ONCOLOGY Nursing

CANCER
Epidemiology 2nd leading cause of death (US) Increasing age 90-95% related to life-style and environmental carcinogens. Pathogenesis of Cancer Cellular Transformation and Derangement Theory Exposure to carcinogens Failure of the Immune Response Theory Failure of the immune system to inability to destroy the cancer cells Proliferative Growth Patterns Four Common Nonneoplastic Growth Pattern: Hyperplasia Metaplasia Dysplasia Anaplasia Neoplasm Is an abnormal mass of tissue The growth persist after cessation of the stimuli that initiated the change Cancer is the common term for all malignant neoplasms How are cancers classified? Categories of Tumors: benign tumors malignant tumors Distinction Between Malignant and Benign differentiation and Anaplasia Rate of growth Local invasion Metastases Differentiation Is the extent to which tumors cells resemble comparable normal cells. Benign well differentiated Malignant poorly differentiated, anaplastic Anaplasia lack of differentiation, hallmark of malignant cells

Rate of growth malignant tumors grow more rapidly than benign tumors Some grow slowly for years and then enter the phase of rapid growth Hormone sensitive tissues Local invasion Benign tumors Capsule Do not penetrate the capsule Do not penetrate normal tissue Surgical enucleation Malignant tumors None Invasive, infiltrating

Destroying normal tissues surrounding them Surgical enucleation difficult and impossible

Metastasis lymphatic, blood vessels, and body cavities. Single most important feature Lung, liver, brain and bones Distant spread of tumors occurs by three routes: spread into body cavities invasion of lymphatics Hematogenous spread CLASSIFICATION OF NEOPLASMS Benign neoplasia Growth remain circumscribed (capsule) Generally not life threatening unless they occur in a restricted area Well differentiated Classified according to the tissue involved: Adenoma glandular tissue Leiomyoma smooth muscle Chondroma cartilaginous tissue Osteoma bone osteoblast Hemangioma blood vessel Lymphangioma lymphatics Neuroma nerve cells Lipoma adipose tissue Papilloma epithelial tissue

 Rhabdomyoma skeletal tissue Fibroma fibrous tissue Malignant Neoplasia no capsule infiltrate surrounding tissue produce secondary lesions may metastasize anaplasia Malignant Neoplasia Types of malignant neoplasm: Solid cancers (Tumors) carcinoma : arises in epithelial cells sarcoma : arises in connective tissue, muscle or bone Hematological cancers Leukemia arises in blood Myeloma arises in bone marrow Lymphoma arises in lymph Tumors are classified according to the tissue involved: adenocarcinoma glandular epithelial tissue osteosarcoma bone osteoblasts leiomyosarcoma- arising from smooth muscle Hemangiosarcoma blood vessels Lymphangiosarcoma lymphatics Neurofibrosarcoma (neurilemic sarcoma) nerve sheath Melanoma melanocytes Comparison of the Characteristics of Benign and Malignant Neoplasm Benign Grows slowly Remains localized Encapsulated Well differentiated mature cells; cells function poorly Extremely unusual when surgically removed Never occur Not harmful to host Very good prognosis Malignant Grows rapidly Infiltrates surrounding tissues Not encapsulated

Poorly differentiated (anaplastic type) Common following surgery Very common Always harmful Poor prognosis

What are the risk factors for cancer? Predisposing factors geographical and environmental factors men lung, colon and prostate cancer women lung, breast and colon in Japan, the death rate from cancer of the stomach is about seven times that in the US increased risk with exposure to asbestos, vinyl chloride and 2 napthylamine association of carcinomas of the oropharynx, larynx and lungs with cigarette smoking age cancer is most common in those older than 55 years old. Certain cancers are particularly common in children younger than 15 years of age Tumors of hematopoietic system (leukemias and lymphomas) Neuroblastomas Wilms tumor Retinoblastomas Sarcomas of bone and skeletal muscle heredity acquired preneoplastic disorder certain clinical condition are associated with an increased risk of developing cancers: cirrhosis of the liver Hepatocellular carcinoma atrophic gastritis of pernicious anemia stomach cancer chronic ulcerative colitis carcinoma of the colon leukoplakia of the oral and genital mucosa squamous cell carcinoma

CARCINOGENIC AGENTS 1. Carcinogenic chemicals alkylating agents cyclophosphamide and busulfan aromatic hydrocarbons cigarette smoke Azo dyes-beta napthylamine bladder cancer (rubber industries) Naturally occurring carcinogens aflatoxin B1, produced by Aspergillus flavus Nitrosamines and amides gastric cancer Miscellaneous agent asbestos, vinyl chloride and metals such as nickels Hormones such as estrogen endometrial cancer 2. Radiation carcinogen (ionizing Radiation) Electromagnetic and particulate radiations are carcinogenic Miners of radioactive ores lung carcinoma Survivors of atomic bomb in Japan leukemia Therapeutic radiation in the neck later developed thyroid cancer Ultraviolet rays Natural radiation especially UVB, derived from the sun can cause skin cancer Particularly common in Australia and New Zealand. 3. Viral and microbial carcinogenesis HPV Epstein Barr virus (EBV Hepatitis B virus (HBV) EBV Burkitt lymphoma Nasopharynbgeal carcinoma B-cell lymphoma Some forms of Hodgkin disease HPV Squamous cell cancer of the uterine cevix ( HPV type 16 and 18) Genital warts (HPV 6 and 11) Hepatitis B. virus Hepatocellular carcinoma HCV also associated with hepatic cancer RNA oncogenic virus Human T-cell lymphotrophic virus type 1

Strong tropism with CD4 T cells Cause leukemia/lymphoma Helicobacter pylori Peptic ulcer Gastric lymphoma Gastric carcinoma

Signs and Symptoms of Cancer C change in bowel or bladder habits A a sore that doesnt heal U unusual bleeding or discharge T thickening or lump in tissue I indigestion or difficulty swallowing O obvious change in wart or mole N nagging cough or hoarseness Staging and Grading of Neoplasia TNM system T - designates a primary tumor N - designates lymph node involvement M - designates metastasis Numbers 0 to 4 designate degree of involvement Laboratory Diagnosis of Cancer Fine Needle Biopsy Involves aspiration of cells and fluids from tumors or masses that occur in readily palpable sites The aspirated cells are smeared, stained and examined Cytologic (papanicolaou) smears Involve examination of cancer cells that are readily shed Exfoliative cytology is used most commonly in the diagnosis of dysplasia, carcinoma in situ, and invasive cancer of the uterine cervix tumors of the stomach, bronchus and urinary bladder Tumor markers Tumor derived or associated molecules that can be detected in blood or other body fluids They are not primary method of diagnosis but rather adjuncts to the diagnosis They may also be value in determining the response to therapy

1. CEA carcino embryonic antigen cancers of the colon pancreas stomach breast Non neoplastic conditions alcoholic cirrhosis, hepatitis, and ulcerative colitis 2. -fetoprotein cancers of the liver testicular cancer Non-neoplastic conditions such as cirrhosis and hepatitis Different Therapeutic Modalities for Cancer 1. Surgical Intervention Still is used in diagnosis and staging of more than 90% of all tumors and as primary treatment in more than 60% of tumors Maybe: Preventive removal or precancerous lesions or benign tumors Diagnostic - biopsy Curative (complete removal) Palliative (decrease symptoms) Adjunctive ( debulking tumor so that radiation and chemo can work) Reconstructive improvement of structure and function of an organ 2. Immunotherapy Designed to enhance the clients own immune response 3. Bone marrow transplant and stem cell transplantation Most commonly used for leukemias , now also for some solid mass tumors, such as breast cancers. 4. Chemotherapy The use of cytotoxic medications and chemicals to: Cure some cancers Decrease tumor size (as an adjunct to surgery or radiation therapies) Prevent or treat suspected metastases

Contraindications Infection Recent surgery Impaired Renal or Hepatic Recent Radiation Therapy Pregnancy Bone Marrow Depression Classification of Chemotherapeutic Agents Cell cycle specific drugs Destroy cells actively reproducing by means of cell cycle Many agents are phase specific of cell cycle, most effect cells in S phase, interfering with DNA and RNA synthesis Cell cycle nonspecific drugs Alkylating Agent; Nitrosureas; Antimetabolites; Antitumor Antibiotics; Mitotic spindle Poisons; Hormonal Agents Types of Chemo Drugs Alkylating Agents Attack the DNA of rapidly dividing cells Examples: Busulfan (Myleran) Chlorambucil ( Leukeran) Cisplatin ( Platinol) Cyclophosphamide (Cytoxan) Lomustine (CeeNU) Melphalan ( Alkeran) Antibiotics Inhibit RNA and protein synthesis of rapidly dividing tissue Examples: Dactinomycin (Cosmegen) Daunorubicin (Cerubidine) Doxorubicin hydrochloride (Adriamycin) Mithramycin (Mithracin) Mitomycin ( Mutamycin) Procarbazine hydrochloride (Matulane) Antimetabolites Inhibit protein synthesis in rapidly dividing cells during S phase

Examples: Azathioprine (Imuran) Cytarabine (Cytosar U) Floxuridine (FUDR) Fluorouracil (5-FU) Hydroxyurea (Hydrea) Mercaptopurine (6-MP, Purinethol) Methotrexate (Mexate) Hormones Tissue specific; inhibit RNA and protein synthesis in tissues that are dependent on the opposite (sex) hormone for development Examples: Androgens Estrogens (estramustine phosphate sodium [Emoyt}) Progestins Steroids (prednisone [Meticorten]) Mitotane (Lysodren) cortisol antagonist Tamoxifen citrate (Nolvadex) estrogen antagonist Immune Agents Involves introduction of noncancerous antigens or other agents into the body to stimulate production of lymphocytes and antibodies Examples: Bacillus of Calmette-Guerin (BCG) vaccine: rpvides active immunity Interferon Alfa-2a (Roferon-A); interferon alfa-2b (Intron A) Safe Handling of Chemotherapeutic Agents Wear mask, gloves and back-closing gown. Skin contact with drug must be washed immediately with soap and water. Eyes must be flushed immediately with copious amount of water. Sterile/alcohol-wet cotton pledgets should be used wrapped around the neck of the ampule or vial when breaking and withdrawing the drug. Expel air bubbles on wet cotton. Vent vials to reduce internal pressure after mixing.

Wipe external surface of syringes and IV bottles Avoid self-inoculation by needle stab. Clearly label the hanging IV bottle with ANTINEOPLASTIC CHEMOTHERAPY. Contaminated needles and syringes must be disposed in a clearly marked special container. leak-proof, puncture-proof Dispose half-empty ampules, vials, IV bottles by putting into plastic bag, sealed and then into another plastic bag or box, clearly marked before placing for removal. Label as Hazardous Waste Handwashing should be done before and after removal of gloves Trained personnel only should be involved in use of drugs

Antineoplastic Drugs; Major Side Effects Alopecia CNS disturbances (neurotixicity) Hepatic disturbances (hepatotoxicity) Hyperuricemia Kidney failure (direct kidney toxic effect Antineoplastic Drugs; Major Side Effects Anorexia, nausea, vomiting Diarrhea Bone marrow depression Stomatitis Blood dyscrasias Nursing Intervention for Chemotherapy Side Effects GI System nausea and vomiting, diarrhea, constipation Administer antiemetic to relieve nausea and vomiting Replace fluid electrolytes losses, low fiber diet to relieve diarrhea Increase fluid intake and fibers in diet to prevent/relieve constipation Integumentary System Pruritus, urticaria and systemic signs Provide a good skin care stomititis Provide good oral care Avoid hot and spicy food

alopecia Reassure that it is temporary Encourage to wear wigs, hats or head scarf skin pigmentation Inform that it is temporary nail changes Reassure that nails may grow normally after chemotherapy Hematopoietic System Anemia Provide frequent rest periods neutropenia Protect from infection Avoid people with infection Thrombocytopenia Protect from trauma Avoid aspirin Genito-Urinary System Hemorrhagic cystitis Provide 2-3 L of fluids per day Urine color changes Reassure that it is harmless Reproductive System Premature menopause or amenorrhea Reassure that menstruation resumes after chemotherapy

skin or hair follicles. Adverse reactions to cancer drugs tend to occur in these organs Chemotherapeutic agents should not be used during pregnancy or lactation. Congenital defects may occur on the fetus

Antiemetic To Relieve Nausea and Vomiting Related to Chemotherapy Dronabinol (Marinol) Ondanastron (Zofran) Granisetron (Kytril) Alprazolam (Zanax) Lorazepam (Ativan) Haloperidol (Haldol) Prochlorperazine (Compazine) Summary of Effects of Chemotherapy Antineoplastic drugs affect both normal and cancer cells by disrupting cell function and division at various points of cell cycle. Most cancer drugs are most effective against cells that multiply rapidly-neoplasms, bone marrow cells, cells in the GI tract and cells in the

Radiation Therapy Treatment of choice for some tumors Can be used to: Kill tumor cells to cure cancer Reduce the size of a tumor Decrease pain Relieve an obstruction Reduce chance of metastasis, if just beginning Used in conjunction with chemotherapy or surgery to shrink or destroy neoplasm Radiation Therapy How it works Radiation provides lethal injury to the DNA of the cell It affects rapidly growing cells that are growing rapidly The goal is to achieve maximum tumor control with minimum damage Examples Alpha particle: fast-moving helium nucleus Penetration: slight Beta particle: fast-moving electron Penetration: moderate Gamma ray: penetrating ray, similar to light ray\ Penetration: high Gold (198 Au): ascites: pleuralo effusions Sodium iodide (1311): thyroid gland Sodium phosphate (32P): erythrocytes Sources of radiation therapy External radiation therapy (Teletherapy) Administered through an X-ray machine External beam radiotherapy or teletherapy Delivers radiation to a tumor by means of an external machine

(cobalt or linear accelerator) at a predetermined distance Internal Radiation Therapy Administered within or near the tumor Brachytherapy Implant (wires, tubes, capsules, rods, etc) placed by a surgeon or oncologist. Usually is temporary Can be ingested or injected into the clients blood stream or a body cavity The radiation is transmitted outside the body Delivers radiation Systemic Interstitial intracavity means

Do not apply heat, avoid direct sunshine or cold Do not apply ointments, powders or lotion on the area. Use soft cotton fabrics for clothing Do not erase markings on the skin. These serves as guides for areas of irradiation

Types: Sealed Source (Brachytherapy) Unsealed Source (oral, IV) RADIATION: Major Side Effects Localized skin irritation Varies based on site Gastrointestinal tract Nausea Vomiting Diarrhea Gonads Temporary sterility Permanent sterility Bone marrow Leukemia Thromobocytopenia Anemia Side Effects of Radiation Therapy 1. Skin reactions Erythema, dry/moist desquamation Atrophy, telangiectasia, depigmentation, necrotic/ulcerative lesions Nursing responsibilities: Observe for early signs of skin reaction and report Keep area dry Wash area with water, no soap and pat dry (do not rub)

2. Infection Due to bone marrow suppression Nursing Responsibilities: Monitor blood counts weekly Good personal hygiene, nutrition, adequate rest Teach signs of infection to report to physician 3. Hemorrhage Platelets are vulnerable to radiation Nursing responsibilities: Monitor platelet count Avoid physical trauma or use of aspirin Teach signs of hemorrhage Monitor stool and skin for signs of hemorrhage Use direct pressure over injection sites until bleeding stops 4. Fatigue Result of high metabolic demands for tissue repair and toxic waste removal Plenty of rest and good nutrition 5. Weight loss Anorexia, pain and effect of Cancer 6. Stomatitis Ulceration of oral mucous membrane Nursing interventions: Administer analgesics before meals Bland diet, no smoking/alcohol Good oral hygiene/ saline rinses q2h Sugarless lemon drops or mint to increase salivation

7. 8. 9. 10. 11. 12.

Diarrhea Nausea and vomiting Headache Hair loss /alopecia Cystitis Social isolation

Principles of Radiation Protection Distance Maintain a distance of at least 3 feet when not performing nursing procedures Time Limit contact for 5 minutes each time, a total of 30 minutes per shift Shielding Use lead shield during contact with client Teaching Guidelines Regarding Radiation Therapy 1. It is painless 2. Lie very still on a special table while the intervention is being given and you may be placed in a special position to maximize tumor irradiation. 3. Each treatment usually lasts for few minutes. You may hear sounds of the machine being operated, and the machine may move during the therapy. 4. As a safety precaution for the therapy personnel, you will remain alone in the treatment room while the machine is in operation. 5. The technologist will be right outside your room observing you through a window or by a closedcircuit TV. You may communicate. 6. There is no residual radioactivity after radiation therapy. Safety precautions are necessary only during the time you are actually receiving irradiation. You may resume normal activities of daily living.

NURSING CARE OF CLIENTS WITH NEOPLASTIC DISORDERS RECEIVING EITHER CHEMOTHERAPY OR RADIATION THERAPY Assessment Obtain a description of onset and progression of symptoms Perform physical assessment to determine general state of health and nutrition Determine clients understanding of disease and treatment plan General Nursing Diagnosis Anxiety/powerlessness Body image disturbance Anticipatory grieving Risk for infection/injury Altered nutrition Pain Fatigue Impaired tissue integrity Caregiver role strain Ineffective individual/family coping Fluid volume disturbance Decisional conflict (choices regarding health or death) related to: Choice or continuation of treatment modality Religious, moral, or ethical beliefs Fatigues related to depletion of body reserve Fear related to: Diagnosis Death Intractable pain Risk for injury related to disease process/therapeutic modalities (radiation, chemotherapy) Psychologic stressors death sentence guilt Anger Fear Powerlessness Body immage disturbance Sexual dysfunction concern

Planning/Implementation Review infection control guidelines with client Teach client to report temperature higher than 37.8 deg.C to physician Instruct client regarding special measures to limit infection and injury Explain side effects that influence appearance and encourage positive adaptations Implement measures to reduce or eliminate nausea such as antiemetics, hypnosis, relaxation modalities, small frequent feedings, adjustment of meal times in relation to therapy Monitor blood work during therapy WBC RBC Platelets Specific Care for Client Receiving Chemotherapy Some medications are oral or IM, but many are given IV. Very irritating, if infiltrated, stop infusion immediately Observe for signs of bleeding; avoid anticoagulants because of decreased platelets Monitor renal function for nephrotoxicity Monitor vital signs; monitor for cardiac toxicity Offer emotional support to client and family Encourage intake of foods rich in the immunestimulating nutrients, especially vitamins A,C, and E, and the mineral selenium Encourage optimal intake of high nutrient density foods; bland or mechanical soft diet may be indicated if stomatitis exist; routinely monitor weight Assess client for pain; administer analgesics as needed Encourage client to become involved indecision making Watch for bone marrow suppression Watch for infection Watch for organ toxicity(GI tract,liver, cardiac, pulmonary, urinary, neurological) Watch for anaphylaxis

Nausea and vomiting Give antiemetics 30-45 minutes prior to treatments Give antiemetics on a round the clock schedule if N/V is severe Use relaxation, therapeutic touch, diverion with music, etc.. Avoid foods, smells, etc.that induce nausea Preparation and Administration of Chemo drugs Some medications are very irritating, if infiltrated, stop infusion immediately Most states require special certification and education to administer chemo drugs These drugs are potentially carcinogenic and corrosive. Follow policies regarding spills safety for the nurse Wear gloves, mask and gown for administration and work in a quiet area in a methodical manner Spills can be very hazardous Follow special spill policies and procedures Special equipment for spills available Nurses should be aware of drugs being given and how to handle client body wastes Specific Care for Clients Receiving external Radiation Avoid washing off the marks placed by the radiologist Instruct client to avoid creams, soaps, powder, and deodorants in the area during the treatment periods Assess skin for erythema, dryness, burning Instruct client to wear cotton, loose-fitting clothing Protect skin from sunlight Apply a non adherent dressing to areas of skin breakdown Reassure others that the client will not be a source of radiation

Brachytherapy Safety Consideration Avoid overexposure to the client and use the principles of time, distnace, and shielding Spend the minimum amount of time with the patient Postpone routine hygiene while implant is in place Use lead Gloves and aprons as a shield when possible Keep pregnant people away Avoid direct contact with radioisotope containers People working with these people a lot must wear a radiation monitor badge to track exposure level to radiation Ascertain if body excreta has to be placed in lead containers for disposal when systemic (metabolized) radiation is used Store radium in lead containers to prevent contamination of environment Patients should be in private room with a private bathroom Handle linens according to facility policy Evaluation / outcomes Remains free from infection Verbalizes feelings about disease and treatment Maintain skin integrity Consumes nutritionally adequate diet Verbalizes details concerning self-care realted to treatment regimen