Monday, February 4, 2008

Cancer Nursing General Considerations

Cancer Nursing General Considerations

• Cancer is a disease of the cell in which the normal mechanisms of control of growth and proliferation are disturbed

• Characteristic features: anaplasia, autonomy, invasiveness, metastasis, angiogenesis

• The malignant cell is able to invade the surrounding tissue and regional lymph nodes

• Metastasis is the secondary growth of the primary cancer in another organ

• Lymph nodes are often the 1st site of distant spread

Differences between Malignant and Benign Tumors:


• Slow expansive growth

• Fully differentiated

• Absent metastasis


• Invasive

• Immature, poorly differentiated

• Metastasis present


• Epidemiology: African Americans continue to have a higher incidence of cancer

• Age is the most outstanding risk factor for cancer

• 80% of all cancers in America are related to lifestyle habits (smoking, alcohol consumption, diet) and environmental carcinogens

• There is a hereditary predisposition to specific forms of cancer

• Infection and viruses are associated with increased risk of certain forms of cancer

• Patterns of incidence and death rates vary with sex, age, race and geographic location

Cancer Incidence by Site and Sex

• Male

• Prostate

• Lung

• Colon

• Bladder

• Lymphoma


• Breast

• Lung

• Colon

• Uterine

• Lymphoma

Cancer Deaths by Site and Sex


• Lung

• Prostate

• Colon

• Lymphoma

• Pancreas


• Lung

• Breast

• Colon

• Pancreas

• Ovarian

Nutrition and Cancer

• Diet does influence the risk of cancer

• High intake of fats may be associated with breast, colon, and prostate cancer

• Low intake of fruit, vegetables, complex carbohydrates, and fiber is linked with cancer of the colon, larynx, esophagus, prostate, bladder, and stomach, and lung

• Salt-cured foods may influence cancers of the esophagus and stomach

• Obesity is linked to cancers of the breast, colon, uterus, and gall bladder

Unified Dietary Guidelines

• A healthy diet would include:

• No more than 10% of total calories from saturated fat

• No more than 30% of total calories from fat; 55% of total calories should come from complex carbohydrates, such as cereals, grains, fruits, and vegetables

• Dietary cholesterol should not exceed 300 mg/day

• Salt consumption should be limited to 6 gram/day (one teaspoon) Detection and Prevention

• Primary prevention and secondary prevention are effective measures in decreasing mortality and morbidity of many cancers

Detection and Prevention

• Primary Prevention

• Make appropriate lifestyle changes

• Stop smoking

• Limit alcohol intake

• Eat a healthy diet

• Be physically active

• Avoid sun exposure

• Genetic counseling for high risk persons

• Chemoprevention

Detection & Prevention

• Secondary Prevention

• Screening and early detection to improve overall outcome and survival

• Testicular cancer

• Prostate cancer

• Breast cancer

• Colon and rectal cancer

• Uterine cancer

• Lung cancer (not routinely screened because there is no cost effective method)*

• For Testicular Cancer

• Self exam

• Age 15-35

• Frequency of exam = annual

For Prostate Cancer

• Beginning at age 50, have a yearly digital rectal examination

• Beginning at age 50, have a yearly prostate specific antigen (PSA) test*

For Breast Cancer

• At any age, routinely perform monthly breast self examination (BSEs)

• Women ages 20 to 39 should have breast examination by a health care provider every

3 years

• Women age 40 and older should have a yearly mammogram and breast examination by a health care provider

• For Colon and Rectal Cancer

• Digital rectal exam/ fecal occult blood test at age 40 should be done annually

• Flexible sigmoidoscopy at age 50 every 3 years (some require a frequency of every 5 years)

• Colonoscopy at age 50 every 5 years (some require a frequency of every 10 years)

• For Uterine Cancer

• Yearly papanicolau (Pap) smear for sexually active females and any female over age


• At menopause, high risk women should have an endometrial tissue sample

• Diagnostic Evaluation:

• Complete medical history and physical examination

• Biopsy of tumor site to determine pathologic diagnosis

• Classification of tumor type is based on tissue and cellular staining

• For most tumors the higher grade, the less differentiated, which is associated with

Poorer prognosis

• Laboratory tests including complete blood count (CBC) with differential, platelet count, and blood chemistries including liver function tests, BUN, and creatinine are done to determine baseline values

• Imaging procedures: CXR, CT scan, MRI

• Staging:

• Staging is necessary at the time of diagnosis to determine the extent of disease (local versus metastatic), to determine prognosis, and to guide proper management

• The American Joint Committee of Cancer (AJCC) has developed a simple classification system (TNM) that can be applied to all tumor types

TNM Classification

ACS’ Seven Warning Signs of Cancer








• Change in bowel or bladder habits

• A sore that does not heal

• Unusual bleeding or discharge

• Thickening in breast or elsewhere

• Indigestion or difficulty in swallowing

• Obvious change in wart or mole

• Nagging cough or hoarseness


• Surgical

• Chemotherapy

• Radiation therapy

• Cancer immunotherapy

Surgical Management

• The principles of surgical management are based on a cooperative, multi-disciplinary approach to various surgical procedures

Types of Surgical Procedures

• Biopsy

• Excisional biopsy

• Reconstructive/rehabilitative surgery

• Palliative surgery

• Treatment of primary tumor

• Resection of metastasis

• Preventive/prophylactic surgery

• Curative surgery

• Debulking surgery Chemotherapy for Cancer

• Chemotherapy is the use of anti-neoplastic drugs to promote tumor cell destruction by interfering with cellular function and reproduction*

Principles of Chemotherapy Administration1

• The intent of chemotherapy is to destrot as many tumor cells as possible with minimal effect on healthy cells

• The goals of chemotherapy:

• Curative complete response of the tumor

• Control to extend the life of the patient when a cure is not possibe

• Palliation reduction of tumor burden to relieve symptoms such as pain and improve quality of life

• Chemotherapeutic Agents can be effective on one of the four phases of the cell cycle

• The cell cycle is divided into four stages;

• G1 phase

• S phase

• G2 phase

• M phase

• Cells not active in the cell cycle are designated as “resting” (G0). Cells in this phase are, for the most part, refractory to chemotherapy

Chemotherapeutic Agents

• Therapeutic strategies:

• High dose/intensive therapy is the administration of high doses of chemotherapy

• Combination therapy is the use of multiple chemotherapeutic agents with different actions to provide maximal kill and minimize drug resistance

Routes of administration:

• Oral

• Intravenous

• Intramuscular subcutaneous

• Intrathecal/intraventricular

• Intraarterial

• Intracavitary

• Intravesical

• Topical

• Most chemotherapeutic agents have dose limiting toxicities that require nursing


• Chemotherapy predictably affects normal, rapidly growing cells (e.g., bone marrow, gastrointestinal tract lining, hair follicles)

• It is imperative that these toxicities be recognized early on by the nurse

Chemotherapeutic Agents

• Alkylating agents:

• Cyclophosphamide

• Busulfan

• Carmustine

• Lomustine

• Carboplatin

• Chlorambucil

• Cisplatin

• Ifosfamide

• Mechloretamine

• Melphalan

• Streptozocin

Major Side Effects common to these drugs:

• Bone marrow suppression; Thrombocytopenia

• Nausea and vomiting

• Alopecia

• Cyclophosphamide & Ifosphamide – hemorrhagic cystitis

Chemotherapeutic Agents

• Antineoplastic Antibiotics:

• Bleomycin

• Dactinomycin

• Daunorubicin

• Doxorubicin

• Mitomycin

Major Side Effects common to these drugs:

• Bone marrow suppression; Thrombocytopenia

• Nausea and vomiting

• Alopecia

• Bleomycin & Mitomycin – pulmonary fibrosis

• Daunorubicin & Doxorubicin – cardiomyopathy

Chemotherapeutic Agents

• Mitotic inhibitors:

• Vinblastine

• Vincristine

• Vindesine

• Teniposide

• Etoposide

Major Side Effects common to these drugs:

• Bone marrow suppression; Thrombocytopenia

• Nausea and vomiting

• Alopecia

• Vesicant

• Neuropathy

• Vincristine – elevated uric acid

Chemotherapeutic Agents

• Anti-Metabolites:

• Cytarabine

• Fludarabine

• 5-Fluouracil

• 6-Meracptopurine

• Methotrexate

• Thioguanine

Major Side Effects common to these drugs:

• Bone marrow suppression; Thrombocytopenia

• Nausea and vomiting

• Alopecia

• Stomatitis, diarhhea

• Methotrexate – nephrototoxicity

• 6 Mercaptopurine & Thioguanine – hepatotoxicity

Principles of Chemotherapy Administration2

• Safety measures in handling chemotherapy

• Personal safety to minimize exposure via inhalation

• Personal safety to minimize exposure via skin contact

• Personal safety to minimize exposure via ingestion

• Safe disposal of antineoplastic agents, body fluids and excreta

Side Effects of Chemotherapy

• Alopecia

• Anorexia

• Fatigue

• Nausea and vomiting

• Mucositis

• Anemia

• Neutropenia

• Thrombocytopenia

Nursing Assessment

• Integumentary System

• Gastrointestinal System

• Hematopoietic System

• Respiratory and Cardiovascular System

• Neuromuscular System

• Genitourinary System

Nursing Diagnoses

Nursing Interventions

• Preventing Infection

• Preventing Bleeding

• Minimizing Fatigue

• Promoting Nutrition

• Minimizing Stomatitis

• Strengthening Coping with Altered Body Image

• Patient Education and Health Maintenance

• Preventing Infection

• Preventing Bleeding

• Minimizing Fatigue

• Promoting Nutrition

• Minimizing Stomatitis

• Strengthening Coping with Altered Body Image

• Patient Education and Health Maintenance

Outcome-Based Evaluation

Radiation Therapy

Special Considerations in Cancer Care

• Pain Management

• Oncologic emergencies

• Clinical trials

• Psychosocial components of care

• Palliative care

I. Pain Management

• Cancer Pain

• Caused by direct tumor infiltration of bones, nerves, viscera, or soft tissue*

Incidence of Cancer Pain:

• The most common symptom associated with cancer

• Found in 1 quarter of patients with newly diagnosed malignancies

• Found in 1/3 of patients undergoing treatment

• Found in 3 quarters of patients with advanced disease*

Causes of Cancer Pain:

• Induced by the disease (cancer itself)

• Secondary to direct tumor involvement of bone, nerves, viscera, or soft tissue

• Secondary to the treatment of cancer (surgery, chemotherapy, radiation, and immunotherapy)

Types of Pain:

• Somatic pain

• Neuropathic pain

• Visceral pain

Somatic Pain

• Caused by direct tumor involvement of sensory receptors in cutaneous and deep tissues

• Most common somatic pain is bone pain caused by metastasis

• Controlled with NSAIDs or oral opioids

Neuropathic Pain

• Results from nerve injury or compression

• Is associated with abnormal sensations, such as paresthesias

• Treatment includes drugs such as tricyclic antidepressants and anticonvulsants (Adjuvants) in combination with opioids

Visceral Pain

• Vague or ill defined

• Referred to cutaneous sites, making it difficult to differentiate from somatic pain (right shoulder pain from liver metastasis)

• Caused by abnormal stretching of smooth muscle walls, ischemia of visceral muscle, and serosal irritation

• Treated with surgery to remove the cause and oral opioids*

Other clinical manifestations of Cancer Pain:

• Fatigue from sleep disturbances

• Loss of appetite or weight loss

• Anxiety or depression

• Change in self concept

• Change in quality of life

Pharmacologic Management of Cancer Pain

• NSAIDs – use to treat mild to moderate pain

• Opioids – use to treat moderate to severe pain; long acting morphine sulfate

• Should use oral route

• Doses should be adjusted

• Most important to administer on a schedule rather than PRN

• Optimal treatment approach is to treat with long-acting drugs paired with short-acting drugs as needed for breakthrough pain

Use of adjuvant drugs:

• anticonvulsants

• antidepressants

• corticosteroids

• muscle relaxants

• Used to enhance the effect of opioids Intraspinal Administration of Opioids

• A catheter is placed into spinal epidural or subarachnoid (intrathecal) space for the management of acute or chronic pain

• Catheter may be placed percutaneously and sutured in site

• Catheter is positioned as near as possible to the spinal segment where the pain is projected

• Preservative free sterile morphine or other analgesic/anesthetic drug is injected into the system at specified intervals

• Intrathecal or epidural drugs may be delivered by patient-controlled analgesia (PCA) pump or may be continuous or bolus infusions

• Spinally administered local anesthetics produce their effects predominantly by action on axons of spinal nerve roots; produce long lasting pain relief with relatively low doses with little or no blunting of patient’s level of responsiveness

Complications of Intraspinal Administration of Opioids:








Nursing Assessment & Interventions

• Assess objectively the nature of the patient’s pain as to location, duration, quality, and impact on daily activities

• Use pain intensity scale of 0 (no pain) to 10 (worst possible pain)

• Assess relief from medications and duration of relief; response and side effects of medications

• Administer drugs orally whenever possible

• Administer analgesia “around the clock” rather than prn

Nursing Assessment & Interventions

• Take careful pain history. Explore pain interventions that have been used and their effectiveness; determine whether the intensity of the pain correlates with the prescribed analgesic

• Re-evaluate the pain frequently

• Use alternative measures to relieve pain such as guided imagery, relaxation, and biofeedback

• Consider referral to pain specialist for intractable pain

• Take measures to prevent and treat side effects of opiates, such as constipation, nausea, and sedation

Nursing Assessment & Interventions

• Provide Education:

• A complete list of each medication prescribed

• A list of potential side effects

• Instruct patients that there is no benefit to suffering and that addiction is not a problem

• Encourage patients to talk to their doctor or nurse about their pain and effectiveness of the treatment plan

• Assure patients that there are other options if the medications prescribed do not work.

Nursing Assessment & Interventions

• Provide Education:

• The patient and family are taught drug administration, pump instruction, catheter and exit site care, monitoring of respiration, and recognition of respiratory depression and its treatment

II. Oncologic Emergencies

• Septic shock = a systemic disease associated with the persistence of micro-organisms or their toxins

• Spinal cord compression = compression on the spinal cord or cauda equina nerve roots from a lesion outside the spinal dura

• Hypercalcemia = an elevated serum calcium level above 11.0 mg/dL

• Superior vena cava syndrome = obstruction and thrombosis of the superior vena cava by a tumor or an enlarged lymph node, resulting in impaired venous drainage of the head, neck, arms, and thorax

Septic Shock1

• Incidence and Risk Factors:

• 45% of cancers with mortality rates exceeding 30%

• Neutropenia > 7 days

• Patients with HIV and with neutropenia

• Prolonged hospitalization

• Elderly patients

• Patients with co-morbid conditions such as diabetes and pulmonary diseases*

• Clinical Manifestations:

• Fever greater than 38.3 C

• Warm, flushed, dry skin

• Hypotension

• Tachycardia

• Tachypnea

• Decreased level of consciousness

• Decreased urine output

Septic Shock2

• Diagnostic Evaluation:

• Vital signs

• Culture, blood, etc…

• Chest x ray

• CT scans as necessary

• ABG evaluation

• BUN and Creatinine

• CBC with differential – elevated WBC with infection*

• Management:

• Antibiotics started immediately

• IV fluids and plasma expanders

• Vasopressors to support blood pressure

• Oxygen to prevent tissue hypoxia

• Vital signs, respiratory status, urine output, signs of bleeding

• Complications are treated aggressively

Spinal Cord Compression

• Incidence:

• 50% of these compressions occur in patients with lung, breast, or colon cancers

• This is the second most common neurologic complication of cancer

Clinical Manifestations:

• Depending on the site of vertebral bony metastasis: cervical, thoracic lumbar spine involvement

• Weakness & unsteadiness

• Changes in sensation: paresthesia, numbness, tingling

Spinal Cord Compression2

• Diagnostic Evaluation:

• Neuro examination

• X ray of the painful site

• Bone scan

• MRI – most useful

• Myelogram with CT scan – no longer used due to MRI


• Treatment is usually palliative

• Treatment goals: relieve pain and restore function

• Corticosteroids

• Radiation therapy

• Surgery (Laminectomy)

Spinal Cord Compression3

• Complications:

• Respiratory impairment (i.e. pneumonia and atelectasis)

• Mobility impairment, including immobility, foot drop

• Sensory losses

• Bladder and bowel dysfunction

Patient Education:

• Facilitate referral to home care services for nursing assessment, intervention and rehabilitation for residual deficits

• Facilitate referral to PT, OT and psychosocial support

• Provide instruction regarding safety issues for residual sensory deficits


• Incidence:

• Most common life-threatening disorder associated with malignancy

• Frequently occurs in patients with cancer of the lung, breast, prostate

Clinical Manifestations:

• Signs and symptoms may vary

• Symptoms may be non-specific

• Nausea/vomiting, anorexia, weakness, constipation, polyuria, polydipsia, change in mental status

• Muscle weakness

• Life-threatening: dehydration, renal failure, coma, death


• Diagnostic Evaluation:

• Serum calcium level greater than 11 mg/dL

• Electrolyte levels, BUN, and creatinine are obtained to determine hydration status and renal function


• Treating the primary with chemotherapy, surgery or radiation

• Hydration with IV normal saline

• Pharmacotherapy: pamidronate (Aredia), diuretics, plicamycin, calcitonin


• Nursing Interventions:

• Prevent and detect hypercalcemia early

• Nausea, vomiting, constipation,lethargy, and anorexia

• Emphasize mobility to minimize bone demineralization and constipation

• Instruct on importance of adequate hydration

• Administer normal saline infusions as prescribed

• Administer medications as prescribed

• Maintain accurate input and output

• Take vital signs every 4 hour

• Monitor electrolyte values & renal function

• Assess mental status

• Assess cardio-respiratory status for signs of fluid overload

Superior Vena Cava Syndrome1

• Incidence:

• 3-4% of patients with cancer develop SVCS

• Most often occurs in men aged 50-75

• Arise from small cell lung cancers

• Other cancers associated with SVCS are: Hodgkin’s, and non-Hodgkin’s lymphoma, thymoma, breast cancer

Clinical Manifestations:

• Signs and symptoms may vary

• Dyspnea and “tight collar” syndrome

• Chest pain, cough and dysphagia

• Cyanosis and edema of the head and upper extremities; collateral circulation with dilated chest wall veins may be visible

• Progressive dyspnea, orthopnea and Neck vein distention

• CNS symptoms/pleural effusion

Superior Vena Cava Syndrome2

• Diagnostic Evaluation:

• 60% of SVCS can be detected by plain chest X ray

• CT scan may be necessary


• Radiation therapy is the gold standard

• Chemotherapy may be used in conjunction with radiation

• Surgery is rarely used

• Thrombolytic/anti-coagulant therapy if a thrombus is suspected

• O2 is given for relief of dyspnea and maintenance of airway

• Analgesics & tranquilizers for discomfort and anxiety

Superior Vena Cava Syndrome3

• Nursing Interventions:

• Administer O2 as prescribed to relieve hypoxia

• Place patient in Fowler’s position

• Limit the patient’s activity and provide a quiet environment

• Reassure the patient that cyanotic color and facial edema will subside with treatment

III. Clinical Trials

• Trials provide a mechanism to test the effectiveness of new drug and other therapies

• Clinical trials are very important in the advancement of cancer treatment

• Phases of Clinical Trials:

• Phase I evaluate drug toxicities

• Phase II determine tumor activity in specific tumor types

• Phase III designed to compare drugs with standard therapy

• Phase IV designed to determine new ways to use the drug

IV. Psychosocial Components of Care

• Nursing Assessment:

• Assess lifestyle prior to illness

• Assess for signs of anxiety and co-existence of depression

• What ADLs can the patient perform?

• What changes in lifestyle have resulted from cancer and its treatment?

• Ascertain the patient’s perception of the disease and treatment

• Evaluate available social support

• Ask patient if alternative modalities are being utilized for cancer treatment

• Try to gain a sense of emotional strengths and potential problem areas. Ask if patient and family have a plan for end of life care as appropriate.

Alternative Therapies

• Echinacea currently under investigation in liver and colon cancer for immune stimulation

• Pau D’arco anticancer activity noted, but studies were discontinued (extremely toxic; nausea, vomiting; potential for hemorrhage

• Green tea chinese remedy; thought to have anticancer activity (linked with high rates of esophageal cancer if consumed heavily)

• Ginseng old chinese remedy; thought to stimulate immune system (overdose may cause hemorrhage, vomiting, or death; estrogen like properties)

Psychosocial Components of Care

• Nursing Diagnoses:

• Anxiety related to complex disease process, treatment options, and prognosis

• Ineffective individual coping related to life-altering disease process

• Fear of death and dying

Nursing Interventions:

• Reducing Anxiety

• Establish and sustain an unhurried approach to give the patient time to organize fears, thoughts and feelings

• Allow patient to share feelings about having cancer

• Reflect and amplify insights and judgments

• Recognize feelings of losing control

• Discuss methods of stress reduction

• Discuss the positive aspects of treatment

• Encourage expression of positive emotions

• Reinforce effective coping behaviours

• Encourage patient to join a support group

• Remain available as problems arise

• Initiate referrals for additional rehabilitation and psychosocial services as appropriate

Nursing Interventions:

• Promoting Effective Coping

• Encourage patient and family members to enroll in cancer education program

• Encourage patient to learn everything about treatment plan, because this promotes a sense of control

• Provide expert physical care

• Assist patient in strengthening support system (family, friends, visitors, etc..)

• Help patient re-adjust expectations and goals to promote ongoing adjustment

• Support patient in coping mechanisms chosen

Nursing Interventions:

• Allaying Fear of Death and Dying

• Educate patient and family about prognosis and end-of-life choices

• Assess and respect the patient’s belief

• Help the patient and family arrive at a consensus on treatment goals

• Facilitate emotional support for the patient

• Provide bereavement support to survivors

V. Palliative Care

• Palliative care, also known as comfort care, is primarily directed at providing relief to terminally ill person through symptom management.

• The goal is not to cure but to provide comfort and maintain the highest possible quality of life for as long as possible

• The focus of palliative care is not on death but on a compassionate, specialized care for the living

Management and Nursing Interventions

• Discuss end-of-life issues early in patient’s treatment plan

• Encourage patients to express their preferences about end-of-life in the form of a legal document. Advance directives or a living will authorize a family member or friend to make decisions for the patient.

• Educate about and provide hospice care

Goals of Hospice:

• Symptom management: pain control, air hunger, agitation, anxiety, GI discomfort

• Counseling: Pastoral care, bereavement counseling for families, facilitate emotional support for patients and families

• Respite care: volunteers are available to help the family care for patients in the home, patients can be transferred to an in-patient setting as necessary

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