N470: Oncology

The formation and development blood cells

hematopoiesis

Where does hematopoiesis occur in adults?

bone marrow and lymphatic tissues

hematopoiesis process (may not be important)

1) Pluripotent stem cell

2) lymphoid progenitor cell

3) b and t stem cells

4) b and t lymphocytes

5) b lymphocytes further to plasma cells

6) myeloid progenitor cell-3 further types

- granulocytes and monocytes line

- erythroid- RBCs

- megakaryocytic line- platelets

2 types of bone marrow and their purpose

1) yellow (adipose): Produces fat, cartilage, and bone

2) Red (hematopoietic): Stem cell produces all three types of cell

- found in flat/irregular bones

Group of malignant disorders affecting the blood and blood forming tissues

leukemia

where do Myeloid leukemias start?

in immature forms of myeloid cells

where do Lymphocytic leukemias start?

in immature forms of lymphocytes

Etiologies of leukemia (5)

1) Smoking

2) genetic

3) radiation & chemical exposures

4) drugs

5) viruses

Patho of leukemia

lack of normal regulatory mechanisms of bone marrow cell proliferation and maturation

General symptoms of leukemia

1) fever

2) fatigue

3) night sweats

4) SOB

5) bruising

6) petechiae

7) bone/joint pain

Secondary (physiological) symptoms of leukemia (5)

1) anemia

2) leukopenia

3) thrombocytopenia

4) swollen lymph nodes

5) enlarged liver or spleen

Acute leukemia patho

- bone marrow cells cannot mature properly

- Immature leukemia cells continue to reproduce and build up

- Without treatment, live only a few months.

Chronic leukemia patho

- cells can mature partly but not completely

- cells live longer, build up, and crowd out normal cells

- most can live for many years.

Abbreviations for types of leukemia

- Acute (A)

- Chronic (C)

- Myeloid cell type (M)

- Lymphoid cell type (L)

Leukemia diagnostic tests (3)

1) Bone Marrow Biopsy: increased # of immature cells (blasts)

2) WBC range: <1000/mm3 to >100,000/mm3 (*differential to identify type)

3) Platelets & Hemoglobin – low

Malignant disorders which arise from lymphatic structures

Lymphoma

Describe Hodgkin Lymphoma (4)

•Presence of Reed Sternberg cells

•Spreads contiguously

•Altered B cells

•80% survival

Describe Non-Hodgkin Lymphoma (2)

•B, T, or NK cells

•Spreads non contiguously

Lymphoma diagnostics (3)

•Biopsy of lymph node(s)

•Lumbar puncture: leukemic cells in CNS

•MRI/CT/PET: infiltrates and/or sites of infection

Treatment for heme cancers (5)

1) Chemotherapy

•Induction

•Consolidation

2) Radiation therapy

•Targeted

•Total Body Irradiation

3) Targeted Therapy

•Specific gene mutation

•Biotherapy

4) Hematopoietic Stem Cell Transplant

•Autologous

•Allogeneic

5) CAR T cell Therapy

Supportive care for leukemia (7)

•Anti-infectives

•Antipyretics

•Transfusions

•Fluids and electrolytes

•Symptom Management

•Psychological

•Spiritual

carcinogenesis stages (3)

1. Initiation

2. Promotion

3. Progression

carcinogenesis stages:

Mutation of cellular DNA, cellular differentiation

Initiation

carcinogenesis stages:

Growth of altered cells; Can still potentially stop cancer growth (Promoting factors)

Promotion

carcinogenesis stages:

Tumor growth rate increases, metastasis occurs through lymph and vascular routes

Progression

Three types of carcinogens

1) viral

2) chem

3) radiation

patho of cancer cells

stem cells --> differentiation --> dedifferentiation

general mutations that promote cancer development

- mutation of proto-oncogenes into oncogenes

- mutations that inactivate tumor suppressor genes

What do cancer cells lack?

- contact inhibition

- apoptosis

how does metastasis occur?

- lymphatic and vascular routes

- angiogenesis

time it takes for tumor to double in size

doubling time

Proliferation time does not increase in CA cells, but instead is ______________

Proliferation time does not increase in CA cells, but instead is continuous

How is the growth rate of cancer determined?

mitotic rate of cells of origin

Why is the geriatric population more likely to die from cancer? (2)

- Symptoms may be attributed to old age leading to later stage at diagnosis

- Comorbidities

Primary prevention of cancer (5)

-Decrease/eliminate exposure to carcinogens

-Healthy diet

-Exercise

-Alcohol in moderation

-Limit UV exposure (Sun/tanning beds)

Secondary prevention of cancer (3)

-Inspection

-Palpation

-Screening

Cancer warning signs (CAUTION) *

C: change in bowel or bladder habits

A: a sore that does not heal

U: unusual bleeding or discharge

T: thickening of a lump

I: indigestion or trouble swallowing

O: obvious change in mole

N: nagging cough or hoarseness

How is extent of cancer (with solid tumors) determined? (4)

- anatomic site

- clinical staging (0-IV)

- histological grading (I-X)

- classification (T, N, M)

classification of cancers

- Tumor: T1-T4

- Node: N1-N3

- Metastasis: M0-M1

4 treatment modalities for cancer

Surgery, Radiation therapy, Chemotherapy, Immunotherapy

What does cancer grade X mean?

cannot tell origin

What does M1 mean in the TNM system?

metastasis present

Most common cancers that cause death (4)*

•Lung

•Prostate OR breast

•Colon/Rectum

•Pancreas

Leading cause of cancer related death in the United States

lung cancer

Risk factors for lung cancer (6)

-Smoking (#1)

-Pollution

-Radiation Exposure

-Asbestos Exposure

-Exposure to Industrial Agents (nickel, coal dust, formaldahyde)

-EGFR gene

Early symptoms of lung cancer (5)

- persistent cough

- blood tinged sputum

- dyspnea

- wheezing

- chest pain

Late symptoms of lung cancer (6)

- anorexia

- fatigue

- weight loss

Metastasis

- SVC syndrome

- pericardial effusion

- dysphagia

Diagnostic tests for lung cancer (4)

-CXR: identifies masses

-CT scan: can i.d. location, mediastinal involvement, lymph node enlargement

-Biopsy (sputum cytology, pleural fluid)

-MRI, PET, Bone scan, CBC, CMP to assist with staging

treatment for lung cancer (4)

- Surgical resection (non small cell; *stage I-IIIA only)

- radiation

- chemotherapy

- targeted therapy

Risk factors for colorectal cancer (4)

-Diet (red/processed meat)

-Lifestyle

-History of IBD

-Heredity

colorectal cancer is most commonly _________________ arising from __________

colorectal cancer is most commonly adenocarcinoma arising from polyps

Symptoms of colorectal cancer (5)

-Anemia

-Rectal bleeding

-Abdominal pain

-Change in bowel habits

-Tenesmus (heavy feeling in bum)

Diagnostic studies for colorectal cancer (5)

-Flexible sigmoidoscopy

-Colonoscopy

-CEA

-FOBT

-Know family history

treatment for colorectal cancer

1) Surgery

•Resection of tumor with clear margins

•Excision of regional lymph nodes

•Colectomy

3) Targeted Therapy

•Avastin, Erbitux

4) Radiation

Risk factors for breast cancer (10)

–Age – most important

–Ethnicity – highest risk for African-American women

–Long hormonal cycle exposure (early menarche & late menopause)

–Pregnancy history: nulliparity & first child after 30yo

–HRT (estrogen + progesterone)

–Benign breast disease combined with family history

–Family history: 15-20% (genetic + environmental)

–Genetics: BRCA1, BRCA2, & p53 tumor suppressor gene (5-10%)

–Hx of mantle radiation @ < 20yo for Hodgkin’s lymphoma

–Dietary: alcohol (2-5 drinks/ day); increased dietary fat

Symptoms of breast cancer (6)

-Skin changes- dimpling, thickening

-Lump

-Nipple discharge

Metastatic Disease

-Dyspnea

-Back pain

-Confusion/altered LOC

Diagnostic Tests for breast cancer (4)

- Mammography

- U/S

- Biopsy

- HER2/hormone receptor status

Treatment for breast cancer (4)

1) Surgery

-Lumpectomy

-Mastectomy

2) Radiation

-External Beam (5x/week 5-7 weeks)

-Brachytherapy (5 days)

-Palliative (bone pain, brain)

3) Chemotherapy

-Treat known or suspected metastatic disease

4) Hormonal Therapy

-Used to treat hormone receptor positive breast cancer

what is triple negative breast cancer?

Negative for estrogen receptor, progesterone receptor, and HER2 receptor. Difficult to treat w/ conventional therapy.

Most common gynecological cancers

1 - Endometrial

2 - ovarian

3 - cervical

Risk factors for endometrial cancer (6)

- Estrogen (unopposed)

- Age

- Nulliparity

- Obesity

- Smoking

- Diabetes

Risk factors for ovarian cancer (7)

- BRCA gene mutation

- Nulliparity

- Early menarche

- Late menopause

- Obesity

- Family history

- Age

Risk factors for cervical cancer

- Exposure to HPV

- Multiple sexual partners or partner with multiple sex partners

- Early age of first intercourse

- Smoking tobacco

- Untreated chronic cervical infections

- STDs

GYN cancers are often __________________ until later stages

GYN cancers are often asymptomatic until later stages

Symptoms of endometrial cancer (2)

- Abnormal uterine bleeding

- Pain

Diagnostic tests for endometrial cancer (2)

- Biopsy

- Hormone Receptor status

Symptoms of ovarian cancer (6)

- Vague symptoms

- Abdominal pain or bloating

- Changes to bowel or bladder

- Early satiety

- Weight loss or weight gain

- Menstrual changes

Diagnostic tests of ovarian cancer (3)

- No specific screening test

- U/S

- Pelvic exam

Symptoms of cervical cancer (6)

- Dysplastic changes are asymptomatic

- Leukorrhea & bleeding

- Pain

- Bowel or bladder changes

- Weight loss

- Anemia

Diagnostic tests of cervical cancer (3)

- Pap smear

- Colposcopy

- Biopsy

treatment for GYN cancers (4)

1) Radiation

- External Beam

- Brachytherapy

2) Surgery

- Vaginal vs Abdominal hysterectomy

3) Chemotherapy

4) Hormone Therapy

Risk factors for prostate cancer (5)

-Age

-Ethnicity

-Family History

-Diet high in red meat and high fat dairy, low intake vegetables

-Occupational (fertilizer, textile, & rubber industries)

Symptoms of prostate cancer (3)

-Asymptomatic in early stages

-Urinary changes

-Pain in lumbosacral area (metastases)

Diagnostic tests for prostate cancer (4)

-PSA testing (risk vs benefit)

-DRE

-Transrectal resection of prostate (biopsy)

-MRI/CT (metastases)

Prostate cancer treatment (5)

1) Active surveillance

2) Radiation

-External beam

-Brachytherapy

3) Hormone Therapy

4) Chemotherapy (palliative)

5) Surgery

-Radical Prostatectomy (retropubic, perineal, laparoscopic, robotic assisted)

-Nerve sparing procedure- cancer limited to prostate only

Post-prostate surgery care (2)

-Catheter 3 way foley

-Perineal care

complications of prostate surgery (3)

-Hemorrhage, DVT, PE, infection

-ED

-Urinary incontinence

general cancer/treatment side effects (7)

1) BMS

2) fatigue

3) GI symptoms

4) integumentary effects- alopecia

5) reproductive loss

6) pain

7) respiratory, hepatic, and renal toxicities

Bone marrow suppression causes _____________ which can increase risk for ____________ and ___________

Bone marrow suppression causes pancytopenia which can increase risk for bleeding and infection

What are specific GI symptoms associated with cancer treatment? (4)

•Nausea/ Vomiting

•Diarrhea

•Mucositis

•Anorexia

Types of oncologic emergencies

1) Infiltrative

2) Obstructive

3) Metabolic

Cancer infiltrates organ or caused by treatment of cancer

Infiltrative onc emergency

Types of infiltrative onc emergencies (2)

1) cardiac tamponade

2) carotid artery rupture

emergency radiation may be indicated for... (2)

1) cardiac tamponade

2) carotid artery rupture

Why might cardiac tamponade occur in an onc patient?

tumor compresses the heart

Why might carotid artery rupture occur in an onc patient?

infiltrated tumor can erode blood vessels

Types of obstructive onc emergencies (3)

1) Superior Vena Cava Syndrome

2) Spinal Cord Compression

3) Intestinal Obstruction

In which cancers is Superior Vena Cava Syndrome most common? (3)*

1) Non-Hodgkin's (NHL)

2) breast

3) lung

Symptoms of Superior Vena Cava Syndrome (3) *think chest-up fluid overload*

1) HA

2) facial/periorbital edema

3) vein distention head/neck/chest

Treatments for Superior Vena Cava Syndrome (3)*

1) radiation to reduce tumor size

2) thrombolytic

3) steroids

Nursing management for Superior Vena Cava Syndrome (3)*

1) elevate HOB

2) O2

3) weights

4) ADLs

In which cancers is Spinal Cord Compression most common? (6)*

1) breast

2) lung

3) prostate

4) GI

5) renal

6) melanoma

Symptoms of Spinal Cord Compression (3)*

1) change in bowel/bladder

2) intense pain in the back

3) motor dysfunction/weakness (change in sensation)

Treatment for Spinal Cord Compression (4)*

1) MRI/CT

2) steroids

3) radiation

4) chemotherapy

Nursing management for Spinal Cord Compression (2)*

1) spinal precautions

2) pain management

Types of metabolic onc emergencies (5)*

1) Hypercalcemia

2) SIADH

3) Tumor Lysis Syndrome

4) DIC

5) Sepsis

In which cancers is Hypercalcemia most common? (2)*

1) MM

2) advanced metastatic cancers (lung, breast, kidney, colon, ovarian, thyroid)

Symptoms of Hypercalcemia (8)*

1) apathy

2) confusion

3) depression

4) fatigue

5) ECG changes

6) muscle weakness

7) anorexia

8) n/v

Treatments for Hypercalcemia >12 (3)*

1) IV fluids

2) bisphosphonate therapy

3) diuretics

Nursing management for Hypercalcemia (3)*

1) Safety precautions

2) monitor labs

3) increase mobility