Nursing Management: Cancer

1
Nursing Management Cancer

• NURS 1228
• Spring 2003
• Nina Green, BSN, RN, Instructor

2
Incidence of Cancer

• Equal in both males and females
• Age distribution is different
• Ages 20-60 the incidence is higher in women
• After age 60 the incidence is higher in men
• Race
• Higher incidence and mortality rate in
  African-Americans
• More predominate in Western countries

3
Incidence of Cancer

• Cancer is the leading cause of death from disease
  in children past infancy
• Most common is leukemia and lymphoma

4
Biology of Cancer

• Normal cell growth
• Uniform in size
• Nuclei characteristic of the tissue to which they
  belong
• Cell growth takes place in two distinct activity
  periods or cycles

5
Defect in cellular proliferation

• Under normal situations there is control of the
  number of cells in the body
• Balance between cellular proliferation and
  cellular death
• Contact inhibition
• If something goes wrong in the control
  mechanisms, it can result in rapid proliferation
  of immature cells

6
Defect in cellular differentiation

• Cells specialize in certain tasks
• This is usually an orderly process of development
• In malignancy, this process is out of control and
  cellular mutations occur
• Hyperplasia is an increase in the number or
  density of normal cells

7
What is a neoplasm?

• Cells with an abnormal growth pattern
• Either benign or malignant
• Any overgrowth of tissue can form a tumor

8
Benign neoplasms

• Composed of cells that look like the tissue of
  origin
• Usually encapsulated
• Grow slowly and by expansion

9
Benign neoplasms

• Do not recur or metastasize
• Do not destroy tissue generally
• Do not cause systemic symptoms or death generally

10
Malignant neoplasm's

• Composed of undifferentiated (or immature) cells.
• Little resembles the tissue of origin
• Grows rapidly
• Expands at periphery and invades and destroys
  surrounding tissue

11
Malignant neoplasms

• Recurs and metastasizes to other parts of the
  body
• Spreads by way of lymph and blood to distant
  parts of the body
• Causes systemic signs and symptoms
• Ultimately, it can cause death

12
What makes a cancer able to metastasize?

• Can be spread by blood/lymph system
• This helps us predict what organs will be
  metastasized
• Spread by direct contact organ to organ
• Iatrogenic spread surgical seeding or invasive
  procedure moving cells from one site to another

13
Oncogenes and Proto-oncogenes

• Genes capable of triggering cancerous conditions
• Normally suppressed
• Can be triggered by invading viruses or other
  carcinogens
• Proto-oncogenes benign forms of oncogenes
  necessary of normal function
• Fragile and easily damaged and mutated

14
Immune response

• Immune response failure
• When the immune system is compromised it fails
  to.
• Suppress oncogenes
• Kill off the cancerous cells that normally form
  within the body
• Normal cell cycle becomes deranged
• Damage occurs to the DNA and proteins inside the
  cell

15
Immunological defects

• If the immunological system is not working
• The body is more susceptible to invasion by
  foreign agents, cancer included
• People with immunological disorders are at higher
  risk for developing certain kinds of malignant
  disorders
• Persons with AIDS
• Persons receiving immunosuppressive therapy for
  neoplastic or non-neoplastic disorders

16
Biological Carcinogens

• Viruses
• HIV, HBV, papilloma viruses, HTLV
• Genetics
• The etiology of cancer is unknown
• It is generally assumed that genetic factors are
  involved

17
Chemical Carcinogens

• Drugs and hormones
• Chemotherapeutic drugs
• Recreational drugs
• DES, estrogen, cortisone, anabolic steroids
• Diet
• Alcohol

18
Carcinogens

• Chemical agents
• Industrial wastes, pesticides, cigarette smoke,
  asbestos, phenol
• Natural body substances in body bile acids
• Food additives sodium saccharine, nitrites
• Physical agents
• Radiation (both solar and ionizing), and radon,
  nuclear radiation

19
Risk factors for cancer

• Non-controllable
• Heredity, age, gender, and poverty
• Controllable
• Stress, diet, occupation, infection, tobacco use,
  alcohol use, use of recreational drugs, obesity,
  and sun exposure

20
Types of malignant neoplasms

• Solid cancers (Tumors)
• Carcinoma arises in epithelial cells
• Sarcoma arises in connective tissue, muscle, or
  bone
• Hematological cancers
• Leukemia arises in blood
• Myeloma arises in bone marrow
• Lymphoma arises in lymph tissue

21
Clinical staging for surgery

• Reveals the extent of cancer spread
• By sampling regional and distant lymph nodes
• By sampling and viewing other organs for tumors
• (an example is the removal of axillary lymph
  nodes during surgery for breast cancer)

22
Grading and staging

• Once cancer diagnosis is made, the tumor is
  graded and staged
• Grading evaluates the amount of differentiation
  of the cancer cells
• Grade 1 (the least malignant) to grade 4 (the
  most malignant)
• Grade 1 is the most differentiated and Grade 4 is
  the least differentiated

23
Grading and staging

• Staging refers to the relative tumor size and
  extent of the disease
• A tumor in situ is stage 0, while a stage 4
  indicates widespread metastasis

24
TNM Staging of Cancer

• Based on the following
• (T) relative tumor size
• (N) presence and extent of lymph node
  involvement
• (M) distant metastases

25
Signs and Symptoms of Cancer

• C (change in bowel or bladder habits)
• A (a sore that doesnt heal)
• U (Unusual bleeding or discharge)
• T (thickening or lump in tissue)
• I (indigestion or difficulty swallowing)
• O (obvious change in wart or mole)
• N (nagging cough or hoarseness)

26
Collaborative Management

• Most treatments for cancer will require
  collaboration with multiple health care
  providers (HCPs)
• Collaborative, outcome driven planning is
  essential to provide the best care with the least
  negative impact upon the client and family

27
Diagnosis of Cancer

• Can only be made with a biopsy
• Types of biopsys
• Needle biopsy
• Incisional biopsy
• Excisional biopsy

28
Diagnostic studies

• Radiological testing
• X-rays
• CTs
• Ultrasounds
• MRIs
• Can only locate and visualize a mass or tumor,
  cannot make the determination of malignancy

29
Diagnostic studies

• Direct visualization
• Sigmoidoscopy
• Cystoscopy
• Endoscopy
• Bronchoscopy
• Exploratory surgery

30
Laboratory tests

• Tumor markers
• Oncofetal antigens
• Hormones
• Tissue specific proteins
• Isoenzymes
• Biopsy
• The only way to be certain of malignancy
• The visualization of changed cells microscopically

31
Other blood tests

• Leukemias are generally suspected when there is
  a blood smear that contains immature forms of
  leukocytes, which is often combined with low
  blood counts

32
Surgical Interventions

• Was once the only treatment available
• Still is used in diagnosis and staging of more
  than 90 of all tumors and as primary treatment
  in more than 60 of tumors
• May be
• Curative (complete removal)
• Palliative (decreases symptoms)
• Adjunctive (debulking tumor so that radiation and
  chemo can work)
• reconstructive

33
Radiation Therapy

• Treatment of choice for some tumors
• Can be used to
• Kill tumor cells to cure cancer
• Reduce the size of a tumor
• Decrease pain
• Relieve an obstruction
• Reduce chance of metastasis, if just beginning

34
How it works

• Radiation provides lethal injury to the DNA of
  the cell
• It affects rapidly growing cells, like tumor
  cells
• It also affects normal cells that are growing
  rapidly
• The goal is to achieve maximum tumor control with
  minimum damage to normal tissue

35
External Radiation

• Source of radiation comes from a machine which
  emits a relatively uniform dosage of radiation to
  all tissues selected for radiation.

36
Internal radiation

• Brachytherapy
• Implant (wires, tubes, capsules, rods, etc)
  placed by a surgeon or oncologist. Usually is
  temporary
• Can be ingested or injected into the clients
  blood stream or a body cavity
• Is a risk to those who are in contact with the
  patient. The radiation is transmitted outside
  the body

37
Brachytherapy safety considerations

• Maintain the greatest possible distance from the
  patient
• Spend the minimum amount of time with the patient
• Use lead gloves and aprons as a shield when
  possible
• Keep pregnant people away
• Avoid direct contact with radioisotope containers

38
Brachytherapy safety considerations

• People working with these people a lot must wear
  a radiation monitor badge to track exposure level
  to radiation
• Patients should be in a private room with a
  private bathroom
• Dispose of bodily wastes according to facility
  policy
• Handle linens according to facility policy

39
Chemotherapy

• The use of cytotoxic medications and chemicals to
  
• Cure some cancers
• Decrease tumor size (as an adjunct to surgery or
  radiation therapies)
• Prevent or treat suspected metastases

40
How chemo works

• It disrupts the cell cycle in various phases by
  interrupting cell metabolism and replication
• It interferes with the ability of the cell to
  synthesize needed enzymes and chemicals
• It is generally given in specific combinations of
  drugs to affect malignant cells at their most
  vulnerable times

41
Types of Chemo drugs

• Alkylating agents
• Antimetabolics
• Cytotoxic antibiotics
• Plant alkaloids (two types)
• Vinca alkaloids
• Etopsodes
• Hormone and hormone antagonists
• Miscellaneous drugs

42
Preparation and administration

• Some medications are oral or IM, but many are
  given IV. Very irritating, if infiltrated, stop
  infusion immediately.
• Most states require special certification and
  education to administer chemo drugs.
• These drugs are potentially carcinogenic and
  corrosive. Follow policies regarding spills.

43
Safety for the nurse

• Wear gloves, mask and gown for administration and
  work in a quiet area in a methodical manner
• Spills can be very hazardous
• Follow special spill policies and procedures
• Special equipment for spills available
• Nurses should be aware of drugs being given and
  how to handle client body wastes.

44
Toxicity

• Watch for bone marrow suppression
• Watch for infection
• Watch for organ toxicity(GI tract, liver,
  cardiac, pulmonary, urinary, neurological)
• Watch for anaphylaxis

45
Nausea and vomiting

• Give antiemetics 30-45 minutes prior to
  treatments
• Give antiemetics on a round the clock schedule if
  N/V is severe
• Use relaxation, therapeutic touch, diversion with
  music, etc..
• Avoid foods, smells, etcthat induce nausea

46
General Nursing Diagnosis

• Anxiety/powerlessness
• Body image disturbance
• Anticipatory grieving
• Risk for infection/injury
• Altered nutrition
• Pain
• fatigue

• Impaired tissue integrity
• Caregiver role strain
• Ineffective individual/family coping
• Altered role
• Fluid volume disturbance
• And many more

47
Immunotherapy

• Biologic response modifiers
• Designed to enhance the clients own immune
  response
• Can consist of the administration of interleukin
  or interferon
• Other kinds of immunotherapy are monoclonal
  antibodies and hematopoietic growth factors

48
Bone marrow and stem cell transplantation

• Most commonly used for leukemia's, now also for
  some solid mass tumors, such as breast cancers
• Stem cell transplantation
• Harvesting from pheresis
• Cord blood stem cells

49
Unproven methods of cancer treatment

• Chemicals and drugs
• Nutrition
• Occult techniques
• Mechanical devices
• Supportive care
• Divine healing

50
Psychologic Stressors

• Death sentence
• Guilt
• Anger
• Fear
• Powerlessness
• Body image disturbance
• Sexual dysfunction concerns

51
Infection

• Tumor itself may cause fistula between two
  incompatible organs (e.g. bowel and bladder)
• Tumor may erode through to the surface causing an
  open lesion
• Tumor may destroy the tissues that feed it and
  then become necrotic causing septicemia
• Immune system impairment

52
Pain

• One of the most serious concerns of clients and
  families because of the reputation of being
  difficult to control
• Causes of cancer pain
• Due to direct tumor involvement
• Due to the treatments
• Due to a cause not related to the cancer or the
  therapy