CANCER / ANEMIA / BREAST CANCER / COLORECTAL CANCER / ONCOLOGY EMERGENCIES

CAUTION UP

- change in bowel or bladder

- a lesion that does not heal

- unusual bleeding or discharge

- thickening or lump

- indigestion or difficulty swallowing

- obvious changes in wart or mole

- nagging cough or persistent hoarsness

- unexplained weight loss

- pernicious anemia

What are cells doing in malignant cancer?

- over or under producing

- not following the cell cycle

- undifferentiated (not producing specialized cells)

- change in DNA

- increased growth of abnormal cells and suppression of cells that would stop the overgrowth

Neoplasm

abnormal tissue growth

Characteristics of malignant neoplasm

- invasive

- non-cohesive

- can grow beyond boarders + displace other tissue

- rapid growth

- metastasize to distant sites

- may be difficult to remove

- can recur

Metastasis

the spread of cancer cells beyond their original site

How does cancer metastasize?

- invading nearby tissues

- traveling through the lymphatic and blood systems

How small does a neoplasm have to be for the immune system to destroy?

less than 1cm

Cancer risk factors

- genetic (direct DNA damage)

- familial syndromes

somatic

- promoter substances

- chemicals

- environmental

- radiation

- viruses

Primary cancer prevention

- avoid high risks

- minimize exposure

- maintain healthy diet

exercise

Secondary cancer prevention

- breast = mammogram

- cervical = pap smear + HPV test

- colorectal = colonoscopy + FIT + FOBT

Cancer diagnostic tests

- CT

- MRI

- X-ray

- ultrasound

- biopsies

- blood work

Stage

how far it has spread through the body

Grade

aggression

How can we maintain homeostasis in our cancer patients?

- prevent dehydration

- minimize + treat symptoms

- maximize comfort

- psychological support

- assess family + community support

How should we educate cancer patients with a new diagnosis?

- basic and slow

- repeat as needed

- give time to process

- listen

- answer questions

- provide education

- inquire about support sources

- confirm understanding

Incisional surgery

- removes a small portion

- mainly for biopsy testing

Extensional

removal of entire tumor and small part of surrounding tissue

Debulking

- removal of large part of tumor

- not able to remove all due to damage of nearby organs

What is radiation therapy mostly used for?

solid neoplasms

What does radiation do?

- shrink a tumor + make it easier to remove

- damages healthy cells but only locally + the cells recover faster

External radiation

- uses semi permanent tattoos or a mesh covering to make precise marks for aiming the radiation beams

Internal / brachytherapy

- allows higher dose of radiation in a smaller area

- temporary or permanent

Cancer meds

- chemotherapy

- targeted therapy

- immunotherapy

- hormonal therapy

What precautions must HCP take when handling chemotherapy?

- approved gowns + gloves

- pharmacists = mix under a hood + facal shield

What does chemotherapy do?

- target cells at different phases in the cell cycle

- kills fast growing cells

- cannot identify cancer cells from healthy cells

Chemotherapy s/e

- infection

- bleeding

- electrolyte imbalances

- N/V/D

- mucositis

Why do patients get side effects from chemo?

- chemo cannot differentiate cancer cells from healthy cells

- more s/e in areas w/ rapid growing cells

- GI tract, WBCs, Hgb, Plts, hair follicles

Complications of N/V/D from chemo

- dehydration

- electrolyte imbalance

- poor nutrition

- immunocompromised

- bleeding

- loss of hair

- mucositis

Types of chemo

- alkylating agents

- antimetabolites

- antitumor antibiotics

- vinka alkaloids

Alkylating agents

- interfere w DNA replication

- not cell specific

Antimetabolites

interfere with chemicals that produce amino acids

Antitumor agents

- inhibits DNA + RNA replication

Vinka alkaloids

permanent damage to cell DNA

What does immunotherapy do?

- stimulates or boosts the immune system to work harder and smarter

- generate treatments that are just like immune system components and uses them to improve the immune system to find and attack cancer cells

Immunotherapy s/e

- flu-like symptoms

- pain

- swelling

- symptoms at application + injection site

What does hormone therapy do?

- stops producing the hormone

- blocks hormones from attaching to cancer cells

- alters hormones so they do not work properly

Hormone therapy s/e

- hot flashes

- erectile dysfunction

- weight gain

- bone loss

Complementary therapies

- acupuncture

- herbal remedies

- dietary changes

- exercises

- meditation

- medical marijuana

What do side effects of cancer depend on?

- disease related

- treatment related

- age

- commodities

- type + severity + duration

What do we need to know in order to treat side effects?

WHAT IS THE CAUSE

N/V medications

- ondansetron

- prochlorperazine

- dexamethasone

N/V

Ondansetron

- blocks vagal nerve receptors

- for moderate n/v

N/V

Prochlorperazine

- depressed chemotherapy trigger zone

- for severe n/v

N/V

Dexamethasone

- prevents serotonin release from gut

- prophylaxis to decrease edema and inflammation

What can we do to treat diarrhea?

- monitor electrolytes (K+ / mag)

- diet changes

- infection / viral testing (C.Diff)

- anti-diarrheal agent

What can we do to treat fatigue?

- develop sleep + wake routine

- exercise

- activities

-things like walking the hallway + sitting up for meals

Xerostomia

dry mouth related to chemo + radiation

Mucositis

- inflammation and ulceration anywhere mouth to rectum

- redness

- swelling of mucosa

- white patches

- areas that bleed with easy touch

- mucosal thinning ulcerations

- signs of infection

Stomatitis

- oral mucositis

- painful

- can interfere with nutrition + quality of life

- can cause infection

Esophagitis

mucocitis of esophagus

Candidaisis

- fungal infection

- thrush

Mucositis / stomatitis Treatment

- good oral hygiene

- mouth moisturizers

- ice chips

- salt + water rinse

- PPIs

- pain meds

- soft toothbrushes

- chlorhexidine mouthwash

- lidocaine + diphenhydramine gels

- decrease acid + protect lining

Who is at the highest risk for mucositis / stomatitis?

patients undergoing radiation to the head, neck, and chest

What should we recommend to support nutrition in cancer patients?

- small + protein dense meals

- cold foods

- pain meds prior to meals

Chemotherapy induced peripheral neuropathy

the loss of sensory or motor function of peripheral nerves associated with exposure to certain anticancer drugs

CIPN alternative interventions

- gloves

- socks

- proper fitting footwear

- avoid contact with extreme cold or hot water + surfaces

- assistive walking devices

- diligent inspect of hands + feet

- caution driving + operating machinery

- moderate activity

CIPN meds

- duloxetine = first line

- anticonvulsants

- tricylclic antidepressants

- topical menthol cream

- strong pain meds

Barriers to pain control

- fear of addiction

- negative s/e (constipation, tiredness, confusion)

- patients cant verbalize certain pain

- cost of pain meds

- lack of education

Neuropathic pain

- nerve compression

- paresthesias

Visceral pain

- felt from internal organs

- vague

- ache or pressure

- poorly localized

-enlarged lymph nodes

Mechanical pain

- structural

- stretching + compression of tissues

Osteodynia pain

- bone pain

- from metastic disease + multiple myeloma

- very painful

- difficult to treat

- treat w/ acetaminophen + steroids

Inflammatory pain

caused by mucositis + ulcerations

Neutropenia

- low WBCs

- infection

Thrombocytopenia

- low plts

- bleeding + bruising

Anemia

- low RBC + Hgb

- low perfusion + oxygenation + circulation

Neutropenic fever

- temp over 38.3 (101)

- mucositis

- abdominal pain

- hypotension

- tachycardia

- tachypnea

- LOC changes

- oncology emergency

- if not treated quick enough can lead to sepsis

What do I do when my neutropenic patient develops a fever

- get vitals

- obtain blood or cultures

- administer antibiotics

Neutropenic precautions

- strict hand washing

- avoid crowds + sick people

- monitor for s/s

- seek medical care immediately if s/s develop

- keep door closed at all times

- no flowers or plants

- no fresh fruits or veggies

Neutropenic fever treatment

- growth factor = increase production of WBCs (filgrastim)

prophylactic and to treat

- antibiotics

- antivirals

- antifungals

Thrombocytopenia do's and don't

do

- use soft toothbrush + mouthwash

- electric razor for shaving

- file nails

- low impact activities

don't

- floss teeth

- razor blade for shaving

- clip + cut nails

- physical injury + falls

Thrombocytopenia s/s

- petechiae + purpura

- spontaneous bleeding

- bruising

Petechiae

small, pinpoint hemorrhages

Purpura

- reddish + purple discolorations on the skin or mucous membranes

- caused by leaking blood vessels

How long should we hold pressure on an IV site after removing it?

5 minutes

What should be monitor for in patients with thrombocytopenia?

- bleeding

- change in LOC

- epistaxis

- hemoptysis

- hematemesis

- rectal bleeding

- ecchymosis

- petechiae

- blood from IV site

When do we transfuse patients with thrombocytopenia?

- bleeding

- expected to have an invasive procedure

- below standard threshold

Breast cancer risk factors

- alcohol + tobacco use

- diet

- weight

- lack of exercise

- nulliparity (never having children)

- not breast feeding

- menstrual history

- hormone replacement therapy

- oral contraceptives

Breast cancer s/s

- non tender lump on breast

- sometimes no symptoms

changes in the nipple

- discharge

- retraction

- scaly + rash

- position

45-54 mammogram frequency

yearly

55 and greater mammogram frequency

every other year

Noninvasive breast cancer (in situ)

- cancer cells are confined within the milk ducts and have not spread

- ductal carcinoma in situ

Invasive breast cancer

- has spread to the surrounding tissue

- infiltrating ductal carcinoma

Carcinomas

skin and tissue lining internal organs

Sarcomas

- connective tissue

- bones

- nerves

- muscle

Infiltrating ductal carcinoma

- swelling

- irritation or dimpling

- pain

- nipple discharge

- upper outer quadrant

- inflammatory

- very aggressive

Paget's disease of the breast

red, itchy, swollen rash of nipple/areola

Fine needle aspiration

- biopsy

- obtain cells or fluid

Excisional

- biopsy

- tissue surgically removed

Masectomies

- radical

- simple (total)

- breast-conserving

Radical mastectomy

- removal of entire affected area of breast

- includes underlying chest muscles + lymph nodes + under arms

Simple (total) mastectomy

removal of complete breast

Breast-conserving mastectomy

- partial mastectomy

- lumpectomy

Brachytherapy

- allows for delivery of higher doses of radiation to specific areas

- device contains radioactive seeds or pellets are implanted into the breast

- remains in place for short periods of time or several days

Lymphedema

- accumulation of fluids in the soft tissue

- caused by removal of lymph nodes + channels in the armpit

- radiation may damage lymph nodes causing scarring and decrease function

- tumors and enlarged nodes blocking flow of lymph fluid

Lymphedema s/s

- swelling

- heaviness of chest, breast, arm, shoulder, etc

- skin dryness + discoloration + thickening + dimpling

- impaired flexibility and movement

- clothes + jewelry tight and difficult to apply

- pain + numbness + tingling

Lymphedema treatment

- elevation of limb

- exercises

- infection prevention (cellulitis)

- compression garments

Breast cancer is more aggressive in . . .

younger women

Breast cancer is more common in . . .

older women

Breast cancer in younger women considerations

- poor survival rate

- body image changes