
Strong seasonings, high-protein drinks
GI problems



Avoid hot, sweet, fatty, spicy foods as needed
Small, frequent feedings of soft to liquid foods
Antinausea drugs
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72
Pain and Discomfort (p. 482)

Pain and discomfort



Severe pain controlled and comfortable position
Pain medication as needed
Preventive therapy to avoid constipation
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73
Enteral: Tube Feeding (p. 483)

When gastrointestinal tract can be used but
patient is unable to eat


Indications include inadequate oral intake, oral
route contraindicated, comatose
Some patients can be fed overnight, allowing them
to be free from tube during day
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74
Parenteral Feeding (p. 483)



When gastrointestinal tract cannot be used
Peripheral vein feeding (for brief period)
Central vein feeding (for extended period)
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75
Cancer Prevention (p. 483)

American Cancer Society, World Cancer
Research Fund, American Institute for Cancer
Prevention

Be as lean as possible within normal range
 Adopt a physically active lifestyle
 Consume a healthy diet
 Limit alcohol consumption
 Do not rely on supplements
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76
Cancer Prevention (cont’d)
(p. 484)

U.S. Food and Drug Administration claims approved
for labels




Low total fat may reduce risk of some cancers
Fiber-containing grain products, fruits and vegetables may
reduce risk of some types of cancer
Fruits and vegetables may reduce risk of some types of
cancer
Ongoing cancer research: foods that may increase or
reduce risk of:




Breast cancer
Gastric cancer
Colorectal cancer
Prostate cancer
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