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Med/Surg-2015 CANCER CANCER Oncology is the specialty dealing with cancer and treatment CANCER DEVELOPMENT Characterized by growth of cells that do not have normal cellular function and may occur in any tissue Can occur at any age, however there are some cancers that only affect a certain age group Tumors/neoplasms-Arise from normal tissue BENIGN Benign tumors have slower growth, they are encapsulated, composed of differential cells, and they don’t metastasize MALIGNANT Malignant tumors invade surrounding tissue These tumors have rapid growth and replication, non-encapsulated which allows them to invade, made up of anaplastic cells that do not function like normal cells from where they originate, malignant tumors send abnormal cells to other sites via the blood or lymphatic system Secondary sites will also eventually grow into malignant tumors TYPES OF TUMORS Histology-study of tissue Carcinomas-largest Make up about 90% of malignancies Develop from epithelial tissue (skin, GI sx, urinary sx, repro organs, and glands)* Sarcomas >5% of malignant tumors Arise from connective tissues (cartilage, bone, muscle, fat, bone marrow and lymphatic system) includes gliomas and neuroblastomas of the brain, Ewing’s sarcoma-affects diaphysis with mets to lung ages 4-25 Dx: CT scan Tx: chemo/radiation TYPES OF TUMORS Leukemia Blastoma Originates in bone marrow Malignant tumors of immature or embryonic tissue Mixed-Tissue Tumor Less common Develop from epithelial and connective tissues; Wilm’s tumor CARCINOGENESIS AND CARCINOGENS Carcinogenesis-transformation of normal cell into malignant cell Disruption occurs with DNA replication during mitosis The new protein production is damaged, resulting in growth of cancerous cells RNA then sends messages to develop more abnormal proteins Carcinogens-cause damage to DNA that leads to development of cancer Box 83-1** Laryngeal cancer-from cigarettes and ETOH* 80% of cancers d/t smoking, diet, ETOH and environmental factors such as radiation, chemicals DNA can carry an oncogene (cancer-causing gene) which is activated by mutation Heredity may transfer defective DNA through sperm or egg cells CANCER GRADING AND STAGING Primary site is the place where the cancer starts Cancer in situ refers to tumor cells that have not invaded surrounding tissue Evidence of metastasis to distant or secondary sites Grading is a system that looks at abnormal cells under a microscope to determine the cells’ degree of differentiation or lack of maturity CANCER GRADING Grade I-resemble normal cells, better prognosis Grade II or III-intermediate phases of differentiation, cells could be slightly to extremely abnormal Grade IV or V-anaplastic tumor, little to no resemblance to the tissue cells from which they develop STAGING Identifies the spread of a tumor** Box 83-3* The tumor, node, and metastasis system is called the TNM system of staging. Tumor size Local invasiveness Extent of lymph node involvement Each category uses a range from 0-4 or AD A tumor T3N4M1 is a large tumor, with node involvement and metastasis* A tumor T1N0M0 is small without node involvement or metastasis* INCIDENCE Cancer is second only to heart disease as the major cause of adult deaths in the United States. All cancers result from a mutation of genes that causes malfunction of cell growth and division. Occurrence increases as an individual ages. Leading causes of cancer deaths: lung cancer (both men and women)**, breast cancer, prostate cancer, colorectal cancer PREVENTION AND EARLY DETECTION Reduce smoking, intake of total dietary fats and calories Decrease total sun exposure Avoid artificial sources of ultraviolet light Perform self-examination for early detection of breast or prostate cancers Maintain routine and consistent exercise Improve screening rates for breast, prostate, colorectal cancer Improve educational strategies related to tobacco cessation and diet SEE WARNING SIGNALS FOR CANCER “CAUTION” CANCER SCREENING GUIDELINES Box 83-2 Breast Cancer Women with increased family risk should start mammograms/ultrasounds earlier BSE by ACS recommends an up and down vertical pattern** May be placed on doxorubicin hcl Side effects include: left ventricular failure, complete alopecia 3-4 weeks, red discoloration of urine** *Myelosuppression may occur: teach patient to avoid those who have recently been vaccinated or crowded areas, activities that may cause bleeding, wash hands TYPES OF MASTECTOMIES Simple or total mastectomy: removal of the breast, with its skin and nipple, but no lymph nodes. In some cases, a separate sentinel node biopsy (sentinel node is the first node to receive drainage from a cancer containing area of the breast) is performed to remove only the first one to three axillary (armpit) lymph nodes. Modified radical mastectomy; This procedure is a simple mastectomy and removal of axillary (underarm) lymph nodes Radical mastectomy:the entire breast, axillary lymph nodes, and the pectoral (chest wall) muscles under the breast. Imaginis Corporation (2008). Mastectomy. Retrieved on January 9, 2009 from http://www.imaginis.com/breasthealth/sentinelnode.asp MASTECTOMY Possible side effects: As with other operations, pain, swelling, bleeding, and infection are possible. The main possible long-term effect of removing axillary lymph nodes is lymphedema (swelling of the arm). This occurs because any excess fluid in the arms normally travels back into the bloodstream through the lymphatic system. Removing the lymph nodes sometimes causes this fluid to remain and build up in the arm. American Cancer Society. (2008). Surgery for breast cancer. Retrieved January 9, 2009 from http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_Surgery_5.asp?sitearea= LYMPHEDEMA Immediately after surgery, the affected arm or breast area may swell. This swelling is usually temporary and gradually disappears over the next 6 to 12 weeks Avoiding Infection: Whenever possible, have your blood drawn, IVs, and injections given in your unaffected arm. Keep your arm clean If necessary, use an insect repellent when outdoors to avoid bug bites. If you get stung by a bee in the affected arm, clean and elevate the arm, apply ice, and contact your doctor or nurse if it becomes infected American Cancer Society. (2007). Lymphedema: What every woman with breast cancer should know. Retrieved January 9, 2009 from http://www.cancer.org/docroot/MIT/content/MIT_7_2x_Lymphedema_and_Breast_Cancer.asp CANCER SCREENING GUIDELINES Colorectal cancer Start early or performed more frequently if they have Crohn’s disease or inflammatory bowel disease Cervical Cancer Age 21 or about 3 years after they begin having vaginal intercourse-have a regular pap test Age 30, should have a pap test q 2-3 years if they have had 3 normal Pap tests in a row Over 30, screened for PAP plus the HPV test Post-menopausal, painless vaginal bleeding could be a sign of uterine cancer** FEMALE REPRODUCTIVE CANCERS Endometrial Cancer report any unexpected bleeding or spotting post menopausal** Ovarian cancer s/s-pelvic pain radiating to the thighs Stages on next slide OVARIAN CANCER STAGES Stage I-The cancer is only within the ovary (or ovaries) or fallopian tube(s). It has not spread to organs and tissues in the abdomen or pelvis, lymph nodes, or to distant sites. *Stage II-The cancer is in one or both ovaries or fallopian tubes and has spread to other organs (such as the uterus, fallopian tubes, bladder, the sigmoid colon, or the rectum) within the pelvis. It has not spread to lymph nodes or distant sites. (American Cancer Society, 2015) OVARIAN CANCER STAGES Stage III-The cancer is in one or both ovaries or fallopian tubes, and one or both of the following are present:has spread beyond the pelvis to the lining of the abdomenhas spread to lymph nodes in the back of the abdomen (retroperitoneal lymph nodes) Stage IV (any T, any N, M1)This is the most advanced stage of ovarian cancer. In this stage the cancer has spread to the inside of the spleen, liver, lungs, or other organs located outside the peritoneal cavity. (American Cancer Society, 2015) DIAGNOSTIC TEST Cytology-study of cells Cytologic examination is done on Sputum, bronchial washings, vaginal and cervical secretions, prostatic secretions, pleural secretions, and gastric washings Used most often to detect cervical cancer Pap test LABORATORY TESTS Tumor markers-specific enzymes, cancer antigens that can indicate malignancies Found in blood (enzymes, antigens, hormones, misc. markers) EX. –Philadelphia chromosome-CML* Ex-PSA-prostate cancer* Useful to monitor tumor response to treatment Detect cancer recurrences Additional test may be needed: x-rays, CT, MRI and ultrasound. NONINVASIVE DIAGNOSTIC PROCEDURES Radiology – Visualize body’s internal structures Mammograms – detect abnormal cellular growth in the breast CT scan-sectional views of body structures, useful for tumors of the chest, brain, and abdominal cavity Ultrasonography – uses sound waves to specific tissues, useful for pelvic, retroperitoneal and peritoneal tumors MRI – detailed sectional images of the body without ionizing radiation, can stage malignant disease in the CNS, spine, head, neck, muscular system. Bone Scan INVASIVE DIAGNOSTIC TECHNIQUES Endoscopy Exploratory surgery and biopsy Biopsy is the single most important to test Dx cancer MOST ACCURATE!! Lymph node biopsy may be done to see if CA has metastasized!!** Frozen section – during biopsy, specimen is removed and the tissue is frozen and sliced thin, pathologist studies the specimen and reports results TREATMENT MODALITIES Surgery Ideal treatment: complete removal of malignant tissues Incisional tissue biopsy-helps with Dx and staging Excisional biopsy – removes tumor and a small margin around the tumor Cryosurgery – malignant tissues are spread Electrocauterization-burned SURGERY Fulguration – destroyed by high-frequency current En bloc resection – removal of the tumor, surrounding tissues and lymph nodes Exenteration – removal of tumor, organ involved and surrounding tissue SURGERY Laser surgery – excise areas of tumors Laser induced interstitial thermotherapy (LITT) – shrinks or destroys tumor with hear; can be curative or palliative Photodynamic therapy (PDT) – chemical introduced into body and remains in or around the tumor cell vs. normal cells; used mainly on tumors under that skin or lining the internal organs that can be reached be fiberoptic instruments or endoscope. The client must remain indoors out of the sun for 6 weeks after therapy SURGERY Prophylactic surgery – used for tumors that are known or suspected to be precancerous Palliative surgery – performed to relieve some of the complications of malignancies; goal is to promote client comfort and quality of life. Bone Marrow Transplant (BMT) – replaces stem cells that develop into blood cells. Obtained from the hip or sternum using small incisions and large bore needles. Autologous – from client Syngeneic – twin Allogeneic – another person BONE MARROW/STEM CELL TRANSPLANT Autologous-self Syngeneic-twin Allogeneic –other person Donated bone marrow is matched to the client’s tissuehuman leukocyte-associated antigen (HLA) on the surface of WBC’s Stem cells (immature cells) are found in peripheral blood, umbilical cord blood, amniotic fluid and peripheral blood stem cells Peripherally obtained by aphaeresis-removal through a large vein and sent to special collection filters in a machine where they are harvested and frozen until needed BONE MARROW/STEM CELL TRANSPLANT Client will receive the donated bone marrow after chemo/radiation. Successful transplants can offer full recovery in 6-12 months Risk of GVH RXN from donor marrow – Donated marrow attacks tissues like liver, skin, GI tract observe for development of skin rash Drugs are given to suppress this reaction CHEMOTHERAPY Goal of Chemo – cure or provide palliation if cancer is not curable Chemotherapy – using chemical agents to destroy cancer cells; goal is to damage the DNA in these abnormal cells and cause apoptosis (Self-destruction) Can destroy normal cells* Tx indications: Widespread or metastic disease Provide cure for certain types of cancer *Temporarily control tumor-related difficulties; not a cure Adjuvant (assistive) therapy after surgery to prevent metastasis from occurring **Palliative chemo-prolongs life and reduces incapacitating sx’s CHEMOTHERAPEUTIC AGENTS Alkylating agents Antibiotics Antimetabolites Antimitotics Hormonal agents Are caustic substances and if they infiltrate will cause extravasation. If this occurs: **Stop medication, follow facilty policy, notify MD, implement MD orders, document all s/s, and monitor client closely CHEMOTHERAPEUTIC AGENTS Actions: Affect cells that rapidly proliferate Malignant neoplasms or cancerous tumors usually consist of rapidly proliferating cells Cancer cells have no biological feedback controls that stop their aberrant growth or proliferation Cancer cells are sensitive to antineoplastic drugs when the cells are in the process of growing or dividing Chemo is administered at the time the cell population is dividing to optimize cell death ACTIONS CONT…. Chemo is administered in cycles to allow recovery of the normal cells and to destroy malignant cells Cell kill theory: 90% of the cancer cells should be killed during the first course of treatment, second course of tx targets the remaining cells and reduces these cells by 90%, continued courses of chemo reduces the # of cancer cells until all cells are killed Every cancerous cell must be killed to be cured; requiring repeated chemo courses BIOTHERAPY (IMMUNOTHERAPY) uses the body’s defenses against tumor cells Biologic response modifiers (BRM)-produced by normal cells to repair, stimulate, or enhance substances in the immune system to hopefully kill cancer cells BIOTHERAPY CSF-part of hematopoietic growth factors that encourage growth and maturation of blood cell components If successful, myelosuppression is reduced and the client can receive higher doses of chemotherapy agents BIOTHERAPY • • • • BRM’s produced in a lab include: Monoclonal antibodies, Interferons, Colony-stimulating factors, Interleukins, Retinoids MOAB-produced by fusing cancer cells and normal cells Specific antibodies to seek out and bind to specific targets on cancer cells Able to improve immune response to cancer and interfere with normal cells Currently used for renal transplant rejections **Nursing Interventions: monitor for anaphylactic reactions (MOAB’s), flushing, pallor, resp. distress,chills, fever, diaphoresis, urticaria, n/v, hypotension BIOTHERAPY Interferons-made by lymphocytes to enhance immune system 3 types: alpha, beta and gamma protect normal cells from parasitic invasion or viruses appear to induce antitumor activity Nursing interventions: teach side effects of flu-like such as fever, fatigue, chills, h/a, myalgia HEMATOPOIETIC GROWTH FACTORS Consist of substances that have the ability to support tissues that are involved in the production of blood, bone marrow and lymph nodes 3 main groups CSF Interleukin 3 erythropoietin INTERLEUKINS Promote immune response of the T lymphocytes to stimulate the immune system to destroy neoplasms BIOTHERAPY Retinoids-derived from retinol or vitamin A Effect of retinoids -antibody and immune responses to suppress proliferation Retinoic acid syndrome-side effect; s/s: respiratory distress, pleural effusions, weight gain NURSING CONSIDERATIONS FOR CLIENTS WITH CANCER Diagnostic procedures and treatments can be uncomfortable to intolerable Will need support after treatment d/t side effects, especially depression Preop and postop teaching Allow clients to participate in their treatment CHEMOTHERAPY Nurses need special training to administer and monitor for side effects Safe handling procedures, drugs extremely toxic Some can be administered orally Parenteral chemo must take special precautionssee book!! Chemo induces vomiting by stimulating neuroreceptors in the medulla Anticipatory n/v may occur before chemo* CHEMOTHERAPY ADMINISTRATION Oral, IM, intracavitary, IV, intraperitoneal, intra-arterial, intrapleural, topical Intra-arterially access usually requires vascular access devices such as PIC, PICC, central venous access device, external catheters, infusion pump **Maybe infused intermittently to enhance the kill rate of cancer cells **Chemo does not differentiate between normal and abnormal cells RADIATION THERAPY May be used as primary therapy, combined with chemo, or palliative tx Reduces tumor size* Directs ionizing radiation to target tissues for damage or destruction of the cells *Kills cells by preventing their ability to reproduce Radiation does damage normal and abnormal cells 3 types of rays involved alpha and beta penetrate the upper layer of the skin gamma penetrate deeply into body tissues RADIATION THERAPY Safety when dealing with radiation: TIME, DISTANCE, AND SHIELDING Employees in radiation dept. must wear special badges that monitor radiation exposure RADIATION THERAPY 2 main types of radiation: using an internal or external radiation beam External-given by machines called linear acceleratorsradiation aimed at cancer but most pass through normal cells monitor side effects-decreased appetite, abd. Cramping, diarrhea and cutaneous irritation , nausea, dysphagia, bone marrow suppression** Nursing Care-aimed at ensuring client and staff safety, keeping healthy cells from hazards Do Not wipe off ink marks!! Avoid using creams and powders on irradiated skin (increases irritation) use only tepid water *if skin is red and warm 2 weeks after tx-notify MD!! RADIATION THERAPY Internal Radiation placing radioactive substances directly into a tumor delivers large amounts of radiation to destroy cancer cells within radioactive sources are encapsulated so as not to contaminate body fluids treat areas such as brain, tongue, breast, vagina, rectum, prostate, etc. RADIATION THERAPY Explain procedure Area treated will not feel hot, notify MD if you observe this Radioactive iodine may be given for thyroid cancer-body fluids will be radioactive for a short time Teach side effects Teach care of skin: Box 83-1 in book pg. 1385 MANAGEMENT OF SIDE EFFECTS N/V Some clients will postpone or forego treatments Antiemetics Guided imagery distraction Massage MANAGE SIDE EFFECTS Stomatitis or mucositis common Avoid ETOH or foods that cause irritation Avoid flossing or using ETOH containing products Rinse mouth after eating and at bedtime *use soft brush when cleaning the teeth and rinse the mouth thoroughly after meals and at bedtime MD may order a swish and swallow preparation-do so in small amounts, the mixture will anesthetize the throat and may cause difficulty in swallowing, talking or even breathing* MANAGE SIDE EFFECTS Fatigue After pain, the second most distressing symptom reported* *due assess to chemo decreasing RBC’s nutrition, rest, work, psychological distress, you should increase fluids and seek medical management MANAGE SIDE EFFECTS Alopecia can occur in eyelashes, eyebrows, pubic and body hair Affects all frequently dividing cells (including cells of the hair follicles in addition to cancerous cells)* encourage wigs, purchase prior to losing hair (can obtain similar color to hair and style) avoid harsh chemicals use mild shampoos monitor for emotional side effects MANAGE SIDE EFFECTS Secondary Infections WBC count is depressed (neutropenic isolation) Teach to avoid activities that could injure Don’t take rectal temps, allow use of razor blades, etc. Avoid persons and places with increased risk for infection! WASH HANDS-STAFF AND VISITORS!! MANAGE SIDE EFFECTS Pain R/T disease, treatment or procedures Monitor pain level!!! Give round the clock pain meds Prevent, rather than tx pain!! MANAGE SIDE EFFECTS Stress Use therapeutic visualization or guided imagery Provide diversional activities MANAGE SIDE EFFECTS Hormone-Related Effects Women who take tamoxifen for breast cancer may experience menopause like sx’samenorrhea, hot flashes, insomnia and depression* Tx: herbal products (check with MD first), clonidine, or other combo drugs could be useful NUTRITIONAL NEEDS Cancer can deplete proteins cachexia **Diet needs to be high in protein, CHO and vitamins Monitor for taste changes, supplements may be needed Alternate forms of fluids, such as popsicles, or foods such as liquid supplements can be helpful* Recommend drinking fluids after meals* Assess for cultural dietary practices CLIENT AND FAMILY TEACHING Self-exams Sign Can be seen by someone else Symptom Noticed by the client like fatigue, nausea, malaise If a patient is going to receive Hospice care The focus is on controlling the symptoms and relieving pain, uses a multidisciplinary approach, and bereavement care is provided to the family** *should have advance directives in place HODGKIN’S DISEASE Most common cancer in young adults More common in men First recognized in 1832 Etiology: viral infections, suppressed immune functions HODGKIN’S DISEASE A&P review Lymph nodes produce and store lymphocytes (2 types) B lymphocytes-protect body from invading germs by changing into plasma cells, then produce antibodies which mark germs for destruction T lymphocytes-destroy infected bacteria or assist immune system to perform their job better Lymph nodes are connected by lymph vessels HODGKIN’S DISEASE Hodgkin’s disease can start anywhere, but usually occurs in the upper chest, neck or axilla S/S-enlarged lymph nodes, low-grade fever, fatigue, night sweats, generalized pruritis Dx-biopsy revealing Reed-Sternberg cells (abnormal B lymphocyte) BOTH TYPES ARE MALIGNANT BECAUSE THEY GROW AND COMPRESS VITAL ORGANS Treatment: Radiation Chemo Combination monoclonal antibodies High-dose chemo and stem cell transplant (American Cancer Society, 2015) NON-HODGKIN’S LYMPHOMA (NHL) There are many different types of nonHodgkin lymphoma. These types can be divided into aggressive (fast-growing) and indolent (slow-growing) types, and they can be formed from either B-cells or T-cells. B-cell non-Hodgkin lymphomas include Burkitt lymphoma, chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), diffuse large B-cell lymphoma, follicular lymphoma, immunoblastic large cell lymphoma, precursor Blymphoblastic lymphoma, and mantle cell lymphoma. (National Cancer Institute) NON-HODGKIN’S LYMPHOMA (NHL) S/S: painless, enlarged single lymph node in the neck, abdominal discomfort, back pain, GI c/o resulting from lymph node involvement TX OF NON-HODGKIN’S LYMPHOMA Chemo Immunotherapy Targeted therapy (newer class of drugs that target these cells that cause cancer) Radiation peripheral stem cell transplant may be used LEUKEMIA Abundance of abnormal WBC’s acute Immature cells proliferate and accumulate in a persons bone marrow Chronic Mature cells become diseased Depends on which line is affected: lymphoid or myeloid · ACUTE LYMPHOCYTIC LEUKEMIA Acute develops quickly Starts in WBC’ in bone marrow and moves quickly to blood Develops from B or T lymphocytes “acute” means that the leukemia can progress quickly If left untreated, may probably be fatal within a few months. ACUTE MYELOID/MYELOGENOUS LEUKEMIA AML starts in the bone marrow quickly moves into the blood can sometimes spread to other parts of the body including the lymph nodes, liver, spleen, central nervous system (brain and spinal cord), and testicles s/s-wt. loss, fever, unusual bleeding from a minor cut* Tx-chemo, stem cell transplant, surgery, radiation* CHRONIC LYMPHOCYTIC LEUKEMIA the cells can mature partly but not completely, may look fairly normal, but they are not. do not fight infection as well as normal white blood cells do leukemia cells survive longer than normal cells, and build up, crowding out normal cells in the bone marrow Mainly affects older adults TX: ALL chemotherapy Targeted therapy Stem cell transplant Steroids (may have increase wt. gain*) CLL chemotherapy Targeted therapy Monoclonal antibodies Stem cell transplant (American Cancer Society, 2015) VARIOUS TYPES OF CANCER/TREATMENTS Laryngeal cancer Causes: smoking cigarettes and consuming large amounts of ETOH, among other reasons TX: laryngectomy, radiation on neck-side effect of this is dry desquamation of the skin* Monitor for xerostomia, stomatitis, dysgeusia (altered sense of taste) VARIOUS TYPES OF CANCER/TREATMENTS Thyroid cancer Causes: smoking, family history/heredity, gender (women) TX-surgery, chemo, radiation, targeted therapy Radioactive iodine Teach that the urine and saliva will be radioactive for a short period of time* VARIOUS TYPES OF CANCER/TREATMENTS Lung cancer One possible treatment is pneumonectomy Others Chest include radiation and chemo tube may be inserted on the side of the pneumonectomy to aid in blood removal (blood can ooze into empty space where lung was) VARIOUS TYPES OF CANCER/TREATMENTS Colon cancer Removal of part of the colon (colostomy) Tx: surgery, chemo (5-FU), radiation. Side effects may need to be tolerated** **Patient teaching: 1. TCDB 2. Leg ROM, early ambulation 3. Arrange for enterostomal therapist (ET) to assist with colostomy care 4. Encourage expression of feelings about changes in body image
