3. CELLULAR ABERRATIONThe Biology Cancer Part 2
DIAGNOSIS Imaging studies Excision or Fine Needle Aspiration Biopsy with microscopic histologic examination Pap smear Blood tests – for example PSA for prostate carcinoma, CEA or AFP for HCC or testicular, CEA for colorectal carcinoma, CA-125 for ovarian carcinoma, ALP for HCC or bone Cytologic examination of blood cells – for leukemia
DIAGNOSTIC AIDS USED TO DETECTCANCER Nuclear medicine imaging – bone, liver, kidney, spleen, brain, thyroid cancers PET – lung, colon, liver, pancreatic, head and neck cancers; Hodgkin and Non-Hodgkin lymphoma and melanoma PET fusion – see PET Radioimmunoconjugates – colorectal, breast, ovarian, head and neck cancers; lymphoma and melanoma
Site Gender Age Evaluation FrequencyBreast F 20-39 Clinical breast Every 3 years examination (CBE) Self breast Every month examination (SBE) >40 CBE Every year SBE Every month Mammogram Every yearColon and F/M >50 Fecal occult Every 5 yearsrectum blood and flexible Every 10 years sigmoidoscopy or colonoscopy or double- Every 5 years contrast barium enema
Site Gender Age Evaluation FrequencyProstate M >50 (or 40-45 if PSA and DRE Every year at high risk)Cervix F >21 or within 3 Pap smear Every year if years after regular Pap; starting to have every 2 years if intercourse liquid Pap testCancer-related M/F >20-39 Pelvic Every yearcheck ups examination Examination for Every 3 years cancers of the thyroid, testicles, ovaries, lymph nodes, oral cavity and skin as well as counseling about health practices 40+ and risk factors Every year Same as 20-39
MANAGEMENT OF CANCER Surgery surgical removal of the entire cancer remains the ideal and most frequently used treatment methodb. Diagnostic surgery – biopsyc. As primary treatmentd. Prophylactic treatmente. Palliative treatmentf. Reconstructive surgery
MANAGEMENT OF CANCER Nursing management in cancer surgeryb. The nurse completes a thorough preoperative assessment for factors that may affect the patient undergoing the surgical procedurec. The patient and family require time and assistance to deal with the possible changes and the outcomes resulting from the surgeryd. The nurse provides education and emotional support by assessing the needs of the patient and family and by discussing their fear and coping mechanisms with them
MANAGEMENT OF CANCER Nursing management in cancer surgeryb. After surgery, the nurse assesses the patient’s responses to the surgery and monitors the patient for possible complications, such as infection, bleeding, thrombophlebitis, wound dehiscence, fluid and electrolyte imbalance, and organ dysfunctionc. The nurse also provides for the patient’s comfort. Postoperative teaching addresses wound care, activity, nutrition, and medication informationd. Plans for discharge, follow-up and home care, and treatment are initiated as early as possible to ensure continuity of care from hospital to home or from a cancer referral center to the patient’s local hospital and health care provider.
MANAGEMENT OF CANCER Radiation therapyb. External radiationc. Internal radiation or brachytherapyd. Radiation dosage – dependent on the sensitivity of the target tissue to radiation and on the tumor sizee. Toxicity – localized to the region being irradiated
MANAGEMENT OF CANCER Nursing Management in Radiation therapyb. The nurse can explain the procedure for delivering radiation and describe the equipment, the duration of the procedure (often minutes only), the possible need for immobilizing the patient during the procedurec. The nurse informs the family about restrictions placed on visitors and health personnel and other radiation precautions, for radioactive implants
MANAGEMENT OF CANCER Chemotherapyb. Antineoplastic agents are used in an attempt to destroy tumor cells by interfering with cellular functions, including replicationc. Used primarily to treat systemic disease rather than localized lesions that are amenable to surgery or radiationd. May be combined with surgery, radiation therapy, or both, to reduce tumor size preoperatively, to destroy any remaining tumor cells postoperatively, or to treat some forms of leukemiae. Goals: cure, control and palliation
UNDERSIRABLE EFFECTS Undesirable Effects: Bone marrow depression Alopecia Retching-nausea/vomiting Fear and anxiety Stomatitis
GENERAL GUIDELINES FORANTINEOPLASTIC DRUGS CBC, platelets - monitor Antiemetics before taking drug Nephrotoxicity - undesirable effect Counseling regarding reproduction issues Encourage handwashing, avoid crowds Recommend a wig for alopecia
PRIMARY GOALS OF CHEMOTHERAPY Achieve a complete cure; permanent removal of all cancer cells from the body. Control or manage the disease, cancer is not eliminated, preventing the growth and spread of the tumor may extend the patient’s life Palliation - reduce the size of the tumor, easing the severity of pain and other tumor symptoms, thus improving the quality of life.
REASON FOR MULTIPLE DRUG USE ANDSPECIAL SCHEDULING Rapid cell division, Tumor cells express a high mutation rate Tumor changes its genetic make-up as it grows hundreds of different clones with different growth rates and physiological properties Drugs affect cells in different ways and at different times in their life cycle
Figure 27.3 Antineoplastic agents and the cell cycle
ALKYLATING AGENTS Action: Causes cell death or mutation of malignant growth by changing the structure of malignant cell growth Indications: Palliative treatment of chronic lymphocytic leukemia; malignant lymphomas; Hodgkin’s disease; breast, lung and ovarian cancers Adverse Effects: Bone marrow depression (leukopenia, thrombocytopenia) Anorexia/alopecia Distressful nausea and vomiting Drugs: Busulfan, carboplatin, carmustine
Figure 27.4 Mechanism of action of alkylating agents
ANTIMETABOLITES Action: Interferes with the building blocks of DNA synthesis Indications: Myelocytic leukemia; acute lymphocytic leukemia; Cancer of the breast, cervix, colon, liver, ovary, pancreas, stomach and rectum Adverse effects: GI disturbance, oral and anal inflammation, bone marrow depression, alopecia, renal dysfunction, thrombocytopenia Drugs: Capecitabine; cytarabine
GENERAL GUIDELINES IN GIVINGANTIMETABOLITES Monitor CBC and platelets weekly Evaluate renal function test Temperature assessment q4-6 hours Asepsis (strict) Bleeding, anemia, infection, and nausea - report Oral hygiene - brush with soft toothbrush Lots of fluids (2-3 L/day) Intake and output, nutritional intake - monitor The protocols for handling and administering - follow Emphasize protective isolation
ANTITUMOR ANTIBIOTICS Action: binding to DNA making it unable to separate (2) inhibiting ribonucleic acid (RNA), preventing enzyme synthesis.
PLANT EXTRACTS VINCA ALKALOIDS Inhibits mitotic division TAXANES Inhibits mitotic division TOPOISOMERASE INHIBITORS Breaks the DNA strands therefore altering the integrity of the genome
Biologic Response Modifiers Interferons (IFNs) Cytokines secreted by lymphocytes and macrophages Slow the spread of viral infections Enhance the activity of existing leukocytes.
Biologic Response Modifiers Interleukins Levamisole (Ergamisole) stimulate B cells, T cells, and macrophages in patients with colon cancer Bacille Calmette-Guéin (BCG) vaccine (TICE, TheraCys) is an attenuated strain of Mycobacterium tuberculosis, used for the pharmacotherapy of certain types of bladder cancer.
Table 27.6 (continued) Hormones and Hormone Antagonists
MANAGEMENT OF CANCER Nursing management in chemotherapyb. Assess fluid and electrolyte imbalancec. Modify risks for infection and bleedingd. Administering chemotherapye. Protecting caregivers
Lab Values Patients with cancer require regular monitoring of lab values by nurses who will anticipate their health care needs. Nursing interventions can include prophylactic measures if abnormal lab values are noted and addressed quickly.
Leukopenia Chemotherapy and radiation therapy can decrease a patients white blood cell (WBC) count and lead to leukopenia . Because neutrophils act as phagocytes, a significant decrease in the neutrophil count places a patient with cancer at high risk for infection.
Neutropenia A measure used to assess a patients risk for infection is the absolute neutrophil count (ANC). ANC less than 500 places the patient at severe risk for infection, and a count less than 100 constitutes extreme risk. The patient may receive medications on a daily basis to stimulate WBC production. The nurse should know the ANC prior to medication administration and take appropriate measures to prevent infection
Anemia Anemia occurs when the patients red blood cells (RBC) are lost or the production rate is decreased; low hemoglobin and hematocrit result. Any abnormal values should be discussed with the primary care provider because the patient with cancer may require blood transfusions before reaching critically low levels. Critical values for hemoglobin and hematocrit are less than 5.0 g/dl.
Thrombocytopenia Thrombocytopenia occurs when platelet counts fall below 100,000. Spontaneous bleeding can occur when platelet levels fall below 20,000. To avoid an emergent situation, the nurse should report platelet count at 40,000. The patient with elevated platelets can also develop bleeding if the platelet function is abnormal.
Hematopoietic Growth Factors or Colony-stimulating factors Medications that help improve these hematologic conditions are hematopoietic growth factors or colony-stimulating factors. These agents stimulate red and/or white blood cell production and maturation. The nurse should be aware of administration techniques, expected therapeutic outcomes, and potential adverse effects.
Colony Stimulating Factors Filigastrim (Neupogen) and sargramostim (Leukine) are used to enhance the WBC count. Pegfiligastrim (Neulasta) for patients with a decreased WBC. These medications may be needed if the patient is receiving antineoplastic agents that suppress the bone marrow. Epoetin alfa recombinant (Procrit) is administered to maintain or increase the patients RBC level. Positive results with this medication can decrease the need for blood transfusions.
Colony Stimulating Factors Oprelvekin (Neumega), also known as interleukin 11, is a growth factor that is used to prevent thrombocytopenia following chemotherapy infusion. This medication allows hematopoietic stem cells and the progenitor cells to proliferate, increasing platelet production. As the plasma volume increases, the nurse may see decreased hemoglobin, decreased serum albumin, and decreased gamma globulins. The nurse must review lab values and administration routes associated with the use of colony-stimulating factors prior to their administration.
Electrolyte Imbalance Electrolytes, essential for normal physiologic function of nerves and muscles, are monitored closely in the patient with cancer. Elevated or decreased electrolyte levels can have life-threatening effects. The nurse must anticipate problems such as cardiac dysrhythmias or uncontrolled bleeding and intervene quickly. Intravenous fluids, oral electrolyte supplements, and/or total parenteral nutrition (TPN) can influence electrolyte balances. The nurse must be able to report current lab values and all sources of ingested or parenteral electrolytes to oncology specialists.
Neutropenia Precautions Neutropenia could be related to the cancer pathology or the result of receiving chemotherapeutic agents. Individuals with an absolute neutrophil count of less than 1,000 cells are considered neutropenic and are at moderate risk for infection. ANC less than 500 creates a severe risk for the patient, and ANC less than 100 places the patient in an extreme risk category.
Nadir The term nadir represents that period of time when blood levels are at their lowest point. The nadir period varies for each antineoplastic agent. Most nadir periods occur approximately 10 to 14 days after the beginning of chemotherapy treatment or several weeks following radiation therapy, depending on the treatment agent and life span of the particular blood cells
Reversed Isolation Precautions An immunocompromised state makes it difficult for the patient with cancer to combat even minor colds; sepsis can result. When assigned to care for a patient who is neutropenic, the nurse must review guidelines regarding care of an immunocompromised patient.
Common Adverse Effects of Chemotherapy and Radiation Fatigue Nausea Pain Vomiting Oral stomatitis Bone/Joint Pain Anorexia Constipation Diarrhea Impaired skin integrity Alopecia All patients do not experience these adverse effects; however, the nurse should be aware of assessment criteria and early intervention strategies
Fatigue: Nursing Intervention Occurs greater than 70% It can occur when the patient reaches the nadir period. Clustering patient care activities can reduce fatigue and provide uninterrupted rest periods. A sign on the patients room door can prompt visitors to check with the nurse before entering.
Nausea and Vomiting: Nursing Intervention Nausea and vomiting occur frequently with the use of chemotherapeutic agents. Some chemotherapy drug regimens include antiemetics prior to administration to promote patient tolerance of the treatment. Specific food choices such as gelatin, popsicles, and soft bland food may minimize queasiness The patient should be encouraged to experiment with his or her diet to increase calories. The patient must consume an adequate number of calories to maintain nutrition balance and enhance quality of life. A dietary consult may be helpful in identifying the patients caloric needs and identifying which foods would be best.
Oral Stomatitis: Nursing Intervention Rapidly dividing cells in the mouth are affected by chemotherapy and radiation treatments, leading to painful mouth sores and chapped lips. Candida albicans (yeast) may occur on the tongue and oral mucosa. Often, excess oral secretions make it difficult for the patient to speak clearly or to eat a substantial amount of food. The patient may find relief from sucking on ice chips or popsicles. Several combinations of mouth rinses are available, depending on the patients need - excess secretions may require diphenhydramine (Benadry) in a mouth rinse, for increased pain may need lidocaine or water and baking soda rinses. Frequent oral care is vital to preserve mucosal integrity. Individual needs and the extent of the stomatitis should be discussed with the primary care provider to determine the best intervention.
Bone/Joint Pain: Nursing Interventions Bone and joint pain increases as cancer advances and as an adverse effect of colony-stimulating factors. Analgesics and anti-inflammatory medications, as well as alternative pain relief measures, can be used. Alternative pain relief measures can include guided imagery, music therapy, relaxation exercises, and massage, if appropriate.
Constipation and Diarrhea: Nursing Interventions The disease process, lack of activity, and frequent use of opioids may result in constipation. High fiber food choices, adequate fluid intake, and stool softeners are used to promote regular elimination and help prevent bloating. Diarrhea can result from frequent use of antibiotics and antiemetics. Dehydration and the loss of electrolytes, minerals, and nutrients can result. Stool specimens may he collected to determine if an infection has occurred. If no infection is detected, antidiarrheal medications may be ordered. It is important to replace lost fluids, maintain electrolyte levels, and prevent sepsis. In either constipation or diarrhea, the nurse should anticipate the patients needs and initiate preventive measures.
Delirium: Nursing Intervention Agitated behavior requiring sedation, also described as delirium, terminal restlessness, mental anguish and agitation, are common problems in cancer patients. Factors such as cachexia, hypoalbuminemia, advanced age, and prior dementia can contribute to this condition. Identification and treatment of delirium may involve such interventions as discontinuation or dose reduction of psychoactive medications, adjustments in fluid administration, or treatment of infections, dehydration, or electrolyte imbalances. Ongoing monitoring and reassessment are critical especially when sedatives, opioids, or other psychoactive medications are required to control patients symptoms. Changes in the patients health and mental status, in laboratory values, and symptoms that suggest drug toxicity should be reported promptly to the oncology specialist. A psychosocial intervention for family caregivers of patients with advanced cancer may be beneficial.
Skin Integrity: Nursing Intervention Maintaining skin integrity is a priority during the treatment and healing process of cancer. Irradiated tissue, at risk for skin breakdown and delayed wound healing, should be assessed at least every shift. Chemotherapy and radiation injure the rapidly dividing cells of the skin. A patient with cancer may remain in bed for long periods of time due to fatigue and pain. The underlying effects to the skin may not be visible immediately, and recovery will depend on the patients response to treatment Adequate nutrition is also an important component in maintaining skin integrity. Cancer-associated cachexia, related to inadequate caloric needs and decreased protein intake, can delay wound healing A skin assessment instrument, such as the Braden Scale, should be used to evaluate the patient each shift and determine specific interventions.
Anorexia: Nursing Intervention Chemotherapy and radiation treatments affect rapidly dividing cells and can alter taste sensation. Mouth rinses with baking soda and water can be used to soothe the mucosa prior to meals. Megestrol acetate (Megace) has been used for appetite enhancement in the patient with advanced cancer. Liquid nutritional supplements, such as health shakes, can also be offered. The use of TPN may be necessary if other means for nutritional support are exhausted.
Chemotherapy Precautions The nurse needs to be familiar with chemotherapy precautions, which are followed for a period of 48 hours after the patients last dose of an antineoplastic agent. Antineoplastic agents are excreted from the body through fluids such as sweat, vomitus, stool, and urine. The nurse should use personal protective equipment (PPE) for each patient contact. PPE includes masks with face shields or goggles, chemotherapy gloves, and a fluid-resistant gown. Handwashing before and after working with the patient is essential. The nurse should cover the commode or toilet with a disposable drape to prevent fluids from splashing while flushing twice. Specified receptacles for linen and trash disposal must be used. Family members must be instructed on and follow the necessary precautions. The facility should have a policy that stipulates precautions and supplies used to protect the staff, patient, and visitors.
MANAGEMENT OF CANCER Bone Marrow Transplantationb. Allogenic (from a donor other than the patient); either a related donor or a matched unrelated donorc. Autologous (from patient)d. Syngeneic (from an identical twin)
MANAGEMENT OF CANCER Nursing Management in Bone Marrow Transplantationb. Implementing pretransplantation carec. Providing care during treatmentd. Providing posttransplantation care
MANAGEMENT OF CANCER Hyperthermia Targeted therapiesc. BRMd. Gene therapye. Growth factors Photodynamic therapy Cancer rehabilitation
SQUAMOUS CELL CARCINOMA SCC The second most common tumor arising on sun- exposed sites in older people, exceeded only by basal cell carcinoma Except for lesions on the lower legs, these tumors have a higher incidence in men than in women The most important cause of cutaneous SCC is DNA damage induced by exposure to UV light Is invasive, can recur and metastasize
SQUAMOUS CELL CARCINOMA Other Risk Factors2. Age older than 50 years3. Light skin; blonde or light brown hair; green, blue, or gray eyes4. Skin that sunburns easily (Fitzpatrick skin types I and II)5. Geography (closer to the equator) (http://emedicine.medscape.com/article/1101535- overview)
SQUAMOUS CELL CARCINOMA Immunosuppression may contribute to carcinogenesis by reducing host surveillance and increasing the susceptibility of keratinocytes to infection and transformation by oncogenic viruses, particularly HPV subtypes 5 and 8 Other risk fatcors include industrial carcinogens (tars and oils), chronic ulcers and draining osteomyelitis, old burn scars, ingestion of arsenicals, ionizing radiation, and (in the oral cavity) tobacco and betel nut chewing
SQUAMOUS CELL CARCINOMA History A new and enlarging lesion that concerns the patient Most lesions are slow growing, while others rapidly enlarges Symptoms such as bleeding, weeping, pain, or tenderness may be noted, especially with larger tumors Numbness, tingling, or muscle weakness may reflect underlying perineural involvement, and this history finding is important to elicit because it adversely impacts prognosis. May be asymptomatic (http://emedicine.medscape.com/article/1101535- overview)
SQUAMOUS CELL CARCINOMA Imaging studies like CT scan are done for patients with neurologic symptoms and with (+) lymphadenopathy FNAB or excision biopsy of palpable lymph nodes Small biopsies of the lesion suspected to be SCC(http://emedicine.medscape.com/article/110153 5-overview)
SQUAMOUS CELL CARCINOMA Surgical treatment options:2. Cryotherapy – for in-situ lesions; makes use of liquid nitrogen3. Electrodesiccation and curettage – for low-risk carcinomas of the trunk and extremities4. Excision with conventional margins (http://emedicine.medscape.com/article/110153 5-overview)
BASAL CELL CARCINOMA BCC The most common invasive cancer in humans Slow-growing tumors that rarely metastasize Have a tendency to occur in sun-exposed areas and in lightly pigmented people Incidence rises sharply with immunosuppression and in people with inherited defects in DNA repair
BASAL CELL CARCINOMA Tumors present clinically as pearly papules often containing prominent dilated subepidermal blood vessels Advanced lesion may ulcerate, and extensive local invasion of bone and facial sinuses may occur after many years of neglect (rodent ulcers)
BASAL CELL CARCINOMA Treatment2. Electrodessication and curettage involves destroying the tumor with an electrocautery device then scraping the area with a curette3. Surgical excision of the lesion including a margin of normal skin. This method is preferred for larger lesions (>2cm) on the cheek, forehead, trunk, and legs4. Radiation therapy - may also be used where tumors are difficult to excise or where it is important to preserve surrounding tissue such as the lip. Its use is declining.5. Cryotherapy - involves destroying the tissue by freezing it with liquid nitrogen. This may be effective for small, well-defined superficial tumors
BASAL CELL CARCINOMA Prevention2. Avoid UVB radiation from sun exposure especially midday sun3. Use protective clothing4. Use sunscreen with an SPF of at least 15. This is especially important for children.5. Have suspicious lesions checked out - If you have a question, get it checked out. Treating premalignant lesions prevents their transformation to potentially metastatic cancers.
MELANOMA A relatively common neoplasm that remains deadly if not caught at its earliest stages Can occur in the oral and anogenital mucosal surfaces, esophagus, meninges, and the eye Melanomas evolve over time from localized skin lesions to aggressive tumors that metastatize and are resistant to therapy Early recognition and complete excision are critical
MELANOMA Usually asymptomatic Itching or pain may be an early manifestation Majority of lesions are greater than 10 mm in diameter at diagnosis Most consistent clinical signs (in pigmented lesions):5. Changes in color6. Changes in size7. Changes in shape
MELANOMA Unlike benign tumors, these tumors show variations in color (shades of black, brown, red, dark blue, and gray) There may be areas of hypopigmentation Borders are irregular and often notched, not smooth, round, and uniform Important warning signs (ABCs): Asymmetry Irregular borders Variegated color
MELANOMA Other features:2. Diameter greater than 6 mm3. Any change in appearance4. New onset of itching5. Or new onset of pain
MELANOMA Prognostic factors:2. Tumor depth - <1.7mm (favorable)3. Number of mitoses – no or few mitoses (favorable)4. Evidence of tumor regression – absence (favorable)5. The presence and number of tumor infiltrating lymphocytes – brisk (favorable)6. Gender – female (favorable)7. Location – location on an extremity (favorable)
MELANOMA The two most important predisposing factors are inherited genes and sun exposure Treatment is by stage
Stage 0 melanoma. Abnormal melanocytes are in the epidermis(outer layer of the skin).
Stage I melanoma. In stage IA, the tumor is not more than 1 millimeter thick,with no ulceration (break in the skin). In stage IB, the tumor is either not morethan 1 millimeter thick, with ulceration, OR more than 1 but not more than 2millimeters thick, with no ulceration. Skin thickness is different on different partsof the body.
Stage II melanoma. In stage IIA, the tumor is either more than 1 but not more than 2millimeters thick, with ulceration (break in the skin), OR it is more than 2 but not morethan 4 millimeters thick, with no ulceration. In stage IIB, the tumor is either more than 2but not more than 4 millimeters thick, with ulceration, OR it is more than 4 millimetersthick, with no ulceration. In stage IIC, the tumor is more than 4 millimeters thick, withulceration. Skin thickness is different on different parts of the body.
Stage III melanoma. Thetumor may be anythickness with or withoutulceration. It has spreadeither (a) into a nearbylymph vessel and mayhave spread to nearbylymph nodes; OR (b) to 1or more lymph nodes,which may be matted(not moveable). Skinthickness is different ondifferent parts of thebody.
Stage IV melanoma. The tumor hasspread to other parts of the body.
MELANOMA Stage 0 (Melanoma in Situ) - Treatment of stage 0 is usually surgery to remove the area of abnormal cells and a small amount of normal tissue around it. Stage I Melanoma3. Surgery to remove the tumor and some of the normal tissue around it.4. A clinical trial of surgery to remove the tumor and some of the normal tissue around it, with or without lymph node mapping and lymphadenectomy.5. A clinical trial of new techniques to detect cancer cells in the lymph nodes.6. A clinical trial of lymphadenectomy with or without adjuvant therapy.
MELANOMA Stage II Melanoma2. Surgery to remove the tumor and some of the normal tissue around it, followed by removal of nearby lymph nodes.3. Lymph node mapping and sentinel lymph node biopsy, followed by surgery to remove the tumor and some of the normal tissue around it. If cancer is found in the sentinel lymph node, a second surgery may be done to remove more nearby lymph nodes.4. Surgery followed by high- dose biologic therapy.5. A clinical trial of adjuvant chemotherapy and/or biologic therapy.6. A clinical trial of new techniques to detect cancer cells in the lymph nodes.
MELANOMA Stage III Melanoma2. Surgery to remove the tumor and some of the normal tissue around it.3. Surgery to remove the tumor with skin grafting to cover the wound caused by surgery.4. Surgery followed by biologic therapy.5. A clinical trial of surgery followed by chemotherapy and/or biologic therapy.6. A clinical trial of biologic therapy.7. A clinical trial comparing surgery alone to surgery with biologic therapy.8. A clinical trial of chemoimmunotherapy or biologic therapy.9. A clinical trial of hyperthermic isolated limb perfusion using chemotherapy and biologic therapy.10. A clinical trial of biologic therapy and radiation therapy.
MELANOMA Stage IV Melanoma2. Surgery or radiation therapy as palliative therapy to relieve symptoms and improve quality of life.3. Chemotherapy and/or biologic therapy.4. A clinical trial of new chemotherapy, biologic therapy, and/or targeted therapy with monoclonal antibodies, or vaccine therapy.5. A clinical trial of radiation therapy as palliative therapy to relieve symptoms and improve quality of life.6. A clinical trial of surgery to remove all known cancer.