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Malignancy pwr point July.11

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					   Malignancy
     2011
   Linda Visser
WVC Nursing Faculty
  Anne Coghlan
WVC Nursing Faculty
2007 Estimated US Cancer Cases*
                    Men                                                       Women
                   766,860                                                    678,060

Prostate                    29%                                             26%       Breast
Lung & bronchus             15%                                             15%       Lung & bronchus
Colon & rectum              10%                                             11%        Colon & rectum
Urinary bladder               7%                                              6%      Uterine corpus
Non-Hodgkin                   4%                                              4%      Non-Hodgkin
   lymphoma                                                                             lymphoma
Melanoma of skin              4%                                              4%      Melanoma of skin
Kidney                        4%                                              4%      Thyroid
Leukemia                      3%                                              3%      Ovary
Oral cavity                   3%                                              3%      Kidney
Pancreas                      2%                                              3%      Leukemia
All Other Sites             19%                                             21%       All Other Sites



         *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.
         Source: American Cancer Society, 2007.
Epidemiological Reports on Cancer
      2007 Estimated US Cancer Deaths*
 Lung & bronchus            31%
                                        Men      Women
                                                         26%   Lung & bronchus
                                       289,550   270,100
 Prostate                     9%                        15%    Breast
 Colon & rectum               9%                        10%    Colon & rectum
 Pancreas                     6%                         6%    Pancreas
 Leukemia                     4%                         6%    Ovary
 Liver & intrahepatic         4%                         4%    Leukemia
     bile duct
                                                         3%    Non-Hodgkin
 Esophagus                    4%                                lymphoma
 Urinary bladder              3%                         3%    Uterine corpus
 Non-Hodgkin                  3%                         2%    Brain/ONS
    lymphoma
                                                         2%     Liver & intrahepatic
 Kidney                       3%                                  bile duct
 All other sites             24%                        23%    All other sites


     ONS=Other nervous system.
     Source: American Cancer Society, 2007.
                           100




   0
       20
            40
                 60
                      80
1930


1935


1940


1945


1950


1955


1960


1965


1970


1975


1980


1985


1990


1995
                                   Women, US,1930-2005




2000
                                 Cancer Death Rates Among




2005
      Cancer Death Rates by Race
      and Ethnicity, US, 2001-2005
400                                                      Men            Women
350
                       313.0
300

250    230.7

                               186.7                    190.0
200
               159.2                                                      159.0
                                       138.8                    142.0
150
                                               95.6                               105.2
100

 50

  0
          White          African       Asian/Pacific      American         Hispanic†
                        American         Islander      Indian/ Alaskan
                                                            Native
Lifetime Probability of Developing Cancer, by Site, Men,
                       2001-2003*
                                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



    † All Sites exclude basal and squamous cell skin cancers and in situ cancers except urinary
    bladder.
* For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2001 to 2003.
‡ Includes invasive and in situ cancer cases
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
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



† All Sites exclude basal and squamous cell skin cancers and in situ cancers except urinary
bladder.those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2001 to 2003.
     * For
 ‡ Includes invasive and in situ cancer cases

 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
                        Per Capita Cigarette Consumption




                          1000
                                 1500
                                        2000
                                               2500
                                                      3000
                                                             3500
                                                                    4000
                                                                           4500
                                                                                  5000




              0
                  500
       1900
       1905
       1910
       1915
       1920
       1925
       1930
       1935
       1940
       1945
       1950




Year
       1955
       1960
       1965
       1970
                                                                                                   2005




       1975
       1980
       1985
       1990
       1995
       2000
       2005
              0
                  10
                          20
                                 30
                                        40
                                               50
                                                      60
                                                             70
                                                                    80
                                                                           90
                                                                                  100




                        Age-Adjusted Lung Cancer Death
                                     Rates*
                                                                                         Tobacco Use in the US, 1900-
   Trends in Consumption of Five or More
Recommended Vegetable and Fruit Servings for
 Cancer Prevention, Adults 18 and Older, US,
                 1994-2007
                   35

                   30
                        24.2   24.4   24.1   24.4   23.6   24.3   24.7
                   25
  Prevalence (%)




                   20

                   15

                   10

                    5

                    0
                        1994   1996   1998   2000   2003   2005   2007
                                             Year
      Cancer Survival*(%) by Site and Race,1996-2002
                                                                        African             %
                    Site                                White          American        Difference


       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.
       I. Influence of Culture
• What did you think when you read the title
  of this power point?
       Ageism & Detection of Ca
           What‘s the risk?
• C
• A
• U
• T
• I
• O
• N
Iggy
Assessment of the Older Adult:
     What‘s the focus?
Higher incidence of cancer in people older
  than 55
  – Reflects lifelong accumulation of DNA
    mutations that result in
     • cell changes and
     • Cancer
         Race & Access:
       What‘s the Connection?

•   White
•   Asian
•   African American
•   Hispanic
•   Compare types of ca with carcinogens.
    Race and Cultural Beliefs
           example
• Latin women: cervical ca screening
  – Access
  – ―Sexual silence‖
    • Sexuality is personal and not be talked about
      openly
    • ―If I have sex @ early age & multiple sex partners I
      am engaging in immoral behavior. Getting a pap
      smear is admitting that I am an immoral person.‖
       – Latina Social, Cultural, & Behavioral Risk Factors for
         Cervical Ca,
         www.Public.asu.edu/~squiroga/ramirez.HTM
                II. Screening
• Does reduce incidence?
• Does reduce some types of deaths?

•   Annual mammography, women > 40
•   Annual clinical breast exam, women > 40
•   Colonoscopy age 50 & then every 10 yrs
•   Annual fecal occult blood, adults, all ages
•   Annual prostate specific antigen (PSA) &
    digital rectal exam, men > 50 yrs
             III. The Cell
• Growth: Mitosis occurs to develop normal
  tissue, or to replace lost or damaged
  normal tissue. A balance is maintained
  between cell birth and cell death
• Oncogenes and tumor suppressor genes
  regulate this process
• Oncogenes were the genes that directed
  early embryonic development.
                  Review of Cell Growth
                                                               G1
                                GO Resting
M




                                                               RNA Synthesized
Cell divides
  Mitosis




           G2 RNA & protein synthesized      S   DNA Synthesized
           The Cell (con‘t)
• At 8 days after conception, these genes
  should be turned off forever by
  ―suppressor genes.‖
• When normal cells are exposed to any
  carcinogen, the normal cell‘s
  DNA can be damaged or mutated.
            IV. Oncogenes
• Mutations damage suppressor genes,
  preventing them from controlling the
  expression of proto-oncogenes.
• The result, is that the proto-oncogens are
  turned on.
• They are then called oncogenes & can
  cause the cell to change from normal cells
  to cancer cells.
     V. Oncogenes Become a
            Problem
• These oncogenes are not abnormal genes
  but are part of every cell‘s normal makeup
  & were important in early development.
• Oncogenes become a problem only if they
  are activated after development is
  complete, as a result of exposure to
  carcinogenic agents or events.
XI. Malignant vs Benign Tumors

Shape: Irregular vs regular
Structure:      Atypical vs very Typical
Rate of Growth:
  Malignant may be rapid vs usually slow
Mode of Growth:
  Malignant infiltrates surrounding tissue vs
  expansion
Progression: Progressive vs stationary
  Malignant vs Benign Tumors
Microscopic: Cells are atypical varying
  degrees of origin vs fairly typical cells of
  tissue of origin.
Tissue Destruction: Commonly causes
  necrosis vs minor tissue destruction.
  Malignant vs Benign Tumors
Vascularity: Moderate to marked vs slight.
Recurrence after surgical removal: Common
 vs rare
Spread: Frequently spreads from distant
 tumors vs does not spread.
   How Do We Determine Benign vs
           Malignant?

• For definitive diagnosis
  – Biopsy
• Supportive diagnostics
  – Symptoms
  – Xrays (CT, MRI, nuclear scans, PET,
    mammography)
  – Tumor markers
  – Abnormal serology
  – Other lab
 Breast Cancer with Sternal
Metastasis from as seen in CT
 bone scan with ―increased
           uptake‖.
 Benign Tumor Pressing on
         Optic Nerve
TX: steroids to < inflammation
 which < pressure on nerve
     Diagnosis of Malignancy
• Biopsy
  – Brush
  – Shave
  – Punch
  – Needle aspiration
  – Incisional
  – Excisional
  – Sentinel lymph node
  – Bone marrow biopsy
Bone Marrow Aspiration Biopsy
            XII. Metastasis
Defined as the spreading of cancer cells
  from the primary site to other parts of the
  body.
Most frequent sites of mets are:
1) Bone, 2) Lung, 3) Brain, 4) Liver.
              Mets (con‘t)
Mets can occur via:
 1) Extension into surrounding tissues.
 (Tumors bully their way into new territory).
 2) Blood vessel penetration by enzymes.
    (Tumor cells enter the blood & get a
    free ride throughout the body).
            Mets (con‘t)
3) Release of tumor cells. (Clumps of cells
break off into blood vessels).

4) Invasion of tissues @ remote sites.
(Cells circulate through the blood & enter
tissues).
              Mets (con‘t)
Three routes for spread:
    1. Local seeding (ex shedding of cells
 from ovary into peritoneal cavity).
    2. Bloodborne mets in capillaries. Most
 common (capillary wall damaged, allowing
 cancer cells to enter surrounding tissue).
    3. Lymphatic spread (ex breast
    cancer).
          VI. Stop: Review
• Neoplastic cells originate from _____cells.
• Transformation of a normal cell into a ca
  cell involves mutation of the _____of the
  normal cell.
• Only ___ cell has to undergo malignant
  transformation for cancer to begin.
• Benign tumors grow by _____________.
             More Review
• Malignant tumors grow by __________.
• Cancer cells have a life span that is ____.
• An example of primary prevention of
  cancer is ________.
• An example of secondary prevention of
  cancer is ________.
• The original tumor is called the ________.
             More Review
• In metastasis, cancer cells move from the
  primary location by breaking off from the
  original group & establishing remote
  colonies. These additional tumors are
  called ____________ or ___________
  ______.
• Even though the tumor is now in another
  organ, it is still a ca from the original
  altered tissue.
  VII. External Factors Causing
             Cancer
• 78-80% of ca in No. America may be the
  result of environmental, or external factors.
• Chemical, physical, or viral agents =
  environmental carcinogens.
 VIII. Chemical Carcinogenesis
• Chemical Carcinogenesis
  – Chemicals used in everyday life
  – Some chemicals, such as tobacco & ETOH
    are mildly carcinogenic; it takes long term
    exposure to large amounts before cancer
    develops.
  Chemical Carcinogenesis
– However, these two substances can act as
  co-carcinogens; when taken together, they
  enhance each other‘s carcinogenic activity.
– Cells not susceptible to chemical
  carcinogenesis to the same degree.
– Normal cells that have ability to divide = ^ risk
  for ca than normal cells that are not capable
  of cell division.
  Chemical Carcinogenesis
– Example, ca common in bone marrow, skin,
  lining of GI tract, ductal cells of breast, & lining
  of lungs.
– All normally undergo cell division.
– Ca of nerve tissue, cardiac muscle, & skeletal
  muscle are rare.
– These cells do not normally undergo cell
  division.
– 30% cancers r/t tobacco use. See Table 27-10.
  IX. Physical Carcinogenesis
• Physical Carcinogenesis
  – Ex: radiation
    Even small doses
    Two types: Ionizing & ultraviolet (UV)
    Examples of ― radiation‖: radon, uranium, radium,
     X-Rays. UV comes from sun; tanning beds,
     germicidal light.
    Most common ca type caused by UV exposure =
     skin ca.
  Physical Carcinogenesis
• Physical Carcinogenesis
  Ex: chronic irritation, such as burn scars.
• Viral Carcinogenesis
  Break DNA chain, inserting own genetic
   material into human DNA chain.
  Called oncoviruses.
           X. Dietary Factors
• Dietary Factors r/t Cancer Development
Rarely independent of other possible
  carcinogenic agents.
   Poorly understood.
Suspected connections
  Low fiber intake      High red meat intake
  Preservatives         High animal fat intake
  Contaminants          Additives.
 XI. Grading & Staging Tumors
• Developed for MDs to standardize
  – Cancer diagnosis
  – Cancer prognosis
  – Cancer tx
• Grading of a tumor classifies cellular
  aspects of the cancer
• Staging classifies clinical aspects of the
  cancer.
                Grading
• Grading always compares the cancer cell
  w/ the normal parent tissue
• Some cancer cells are aggressive &
  spread rapidly (―high-grade‖ cancers)
                  Grading
• Gx Grade cannot be determined
• G1 Cells well differentiated; closely
  resemble parent cells
  – Considered low grade of malignant change
  – Malignant but relatively slow growing
• G2 Cells moderately differentiated; retain
  some characteristics of parent cells
  – More malignant characteristics than G1 cells
                    Grading
• G3 Cells poorly differentiated; parent
  tissue can be determined
  – Cells have few normal cell characteristics
• G4 Cells poorly differentiated; retain no
  normal cell characteristics
  – Difficult to figure out tissue of origin,
    sometimes impossible
                Staging
• Determines exact location of cancer &
  degree of metastasis at diagnosis.

    • Clinical staging
    • Surgical staging
    • Pathologic staging
                     Staging
• 1) Clinical staging – assesses client‘s
  clinical manifestations & evaluates clinical
  signs for tumor sz & possible spread.

  • Obtaining ca cells for biopsy (no major surg)
                 Staging
• 2) Surgical staging – assesses tumor size,
  number, sites & spread by inspection at
  surgery.
                 Staging
• 3) Pathologic staging – pathologic
  examination of tissues obtained at surgery
  determine tumor size, number, sites &
  spread
      XII. TNM Staging System
      Tumor, Node, Metastasis
          Extent of Primary Tumor (T)
•   Tx
•   To
•   Tis
•   T1, T2, T3, T4
                  TNM
  Presence or absence & extent of regional
         lymph node involvement (N)
• Nx
• No
• N1, N2, N3
                  TNM
 Presence or absence of distant metastasis
                   (M)
• Mx
• Mo
• M1
            Tumor Markers
• Highly specialized blood tests to detect
  tumor markers.
• Tumor markers are proteins & hormones
  produced by certain tumors.
• As tumor ^ in size, tumor marker levels ^.
• Ex: prostates-specific antigen, PSA which
  ^ proportionately to total mass of prostate
  gland. Normal is < 4 ng/mL.
 XIII. Treatments for Cancer

– Surgery
  • debulking
– Radiation
  • Brachytherapy
  • Teletherapy
– Chemotherapy
– Stem Cell Replacement
XIV. Surgical Treatment of
         Cancer

• Debulking

• Excision

• 2nd Look Surgery
 XV. Issues Related to Healing

• Relevant lab tests

• Time

• Nutrition
            XVI. Radiation
• Side effects/treatment

• Specific Nursing Care



• LONG TERM ISSUES
Dry Desquamation: 2-3 weeks
       after radiation
Mucositis: mucous membranes
Scar tissue: debilitating for
        many years
                 Radiation
• Disruption of all cells

• Risk vs benefit

• Exposure
Xerostomia from external beam
          radiation
   xero + stoma (Greek for mouth)
    - no saliva d/t radiation effects -
           XVII. Teletherapy
• Source is external to patient
• Patient education:
  – Area will be marked
  – Important to follow regimen
  – Expect irritation & hair loss at site
  – Care of skin
  – FATIGUE
  – Change in taste sensation
  – Avoid SUN
        XVIII. Brachytherapy
• Radiation therapy is within the patient
• Unsealed: IV or oral, peritoneal, spinal.
• Not confined to one body area, but have
  an affinity for one type of tissue.
• Sealed: Implanted within or near the
  tumor.
Brachytherapy for Prostate
         Cancer
Brachytherapy in Prostate
     Cancer: seeds
Close up of where the seeds
        are placed
    Brachytherapy in Breast
  Cancer: leads in the breast
bring radioactive source inside
 or next to the area requiring
       treatment (sealed)
Cesium Implant in Cancer of the
          Tongue
        XIX. Chemotherapy
• Anti-neoplastics
• Anti-angiogenics
• Biological Response Modifiers
  (Immunotherapy)
• Hormone Therapy
• Monoconal antibiotics
•
        General Notes about
          Chemotherapy
• Smaller the tumor burden-easier to treat
  the patient.
• More effective after debulking
• More effective at high doses
• Plural therapy is the norm
                  Key Terms
• Terms r/t administration of Anti-neoplastic
  chemotherapeutic agents
  – Nadir
  – Absolute Neutrophil Count
  – Myelosuppression
  – Extravasation
     • Vesicant
     • Irritant
  – Hemorrhagic Cystitis
                  Nadir
• Time of lowest levels of WBC counts after
  chemotherapy
• What is the patient at risk for?
• How will you know the patient‘s risk?
      Absolute Neutrophil Count
•   ANC
•   WBCs x (% neutrophils + bands)
•   Example: WBCs are 1000
•   Neutrophils are 25%
    Bands are 2 %
                      = .27

• 1000 x .27 = 270 ANC
   What does the ANC Mean?
• ANC < 2000 = Neutropenia
  – Slight risk of infection
• ANC 1000-1500 = Mild Neutopenia
  – Minimal risk of infection
• ANC 500-1000 = Moderate Neutropenia
  – Moderate risk of infection
• ANC <500 = Severe Neutropenia
  – Severe risk of infection risk of infection
           Myelosuppression
•   Thrombocytopenia
•   When do we worry about it?
•   What should be avoided?
•   Platelet administration?
            Extravasation
• Movement of the IV needle so the drug
  leaks into the surrounding tissues.
• Vesicant:
• Irritant:
• Documentation of Extravasation
    Patient Education Prior to
             Therapy
• Importance of contraceptive use
• Importance of adequate nutritional
  intake—monitor weight
• Importance of adequate fluid intake
• Importance of oral care
• Energy conservation measures
• Community support groups
     Patient Education Prior to
              Therapy
• Avoid alcohol (increases risk of toxicity)
• Avoid aspirin (increases risk of bleeding
• Importance of infection prevention
  Measures to Reduce Risk of
          Infection
• Hand washing
• Up to date on immunizations
  before beginning therapy
• Avoid large crowds or those you know are
  ill
      Reducing Infection Risk
• Wear gloves when gardening/working
  outside
• Wash all fruits & veggies; cook thoroughly;
  no raw meats or unpasteurized foods
• KEEP ALL LAB APPOINTMENTS!!!!!
  Know your Nadir
Chemotherapeutic Agents
          Anti-Neoplastics
• Can be administered through many
  different routes.
• CELL CYCLE SPECIFIC
• CELL CYCLE NON-SPECIFIC
            Review of Cell Cycle
                                               G1
M
                   GO Resting
Alkaloids
  Vinca




      G2                        S Antimetabolites
           Anti-neoplastics
•   Alkylating agents
•   Anti-metabolites
•   Mitotic Inhibitors
•   Cytoxic Antibiotics
•   Topoisomerase Inhibitors
           Alkylating Agents
• Cisplatin
  – Cell cycle non specific

  – Common side effects

  – Serious side effects


• Nadir
Nursing Interventions: Cisplatin
• Assess pt for: dizziness, tinnitus, hearing
  loss, uncoordination, and numbness and
  tingling of extremities—may be irreversible
• Adequate fluid intake to protect renal
  function! Strict I&O
• Ensure intravenous placement; adjust rate
  or increase dilution if needed to prevent
  painful administration
                  Antimetabolite
• fluorouracil (5 FU); methotrexate; Cytosar
   – Cell cycle specific

   – Common side effects

   – Serious side effects


• Nadir
• ―Leucovorin rescue‖ to be given with high doses of
  methotrexate
       Nursing Interventions:
         Antimetabolites
• Sunscreen
• Increased fluid intake
• Necessary follow up visits and lab work
Mitotic inhibitors-Vinca Alkaloids
• vincristine (Oncovin); Etoposide (VP 16 or
  VePesid)
• paclitaxel(Pacific Yew Tree) Taxol
  – Cell cycle specific

  – Common side effects

  – Serious side effects

• Nadir
    Topoisomerase Inhibitors
• Camptosar (irinotecan)
  – Cell cycle specific

  – Common side effects

  – Serious side effects


• Nadir
          Cytotoxic Antibiotics
• Bleomycin; doxorubicin (Adriamycin)
  – Cell cycle non specific

  – Common side effects

  – Serious side effects

• Nadir
             Hormones
• Compete for receptor sites
• These are NOT A CURE but they do slow
  growth of tumors
• Androgens and anti-estrogen receptors
• Estrogens and anti-androgen receptors
      Monoclonal Antibodies
• Interfere with cellular processes necessary
  for cancer cell survival
• Herceptin (trastuzumab)-Breast cancer
• Rituxin (rituximab)-non Hodgkins
• Other cancers where these are looking
  promising are lymphomas and colorectal
  cancer
    Adverse Effects of Monoclonal
             Antibodies
•   Fever, chills, hypotension
•   Anaphylaxis
•   N,V,D
•   Anemia
•   Cardiac and liver toxicity
•   Tumor lysis syndrome
     Anti-angiogenics Avastin
• Work by interfering with the malignant
  cells ability to create their own blood
  supply
• Ability of malignant cells to adequately
  supply a growing tumor is compromised
        Targeted Therapies
• Development of proteins specific to growth
  patterns of specific cancers
Anti-Neoplastics Administration
           Protocol
• Weigh your patient
• Calculate the BSA and double check the
  dose ordered (Nurse to Nurse)
• Check the patient‘s recent lab work
• Hx of patient‘s response to last round of
  chemo - any concerns
• Patient assessment
Anti-Neoplastics Administration
           Protocol
• Clarify with physician any concerns-
  dose/labs prior to mixing
• Premedicate for nausea, anxiety, diuresis
  if indicated for treatment
• Check IV site
    Preparing Anti-Neoplastic
          Medications
• Have all of the previous completed
• Personal protective equipment
• Laminar hood
• Do not do this when rushed!!!
• When you are done, and med is drawn
  up—double check with another nurse
  AGAIN
• Know any particular extravasation
  procedure for the drug you are giving and
  have it on hand!
 Administering Anti-Neoplastics
• Make sure that patient is comfortable and
  premedicated
• Once more, check IV placement
• Begin infusion slowly at first and watch
  patient closely for any side effects
• Check patient at regular intervals
 Biological Response Modifiers
• Cytokines
   – Stimulate the immune response & bone marrow recovery
• Interleukins
   – Help to recognize and destroy abnormal body cells
     (melanoma!)
• Interferons
   – Protect the non infected cells from viral infection and
     replication
• Colony stimulating factors
   – Support cancer therapy & hasten bone marrow recovery
 More About Colony Stimulating
           Factors
• Leukopenia-Leukine
• Neutropenia-Neupogen (filgrastim)
   – Not to be used within 24hr of chemo or radiation
• Fatigue-Epogen, Procrit (epoetin alfa) daily or Aranesp
  (weekly)
   – Avoid in patients with hypertension
   – Watch for seizure activity
   – Not to be given to those with cancers of the bone marrow
• Thrombocytopenia-Neumega (oprelvekin)
   – Causes cardiac stimulation-watch for tachycardia,
     dysrhythmias and edema
       Stem Cell Transplant
• To rescue and restore function of the
  blood cell producing system
          Graft vs Host Disease
• Acute: happens in days 7-100 after transplant
   – 30-40% of identical transplant recipients
   – 60-80% of those with 1 antigen mismatch
• Symptoms
   – Painful, pruritic maculopapular rash—palms and soles
     progressing to trunk, chest and upper back
   – Diarrhea, nausea, anorexia---GI bleed and hyperbilirubinemia
       Graft vs Host Disease
• Chronic: occurs after 100 days
  – Patient is no longer at the transplant center—
    be aware
  – 40% of identical transplant recipients
  – 70% of those with 1 antigen mismatch
• Symptoms
  – Can affect any organ but typically-alopecia,
    thickened tight fragile skin/pain oral mucosal
    dryness/jaundice/bile duct
    damage/cataracts/photophobia/recurrent resp
    infections/anorexia/diarrhea/weight loss
      Treatment of Graft-Host
             Disease
• Long term immunosuppression
• Cyclosporine
• Steroids

• Common Nsg Dx
  – Altered skin integrity
  – Risk for infection
  – Electrolyte imbalance
      Common SE in the Patient
      Receiving Chemotherapy
•   Fatigue
•   Myelosuppression
•   Anorexia
•   Nausea
•   Stomatitis/mucositis
•   Diarrhea
•   Altered nutritional status
•   Alopecia
•   Venous fragility
•   Hypersensitivity
           Chapter 24
      Note: Pay Attention to
• Best Practice Boxes
• Intervention Activities Boxes
• Client Education Guide Boxes
                     Fatigue
• ―A subjective state of overwhelming
  sustained exhaustion and decreased
  capacity for physical and mental work that
  is unrelieved by rest.‖*
• Most distressing and most common side
  effect of chemotherapy (radiation therapy
  also)

      *Escalante, CP (2001). A Fatigue Clinic in a
    Comprehensive Cancer Center. Cancer, 92, 1708-
                        1713
     Fatigue: Causative Factors
•   Pain
•   Emotional distress
•   Sleep disturbance
•   Anemia
•   Nutrition
•   Activity level
       Fatigue: Assessment
• What assessments will you want to
  perform?
          Fatigue: Interventions
• ―It has been shown that exercise, including
  walking and aerobic and resistance
  training have beneficial effects on some
  symptoms related to cancer, including
  fatigue, distress, anxiety, and depressive
  symptoms.‖*
• *National Comprehensive Cancer Network. Cancer-related fatigue.
  In: Clinical Practice Guidelines in Oncology. Access June 20, 2006,
  at: http://www.nccn.org/professionals/physician)gls/default.asp
       Fatigue: Interventions
• What interventions will you initiate?
           Myleosuppression
•   Thrombocytopenia
•   When do we worry about it?
•   What should be avoided?
•   Platelet administration?
       Immunosuppression
• Neutropenia based on ANC
• Treatment
  – Neupogen
  – Neulasta
       Nausea and Vomiting
• 70%-80% of patients receiving chemo
  experience this
• Anticipatory, acute, breakthrough and
  delayed
• What are some of the antiemetics used?
• What route works best?
                     Nausea
• Anticipatory-before chemo even begins
  – Ativan (?what‘s the generic)
• Acute
  – Compazine, phenergan, Anzemet, Zofran,
    Dexamethasone
• Breakthrough
  – Ativan, Reglan
• Delayed
  – Aloxi (palonosetron)
              Nausea
• Don‘t underestimate the power of
  anticipatory or delayed nausea—MANAGE
  THESE EARLY—if the pt feels they are
  going to get nauseated—TREAT
• Give meds before meals to encourage
  intake
        Altered Nutritional State
•   Anorexia
•   Increased metabolic demands
•   Inability to take in adequate nutrients
•   Malnutrition
•   Cachexia
Cachexia
     Stomatitis and Mucositis
• Painful
• Exacerbate nutritional deficits
• Prevention

• Treatment
                Diarrhea
• Most often due to antimetabolites
• Watch closely for electrolyte disturbance
• Careful treatment of diarrhea in the
  immunocompromised
                  Diarrhea
•   Stress the need for fluids
•   Yogurt
•   Add bulk to diet as tolerated
•   Watch closely for electrolyte disturbances
                  Alopecia
• Hair loss is copious and in clumps
• Prepare the patient
• Purchase hats, scarves and wigs before it
  happens and while the patient has the
  energy to try out these things
• Tell patient that hair loss is total body, not
  just the head
• Reassure the patient that hair will grow
  back; may not be same color or texture
             Venous Fragility
•   Naturally occurring with aging
•   Complication with cytotoxic agents
•   Thrombocytopenia
•   Leukopenia
•   Capillary leak syndrome
           Hypersensitivity
• Anaphylaxis
  – Cisplatin
  – Bleomycin


• May give prophylactic steroids and
  antihistamines in advance of infusion
                 Toxicities
•   Cardiac
•   Neurologic
•   Renal
•   Pulmonary
                XX. Pain
• Remember, pain is __________________.

• TREAT, TREAT, TREAT for quality of life.

• Anticipate side effects.
• More on pain in power point slides ahead.
               Website
• You Tube The Pain of Childhood Cancer
• pain
• Fear
                Website
• http://www.youtube.com/watch?v=oPumO
  pv6jyU Brazil hospital innovative
  treatments

Video themes (on cancer treatment):
1. Cancer can be cured
2.   Positive image of the patient
3.   Compassion for the patient
  XXI. Oncologic Emergencies
• Sepsis
• Disseminated Intravascular Coagulation—
  DIC
• Syndrome of Inappropriate Antidiuretic
  Hormone—SIADH
• Hypercalcemia
• Spinal Cord Compression
• Superior Vena Cava Syndrome
• Tumor Lysis Syndrome
                    Sepsis
• Recognition:
  – FEVER-MAYBE NOT!
  – Decreased BP
  – Altered mental status
  – Grossly decreased tissue perfusion
• Prevention:
  – Anticipate potential sources of infection
  – Get those CULTURES
  – Treat ASAP
                    DIC
• Complex hematological disorder where
  clotting factors and platelets are used up
  and bleeding ensues
                          SIADH
•   Tumors can secrete their own ADH
•   What does ADH do?
•   HYPONATREMIA
•   Symptoms:
    – Weakness, cramps, decreased appetite and fatigue are early
      sx
    – Personality changes, confusion and seizures, coma and
      death are late sx
• Treatment:
    – Fluid restriction, Na+ supplement
    – Medication, chemo and radiation
                Hypercalcemia
• Causes:
  – Bone metastasis and parathyroid hormone release
• Symptoms:
  – Fatigue, anorexia, nausea, vomiting to muscle weakness,
    loss of deep tendon reflexes, ileus…….hmmm, do any of
    these resemble side effects of chemo or radiation?
• Treatment:
  – Sometimes as simple as hydrate or glucocorticoids, but
    patient may need dialysis
    Spinal Cord Compression
• Symptoms:
  – Will be related to where the compression is
• Treatment:
  – High dose corticosteroids/radiation/palliation
Superior Vena Cava Syndrome
• Where is the superior vena cava located?
• Because of tumor growth this becomes
  compressed and obstructs the return of
  blood to the central circulation
• Most oft a result of lymphoma and lung
  cancer
• Treatment:
  – Radiation, surgical placement of shunt
      Tumor Lysis Syndrome
• Excessive dump of K+ into the blood
  stream from breakdown of cells—life
  threatening cardiac arrhythmias
• Indirect elevation of uric acid—leading to
  uric acid crystals in the renal system—
  renal then liver failure
• Treatment: Prophylactic HYDRATION
• Most often lymphomas, and leukemias
• 5 L fluid per day before chem and 3 L
  each day for 3-5 days
         Hemorrhagic Cystitis
• Marked by large quantities of blood in the
  urine
• Cause
  – Side effect of radiation therapy or
  – Treatment with cyclophosphamide, page 492,
    Iggy
   XXII. Focus on the Patient
• Courage
• Communication Themes of the Patient
• Communication Techniques of the Nurse
            XXIII. Courage
• Cancer patients are some of the bravest
  people you will ever know. It is truly a
  privilege to be able to take care of them,
  whatever the outcome of treatment.
• http://www.upenn.edu/ARG/archive/ccta/in
  tor.html
 XXIV. Communication Themes
          of Patient

• Listen to the expressions of these patients,
  as they communicate through art.
Communication Themes of the
         Patient

    What did you hear?
       XXV. Communication
       Techniques of Nurse

• How can the nurse best communicate with
  the patient and his/her family?



• Link up the themes with the nurse‘s
  therapeutic response.
  – The nurse‘s best therapeutic tool is _______
                Being With
•   Sit down.
•   Take time.
•   Presence in the midst of tasks.
•   Being with as opposed to being there.
            Fostering Hope
• Key: listen, really listen. Listen more than
  speak.
• Hope can be directed – where headed
  – For the day
  – For the hour
  – Hope can be instilled as well as directed
• Hope gives strength
  – Spiritual connection
  – Absence of spiritual recognition
      XXVI. End of Life Care
• Palliative Care-a philosophy that provides
  a compassionate and supportive approach
  to clients & families who are living with life
  threatening illnesses.
  – Holistic approach
  – Does not hasten death
  – Does not postpone death
  – Provides relief of sx experienced by the dying
    client
      Palliative Care (con‘t)
– Provides emotional support
– Provides spiritual support
– Improves quality of care at the end of life
             Death & Dying
• Death and Dying
  – Goals of care
    • Assess client needs
    • Manage symptoms
    • Promote meaningful interactions between client
      and significant others
    • Facilitate a peaceful death
                   Hospice
• Hospice care
  – seeks an interdisciplinary approach
  – to facilitate both quality of life and a ―good‖
    death
  – for clients who are nearing the end of their
    lives.
            Hospice (con‘t)
• What disciplines are involved in an
  ―interdisciplinary‖ approach?

• What does ―quality of life‖ mean for the
  dying patient?
            Hospice (con‘t)
• The word ‗Hospice‘ means ―hospitality‖ –
  resting place for weary or ill travelers.

• Became synonymous with care of
  terminally ill with founding of Our Lady‘s
  Hospice in Dublin by Sister May
  Aikenhead of the Irish Sisters of Charity, a
  colleague of Florence Nightingale.
            Hospice (con‘t)
• Refer to Hospice Handouts
  – Hospice Worksheet for Determining
    Prognosis - All Diagnoses
  – Hospice Worksheet for Determining
    Prognosis – Breast Cancer
  – Hospice Worksheet for Determining
    Prognosis – Lung Cancer
  – CWH Admission to Hospice Program
  – CWH Care Planning for Hospice Patients
  – Hospice Algorithm Process
  Alternative (Complementary)
            Therapies
• What therapies are considered
  ‗alternative‘?

• How effective are they?
  – How is effectiveness measured?
  – How much do they cost?


• What ‗nurse bias‘ surrounds alternative
  therapies?
                Cancer Pain

• Pain is what the client says it is; self report most
  reliable.
• 3 major types of pain: acute, chronic cancer,
  and chronic noncancer.
• Acute pain warns the body, causing sympathetic
  responses, such as ^ HR, ^ BP & P, dilated
  pupils, & sweating.
  Chronic Pain vs Chronic Non
  Ca Pain or Chronic Ca Pain
• Chronic pain does not cause sympathetic
  reaction; therefore some clients do not
  appear to be in pain, even when they are.
• Chronic non cancer pain i.e. chronic back
  pain
• Chronic cancer pain. Pain associated w/
  ca or progressive dz. Cause of pain is
  usually life threatening i.e. cancer or AIDS.
 Concept Map Chronic Cancer
           Pain
• Iggy, page 416, 6th Edition
• The nurse took one aspect of the patient‘s
  care, pain, and diagrammed it out.
• How did the nurse know what to assess
  when analyzing the patient‘s pain?
         Pain Management
• Refer to Hospice Handouts
  – Standards of Practice
  – Pain Management for the Hospice Patient
  – How Does the Patient Describe the Pain
  – Pain Treatment Algorithm
  – Opiate Analgesic Dose Equivalents
  – Pain: Signs and Symptoms
  – Assessing & Reporting Pain to Physician
  – Examples of Opioid Resistant Pain
– How is effectiveness measured?
– How much do they cost?
      Algorithm: Constipation
• It is true that constipation can be more
  distressing to the client with cancer than
  the pain itself
• How can that be?
• See Hospice Pain algorithm
• See Hospice Bowel Program algorithm
        Gate Control Theory
• Gate Control Theory.
  – Nerve fibers transmit pain impulses.
     Impulses travel to dorsal horns of spinal
    cord.
  – Cells of substantia gelatinosa can stop (‗close
    the gate‘) of the transmission of pain to the T-
    cells.
       Gate Control Theory
– Gating exists in nerve fibers as well.
– Nerves descending from thalamus & cerebral
  cortex regulate thoughts & emotions.
– When pain occurs, humans can modify the
  perception of pain by what they think about
  and feel, emotionally (i.e. imagery or distraction).
            Stages of Grief
             Kubler-Ross
• Are Kubler-Ross Stages of Grief
  useful/helpful in cancer grief?

  – For the patient?
  – For the patient‘s family?
  – For the patient‘s extended family & friends?
  – For the nurse?
Melanoma
  Note the area of
     punch biopsy on the
  foot
Squamous Cell Skin Cancer
B
A
S
A
L

C
E
L
L
Laminar Hood
People will forget what you said,
people will forget what you did,
but people will never forget how
     you made them feel.
                  Maya Angelou

				
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