SKIN CANCER (MALIGNANT MELANOMA Most common cancer in the US. 1 in 5 Americans will develop skin cancer by age 70. The cost of skin cancer treatment is estimated at 8.1 Billion USD... SKIN CANCER (MALIGNANT MELANOMA Most common cancer in the US. 1 in 5 Americans will develop skin cancer by age 70. The cost of skin cancer treatment is estimated at 8.1 Billion USD. Skin cancer is readily seen and detected; Early intervention is possible. Risk Factors UV radiation exposure Sunlight Tanning beds Light-skinned people Family history Large number of nevi, or have dysplastic nevi Skin damage is cumulative; manifestations appear 20-50 years after exposure. Preventive Measures Avoid sunlight exposure between 10am and 4pm. Wear protective clothing, including sunglasses. Seek shaded areas when outdoors. Apply sunscreen on exposed skin 20 minutes before exposure. (SPF 15, UVA-UVB) Re-apply after 20 minutes of sun exposure. Use lip balm with SPF 15. Avoid use of tanning beds. Quit smoking. Melanoma A cancerous neoplasm characterized by neoplastic melanocytes present in the epidermis and the dermis (and sometimes the subcutaneous cells). Radial Phase Tumor spreads radially in the epidermis. Most amenable for treatment. Vertical Phase Vertical growth into the dermal layer. Leads to metastasis. Melanomas that progress more rapidly from the radial to the vertical growth phase are considered more aggressive types. Clinical Manifestations Change in a nevus. New growth on the skin. Dark, red, blue with irregular shape. Lower extremities (women), Trunk, head, neck (men) May have itching, ulceration, rapid growth, bleeding Assessing ABCD in Moles A for Asymmetry The lesion does not appear balanced on both sides. The lesion has an irregular surface with irregular topography (uneven elevations) either palpable or visible. B for Irregular Border Angular indentations or multiple notches appear in the border The border is fuzzy or indistinct, as if rubbed with an eraser C for Variegated Color Benign moles are usually a uniform light to medium brown. Colors that may indicate malignancy if found together within a single lesion are shades of red, white, and blue; shades of blue are ominous. White areas within a pigmented lesion are suspicious. Some melanomas, are not variegated but are uniformly colored (bluish-black, bluish-gray, bluish-red). D for Diameter A diameter >6 mm (about the size of a pencil eraser) is considered more suspicious. E for Evolving Benign moles appear the same over time. When a mole starts to change in appearance, in size, shape, color, or elevation, it may suggest malignancy. Diagnostics Excisional skin biopsy (Confirmatory) Elevated Lactic Dehydrogenase (Metastasis) CBC, CXR, Creatinine, Liver Function Tests MRI imaging, PET scan for metastasis evaluation TNM Staging Medical Management Surgical excision - small, superficial lesions. Wide local excision – deeper lesions Sentinel lymph node biopsy with lymph node dissection Radiation Therapy – if with lymph node involvement. Stage 3 and Stage 4 Pembrolizumab, Nivolumab, or Ipilimumab (enhances T-cells) Targeted Therapy BRAF inhibitors (Dabrafenib, Encorafenib, and Vemurafenib) MEK inhibitors (Trametinib, Cobemetinib, and Binimetinib) Nursing Management Comfort measures and Pain medications after skin surgery Psychological support for possible disfigurement. BRAF inhibitors may cause squamous cell carcinomas. End of life support PROSTATE CANCER Most common cancer in men. Common in the US and Europe. Rare in Africa, Asia, Central and South America, and China. African Americans have a high risk for Prostate Cancer. Risk Factors African Americans Increasing age (more than 65 years old) Familial predisposition HPC1, BRCA1, BRCA2 mutations Diet high in red meat, dairy, fat Androgens and estrogens Clinical Manifestations May be asymptomatic (early stage) Urinary obstruction Hematuria Painful ejaculation Sexual dysfunction Symptoms of Metastasis (1st indications of cancer) Backache, Hip pain Perineal and rectal discomfort Anemia, weight loss, weakness Oliguria Pathologic fractures Diagnostics Elevated serum PSA (prostate specific antigen) Stony hard and fixed prostate during DRE. Prostate Biopsy (most definitive) Gleason Score (Tumor Grading) Increase in score, increased aggressiveness Lower score, well-differentiated cells, less aggressive tumor Medical Management Non-surgical watchful waiting Sipuleucel-T (Therapeutic vaccine) Abiraterone Acetate and Cabazitaxel Surgical Management Radical Prostatectomy Removal of: Prostate Seminal vesicles Tip of vas deferens Surrounding fat, nerves, blood vessels S/E: Erectile Dysfunction (common) Radiation Therapy Teletherapy (External Beam Radiotherapy, EBRT) Higher doses of EBRT for high risk cancers Androgen Deprivation Therapy Orchiectomy Medical/Drug Castration (LH antagonists) Brachytherapy (Internal, Sealed Source) Interstitial placement of 80-100 seeds Avoid close contact with pregnant women and infants. Strain urine for seeds. Condom use during sex to prevent seed passage. Side Effects of Radiotherapy Rectal, Bowel, Prostate inflammation Pain during urination Pain during ejaculation Rectal urgency, tenesmus, diarrhea Painless hematuria Hormonal Strategies Androgen Deprivation Therapy Suppress androgenic stimuli to the prostate Decreases testosterone levels Prevents conversion of DHT (Dihydrotestosterone) Bilateral Orchiectomy – decreases 93% of testosterone LH Releasing Hormone Antagonists (i.e. Leuprolide, Goserelin) Ketoconazole (inhibits cytochrome P450 enzyme) Side-Effect: Hypogonadism Hot flushes Loss of libido Decreased bone density Decreased muscle mass Gynecomastia Breast or nipple tenderness Lipid alterations Anemia Chemotherapy and Other Modalities Anti-angiogenic chemo agents Docetaxel-based chemotherapy Gene-based therapy Cryosurgery – freezing of prostate tissue Bone Metastasis Opioid analgesics for Bone Pain Prednisone for bone pain EBRT for bone pain Strontium or Samarium IV for bone lesion treatment Bisphosphonates (i.e. Pamidronate) for bone fractures Nursing Considerations: Post-Surgery Hemorrhage Discontinue aspirin, NSAIDs, antiplatelet meds 10-14 days before surgery. ARTERIAL hemorrhage requires SURGICAL intervention Bright red drainage, multiple clots indicate arterial bleeding. VENOUS hemorrhage requires TRACTION to the catheter Monitor drainage to ensure urine flow and patency of catheter. Risk for Infection Aseptic technique during dressing changes. AVOID rectal thermometers, rectal tubes and enemas. Sitz bath may be done for comfort when sutures are removed. Antibiotics as prescribed. WOF: Fever, chills, sweating, myalgia, dysuria, urinary frequency and urgency Venous Thromboembolism Promote EARLY AMBULATION Antithrombotic agents as prescribed DBCT exercises Potential Catheter Problems Avoid overdistention of the bladder. Monitor drainage bag for bloody urine. (Pink to amber) Monitor for HYPOtension Irrigating fluid (50ml) to clear obstruction Drainage tube secure to the inner thigh. Anticholinergics for bladder spasm as prescribed. Urinary Incontinence Increase voiding frequency. AVOID positions that encourage the urge to void. Decreasing fluid intake before activities. Use of absorbent pads, extra clothing. Know the location of public toilets. Perineal exercises Sexual Dysfunction PDE-5 inhibitors(sildenafil, tadafil) for erectile dysfunction. Penile implants or negative pressure devices. Referral to a sex therapist Others: Avoid straining, heavy lifting (i.e. Valsalva) to prevent hematuria. Avoid long distance trips, strenuous exercises. (prevent bleeding) Avoid dehydration. (prevents clot formation) Avoid bladder irritants (i.e. alcohol, spicy foods, coffee, tea) Read more