Topic 6: Ch 16 Cancer

initiation, promotion, and progression

what are the stages of cancer development

initiation

the first stage of cancer development in which cancer cells arise from normal cells because of changes in genes, a mutation in the cell’s genetic structure that can be caused by viruses, hormones, radiation, chemicals, genetic factors, and unknown factors

carcinogens

cancer-causing agents that are capable of producing cell alterations

examples:

• chemicals: benzene, arsenic, formaldehyde

• radiation: UV rays

• viral: DNA and RNA viruses (oncogenic), EPV, AIDS, HPV

promotion

the second stage of cancer development that is characterized by the reversible proliferation of the altered cells, an increased in altered cells increases likelihood of more mutations and the activity is reversible

obesity, smoking, alcohol use, physical inactivity

what are promoting factors that are modifiable

complete carcingoens

carcinogens that are capable of both initiating and promoting cancer development; ie. cigarret smoke

latent period

the time between the first genetic alteration and the actual clinical evidence of cancer; includes both initiation and the promotion stages

progression

the last stage stage of cancer development in which increased growth rate of the tumor, increased invasiveness, and metastasis occurs

metastasis

The spread of the cancer to a distant site, MC sites are lungs, liver, bone, and brain, begins with the rapid growth of the primary tumor. As the tumor grows, it develops its own blood supply, critical to its survival and growth, and then travels to distant sites

benign neoplasms

tumors that are well differentiated

• usually encapsulated

• normally differentiated

• no metastasis

• rare occurence

• slight vascularity

• expansive mode of growth

• fairly normal cells, like parent cells

malignant neoplasms

tumors that range from well-differentiated to undifferentiated and have the ability to invade and metastasize

• rarely encapsulated

• poorly differentiated

• capable of metastasis

• possible recurrence

• moderate-marked vascularity

• infiltrative and expansive mode of growth

• cells abnormal and become more unlike parent cells

• limit alcohol use

• get regular physical activity (30 min or more of moderate physical activity 5x/week)

• maintain a normal weight

• have regular physical exams

• obtain regular colorectal screenings

• avoid smoking and tobacco use

• get regular mammograms and pap smears

• be familiar with family history and RF with cancer

• obtain adequate rest of at least 6-8 hours per night

• use sunscreen with a sun protection factor of 15+, avoid tanning beds

• eliminate, reduce, or change the perception of stressors and enhance the ability to effectively cope with stress

• eat a balanced diet that includes veggies and fruits, whole grains, and fiber; reduce dietary fat and preservatives; limit smoked and salt-cured meats with high nitrite concentrations

what does prevention and early detection of cancer includeq

Change in bowel or bladder habits

A sore that does not heal

Unusual bleeding or discharge from any body orifice

Thickening or a lump in the breast/elsewhere

Indigestion or difficulty swallowing

Obvious change in a wart or mole

Nagging cough or hoarseness

what is the CAUTION acronym for the warning signs of cancer

cure, control, and palliation

what are the treatment goals for a patient with cancer

• tumor histology

• patient’s physiologic status (ie. presence of comorbid conditions)

• psychological status

• personal desires

• treatment modalities like surgery, radiation, and chemotherapy

• length of therapy

• combination of therapy

what are the main factors that determine/influence treatment modalities for money

cure

when this is the goal of cancer treatment we expect treatment to have the greatest chance of eradicating the cancer

control

this is the goal of treatment for cancers that we cannot completely eradicate but are responsive to anticancer therapies

palliation

this is the goal of treatment when the goals are symptom control or relief and maintaining a satisfactory quality of life

surgery

the oldest form of cancer treatment that can eliminate or reduce the risk for cancer development

• Prophylactic removal of nonvital organs has been successful in reducing the risk of some cancers

• allows for removal of all or as much as possible of the resectable tumor as possible which can allow for cure or control

• debulking/cytoreductive if the tumor can’t be completely removed like a tumor attached to a vital organ

• can make chemo or radiation more effective

• may need treatment before to reduce tumor size and improve surgical outcome

• can be supportive/palliative

  • inserting a feeding tube to maintain nutrition during head and neck cancer treatment

  • placing a central venous access device to deliver chemo

  • prophylactic surgical fixation of bones at risk for pathologic fracture

chemotherapy

the use of chemicals as a systemic therapy for cancer that is the mainstay of cancer treatment for most solid tumors and hematologic cancers which can offer some cure for some cancers, control others, and offer palliative relief of symptoms

• goal is to elimiate or reduce the number of cancer cells

• pose a hazard to HCP who don’t follow safe handling instructions

• risk in handling the body fluids/excretions of those duringIV the first 48 hours of receiving the therapy

• MC givne IV

  • concerns: venous access problems, device/catheter related infection, extravasation

  • may cause severe local tissue breakdown and dnecrossis

• regional treatment: delivere directly to site which allows higher concentrations to be delivered to the tumor with less systemic toxicity

• can’t dinstiguish normal and cancer cells so it will destroy normal cells as well

what are the methods of admin/considerations for chemotherapy drugsa

acute toxicity

occurs during and right after chemo drug administration that includes anaphylactic and hypersensitivity reactions, extravasation or flare reactions, anticipatory N/V, and dysrhythmias

delayed effects

effects of chemo drugs that include delayed N/V, mucositis, alopecia, skin rashes, bone marrow suppression, altered bowel function, neurotoxicities

chronic toxicities

involve damage to organs like the heart, liver, kidneys and lungs, that can be either long term effects that develop during or right after treatment and persist during treatment and manifest later

when the tumor burden is low, therapy is not interrupted, and the patient receives the intended dose

when is chemotherapy most effective

radiation

cancer therapy that uses high-energy beams or waves that, when absorbed into tissue, produce ions in the cells; the energy in ionizing radiations acts to break the chemical bonds in DNA, damaging the DNA is damaged causing cell death

used to treat a carefully defined area of the body and is not the main treatment for systemic disease

simulation

a process by which the radiation treatment fields are defined, filmed, and marked out on the skin, done using imaging techniques, physical assessment, and surgical reports

brachytherapy

“close” or internal radiation treatment that consists of the implantation or insertion of radioactive materials directly into the tumor (interstitial) or near the tumor, which allows for direct delivery of radiation to the target with minimal exposure to surrounding healthy tissue

• hyperuricemia which can cause secondary gout and obstructive uropathy

  • monitor uric acid level

  • can give allopurinol prophylactically

  • maintain increased fluin intake

• Cardiotoxicity can cause ECG changes and rapidly progressive HF

  • monitor heart with ECG and cardiac EF

  • drug therapy may need to be framed

  • admin antidysrhythmia drugs as ordered

• Pericarditis and myocarditis: monitor for s/s ie. dyspnea

• fatigue:

  • assess for reversible causes

  • reassure patient that it is common

  • rest when fatigued

  • encourage moderate exercise as tolerated

• anorexia:

  • monitor weight

  • eat small, frequent meals of high protein and high calorie foods

  • Encourage to eat gently, but do not nag

  • keep a food diary

  • serve food in pleasant environments

• constipation: take stool softeners, eat high fiber foods, increase fluids and activity

• diarrhea:

  • give antidiarrheal drugs as needed

  • encourage low-lifer, low-residual diet

  • encourage fluid intake of at least 3 L/day

• hepatotoxicity: monitor LFTs

• N/V

  • eat and drink when not nauseated

  • give prophylactic antiemetics before treatments and as needed

  • take on a scheduled basis for 2-3 days after chemo

  • use diversional activities

• stomatitis, mucositis, and esophagitis

  • assess oral mucosa daily, keep clean and moist

  • use nutritional supplements

  • be aware that eating, swallowing, and talking may be difficult

  • avoid irritating spicy/acidic foods, too hot/cold food

  • teach how to choose moist, bland, and softer foods

  • use artificial saliva to manage dryness

  • apply topical anesthetics

• hemorrhage cystitis

  • increase fluid intake1-3 days after treatment, monitor for urgency, frequency, and hematuria, give cytoprotectants, provide supportive care to manage s/s

• nephrotoxicity

  • monitor BUN and serum Cr, avoid potentiating drugs, alkalinize the urine by adding sodium bicarbonate to IV infusion, give allopurinol or rasburicase for TLS prevention

• reproductive problems: discuss risks, offer opportunities for banking before treatment

• anemia: monitor Hgb and Hct, give iron supplements and erythropoietin, encourage intake of foods that promote RBC production

• leukopenia: monitor WBCs, report fever, avoid large crowds/people with infections

• thrombocytopenia: observe for s/s of bleeding, monitor platelets

• alopecia: coping ways, cut long hair before therapy, avoid excessive shampooing/brushing/combing/use of electric hair dryers/curler/curling irons, discuss impact on self-image

• acneiform eruptions, acral erythema, hyperpigmentation, photosensitivity, telangiectasia

  • avoid the sun, implement symptomatic management

• chemo brain: problems with concentration, memory lapses, trouble remembering details, taking longer to finish takss,

  • use detailed daily planner, get enough sleep and rest, exercise brain, no multitasking

• intracranial pressure: monitor neuro status, control with corticosteroids

• peripheral neuropathy: antiseizure drugs

• pneumonitis: develops 2-3 months after start of treatment

  • monitor for dry, hacking cough, fever, and dyspnea with exertion, encourage activity and respiratory exercises

what are common problems caused by chemotherapy and radiation therapy

mucositis

irritation, inflammation, and/or ulceration of the mucosa that is very sensitive to chemo and radiation

xerostomia

dry mouth

dysgeusia

tast loss that may develop during chemo/radiation

odynophagia

painful swallowing caused by oropharyngeal/esophageal irritation/ulceration during chemo/radiation

• cleanse the skin gently with mild soap, tepid water, a soft cloth, and a gentle patting motion

• apply nonmedicated, nonperfumed, moisturizing lotion or cream to alleviate dry skin

• rinse the area with saline solution, expose the area to air as often as possible, change dressings as soon as they become wet

• observe the area daily for signs of infection

• avoid tight-fitting clothes over the treatment fields

• avoid harsh fabrics

• use gentle detergents

• avoid direct exposure to the sun

• avoid all sources of excessive heat on the treatment field

• avoid exposing the treatment field to cold temperatures

• avoid swimming in salt water or chlorinated pools during treatment

• avoid using potential irritants, tape, dressing, adhesive bandages

• continue to protect skin after treatment is completed

what are patient/caregiver teachings to reduce radiation skin reactions

• malnutrition

• altered tasts (dysgeusia)

• cancer cachexia

• infection (leading cause of death in cancer patient)

  • common sites: lungs, GU, mouth, rectum, peritoneal, blood (septicemia)

• oncologic emergencies

  • obstructive: tumor obstruction of organ/BV

  • metabolic: prodcution of ectopic hormones

  • infiltrative: inflitraties major organs

• pain

• coping: fears of dependency, loss of control, relationship stress, financial burden, fear of death, anxiety/fear of treatment

what are the complications of cancer

mayo, butter/margarine/sour cream, peanut butter, whipped cream, corn oil, jelly, ice cream, honey

what are examples of high calorie foods that may be recommeneded in nutrition therapy for cancer patients

cancer cachexia (wasting syndrome)

a complex, multifactorial syndrome characterized by anorexia and/or unintended loss of weight and appetite that is accompanied by generalized tissue wasting, skeletal muscle atrophy, immune dysfunction, and metabolic problems; nutritional therapy cannot reverse weight loss; common is those with upper GI and pancreatic cancers; associated with increased mortality; best tx is to treat the cancer, increase intake, and use megestrol acetate

• location: where is the pain, in more than one place, a new location, does is correlate with known diagnosis

• intensity: how bad is it, rate on a scale of 0-10

• quality: what does it feel like (sharp, dull, burning, shooting, aching

• pattern: has the pain changed, getting better/worse/unchanged, what makes it better/worse

• relief measures: what do you do to control your pain, do you use meds, do the relief measures help musch/how much

what does the pain assessment in cancer patient include

• ability to cope with previous stressful events

• ability to express feelings/concerns

• age at the time of diagnosis

• attitude associated with the cancer

• availability of significant others/support system

• Negative body image may intensify psychologic impact of cancer

• extent of disease

• experience with cancer such as personal or others

• symptoms may intensify the psychological impact of cancer

what factors affect the patient’s ability to cope with cancer