2. 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.
3. 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.
4. 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
5.
6.
7.
8.
9.
10.
11.
12. True or False
The risk of dying from cancer in the US is increasing.
13.
14.
15. Pathophysiology of the
Malignant 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.
16. 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
17. Cancer Development (Malignant
Transformation)
Initiation
Promotion
Progression
Metastasis
Extension into surrounding tissues
Penetration into blood vessels
Release of tumor cells
Invasion of tissue
28. True or False
Electronic devices, like cell phones, can
cause cancer in the people who use them.
29. True or False
What someone does as a young adult has little
impact on his or her chances of getting
cancer later in life.
30. 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
31. Detection and Prevention of
Cancer
Primary Prevention: Nurses play a key role
in cancer prevention
Avoidance of Known carcinogens
Modification of associated factors
Removal of “at risk” tissues
Chemoprevention
32. Detection and Prevention of
Cancer
Secondary Prevention:
Promotion of cancer screenings
Gene therapy for cancer prevention
33.
34.
35.
36.
37.
38.
39.
40.
41.
42. 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
43. STAGING: Determines the size of the tumor
and the existence of metastasis. TNM system;
T = extent of primary tumor
N = lymph node involvement
M = extent of metastasis
GRADING: Classification of tumor cells
obtained through cytology (biopsy). I to IV:
I = Closely resemble tissue of origin
IV = Poorly differentiated (more
aggressive and less responsive to
treatment)
44. Question 1
What are the odds of a man dying from
cancer in the U.S.?
A. 1 in 2
B. 1 in 4
C. 1 in 25
D. 1 in 50
45. Question 2
What race has the highest incidence of
cancer?
A. African American
B. Hispanic/Latino
C. Asian
D. Caucasian
46. Question 3
An example of a primary prevention
strategy for reducing cancer risk would be:
A. Yearly mammography for women older
than 40 years
B. Regular physical exercise
C. Colonoscopy at age 50 years and then
every 10 years
D. Avoiding red meat in the diet
47.
48.
49.
50.
51.
52. Cancer Therapy Goals and
Response
Prevention Neoadjuvant
Cure Chemo-
Control prevention
Palliation Myeloablation
Adjuvant Immuno-
suppression
p. 17
53. Management of Cancer
Surgery
Diagnostic
Primary Treatment
Prophylactic
Palliative
Second-look
Reconstructive or
rehabilitation
57. Radiation Therapy (See charts on p. 420)
Ionizing
Control malignant disease
Palliative
External (teletherapy)
Internal (brachytherapy)
Dosage
Toxicity
Skin
Mucous membranes
Bone marrow
58.
59.
60. Best Practice for Patient Safety
& quality Care and
patient/family education
See page 417
61. 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
62. 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
67. 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
70. Nitrogen Mustards
Disrupts normal nucleic acid function in
DNA and RNA to inhibit reproduction
chlorambucil (Leukeran)
estramustine (Emcyt)
mechlorethamine (Mustargen)
melphalan (Alkeran)
thiotepa
72. 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
73. Routes of Administration
Oral
Subcutaneous or intramuscular
Itra-arterial
Intrathecally
Intraperitoneal
Intrapleural
Intravesicular
Intravenous
p. 95
76. Vesicants
Agents that cause
extravasation if
deposited into subq
tissue
Vesicants are:
Dactinomycin
Daunorubicin
Adriamycin
Nitrogen mustard
Mitomycin
Vinblastine
Vincristine
Vindesine
77. 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
78. S/S associated with vesicant extravasation,
irritation and flare reaction
Pain
Redness
Swelling
Blood return
Ulceration
p. 107
83. • 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
84. GENERAL SIDE EFFECTS OF CHEMOTHERAPEUTIC DRUGS
Immediate side effects:
Nausea, vomiting, fever, allergy, hypotension, arrhythmia,
thrombophlebitis
Reversible side effects:
Bone marrow suppression (leucopenia, thrombopenia),
inflamed mucosa, stomatitis, enteropathy, diarrhea, alopecia,
changes in skin pigmentation, hyperkeratosis, hepatotoxicity,
nephrotoxicity, amenorrhea, aspermogenesis
Irreversible side effects:
Cardiotoxicity, hepatotoxicity, nephrotoxicity,
neurotoxicity, ototoxicity, mutagenesis/carcinogenesis-> malignancy
Indirect effects:
Immunosuppression, increased infection rate,
increased blood urea (kidney failure)
85. 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
86. 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
87. 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
88. 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
89. 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
90. 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
91. Thrombocytopenia assessment
Petechiae/bruising Headaches
Overt bleeding Hypotension
Enlarged liver or Tachycardia
spleen Prolonged
Occult or overt menstruation
blood in stool or
urine
92. 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
93. 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)
94. Antiemetic Therapy for CINV
Ondansetron (Zofran)
Granisetron (Kytril)
Granisetron transdermal (Sancuso)
Dolasetron (Anzemet)
Palonosetron (Aloxi)
Drug combinations are individualized for best effect
95. Mucositis
Clinical Manifestations
Taste changes Changes in color of
Swallowing oral mucosa
difficulty Oral moisture
Hoarseness changes
Pain with Edema
swallowing or Ulcerations
talking
96. Mucositis Assessment
Perform thorough oral assessment:
Standard instrument
Penlight
Gloved finger
Inspect under tongue and along inner
cheeks, gums, inspect hard & soft palate
97.
98.
99.
100. 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
101. 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
102. Side Effects of
Hormone Therapy
Masculinizing effects in women
Feminizing effects in men (gynecomastia)
Risk for venous thromboembolism
Acne
Hypercalcemia
Liver dysfunction
Bone loss
103. 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
104. Fatigue (#1 complaint)
Definition:
Persistent, subjective sense
of tiredness related to
cancer or cancer treatment
that interferes with usual
functioning
106. Immunotherapy: Biological
Response 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
107. Colony-stimulating factors
Aranesp and Procrit
Stimulates erythropoiesis
Administered SC
Neupogen
Regulates the production of neutrophils
within the bone marrow
Administered SC, IV
108. 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
109. Oncologic Emergencies
Sepsis and disseminated
intravascular coagulation
Collaborative management includes:
Prevention (the best measure)
Intravenous antibiotic therapy
Anticoagulants, cryoprecipitated
clotting factors
110. Syndrome of Inappropriate Antidiuretic
Hormone (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
111. Spinal Cord Compression
Tumor directly enters the spinal cord or the vertebrae
collapse from tumor degradation of the bone.
(Continued)
112. 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
113. 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)
115. 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)
117. 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.
118. 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
119. A 40-year-old woman was admitted to the oncology
unit for severe dehydration from nausea and
vomiting associated with chemotherapy 10 days ago.
She has had two adjuvant treatments for breast
cancer with doxorubicin (Adriamycin) and
cyclophosphamide (Cytoxan). She has a Groshong
port that was inserted 2 months ago for
chemotherapy administration.
120. (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 stockings
What is the rationale for each of the provider’s orders?
121. (cont’d)
Which of the provider’s orders should be
implemented immediately?
A. Administer D5½NS at 125 mL/hr
B. Administer clear liquid diet
C. Apply support stockings
D. CBC, Ca level, and basic metabolic
panel
122. (cont’d
)
Two hours later, the patient reports
difficulty swallowing because of sores in
her mouth.
1. What does the nurse suspect is the
problem with the patient’s mouth?
2. What nursing interventions should be
implemented?
123. (cont’d
)
Match each chemotherapy side effect below with
the correct intervention.
A. Anemia
B. Neutropenia
C. Thrombocytopenia
1. Inspect IV sites every 4 hours for signs of
infection.
2. Avoid IM injections and venipunctures.
3. Administer epoetin alfa subcutaneously once a
week.
125. Question 1
What is the expected outcome related to hair
loss for a patient who is undergoing
chemotherapy?
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.
126. Question 2
A patient who is receiving radiation
therapy for breast cancer would experience
which side effect?
A.Fatigue
B. Mucositis
C.Hair loss
D.Nausea and vomiting
127. Question 3
When is the patient with acute leukemia at
greatest risk of developing tumor lysis
syndrome?
A.After the first cycle of chemotherapy
B. After the second cycle of chemotherapy
C.After the last cycle of chemotherapy
D.Anytime during the patient’s treatment
course
Editor's Notes
The answer is you can increase your cancer risk if you overuse your barbecue. Research shows grilling and broiling meat creates cancer-causing substances—especially if they're well done or burnt. However, this idea is still a theory. It makes sense to limit your exposure to those chemicals, but the best nutrition advice for preventing cancer is to choose a diet consisting mostly of vegetables, fruits, and whole grain products.
The answer is you can increase your cancer risk if you overuse your barbecue. Research shows grilling and broiling meat creates cancer-causing substances—especially if they're well done or burnt. However, this idea is still a theory. It makes sense to limit your exposure to those chemicals, but the best nutrition advice for preventing cancer is to choose a diet consisting mostly of vegetables, fruits, and whole grain products.
Available evidence does NOT suggest a link between household use of pesticides and cancer. On the other hand, these products can be dangerous if precautions regarding breathing and direct contact are not followed. Precautions for pesticide use are especially important for agricultural workers who may be exposed at higher levels than people who occasionally spray a bug in their home or garden.
Air pollution does contribute to lung cancer risk, but has a greater impact on heart disease, asthma, and chronic bronchitis. Being a smoker, or even being frequently exposed to second hand smoke is more dangerous than the level of air pollution encountered in US cities.
It’s common for people to pay more attention to an injured part of their body, and some people discover tumors while rubbing a painful area. This doesn’t mean that the injury caused the cancer. In rare cases, longstanding injuries that don’t heal can increase cancer risk, but these account for a small fraction of cancer cases. Longstanding infections, such as certain forms of hepatitis or the bacteria that contribute to stomach ulcers, lead to more cancers than injuries do.
The kind of radiation emitted by cell phones, microwave ovens, and related appliances does not cause the kinds of DNA changes that are caused by ionizing radiation such as gamma rays and x-rays. The available evidence does not implicate cell phones as a cause of cancer. Keeping your hands free and your eyes on the road while driving is a more significant issue.
Most cases of cancer are the consequence of many years of exposure to several risk factors. What you eat, whether you are physically active, whether you are sunburned, and especially, whether you smoke as a young person have a substantial influence on whether you develop cancer later in life.
Specialists in cancer surgery know how to safely take biopsy samples and to remove tumors without causing spread of the cancer. In many cases, surgery is an essential part of the cancer treatment plan.
Charts on p 420
Recognize symptomsIdentify and manage underlying causeIron supplements may be neededConsider transfusionsConsider recombinant erythropoietinSymptom managementMonitor labs
Maintain bleeding precautionsPrevent injury & provide safe environmentMaintain integrity of skin, GI, GU systemsAdminister platelet transfusionsInstruct patient on safety measures (i.e. preventing injury, medications to avoid, symptoms to report)
Treat prophylacticallySelect appropriate antiemetic based on treatment regimenConsider cumulative effectsAdminister through entire anticipated period of nausea and vomiting
See page 423, chart 24-8
Mouth care q 2Avoid commercial mouthwashes that contain alcoholSoft toothbrush, unless plt<40K then no toothbrush, toothettes or gauze only.MILD stomatitis: generalized erythema, limited ulcerations, small white patches 1. NS rinses q 2 while awake, q 6 @ noc 2. Remove dentures except for meals 3. Avoid spicy foodsSEVERE stomatitis: confluent ulcerations, with white patches covering > 25% of mucosa 1. Obtain tissue c/s as ordered 2. Cleanse as prescribed – toothettes or gauze 3. Pain control with systemic analgesic I.e. MS gtt.Lip lubricant for both
Appearance of the face, neck, upper arms, and chest in a patient with superior vena cava syndrome.
I&O: Because the patient was admitted with dehydration, it is very important to monitor I&O.Using port for blood draws/IV fluids: When the patient has nausea and vomiting, you often see a decrease in electrolytes from the excessive fluid volume loss.Call for vomiting or >100° F temp: Any temperature elevation may be a sign of infection and should be reported immediately.D5½NS: This is to replace fluids.Ondansetron: This medication is to prevent nausea and vomiting caused by cancer chemotherapy.Clear liquid diet: This is to replace fluids and to provide some nutrition with decreased risk of nausea and vomiting.CBC, Ca, BMP: When the patient has nausea and vomiting, you often see a decrease in electrolytes from the excessive fluid volume loss.Bed rest, bathroom privileges: Because the patient is weak and dehydrated, these restrictions are for safety. Having bathroom privileges is often less stressful than using a bedpan.Knee-high stockings: There is a concern for DVT with prolonged bedrest, so support hose is ordered for the patient to increase venous return and prevent pooling of the blood.
ANS: ABased on the patient’s diagnosis, IV fluids should be started first. The patient is admitted with dehydration, so the Groshong port should be accessed and IV fluids initiated immediately. The provider has ordered clear liquids, but because the patient has been experiencing nausea and vomiting, she may not be able to ingest enough fluids to correct the dehydration. The laboratory values are ordered for the morning, so they should not be obtained until then. The support stockings can be obtained by the UAP while IV fluids are started.
The patient is most likely experiencing mucositis (sores in mucous membranes). With chemotherapy mucous membrane cells are killed more rapidly than they are replaced, resulting in the formation of mouth sores. Mouth sores are painful and interfere with eating.Examine the mouth and between the teeth every 4 hr for fissures, blisters, lesions, or drainage. Document the findings. Provide frequent good mouth care. Encourage the patient to avoid mouthwashes that contain alcohol. For mouth care, use a soft-bristled toothbrush or disposable mouth sponges. Do not use dental floss or pressure gum cleaners. Rinse the mouth with ½ peroxide and ½ normal saline every 8 hr. Normally the patient should drink at least 2 L of fluids, but due to the patient’s nausea and vomiting, this isn’t possible. Continue to monitor IV fluid replacement.(See Chart 24-9, in textbook, p. 424.)
ANS:A (Anemia) = 3 (Administer epoetin alfa subcutaneously once a week.)B (Neutropenia) = 1 (Inspect IV sites every 4 hours for signs of infection.)C (Thrombocytopenia) = 2 (Avoid IM injections and venipunctures.)