Transcript cancer

Cancer
Introduction
2nd most common cause of death
 5-year survival rate is now 62% for those
who are disease free, in remission, or
under treatment

Defect in Cellular Proliferation

Cancer cells are characterized by the loss of
contact inhibition
 Grow on top of one another and on top of or
between normal cells

Cancer cells respond differently than normal
cells to intracellular signals regulating
equilibrium
 Divide indiscriminately and haphazardly
Defect in Cellular Proliferation

Stem cell theory
 Loss of intracellular control of
proliferation results from mutation of
stem cells
Defect in Cellular Proliferation
 Once mutated, the cell can
• Die
• Recognize damage and repair itself
• Survive and pass on damage
 Surviving mutated cells have potential to
become malignant
Normal Cellular Differentiation
Fig. 15-2
Defect in Cellular Proliferation

Pyramid effect
 Each cell division creates two or more
offspring cells
• Continuous tumor growth
Defect in Cellular Differentiation

Protooncogenes
 Normal cellular genes that are
important regulators on normal
cellular processes
 Mutations that alter their expression
can activate them to act as oncogenes
(tumor-inducing)
Defect in Cellular Differentiation

Tumor suppressor genes
 Suppress growth of tumors
 Mutations render them inactive
Benign versus Malignant Tumors
Characteristic Benign
Malignant
Differentiation
Well differentiated
Anaplastic
Growth Rate
Slow
Rapid
Mode of growth
Expansive
Infiltrative and
expansive
Metastases
None
Can spread to
distant sites
Prognosis
Usually harmless
Can be fatal if not
treated
Development of Cancer

Chemical, environmental, genetic,
immunologic, viral, or spontaneous in
origin

Initiation
 Mutation of genetic structure
 Has potential to develop into clone of
neoplastic cells
Process of Cancer Development
Fig. 15-3
Development of Cancer

Promotion
 Characterized by the reversible
proliferation of altered cells
 Activities of promotion (e.g. obesity,
smoking, alcohol) are reversible
 Latent period
• Initial genetic alteration to clinical
evidence of cancer
Development of Cancer

Progression
 Characterized by increased growth
rate of tumor as well as its invasiveness
and metastasis
 Metastasis = spread of cancer from
primary (initial) site to distant site
{See Figure 15-5 in the textbook}
Development of Cancer

Progression
• Metastasis process begins with rapid
growth of primary tumor
Tumor angiogenesis
- formation of
blood vessels within the tumor; critical
for tumor survival
Role of Immune System
Immune response is to reject or destroy
cancer cells if perceived as non-self
 May be inadequate as cancer cells arise
from normal human cells
 Some cancer cells have changes on their
surface antigens
 Tumor-associated antigens (TAAs)

{See Figure 15-6 in the textbook}
Role of Immune System
 Response to TAAs is termed
immunologic surveillance
• Lymphocytes continually check cell
surfaces and detect and destroy cells
with abnormalities
Role of Immune System

Cancer cells evade immune system b/c of
 Suppression of factors that stimulate T
cells
 Weak surface antigens allow cancer
cells to “sneak through” surveillance
Tumor Escape Mechanism
Blocking antibodies prevent T cells from interacting with TAAs
and from destroying the malignant cell
Fig. 15-8
Role of Immune System
 Development of tolerance of immune
system
 Suppression of immune response to
products secreted by cancer cells
 Induction of suppressor T cells
 Blocking antibodies that bind TAAs
Classification of Cancer

Anatomic Site Classification
 Identified by
• tissue origin
• anatomic site
• behavior of the tumor (benign vs. malignant)
Classification of Cancer

Anatomic Site Classification
 Carcinomas originate from embryonal
ectoderm and endoderm
 Sarcomas originate from embryonic
mesoderm
 Lymphomas and leukemias originate
from hepatopoietic system
Classification of Cancer

Histologic Analysis Classification
 Based on cellular appearance and
differentation
• Grade 1: Differ slightly from normal; well
differentiated
• Grade 2: More abnormal; moderately
differentiated
• Grade 3: Vert abnormal; poorly
differentiated
• Grade 4: Immature, primitive and
undifferentiated cells; difficult to
determine cell of origin
Classification of Cancer

Clinical Staging
 0: cancer in situ
 1: tumor limited to tissue of origin
 2: limited local spread
 3: extensive local and regional spread
 4: metastasis
Classification of Cancer

TNM Classification (Table 15-5)
 Tumor size
 Spread to lymph nodes
 Metastasis
Cancer Prevention and Detection
Reduce or avoid exposure to known or
suspected carcinogens
 Eat balanced diet
 Exercise regularly
 Adequate rest
 Health examination on a regular basis

Cancer Prevention and Detection
Eliminate, reduce, or change perceptions
of stressors and enhance ability to cope
 Enjoy consistent periods of relaxation
and leisure
 Know 7 warning signs of cancer
 Self-examination
 Seek medical care if cancer is suspected

Seven Warning Signs of Cancer
Change in bowel or bladder habits
 A sore throat that does not heal
 Unusual bleeding or discharge from body
orifice
 Thickening or lump in breast or
elsewhere
 Indigestion of difficulty in swallowing
 Obvious change in wart or mole
 Nagging cough or hoarseness

Diagnosis of Cancer

Biopsy involves histologic examination by
a pathologist of a piece of tissue
 Needle
 Incisional
 Excisional
Collaborative Care of Cancer

Goals
 Cure
 Control
 Palliation
Collaborative Care of Cancer

Factors that determine treatment
modality
 Cell type
 Location and size of tumor
 Extent of disease

Physiologic and psychologic status and
expressed needs also determine treatment
Major Treatment Modalities
Surgery
 Radiation
 Chemotherapy
 Biologic Therapy
 Bone marrow or stem cell transplant

Collaborative Care of Cancer

Surgical therapy
 to cure or control
 Slow cancers are most amenable
 Margin of normal tissue must
surround tumor
Collaborative Care of Cancer

Radiation therapy
 Emission and distribution of energy through
space or material medium
 Energy produced breaks bonds in DNA,
leading to death at time of reproduction
 Affects both cancer as well as normal cells
 Normal tissues are usually able to recover
Collaborative Care of Cancer

Radiation therapy
 Teletherapy
• Given via external beam from a
machine
• Most common
 Brachytherapy
• Radioactive material implanted in or
close to the tumor
• Patient is radioactive
Precautions:
time, distance, shielding
Nursing Management:
Patients Undergoing Radiation

Fatigue
 Possibly due to accumulation of
metabolites from cell destruction
 Rest before activity
 Get assistance with activity
 Maintain nutritional status
Nursing Management:
Patients Undergoing Radiation

Anorexia
 Monitor carefully to avoid weight loss
• Weigh twice weekly
 Small, frequent, high-protein, highcalorie meals
 Supplements
Nursing Management:
Patients Undergoing Radiation

Bone Marrow Suppression
 If bone marrow is within treatment
field
 Kills RBCs, WBCs, platelets
 Not as significant as with
chemotherapy
 Monitor blood counts
 May need transfusion for anemia
Nursing Management:
Patients Undergoing Radiation

Skin Reactions
 Occurs within treatment field
 Lubricate dry skin with nonirritating
lotion or solution (no metal, alcohol,
perfume, or additives)
 Wet desquamation must be kept clean
and protected from further damage
Nursing Management:
Patients Undergoing Radiation

Skin Reactions
 Prevention of infection
 Facilitate wound healing
 Protect irritated skin from extremes in
temperature
 Avoid constricting garments, harsh
chemicals, and deodorants
 See Table 15-12
Nursing Management:
Patients Undergoing Radiation

Oral, Oropharynx, and Esophageal
Reactions
 Teach patients to examine oral cavity
 Dental work before initiation of
radiation therapy
 Saliva substitutes for dry mouth
 Oral care (brushing and flossing unless
contra-indicated)
Nursing Management:
Patients Undergoing Radiation

Oral, Oropharynx, and Esophageal
Reactions
 Pain relief
 Frequent feedings of soft,
nonirritating, high-protein, highcalorie foods
 Avoidance of extremes in temperature,
alcohol, and tobacco
Nursing Management:
Patients Undergoing Radiation

Pulmonary Effects – pneumonitis (cough,
SOB, fever, night sweats)
 Treatment
• Bronchodilators
• Expectorants/cough suppressants
• Bed rest
• Oxygen
Nursing Management:
Patients Undergoing Radiation

Gastrointestinal Effects – ↓ secretion of
HCl, mucus, pepsin → N&V, diarrhea
 Prophylactic administration of
antiemetics
 Assess for S/S of alkalosis and
dehydration
 I&O
 nonirritating diet
 Antidiarrheal medications
Nursing Management:
Patients Undergoing Radiation

Reproductive Effects
 Risk of infertility
 Inform patient on expected sexual side
effects
 Consider harvesting sperm or ova
 Refer to counseling if needed
Nursing Management:
Patients Undergoing Radiation

Coping
 Assist in planning for transportation,
nutrition, and emotional support
 Patient teaching of symptom
management to maintain highest
possible quality of life
Chemotherapy

Goal is to reduce number of cancer cells
in the tumor site(s)
 Several factors determine response of
cancer cells
 Cancer cells can escape death by
staying in the G0 phase
 Main problem is presence of drugresistant resting and noncycling cells
Chemotherapy
Effect on cells
Cell cycle non-specific
 Cell cycle phase-specific

Chemotherapy
Methods of Administration



Oral
IM
IV
 Many agents are vesicants, causing severe tissue
breakdown and necrosis if infiltration occurs
 S/S infiltration: pain, redness, swelling, vesicles
 Central vascular access devices permit frequent,
continuous, or intermittent administration
• Can be used to administer additional fluids
• Major types

Silastic right atrial catheters
 Implanted infusion ports
 Infusion pumps
Chemotherapy
Methods of Administration

Intrathecal – into subarachnoid space via lumbar
puncture
Intraarterial – into artery the supplies tumor
 Intravesical (bladder)
 Intraperitoneal

Chemotherapy:
Classification of Drugs
Alkylating Agents
 Antimetabolites
 Anti-tumor antibiotics
 Plant Alkaloids
 Nitrosoureas
 Corticosteroids
 Hormone Therapy

Chemotherapy
Regional Administration

Delivery of drug directly into the tumor
site

Higher concentrations can be delivered
with reduced systemic toxicity
Chemotherapy
Effects on Normal Tissues

Chemotherapeutic agents cannot
distinguish between normal and cancer
cells

Body’s response to products of cellular
destruction in circulation may cause
fatigue, anorexia, and taste alterations
Chemotherapy
Effects on Normal Tissues
Acute toxicity
 Vomiting
 Allergic reactions
 Arrhythmias
 Delayed effects
 Mucositis
 Alopecia
 Bone marrow suppression

Chemotherapy
Effects on Normal Tissues

Chronic toxicities
 Damage to
• Heart
• Kidney
• Liver
• Lungs
Chemotherapy
Treatment Plan
Rapidly dividing cells are most sensitive
(tumor cells, hair, GI, reproductive, &
blood cells)
 Effects are systemic and therefore kill
primary and metastatic cancer cells
 Carefully calculated according to body
weight or body surface area
 Drugs usually given in combination

Chemotherapy
Treatment Plan

Selection of principles of combination
chemotherapy
 Drugs used are effective against cancer
being treated
 Synergistic effect occurs when
combined
 Includes cell cycle phase-specific and
cell cycle nonspecific drugs with
different mechanisms of action
Chemotherapy
Treatment Plan
 Combination of drugs with different
toxic side effects
 Include drugs that cause nadir (lowest
level of peripheral blood cell counts
secondary to bone marrow depression)
at different time intervals
Chemotherapy
Treatment Plan

Timed to maximize cancer cell kill and
minimize damage to normal cells eg.
every 3-4 weeks for 6 – 10 treatments
Chemotherapy
Side Effects – Table 15-11, p. 306-307
Alopecia (hair loss)
 Generally reversible
 New hair often different color and
texture
 Wigs, bandanas, scarves
 Anorexia
 Fatigue
 Nausea & vomiting
 Mucositis

Chemotherapy
Treatment Plan

Bone marrow suppression – more severe than
with radiotherapy
 Leukopenia,neutropenia
• Risk for infection
• See NCP 30-3, p. 734
 Anemia
• Activity intolerance, Hypoxemia
• See NCP 30-1, p. 708
 Thrombocytopenia
• Risk for bleeding
• See NCP 30-2, p. 725
Nursing Management
Chemotherapy

Nurse must differentiate between
tolerable side effects and toxic side effects

Serious reactions must be reported
 Some toxicities are not reversible
Nursing Management
Nursing Implementation

Administration of antiemetic drugs

Monitor lab results, particularly WBCs,
platelet, and RBCs
 Assess for signs of bleeding if platelet
count falls below 50,000/μl
Nursing Management
Nursing Implementation
Patient must be told what to expect to
decrease anxiety
 Encourage discussion of fears
 Reassure patient that situation is only
temporary
 Inform patient of supportive care that
will be provided

Late Effects of Radiation and
Chemotherapy

Risk for leukemias and other secondary
malignancies resulting from therapy

Secondary malignancies other than
leukemia have been reported
 Includes breast, ovarian, uterine,
thyroid, and lung cancers
Late Effects of Radiation and
Chemotherapy

Cancer survivors at risk for leukemiaa
and other secondary malignancies
Biologic Therapy

Alters biologic response to tumor cells
 Direct anti-tumor effect
 Restore, augment, or modulate
immune system
 Other effects – interfere with
metastasis, differentiation
Bone Marrow and Stem Cell
Transplantation
Allows for safe use of very high doses of
chemotherapy or radiation therapy
 Procedure with many risks, including
death
 Highly toxic

Bone Marrow and Stem Cell
Transplantation

Allogeneic
 From donor
 Goal is to administer large doses of
systemic therapy
 Then “rescue” bone marrow through
engraftment and subsequent normal
proliferation and differentiation of
donated marrow
Bone Marrow and Stem Cell
Transplantation

Autologous
 Patient receives their own bone
marrow
 Marrow is removed, treated, stored,
and reinfused
Bone Marrow and Stem Cell
Transplantation

Syngeneic
 Obtaining stem cells from one identical
twin and infusing them into the other
Bone Marrow and Stem Cell
Transplantation

Harvesting
 Procedure conducted in the OR
 Multiple aspirations carried out
• Usually iliac crest or sternum
 May be treated to remove cancer cells
if autologous
 Cryopreserved
Bone Marrow and Stem Cell
Transplantation

Complications
 Bacterial, viral and fungal infections
are common
• Prophylactic antibiotic therapy
 Graft-versus-host disease
• Lymphocytes from donated marrow
recognize recipient as foreign
• Attack organs such as skin, liver, and
intestines
Bone Marrow and Stem Cell
Transplantation

Peripheral stem cell transplant
 Peripheral or circulating stem cells are
capable of repopulating bone marrow
 Mobilization of stem cells from
marrow to peripheral blood done using
chemotherapy or hematopoietic growth
factors
Bone Marrow and Stem Cell
Transplantation

Cord blood stem cells
 Umbilical cord blood can be typed and
cryopreserved
 May have insufficient numbers of stem
cells to permit transplant to adults
Management of Cancer Pain
Patient report should always be believed
and accepted as primary pain assessment
data
 Drug therapy should be used following
WHO analgesic ladder (Refer to
McCaffery in course pack)
 Nonpharmacologic interventions can be
effectively used

Cancer
Psychologic Support
Emphasis placed on maintaining optimal
quality of life
 Positive attitude of patient, family, and
health care providers has significant
positive impact on quality of life for
patient
 May also influence prognosis

Cancer
Psychologic Support
Continue to be available
 Exhibit caring attitude
 Listen actively to fears and concerns
 Provide relief from distressing symptoms
 Maintain relationship based on trust and
confidence

Cancer
Psychologic Support
Use touch to exhibit caring
 Assist patient in setting realistic shortterm goals
 Assist in maintaining usual lifestyle
patterns
 Maintain hope, which can vary
 Provides control over what is occurring
 Basis of positive attitude
