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The Good....
The Bad...
And The Ugly
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OVERVIEW
CANCER,
TREATMENTMODALITIES,
ANDSIDE EFFECTS
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O JE TIVES
Upon completion of this session, the learner will be able to:
1. List cancer statistics related to incidence, cases, and deaths.
2. Define cancer.
3. Explain theories of causation, grading, and staging of cancer.
4. Discuss various treatment modalities available for cancer.
5. State principles of cancer treatment.
6. Examine common side effects, complications, and nursing
management related to treatment modalities.
7. Review basic solid tumors and hematological malignancies.
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Glossary of Terminology
Neoplasm new plasmaabnormal tissue growth with rapid
growth
Benign no metastasis
Malignant
local invasion and destructive growthwickedMetastasis
spread form primary via lymphatic and/or
circulatory system
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STATISTICSCancer is the second leading cause of death in
the United States
Cancer affects one in three families
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STATISTICSIncidence:
#1 Skin
Male Female
Prostate Breast
Lung Lung
Colon/Rectum Colon/Rectum
Death:
Male: Female:
Lung Lung
Prostate Breast
Colon/Rectum Colon/Rectum
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CANCER
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THEORIES OF CAUSATION
Environmental(tobacco, occupational, pesticides,asbestos)
Radiation(UV, radon)
Genetics(BRCA)
Hormonal Imbalances
Viral(HIV, H Pylori, HPV)
Stress
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DEFINITIONS
1. Cancer is a disease of the cell
2. Large group of diseases characterized by:
a. Abnormal cell structure(no differentiation)
b. Uncontrolled growth (proliferation)
c. Ability to spread (metastasis)
d. Ability to invade normal tissue (lack contactinhibition
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Differen tiat ion =Maturat ion
&
Pro l i ferat ion = Div is ion
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Cancer cells follow no rulesand have the ability to
stimulate the growth of a newblood supply
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Grading and Differentiation
(need tissue diagnosis):Grade 1 = Well-Differentiated
Grade 2 = Moderately differentiated
Grade 3 = Poorly-differentiated
Grade 4 = Undifferentiated
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TNM STAGINGT= Tumor T0-T4
N = Node No-N3
M = Metastasis
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TREATMENT MODALITIES
(THE GOO )
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SURGERYCurative
Prophylactic
Diagnostic
Staging
Palliative
Adjuvant or Supportive
Reconstructive/Rehabilitative
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RADIATION
Highest energy rays
that can kill any cell or
tissue
May be external source
(brachytherapy)
Curative
Palliative
60% will receive XRT Divided into doses or
fractions
(Preserve normal
cellular growth)
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CHEMOTHERAPY
CHEMOTHERAPY
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Chemotherapy
Cytotoxic drugs that destroy cancer cells or prevent
cellular replication by interfering with DNA and
RNA and vital cellular proteins
Goal is to reduce the number of cells to a small
number that can be (theoretically) handled by the
immune system
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BIOTHERAPY Treatment that alters the bodys biological response
Uses bodys own immune system to treat cancer
Alters the immune system with either stimulatory or
suppressive effect
Produce anti-tumor activities
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HORMONAL THERAPY
used against hormonally sensitive tumors like
breast and prostate
creates unfavorable growth environment
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PRINCIPLES OFCANCER TREATMENT
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GOALS
CURE
CONTROL
PALLIATION
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MEASURE TUMOR RESPONSE
Complete Response
Partial Response
Stable Disease
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SIDE EFFECTS
AND
MANAGEMENTTHE BAD)
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MYELOSUPPRESSIONNEUTROPENIA
THROMBOCYTOPENIA
ANEMIA
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NEUTROPENIA
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Pathophysiology Damage to stem cells in bone marrow with
decreased ability to make these important cells
Hematologic malignancies cause the malignant
cells to crowd the bone marrow and therefore
difficult to make normal amount of normal cells
Solid tumors metastasize to bone marrow with a
decreased normal cell production Radiation damages bone marrows ability to make
cells
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Neutropenia/Leukopenia
Assess risk factors
(Age, renal and liver function, nutrition, bone marrow, other
medications, prior chemotherapy and/or radiation)
Manifestations include fever >38 C or 100.4F (no classic signs)
cough, SOB
skin redness or tenderness, (mouth, perianal, rectal)
urinary symptoms (dysuria frequency, hematuria, hesitancy)
indwelling devices (VADs, pain, edema, swelling,
induration at site)
sepsis (hypotension, agitation, decreased urine)
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Neutropenia/Leukopenia
Prevention:
No fresh fruits or vegetables, no pepper, live
plants or potting soil
No exposure to live vaccines or pet excreta
Avoid others with colds
Strict hand washing and personal hygiene
Mouth care at least 4 times daily
No trauma or invasive procedures
Prevent constipation and pressure sores
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Neutropenia/Leukopenia
Management: BC lines and peripheral, urine, sputum
CXR and good physical assessment
Antibiotics immediately (broad spectrum coverage) Administer neupogen or leukine
Patient education (temperature at least 2 times daily)
Vital signs at least every 4 hours or more
Assess for chills, SOB, cough, pain
***This is life-threatening for patients and
requires immediate attention
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BLEEDING&
NO CLOTTING=
THROMBOCYTOPENIA
(NO PLATELETS)
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ThrombocytopeniaManagement
Institute bleeding precautions
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ANEMIA
DECREASED RED BLOOD CELLS
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Anemia Assess for
chemotherapy
kidney damage
tumor infiltration of bone marrow, XRT
bleeding, hemorrhage
age
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Anemia
Management:
Rest, slow position changes
Oxygen
Iron
Transfusion
Epogen (Hct
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Leukine
they are glycosylated proteins that function to regulate cell
reproduction, cell maturation, and cell function of blood cells
Hematopoietic
Growth Factors
Neupogen
NeumegaProcrit
Aranesp Neulasta
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I SymptomManagement
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Symptom Management
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Nausea/Vomiting
* * * As many as 60% patients exper iencenausea and vomiting
Patterns
Anticipatory (starts and may last several hours to days)
Acute (0-24 hours)
Delayed (1-4 days)
medications, ICP, SIADH, stress
Assess for weight loss, albumin, hydration
y p g
NAUSEA AND VOMI TING
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Nausea/Vomiting
SeratoninInhibitors/Antagonists
receptors on vagus nerve
and in the CTZ
effectiveness may be
enhanced by concurrent
administration of decadron
act by blocking seratonin
from binding to receptors in
GI tract (not indicated for
anticipatory or delayed
N&V)
Ondansetron (Zofran)
Dolestron (anzemet)
Ganisetron (Kytril)
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Nausea/VomitingPhenothiazines
only mildly useful as single
agents better in combination with
other antimetics
block dopamine receptors in
CTZ works well for XRT, and
morphine associated nausea
Prochlorperazine
(compazine) Chlorpromazine
(Thorazine)
Promethazine (Phenergan) Thiethylperazine (torecan)
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Nausea/Vomiting
Glucocorticosteroids
effective with mild emeticdrugs
may block prostaglandin
release from hypothalmus
Dexamethasone
(decadron) Methylprednisone
(solumedrol)
prednisone
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Nausea/Vomiting
Metoclopramide (reglan)
Most effective agent
against Cisplatin Do not use with GI
obstruction
Blocks CTZ and promotesgastric emptying
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Nausea/VomitingCannabinoids
effective with some
refractory cases Dronabinol (marinol)
Butyrophonones
Inapsine (droperidol)
Haldol
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Nausea/VomitingAntihistamines
good with motion sickness
blocks extrapyrammidaleffects of other antimetics
not effective as single
agents
Hydroxyzine (vistaril,atarax)
Diphenhydramine
(benadryl)
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Nausea/Vomiting
Benzodiazepines
amnesiac effect in drugcombinations
blocks short term memory
Diazepam (valium)
Lorazepam (ativan)
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Nausea/VomitingAnticipatory N & V
need to mediate the
response of the centers inthe cerebral cortex which
result in anticipatory
nausea and vomiting
ativan
valium
dronabinol
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Nausea/VomitingACUTE N&V:
mild potential drugs
suggested to usephenothiazide =/- steroidor low dose reglan =/-steroids
moderate potential benefitfrom po/IV 5-HT3antagonist =/- steroid orreglan =/- steroid
high potential benefit from
po/IV 5-HT3 antagonist
PLUS a steroid =/- a
benzodiazepine
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Nausea/VomitingDelayed N&V corticosteroids
commonly used in
combination with 5-
HT3 antagonist or
reglan
result of unknown
mechanism
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Other Notable Side Effects
HOWDO WE
TREAT???
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Up to 80% develop mouth
sores
Assess and prevent
NSS mouth rinses
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Damage is to shaft (thinning
and breakage)
Damage to roots (completealopecia)
Loss begins about 2 weeks
after treatment
Regrowth may take up to 3-5
months after treatment
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50-100%patients
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SKIN REACTIONS Hypersensitivity
Hyper pigmentation
Photo sensitivity
Radiation recall
Radiation enhancement
Ulceration Palmar-Planter
Erythrodysestheses (PPE)
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THE UGLY
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Cardiac Toxicity
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Pulmonary
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Urologic
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Renal/Nephrotoxicity
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Hepatotoxicity
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Neurotoxicity
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Ocular Toxicities
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???WHICH TREATMENT DO I CHOOSE??
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SOLID TUMORS
Neurological:
Brain
Spinal Cord
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SOLID TUMORS
Head and Neck
Bone and Soft Tissues
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SOLID TUMORS
LUNG
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SOLID TUMORS
Esophageal
Gastric Colorectal
Pancreatic
Hepatocellular
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SOLID TUMORSGU
CANCERS
Kidney
BladderProstate
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SOLID TUMORS
GENITALCANCER
Cervical
Endometrial
Ovarian
Testicular
Breast
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SKIN CANCER
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LEUKEMIASACUTE:
AML
ALL
CHRONIC:
CML
CLL
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LYMPHOMAS
Non-Hodgkins
&
Hodgkins
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MULTIPLEMYELOMA
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HEMTOLOGICAL MALIGNANCIES
IDIOPATHIC
THROMBOCYTOPENIC
PURPURA (ITP)
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HEMTOLOGICAL MALIGNANCIES
THROMBOTIC THROMBOCYTOPENIAPURPURA TTP)
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HEMTOLOGICAL MALIGNANCIES
PL STICNEMI
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REFERENCES
Fishman, M., & Orlowski, M.M. (Eds.). (1999). Cancer
chemotherapyguidelines and recommendations for practice: ONS (2nded.).
OncologyNursing Press Inc.
Groenwald, S.L., Froygl, M.H., Goodman, M., & Yarbo, C.H. (Eds.).
(2002). Cancer nursing: Principles and practice (5thed.). Boston: Jones and Bartlett
Publishing
Itano, J.K. & Taoka, K.N. (1998). Core curriculum for oncology nursing(3rded.).
Philadelphia: W.B. Saunders.