Cancer is a group of over 200 diseases characterized by uncontrolled and unregulated cellular growth
- => Second most common cause of death in the U.S.
- Incidence increases with age (most imporatnt risk factor)
- Incidence higher in men
- Incidence, mortality higher in African Americans
- Prostate, breast most common but Lung with highest mortality rate
- -turn of century
**Cancer Cell Characteristics
- =>Defect in cellular proliferation
- -Cell division is usually activated ONLY in the presence of cell degeneration
- -Proliferation control: Contact inhibition
- -they're not dividing normally and loss of contact inhibition (they don't adhere to the tissue surface in a nice organized level,)
- -Indiscriminate and continuous division, without any kind of boundaries (vs normal cells who respect boundaries, and don't grow on top of other cells.
- -Stem cell theory: a loss of intracellular control of proliferation in a mutated cell; a normal cell will divide in a controlled manner, but mutated stem cells give rise to cancer cells.
- -when cancer cells are being treated to chemo, they can mutate further and tend to escape chemo drugs.
- =>Defect in cellular differentiation
- -normal cell gives rise from stem cell to perform ONE function (maturity), BUT cancer cell revert to fetal cell characteristics;
- No longer perform their designated function; they just keep growing
- Tissue of origin may not be determined because so reverted back to fetal characterisstics.
- =>Defects in cellular differentiation and proliferation may be due to mutations in
- -Protoncongenes: normal cell genes that are important regulators of normal cell process-promotes growth BUT Tumor Suppressorr Genes: SUPPRESS growth. Mutations alter the expression of protooncogenes and activate them into oncogenes (tumor inducing)
Proto (promotes) onco (cancer) genes: Normal cellular genes that regulate growth, Mutations can cause them to function as oncogenes (genes in cancer cell that are proliferating to make more cancer cells)
Tumor suppressor genes:
Normal cellular genes that suppress growth, BRCA1 and BRCA2 (breast cancer genes), p53 (mutated tumor suppressor genes) examples of mutations
**Benign vs. Malignant
- -Regular consistent shape
- -Cell growth: orderly, controlled, encapsulated (not invading other tissues around it)
- -Adherence: Present
- -Migration: Absent
- -Differentiation: Well differentiatioed (matturity level)
- => Malignant:
- -Shape: irregular, pleomorphic (variability in size and shape of cell, or nuclei)
- -Cell growth: random, uncntrolled, grow on top of each other
- -Adherence: Absent
- -Migration: Present
- -Differentiation: Undifferentiated, "how undifferentiated, can tell you how old the cancer cells have been mutating--not staging"
**Malignant Neoplasms: Categories of malignant neoplasms:
Carcinomas- grown from epithelial cells (skin, stomach, colon, breast, rectal)
Sarcomas- arise from muscle, bone, fat, or connective tissue.
Lymphomas- arise from lymphoid tissue
Leukemias and myelomas- arise from blood-forming organs
- Chemical: Tobacco, ETOH
- Virus: HPV
- Radiation: Ionizing, X-Rays
- Physical: Asbestos, Wood dust, Lead
- -Dr. POTT & chimney sweeps -> scrotal cancers
- -long latency period makes it difficult to pinpoint the cause
The initiation of cancer formation
Normal cells becomes altered as a result of a carcinogen exposure
Malignant cells release tumor angiogenesis factor (TAF) stimulating the formation of capillaries to supply the tumor with nutrients
Multiplicity Theory: Many factors lead to the development of cancer. Majority factors are environmental (continuous exposure to carcinogens)
-60-90 pecent: smoking
**Stages of Cancer Development
- =>Initiation (Stage 1)
- Mutation in the cell’s genetic structure resulting from internal error or exposure to carcinogen
- -initial mutation is reversible since most cells will undergo apoptosis and can't duplicate.
- -Some cells can repair their dna to avoid becoming a cancer cell; before division
- -If cell death does not occur before division, then mutation passes to daughter cell.
- Multifactorial causes - can be inherited from parent or acquired
- Most cells do not develop into a tumor-certain drugs (alkylating and immunosuppressives) can cause cancer --Leukemias, and lymphomas
- =>Promotion (Stage 2)
- Reversible proliferation of altered cells
- Promoting factors include tobacco, alcohol, physical inactivity, poor diet
- -Some factors (cig smoke) are both initators (cause mutation) and cause promotion and divison to grow D:
- =>Progression (Stage 3)
- -FINAL Stage
- characterized by increased growth rate of the tumor, increased invasiveness, and metastasis (spread to another side)
- Series of changes to cell
- Increased growth rate, invasiveness, and metastasis
- Tumor angiogenesis critical --allows metastasis & growth --Hematogenous metasasis::penetrating blood vessels (most don't survive-due to blood turbulence and imme system cells) but tumor protection include combination of tumor cells, plt and fibrin deposits
- -In order to surve metastasis, tumors need vascularization facilitated by tumor angiogenesis
multistep process after angiogenesis of the tumor.
Mechanically invades surrounding tissueMay penetrate the walls of lymph or vascular vessels
- =>Embolization (chuck of something that goes through your system--> freeway to anywhere in the body)
- Tumor cells enter circulation and are carried to other organs (like liver /: )
- Most tumor cells do not survive this process
- -Increased chance of having distal tumor if this repeatedly happen
- Embolic tumor cell adheres to blood vessels of distant organs
- Establish new environment through proliferation and angiogenesis
Lymphocytes check cell surfaces for tumor associated antigens; response of immune system to antigens that have liveed in cells, body knows if you're self or something different. Know which tumor antigens are cancer cells.
- =>Immune response: Cytotoxic T cells, NKCs (natural killer cells) , macrophages, B lymphocytes
- -NKs are leukocytes that bind to certain tumor cells without the stimulation of antigens, kill by inserting granules of cytolitic protein called paraperformins?
- =>Means by which the cancer cells avoid those mechanisms is termed immunological escape
- -cancer cells arise from normal cells so body might not always realize they're different
- -cancer cell can suppression t-cell stimulation, might have weak surface antigens, blocking antibodies...so they fight back ):
- -immunlogical escape: T cell suppression, etc.
**Levels of Cancer Prevention
Primary: Goal is to prevent or delay the development of cancer (not smoking, limit alcohol, living healthy)
Secondary: Goal is early detection and treatment ( Screening of asymptomatic or subclinical people)
Tertiary: Goal is to detect complications and recurrence in cancer survivors (cancer is already established)
- NO TOBACCO
- Moderate alcohol consumption
- Adequate rest/sleep
- Good nutrition: Fiber (decrease colon cancer risk)Vitamins
- Avoid obesity
- Avoid chronic stress
- Limit sun exposure
- Avoid/limit occupational exposures (asbestos)
-PAP: 21 years for cervical cancer, every 3 until 30, and every 5 until you're 65
-HPV testings starts at 20-CBE/BSE (clinical breast exam and Self ): 20 years (Every 3 yrs then yearly after 40)
-Mammography: 40, yearly
-PSA(Prostate specific antigen)/DRE (Digital Rectal Exam): > 50 years should discuss with PCP, dpends on PSA level
-LDCT(low dose computed tomography--lung cancer surveillance): males/Females > 55 who meet critera; yearly
FOBT (Fecal Occult BLood Test), Sigmoidoscopy, colonoscopy: Males & Females >50; depends on test, results
**Warning Signs for Cancer: CAUTION
C: Change in bowel or bladder habits
A: A sore that doesn't heal
U: Unuusal bleeding or discharge
T: Thickening or lump in breast or elsewhere
I: Indigestion or difficulty swallowing
O: Obvious change in wart or mole
N: Nagging couch or hoarseness
=>Laboratory studies (blood, urine, stool)
=>Imaging studies: CT
- Needle aspiration: aspiration of a small amount of core tissue (breast mass
- Incisional biopsy: Removal of a piece of tumor; used for diagnosing
- Excisional biopsy: removal of whole tumor to obtain clean margin; used for diagnosis, treatment
- Exfoliative cytology: analysis of cells in fluids/secretions (sputum, cervical washing, peritoneal fluid--put cells under scope)
=>Tumor Markers:PSA, CA 125; useful for monitoring onging treatment, not great for diagnosisng cancer.
Stage 0: cancer in situ (still in normal location)
Stage I: tumor limited to tissue of origin, localized (maybe spread a little, but beyond original tumor size)
Stage II: limited local spread
Stage III; extensive local and regional spread
- Stage IV: metastasis (body)
- note: don't grade back! Even after treatment.
**TNM Classification System
=> T: Charcteristics of the primary tumor, T0 (No evidence of primary tumor) to T4: defining the tumor size
=> N: Involvement of adjacent lymph nodes. N0 (no involvement) to N4 indicates advancing nodal diseases
=> M: Evidence of metastasis. M0 (indicates no metastasis) or M4 (metastasis is present)
Surgery- go-to. Not the best candidate: A cancer that arises from tissue with slow rate of proliferation. A margin of normal tissue must surround the tumor at the time of surgery to know you got it all.
Radiation: Up to 60% of cancer patients, in conjuction with chemo or surgery.
Chemotherapy: used in many solid tumors, the primary therapy for leukemia (not just one tumor) and lymphomas
Biologic/Targeted Therapy: new wave of the future.
**Goals of Treatment
=>Cure: Goal is to eradicate the cancer
=>Control: Goal is to manage the cancer
=>Palliation: Goal is to provide symptom relief and improve quality of care. When cancer isn't curable, debulking/cytoreductive surgery and making life more manageable.
Prophylactic surgical intervention: women that carry BRCA, maybe they have familial history--so they get masectomy. OR getting rid of bening polyps. Any precancer cells of skin or cervix (mole)
Primary treatment: aimed at cure, five year survival without recurrance is considered cure. If rapid rate of growth like testicular (then within two years)
Combination treatment: surgery, chem and radiation combined
Supportive and palliative treatment: debulking, laminectomy, venous access device
Rehabilitative treatment: construction, ex: transferring rectus abdominal muscle and make a breast.
- Use of high-energy ionizing radiation to interrupt cellular growth; breaks down dna bonds, must be focused on that tumor. Cellular replication is impaired or prohibited
- Radiation damage depends on the mitotic rate of the cancer
- Some tumors are more radiosensitive than others
- Limited by maximal tolerated dose
- Can be curative or palliative
- =>Types include
- Electromagnetic- Xrays, Gamma rays
- Particulate: electron or proton beams
- -delivered by linear accelerator.
**External Radiation aka TELETHERAPY
Teletherapy- External source of radiation
Most common form of radiation treatment delivery
Intensity-modulated radiotherapy (IMRT)
Side Effects: Fatigue, headache, GI effects, skin irritation (scaling, erythema, dryness), alopecia, myelosuppression (pancytopenia), reproductive effects-sperm banks
**External Radiation Implementation (Tele)
=>Offer psychosocial support and teaching
=>Promote adequate nutrition
- =>Provide skin care
- Avoid lotions, creams, perfume to irradiated areas
- Wash with lukewarm water, pat dry (some doctors may order a mild soap)
- Avoid exposure to sunlight or artificial heat (heating pad)
- Apply aloe vera gel/cream as ordered
- =>Observe for “wet” reaction
- Weeping of skin
- Apply antibiotic lotion or steroid cream as ordered
- Expose site to air
- Notify doctor (they may delay next treatment to allow for skin healing)
**Internal Radiation aka Brachytherapy
- =>Insertion of radioactive substance within a patient
- Can be unsealed(liquid) or sealed (radon seed-initially radioactive-limit contact with children. Left in forever o: ), permanent or temporary (considered radioactive for the time only when seed is in)
- -Catherthers, baloons and needles deliver insertion
- -like with prostate cancer-put it in rectum.
allows for direct dose to target tissue with minimal exposure to surrounding healthy tissues; usually used as supplemental to teletherapy as "boost"
- =>Used for variety of cancers
- Prostate, breast, lung, esophageal, gynecological, head and neck, sarcomas, thyroid
- =>Side effects
- Depends on the site and concurrent use of external radiation
**Temporary Brachytherapy Interventions
- Maintain bed rest when radiation source in place
- Insert Teflon Foley catheter (radiation decomposes rubber b/c radiation will be exposed)
- =>Observe for dislodging of radiation implant
- Avoid direct contact around implant site
- If radiation source falls out, do not touch with hand, use foot-long applicator and place in lead container
**Radiation Safety Measures
Wear radiation badge-measures amout of radiation you're exposed to and makes sure it's down to a safe level.
Do not allow visitors under 18 or pregnant in room
Mark patient’s room and chart with “radiation safety precautions”
- Body fluid is considered radioactive for internal therapyUse the principles of time, distance and shielding
- -know risks of treatment. (lead vest)
Systemic cancer therapy; for solid tumors and hematological malignancies.
Primary treatment for many cancers
Also used for control and palliation
Most effective with younger, rapidly dividing, small tumors (greater chance when the cell is mostly active and constantly dividing)
Side effects due to destruction of normal cells: lose hair, bone marrow supression (pancytopenia).
-Intrathecal or intraventricular:
- => PO:
- => SQ/IM:
- => IV-venous access, necrosis if infiltrated (vesicants cause severe tissue breakdown)
- =>Other routes
- -intraarterial: via the arterieas, for treatment of osteognic sarcoma, cancers of head/neck, bladder, brain and crvix, melanoma, primary liver cancer and metastaic liver disease, can use external infusion or implanted infusion pump
- -Intraperitoneal: for treatment of perioteneal metastases, primary colorectal and ovarian cancer, ascites. Temporary silastic catheters are percuatneously or surgically placed into periotneal cavity for short term chemo. Chemo "dwells" for 1-4 hours
cancers that metastasize to the CNS are difficult to treat b/c of blood-brain barrier often prevents distribution of chemotherapy to this area. Intrathecal chemo inovles lumbar punction and injection into subarachnoid space. "Ommaya Reservoir" ofte inserted for more consisten drug distribution
bladder chemo: involves instillation of ehemo into bladder. Vhemo instilled into the bladder via Urinary Cath and retained 1-3 hours.
**Chemotherapy Safety Guidelines (OSHA)
Obtain special training for drug administration
Wear non-latex (nitrile) gloves and disposable gown
Use Luer-lok syringes (no sharps)
Double bag chemotherapy drugs once prepared to transport to prevent spills
Have equipment ready for accidental spills (spill kit)-immediately contained so nobody is exposued to that medicine.
Dispose all hazardous waste in appropriate containers
When infusing vesicant drugs, monitor IV carefully
-patient is considered contaminated after chemotherapy for 48 hours.
**Chemotherapy Side Effects
Acute toxicity: Anaphylaxis and hypersensitivity reactions, extravasation, anticipatory N/V, cardiac dysrhythmias
Delayed effects: Alopecia, bone marrow suppression, fatigue, altered bowel function, N/V, skin rashes, neurotoxicity "Nadir"-low wbcs, occurs 7-10 days after last day of treatment (neutropenic precautions, but eventually will recoveer)
Chronic toxicity/ organ damage
**CHEMO vs RADIATION:
- the major diffeierence in clinical manifestation is that with radiaton (a local therapy) only bone marrow twithin the treatment field is affected. BUT with chemotherapy (a systemic therapy), bone marrow funtion throughtout the body is affected. hterefore effects are more profound with chemo when the two therapies are combined
- -onsert of bone marrow suppression is related to the life span of the type of blood cells. WBC affected most acute (1-2 weeks), plt in 2-3 weeks, and RBCS (4 months)-Nadir occurs 7-10 days after initation of treatment
-Neutropenia more common chemo than radiation
-Thrombocytopenia: <50 K of plt count.
-Radiaton skin changes:
erythema within day followed by dry desquamalates with weeping of serous fluid. Most evident in skin folds or pressure--goal: prevent infection. No heating pads, ice packs, water, constrictive garments, deodorants. Lubricate dry skin w/ nonirritating lotion emolient (no alcohol or perfume) Keep tissues clean with NS and vaseline petrolatum gauze. Expose area to air, avoid sun, clean with soap and water, use an electric shaver.
-Chemo skin changes:
mild erythema, hyperpigmentation alopecia (har doesn't grow back for a month after therapy is complete
-Anemia:for both radiation and chemo (RBC growth factors -Procrit/Epoetin)
-Fatigue: caused by anemia, accumulation of toxic substance left in blody after cells killed, need for extra energy to repair and heal body, lack of sleep.
-GI tract most sensitive due to relase of seotonin -> stimulates chemoreceptor trigger zone and vommitting center in brain, and cell death
-Diarrhea: pelvic readiation, recommend diet LOW in fiber and residue, avoid milk (radiation causes temp lactose intolerance)
-Mucositis: irritation, inflammation and or/ulceration of mucosa. Xerostoma.Dysgeusia (taste loss) Dyspagea (difficulty swallowing)
**Biologic and Targeted Therapy
ex: monoclonal antibodies: molecule engineered to attach to cancer cells and kill them (specific defects on a cell)
Uses living organisms, substances produced by these organisms, or synthetic versions to treat cancer
Examples include monoclonal antibodies, cytokines, bacteria, cancer-killing viruses, vaccines, gene therapy
Some therapies stimulate the body’s immune response while others target cancer cells directly
2. Blocking growth signals.
- 1. Making a cancer cell more visible to the immune system. A monoclonal antibody can be directed to certain parts, "marking it" so the immune system can find it and destory it. Example Rituxan/CD20. Lights up cancer cell like christmass tree.
- => Riggors/Seizuing activity: Immediately give them demerol!
Receptor sites on cell's surface are blocked so they cannot receive message to keep growing. Example: ERbitux/EGRF (Epidermal growth factor receptor)
- 3. Stop new blood vessels from forming. Cancer cells rely on blood vessel for oxygen and nutrients. Cancer cells send out "growth signals"-Monoclonal antibodies block these signals so blood supply is cut off and tumor shrinks or dies.
- Ex. Avastic/VEGF (Vascular Endothelial Growth Factor.
- -Cuts out the blood Supply.
- =>General side effects include
- Flu like symptoms
- Infusion/injection site reactions
- Allergic reactions
- End-organ toxicity
=>Information on clinical trials available via NCI website: http://www.cancer.gov
-use vector or virus to deliver genes to the cell, replace defective gene with healthy ones o:
Experimental technique that uses genes to treat or prevent disease
Replacement of a missing or defective gene with a functional, healthy copy, which is delivered to target cells with a "vector."
Viruses are commonly used as vectors because of their ability to penetrate a cell’s DNA
-can be done outside the body by extracting bone marrow and corrected copy of gene is introduced and allowed to penetrate the cells dna before injecting back into the body.
Mitochondrial gene therapy passes final U.K. vote (2/24/15)combine DNA from two biological parents and an egg donor (3 people!!)Women that have mutations in the DNA of their mitochondria can lead to heart problems, seizures, and blindness in offspringTherapy allows women to have genetically related children who don’t carry the mutationsControversial because it would modify the DNA of an embryo in a way that could be passed on to future generations
*Molecularly Targeted Therapy
- Drugs designed at the molecular level of the cell to specifically attack and kill only the cancer cells of a specific type of cancer (not all rapidly dividing cells)
- Limited systemic side effects (nausea/ vomiting, hair loss)
- Can target the cancer with an effective and non-toxic therapy
- -Targeted theapy: intereferes with cancer growth by targeting specific cell receptors and pathways that are imp in tumor growth--can work on cell surface or at intracellular level.
- ex: Epideramal growth factor receptor (EGFR)
- -SE: flu like symptoms
- -MoAbs: capillary leak syndrome leads to pulm edema; administered by infusion
- -IV meperidine (Demerol) to control severe chills or rigors associated with biological agents.
Manipulate cell energy systems, Allows body to attack and shut down cancerous cells
Specifically designed not to attack DNA, but work on the energy-producing machinery in cancer cells
Dramatically slow down and halt cancer growth
Significantly reduce the side effects suffered by patientsIn contrast, 50% of all chemo drugs are platinum-based, damages DNA, cannot differentiate healthy cells
**Nursing Management: Cancer Treatment
- =>Provide skin care
- Protect skin from irritants and temperature extremes
- Use nonirritating lotion for dry skin
- Observe for wet reactions
- =>Promote good nutrition
- Assess for stomatitis, dry mouth, loss of taste, anorexia, N/V, D/C
- Encourage good dental hygiene
- Administer viscous lidocaine for mouth ulcers
- Offer soft, high protein and high calorie foods frequently. Bland, non spicy
- Involve family members
- =>Manage nausea and vomiting
- Aggressive use of antiemetics
- Use of antianxiety medications
- =>Monitor for/ prevent complications of myelosuppression
- Monitor CBC
- Meticulous hygiene
- Neutropenic precautions
- Avoid injury with thrombocytopenia
- Management of activity intolerance
**Nursing Management: Hematological disruptions
- 1. White blood cell suppression
- Meticulous hand washing/asepsis
- Avoid exposure to others with illnesses
- Room assignment
- Assess for signs of infection
- <2K: change in therapy
- <1K: neutropenic precautions
- 2. Platelet suppression
- Use soft toothbrush
- Avoid venipunctures when possible
- Monitor for bleeding<50,000: assess for bleeding and precautions
- 3. Red blood cell suppression
- Monitor Hct
- Monitor BP
**Expected/Potential Side Effects of Chemo/Biological agent Admin
- => Immediate:
- 1. Chrmo Precautions x48 hours
- 2. Allergic/Hypersensitivity reactions: Immediate or delayed
- => Delayed:
- N/V: 16 mg Zofran IVPG, Kytril
- Anxiety: Ativan or steroiods (decadron)
- depression: Journals and exercise--walking; Reglin
- Constipation: More than two days is deathly, chemo sitting in gut.
- Diarrhea: 6-8 waterly stools a day. Enforce BRAT diet (bananas, rice), immodium 2 after each loose stool, don't exceed 8/day-sandostatin (SubQ); worry about CDiff
- Anorexia- Miracle mouthwahs (lidocaine and kerofate), megace (helps with appetite) and myrenol
- Fatigue: #1; empower patients to ask for help and let them sleep=healing.
- Changes in CBC
- "Nadir"= pancytopenia (expected with most themo), Neupogen ordered? Ask for parameters! Neulasta-only one dose. (Neutropenic: HAND WASHING, no flowers, no fruit)
- H&H: <10: procrit (hgb), RBC turn around every 28 days, each RBC unit increases hemoglobin by 1 gram
- Platelets: don't transfuse until teens ! Teach to avoid injuries
;"thinning", Lose heat in winter-teach to wear beaniesStomatitis: mouth sores
: prevent injury, "can you pick up the nickle?" Velcro on shoes and zippers
- Rash: Can be disfiguring-antiboitics.
- =>Nursing Interventions:
- 1. Double Gloves
- 2. Double Flush to dilute
- 3. Signage on the door
- 4. Rigors or cold
- => DEMEROL and tell charge nurse
- 5. Benadryl and Tylenol Upfront
1. Superior Vena Cava Syndrome
2. Spinal Cord Compression -by malignant tuor in epidural space of spinal cord (back pain taht's agravvated by valsalva maneuver)
3. Third Space Synndrom: shift fluid from vascular to intersttial space secondary to extensive surgical procedures, biological therapy or septic shock.
1. Syndrom of Inappropriate Antidretic Hormone (SIADH)-most frequent in lung carciona: weight gain w/o edema, anorexia, n/v, oligura, decrease in reflexes and coma
2. HYPERCalcemia (affecteed by low albumin levels)-hydrate and biophosphaeges
3. Tumor lysis syndrom-rapid release of intracellular components in response to chemo. Four hallmarks: hyperuricemia, hyperphsphatema, hyperkalemia and HYPOcalcemia. Occurs within 1-2 days of initiation of therapy. Primary treatment: increase urine production thru hydration and decrease uric acid concentrations using allopurion
occur when malignant tumors infiltrate major organts or secondary to cancer therapy
- => Cardiac tamponde: results from fluid accumulation in the pericardial sac, constriction of the pericardium by tumor or pericarditis. Manifestation: heavy feeling over ches SOB, tachycardia, cough, dysphaga, hiccups.
- -Emergency treatment: reduction of fluid around heart and includes surgical establishement of a pericardial window or an indwlling pericardial cath. Give oxygen, IV hydration ans vasopressor therapies
- => Carotid Artery Rupture: Rupture of carotid occurs most frequently in pts with cancer of head/neck secondary to invasion of arterial wall by tumor or to erosion follwing surgery/radiation.
- -Bleeding can manifestation as minor oozing to spurting fo blood "blowout" or artery. IV fluids and stailize the pt for surgery--ligation of artery above and below the rupture!