ch 18 cancer development

cancer

• malignancy

• abnormal cell growth where cell regulation is lost, resulting in new tissues that serve no function

risk factors for cancer

• aging - leading bc of decreased immunity

• chronic inflammation

• smoking

• alcohol

• chemicals (asbestos, radon)

action alert - oral cancer treatment

• many new cancer tx come in oral form

• presents challenges

• adherence can be an issue bc pts take oral drugs at home vs coming in for scheduled dosing

• emphasize importance of taking drug as prescribed and safe handling

• wear gloves when handling drug

• med shouldn’t be stores in same container as other meds

biology of NORMAL cells

• Specific morphology

• Smaller nuclear-to-cytoplasmic ratio

• Differentiated function - Cells have their own function and job. 

• Tight adherence (CAM) - Nothing can get through the cells. 

• Non-migratory - Cells stay in their specific area. 

• Orderly and well-regulated growth

biology of CANCER cells

• Anaplasia

• Large nuclear-to-cytoplasmic ratio

• Specific functions lost

• Loose adherence (No CAM) - Cancer cells are able to get through. 

• Migration (metastasis)

• No contact inhibition - Cancer cells can touch and won’t think anything of it. 

• Rapid or continuous cell division

• Abnormal chromosomes (aneuploidy)

• Serve NO useful function

cancer classification - grading

• high grade = more aggressive and faster growth

• low grade = less aggressive and slower growth

cancer classifications - ploidy

Structure and amount of chromosomes. The normal amount of chromosomes is 46.

cancer classification - staging

• goes 0-4

• stage 1 = not spread, but growing

• stage 2 and 3 = spread and in lymph and tissue

• stage 4 = metastasized everywhere to distant parts of body

cancer classification - in situ

• stage 0 cancer

• hasn’t spread anywhere, not growing

• seen in early breast cancer

• in original place, the in situ cells are not malignant or cancerous

• they can become cancerous and spread

• called zero cancer now

TNM

T - primary tumor

N - node

M - metastasis

primary tumor grading

• Tx - primary tumor can’t be assesed

• T0 - no evidence of primary tumor

• Tis - carcinoma in situ

• T1, T2, T3, T4 - increasing size and/or local extent of primary tumor; T1 is <2 cm, T2 is 2-5 cm, T3 >5 cm or invaded into surrounding tissue, and T4 is tumor invading into other organs

regional lymph nodes

• Nx - can’t be assesed

• N0 - no node metastasis

• N1, N2, N3 - increasing involvement of lymph nodes; N1 is 1-3, N2 is 4-6, N3 is >7

distant metastasis

• Mx - can’t assess

• M0 - no distant metastasis

• M1 - distant metastasis

primary tumors

identified by tissue from which it arose (parent tissue)

secondary (metastic) tumor

Cancer cells move from primary location. Additional tumor(s)

cancers associated w a known viral origin

• Epstein-barr virus

• Hepatitis B and C virus

• HPV

• Human Lymphotropic virus Type

• HIV-1

primary prevention of cancer

• Avoidance of known or potential carcinogens

• Modifying associated risk - Stop smoking or drinking alcohol. 

• Removal of “at risk” tissue - If you have mutations of BRCA genes, can have breasts removed. 

• Chemoprevention

• Vaccination (HPV)

secondary prevention of cancer

screenings: mammograms, fecal occult blood test, colonoscopy

7 warning signs of cancer

C = Changes in bowel or bladder habits

A = A sore that does not heal

U = Unusual bleeding or discharge - After 52 there should be no more bleeding because of menopause

T = Thickening of lump in breast or elsewhere

I = Indigestion or difficulty swallowing - Esophageal cancer; adenocarcinoma. 

O = Obvious change in wart of mole - Skin cancer. 

N = Nagging cough or hoarseness - Lung cancer

symptoms that occur w/ different types of cancer

• persistent cough for >3 moths = lung cancer

• swollen lymph nodes in axillary = breast cancer

• swollen lymph nodes over clavicle = lung cancer

surgery to remove tumor

• Prophylaxis: removes at risk tissue

• Diagnosis: Biopsy to test if it is cancer 

• Curative: Complete healing - able to cut it out and it is fine because it hasn’t metastasized

• Control: debulking tumors; not cure; removes part of tumor if you can’t remove whole thing; can alleviate symptoms

• Palliative: comfort/quality of life, no cure

• Reconstruction: increases function or restores appearance

radiation tx for cancer

• Local treatment – only on target tissues

• Ionizing radiation

• Exposure – Amount of radiation delivered

• Radiation dose – Amount of radiation absorbed (grays Gy)

• Dosimeter for nurses - measures an absorbed dose of ionizing radiation

action alert - radiation

• nurse needs to take precautions when caring for pt undergoing radiation

• time is the length of exposure to radiation field; limit time

• distance is how far from radiation source; farther away = less exposure

• shielding is using material to avoid exposure

action alert - skin in radiation

• skin in radiation path becomes photosensitive

• increases risk for sunburn and sun damage

• avoid direct skin exposure to sun during treatment for at least 1 yr after completion of radiation

teletherapy

• EXTERNAL source, the patient is NOT radioactive. 

• Stereotactic body radiotherapy

brachytherapy

• INTERNAL source, the patient radioactive for a time period (7-14 days)

• RN can go in but has to wear PPE and be in there for short period of time during radioactive period

• Thyroid cancer - Iodine 131

care of pt w/ brachytherapy

• pt has private room and bath

• place caution sign on door

• place portable lead shields btwn pt and door

• keep door to room closed

• wear dosimeter at all times while caring for pts

• wear lead apron at all times - always keep front of apron facing source

• if attempting to conceive, do not perform direct care regardless of gender

• preg nurses shouldn’t care for pts

• never touch radioactive source w bare hands

systemic therapy - chemo

• Can be used alone, before or after treatment, or in combination

• Kills cancer cells and normal cells

• Neoadjuvant chemotherapy – used to shrink tumor before surgery or radiation

• Adjuvant chemotherapy is following surgery or radiation.

• Genomic profiling allows individualized approach

• Places patients at high risk for infection, immunosuppression, complications

​​• Nadir

nadir

• time when bone marrow activity and WBC are at lowest levels after cytotoxic tx

• occurs at different times for different drugs

• typically 7-10 days after administration

common chemo drugs

• antimetabolites

• antitumor antibiotics

• antimitotics

• alkylating agents

• topoisomerase inhibitors

memory hook

• Chemo - Think “kills fast, hits healthy too” → wide systemic effects

• Targeted - Think “precision strike” -> fewer systemic but specific side effects

• Immuno - Think “immune booster” -> watch for immune system overreaction

• Monoclonal Antibodies - Think “smart missiles” -> infusion-related reactions most common

risks of chemo

• Infection risk - Bone marrow suppression and neutropenia. 

• Anemia, thrombocytopenia risk - Bone marrow suppression and impaired clotting. 

care of pt w myelosuppresion and neutropenia from chemo

• pt in private room

• good handwashing before touching pt or belongings

• ensure pt room and bathroom cleaned once/day

• monitor v/s q4hrs

• inspect pt skin and muscous membranes for fissures and abscesses

• inspect iv site for infection

• change wound dressings daily

• use aseptic technique for invasive procedures

• notify HCP if anything infected

• encourage activity at appropriate level

• keep equipment in pt room

• sick visitors should be restricted

• monitor WBC daily

• avoid indwelling catheters

• provide perineal hygiene at least daily

critical rescue - reduced immunity

• monitor pts w reduced immunity to recognize signs of infection

• any temp above 100.4 needs to be reported

• when iv antiinfective drugs are started, neutropenic pt admitted

• pt w neutropenia doesn’t pose infection risk to other people, but people can be infection risk to pt

action alert - interventions for neutropenia

• priority intervention is to protect from infection in hospital and teach how to reduce infection rx at home

• total pt assessment (common symptoms associated w/ infection, skin and mucous membrane inspection, lung sounds, inspection of venous access device insertion sites) must be performed routinely

• monitor decreased neutrophils

• notify HCP if neutrophil decreases

preventing injury for pt w/ thrombocytopenia

• Use caution when repositioning

• Avoid IM injections and venipunctures; when necessary, use smallest-gauge needle

• Apply firm pressure to needlestick site until site no longer bleeds

• Apply ice to areas of trauma

• Test urine and stool for blood

• Avoid trauma to rectal areas - anal; rough sex

• Use soft things for oral care

• Wear firm sole shoes

preventing injury or bleeding from chemo effects

• Use electric shaver

• Use soft-bristled toothbrush

• Do not have dental care without consulting HCP

• Do not take aspirin unless prescribed

• Do not participate in any activities that can cause harm

• Avoid hard foods

• Avoid burning mouth

• Check skin and mouth daily for bruises

• Avoid trauma w/ intercourse and no anal

• Take stool softeners to prevent straining; no enemas

• No shoes or clothes that are too tight

• Avoid blowing nose or placing objects near in nose

side effects of chemo

• Chemotherapy-induced nausea and vomiting (CINV) most common - Can give ondansetron or other antiemetics

• Mucositis: mouth sores

• Alopecia: hair loss

• Cognitive changes

• Chemotherapy-induced peripheral neuropathy (CIPN) - teach them to be careful w/ hot baths, use ice chips in mouth

• Cachexia: extreme body wasting

drug alert - serotonin antagonists

• serotonin antagonists, such as odansetron, can prolong QT interval

• ECG monitoring recommended in pts w electrolyte abnormalities, HF, or bradyarrhythmias or in pts taking other meds that can cause QT prolongation

main emergencies with chemo

• fever

• hypercalcemia

• tumor lysis syndrome

why is fever emergency in pt getting chemo

fever is indicative of an infection; any elevation in temp can make them head to sepsis

What does Hypercalcemia mean in a cancer patient and what are the patient’s survival chances with hypercalcemia

• It can indicate that the tumor is metastasizing.

• Hypercalcemia is the first sign of metastasis.

• It can cause dysrhythmias, coma, confusion; as it increases, it can place a strain on the kidneys and impair renal function. 

• if pt’s calcium levels are extremely high, then the nurse can give pt calcium gluconate and NS to dilute the calcium

tumor lysis syndrome w chemo

• Large numbers of tumor cells are destroyed rapidly.

• Early s/s stem from electrolyte imbalances and can cause lethargy, n/v, anorexia, flank pain, muscle weakness, cramps, seizures, and altered mental status.

• Hydration can prevent and manage this by increasing the kidney flow rates, preventing uric acid buildup in the kidneys, and diluting the potassium levels.

• Management becomes more aggressive for pts who develop hyperkalemia or hyperuricemia.

critical rescue - DIC

• DIC is life-threatening problem w high mortality rate, even w proper tx

• identify pts at greatest risk for sepsis and DIC

• prevention of sepsis and DIC is a priority nursing intervention

• practice aseptic technique during invasive procedures and during contact w non-intact skin and mucous membranes

• teach s/s of early infection and to seek prompt help

critical rescue - fluid overload

• monitor pts at least q2hrs for s/s of fluid overload

• s/s - bound pulse, increased neck vein distention, crackles, peripheral edema, reduced urine output

• important bc pulm edema can occur very quickly and lead to death

• when symptoms indicate that FO from oncologic emergencies isn’t responding to tx or getting worse, respond by notifying HCP asap