NU 428 Intro to Oncology
What is cancer? What is the fastest growing cancer?
Uncontrolled group of cells.
Melanoma – fastest growing cancer rate.
What are the two biologic processes behind the growth of cancer?
1) Defect in Cellular Proliferation:
A. Usually activated because of cell degeneration or death.
B. Contact Inhibition - Normal cells don’t invade the territory of another. It's like a fence between the cell's territory.
Cancer cells divide haphazardly, indiscriminately & continuously. Where a normal cell divides into two cells, a cancer cell can divide into many more cells in one division. The rate of division is not faster, per say, but the cell divides haphazardly and can't control how it grows.
Pyramid Effect: Each cell division causes a mass of cells, abnormal division where the cell can't control anything.
Doubling Time: Time it takes for cancer mass to double.
2) Defective Cellular Differentiation:
2 genes affected by differentitaion mutations
Protooncogenes – Promote growth.
Oncogenes – Protooncogenes that have mutated and do not understand how growth is supposed to occur.
Tumor Suppressor Genes – Suppress growth of tumors.
Difference between malignant & nonmalignant –ability to invade & metastisize.
What are the 3 phases of cancer development?
Mutation occurs in the DNA of a cell.
DNA is permanently rearranged. It can either:
- 1. Die
- 2. Self repair
- 3. Survive & pass on mutation
Options 1 and 2 are great and do not turn into cancer. Option 3 turns into cancer.
Cell has potential to clone self.
If not destroyed before cloning & reproducing then proliferation can occur.
- Carcinogen - smoking
- Chemical – cleaning supplies
- Viral – Epstein Barr virus (mono) is associated with a form of lymphoma
- Genetic Susceptibility
Reversible proliferation: at this point, our bodies can reverse the process in theory. IF the mass is small enough, the body can destroy it.
Lifestyle habits: Play a large role in whether or not the body can fight off cancer on its own.
Complete carcinogen: Cigarette smoke is a complete carcinogen (it can cause cancer all by itself).
Latent period – time between genetic alteration & clinical evidence. If it's short, the cancer is probably a fast-growing one.
Critical Mass: the point at which cancer cells become evident.
- 1 cm mass – smallest to palpation
- 0.5 cm mass – smallest diagnostically with MRI.
Increased growth rate of tumor & by increased invasiveness & metastasis.
Metastasis: Goes from one place to a distant place
Is a multistep process.
Tumor Angiogenesis: Tumor's ability to cells to establish its own blood supply away from the original site. No angiogenesis, no metastasis.
Invades surrounding tissues.
- Cells penetrate walls of lymph or blood vessels.
- Hematogenous metastasis – travel via bloodstream.
- Skip metastasis – travel via lymph & may skip nearer lymph nodes.
- Once in a new site a blood supply is established & tumor growth begins.
What are the roles of the immune system in fighting against cancer?
Identifies self from non-self
Immunologic Surveillance – identifies antigens on surface of malignant cells
- Cytotoxic T cells, natural killer cells, macrophages, & B lymphocytes work to ID and destroy.
Oncofetal Antigens – type of tumor antigen
- Found in fetal period and reflect a shift in the cell to regain its embryonic capability to differentiate.
- Used to monitor effects of therapy and tumor recurrence.
What are the purposes of classification of cancer?
Relays information to healthcare team.
Determines the best treatment plan.
Evaluates treatment plan.
How is a tumor identified anatomically?
Tumor is identified by:
1. Tissue of origin
- Carcinomas - (skin, glands, mucous membrane linings, GI & GU tract)
- Sarcomas - (connective tissue, muscle, bone, fat)
- Lymphomas & leukemias – (blood & lymph)
2. Anatomic Site
3. Tumor behavior (benign or malignant)
How is a tumor graded histologically?
Appearance & degree of differentiation are evaluated.
Poorly differentiated tumors - worse prognoses.
Grade I –Slightly different from normal (mild dysplasia) & well differentiated (low grade).
Grade II –More abnormal (moderate dysplasia) & moderately differentiated (intermediate grade).
Grade III – Very abnormal (severe dysplasia) & poorly differentiated (high grade).
Grade IV – Immature & primitive (anaplasia) & undifferentiated; cell of origin is difficult to determine (high grade).
Grade X – Cannot be assessed.
How is a tumor staged clinically?
Based on extent of disease rather than cell appearance.
Stage 0 – Cancer in situ (localized to specific site of origin).
Stage I – Tumor limited to original tissue with localized growth.
Stage II – Limited local spread (has gone to other surrounding tissues).
Stage III – Extensive local & regional spread.
Stage IV – Metastasis (spread to distant site).
What is the TNM classification for cancer?
- T 0 - No evidence of primary tumor
- T is - Carcinoma in situ: growing in normal place but could become cancer, "pre-cancer" cells.
- T 1-4 - Ascending degrees of tumor size & involvement
- T x – Tumor cannot be measured or found
N – Spread to lymph nodes
- N 0 – No evidence of disease in lymph nodes
- N 1-4 – Ascending degrees of nodal involvement
- N x – Regional lymph nodes unable to be clinically assessed
M – Metastasis
- M 0 – No evidence of distant metastasis
- M 1-4 – Ascending degrees of metastatic involvement of the host, including distant nodes
- M x – Cannot be determined
What are the methods of prevention and detection of cancer?
- Reduce carcinogens
- Balanced diet
- Regular exercise
- Consistent rest
- Regular health exams
- Reduce or eliminate stressors
- Know & intervene on 7 warning signs of CA
- Learn and practice screenings
- Self examination
- Seek professional help if changes are noted
What are the 7 warning signs of cancer?
C – hange in bowel or bladder habits.
A – sore throat that doesn’t heal.
U – nusual bleeding or discharge from any body orifice.
T – hickening or a lump in the breast or elsewhere.
I – ndigestion or difficulty in swallowing.
O – bvious change in a wart or mole.
N – agging cough or hoarseness.
What are the ACA's recommendations for early detection of cancer?
- Women 40 & older
- Annual mammogram & clinical breast exam. BSE monthly.
Colon & rectum
- Men & women age 50 & older
- Fecal occult blood test q year & colonoscopy q 10 years.
- At age 50
- PSA & digital rectal exam based on risk and doctor recommendations.
- Pap test 3 years after initiation of vaginal intercourse and no later than age 21.
- Paps every 1-2 years if Pap test is liquid based vs slide based.
How is cancer diagnosed? What is the only definitive way to diagnose cancer?
ID Risk Factors
Specific Diagnostic Studies:
- Cytology studies (pap)
- Chest x-ray
- Sigmoidoscopy or Colonoscopy
- Liver function studies
- Radioisotope scans (bone, lung, liver, brain)
- PET scan
- Tumor markers
- Bone Marrow Exam
Biopsy is the only definitive of cancer diagnosis.
Histologic exams on tissue.
Needle – Needle aspiration
Incisional – Scalpel or dermal punch
Excisional – Entire tumor
What are the goals of cancer treatment?
- Time varies with cancer type
- Goal chronic cancers
- Treatment followed by maintenance therapy & careful follow ups
Palliation: Relief & control of symptoms
All goals are achieved through 4 treatment modalities:
4. Biologic therapy
What are the benefits of surgical therapy?
Cure & Control
- Cancers with slow proliferation respond best.
- Regional lymph nodes - removed or biopsied
- Feeding tubes, Colostomy, suprapubic cystostomy
Palliative Care – makes person comfortable
- Debulking: can be done when tumor cannot be completely removed (example is a brain tumor)
- Laminectomy – usually go in and remove as much as possible for better QOL.
- Feeding tubes
- Suprapubic cystostomy – allows them to urinate
What is the goal of chemotherapy? How do cancer cells respond to chemotherapy?
Goal of chemotherapy
- Reduce # of cancer cells.
Cancer cell response factors to chemo:
- Mitotic rate – more rapid growth = greater response.
- Size of the tumor – Smaller = greater response.
- Age of the tumor – Younger = respond better.
- Location – Certain sites protect tumor.
- Presence of resistant tumor cells – Mutant cells may be resistant to chemo.
Brain tumors do not respond well to almost anything. Can't get most therapeutic agents through the BBB. Most the time have to radiate brain tumors.
What are the different types of chemo?
Cell cycle-nonspecific chemotherapeutic drugs
- Replication, proliferation & resting phase.
Cell cycle phase-specific chemotherapeutic drugs
- Replication & proliferation.
- Biggest effect = specific phases of cell cycle.
What should a nurse know about chemo preparation and administration?
Dangerous to healthcare workers: Only chemo trained nurses should handle, prepare and administer.
Methods of Administration:
Oral & peripheral IV – most common methods. MUST WATCH IV SITE. If it infiltrates, it will destroy all surrounding tissue in a short period of time.
Central Vascular Access Device: usually for long-term chemo.
- Permanent devices for frequent, continuous, or intermittent usage.
- Indication - limited vascular access or anticipated long term need.
- Decreased extravasation & reduced venipuncture.
- Common with peripheral IV.
- Infiltration into tissues surrounding infusion site.
- Vesicants cause severe local tissue breakdown & necrosis.
- Pain, swelling, redness & vesicles on the skin are signs.
- Tissues ulcerate & necrose.
- Skin grafts.
- Stop infusion and call doc!
Can cause systemic infection.
Monitor temp and CBC frequently
Regional Chemotherapy Administration:
- Intraarterial Chemotherapy: Via arterial vessel
- Intraperitoneal Chemotherapy: Via peritoneal cavity
- Intrathecal or Intraventricular Chemotherapy: Via lumbar puncture
- Intravesical Bladder Chemotherapy: Via the bladder
What are some side effects of chemo?
- Allergic reaction
- Mucositis – erosion of the mouth
- Alopecia – hair loss
- Bone marrow suppression – close watch on CBC
- Damage to organs – can be lifelong
What is the treatment plan regarding chemo?
Most given in combination with radiation.
Calculated according to body wt.
Chosen based on responsiveness of the tumor.
Principles of combination therapy:
- Effective against specific cancers
- Synergistic effects
- Should include cell cycle phase-specific & cell cycle-nonspecific drugs
- Should include different side effects
- Combos should cause nadirs (lowest level of peripheral blood cell count) at different times. One will cause low WBCs and one will cause low platelets. Want those types to cause those lows (nadirs) at different times as to not place the body in too weak or fragile of a state.
All given according to a schedule with times of rest.
May be repeated several times.
What are the principles of radiation therapy?
Breaks DNA bond of cells.
Cumulative doses best.
Most normal tissue can recover.
GI tissues, oral tissues, bone marrow respond best.
Cartilage, bone, & kidney cells respond poorly.
Simulation – Fluoroscopy identifies the structures to be radiated & marks are placed.
- Teletherapy - Use beams to target site.
- Brachytherapy – “Close radiation”. Implantation of radioactive materials directly into or around the tumor.
- Principles of time, distance, & shielding are important. Staff should be specifically trained.
Goals of Radiation Therapy:
- Control: Used initially & subsequently if needed.
- Palliation: Used to control distressing symptoms
How do chemo and radiation affect bone marrow?
Bone Marrow Suppression
Causes infections, hemorrhage and fatigue.
Potentially life threatening
Chemo – systemic / Radiation - local
Bone marrow effected at same rate as the life span of the cell in question.
WBC’s – 1-2 wks.
- Neutropenia – severe infection & sepsis.
- Handwashing - primary intervention.
- Watch s/s of infection.
- Treatment - WBC growth factors (Neupogen, Neulasta) and as a prophylaxis also.
Platelets – 2-3 wks.
- Thrombocytopenia – spontaneous bleeding or hemorrhage.
- Avoid invasive procedures.
- Platelet transfusion if count falls below 20,000 mL
RBC’s – 2-3 months.
- Anemia becomes problematic 3-4 mos after therapy begins.
- RBC growth factors may be given (Aranesp & Procrit).
Monitor blood counts carefully.
Nadir usually comes at 7-10 days after initiation of therapy.
How should a nurse manage fatigue as a side effect of chemo and radiation?
Begins during 3rd to 4th wk.
Encourage rest before activity and activity when feeling more energetic.
Remain active as much as possible.
What are GI effects of chemo and radiation?
GI Effects – due to sensitivity of GI tissues:
Nausea & Vomiting
- Reglan, Compazine, Zofran, Kytril, Anzemet, Aloxil, and Decadron
- Emend is 1st drug to be known effective in preventing N&V on day of therapy.
- Medicate 1 hr before treatment.
- Monitor careful I & O.
- Diet modification, antidiarrheals, antimotility agents, and antispasmodics.
- Low fiber low residue.
- Limit roughage.
- Avoid irritating foods.
- Monitor I & O and # & character of daily stools.
Mucositis: Irritation, inflammation, and/or ulceration of mucosa.
Xerostomia – due to damaged salivary glands
- Meticulous oral care and saliva substitutes.
Dysgeusia – loss of taste, progressive during therapy.
- Characterized by “lump” in throat
Odynophagia: painful swallowing
- May require analgesics
Careful oral assessments vital.
Teach patient to examine oral cavity.
Teach meticulous oral care.
Kepivance – given IV and stimulates cells on surface layer of the mouth to grow.
- Peaks at 4 weeks and resolves quickly when treatment ends.
- Body weight twice weekly.
- Small, frequent meals - better tolerated than large, heavy meals.
- Feeding - soft & nonirritating, high protein, high calorie.
- Nutritional supplements should be encouraged.
- Enteral or parenteral nutrition may be indicated.
What are some skin reactions caused by chemo and radiation?
Erythema - 1-24 hrs after treatment.
Wet Desquamation –Dermis is exposed & oozing occurs. Keep area clean & protected. No lotions or applications. Burow’s solution soaks.
Dry Desquamation – associated with pruritus. Lubricate.
No heating pads, ice packs, hot water bottles on irradiated area. Could cause tissue damage. They lose sensation on radiated area.
Palmar-plantar erythrodyesthesia (PPE) – hand/foot syndrome
- Redness and tingling of palms of hands and soles of feet.
- Can cause moist desquamation, ulceration, blistering and pain.
- Withhold chemo for 1 – 2 weeks if severe.
Radiation – effects are local
Chemo – effects are systemic
What are some pulmonary and cardiovascular effects of chemo and radiation?
- Pneumonitis – inflammation of lung tissues. Tx is bronchodilators, expectorants, bed rest & oxygen if symptomatic.
- Pulmonary fibrosis may develop 6 months to 2 yrs after treatment and may be chronic.
- Cough & dyspnea - due to unplugging of blocked alveoli. Tx is cough suppressant.
- Radiation damage to pericardium, myocardium, valves and coronary blood vessels.
- Preexisting CAD is risk factor.
- Dose adjustments may need to be made to offset potential risk.
What are the effects of chemo and radiation on the reproductive system?
Permanent Aspermia – recovers in 2-5 years or not at all.
No avenue of repair for ovarian function. Use shielding.
Prior counseling is advised & banking of sperm or ova may be desired.
Recommend men and women to bank sperm and eggs before chemo if having abd or pelvic radiation. If not pelvic or abd radiation, could just use shield to protect it. But chemo also causes reproductive ramifications.
What are some late risks of chemo and radiation?
Cancer survivors at risk for leukemias & other secondary malignancies.
Secondary malignancies = usually resistant to therapy.
Multisystem organ dysfunction
How does biologic therapy treat cancer? Target therapy?
Biologic therapy modifies the relationship between the host & tumor:
1. Direct antitumor effects.
2. Restore or improve host immune mechanisms.
3. Can interfere with cell’s ability to metastasize or differentiate.
Targets and disables pathways important in tumor growth.
Targets cancer cells without damaging normal cells.
What are some symptoms of biologic and target therapy?
Stimulate the release of other endogenous biologic agents.
Causes systemic immune and inflammatory responses.
- Flu-like symptoms: Acetaminophen q 4 hrs is tx.
- Orthostatic Hypotension
- Various neurologic symptoms
- Various skin rashes
Symptoms directly related to dose and schedule.
What are some nursing management principles a nurse should implement when caring for a patient on biologic or targeted therapy?
More severe symptoms
- Critical care nursing skills
Tylenol before treatment and q 4 hrs as ordered for flu-like symptoms.
Demerol IV as ordered: Control chills
Plan periods of rest.
Assist with ADLs.
Monitor adequate oral intake.
Why are hematopoietic growth factors used in conjunction with chemo and radiation?
- Stimulate production, maturation, regulation, and activation of hematologic cells.
- Only for anemia with chemotherapy
- Lowest dose should be used
What are the principles of hematopoietic stem cell transplantation?
AKA “bone marrow transplant”.
Goal is cure.
Has many risks & some pts die from complications.
Types of Marrow Transplants:
- Comes from an HLA (human leukocyte antigen)compatible donor.
- Often from a family member - can be from marrow registry.
- Most likely to cause graft vs. host disease.
2) Autologous: Receive own marrow. Marrow is treated and reinfused.
3) Syngenic: Stem cells from an identical twin are infused.
What should a nurse know about the stem cell harvesting procedure?
Done in an OR under general or spinal anesthesia.
Multiple bone marrow aspirants
- Taken from the iliac crest &/or sternum.
- Takes 1-2 hrs.
Donor - pain at the collection site
- Mild analgesics
After harvest, autologous bone marrow treated.
After allogenic procedures bone marrow can be infused within a few hours.
Goal is to kill cancer cells with large doses of chemo/radiation & “rescue” the bone marrow.
Complications are multiple infections from the immunosuppression & graft-versus-host disease.
- Monitor CBC
What are some nutritional complications of cancer?
- High calorie foods in small, frequent meals.
- Suggest to primary provider that supplements should be implemented when patient has lost 5% body wt.
- Once a 10 lb loss has occurred, nutritional status is difficult to maintain.
- Enteral or parenteral nutrition may be necessary in some cases.
Altered Taste Sensation:
- Bitter, sweet, salty, & sour tastes may be altered.
- Avoid foods that patient doesn’t like.
- Encourage client to experiment with spices.
What is the primary cause of death complication in cancer patients?
Infection – primary cause of death in CA pts.
Can result d/t:
- Ulceration & necrosis
- Compression of vital organs
Notify doctor for temp > 100.4.
What are some emergent complications of cancer and what are their treatments?
Superior Vena Cava Syndrome
- Tumor obstructs superior vena cava.
- Manifestations - edema & swelling of upper extremities, headache, seizures.
- Treatment - radiation to shrink tumor size.
Spinal Cord Compression
- Malignant tumor in epidural space of spinal cord.
- Manifestations - intense back pain, motor weakness, numbness in arms & legs.
- Radiation & surgery are treatments.
Third Space Syndrome
- Shifting of fluid from intravascular to extravascular.
- Treatment - fluid replacement.
Syndrome of Inappropriate Antidiuretic Hormone
- Abnormal or sustained production of ADH.
- Causes fluid retention & low Na+.
- Symptoms - wt gain, weakness, N/V, personality changes, seizures & coma.
- Treatment - fluid restriction.
- From bone cancer or bone mets.
- Cells secrete a parathyroid hormone-like substance. Parathyroid controls calcium regulation.
- Manifestations - apathy, weakness, fatigue, dysrythmias, N/V.
- Treatment - control of primary disease, hydration, diuretics, & bisphosphonates (Aredia & Zomeda are drugs of choice).
Tumor Lysis Syndrome
- Rapid destruction of cancer cells.
- Can result in acute renal failure.
- 4 hallmark signs: hyperuricemia, hyperphosphatemia, hyperkalemia, & hypocalcemia.
- Goal - prevention of acute renal failure (ARF) & severe electrolyte imbalances.
- Treatment - hydration & decreasing uric acid (Allopurinol).
Septic Shock & Disseminated Intravascular Coagulation.
- Fluid accumulation in the pericardial sac, constriction of the pericardium by a tumor, or pericarditis secondary to radiation.
- Manifestations - SOB, tachycardia, dysphagia, muted heart sounds, & extreme anxiety.
- Treatment - surgery to release pressure.
Carotid Artery Rupture
- Head & neck tumors invade carotid artery.
- Apply direct pressure to site with finger.
- Carotid artery must be surgically ligated & tumor must be reduced.
What are the principles of management of cancer pain?
Inadequate pain assessment - single greatest barrier to effective pain mgt.
Always believe the patient.
Fear of addiction is not warranted.
Analgesics should be given round the clock with additional doses as needed.
Appropriate opioid doses are whatever is necessary to control the pain with the least side effects.
How should a nurse assist a patient in coping with the diagnosis of cancer?
Assess support systems.
Give written information about condition.
Help set realistic short & long term goals.
Assist with maintaining usual lifestyle patterns.