normally people older than 65, higher in men than women
1.5 million in US diagnosed every year
more than 560,000 die from a malignant process every year.
in order of frequency
lung, prostate, breast.
more deaths than heart disease in people younger than 85.
African Americans have less chance of survival due to exposure risks, economic, education, and access to health
genetics and familial factors
role of the immune system
virus gets into the genetic structure of a cell=cancer. accounts for 100% of cervical cancer, 80-90% anal cancer.
strongly associated with cancers of the lung, head and neck, esophagus, pancreas, cervix, and bladder. Tobacco may also act synergistically with other substances, such as alcohol, asbestos, uranium, and viruses, to promote cancer development
Cancers of the breast, prostate, and uterus are thought to depend on endogenous hormonal levels for growth.
Patients who are immunoincompetent are more prone to cancer, transplant recipients who receive immunosuppressive therapy to prevent organ rejection have an increased incidence of lymphoma, Kaposi’s sarcoma, squamous cell cancer of the skin, and cervical and anogenital cancers.
1.A series of cellular and genetic changes that cause a loss of normal cell regulation; this is the hallmark of malignancy
2.Abnormal cell proliferation or growth
3.Unchecked local growth and invasion of surrounding tissue
4. The ability to metastasize to distant organs
*monoclonal origin of cancer (proliferates and doesn’t care whats around it)
*Pleomorphism: Cells vary in size and shape
*Polymorphism: Nucleus is enlarged and variable in shape
*Chromosomal mutations including translocations, deletions, amplification, and aneuploidy (abnormal number of chromosomes)
*Production of surface enzymes that aid in invasion and metastasis
Loss of antigens that label the cell as “self”
*Production of new tumor-associated antigens that label the cell as “non-self”
*Increased rate of anaerobic metabolism
*Loss of contact inhibition, which normally halts cell division once cells are in contact with one another
*Defect in cell recognition and adhesion (cancer cells do not recognize and adhere to each other as normal cells do)
*Loss of control of proliferation
Increased mitotic index: Tumors have a larger number of cells that are in mitosis
*Abnormal lifespan: Cancer cells tend to live longer than do normal cells
Tumors classified on the basis of growth are described as benign or malignant.
well differentiated cells that resemble cells in that tissue of origin.mode of growth
grow by expansion but don’t invade surrounding tissue
Rate of growth
usually progressive and slow. may just stop growing or even regress
doesn’t spread by metastasis.
undifferentiated, don’t resemble cells in the tissue of origin.mode of growth
it invades, infiltrates surrounding tissues, have abnormal regulation of growth. The cells continue to grow, even at the expense of their host.
Rate of growth
variable depends on differentiation. The more undefined the more rapid.
gets to blood and lymph channels so it can metastasize to other areas in the body.
It gains access to the blood and lymphatic channels
Malignant tumors metastasizes to other areas of the body. Cells of malignant tumors are undifferentiated. Malignant tumors demonstrate variable rate of growth; however, the more anaplastic the tumor, the faster its growth. A malignant tumor grows at the periphery and sends out processes that infiltrate and destroy surrounding tissues.
resting phase, inactive phase can be after mitosis or during G1 phase
RNA and protein synthasis
the cell creates 2 copies of its DNA in preparation for dividing
Premitotic phase; DNA synthesis is complete, mitotic spindle forms, goes through a 2nd growth phase and makes more proteins
or mitosis, the cell splits into 2 daughter cells/ cell division, mitosis happens more in malignant cells than normal cells
Cellular proto-oncogenes act as an “on switch” for cellular growth. When proto-oncogenes are mutated, cell growth and differentiation are stimulated.
tumor suppressors normally turn off uneeded cells proliferation. with cancer the suppressor gene is mutated and they just keep growing, this also effects mutation in apoptical signal so the mutated cell wont kill itself
“The two hit theory”
Categories of agents or factors implicated in carcinogenesis include viruses and bacteria, physical agents, chemical agents, genetic or familial factors, dietary factors, and hormonal agents.
Carcinogenesis is a multistep process
initiation, promotion, progression, and metastasis
*initiation= Altered DNA
*metastasis= tumor cells spread to body cavities via lymphatic and blood circulation
the spread of malignant cells from the primary tumor to distant sites like body cavities, blood and lymphatic system.
Most commonly bones, lungs, liver, CNS
Breast tumors normally metastasize via axillary, clavicular, and thoracic lymph channels.
Vascular endiothelial growth factor, they stimulate new blood vessels. There are therapies to combat the VEGF
these options depend on tumor type, stage, grade, functional or performance status of the patient, organ function.
the most important factors are:
Performance status is used to quantify cancer patients’ general well-being and ability to perform daily activities
trying to reduce the risk by educating on avoiding known carcinogens.
Make dietary and lifestyle changes, daily use of tamoxifen can reduce womens risks.
focus on early detection. cancer screening, mammograms, digital rectal examinations, and prostate-specific antigen (PSA) blood tests, pap test PSA levels
*evaluate body systems and organs
*obtain cells for path to allow tumor staging/grading
Performance status is used to quantify cancer patients’ general well-being and ability to perform daily activities.
we use the TNM system
T= extent of primary tumor.
N= the absence or presence and extent of regional lymph node metastasis.
M= The absence or presence of metastasis.for T=Tumor
TX= primary tumor cannot be assessd
T0= no evidence of primary tumor
TIS= carcinoma in situ (on site)
T1, T2, T3, T4 = increase in size/or local extent of the primary tumor
NX= regional lymph nodes cannot be assessed
N0= no regional lymph nodes metastisis
N1,2,3= increasing involvement of regional lymph nodes
M= distance of the metastisis
MX=distance metastisis cannot be measured
M0= no distance metastisis
M= distance metastisis
Tumor size nodel involvement
matastasized.Stage I. This stage is usually a small cancer or tumor that has not grown deeply into nearby tissues. It also has not spread to the lymph nodes or other parts of the body. It is often called early-stage cancer.
Stage II and III. These stages indicate larger cancers or tumors that have grown more deeply into nearby tissue. They may have also spread to lymph nodes but not to other parts of the body.
Stage IV. This stage means that the cancer has spread to other organs or parts of the body. It may also be called advanced or metastatic cancer. You have nodol involvement.
hodgkins patient still has 80% chance of survival
refers to classification of the tumor cells, histology of the cell
GX cannot be assessed
G1 Well-differentiated (resembles tissue of origin)
G2 Moderately differentiated
G3 Poorly differentiated (little resemblance to tissue of origin)
G4 Undifferentiated (unable to tell tissue of origin)
biopsy, normally taken from the tumor and or lymph nodes near the tumor.SURGERY AS PRIMARY TREATMENT
remove entire tumor or as much as possible (debulking)
LOCAL EXCISION when mass is small, includes removal of the mass and small amount of surrounding tissue.
includes removal of primary tumor, lymph nodes, adjacent structures, and surrounding tissue that may be at high risk of spreading. This can result in disfigurement or altered function.
removing non vital tissue or organs that are likely to develop cancer. family history, genetic predisposition,
positive BRCA1 or BRCA2 gene findings
presence or absence of symptoms.
examples are :
colectomy (resection of colon)
oophorectomy (removal of ovaries)
cure is not possible but it can make patient comfortable. Ulcerations, obstructions, hemorrage, pain.
it relieves complications of cancer
Combining other treatment methods, such as radiation and chemotherapy, with surgery also contributes to postoperative complications, such as infection, impaired wound healing, altered pulmonary or renal function, and the development of venous thromboembolism (VTE), also known as deep vein thrombosis (DVT). Some cancer types result in an increase in circulating procoagulants, which can significantly increase the risk for DVT.
Approximately 50% of patients with DVT are asymptomatic. The nurse should inquire about an ache or pain in the calf, aggravated by standing or walking. In addition, it is important to assess for asymmetry of the limbs, as slight swelling may be noted as well as erythema and warmth of the involved extremity. Venous distention in the affected limb that persists despite elevation of the extremity may be noted. Patients may also present with low-grade fever and tachycardia.
When injected into the patient, these agents serve as antigens that stimulate an immune response. The hope is that the stimulated immune system will then eradicate malignant cells. Extensive animal and human investigations with BCG have shown promising results, especially in treating localized malignant melanoma. In addition, BCG bladder instillation is a standard form of treatment for localized bladder cancer
Palliative radiation therapy is used to relieve the symptoms of metastatic disease, especially when the cancer has spread to brain, bone, or soft tissue, or to treat oncologic emergencies, such as superior vena cava syndrome (SVCS) or spinal cord compression.
there are 2 types of radiation
*Given to the area where the cancer started or to another part of the body to which the cancer spread.
*The actual delivery of radiation treatment is painless. But the radiation itself may cause some discomfort over time.
*Most common kind of radiation therapy
*Radiation will not make you lose your hair, unless radiation is given to your head
*skin can trun pink, red, or tan, and may be sensitive and irritate, peeling, ulcer.
*don’t lose hair unless it is around the head.
*patient is never radioactive
*Use fluoroscopy, the critical area is identified
*skin is marked so that the field can be reproduced on a daily basis.
*Patient is NOT radioactive.often used for palliation to control distressing symptoms can reduce tumor size
Internal radiation implantation, or BRACHYTHERAPY, delivers a high dose of radiation to a localized area.
This internal radiation can be:
implanted into or next to the tumor by means of needles, seeds, beads.
permanent brachytherapy pellets implanted for several weeks or months.
Catheters into body cavities (e.g., vagina, chest, rectum, uterus. used a lot for gynecologic cancers.
The patient is maintained on bed rest and log-rolled to prevent displacement of the intracavitary delivery device. The head of the bed must not be elevated greater than 15 degrees due to the risk of perforating the uterus with the appliance. An indwelling urinary catheter is inserted to ensure that the bladder remains empty. This minimizes the exposure of the bladder to radiation. Low-residue diets and antidiarrheal agents, such as diphenoxylate (Lomotil), are provided to prevent bowel movements during therapy to prevent displacement of the radioisotopes. Pain management is also a priority for these patients, as the presence of the appliance can be painful. Patient-controlled analgesia is a common method used for pain management in this population.
Temporary brachytherapy are
cylinders, hollow needles, catheters, tubes, fluid filled balloons.
With internal radiation therapy, the farther the target tissue is from the radiation source, the lower the dosage. This spares the noncancerous tissue from the radiation dose and toxicity. Brachytherapy may also be administered orally, as with the isotope iodine-131, which is used to treat thyroid carcinomas.
explain procedure for radiation delivery.
Duration of procedure
restrictions placed on family if radioactive implants are involved.protect skin and mucosa.
patient should avoid using ointments, lotion or powder on treated area.
Clean with mild soap and fingertips not a wash cloth and gently pat dry.
Dont remove markings.
Emollients such as Aquaphor® may be used as directed by the radiation oncologist to soothe and moisturize irritated skin. However, even approved emollients should not be used up to 4 hours before the treatment time.
use electric razors
avoid constrictive clothing
avoid sun exposure, heating lamps, pads, ice packs may cause thermal injury.
advises the client undergoing radiation therapy to use a soft toothbrush and avoid electronic toothbrushes to avoid skin lacerations.
focus on nutritional status, and general feeling of well being
*Patient is radioactive
*radioactive materials directly placed in patient.
TIME= spend no more than 30 min with patient per 8 hour shift
DISTANCE= when not providing direct care stand 6ft from patient.
SHIELD=use a lead shield as a buffer
NURSING CARE*Have patient wear radiation badge.
*Follow policies such as double flushing toilet.
*no pregnant individuals
*no children visitors
*organize care outside of room when possible (meds)
*staff and family education
*emergency action if source dislodges
stomatitis/xerostomia dry mouth, change of taste.
esophagus irritation, chest pain, vomiting and diarrhea
sites containing bone marrow, ie illiac crest and sternum you may see anemia and leukopenia, decrease in wbc and thrombocyteopenia less platelets
To prevent renal damage, it is helpful to dilute the urine by increasing fluids as tolerated
Each time a tumor is exposed to a chemotherapeutic agent, a percentage of tumor cells (20% to 99%, depending on dosage) are destroyed. Repeated doses of chemotherapy are necessary over a prolonged period to achieve regression of the tumor. Eradication of 100% of the tumor is almost impossible. Instead, the goal of treatment is eradication of enough of the tumor so that the remaining tumor cells can be destroyed by the body’s immune system.
cell cycle-specific agents
prevent the cell from making a copy of RNA and DNA, interferes at the S stage in the cell cycle.cell cycle-nonspecific agents
such as the vinca or plant alkaloids
prevent the cell from dividing into 2 daughter cells, it interferes with the M stage, mitosis stage.
Because cancer is cells dividing rapidly the medication hones in on these cells and is good at killing cancer cells.
Chemo can damage normal cells that are dividing this is what causes the side affects like hair loss.
hairorgan system =Hair
cells affected =hair follicle
physical effect =alopecia
basal layer of epidermis
abnormal pigmentation nail dystrophy
type 2 alveolar epithelial cells
progenitor stem cells
failure to produce blood cells
Body’s response to product of cellular destruction in circulation may cause fatigue, anorexia, and taste alterations:vomiting, allergic reactions, arrhythmias, mucositis, alopecia, bone marrow suppression
chronic toxicities damage to
heart, kidneys, liver, lungs
*IV most common, the concern is Extravasation (leakage of drug into surrounding tissue)
*Intracavitary =pleural or peritoneal
the methods can be
Dosage of antineoplastic agents is based primarily on the patient’s total body surface area, previous response to chemotherapy or radiation therapy, function of major organ systems, and performance status.
They use the Mosteller Equation for calculation of body surface area is the most commonly used formula in the United States
Mosteller Equation used for dosing how much chemo to give a patient.
Use BSA =body surface area
Mosteller Equation for calculation of body surface area is the most commonly used formula in the United States: square root of (height in cm × weight in kg) ÷3600Since chemotherapeutic medications have a narrow index of safety, it is recommended that dosage be determined using a standard
body surface area =(BSA) formula.
calculate the BSA using the Mosteller Equation (take the square root of height in cm × weight in kg ÷ 3,600).
there are 2.5cm in an inch so times the inches by 2.5
*Wear gloves that have been tested with chemotherapeutic agents when handling antineoplastic drugs and the excretions of patients who received chemotherapy.
*Wear disposable, nonabsorbent long-sleeved gowns with cuffs when preparing and administering chemotherapy agents.
*Use Luer-Lok fittings on all IV tubing used to deliver chemotherapy.
*Dispose of all equipment used in chemotherapy preparation and administration in appropriate, leak-proof, puncture-proof containers.
*Dispose of all chemotherapy wastes as hazardous materials.
Special care must be taken whenever IV vesicant agents are administered
Vesicants are agents deposited into the subcutaneous tissue. (extravasation), cause tissue ulceration and necrosis, and damage to underlying tendons, nerves, and blood vessels.
pH of many antineoplastic drugs is responsible for the severe inflammatory reaction as well as the ability of some of these drugs (e.g., anthracyclines) to bind to tissue DNA. Sloughing and ulceration of the tissue may be so severe that skin grafting may be necessary. The full extent of tissue damage may take several weeks to become apparent.
while administering daunorubicin through a peripheral I.V. line the client hopefully won’t exhibiting signs of extravasation, which occurs when the medication leaks into the surrounding tissues and causes swelling, burning, or pain at the injection site.
Be concerned if:
*Absence of blood return from the IV catheter
*Resistance to flow of IV fluid
*Swelling, pain, or redness at the site, or if using a central venous access device, pain in the upper arm, upper back, chest, neck, or jaw
If extravasation occurs:
*The medication administration should be stopped immediately.
*The nurse should attempt to aspirate any residual drug from the IV line.
*If an antidote is indicated, the nurse should administer it immediately.
If frequent, prolonged administration of antineoplastic vesicants is anticipated, central venous access devices may be inserted to promote safety during medication administration and reduce problems with access to the circulatory system. Complications associated with their use include infection and thrombosis.
epithelium, bone marrow, hair follicles, sperm, gi.
Nausea and vomiting are the most common side effects of chemotherapy and may persist for as long as 24 to 48 hours after its administration. Delayed nausea and vomiting may persist for up to 1 week after chemotherapy. The vomiting centers in the brain are stimulated by the following mechanisms
give prescribed ondansetron (Zofran)
include serotonin antagonists, such as ondansetron, granisetron, dolasetron, and palonosetron, which block serotonin receptors of the GI tract and CTZ, and dopaminergic blockers, such as metoclopramide (Reglan), which block dopamine receptors of the CTZ. Newer agents include neurokinin-1 receptor antagonists.
Nausea and vomiting involve multiple pathways; therefore, corticosteroids, phenothiazines, sedatives, and antihistamines are helpful, especially when used in combination with serotonin blockers to provide improved antiemetic protection. Delayed nausea and vomiting that occur longer than 48 to 72 hours after chemotherapy are troublesome for some patients. To minimize discomfort, antiemetic medications may be necessary for the first week at home after chemotherapy.
can also be used to administer additional fluids.
MAJOR TYPES ARE:
*silastic right atrial catheters
*Implanted infusion ports
found in urine, feces, sweat, vomitus, breast milk and seminal fluid
consider all bodily fluids as contaminated for at least 48 hours after completion of drug administration
cover toilets without a lid before flushing to avoid spray contamination. encourage use of toilet not urinal/bedpan
protect the skin incontinent patients
diapers can be conminated too
wear ppe when emptying foley catheters, urinals etc
Wash linens twice.
rbc differential 4200-5900
hemoglobin men 14-18g/dl
hemoglobin women 12-16g/dl
hematocrit men 42%-52%
hemotocrit women 37%-47%
WBC 4300 to 10,800
SEGS 40%-70% (mature)
Band 0%-3% (babies)
neutrophils 40%-60% 1500-8000ANC =SEGS+BANDXWBC
#1 reason treatment held is
Suppression of bone marrowwhich is leukopenia, neutropenia, and thrombocytopenia,
When neutrophils get down to 1500 may hold treatment
decrease in circulating wbc
less than 4300
common problems 32 min
body should have 1500-8000
40%-60% of your wbc count.
decrease in neutrophils
increased risk for infection
can be dose limiting due to toxicity
Neutropenia is an abnormally low ANPRisk of infectionR/T decreased resistance secondary to neutropenia/leukopenia
ANC<1000/mm3: threshold of moderate severity with increased risk of infection. Watch them closely
ANC<500/mm3 they should be on neutropenic precautions such as:
no raw foods, fruits and flowers,
they wear the mask.
colony stimulating factors
Give them this as the 1st line of defense along with antibiotics.
give this to patient to boost neutrophills.
Decreases risk of infection with patients with neutropenia.
Nadir is when patient has lowest amount of WBC RBC neutrophils and platelets.if they have ANC <500 and temp above 100.4 neutropenic fever 38.0 degree cellcius.
iv antibiotic within 2 hours.
Ask when was there last dose.
Calculate the ANC
recommended for practice with neutropenic patients
adherence to general published infection control recommendations is crucial for all patients with cancer
Hand hygiene with soap and water or alcohol-based hand rubs is the most effective means of preventing transmission of infection.
BRM colony stimulating factors (CSFs) (example neupegen)
central line associated blood stream infection.
central venous catheter care bundles of interventions are recommended
Patient education for neutropenia:
*get flu vaccine prior to treatment
*no animal care
start being concerned<100,000
<50,000 moderate risk of bleeding,you may be able to put a central line in but patient probably won’t be cleared for surgery
<40,000 don’t floss
<20,000 severe risk, increased risk of spontaneous bleeding, ie nose bleed.
avoiding use of a blood pressure cuff or tourniquet below 20,000
<10,000 severe hemorrhage.
under 10,000 be concerned about inracranial and gi bleeds.complication thrombocytopenia, a decrease in the circulating platelet count, is the most common cause of bleeding in patients with cancer and is usually defined as a count less than 100,000/mm3. The risk of bleeding increases as the count drops lower. The risk of spontaneous bleeding occurs with a count of less than 20,000/mm3.
*A client with a platelet count less than 40,000/mm3 is at risk for bleeding and shouldn’t floss his teeth.
*Using an electric razor is appropriate because doing so helps minimize the risk of cutting when shaving.
*Taking a stool softener helps decrease potential trauma to the GI tract that may cause bleeding. Removing throw rugs from the house helps prevent falls, which could lead to uncontrolled bleeding.
Platelet count of 60,000/mm3 may indicate that bleeding is occurring
petechiae- itchless rash, no itch but you have little red bumps.
bloody nose- epistaxis,
coughing up blood-hemoptysis,
bloody vomit -hematemisis
bloody poo -melena
bloody urine- hematuria
prolonged bleeding or oozing around wounds and vascular lines.
no injections of any kind
no NSAID’s ie, ibuprophen, maybe a little tylenol.
avoiding use of a blood pressure cuff or tourniquet below 20,000
decrease activity so not to hemorage.
use soft toothbrushavoid drinking alcohol
no rugs so you don’t fall
Erythropoietin stimulating agents (ESAs) stimulate RBC production.
decrease in red blood cells, 02 sats.
BRM colony stimulating factors (CSFs) (example neupogen, given to cancer patients who are neutropenic)
treat with salt and soda
bicarbonate and soda
mucositis is whole gi tract.all the way through the gi tract. pain and diarrhea.
respiratory issues it can impair airway.
inflamed membranes and C/O sorenes, may need iv treatment.
level of comfort
diet and nutrition
*distention of neck and chest veins
*headache2. spinal cord compression
presence of malignant tumor in epidural space.
3. Sensory parasthesia and loss
4. Autonomic dysfunction
5. change in bowel or bladder function
Superior vena cava syndromespinal cord compressions
fluid tumors pushing against heart.
tumor lysis syndrome
SIADH syndrome of inappropriate secretion of antidiuretic hormones
*distention of neck and chest veins
happens when cancer grows in, or near, the spine and presses on the spinal cord and nerves. Any type of cancer can spread to the bones of the spine, but MSCC is more common in people with breast, lung or prostate cancers, lymphoma, or myeloma.
*intense, localized, persistent back pain.
*motor weakness and dysfunction.
oncologic emergency involves the accumulation of fluid in the pericardial space.
NURSING INTERVENTIONS FOR CARDIAC TAMPONADE
• Assessment for pulsus paradoxus
• Maintaining the oxygen saturation of over 92%
• Teaching the patient how to use pursed-lip breathing
• Assessment for pulsus paradoxus which is ( is an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. When the drop is more than 10 mm Hg, it is referred to as pulsus paradoxus).
tumor lysis syndrome
your patient will have hyperkalemia, hyperphosphatemia, and hyperuricemia.nursing treatment:
aggressive hydration, Nursing considerations include strict monitoring of urine output and intake, monitoring of weight changes, and assessment of signs and symptoms of electrolyte disturbances.
emergency with chemo
emergency with chemo
no first response.
treatment both heparin and replacing blood clotting factors
emergency with chemo
decreased urine output
Adequate hydration, diuresis, alkalinization of the acid crystals, and administration of allopurinol (Zyloprim) may be used to prevent renal toxicity.
treatment for HSCT
either autologous, allogeneic, & syngeneic
taking stem cells from donor to patient.
nursing management focuses on:
assessing for adverse effects:
fever, chills, shortness of breath, chest pain, hives, nausea, vomiting, hypotension or hypertension, tachcardia, anxiety and taste changes
*infused bone marrow acquired from donor to matched recipient.
*goal is to administer large doses of systemic therapy.
*then replace bone marrow through engraftment and subsequent normal proliferation and differentiation of donated marrow.
comes from your own bone marrow prior to chem treatment and harvested.
*goal is to administer large doses of systemic therapy
*Rescue bone marrow
Marrow is removed, treated, stored, and reinfused.
*Less risky than allogeneic but may have higher relapse rate due to undetected cells in marrow.
from an identical twin.
Monitor patient for at least 3 mths
activity intolerance R/T impaired oxygen transport AEB diminished RBC count and C/O fatigue
you can have them
likely to be effective
Acute or chronic or nausea
factors that decrease tolerance of pain and discomfort
pain meds before treatment or procedure.
take at first sign of discomfort.
hot cold packs
mobility excercisewhat to do for
give antiemetics prior to chemo/radiation
eat small frequent meals
eat bland and chilled foods.
work toward patient goals
assist with advance planning to help prepare patient and family for expected deathHospice
promote dignity and quality of life during the dying process, rather than provide curative treatments to prolong life.