Nursing Management of the Patient with Cancer What Is Cancer ??? A group of diseases (> 200!) Arise from a single cell that has gone wrong Multi-step process - numerous mutations accumulate over many years Uncontrolled growth, abnormal cells spread Many cancers can be ?chronic diseases? May result in death if allowed to progress Epidemiology Most occur in people over 65 Higher in men than women 1.3 million Americans diagnosed each year 5 year survival rate lower in AA than Caucasians Change in the US Death Rates* by Cause, 1950 & 2004 * Age-adjusted to 2000 US standard population. Sources: 1950 Mortality Data - CDC/NCHS, NVSS, Mortality Revised. 2004 Mortality Data: US Mortality Public Use Data Tape, 2004, NCHS, Centers for Disease Control and Prevention, 2006 Heart Diseases Cerebrovascular Diseases Pneumonia/ Influenza Cancer 1950 2004 Rate Per 100,000 2007 Estimated US Cancer Deaths* ONS=Other nervous system. Source: American Cancer Society, 2007. Men 289,550 Women 270,100 26% Lung & bronchus 15% Breast 10% Colon & rectum 6% Pancreas 6% Ovary 4% Leukemia 3% Non-Hodgkin lymphoma 3% Uterine corpus 2% Brain/ONS 2% Liver & intrahepatic bile duct 23% All other sites Lung & bronchus 31% Prostate 9% Colon & rectum 9% Pancreas 6% Leukemia 4% Liver & intrahepatic 4% bile duct Esophagus 4% Urinary bladder 3% Non-Hodgkin 3% lymphoma Kidney 3% All other sites 24% Lifetime Probability of Developing Cancer, by Site, Women, US, 2001-2003* Site Risk All sites? 1 in 3 Breast 1 in 8 Lung & bronchus 1 in 16 Colon & rectum 1 in 19 Uterine corpus 1 in 40 Non-Hodgkin lymphoma 1 in 55 Ovary 1 in 69 Melanoma 1 in 73 Pancreas 1 in 79 Urinary bladder? 1 in 87 Uterine cervix 1 in 138 Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.1.1 Statistical Research and Applications Branch, NCI, 2006. http://srab.cancer.gov/devcan * For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2001 to 2003. ? All Sites exclude basal and squamous cell skin cancers and in situ cancers except urinary bladder. ? Includes invasive and in situ cancer cases Lifetime Probability of Developing Cancer, by Site, Men, 2001-2003* * For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2001 to 2003. Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.1.1 Statistical Research and Applications Branch, NCI, 2006. http://srab.cancer.gov/devcan ? All Sites exclude basal and squamous cell skin cancers and in situ cancers except urinary bladder. Site Risk All sites? 1 in 2 Prostate 1 in 6 Lung and bronchus 1 in 12 Colon and rectum 1 in 17 Urinary bladder? 1 in 28 Non-Hodgkin lymphoma 1 in 47 Melanoma 1 in 49 Kidney 1 in 61 Leukemia 1 in 67 Oral Cavity 1 in 72 Stomach 1 in 89 ? Includes invasive and in situ cancer cases Cancer Survival*(%) by Site and Race,1996-2002 All Sites 68 57 11 Breast (female) 90 77 13 Colon 66 54 12 Esophagus 17 12 5 Leukemia 50 39 11 Non-Hodgkin lymphoma 64 56 8 Oral cavity 62 40 22 Prostate 100 98 2 Rectum 66 59 7 Urinary bladder 83 65 18 Uterine cervix 75 66 9 Uterine corpus 86 61 25 *5-year relative survival rates based on cancer patients diagnosed from 1996 to 2002 and followed through 2003. Source: Surveillance, Epidemiology, and End Results Program, 1975-2003, Division of Cancer Control and Population Sciences, National Cancer Institute, 2006. Site White % Difference African American Pathophysiology Cancer is a disease process that begins when abnormal cell is transformed by genetic mutation of the cellular DNA Abnormal cell forms a clone that proliferates abnormally Cells acquire invasive characteristics that causes changes in surrounding tissues Pathophysiology continued? Once infiltrated by cells, cells are carried to other areas of the body ? this process is called metastasis Tumors Benign slow growing non-invasive (encapsulated) remains local effects due to ?pressure? resembles cell of origin differentiated not recurrent Malignant ?faster? growing invasive usually distant spread effects due to tissue destruction resembles immature cell undifferentiated recurrent Characteristics of Malignant Cells Despite individual differences all cancer cells share some common characteristics Examples: cell membrane, specific proteins, nuclei, chromosomal abnormalities, rate of mitosis/growth Cell membranes are altered allowing movement of fluid in and out Characteristics of Malignant Cells continued? Cell membrane contains tumor specific antigens (proteins) CEA (carcinoembryonic antigen) PSA (prostate specific antigen) Invasion & Metastasis Invasion (growth of primary tumor into surrounding host tissues Mechanical pressure Less adherent malignant cells may break off invading adjacent tissue May also produce destructive enzymes Patterns of metastasis can be partially explained by circulatory patterns Lymphatic spread ? most common Hematogenous spread ? directly related to vascularity of the tumor Angiogenesis ? growth of new capillaries from host tissue by release of growth factor ? helps tumor obtain nutritrients Carcinogenesis ? 3 step cellular process ? TP53 ? keeps cells from dying Apoptosis genes Normal cellular genes which tell ?bad or mutated? cells to die. ?Apoptosis? or ?programmed cell death? is a very normal and organized process When these genes are mutated, the ?bad? cells don?t understand the ?signal? to die Cancer - in a nutshell Too many accelerators oncogenes Too few brakes tumor suppressor genes No auto mechanics DNA repair genes No junkyards Apoptosis genes Etiology Viruses and bacterias ? Epstein Barr Physical agents ? Exposure to sunlight, radiation, and tobacco Chemical agents ? 75% are related to environment Tobacco smoke is most lethal chemical agent ? results in 30% of cancer deaths Asbestos, pesticides, arsenic, soot Liver, lungs, kidneys most affected as filtering organs Genetic & familial factors ? almost all cancers have been shown to run in families Dietary factors ? proactive (fiber) versus carcinogenic ? fats, alcohol, salt cured and smoked meats, nitrates Hormonal agents ? tumor growth may be promoted by disturbances in hormone balance ? exogenous versus endogenous Role of the Immune System Some evidence that the immune system (macrophages & T lymphocytes) can detect malignant cells and destroy them Immunocompromised patients have higher incidence of CA Failure to recognize as different from normal cells Produce substances that impair the immune response Combine with antibodies to hide or disguise tumor cells Detection and Prevention of Cancer Primary prevention ? reducing risk of CA in healthy individuals ? avoiding carcinogens or modifying their lifestyle Secondary prevention ? detecting and screening to achieve early diagnosis and prompt intervention to halt CA process Genetic screening, self examination, regular screening Diagnosis of CA Blood work MRI CT Ultrasound Endoscopy PET X ray Classification of Cancer Standardized way of communicating Assists in determining most effective treatment plan Evaluate the treatment plan Help determine prognosis Compare like groups Treatment Options & Prognosis Dependent on staging and grading Staging determines the size of the tumor and the existence of metastasis TNM ? tumor, lymph nodes and metastasis Sentinel nodes Grading refers to the classification of the tumor cells Define type of tissue tumor originated from, degree to which tumor cells maintain histologic and functional characteristics of origin tissue Determined by cytology, biopsy or surgical excision Assigned #s I - IV Histological grading The higher the grade - the more aggressive the cancer Grade I - well differentiated (most like a normal cell) Grade II - moderately differentiated Grade III - poorly differentiated Grade IV ? anaplastic (most aggressive) Management of CA Cure, control and palliation Surgery Diagnostic Method of treatment Prophylactic Palliative Reconstructive Radiation Chemotherapy Targeted therapies Radiation Therapy Ionized radiation used to interrupt cellular growth More than 50% of patients with CA get radiation therapy May be used to cure, control or palliatively External versus internal ? varies based on depth of tumor Interstitial Intercavitary Brachytherapy ? implanted versus oral Intended to kill 95% of tumor while preserving normal tissue Radiation Toxicity Localized to region being irradiated May increase with chemotherapy Acute local reactions occur when normal cells are also destroyed and cellular death exceeds regeneration Tissues most affected are those that normally proliferate quickly Skin Lining of GI tract ? including oral cavity Bone marrow Toxicity & Systemic Effects Stomatitis Radiation burns Anemia, leukopenia, thrombocytopenia ? if sternum or iliac crest irradiated Cytoprotectant ? scavenger of free radicals ? prevents damage to DNA ? Ethyol Systemic Effects ? fatigue, malaise and anorexia Chemotherapy Antineoplastic agents used in an attempt to destroy tumor cells by interfering with cellular functions including replication Usually used to treat systemic disease versus localized disease May be used in combination with other therapies Each exposure to chemo agent destroys 20 ? 99% of tumor cells Repeated doses over time used to achieve regression Actively proliferating cells are most susceptible to chemo Nondividing cells capable of future proliferation least susceptible Repeated cycles ? ?rounds? ? needed to get nondividing cells as they become active Cell Cycle Agents Most affect the S phase ? DNA synthesis phase Some affect the M phase ? mitosis ? cell division phase Also cell cycle ? non specific agents which have a prolonged effect Many chemo plans combine both Increases cell kill Decreases development of drug resistant cells May be classified by chemical group ? alkylating, nitrosoureas, metabolites, antitumor antibiotics Administration of Chemo May be administered in hospital, clinic or home setting Extensive patient education is essential if chemo is to be administered at home Route of Administration Depends on the Type of agent Required dose Type, location and extent of tumor May be given topically, orally, IV, IM, SQ, arterial, intracavitary or intrathecally Dosage Determined by Patient?s total body surface area Response to previous chemotherapy or radiation Function of major organs Extravasation Vesicants cause tissue necrosis ? damage to underlying tendons, nerves, blood vessels ? often related to the pH of the agent Sloughing and ulceration can result Stop infusion immediately and apply ice, inject a neutralizing agent as appropriate Toxicities associated with Chemotherapy and Radiation Therapy GI ? most common Mucositis, stomatitis, esophagitis Nausea & vomiting Anorexia/cachexia Diarrhea/constipation Hepatotoxicity Hematologic Leukopenia Anemia Thrombocytopenia Chemotherapy/Radiation Induced Nausea and Vomiting (CINV or RINV) Types of N & V Acute: lasts 12-24 hrs Delayed: occurs after 24 hrs and may persist up to 5 days after chemo. Less apparent w/ radiotherapy Anticipatory: conditioned response resulting from patient?s expectation Breakthrough: anytime Refractory: anytime Toxicities associated with Chemotherapy and Radiation Therapy Integumentary Alopecia Skin reactions GU Cystitis Sexual Issues Nephrotoxicity Respiratory Pneumonitis Pulmonary Fibrosis CV Pericarditis, myocarditis MI, arrhythmias CHF Biochemical Hyperuricemia/tumor lysis syndrome Miscellaneous Fatigue Pain Pancytopenia Many factors in oncology patients Invasion of the bone marrow by tumor cells Chemicals produced and secreted by tumors Poor nutrition of anorectic patients Surgical changes to the gastrointestinal tract Radiation treatments Drugs, concurrent diseases, conditions Signs and Symptoms of Infection Systemic Fever - most important sign of infection in immunocompromised patients may be absent, delayed or subnormal in patients receiving steroids and in severely compromised patients Chills Tachypnea Tachycardia Sweating Oral Fungal Infections Oral Herpetic Infections Herpetic Infections Chemotherapy Mucosal Effects (Apthous Ulcer - not herpetic) Signs and Symptoms of Infection Skin / Wound Erythema Exudate / pus (rare if shortage of WBCs) Fever Heat (often absent) Induration Lesion Pain / tenderness Pruritus Swelling (often absent) Fatigue Cancer-related fatigue: persistent, subjective sense of tiredness r/t cancer or cancer treatment that interferes with usual functioning Commonly associated with many diseases Impacts all dimensions of QOL Nursing Responsibilities Knowledge of safe handling of cytotoxic drugs. Vesicant management. Allergic reactions. Patient & family education & support. Management of vascular access devices Explicit documentation. Knowledge of symptom management of chemo-related side-effects. Other Therapies Hyperthermia Targeted Therapies Biologic Response Modifiers Gene Therapy Growth Factors Unproven or unconventional therapies Gernotologic Considerations Impaired immune system Altered drug absorption, distribution, metabolism and elimination Chronic diseases Diminished renal, respiratory and cardiac reserves Decreased tissue integrity Delayed healing Decreased strength Decreased neurosensory function Altered social and economic resources Hospice May be provided in acute care setting or home setting Multidisciplinary team focused on helping improve/maintain quality of life for the patient and family Focus on emotional and physical support Oncologic Emergencies Superior Vena Cava Syndrome Spinal Cord Compression Hypercalemia Pericardial Effusion DIC SIADH Tumorlysis Syndrome
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