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:
BENIGN
• Slow expansive growth
• Fully differentiated
• Absent metastasis
MALIGNANT
• Invasive
• Immature, poorly differentiated
• Metastasis present
Etiology
• 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
Female
• Breast
• Lung
• Colon
• Uterine
• Lymphoma
Cancer Deaths by Site and Sex
Male
• Lung
• Prostate
• Colon
• Lymphoma
• Pancreas
Female
• 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
18
• 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
C
A
U
T
I
O
N
• 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
Management
• 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
Iinterventions
• 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:
• RESPIRATORY DEPRESSION
• URINARY RETENTION
• PRURITUS
• INFECTION
• LEAKAGE
• TECHNICAL PROBLEMS
• DEVELOPMENT OF TOLERANCE
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
Management:
• 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
Hypercalcemia1
• 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
Hypercalcemia2
• Diagnostic Evaluation:
• Serum calcium level greater than 11 mg/dL
• Electrolyte levels, BUN, and creatinine are obtained to determine hydration status and renal function
Management:
• Treating the primary with chemotherapy, surgery or radiation
• Hydration with IV normal saline
• Pharmacotherapy: pamidronate (Aredia), diuretics, plicamycin, calcitonin
Hypercalcemia3
• 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
Management:
• 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
