Cancer Development and Care of Patients with Cancer

Presented by: Marsha Woodall MBA, MSN, RN

Revised 2012For NIP 210

Objectives:Relate the incidence of cancer and determine

the role of nurses in the prevention and early detection of cancer.

Differentiate between benign and malignant neoplasms.

Identify factors which may contribute to the development of cancer.

Explain local and systemic effects of cancer.

Objectives cont.Review the latest American Cancer Society

statistics.Identify some specific chemotherapeutic

agents.Summarize the socio-cultural considerations

of caring for clients with cancer.

EpidemiologyAffects every age

groupMost occur in people

over age 65More than 1.2

million Americans are diagnosed each year

More than 560,000 deaths/yr in USA

Leading causes of cancer in men: lung, prostate, colorectal

Leading causes of cancer in women: lung, breast, colorectal

True or FalseThe risk of dying from cancer in the US is increasing.

Pathophysiology of the Malignant ProcessCANCER is a disease

process that begins when an abnormal cell is transformed by the gentic mutation of the cellular DNA. This begins to proliferate abnormally invading tissues,lymph & blood vessels which carry the cells to other areas of the body. This is called METASTASIS.

Characteristics of Benign and Malignant Neoplasms (Refer to Table 23-1 on page 402)

Benign Malignant

Cell CharacteristicsMode of GrowthRate of Growth

MetastasisGeneral Effects

Cancer Development (Malignant Transformation)InitiationPromotionProgressionMetastasisExtension into surrounding tissuesPenetration into blood vesselsRelease of tumor cellsInvasion of tissue

Metastatic MechanismsLocal Seeding

Bloodborne Metastasis

Lymphatic Spread

EtiologyChemical Agents Physical Agents VirusesDietary Factors Immune function Genetic and Familial

FactorsAgeGenetic Risk

True or FalseRegularly eating meat cooked on a charcoal

grill won’t increase you risk for cancer

True or FalseYou can prevent skin cancer by putting on

one application of sunscreen at the start of each day.

True or FalseHousehold bug spray can cause cancer

True or FalseLiving in a polluted city is a greater risk for

lung cancer than smoking a pack of cigarettes a day

True or FalseSome injuries can cause cancer later in life.

True or FalseElectronic devices, like cell phones, can

cause cancer in the people who use them.

True or FalseWhat someone does as a young adult

has little impact on his or her chances of getting cancer later in life.

Cancer Assessment ConsiderationsSee chart 23-9 p. 405

C hange in bowel or bladder habitsA sore that does not healU nusual bleeding or dischargeT hickening or lump in breast or other part of bodyI ndigestion or difficulty in swallowingO bvious change in wart or moleN agging cough or hoarseness

Detection and Prevention of CancerPrimary Prevention: Nurses play a

key role in cancer preventionAvoidance of Known carcinogensModification of associated factorsRemoval of “at risk” tissuesChemoprevention

Detection and Prevention of Cancer

Secondary Prevention:

Promotion of cancer screenings

Gene therapy for cancer prevention

Stages of Cancer Cell InvasionIn situ – noninvasive neoplasmLocalized – invasive neoplasm

confined to the organ of originRegional – invasive neoplasm that

extends into surrounding tissueDistant – a neoplasm that spreads to

distant parts of the body

STAGING: Determines the size of the tumor and the existence of metastasis. TNM system;

T = extent of primary tumorN = lymph node involvementM = extent of metastasis

GRADING: Classification of tumor cells obtained through cytology (biopsy). I to IV:

I = Closely resemble tissue of originIV = Poorly differentiated (more aggressive and less responsive totreatment)

Question 1What are the odds of a man dying from cancer in the U.S.?

A.1 in 2B.1 in 4C.1 in 25D.1 in 50

Question 2What race has the highest incidence of cancer?

A.African AmericanB.Hispanic/LatinoC.AsianD.Caucasian

Question 3An example of a primary prevention strategy for reducing cancer risk would be:

A.Yearly mammography for women older than 40 years

B.Regular physical exerciseC.Colonoscopy at age 50 years and

then every 10 yearsD.Avoiding red meat in the diet

Cancer Therapy Goals and ResponsePreventionCureControlPalliationAdjuvant

Neoadjuvant Chemo-prevention

Myeloablation

Immuno-suppressionp. 17

Management of CancerSurgery

DiagnosticPrimary TreatmentProphylacticPalliativeSecond-lookReconstructive or rehabilitation

True or FalseTreating cancer with surgery causes it to

spread throughout the body.

Treatment StrategiesCombination versus single-agent therapy

Dose or dose intensity of chemotherapy

Hormone receptor status

p. 18

Measuring ResponseComplete response (CR)Partial response (PR)Stable disease (SD)Progressive disease (PD)Relapse

p. 19-20

Radiation Therapy (See charts on p. 420)IonizingControl malignant diseasePalliativeExternal (teletherapy)Internal (brachytherapy)DosageToxicity

SkinMucous membranesBone marrow

Best Practice for Patient Safety & quality Care and patient/family educationSee page 417

ChemotherapyAntineoplastic agents used to kill tumor cells by interfering with cellular functions and reproduction

Used primarily to treat systemic disease

Goals:CureControlPalliation

Cell CycleG1 phase - RNA

and protein synthesis

S phase - DNA synthesis

G2 phase - premitotic; DNA synthesis complete

Mitosis - cell division occurs

Go phase - Rest

G2

S M

G1Go

Classification of Chemo agentsCell cycle - specific drugsCell cycle - nonspecific drugsAlkylating agentsNitrosureasAntimetabolitesAntitumor antibioticsPlant alkaloidsHormonal agentsMiscellaneous agents

Alkylating AgentsBreaks DNA helix strand, thereby

interfering with DNA replication

Agents given via different routes depending on the medication

Alkylating AgentsExamples:Carboplatin (Paraplatin)Cis-Platinum, PlatinolCyclophosphamide (Cytoxan) Dacarbazin (DTIC)Thiotepa (Thioplex)

AntimetabolitesIncorporate into the normal cell

constituents making them nonfunctional

Inhibit the normal function of a key enzyme

Acts in S phase; inhibits production for DNA synthesis. Leading to strand breaks of premature chain termination

Chemotherapy AgentsAntimetabolites

capecitabine (Xeloda)cytarabine (Cytosar-U)floxuridine (FUDR)fludarabine (Fludara)fluorouracil (Efudex)

Antitumor Antibiotics

bleomycin (Blenoxane)dactinomycin (Cosmegen)daunorubicin (Cerubidine)doxorubicin (Adriamycin PFS)epirubicin (Ellence)

Inhibit DNA-dependent RNA synthesis or delay or inhibit mitosis

Nitrogen Mustards

chlorambucil (Leukeran)estramustine (Emcyt)mechlorethamine (Mustargen)melphalan (Alkeran)thiotepa

Disrupts normal nucleic acid function in DNA and RNA to inhibit reproduction

Plant Alkaloids

docetaxel (Taxotere)etoposide (VePesid)irinotecan (Camptosar)paclitaxel (Taxol)vinblastine (Velban)vincristine (Oncovin, Vincasar PFS)

Inhibit formation of spindle fibers, arresting the metaphase stage of cell division

Cytoprotective (Rescue) AgentsAdministered to reduce side effects and

toxicity of chemotherapeutic agentsChemotherapy agent must be active long

enough to kill malignant cellsThen the rescue agent is given to prevent

destruction of healthy cells

amifostine (Ethyol)dexrazoxane (Zinecard)leucovorin

Routes of AdministrationOralSubcutaneous or intramuscularItra-arterialIntrathecallyIntraperitonealIntrapleuralIntravesicularIntravenous

p. 95

Intrathecal route

Mediport or Portacath

VesicantsAgents that cause extravasation if deposited into subq tissue

Vesicants are:DactinomycinDaunorubicinAdriamycinNitrogen mustardMitomycinVinblastineVincristineVindesine

Indications of ExtravasationAbsence of blood return from the IVFlow is resistantSwelling, pain, or redness at site

Venous access device• Referred to as VAD• Inserted to promote safety

while administering vesicants• Complications: infection,

thrombosis

S/S associated with vesicant extravasation, irritation and flare reaction

PainRednessSwellingBlood returnUlceration

p. 107

Toxicity with chemotherapyGI

Nausea/VomitingStomatitis/Mucositis

MyelosuppressionLeukopeniaAnemiaThrombocytopeniaNeutropenia

RenalCisplatin, MTX, Mitomycin = Kidney toxicityhyperkalemia, hyperphosphatemia,

hypocalcemiaMonitor BUN, serum creatinine, creat inine

clearance,electrolytes

• Cardiopulmonary– Daunorubicin, Doxorubicin may

cause irreversible cardiac toxicities– Bleomycin, BCNU, Busulfan cause

lung toxicities (pulmonary fibrosis)• Reproductive

– possible sterility• Neurological

– Vincristine can cause peripheral neuropathy, loss of deep tendon reflexes, paralytic ileus

– Cisplatin can cause peripheral neuropathy and hearing loss

• Fatigue

GENERAL SIDE EFFECTS OF CHEMOTHERAPEUTIC DRUGS

Immediate side effects:Nausea, vomiting, fever, allergy, hypotension, arrhythmia, thrombophlebitis

Reversible side effects:Bone marrow suppression (leucopenia, thrombopenia), inflamed mucosa, stomatitis, enteropathy, diarrhea, alopecia, changes in skin pigmentation, hyperkeratosis, hepatotoxicity, nephrotoxicity, amenorrhea, aspermogenesis

Irreversible side effects:Cardiotoxicity, hepatotoxicity, nephrotoxicity, neurotoxicity, ototoxicity, mutagenesis/carcinogenesis-> malignancy

Indirect effects:Immunosuppression, increased infection rate, increased blood urea (kidney failure)

Systemic side EffectsChemotherapy causes side effects by

exerting its greatest effect on rapidly generating cells

Chemotherapy + radiation, biologic and/or hormonal therapy = increased toxic effects

Physiological deficits and co-morbidities can enhance toxicities

MyelosuppressionSuppression of bone marrow activityCan result in a decrease in any

combination of WBC, RBC or platelets

Most common dose-limiting toxicityPotentially LETHAL

NadirPoint at which the lowest blood-cell

count is reachedUsually 7-10 days after treatmentOnset and duration depends on

agent usedWBC & platelets are usually 1st to

dropAnemia is seen later

NeutropeniaBone marrow constantly produces

neutrophilsLife span of neutrophil is 7-12

hoursChemo agents suppress bone

marrow and damage stem cellsResulting in decreased neutrophil

count as mature neutrophils die & aren’t replaced

AnemiaRBC production is result of

erythropoiesis, which is regulated by erythropoietin (EPO)

Normal erythrocyte life span = 120 days

Delayed anemia effects due to limited bone marrow reserve and late effects of treatment

Difficult to limit to single etiology

ThrombocytopeniaDestruction or injury to stem cells

leads to dysfunction and suppression of platelet production

Normal life span – 7-10 daysNo bone marrow reserve of

precursorsSome chemo agents have

thrombocytopenia as their dose-limiting toxicity

Thrombocytopenia assessmentPetechiae/

bruisingOvert bleedingEnlarged liver

or spleenOccult or overt

blood in stool or urine

HeadachesHypotensionTachycardiaProlonged

menstruation

Risk of BleedingPlatelet Count

100,000

50,000

<15,000

Risk level/interventionChemotherapy reduced

or held

Increased risk of bleeding; initiate precautions (no injections, etc.)

Severe risk exists for spontaneous hemorrhage; frequent check of platelet counts/transfusions

Nausea and VomitingAnticipatory – occurs before or during

treatment (25% incidence)Acute – occurs within 24 hoursDelayed – occurs at least 24 hours after

therapy and may persist up to 6 days (Cisplatin associated with highest incidence)

Antiemetic Therapy for CINVOndansetron (Zofran)Granisetron (Kytril)Granisetron transdermal (Sancuso)Dolasetron (Anzemet)Palonosetron (Aloxi)

Drug combinations are individualized for best effect

Mucositis Clinical ManifestationsTaste changesSwallowing

difficultyHoarsenessPain with

swallowing or talking

Changes in color of oral mucosa

Oral moisture changes

EdemaUlcerations

Mucositis AssessmentPerform thorough oral assessment:

Standard instrumentPenlightGloved fingerInspect under tongue and along inner cheeks, gums, inspect hard & soft palate

Mucositis ManagementPrevention

Oral care protocolsPatient educationTreat dental

problems before cytotoxic therapy

High protein dietFluid intake > 1500

ml/dCryotherapy ofr

bolus 5-FU

TreatmentNo evidence-based

recommendationsGoal is symptom

relief, prevention of further damage

Oral agents & hygiene

Systemic pain medications

Culture lesions

Hormonal ManipulationSome hormones make hormone-sensitive

tumors grow more rapidly. Some tumors require specific hormones to

divide; decreasing the hormone amounts to hormone-sensitive tumors can slow cancer growth rate

Side Effects of Hormone TherapyMasculinizing effects in womenFeminizing effects in men (gynecomastia)Risk for venous thromboembolismAcneHypercalcemiaLiver dysfunctionBone loss

Photodynamic Therapy Selective destruction of cancer cells via

chemical reaction triggered by different types of laser light

Patient teachingGeneral sensitivity to light for up to 12

weeks after injection of photosensitizing drug

Fatigue (#1 complaint)

Definition: Persistent, subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning

Fatigue Risk FactorsMalnutritionImmobilityInsomniaStressDepression/

anxietyAnemia

Comorbidities HypoxiaInfection/feverPainCancer therapy

Immunotherapy: Biological Response Modifiers (BRMs)Modify patient’s biological

responses to tumor cellsCytokines—enhance immune

systemInterleukins, interferonsSide effects—generalized,

sometimes severe inflammatory reactions, peripheral neuropathy, skin rashes

Colony-stimulating factorsAranesp and Procrit

Stimulates erythropoiesisAdministered SC

NeupogenRegulates the production of neutrophils within the bone marrow

Administered SC, IV

Colony-stimulating factorsNeulasta

Regulates the production of neutrophils within the bone marrow

Administered SCGM-CSF

Induces committed progenitor cells to divide and differentiate in the GM pathways

Administered SC, IV

Oncologic EmergenciesSepsis and disseminated intravascular coagulation

Collaborative management includes:Prevention (the best measure)Intravenous antibiotic therapyAnticoagulants, cryoprecipitated clotting factors

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)Water is reabsorbed to excess by the

kidney and put into system circulation.SIADH is most commonly found in

carcinoma of the lungCollaborative management includes:

Fluid restrictionIncreased sodium intakeDrug therapy with demeclocycline that works

in opposition to antidiuretic hormone

Spinal Cord CompressionTumor directly enters the spinal cord or the

vertebrae collapse from tumor degradation of the bone.

(Continued)

Spinal Cord Compression (Continued)

Collaborative management includes:Early recognition and treatmentPalliativeHigh-dose corticosteroids High-dose radiationSurgeryExternal back or neck braces to reduce pressure in the spinal cord

HypercalcemiaOccurs most often in clients with

bone metastasisFatigue, loss of appetite, nausea and

vomiting, constipation, polyuria, severe muscle weakness, loss of deep tendon reflexes, paralytic ileus, dehydration, electrocardiographic changes

(Continued)

Hypercalcemia (Continued)Collaborative management includes:

Oral hydrationDrug therapyDialysis

Superior Vena Cava SyndromeSuperior vena cava is compressed or

obstructed by tumor growth.Condition can lead to a painful, life-

threatening emergency.Signs include edema of face, Stokes’

sign, edema of arms and hands, dyspnea, erythema, and epistaxis.

(Continued)

Appearance of SVC Syndrome

Superior Vena Cava Syndrome (Continued)

Late-stage signs include hemorrhage, cyanosis, change in mental status, decreased cardiac output, and hypotension.

Collaborative management includes high-dose radiation therapy, but surgery only rarely.

Tumor Lysis SyndromeLarge numbers of tumor cells are

destroyed rapidly, resulting in intracellular contents being released into the bloodstream faster than the body can eliminate them.

Collaborative management includes:PreventionHydrationDrug therapy

A 40-year-old woman was admitted to the oncology unit for severe dehydration from nausea and vomiting associated with chemotherapy 10 days ago. She has had two adjuvant treatments for breast cancer with doxorubicin (Adriamycin) and cyclophosphamide (Cytoxan). She has a Groshong port that was inserted 2 months ago for chemotherapy administration.

The health care provider’s orders are as follows:Strict I&O every 12 hoursMay use port for blood draws and IV fluidsCall for vomiting or temp of 100° F or greaterD5½NS at 125 mL/hrOndansetron (Zofran) 8 mg IV every 8 hrsClear liquid diet and progress as toleratedCBC, Ca level, and basic metabolic panel in AMBed rest with bathroom privilegesKnee-high support stockings

What is the rationale for each of the provider’s orders?

(cont’d)

Which of the provider’s orders should be implemented immediately?A. Administer D5½NS at 125 mL/hrB. Administer clear liquid dietC. Apply support stockingsD. CBC, Ca level, and basic

metabolic panel

(cont’d)

(cont’d)

Two hours later, the patient reports difficulty swallowing because of sores in her mouth.

1. What does the nurse suspect is the problem with the patient’s mouth?

2. What nursing interventions should be implemented?

(cont’d)Match each chemotherapy side effect below with the correct intervention.A. AnemiaB. NeutropeniaC. Thrombocytopenia

1. Inspect IV sites every 4 hours for signs of infection.

2. Avoid IM injections and venipunctures.3. Administer epoetin alfa subcutaneously

once a week.

Chapter 24

Audience Response System Questions

124

Question 1What is the expected outcome related to hair loss for a patient who is undergoing chemotherapy?

A.Hair loss may be permanent.B.Hair regrowth usually begins about 1

month after completion of chemotherapy.

C.New hair growth will likely be identical to previous hair growth in color and texture.

D.Viable treatments exist for the prevention of alopecia.

Question 2A patient who is receiving radiation therapy for breast cancer would experience which side effect?

A.FatigueB.MucositisC.Hair lossD.Nausea and vomiting

Question 3When is the patient with acute leukemia at greatest risk of developing tumor lysis syndrome?

A.After the first cycle of chemotherapyB.After the second cycle of

chemotherapyC.After the last cycle of chemotherapyD.Anytime during the patient’s

treatment course