Introduction to Oncology Nursing (HS 2nd Ed. Chap 13) PDF

Introduction to Oncology Nursing (HS 2nd Ed. Chapt 13) N216 Dr. Kobayashi 1  2009 Estimated US Cancer Cases* Objective 1 Men Women...

Introduction to Oncology Nursing (HS 2nd Ed. Chapt 13) N216 Dr. Kobayashi 1  2009 Estimated US Cancer Cases* Objective 1 Men Women 766,130 713,220 Prostate 25% 27% Breast Lung & bronchus 15% 14% Lung & bronchus Colon & rectum 10% 10% Colon & rectum Urinary bladder 7% 6% Uterine corpus Melanoma of skin 5% 4% Non-Hodgkin lymphoma Non-Hodgkin 5% lymphoma 4% Melanoma of skin Kidney & renal pelvis 5% 4% Thyroid Leukemia 3% 3% Kidney & renal pelvis Oral cavity 3% 3% Ovary Pancreas 3% 3% Pancreas All Other Sites 19% 22% All Other Sites *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, 2009.  2018 Estimated US Cancer Deaths Lung & bronchus 26% Men Women 25% Lung & bronchus 323,630 286,010 Prostate 9% 14% Breast Colon & rectum 8% 8% Colon & rectum Pancreas 7% 7% Pancreas Liver & intrahepatic 6% 5% Ovary bile duct 4% Uterine corpus Leukemia 4% 4% Leukemia Esophagus 4% 3% Liver & intrahepatic Urinary bladder 4% bile duct Non-Hodgkin 4% 3% Non-Hodgkin lymphoma lymphoma 3% Brain/ONS Kidney & renal pelvis 3% 25% All other sites All other sites 25% ONS=Other nervous system. Source: American Cancer Society, 2018.  US Mortality, 2009 Cause of Death No. of % of all Rank deaths deaths 1. Heart Diseases 616,067 26.0 2. Cancer 562,875 23.1 3. Cerebrovascular diseases 137,119 5.7 4. Chronic lower respiratory diseases 124,583 5.1 5. Accidents (unintentional injuries) 121,599 5.0 6. Diabetes mellitus 72,449 3.0 7. Alzheimer disease 72,432 3.0 8. Influenza & pneumonia 56,326 2.3 9. Nephritis* 45,344 1.9 10. Septicemia 34,234 1.4 *Includes nephrotic syndrome and nephrosis. Source: US Mortality Data 2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 4 2009.  What is cancer (Objective 3) Malignant neoplasm: a group of cells display…. Uncontrolled growth (cell division beyond the normal limits), invasion (intrusion on and destruction of adjacent tissues), metastasis (spread to other locations in the body via lymph or blood) 5  Cancer Terminology Carcinoma: cancer originated from epithelial cells Sarcoma: cancer of the connective tissue Onocogene: Activated oncogenes can cause those cells to survive and proliferate Proto-oncogene: a normal gene that can become an oncogene due to mutations or increased expression. Proto-oncogenes code for proteins that 6  Cancer Terminology Apoptosis: Many cells normally undergo a programmed form of death P53: cancer suppressor gene, often mutated resulting in cancer. Induce apoptosis, DNA repair, maintain normal cell cycle (proto-oncogene) Contact inhibition and cell-to-cell adhesion 7  Cancer Terminology -plasia (growth) (Ana)plasia – loss of differentiation (Hyper)plasia– increased number of cells (Dys)plasia - maturation abnormality (Meta)plasia - cell type conversion (Neo)plasia - abnormal proliferation 8 Overview of Cervical Carcinogenesis 9  Stages of Cancer Objective 9 Staging (for treatment plan and prognosis): size of tumor and existence of metastasis (TNM: T: primary tumor size; N: lymph node involvement; M: metastasis), usually I to IV (0: cancer in situ) * Staging is different depending on types of cancer 10  Causes and Risks (Objective 2) Virus and bacteria: HPV (cervical cancer), HBV, HCV (hepatic cancer), H- pylori (gastric cancer) Physical: Ultraviolet, radiation (hematologic, skin) Chemical: Tobacco smoke (lung) Genetics, familial factors: breast cancer, gastric cancer Hormonal: (promoting cancer growth) breast cancer, endometrial cancer Obesity and over-weight: obesity- 11  Prevention (Objective 2) Behavioral factors: Refrain from tobacco smoke Diet (↓fat, ↓ alcohol, ↓ red meat, smoked foods, ↑veggies & fruits) Sun protection Environmental factors: Secondhand smoke Chemical exposure (dioxins, pesticides) Vaccine: HPV vaccine 12  7 Warning Signals of Cancer “CAUTION” Objective 7 C: Change in bowel/bladder habits A: A sore that does not heal U: Unusual bleeding/discharge T: Thickening/lump I: Indigestion/difficulty swallowing O: Obvious change in wart/mole N: Nagging cough/hoarseness 13 5 Most common Areas of Metastasis Objective 4 Lymphatic tissues Liver lung Bone Brain 14 Management of Cancer 15 Management of Cancer Diagnosis Cure Control Palliation 16  Diagnostic tests (Objective 8) Lab tests: tumor markers: PSA, CEA, CA-125 Biopsy Imaging (CT, MRI, PET) PET: positron emission tomography 3D image of the body and the radioactive particles concentrate in the area of abnormalities 17  Treatment Overview (Objective 11) Surgery (with/without draining lymph nodes): Primary approach to remove cancer and surrounding tissues For diagnosis (biopsy) or palliation Radiation: To cure or control cancer, or to relieve symptoms (palliative) Hematopoietic stem cell (HCT) or bone marrow (BM) transplantation: to cure or control cancer 18  Antineoplastic Medications Chemotherapy: kill cells that divide rapidly, one of the main properties of cancer cells Immuno-therapy: block immuno- suppression, enhance cancer specific T cell killing (CAR T cell therapy) Targeted therapy: block proliferation of cancer cells (block uncontrolled proliferation in cancer cells) 19  Surgery Diagnostic (biopsies) Primary treatment: Remove cancer only surrounding tissues with/without draining lymph nodes Prophylactic Palliative Reconstructive 20  Nursing Care for Surgical Procedure Please review peri-op nursing lectures given in Sem1 21  Radiation To cure or control cancer, or to relieve symptoms (palliative) Body cells that undergo frequent cell division (in S, G2, and M phases of a cell cycle) are most sensitive to radiation therapy (bone marrow, lymphatic tissue, epithelium of the gastrointestinal tract, hair cells, gonads). Muscle, cartilage and connective tissues are radio-resistant. 22  Radiation External and internal radiation therapy External radiation Total radiation dose is delivered over several weeks (fractionated doses) to give time to restore healthy tissues and BM function Skin: burns, irritation 23  Internal radiation (sealed/unsealed) (Objective 12) Sealed (implant; brachytherapy): Placement can be a few minutes (HD) to 24 hours (LD) Complete bed rest, log-rolling, Foley catheter Unsealed (I-131 for example): I-131 half life is about 8 days (depending on dose) While radiation is still high, apply precaution principles 24 Application of Brachytherapy 25  Radiation Internal radiation (sealed/unsealed) Provider precaution principles for radiation: Time (duration) Distance Shield 26  Internal Radiation (Cont.) “In private room, limit visiting hours to 30 minutes, maintain 6-feet distance from patient” →Radiation precaution principles: necessary for external radiation? In addition: Restriction for visitors (no children or pregnant women) No pregnant RN assigned 27  Palliative care (Objective 18) Goal for cancer patients: To provide highest quality of life possible while surviving with cancer To relieve from suffering, treatment of pain and other distressing symptoms To provide psychological and spiritual care To provide a support system to sustain and rehabilitate the individual's family Hospice and palliative care are not the28 Oncology Symptom Management 29  Cancer related Symptoms Pain (review Sem 1 pain lectures) GI symptoms: Anorexia, cachexia Chemotherapy/Radiation related symptoms 30  Cancer Pain (Objective 10) 80% of cancer patients experience pain Cancer pain is influenced by physical and psychosocial factors Causes of cancer pain - By cancer itself Bone metastasis (breast, prostate) Nerve compression (breast, prostate) Ischemia (KS), organ obstruction (colon, gastric) Ulceration, infection, necrosis (breast, head/neck) - Diagnostic procedures - Cancer treatments (tissue necrosis, 31  Cancer Pain Aggravating Pain factors - Anxiety/fear - Anger/depression Anxiety - Fatigue - Social isolation Fear 32  Pain Management Adjuvant medications: Anticonvulsants (Neurontin for peripheral neuropathy with mitotic inhibitors) Antidepressants (↑ energy) Antiemetics Anti-anxiety For bone, nerve, brain pain and reduce inflammation Steroids 33  Pain Management Radiation: 2- 4 weeks for full effect – Up to 75% get pain relief (by reducing size of tumor) – Indications Painful bone mets Epidural spinal cord compression Cerebral mets/headache Nerve compression/infiltration 34  GI-related management (Objective 15) Common cancer related nutritional problems: Anorexia Alteration in taste: salty, sour, metallic taste Malabsorption Cancer impairs enzyme production: secretes hormones and enzymes to cause GI irritation or ulcers; interferes protein and fat digestion. Chemo treatments also damage GI tract. Cachexia in advanced cancer 35  Nutritional management Make every effort to maintain adequate nutrition orally. Appetite enhancers: corticosteroids, etc* Avoid certain smells (perfumes, smells of fish or meat) Small and frequent meals (to reduce gastric distention) and patient’s food preference Include family members to plan for food preparation Nutritional supplements: high protein (between meals) 36  Nutritional management Chemo-Cuisine : Odorless and colorless (white) to decrease stimuli to medulla (vomiting center) Suggest foods that are high-calorie, high-protein, as patients tolerate Encourage fluid intake, but not during meal time (to decrease gastric distention) Support patient to decrease fear/anxiety Administer appetite stimulants 37  Nutritional management Non-oral nutritional support: NG tube feeding (< a few weeks), G tube or J tube for a longer term for enteral nutrition For malabsorption: enzyme and/or vitamin replacement Parenteral nutrition for severe malabsorption: TPN (via central line: PICC, Port-A-Cath, tunneled catheters) 38  Treatment-related Symptoms Chemotherapy and radiation therapies target rapidly dividing cells Which organs have cells that are rapidly dividing? GI: Hair: Mucous membrane: Bone marrow: 39 40  Oncologic Emergencies (Objective 16) (HS PP 233-236) Superior vena cava syndromes Obstruction of venous circulation due to compression or invasion of the superior vena cava by tumor (lung cancer, lymphoma), enlarged LN, thrombosis S/S: dilation of chest/neck vessels & facial edema RX:  HOB, O2, chemo, surgery Spinal cord compressions (Resulted from tumor, lymphoma) Initial symptom: Pain on the back or neck to chest or abdomen Numbness & tingling 41  Oncologic Emergencies Hypercalcemia (>11mg/dL) Potentially life-threatening metabolic abnormality. Ca++ released from bone is more than excretion by kidney Usually caused by bony mets (suspect with unexplained n/v) RX: meds, hydration, dialysis Pericardial effusion and cardiac tamponade Accumulation of fluid/blood in pericardial space. (Normal 15-50ml) Lung, esophagus, breast cancers (adjacent thoracic tumors) S/S of heart failure 42  Oncologic Emergencies DIC (Disseminated Intravascular Coagulation: consumption coagulopathy) Complex disorder of coagulation or destruction of clots, resulting in thrombosis or bleeding Hematologic cancers (leukemia), prostatic cancer, cancers in GI tract, lung cancer Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) Continuous uncontrolled release of ADH, resulting in increased extracellular volume, water intoxication, hyponatremia, increased excretion of urinary sodium. Causing cancer: small cell lung cancer 43  Oncologic Emergencies Tumor lysis syndrome Radiation or chemo-induced cell lysis of cancer cells (leukemia, lymphoma, small cell lung cancer) Hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia, renal failure 44