Cancer Lecture, Spring 2012

OncOlOgy nursing

What is Cancer ?

• An alteration in cell growth

• A common health problem in the United states and Canada

• A disease that can effect anyone

• One of the most feared diagnoses

Neoplasms

Tumor Growth

Tumor Cell Division

Incidence and Mortality

• Annual newly diagnoses of 1.5 million people • Occurs in 1 of every 3 persons living in North

America • More than 10 million Americans with a history

of cancer are still alive, with nearly 5 million considered cured

(American Cancer Society[ACS]2008)

Features of Normal Cell Growth

• Limited Cell Division

• Apoptosis

• Specific Morphology

• A small nuclear-to-cytoplasmic ratio

• Differential Function

• Tight Adherence

• Non-migratory

• Orderly & well-regulated cell growth

Features of Cancer Cells: Benign

• Continuous or inappropriate cell growth

• Specific morphologic features

• Small nuclear-to-cytoplasmic ratio

• Many differentiated functions

• Tight adherence

• No migration

• Growth- Expansion

• Normal chromosomes(eupliod)

• Low mitotic index

Features of Cancer Cells: Malignant

• Rapid or continuous cell division

• Anaplastic appearance • Large nuclear-to-

cytoplasmic ratio

• No differentiated function

• Loose adherence

• Migration

• Growth –Invasion

• Abnormal chromosomes (aneuploid)

• High mitotic index

Cancer Development (Carcinogenesis/ Oncogenesis)

• Malignant transformation –The process of changing a normal cell

into a cancerous cell • Initiation • Promotion • Progression • Metastasis

Metastasis

• Metastasis occurs through a progression of steps: – Extension into surrounding tissues – Blood vessel penetration – Release of tumor cells – Invasion – Local seeding – Blood borne metastasis – Lymphatic spread

Steps of Metastasis

Metastasis

Cancer Classification

• Grading Iggy pg 406 – I - low grade malignant , slow growing – II- moderately differentiated from normal cell – III- poorly differentiated, able to tell tissue of

origin – IV- no normal cell differentiation tissue of origin

impossible to determine • Staging Iggy pg 407

– TNM (tumor, node, metastasis) – Useful for treatment options and prognosis determination

Caution: Seven Warning Signs of Cancer

• Change in bowel or bladder habits

• A sore that doesn’t heal

• Unusual bleeding or discharge

• Thickening/lump in the breast or elsewhere

• Indigestion or difficulty swallowing

• Obvious change in a wart or mole

• Nagging cough or hoarseness

Diagnostic tests

• CBC

• Chemistry

• Protein tumor markers (PSA, CEA)

• X-ray

• MRI

• CT

• Ultrasound

• Nuclear Imaging

• Biopsy

• Endoscopy

• Laparoscopy

Treatment and Management

• Goal is: survival prolongment and/or improvement of quality of life – surgery

– radiation – chemotherapy – hormonal manipulation – immune therapy – photodynamic therapy – gene manipulation – target therapy

Types of Surgeries Iggy pg 417

• Diagnostic- biopsy

• Prophylactic- removal of at risk tissue

• Curative- removal of all cancerous tissue

• Cytoreductive (“debulking”)- removing part of the tumor and leaving a known amount of gross tumor

• Palliative- focused on improving quality of life and not focused on cure

• Reconstructive- increase function, enhanced appearance or both

Radiation Therapy • Purpose is to destroy the cancer cells with minimal

exposure to normal cells

• Side Effects: limited to tissue exposed to the radiation (varies according to site)

-hair loss, altered taste, fatigue, tissue - fibrosis, scarring, direct skin becomes dry/broken down/red

( *** Iggy Chart 24-2 skin protection during radiation

therapy*** AND **chart 24-1 precautions for sealed implants***) pg 420

Chemotherapy

• The treatment of cancer with chemical agents

– Cure

– Increase survival time

• Damages the DNA and interferes with cell division

– Better for rapid growing cancers

Chemotherapy Side effects

• Effects all cells not just cancer cells

• Side Effects: Neutropenia, thrombocytopenia, alopecia, N/V, mucositis, anxiety, sleep disturbances, cognitive changes, altered bowel elimination.

• See Iggy Chart 24-4 pg 426 – Care of patients with Neutropenia

Nursing Care – Patient Centered Care

• Infection Control

• Nausea and Vomiting – From the Chemo agents

• Mucositis

• Changes in cognitive function

• Peripheral neuropathy

• Alopecia

Anticancer Drugs by Classification

• Alkylating Agents – Cause changes in the DNA strands preventing the

cancer cells from dividing

• Antitumor Antibiotics – Inhibit Protein and RNA synthesis and bind to DNA

causing fragmentation.

• Miotic Inhibitors – Inhibit cell division by disrupting the microtubules

Anti-Cancer Drugs by Classification

• Antimetabolites – Disrupt metabolic process and can inhibit

enzymes synthesis.

• Plant Alkaloids – Derived from natural products that cause a

blocking in the cell division at the “M” Phase.

Anti-Cancer Drugs by Classification

• Hormonal & Anti-hormonal Agents – Hormones help regulate body mechanisms such

as growth, metabolism, and reproduction. – Many anti-hormone agents have been developed

to interfere with the interaction between the hormone molecule and its receptor site, which stimulates cell growth and proliferation.

• Biologic Response Modifiers – A class of pharmacologic agents that enhance the

body’s immune system.

Nutrition

• Cancer can cause devastating weight loss and malnutrition

• Nutrition therapy maximizes drug therapy, alleviates side effects of disease and treatments, improves quality of life

Nutritional deficit causes

• Anorexia

• Taste changes

• Cachexia- extreme body wasting

• Wasting Syndrome

• Diarrhea

• Nausea

• Xerostomia- severe dryness of the mouth

• Stomatitis

• Fatigue

Common Nursing Diagnosis (Just a few)

• Risk for nutritional imbalance, less than body requirements related to GI side effects of chemotherapy

• Risk for nutritional imbalance, less than body requirements r/t anorexia and fatigue

• Risk for impaired oral mucous membrane related to the side effects of chemotherapy or radiation therapy

• Risk for infection related to bone marrow suppression

Common Nursing Diagnosis

• Disturbed body image related to hair thinning or hair loss

• Risk for impaired skin integrity related to diarrhea caused by chemotherapy

• Risk for chronic pain related to disease process, injury or surgical procedure

• Risk for Impaired physical mobility related to pain and/or fatigue

• Interrupted family process related to situational crisis

OncOlOgical EmErgEnciEs

Oncologic Emergencies

• Sepsis and disseminated intravascular coagulation - DIC

• Collaborative management includes:

– Prevention (the best measure) – IV antibiotic therapy – Anticoagulants, cryoprecipitated clotting factors

Hypercalcemia

• Occurs most often in patients with bone metastasis

• Fatigue, loss of appetite, nausea and vomiting,

constipation, polyuria, severe muscle weakness, loss of deep tendon reflexes, paralytic ileus, dehydration, electrocardiographic changes

Hypercalcemia (Cont’d)

• Collaborative management includes: – Oral hydration – Normal saline IV – Drug therapy – Dialysis

Superior Vena Cava Syndrome

• SVC compressed or obstructed by tumor or formation of clots

• Painful, life-threatening emergency

• Manifestation – edema of face, around

eyes, chest/trunk can progress to arms, hands, dyspnea, stokes sign

Tumor Lysis Syndrome

• When a lg # of tumor cells are destroyed rapidly

• Their intracellular contents (ie. K+ and purines) are released into bloodstream faster than body can eliminate them

• Can lead to hyperkalemia, hyperuricemia (liver converting purines into uric acid-crystals build up in kidneys) and can cause – CRF: tx may require kayexalate or dialysis, insulin drips,

drugs that increase excretion of purines such as: Aolprim and Zyloprim.

Tumor Lysis Syndrome

Prevention and Detection of Cancer • Reduce or avoid exposure to known or

suspected carcinogens and cancer promoting agents

• Eat a balanced diet Reduce the amount of fat and preservatives including smoked and salt cured meats

• Participate in a regular exercise

• Obtain adequate, consistent periods of rest

• Have a health examination on a regular basis

• Eliminate, reduce, or change the perceptions of stressors

• Enjoy consistent periods of relaxation and leisure

• Know the seven warning signs of cancer (i.e. CAUTION)

• Learn to practice self examinations

• Seek immediate care as needed

The End- Questions?