Cancer Prevention and Control 1.

Prevention involves measures to avoid or reduce exposure to carcinogens - activities are aimed at interventions before pathologic change has begun 2. Screening helps to identify high-risk populations and individuals 3. Early Detection involves finding a precancerous lesion or a cancer at its earliest, most treatable stage - also called secondary prevention - methods a. inspection b. palpation c. use of tests or procedures Approaches to Cancer prevention 1. Education 2. Regulation prohibit the sale of tobacco and alcohol to minors, limiting smoking in public places, imposing excise taxes, regulating the use of manufactured carcinogens such as asbestos, and prohibiting carcinogens in foods 3. Host modification - aims to alter the bodys internal environment to decrease the risk of or to reverse a carcinogenic process Cancer Prevention 1. Skin: Avoid exposure to sunlight 2. Oral: Annual oral examination 3. Breast: Monthly BSE from age 20 4. Lungs: Avoid cigarette smoking; annual chest x-ray 5. Colon: DRE for person over age 40. Rectal biopsy, proctosigmoidoscopic examination, Guiac stool examination for persons age 50 and above 6. Uterus: annual Paps smear from age 40 7. Basic: annual physical examination and blood examination Dietary Recommendations against cancer 1. Avoid obesity 2. Cut down on total fat intake 3. Eat more high fiber foods raw fruits and vegetables, whole grain cereal 4. Include food rich in vitamin A and C in daily diet 5. Include cruciferous vegetables in the diet: brocolli, cabbage, cauliflower, brussel sprouts 6. Be moderate in the consumption of alcoholic beverages 7. Be moderate in the consumption of salt-cured, smoked-cured and nitrate-cured foods Recommendations of the American Cancer Society for Early Cancer Detection 1. For detection of breast cancer a. Beginning at age 20, routinely perform monthly breast self-examination b. Women ages 20-39 should have breast examination by a healthcare provider every 3 years c. Women age 40 and older should have a yearly mammogram and breast self-examination by a healthcare provider 2. For detection of colon and rectal cancer a. all persons age 50 and older should have a yearly fecal occult blood test b. digital rectal examination and flexible sigmoidoscopy should be done every 5 years c. Colonoscopy with barium enema should be done every 10 years 3. For detection of uterine cancer a. yearly papanicolao (Pap) smear for sexually active females and any female over age 18 b. At menopause, high-risk women should have an endometrial tissue sample 4. For detection of prostate cancer a. beginning at age 50, have a yearly digital rectal examination b. beginning at age 50, have a yearly prostate-specific antigen (PSA) test American Cancer Societys seven warning signs of cancer (uses acronym CAUTION US): 1. Change in bowel or bladder habits

2. 3. 4. 5. 6. 7. 8. 9.

A sore that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestions or difficulty in swallowing Obvious change in wart or mole Nagging cough or hoarseness Unexplained Anemia Sudden loss of weight

Diagnostic tests of Cancer 1. Biopsy/cytology a. Histologic and cytologic examination of specimens are performed by the pathologist on tissues collected by needle aspiration of solid tumors, exfoliation from epithelial surface, and aspiration of fluid from blood or body cavities b. Tissues may be obtained by excisional biopsy, incisional biopsy, and needle biopsy c. By examination of these tissues, the name, grade, and stage of the tumor can be identified 2. Papanicolao Test (Pap Smear) Class I: Normal Class II: Inflammation Class III: Mild to moderate dysplasia Class IV: Probably malignant Class V: Malignant 3. Ultrasound 4. MRI 5. X-rays 6. CT scan 7. Radiographic techniques 8. Antigen Skin test 9. Laboratory tests a. Alpha-feto-protein b. HCG c. Prostatic Acid Phosphatase (PSA) d. Carcinoembroyenic antigens (CEA) 10. Endoscopic examination 11. Monoclonal antibodies Tumor markers 1. Tumor markers are protein substances found in the blood or bloody fluids 2. Are released either by the tumor itself, or by the body as a defense in response to the tumor (called host response) 3. Tumor markers are derived from the tumor itself. And include the ff: a. Oncofetal antigens, present normally in fetal tissue, may indicate an anaplastic process in tumor cells; carcinoembyonic antigen (CEA) and alpha-fetoprotein (AFP) are examples of oncofetal antigens. b. Hormones are present in large quantities in the human body; however, high levels of hormones may indicate a hormone-secreting malignancy; hormones that may be utilized as tumor markers include the antidiuretic hormone (ADH), calcitonin, catecholamines, human chorionic gonadotropin (HCG), and parathyroid hormone (PTH) c. Isoenzymes that are normally present in a particular tissue may be released into bloodstream if the tissue is experiencing rapid, excessive growth as the result of tumor; are examples include neuron-specific enolase (NSE) and prostatic acid phosphatase (PAP) d. Tissue-specific proteins identify the type of tissue affected by malignancy; an example of a tissue-specific protein is the protastic-specific antigen (PSA) utilized to identify prostate cancer 4.Host-response tumor makers include the following: a. C-reactive protein

b. Interleukin-2 c. Lactic dehydrogenase d. Serum Ferritin e. Tumor necrosis factor Staging 1. The TNM tumor system is utilized for classifying tumors a. T indicates the tumor size 1) T0 indicates no evidence of tumor 2) T is indicates tumor in situ 3) T1,T2,T3,T4 indicate progressive degrees of tumor size and involvement b. N indicates lymph node involvement 1) N0 indicates no abnormal lymph nodes detected 2) N1a, N2a indicate regional nodes involved with increasing degree from N1a to N2a, no metastases detected 3) N1b, N2b, N3b indicate regional lymph nodes involvement with increasing Degree from N1b to N3b, metastasis suspected 4) Nx indicates inability to assess regional nodes c. M indicates distant metastases 1) M0 indicates no evidence of distant metastasis 2) M1, M2, M3 indicate ascending degrees of distant metastasis and includesdistant lymph nodes Different Modalities for Cancer 1. Surgical interventions 2. Chemotherapy 3. Radiation therapy 4. Immunotherapy 6. Bone Marrow transplantation Surgical Intervention 1. Preventive surgery- removal of precancerous lesions or benign tumors 2. Diagnostic surgery- biopsy 3. Curative surgery- removal of an entire tumor 4. Reconstructive surgery improvement of structures and function of an organ 5. Palliative surgery relief of distress in signs and symptoms; retardations of metastasis Common Nursing Techniques and Procedures A. Radiation therapy 1. Is used to kill a tumor, reduce the tumor size, relieve obstruction, or decrease pain 2. Causes lethal injury to DNA, so it can destroy rapidly multiplying cancer cells, as well as normal cells 3. Can be classified as internal radiation therapy (brachytherapy) or external radiation therapy (teletherapy) B. The client undergoing brachytheraphy (internal radiation) 1. Sources of internal radiation a. Implanted into affected tissue or body cavity b. Ingested as a solution c. Injected as a solution into the bloodstream or body cavity d. Introduced through a catheter into the tumor 2. Side effects of internal radiation a. Fatigue b. Anorexia c. Immunosuppression d. Other side effects similar to external radiation 3. Priority nursing diagnoses: Impaired tissue integrity; fatigue; anxiety; risk for infection; Social isolation; Imbalanced nutrition: less than body requirements 4. Client education

a. Avoid close contact with others until treatment is completed b. Maintain daily activities unless contraindicated, allowing for extra rest periods as needed c. Maintain balanced diet; may tolerate food better if consumes small, frequent meals d. Maintain fluid intake ensure adequate hydration (2-3 liters/day) e. If implant is temporary, maintain bed rest to avoid dislodging the implant. f. Excreted body fluids may be radioactive; double-flush toilets after use g. Radiation therapy may lead to bone marrow suppression 5. Nursing management of client receiving internal radiation a. Exposure to small amounts of radiation is possible during close contact with persons receiving internal radiation: understand the principles of protection from exposure to radiation: time, distance, and shielding 1) Time: minimize time spent in close proximity to the radiation source; a common standard is to limit contact time to 30 minutes total per 8-hour shift; minimum distance of 6 feet used when possible 2) Distance: maintain the maximum distance possible from the radiation source 3) Shielding: use lead shields and other precautions to reduce exposure to radiation b. Place client in private room c. Instruct visitors to maintain at least a distance of 6 feet from the client and limit visitors to 10-30 minutes d. Ensure proper handling and disposal of body fluids, assuring the containers are marked appropriately e. Ensure proper handling of bed linens and clothing f. In the event of a dislodged implant, use long-handled forceps and place the implant into a lead container; never directly touch the implant g. Do not allow pregnant woman to come into any contact with radiation h. If working routinely near radiation sources, wear a monitoring device to measure exposure i. Educate client in all safety measures 6. Evaluation: client demonstrates measures to protect others from exposure to radiation, identifies interventions to reduce risk of infection, remains free from infection, achieves adequate fluid and nutritional intake activities of daily living (ADLs) at level of ability The client undergoing external radiation therapy (teletheraphy) 1. The radiation oncologist marks specific locations for radiation treatment using a semipermanent type of ink a. Treatment is usually given 15-30 minutes per day, 5 day per week, for 2-7 weeks b. The client does not pose a risk for radiation exposure to other people 2. side effects of external radiation therapy a. Tissue damage to target area (erythema, sloughing, hemorrhage) b. Ulcerations of oral mucous membranes c. Gastrointestinal effects such as nausea, vomiting, and diarrhea d. Radiation pneumonia e. Fatigue f. Alopecia g. Immunosuppression 3.Priority nursing diagnoses: risk for infection; impaired skin integrity; social isolation; disturbed body image; anxiety; fatigue 4. Client education exam for external radiation a. Wash the marked area of the skin with plain water only and pat skin dry; do not use soaps, deodorants, lotions, perfumes, powders or medications on the site during the duration of the treatment; do not wash off the treatment site marks b. Avoid rubbing, scratching, or scrubbing the treatment site; do not apply extreme temperatures (Heat or Cold) to the treatment site ; if shaving, use only an electric razor c. Wear soft, loose-fitting over the treatment area d. Protect skin from sun exposure during the treatment and for at least 1 year after the treatment is completed; when going outdoors, use sun-blocking agents with sun protector

factor (SPF) of at least 15 e. Maintain proper rest, diet, and fluid intake as essential to promoting health and repair of normal tissues f. Hair loss may occur; choose a wig, hat, or scarf to cover and protect head (refer to care of client with alopecia later in chapter) 5. Nursing management of the client receiving external radiation a. Monitor for adverse side effects of radiation b. Monitor for significant decreases in white blood cell counts and platelet counts c. Client teaching (refer to later sections for management of immunosuppression, thrombocytopenia 6. Evaluation; client identifies interventions to reduce risk of infection, remains free from infection, achieves adequate fluid and nutritional intake, participates in activities of daily living (ADLs) at level of ability, and maintains intact skin. The Client Undergoing a Bone Marrow Transplant (BMT) 1. BMT used in the treatment of leukemias, usually in conjunction with radiation or chemotherapy a. Autologous BMT the client is infused with own bone marrow harvested during remission of disease b. Allogenic BMT the client is infused with donor bone marrow harvested from a healthy individual 2. The bone marrow is usually harvested from the iliac crest, then frozen and stored until transfusion 3. Before receiving the BMT, the client must first undergo a phase of immunosuppressive therapy to destroy the immune system, infection, bleeding, and death are major complications that can occur during this conditioning phase 4. After immunosuppression, the bone marrow is transfused intravenously through a central line 5. Side of BMT a. malnutrition b. infection related to immunosuppression c. bleeding related to thrombocytopenia 6. Priority Nursing Diagnoses a. Risk for infection b. Risk for hemorrhage c. Risk for imbalanced nutrition d. Social isolation e. Anxiety 7. Nursing Management of client undergoing a bone marrow transplant a. Monitor for graft-versus-host disease b. Provide private room for the hospitalized client; client will be hospitalized for 6-8 weeks c. Encourage contact with significant others by using telephone, computer, and other means of communication to reduce feelings of isolation d. Refer to management for imbalanced nutrition, immunosuppression and thrombocytopenia 8. Evaluation: client evaluates understanding of risks and participates in activities that reduce risk of infection, hemorrhage, and malnutrition; client demonstrates effective coping mechanism The Client Undergoing other therapeutic interventions 1. Immunotherapy/biologic response modifiers (BMR) a. Enhances the persons own immune responses in order to modify the biologic processes resulting in malignant cells b. Currently considered experimental in use c. Monoclonal antibodies: antibodies are recovered from an inoculated animal with a specific tumor antigen, then given to the person with that particular cancer type; the goal is: destruction of the tumor d. Cytokines: normal growth-regulating molecules possessing antitumor abilities 1) Interleukin-2(IL-2) increases immune response effective and destroys abnormal cells 2) Interferons are substances produced by cells to protect them from viral infection

and

replication; interferon-alpha 2b is most commonly used 3) Hematopoietic growth factors such as granulocyte colony- stimulating factor (G-CSF) and erythropoietin, balance the suppression of granulocytes and erythrocytes resulting from chemotherapy e. natural killer cells (NK cells) : exert a spontaneous cytotoxic effect on specific cancer cells; they also secrete cytokines and provide a resistance to metastasis 2. Gene therapy a. Current use in investigational b. Increases susceptibility of cancer cells to the destruction by other treatments; insertion of specific genes enhances ability of clients own immune system to recognize and destroy cancer cells 3. Photodynamic theory a. Used to treat specific superficial tumors such as those of the surface of bladder, bronchus, chest wall, head, neck and peritoneal cavity b. Photofirin, a photosensitizing compound, is administered intravenously where it is retained by malignant tissue c. Three days after injection, the drug is activated by a laser treatment which continue for 3 more days d. The drug produces a cytotoxic oxygen molecule (singlet oxygen) e. During intravenous administration, monitor for chills, nausea, rash, local skin reactions, and temporary photosensitivity f. Drug remains in tissues 4-6 weeks after injection; direct or indirect exposure to sun activates drug, resulting in chemical sunburn; educate client to protect skin from exposure to sun Oncologic Emergencies: Diagnosis and Management 1. Spinal Cord Compression a. Occurs secondary to pressure from expanding tumors b. Early symptoms include back and leg pain, coldness, numbness, tingling, paresthesias, progression leads to bowel and bladder dysfunction, weakness, and paralysis c. Early detection is essential: investigate all complaints of back pain or neurological changes d. Treatment is aimed at reducing tumor size by radiation and/or surgery to relieve compression and prevent irreversible paraplegia; may receive corticosteroids to reduce cord edema e. Nursing interventions include early recognition of symptoms, neurological checks and medication administration 2. Superior vena cava syndrome a. Compression or obstruction of the superior vena cava (SVC) b. Usually associated with cancer of the lungs and lymphomas c. signs and symptoms are the result of blockage of venous circulations of head, neck, and upper trunk d. Early signs and symptoms are periorbital edema and facial edema e. Symptoms progress to edema of neck, arms, and hands, difficulty swallowing, shortness of breath f. Late signs and symptoms are cyanosis, altered mental status, headache, and hypotension g. Death may occur if compression is not relieved h. Treatment included high-dose radiation to shrink tumor and relieve symptoms i. Nursing interventions include: a. Monitoring vital signs b. providing oxygen support c. preparing tracheostomy if necessary d. initiating seizure precautions e. administering corticosteroids to reduce edema 3. Disseminated intravascular coagulopathy (DIC) a. Severe disorder of coagulation, often triggered by sepsis, whereby abnormal clot

formation occurs in the microvasculature; this process depletes the clotting factors and platelets, allowing extensive bleeding to occur tissue hypoxia occurs as a result of the blockage of blood vessels from the clots b. Signs and symptoms are related to decreased blood flow to major organs (tachycardia, oliguria, dyspnea) and depleted clotting factors (abnormal bleeding and hemorrhage) c. Treatment includes anticoagulants to decrease stimulations of coagulation and transfusion of one or more of the following: 1) fresh frozen plasma (FFP) 2) cryoprecipitate 3) platelets 4) packed RBC d. Nursing interventions include assessing client, monitoring for bleeding, applying pressure dressings to venipuncture sites, and preventing risk of sepsis e. Mortality for clients experiencing DIC is greater than 70% despite aggressive treatment 4. Cardiac tamponade a. Pericardial effusion secondary to metastases or esophageal cancer can lead to compression of heart, restricting heart movement and resulting in cardiac tamponade b. Signs and symptoms are related to cardiogenic shock or circulatory collapse: anxiety, cyanosis, dyspnea, hypotension, tachycardia, tachypnea, impaired levels of consciousness, and increased central venous pressure c. Pericardiocentesis is performed to remove fluid from pericardial sac d. Nursing interventions 1) administering oxygen 2) maintaining intravenous line 3) Monitoring vital signs 4) hemodynamic monitoring 5) administration of vasopressor agents