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					Cancer
         Med/Surg-2009
CANCER
     • Oncology is the specialty dealing
       with cancer and treatment
Cancer Development
       • 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
Benign or malignant
        • 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
Types of Tumors
       • Histology-study of tissue
          – 3 categories
             • 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, and may include various types of
            leukemias and lymphomas
          – Ewing’s sarcoma-affects diaphysis with mets
            to lung
          – ages 4-25
          – Dx: CT scan
          – Tx: chemo/radiation
Types of tumors
       • Mixed-Tissue Tumor
         – Less common
         – Develop from epithelial and connective
           tissues; Wilm’s tumor
Carcinogenesis and Carcinogens
       • 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
       • 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
Cancer Grading and Staging
       • 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
Staging
          • Identifies the spread of a tumor
          • 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 T1N0MO 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
Incidence
        • 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, breast cancer,
          prostate cancer, colorectal cancer
Laryngeal cancer
 is caused by
smoking and
excessive alcohol
 intake



  No S/S for early
  detection




 S/S-painless
 vaginal bleeding
  in elderly is sign
 of uterine cancer
Types of Mastectomies
       • 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
Mastectomy
      • 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=
Lymphedema
     • 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
Prevention and Early Detection
          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”
Cancer Screening Guidelines
       • Box 82-2
       • Breast Cancer
         – Women with increased family risk should
           start mammographies earlier
       • Colorectal cancer
         – Start early or performed more frequently if
           they have Crohn’s disease
       • Cervical Cancer
         – Age 30, should have a pap test q 2-3 years
           if they have had 3 normal Pap tests in a
           row
Diagnostic Test
        • 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
Laboratory Tests
        • Tumor markers-specific enzymes,
          cancer antigens that can indicate
          malignancies
          – Found in blood
            • EX. –Philadelphia chromosome-CML
          – Useful to monitor tumor response to
            treatment
          – Detect cancer recurrences
          – Additional test may be needed: x-
            rays, CT, MRI and ultrasound.
Noninvasive Diagnostic Procedures
        • 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
Invasive Diagnostic Techniques
        • 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
Treatment modalities
       • 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
Surgery
          • 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
          • 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
          • 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
Bone Marrow Transplant
       • 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
Chemotherapy
       • 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)
       • 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
      • 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
Antineoplastic drugs
       • Used in the tx of malignant
         diseases
         – Cure, control, or palliative relief
Antineoplastic Drugs
        • 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
Actions Cont….
           • 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
Alkylating drugs
        • Interfere with process of cell
          division of malignant and normal
          cells
          – Drug binds with DNA, preventing
            DNA replication
          – Malignant cells appear to be more
            susceptible to these drugs
             • EX: Busulfex-CML
             • Cytoxan-Hodgkin’s, leukemia, multiple
               myleoma
             • Mustargen-Hodgkin’s disease, leukemia
Antineoplastic antibiotics
         • Interfere with DNA and RNA synthesis
           and delay or inhibit cell division,
           including reproduction of malignant
           cells
         • Cell-cycle specific-active throughout
           DNA replication and mitosis
         • EX:
           – Adriamycin-acute leukemia, Wilm’s tumor
           – Idamycin-leukemia
           – Mutamycin-adenocarcinoma of stomach,
             pancreas
           – Mithracin-malignant testicular tumors
Antimetabolites
        • Interfere with metabolic functions
          of cells, changes DNA’s
          reproductive ability
          – Inhibit cell growth and proliferation
        • EX:
          – Leustatin-hairy cell leukemia
          – Adrucil-carcinoma of breast,
            stomach, pancreas, colon
          – Fludara-CLL
Hormones
      • Appear to counteract male or female
        hormones in hormone-dependent
        tumors
      • EX:
           –   Teslac-breast cancer
           –   Depo-Provera-endometrial or renal cancer
           –   Megace—breast or endometrial cancer
           –   Nolvadex/tamoxifen**-breast cancer
           –   Zoladex, Lupron (Gonadotropin-Releasing
               Hormones)
Mitotic Inhibitors
         • Interfere with or stop cell division
         • EX:
            – Taxol-ovarian cancer
            – Velban
            – Oncovin, Vincasar**-acute leukemia
Miscellaneous Antineoplastic Drugs
        • EX:
          – Oncaspar-ALL
          – Platinol/cisplatin-metastatic
            testicular tumors, bladder cancer,
            ovarian tumors
Uses:
        – Antineoplastic drugs are given alone
          or combo
        – Combo produces better results
Adverse Reactions:
          – Intensity increases with higher
            doses
          – Bone marrow suppression, n/v,
            stomatitis, diarrhea, alopecia
          – Toxic
          – Hyperuricemia (increase fluids)
Contraindications
          – Leukopenia
          – Thrombocytopenia
            • Platelets <100,000
          – Anemia
          – Infections
          – Renal disease
Contraindications
            • Alkylating Drugs: antagonize effects of
              antigout drugs (increase serum uric acid
              levels), cisplatin/Platinol increases risk
              of ototoxicity when used with loop
              diuretics and when used with
              aminoglycosides increase
              nephrotoxicity and ototoxicity
            • Antimetabolites: antagonize antigout
              drugs
            • Antineoplastic Antibiotics: decrease
              digoxin levels when administered with
              bleomycin
            • Hormones: Bicalutamide increases
              effects of oral anticoagulants, estrogen
              decreases effects of tamoxifen
Assessment:
         – 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
Implementation
         – 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
Side effects
        • Alopecia
          Occurs 10-21 days after tx cycle
          complete
        • Anorexia
           – Common
           – Offer small, frequent meals,
             breakfast tolerated best
           – High protein
Side Effects:
        • 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:
             • RBC’s
                –Results in anemia
        • N/V
          – Antiemetics
          – Diversional activities
Side Effects
        • Stomatitis
          – Cells in mouth are particularly sensitive to
            the effects of antineoplastic
          – Occurs 5-7 days after chemo and continue
            up to 10 days after therapy
          – Provide good mouth care with NS or
            alchohol-free mouthwash, lemon/glycerin
            swabs should be avoided
        • Tissue Integrity
          – Vesicants
          – Monitor for extravasation
Education
       •    Explain tx and procedure
       •    Avoid alcohol
       •    Keep all appointments
       •    Do not take nonprescription drugs
            unless ordered
Biotherapy (immunotherapy)
       • 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
       • 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
       • 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
        • 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
        • Interleukins-promote T lymphocyte
          immune response to destroy
          neoplasms
             – Nursing Interventions: monitor for
               hypotension, edema, tachycardia,
               dyspnea
Biotherapy
        • 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
Radiation therapy (radiotherapy)
        • May be used as primary therapy,
          combined with chemo, or palliative tx
        • 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)
        • Safety when dealing with radiation:
          TIME, DISTANCE, AND SHIELDING
          – Employees in radiation dept. must
            wear special badges that monitor
            radiation exposure
Radiation therapy
        • 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-abd.
                Cramping, diarrhea and cutaneous
                irritation
              • *Do Not wipe off ink marks!!
                  – *Side effects: nausea, dysphagia,
                    bone marrow suppression
              • Linear accelerators and betatrons can
                deliver high doses without damaging
                organs
Radiation therapy
        • 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)
NURSING PROCESS
     • Assessment
       – Nursing Diagnosis-think priorities, body
         systems, location of cancer
       – Planning-education, support
       – Implement-teach about disease,
         treatments, side effects
       – Evaluation-outcomes met/unmet??
Nursing Considerations for Clients
with Cancer
        • 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
Chemotherapy
       • 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
Chemotherapy Administration
       • Oral, IM, intracavitary, IV, intraperitoneal,
         intra-arterial, intrapleural, topical
       • Intra-arterially access usually requires
         vascular access devices such as PIC,
         PICC, central venous access device,
         external catheters, infusion pump
       • **Maybe infused intermittently to enhance
         the kill rate of cancer cells
       • **Chemo does not differentiate between
         normal and abnormal cells
Radiation Therapy
       • Explain procedure
       • Area treated will not feel hot, notify
         MD if you observe this
       • Radioactive iodine may be given for
         thyroid cancer-body fluids will be
         radioactive for a short time
       • Teach side effects
       • Teach care of skin: Box 82-1 in book
         pg. 1344
Manage Side Effects
       • N/V
         – Antiemetics
         – Guided imagery
         – distraction
         – Massage
         – Use a soft brush when cleaning the
           teeth
Manage Side Effects
      • Stomatitis or mucositis common
        – Avoid ETOH or foods that cause irritation
        – Avoid flossing or using ETOH containing
          products
        – Rinse mouth after eating and at bedtime
        – Solution using 1 tsp. salt, ½ tsp. baking
          soda and 500 ml of water is
          recommended
        – MD may order a swish and swallow
          preparation
Manage Side Effects
       • Fatigue
         –not uncommon
         –assess nutrition, rest, work,
          psychological distress, you
          should increase fluids and
          seek medical management
Manage Side Effects
       • Alopecia
         – can occur in eyelashes, eyebrows,
           pubic and body hair
         – encourage wigs, purchase prior to
           losing hair (can obtain similar color
           to hair and style)
         – avoid harsh chemicals
         – use mild shampoos
         – monitor for emotional side effects
Manage Side Effects
       • Secondary Infections
         – WBC count is depressed
           (neutropenic)
         – Teach to avoid activities that
           could injure
         – Don’t take rectal temps, allow
           use of razor blades, etc.
         – WASH HANDS-STAFF AND
           VISITORS!!
Manage Side Effects
       • Pain
         –R/T disease, treatment or
          procedures
         –Monitor pain level!!! Give
          round the clock pain meds
         –Prevent, rather than tx pain!!
Manage Side Effects
       • Stress
         –Use therapeutic visualization
           or guided imagery
         –Provide diversional activities
Manage Side Effects
       • Hormone-Related Effects
         – Women who take tamoxifen for
           breast cancer may experience
           menopause like sx’s-amenorrhea,
           hot flashes, insomnia and
           depression
         – Tx: herbal products (check with
           MD first), clonidine, or other
           combo drugs could be useful
Nutritional Needs
       • Cancer can deplete proteins
         assess for stomatitis
       • **Diet needs to be high in protein,
         CHO and vitamins
            • Monitor for taste changes,
              supplements may be needed
       • Assess for cultural dietary practices
Client/Family Teaching
       • Encourage BSE’s, testicular exams
       • Teach warning signs of cancer by
         American Cancer Society
       • Provide written and/or verbal info
         about tx, procedures, side effects,
         and other issues
       • Often chemo or radiation side effects
         must be tolerated to achieve optimal
         effects from drug therapy
How Does Chemotherapy Work?

       • There are 5 phases in the cell
         cycle, designated by letters and
         numbers:
       • G0 = Resting stage
         G1 = RNA and protein synthesis
         S = DNA synthesis
         G2 = Construction of mitotic
         apparatus
         M = Mitosis
The Cell Cycle
         • G0 phase (resting stage): Cells have not yet
           started to divide. Cells spend much of their
           lives in this phase. Depending on the type of
           cell, it can last for a few hours to a few years.
           When the cell is signaled to reproduce, it
           moves into the G1 phase.
         • G1 phase: During this phase, the cell starts
           making more proteins to get ready to divide.
           This phase lasts about 18 to 30 hours.
         • S phase: In the S phase, the chromosomes
           containing the genetic code (DNA) are copied
           so that both of the new cells formed will have
           the right amount of DNA. This phase lasts
           about 18 to 20 hours.
         • G2 phase: The G2 phase is just before the cell
           starts splitting into two cells. It lasts from 2 to
           10 hours.
The Cell Cycle
       • M phase (mitosis): In this phase, which lasts
         only 30 to 60 minutes, the cell actually splits
         into 2 new cells.
       • This cell cycle is important to cancer doctors
         (oncologists) because many chemotherapy
         drugs work only on actively reproducing cells
         (not on cells in the resting phase, G0). Some
         of these drugs specifically attack cells in a
         particular phase of the cell cycle (the M or S
         phases, for example). Understanding how
         these drugs function helps oncologists
         predict which drugs are likely to work well
         together. Doctors can also effectively plan
         how often doses of each drug should be
         given based on the timing of the cell phases.

       • American Cancer Society-2006
Hodgkin’s Disease
         Most common cancer in
           young adults
       •   More common in men
       • First recognized in 1832
       • Etiology: viral infections,
           suppressed immune functions
Hodgkin’s Disease
         A&P review
       •      Lymph nodes produce and store
          lymphocytes (2 types)
       •     B lymphocytes-protect body from
          invading germs by changing into
          plasma cells, then produce antibodies
          which mark germs for destruction
       • T lymphocytes-destroy infected
          bacteria or assist immune system to
          perform their job better
       • Lymph nodes are connected by
          lymph vessels
Hodgkin’s Disease
       • Hodgkin’s disease can start
         anywhere, but usually occurs in
         the upper chest, neck or axilla
       •    S/S-enlarged lymph nodes, low-
         grade fever, fatigue, night sweats,
         pruritis
       • Dx-biopsy revealing Reed-
         Sternberg cells (abnormal B
         lymphocyte)
Hodgkin’s
       o    2 types of Hodgkin’s:Classical and
          Nodular
           Classical: 4 subtypes
       1. nodular sclerosis Hodgkin disease-most
          common 60-80%, occurs younger people
       2. mixed cellularity Hodgkin disesase-affects
          15-30% of population and affects the
          upper half of the body
       3. lymphocyte-rich Hodgkin disease-occurs
          in the upper half of body in small
          lymphocytes
       4. lymphocyte-depleted Hodgkin disease-
          least common form seen in older people,
          involves lymph nodes in the abdomen,
          spleen, liver and bone marrow
Hodgkin’s
       • Nodular lymphocyte predominant
         Hodgkin disease
       • May contain Reed-Sternberg cells
         and normal lymphocytes, most
         commonly seen in lymph nodes of
         neck and axilla
Both types are malignant because
they grow and compress vital organs

        •   Treatment:
        •    Radiation
        •    Chemo
        •    Combination
        •    Stem cell transplant
        •     Prognosis good-60-70% achieve
            complete remission after tx
Non-Hodgkin’s Lymphoma (NHL)
        •    In 2002, the American Cancer
          Society estimated that 24,400 people
          will die from this disease
           Affects more men than women
        • NHL has malignant lymphoid cells that
          infiltrate many areas
        • Cause unknown
        • S/S: painless, enlarged single lymph
          node in the neck, abdominal
          discomfort, back pain, GI c/o resulting
          from lymph node involvement
Non-Hodgkin’s Lymphoma (NHL)
       • There are 2 types of lymphomas:
         Hodgkin’s and non-Hodgkin’s; the
         difference is the appearance of cells
         under a microscope
       • B cell lymphomas are more common
         and account for 85% of lymphomas
         Chronic lymphocytic leukemia (CLL)
         affects the blood and bone marrow and
         account for 7% of lymphomas
          Not curable, but clients can live over
         10 years with this lymphoma
Tx of non-Hodgkin’s lymphoma
       •    Chemo
       •    Radiation
       •    Combination
       •    Bone marrow transplant or
           peripheral stem cell transplant
           may be used
LEUKEMIA
     •     Abundance of abnormal WBC’s
     •     Type of leukemia depends on
         which cell line is affected:
         lymphoid or myeloid
Acute Lymphocytic Leukemia
       •  Acute develops quickly
       •  Starts in WBC’ in bone marrow
        and moves quickly to blood
       • Develops from B or T
        lymphocytes
       • Acute leukemia-bone marrow
        cells are unable to mature
        properly, immature leukemic cells
        called blasts reproduce and
        accumulate, without tx, may not
        live long (months)
ALL
      •     Chronic leukemia-cells mature
          but not completely and do not
          fight infection as well as normal
          WBC’s, instead, they live longer,
          build up and crowd out normal
          cells
Tx:
      •      Remission induction to
          decrease tumor cell burden using
          drugs
      •      Cyclophosphamide
      •      Vincristine
      •      Dexamethasone or prednisone
      •      L-asparaginase
      •      Doxorubicin (Adriamycin) or
          daunorubicin
Consolidation
       •  Intermittent tx using a drug
        regimen in high doses
       • Drugs known as colony
        stimulating factors (GM-CSF or G-
        CSF) keep the WBC count up
   Maintenance program
      • Methotrexate with 6-
       mercaptopurine (6-MP) combined
       with vincristine and prednisone
       for about 2 years
      • Approx. 80% of clients will have
       response to these treatments
       meaning that the leukemia can no
       longer be seen in the bone
       marrow
CNS Prophylaxis
      • ALL may spread to the coverings
        of the brain and spinal cord
      • Methotrexate and cytarabine is
        given directly into the spinal fluid
      • Radiation therapy to the brain
        may be added
High risk clients for relapse may
undergo a stem cell transplant/bone
marrow transplant

         • Allogenic-matched donor or
          sibling
           – Risk for GVH disease**
         • Autologous-self
Chronic Lymphocytic Leukemia
(CLL)
       • Starts in lymphocytes of bone
         marrow and invades blood or
         other parts of the body
       • Survival rate 6-8 years
       • Stem-cells normally divide to
         form new stem cells which go
         through a series of changes to
         form RBC’s, WBC’s and platelets
CLL
      •   Tx
      •   Low risk CLL: survival 20-25 years,
        no immediate treatment, if needed
        based upon symptoms chemo is the tx
        of choices
      • Intermediate and high risk CLL: live
        8-10 years, need tx immediately, drug
        of choice is chlorambucil, however,
        cyclophosphamide may be used if
        chlorambucil causes side effects
      •    Fludarabine is a newer drug used to
        tx recurring CLL
Acute Myeloid Leukemia (AML)
      • Seen mainly in adults-90%
      • Begins in cells that normally develop
        into WBC’s
      • Starts in the bone marrow and quickly
        moves to the blood
        – Nurses should observe for cuts that are
          small, yet drain fluid
      • Nurses should observe for cuts that
        are small, yet drain fluid
      • Many subtypes depending on the
        microscopic appearance of cells;
        ranges from MO-M7, the prognosis
        varies with each subtype
AML
      • TX: 2 chemo drugs such as cytarabine
        and anthracycline drug such as
        daunorubicin or idarubicin
      • A third chemo drug that is a
        greanulocyte colony stimulating factor
        may improve the response to chemo
      • This tx is intensive and may last one
        week
      • Normal bone marrow cells as well as
        the leukemic cells will be destroyed
      • Remission induction usually does not
        destroy all the leukemia cells
AML
      • Consolidation therapy is given
        after remission induction to
        destroy any remaining leukemia
        cells and prevent relapse
        – Option s for AML consolidation: high
          doses cytarabine chemo, allogeneic
          stem cell transplant, autologous
          stem cell transplant
Ablation Therapy
       • Use heat to treat cancer, when
         cells are not subjected to higher
         than normal temps, the cells
         change and make them more
         likely to be affected by radiation
         and/or chemo
       • Heat (by radio waves, US waves or
         other forms of energy) is used on
         very small areas such as a tumor,
         the heat ablates (destroys) the
         cancer cells
Ablation therapy
       • Heat is applied:
         – External-aim energy waves at the
           tumor near the body surface
         – Internal-needle or probe is inserted
           into the tumor, the tip releases
           energy which heats the surrounding
           tissue
         – Radiofrequency ablation is the most
           common used technique
           • Uses high energy radio waves for
             treatment
Chronic Myelogenous Leukemia
(CML) • Involves the maturing white blood
          cell-myelocyte
        • Staging system is determined by
          whether or not the disease is in
          the chronic phase (involving all
          mature cells) or blast phase (early,
          immature cells)
        • Tx: Gleevac is successful early,
          otherwise interferon, alpha (type
          of immunotherapy) or chemo will
          be used

				
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