Cancer

1. Med/Surg-2013 Cancer

2. Oncology is the specialty dealing with cancer and treatment CANCER

3. Characterized by growth of cells that do not have normal cellular function and may occur in any tissue • Can occur at any age, however there are some cancers that only affect a certain age group • Tumors/neoplasms-Arise from normal tissue Cancer Development

4. Benign tumors have slower growth, they are encapsulated, composed of differential cells, and they don’t metastasize Malignant tumors invade surrounding tissue These tumors have rapid growth and replication, non-encapsulated which allows them to invade, made up of anaplastic cells that do not function like normal cells from where they originate, malignant tumors send abnormal cells to other sites via the blood or lymphatic system Benign or malignant

5. Histology-study of tissue • Carcinomas-largest • Make up about 90% of malignancies • Develop from epithelial tissue (skin, GI sx, urinary sx, repro organs, and glands)* • Sarcomas • >5% of malignant tumors • Arise from connective tissues (cartilage, bone, muscle, fat, bone marrow and lymphatic system) includes gliomas and neuroblastomas of the brain, • Ewing’s sarcoma-affects diaphysis with mets to lung • ages 4-25 • Dx: CT scan • Tx: chemo/radiation Types of Tumors

6. Leukemia • Originates in bone marrow • Blastoma • Malignant tumors of immature or embryonic tissue • Mixed-Tissue Tumor • Less common • Develop from epithelial and connective tissues; Wilm’s tumor Types of tumors

7. Carcinogenesis-transformation of normal cell into malignant cell • Disruption occurs with DNA replication during mitosis • The new protein production is damaged, resulting in growth of cancerous cells • RNA then sends messages to develop more abnormal proteins • Carcinogens-cause damage to DNA that leads to development of cancer • Box 83-1** • Laryngeal cancer-from cigarettes and ETOH* • 80% of cancers d/t smoking, diet, ETOH and environmental factors such as radiation, chemicals • DNA can carry an oncogene (cancer-causing gene) which is activated by mutation • Heredity may transfer defective DNA through sperm or egg cells Carcinogenesis and Carcinogens

8. Grading is a system that looks at abnormal cells under a microscope to determine the cells’ degree of differentiation or lack of maturity • Grade I-resemble normal cells, better prognosis • Grade II or III-intermediate phases of differentiation, cells could be slightly to extremely abnormal • Grade IV or V-anaplastic tumor, little to no resemblance to the tissue cells from which they develop Cancer Grading and Staging

9. Identifies the spread of a tumor** • Box 83-3* • The tumor, node, and metastasis system is called the TNM system of staging. • Tumor size • Local invasiveness • Extent of lymph node involvement • Each category uses a range from 0-4 or A-D • A tumor T3N4M1 is a large tumor, with node involvement and metastasis* • A tumor T1N0M0 is small without node involvement or metastasis* Evidence of metastasis to distant or secondary sites Primary site is the place where the cancer starts Cancer in situ refers to tumor cells that have not invaded surrounding tissue Staging

10. Cancer is second only to heart disease as the major cause of adult deaths in the United States. All cancers result from a mutation of genes that causes malfunction of cell growth and division. Occurrence increases as an individual ages. Leading causes of cancer deaths: lung cancer (both men and women)**, breast cancer, prostate cancer, colorectal cancer Incidence

11. Simple or total mastectomy: removal of the breast, with its skin and nipple, but no lymph nodes. In some cases, a separate sentinel node biopsy (sentinel node is the first node to receive drainage from a cancer containing area of the breast) is performed to remove only the first one to three axillary (armpit) lymph nodes. Modified radical mastectomy: removal of the entire breast, nipple/areolar region, and often the axillary lymph nodes. This is the most common form of mastectomy performed today. Radical mastectomy: removal of the entire breast, nipple/areolar region, the pectoral (chest) major and minor muscles, and lymph nodes. This procedure is rarely performed today. Imaginis Corporation (2008). Mastectomy. Retrieved on January 9, 2009 from http://www.imaginis.com/breasthealth/sentinelnode.asp Types of Mastectomies

12. Possible side effects: As with other operations, pain, swelling, bleeding, and infection are possible. The main possible long-term effect of removing axillary lymph nodes is lymphedema (swelling of the arm). This occurs because any excess fluid in the arms normally travels back into the bloodstream through the lymphatic system. Removing the lymph nodes sometimes causes this fluid to remain and build up in the arm. American Cancer Society. (2008). Surgery for breast cancer. Retrieved January 9, 2009 from http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_Surgery_5.asp?sitearea= Mastectomy

14. Immediately after surgery, the affected arm or breast area may swell. This swelling is usually temporary and gradually disappears over the next 6 to 12 weeks • Avoiding Infection: • Whenever possible, have your blood drawn, IVs, and injections given in your unaffected arm. • Keep your arm clean • If necessary, use an insect repellent when outdoors to avoid bug bites. If you get stung by a bee in the affected arm, clean and elevate the arm, apply ice, and contact your doctor or nurse if it becomes infected American Cancer Society. (2007). Lymphedema: What every woman with breast cancer should know. Retrieved January 9, 2009 from http://www.cancer.org/docroot/MIT/content/MIT_7_2x_Lymphedema_and_Breast_Cancer.asp Lymphedema

15. Reduce smoking, intake of total dietary fats and calories Decrease total sun exposure Avoid artificial sources of ultraviolet light Perform self-examination for early detection of breast or prostate cancers Maintain routine and consistent exercise Improve screening rates for breast, prostate, colorectal cancer Improve educational strategies related to tobacco cessation and diet • SEE WARNING SIGNALS FOR CANCER • “CAUTION” Prevention and Early Detection

17. Box 83-2 • Breast Cancer • Women with increased family risk should start mammograms/ultrasounds earlier • Colorectal cancer • Start early or performed more frequently if they have Crohn’sdisease or inflammatory bowel disease • Cervical Cancer • Age 21 or about 3 years after they begin having vaginal intercourse-have a regular pap test • Age 30, should have a pap test q 2-3 years if they have had 3 normal Pap tests in a row • Over 30, screened for PAP plus the HPV test Endometrial Cancer report any unexpected bleeding or spotting post menopausal** Cancer Screening Guidelines

18. Cytology-study of cells • Cytologic examination is done on • Sputum, bronchial washings, vaginal and cervical secretions, prostatic secretions, pleural secretions, and gastric washings • Used most often to detect cervical cancer • Pap test Diagnostic Test

19. Tumor markers-specific enzymes, cancer antigens that can indicate malignancies • Found in blood (enzymes, antigens, hormones, misc. markers) • EX. –Philadelphia chromosome-CML* • Ex-PSA-prostate cancer* • Useful to monitor tumor response to treatment • Detect cancer recurrences • Additional test may be needed: x-rays, CT, MRI and ultrasound. Laboratory Tests

21. Radiology – Visualize body’s internal structures Mammograms – detect abnormal cellular growth in the breast CT scan-sectional views of body structures, useful for tumors of the chest, brain, and abdominal cavity Ultrasonography – uses sound waves to specific tissues, useful for pelvic, retroperitoneal and peritoneal tumors MRI – detailed sectional images of the body without ionizing radiation, can stage malignant disease in the CNS, spine, head, neck, muscular system. Bone Scan Noninvasive Diagnostic Procedures

22. Endoscopy • Exploratory surgery and biopsy • Biopsy is the single most important to test Dx cancer • MOST ACCURATE!! • Frozen section – during biopsy, specimen is removed and the tissue is frozen and sliced thin, pathologist studies the specimen and reports results Invasive Diagnostic Techniques

23. Surgery • Ideal treatment: complete removal of malignant tissues • Incisional tissue biopsy-helps with Dx and staging • Excisional biopsy – removes tumor and a small margin around the tumor • Cryosurgery – malignant tissues are spread • Electrocauterization-burned Treatment modalities

24. Fulguration – destroyed by high-frequency current En bloc resection – removal of the tumor, surrounding tissues and lymph nodes Exenteration – removal of tumor, organ involved and surrounding tissue Surgery

25. Laser surgery – excise areas of tumors Laser induced interstitial thermotherapy (LITT) – shrinks or destroys tumor with hear; can be curative or palliative Photodynamic therapy (PDT) – chemical introduced into body and remains in or around the tumor cell vs. normal cells; can only penetrate tissue that is less than 11/8 inch thick and is used on tumors under that skin or lining the internal organs that can be reached be fiberoptic instruments or endoscope. The client must remain indoors out of the sun for 6 weeks after therapy Surgery

26. Prophylactic surgery – used for tumors that are known or suspected to be precancerous • Palliative surgery – performed to relieve some of the complications of malignancies; goal is to promote client comfort and quality of life. • Bone Marrow Transplant (BMT) – replaces stem cells that develop into blood cells. Obtained from the hip or sternum using small incisions and large bore needles. • Autologous – from client • Syngeneic – twin • Allogeneic – another person Surgery

27. Donated bone marrow is matched to the client’s tissue-human leukocyte-associated antigen (HLA) on the surface of WBC’s Stem cells are found in peripheral blood and umbilical cord blood Peripherally obtained by aphaeresis-removal through a large vein and sent to special collection filters in a machine where they are harvested and frozen until needed Client will receive the donated bone marrow after chemo/radiation. Successful transplants can offer full recovery in 6-12 months Risk of GVH RXN – observe for development of skin rash Bone Marrow Transplant

28. Goal of Chemo – cure or provide palliation if cancer is not curable • Chemotherapy – using chemical agents to destroy cancer cells; goal is to damage the DNA in these abnormal cells and cause apoptosis (Self-destruction) • Can destroy normal cells* • Tx indications: • Widespread or metastic disease • Provide cure for certain types of cancer • *Temporarily control tumor-related difficulties; not a cure • Adjuvant (assistive) therapy after surgery to prevent metastasis from occurring Chemotherapy

29. Chemo agents are designed to be effective during the phases of cell division, malignant cells are susceptible to chemo drugs GI tract and bone marrow cells can suffer from damages obtained through antineoplastic (anticancer) drugs Hospital protocols dictate detailed directions to specific routes of drug administration, etc Chemo drugs are continued into remission occurs-partial or complete **Palliative chemo-prolongs life and reduces incapacitating sx’s Chemotherapy

30. Alkylating agents Antibiotics Antimetabolites Antimitotics Hormonal agents Chemotherapeutic agents

31. Actions: • Affect cells that rapidly proliferate • Malignant neoplasms or cancerous tumors usually consist of rapidly proliferating cells • Cancer cells have no biological feedback controls that stop their aberrant growth or proliferation • Cancer cells are sensitive to antineoplastic drugs when the cells are in the process of growing or dividing • Chemo is administered at the time the cell population is dividing to optimize cell death Chemotherapeutic agents

32. Chemo is administered in cycles to allow recovery of the normal cells and to destroy malignant cells • Cell kill theory: 90% of the cancer cells should be killed during the first course of treatment, second course of tx targets the remaining cells and reduces these cells by 90%, continued courses of chemo reduces the # of cancer cells until all cells are killed • Every cancerous cell must be killed to be cured; requiring repeated chemo courses Actions Cont….

33. uses the body’s defenses against tumor cells • Biologic response modifiers (BRM)-produced by normal cells to repair, stimulate, or enhance substances in the immune system to hopefully kill cancer cells Biotherapy (immunotherapy)

34. CSF-part of hematopoietic growth factors that encourage growth and maturation of blood cell components • If successful, myelosuppression is reduced and the client can receive higher doses of chemotherapy agents Biotherapy

35. BRM’s produced in a lab include: Monoclonal antibodies, Interferons, Colony-stimulating factors, Interleukins, Retinoids • MOAB-produced by fusing cancer cells and normal cells • Specific antibodies to seek out and bind to specific targets on cancer cells • Able to improve immune response to cancer and interfere with normal cells • Currently used for renal transplant rejections • **Nursing Interventions: monitor for anaphylactic reactions (MOAB’s), flushing, pallor, resp. distress,chills, fever, diaphoresis, urticaria, n/v, hypotension Biotherapy

36. Interferons-made by lymphocytes to enhance immune system • 3 types: alpha, beta and gamma • protect normal cells from parasitic invasion or viruses • appear to induce antitumor activity • Nursing interventions: teach side effects of flu-like such as fever, fatigue, chills, h/a, myalgia Biotherapy

37. Produced by genetically fusing cancer cells with normal cells* When used, the nurse needs to be aware of the possibility of acute anaphylactic reactions* Monoclonal antibodies

38. Type and location of lesion • Anxiety or fear of patient • Take v/s, weight • Some drugs (cisplatin/Platinol) may require hydration prior to administration • Lab tests: CBC • Ongoing assessment: lab tests (CBC, liver function) • Nursing Dx Assessment:

39. Requires special training and education to administer antineoplastic drugs • Oral administration-most are absorbed when GI tract functions WNL, wear gloves when administering • Parenteral administration-wear disposable plastic gloves (drugs can be absorbed through skin); cisplatin/Platinol cannot be administered or prepared with needles containing aluminum (precipitate) • IV-most common, use pump Implementation

40. AlopeciaOccurs 10-21 days after tx cycle complete • Anorexia • Common • Offer small, frequent meals, breakfast tolerated best • High protein Side effects

41. Bone Marrow Suppression • Decreased blood cell production • WBC’s • Leukocytes • Thrombocytes, platelet count <100,000 mm3 • Watch for bleeding!!! • Hold pressure at injection sites for 3-5 minutes • Avoid electric razors, nail trimmers, dental floss, firm toothbrushes, or any sharp objects • Anemia • Decreased RBC’s characterized by fatigue, dizziness, SOB, and palpitations Side Effects:

42. RBC’s • Results in anemia • N/V • Antiemetics • Diversional activities Side Effects:

43. Interleukins-promote T lymphocyte immune response to destroy neoplasms • Nursing Interventions: monitor for hypotension, edema, tachycardia, dyspnea Biotherapy

44. Retinoids-derived from retinol or vitamin A • Effect of retinoids -antibody and immune responses to suppress proliferation • Retinoic acid syndrome-side effect; s/s: respiratory distress, pleural effusions, weight gain Biotherapy

45. May be used as primary therapy, combined with chemo, or palliative tx • Reduces tumor size* • Directs ionizing radiation to target tissues for damage or destruction of the cells • Kills cells by preventing their ability to reproduce • Radiation does damage normal and abnormal cells • 3 types of rays involved • alpha and beta penetrate the upper layer of the skin • gamma penetrate deeply into body tissues Radiation therapy (radiotherapy)

46. Safety when dealing with radiation: TIME, DISTANCE, AND SHIELDING • Employees in radiation dept. must wear special badges that monitor radiation exposure Radiation therapy (radiotherapy)

47. 2 main types of radiation: using an internal or external radiation beam • External-uses deep and surface x-rays along with cobalt, radioactive isotopes and radium • Nursing Care-aimed at ensuring client and staff safety, keeping healthy cells from hazards • monitor side effects-decreased appetite, abd. Cramping, diarrhea and cutaneous irritation • *Side effects: nausea, dysphagia, bone marrow suppression Do Not wipe off ink marks!! • Linear accelerators and betatrons can deliver high doses without damaging organs Radiation therapy

48. Internal Radiation • Brachytherapy-placing radioactive substances directly into a tumor • delivers large amounts of radiation to destroy cancer cells within • radioactive sources are encapsulated so as not to contaminate body fluids • treat areas such as brain, tongue, breast, vagina, rectum, prostate, etc. • Radiation S.E. – nausea, fatique, malaise • Avoid using creams and powders on irradiated skin (increases irritation) Radiation therapy

49. Diagnostic procedures and treatments can be uncomfortable to intolerable Will need support after treatment d/t side effects, especially depression Preop and postop teaching Allow clients to participate in their treatment Nursing Considerations for Clients with Cancer

50. Nurses need special training to administer and monitor for side effects • Safe handling procedures, drugs extremely toxic • Some can be administered orally • Parenteral chemo must take special precautions-see book!! Chemo induces vomiting by stimulating neuroreceptors in the medulla Anticipatory n/v may occur before chemo* Chemotherapy