The Big C: CANCER

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The Big C CANCER

• By Diana Blum RN MSN
• Metropolitan Community College

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Definition

• According to the American Cancer Society
• A large group of diseases characterized by
  uncontrolled growth and spread of abnormal cells

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2nd leading cause of death in USA
Metastasizing cancer Cell 1 out of 4 Americans
will have CA at some time in their life
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Common Sites

• MEN
• Prostate
• Lung
• Colorectal
• Bladder
• Lymphoma
• Melanoma of Skin
• Oral
• Kidney
• Leukemia
• Stomach

• Women
• Breast
• Lung
• Colorectal
• Corpus Uteri
• Ovarian
• Lymphoma
• Melanoma of Skin
• Bladder
• Cervical
• Pancreas

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Top 3 Cancers that cause Deaths

• Men
• Lung
• Prostate
• Colorectal

• Women
• Lung
• Breast
• Colorectal

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• Early Diagnosis Is Key for survival

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Normal Cell

• Single small nucleus
• Performs a specific function when it matures
• Able to recognize other cells and identify tissue
  of origin
• Reproduce in a controlled manner
• Remain in their tissue of origin except blood
  cells

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Neoplasm (aka TUMOR)

• Cells that reproduce abnormally and in an
  uncontrolled manner

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Benign Tumors

• Harmless
• Do not spread
• Can create pressure or obstruct organs
• 3 types
• Fibroma fibrous connective tissue
• Lipoma fat tissue
• Leiomyoma smooth muscle tissue

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Malignant Tumors

• Cancer cells characteristics
• Change in appearance from normal cells/origin
• Inability to properly perform function
• Not recognized by other cells
• Random disorganized uncontrolled growth pattern
• Continue to divide when theres no need
• Can migrate to other organs

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Malignant continued

• Tend to press on normal tissue and organs as the
  grow
• Rob normal cells of nutrients
• Invasive with all tissues
• Regional invasion movement into adjoining cells
• Metastasis to spread to distant sites
• Most common sites are liver, brain, bone, and
  lungs
• Treatment is more difficult with mets

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4 types of Malignancies

• Carcinoma skin, glands, lining of digestive
  urinary and reproductive tracts
• Sarcoma bone, muscle, other connective tissues
• Melanomas pigment cells in the skin
• Leukemias and lymphomas blood forming tissues
  lymphoid tissue, plasma cells, and bone marrow

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Malignant Transformation

• 4 steps
• Initiation DNA exposed to carcinogen
• Promotion sufficient exposure to agent to
  encourage/enhance cell growth
• Progression accelerated growth, enhanced
  invasion, altered appearance and activity
• Metastasis tumor develops blood vessels
• Penetrates capillaries and form fibrin network
  (undetectable by immune system)
• Dissolve lining of blood vessels to invade
  surrounding tissue
• Set up their own blood supply

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Staging
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Stage 1

• The malignant cells are confined to the tissue of
  origin. Not invasive with other tissues

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Stage 2

• Limited spread of the cancer in the local area
  usually near lymph nodes

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Stage 3

• The tumor is larger or has spread from the local
  site of origin into nearby tissues
• regional lymph nodes are likely to be involved

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Stage 4

• The cancer has metastasized to distant parts of
  the body

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THE TNM Staging System

• Specifies the status of the primary tumor,
  regional lymph nodes, and distant mets
• T tumor
• N regional nodes
• M distant mets

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TNM Continued

• Tprimary tumor
• T0 no signs of tumor after treatment
• Tis malignancy in epithelial tissue but not in
  basement membrane
• T1 minimal size and extension
• T2, T3progressive increase in size and extension
• T4large size and extension

• Nregional nodes
• N0no regional nodes involved
• N1minimal node involvement
• N2increased involvement of regional nodes
• N3extensive involvement of regional nodes
• Mdistant mets
• M0no distant mets
• M1distant mets present

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practice

• You are caring for a client who has cancer. The
  cancer is staged T4,N3, M1 how would you
  interpret the information???

• Primary tumor is large in size with extension
  that extensively involves the lymph nodes and
  distant mets are present.

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Risk Factors

• No single cause identified
• Carcinogens exposure
• (chemicals, radiation, viruses)
• Cigarettes, asbestos, nitrates
• Steroids, estrogens, tar, soot, asphalt, arsenic,
  corticosteroids, alkylating agents
• Heredity and hormones also play factor
• Familial cancersappear at a high rate than
  expected. No single gene pinpointed
• Hereditypredictable patterns of inheritance
  found on a single gene

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7 warning signs of Cancer

• C change in bowel or bladder
• A a sore that does not heal
• U unusual bleeding or discharge
• T Thickening or lump in a breast or elsewhere
• I Indigestion or difficulty swallowing
• O Obvious change in a wart or mole
• N Nagging cough or hoarseness

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Prevention and Detection

• Health promotion
• Avoid Carcinogens
• ID high risk people

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Health Promotion

• Low fat, low cal, no added preservative, high
  fiber diet with at least 5 fruits and veggies
  daily
• Avoid Alcohol
• Avoid salt cured, smoked, or nitrate preserved
  foods
• Balance activity and rest with stress management

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Avoid carcinogens

• Avoid over exposure from the sun
• Do not smoke
• Avoid second hand smoke
• Wear a mask at work

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ID High risk people

• This helps researchers recognize factors that
  contribute to cancers
• See doctor at least every 6 months

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Diagnosis

• H P
• Physical Exam
• Diagnostic Tests
• Biopsy the removal of cells cut from a sample
• Smear blood cells under microscope to check for
  leukemia
• CT Scan used fto detect head and neck Ca, joints
  and soft tissue
• MRI detects CNS , spinal, neck, bones, joints,
  lung, kindey, etc.
• PET(positron Emission Tomography) used to detect
  solid tumors in the brain and breast and to
  assess cancer treatment
• Lab Alpha fetoprotein , Ca50, Ca 125, PSA, etc.
  (see page 327)

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Treatments

• Surgery
• Done for
• diagnosis
• Symptom relief
• maintain function
• Reconstruction
• Possible cure

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Surgery continued

• Preop/postop care varies
• The recommended treatment is based on the
  cancers type, location, and mets

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Radiotherapy

• Uses ionizing radiation
• Dose 1 gray equals 100 rads
• Used to treat malignant cells
• Has delayed and immediate effects
• Delayed altered DNA which impairs the cells
  ability to reproduce
• Immediate cell death due to damage of cell
  membrane

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Caregiver Safety with radiation

• The less time spent near the source the less
  exposure
• Unless direct care being given stay 6 ft away
  from the source
• Effective shielding depends on type of rays (the
  denser the material the more protection)

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External radiation

• PROCEDURE
• Source is outside the body
• Special xray machine provides treatment
• of treatments depends on the doctor
• Example 5 times a week for 2-8 weeks
• PATIENT PREP
• Treatment simulation to determine exact dosage
  needed and schedule
• The skin is marked with permanent, waterproof
  ink, by the radiologist for the exact site
• Instruct client not to remove markings without
  permission

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Internal Radiation (Brachytherapy)

• PROCEDURE
• Sources
• Iodine, phosphorus, radium, iridium, radon,
  cesium
• Instruct client that they pose a threat unitl the
  source is removed unless permanently implanted
  small beads used
• 2 TYPES
• Sealed
• Unsealed

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Sealed

• Source is sealed in a container and inserted into
  the body (CESIUM)
• Sources may be placed in threads, beads, needles,
  seeds, or molds
• To protect visitors from exposure the client
  needs
• To be placed in isolation
• Have a sign on the door indicating radiation
• No pregnant women or kids under 18 allowed in
  room
• Limit time with visitors
• Have organized schedule for cares

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Between scrotum and anus
Intracavity such As bladder
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• Staff to wear film badges to monitor exposure
• Recognize that Sealed sources can become
  dislodged
• Portable lead shields provides minimal protection
  Immediately notify MD if source becomes
  dislodged.
• Do not touch source with bare hands

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Unsealed

• Body fluids may be contaminated
• Must wear gloves when working with patient
• Contaminated fluids, dressings, etc may require
  additional precautions depending on the agency.
• Disposable utensils are recommended
• Equipment being removed from room must be checked
  for radiation level first

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Radiation side effects

• Normal cells may be harmed (hair follicles, bone
  marrow, lining of gi tractand urinary tract)
• Anemia-deficiency of RBC
• Low WBCs
• Take 2-6 wks to recover
• Bruising/Bleeding( low platelets)
• Takes 2-6 wks to recover
• Alopecia (hair loss)
• Anorexia
• Dry mouth
• Harms reproductive cells

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See chart 24-9 on page 331
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Nursing Implications

• Teach pt to avoid exposure to sun, trauma, harsh
  chemicals, soaps
• Teach pt to leave markings alone and to not use
  lotion during treatment
• New hair may be different texture and color
• Wig is okay to wear
• Encourage dental care
• Small frequent feedings
• Monitor I/O
• Increase fluid intake
• Encourage C DB

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Chemotherapy

• Use of chemical agents to treat (Antineoplastics)
• Destroy rapidly dividing cells
• Curative in some cases
• Decreases symptoms in others

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Antineoplastics (see table 24-10)

• Cell cycle phase specific- only works in a
  certain phase
• Cell cycle phase non specific-works in all stages
  and phases
• 5 types
• Cytotoxic agents Taxol, ifex, adriamycin, folex
• Hormones and Hormone antagonists femara, emcyt,
  evista
• Biologic response modifiers interferons,
  interleukins
• Angiogenesis inhibitors brand new and being
  studied

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Chemo continued

• Administered by doctor or certified nurse
• Given inpt or outpt
• Routes po, iv, intracavity, or intrathecal
• Intra cavity installed into cavity like bladder
• Intrathecal is given in subarachnoid space
• Perfusiontechnique where drug is injected into
  artery supplying the tumor

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Side Effects (see table 24-11)

• Act on normal cells as well
• Same as radiation
• Bone marrow supression- most dangerous
• N/V
• alopecia
• Client is also at risk for toxic effects
• to heart (adriamycin)-causes heart failure
• lung (Blenoxane)-pulmonary fibrosis and
  inflammation
• nerve tissue (Velbane, Oncovin)- numbness,
  tingling, loss of deep tendon reflexes.
• kidney, bladder

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Biotherapy

• Agents work by affecting biological processes
  including
• hematopoietic growth factors (eyrthropoietin(produ
  ction of RBC), numega, colony stimulating
  factors)
• Biologic response modifiers (not first line
  treatment still being studied), and
• Monoclonal antibodies (specific for proteins on
  surface of cancer cell)

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Transplants and hormone therapy

• Bone marrow- used with leukemia/lymphoma
• Stem cell- bone marrow depression
• Both are done to restore blood manufacturing
  cells
• Hormone therapy-used to supress natural hormone
  secretion, block hormone actions, or provide
  supplemental hormones

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Nursing Assessment- diagnostic phase

• Health History
• Chief complaint, past medical hx, family history,
  system review (lumps, lesions, pain, fatigue,
  easy bruising, ha, hemoptysis, vision
  disturbance, loss of appetite, etc.(see pg 325)
• Examination
• Vs, ht, wt, inspect face, scalp, mouth for
  lesions
• Ascultate lungs, and look at respiratory effort
• Inspect breasts for symmetry, dimpling, lumps
• Palpate abd, scrotum, etc

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Nursing DX- diagnostic phase

• Ineffective coping r/t fear of diagnosis
• Goal acceptance of need for medical evaluation
  and treatment
• Aeb patient seeks medical tx and evaluation
• (see pages 336-337)

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Interventions- diagnostic phase

• Ineffective copingencourage to learn the warning
  signs
• stress that medical evaluation is needed for
  correct diagnosis
• Anxiety remain hopeful, dont give false
  reassurance, dont use clichés, recognize the pts
  feelings
• Explain procedures

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Treatment phase- assessment

• Obtain complete drug profile
• Review systems to check for those related to tx
• Assess pt knowledge
• Explore pt adaptations
• Physical exam note general appearance, LOC,
  posture, gait, emotional state, head to toe assess

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Treatment phase- Nursing DX

• Anxiety related to effects and outcomes of tx
• Goal reduce anxiety aeb patient states anxiety
  is reduced and demonstrates a relaxed manner
• See page 338-339

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• Risk for injury
• Ineffective coping
• Anxiety
• Risk for infection
• Imbalanced nutritionlt less than body requirements
• See pages 339-342

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Recovery and rehab

• Periodic check ups
• Rehab restores pt to highest level of functioning
  possible

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Terminal illness

• 2nd leading cause of death
• Oncology clinical nurse is great resource for the
  patient

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Oncological emergencies

• Hypercalcemia
• Syndrome of inappropriate antidiuretic hormone
  (fluid does not come off)
• Disseminated intravascular coagulation (DIC)
• Superior Vena Cava Syndrome (redness/edema of
  face, tachycardia, distended neck veins)
• Teach client not to bend forward
• Spinal cord compression secondary to tumor

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