NRSG 326 Final

Most commonly diagnosed cancer types

lungs, prostate, colorectal

Inequities in Cancer Care - who is underserved?

- Homeless / unstable housing

- 69 yrs+

- Remote locations

- Education levels (health literacy)

- Immunocompromised, comorbidites

- Trauma/fear/denial

- Language barriers

- Persons who use substances are not treated the same as those who don't

- Stigma towards body side/weight

- Gender identity

- Racism

Cancer Warning signs (CAUTION UP)

- Changes in bowel or bladder

- Alesion that does not heal

- Unusual bleeding or discharge

- Thickening or lump (breast, testicle, etc.)

- Indigestion or difficulty swallowing

- Obvious changes in wart or mole

- Nagging cough or persistent hoarseness

- Pernicious anemia

Colon Screening

Who, Test, How often?

- Generally anyone between the ages 50-74

- Younger than 74 with a personal hx of precancerous lesions

- Younger than 74 with a significant family hx of colon cancer (colonoscopy every 5 years)

- Fecal immunochemical tests (FIT) --> if this comes back positive then follow up with colonoscopy

- Every 2 years

Cervical Screening

Who, Test, How often?

- Anyone with a cervix from ages 25-69

- If you've had a HPV vaccine

- You've ever had any sexual contant with another person of any gender

- PAP Test, self-cervical screening

- Every 3-5 years

Lung Screening

Who, Test, How often?

- Those at high risk (occupation, smoking) ages 55-74

- CT Scan

- Every 3 years

Breast Screening

Who, Test, How often?

- People not at risk start at age 40, if higher risk start earlier

- Mammogram

- Every 2 years

Prostate Screening

Who, Test, How often?

- Those with prostates, age 50+

- Digital rectal exam, PSA (prostate specific antigen)

- Every 3 years

Healthy vs Cancerous cells

Healthy:

- large cytoplasm

- single nucleus

- single nucleolus

- fine chromatin

Cancerous:

- small cytoplasm

- multiple nuclei

- multiple & large nucleoli

- course chromatic

What is a characteristic of cancer cell appearance?

Cancer cells have no regular borders and their shape is different.

How do cancer cells grow in relation to their surroundings?

Cancer cells will grow despite what they bump into and just keep growing.

How do cancer cells communicate with each other?

Cancer cells don't communicate with each other, whereas normal cells do.

What happens to damaged cancer cells?

Damaged cancer cells do not undergo apoptosis and continue to multiply.

What can happen to the location of a tumor?

A tumor can move to another location and continue to grow and spread.

Initiation is caused by?

Inherited mutation

- Ex. breast cancer gene

Error in DNA replication

Exposure to chemical, radiation, viral, & bacterial agents, such as

- Cigarettes or asbestos

- X-rays

- Human papillomavirus (HPV)

- Helicobacter pylori

What is promotion in the context of cancer?

Reversible proliferation of altered cells

What is the latent period for promotion?

May take 1-40 years

What are some promoting agents for cancer?

Dietary fat, Obesity, Alcohol consumption, Physical and psychological stress

Which agents may initiate and promote cancer?

Tobacco and Alcohol

Progression

- Increased growth rate of tumor

- Increased invasiveness

- Metastasis

Modifiable risk factors

- Weight

- Nutrition

- Alcohol intake

- Activity intake

- Social

Non-modifiable risk factors

- Hx smoking

- Family Hx

- Age

- Gender / sex assigned at birth

- Past MI

Metastasis

- Not all cancers

- Can be "predictable" with certain cancers - colorectal --> liver

- Common sites: brain, bone, liver, adrenal glands

- Neighbouring tissue, penetrate walls of lymphatic or vascular vessels

- Becomes harder to treat once it starts spreading

Metastasis - Assessments

Blood tests, Xray, CT, MRI, PET scans, and bone scans

Diagnostics

Xray, US, CT, MRI, Colonscopy, Biopsy

Large irregularly shaped skin lesion

Biopsy

Blood detected in fecal stool sample

Colonoscopy

Ovarian mass found on pelvic exam

US, CT

Mammogram shows 4cm mass

US, biopsy

Lower back pain, with changes in sensation to lower extremities

MRI

Ongoign cough, family hx of lung ca

Xray first then CT

Blood found in urinalysis

US, CT

CLASSIFICATION

Anatomical site classification

- Tissue the tumor comes from ex. Carcinoma (resp, GI, GU tract), sarcoma (connective tissues), leukemia (bone marrow), etc.

Histological grading

How abnormal do the cells appear?

Clinical Staging

Extent of the disease process

TNM

Extent of the disease process

Why is classification important

The purpose is to drive the treatment/options, decision making

CLINICAL STAGING

Stage 0:

Cancer in situ

Stage I

Tumor limited to the tissue of the origin

Stage II

limited local spread

- The tumor is usually small and hasn't grown out of the organ it started in to nearby tissue/lymph

Stage III

Extensive local and regional spread

- The tumor has grown outside of the organ it started in to nearby tissue/lymph

Stage IV

Metastasis

- The cancer has spread through the blood or lymph to a distance site in the body (metastatic spread)

TNM - what does it stand for

Primary Tumor Size (T)

Lymph Nodes (N)

Metastases (M)

TX

Unable to measure tumor

T0

No evidence of tumor

Tis

Tumor hasn't grown into nearby tissue

T1 to T4

Tumor has grown into nearby tissues

1-4 describes how much the tumor has grown

NX

Unable to evaluate lymph nodes

N0

No cancer found in lymph nodes

N1 to N3

Cancer has spread into lymph nodes (numbers 1-3 are based on how many nodes are involved and how much cancer is found in them)

M0

Cancer hasn't spread to other parts of the body

M1

Cancer has spread to other parts of the body

Complications from cancer

Pain

- d/t tumor growing, pressing on bones, nervers or organs

Clotting/VTE

- Cancer thickens blood, clots form easier

Malnutrition

- Gain d/t fluid intake

Altered taste

- Cancer cells suppress appetite, change the way things taste

Infection

TREATMENT OPTIONS: SURGERY

What are components of cure/control?

- Good for slowing growing tumors

- Take a margin around the tumor

- Preventative measures taken to reduce seeding

- May need adjunctive therapy (chemo and/or radiation)

TREATMENT OPTIONS

Support & Palliation

- Feeding tubes

- Colostomy: rectal abscess or bowel obs

- Cystostomy /urostomy

- Debulking: pain/pressure

- Laminectomy: spinal cord compression

Debulking (cytoreductive) procedure

Remove as much as possible & then pt receives chemo &/or radiation

TREATMENT OPTIONS: Chemotherapy

- Many types - important to know what your patient is receiving so that you can monitor for side effects/complications

- Can help target cancer cells

- Student RNs cannot give meds for cancer, need extra qualificatons

Routes of administration

Systemic Administration

- PO

- IV CL to avoid extravasation

- Infusion pumps: continue infusion (IV, SQ, intra-arterial, epidural)

Routes of administration

Regional Administration

- Intra-arterial, intraperitoneal (abdomen), intrathecal (lower spine), intravesical bladder

What is the primary method of radiation treatment?

Bombarding tissues with radiation

What are the two types of radiation treatment?

External and internal radiation

What is internal radiation also known as?

Brachytherapy

How does radiation energy affect cancer cells?

It breaks DNA bonds, leading to cellular death

What is the purpose of cumulative doses of radiation?

Cancer cells are vulnerable to cumulative doses

What is the function of external radiation treatment machines?

They deliver radiation from outside the body

What is the benefit of internal radiation (brachytherapy)?

It has fewer side effects due to being implanted near or into the tumor

What are the two main goals of radiation treatment?

Cure or comfort

What determines the side effects of radiation treatment?

The part of the body treated and its impact on surrounding tissues

Common Side Effects of Chemotherapy & Radiation

- Fatigue

- Anorexia

- Hematologic/Immune

- Integument

- Resp

- GI

- CVS

- Reproductive

Fatigue (patho - what causes the side effect)

and Treament/Considerations

Patho

- Immune response, body working hard to fight it as it is also losing good cells

- High metabolic waste

- Lower hemoglobin --> tired

- Infection --> tired

Treatment

- Rest and movement balance

- Adequate nutrition

Anorexia (patho and treatment)

Patho

- Loss of appetite

Treatment

- Let people eat whatever they want but do encourage high protein/calorie count

Hematologic/Immune (patho and treatment)

Patho

- Lower hemoglobin

- Lower WBCs

- Immunocompromised

- #1 complication of cancer is infection

Treatment

- Isolate patient

- Can potentially transfuse if low RBC (hemoglobin less than 80)

- Soft bristled toothbrush (prevent blood loss)

Integument (patho and treatment)

Patho

- External radiation, alopecia

Treatment

- No temp extremes, moisturizer

Resp (patho and treatment)

Patho:

- Pneumonitis

Treatment:

- Monitor pt, do not treat w antibiotics (not an infection)

- Assess lungs, is it getting worse/better

GI (patho and treatment)

Patho

- Diarrhea very common, lining of GI tract is dividing cause GI upset

Treatment

- Manging S&S

CVS (patho and treatment)

Patho

- Dysrhytmias

- MI

Treatment

- Monitor both, interfere if needed

Reproductive (patho and treatment)

Patho

- Reduced fertility, changes in fertility

Treatment

- Save eggs or sperm

Is there an increased risk of developing cancer from chemo?

Yes

If someone survives cancer and it comes back, is the second time as effective

No

What is a treatment option that modifies the host-tumor relationship?

Biological & Targeted Therapy

What are some examples of biological and targeted therapies?

Interferon, IL, monoclonal antibodies, growth factors

What type of effects do biological and targeted therapies have on tumors?

Direct antitumor effects

What is one goal of biological and targeted therapy in relation to the immune system?

Restore, augment or restore host immune mechanisms

How do biological and targeted therapies affect cancer cells?

Interfere with cancer cells' ability to metastasize or differentiate

What is an example of an interleukin used in biological therapy?

IL-2 (interleukin 2)

What are emergency scenarios related to cancer obstruction emergencies

- Superior vena cava syndrome

- Spinal cord compressino

- 3rd space syndrome

- Intestinal obstruction

Superior vena cava syndrome

What is it

S&S

Diagnostic/Tx

What is it

- Obstruction of the SVC by a tumor

S&S

- Facial edema, periorbital edema, distention of neck/chest veins, headache, seizure

- Diagnosis: Chest Xray

- Tx: Radiation +/- chemotherapy

Spinal cord compression

What is it

S&S

Diagnostic/Tx

What is it

- Tumor in the epidural space of the SC

S&S

- Back pain (intense, localized persistent)

- Valsala can increase pain

- Motor weakness/dysfunction, paresthesia (an abnormal sensation of the skin (tingling, prickling, chilling, burning, numbness), loss of autonomic dysfunction (change in bowel or bladder function)

Diagnostic

- CR, CT, or MRI

Tx

- Surgery and/or radiation

3rd space syndrome

What is it

S&S

Dx/Tx

What is it

- Shift of fluids from vascular space to interstitial space (sepsis, surgery, biological treatment)

S&S

- Edema, decreased BP, electrolyte changes (increase Na+)

Dx:

- Physical assessment (edema), labs

- Increased hematocrit, CVP monitoring which measures preload

Tx: fluid and electrolytes, plasma proteins

Intestinal Obstruction

What is it

S&S

Dx & Tx

What is it

- GI obstruction

S&S

- Pain, N/V (fecal), constipation

Dx

- Xray

Tx

- Medical (NG) partial or OR

Cancer complications: Metabolic Emergences

- Syndrome of inappropriate ADH (antidiuretic hormone)

- Hypercalcemia

- Tumor lysis syndrome

- Septic shock

- DIC

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

- Abnormal or sustained production of ADH - Some ca cells can produce and release ADH, some chemo drugs can stimulate the release of ADH from the pituitary or ca cells

- Weight gain, anorexia, n/v, personality changes, seizure, coma

Hyponatremia = S/S of fluid overload

- Diagnosis: Labs Na

Tx: fluid restriction, 3% NaCl

Hypercalcemia

- Usually involves bone cancer or stimulation of the parathyroid

- Calcemia do the opposite of the prefix

Hyper - "things go down"

S/S: apathy, depression, muscle weakness, ECG changes, n/v, constipation

- Diagnosis: Serum Ca

Tx: treat underlying cause, IV fluid, diuretics, IV phosphate, bisphosphonate mediation (inhibits osteoclasts - breakdown bone)

Tumor lysis syndrome

- Chemo = rapid destruction of tumour cells - usually occurs 24-48 hrs post initiation of chemo

- S/S: hyperuricemia (uric acid is produced as a byproduct of breaking down cellular material and can cause renal failure), hyperphosphatemia, hyperkalemia (ECG), hypocalcemia

- Diagnosis: Labs (lytes, kidney function, uric acid)

Tx: prevent/treat renal failure - fluid, meds to decrease BUN

Septic Shock

- Distributive shock - vasodilation & leaky capillaries

Decreased CO = decreased perfusion

S&S

- Early ↑HR, RR

Later ↓BP ↓End organ perfusion

- Dx & Tx Lactate

? Cultures (blood, urine, wound)

Tx: Isotonic fld, IV abx, vasopressors

DIC (Disseminated intravascular coagulation

Simultaneous bleeding & clotting. Causes: septic shock, liver ca

S&S

- Bleeding at wound sites, nose, gums, or mouth; bld in stool and/or urine; petechiae.

Dx & Tx

- ↓ platelet, ↑ D-dimer, ↓ fibrinogen, ↑clotting times

Cancer complications: Infiltrative Emergencies

- Cardiac tamponade

- Carotid artery rupture

Cardiac Tamponade

What is it

S&S

Dx & Tx

What is it

- Fluid accumulation in the pericardial sac - restricts ventricular filling (preload)

S&S

- CP, anxiety, SOB, tachycardia, cough, decreased LOC, pulsus paradoxus, muffled heart sounds

Diagnosis: U/S

Tx: Emergency needle compression and/or pericardial window

Carotid Artery Rupture

What is it

S&S

Dx & Tx

What is it

- Commonly with ca of the head/neck, ca invades vessel wall, can also be caused by damage from surgery or radiation

S&S

- Bleeding, hematoma, neuro changes

Diagnosis: u/s

Tx: control bleeding, blood, surgery

Functions of the kidney

- Excretion of wastes: urea & uric acid

- Reabsorption or excretion of glucose, water, sodium chloride, potassium, magnesium, calcium, bicarbonate, and phosphate

- Acid-base balance

- Hormone secretion

- Erythropoietin (regulates the production of RBCs in bone marrow)

- Renin (controls blood pressure - RAAS)

- Calcitriol (Active form of Vit D)