Transcript Cancer Oct 22x

NURSING CARE OF
THE PATIENT WITH
HEMATOLOGIC/NEOPLASTIC DISORDERS
Presented by:
Mary Lesperance, MSN, ARNP-C
LEARNING OBJECTIVES
• Define anemia, causation &
diagnosis
• Define cancer
• List types of cancer & understand
methods for detection and
diagnosis
OBJECTIVES (2)
• Describe classification systems
for cancer.
• Discuss treatment options and and
how they are chosen
• Identify classifications of
chemotherapeutic agents and
administration
OBJECTIVES (3)
• Explain role of nurse in prevention and
detection of cancer
• Describe complications that can occur
• Describe nursing management of patient
receiving therapy
Nursing Responsibility
• Importance of knowledge
– Education
– Support
– Care
HEMATOLOGY
ANEMIAS
ANEMIA
• Greek: “Without blood”
• Qualative or quantative deficiency of hemoglobin in
RBC
• Carries O2 from lungs-tissues
• Causes:
– blood loss
– blood destruction (hemolysis)
– Deficient red blood cell production
– Lack of iron in body
ANEMIA
•
Most common ww deficiency disease
– WHO 1/3 ww population
•
Iron deficiency anemia most common
hematologic disease of infants and children
US & WW
– Low iron 2o cow’s milk (iron-poor & interferes
with absorption in gut)
Effects
• Children: Development delays & behavior
disturbances (May be irreversible after age 4)
• Adults: May be subtle or dramatic
– Pica (dirt, paper, wax, ice, hair)
– Pallor, weakness, fatigue, general malaise, poor
concentration
– Severe: body compensation – increased cardiac,
palpitations, sweatiness, heart failure (not enough
hgb = not enough O2 circulating)
S/S R/T ANEMIA
•
•
•
•
•
•
•
Fatigue
Shortness of breath
Ataxia
Headache
Coldness in hands and feet
Pale Skin
Decreased concentration
LABORATORY - Anemia
•
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•
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•
•
Hemoglobin (Hgb)
Hematocrit (Hct)
Red blood cell (RBC)* (Micro vs Macro)
Serum ferritin
Serum iron
Total iron-binding capacity (TIBC)
Reticulocytes
Methylmalonic acid (vitamin B 12)
Homocysteine
LABORATORY - CBC
• Hemoglobin –
– Measures 02 capacity of blood
– Low levels usually indicate anemia
– Lacks specificity to reflect body iron stores
• Hematocrit –
– % of volume of blood occupied by RBCs
– Less accurate than Hgb:
• Falsely elevated in hyperglycemia & dehydration
• Time & temperature sensitive
BIOLOGY - Hgb
• Protein in the RBC’s –
• Iron-rich
• Iron is one of building
blocks of Hgb
•
•
•
•
Polypectide chain
Heme (red)
Iron (blue)
Alpha/beta chains
HGB MOLOCULE
SERUM IRON
• Measures amount of iron in blood
• Does not fall until iron stores (serum ferritin) are
depleted
• Diagnostic value lower
–
–
–
–
Day to day fluctuations
Increases with ingestion
Decreases due to infection, inflammation, malignancy
Need to look at other values (TIBC)
SERUM FERRITIN
• Serum Ferritin (one of most useful est. of total
iron stores)
– Intracellular – stored in tissues
– Plasma/Serum – released into blood
– High - sign of increased stores, Low usually due to
iron deficiency
– High can be due to malignancies, infection and/or
inflammation, many transfusions
TOTAL IRON-BINDING CAPACITY (TIBC)
• Measure of amt of iron that transferrin can
carry
• Increases with iron deficiency (body tries to
capture more)
• Diagnostic:
– High: iron deficiency, normal pregnancy
– Low: inflammation, infection, malignant tumors,
malnutrition
SERUM IRON
• Iron (red) stored inside
ferritin and absorbed
in duodenum
• (why slow-release may
be ineffective to
prevent upset
stomach, but slow
release won’t be
absorbed as well)
TRANSFERRIN
Transfers iron to areas requiring
FOLIC ACID + VITAMIN B12
• Folic Acid – DNA synthesis of RBCs
• Vitamin B12 – transports folic acid from serum
to RBC
•
B12 Def Folic Def
– Methylmalonic acid Elev.
Normal
– Homocysteine level Normal or Elevated
–
Elev.
SICKLE CELL ANEMIA
• Autosomal recessive genetic disease
• Protective of malaria – most died in 20’s
– High infant death “ogbanjes” – “children who come and go”
• 340,000 born each year ww – majority in belt around
Med. Sea (Greece, Italy, Saudi, Africa)
– Nigeria >100,000/yr – 75% die between 1-5
• US – 85% reach 18; few live past 50
– 1/500 African-American births; 1, 1000-1400 Hispanic
(lots of notes in ppt)
Sickle cell conditions are inherited from parents in much the
same way as blood type, hair color and texture, eye color
and other physical traits. The types of hemoglobin a person
makes in the red blood cells depend upon what hemoglobin
genes the person inherits from his or her parents. Like most
genes, hemoglobin genes are inherited in two sets…one
from each parent.
If one parent has Sickle Cell Anemia and the other is
Normal, all of the children will have sickle cell trait. (Most
people with sickle cell trait are healthy.
If one parent has Sickle Cell Anemia and the other has
Sickle Cell Trait, there is a 50% chance (or 1 out of 2) of
having a baby with either sickle cell disease or sickle cell
trait with each pregnancy.
When both parents have Sickle Cell Trait, they have a 25%
chance (1 of 4) of having a baby with sickle cell disease
with each pregnancy.
SICKLE CELL DISEASE
• Most common in US:
– Hgb SS (sickle cell anemia)
– Hgb SC disease
– Hgb sickle beta-thalessemia
• Causes deoxygenation of heme – hydrophobic
interactions – distorting RBC into ‘sickle’ shape – stiff &
sticky – form clumps.
• See notes on next page)
• People with sickle cell conditions make a different form
of hemoglobin A called hemoglobin S (S stands for
sickle). Red blood cells containing mostly hemoglobin S
do not live as long as normal red blood cells (normally
about 16 days). They also become stiff, distorted in
shape and have difficulty passing through the body’s
small blood vessels. When sickle-shaped cells block
small blood vessels, less blood can reach that part of
the body. Tissue that does not receive a normal blood
flow eventually becomes damaged. This is what causes
the complications of sickle cell disease .
SICKLE CELL ANEMIA
• Present @ birth – s/s usually after 4 mos.
– (testing @ birth, genetic testing)
– Pneumonia and infections major cause of death in
children with Sickle Cell Anemia
– Other – meningitis, influenza, hepatitis
• S/S vary from mild to severe
• Sickle Cell trait (AS) is an inherited condition in which
both hemoglobin A and S are produced in the red blood
cells, always more A than S. Sickle cell trait is not a type
of sickle cell disease. People with sickle cell trait are
generally healthy.
Complications
•
•
•
•
•
•
•
•
•
Low RBCs
Pain Episodes
Strokes
Increased infections
Leg ulcers
Bone damage
Jaundice
Gallstones
(pain is most common
side effect)
•
•
•
•
•
Delayed growth
Lung blockage
Kidney damage
Priapism
Sequestration in liver or
spleen
• Eye damage
The sickle cells also block the flow of blood
through vessels resulting in lung tissue
damage (acute chest syndrome), pain
episodes (arms, legs, chest and abdomen),
stroke and priapism (painful prolonged
erection). It also causes damage to most
organs including the spleen, kidneys and liver.
Damage to the spleen makes sickle cell
disease patients, especially young children,
easily overwhelmed by certain bacterial
infections
S/S R/T Pain
• Chronic or Acute/Sudden Pain –
• Almost all have painful crisis @ some point
– Sickled RBCs “clump” in bloodstream
– Major cause of hospitalization, E.D. visits
– Pain for hours to days
Prevention/Relief of Symptoms
•
Goals
1.
2.
3.
4.
Relieve pain
Prevent infections (prophylactic pcn)
Prevent eye damage; strokes
Control complications
Medications
• Hydroxuria
– Chemotherapy w/ multiple side effects that go
along with chemo: N/V/A, stomatitis, diarrhea,
etc.
– Improved growth
– Prevents organ damage
– Decreases need for transfusions
– Hydroxyurea –
• Improved growth, prevents organ damage, decreases
need for transfusions, (side effects)
FINAL THOUGHTS
• EDUCATION (Professionals & patients)
– Increased fluids
– Self-Care (keep as active as possible, not being
active is worse for contractures)
• PAIN CONTROL
– PAIN IS WHAT THE PATIENT SAYS IT IS!!!
– Minorities – mainly – causes issues
Cancer Statistics 2006
A Presentation From the
American Cancer Society
US Mortality, 2003
Rank
Cause of Death
# deaths
% deaths
•
•
•
1.
Heart Diseases
685,089
28.0
2.
Cancer
556,902
22.7
•
•
•
•
•
•
•
•
•
•
•
•
9.
3.
Cerebrovascular diseases
157,689
6.4
4.
Chronic respiratory diseases 126,382
5.2
5.
Accidents
6.
Diabetes mellitus
7.
Influenza and pneumonia
8.
Alzheimer disease
109,277 4.5
74,219
3.0
65,163
63,457
2.7
2.6
Source: US Mortality Public Use Data Tape 2003, National Center for Health Statistics, Centers for Disease Control
and Prevention, 2006.
2008 Estimated US Cancer Cases*
Men
720,280
Prostate
25%
Lung & bronchus
15%
Colon & rectum
10%
Urinary bladder
7%
Melanoma of skin
5%
Non-Hodgkin
lymphoma
5%
Kidney
4%
Oral cavity
3%
Women
679,510
26% Breast
14%
Lung & bronchus
10%
Colon & rectum
6%
Uterine corpus

4%
4%
Non-Hodgkin
lymphoma
Melanoma of skin

4% Thyroid
3%
Ovary
Leukemia
3%

Pancreas
3%
3%
Kidney
20%
3%
Leukemia
23%
All Other Sites
All Other Sites
*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.
Source: American Cancer Society, Cancer Facts & Figures 2007
.
.
Now we will turn our attention to the number of new
cancers anticipated in the US this year. It is
estimated that almost 1.4 million new cases of
cancer will be diagnosed in 2006. Cancers of the
prostate and breast will be the most frequently
diagnosed cancers in men and women,
respectively, followed by lung and colorectal
cancers both in men and in women.
2006 Estimated US Cancer Deaths*
Lung & bronchus
31%
Colon & rectum
10%
Men
291,270
Women
273,560
26% Lung & bronchus
Prostate
9%
15%
Breast
Pancreas
6%
10%
Colon & rectum
Leukemia
4%

6% Pancreas
Liver & intrahepatic
bile duct
4%

6% Ovary

Esophagus
4%
4% Leukemia

Non-Hodgkin
lymphoma
3%
3% Non-Hodgkin
lymphoma

3% Uterine
Urinary bladder
3%

2% Multiple myeloma
Kidney
3%

2% Brain/ONS
All other sites
23%
ONS=Other nervous system.
Source: American Cancer Society, 2006.
23%
All other sites
Lung cancer is, by far, the
most common fatal cancer
in men (31%), followed by
colon & rectum (10%), and
prostate (9%). In women,
lung (26%), breast (15%),
and colon & rectum (10%)
are the leading sites of
cancer death.
Change in the US Death Rates* by Cause,
1950 & 2003
Rate Per 100,000
600
586.8
1950
500
2003
400
300
231.6
193.9
180.7
200
100
53.3
190.1
48.1
21.9
0
Heart
Diseases
Cerebrovascular
Diseases
Pneumonia/
Influenza
Cancer
* Age-adjusted to 2000 US standard population.
Sources: 1950 Mortality Data - CDC/NCHS, NVSS, Mortality Revised.
2003 Mortality Data: US Mortality Public Use Data Tape, 2003, NCHS, Centers for Disease Control and
Prevention, 2006
Cancer Death Rates*, by Race and Ethnicity,
US,1998-2002
400
Men
Women
339.4
350
300
250
200
242.5
194.3
164.5
148.0
150
171.4
159.7
99.4
113.8
111.0
100
50
0
White
African
American
Asian/Pacific
Islander
American
Indian/ Alaskan
Native
Hispanic†
*Per 100,000, age-adjusted to the 2000 US standard population.
†Hispanic is not mutually exclusive from whites, African Americans, Asian/Pacific Islanders, and American Indians/
Alaska Natives.
Source: American Cancer Society, Cancer Facts & Figures 2007.
Overall, cancer death rates are higher in men than
women in every racial and ethnic group. African
American men and women have the highest rates of
cancer mortality. Asian and Pacific Islander men and
women have the lowest cancer death rates, about half
the rate of African American men and women,
respectively.
Note: Rates for populations other than white and
African American may be affected by problems in
ascertaining race/ethnicity information from medical
records. This is likely to result in reported death rates
that are lower than true death rates.
Cancer Death Rates* by Sex and Race, US, 1975-2002
500
Rate Per 100,000
450
African American men
400
350
300
White men
250
African American women
200
White women
150
100
50
0
1975
1978
1981
1984
1987
1990
1993
1996
1999
*Age-adjusted to the 2000 US standard population.
Source: Surveillance, Epidemiology, and End Results Program, 1975-2002, Division of Cancer Control and
Population Sciences, National Cancer Institute, 2005.
2002
100
4500
90
4000
80
Per capita cigarette
consumption
3500
70
3000
60
Male lung cancer
death rate
2500
2000
50
40
1500
30
1000
20
500
2000
1995
1990
1980
1975
1970
1965
1960
1955
1950
1945
1940
1935
1930
1925
1920
1915
1910
1905
0
1985
10
Female lung cancer
death rate
0
Age-Adjusted Lung Cancer Death
Rates*
5000
1900
Per Capita Cigarette Consumption
Tobacco Use in the US, 1900-2002
Year
*Age-adjusted to 2000 US standard population.
Source: Death rates: US Mortality Public Use Tapes, 1960-2002, US Mortality Volumes, 1930-1959, National
Center for Health Statistics, Centers for Disease Control and Prevention, 2005. Cigarette consumption: US
Department of Agriculture, 1900-2002.
The last set of slides describes at the prevalence of cancer risk
factors, such as tobacco use and physical inactivity, and the
prevalence of cancer screening, such as use of mammography.
Tobacco use is a major preventable cause of death, particularly
from lung cancer. The year 2004 marks the anniversary of the
release of the first Surgeon General’s report on Tobacco and
Health, which initiated a decline of per capita cigarette smoking
in the United States. As a result of the cigarette smoking
epidemic, lung cancer death rates showed a steady increase
through 1990, then began to decline among men. The lung
cancer death rate among US women, who began regular
cigarette smoking later than men, continues to increase slightly.
Childhood Cancer
• #1 cause of death by disease children &
adolescents
• 12,000 dx In U.S. every year; over 3000 will die
from it
• One in 300 Americans will develop cancer
before age of 20
• Median age of adults – 67
• Median age of children – 6
(NCI)
Cancer Incidence & Death Rates* in Children 0-14 Years,
1975-2002
18
Rate Per 100,000
16
Incidence
14
12
10
8
6
Mortality
4
2
0
1975
1978
1981
1984
1987
1990
1993
1996
1999
2002
*Age-adjusted to the 2000 Standard population.
Source: Surveillance, Epidemiology, and End Results Program, 1975-2002, Division of Cancer Control and
Population Sciences, National Cancer Institute, 2005.
Trends in Survival, Children 0-14 Years, All Sites Combined
1974-2001
Year of
Diagnosis
Age

0-4

1974 - 1976

5-9
78.3
55.5
1974 - 1976
78.6
1995 - 2001
Years

56.8
1995 - 2001
Years

5 - Year Relative Survival Rates *

10 - 14
1974 - 1976
55.1
1995 - 2001
Years

*5-year relative survival rates, based on follow up of patients through 2002.
Source: Surveillance, Epidemiology, and End Results Program, 1975-2002, Division of Cancer Control and
Population Sciences, National Cancer Institute, 2005.
79.2
The 5-year relative survival rate
for all three age groups
increased significantly between
the mid 1970s and late 1990s.
For example, the 5-year relative
survival rate increased from
55.1% in 1974-76 to 79.2% in
1995-2001 for cases diagnosed
among children 10-14 years old.
CANCER
• Group of >200 diseases
• Characterized by uncontrolled and/or
unregulated growth of cells
• Most feared of all diseases
• Often synonymous with death, pain,
disfigurement
• Second most common cause of death in U.S.
Normal Cellular Proliferation
• Stem Cell – all cells from fertilized ova
• Differentiate (very, very important! Test
question)
– Predetermined
– Mature functioning cell of only that tissue
– Stable and orderly progression
– Respects boundaries and territory
– Degenerates and dies
APOPTOSIS
• Equilibrium between cell growth and death
• Pro-apoptotic vs. anti-apoptotic stimuli
• Programmed cell death
• Remove old, dead, unwanted
MUTATION
• Mutation
– Single gene theory – clonal evolution/mutation
• Genetic and/or environmental and/or virus damages
DNA
– Age (77% >55) lifelong accumulations of DNA mutations –
may be unable to repair all or cell-mediated immunity
reduced
– Proto-ononcogens – regulate normal processes (passed
from prev. generations & may be over/under expressed)
– Tumor suppressor genes (p53) may be abnormal
(supresses tumors)
Cancer Causes
•
•
•
•
•
•
•
78-80% may be environmental/external
Viruses
Hormones
Radiation
Chemicals
Hereditary Factors
Unknown Factors
Heredatary -Genetic Example - BREAST
(autosomal
dominant)
BRCA 1
(1994)
BRCA 2
(1995)
Breast
56-85%
56-85%
Ovarian
26-85
<10%
Male Breast
No
Ca
Other Cancers Prostate
Yes
Colon
KNOWN CARCINOGENS
–
–
–
–
–
Alcohol
Liver, esophagus, mouth
Hair DyesBladder
RadiationBone marrow, thyroid, etc
Pesticides
Lung
Tobacco Lung, esophagus, mouth
pharynx, larynx, pancreas,
bladder, kidney, liver,
stomach, colon, leukemia
– Sun
Skin, eyes
Defect in Proliferation
Any of previous may occur and cause:
• UNREGULATED GROWTH
• UNREGULATED PROLIFERATION
• DE-DIFFERATION
• Eventually form visible mass/tumor (Primary)
• May break off and lodge elsewhere
(Metastasis)
Benign vs Malignant
Encapsulated
Differentiated
Metastasis
Recurrence
Vascularity
Growth
Cell
Malignant
Rare
Poorly
Frequent
Frequent
Moderate to Marked
Infilt//expansive
Abnormal, become
more unlike parent
cell
Benign
Usually
Partially
Absent
Rare
Slight
Expansive
Fairly normal
Some Causes
• Alcohol
– Synergistic with smoking (oral, pharynx, larynx, esophagus, liver
& anemias!)
• Radiation
– External Beam
– Sun
• Viral
– HPV – cervical dysplasia
– HPV – SCC - Head & neck **New**
– HBV – hepatoma
Cause/Prevention
• Tobacco
– 30% of cancers
– 90% Lung cancers
• Diet
– Colon Cancer & fiber intake
– Breast cancer and too much fat intake
– Fruits and vegetables protective
Screening - USHPTF
• PAP (yearly)
• Breast: CBE (clinical breast exam),
Mammogram, SBE
• FOB (fecal occult blood)
• Colonoscopy
• Testicular
• Skin
7 Warning Signals
C
A
U
T
I
O
N
Change in bowel/bladder
A Sore that does not heal
Unusual bleeding or discharge
Thickening/lump - breast or elsewhere
Indigestion or difficulty swallowing
Obvious change in wart or mole
Nagging cough or hoarseness
The ABCDEs of
Melanoma Diagnosis
Asymmetry
One half of the lesion is shaped
differently than the other
Border
Color
Evolution
The border of the
lesion is irregular,
blurred, or ragged
Inconsistent pigmentation, with
varying shades of brown and black
Diameter
>6 mm, or a
progressive
change in size
History of change in the lesion
Photos courtesy of the American Cancer Society.
TYPES OF CANCER
& CANCER STAGING
T.C. - CASE STUDY
•
•
•
•
•
47 YOCF
Married – 19 years, 1 son
RN
PMHx – Hep C
PSHx –
•
•
•
•
tubal ligation – 1994
Liver bx 1997
C-Spine surgery following MCA with chronic pain
R & L meniscus repairs ’97 & ‘05
TC – Case Study #2
Present Complaint
• 9/2006 – developed severe LLQ abd pain –
– CT Scan showed ovarian cysts – advised to get transvaginal
ultrasound.
• 11/06 – Persistent LLQ pain: Ascites + CA-125: 882
(0-35)
• Laporatomy, TAH,BSO :
TC – Cast Study - Diagnosis
• Dx: STAGE IIIb left ovarian cancer, high-grade
papillary serous cystadenocardinoma with
ascites, omental deposits and involvement of
1 pelvic lymph node.
TC – Case Study – Treatment
• Ports:
– Intraperitoneal
– Central intravenous
• Chemotherapy: cisplatin & Taxol
intraperitoneal & I.V. Taxol X 6, day 1, 8, 15
(Completed 4/29/2007)
T.C. – Follow up
•
•
•
•
Remove ports
Q 3 mo CT Scans and Tumor markers
Negative in July and October 2007
February, 2008 – increased fatigue
– CT: Nodes to chest, abdomen, pelvis
– CA125 increased (69)
• Back to treatment
TC - Treatment
• Taxotere- Cisplatin – d 1, 8, 15
– Allergic reaction on 2nd cycle – hypoxia, flushing,
edema – (no more cisplatin!)
• Held for severe anemia & blood transfusions
• Restarted Gemcitibine/Taxotere
– Decreased to 2 weeks, then every other with
neupogen supplement.
TC - Current
• Last chemo 3/04/09
• Ca125 – 43.6
• Palliative Study – Intervention ARNP
• Just took her to Hospice this past week… she
just turned 50 yrs of age
TYPES OF CANCERS
• HEMATOLOGICAL
– (Leukemias, Myelomas, etc.)
• LYMPH
– (Hodgkin's, Lymphomas)
• SOLID TUMORS
– Brain, Lung, Breast, Sarcomas, GI/Colon, Kidneys,
etc.
Definitions
• CARCINOMA
-
starts from Skin & Epithelial
• ADENOCARCINOMA - Glands
• SARCOMAS
- connective tissue,
muscle, bone & fat
• LYMPHOMAS & LEUKEMIAS –
lymph & hematopoietic system
-
Types & Sites
• Same cancer very different
– Adenocarcinoma – (came from the gland, but it is
now in lung/pancreas
– Glandular origin – different sites
• Sites with different cancers; i.e., Kidney
– renal cell (most common)
– Wilm’s tumor (usually children)
– Transitional cell (similar to bladder cancer)
Metastasis
• Angiogenesis –
(cuts off blood supply, lots of side effects)
– new blood supply > 2mm
• Motility
– Travel from primary
• Cell Adhesion
– Proteins mediate adhesion
• Proteolytic enzymes
– Secrete to cross barriers
• Immunogenicity (strong & immune)
Laboratory
• Hematology - anemia, blasts, lymphs, etc.
• Chemistry - Kidney, Liver,
• Tumor Markers
– PSA*
- CA 72-4 - CA 15-3
– CEA
- CA 50
- AFP
– CA 125*
- CA 19-9
– *Screening + monitoring
– CA125 = if # going down we know the chemo is
working
MORE LABORATORY
• Cytology,
• Bone marrow examination,
• Biopsy results
Biopsy Open or Needle
•
•
•
•
•
•
•
•
Breast
Liver
Fat aspirate
Bone Marrow Biopsy
Anywhere tumor can be easily accessed
OR
EUS (Endoscopic Ultrasound)
Other – with surgical excision
Sentinel Node Biopsy
• Used with original surgical removal of tumor
• Lymphatics do not always follow anatomical
patterns – must map
• Mapping of lymphatics to find sentinel node
• radiocolloid + intraoperative blue dye
improves accuracy of mapping
Primary vs Metastatic
• Liver Cancer (call it the original)
• Brain Cancer
• Bone Cancer
• Lymph
Lymphatic Metastases
• Spread first through afferent channels
• Sentinel Lymph Node is first node along those
channels
• SLNs are immuno-suppressed and proven to
be sites of early metastases (signal lymph nodes)
• Removal of all nodes difficult, impossible to bx
all & cause many patient problems
Cancer Staging
• Very important to treatment choices
– Describes how far cancer has spread
– Place with similar prognosis and treatment in the
same staging group
STAGING
•
•
•
•
•
•
Recurrent
Stage 0
Stage I
Stage II
Stage III
Stage IV
(locally vs distant)
In situ (still in original cell)
limited to tissue of origin
limited local spread
extensive local & regional spread
metastasis
TNM STAGING
• Define I through IV Grouping
• Specific to each cancer, but --• T–
• N–
• M–
Tumor (T0 – T4)
Lymph Nodes (N0 – N4)
Metastasis (M0 or M1)
Overall
– Definitions different for each cancer, (some have
IIa, IIb)
– Some IIIa vs IIIb huge difference
– Stage IV in some cancers curable, treatable; others
not
– Leukemia, lymphomas, hematological
• Defined by blood count, extent of bone marrow
involvement or presence/absence of symptoms.
Goals of Cancer Treatment
• Cure
• Control
• Palliation
Treatment Options
• Dependent upon
– Diagnosis
– Staging
• Biopsy results
• Radiological Studies
– CT, MRI, PET
• Laboratory Tests
– Pt age, physical condition, prognosis. preferences
Treatment Options
• Team decision with strong patient/family input
• Protocols dependent upon diagnosis and staging and
history
• All research based and approved by FDA or under
research protocol
• Dependent upon patient age, health, prognosis
• Best treatment often research protocol
Treatment Options
• Surgical
• Radiation
• Chemotherapy
• Bone Marrow & Stem Cell Transplantation
• Palliation
(In any combination or order dependent upon criteria
of cancer)
Surgical
• Diagnosis/Staging
• Cure/Control
– Margin of tissue to cure, preventive,
debulking,lumpectomy, thyroidectomy, resection
(ostomy for palliation or cure)
• Palliation of symptoms
• Rehabilitation
– Reconstruction, continent ostomies
Radiation Therapy
• External, Internal, brachy, seeds
• Cure
– Alone and in combination
• Control
– For periods of time
• Palliation
– Pain, obstruction, compression, bleeding
Chemotherapy
• Primary
– No other effective treatment available
– Induction (leukemias, etc)
• Neoadjuvant
– Prior to alternative treatment
• Adjuvant
– Systemic therapy along with surgery, radiation, etc.
(Concurrently or sequentially)
Chemotherapy
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Fairly recent (1950’s – nitrogen mustard)
Not completely understood
Need to know cell biology
Cell cycle made up of five phases
– Time for different cellular processes that result in
reproduction or death of cell
Cancer Drugs
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Alkylating Agents
Anti-Tumor Antibiotics
Antimetabolites
Plant Derivatives
Hormones and Hormone Inhibitors
Angiogenesis inhibitors
PRINCIPLES OF COMBINATION DRUGS
• Drugs with single agent activity
• Avoid drugs with overlapping toxicities
• Administer at optimal dose and schedule (as
determined by clinical trials)
• At regular intervals and minimize time
between cycles
Cell Cycle
• Only some cells actively proliferating
• 5 Phases – periods for cellular processes
– G1 – RNA & protein synthesis
– S - DNA replicated (short)
– G2 – after DNA & before cell division
– M - Mitosis (cell division)
– G0 - resting (dormant)
Biologic Response
modulators:
Asparaginase;
Pegaspargase
Anti-metabolites
Methotrexate,
Plant Derivatives
Vincristine
Vinblastine
Non Cell Cycle Specific:
Alkylating agents; anti-tumor
antibiotics; hormones, hormone
inhibitors
5FU;
Mercaptopurine,
cytarabine,
topetecan
Bleomycin,
Etopaside,
Paclitaxel
Common Toxicities
(FRIENDLY FIRE)
• Myelosuppression
– Can be life threatening (neutropenia)
• Nausea & Vomiting
– Causes of stopping therapy (much better now)
• Mucous Membrane Ulceration
– Alimentary tract (Diarrhea also)
• Alopecia
Toxicities - Myelosuppression
• Most common dose-limiting side effect
• (Try to give the most we can w/out infection)
– WBC/ANC – Neutropenia –
– Infection Risk
• Instruct in precautions – vegetables, fruit, crowds
– Take temperature 2X day
• Antibiotics??
Myelosuppression Thrombocytopenia
– Decreased Platelet Count – at risk for bleeding
– Monitor bleeding, bruising, petechiae
– No IM injections; pressure for SQ, etc.
– No aspirin, no rectal suppositories
– Soft toothbrush, no water picks, dental floss
– Electric shaving devices – no razors
– Safety important
ANEMIA - Symptoms
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Easily fatigued, weakness, listlessness
Dyspnea on exertion
Pallor (conjunctiva, nail beds)
Decreased thought processes
Headache, dizziness
Hypotension
Tachycardia
Tachypnea
Nursing Interventions
• Assessment/Instruction/monitoring/
– Mouth Care
– Regular medication administration of
anti-emetics, anti-diarrheals
– Analgesics
– Skin Care
Why does chemotherapy fail?
• After chemotherapy, bulk of tumor dies
but resistant cells survive (all you need are 1 or 2
cells left over that grow…)
• Regrowth of tumor by cells selected to be
resistant
• Slow growing better-differentiated cells
die & fast growing undifferentiated cells
form bulk of tumor – vascularity
PROGRESSION
• Side-effects of chemotherapy/treatment do
not all disappear
• Chemotherapy resistance
• Tumor regrows – (doubling time)
PROGRESSION
• Tumor Necrosis Factor – (Inflammatory response)
– Cytokines (small protein hormones made by WBCs (neutrophils,
eisonphils, lymphocites, etc – increase immune response) –
causes fever
– Cause inflammation
– Increases resting energy expenditure
– Increases urinary nitrogen
– Decreases Protein
• Cachexia – all side effects - Death
Late Effects
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CNS - thought, sight, hearing
Immune –
Cardiovascular – anthracyclines injure the heart
Pulmonary – fibrosis
Gastrointestinal
Renal
Endocrine - Reproductive
Musculoskeletal
Second Malignancy
CANCER FREE –
THEN WHAT?
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10,000,000 Cancer Survivors
Where do we go from here
Pediatric
Adult
Other thoughts
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Physical
Psychosocial
Financial
Stigma