Cancer
Cancer is a group of more than 200 diseases characterized by uncontrolled and unregulated growth of cells.
It is a major health problem that occurs in people of all ethnicities.
Classification of Cancer:
Continuous, indiscriminate, proliferates continuous
Prevention
Elimination of predisposing risk factors reduces the incidence of cancer and increases the survival of patients who have cancer.
Early detection and prompt treatment are directly responsible for increased survival rates in patients with cancer.
Prevention
Diagnostics
Diagnostic studies to be performed will depend on the suspected primary or metastatic sites of cancer.
Examples of studies include;
Cytology studies (pap smear, bronchial washings.
Tissue biopsy
Complete blood count, chemistry profile
Sigmoidoscopy or col
Biopsy
The biopsy procedure is the only definitive means of diagnosing cancer, and is essential in planning a treatment regimen for the patient.
It involves the surgical acquisition of tissue from the suspicious area for histologic exam by a pathologist.
A biops
Needle biopsies
are performed to sample suspicious masses that are easily accessible, such as some growths in the breast, lung, liver, and kidney
Needle biopsies are fast, relatively inexpensive, and easy to perform and usually require only local anesthesia
In general, t
Needle aspiration biopsy
involves aspirating tissue fragments through a needle guided into an area suspected of bearing disease.
Large core biopsy cutting needles will deliver an actual piece of tissue (core) that can be analyzed with the advantage of preserving the histologic ar
Excisional biopsy
biopsy involves the surgical removal of the entire lesion, lymph node, nodule, or mass; therefore its therapeutic as well as diagnostic.
is most frequently used for easily accessible tumors of the skin, breast, upper and lower gastrointestinal tract, and
Incisional biopsy
biopsy is performed if the excisional biopsy is not feasible.
An incisional biopsy is a partial excision, and is usually performed with a scalpel or dermal punch.
biopsy is performed if the tumor mass is too large to be removed.
In this case, a wedge of t
The goal of cancer treatment is
Cure
Control
Palliation
Factors that determine the therapeutic approach are;
Cell type
Location
Size
Systemic extent of the disease
The treatment options offered to cancer patients should be based on realistic and achievable goals for each specific type o
Multiple modalities are commonly used in cancer treatment
A variety of approaches, including surgery, radiation, chemotherapy, and targeted therapies, may be used at various times throughout treatment.
Surgical removal of the entire cancer remains the ideal and most frequently used treatment method.
The specific
Recent developments in the ability to identify genetic markers
indicative of a predisposition to develop some types of cancer may play a role in decisions concerning prophylactic surgeries.
Because of the long term physiologic and psychological effects are unknown, prophylactic surgery is offered selectively to patie
When cure is not possible
the goals of treatment are to make the patient as comfortable as possible and to promote a satisfying and productive life for as along as possible.
Whether the period extremely brief or lengthy, the major goal is a high quality of life�with quality define
Palliative surgery
is performed in an attempt to relieve complications of cancer, such as ulcerations, obstructions, hemorrhage, pain, and malignant effusions.
Colon cancer
Honest and informative communication with the patient and family about the goal of surgery is essenti
Reconstructive surgery
may follow curative or radical surgery and is carried out in an attempt to improve function or obtain a more desirable cosmetic effect.
may be indicated for breast, head and neck, and skin cancers
Postoperative nursing care of cancer patients requires spe
Chemotherapy
Chemotherapy is now the mainstay of cancer therapy used in the treatment of most solid tumors and hematologic malignancies (leukemia's, lymphomas, myeloma, and myelodysplastic syndromes).
The goal of chemotherapy is to eliminate or reduce the number of ma
The effect of chemotherapy
is at the cellular level.
All cells (cancer and normal cells) enter the cell cycle for replication and proliferation.
The effects of chemotherapeutic agents are described in relation to the cell cycle.
The two major categories of chemotherapeutic drugs ar
specific guidelines for administration of chemotherapeutic drugs
It is very important to know
It also important to understand that drugs may pose an occupational hazard to health care professionals who do not follow safe handling guidelines.
There may be some risk in handling the body fluids and excretions of persons r
The route of administration Chemotherapy
usually depends on the type of agent, the required dose, and the type, location, and extent of tumor being treated
Dosage of antineoplastic agents
is based primarily on the patients total body surface area, previous response to chemotherapy or radiation therapy, and function of major organ systems.
Special care must be taken whenever intravenous vesicant agents are administered.
Vesicants
are those agents that, if deposited into the subcutaneous tissue (extravasation), cause tissue necrosis and damage to underlying tendons, nerves, and blood vessels.
Although the complete mechanism of tissue destruction is unclear, it is known that the pH
Indications of extravasation
During administration of vesicants include;
Absent blood return from the IV catheter.
Resistance to flow of IV fluid.
Swelling, pain, or redness at the site.
If extravasation is suspected, the medication administration is stopped immediately, and ice is a
To minimize risk of extravasation
Dilute in appropriate amount diluent
Select infusion site in following order of desirability: Hickman, subclavian cath, fore arm, dorsum of hand, wrist, antecubital fossa.
Insert needle into peripheral vein with one venipuncture only.
Do not obscure perip
Ommaya Reservoir
Attached to a tube that extends down into the scalp
Combined medication therapy
relies on agents of differing toxicities and with synergistic actions.
Combination drug therapy also prevents the development of drug resistant mechanisms.
When chemotherapy agents are used in combination, clients can experience an increase in toxicities.
Radiation therapy
is a local treatment for cancer.
Along with surgery, it is one of the oldest methods of cancer treatment.
Radiation is the emission and distribution of energy through space or a material medium.
The local energy in ionizing radiation and resultant generat
Two types of ionizing radiation
electromagnetic rays (x-rays and gamma rays) and particles (electrons�beta particles, protons, neutrons, and alpha particles)�can lead to tissue disruption.
The primary difference between x-rays and gamma rays is that gamma rays are emitted from a radioac
Rapidly dividing cells include
cells in the GI tract, oral mucosa, and bone marrow, they divide quickly and exhibit early acute responses to radiation.
No citrus or alcohol based things used!
Slower growing tissues and tissues at rest are relatively radioresistant (less sensitive to th
Radiation is used to treat
A carefully defined area of the body to achieve local control of disease.
As radiation only has an effect on tissues within the treatment field, it is not appropriate as an independent modality for clients with systemic disease.
You may put hydrating loti
Teletherapy
(external beam radiation) is the most common form of radiation treatment therapy.
A linear accelerator, which generates ionizing radiation from electricity and can have multiple energies, is the most commonly used machine for delivering external beam radi
Internal radiation therapy
Also called
brachytherapy
, which means close.
It consists of the implantation or insertion of radioactive materials directly into the tumor or in close proximity adjacent to the tumor.
The specific radioisotope for implantation
Is selected on the basis of its half life, which is the time it takes for half of its radioactivity to decay.
Clients with temporary implants are radioactive only during the time the source is in place.
This internal radiation can be implanted by of needl
Brachytherapy
May also be administered orally, as with the isotope iodine 131, which is used to treat thyroid carcinomas.
Intracavitary radioisotopes
Are frequently used to treat gynecologic cancers.
In these malignancies, the radioisotopes are inserted into specially positioned applicators after the position is verified by x-ray.
These radioisotopes remain in place for a prescribed period and then are
Interstitial implants
used in treating such malignancies as prostate, pancreatic, or breast cancer, may be temporary or permanent, depending on the radioisotope used.
These implants usually consist of seeds, needles, wires, or small catheters positioned to provide a local radi
Safety precautions used in caring for a patient receiving brachytherapy
Assigning the patient to a private room , posting appropriate notices about radiation safety precautions, having staff members wear dosimeter badges, making sure that pregnant staff members are not assigned to the patient, prohibit visits by children or p
Patients with seed implants
may be able to return home, radiation exposure to others is minimal.
Alterations in oral mucosa secondary to radiation therapy include
stomatitis, xerostomia (dryness of the mouth), change and loss of taste, and decreased salivation.
The entire GI mucosa may be involved, and esophageal irritation with chest pain and dysphagia may result.
Anorexia, N/V, and diarrhea may occur if the stoma
Bone marrow cells
proliferate rapidly, and if sites containing bone marrow (iliac crest, sternum) are included in the radiation field, anemia, leukopenia (decreased WBC), and platelets may result.
The patient is then at increased risk for infection and bleeding until blood
Certain systemic side effects are commonly experienced by patients receiving radiation therapy
They include fatigue, malaise, and anorexia
This syndrome may be secondary to substances released when tumor cells break down.
The effects are temporary and subside when the treatments are over.
Late effects of radiation therapy
may occur in various body tissues.
These effects are chronic, usually produce fibrotic changes due to a decreased vascular supply, and are irreversible.
These late effects can be most severe when they involve vital organs such as the heart, lungs, CNS, an
Client teaching with radiation therapy:
Wash irradiated area gently each day with water alone or mild soap; use hand rather than washcloth. Rinse soap thoroughly.
Do not remove skin markings.
Pat dry with soft towel.
Avoid powders, lotions, creams or ointments to radiation site unless recommend
Neutropenia
is most common in clients receiving chemotherapy and can place the client at serious risk for infection and sepsis.
Monitor temperature routinely.
Any sign of infection should be treated promptly as fever in the setting of neutropenia is a medical emergen
White blood cell growth factors
filgrastim (Neupogen), Pegfilgrastim (Neulasta)
are routinely used to reduce the duration of chemotherapy-induced neutropenia, and as a prophylactic measure to prevent neutropenia when highly myelosuppressive chemotherapy drugs are used.
Risk of serious bleeding
is generally not apparent until the platelet count falls below 50,000 uL.
Platelet transfusions may be necessary and are usually administered when platelet counts fall below 20,000 uL.
Normal platelet count 150,000-400,000
Nausea and vomiting
are common sequelae of chemotherapy, and in some instances radiation therapy
Give antiemetic 30 min-1 hr before chemo
Aprepitant (Emend)
is the first agent in a class of antiemetics known as neurokinin 1 receptor antagonists, and is effective in preventing nausea and vomiting on the day of chemotherapy, as well as for delayed symptoms.
Diarrhea
is a reaction of the bowel mucosa to radiation and to certain antineoplastic agents.
With pelvic radiation, treating clients with a full bladder may be done to move the small bowel out of the treatment field.
Both radiation and chemotherapy- induced diarr
Do not use
heating pads, ice packs, and hot water bottles in the treatment field.
Avoid constricting garments, harsh chemicals, and deodorants as they may traumatize the skin.
Lubricate dry skin with a nonirritating lotion emollient (such as aloe vera) that contains
Alopecia
(hair loss) associated with radiation is local whereas chemotherapy affects hair throughout the body.
Often new hair has a different color and texture than the hair that was lost.
Alopecia caused by the administration of chemotherapeutic agents is usually
Immediate pulmonary effects of radiation
can be alarming to the clients because they may mimic symptoms that precipitated the cancer diagnosis.
Cough and dyspnea may increase during and at completion of therapy.
The cough becomes more productive as alveoli that had been blocked are opened as the
Radiation to the thorax
can damage the pericardium, myocardium, valves, and coronary blood vessels.
The pericardium is the most commonly involved, with pericardial effusion or pericarditis the key problems.
The testes
are highly sensitive to radiation, and protection of the testicles with a testicular shield should be done whenever possible.
Testicular failure can result in recovery or permanent failure, depending on the dose of radiation.
There is no avenue for repair
Chemotherapy can have long term effects
related to the loss of cells' proliferative reserve capacity, including cataracts, arthralgias, endocrine alterations, renal insufficiency, hepatitis, osteoporosis, neurocognitive dysfunction, or other effects depending on the agents.
The cancer survivor
Alkylating agents and high dose radiation
are the most frequently implicated therapies.
The potential risk for developing a secondary malignancy does not contraindicate the use of cancer treatment.
Biologic therapy, or biologic response modifier therapy
consists of agents that modify the relationship between the host and the tumor by altering the biologic response of the host to the tumor cells.
Biologic agents may affect host tumor response in three ways;
They have direct antitumor effects.
They restore
Targeted therapies include
epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitors, BCR-ABL tyrosine kinase inhibitors, CD20 monoclonal antibodies (MoAb), angiogenesis inhibitors, proteasome inhibitor, and other targeted therapies.
The administration of one biologic agen
Biologic therapy Common side effects
constitutional
flu-like symptom
s; including headache, fever, chills, myalgias, malaise, weakness, photosensitivity, anorexia, and nausea.
With interferon therapy, these flu like symptoms almost invariably appear.
(Not a reason to quit treatment)
With int
Hematopoietic growth factors
are used to support cancer cleints through the treatment of the disease.
Colony stimulating factors (CSF) are a family of glycoproteins produced by various cells.
CSFs stimulate production, maturation, regulation, and activation of cells of the hematopoie
Bone marrow transplantation (BMT) and peripheral stem cell transplantation (PSCT)
are effective, lifesaving procedures for the treatment of a number of malignant and nonmalignant diseases.
BMT and PSCT allow for the safe use of very high doses of chemotherapy agents and/or radiation therapy in clients whose tumors have developed resist
The goal of HSCT
is cure.
Overall cure rates are still low but are steadily increasing.
Even when cure is not achieved, transplantation can result in a period of remission.
The approach is to eradicate diseased tumor cells and/or clear the marrow of its components to make
In allogenic transplantation stem cells
are acquired from a donor who, through human leukocyte antigen (HLA) tissue typing, has been determined to be HLA matched to the recipient.
HLA typing involves testing WBCs to identify genetically inherited antigens compatibility of transplanted tissue.
A
Syngeneic transplantation
is a type of allogenic transplant that involves obtaining stem cells from one identical twin and infusing them into the other.
In autologous transplantation
clients receive their own stem cells back following myeloablative (destroying bone marrow) chemotherapy.
The aim of autologous transplantation is purely rescue.
Restoration usually takes 4 to 6 weeks depending on the particular conditioning regimen admini
The bone marrow harvest procedure
takes about 1 to 2 hours, and the client can be discharged following recovery.
Postharvest, the donor may experience pain at the collection site that may last up to 7 days after the procedure and can be treated with mild analgesics.
The donor's body will
Umbilical cord blood
is also rich in hematopoietic stem cells, and successful allogenic transplants have been performed using this source.
A disadvantage of cord blood is the possibility of insufficient numbers of stem cells to permit transplant to adults.
Once engraftment is
Gene therapy
is an experimental therapy that involves introducing material into a person's cells to fight disease.
Infection
is a primary cause of death in the client with cancer.
Infection occurs as a result of the ulceration and necrosis caused by the tumor, compression of vital organs by the tumor, and neutropenia caused by the disease process or the treatment of cancer.
Ins
Obstructive emergencies
are primarily caused by tumor obstruction of an organ or blood vessel.
They include
superior vena cava syndrome
, spinal cord syndrome, third space syndrome and intestinal obstruction.
Superior vena cava syndrome
results from obstruction of the superior vena cava by a tumor or thrombosis.
The clinical manifestations include facial edema, periorbital edema, distention of the head, neck, and chest, headache and seizures.
A mediastinal mass is often visible on chest
Spinal cord compression
is a neurologic emergency caused by the presence of a malignant tumor in the epidural space of the spinal cord.
The most common primary tumors that produce this problem are breast, lung, prostrate, GI, and renal tumors and melanoma.
The manifestations are
Radiation therapy in conjunction with prompt initiation of corticosteroids
is generally associated with initial improvement (initial treatment).
Surgery for radioresistant tumors.
Hypercalcemia
Complications
Hypercalcemia can occur in the presence of cancer that involves metastatic disease of the bone or multiple myeloma, or when a parathyroid hormone like substance is secreted by cancer cells in the absence of bony metastasis.
Hypercalcemia res
Acute tumor lysis syndrome (TLS)
is a metabolic complication characterized by rapid release of intracellular components in response to chemotherapy.
The four hallmarks of TLS are;
Hyperuricemia
Hyperphosphatemia-
TX with calcium
Hyperkalemia
Hypocalcemia-
TX with phospherus
Two treatment
Pain
Under treatment of cancer pain is common and causes needless suffering, hampers quality of life, and increases the burden on family caregivers.
Inadequate pain assessment is the single greatest barrier to effective pain management.
Data such as vital sign