cancer development and cancer nursing created by marsha woodall mba, msn, rn
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Cancer Development and Care of Patients with Cancer
Presented by: Marsha Woodall MBA, MSN, RN
Revised 2012For NIP 210
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.
EpidemiologyAffects every age
groupMost occur in people
over age 65More than 1.2
million Americans are diagnosed each year
More than 560,000 deaths/yr in USA
Leading causes of cancer in men: lung, prostate, colorectal
Leading causes of cancer in women: lung, breast, colorectal
True or FalseThe risk of dying from cancer in the US is increasing.
Pathophysiology of the Malignant ProcessCANCER 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 CharacteristicsMode of GrowthRate of Growth
MetastasisGeneral Effects
Cancer Development (Malignant Transformation)InitiationPromotionProgressionMetastasisExtension into surrounding tissuesPenetration into blood vesselsRelease of tumor cellsInvasion of tissue
Metastatic MechanismsLocal Seeding
Bloodborne Metastasis
Lymphatic Spread
EtiologyChemical Agents Physical Agents VirusesDietary Factors Immune function Genetic and Familial
FactorsAgeGenetic 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 ConsiderationsSee chart 23-9 p. 405
C hange in bowel or bladder habitsA sore that does not healU nusual bleeding or dischargeT hickening or lump in breast or other part of bodyI ndigestion or difficulty in swallowingO bvious change in wart or moleN agging cough or hoarseness
Detection and Prevention of CancerPrimary Prevention: Nurses play a
key role in cancer preventionAvoidance of Known carcinogensModification of associated factorsRemoval of “at risk” tissuesChemoprevention
Detection and Prevention of Cancer
Secondary Prevention:
Promotion of cancer screenings
Gene therapy for cancer prevention
Stages of Cancer Cell InvasionIn situ – noninvasive neoplasmLocalized – invasive neoplasm
confined to the organ of originRegional – invasive neoplasm that
extends into surrounding tissueDistant – a neoplasm that spreads to
distant parts of the body
STAGING: Determines the size of the tumor and the existence of metastasis. TNM system;
T = extent of primary tumorN = lymph node involvementM = extent of metastasis
GRADING: Classification of tumor cells obtained through cytology (biopsy). I to IV:
I = Closely resemble tissue of originIV = Poorly differentiated (more aggressive and less responsive totreatment)
Question 1What are the odds of a man dying from cancer in the U.S.?
A.1 in 2B.1 in 4C.1 in 25D.1 in 50
Question 2What race has the highest incidence of cancer?
A.African AmericanB.Hispanic/LatinoC.AsianD.Caucasian
Question 3An example of a primary prevention strategy for reducing cancer risk would be:
A.Yearly mammography for women older than 40 years
B.Regular physical exerciseC.Colonoscopy at age 50 years and
then every 10 yearsD.Avoiding red meat in the diet
Cancer Therapy Goals and ResponsePreventionCureControlPalliationAdjuvant
Neoadjuvant Chemo-prevention
Myeloablation
Immuno-suppressionp. 17
Management of CancerSurgery
DiagnosticPrimary TreatmentProphylacticPalliativeSecond-lookReconstructive or rehabilitation
True or FalseTreating cancer with surgery causes it to
spread throughout the body.
Treatment StrategiesCombination versus single-agent therapy
Dose or dose intensity of chemotherapy
Hormone receptor status
p. 18
Measuring ResponseComplete response (CR)Partial response (PR)Stable disease (SD)Progressive disease (PD)Relapse
p. 19-20
Radiation Therapy (See charts on p. 420)IonizingControl malignant diseasePalliativeExternal (teletherapy)Internal (brachytherapy)DosageToxicity
SkinMucous membranesBone marrow
Best Practice for Patient Safety & quality Care and patient/family educationSee page 417
ChemotherapyAntineoplastic agents used to kill tumor cells by interfering with cellular functions and reproduction
Used primarily to treat systemic disease
Goals:CureControlPalliation
Cell CycleG1 phase - RNA
and protein synthesis
S phase - DNA synthesis
G2 phase - premitotic; DNA synthesis complete
Mitosis - cell division occurs
Go phase - Rest
G2
S M
G1Go
Classification of Chemo agentsCell cycle - specific drugsCell cycle - nonspecific drugsAlkylating agentsNitrosureasAntimetabolitesAntitumor antibioticsPlant alkaloidsHormonal agentsMiscellaneous agents
Alkylating AgentsBreaks DNA helix strand, thereby
interfering with DNA replication
Agents given via different routes depending on the medication
Alkylating AgentsExamples:Carboplatin (Paraplatin)Cis-Platinum, PlatinolCyclophosphamide (Cytoxan) Dacarbazin (DTIC)Thiotepa (Thioplex)
AntimetabolitesIncorporate 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
Chemotherapy AgentsAntimetabolites
capecitabine (Xeloda)cytarabine (Cytosar-U)floxuridine (FUDR)fludarabine (Fludara)fluorouracil (Efudex)
Antitumor Antibiotics
bleomycin (Blenoxane)dactinomycin (Cosmegen)daunorubicin (Cerubidine)doxorubicin (Adriamycin PFS)epirubicin (Ellence)
Inhibit DNA-dependent RNA synthesis or delay or inhibit mitosis
Nitrogen Mustards
chlorambucil (Leukeran)estramustine (Emcyt)mechlorethamine (Mustargen)melphalan (Alkeran)thiotepa
Disrupts normal nucleic acid function in DNA and RNA to inhibit reproduction
Plant Alkaloids
docetaxel (Taxotere)etoposide (VePesid)irinotecan (Camptosar)paclitaxel (Taxol)vinblastine (Velban)vincristine (Oncovin, Vincasar PFS)
Inhibit formation of spindle fibers, arresting the metaphase stage of cell division
Cytoprotective (Rescue) AgentsAdministered to reduce side effects and
toxicity of chemotherapeutic agentsChemotherapy agent must be active long
enough to kill malignant cellsThen the rescue agent is given to prevent
destruction of healthy cells
amifostine (Ethyol)dexrazoxane (Zinecard)leucovorin
Routes of AdministrationOralSubcutaneous or intramuscularItra-arterialIntrathecallyIntraperitonealIntrapleuralIntravesicularIntravenous
p. 95
Intrathecal route
Mediport or Portacath
VesicantsAgents that cause extravasation if deposited into subq tissue
Vesicants are:DactinomycinDaunorubicinAdriamycinNitrogen mustardMitomycinVinblastineVincristineVindesine
Indications of ExtravasationAbsence of blood return from the IVFlow is resistantSwelling, 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
PainRednessSwellingBlood returnUlceration
p. 107
Toxicity with chemotherapyGI
Nausea/VomitingStomatitis/Mucositis
MyelosuppressionLeukopeniaAnemiaThrombocytopeniaNeutropenia
RenalCisplatin, MTX, Mitomycin = Kidney toxicityhyperkalemia, hyperphosphatemia,
hypocalcemiaMonitor BUN, serum creatinine, creat inine
clearance,electrolytes
• 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 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)
Systemic side EffectsChemotherapy 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
MyelosuppressionSuppression of bone marrow activityCan result in a decrease in any
combination of WBC, RBC or platelets
Most common dose-limiting toxicityPotentially LETHAL
NadirPoint at which the lowest blood-cell
count is reachedUsually 7-10 days after treatmentOnset and duration depends on
agent usedWBC & platelets are usually 1st to
dropAnemia is seen later
NeutropeniaBone marrow constantly produces
neutrophilsLife span of neutrophil is 7-12
hoursChemo agents suppress bone
marrow and damage stem cellsResulting in decreased neutrophil
count as mature neutrophils die & aren’t replaced
AnemiaRBC 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
ThrombocytopeniaDestruction or injury to stem cells
leads to dysfunction and suppression of platelet production
Normal life span – 7-10 daysNo bone marrow reserve of
precursorsSome chemo agents have
thrombocytopenia as their dose-limiting toxicity
Thrombocytopenia assessmentPetechiae/
bruisingOvert bleedingEnlarged liver
or spleenOccult or overt
blood in stool or urine
HeadachesHypotensionTachycardiaProlonged
menstruation
Risk of BleedingPlatelet Count
100,000
50,000
<15,000
Risk level/interventionChemotherapy reduced
or held
Increased risk of bleeding; initiate precautions (no injections, etc.)
Severe risk exists for spontaneous hemorrhage; frequent check of platelet counts/transfusions
Nausea and VomitingAnticipatory – occurs before or during
treatment (25% incidence)Acute – occurs within 24 hoursDelayed – occurs at least 24 hours after
therapy and may persist up to 6 days (Cisplatin associated with highest incidence)
Antiemetic Therapy for CINVOndansetron (Zofran)Granisetron (Kytril)Granisetron transdermal (Sancuso)Dolasetron (Anzemet)Palonosetron (Aloxi)
Drug combinations are individualized for best effect
Mucositis Clinical ManifestationsTaste changesSwallowing
difficultyHoarsenessPain with
swallowing or talking
Changes in color of oral mucosa
Oral moisture changes
EdemaUlcerations
Mucositis AssessmentPerform thorough oral assessment:
Standard instrumentPenlightGloved fingerInspect under tongue and along inner cheeks, gums, inspect hard & soft palate
Mucositis ManagementPrevention
Oral care protocolsPatient educationTreat dental
problems before cytotoxic therapy
High protein dietFluid intake > 1500
ml/dCryotherapy ofr
bolus 5-FU
TreatmentNo evidence-based
recommendationsGoal is symptom
relief, prevention of further damage
Oral agents & hygiene
Systemic pain medications
Culture lesions
Hormonal ManipulationSome 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 of Hormone TherapyMasculinizing effects in womenFeminizing effects in men (gynecomastia)Risk for venous thromboembolismAcneHypercalcemiaLiver dysfunctionBone loss
Photodynamic Therapy Selective destruction of cancer cells via
chemical reaction triggered by different types of laser light
Patient teachingGeneral 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
Fatigue Risk FactorsMalnutritionImmobilityInsomniaStressDepression/
anxietyAnemia
Comorbidities HypoxiaInfection/feverPainCancer therapy
Immunotherapy: Biological Response Modifiers (BRMs)Modify patient’s biological
responses to tumor cellsCytokines—enhance immune
systemInterleukins, interferonsSide effects—generalized,
sometimes severe inflammatory reactions, peripheral neuropathy, skin rashes
Colony-stimulating factorsAranesp and Procrit
Stimulates erythropoiesisAdministered SC
NeupogenRegulates the production of neutrophils within the bone marrow
Administered SC, IV
Colony-stimulating factorsNeulasta
Regulates the production of neutrophils within the bone marrow
Administered SCGM-CSF
Induces committed progenitor cells to divide and differentiate in the GM pathways
Administered SC, IV
Oncologic EmergenciesSepsis and disseminated intravascular coagulation
Collaborative management includes:Prevention (the best measure)Intravenous antibiotic therapyAnticoagulants, cryoprecipitated clotting factors
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 lungCollaborative management includes:
Fluid restrictionIncreased sodium intakeDrug therapy with demeclocycline that works
in opposition to antidiuretic hormone
Spinal Cord CompressionTumor 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 treatmentPalliativeHigh-dose corticosteroids High-dose radiationSurgeryExternal back or neck braces to reduce pressure in the spinal cord
HypercalcemiaOccurs most often in clients with
bone metastasisFatigue, loss of appetite, nausea and
vomiting, constipation, polyuria, severe muscle weakness, loss of deep tendon reflexes, paralytic ileus, dehydration, electrocardiographic changes
(Continued)
Hypercalcemia (Continued)Collaborative management includes:
Oral hydrationDrug therapyDialysis
Superior Vena Cava SyndromeSuperior 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)
Appearance of SVC Syndrome
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 SyndromeLarge 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:PreventionHydrationDrug therapy
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.
The health care provider’s orders are as follows:Strict I&O every 12 hoursMay use port for blood draws and IV fluidsCall for vomiting or temp of 100° F or greaterD5½NS at 125 mL/hrOndansetron (Zofran) 8 mg IV every 8 hrsClear liquid diet and progress as toleratedCBC, Ca level, and basic metabolic panel in AMBed rest with bathroom privilegesKnee-high support stockings
What is the rationale for each of the provider’s orders?
(cont’d)
Which of the provider’s orders should be implemented immediately?A. Administer D5½NS at 125 mL/hrB. Administer clear liquid dietC. Apply support stockingsD. CBC, Ca level, and basic
metabolic panel
(cont’d)
(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?
(cont’d)Match each chemotherapy side effect below with the correct intervention.A. AnemiaB. NeutropeniaC. 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.
Chapter 24
Audience Response System Questions
124
Question 1What 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.
Question 2A patient who is receiving radiation therapy for breast cancer would experience which side effect?
A.FatigueB.MucositisC.Hair lossD.Nausea and vomiting
Question 3When is the patient with acute leukemia at greatest risk of developing tumor lysis syndrome?
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