Cancer

Introduction



2 nd most common cause of death



5-year survival rate is now 62% for those who are disease free, in remission, or under treatment

Defect in Cellular Proliferation



Cancer cells are characterized by the loss of contact inhibition



Grow on top of one another and on top of or between normal cells



Cancer cells respond differently than normal cells to intracellular signals regulating equilibrium



Divide indiscriminately and haphazardly

Defect in Cellular Proliferation



Stem cell theory



Loss of intracellular control of proliferation results from mutation of stem cells

Defect in Cellular Proliferation



Once mutated, the cell can

•

Die

•

Recognize damage and repair itself

•

Survive and pass on damage



Surviving mutated cells have potential to become malignant

Normal Cellular Differentiation Fig. 15-2

Defect in Cellular Proliferation



Pyramid effect



Each cell division creates two or more offspring cells

•

Continuous tumor growth

Defect in Cellular Differentiation



Protooncogenes



Normal cellular genes that are important regulators on normal cellular processes



Mutations that alter their expression can activate them to act as oncogenes (tumor-inducing)

Defect in Cellular Differentiation



Tumor suppressor genes



Suppress growth of tumors



Mutations render them inactive

Benign versus Malignant Tumors

Characteristic Benign Malignant

Differentiation

Well differentiated Anaplastic Rapid

Growth Rate

Slow

Mode of growth

Expansive

Metastases

None

Prognosis

Usually harmless Infiltrative and expansive Can spread to distant sites Can be fatal if not treated

Development of Cancer



Chemical, environmental, genetic, immunologic, viral, or spontaneous in origin



Initiation



Mutation of genetic structure



Has potential to develop into clone of neoplastic cells

Process of Cancer Development Fig. 15-3

Development of Cancer



Promotion



Characterized by the reversible proliferation of altered cells



Activities of promotion (e.g. obesity, smoking, alcohol) are reversible



Latent period

•

Initial genetic alteration to clinical evidence of cancer

Development of Cancer



Progression



Characterized by increased growth rate of tumor as well as its invasiveness and metastasis



Metastasis = spread of cancer from primary (initial) site to distant site

{See Figure 15-5 in the textbook}

Development of Cancer



Progression

•

Metastasis process begins with rapid growth of primary tumor



Tumor angiogenesis - formation of blood vessels within the tumor; critical for tumor survival

Role of Immune System



Immune response is to reject or destroy cancer cells if perceived as non-self



May be inadequate as cancer cells arise from normal human cells



Some cancer cells have changes on their surface antigens



Tumor-associated antigens (TAAs)

{See Figure 15-6 in the textbook}

Role of Immune System



Response to TAAs is termed immunologic surveillance

•

Lymphocytes continually check cell surfaces and detect and destroy cells with abnormalities

Role of Immune System



Cancer cells evade immune system b/c of



Suppression of factors that stimulate T cells



Weak surface antigens allow cancer cells to “sneak through” surveillance

Tumor Escape Mechanism

Blocking antibodies prevent T cells from interacting with TAAs and from destroying the malignant cell Fig. 15-8

Role of Immune System



Development of tolerance of immune system



Suppression of immune response to products secreted by cancer cells



Induction of suppressor T cells



Blocking antibodies that bind TAAs

Classification of Cancer



Anatomic Site Classification



Identified by

•

tissue origin

•

anatomic site

•

behavior of the tumor (benign vs. malignant)

Classification of Cancer



Anatomic Site Classification



Carcinomas originate from embryonal ectoderm and endoderm



Sarcomas originate from embryonic mesoderm



Lymphomas and leukemias originate from hepatopoietic system

Classification of Cancer



Histologic Analysis Classification



Based on cellular appearance and differentation

•

Grade 1: Differ slightly from normal; well differentiated

•

Grade 2: More abnormal; moderately differentiated

•

Grade 3: Vert abnormal; poorly differentiated

•

Grade 4: Immature, primitive and undifferentiated cells; difficult to determine cell of origin

Classification of Cancer



Clinical Staging



0: cancer in situ



1: tumor limited to tissue of origin



2: limited local spread



3: extensive local and regional spread



4: metastasis

Classification of Cancer



TNM Classification (Table 15-5)



Tumor size



Spread to lymph nodes



Metastasis

Cancer Prevention and Detection



Reduce or avoid exposure to known or suspected carcinogens



Eat balanced diet



Exercise regularly



Adequate rest



Health examination on a regular basis

Cancer Prevention and Detection



Eliminate, reduce, or change perceptions of stressors and enhance ability to cope



Enjoy consistent periods of relaxation and leisure



Know 7 warning signs of cancer



Self-examination



Seek medical care if cancer is suspected

Seven Warning Signs of Cancer



C hange in bowel or bladder habits



A sore throat that does not heal



U nusual bleeding or discharge from body orifice



T hickening or lump in breast or elsewhere



I ndigestion of difficulty in swallowing



O bvious change in wart or mole



N agging cough or hoarseness

Diagnosis of Cancer



Biopsy involves histologic examination by a pathologist of a piece of tissue



Needle



Incisional



Excisional

Collaborative Care of Cancer



Goals



Cure



Control



Palliation

Collaborative Care of Cancer



Factors that determine treatment modality



Cell type



Location and size of tumor



Extent of disease



Physiologic and psychologic status and expressed needs also determine treatment

Major Treatment Modalities



Surgery



Radiation



Chemotherapy



Biologic Therapy



Bone marrow or stem cell transplant

Collaborative Care of Cancer



Surgical therapy



to cure or control



Slow cancers are most amenable



Margin of normal tissue must surround tumor

Collaborative Care of Cancer



Radiation therapy



Emission and distribution of energy through space or material medium



Energy produced breaks bonds in DNA, leading to death at time of reproduction

 

Affects both cancer as well as normal cells Normal tissues are usually able to recover

Collaborative Care of Cancer



Radiation therapy



Teletherapy

•

Given via external beam from a machine

•

Most common



Brachytherapy

• •

Radioactive material implanted in or close to the tumor Patient is radioactive



Precautions: time, distance, shielding

Nursing Management: Patients Undergoing Radiation



Fatigue



Possibly due to accumulation of metabolites from cell destruction



Rest before activity



Get assistance with activity



Maintain nutritional status

Nursing Management: Patients Undergoing Radiation



Anorexia



Monitor carefully to avoid weight loss

•

Weigh twice weekly



Small, frequent, high-protein, high calorie meals



Supplements

Nursing Management: Patients Undergoing Radiation



Bone Marrow Suppression



If bone marrow is within treatment field



Kills RBCs, WBCs, platelets



Not as significant as with chemotherapy



Monitor blood counts



May need transfusion for anemia

Nursing Management: Patients Undergoing Radiation



Skin Reactions



Occurs within treatment field



Lubricate dry skin with nonirritating lotion or solution (no metal, alcohol, perfume, or additives)



Wet desquamation must be kept clean and protected from further damage

Nursing Management: Patients Undergoing Radiation



Skin Reactions



Prevention of infection



Facilitate wound healing



Protect irritated skin from extremes in temperature



Avoid constricting garments, harsh chemicals, and deodorants



See Table 15-12

Nursing Management: Patients Undergoing Radiation



Oral, Oropharynx, and Esophageal Reactions



Teach patients to examine oral cavity



Dental work before initiation of radiation therapy



Saliva substitutes for dry mouth



Oral care (brushing and flossing unless contra-indicated)

Nursing Management: Patients Undergoing Radiation



Oral, Oropharynx, and Esophageal Reactions



Pain relief



Frequent feedings of soft, nonirritating, high-protein, high calorie foods



Avoidance of extremes in temperature, alcohol, and tobacco

Nursing Management: Patients Undergoing Radiation



Pulmonary Effects – pneumonitis (cough, SOB, fever, night sweats)



Treatment

•

Bronchodilators

•

Expectorants/cough suppressants

•

Bed rest

•

Oxygen

Nursing Management: Patients Undergoing Radiation



Gastrointestinal Effects – ↓ secretion of HCl, mucus, pepsin → N&V, diarrhea



Prophylactic administration of antiemetics



Assess for S/S of alkalosis and dehydration

  

I&O nonirritating diet Antidiarrheal medications

Nursing Management: Patients Undergoing Radiation



Reproductive Effects



Risk of infertility



Inform patient on expected sexual side effects



Consider harvesting sperm or ova



Refer to counseling if needed

Nursing Management: Patients Undergoing Radiation



Coping



Assist in planning for transportation, nutrition, and emotional support



Patient teaching of symptom management to maintain highest possible quality of life

Chemotherapy



Goal is to reduce number of cancer cells in the tumor site(s)



Several factors determine response of cancer cells



Cancer cells can escape death by staying in the G 0 phase



Main problem is presence of drug resistant resting and noncycling cells

Chemotherapy

Effect on cells



Cell cycle non-specific



Cell cycle phase-specific

Chemotherapy

Methods of Administration

  

Oral IM IV



Many agents are vesicants, causing severe tissue breakdown and necrosis if infiltration occurs

 

S/S infiltration: pain, redness, swelling, vesicles Central vascular access devices permit frequent, continuous, or intermittent administration

• •

Can be used to administer additional fluids Major types



Silastic right atrial catheters



Implanted infusion ports



Infusion pumps

Chemotherapy

Methods of Administration



Intrathecal – puncture into subarachnoid space via lumbar



Intraarterial – into artery the supplies tumor



Intravesical (bladder)



Intraperitoneal

Chemotherapy:

Classification of Drugs



Alkylating Agents



Antimetabolites



Anti-tumor antibiotics



Plant Alkaloids



Nitrosoureas



Corticosteroids



Hormone Therapy

Chemotherapy

Regional Administration



Delivery of drug directly into the tumor site



Higher concentrations can be delivered with reduced systemic toxicity

Chemotherapy

Effects on Normal Tissues



Chemotherapeutic agents cannot distinguish between normal and cancer cells



Body’s response to products of cellular destruction in circulation may cause fatigue, anorexia, and taste alterations

Chemotherapy

Effects on Normal Tissues



Acute toxicity



Vomiting



Allergic reactions



Arrhythmias



Delayed effects



Mucositis



Alopecia



Bone marrow suppression

Chemotherapy

Effects on Normal Tissues



Chronic toxicities



Damage to

•

Heart

•

Kidney

•

Liver

•

Lungs

Chemotherapy

Treatment Plan



Rapidly dividing cells are most sensitive (tumor cells, hair, GI, reproductive, & blood cells)



Effects are systemic and therefore kill primary and metastatic cancer cells



Carefully calculated according to body weight or body surface area



Drugs usually given in combination

Chemotherapy

Treatment Plan



Selection of principles of combination chemotherapy



Drugs used are effective against cancer being treated



Synergistic effect occurs when combined



Includes cell cycle phase-specific and cell cycle nonspecific drugs with different mechanisms of action

Chemotherapy

Treatment Plan



Combination of drugs with different toxic side effects



Include drugs that cause nadir (lowest level of peripheral blood cell counts secondary to bone marrow depression) at different time intervals

Chemotherapy

Treatment Plan



Timed to maximize cancer cell kill and minimize damage to normal cells eg. every 3-4 weeks for 6 – 10 treatments

Chemotherapy

Side Effects – Table 15-11, p. 306-307



Alopecia (hair loss)



Generally reversible



New hair often different color and texture



Wigs, bandanas, scarves



Anorexia



Fatigue



Nausea & vomiting



Mucositis

Chemotherapy

Treatment Plan



Bone marrow suppression – more severe than with radiotherapy



Leukopenia,neutropenia

•

Risk for infection

•

See NCP 30-3, p. 734



Anemia

• •

Activity intolerance, Hypoxemia See NCP 30-1, p. 708



Thrombocytopenia

•

Risk for bleeding

•

See NCP 30-2, p. 725

Nursing Management

Chemotherapy



Nurse must differentiate between tolerable side effects and toxic side effects



Serious reactions must be reported



Some toxicities are not reversible

Nursing Management

Nursing Implementation



Administration of antiemetic drugs



Monitor lab results, particularly WBCs, platelet, and RBCs



Assess for signs of bleeding if platelet count falls below 50,000/μl

Nursing Management

Nursing Implementation



Patient must be told what to expect to decrease anxiety



Encourage discussion of fears



Reassure patient that situation is only temporary



Inform patient of supportive care that will be provided

Late Effects of Radiation and Chemotherapy



Risk for leukemias and other secondary malignancies resulting from therapy



Secondary malignancies other than leukemia have been reported



Includes breast, ovarian, uterine, thyroid, and lung cancers

Late Effects of Radiation and Chemotherapy



Cancer survivors at risk for leukemiaa and other secondary malignancies

Biologic Therapy



Alters biologic response to tumor cells



Direct anti-tumor effect



Restore, augment, or modulate immune system



Other effects – interfere with metastasis, differentiation

Bone Marrow and Stem Cell Transplantation



Allows for safe use of very high doses of chemotherapy or radiation therapy



Procedure with many risks, including death



Highly toxic

Bone Marrow and Stem Cell Transplantation



Allogeneic



From donor



Goal is to administer large doses of systemic therapy



Then “rescue” bone marrow through engraftment and subsequent normal proliferation and differentiation of donated marrow

Bone Marrow and Stem Cell Transplantation



Autologous



Patient receives their own bone marrow



Marrow is removed, treated, stored, and reinfused

Bone Marrow and Stem Cell Transplantation



Syngeneic



Obtaining stem cells from one identical twin and infusing them into the other

Bone Marrow and Stem Cell Transplantation



Harvesting



Procedure conducted in the OR



Multiple aspirations carried out

•

Usually iliac crest or sternum



May be treated to remove cancer cells if autologous



Cryopreserved

Bone Marrow and Stem Cell Transplantation



Complications



Bacterial, viral and fungal infections are common

•

Prophylactic antibiotic therapy



Graft-versus-host disease

•

Lymphocytes from donated marrow recognize recipient as foreign

•

Attack organs such as skin, liver, and intestines

Bone Marrow and Stem Cell Transplantation



Peripheral stem cell transplant



Peripheral or circulating stem cells are capable of repopulating bone marrow



Mobilization of stem cells from marrow to peripheral blood done using chemotherapy or hematopoietic growth factors

Bone Marrow and Stem Cell Transplantation



Cord blood stem cells



Umbilical cord blood can be typed and cryopreserved



May have insufficient numbers of stem cells to permit transplant to adults

Management of Cancer Pain



Patient report should always be believed and accepted as primary pain assessment data



Drug therapy should be used following WHO analgesic ladder (Refer to McCaffery in course pack)



Nonpharmacologic interventions can be effectively used

Cancer

Psychologic Support



Emphasis placed on maintaining optimal quality of life



Positive attitude of patient, family, and health care providers has significant positive impact on quality of life for patient



May also influence prognosis

Cancer

Psychologic Support



Continue to be available



Exhibit caring attitude



Listen actively to fears and concerns



Provide relief from distressing symptoms



Maintain relationship based on trust and confidence

Cancer

Psychologic Support



Use touch to exhibit caring



Assist patient in setting realistic short term goals



Assist in maintaining usual lifestyle patterns



Maintain hope, which can vary



Provides control over what is occurring



Basis of positive attitude