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List a few statistics that describe the incidence of cancer
- Number one leading cause of death in people under the age of 85 (US)
- Over 10 million people have cancer
- In 1970 the five year survival rate was 50%, in 2005 the five year survival rate was 74%
- 30% of people now living will have a cancer diagnosis
- 1500 people die of cancer each day, half are over age 65 and 35% are preventable with early detection.
- Incidence is increasing, with melanoma rising higher than any other cancer, but the death rate is leveling off.
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List the top 3 incidences of cancer by site and cause of death for women
- Site: Breast, Lung, Colon
- Death: Lung, Breast, Colon
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List the top 3 incidences of cancer by site and cause of death for men
- Site: Prostate, Lung, Colon
- Death: Lung, Prostate, Colon
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Define: Proto-oncogene
A normal cell which, when altered by mutation, may become an oncogene and contribute to cancer
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Define: Oncogene
A tumor producing gene
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Define: Anti-oncogene
A tumor suppressing gene
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List a few characteristics of cancer
- Decreased contact inhibition
- Decreased cohesion
- Produces proteins, hormones, & other substances to enchance growth
- Tumor Angiogenic Factor (TAF) formation of blood vessels
- Not encapsulated
- Undifferentiated
- Vascularity
- Mode of growth
- Cell characteristics
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Define: Initiation
Stage where a chemical, physical, or biological agent (carcinogen) or an inherited gene alters the DNA in the cell causing a mutation
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Give examples: Chemical carcinogens
- Cigarette smoke
- Asbestos
- Nitrites
- Vinyl chloride
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Give examples: Carcinogenic drugs
- Radioisotopes
- Immunosuppressives (Azathioprine, Antimetabolites, Alkylating agents, Corticosteriods)
- Cytoxic agents (Cyclophosamide)
- Hormones (Diethylstilbesterol, Prenatal estrogen, Postnatal estrogen, Androgenic-anabolic steroids)
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Give examples: Physical carcinogens
Radiation (ionizing, rocks, x-rays, UV light, sun, tanning booths, electromagnetic fields)
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Give examples: Biological carcinogens
- Viruses (hepatitis B, Epstein Barr virus, HPV, herpes virus, HIV)
- Diet (fats, fiber, Vitamin B deficiency, charcoal grilling, food additives, obesity)
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Define: Promotion
The reversible proliferation of the mutated cell
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List: 3 ways that cancer metastasizes
- Implantation: cancer embeds along the body organ, uses tumor angiogenesis
- Lymph system: cancer moves to local lymph nodes, but may also "skip" nodes
- Blood vessels (Hematogenesis): cancer cells enter circulation and use enzymes
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List risk factors and ACS screening for: Lung cancer
- Risk factors: 20 year pack history, asbestos, uranium, COPD
- ACS screening: none
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List risk factors and ACS screening for: Prostate cancer
- Risk factors: Benign Prostatic Hyperplasia (BPH), African American, age
- ACS screening: Prostate-Specific Antigen (PSA) and digital exam after age 50, 45 for African Americans with positive family history
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List risk factors and ACS screening for: Breast cancer
- Risk factors: Caucasian, early menarche, late menopause, fibrocystic disease, infertility, first pregnancy after age 30, maternal history of breast cancer, obesity
- ACS screening: monthly self exams starting at age 20, ages 20-39 Clinical breast Exam (CBE) every 3 years, ages 40 and up mammogram and CBE annually
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List risk factors and ACS screening for: Colorectal cancer
- Risk factors: ulcerative colitis, familial polyposis, high fat/low fiber diet
- ACS screening: one of the following after age 50 - fecal occult exam & fecal immunochemical test (FIT) yearly, flexible sigmoidoscopy every 5 years, double-contrast barium enema every 5 years, colonoscopy every 10 years
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List risk factors and ACS screening for: Uterine or Cervical cancer
- Risk factors: early intercourse with multiple partners, poor hygiene, STDs, cervical dysplasia
- ACS screening: screen annually 3 years after starting intercourse (no later than age 21), at age 30 with 3 negative exams are rescreened & HPV screened every 2-3 years, after age 70 with 3 negative exams may stop screening. Women with a total hysterectomy can stop having cervical screenings unless surgery was treatment for cervical cancer
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Acronym: CAUTION
- C: change in bowel/bladder habits
- A: a sore that does not heal
- U: unusual 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 cough or hoarseness
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List: 3 different types of biopsies
- Needle: aspiration (bone marrow, prostate, breast, liver, kidney)
- Incisional: portion of the lesion to make diagnosis (dermal punch)
- Excisional: remove entire tumor
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Define: Debulking or Cytoreductive cancer surgery
Removal of a portion of the tumor
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Define: Supportive cancer surgery
Provision of supportive care, such as feeding tubes
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Define: Palliative cancer surgery
Removal of cancer to reduce symptoms
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List: Surgical cure criteria
- Slow growing
- Clean margins
- Prevent seeding
- No local spread
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Histology: Grade I Tumor
Well differentiated (mild dysplasia)
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Histology: Grade II Tumor
Moderately differentiated (moderate dysplasia)
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Histology: Grade III Tumor
Poorly differentiated (severe dysplasia)
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Histology: Grade IV Tumor
Anaplastic
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Define: TNM staging
- Tumor, Nodes, Metastasis
- 0-4 scale used to identify the course and extent of a cancer diagnosis
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List: 3 side effects common to all radiation patients
- Fatigue
- Anorexia/taste changes
- Skin reactions ("baby skin" rule)
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What localized side effects would you anticipate for a patient receiving teletherapy for: Lung or Breast cancer
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What localized side effects would you anticipate for a patient receiving teletherapy for: Brain cancer
- Increased ICP
- Peripheral neuropathy
- Fatigue
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What localized side effects would you anticipate for a patient receiving teletherapy for: Pelvic or Colon cancer
- Constipation
- Hepatotoxicity
- N/V/A/D
- Inflammation of the mucosa
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What localized side effects would you anticipate for a patient receiving teletherapy for: Prostate cancer
- Reproductive dysfunction
- Hemorrhagic cystitis (dysuria, hematuria, hemorrhage)
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Nursing care for: a patient receiving brachytherapy/intracavity radiation
- Private room (lead lined, radiation hazard marking)
- Bedrest
- Elimination: foley catheter
- Diet: low residue
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How do you handle the accidental dislodgement of an intracavity device?
- Using tongs, place the device in a lead lined container. Do not handle directly!
- Notify safety officer
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Are the body fluids of a patient receiving intracavity radiation radioactive?
No. The radiation is contained within the device. The body fluids, while affected by the radiation, do not themselves become radioactive.
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Nursing care for: a patient receiving unsealed radiation
- Private room (lead lined, radiation hazard marking for 96 hours)
- Elimination: flush 3x
- Diet: use of disposable utensils
- Hospital clothes and linens
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List: 3 ways to protect yourself from radiation exposure
- Time: shortest time possible (ALARA)
- Distance: inverse square rule
- Shielding
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Define: Inverse square law
- The further you get away from the source of radiation the less exposure you suffer.
- (I1/I2) = (D22/ D12)
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Define: Cell cycle specific chemotherapy
Has effect on cells in the process of cellular replication and proliferation
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Define: Cell cycle nonspecific chemotherapy
Has effect on cells in the process of cellular replication, proliferation, and rest
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Which normal cells are most affected by chemotherapy?
Cells with a high rate of proliferation (i.e. lining of the mouth and GI tract) - kills them
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Why are chemotherapy drugs used in combination?
- Drug effectiveness
- Synergistic effect
- Cycle specific + nonspecific drugs
- Different side effects
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What is Megace used for?
Appetite stimulant
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Extravasation Protocol
- Stop the drug infusion
- Leave the needle in place
- Administer the antidote
- Remove needle
- Use hot/cold packs
- Assess site
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Safety precautions when handling/administering chemotherapy (nurse focused)
- Only give chemo if you've been trained
- Chemo is stored separately from other meds
- Gown, gloves, goggles, and respirator mask
- Disposal of syringes, tubing, gauze, etc. in HAZARD container
- Glove when handling excreta
- Avoid giving chemo when pregnant, trying to get pregnant, or breast feeding
- Periodic health screening
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Define: Biological Response Modifiers (BRM)
- Natural substances normally produced in small amounts by the immune system
- Boost the body's response to fight tumors and foreign substances
- Fights indirectly by stimulating the immune system
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Biological Response Modifier: Interferon
- Function: Inhibits DNA protein synthesis and causes tumor antigen expression on tumors
- S/E: flu like symptoms (give Tylenol before/during administration)
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Biological Response Modifier: Interleukin 2
- Function: Activates NK cells, lymphokine activated killing cells, and tumor infiltrating lymphocytes
- S/E: neurological, fever, chills, renal/liver dysfunction
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Biological Response Modifier: Monoclonal Antibodies
- Function: Binds to tumor antigens and tries to destroy them, may be able to bind chemo or dyes to antibodies that will seek cancer cells
- S/E: fever, chills, vomiting (need premedicated with Tylenol, Benadryl, Merperdine)
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Biological Response Modifier: Tumor Necrosis Factor
- Function: Damages the capillaries of the tumor, activates the immune system
- S/E: capillary leak syndrome
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Biological Response Modifier: Neupogen, G-CSF/Neulasta
- Function: Causes the proliferation and differentiation of granulocytes
- S/E: bone pain, fever, chills, rash, myalgias
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Biological Response Modifier: Leukine, GM-CSF/Prokine
- Function: Causes the proliferation and differentiation of granulocytes and macrophages
- S/E: bone pain, fever, chills, rash, myalgias, fluid retention
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Biological Response Modifier: Procrit, Aranesp
- Function: Causes the proliferation and differentiation of erythrocytes
- S/E: hypertension, fever, N/V/D, SOB, tingling sensation
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Biological Response Modifier: Neumega, Multi-CSF/Oprelvekin
- Function: Causes the proliferation and differentiation of platelets, granulocytes, and monocytes
- S/E: bone pain
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Describe: Pain ladder
- Step 1: Non-opioid + adjuvant (ASA, paracetamol, NSAIDs)
- Step 2: Opioid for mild to moderate pain + non-opiod + adjuvant (codeine)
- Step 3: Opiod for moderate to severe pain + non-opioid + adjuvant (morphine, oxycodone, fentanyl)
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Nursing care for: cancer patient with diagnoses of nutrition and goals of nutrition
- Assessment: nutritional status
- Interventions: avoid judgmental statements, administer antiemetics, teach to eat slowly, bland/lukewarm/high calorie/high protein/small/frequent feedings, stimulate salivation, remove unpleasant sights/smells, relaxation techniques, avoid gas producing foods, teach to increase protein rich foods
- Note: High protein foods - double strength milke (1 cup = 14g), yogurt (10g), eggs (6g), cottage cheese (1/2 cup = 15g), beef (3oz = 21g), tuna (6oz = 44.5g)
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Nursing care for: cancer patient with diagnoses of altered mucous membranes
- Assessment: oral mucousa daily for ulcers, candida, herpes, xerostomia (dry-mouth), stomatitis, and fit of dentures
- Interventions: use toothettes, mouthwashes of baking soda/saline q2h, topical anesthetics or oncology mouthwash, avoid irritating foods, apply artificial saliva/petroleum jelly to lips
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Nursing care for: cancer patient with diagnoses of body image disturbance
- Assessment: body image, alopecia, post surgical, weight loss
- Interventions: provide support, select wig (chemo - hair grows back but may be different), use gentle products on hair, makeup tips, educate about special clothing and prosthetics
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Nursing care for: cancer patient with diagnoses of risk for infection
- Assessment: signs of infection
- Interventions: maintain personal hygeine, monitor for signs of infection, avoid crowds, avoid dental work when WBCs are low, no immunizations w/o doctor approval
- Note: Neutropenic precautions - private room, handwashing, screen visitors, no fresh fruit/vegetables/flowers/plants, no stagnant water, Neupogen/Neulasta, report fever of 100.4 to doctor
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Nursing care for: cancer patient with diagnoses of risk for injury/bleeding
- Assessment: overt or covert bleeding (GI bleeding), platelet counts
- Interventions: avoid IM/SC injections (hold pressure for 5 minutes, use small bore needles), BPs infrequently, provide safe environment, use soft toothettes, no flossing, no toothpicks, avoid straining on stool, rectal, or vaginal trauma (gentle lubricated secual intercourse), use electric razors, avoid tight clothing, avoid ASA NSAIDS, avoid anticoagulants, use of Neumega
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Nursing care for: cancer patient with diagnoses of fatigue
- Assessment: fatigue level, keep log, usually begins during first week (over 70% of patients on chemo are anemic)
- Interventions: sleep and naps, mild exercise, use of Procrit and Aranesp (lasts 3x longer than Procrit)
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Normal value for: RBCs
- Men: 4.7 - 6.1 million
- Women: 4.2 - 5.4 million
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Normal value for: WBCs
5,000 - 10,000
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Normal value for: Platelets
150,000 - 350,000 (below 20,000: spontaneous bleeding)
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Tumor Marker: CEA
- Carcinoembryonic antigen
- Disappears during last 3 months of fetal life
- Elevated with GI cancer, also with breast, liver, and lung cancer
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Tumor Marker: AFP
- Alpha Fetoprotein
- Produced by fetal liver
- Elevated with liver cancer, also with Hodgkin's lymphoma and renal cancer
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Tumor Marker: CA 125
Elevated with ovarian cancer
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Tumor Marker: CA 19-9
Elevated with biliary and pancreatic cancer, also lung cancer and cystic fibrosis
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Tumor Marker: CA 15-3
Elevated with metastatic breast cancer
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Tumor Marker: PSA
- Prostatic Specific Antigen
- Elevated with prostate cancer
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Oncological crisis: Infection
- Symptoms: fever, blood work
- Treatment: antibiotics, antipyretics
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Oncological crisis: Paraneoplastic disease
- Symptoms: SAIDH, insulin, hypercalcemia, ACTH
- Treatment: manage symptoms, treat tumor
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Oncological crisis: Tumor syndrome lysis
- Symptoms: hyperuricemia, hyperphosphatemia, hyperkalemia, hypocalcemia
- Treatment:hydration to increase urine production and treat electrolyte imbalances
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Oncological crisis: Hypercalcemia
- Symptoms: bone problems, A/N/V, renal stones (hematuria, flank pain)
- Treatment: calcitonin, mithramycin, monitor cardiac status
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Oncological crisis: Super vena cava syndrome
- Symptoms: facial edema, cough, distension of neck and chest veins
- Treatment: palliative radiation
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Oncological crisis: Disseminated intravascular coagulation (DIC)
- Symptoms: bleeding from 3 separate sites (clotting/bleeding at the same time), increased PTT & PT, decreased platelet count
- Treatment: heparin, platelets, fresh frozen plasma (FFP)
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Oncological crisis: Spinal cord compression
- Symptoms: intense back pain, motor weakness, dysfunction, parathesia
- Treatment: palliative radiation
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What is the role of the immune system in cancer development?
Surveillance - altered cells are made but usually destroyed by the immune system
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What is the purpose of a bone marrow transplant? Nursing implications?
- Purpose: to replenish healthy marrow after high dose chemo or radiation is given to destroy cancer cells
- Nursing implications: reverse isolation precautions, sterile drinking water, mouth care q2h, takes 2-4 weeks for marrow to start working
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What is the purpose of a peripheral stem cell transplant? Nursing implications?
- Purpose: to replenish healthy undifferentiated cells back into the body after high dose chemo or radiation is given to destroy cancer cells
- Nursing implications: reverse isolation precautions, sterile drinking water, mouth care q2h
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