Oncology

Nursing

Care of
Clients with Cancer
Jessie T. Orao, RN, RM
MN Student - SPC

CANCER TREATMENT MODALITIES

OBJECTIVES

After 1.5 hours of lecture, the learners are expected to:

1. 2. 3. 4.

5.

enumerate the treatment modalities for cancer; discuss surgical interventions for cancer; identify the importance of radiation therapy, its principles and sources; describe chemotherapy mechanism of action, side-effects and nursing care; and determine the indications of immunotherapy and bone marrow transplant in relation to cancer management.

WORDS TO PONDER

Trust in the LORD with all your

heart and do not lean upon your own understanding. In all your ways take notice of HIM, and HE HIMSELF will make your paths straight.

Proverbs 3:5-6

NURSING WORDS

Options are thousands but choice for action limits us to few, even only to one and series of it among emerging choices. This one act can make the whole difference. Act as if it is your last, so you give it all. Act as if you have it all, so you can reap it. Act as if you are sure, so you can hit it all. Action defines your results. It comes from a choice you make among many options.
CARL E. BALITA

MANAGEMENT

http://www.cancer.org

MANAGEMENT

Goals
Cure complete eradication of malignant disease Control prolonged survival and containment of cancer cell growth Palliation relief of symptoms associated with the disease

TREATMENT MODALITIES

MANAGEMENT

Bone Marrow Transplantation

Surgical Interventions

Radiation Therapy

Immunotherapy

Chemotherapy

MANAGEMENT

http://www.cancernet.nci.nih.gov

Surgery A. Diagnostic Surgery

biopsy

MANAGEMENT

B. Primary Method of Treatment

prophylactic Palliative reconstructive

Surgery
Diagnostic Surgery

MANAGEMENT

Diagnostic surgery is the definitive method of identifying the cellular characteristics that influence all treatment decisions.

Surgery
Diagnostic Surgery

MANAGEMENT

Biopsy is usually performed to obtain a tissue sample for analysis of cells suspected to be malignant. The most

definitive method for diagnosing CA.

Excisional biopsy is most frequently used for easily accessible tumors of the skin, breast, upper and lower gastrointestinal tract and upper respiratory tract. Incisional biopsy is performed if the tumor mass is too large to be removed. Needle biopsies are performed to sample suspicious masses that are easily accessible, such as some growths in the breasts, thyroid, lung, liver, and kidney

Surgery
Needle biopsies

MANAGEMENT

Fine needle breast biopsy

Surgery

MANAGEMENT

Stereotactic biopsy of a brain lesion

Surgery
Diagnostic Surgery

MANAGEMENT

Exfoliative cytology used to study cells that the body has shed during the normal sequence of body tissue growth and development

Surgery

MANAGEMENT

Surgery as Primary Treatment GOAL

remove the entire tumor or as much as is feasible (a procedure sometimes called debulking) and any involved surrounding tissue, including regional lymph nodes.

Surgery
Surgery as Primary Treatment A. Prophylactic Surgery

MANAGEMENT

Prophylactic surgery involves removing nonvital tissues or organs that are likely to develop cancer. The following factors are considered when electing prophylactic surgery:
Family history and genetic predisposition Presence or absence of symptoms Potential risks and benefits Ability to detect cancer at an early stage Patients acceptance of the postoperative outcome

Surgery
Surgery as Primary Treatment

MANAGEMENT

A. Prophylactic Surgery Colectomy, mastectomy, and oophorectomy

Example: a strong family history of breast cancer, positive BRCA-1 or BRCA-2 findings, an abnormal physical finding on breast examination such as progressive nodularity and cystic disease, a proven history of breast cancer in the opposite breast, abnormal mammography findings, and abnormal biopsy results may be factors considered in making the decision to proceed with a prophylactic mastectomy (Houshmand, Campbell, Briggs, McFadden & Al-Tweigeri, 2000; Zimmerman, 2002).

Surgery
Surgery as Primary Treatment B. Palliative Surgery GOAL

MANAGEMENT

to make the patient as comfortable as possible and to promote a satisfying and productive life for as long as possible.

Surgery
Surgery as Primary Treatment B. Palliative Surgery

MANAGEMENT

Palliative surgery is performed in an attempt to relieve complications of cancer, such as ulcerations, obstructions, hemorrhage, pain, and malignant effusions. Communication: Honest and informative

MANAGEMENT

Surgery
Surgery as Primary Treatment C. Reconstructive Surgery GOAL

MANAGEMENT

improve function or obtain a more desirable cosmetic effect

Surgery
Surgery as Primary Treatment C. Reconstructive Surgery GOAL

MANAGEMENT

improve function or obtain a more desirable cosmetic effect

Reconstructive surgery may be indicated for breast, head and neck, and skin cancers

Surgery

MANAGEMENT

Surgery as Primary Treatment Local excision is warranted when the mass is small. It includes removal of the mass and a small margin of normal tissue that is easily accessible. Wide or radical excisions (en bloc dissections) include removal of the primary tumor, lymph nodes, adjacent involved structures, and surrounding tissues that may be at high risk for tumor spread. Outcome: disfigurement and altered functioning

Surgery
Surgery as Primary Treatment

MANAGEMENT

Video-assisted endoscopic surgery is replacing surgeries associated with long incisions and extended recovery periods. Salvage surgery is an additional treatment option that uses an extensive surgical approach to treat the local recurrence of the cancer after a less extensive primary approach is used. Example: A mastectomy to treat recurrent breast cancer after primary lumpectomy and radiation is an example of salvage surgery.

Surgery
Surgery as Primary Treatment

MANAGEMENT

Electrosurgery makes use of electrical current to destroy the tumor cells. Cryosurgery uses liquid nitrogen to freeze tissue to cause cell destruction. Chemosurgery uses combined topical chemotherapy and layer-by-layer surgical removal of abnormal tissue.

Surgery
Surgery as Primary Treatment

MANAGEMENT

Laser surgery (light amplification by stimulated emission of radiation) makes use of light and energy aimed at an exact tissue location and depth to vaporize cancer cells. Stereotactic radiosurgery (SRS) is a single and highly precise administration of high-dose radiation therapy used in some types of brain and head and neck cancers.

Surgery

MANAGEMENT

Post-operative Considerations 1. 2. 3. 4. body image self-esteem functional abilities rehabilitation

Surgery
Nursing Management

MANAGEMENT

complete a thorough preoperative assessment for all factors that may affect patients undergoing surgical procedures. provide education and emotional support by assessing patient and family needs and exploring with the patient and family their fears and coping mechanisms, encouraging them to take an active role in decision making when possible. communicate frequently with the physician and other health care team members to be certain that the information provided is consistent.

Surgery
Nursing Management

MANAGEMENT

assess the patients responses to the surgery and monitors for possible complications, such as infection, bleeding, thrombophlebitis, wound dehiscence, fluid and electrolyte imbalance, and organ dysfunction address wound care, activity, nutrition, and medication information. plan for discharge, follow-up and home care, and treatment are initiated as early as possible to ensure continuity of care from hospital to home or from a cancer referral center to the patients local hospital and health care provider.

MANAGEMENT

Radiation Therapy

MANAGEMENT

It uses ionizing radiation to interrupt cellular growth. Palliative radiation therapy is used to relieve the symptoms of metastatic disease, especially when the cancer has spread to brain, bone, or soft tissue, or to treat oncologic emergencies, such as superior vena cava syndrome or spinal cord compression. IORT (intraoperative radiation therapy) used for gastric, pancreatic, colorectal, bladder, and cervical cancers and sarcomas which involves delivering a single dose of high-fraction radiation therapy to the exposed tumor bed while the body cavity is open during surgery.

Radiation Therapy

MANAGEMENT

Two types of ionizing radiation (can lead to tissue disruption)

1. electromagnetic rays (x-rays and gamma rays) 2. particles (electrons [beta particles], protons, neutrons, and alpha particles

Sources:
1. External 2. Internal a. sealed b. Unsealed

TYPES
2. Internal Radiation Therapy. This is administered within or near the tumor or in the systematic circulation. delivers a high dose of radiation to a localized area. The specific radioisotope for implantation is selected on the basis of its half-life.
A. Sealed source (brachytherapy). The radioisotope is placed within or near the tumor. The radioactive material is enclosed in a sealed container. Sealed source is used for both intracavity and interstitial therapy. Intracavity RT is used to treat cancers of the uterus and cervix.
Jessie T. Orano, RN, RM - St. Alexius College

Jessie T. Orano, RN, RM - St. Alexius College

Jessie T. Orano, RN, RM - St. Alexius College

TYPES

Jessie T. Orano, RN, RM - St. Alexius College

TYPES

The radioisotope is placed in the body cavity, generally for 24 to 72 hours (cesium 137 or radium 226). Interstitial therapy radioisotope is placed in needles, beads, seeds, ribbons, or catheters, implanted directly into the tumor ( iridium 192, iodine 125 cesium 137, gold 198, and radium 222). In SSIR, radioisotope cannot circulate through clients body nor contaminate the clients urine, sweat, blood or vomitus. Direct contact with sealed source container results to radiation exposure.
Jessie T. Orano, RN, RM - St. Alexius College

EXAMPLE
Radioactive Seed

Jessie T. Orano, RN, RM - St. Alexius College

EXAMPLE
Radioactive Beads

Jessie T. Orano, RN, RM - St. Alexius College

TYPES
B. Unsealed source. The radioisotope may be administered intravenously, orally or by instillation directly into the body cavity. Radioisotopes circulates in the body. Urine, sweat, blood or vomitus contain the radioactive isotope. Examples:

Iodine 131 for Graves disease and thyroid cancer Alrontium chloride for relief of painful bony metastasis

ALERT: Iodine is eliminated within 48 hours.

Jessie T. Orano, RN, RM - St. Alexius College

Radiation Therapy
Radiation Dosage

MANAGEMENT

The radiation dosage is dependent on the sensitivity of the target tissues to radiation and on the tumor size. The lethal tumor dose is defined as that dose that will eradicate 95% of the tumor yet preserve normal tissue.

Radiation Therapy
Radiation Dosage

MANAGEMENT

Radiation destroys cancer cells by affecting cell structure and the cell environment. It is used in fractionated (divided) doses to prevent destructive side effects;

however, side effects can occur in the area being treated because of damage to normal cells.

Radiation Therapy

MANAGEMENT

Radioactive Stent

Radiation Therapy

MANAGEMENT

Radioactive Seed

Radiation Therapy

MANAGEMENT

Radioactive Beads

Radiation Therapy

MANAGEMENT

D Distance

T Time

S Shielding

Radiation Therapy

MANAGEMENT

D Distance

Maintain a distance of at least 3 feet when not performing nursing procedures.

The greater the distance maintained from the radiation source, the less the exposure dose to ionizing rays

Radiation Therapy
T Time

MANAGEMENT

Limit contact with the client or 5 minutes each time a total of 30 minutes per 8-hour shift.

The lesser the time spent close to the radiation source, the lesser the amount of radiation exposure

MANAGEMENT
Wear a dosimeter film badge at all times while caring for clients

S Shielding

Shielding is the physical barrier between a person and a radiation source. Use lead shield/lead apron during contact with client

The more tightly packed particles and atoms literally absorb more radiation

PRINCIPLES

Jessie T. Orano, RN, RM - St. Alexius College

Jessie T. Orano, RN, RM - St. Alexius College

Jessie T. Orano, RN, RM - St. Alexius College

MANAGEMENT
Private room Private bath Radioactive Material sign on the door

Radiation Therapy

MANAGEMENT

Nursing responsibilities include knowledge about the following:

1 2 3 4

Radiation source being used Method of administration Start of treatment Length of treatment Prescribed nursing precautions

Radiation Therapy
1.

MANAGEMENT

2.
3. 4. 5.

To avoid exposure to radiation while the patient is receiving therapy, consider the following: DTS If exposed to penetrating radiation, wear film badges on the front of the body. Take appropriate measures associated with sealed sources of radiation implanted within a patient. Know that all casing material absorbs radiation. Do not linger longer than necessary in giving patient care, even though all precautions are followed.

Radiation Therapy

MANAGEMENT

6. Be alert of implants that may have become loosened (those inserted in cavities that have access to the exterior). Example: check the emesis basin following mouth care for patient with an oral implant. 7. Notify the radiation therapist of any implant that has moved out of position. 8. Use long-handled forceps or tongs and hold at arms length when picking up any dislodged radium, needle, seeds, or tubes. 9. Do not discard any dressing or linens unless you are sure that no radioactive source is present.

CLIENT EDUCATION
Field markings are made with what are called felt-tipped pens, or Edding marker pens, onto the patients skin. These of course, fade off because of sweating, washing or moisturizing cream applications.

Jessie T. Orano, RN, RM - St. Alexius College

Radiation Therapy
ALERT:

MANAGEMENT

Never pick-up radioactive source with your hands.

Deposit the radioactive source in the lead container kept in the clients room.

MANAGEMENT

Nursing Considerations for Radiation Safety

1. 2. 3. 4.

5.
6. 7. 8.

Minimize amount of time near a radioactive source. (30 mins in 8 hour shift) Maximize distance from radioactive source. (6ft) Use required shielding to minimize exposure. Wear film badges or pocket ion chambers to monitor exposure. Wear rubber gloves to dispose of any soiled matter that may be contaminated. Provide specific laundry and housekeeping directions. Keep the patient restricted to her room and allow NO visitors who are or maybe pregnant or who are younger than 18 years of age. Explain that a discharge survey is usually performed by Radiation Safety Department personnel before the patient leaves the room.

MANAGEMENT

Chemotherapy

MANAGEMENT

CHEMOTHERAPY

- an approach that uses chemicals to destroy cancer cells on selective basis. The cytotoxic agents used in cancer treatments generally do not kill the cancer cells directly but instead impair their ability to replicate by interfering with DNA and RNA activities.

Chemotherapy may be used as 1.) Adjuvant therapy 2.) Neoadjuvant therapy 3.) Chemoprevention 4.) Myeloablation

ADJUVANT THERAPY a course of chemotherapy used in conjunction with another treatment modality ( surgery, radiation, biotherapy ) and aimed at treating micro-metastasis NEO-ADJUVANT CHEMOTHERAPY administration of chemotherapy to shrink the tumor prior to surgical removal of the tumor

PRIMARY THERAPY the treatment of clients with localized cancer for which there is an alternative but less than completely effective treatment. INDUCTION CHEMOTHERAPY the drug therapy given as the primary therapy for clients with cancer for which no alternative treatment exists. COMBINATION CHEMOTHERAPY administration of two or more chemotherapeutic agents in the treatment of cancer, allowing each medication to enhance the action of the other or to act synergistically.

Classification of Chemotherapy Drugs

CYTOPROTECTIVE AGENTS
Protect

normal tissue by binding with metabolites of other cytotoxic drugs Dexrazoxane Mesna
for methotrexate toxicity Leucovorin

FOLIC ACID ANALOGS

Antidote

HORMONE AND HORMONE INHIBITORS

Interfere

with binding of normal hormones to receptor proteins Manipulate hormone levels After hormone environment Usually palliative,not curative Androgens, Antiandrogens, Antiestrogens, Estrogens, Gonadotropin, Progestins

Chemotherapy

MANAGEMENT

Chemotherapy

MANAGEMENT

Chemotherapy

MANAGEMENT

MANAGEMENT

Classification of Chemotherapy Drugs

Classification of Chemotherapy Drugs

CYCLE SPECIFIC

MANAGEMENT

CHEMOTHERAPY
1. Antimetabolites - It interferes with the biosenthesis of metabolites or nucleic acids necessary for RNA and DNA synthesis. - Attack during S phase of cell cycle Examples Cytarabine, Methotrexate, Pentostatin, 5Fluorouracil, 6-mercaptopurine, 6thioguanine

MANAGEMENT

CHEMOTHERAPY
Common Side Effects Nausea and vomiting Diarrhea Bone Marrow suppression Stomatitis Renal Toxicity Hepatoxicity

MANAGEMENT

CHEMOTHERAPY
Methotrexate C antineoplastic E evaluate tumor size A no specific S avoid alcohol Report black tarry stool and sore throat E keep the antidote leucovorine at the bedside. May cause birth detects. Administer antiemetic to counteract nausea and vomiting The drug depresses the bone marrow and damage the liver Sample question: which blood profile is monitored if a patient will receive methotrexate? a. uric acid b. S. G. O. T. c. creatinine d. W.B.C.

MANAGEMENT

CHEMOTHERAPY
2. Mitotic Spindle Poisons - It arrests metaphase by inhibiting mitotic tubular formation; inhibits DNA and protein synthesis

Examples Etoposide, Vinblastine, Vincristine, Docetaxel, Paclitaxel, Etoposide, Teniposide Common Side Effects Bone Marrow suppression, Neuropathies, Stomatitis

A. Enzymes Useful only for leukemias

Example: Asparaginase

B. Plant Alkaloids Cycle-specific to M Phase Prevent mitotic spindle formation Example: Vinblastine, vincristine

Classification of Chemotherapy Drugs

CYCLE-NONSPECIFIC

MANAGEMENT

1.

Alkylating Agents

- It alters DNA structure by misreading DNA code, initiating breaks in the DNA molecule and cross-link DNA strands Examples: Busulfan, Carboplatin, Chlorambucil, Cisplatin, Cyclophosphamide, Melphalan, Thiotepa

MANAGEMENT

CHEMOTHERAPY
Common Side Effects: Bone marrow suppression Nausea Vomiting Cystitis Stomatitis Alopecia Gonadal Suppression Renal Toxicity

MANAGEMENT

CHEMOTHERAPY
Cytoxan (Cyclophosphamide)

C Antineoplastic E Decreased tumor size A Best given in the morning to prevent hemorrhagic cystitis S Alopecia is temporary; report sore throat; report hematuria dysuria immediately E Monitor CBC Increase fluid intake and output Assess for signs and symptoms of nephrotoxicity. Monitor CBC.

MANAGEMENT

CHEMOTHERAPY
Cytoxan (Cyclophosphamide)

Sample Questions: a nurse should include which of the following strategies in the care plan of a child who is receiving cyclophosphamide (Cytoxan) for treatment of Hodgkins disease?
a. b. c. d.

monitor the childs intake and output assess the childs apical heart rate place a footboard at the end of the childs bed evaluate the childs hemoglobin level

MANAGEMENT

CHEMOTHERAPY
2. Antitumor Antibiotic - It interferes with DNA synthesis by binding DNA; prevents RNA synthesis
Examples Bleomycin, Dactinomycin, Doxorubicin, Idarubicin, Mitomycin, Mitoxantrone, Plicamycin

MANAGEMENT

CHEMOTHERAPY
Common Side Effects Bone Marrow suppression Nausea and vomiting Alopecia Anorexia Cardiac Toxicity

MANAGEMENT

CHEMOTHERAPY
Adriamycin (Doxorubcin) C Antineoplastic Antibiotic E (-) infection CBC changes A Best taken in the morning S May turn the urine red, can cause diarrhea and alopecia E Increase fluid intake the drug can cause hyperuricemia Asses for Allergy Sample question: which of the following statements if made by a patient who is administered doxocrubicin hydrochloride (adriamycin) would indicate to nurse that the patient needs further instruction about the adverse effects of the drugs?
a. b. c. d.

my hair is going to fall out my urine will turn red I can expect to become constipated I may develop an irregular heartbeat

MANAGEMENT

CHEMOTHERAPY
Oncovin (Vincristine) C antineoplastic E evaluate tumor size A no specific S may cause alopecia nausea vomiting and constipation Use birth control it is teratogenic E instruct the patient that the drug is not taken during pregnancy Sample question: To which of the following nursing measures should a nurse give priority in the care of a patient who is receiving vincrestine sulfate (oncovin)?
a. b. c. d.

limiting environment stimuli observing for gum hyplasia monitoring for cardiac dysrhythmias increasing dietary fiber content

MANAGEMENT

CHEMOTHERAPY
Administration of Chemotherapeutic Agents:
It maybe administered in the hospital, clinic, or home setting by topical, oral, intravenous, intramuscular, subcutaneous, arterial, intracavitary, and intrathecal routes.

Special Problems:
1.
2.

EXTRAVASATION TOXICITY

MANAGEMENT

CHEMOTHERAPY
3. Nitrosureas - Similar to the alkylating agents; it can cross the Blood-Brain Barrier
Examples Carmustine, Lomustine, Semustine, Streptozocin Common Side Effects: Delayed and cumulative myelosuppresion, nausea and vomiting

MANAGEMENT

CHEMOTHERAPY
4. Topoisomerase Inhibitors - Induce breaks in the DNA strand by binding to enzyme topoisomerase, preventing cells from dividing.
Examples Irinotecan, Topotecan

Common Side Effects Bone Marrow suppression, diarrhea, nausea and vomiting, hepatotoxicity

MANAGEMENT

NUTRITION NOTES Reducing Cancer Risk Encourage patient to consume these foods:
Fruits and vegetables, especially those rich in vitamin C or carotene Cruciferous vegetables (cabbage, broccoli, brussels sprouts) Whole grains

Encourage patient to limit these foods:

Excessive meat, especially when smoked, salted, charbroiled, or cooked at high temperature Excessive fat (more than 30% of daily calories) Excessive calories Alcohol

PARTING WORDS

Theres only one corner of the universe you can be certain of improving, and thats your own self. Commit to your self and struggle to become a better player of your life.