Objectives: Relate the incidence of cancer and determine the role of nurses in the prevention and early detection of cancer. Differentiate between benign and malignant neoplasms. Identify factors which may contribute to the development of cancer. Explain local and systemic effects of cancer.
Objectives cont. Review the latest American Cancer Society statistics. Identify some specific chemotherapeutic agents. Summarize the socio-cultural considerations of caring for clients with cancer.
Epidemiology Affects every age group Leading causes of cancer Most occur in people in men: lung, prostate, over age 65 colorectal More than 1.2 million Leading causes of cancer Americans are diagnosed in women: lung, breast, each year colorectal More than 560,000 deaths/yr in USA
True or FalseThe risk of dying from cancer in the US is increasing.
Pathophysiology of theMalignant Process CANCER is a disease process that begins when an abnormal cell is transformed by the gentic mutation of the cellular DNA. This begins to proliferate abnormally invading tissues,lymph & blood vessels which carry the cells to other areas of the body. This is called METASTASIS.
Characteristics of Benign and Malignant Neoplasms(Refer to Table 23-1 on page 402) Benign Malignant Cell Characteristics Mode of Growth Rate of Growth Metastasis General Effects
Cancer Development (MalignantTransformation) Initiation Promotion Progression Metastasis Extension into surrounding tissues Penetration into blood vessels Release of tumor cells Invasion of tissue
Metastatic Mechanisms Local Seeding Bloodborne Metastasis Lymphatic Spread
Etiology Chemical Agents Physical Agents Viruses Dietary Factors Immune function Genetic and Familial Factors Age Genetic Risk
True or FalseRegularly eating meat cooked on a charcoal grill won’t increase you risk for cancer
True or FalseYou can prevent skin cancer by putting on one application of sunscreen at the start of each day.
True or FalseHousehold bug spray can cause cancer
True or FalseLiving in a polluted city is a greater risk for lung cancer than smoking a pack of cigarettes a day
True or FalseSome injuries can cause cancer later in life.
True or FalseElectronic devices, like cell phones, can cause cancer in the people who use them.
True or FalseWhat someone does as a young adult has little impact on his or her chances of getting cancer later in life.
Cancer Assessment Considerations See chart 23-9 p. 405 C hange in bowel or bladder habits A sore that does not heal U nusual bleeding or discharge T hickening or lump in breast or other part of body I ndigestion or difficulty in swallowing O bvious change in wart or mole N agging cough or hoarseness
Detection and Prevention ofCancer Primary Prevention: Nurses play a key role in cancer prevention Avoidance of Known carcinogens Modification of associated factors Removal of “at risk” tissues Chemoprevention
Detection and Prevention ofCancer Secondary Prevention: Promotion of cancer screenings Gene therapy for cancer prevention
Stages of Cancer Cell Invasion In situ – noninvasive neoplasm Localized – invasive neoplasm confined to the organ of origin Regional – invasive neoplasm that extends into surrounding tissue Distant – a neoplasm that spreads to distant parts of the body
STAGING: Determines the size of the tumorand the existence of metastasis. TNM system; T = extent of primary tumor N = lymph node involvement M = extent of metastasisGRADING: Classification of tumor cellsobtained through cytology (biopsy). I to IV: I = Closely resemble tissue of origin IV = Poorly differentiated (more aggressive and less responsive to treatment)
Question 1What are the odds of a man dying fromcancer in the U.S.?A. 1 in 2B. 1 in 4C. 1 in 25D. 1 in 50
Question 2What race has the highest incidence ofcancer?A. African AmericanB. Hispanic/LatinoC. AsianD. Caucasian
Question 3An example of a primary preventionstrategy for reducing cancer risk would be:A. Yearly mammography for women older than 40 yearsB. Regular physical exerciseC. Colonoscopy at age 50 years and then every 10 yearsD. Avoiding red meat in the diet
Cancer Therapy Goals andResponsePrevention NeoadjuvantCure Chemo-Control preventionPalliation MyeloablationAdjuvant Immuno- suppression p. 17
Management of Cancer Surgery Diagnostic Primary Treatment Prophylactic Palliative Second-look Reconstructive or rehabilitation
True or FalseTreating cancer with surgery causes it to spread throughout the body.
Treatment Strategies Combination versus single-agent therapy Dose or dose intensity of chemotherapy p. 18 Hormone receptor status
Radiation Therapy (See charts on p. 420) Ionizing Control malignant disease Palliative External (teletherapy) Internal (brachytherapy) Dosage Toxicity Skin Mucous membranes Bone marrow
Best Practice for Patient Safety& quality Care andpatient/family education See page 417
Chemotherapy Antineoplastic agents used to kill tumor cells by interfering with cellular functions and reproduction Used primarily to treat systemic disease Goals: Cure Control Palliation
Cell Cycle G1 phase - RNA and G2 protein synthesis S phase - DNA synthesis G2 phase - M S premitotic; DNA synthesis complete Mitosis - cell division occurs Go phase - Rest G1 Go
Antimetabolites Incorporate into the normal cell constituents making them nonfunctional Inhibit the normal function of a key enzyme Acts in S phase; inhibits production for DNA synthesis. Leading to strand breaks of premature chain termination
Nitrogen Mustards Disrupts normal nucleic acid function in DNA and RNA to inhibit reproduction chlorambucil (Leukeran) estramustine (Emcyt) mechlorethamine (Mustargen) melphalan (Alkeran) thiotepa
Cytoprotective (Rescue) Agents Administered to reduce side effects and toxicity of chemotherapeutic agents Chemotherapy agent must be active long enough to kill malignant cells Then the rescue agent is given to prevent destruction of healthy cells amifostine (Ethyol) dexrazoxane (Zinecard) leucovorin
Routes of Administration Oral Subcutaneous or intramuscular Itra-arterial Intrathecally Intraperitoneal Intrapleural Intravesicular Intravenous p. 95
Vesicants Agents that cause extravasation if deposited into subq tissue Vesicants are: Dactinomycin Daunorubicin Adriamycin Nitrogen mustard Mitomycin Vinblastine Vincristine Vindesine
Indications of Extravasation Absence of blood return from the IV Flow is resistant Swelling, pain, or redness at site Venous access device • Referred to as VAD • Inserted to promote safety while administering vesicants • Complications: infection, thrombosis
S/S associated with vesicant extravasation,irritation and flare reaction Pain Redness Swelling Blood return Ulceration p. 107
• Cardiopulmonary – Daunorubicin, Doxorubicin may cause irreversible cardiac toxicities – Bleomycin, BCNU, Busulfan cause lung toxicities (pulmonary fibrosis)• Reproductive – possible sterility• Neurological – Vincristine can cause peripheral neuropathy, loss of deep tendon reflexes, paralytic ileus – Cisplatin can cause peripheral neuropathy and hearing loss • Fatigue
GENERAL SIDE EFFECTS OF CHEMOTHERAPEUTIC DRUGSImmediate side effects: Nausea, vomiting, fever, allergy, hypotension, arrhythmia, thrombophlebitisReversible side effects: Bone marrow suppression (leucopenia, thrombopenia), inflamed mucosa, stomatitis, enteropathy, diarrhea, alopecia, changes in skin pigmentation, hyperkeratosis, hepatotoxicity, nephrotoxicity, amenorrhea, aspermogenesisIrreversible side effects: Cardiotoxicity, hepatotoxicity, nephrotoxicity, neurotoxicity, ototoxicity, mutagenesis/carcinogenesis-> malignancyIndirect effects: Immunosuppression, increased infection rate, increased blood urea (kidney failure)
Systemic side Effects Chemotherapy causes side effects by exerting its greatest effect on rapidly generating cells Chemotherapy + radiation, biologic and/or hormonal therapy = increased toxic effects Physiological deficits and co-morbidities can enhance toxicities
Myelosuppression Suppression of bone marrow activity Can result in a decrease in any combination of WBC, RBC or platelets Most common dose-limiting toxicity Potentially LETHAL
Nadir Point at which the lowest blood-cell count is reached Usually 7-10 days after treatment Onset and duration depends on agent used WBC & platelets are usually 1st to drop Anemia is seen later
Neutropenia Bone marrow constantly produces neutrophils Life span of neutrophil is 7-12 hours Chemo agents suppress bone marrow and damage stem cells Resulting in decreased neutrophil count as mature neutrophils die & aren’t replaced
Anemia RBC production is result of erythropoiesis, which is regulated by erythropoietin (EPO) Normal erythrocyte life span = 120 days Delayed anemia effects due to limited bone marrow reserve and late effects of treatment Difficult to limit to single etiology
Thrombocytopenia Destruction or injury to stem cells leads to dysfunction and suppression of platelet production Normal life span – 7-10 days No bone marrow reserve of precursors Some chemo agents have thrombocytopenia as their dose-limiting toxicity
Thrombocytopenia assessment Petechiae/bruising Headaches Overt bleeding Hypotension Enlarged liver or Tachycardia spleen Prolonged Occult or overt menstruation blood in stool or urine
Risk of Bleeding Platelet Count Risk level/intervention 100,000 Chemotherapy reduced or held 50,000 Increased risk of bleeding; initiate precautions (no injections, etc.) Severe risk exists for <15,000 spontaneous hemorrhage; frequent check of platelet counts/transfusions
Nausea and Vomiting Anticipatory – occurs before or during treatment (25% incidence) Acute – occurs within 24 hours Delayed – occurs at least 24 hours after therapy and may persist up to 6 days (Cisplatin associated with highest incidence)
Antiemetic Therapy for CINV Ondansetron (Zofran) Granisetron (Kytril) Granisetron transdermal (Sancuso) Dolasetron (Anzemet) Palonosetron (Aloxi)Drug combinations are individualized for best effect
MucositisClinical Manifestations Taste changes Changes in color of Swallowing oral mucosa difficulty Oral moisture Hoarseness changes Pain with Edema swallowing or Ulcerations talking
Mucositis Assessment Perform thorough oral assessment: Standard instrument Penlight Gloved finger Inspect under tongue and along inner cheeks, gums, inspect hard & soft palate
Mucositis Management Prevention Treatment Oral care protocols No evidence-based Patient education recommendations Treat dental problems Goal is symptom relief, before cytotoxic therapy prevention of further High protein diet damage Oral agents & hygiene Fluid intake > 1500 ml/d Systemic pain Cryotherapy ofr bolus 5- FU medications Culture lesions
Hormonal Manipulation Some hormones make hormone-sensitive tumors grow more rapidly. Some tumors require specific hormones to divide; decreasing the hormone amounts to hormone- sensitive tumors can slow cancer growth rate
Side Effects ofHormone Therapy Masculinizing effects in women Feminizing effects in men (gynecomastia) Risk for venous thromboembolism Acne Hypercalcemia Liver dysfunction Bone loss
Photodynamic Therapy Selective destruction of cancer cells via chemical reaction triggered by different types of laser light Patient teaching General sensitivity to light for up to 12 weeks after injection of photosensitizing drug
Fatigue (#1 complaint) Definition: Persistent, subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning
Immunotherapy: BiologicalResponse Modifiers (BRMs) Modify patient’s biological responses to tumor cells Cytokines—enhance immune system Interleukins, interferons Side effects—generalized, sometimes severe inflammatory reactions, peripheral neuropathy, skin rashes
Colony-stimulating factors Aranesp and Procrit Stimulates erythropoiesis Administered SC Neupogen Regulates the production of neutrophils within the bone marrow Administered SC, IV
Colony-stimulating factors Neulasta Regulates the production of neutrophils within the bone marrow Administered SC GM-CSF Induces committed progenitor cells to divide and differentiate in the GM pathways Administered SC, IV
Oncologic Emergencies Sepsis and disseminated intravascular coagulation Collaborative management includes: Prevention (the best measure) Intravenous antibiotic therapy Anticoagulants, cryoprecipitated clotting factors
Syndrome of Inappropriate AntidiureticHormone (SIADH) Water is reabsorbed to excess by the kidney and put into system circulation. SIADH is most commonly found in carcinoma of the lung Collaborative management includes: Fluid restriction Increased sodium intake Drug therapy with demeclocycline that works in opposition to antidiuretic hormone
Spinal Cord Compression Tumor directly enters the spinal cord or the vertebrae collapse from tumor degradation of the bone. (Continued)
Spinal Cord Compression (Continued) Collaborative management includes: Early recognition and treatment Palliative High-dose corticosteroids High-dose radiation Surgery External back or neck braces to reduce pressure in the spinal cord
Hypercalcemia Occurs most often in clients with bone metastasis Fatigue, loss of appetite, nausea and vomiting, constipation, polyuria, severe muscle weakness, loss of deep tendon reflexes, paralytic ileus, dehydration, electrocardiographic changes (Continued)
Superior Vena Cava Syndrome Superior vena cava is compressed or obstructed by tumor growth. Condition can lead to a painful, life- threatening emergency. Signs include edema of face, Stokes’ sign, edema of arms and hands, dyspnea, erythema, and epistaxis. (Continued)
Superior Vena Cava Syndrome (Continued) Late-stage signs include hemorrhage, cyanosis, change in mental status, decreased cardiac output, and hypotension. Collaborative management includes high- dose radiation therapy, but surgery only rarely.
Tumor Lysis Syndrome Large numbers of tumor cells are destroyed rapidly, resulting in intracellular contents being released into the bloodstream faster than the body can eliminate them. Collaborative management includes: Prevention Hydration Drug therapy
A 40-year-old woman was admitted to the oncologyunit for severe dehydration from nausea andvomiting associated with chemotherapy 10 days ago.She has had two adjuvant treatments for breastcancer with doxorubicin (Adriamycin) andcyclophosphamide (Cytoxan). She has a Groshongport that was inserted 2 months ago forchemotherapy administration.
(cont’d)The health care provider’s orders are as follows: Strict I&O every 12 hours May use port for blood draws and IV fluids Call for vomiting or temp of 100° F or greater D5½NS at 125 mL/hr Ondansetron (Zofran) 8 mg IV every 8 hrs Clear liquid diet and progress as tolerated CBC, Ca level, and basic metabolic panel in AM Bed rest with bathroom privileges Knee-high support stockingsWhat is the rationale for each of the provider’s orders?
(cont’d)Which of the provider’s orders should beimplemented immediately?A. Administer D5½NS at 125 mL/hrB. Administer clear liquid dietC. Apply support stockingsD. CBC, Ca level, and basic metabolic panel
(cont’d )Two hours later, the patient reportsdifficulty swallowing because of sores inher mouth.1. What does the nurse suspect is the problem with the patient’s mouth?2. What nursing interventions should be implemented?
(cont’d )Match each chemotherapy side effect below withthe correct intervention.A. AnemiaB. NeutropeniaC. Thrombocytopenia1. Inspect IV sites every 4 hours for signs of infection.2. Avoid IM injections and venipunctures.3. Administer epoetin alfa subcutaneously once a week.
Question 1What is the expected outcome related to hairloss for a patient who is undergoingchemotherapy?A.Hair loss may be permanent.B. Hair regrowth usually begins about 1 month after completion of chemotherapy.C.New hair growth will likely be identical to previous hair growth in color and texture.D.Viable treatments exist for the prevention of alopecia.
Question 2A patient who is receiving radiationtherapy for breast cancer would experiencewhich side effect?A.FatigueB. MucositisC.Hair lossD.Nausea and vomiting
Question 3When is the patient with acute leukemia atgreatest risk of developing tumor lysissyndrome?A.After the first cycle of chemotherapyB. After the second cycle of chemotherapyC.After the last cycle of chemotherapyD.Anytime during the patient’s treatment course