Ovarian Cancer Overview for Health Care Providers group · • 2) Site-Specific Ovarian Cancer ... BRCA 1 Hereditary Breast and Ovarian Cancer . ... • RMI= U/S score x menopausal

Ovarian Cancer Overview for Health Care Providers

• Created by the GOC CoP Nursing group: – Heidi Thomas, Joanne Power, Janet

Giroux, Nancy Drummond, Lynne Jolicoeur, Joanne Brodeur and Elisha Andrews

– Reviewed and edited by Dr. L. Elit

The slides presented are meant to be used as an orientation package for health care providers new to gynecologic oncology; to review the management and treatment of ovarian cancer with a focus on epithelial subtypes Variation across the country can occur in accordance within provincial guidelines. Remember that not all patients are the same and that some deviation CAN and often does occur.

Components of an Ovary

Incidence of Ovarian cancer • Incidence

– In 2013 it is estimated 2,600 women will be diagnosed and 1,750 women will die from ovarian cancer in Canada

– Median age of diagnosis is 56.3 years – 2.9% of all cancers diagnosed in women are ovarian

• Mortality – Ovarian cancer is the most lethal of all gynecologic cancers – It is the 5th leading cause of cancer deaths overall – 5 year survival rate is 45.5%

• Lifetime Risk – 1.5% or 1 in 68 women

Canadian Cancer Society’s Advisory Committee on Cancer Statistics. Canadian Cancer Statistics 2013.

Stage and Survival Stage 5 Year Survival

Rate

I 89%

II 66%

III 34%

IV 18%

Surveillance, Epidemiology, and End Results Program (SEER). National Cancer Institute, 2014.

Ovarian Cancer: Three Types • Epithelial cell cancer

– Starts in the cells that cover the outer surface of the ovary

• Germ cell tumours – Start in the egg cells within

the ovary & generally occurs in younger women/girls

• Sex Cord Stromal tumours – Start in the connective

tissue cells that holds the ovary together

8%25%

65%

Epithelial Germ Cell Sex Cord Stroma

Epithelial Subtypes

• Serous • Endometrioid • Undifferentiated • Borderline • Clear Cell • Mucinous

Epithelial Ovarian Cancer

Pathophysiology • Paradigm Shift in past 7 – 8 years • Ovarian Cancer begins in the fallopian tubes and falls

on to the ovarian epithelial surface


Fallopian tube

Fallopian tube

Ovarian Cancer Risk Factors Increase Decrease

Age Oral Contraceptive Use Positive Family history of

Ovarian or Breast Ca Pregnancy and Breastfeeding

Infertility/low parity (not bearing children) Salpingectomy

Personal cancer history of Breast, Colon or Uterine

Ca

Hysterectomy/Removal of Both Ovaries + tubes


Oral Contraceptives Duration of Use Decrease in Risk ALL YOUNG WOMEN Never 0 3 months – 4 years 30-40% 5 – 9 years 60% 10 years and greater 80% BRCA Carriers 50-60%


Pregnancy and Breastfeeding No of term pregnancies Decrease in Risk 0 0 1 40% 2 47% 3 52% 4 64% 5 67% > 6 71% BRCA 1 or 2, or both 12%/birth


Familial Oncology Genetics • 10% overall risk • Patients at high-risk

– +/- Genetic Testing – BRCA 1 or 2 mutation – Hereditary Non Polyposis

Colon Cancer – Familial Ovarian/Breast

Cancer – Ethnicity – Personal history of Serous/

Endometrioid Ovarian Cancer

• Counseling – Breast Cancer risk – Screening Programs for

breast cancer – Prophylactic oophorectomy,

hysterectomy & mastectomy – Genetic counseling and

testing


Hereditary syndromes in Ovarian cancer

• 1) Hereditary Breast Ovarian Cancer Syndrome (causes

• 90% of hereditary ovarian cancers)

• BRCA1 & BRCA2 mutations

• 2) Site-Specific Ovarian Cancer

• 3) Hereditary Non-polyposis Colon Cancer (Lynch II)

Hereditary syndromes only account for 10% of epithelial ovarian cancers Epithelial Ovarian Cancer

BRCA mutations and ethnicity • 4 founder mutations among

Ashkenazi Jews – Prevalence 1 in 40

• Other groups with BRCA1/2

mutation families: – French-Canadian – Mennonite – Icelandic – Scandinavian


BRCA 1 Hereditary Breast and Ovarian Cancer

Breast cancer 85%

Average Risk of Ovarian Cancer Up to Age 50 BRCA1 20% General Pop 1.7%

Second primary breast cancer 40%-60%

Average Risk of Ovarian Cancer up to Age 80 BRCA1 50% General Pop 1.4%

BRCA2 Hereditary Breast and Ovarian Cancer

breast cancer (30%-85%)

ovarian cancer (10%-20%)

male breast cancer (6.7%)

Average Risk of Ovarian Cancer Up to Age 50 BRCA2 3% General Pop 1.7%

Average Risk of Ovarian Cancer up to Age 80 BRCA2 20% General Pop 1.4%

Red Flags • BRCA 1 and 2

mutations • Breast cancer prior to age of

50 • Ovarian cancer at any age • Multiple primary cancers • Ashkenazi Jewish ancestry • Relatives of a BRCA

mutation carrier

• HNPCC (Lynch II) • Onset of colorectal cancer

before age 50 • Onset of endometrial cancer

before age 50 • Two or more HNPCC

cancers in an individual or family

Signs and symptoms • Bloating, increased

abdominal girth • Pelvic or abdominal

pain • Dyspepsia, indigestion,

early satiety • Urinary symptoms

(urgency or frequency) • Muscle wasting of

extremities/face

• Fatigue • Gas, change in bowel

habits • Rectal/bladder pressure • Unusual vaginal

bleeding • Weight loss or weight

gain • SOB on exertion or at

rest *June 2007 ACS, SOGC (US), GCF, IGCS Epithelial Ovarian Cancer

Symptoms: exfoliation and implantation of cancer cells on surfaces of peritoneal cavity

• Ovarian cancer cells shed

from original site in the ovary and land anywhere on lining of pelvic abdominal peritoneum, causing:

• Ascites • Bowel Obstruction • Pleural Effusion

Most problems relate to the abdominal area where the disease tends to stay Epithelial Ovarian Cancer

Diagnosis • Adnexal mass found on physical

exam • Relatively immobile and

painless • Irregular • Solid or mixed solid and

cystic components

Rectovaginal Exam

Transvaginal ultrasound CA-125 blood test Epithelial Ovarian Cancer

Diagnosis – Imaging studies (ultrasound, CT, MRI) – Blood tests (CA-125) – Biopsy of omental cake or other solid lesions – Analysis of peritoneal fluid (ascites) or pleural fluid

Ultrasound image CT image Epithelial Ovarian Cancer

Risk of Malignancy Index • Formula used to calculate risk of malignancy for pelvic mass • RMI= U/S score x menopausal score X CA125 value

Ultrasound features RMI II Score Multilocular cyst 1=no or one abnormality Presence of solid areas 4=two or more abnormalities Bilateral lesions Ascites Presence of intrabdominal mets Premenopausal 1 Postmenopausal 4 CA 125 u/mL

CA-125 • A mucin-like glycoprotein that increases in response to disturbances of

the peritoneal surface • Known as a tumor associated antigen • In patients <50 years of age an elevated CA-125 is associated with a

malignant mass <25% of the time • In patients >50 years of age this association increase to 80% of the

time • Is not a screening or diagnostic test • Nonspecific tumour marker with variations in interpretation depending

on the patient’s medical history & age • Level does not correlate with burden of disease • False positive & negative results


CA-125 • Non Malignant Conditions That May Elevate CA-125 Concentrations


Spread of Ovarian Cancer


Medical Management Includes

• Awareness of multisystem dysfunction – Peritoneal Ascites – Pleural Effusions – Bowel Obstructions – Malnutrition – Side Effects from

Chemotherapy – Blood Clots (VTEs or CAT) – Pain Management – Psychosocial Care


Treatment of Ovarian Cancer • Surgery • Chemotherapy

– Neo-adjuvant – Adjuvant

• Clinical trials • Palliative care

Intravenous chemotherapy

Intraperitoneal chemotherapy


Goals of Care • Communication & Education

– Patient’s goals & expectations – Incorporate combination of interventions – Improve QoL

• Alleviation of symptoms – Managing GI side effects/complications presents unique

challenges – Support active & functional life

– Obtain benefits of therapy – Optimize interventions & monitoring


Role of Neoadjuvant Chemotherapy vs. Primary Debulking

• Majority of patients present with advanced disease (Stage 3C/4) • Goal of surgery is complete resection of all macroscopic disease • Surgery has been standard of care as primary treatment of ovarian

cancer however advanced disease presents challenges as patients considerably sicker

• Primary cytoreductive/debulking surgery is associated with higher complications including: – Post op infections – Venous complications – Fistulae – Hemorrhage – Postop mortality/morbidity Vergote, Gynecologic Oncology, 2010, 119(1), 1-2

Role of Neoadjuvant Chemotherapy vs. Primary Debulking

• Neoadjuvant chemotherapy (3 cycles) followed by interval debulking surgery found not to be inferior to primary debulking

• Only patients with Stage 3C or 4 should be considered for neoadjuvant chemo

• Postop complications and mortality rates were decreased after neoadjuvant chemo vs primary debulking

• Overall survival and progression free survival similar between two groups

Vergote, Gynecologic Oncology, 2010, 119(1), 1-2

Procedures Required For Surgical Staging of Ovarian Cancer

• Surgery is the main diagnostic tool Ovarian Cancer


Surgical Management • Based on the spread pattern of ovarian cancer • Operation: Total abdominal hysterectomy, bilateral salpingo-

oophorectomy with staging, pelvic lymph node dissection, omentectomy and debulking

• Two goals of surgery: – Diagnose – Stage – Remove all gross disease

• Disease completely resected ↑ survival outcomes • Incomplete resection, goal is to ↓ tumour burden (Poorer

prognostic factor)


Definition of Terms • Omentectomy: The surgical removal of a sheet of fat

that is located under the fascia, attached to the bottom edge of the stomach and liver.

• Staging: The process of obtaining specimens intra-operatively to determine the spread of ovarian cancer which determines the stage of ovarian cancer the patient has.

• Debulking: The removal of all visible tumor that can be safely removed without damaging major organs.


The Importance of Specialty Care

• % Comprehensive Staging

• 35% General Surgeon • 52% OB/Gyn • 97% Gyn/Onc

• Studies have shown Gynecologic Oncologists have higher rates of complete and “optimal resection” of ovarian cancer at initial surgery and are more likely to perform comprehensive surgical staging as well as provide care that results in 25% improved survival for women as compared to Ob/Gyn and General Surgeons

• Source: Junor et al, Brit J

Ob/Gyn, 11/99 • McGowen et al Ob/Gyn 1985



Advanced Disease • Patients with advanced disease can

achieve complete remission – >80% of those who completely respond to chemotherapy

eventually relapse

• 5 year survival is related to volume of residual disease – 40-75% if microscopic (no residual disease) – 30-40% if macroscopic (<1-2cm residual disease) – 5% if suboptimally debulked (>1-2cm)

Bhoola & Hoskins, 2006

FIGO Staging • https://www.sgo.org/wp-

content/uploads/2012/09/FIGO-Ovarian-Cancer-Staging_1.10.14.pdf

Updated FIGO staging Jan 1, 2014

https://www.sgo.org/wp-content/uploads/2012/09/FIGO-Ovarian-Cancer-Staging_1.10.14.pdf





Postoperative care pain management options

PCA Epidural

Grass, 2005

PCA (Patient controlled analgesia) • Infusion pump with opioids available • When patient experiences pain, they can push a

button and PCA will administer controlled amount of opioids intravenously

• Has advantages/disadvantages • Prescriber orders type and dose of opioid, allotting

timing for injection availability and lock out period to prevent over dose or adverse effects (respiratory depression)

• Each institution has it’s own training specific to PCA use

Epidural Pain Management • Analgesia:

– Agents diffuse across meninges & CSF & into neural tissue of cord to act on analgesic receptors of the dorsal horn; systemically by the epidural vasculature & across the dura to penetrate the cord

• Local Anesthetics: – Agent diffuse from epidural space to nerve roots, blocking impulse

conduction – Lower concentrations usually block transmission of pain &

temperature along sensory fibers without blocking the transmission of touch, pressure or motor impulses

• Frequently a combination of opioid and local anesthetic is used, reducing the total amount of each agent required to relieve pain

• Side effects: pruritis, increased susceptibility to UTI, prolonged hospitalization

Chemotherapy • Intravenous chemotherapy with Carboplatin &

Paclitaxel is the standard of practice for epithelial ovarian cancer

• Chemotherapy is given – Cure – Control disease – Palliate symptoms


Intraperitoneal Chemotherapy • Exfoliation of cells

implant on surfaces of peritoneal cavity

• IV Taxol 135 mg/m² for 24 hrs day 1 and IP Cisplatin 100 mg/m² day 2 and IP taxol 60 mg/m² day 8 every 21 days for 6 cycles.


Intraperitoneal Chemotherapy

• National Cancer Institute & Gynecologist Oncologist of Canada – IP chemotherapy for patients with newly diagnosed stage III,

optimally debulked ovarian cancer • Armstrong et al. (2006) GOG 172 Clinical Trial

– IP chemotherapy improves progression-free survival (PFS) & overall survival

Ovarian cancer experts: Deborah Armstrong, M.D. & Robert Bristow, M.D.


Improvements in staging, cytoreductive surgery and adjuvent therapies have improved 5 year survival


Paclitaxel • Often given in combination with Carboplatin • Has potential for hypersensitivity reactions, pts need to be premedicated with

steroids • Indicated for patients with ovarian cancers, cervical cancers and endometrial

cancers. • Potential side effects:

– Alopecia -Neutrophil nadir—Day 10-12 – Mucositis -Platelet nadir—Day 8-9 – Myelosuppresion -Cardiovascular—hypotension, bradycardia, – Myalgia, arthralgia hypertension – Peripheral neuropathy -Injection site reactions—erythema, tenderness, – Visual disturbances skin discoloration, swelling—extravasation – Ototoxicity hazard irritant – Diarrhea -Elderly patients have more myelosuppression, – Nausea, vomiting neuropathy and cardiovascular toxicities

Carboplatin • Usually infused over 60 minutes. • Often given in combination with Taxol.

– Taxol should be given before Carboplatin to increase efficiency and limit myelopsuppression.

• Indicated for patients with ovarian cancers, cervical cancers and endometrial cancers.

Side effects: -↓Na, ↓Mg, ↓Ca, ↓K -Vomiting -↑ Creatinine -↑liver function

– Myleosupression (Neutropenia/thrombrocytopenia) – Neuropathies – Ototoxicity – Potential allergic reaction (typically in 2nd line)

Hypersensitivity Reaction (HSR)

• “An exaggerated or inappropriate immune response that may be localized or systemic, occurring during or within hours of a drug administration.”

• Can be prevented with: – steroids – Ranitidine – Benadryl – Longer infusion time

Polovich, White & Kelleher, 2005, p78

Cisplatin • Pre-treatment hydration VERY important

before Cisplatin. • Compatible with NS (normal saline) Side effects: - Significant nausea and vomiting

– Myelosuppression – Nephrotoxicity – ↓Mg – Neurotoxicity and autotoxicity

Peglated Lipsomal Doxorubicin

• Anthracycline • Molecules of the drug are enclosed (encapsulated) in a fatty coating

known as liposome – The liposome allows the doxorubicin to remain in the body for

longer so that a greater amount of chemotherapy is delivered to the cancer cells, while having fewer side effects on healthy tissue

• Cumulative dose • Sore mouth and ulcers • Skin changes

– Soreness and redness of the palms of hands & soles of feet (PPE—Palmar plantar erythema)

• Cardiomyopathy – Echo or MUGA scan

Topotecan • Used as second line chemotherapy option in platinum sensitive disease • Common side effects:

– Neutropenia, thrombocytopenia, anemia, myelosuppression – Neutrophil nadir—Day 12-15 – Platelet nadir—Day 15 – Neutropenic colitis (typhilits)-life threatening condition, caused by

transmural inflammation of the cecum, ascending colon and ileum—consider if pts present with fever, neutropenia and abdominal pain

– Nausea/vomiting – Diarrhea, constipation – Rash – Alopecia

Gemcitabine • Salvage Therapy for patients with disease recurrence • Side effects:

– Myleosuppressive—leukopenia, anemia, thrombocytopenia – Leg swelling – Pulmonary side effects (pulmonary edema, interstital

pneumonitis, pulmonary fibrosis) – Increased number of visits and infusions (Day 1,8,15 q21

days)

Nursing considerations for chemotherapy • Neutropenia

– Decreased production of white blood cells – Severe neutropenia occurs when patients

neutrophil count is <0.5X109

– Chemotherapy is postponed if neutrophils are <1.5x109

– Consideration of G-CSF products or does reduction/delay

– Occurs at time of nadir • (7-10 days post chemo)

Insufficient Neutrophils

Neutrophils

Nursing considerations for chemo administration

• Neutrophils must be > 1.5 x109 to proceed with chemo

• Neutrophil count < 1.0- 1.4 x109 --Individualized consideration by physician/centre policy about administration

• Neutrophil count < 1.0 x109 , chemo delayed

Nursing considerations for chemotherapy

• Anemia – Low red blood cell count – Normal Hgb 120-160 g/dL – Chemotherapy can still be given if patient anemic and

patient is asymptomatic – Blood transfusion if symptomatic

• SOB • Extreme fatigue • Heart palpitations/vertigo

Nursing considerations for chemotherapy

• Thrombocytopenia – Decreased platelet count under 100 X 109

– Normal 140-440 x 109

– Signs of low platelet count: bleeding or bruising more easily.

– Management • Delay treatment • Potential platelet transfusion • Advise patient of signs/symptoms

Nausea & Vomiting

https://www.cancercare.on.ca/CCO_DrugFormulary/Pages/FileContent.aspx?fileId=97473



Taste Changes & Nutritional Alterations

• Chemotherapy drugs most commonly associated with taste changes include – Carboplatin – Cisplatin – Paclitaxel

• Loss of appetite • Mouth care • Mucosal inflammation • Eating takes effort • Consider switching to plastic

cutlery (Metal Taste) • Cachexia

– A state of malnutrition & protein (muscle) wasting




Mucositis (stomatitis) • Mouth sores--Causes swelling, pain, leads to

malnutrition and dehydration. • Patient could obtain a prescription for magic

mouthwash




Peripheral Neuropathy • Any injury, inflammation, or degeneration of the peripheral nerves

(Almadrones, Armstrong, Gilbert & Schwartz, 2002) • Many contributing factors • Taxanes & Platinum analogs

– PN enhanced by other factors, including cumulative dose, rapid infusion times, high single dose, & prior or concurrent use of other neurotoxic drugs or agents

– Incidence estimated at 3-7% single agent & up to 38% with multiple agents

• Quality of Life Issues – Painful (burning, sharp, stabbing, electric), numbness, tingling,

weakness, sensory loss, perception of wearing a sock or glove, muscle weakness & loss of dexterity/coordination

– Strategies to alleviate symptoms & prevent injury

Constipation • Insufficient or irregular evacuation of the bowels • Symptoms: – Anorexia, nausea/vomiting, coliky abdominal pain,

bloating, tenesmus • Encourage patient to: – add fiber to their diet, drink plenty of water, increase

physical activity • Review use and indication of laxatives (stool

softeners, stimulants etc). https://www.cancercare.on.ca/CCO_DrugFormulary/Page

s/FileContent.aspx?fileId=154797



Diarrhea • Excessive and loose bowel movements • Can lead to: – Dehydration – Electrolyte imbalances – Skin breakdown • Management – Drink plenty of water and add electrolyte sports drinks – Eat small frequent meals (BRAT diet) – Avoid foods that are high in fat/fiber – Stop laxatives!

Fatigue • Overwhelming & sustained exhaustion & capacity for physical

and/or mental work • Most common complaint related to:

-cancer itself -dehydration -cancer treatment -environmental -anemia -depression -chronic pain -insufficient sleep or rest -stress -inadequate nutritional

intake

https://www.cancercare.on.ca/cms/one.aspx?portalId=1377&pageId=156541



Anxiety/depression

• Anxiety—a feeling of fear or nervousness • Depression—a serious medical condition where a

person feels sad/hopeless • ESAS and Distress Thermometer given to patients at

each visit. • Refer appropriately to services such as Psychosocial

Oncology




Hair loss (alopecia) • Complete loss of hair on body including head, eyelashes,

eyebrows, arms, legs, nose etc. • Duration for the length of the treatment. It is not permanent. • Regrowth is usually 2-4 months after chemotherapy • May regrow back slightly different in color and texture. • Look Good Feel better Program and CanSupport

Fertility • Loss of the ability to have children • May be related to the chemotherapy, surgical

procedure, age and general health status. • Important to discuss this with patient as early as

possible and offer appropriate support • Emphasize birth control measures for young women

with functioning ovaries • Consider referral to fertility specialist - http://fertilefuture.ca/

http://fertilefuture.ca/

Recurrence • 75% of patients recur (not curable at this point)

• Platinum refractory (progresses on treatment) • Platinum resistant (recurs less than 6 months after completing

prior chemotherapy treatment) • Platinum sensitive ( recurs more than 6 months after completing

prior chemotherapy treatment) • Encourage clinical trials • 2nd line therapies (not curative) Caelyx, gemcitabine, etoposide,

topotecan, taxanes, vinorelbine • Median survial time is 2 years for women with bulky disease to

more than 5 years for those with small volume disease. Fewer than 50% of women survive 5 years after the diagnosis


Carcinomatosis


Specific Issues • Decision to start treatment made on a case

by case basis because no survival advantage to starting chemotherapy when patient is asymptomatic

• Can be viewed more as a chronic illness • May go through repeated cycles of

aggressive chemotherapy with little respite • Symptom management and good palliative

care

Common Symptoms Experienced by Women with Recurrent Ovarian Cancer

• Abdominal Changes (Bowels & Ascites) – Cramping – Bloating – Swelling – Pressure/Heaviness/Tightness – Distended hard abdomen – Constipation – Diarrhea – Indigestion – Nausea

•Bankhead, Kehoe, Austoker, 2005; Fitch, Gray & Franssen, 2000; Fox & Lyon, 2007; Lockwood-Rayermann, 2007

Ascites

• Tumor implants block or impede normal peritoneal lymph flow

• Peritoneal surfaces produce an increased amount of fluid

• Symptoms of early satiety, anorexia, indigestion, decreased bowel motility, constipation and decreased bladder capacity. Abdominal skin becomes taut and shiny

Assessing for Ascites

Treatment for Ascites 2) Non-invasive • Diet:

– Frequent, small meals high protein, low sodium.

– Decrease total fluid volume • Rest (on left side, feet elevated)

– Alleviate pressure on internal organs,

– Improve vascular return from lower extremities

– Facilitate lymphatic flow – Improve diuresis

1) Paracentesis

Pleural Effusion • Flow of pleural fluid form the parietal pleura to

the visceral pleura is impaired. • Carcinomatous involvement of the parietal

and/or visceral pleura, these membranes suffer an inflammatory response and injury with resulting increased output and accumulation of fluid in the pleural space.

• Symptoms shortness of breath, hypoxia, pleuritic chest pain and cough

Thoracentesis • Chest tube • Sclerosing the pleural cavity (pleurodesis) The goal

of this therapy is to obliterate the pleural space through fibrosing (scarring) the tissues, thus preventing reaccumulation of fluid.

Malignant Bowel Obstruction • Progressive growth of tumor

on or near the bowel • May be small (acute) or

large bowel obstruction • Symptoms nausea, vomiting

abdominal pain and cramping, diarrhea or constipation

• Both may require bowel diversion (ileostomy/colostomy)

Blockage of large intestine Due to tumour

• Overall incidence of MBO with advanced cancer is 3%

• The incidence of MBO in ovarian cancer patients is between 5 to 42%

• Incidence of MBO in GI cancer patients is 4 to 24%

• Other cancers such as breast, lung, or melanoma also have the ability to spread to the abdomen and cause MBO. Incidence for each cancer is not explicitly described in the literature.

MBO - Incidence

MBO – Where does it occur? • Small bowel is more

commonly involved than the large bowel (61% vs. 33% respectively)

Why is MBO important for Nurses to discuss?

• Physical Symptoms: – Pain (60% of pts.) – Nausea (60 – 70% pts.) – Vomiting – Cramping/borborgami – Change in BM (none or

thin/diarrhea) • Complex management

– Anticipate interventions

• The bigger picture: – MBO can be a terminal

condition – In the setting of

carcinomatosis median survival is < 3months

Pathophysiology of MBO

CONTINUOUS PAIN Exacerbated by tumor

mass

Contributing factors: •Bowel edema •Fecal impaction •Constipating drugs •Hypokalemia

NAUSEA & VOMITING Ripamonti 2007

Signs and Symptoms of MBO

Most common symptoms experienced by patients with MBO:

• Intestinal colic 72-76%

• Abdominal pain 92% • Vomiting 68-100%

Consequences of Bowel obstruction

• Metabolic disorders/malnutrition • Renal failure • Electrolyte instability • Strangulation/perforation of the bowel • Compromised mucosal blood flow with

potential for translocation of endotoxins across the bowel wall

Management: ACUTE • NPO • Hydration (IV fluids or SC) • NG tube

TPN – only considered in patients who would have a clinical or life-extending benefit - it is not

recommended for terminally ill patients

• Goal: relieve symptoms of nausea, vomiting, pain and dehydration – Try to reverse bowel

obstruction

Important to differentiate between partial and complete obstruction as prokinetic agents are inappropriate in complete bowel obstruction

Parenteral routes must be

used as absorption orally is variable and not predictable

Symptom control: Pain in MBO Analgesics should not

be avoided for fear of aggravating the obstruction

Choice of medication and dosage are titrated based on effect

If colicky pain persists despite the use of an opioid, Buscopan may be a useful adjuvant

1. Non-opioid +/- Adjuvant

Analgesics: WHO GUIDELINES

Surgical management • Surgery is considered

for unifocal bowel obstruction and each patient should be evaluated to see if they are a surgical candidate

• Purpose: palliate symptoms of obstruction by: – stoma formation, – bypassing the obstruction – resecting a portion of

bowel – placement of colorectal

stent • Post-op morbidity 5 – 90% • Post-op mortality

Surgical management • Surgical complications include:

• Entero-cutaneous or entero-vaginal fistula

• Anastomosis leaks • Short bowel syndrome • DVT/PE • GI Bleed • Sepsis

• Suitability for surgery should be assessed to justify any surgical intervention – this includes assessing the general condition of the patient, evidence of mechanical obstruction, reasonable expectation of survival and quality of life. (Alberta Cancer Board, 2001, p. 46).

Guidelines to direct which patients with MBO are surgical candidates are not clear

Parameters suggesting surgery is inadvisable include: ascites ≥ 3 L, a palpable abdominal mass, pre-operative weight loss >9 kg, carcinomatosis, previous RT

Rate of inoperable cases in patients with MBO is 6.2% to 50%

Percutaneous Endoscopic Gastrostomy (PEG) Tube

• An alternative to NGT in patients whose symptoms are refractory to pharmacologic measures

• Achieves intestinal decompression

• Complications from PEG tubes include tube obstruction requiring replacement, digestion of surrounding skin, abscess formation, pain when the tube is inadvertently tugged

Nursing Considerations for patients with MBO

Nursing care for the Whole person

• Inability to eat • Alteration in activity • Deterioration of mental abilities • Social isolation • Waiting • Lack of direction • Personal reflection

Every patient indicated that nursing staff could be

a major source of support- providing an

opportunity to reflect on their situation and

meaning of the illness.

Radiation Therapy • The use of high-energy x-rays to destroy cancer cells • May be used to relieve side effects of progressive cancer in select

cases (isolated pelvic/vaginal vault recurrence) • Side effects of treatment

– Fatigue – Mild skin reactions – Nausea – Diarrhea – Cystitis – Vaginal stenosis – Skin integrity

Clinical Trials • Provide novel treatments that show promise

in treatment of ovarian cancer • Available clinical trials should always be

presented as an option to eligible patients

Nursing Management • Therapeutic Communication

– Attentive Listening • Understanding of disease process—from diagnosis to palliation • Be sensitive to patient changes • Encourage your patient and/or family to express their feelings • Promote a therapeutic environment • Assist in adapting to new body changes • Collaborate with other professionals • Care for the “Caregiver”

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