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Definition
Family of complex diseases Affect different organs and organ systems Cancer results when normal cells mutate into abnormal cells that take over normal tissue Eventually harm and destroy host
Biology of Cancer
Defect in cellular proliferation- cancer cells respond differently than normal cells to intracellular signals Cancer cells divide indiscriminately & haphazardly
Defect in Cellular Differentiationnormally there is an orderly process that progresses cells from a state of immaturity to a state of maturity; as cancer cells mature, they dedifferentiate or change from the normal
Types of Cancer
Carcinomas: solid tumors arising from epithelial cells Sarcomas: derived from muscle, bone, fat, & other connective tissue Lymphomas: originate in lymphoid tissue Leukemias: originate in the cells in bone marrow that make blood Myeloma: develops in the plasma cells of bone marrow
Oncology
Study of cancers Oncology nurses specialize in the care, treatment of clients with cancer
Cancer is Contagious All Cancer patients have pain The treatment is worse than the disease Sexual activity & other aspects of normal life must be forfeited Cancer is a death sentence
Cancer accounts for about 25% of death on yearly basis (2001) Males: 3 most common types of cancer are prostate, lung and bronchial, colorectal Females: 3 most common types of cancer are breast, lung and bronchial, & colorectal
Heredity: 5 10% of cancers; genetic testing can trace some breast and colon cancers Age: 70% of all cancers occur in persons > 65 Gender: a factor for certain types of cancer Poverty: at greater risk due to access to health care
Stress: Leads to greater wear and tear on body in general due to impaired immune system secondary to uncontrolled stress Type C personality (cancer personality) persons who tend to others needs to exclusion of their own
Diet: certain preservatives in pickled, salted foods; fried foods; high-fat, low fiber foods; charred foods Occupational risk: exposure to know carcinogens, radiation, high stress Infections: especially specific organisms and organ (e.g. papillomavirus causing genital warts & leading to cervical cancer)
Tobacco Use: Lung, oral and laryngeal, esophageal, gastric, pancreatic, bladder cancers Alcohol Use: also tied with smoking Sun Exposure (radiation): e.g. skin cancer (melanoma)
Recreational Drug Use: promotes unhealthy lifestyle Obesity: Excessive body fat linked to risk of hormone dependent cancers (ie: breast, bowel, ovary, prostate)
Overall cancer death rate Lung cancer death rate Breast cancer death rate death rate from cancer of the uterus/cervix colorectal cancer death rate
Oropharyngeal cancer death rate Prostate cancer death rate Rate of melanoma death rate protective measures to risk of skin cancer women who receive Pap Test women who receive mamogram
Change in bowel habits A sore that sore not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty in swallowing Obvious change in wart or mole
Screening examination recommendations by American Cancer Society: Breast Cancer: self-breast exam, breast examination by health care professionals, screening mammogram Colon and Rectal Cancer: fecal occult blood, flexible sigmoidoscopy, colonoscopy Cervical, Uterine Cancer: Papanicolaou (Pap) test Prostate Cancer: digital rectal exam, Prostate-specific antigen (PSA) test
External: chemicals, radiation & viruses Internal: hormones, immune conditions, inherited mutations
Known Carcinogens
Viruses- may play a role in cell mutation Drugs & Hormones Chemical Agents- Ie: arsenic found in pesticides; hydrocarbons found in soot; benzopyrene found in cigarette smoke Physical Agents- Ie: Radiation; Radon
Benign- Localized, non-cancerous growths; solid mass with well-defined borders; frequently encapsulated Malignant- tumors that grow aggressively; no cohesion; irregular shape. Malignant tumors can metastasize (spread).
Tumor Sites
Primary tumor: the original site of the malignancy Secondary tumor: areas where malignancy has spread i.e. metastasis (metastatic tumor)
Metastasis
Tumor cells travel through blood or lymph circulation to other body areas and invade tissues and organs in another part of the body Common sites of metastasis are lymph nodes, liver, lungs, bones, brain
Progress in deviation with each generation and do no stop growing and die, as do normal cells Are irreversible, i.e. they do not revert to normal cells once malignant Ability to promote their own survival by hormone production; divert nutrition from host cells
Effects of Cancer
Disruption of Function - can be due to obstruction or pressure Leads to anoxia and necrosis of organs Ie; increased intracranial pressure Loss of function: Ie: bowel or bladder obstruction Interrupted vascular/venous blockage Ie: Ascites; disturbed liver functioning
Hematologic Alterations: can impair function of blood cells Abnormal WBCs impaired immunity Diminished RBCs and platelets anemia & clotting disorders Infections: fistula can develop and tumors may become necrotic & lead to septicemia; erode skin surface breakdown of
Hemorrhage: tumor erosion, bleeding, severe anemia Anorexia-Cachexia Syndrome: wasted appearance of client Unexplained rapid weight loss; anorexia with altered smell and taste Catabolic state: use of bodys tissues and muscle proteins to support cancer cell growth
Paraneoplastic Syndromes: ectopic sites with excess hormone production Parathyroid hormone hypercalcemia secretion of insulin hypoglycemia Antidiuretic hormone (ADH) fluid retention, HTN & peripheral edema
Adrenocorticotropic hormone (ACTH): cause excessive secretion of cortisone (ie: fluid retention, glucose levels)
Pain: major concern of clients and families associated with cancer Types of cancer pain: Acute: symptom that led to diagnosis Chronic: may be related to treatment or to progression of disease
Direct tumor involvement including metastatic pain- primary cause of pain experienced by those with cancer Nerve compression Involvement of visceral organs
Physical Stress: body tries to respond and destroy neoplasm Fatigue Weight loss Anemia Dehydration Electrolyte imbalances
Psychological Stress Cancer equals death sentence Guilt from poor health habits Fear of pain, suffering, death Stigmatized
Collaborative Care
Determine location of cancer: X-rays Computed tomography Ultrasounds Magnetic resonance imaging Nuclear imaging Angiography
Diagnosis of cell type: Tissue samples: from biopsies, shedded cells (e.g. Papanicolaou (PAP) smear), & washings Cytologic Examination: tissue examined under microscope
Grading: Evaluates degree of differentiation and rate of growth Grade 1 (least aggressive) to Grade 4 (most aggressive) Staging: Relative tumor size and extent of disease TNM (Tumor size; Nodes: lymph Node involvement; Metastases)
Tumor markers: specific proteins which indicate malignancy PSA (Prostatic-specific antigen): prostate cancer CEA (Carcinoembryonic antigen): colon cancer Alkaline Phosphatase: bone metastasis
Direct Visualization: Sigmoidoscopy Cystoscopy Endoscopy Bronchoscopy Exploratory surgery; lymph node biopsies to determine metastases
Other non-specific tests: CBC, Differential Electrolytes Blood Chemistries: (liver enzymes: alanine aminotransferase (ALT); aspartate aminotransferase (AST) lactic dehydrogenase (LDH)
Treatment Options
Treatment Goals
Cure: free of disease after treatment normal life Control: Goal for chronic cancers Palliative Care: Quality of life maintained at highest level for the longest possible time
Chemotherapy
Chemotherapy: involves use of cytotoxic medications that kill both normal cells and cancerous cells is usually administered IV through a central line
Chemotherapy (cont.)
Classes of Chemotherapy Drugs: Alkylating agents: Action: create defects in tumor DNA Ex: Nitrogen Mustard, Cisplatin Toxic Effects: reversible renal tubular necrosis Antimetabolites: Action: phase specific Ex: Methotrexate; 5 fluorouracil Toxic Effects: nausea, vomiting, stomatitis, diarrhea, alopecia, leukopenia
Chemotherapy (cont.)
Antitumor Antibiotics: Action: non - p hase specific; interfere with DNA Ex: Actinomycin D, Bleomycin, adriamycin (doxorubicin) Toxic Effect: damage to cardiac muscle
Chemotherapy (Cont.)
Miotic inhibitors: Action: Prevent cell division during M phase of cell division Ex: Vincristine, Vinblastine Toxic Effects: affects neurotransmission, alopecia, bone marrow depression
Chemotherapy (Cont.)
Hormones: Action: stage specific G1 Ex: Corticosteroids Hormone Antagonist: Action: block hormones on hormone - b inding tumors ie: breast, prostate, endometrium; cause tumor regression Ex: Tamoxifen (breast); Flutamide (prostate) Toxic Effects: altered secondary sex characteristics
Chemotherapy (Cont.)
Effects of Chemotherapy Tissues: (fast growing) frequently affected Examples: mucous membranes, hair cells, bone marrow, specific organs with specific agents, reproductive organs (all are fetal toxic; impair ability to reproduce)
Extreme care for correct dosage; double check with physician orders, pharmacists preparation Proper management clients excretement
&
Surgery
Done for Diagnosis, staging, and sometimes treatment of cancer Involves removal of body part, organ, sometimes with altered functioning (e.g. colostomy) Debulking (decrease size of) tumors in advanced cancer cases
Surgery (cont.)
Reconstruction and rehabilitation (e.g. breast implant post mastectomy) Psychological support to deal with surgery as well as cancer diagnosis
Radiation Therapy
Treatment choice for some tumors to kill or reduce tumor, relieve pain or obstruction
Delivery: Teletherapy (external): radiation delivered in uniform dose to tumor Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is placed in tumor or next to it Combination
Goals: Maximum tumor control with minimal damage to normal tissues Caregivers must protect them- selves by using shields, distancing and limiting time with client, following safety protocols
Biotherapy (Immunotherapy)
Modification of biologic processes that result in malignancies; based on boosting the patients immune system function Used for hematological malignancies, renal and melanoma
Photodynamic Therapy
Client giving photosensitizing compound which concentrates in malignant tissue; Later they are given laser treatment to destroy tumor Ex: Photofrin
Stimulation of nonfunctioning marrow or replace bone marrow Common treatment for leukemias
Pain Control
Includes pain directly from cancer, cancer treatment, or unrelated pain Necessary for continuing function or comfort in terminally ill clients Goal: maximum relief with minimal side effects
Utilize multiple combinations of analgesics (narcotic and non-narcotic) and adjuvants such as steroids or antidepressants; includes around the clock (ATC) schedule with additional medications for break-through pain Utilize multiple routes of medications
May involve injections of anesthetics into nerve, surgical severing of nerves, radiation May need to progress to stronger pain medications as pain increases and client develops tolerance to pain medication
Anxiety
Therapeutic interactions with client and family; community resources such as American Cancer Society, I Can Cope Availability of community resources for terminally ill (Hospice care in-patient, home care)
Includes loss of body parts (e.g. amputations); appearance changes (skin, hair); altered functions (e.g. colostomy); cachexic appearance, loss of energy, ability to be productive Fear of rejection, stigma
Anticipatory Grieving
Facing death and making preparations for death: will be consideration Offer realistic hope that cancer treatment may be successful
Organ obstruction from tumors Pathological fractures risk secondary to bone loss as seen in metastasis
Consultation with dietician, lab evaluation of nutritional status Managing problems with eating: anorexia, nausea and vomiting May involve use of parenteral nutrition
Oral, pharyngeal, esophageal tissues (due to chemotherapy, bleeding due to low platelet counts, fungal infections such as thrush) Teach inspection, frequent oral hygiene, specific non-irritating products, thrush control
Oncologic Emergencies
Concern: compression of heart by fluid in pericardial sac, compromised cardiac output Treatment: pericardiocentesis
Concern: obstruction of venous system with increased venous pressure and stasis; facial and neck edema with slow progression to respiration distress Treatment: respiratory support; decrease tumor size with radiation or
Concern: Early recognition of infection Treatment: prompt treatment with antiifective agents essential
Concern: pressure from expanding tumor can cause irreversible paraplegia; back pain initial symptom with progressive paresthesia and leg pain and weakness Treatment: early detection and radiation of tumor or surgical decompression
Obstructive Uropathy
Concern: blockage of urine flow; undiagnosed can result in renal failure Treatment: restore urine flow
Hypercalcemia
Concern: high calcium from ectopic parathyroid hormone or metastases Behaviors: fatigue, muscle weakness, polyuria, constipation progressing to coma, seizures Treatment: restore fluids with intravenous saline; loop diuretics; more definitive treatments
Hyperuricemia
Concern: occurs with rapid necrosis of tumor cells as with chemotherapy; can result in renal damage and failure Prevention and treatment with fluids and Alopurinol (Zyloprim)
Concern: ectopic ADH production from tumor leads to excessive hyponatremia Treatment: restore sodium level by giving IV replacement
Pediatric Cancer
Cancer is main cause of death for children between 1-15 yrs (second to accidents) Increasing rate of incidence in infants recently seen >55% of children w/ bone cancer survive 5 year survival rate approx. 87% with Hodgkins Disease
Leukemia: most common childhood cancer; cells change in the bone marrow Neuroblastoma: cancer of the nervous system; most common site: abdomen Brain Tumors: 5 year survival rate 58%
Hodgkins Disease & other lymphomas: 5 year survival rate 87% Osteosarcoma: most common bone cancer; uncommon under age 10; 5 year survival rate 56% Wilims Tumor-Kidney Cancer: mostly under 5 years of age; 5 year survival rate 84%
Ewings Sarcoma: shaft of bone; rare but fast growing; 5 year survival rate 87% Rhabdomyosarcoma: cancer of muscles that connect to bones; 2-6 & 14-18; 2 year survival rate 70% Retinoblastoma: eye cancer; inheritable; under age 2; survival rate is 70%-90%