Cancer - AH

Chapter 18: Concepts of Care for Patients with Cancer

Concepts of Cancer Care

  • Priority Concepts
        - Cellular regulation
        - Immunity

  • Interrelated Concepts
        - Clotting
        - Sensory perception

Cellular Regulation

  • Definition: The genetic and physiological processes that control cellular growth, replication, differentiation, and function to maintain homeostasis.

  • Important Note: All cancer cells originated as normal cells but may have lost the function of cellular regulation, leading to cancer.

Normal Cells versus Cancer Cells

Normal Cells:

  • Characteristics:
        - Small, uniformly shaped nuclei
        - Relatively large cytoplasmic volume
        - Uniformity in cell size and shape
        - Organized into discrete tissues

Cancer Cells:

  • Characteristics:
        - Large, variably shaped nuclei
        - Relatively small cytoplasmic volume
        - Variability in cell size and shape; disorganized arrangements
        - Presence of differentiated cell structures may vary
        - Normal presentation of cell surface markers and associated functions is often lost
        - Elevated levels of specific cell markers
        - High levels of dividing cells
        - Poorly defined tumor boundaries

Comparison of Normal and Abnormal Cells

Characteristic

Normal Cell

Benign Tumor Cell

Malignant Cell

Cell Division

None or slow

Continuous or inappropriate

Rapid or continuous

Appearance

Distinct, recognizable appearance

Specific morphologic features

Anaplastic; irregular appearance

Nuclear-to-Cytoplasmic Ratio

Smaller

Smaller

Larger

Differentiated Functions

Many

Many

Some or none

Adherence

Tight

Tight

Loose, migratory

Growth

Well regulated

Expansion

Invasion

Chromosomes

Diploid (euploid)

Diploid (euploid)

Aneuploida

Mitotic Index

Low

Low

High

Cancer Development

  • Terms:
        - Carcinogenesis
        - Oncogenesis
        - Malignant Transformation

  • Stages of Cancer Development:
        - Initiation: The first steps where normal cells begin to transform
        - Promotion: The encouragement of cell growth, signalling pathways activated
        - Progression: Further changes in cancer cells that enable them to invade and metastasize
        - Metastasis: The spread of cancer cells away from the primary site to establish secondary tumors.

Primary and Secondary Tumors

  • Primary Tumors: Identified by the tissue from which they originated (the parent tissue).

  • Secondary (Metastatic) Tumors: Result from cancer cells that have migrated from the primary location, establishing new colonies elsewhere in the body.

Steps of Metastasis

  • The sequential stages of metastasis include:
        - Malignant transformation
        - Tumor vascularization
        - Blood vessel penetration
        - Establishing distant sites of growth

Cancer Classification

  • Grading: Classification based on the appearance of cancer cells compared to normal cells.

  • Ploidy: Analysis of chromosome number in cells.

  • Staging: Describes the extent of cancer, typically classified as clinical, surgical, and pathologic stages.

  • TNM System:
        - T: Tumor size and extent
        - N: Node involvement (lymph nodes)
        - M: Metastasis (spread to distant sites)

  • Doubling Time: The time it takes for tumors to double in size; Mitotic Index: Measure of the percentage of dividing cells in a tissue sample

Cancer Etiology and Genetic Risk

  • Factors contributing to cancer include:
        - Exposure to Carcinogens: Substances that promote cancer (e.g., chemicals, radiation).
        - Genetic Predisposition: Family history and inherited mutations that increase cancer risk.
        - Immunity: Immune function and responses that may play a role in cancer development.

External Factors Causing Cancer

  • Chemical Carcinogenesis:
        - Approximately 30% of cancers are linked to tobacco use.

  • Physical Carcinogenesis:
        - Radiation exposure and chronic irritants can lead to cancer.

  • Viral Carcinogenesis:
        - Certain oncoviruses are known to promote cancer development.

Factors Influencing Cancer Development

  • Personal Factors including age and genetic predisposition play crucial roles in individual susceptibility to cancer.

Genetic Testing for Cancer Predisposition

  • Important Note:
        - Genetic testing does not diagnose cancer but provides information regarding risk and predisposition to certain cancers.
        - Involvement of a genetic counselor is advised prior to and post-testing.

Health Equity: Cancer Incidence

  • Access to care along with variations in socioeconomic background has a significant impact on the development of cancer.

Health Promotion: Cancer Prevention

  • Primary Prevention Strategies include:
        - Avoidance of known or potential carcinogens.
        - Modifying risk factors associated with cancer.
        - Surgical removal of tissue that may be at risk for cancer (e.g., polyps).
        - Chemoprevention (use of medications to reduce cancer risk).
        - Vaccination, such as HPV vaccine.

  • Secondary Prevention Strategies consist of regular cancer screening to identify cancer early.

Impact of Cancer on Physical Function

  • Effects of cancer on various systems and functions:
        - Impairments in immunity and clotting processes.
        - Compromised gastrointestinal function, impacting nutrient absorption.
        - Peripheral nerve sensory perceptions may be affected.
        - Central motor and sensory deficits.
        - Impaired respiratory and cardiac functions, limiting physical performance.
        - Cancer-related pain can significantly affect quality of life.

Cancer Management

  • Various treatment modalities include:
        - Surgery: Options vary from curative to palliative care.
        - Radiation: Use of high-energy radiation to eradicate cancer cells.
        - Chemotherapy: Systemic treatment using cytotoxic drugs.
        - Immunotherapy: Utilizes the body’s immune system to combat cancer.
        - Photodynamic Therapy: Utilizes light-sensitive compounds to selectively destroy cancer cells.
        - Hormonal Therapy: Aimed at hormone-sensitive cancers.

Surgery as Cancer Treatment

  • Types of Surgery include:
        - Prophylactic: Removal of tissue to prevent cancer.
        - Diagnostic: Procedures done for diagnostic purposes.
        - Curative: Aiming to remove all cancerous tissue.
        - Debulking: Reducing the bulk of a large tumor.
        - Palliative: Alleviate symptoms without curing the disease.
        - Restorative: To restore function or appearance after surgical removal.

Radiation Therapy

  • Purpose: High-energy radiation is utilized to kill cancer cells.

  • Administration: Typically given in divided doses over a specified period.

  • Delivery Methods include:
        - External Beam: Radiation delivered from an external source.
        - Brachytherapy: Internal radiation therapy where radioactive sources are placed near or in the tumor.

Side Effects of Radiation Therapy

  • Varies depending on the site of radiation treatment; common side effects include:
        - Acute effects and long-term complications.
        - Radiation Dermatitis: Skin reactions that may occur.
        - Altered taste and fatigue.
        - Bone marrow suppression leading to blood count anomalies.

Systemic Therapy

  • Refers to the pharmacologic treatments that affect the entire body such as:
        - Chemotherapy and Immunotherapy used in isolation or combined.

  • Types of Systemic Therapy include:
        - Neoadjuvant Chemotherapy: Aims to shrink the tumor before the primary treatment.
        - Adjuvant Chemotherapy: Administered following surgery to eliminate remaining cancer cells.

Combination Chemotherapy

  • Involves using multiple drugs with different mechanisms of action to more effectively disrupt cancer cell division.

Chemotherapy Drugs

  • Types of chemotherapy drugs include:
        - Antimetabolites: Interfere with the production of nucleotides.
        - Antitumor Antibiotics: Target DNA synthesis.
        - Antimitotics: Affect mitosis and cell proliferation.
        - Alkylating Agents: Modify DNA to prevent replication.
        - Topoisomerase Inhibitors: Interfere with the enzymes that manage DNA structure.

Treatment Issues in Cancer Therapy

  • Important considerations:
        - Dosage and Scheduling: Critical for treatment success.
        - Administration Routes: Can include intrathecal, intraperitoneal, intravesicular, topical, or intra-arterial routes.
        - Extravasation Monitoring: Watching for tissue leakage during IV infusions.
        - Oral Anticancer Drugs: Education about potential toxicities is essential.

Extravasation

  • Condition highlighting tissue damage due to chemotherapy extravasation, requiring careful monitoring of the access site during infusion.

Handling Safety of Chemotherapy Agents

  • Recommendations include:
        - Avoiding direct skin contact with chemotherapeutic agents.
        - Proper disposal of waste from chemotherapy.
        - Precautions to ensure safety for both patients and caregivers.

Side Effects of Chemotherapy

  • Both temporary and permanent toxic effects on normal tissues are possible.

  • The CTCAE (Common Terminology Criteria for Adverse Events) is a standardized scale used for assessing and documenting common chemotherapy side effects.

  • Examples include:
        - Neutropenia: Decrease in white blood cells leading to increased infection risk.
        - Thrombocytopenia: Low platelet count, increasing bleeding risk.
        - Alopecia: Hair loss as a common side effect.
        - Mucositis: Inflammation of the mucous membranes.
        - Skin Changes: Various dermatologic reactions.
        - Anxiety: Psychological symptoms often accompanying treatment.

Bone Marrow Suppression

  • Nursing care focused on protection against infection:
        - Providing education to patients and families about infection signs, proper handwashing, and precautions.
        - Recommendations for use of electric shavers to minimize cuts and injuries.
        - Emphasizing the avoidance of contact sports and activities that may lead to trauma.

Chemotherapy-Induced Nausea & Vomiting

  • Occurs at any time during treatment, with acute nausea being the most common.

  • Management strategies involve drug therapy to control these side effects.

Mucositis Management

  • Recommendations include:
        - Use of ice water or ice chips to soothe oral discomfort.
        - Regular oral assessments and diligent oral hygiene practices.

Alopecia Management

  • Patients should be advised to:
        - Avoid direct sunlight exposure, use sunscreen, or cover their heads if experiencing hair loss.
        - Plan for hair loss in advance and consider options like wigs.

Cognitive Function Changes

  • “Chemo brain”: Refers to cognitive side effects such as reduced concentration, memory loss, and challenges in learning new information.

  • Important to support patients with cognitive training resources.

Chemotherapy-Induced Peripheral Neuropathy

  • Defined as the loss of sensory perception and motor function due to certain chemotherapeutic agents.

  • Education on injury prevention is crucial, and coordination with occupational therapy may be necessary.

Immunotherapy

  • Aims to harness the body’s immune system to combat foreign cells, with potential adverse immune-related reactions (ir-AEs) needing careful management.

Monoclonal Antibodies

  • Combination of immunotherapy and targeted therapy, monitoring for infusion reactions during initial treatment.

  • Possible symptoms include fever, chills, rash, and hypotension among others; premedication may be utilized to minimize risks.

Targeted Therapy

  • Focuses on actions directly against cancerous cells, personalized to each patient’s cancer type based on specific pathways evaluated in their cancer cells.

Endocrine Therapy

  • Hormones may enhance tumor growth; includes treatments such as:
        - Aromatase Inhibitors
        - Gonadotropin-Releasing Hormone Analogs
        - Anti-androgens
        - Antiestrogens

  • Side effects depend on the specific therapy opted for.

Colony-Stimulating Factors as Supportive Therapy

  • These agents support chemotherapy recovery by enhancing bone marrow function post-myelotoxic treatment.

  • Common side effect experienced: bone pain.

Oncologic Emergencies

  • Critical conditions that may arise include:
        - Sepsis
        - Disseminated Intravascular Coagulation
        - Syndrome of Inappropriate Antidiuretic Hormone
        - Spinal Cord Compression
        - Hypercalcemia
        - Superior Vena Cava Syndrome
        - Tumor Lysis Syndrome

Case Study Analysis

Case 1:

  • A 44-year-old woman with breast cancer admitted for severe dehydration due to chemotherapy-induced nausea and vomiting.

  • Previous adjuvant treatments include doxorubicin and cyclophosphamide.

  • Provider's Orders include:
        - Strict input and output monitoring every 12 hours.
        - Use of the port for blood draws and IV fluids.
        - Call for any vomiting or febrile episodes (temperature ≥ 100º F).
        - D5½ NS administration at 125 mL/hr.
        - Ondansetron 8 mg IV every 8 hours.
        - Clear liquid diet, advancing as tolerated.
        - CBC, calcium level, and basic metabolic panel to be done in the morning.
        - Bed rest with bathroom privileges.
        - Use of knee-high support stockings.

Case Study Questions:

  1. Nurse's Rationale: Assess the reason behind each provider order.

  2. Priority Implementation: Identify which order should be prioritized in patient care:
        - A. Clear liquid diet
        - B. Support stockings
        - C. Lab sample collection
        - D. IV fluid administration

  3. Anticipation of Complications: Following reports of mucositis, determine nursing interventions necessary to address these symptoms.

Practice Questions

  1. Chemotherapy and Alopecia: Discuss expected outcomes regarding hair loss in chemotherapy patients.
        - A. Permanent hair loss may occur.
        - B. Treatments are available to prevent hair loss.
        - C. New hair growth typically resumes about one month post-chemotherapy.
        - D. New hair growth usually shares previous color and texture.

  2. Radiation Side Effects: Assess which side effect should be monitored in patients undergoing radiation therapy for breast cancer.
        - A. Fatigue
        - B. Hair loss
        - C. Mucositis
        - D. Nausea and vomiting

  3. Tumor Lysis Syndrome Risk: Assess when the risk for tumor lysis syndrome is highest in a Non-Hodgkin’s lymphoma patient.
        - A. After the first chemotherapy cycle
        - B. During the second chemotherapy cycle
        - C. At any point during the treatment
        - D. While receiving concurrent radiation and chemotherapy

  4. Primary Prevention Strategies: Recommend a primary prevention strategy for a client concerned about potential cancer development.
        - A. Mole removal on the abdomen
        - B. Annual fecal occult blood tests
        - C. Baseline colonoscopy at age 50
        - D. Discussion regarding mammograms for women