Cancer General

Cancer

• a group of diseases characterized by uncontrolled and unregulated growth of cells

  • Carcinogens may be 

    • Chemical/Physical

    • Radiation

    • Viral 

    • Dietary

  • Age

    • Immune response

    • Genetic risk (check family history)

Warning Signs of CA…CAUTION

• Change in bowel or bladder habits

• A sore that does not heal

• Unusual bleeding or discharge

• Thickening or lump in the breast or elsewhere

•  Indigestion or difficulty in swallowing

• Obvious change in a wart or mole

• Nagging cough or hoarseness

Benign cancer

• Normal cells growing in the wrong place or at the wrong time (Friendly, if you will). Causes a mass effect that can compress neighboring tissues.

• Usually encapsulated, but can grow to be large in size.

• Does not metastasize

• Rarely reoccurs

Malignant cancer

• Abnormal cells that serve no useful function and are harmful to body tissues

• Rapid cell division, but cancer cells do not grow or divide faster than normal cells

• Frequently metastasizes and reoccurs

• Cells abnormal, expand and infiltrate other tissues…metastasize

Main Sites of Metastasis: 

• brain and cerebrospinal fluid, lungs, liver, and bone 

Tumors can be classified by

• Anatomic site

• Histology 

  • Grading severity: do cells resemble the tissue of origin?

  • 1 to 4 (worst) with X being undeterminable

• Extent of disease

  • Clinical Staging

  • TNM

  • 0 to 4

Carcinomas originate from

• Embryonal ectoderm (skin, glands) 

• Endoderm (of respiratory tract, GI and GU tracts) mucous membrane 

Sarcomas originate from

• Embryonal mesoderm (connective tissue, muscle, bone, and fat)

Lymphomas and leukemias originate from

• Hematopoietic system

Five grades of abnormal cells using histology

• Grade I

  • Cells differ slightly from normal cells and are well differentiated

• Grade II

  • Cells are more abnormal and moderately differentiated

• Grade III

  • Cells are very abnormal and poorly differentiated

• Grade IVmost dangerous and aggressive

  • Cells are immature and primitive and undifferentiated

  • Cell of origin is difficult to determine

  • Highly aggressive

• Grade X: undeterminable

Classification of Cancer…Clinical Staging

• 0: Cancer in situ (local and no tendency to invade)

• I: Tumor limited to tissue of origin; localized tumor growth

• II: Limited loc0-3al spread

• III: Extensive local and regional spread

• IV: Metastasis (growth and spread to distant sites)- moves to lymphatic system and spreads easily 

TNM classification system for

•  solid tumors, not blood tumors 

  • Anatomic extent of disease is based on three parameters:

    • Tumor size and invasiveness (T)

      • IS = in one place

      • 1-4

    • Spread to lymph nodes (N)

      • 0 (can’t feel it) -3 (worst)

    • Metastasis (M)

      • 0, 1

Diagnostics

• Cytology studies

• Chest x-ray

• Liver function studies, CBC, chemistry profile

• Endoscopic examinations

• Radioisotope scans, PET scan

• Tumor markers: substances, like proteins or genetic material, found in blood, urine, or body tissues that may indicate cancer (what puts them at risk) 

• Genetic markers: alterations in a person's genes that can be inherited or acquired and may increase cancer risk (genes that lead to cancer) 

• Biopsy

Surgery

• Prophylaxis

• Diagnosis

• Cure

• Control

• Palliation

• Second-look surgery

• Reconstruction or rehabilitation

Radiation Therapy

• Destroys cancer cells with minimal damaging effects of surrounding normal cells

Radiations Delivery types:

• Teletherapy

• Brachytherapy

Care of a pt undergoing radiation tx: bradytherapy

• (internal radiation)

  • Private room, door closed

  • Visitors 30 minutes, 6 feet away

  • No pregnancy

  • Do not pick up any internal radiation implant.  Need to use long-handled forceps and place in lead container.

  • Nurse: PPE, cluster care, step back when speaking to patient 

Care of a pt undergoing radiation tx: Teletherapy

• (external beam radiation)

  • Do not wash radiation marking off skin→ kills cancer and skin cells 

  • Good nutrition and rest

  • Monitor skins for irritations/burns

  • No powders, ointments, lotions, deodorant or sun

Cancer management

• surgery

• radiations

• chemoherapy

• hormone therapy

• photodynamic therapy

• immunotherapy

• target therapy

hormone therapy

• Some hermes make hormone sensitive tumors grow more rapidly 

• corticosteroids help this 

• SE: masculizing and feminizing effects 

photodynamic therapy

• Injection of a cytotixic compound which is relatively inactive until activated by a laser beam agter collecting in the tumor 

• SE: sensitivity to light for up to 12 wks after 

Immunotherapy

• Helps the immune system fight cancer 

• Example: cell transfer or other cells 

Target theory

• Drugs or other substances to preicsesly identify and attack certain types of cancer cells 

• SE: more acutely and are dose limited 

Radiation Therapy: side effects

• Taste changes, anorexia

• Fatigue

• Tissue fibrosis/scarring esp. lungs

• Xerostomia (dry mouth)

• Skin: wet (active burns, worse, increase risk of infections) or dry desquamation (skin shedding).  Redness is normal but open sloughing is a threat to patient-keep dry skin moist, keep wet skin infection free.  NO perfumed lotions

Radiation Therapy nursing care

• Keep dry skin mosit

• Keep wet skin infection free 

• No perfumed lotions 

Chemotherapy

• Some selectivity for killing cancer cells over normal cells

• Systemic effects

• Affects rapidly-dividing cells: skin, hair, intestinal tissues, spermatocytes, blood-forming cells

• IV given through PICC, central, or midline NOT A REGULAR IV 

Care of Pt Undergoing Chemotherapy

• Instruct on vascular access devise and medications

• Educate not to touch medication with unprotected hands

• Monitor IV infusion carefully, can cause extravasation

• Monitor VS, skin, nutrition, emotional status

• If n,v problems, may need to administer an antiemetic 30 to 60 minutes prior to treatments

• Use neutropenic precautions: private room, allow, but restrict visitors, no plants or fresh flowers, well washed fruits, cooked vegetables infection precautions.  Monitor for low WBCs.

• Monitor for low blood counts such as platelets and RBCs.  May need to assist pts with ambulation for safety purposes and to prevent bleeding.

• If pt states has mucositis or stomatitis, may need to administer topical anesthetic prior to meals. 

Extravasation Injury Due to Chemotherapy

• Dosage

• Scheduling

• Administration

• Extravasation- Vesicants.

• Nurses must have knowledge about drug use, dosage ranges, side/adverse effects, schedule, specific precautions

• PPE must be used when administering oral and IV chemotherapy

Chemotherapy Drug Therapy

• Cell Cycle Nonspecific

  • Alkylating…Ex. Chlorambucil

  • Damages DNA to make cell die

• Antitumor Antibiotics…Ex. bleomycin, doxorubicin

  • Inhibits synthesis of DNA making it hard to replicate

• Platinum Drugs…Ex. carboplatin, cisplatin

  • Miscodes information to inhibit DNA replication and cells die

Cell Cycle Specific durg therapy

• Antimetabolites…Ex. methotrexate, hydroxyurea

• Mimics naturally occurring substances to interfere with metabolism

Mitotic Inhibitors drug therapy

• Vinca Alkaloids…Ex. vinblastine, vincristine

• Inhibits mitosis (cell division)

Chemotherapy: Side effects and Complications

• Bone marrow suppression: Decreased WBC, Platelets, RBC

  • Tx: epoetin alfa (R), filgrastim (W- infection), oprelvekin (P- bleeding)

• Chemotherapy-induced nausea and vomiting (CINV)

• Mucositis

• Alopecia

• Peripheral neuropathy

• Anxiety

• Fatigue

• Long term: Damage to organs

Collaborative Care

• Differentiate between toxic side effects of drugs and progression of malignant process

• Report serious reactions to physician

• Treat drug side effects (anorexia, fatigue, bone marrow suppression, mucositis, N&V)

• Manage alopecia

  • Hair usually returns but may be different color & texture. 

  • Hair cut and buy wig before alopecia begins

• Support patient & family

• Protect patient against illness

• Frequent hand washing with immunocompromised patients

• Pain management: pharmacologic, nonpharm

Breast Cancer: causes and risk factors and prevention/ health promotion

• Causes/Risk Factors: 

  • Genetics, hx, females, over age 65, oral contraceptives, high fat-low fiber diet, alcohol, smoking, hormone replacement, obesity

• Prevention/Health Promotion:

  •  healthy weight and lifestyle, breast and mammogram screening (Table 56-1), Avoid hormone replacement and estrogen

breast cancer clinical manifestations and early screening

• Clinical manifestations: 

  • Breast change, lump-fixed and nontender, nipple discharge, dimpling, or retraction, ulcerations, enlarged lymph nodes

  • Not painful

• Early Screening: 

  • self-breast exams (monthly- after period→ same time monthly), mammograms (yearly especially if family hx)

  • A lump that is movable then a fixed lump 

    • Fixed, nontender, nipple discharge and retraction= BC

breast cancer labs and diagnostics

• Labs: 

  • BRCA1, BRCA2, HER2

• Diagnostic tests: 

  • Ultrasound, biopsy

Breast CA medical management and surgical care

• Medical Management: 

  • hormone tx (if meds don’t work then go to chemotherapy and radiation), selective estrogen, chemo, radiation

• Surgical- 

  • Preop, postop: lumpectomy, mastectomy (remvoes breast), radical mastectomy (removing breast and lymp nodes→ high risk for lymphedema)

breast cancer nursing management

• HOB elevated, No IV or BP on operative side (especially if lymph node removes because of decreased perfusion), wound and drain care post surgery, supportive bra, possible sling (prevent wound opening), emotional support

breast cancer complications

• Lymphedema-accumulation of lymph fluid in the tissues of the arm because the lymph nodes are either removed or damaged and can no longer return lymph fluid to the circulation. Nerve pain.

breast cancer home care

• arm exercises, supportive sleeve (tight fixed sleeve that increase perfusion) or elastic bandage, support group, report complications

Lung Cancer causes and prevention

• Causes/Risk Factors: 

  • Genetics, smoking, radiation, environmental irritants

• Prevention/Health Promotion: 

  • Discuss the effect of no smoking with the pt, protective equipment when in presence of irritants, screening

lung cancer clinical manifestations and labs

• Clinical manifestations: 

  • chronic cough usually 1st→ doesn’t go away, hemoptysis: blood spit up, chest pain (shapr pain in lung), fatigue, fever, hoarseness, dyspnea, altered breath sounds, clubbing, SOB. stop O2 perfusion in blood

• Labs: sputum test 

lung cancer diagnostics and medical management and surgery

• Diagnostic tests: 

  • thoracoscopy, bronchoscopy, CXR, CT scan, pulmonary function test

• Medical Management: 

  • bronchodilators, corticosteroids, rid of cancer→ chemo, radiation, thoracentesis

  • Initially symptom treatment 

• Surgical- 

  • Thoracotomy, Lobectomy, Pneumonectomy, VS, o2, chest tube, O2, airway, pain

lung cancer nursing and home management

• Nursing Management: 

  • Monitor airway, lungs, nutrition, fluids, pt in Fowler’s, ABC 

• Home Management: 

  • rest, nutrition-high protein, smoking cessation, support group, report complications

kidney cancer causes and preventions

• Causes: 

  • smoking, obesity, genetics, HTN, chemical exposure

• Prevention/Health Promotion: 

  • Discuss the effect of no smoking with the pt, protective equipment when in presence of irritants, screening

kidney cancer clinical manifestations

• Clinical manifestations: 

  • Asymptomatic initially, Anemia, hypertension, hematuria, flank or low back pain, fatigue, weight loss, fever, lump, increase BP, edema 

kidney cancer diagnostics, medical management, and surgical

• Diagnostic: 

  • CT scan, US, BUN, Creatinine, I&O, renal function

• Medical Management: 

  • chemo, radiation, immunotherapy, targeted therapy

• Surgical: 

  • Nephrectomy, drain,

kidney cancer nursing and home management

• Nursing Management: 

  • I/O, pain (opioids around the clock (one to hold them through the day and one for night [8am, 8pm, and sometimes 3pm for break through pain + one more med])  and then additional pain medications if breakthrough pain occurs),

  • VS, Drain and wound care, and electrolyte management

• Home Management: quitting smoking, weight management, BP contro

bladder cancer causes and preventions

• Causes/Risk Factors: 

  • Genetics, age, smoking, environmental irritants, radiation, chronic UTI

• Prevention/Health Promotion: 

  • Discuss the effect of no smoking with the pt, protective equipment when in presence of irritants, screening

bladder cancer clinical manifestations

• hematuria, frequent urination, dysuria, back pain (similar to UTI)

bladder cancer labs, diagnostics, medical management, surgical

• Labs: UA, urine for cytology

• Diagnostic tests: cystoscopy with biopsy, CT scan

• Medical Management: 

  • radiation, immunotherapy, targeted therapy, chemo

• Surgical- 

  • TURBT (trans-urethral removal bladder tumor- will have continue bladder irriatgtion→ prevent clots), cystectomy

bladder cancer nursing management

• I/O, CBI-catheter care, Encourage fluid intake, stool softener, check for post surgery complications include bladder spasm, urinary incontinence, hemorrhage, and infection.

bladder cancer home management

• rest, nutrition, smoking cessation, may need catheter care at home (maybe for a few months), support group, report complications

Skin Cancer

• Grows slowly

• Incidence increases with age

• Most common sites:

  • Face, head, neck, back of hands, arms

• Visibility increases likelihood of early detection

• Rarely fatal but causes disfigurement and disability

skin cancer risk factors

• Tendency to sunburn

• + Family Hx of skin cancer

• Lack of skin pigmentation

• Genetic, hormonal and immunologic factors

• Societal & lifestyle changes leading to greater skin exposure

• Indoor tanning

ABCDEs of melanoma

• “A” stands for asymmetrical. Does the mole or spot have an irregular shape with two parts that look very different?

• “B” stands for border. Is the border irregular or jagged?

• “C” is for color. Is the color uneven?

• “D” is for diameter. Is the mole or spot larger than the size of a pea?

• “E” is for evolving. Has the mole or spot changed during the past few weeks or months?

Skin CA…Basal Cell

• Most common; least deadly

• Nodular, ulcerative

• SUN EXPOSURE, genetic skin type, X-Ray irradiation

• Papule with eroded center

• Excisional surgery for removal, cryosurgery, electrosurgery, phototherapy

• 95% cure, rare metastases

Skin CA…Collaborative Care

• Early detection

• Remove cancerous lesions

• Melanoma requires additional chemotherapy

  • UV Protection

  • Sunscreen

  • Proper covering

  • Avoidance of direct sun rays 10A-2P

• Avoid sunlight when using photosensitizing agents 

To prevent the debilitating cycle of fatigue-depression-fatigue that can occur in patients with cancer, an appropriate nursing intervention is to

Have the patient rest after expending any major energy

Encourage the patient to implement a daily walking program 

Teach the patient to ignore the fatigue to maintain normal daily activities

Prevent depression by informing the patient to expect fatigue during cancer treatment

A nurse plans a community education program related to prevention of the cancer with the highest death rates in both women and men.  What should the nurse include in the teaching plan?  

Smoking cessation

Screening with colonoscopy

Regular examination of reproductive organs

Use of sunscreen as protection from ultraviolet light

A 68-year-old female has a family history of breast cancer (mother, grandmother, and sister). She has not married or had children. She smoked cigarettes but quit 2 years ago. She consumes 2 to 3 alcoholic drinks per day. Today is her annual check-up and she asks about her risk for breast cancer.

What are her risk factors for developing this disease? (List all that apply.)

What post-mastectomy exercises should the nurse include when teaching the patient that has undergone a left mastectomy? Select all that apply.

a. Beginning exercises should not stress the incision and can be started 3 days post-surgery.

b. Squeeze with the left hand using a soft round object.

c. Tie a rope to the knob of a closed door and swing the rope in a circle.

d. Face the wall and slowly walk your hands up and down the wall.

e. Strenuous exercises may begin as soon as you are home, even though you still have some pain.

A patient has just returned to the nursing unit post-bronchoscopy.  Which of the following is most appropriate for the RN to delegate to the nursing assistant?

a. Assess the lung sounds.

b. Give the patient a drink of water.

c. Obtain vitals as per protocol.

d. Chart post-procedure assessments.

What is the expected outcome related to hair loss for a patient who is undergoing chemotherapy?

a. Hair loss may be permanent.

b. Hair regrowth usually begins about 1 month after completion of chemotherapy.

c. New hair growth will likely be identical to previous hair growth in color and texture. 

d. Viable treatments exist for the prevention of alopecia.

What health promotion teaching should the nurse provide to a 49-year-old patient asking about breast health? Select all that apply.

a. Have a screening mammogram every year.

b. Ask your provider to perform a clinical breast examination.

c. A diagnostic mammogram should be completed every 5 years.

d. Notify your provider immediately if you notice any lumps in your breasts.

e. Have a CEA lab test done every 2 years

The nurse receives a patient that has undergone a left radical mastectomy from the PACU.  What postoperative interventions should the nurse implement

a. Instruct the student nurse to avoid taking BP in the patient’s right arm.

b. Have the student nurse check vital signs every hour for 3 hours.

c. Measure the Jackson-Pratt tube drainage and assess for color and odor.

d. Position the patient supine to facilitate drainage