ONCOLOGY
ESSENTIAL CONCEPTS OF CANCER
NURSING MANAGEMENT OF PATIENTS WITH CANCER
Cancer Defined
A disease process that begins when an abnormal cell is transformed by the genetic mutation of cellular DNA (Normal cells mutate into abnormal cells)
Group of complex diseases; affect different organs and organ systems
The abnormal cells have invasive characteristics and infiltrate other tissues. This phenomenon ismetastasis.
Cancer cells are described as malignant. These cells demonstrate uncontrolled growth that does not follow physiologic demand.
Oncology
Study of cancers
Oncology nurses specialize in the care, treatment of clients with cancer
Incidence and Prevalence
Cancer accounts for about 25% of death on yearly basis
Three most common types of cancer
Among males:
Prostate,
Lung, bronchial
Colorectal
Among females:
Breast
Lung and bronchial
Colorectal
Incidence
Incidence rate of all cancers
All Jordanians (2003) 72.9/100.000
Male Jordanian70.7/100.000
Female Jordanian 75.2/100.000
Comparison among Countries
Country Male Female
Algeria111.0 69.2
Kuwait106.7 127.3
Denmark327.0 304.9
Ireland316.6 267.2
USA, white 385.0 273.6
USA, Black 450.5 253.7
Jordan137.6 134.3
Cancer incidence by site and sex in USA (1994)
Male Type Percent
Prostate 32
Lung 16
Colon or rectum 12
Urinary Tract 9
Leukemia and lymphoma 7
Female
Breast 32
Colon and rectum 13
Lungs 13
Uterus 8
Leukemia and lymphoma6
Cancer incidence by site and sex in Jordan (1997)
Male Type Percent
Bladder 10.5
Lungs 10.3
Leukemia 9
Prostate 7.3
Lymphoma 6.6
Brain & CNS 5.8
Skin 5.8
Stomach 4.9
Colon4.4
Larynx 3.8
Cancer incidence by site and sex in Jordan (1997)
Female: Type Percent
Breast28.3
Skin5.9
Leukemia 5.4
Lymphoma 5.1
Colon5
Uterus 4.5
Thyroid 4.5
Brain & CNS4
Stomach 3.1
Cervix2.9
Risk factors for cancer (1)
some are controllable; some are not
Heredity:
5 –10% of cancers; documented with some breast and colon cancers
Age:
70% of all cancers occur in persons > 65
Lower socio-economic status
Stress
Leads to greater wear and tear on body in general
5.Diet:
Certain preservatives in pickled
Salted foods;
Fried foods;
High-fat, low fiber foods;
High fat foods
Diet high in red meat
Risk factors for cancer (1)
Occupational risk:
Exposure to know carcinogens, radiation, high stress
Infections:
Especially specific organisms and organ (e.g. papillomavirus causing genital warts and leading to cervical cancer.
Tobacco Use:
Lung
Oral
Laryngeal
Esophageal
Gastric
Pancreatic
Bladder
Alcohol Use:
Same as smoking
Sun Exposure (radiation):
Skin cancer
Nursing role: Health promotion to lower risks
Routine medical check up and screenings
Client awareness to act if symptoms of cancer occur
Screening examination recommendations by American Cancer Society; specifics are made according to age and frequencies
ACS: recommendation for screening
Breast Cancer:
Self-breast exam
Breast examination by health care professionals
Screening mammogram
Colon and Rectal Cancer:
fecal occult blood
Flexible sigmoidoscopy
Colonoscopy
Cervical, Uterine Cancer:
Papanicolaou (Pap) test
Prostate Cancer:
Digital rectal exam
Prostate-specific antigen (PSA) test
Theories of Carcinogenesis
Cells begin to mutate:
Change the DNA to unnatural cell reproduction
Oncogenes/Tumor Suppressor Genes Abnormalities:
Oncogenes are genes that promote cell proliferation and can trigger cancer
Tumor suppressor genes normally suppress oncogenes but are damaged
Exposure to Carcinogens (1)
Act by directly altering the cellular DNA (genotoxic)
Act by affecting the immune system (promotional)
Depends on:
Dose (amount)
Duration (time)
Exposure to Carcinogens (2)
Viruses
Viruses break the DNA chain and mutates the normal cells DNA
Epstein-Barr virus
Human papilloma virus
Hepatitis virus
Drugs and Hormones
Sex hormones often affect cancers of the reproductive systems (estrogen in some breast cancers; testosterone in prostate cancer)
Glucocorticoids and steroids alter immune system
Exposure to Carcinogens (3)
Chemical Agents
Industrial and chemical
Can initiate and promote cancer
Examples: hydrocarbons in soot ; arsenic in pesticides; chemicals in tobacco
Physical Agents
Exposure to radiation
Ionizing radiation found in x-rays, radium, uranium
UV radiation
Sun, tanning beds
Immune function
Protects the body from cancerous cells
Increased rate of cancer in immunocompromised patients
Types of neoplasms
Benign:
Localized growths respond to body’s homeostatic controls
Encapsulated
Stop growing when they meet a boundary of another tissue
Can be destructive
Malignant
Have aggressive growth, rapid cell division outside the normal cell cycle
Not under body’s homeostatic controls
Cut through surrounding tissues causing bleeding, inflammation, necrosis (death) of tissue
Metastasis:
Malignant tumors (neoplasm) can metastasize
Tumor cells travel through blood or lymph circulation to other body areas and invade tissues and organs there.
Primary tumor:
The original site of the malignancy
Secondary tumor (sites):
Areas where malignancy has spread i.e. metastasis (metastatic tumor)
Common sites of metastasis are lymph nodes, Liver, Lungs, Bones, Brain
50 –60 % of tumors have metastasized by time primary tumor identified
Characteristics of neoplasms (1)
Cancerous cells must avoid detection by immune system
Malignant neoplasms can recur after surgical removal of primary and secondary tumors and other treatments
Malignant neoplasms vary in differentiation.
Highly differentiated are more like the originating tissue
Undifferentiated neoplasms consist of immature cells with no resemblance to parent tissue and have no useful function
Characteristics of neoplasms (2)
Malignant cells progress in deviation with each generation and do not stop growing and die, as do normal cells
Malignant cells are irreversible, i.e. do not revert to normal
Malignant cells promote their own survival by hormone production, cause vascular permeability; angiogenesis; divert nutrition from host cells
Effects of Cancer (1)
Disturbed or loss of physiologic functioning, from pressure or obstruction
Anoxia
Necrosis of organs
Loss of function:
Bowel or bladder obstruction
Increased intracranial pressure
Interrupted vascular/venous blockage
Ascites
Disturbed liver functioning
Motor and sensory deficits
Cancer invades bone, brain or compresses nerves
Respiratory difficulties
Airway obstruction
Decreased lung capacity
Effects of Cancer (2)
Hematologic Alterations:
Impaired function of blood cells
Secondary to any cancer that invades the bone marrow (leukemia)
May also be caused by the treatment
Abnormal WBCs: impaired immunity
Diminished RBCs
Diminished Platelets: anemia and clotting disorders
Effects of Cancer (3)
Infections: fistula development and tumors may become necrotic; erode skin surface
Hemorrhage: tumor erosion, bleeding, severe anemia
Anorexia-Cachexia Syndrome: wasting away of client
Unexplained rapid weight loss, anorexia with altered smell and taste
Catabolic state: use of body’s tissues and muscle proteins to support cancer cell growth
Effects of Cancer (4)
Paraneoplastic Syndromes:
Ectopic sites with excess hormone production
Parathyroid hormone (hypercalcemia)
Ectopic secretion of insulin (hypoglycemia)
Antidiuretic hormone (ADH: fluid retention)
Adrenocorticotropic hormone (ACTH)
Effects of Cancer (5)
Pain: major concern of clients and families
Types of cancer pain
Acute: symptom that led to diagnosis
Chronic: may be related to treatment or to progression of disease
Causes of pain
Direct tumor involvement including metastatic pain
Nerve compression
Involvement of visceral organs
Effects of Cancer (6)
Physical Stress:
body tries to respond and destroy neoplasm
Fatigue
Weight loss
Anemia
Dehydration
Electrolyte imbalances
Effects of Cancer (7)
Psychological Stress
Cancer equals death sentence
Guilt from poor health habits
Fear of pain, suffering, death
Stigmatized
Collaborative Care (Diagnostic Tests) (1)
Used to diagnose cancer
Determine location of cancer
X-rays
Computed tomography
Ultrasounds
Magnetic resonance imaging
Nuclear imaging
Angiography
Diagnostic Tests (2)
Diagnosis of cellular type of can be done through tissue samples from biopsies, shedded cells.
Cytologic Examination:
Tissue examined under microscope
Identification System of Tumors:
Classification
Grading
Staging
Diagnostic Tests (3)
Classification:
according to the tissue or cell of origin, e.g. sarcoma, from supportive
Grading:
Evaluates degree of differentiation and rate of growth
Grade 1 (least aggressive) to Grade 4 (most aggressive)
Staging:
Relative tumor size and extent of disease
TNM (Tumor size; Nodes: lymph node involvement; Metastases)
Diagnostic Tests (4)
Tumor markers: specific proteins which indicate malignancy
PSA (Prostatic-specific antigen): prostate cancer
CEA (Carcinoembryonic antigen): colon cancer
Alkaline Phosphatase: bone metastasis
Diagnostic Tests (5)
Direct Visualization
Sigmoidoscopy
Cystoscopy
Endoscopy
Bronchoscopy
Exploratory surgery
Lymph node biopsies to determine metastases
Diagnostic Tests (6)
Other non-specific tests
CBC, Differential
Electrolytes
Blood Chemistries:
Liver enzymes
RFT
Treatment (1)
Treatment Goals: depending on type and stage of cancer
Cure
Recover from specific cancer with treatment
Alert for reoccurrence
May involve rehabilitation with physical and occupational therapy
Control: of symptoms and progression of cancer
Continued surveillance
Treatment when indicated (e.g. some bladder cancer, prostate cancer)
Palliation of symptoms: may involve terminal care if client’s cancer is not responding to treatment
Treatment Options
Depend on type of cancer:
Alone or in combination
Chemotherapy (1)
Effects are systemic and kills the metastatic cells
Often combinations of drugs in specific protocols over varying time periods
Much more effective then a single agent
Consider the timing of the nadir of each drug
The time when the bone marrow activity and WBC counts are at their lowest levels after chemo
Different times for different drugs
Cell-kill hypothesis:
with each cell cycle a percentage of cancerous cells are killed but some remain; repeating chemo kills more cells until those left can be handled by body’s immune system
Classes of Chemotherapy Drugs (1)
Alkylating agents
Action: create defects in tumor DNA
Examples: Nitrogen Mustard, Cisplatin
Antimetabolites:
Action: similar to metabolites needed for vital cell processes
Metabolites interfere with cell division
Examples: Methotrexate; 5 fluorouracil
Toxic Effects: nausea, vomiting, stomatitis, diarrhea, alopecia, leukopenia
Antitumor Antibiotics:
Action: interfere with DNA
Examples: Actinomycin D, Bleomycin
Toxic Effect: damage to cardiac muscle
Classes of Chemotherapy Drugs (2)
Antimiotic agents
Action: Prevent cell division
Examples: Vincristine, Vinblastine
Toxic Effects: affects neurotransmission, alopecia, bone marrow depression
Hormone agonist
Action: large amounts of hormones upset the balance and alter the uptake of other hormones necessary for cell division
Example: estrogen, progestin, androgen
Classes of Chemotherapy Drugs (3)
Hormone Antagonist
Action: block hormones on hormone-binding tumors (breast, prostate, and endometrium); cause tumor regression
Decreasing the amount of hormones can decrease the cancer growth rate
Does not cure, but increases survival rates
Examples: Tamoxifen (breast); Flutamide (prostate)
Toxic Effects: altered secondary sex characteristics
Classes of Chemotherapy Drugs (4)
Hormone inhibitors
Aromatase inhibitors (Arimidex, Aromasin)
Prevents production of aromatase which is needed for estrogen production
Used in post menopausal women
Side effects (Masculinizing effects in women, Fluid retention)
Effects of Chemotherapy
Tissues (fast growing) frequently affected
Examples:
Mucous membranes
Hair cells
Bone marrow
Specific organs with specific agents, reproductive organs (all fetal toxic, impair ability to reproduce).
Administration of chemotherapeutic agents
Trained and certified personnel, according to established guidelines
Preparation
Protect personnel from toxic effects
Drugs absorbed through skin and mucous membranes
Protective clothing and extreme care
Extreme care for correct dosage; double check with physician orders, pharmacist’s preparation
Proper management clients’stool
Routes
Oral
Body cavity (intraperitoneal or intrapleural)
Intravenous
Use of vascular access devices because of threat of extravasation (leakage into tissues) and long-term therapy
If the drug is a vessicant it may result in pain, infection and tissue loss
Types of vascular access devices
PICC lines (peripherally inserted central catheters)
Tunnelled catheters (Hickman, Groshong)
Surgically implanted ports (accessed with 90o angle needle)
Portacath
PICC Line
Managing side effects of chemotherapy (1)
Nausea and vomiting
80% of patients will develop it
Antiemetics such as:
Zofran
Tigan
Compazine
Ativan to control the symptoms
Monitor for dehydration and need for IV fluids
Managing side effects of chemotherapy (2)
Bone marrow suppression
Decreased number of RBC
Leads to hypoxia, fatigue
Hgb 9.5-10 gm/dl require oral iron supplements
Hgb below 8 gm/dl require transfusion
May use Epogen to stimulate RBC production
Managing side effects of chemotherapy (3)
Decrease number of WBC (normal 4,500-11,000 mm3) especially neutrophils (normal 3,000-7,000 cells/cc)
Neutropenia-count below 2000
Patient at extreme risk for infection
May order granulocyte colony stimulating factor (leukine) to stimulate bone marrow to increase WBC count
Neutropenic precautions
Private room
Good handwashing
Monitor temp q 4 hours, monitor for chills, UTI, pneumonia
Limit visitors to healthy adults
No flowers or plants
Monitor neutrophil count
Managing side effects of chemotherapy (4)
Thrombocytopenia
Drop in platlet count (normal 150,000-400,000/mm3) below 100,000
Test pt for bleeding in stool and urine
Avoid punctures for IV or IM
Handle pt gently
Use electric razor
Avoid placing foley or rectal thermometers
Avoid oral trauma with soft bristle brushes, avoid flossing, avoid hard candy
Watch for LOC, pupil changes that might indicate intracranial bleeds
Stool softeners to avoid straining
Managing side effects of chemotherapy (5)
Mucocitis
Inflammation and ulceration of mucous membranes and entire GI tract
Rinse mouth with ½normal saline and ½peroxide every 12 hours
Topical analgesic medication
Avoid mouthwashes with alcohol
Avoid spicy or hard food
Watch nutritional status
Managing side effects of chemotherapy (6)
Alopecia
Hair loss
2-3 weeks after treatment is started
Affects all the hair, including eyebrows, eyelashes
Within 4-8 weeks after treatment hair begins to grow back
Before hair loss, have the pt pick out a wig that is similar to hair color
Managing side effects of chemotherapy (7)
Peripheral neuropathy
Numbness and tingling to fingers and toes in a glove and sock pattern
May cause gait and possible fall problems
Provide emotional and spiritual support to patient and families
Surgery
Diagnosis, staging, and sometimes treatment of cancer
May be prophylaxis or removal of at risk tissue or organ prior to development of cancer (breast cancer)
Involves removal of body part, organ, sometimes with altered functioning (e.g. colostomy)
Debulking (decrease size of) tumors in advanced cases
Reconstruction and rehabilitation (e.g. breast implant post mastectomy)
Palliative surgery to improve the quality of life
Removal of tumor tissue that is causing pain or obstruction
Psychological support to deal with surgery as well as cancer diagnosis
Radiation Therapy (1)
Treatment of choice for some tumors to kill or reduce tumor, relieve pain or obstruction
Destroy cancer cells with minimal exposure to normal cells
Cells die or are unable to divide
Delivery
Teletherapy (external): radiation delivered in uniform dose to tumor
Beam radiation
Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is placed in tumor or next to it in the form of seeds
Radiation source within the patient so pt emits radiation for a period of time and is a hazard to others
Combination
Radiation Therapy (2)
Goals
Maximum tumor control with minimal damage to normal tissues
Caregivers must protect selves by using shields, distancing and limiting time with client, following safety protocols
Private room
Caution sign on the door for radioactive material
Dosimeter film badge by staff
No pregnant staff
Limit visitors to ½hour per day and keep them at least 6 ft from the source
Radiation Therapy (3)
Treatment Schedules
Planned according to radiosensitivity of tumor, tolerance of client
Monitor blood cell counts
5.Side Effects
Skin (external radiation): blanching, erythema, sloughing, breakdown
Use mild soak
Dry skin with a patting motion, not rubbing
Don’t use powders or lotions unless prescribed by radiologist
Wear soft clothing over the site
Avoid the sun and heat
Radiation Therapy (4)
b.Ulcerated mucous membranes: pain, lack of saliva (xerostoma)
c.Gastrointestinal: nausea and vomiting, diarrhea, bleeding, sometimes fistula formation
d.Radiation pneumonitis
1-3 months after treatment
Cough, SOB, fever
Treated with steroids to decrease inflammation
Biological Response Modifiers
Monoclonal antibodies (inoculate animal with tumor antigen and retrieve antibodies against tumor for human)
Antibodies target specific substances needed by the cancer cell for growth (Herceptin for breast cancer)
Gene therapy
experimental
May insert gene into the tumor cells to make them more susceptible to being killed by antiviral agents
May insert genes for cytokines that increase their effectiveness in killing cancer cells
Angiogenesis inhibitor drugs
Prevent new blood vessels from forming and delivering blood to the tissue
Bone Marrow Transplant (BMT)
Bone Marrow Transplantation and Peripheral Blood Stem Cell Transplantation
Stimulation of nonfunctioning marrow or replace bone marrow
Common treatment for leukemias
Pain Control
Includes pain directly from cancer, treatment, or unrelated
Necessary for continuing function or comfort in terminally ill clients
Goal is maximum relief with minimal side effects
Multiple:
Combinations of analgesics (narcotic and non-narcotic)
Adjuvants such as steroids or antidepressants
Iincludes around the clock (ATC) schedule with additional medications for break-through pain
Routes of medications
May involve injections of anesthetics into nerve, surgical severing of nerves radiation
May need to progress to stronger pain medications as pain increases and client develops tolerance to pain medication
Nursing Diagnoses for Clients with Cancer
Anxiety
Therapeutic interactions with client and family
Community resources
الملاذ
KHCC
Availability of community resources for terminally ill