cancer

biology of cancer

two major dysfunctions present in the process of cancer development: defective cell proliferation and defective cell differentiation

development of cancer

initiation: cancer cells arise from normal cells because of changes in genes; mutation in the cells genetic structures

promotion: the reversible proliferation of the altered cells; increase in the altered cell population increases the likelihood of more mutations; promoting factors include obesity, cigarette use, and alcohol use

progression: increased growth rate of the tumor, increased invasiveness, and metastasis; first is rapid growth of the tumor, then it develops its own blood supply (angiogenesis); tumor cells can detach from the primary tumor and invade surrounding the tumor and penetrate the walls of lymph or vascular vessels for metastasis

benign vs malignant neoplasms

benign neoplasms are well differentiated

malignant neoplasms range from well differentiated to undifferentiated

major difference is the ability of malignant tumor cells to invade and metastasize

classification of cancer

anatomic site

histologic

extent of disease

anatomic site classification

the tumor is identified by the tissue of origin, anatomic site, and behavior of the tumor

carcinomas originate from skin/glands and membrane lining of the respiratory, GI, and GU tract

sarcomas originate from connective tissue, muscle, bone, and fat

lymphomas and leukemias originate from the hematopoietic system

histologic grading tumors

grading is based on the degree to which the cells resemble the tissue of origin

poorly differentiated tumor have a poorer prognosis

grade 1-4: cells progressively get more abnormal

extent of disease

staging is based on the anatomic extent of disease

different for specific types of cancer

guides tx selection

clinical staging: stage 0-4

TNM classification to determine the anatomic extent of cancer involvement

treatment

cure it

control it

provide palliation

surgery

prevention- removal of non vital organs to prevent cancer

dx/determine the diagnostic and tx plan- clinical staging and biopsy

cure and/or control of cancer- removal of localized cancer tissue; primary site or site of metastisis

supportive care- insertion of therapeutic devices

rehabilitation- reconstructive surgery

palliation of symptoms- relief of pain, obstruction, hemorrhage

chemotherapy

cure- burkitt’s lymphoma, wilms’ tumor, neuroblastoma, acute lymphocytic leukemia, hodgkin’s lymphoma, testicular cancer

control- breast cancer, non hodgkin’s lymphoma, small cell lung cancer, ovarian cancer

palliation- relieve pain, obstruction, and improve sense of well being

effects of chemo on normal tissues

chemo side effects result from the destruction of normal cells; especially those that are rapidly proliferating

bone marrow, GI lining, and integumentary

acute toxicity: anaphylactic and hypersensitivity reactions, extravasation or flare reactions; anticipatory n/v, dysrhythmias

delayed effects

chronic toxicities

bone marrow suppression:

• neutropenia- r/f infection

• anemia- RBC/H&H is low; fatigue and decreased oxygen to tissues

• thrombocytopenia- r/f bleeding

radiation therapy

uses high energy beams or waves that produce ions in the cells

the energy in ionizing acts to break the chemical bonds in DNA

DNA is damaged which causes cell death

deliver max doses while sparing critical structures

better for localized areas than systemic disease

can be delivered externally or interanally

nursing management

bone marrow suppression: infection, hemorrhage, and overwhelming fatigue; monitor CBC; infection control, bleed precautions, cluster care

fatigue: interferes with day to day function; r/t anemia, toxins left in body, need for extra energy to repair and heal, or lack of sleep; help pts identify days and times when they feel better for activity and encourage rest before; walking program

GI: cells of the mucosal lining are highly proliferative; n/v/d; antiemetic, antidiarrheals, antimotility, antispasmodics; diet adjustments and non drug therapy; f/e replacements; sitz baths to ease discomfort

mucositis: xerostomia (dry mouth), assist in cleaning teeth, moistening food, and swallowing; dysgeusia (taste loss), nutrition may be compromised; oral assessment; keep mouth moist, clean, and debris free; oral care before and after each meal and at bed; soft toothbrush; topical analgesics, antibiotics, or antifungals may be needed

anorexia: small, frequent meals; high protein and high cal; nutritional supplements; may need enteral or parenteral nutrition

skin reactions: radiation skin changes (dry and wet desquamation); alopecia (cold caps); goal is to prevent infection and promote wound healing; protect from temperature extremes; avoid constricting garments; lubricate skin with nonirritating lotion emollient

pulmonary: pneumonitis, pulmonary fibrosis, pulmonary edema

cardio: pericardial effusion and pericarditis; monitor for ECG changes

cognitive: chemo brain (mental cloudiness or fog); thinking or memory problems; can be short term or years

reproductive: consider freezing eggs; embryos

immunotherapy and targeted therapy

uses the immune system to fight cancer

some types are known as biologic therapy

can boost or manipulate the immune system and create an environment that is not conducive for cancer to grow

can attack cancer cells directly

targeted therapy interferes with cancer growth by targeting specific cell receptors and pathways that are important in tumor growth

patients may not report side effects due to a fear of the drug getting stopped, manage flu like s/s, capillary leak syndrome and pulmonary edema require critical care nursing

hormone therapy

the hormones estrogen and progesterone can enhance the growth of some breast cancers

androgen (testosterone) can enhance the growth of some prostate cancers

when given as a cancer tx, hormone therapy drugs can block the effects of the hormone and stop the growth of cancer cells

complications of cancer

malnutrition: soft non irritating high protein high cal foods; avoid temp extremes, tobacco, alcohol, and spicy or rough foods; nutritional supplements

altered taste: avoid foods they do not like; avoid strong smells, drink more water with food, oral care before eating, eat smaller amounts more often, use plastic utensils

cancer cachexia: anorexia and/or unintended loss of weight and appetite; general tissue wasting, skeletal muscle atrophy, immune dysfunction, and metabolic problems; best tx is to treat the cancer

infection: leading cause of death; assessment of fever, determine possible cause, CBC; common sites are lungs, GU, mouth, rectum, peritoneal cavity, and blood

oncologic emergencies: obstructive, metabolic, and infiltrative emergencies

cancer pain

pain assessment:

• VS and pt behavior are not reliable

• obtain a comprehensive pain assessment

• distinguish between types of pain

• always believe the pt

pain management:

• NSAIDs, opioids, and adjuvant pain meds should be used depending on the character and cause of pain

• dosages are adjusted to control pain with the fewest side effects- usually very high doses