Cancer

Facts
Cancer affects all ages, most common >65 Higher rate in men Higher rate in industrialized nations 1.4 million are diagnosed each year 2nd to Cardiovascular disease as a cause of death in US > 500,000 die yearly from a malignant process

Most Common Cancers

Common Cancers Among Males 1. Lung 2. Prostate 3. Colorectal Common Cancers Among Females 1. Lung 2. Breast 3. Colorectal

Pathophysiology

Cancer begins when an abnormal cell is transformed by the genetic mutation of the cellular DNA. This cell forms a clone and begins to proliferate abnormally ignoring cell growth signals The cells acquire invasive characteristics

Pathophysiology

Changes occur in the surrounding tissues The cancer cells infiltrate these tissues and gain access to lymph and blood vessels, which carry the cells to other areas of the body

Defect in Cellular Proliferation

Stem cell theory Loss of intracellular control of proliferation results from mutation of stem cells DNA is substituted or permanently rearranged

Defect in Cellular Proliferation

Once mutated Cell can die from damage or by initiating programmed cellular suicide (apoptosis) Can recognize damage and repair itself Survive and pass on damage Surviving mutated cells have potential to become malignant

Defect in Cellular Proliferation

Cancer cells are characterized by the loss of contact inhibition Grow on top of one another and on top of or between normal cells Cancer cells respond differently than normal cells to intracellular signals regulating equilibrium Divide indiscriminately

Defect in Cellular Proliferation

Benign noncancerous Malignant cancerous Pyramid effect Each cell division creates two or more offspring cells Continuous tumor growth

Defect in Cellular Differentiation

Oncogenes responsible for cellular functions of growth and differentiation Proto-oncogenes Normal cellular genes that are important regulators on normal cellular processes act as on switch for cellular growth Mutations that alter their expression can activate them to act as oncogenes (tumorinducing)

Defect in Cellular Differentiation

Tumor suppressor genes (anti-oncogenes) 1. Protects the cell from becoming a cancer cell 2. When this suppressor gene is mutated (and its function of protecting is diminished) the cell can progress to cancer 3. Determine whether cells live or die after their DNA has been damaged 4. Therefore, they suppress growth of tumors

Mutations render them inactive (which leads to an increase)

Defect in Cellular Differentiation

Tumors classified as benign neoplasm Well differentiated Encapsulated Expansive mode of growth Characteristics similar to parent cell

Apoptosis cell suicide

Defect in Cellular Differentiation

Tumors classified as malignant neoplasm Able to metastasize Infiltrative and expansive Frequent recurrence Moderate to marked vascularity

Development of Cancer
The Origin may be chemical, environmental, genetic, immunologic, viral, or spontaneous in origin The Progression Characterized by increased, rapid growth rate of tumor, as well as, its invasiveness and metastasis. Development of its own blood supply is critical for survival Tumor angiogenesis is formation of blood vessels within the tumor

Role of Immune System

Immune response is to reject or destroy cancer cells if perceived as nonself 1 Cancer cells have antigens on the cell membrane referred to as TumorAssociated Antigens (TAAs) TAAs are capable of stimulating immune responses (with T lymphocytes, Natural Killers, ) 2

Role of Immune System

Escape mechanisms by which cancer cells evade immune system Tumors do not have TAAs to be recognized as foreign TAAs combine with immune system antibodies and disguise themselves to evade recognition Factors increasing Suppressor T cells 1

Diagnosis

Evaluation includes identifying the stage and grade of the tumor Done prior to treatment to provide baseline Treatment options and prognosis are based on staging and grading Anatomic Site Classification Identified by tissue origin anatomic site behavior of the tumor

Classification

Anatomic Site Classification Carcinomas originate from the embryonic endoderm or ectoderm Sarcomas - originate from embryonic mesoderm Lymphomas and leukemias originate from hematopoietic system

Grading
Appearance of cells and degree of differentiation are evaluated Grade 1: Cells differ slightly from normal cells and are well differentiated Grade 2: Cells more abnormal and moderately differentiated Grade 3: Cells very abnormal and poorly differentiated

Grading
Grade 4: Cells immature and primitive and undifferentiated; cell of origin difficult to determine

Staging

Clinical Staging 0: cancer in situ 1: tumor limited to tissue of origin 2: limited local spread 3: extensive local and regional spread 4: metastasis

Classification System
TNM Classification 1. Determines the size of the tumor 2. The existence of local invasion 3. The existence of distant metastasis

Prevention and Detection of Cancer

Reduce or avoid exposure to known or suspected carcinogens Eat balanced diet Exercise regularly Adequate rest Health examination on a regular basis

Prevention and Detection of Cancer

Eliminate, reduce, or change perceptions of stressors and enhance ability to cope Enjoy consistent periods of relaxation and leisure Know 7 warning signs of cancer Self-examination Seek medical care if cancer is suspected

Seven Warning Signs of Cancer

Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or lump in the breast, testicles, or elsewhere Indigestion or difficulty swallowing Obvious change in the size, color, shape, or thickness of a wart, mole, or mouth sore Nagging cough or hoarseness

Diagnosis of Cancer
Patient may experience fear and anxiety Clear and repeated explanations may be necessary Diagnostic plan includes Health history (emphasis on risk factors) Physical exam Specific studies

Diagnosis of Cancer

Biopsy involves histologic examination by a pathologist of a piece of tissue Needle Incisional Excisional

Management

Goals Cure - therapy may involve surgery alone or extended periods of systemic therapy Control- treatment plan has initial course and maintenance therapy Palliation- goal is relief or control of symptoms and maintenance of quality of life

Collaborative Care

Factors that determine treatment modality Cell type Location and size of tumor Extent of disease Physiologic and psychologic status and expressed needs also determine treatment

Clinical Trials
Phase 1: small group of people tested to evaluated safety, determine dosage, and identify side effects Phase 2: larger group to test efficacy and further evaluated safety Phase 3: larger group tested to confirm efficacy, monitor side effects, and collect information allowing drug or treatment to be used safely

Surgery
Surgical removal ideal and most frequently used treatment Diagnostic 1 Primary 2 Prophylactic 3 Palliative 4 Reconstructive 5

Radiation Therapy
Localized treatment so only the tissues that are within the treatment field will be affected by the radiation therapy Ionizing breaks bonds in DNA so causes cell death, therefore no proliferation Normal tissues are usually able to recover

Chemotherapy

Goal is to reduce number of cancer cells in the tumor site(s) Several factors determine response of cancer cells Cancer cells can escape death Main problem is presence of drug- resistant resting and noncycling cells

Function of Chemotherapy

Works at the cellular level NORMAL cells produce to meet the needs of the body and only enough cells are produced to replace the dying cells. CANCER CELLS continue to produce beyond the need for cellular replacement, therefore there will be a greater number of cancer cells than normal cells producing.

Dividing Cells

Chemotherapy has its greatest effect in the early stage of a tumor when the total number of cancer cells is small and a greater percentage of these cells are actively dividing and most sensitive to the chemotherapy Cancer cells of short generation time are more sensitive to the effects of chemotherapy, cancer cells with a long generation time are more resistant to chemotherapy

Pharmacologic Effect on Cell Cycle

Cell cycle specific cause cellular damage only at a specific phase of the cycle Most effective against actively growing tumors Cell cycle non-specific agents are usually more DOSE dependent. number of cells killed directly proportional to the drug dose administered

Chemotherapy
Classification of Drugs

Alkylating Agents/Cell cycle non specific Nitrosureas/Cell cycle non-specific Antitumor Antibiotics/non-specific Antimetabolites/ Cell cycle specific (S)phase Plant (Vinca) Alkaloids Cell specific

Chemotherapy
Classification of Drugs
Classified in relating to the cell cycle

Nitrosoureas Corticosteroids Hormone therapy Miscellaneous

Miscellaneous Agents
Combining medication therapy prevents development of drug resistant mechanisms

Hormonal Agents Glucocorticoids Prednisone , Decadron, Medrol Antiestrogen Agents Deprovera, progestational agents Tamoxifen Interferons

Chemotherapy
Methods of Administration
May be done in the hospital, outpatient center, home setting Route depends on type of agent, required dose, type, location, and extent of tumor Subcutaneous Topical Infusion Oral IM IV Intraarterial

Method of Chemotherapy Intracavitary

Intr

Method of Chemotherapy Intrathecal

Chemotherapy
Methods of Administration

Central vascular access devices permit frequent, continuous, or intermittent administration Can be used to administer additional fluids Major types Atrial catheters Implanted infusion ports Infusion pumps

Nursing Interventions

Prior to administration Check current values (agency policy) Verify written consent Explain procedure to patient Double check drug (policy of hospital) may require two signatures Obtain spill kit

Interventions Cont.

Constant monitoring Documenting during administration Extravasation policy (drug dependent) D/C immediately Leave needle in place IV antidote if applicable

Extravasation

Common Side Effects

Alkylating Agents Bone marrow suppression Alopecia- Caused by damage to the stem cells, usually begins 3 weeks after treatment initiation, re-growth begins 8 weeks post last treatment Nausea & Vomiting

Side Effects
Antimetabolites Nausea, Vomiting and Diarrhea (N,V,&D) Bone marrow suppression Stomatitis

Side Effects
Antitumor Antibiotics Bone marrow suppression N,V, &D Anorexia Alopecia Cardiac Toxicity

Side Effects
Plant (Vinca) Alkaloids Bone marrow suppression Neuropathies Stomatitis

ROBOTIC RADIOSURGERY
Pain free Non-surgical Non-invasive No anesthesia Outpatient procedure No head or body frame No implanted markers CyberKnife

Nursing Management
Nursing Interventions

Fatigue Encourage patient to identify times of day when feeling better may allow for more activity Rest before activity Get assistance with activity Reproductive Effects Inform patient of expected sexual side effects Refer to counseling if needed Sperm bank freezing

Nursing Management
Nursing Interventions

Nutritional Status/Anorexia Monitor carefully to avoid weight loss Weight twice weekly Small, frequent, high-protein, high-calorie meals supplements, non-irritating diet Gastrointestinal Effects Prophylactic administration of antiemetics Assess for S/S of alkalosis and dehydration I&O Antidiarrheal medications

Nursing Management
Nursing Intervention

Skin Reactions Dry skin should be lubricated with nonirritating lotion or solution that contains no alcohol, perfume, or additives. Washed with water and mild soap. Kept clean and protected from further damage Prevention of infection Facilitate wound healing Protect irritated skin from extremes in temperature Avoid constricting garments, harsh chemicals, and deodorants

Nursing Management
Nursing Interventions

Oral, Oropharynx, and Esophageal Reactions Teach patients to examine oral cavity Dental work should be performed before initiation of radiation therapy Saliva substitutes Oral care Pain relief Frequent feedings of soft, nonirritating, highprotein, high-calorie foods Avoidance of extremes in temperature, alcohol, and tobacco

Nursing Management
Nursing Interventions

Pulmonary Attention Treatment Bronchodilators Expectorants/cough suppressants Bed rest Oxygen

Nursing Management
Nursing Interventions

Coping Assist in planning for transportation, nutrition, and emotional support Patient teaching of symptom management to maintain highest possible quality of life

Chemotherapy
Effects on Normal Tissues

Chemotherapeutic agents cannot distinguish between normal and cancer cells Bodys response to products of cellular destruction in circulation may cause fatigue, anorexia, and taste alterations

Chemotherapy
Effects on Normal Tissues
Acute toxicity Vomiting Allergic reactions Arrhythmias Delayed effects Mucositis Alopecia Bone marrow suppression

Chemotherapy
Effects on Normal Tissues

Chronic toxicities Damage to Heart Kidney Liver Lungs

Chemotherapy
Treatment Plan
Complementary and Alternative Medicine (CAM) Managing treatments a challenge for patients and their clinicians Need to find balance between quality of life - with toxic and life saving treatments Many want holistic or nontraditional approach to coincide with traditional

Chemotherapy
Treatment Plan
Drugs usually given in combination Carefully calculated according to body weight or body surface area

Must differentiate between tolerable side effects and toxic side effects Serious reactions must be reported Some toxicities are not reversible

Chemotherapy
Treatment Plan

Selection of principles of combination chemotherapy Drugs used are effective against cancer being treated Synergistic effect occurs when combined Includes cell cycle phase-specific and cell cycle nonspecific drugs with different mechanisms of action Combination of drugs with different toxic side effects Include drugs that cause nadir

Nursing Management
Nursing Interventions

Administration of antiemetic drugs Monitor lab results, particularly WBCs, platelet, and RBCs Assess for signs of bleeding if platelet count falls below 50,000/l, again hospital policy prevails, could be lower

Nursing Management
Nursing Intervention

Patient must be told what to expect in order to decrease anxiety Encourage discussion of fears Reassure patient that situation is only temporary Inform patient of supportive care that will be provided

Late Effects of Radiation and Chemotherapy

Risk for leukemias and other secondary malignancies resulting from therapy Secondary malignancies other than leukemia have been reported Includes breast, ovarian, uterine, thyroid, and lung cancers Fibrosarcomas have been reported Secondary malignancies usually resistant to therapy

Targeted Therapy
Wants to minimize negative effect on healthy tissues by addressing specific cancer cell functions Malignant transformation Cell communication pathways Processes for growth Processed for metastasis Genetic coding This therapy uses the immune system through biologic response modifiers (BRM)

Targeted Therapy Biologic Response Modifiers

Interferons (IFNs) Cytokines with antiviral and antitumor properties 1 IFN - used for hairy leukemia (Kaposis) Cannot be administered orally Interleukins (IFs) Induce biologic activities that activate immune system to alter the function of cancer cells 2

Targeted Therapy Biologic Response Modifiers

Interferons Side Effects Flu-like syndrome Anorexia/weight loss Fatigue Lethargy Depression Changes in cognitive function Bone marrow suppression

Targeted Therapy Biologic Response Modifier

Interleukins Side Effects Hypotension Ascites Flulike symptoms Fatigue, Anorexia, diarrhea Pulmonary edema Additional toxicities Renal, cardiovascular, pulmonary, GI, and integumentary toxicities Bone marrow suppression Changes in cognitive function

Targeted Therapy Biologic Response Modifier

Monoclonal Antibodies (MoAbs) Destroy cancer cells, spare normal cells 1 Administered by infusion Can experience infusion-related symptoms 2 Risk of anaphylaxis Side effects Capillary leak syndrome 3 Hepatotoxicity 4 Bone marrow depression CNS effects Cardiac dysfunction

Targeted Therapy
Hematopoietic Growth Factors
Hematopoietic Growth Factors 1 Colony-stimulating factors Glycoproteins that stimulate production, maturation, regulation, and activation of cells in hematologic system May hasten recovery from bone marrow depression or reestablish bone marrow function Erythropoietin Stimulates RBC production therefore decreases symptoms of chronic anemia and reducing need for transfusions Made by kidneys

Targeted Therapy
Hematopoietic Growth Factors Oprelvekin Platelet growth factor Indicated for prevention of severe thrombocytopenia and reduction of need or platelet transfusions Adverse effects include edema, dyspnea, tachycardia, and conjunctiva redness

Targeted Therapy
Toxic Side Effects of Biologic Agents Flu-like syndrome CNS Symptoms Renal-hepatic symptoms GI Disturbances Hematologic Disorders Bone Pain Cardiovascular-pulmonary Integumentary Endocrine Miscellaneous

Targeted Therapy

Nursing Interventions for flu-like syndrome Administration of acetaminophen before treatment and q4h after treatment Generalized comfort measures Monitor VS Plan rest periods Assist with ADLs

Bone Marrow and Stem Cell Transplantation

Bone Marrow Transplantation (BMT) Peripheral Blood Stem Cell Transplantation (PBSCT) Allows for safe use of very high doses of chemotherapy or radiation therapy Procedure with many risks, including death Highly toxic

Types of Bone Marrow Transplantation

Based on source of donor cells Allogeneic Autologous Syngeneic

Bone Marrow and Stem Cell Transplantation

Allogeneic BMT (AlloBMT)
Infused bone marrow acquired from donor matched to recipient Either high or low dose chemo Then rescue bone marrow through engraftment and subsequent normal proliferation and differentiation of donated marrow Side Effects Infection, sepsis, alopecia, N,V,&D, stomatitis, sterility, cardiac dysfunction, liver disease

Bone Marrow and Stem Cell Transplantation

Autologous (AuBMT) For pts who do not have a suitable donor Patient receives their own bone marrow Marrow is removed, treated, stored, and reinfused Syngeneic Obtaining stem cells from one identical twin and infusing them into the other

Bone Marrow and Stem Cell Transplantation

Harvesting Procedure conducted in the OR Multiple aspirations carried out Usually iliac crest or sternum Cryopreserved Complications Viral and fungal infections are common Prophylactic antibiotic therapy

Bone Marrow and Stem Cell Transplantation

Complications Graft-versus-host disease T lymphocytes from donated marrow recognize recipient as foreign Attack organs such as skin, liver, and intestines

Bone Marrow and Stem Cell Transplantation

Cord blood stem cells Umbilical cord blood (after childbirth) can be typed and cryopreserved Used to treat hematopoietic and genetic disorders May have insufficient numbers of stem cells to permit transplant to adults

Gene Therapy

Approaches that correct genetic defects or manipulate genes to induce tumor cell destruction Transfer of exogenous genes into cells of patients in effort to correct defective gene Investigational

Complications of Cancer
Altered taste sensation Can teach patient to experiment with spices and seasonings in attempt to mask alterations Infection Can cause death related to neutropenia Superior vena cava syndrome Obstruction by compressions by tumor Manifestations include Facial edema Distention of neck and chest veins Seizures, Headache

Complications of Cancer

Spinal cord compression Presence of malignant tumor in epidural space Manifestations Intense, localized, persistent back pain Motor weakness and dysfunction Sensory paresthesia and loss Autonomic dysfunction Change in bowel or bladder function

Complications of Cancer
Third Space Syndrome Shifting of fluid from vascular space to interstitial space Patients exhibit signs of hypovolemia Treatment includes replacement of fluid & electrolytes, and plasma proteins Hypervolemia can occur during recovery

Complications of Cancer
Syndrome of Inappropriate Anti-Diuretic Hormone (SIADH) Abnormal or sustained production of ADH Cancer cells able to manufacture, store, and release ADH Some chemotherapeutic agents stimulate release Treatment with fluid restriction or IV 3% NaCl

Complications of Cancer

Hypercalcemia Parathyroid hormone-like substance is secreted from cancer cells Immobility and dehydration can contribute to or exacerbate Primary manifestations Apathy/depression Fatigue Muscle weakness Polyuria and nocturia Anorexia, N&V

Complications of Cancer

Hypercalcemia Can be life-threatening Treatment is aimed at primary disease Acute is treated by hydration, diuretic, and a bisphosphonate

Complications of Cancer

Tumor lysis syndrome Metabolic complication triggered by chemotherapy Results from rapid destruction number of tumor cells Can cause fatal biochemical changes Four hallmark signs Hyperuricemia Hyperphosphatemia Hyperkalemia Hypocalcemia

Complications of Cancer

Tumor lysis syndrome Primary goal is preventing renal failure and severe electrolyte imbalances Primary treatment Increasing urine production with hydration therapy Decreasing uric acid concentrations

Complications of Cancer

Cardiac tamponade Fluid accumulation in the pericardial sac, constriction of pericardium, or pericarditis Cardiac tamponade Manifestations Dyspnea Tachycardia Anxiety Decreased LOC Pulsus paradoxus Distant, muted heart sounds

Complications of Cancer

Cardiac tamponade Management aimed at reduction of fluid around the heart and includes surgical establishment of pericardial window or indwelling pericardial catheter

Complications of Cancer

Carotid artery rupture Invasion of artery wall by tumor or erosion following surgery or radiation Bleeding can manifest as minor oozing in case of blowout Pressure should be applied IV fluids and blood administered to stabilize for surgery

Management of Cancer Pain

Patient report should always be believed and accepted as primary pain assessment data Drug therapy should be used following WHO analgesic ladder Nonpharmacologic interventions can be effectively used

Cancer
Psychologic Support
Emphasis placed on maintaining optimal quality of life Positive attitude of patient, family, and health care providers has significant positive impact on quality of life for patient May also influence prognosis Continue to be available Exhibit caring attitude Listen actively to fears and concerns Provide relief from distressing symptoms

Cancer
Psychologic Support

Maintain relationship based on trust and confidence Use touch to exhibit caring Assist patient in setting realistic short- term goals Assist in maintaining usual lifestyle patterns Maintain hope, which can vary Provides control over what is occurring Basis of positive attitude

Cancer
Gerontologic Considerations

Clinical manifestations may be mistaken for age-related changes Vulnerable to complications of cancer and cancer therapy Functional status considered in treatment