CARE OF PATIENTS WITH CANCERA. Characteristics of Normal Cells

The Biology of Normal Cells1) Have limited cell division2) Undergo Apoptosis3) Show specific morphology4) Perform specific differentiated functions5) Adhere tightly together6) Non migratory7) Grow in orderly and well regulated manner8) Are euploid

* Normal cell growth (cell cycle) consists of 5 intervals or phases * Differentiation – refers to the process whereby cells develop specific structures and functions in order to specialize in certain tasks

* Cellular adaptationa. Hypertrophy – refers to an increase in size of normal cellsb. Atrophy – refers to the shrinkage of cell sizec. Hyperplasia – refers to an increase in the number of normal cellsd. Metaplasia – refers to a conversion from the normal patters of

differentiation of one type of cell into another type of cell not normal for that tissue

e. Dysplasia – refers to an alteration in the shape, size, appearance and distribution of cells

f. Anaplasia – refers to disorganized, irregular cells that have nor structure and have loss of differentiation; the result is always malignant

B. Evolution of Cancer Cells1. Cancer – refers to a disease whereby cells mutate into abnormal cells

that proliferate abnormallyNeoplasia – refers to an abnormal cell growth or tumor

- a mass of new tissue functioning independently and serving no useful purpose

2. Invasion – occurs when cancer cells infiltrate adjacent tissues surrounding the neoplasm3. Metastasis – occurs when malignant cells travel through the blood or lymph system and invade other tissues and organs to form a secondary tumor

C. Characteristics of malignant cells1. Rapid cell division and growth: regulation of the rate of mitosis is lost2. No contact inhibition: cells do not respect boundaries of other cells and

invade their tissue areas3. Loss of differentiation: cells lose specialized characteristics of function for

that cell type and revert back to an earlier, more primitive cell type4. Ability to migrate (metastasize): cells move to distant areas of the body and

establish new site malignant lesions (tumors)5. Alteration in cell structure: differences are evident between normal and

malignant cells with respect to cell membrane, cytoplasm and overall cell shape

6. Self-survivala. may develop ectopic sites to produce hormones needed for own

growthb. can develop a connective tissue stroma to support growthc. May develop own blood supply by secreting angiotensin growth

factor to stimulate local blood vessels to grow into tumor

D. Epidemiology of Cancer1. Incidence of cancer

a. Cancer affects every age group though most cancer and cancer deaths occur in people older than 65 years of age

b. Cancer ranks 3rd as the cause of morbidity in the Philippinesc. Highest incidence of all cancer is prostate cancerd. Highest cancer incidence in males in order of frequency: prostate

cancer, lung cancer and colorectal cancere. Highest cancer incidence in females in order of frequency: breast

cancer, lung cancer and colorectal cancer

2. Common sites of cancer and their sites of metastasis

Cancer Type Sites of Metastasis1. Brain Cancer Central Nervous System2. Breast cancer Brain

LiverRegional lymph nodesVertebrae

3. Colon cancer BrainLiverLungLymph nodesOvaries

4. Lung cancer BoneBrainLiverLymph nodesPancreasSpinal cord

5. Prostate cancer BladderBoneLiver

External factors causing CANCER1. Chemical Carcinogens- over 1,000 chemicals are known to be carcinogenic

• Alcoholic beverages (Liver, esophagus, mouth, breast colon) -- serves as a promoter in cancers of the liver and esophagus

- when combined with tobacco, the risks for other cancers are even higher• Anabolic Steroid (Liver)• Arsenic (Lung; Skin)• Asbestos (Lung; peritoneum)• Benzene (Leukemia Diesel exhaust (Lung) Hair dyes (bladder) Pesticides (Lungs) Sunlight (Skin; eyes) Tobacco (Lungs; esophagus; mouth; pharynx; larynx

smokeless tobacco (snuff and chewing tobacco) increases the risk of oral and esophageal cancers* long-term exposure to secondhand smoke increases the risk for lung and

bladder cancers

2. Physical Carcinogens– Radiation– Chronic Irritation- GERD

3. Viral Carcinogens- some viral infections tend to increase risk of cancerEx: Epstein Barr Genital herpes Papillomavirus

Hepatitis B Human cytomegalovirus

4. Dietary Factors- diets in high fat, low in fiber and those containing nitrosamines found in

preserved meats and pickled foods promote certain cancers such as colon, breast, esophageal and gastric

Personal factors causing CANCER1. Immune Functions2. Age a. Increased risk for people over age of 65 b. Factors attributed to cancer in elderly include hormonal changes, altered immune responses and the accumulation of free radicals c. Age has been identified as the single most important factor related to the development of cancer

3. Gender a. certain cancers are more commonly seen in specific genders

ex: breast cancer –more common in female colon cancer – more common in males

4. Genetic Risk- 15% of cancers may be attributed to a hereditary component

Ex: Breast, colon, lung, ovarian and prostate cancers5. Race – can affect any population - African-Americans experience a higher rate of cancer than any other racial or ethnic group

CARCINOGENESIS: Transformation of Normal Cells into Cancer Cells1. Initiation – occurs when carcinogen damages DNA

- carcinogenesis cause changes in the structure and function of the cell at the genetic or molecular level. This damage may be reversible or may lead to genetic mutations if not repaired; however the mutations may not lead immediately to cancer 2. Promotion – occurs with additional assaults to the cell, resulting in further genetic damage3. These genetic events result in a malignant conversion4. Progression – the cells are increasingly malignant in appearance and behaviour and develop into an invasive cancer with metastases to distant body parts

Comparison of the Characteristics of Normal and Cancer CellsCharacteristic Normal Cells Cancer CellsMitotic cell division Mitotic division lead to 2

daughter cellsMitosis leads to multiple daughter cells that may or may not resemble the parent. Multiple mitotic spindles

Appearance 1. Cells of same type homogeneous in size, shape, and growth2. Cells cohesive, form regular pattern of expansion3. Uniform size to nucleus4. Have characteristic pattern of organization5. Mixture of stem cells (precursors) and well-differentiated cells

1. cells larger and grow more rapidly than normal; pleomorphic2. Cells not as cohesive; irregular patterns of expansion3. Larger, more prominent nucleus4. Lack characteristic pattern of organization of host cell5. Anaplastic, lack of differentiated cell characteristics, specific functions

Growth pattern 1. do not invade adjacent tissue2. Proliferate in response to specific stimuli3. Grow in ideal conditions (ex: nutrients, oxygen, space, correct biochemical environment)4. Exhibit contact inhibition5. Cell birth equals or is less than cell death6. Stable cell membrane7. Constant or predictable growth rate8. Cannot grow outside specific environment (ex: breast cells grow only in breast)

1. invade adjacent tissues2. Proliferation in response to abnormal stimuli3. Grow in adverse conditions such as a lack of nutrients4. Do not exhibit contact inhibition5. Cell birth exceeds cell death6. Loss of cell control a result of cell membrane changes7. Growth rate erratic8. Able to break off cells that migrate through bloodstream or lymphatics or seed to distant sites and grow in other sites

Function 1. have specific, 1. serve no useful purpose

designated purpose2. Contribute to the overall well-being of the host3. Function in specific, predetermined manners(ex: cells in the thyroid secrete thyroid hormone)

2. do not contribute to the well-being of the host; parasitic, actually feed off host without contributing anything3. If cells function at all, they do not function normally or they may actually cause damage (ex: lung cancer cells secrete ACTH and cause excessive stimulation of adrenal cortex)

Other 1. develop specific antigens, characteristic of the particular cell formed2. Chromosomes remain constant throughout cell division3. Complex metabolic and enzyme pattern4. Cannot invade, erode, or spread5. cannot grow in present of necrosis or inflammation

1. develop antigens completely different from a normal cell2. chromosomal aberrations3. have more primitive and simplified metabolic and enzyme pattern4. invade, erode and spread5. grow in presence of necrosis and inflammatory cells such as lymphocytes and macrophages6. exhibit periods of latency that vary from tumor to tumor7. have own blood supply and supporting stroma

Metastasis- ability of cancer cells to spread from the original site of the tumor to distant organs Stages: 1. Detachment

* tumor cell loses cohesiveness and it has increasing motility* tumor cell detaches from the primary tumor and create defects in the

basemement membranes with resulting stromal invasion and spread into the circulation 2. Migration

* Cancer cells migrate via the lymph or blood circulation or by direct extension

* the lymphatic system provides the most common pathway for the initial spread of malignant cancer cells

* The blood vessels carry cancer cells from the primary tumor to the capillary beds of the lungs, liver and bones

* Direct tumor extension of tumors to adjacent tissues also occurs 3. Dissemination

* Cancer cells are established at the secondary site which may result from entrapment due to the size of the tumor clump, adherence to cells at the new site through specific interactions, or by binding to exposed basement membrane 4. Angiogenesis

* Vascularization of the tumor

The Immune System and Cancer Two critical components of the immune response 1. the ability to recognize a pathogen as foreign 2. the ability to mount a response to eliminate the pathogen

* T-cell lymphocyte, macrophages, and antigens recognize cancers cells as non-self and destroy them

Immune Surveillance Theory – proposes that immune responses, particularly cell-mediated responses, provide a defense against cancer cells by recognizing the

antigens on the surface of some neoplastic cells as foreign

- they are killed by cytotoxic T cells that have receptors for specific tumor antigens and by interferon-activated natural killer (NK) lymphocytes and macrophages

- macrophages phagocytize the pathogen and present it as antigen to T and B lymphocytes

Failure of Immune Defenses- the immune system may be unable to recognize cancer cells as foreign or to mount an immune response due to the following: a. it’s immature, old or weak b. malnutrition or chronic ailment c. cancer cells escape detection because they resemble normal cells. Others produce substances that shield them from recognition or they may be coated with fibrin d. use of immunosuppressive drugs which can suppress immune system

Classification of Neoplasms1. Benign – from latin word “benigunus”- kind2. MalignantComparision of the characteristics of Benign and Malignant neoplasmCharacteristic Benign Neoplasm Malignant NeoplasmSpeed Growth Grows slowly

Usually continues to grow throughout life unless surgically removedMay have periods of remission

Usually grows rapidlyTends to grow relentlessly throughout lifeRarely, neoplasm may regress spontaneously

Mode of Growth Grows by enlarging and expandingAlways remains localized; never infiltrates surrounding tissues

Grows by infiltrating surrounding tissuesMay remain localized (in situ) but usually infiltrates other tissues

Capsule Almost always contained within a fibrous capsuleCapsule does not prevent expansion of neoplasm but does prevent growth by nfiltrationsCapsule advantageous because encapsulated tumor can be removed surgically

Never contained within a capsuleAbsence of capsule allows neoplastic cells to invade surrounding tissuesSurgical removal of tumor difficult

Cell characteristics Usually well differentiatedMitotic figures absent or scantyAnaplastic cells absentCells function poorly in comparison with normal cells from which they ariseIf neoplasm arises in glandular tissue, cells may secrete hormones

Usually poorly differentiatedLarge numbers of normal and abnormal mitotic figures presentCells tend to be anaplasticCells too abnormal to perform any physiologic functionsOccasionally a malignant tumor arising in glandular tissue secretes hormnes

Recurrence Unusual when surgically removed

Common following surgery because tumor cells spread into surrounding tissues

Metastasis Never occur Very commonEffect of Neoplasm Not harmful to host unless

located in area where it compresses tissue or obstructs vital organsDoes not produce cachexia (weight loss,

Always harmful to hostCauses death unless removed surgically or destroyed by radiation or chemotherapyCauses disfigurement,

debilitation, anemia, weakness, wasting)

disrupted organ function, nutritional imbalancesMay result in ulcerations, sepsis, perforations, hemorrhage, tissue sloughAlmost always produces cachexia, which leaves person prone to pneumonia, anemia, and other conditions

Prognosis Very goodTumor generally removed surgically

Depends on cell type and speed of diagnosisPoor prognosis if cells are poorly differentiated and evidence of metastatic spread existsGood prognosis indicated if cells still resemble normal cells and there is no evidence of metastasis

Classification of cancer according to tissue of origin1. Carcinoma - refers to a tumor that arises from epithelial tissue; the name of

the cancer identifies the location example: basal cell carcinoma 2. Sarcoma - refers to a tumor arising from supportive tissues; the name of the cancer identifies the specific tissue affected example: osteosarcoma

Tissue of Origin Benign Neoplasms Malignant NeoplasmsConnective TissueBoneFibrous tissueAdipose tissue

OsteomaFibromaLipoma

OsteosarcomaFibrosarcomaLiposarcoma

Epithelial TissueGlandularSurface

AdenomaPapilloma

AdenocarcinomaSquamous cell carcinoma

HematopoieticErythrocytesGranulocytesLymphatic tissue

ErythroleukemiaLeukemiaHodgkin’s disease, malignant lymphoma

LymphocytesPlasma cells

Lymphocytic leukaemiaMultiple myeloma

Cancer Prevention and Control1. Prevention – involves measures to avoid or reduce exposure to carcinogens - activities are aimed at interventions before pathologic change has begun2. Screening – helps to identify high-risk populations and individuals3. Early Detection – involves finding a precancerous lesion or a cancer at its earliest, most treatable stage

- also called secondary prevention - methods

a. inspectionb. palpationc. use of tests or procedures

Approaches to Cancer prevention1. Education2. regulation – prohibit the sale of tobacco and alcohol to minors, limiting smoking in public places, imposing excise taxes, regulating the use of manufactured carcinogens such as asbestos, and prohibiting carcinogens in foods

3. host modification- aims to alter the body’s internal environment to decrease the risk of or to

reverse a carcinogenic process

Cancer Prevention1. Skin: Avoid exposure to sunlight2. Oral: Annual oral examination3. Breast: Monthly BSE from age 204. Lungs: Avoid cigarette smoking; annual chest x-ray5. Colon: DRE for person over age 40. Rectal biopsy, proctosigmoidoscopic examination, Guiac stool examination for persons age 50 and above6. Uterus: annual Pap’s smear from age 407. Basic: annual physical examination and blood examination

Dietary Recommendations against cancer1. Avoid obesity2. Cut down on total fat intake3. Eat more high fiber foods – raw fruits and vegetables, whole grain cereal4. Include food rich in vitamin A and C in daily diet5. Include cruciferous vegetables in the diet-brocolli, cabbage, cauliflower, brussel sprouts6. Be moderate in the consumption of alcoholic beverages7. Be moderate in the consumption of salt-cured, smoked-cured and nitrate-cured foodsRecommendations of the American Cancer Society for Early Cancer Detection 1. For detection of breast cancer

a. Beginning at age 20, routinely perform monthly breast self-examinationb. Women ages 20-39 should have breast examination by a healthcare provider

every 3 yearsc. Women age 40 and older should have a yearly mammogram and breast

self-examination by a healthcare provider 2. For detection of colon and rectal cancer

a. all persons age 50 and older should have a yearly fecal occult blood testb. digital rectal examination and flexible sigmoidoscopy should be done every

5 yearsc. Colonoscopy with barium enema should be done every 10 years

3. For detection of uterine cancera. yearly papanicolao (Pap) smear for sexually active females and any female

over age 18b. At menopause, high-risk women should have an endometrial tissue sample

4. For detection of prostate cancera. beginning at age 50, have a yearly digital rectal examinationb. beginning at age 50, have a yearly prostate-specific antigen (PSA) test

American Cancer Society’s seven warning signs of cancer (uses acronym CAUTION):

1. Change in bowel or bladder habits2. A sore that does not heal3. Unusual bleeding or discharge4. Thickening or lump in breast or elsewhere5. Indigestions or difficulty in swallowing6. Obvious change in wart or mole

7. Nagging cough or hoarseness

Diagnostic tests of Cancer1. Biopsy/cytology

a. Histologic and cytologic examination of specimens are performed by the pathologist on tissues collected by needle aspiration of solid tumors, exfoliation from epithelial surface, and aspiration of fluid from blood or body cavities

b. Tissues may be obtained by excisional biopsy, incisional biopsy, and needle biopsy c. By examination of these tissues, the name, grade, and stage of the tumor can be identified2. Papanicolao Test (Pap Smear)

Class I: NormalClass II: InflammationClass III: Mild to moderate dysplasiaClass IV: Probably malignant

Class V: Malignant3. Ultrasound4. MRI5. X-rays6. CT scan7. Radiographic techniques8. Antigen Skin test9. Laboratory tests

a. Alpha-feto-proteinb. HCGc. Prostatic Acid Phosphatase (PSA)d. Carcinoembroyenic antigens (CEA)

10. Endoscopic examination11. Monoclonal antibodiesC. Tumor markers

1. Tumor markers are protein substances found in the blood or blody fluids 2. Are released either by the tumor itself, or by the body as a defense in response to the tumor (called host response) 3. Tumor markers are derived from the tumor itself. And include the ff:

a. Oncofetal antigens, present normally in fetal tissue, may indicate an anaplastic process in tumor cells; carcinoembyonic antigen (CEA) and alpha-fetoprotein (AFP) are examples of oncofetal antigens.

b. Hormones are present in large quantities in the human body; however, high levels of hormones may indicate a hormone-secreting malignancy; hormones that may be utilized as tumor markers include the antidiuretic hormone (ADH), calcitonin, catecholamines, human chorionic gonadotropin (HCG), and parathyroid hormone (PTH)

c. Isoenzymes that are normally present in a particular tissue may be released into bloodstream if the tissue is experiencing rapid, excessive growth as the result of tumor; are examples include neuron-specific enolase (NSE) and prostatic acid phosphatase (PAP)

d. Tissue-specific proteins identify the type of tissue affected by malignancy; an example of a tissue-specific protein is the protastic- specific antigen (PSA) utilized to identify prostate cancer 4.Host-response tumor makers include the following:

a. C-reactive proteinb. Interleukin-2c. Lactic dehydrogenased. Serum Ferritin

e. Tumor necrosis factorStaging 1. The TNM tumor system is utilized for classifying tumors a. T indicates the tumor size 1) T0 indicates no evidence of tumor 2) Tis indicates tumor in situ 3) T1,T2,T3,T4 indicate progressive degrees of tumor size and involvement b. N indicates lymph node involvement

1) N0 indicates no abnormal lymph nodes detected 2) N1a, N2a indicate regional nodes involved with increasing degree from N1a to N2a, no metastases detected 3) N1b, N2b, N3b indicate regional lymph nodes involvement with increasing Degree from N1b to N3b, metastasis suspected 4) Nx indicates inability to assess regional nodes c. M indicates distant metastases

1) M0 indicates no evidence of distant metastasis 2) M1, M2,M3 indicate ascending degrees of distant metastasis and includes distant lymph nodes

Different Modalities for Cancer1. Surgical interventions2. Chemotherapy3. Radiation therapy4. Immunotherapy6. Bone Marrow transplantation

Surgical Intervention1. Preventive surgery- removal of precancerous lesions or benign tumors2. Diagnostic surgery- biopsy3. Curative surgery- removal of an entire tumor4. Reconstructive surgery – improvement of structures and function of an organ5. Palliative surgery – relief of distressin signs and symptoms; retardations of metastasis

Common Nursing Techniques and Procedures A. Radiation therapy

1. Is used to kill a tumor, reduce the tumor size, relieve obstruction, or decrease pain

2. Causes lethal injury to DNA, so it can destroy rapidly multiplying cancer cells, as well as normal cells

3. Can be classified as internal radiation therapy (bachytherapy) or external radiation therapy (teletherapy) B. The client undergoing brachytheraphy ( internal radiation)

1. Sources of internal radiationa. Implanted into affected tissue or body cavityb. Ingested as a solutionc. Injected as a solution into the bloodstream or body cavityd. Introduced through a catheter into the tumor

2. Side effects of internal radiationa. Fatigueb. Anorexiac. Immunosuppressiond. Other side effects similar to external radiation

3. Priority nursing diagnoses: Impaired tissue integrity; fatigue; anxiety; risk for infection; Social isolation; Imbalanced nutrition: less than body requirements

4. Client educationa. Avoid close contact with others until treatment is completedb. Maintain daily activities unless contraindicated, allowing for extra rest

periods as neededc. Maintain balanced diet; may tolerate food better if consumes small,

frequent mealsd. Maintain fluid intake ensure adequate hydration (2-3 liters/day)e. If implant is temporary, maintain bedrest to avoid dislodging the implant.f. Excreted body fluids may be radioactive; double-flush toilets after useg. Radiation therapy may lead to bone marrow suppression

5. Nursing management of client receiving internal radiation a. Exposure to small amounts of radiation is possible during close contact with

persons receiving internal radiation: understand the principles of protection from exposure to radiation: time, distance, and shielding

1) Time: minimize time spent in close proximity to the radiation source; a common standard is to limit contact time to 30 minutes total per 8-hour shift; minimum distance of 6 feet used when possible

2) Distance: maintain the maximum distance possible from the radiation source

3) Shielding: use lead shields and other precautions to reduce exposure to radiation

b. Place client in private room c. Instruct visitors to maintain at least a distance of 6 feet from the client and limit visitors to 10-30 minutes d. Ensure proper handling and disposal of body fluids, assuring the containers are marked appropriately e. Ensure proper handling of bed linens and clothing f. In the event of a dislodged implant, use long-handled forceps and place the implant into a lead container; never directly touch the implant g. Do not allow pregnant woman to come into any contact with radiation sources; screen visitors and staff for pregnancy h. If working routinely near radiation sources, wear a monitoring device to measure exposure i. Educate client in all safety measures 6. Evaluation: client demonstrates measures to protect others from exposure to radiation, identifies interventions to reduce risk of infection, remains free from infection, achieves adequate fluid and nutritional intake, and participates in activities of daily living (ADLs) at level of ability

C. The client undergoing external radiation therapy (teletheraphy)1. The radiation oncologist marks specific locations for radiation treatment using

a semipermanent type of inka. Treatment is usually given 15-30 minutes per day, 5 day per week, for 2-7

weeksb. The client does not pose a risk for radiation exposure to other people

2. side effects of external radiation therapya. Tissue damage to target area (erythema, sloughing, hemorrhage)b. Ulcerations of oral mucous membranesc. Gastrointestinal effects such as nausea, vomiting, and diarrhead. Radiation pneumoniae. Fatiguef. Alopecia

g. Immunosuppression3.Priority nursing diagnoses: risk for infection; impaired skin integrity; social

isolation; disturbed body image; anxiety; fatigue4. Client education exam for external radiation

a. Wash the marked area of the skin with plain water only and pat skin dry; do not use soaps, deodorants, lotions, perfumes, powders or medications on the site during the duration of the treatment; do not wash off the treatment site marks

b. Avoid rubbing, scratching, or scrubbing the treatment site; do not apply extreme temperatures (Heat or Cold) to the treatment site ; if shaving, use only an electric razor

c. Wear soft, loose-fitting over the treatment aread. Protect skin from sun exposure during the treatment and for at least 1 year

after the treatment is completed; when going outdoors, use sun-blocking agents with sun protector factor (SPF) of at least 15

e. Maintain proper rest, diet, and fluid intake as essential to promoting health and repair of normal tissues

f. Hair loss may occur; choose a wig, hat, or scarf to cover and protect head (refer to care of client with alopecia later in chapter)

5. Nursing management of the client receiving external radiationa. Monitor for adverse side effects of radiationb. Monitor for significant decreases in white blood cell counts and plateletcountsc. Client teaching (refer to later sections for management of

immunosuppression, thrombocytopenia 6. Evaluation; client identifies interventions to reduce risk of infection, remains

free from infection, achieves adequate fluid and nutritional intake, participates in activities of daily living (ADLs) at level of ability, and maintains intact skin.The Client Undergoing a Bone Marrow Transplant (BMT) 1. BMT – used in the treatment of leukemias, usually in conjunction with radiation or chemotherapy

a. Autologous BMT – the client is infused with own bone marrow harvested during remission of disease

b. Allogenic BMT – the client is infused with donor bone marrow harvested from a healthy individual2. The bone marrow is usually harvested from the iliac crest, then frozen and stored until transfusion3. Before receiving the BMT, the client must first undergo a phase of immunosuppressive therapy to destroy the immune system, infection, bleeding, and death are major complications that can occur during this conditioning phase4. After immunosuppression, the bone marrow is transfused intravenously through a central line5. Side of BMT

a. malnutritionb. infection related to immunosuppressionc. bleeding related to thrombocytopenia

6. Priority Nursing Diagnosesa. Risk for infectionb. Risk for hemorrhagec. Risk for imbalanced nutritiond. Social isolatione. Anxiety

7. Nursing Management of client undergoing a bone marrow transplanta. Monitor for graft-versus-host disease

b. Provide private room for the hospitalized client; client will be hospitalized for 6-8 weeks

c. Encourage contact with significant others by using telephone, computer, and other means of communication to reduce feelings of isolation

d. Refer to management for imbalanced nutrition, immunosuppression and thrombocytopenia8. Evaluation: client evaluates understanding of risks and participates in activities that reduce risk of infection, hemorrhage, and malnutrition; client demonstrates effective coping mechanisms

The Client Undergoing other therapeutic interventions1. Immunotherapy/biologic response modifiers (BMR)

a. Enhances the person’s own immune responses in order to modify the biologic processes resulting in malignant cells

b. Currently considered experimental in usec. Monoclonal antibodies: antibodies are recovered from an inoculated animal

with a specific tumor antigen, then given to the person with that particular cancer type; the goal is: destruction of the tumor

d. Cytokines: normal growth-regulating molecules possessing antitumor abilities1) Interleukin-2(IL-2) increases immune response effective and

destroys abnormal cells2) Interferons are substances produced by cells to protect them from

viral infection and replication; interferon-alpha 2b is most commonly used

3) Hematopoietic growth factors such as granulocyte colony- stimulating factor (G-CSF) and erythropoietin, balance the suppression of granulocytes and erythrocytes resulting from chemotherapy

e. natural killer cells (NK cells) : exert a spontaneous cytotoxic effect on specific cancer cells; they also secrete cytokines and provide a resistance to metastasis

2. Gene therapya. Current use in investigationalb. Increases susceptibility of cancer cells to the destruction by other treatments;

insertion of specific genes enhances ability of client’s own immune system to recognize and destroy cancer cells3. Photodynamic theory

a. Used to treat specific superficial tumors such as those of the surface of bladder, bronchus, chest wall, head, neck and peritoneal cavity

b. Photofirin, a photosensitizing compound, is administered intravenously where it is retained by malignant tissue

c. Three days after injection, the drug is activated by a laser treatment which continues for 3 more days

d. The drug produces a cytotoxic oxygen molecule (singlet oxygen)e. During intravenous administration, monitor for chills, nausea, rash, local skin

reactions, and temporary photosensitivityf. Drug remains in tissues 4-6 weeks after injection; direct or indirect exposure

to sun activates drug, resulting in chemical sunburn; educate client to protect skin from exposure to sun

Oncologic Emergencies: Diagnosis and Management1. Spinal Cord Compression

a. Occurs secondary to pressure from expanding tumorsb. Early symptoms include back and leg pain, coldness, numbness, tingling,

paresthesias, progression leads to bowel and bladder dysfunction, weakness, and paralysis

c. Early detection is essential: investigate all complaints of back pain or neurological changes

d. Treatment is aimed at reducing tumor size by radiation and/or surgery to relieve compression and prevent irreversible paraplegia; may receive corticosteroids to reduce cord edema

e. Nursing interventions include early recognition of symptoms, neurological checks and medication administration2. Superior vena cava syndrome

a. Compression or obstruction of the superior vena cava (SVC)b. Usually associated with cancer of the lungs and lymphomasc. signs and symptoms are the result of blockage of venous circulations of head,

neck, and upper trunkd. Early signs and symptoms are periorbital edema and facial edemae. Symptoms progress to edema of neck, arms, and hands, difficulty swallowing,

shortness of breathf. Late signs and symptoms are cyanosis, altered mental status, headache, and

hypotensiong. Death may occur if compression is not relievedh. Treatment included high-dose radiation to shrink tumor and relieve symptomsi.Nursing interventions include:

a. Monitoring vital signsb. providing oxygen supportc. preparing tracheostomy if necessaryd. initiating seizure precautionse. administering corticosteroids to reduce edema

3. Disseminated intravascular coagulopathy (DIC)a. Severe disorder of coagulation, often triggered by sepsis, whereby abnormal

clot formation occurs in the microvasculature; this process depletes the clotting factors and platelets, allowing extensive bleeding to occur tissue hypoxia occurs as a result of the blockage of blood vessels from the clots

b. Signs and symptoms are related to decreased blood flow to major organs (tachycardia, oliguria, dyspnea) and depleted clotting factors (abnormal bleeding and hemorrhage)

c. Treatment includes anticoagulants to decrease stimulations of coagulation and transfusion of one or more of the following:

1) fresh frozen plasma (FFP)2) cryoprecipitate3) platelets4) packed RBC

d. Nursing interventions include assessing client, monitoring for bleeding, applying pressure dressings to venipuncture sites, and preventing risk of sepsis

e. Mortality for clients experiencing DIC is greater than 70% despite aggressive treatment4. Cardiac tamponade

a. Pericardial effusion secondary to metastases or esophageal cancer can lead to compression of heart, restricting heart movement and resulting in cardiac tamponade

b. Signs and symptoms are related to cardiogenic shock or circulatory collapse: anxiety, cyanosis, dyspnea,hypotension, tachycardia,tachypnea,impaired levels of consciousness, and increased central venous pressure

c. Pericardiocentesis is performed to remove fluid from pericardial sacd. Nursing interventions

1) administering oxygen2) maintaining intravenous line3) Monitoring vital signs4) hemodynamic monitoring5) administration of vasopressor agents

COMMON CANCER DISORDERSI. BREAST CANCER

- unregulated growth of abnormal cells in breast tissue Etiology and pathophysiology A. cause is unknown but many risk factors influence development

1. Female gender and white Caucasian race2. family history of mother or sister with breast cancer3. medical history of cancer of other breast, endometrial cancer or atypical

Hyperplasia4. Menarche before age 12 (early) or menopause after age 50(Late)5. First birth after 30 years of age, oral contraceptive use (early or prolonged),

prolonged use of estrogen replacement therapy6. Lifestyle factors: high-fat diet, obesity, high socioeconomic status, breast

trauma, smoking, ingesting more than 2 alcoholic drinks daily7. Exposure to radiation through chest x-ray, fluoroscopy

B. Begins as a single transformed cells and is hormones-dependent; does not develop in women without functioning ovaries who never received hormones replacement therapy

C. Most often occurs in ductal areas of breast D. Noninvasive: does not penetrate surrounding tissues; may be ductal or lobular; usually diagnosed through mammogram or nipple discharge E. Invasive: penetration of tumor into surrounding tissue Manifestations1. Lump in upper outer quadrant of breast, usually nontender but may be tender2. dimpling of breast tissue surrounding nipple, or bleeding from the nipple3. Asymmetry with affected breast being higher4. Regional lymph nodes swollen and tender

Management1. Radiation therapy 2. Mastectomy

a) Segmental mastectomy – or lumpectomy; removes the tumor and margin of breast tissue surrounding the tumor

b) simple mastectomy – removal of the complete breast but no other structuresc) Modified radical mastectomy – removal of the breast and axillary lymph

nodes but chest wall muscles are not resectedd) Radical mastectomy – removal of the breast, axillary lymph nodes and

underlying chest wall musclese) Breast reconstruction – may be performed at the time of mastectomy or may

be done at a later time; can be accomplished through submuscular breast implant, placing an implant after using a tissue expander, using muscles with intact blood supply from the back or abdomen, or creating a free muscle flap with the gluteus maximus muscle3. Medication therapy

a. Tamoxifen (Novadex) interferes with estrogen activity for treating advanced breast cancer

b. Chemotherapy – when axillary nodes are involved

Care of patient undergoing mastectomy1. Maintain usual postoperative assessment2. Begin emotional support before surgery and continue in postoperative period3. Turn, cough and deep breathe to prevent respiratory complications; restrictive surgical dressing may decrease chest expansion4. Position client on back or unaffected side5. Jackson-Pratt drain or Hemovac may be in place to drain fluids that accumulate when lymph nodes are removed6. Note signs of bleeding on dressing and reinforce pressure dressing as needed7. Encourage early range of motion exercise to prevent contractures are lymphedema8. Use unaffected arm only to provide IV fluids and take blood pressure9. Discharge instructions

a) Use caution when lifting heavy objects with arms on affected sideb) Avoid injury and infection on affected side; wear rubber gloves when

washing dishes and garden gloves when working outsidec) Don’t allow procedures, such as blood pressure or venipunctures on the

affected sided) Refer client to support group for psychosocial support

B. PROSTATE CANCER- unregulated growth of abnormal cells in the prostate gland

Etiology/pathophysiology1. Adenocarcinoma is most common type; high levels of testosterone may play a

Role2. Usually begins in peripheral tissue on back and sides of the gland3. Metastasis via lymph and venous changes is common; bony tissue is major

site of distant metastasis- especially pelvic bones and spine4. Is seen predominantly over 40 years of age

Clinical Manifestations1. Clients in early stages often show no symptoms; tumor may be found during

digital prostate exam2. Genitourinary: dysuria, frequency, reduced force of stream, hematuria,

nocturia,abnormal prostate found on DRE3. Musculoskeletal: back pain, migratory bone pain, bone or joint pain4. Neurologic: nerve pain, muscle spasms, bowel or bladder dysfunction,

bilateral weakness of lower extremities

5. Systemic: fatique and weight loss

Diagnostic and Laboratory tests1. Prostate-specific antigen (PSA) levels2. Transurectal ultrasound (obtained if PSA results are abnormal)3. tissue biopsy4. bone scan5. MRI6. CT scans to detect metastasis

Therapeutic Management1. Hormone therapy2. Radiation therapy3. Brachy therapy (Radioactive seeds implanted in the prostate)4. Prostatic cryosurgery5. Surgery

a) Orchiectomy – decreases androgen productionb) Radical procedures include removal of gland, capsule,ampulla,vas

deferens,seminal vesicles, adjacent lymph nodes, and cuff of bladder neck

c) Suprapubic prostatectomy – abdominal and bladder incisions to remove prostate tissue

d) Retropubic prostatectomy – low abdominal incision without opening bladder

e) Perineal prostatectomy – incision between scrotum and anus (perineal area)

f) Homium laser – laser treatment; less bleeding, fewer complications and shorted hospital day

6. Medication therapya. estrogen therapy of luteinizing hormone antagonist (Lupron) given

to slow rate of growth and extension of tumor

Nursing Management of Patient Undergoing Prostate Surgery1. Maintain usual postoperative assessment2. If dressings are present, monitor for drainage and change as needed3. Monitor vital signs closely for 24 hours, observing for signs of hemorrhage (frank blood in urine, large blood clots, decreased haemoglobin and hematocrit, tachycardia, and hypotension)4. IN clients who have a urinary catheter following surgery, traction may be applied against the prostatic fossa to prevent bleeding; the balloon at the tip of the catheter exerts pressure to prevent hemorrhage; the surgeon positions the external end of the catheter by anchoring it tightly to the client’s inner thigh to maintain traction; the catheter should not be repositioned5. A client who has a large indwelling catheter may feel the urge to void, which results from stimulation of the micturition center, explain to the client that this is a normal sensations; efforts by the client to void or strain will increase the risk of bleeding and aggravate pain6. Continuous bladder irrigation (CBI) may be ordered on a client postoperatively

a. The purpose of the CBI is to prevent the formation of blood clotsb. If blood clots do form, the urinary catheter will become plugged and prevent

outflow of urine; the obstruction will also cause bladder spasms and painc. A key nursing intervention for the client in CBI is to keep the outflow from the

catheter light pink or clear; the rate of administration of the irrigating solution is therefore titrated to keep the color of the outflow this color and prevent blood clots from forming; it is essential to calculate intake and output to determine true urine output

d. Indications that the rate of the irrigations is inadequate include: decreased outflow from the catheter; bladder spasms; and dark-colored or frankly bloody drainage7. Monitor client for signs of hemorrhage;bladder spasms and frank bloody output may indicate bleeding8. The irrigating solution used during and after surgery may be absorbed causing fluid shifts and dilutional hyponatremia, referred to as TURP syndrome; monitor the client for signs of hyponatremia and bradycardia, nausea and vomiting, monitor serum sodium levels and haemoglobin and hematocrit; in addition, other signs of volume excess will also be evident, including hypertension and confusion9. If manual irrigations are ordered, maintain sterile technique10. Medicate as needed for pain