Oncologic Nursing PDF

ONCOLOGIC NURSING Esther Sunday C. Faller, RMT, MD Clinical Aspects of Cancer Diagnosis Cancer is not a single disease, but a group of heterogeneous diseases that share common biological properties All cancers result from mutations in oncogenes and tumor suppressor genes Proliferative Growth Pa...

ONCOLOGIC NURSING Esther Sunday C. Faller, RMT, MD Clinical Aspects of Cancer Diagnosis Cancer is not a single disease, but a group of heterogeneous diseases that share common biological properties All cancers result from mutations in oncogenes and tumor suppressor genes Proliferative Growth Patterns Benign Growth Patterns ▪ Abnormal cell differentiation and growth lead to an abnormal mass of tissue called a Hypertrophy is an increase in cell size resulting in neoplasm (which can be benign or malignant) an increase in organ size ▪ Cancer refers to all malignant tumors Hyperplasia is a reversible increase in the number of cells in an organ or a tissue in response to a specific growth stimulus Metaplasia is the conversion of one cell type to another cell type not usually found in the involved tissue Dysplasia is characterized by abnormal cell changes in the size, shape, or organization of cells Tumor Terminology Tumor Growth ▪ Neoplasms consist of: ▪ Factors influencing tumor growth: o Parenchymal tissue: The functional part o Duration of the cell cycle of the tumor o Number of actively dividing cells o Stroma: Supportive connective tissue o Cell loss and blood vessels ▪ Tumors are classified by: o Tissue of origin o Benign or malignant nature Comparison of Benign and Malignant Tumors Classification of Human Tumors Tumor Type Cell/Tissue of Origin Benign Tumors Malignant Tumors Mesenchymal Tumor Fibroblast Fibroma Fibrosarcoma Fat cell Lipoma Liposarcoma Blood vessels Hemangioma Angiosarcoma Smooth muscle cell Leiomyoma Leiomyosarcoma Striated muscle cell Rhabdomyosarcoma Rhabdomyosarcoma Cartilage Chondroma Chondrosarcoma Bone cell Osteoma osteosarcoma Epithelial tumors Squamous epithelium Epithelioma (papilloma) Squamous cell carcinoma Transitional epithelium Transitional cell papilloma Transitional cell carcinoma Glandular/ductal Adenoma Adenocarcinoma epithelium Neuroendocrine cells Carcinoid Oat cell carcinoma Internal-organ specific Liver cell Liver cell adenoma Liver cell carcinoma Kidney cell Renal cell adenoma Renal cell carcinoma  Tumor Type Cell/Tissue of Origin Benign Tumors Malignant Tumors Tumors of blood cell and White blood stem cells - Leukemia lymphocytes Lymphoid cells - Lymphoma Plasma cells - Multiple myeloma Tumors of neural cell Neuroblast Ganglioneuroma Neuroblastoma precursors Tumor of glial cells and Glial cells - Glioma neural supporting cells Meningeal cells Meningioma - Schwann cells Schwannomas Malignant schwannoma Germ cell tumors Embryonic cells teratoma Embryonal carcinoma Teratocarcinoma Seminoma/dysgerminoma Characteristics of Cancer Cells ▪ Altered cell differentiation: o Abnormal appearance and metabolism o Presence of tumor-specific antigens o Loss of normal cell functions ▪ Appearance changes: More undifferentiated = more aggressive ▪ Altered metabolism: Cell membrane changes aid in invasion and metastasis ▪ Tumor-specific antigens: Mark the cell as “non-self” ▪ Altered cellular function: Continuous, uncontrolled growth ▪ Metastasis: A hallmark of malignant tumors Molecular Pathogenesis of Cancer ▪ Seven fundamental changes in cell physiology: 1. Self-sufficiency in growth signals 2. Insensitivity to growth-inhibitory signals 3. Evasion of apoptosis 4. Defects in DNA repair 5. Limitless replication potential 6. Sustained angiogenesis 7. Ability to invade and metastasize Carcinogenesis Process Carcinogenic Factors ▪ Carcinogenesis: Transformation of normal ▪ Heredity: Genetic predisposition cells into cancer cells ▪ Hormonal factors: Influence tumor ▪ Stages: development o Initiation: Genetic mutations occur ▪ Environmental agents: Chemicals, radiation, o Promotion: Expansion of initiated cells etc o Progression: Development of ▪ Oncogenic viruses: HPV, EBV, HBV, aggressive, malignant traits HCV, HHV-8 ▪ Bacteria & parasites: H. pylori, S. hematobium, O. viverrini ▪ Immune system deficiencies: Increased susceptibility Routes of Tumor Spread ▪ Tumors spread by: o Direct extension: Local invasion of adjacent organs o Metastasis by implantation: Seeding of tumor cells into surrounding areas o Metastasis through lymphatic or circulatory system ▪ Most common route: Lymphatic system Metastasis ▪ Metastasis: Spread of cancer cells from a primary tumor to distant organs and sites ▪ Essential hallmark of malignant tumors Genetics and Disease-Associated Cancer and Genetic Mutations ▪ Disease-associated mutations alter protein ▪ Cancer develops from mutations in DNA function ▪ All cancer is genetic, but not all is inherited ▪ These mutations can lead to: ▪ Most cancers arise from acquired mutations o Genetic instability ▪ Acquired mutations affect genes that o Unregulated cell growth control cell growth, leading to unregulated o Tumorigenesis (the formation of division and tumor formation tumors) ▪ Genetic mutations as a root cause for various diseases The Human Genome Project (HGP) ▪ The HGP mapped the human genome and was a breakthrough in understanding genetic components of human diseases ▪ Significant step forward in genetics research ▪ However, much more research is still required to understand the full complexity of genetic disease ▪ Ongoing work to explore cancer-related mutations and genetic susceptibility Sporadic vs. Familial vs. Inherited Risk ▪ Sporadic Risk: o Cancer risk in the general population o Not attributed to any known factors ▪ Familial Risk: o Cancer patterns that do not fit known inherited cancer syndromes o Occurs in multiple family members without a clear inheritance pattern ▪ Inherited Risk: o Cancer that is consistent with known inherited cancer syndromes o Inherited mutations passed down through families Cancer Risk Assessment ▪ Family Evaluation: o A cancer risk assessment is needed for families with suspected genetic susceptibility ▪ Thorough Evaluation: o Assess the family history of cancer o Identify potential genetic mutations and risks ▪ Essential for early detection and preventive strategies Cancer Genetic Counseling Cancer Genetic Testing ▪ A process that includes: ▪ Offered to individuals at risk for mutations o Psychosocial assessment and emotional in cancer-susceptibility genes support ▪ Testing identifies specific mutations that o Anxiety reduction for individuals and increase cancer risk families at risk ▪ Helps determine if preventive measures or o Grief counseling to address loss or fear early detection strategies are necessary o Decision-making regarding genetic ▪ Can guide treatment options based on testing genetic findings ▪ Helps individuals understand their risks and available options Importance of Cancer Prevention and Early Detection ▪ Identifying cancer-causing agents and limiting exposure ▪ Role of oncology nurses in prevention and education ▪ Early detection and screening for high-risk populations Role of Oncology Nurses ▪ Use of epidemiology and cancer patterns to develop educational programs ▪ Increasing awareness and prevention activities ▪ Targeting screening to populations at high risk for specific cancers Cancer Prevention Guidelines ▪ Primary Prevention: Preventing cancer from developing ▪ Secondary Prevention: Early detection and treatment of cancer during the most curable stage ▪ Importance of prevention, screening, and early detection in the fight against cancer Socioeconomic Factors and Cancer Disparities ▪ Poverty is the leading predictor of cancer disparities ▪ Socioeconomic status influences cancer rates and mortality more than biological factors ▪ Addressing disparities to improve cancer outcomes Environmental Risks for Cancer ▪ Chemicals: Benzene, asbestos, vinyl chloride, arsenic ▪ H. pylori infection and gastric adenocarcinoma ▪ High-frequency ionizing radiation (IR), ultraviolet (UV) radiation, and non-ionizing radiation Tobacco and Alcohol Risks ▪ Smoking: Established causal relationship with multiple cancers ▪ Excessive alcohol consumption increases cancer risk Diet, Obesity, and Cancer Risk ▪ High-energy, dense foods and inactivity contribute to obesity ▪ Obesity is a major risk factor for various cancers Chemoprevention ▪ Cancer prevention trials focus on behavior modifications ▪ Deliberate interventions aimed at interfering with carcinogenesis Genetic Risk and Testing ▪ Importance of thorough family history in identifying genetic risks ▪ Role of genetics in modifying cancer risk due to environmental exposures Early Detection and Screening ▪ Importance of health-promoting activities and early detection techniques ▪ Focus on educating the public about early screening to reduce cancer mortality The American Cancer Society (ACS) recommends the following screening guidelines for early cancer detection in asymptomatic people: Breast cancer o Regular mammography, starting at age 45, with annual screening until age 54 and biennial screening after that Cervical cancer o Screening starting at age 25, with a primary HPV test every 5 years for people ages 25–65 Colorectal cancer o Regular screening starting at age 45, with a stool-based test or visual exam Lung cancer o Yearly screening with a low-dose CT (LDCT) scan for people ages 50–80 who smoke or used to smoke Prostate cancer o Informed decision-making for asymptomatic men who have at least a 10-year life expectancy The ACS also recommends that people ages 76 to 85 talk with their health care provider about whether to continue screening, and that people over 85 should no longer be screened. Tumor Markers ▪ Tumor markers are either proteins produced by cancer cells or proteins released by the body in response to cancer or other conditions Role of Tumor Markers ▪ Diagnostic Aid: o Used with patient history, physical examination, and other diagnostic tests to help identify specific cancers ▪ Prognosis: o Can indicate the prognosis of certain cancers ▪ Recurrence & Treatment Effectiveness: o Help detect cancer recurrence and assess how effective the treatment is Tumor Markers Prostate-specific antigen (PSA) o Elevated in prostate cancer and benign prostatic hyperplasia o Prostate cancer screening should be accompanied by digital rectal exam (DRE) to evaluate the prostate gland for irregularities o Useful in evaluating response to treatment and recurrence in patients treated with surgery or radiation therapy S-100 o Elevated in patients with metastatic melanoma Thyroglobulin o Elevated in many thyroid diseases, including some forms of thyroid cancer o A rise in thyroglobulin post-thyroidectomy indicates cancer recurrence Estrogen and Progesterone receptors o Breast cancer tissue has been tested for the presence of estrogen and progesterone receptors o Provide an indication of the aggressiveness of the cancer and how likely the cancer will be to respond to specific types of endocrine therapy CA 15-3 and CA 27-29 o Both tests are commonly used to monitor for recurrence in women who have been treated for breast cancer o CA 27-29 test may be more sensitive than the CA 15-3 Tumor Markers Carcinoembryonic antigen (CEA) and CA 19-9 o Tumor markers commonly elevated in advanced colorectal cancer CA-125 o Of women with advanced epithelial ovarian cancer, the most common form of ovarian cancer, 90% will have an elevated CA-125 level Human Chorionic Gonadotropin (HCG) and Alpha-fetoprotein (AFP) o Female patients with germ cell ovarian tumors and men with nonseminomatous testicular cancer often display elevated levels of HCG and/or AFP Beta-2-macroglobulin (B2M) o Elevated in persons with multiple myeloma, chronic lymphocytic leukemia, and some lymphomas, as well as some types of kidney disease HER-2/neu o Marker that is overexpressed or elevated in one third of persons diagnosed with breast cancer o Used to predict response to therapy Chromogranin A (CgA) o Most sensitive tumor marker for carcinoid tumors (carcinoid, neuroblastoma, and small cell lung cancers) Diagnostic Imaging Methods ▪ Imaging techniques that often replace invasive procedures for diagnosing and staging cancer Role of Diagnostic Imaging ▪ Guiding Biopsy: o Imaging helps guide surgeons to the right area for biopsy ▪ Clinical Collaboration: o Informed by patient history, clinical interaction, and radiology specialists Diagnostic Imaging Methods X-ray o Allow visualization of internal structures of the body and permit the distinction to be made between normal and abnormal structure and function Mammography o X-ray study used to screen for malignancies of the breast Computed Tomography (CT) o Special x-ray equipment used to obtain images from a variety of angles through the body and then employs computer processing to reproduce a detailed cross-sectional image of tissues and organs Magnetic Resonance Imaging (MRI) o Interaction of atomic nuclei and radio waves placed in a strong magnetic field Ultrasound o Uses a set of reflections of high frequency sound waves from internal tissues of the body that have been focused for viewing Nuclear Medicine o Based on the principle of tagging a physiologic substance in the body and measuring its flow, distribution, or presence in the target organ system Positron Emission Tomography (PET) o Uses radioactive positively charged particles to detect subtle changes in the body’s metabolism and chemical activities Positron Emission Tomography with Computed Tomography (PET-CT) o Fusion of two imaging modalities, which results in significantly improved diagnostic accuracy Lymphoscintigraphy o Nuclear medicine imaging technique that utilizes radiolabeled monoclonal antibodies to visualize microscopic sites of metastasis or suspected malignancy Staging ▪ Staging describes the extent or spread of cancer from its original site. Types of Staging 1. Surgical Staging: o Involves invasive surgical techniques to visualize structures and assess the spread of disease 2. Clinical Staging: o Based on professional judgment regarding tumor size, location, and physical examination findings 3. Pathologic Staging: o Involves examining tissue samples both grossly and microscopically to determine tumor characteristics and aggressiveness Diagnosis and Staging of Hematologic Malignancies Cytogenetics o Use of molecular biologic testing to observe gene translocations and rearrangements Fluorescent In Situ Hybridization (FISH) o Detects structural and numerical abnormalities on chromosomes Immunophenotyping o Uses antibodies to identify chromosomal aberrations Flow Cytometry o Detects and quantifies cellular antigens Surgical Methods Used for Diagnosis and Staging of Cancer Tissue Biopsy o Definitive method for the diagnosis of a malignancy o Involves obtaining a portion of tissue or excising the entire target tissue Incisional or Core Biopsy o Representative sample of the actual target tissue is obtained Sentinel Lymph Node Biopsy o Nuclear medicine imaging studies are performed to identify the sentinel node o Identification involves injecting a radioactive material, tagged with a cancer antigen-specific monoclonal antibody and blue dye into the area of the tumor Axillary Lymph Node Biopsy o Critical step in staging breast cancer Cancer Treatment Modalities  Surgery Surgery ▪ Surgery is a branch of medicine that uses manual and instrumental techniques to diagnose and treat injury, deformity, and disease Surgical Oncology ▪ Surgical oncology focuses on the surgical management of malignant neoplasms, including biopsy, staging, and surgical resection Prevention and Identification of Risk Factors ▪ Prevention: Surgery remains one of the best options for many high-risk individuals ▪ Balance of Risk and Benefit: Cancer risk must be weighed against the benefits and risks of surgery Diagnosis and Staging of Cancer ▪ Histologic Diagnosis: Accurate histologic diagnosis is crucial for identifying malignancy and planning treatment ▪ Staging: Determines the extent of the disease to guide therapy Treatment ▪ Surgical Intervention: Potential benefits must be weighed against surgical risks Rehabilitation and Reconstruction ▪ Post-Surgery Issues: Surgical rehabilitation addresses functional and cosmetic concerns resulting from anatomical defects Palliation ▪ Palliative Surgery: Surgical oncology team may provide consultations to relieve pain, symptoms, or functional abnormalities in incurable cancer patients Definitive Surgery for Primary Cancer ▪ Goal: Remove cancer with clear tissue margins to ensure complete excision ▪ Adjuvant Modalities: May be used alongside definitive surgery for better outcomes Cytoreductive Surgery (Surgery for Residual Disease) ▪ Purpose: Removing remaining cancerous tissue to enhance the effect of other treatments Surgery for Metastatic Disease ▪ Curative Surgery: May be curative based on cancer type, metastatic location, and available treatments Surgery for Oncologic Emergencies ▪ Emergency Surgery: Performed for complications arising from the cancer itself or its treatment Surgery for Reconstruction and Rehabilitation ▪ Reconstruction and Rehabilitation: Restoring functionality and appearance after cancer surgery Palliative Surgery ▪ Palliative Goal: Surgery aimed at improving quality of life by addressing symptoms or complications Innovative Surgical Techniques ▪ Ductal Lavage & Fine-Needle Aspiration (FNA): Used in early cancer detection and clinical trials ▪ Sentinel Lymph Node Biopsy: Involves intraoperative lymphatic mapping with vital blue dye or radioactive tracer Advanced Surgical Methods ▪ Radio-Guided Surgery: Uses radioactive tracers for tumor localization ▪ Video-Assisted Thoracoscopic Surgery (VATS): Beneficial for treating metastatic pleural effusions Laser Surgery ▪ LASER Surgery: Precise removal of cancerous tissue or symptom relief Cryosurgery and Cryotherapy ▪ Cryosurgery: Uses liquid nitrogen to destroy cancerous tissues Radiofrequency Ablation (RFA) ▪ Destroys tumors through thermal coagulation and protein denaturation Laparoscopy ▪ Allows diagnosis of intraperitoneal and retroperitoneal masses without large incisions Biologic Therapies and Adjuvant Therapies ▪ Role in Treatment: Decreases neutropenia-related complications and infections, enhancing overall treatment outcomes Nurses in Surgical Oncology ▪ Key Role: Nurses provide essential support in education, care, and rehabilitation for cancer patients and their families at every stage of treatment  Radiation Therapy Radiation therapy is the use of ionizing radiation in the treatment of patients with benign and malignant diseases Radiation oncology is the medical discipline concerned with the causes, prevention, and treatment of cancer involving special expertise in the therapeutic use of radiation therapy, either alone or in conjunction with surgery, chemotherapy, biotherapy, heat, or oxygen Radiation Types ▪ Electromagnetic Radiation: Includes radio waves, microwaves, visible light, X-rays, and gamma rays ▪ Particulate Radiation: Includes electrons, protons, neutrons, negative pi-mesons, and heavy ions ▪ Common Ionizing Radiation Types Used in Therapy: X-rays, gamma rays, and electrons Radiosensitivity of Cells ▪ Factors Affecting Sensitivity: o Tissues with rapid cell division (mitotic cells) are more sensitive to radiation than tissues with slower or non-dividing cells o The presence of oxygen increases radiosensitivity Tumor Radiosensitivity & Radiocurability ▪ Radiosensitivity of Tumors: o Depends on the tumor type, size, oxygenation, and vascularization ▪ Normal Tissue Tolerance: o Balancing tumor destruction with the protection of surrounding healthy tissue is key to effective treatment Fractionation in Radiation Therapy ▪ Dividing the total radiation dose into smaller, equal daily doses ▪ Purpose: Reduces damage to normal tissues while maximizing tumor destruction The "Four R's" of Radiobiology 1. Repair: Cells recover from sublethal damage between doses 2. Redistribution: Fractionating the dose disrupts the cell cycle, making more cells enter the radiosensitive mitotic phase 3. Repopulation: Healthy cells regenerate after radiation damage 4. Reoxygenation: Oxygen enhances the effectiveness of radiation, especially with gamma rays Administration of Radiation Therapy ▪ External beam radiation (teletherapy) o Delivered by a machine such as the linear accelerator ▪ Brachytherapy o Placement of a sealed radioactive source in or near the tumor or tumor bed, either permanently or temporarily ▪ Radiosensitizers o Agents that enhance radiation damage to tumor cells when they are present at the same time radiation is administered ▪ Radioprotectors o Act as “radical scavengers, ” interacting with ionized particles to prevent DNA damage to healthy tissue Nursing Management in Radiation Therapy ▪ Regardless of how radiation is administered, the role of the nurse includes: o Patient and family education o Assessment and management of symptoms o Coordination of care o Providing emotional support throughout treatment ▪ Patients need information regarding what to expect during planning and treatment, the onset and duration of possible side effects, self-care measures, and follow-up care External Radiation Therapy ▪ External radiation is the most common treatment method in radiation therapy ▪ Patients who are candidates for radiation are typically referred to the radiation facility by one of their physicians ▪ External radiation is given daily, Monday through Friday, for 2 to 8 weeks ▪ Palliative treatments, such as bone metastases, may be delivered at a higher daily doses over 2 to 3 weeks General Side Effects ▪ Acute side effects occur during therapy or within 2 to 3 months of completion ▪ Late side effects may occur months to years later ▪ Skin reactions experienced during the course of radiation can range from erythema or hyperpigmentation, to dry desquamation, when basal-layer stem cells become depleted; or moist desquamation, when stem cells are eradicated from the basal layer, causing ulceration ▪ Fatigue and bone marrow suppression are also common side effects Site-Specific Side Effects: ▪ Head and Neck: Oral mucositis, xerostomia, taste changes, tooth decay and caries, osteoradionecrosis ▪ Chest: Esophagitis, nonproductive cough, radiation pneumonitis, radiation fibrosis ▪ Breast/Chest Wall: Skin reactions ▪ Abdomen: Nausea and vomiting ▪ Pelvis: Diarrhea, cystitis, erectile dysfunction, vaginal stenosis, sterility ▪ Brain: Cerebral edema, alopecia, scalp irritation, cognitive dysfunction Internal Radiation Therapy ▪ Brachytherapy allows delivery of a high dose of radiation to a specific tumor volume, with a rapid falloff in dose to adjacent normal tissues ▪ Non-sealed radioactive therapy consists of oral ingestion of a radionuclide such as Iodine-131 Radiation Safety ▪ Nursing care and radiation safety precautions required for implants are dependent on the: type of radioactive isotope, dose, and method of administration ▪ ALARA (as low as reasonably achievable) is the acronym for a guideline used for radiation protection of staff involved in the care of patients receiving radiation Other Treatment Options in Radiation Therapy ▪ Stereotactic radiation therapy (SRS): Delivers a large dose of external beam radiation to a precisely targeted area of the brain with minimal damage to surrounding tissue ▪ Intensity-modulated radiation therapy (IMRT): Advanced form of 3D CRT treatment planning in which varying intensities of small subdivisions of beams are used to custom design optimal radiation dose distributions ▪ Intraoperative radiation therapy (IORT): Delivery of radiation therapy during a surgical procedure ▪ Radiopharmaceuticals: Strontium-89 and samarium-153 can offer effective pain relief for multiple sites of malignant bone lesions ▪ Photodynamic therapy (PDT): Primarily used to alleviate obstruction of lumens (esophagus and bronchi) ▪ Radioimmunotherapy (RIT): Delivers radiation to the cancer cells by attaching radionuclides to monoclonal antibodies to form radioimmunoconjugates that target a specific antigen expressed on tumor cells (CD20)  Chemotherapy Chemotherapy is the use of cytotoxic drugs in the treatment of cancer One of the four treatment modalities (surgery, radiation, and biotherapy) Chemotherapy may be used in six ways: 1. Adjuvant therapy – a course of chemotherapy used in conjunction with another treatment modality and aimed at treating micrometastases 2. Neoadjuvant chemotherapy – administration of chemotherapy to shrink a tumor before it is removed surgically 3. Primary therapy – the treatment of patients who have localized cancer for which an alternative but less than completely effective treatment is available 4. Induction chemotherapy – drug therapy given as the primary treatment for patients who have cancer 5. Combination chemotherapy – administration of two or more chemotherapeutic agents to treat cancer; this allows each medication to enhance the action of the other or act synergistically with it 6. Myeloblative therapy – dose-intensive therapy used in preparation for peripheral blood stem cell transplantation Principles of Chemotherapy ▪ Cell Generation Cycle o Chemotherapeutic drugs are most active against frequently dividing cells, or in all phases of the cell cycle except G0 ▪ Tumor Growth o Cancer cells grow by means of a pyramid effect; however, they grow at the same rate as the tissue from which they originated o Time required for a tumor mass to reach a certain size is called the doubling time o During the early stages of tumor growth, doubling time is more rapid than at later stages; this pattern is called Gompertzian function Factors Influencing Chemotherapy Selection and Administration ▪ Blood-Brain Barrier o Administration via the intrathecal route (Ommaya reservoir) effectively bypasses the BBB and permits delivery of drugs directly into the CSF ▪ Chemoprevention o Reducing cancer risk in individuals who are highly susceptible to certain cancers by prescribing certain products or drugs that may reduce or suppress the carcinogenesis ▪ Chronotherapy or Circadian Rhythm o Circadian rhythm: Regular, repeated fluctuation in biologic functions during a 24-hour period o Circadian variables: Influence absorption, metabolism, distribution, and elimination ▪ Cytoprotectants o Used to prevent or decrease specific system effects related to certain drug therapies ▪ Liposomes o Possible to manipulate chemotherapy drugs and tailor them to penetrate specific target tissues ▪ Radiosensitizers o Compounds that enhance the sensitivity of tumors to the effects of radiation, but not to normal tissue Chemotherapy Drug Classification ▪ Cell cycle phase-specific drugs o Active on cells undergoing division in the cell cycle ▪ Cell cycle phase-nonspecific drugs o Active on cells in either a dividing or resting state ▪ Alkylating agents o Act primarily to form a molecular bond with the nucleic acids, which interferes with nucleic acid duplication, preventing mitosis ▪ Antibiotics (antitumor agents) o Disrupt DNA transcription and inhibit DNA and RNA synthesis ▪ Antimetabolites o Exhibit their action by blocking essential enzymes necessary for DNA synthesis or by becoming incorporated into the DNA and RNA, so that a false message is transmitted ▪ Hormones o Prevent cell division and further growth of hormone-dependent tumors ▪ Antihormonal agents o Derive their antineoplastic effect from their ability to neutralize the effect or inhibit the production of natural hormones used by hormone-dependent tumors ▪ Nitrosoureas o Action is similar to that of the alkylating agents; synthesis of both DNA and RNA is inhibited ▪ Corticosteroids o Exert an anti-inflammatory effect on body tissues ▪ Vinca plant alkaloids o Exert a cytotoxic effect by binding to microtubular proteins during metaphase, causing mitotic arrest ▪ Miscellaneous agents o Act by a variety of mechanisms Cell Kill Hypothesis ▪ Every tumor cell must be killed to cure cancer ▪ With each course of the drug therapy, a given dose of chemotherapeutic drug kills only a fraction, not all, of the cancer cells present ▪ Repeated courses of chemotherapy must be used to reduce the total number of cancer cells Factors Considered in Drug Selection ▪ Patient’s eligibility for chemotherapy (confirmed diagnosis; age; bone marrow, nutritional, cardiac, hepatic, respiratory, and renal status; previous therapies) ▪ Cancer cell type ▪ Rate of drug absorption ▪ Tumor location (many drugs do not cross the BBB) ▪ Tumor load (larger tumors are generally less responsive to chemotherapy) ▪ Tumor resistance to chemotherapy (tumor cells can mutate and produce variant cells distinct from the tumor stem cell of origin) Chemotherapy Dosing Listings Combination Chemotherapy ▪ Standard-dose therapy – usual adult dose ▪ Most often given in combination because administered this enhances the effect of the drugs on the ▪ High-dose therapy – an increased drug tumor cell kill dose is given to achieve tumor cell deathas ▪ Provides additional benefits that are not (myelosuppression) possible with single-drug treatment ▪ Dose intensity – specific drugs are administered at a greater dose than standard therapy and at short intervals ▪ Dose density – refers to increased drug doses and combinations of varied drugs and is sometimes stated as doublet or triplet therapy in cancer protocols Chemotherapy Administration: Calculation of Drug Dosage o Drug dosage for cancer chemotherapy is based on body surface area (BSA) in both adults and children o All drug calculations should be verified by a second person to ensure dose accuracy Drug Reconstitution o When the drugs are prepared and reconstituted, aseptic technique must be used in accordance with manufacturer’s current recommendations o All syringes of reconstituted drugs are immediately labeled with the name of drug Administration Guidelines o Routes: oral, subcutaneous and intramuscular, topical, intraarterial, intracavity, intraperitoneal, intrathecal, intravenous o Vein selection and venipuncture: select a vein that is large enough to allow adequate blood flow around the IV device o Procedure for administering chemotherapeutic drugs: ✓ Verify the patient’s identification, drug, dose, route, and time of administration against the physician’s orders ✓ Review drug allergy history with the patient ✓ Anticipate and plan for possible side effects or major system toxicity ✓ Review appropriate laboratory data and other tests ✓ Verify informed consent for treatment ✓ Select the appropriate infusion therapy equipment and supplies Safe Handling of Chemotherapeutic Agents ▪ Drug Preparation o All chemotherapeutic drugs should be prepared according to the package insert in a class II biologic safety cabinet ▪ Drug Administration o Wear protective equipment (gloves, gown, eyewear) ▪ Disposal of Supplies o Place all unused supplies or drugs in containers in a lek-proof, closeable, puncture-proof, appropriately labeled container ▪ Management of Chemotherapy Spills o Chemotherapy spills should be cleaned up immediately by properly protected personnel trained in the appropriate procedures Caring for Patients Receiving Chemotherapeutic Drugs Extravasation Management o Vesicant extravasation: accidental leakage of a drug into the subcutaneous tissue that causes pain, necrosis, or sloughing of tissue o Vesicant: agent that can produce a blister, tissue destruction, or both o Irritant: agent that can cause aching, tightness, and phlebitis at the injection site or along the vein line with or without an inflammatory reaction o Flare: local allergic reaction without pain that usually is accompanied by red blotches along the vein line o Delayed extravasation: symptoms occur 48 hours or more after the drug is administered Anaphylaxis o Drugs and supplies needed to manage these complication must be readily available Alternative Care Settings ▪ Options for giving chemotherapy in outpatient settings include ambulatory care centers, physicians’ offices, extended care facilities, and home health agencies ▪ Home health care has expanded extensively to include more care options for oncology patients ▪ Criteria specific to home administration of chemotherapy include the following: 1. A caregiver is available who is able and willing to assist 2. The patient’s physical condition is stable and within the range of home care capabilities 3. Living conditions are stable and suitable 4. The patient has access to emergency assistance  Biotherapy Biotherapy may be defined as treatment with agents derived from biologic sources and/or affecting biologic responses Recombinant DNA technology allowed production of large quantities of purified products It includes treatments affecting other biologic responses such as growth and differentiation factors, chimeric molecules, and agents that may affect the ability of tumor cells to metastasize ▪ Active immunotherapy consists of giving a tumor-bearing host agents that are designed to elicit an immune response capable of retarding or eliminating tumor growth o Active specific immunotherapy is immunization with tumor cells or tumor cell extracts, o Active nonspecific immunotherapy is an attempt to boost overall immunity through the use of adjuvants ▪ Passive immunotherapy is the administration or transfer of previously sensitized immunologic reagents such as antisera or immune-reactive cells to a tumor-bearing host ▪ Adoptive immunotherapy refers to the passive transfer of sensitized cells such as lymphocytes or macrophages Major Agents in Use 1. Interferons (IFN): Renders uninfected cells resistant to attack by the offending virus Lymphokines- Interleukins: Interleukin-2 (IL-2) is a potent modulator of immune responses 2. Hematopoietic Growth Factors (HGFs): Responsible for the proliferation, differentiation, and maturation of hematopoietic cells in vitro 3. Monoclonal Antibodies: Produces immunoglobulins against the invading antigen from B cell-derived plasma cells 4. Radioimmunotherapy: Combines radioactive isotopes such as iodine-131 (I-131) and yttrium-90 (Y- 90) with a MoAb 5. Epidermal Growth Factor Receptor-Tyrosine Kinase Inhibitors: Responsible for activating multiple downstream signaling pathways governing tumor growth 6. Angiogenesis Inhibitors: Class of drugs that inhibit the formation of blood vessels  Bone Marrow and Stem Cell Transplant Hematopoietic stem cell transplantation (HSCT) is the process of replacing diseased or damaged bone marrow with normally functioning bone marrow HSCT is used in the treatment of a wide variety of malignant and nonmalignant diseases Developments in antibacterial, fungal, and viral therapies, blood-banking techniques, chemotherapeutic regimens, growth factors, graft-versus-host disease prophylaxis and treatment, and tissue typing has made HSCT a more effective, viable treatment option Types of Hematopoietic Stem Cell Transplantation ▪ Autologous transplant o Transplant in which the patient’s own bone marrow or stem cells are collected (harvested), placed in frozen storage (cryopreserved), and reinfused into the patient after the conditioning regimen o Patient is his own donor ▪ Allogeneic transplant o Transplant in which the patient receives someone else’s bone marrow or stem cells o Can be syngeneic (donor is the patient’s identical twin), related (donor is related to the recipient, usually a sibling), or unrelated (donor is no relation to the recipient) Sources of Stem Cells ▪ Autologous peripheral blood stem cells: Collection of PBSCs for hematopoietic support after high- dose chemotherapy (HDCT) ▪ Allogeneic peripheral blood stem cells: Faster engraftment and decreased transplant-related mortality ▪ Bone marrow harvest: Harvesting is the process of obtaining bone marrow for transplantation ▪ Unrelated donors: National Marrow Donor Program developed a central registry of cord blood banks to enable transplant centers to search cord blood banks more efficiently ▪ Cord blood transplantation: Umbilical cord blood is rich in stem cells and used in place of bone marrow or PBSCs ▪ Human leukocyte antigen testing: Tissue typing of the patient and potential donor is the first step in identifying whether a patient has a compatible donor Indications for Hematopoietic Stem Cell Transplantation ▪ Hematopoietic stem cell transplantation is a treatment modality for a variety of malignant and nonmalignant diseases ▪ Allogeneic transplant is used in the treatment of hematologic malignancies, marrow failure, severe combined immunodeficiency syndromes (SCIDs), and some inherited metabolic disorders ▪ Autologous BMT is used primarily for the treatment of diseases in which the patient’s own bone marrow contains adequate stem cells that can eventually generate functioning erythrocytes, leukocytes, and platelets Hematopoietic Stem Cell Transplantation Process ▪ Pretreatment work-up: Done to establish the recipient’s physical and psychosocial status ▪ Conditioning regimens: Process of preparing the patient to receive bone marrow or stem cells ▪ Nonmyeloablative conditioning regimens: Used for allogeneic and autologous transplant in a wide range of malignant and nonmalignant diseases ▪ Transplantation of marrow, stem cells, and cord blood: After completion of the condition regimen, the bone marrow, peripheral stem cells, or cord blood must be infused ▪ Engraftment period: Time immediately after transplant, when the transfused stem cells migrate, by some unknown phenomenon, to the recipient’s bone marrow space and begin to regenerate Complications of Hematopoietic Stem Cell Transplantation ▪ Infection o Most common posttransplant complication ▪ Pulmonary complications o Interstitial pneumonia accounts for 40% of transplant-related deaths o Most common viral cause is CMV ▪ Veno-occlusive Disease (VOD) o VOD of the liver occurs in approximately 20% of patients undergoing allogeneic HSCT and 10% of patient undergoing autologous HSCT o A complication of the conditioning regimen ▪ Graft-versus-Host Disease (GVHD) o Complication that can occur after allogeneic transplantation o Two types: acute GVHD (occurring before 100 days after HSCT) and chronic GVHD (occurring 100 days after transplant) ▪ Recurrence o Remains the most significant problem after transplantation o Relapse is more frequent after autologous HSCT, presumably because hidden malignant cells in the transplanted stem cells ▪ Graft Failure (Rejection) o Rare occurrence, but an incidence of 5% to 15% has been reported o Failure of marrow recovery to occur or the loss of marrow function after an initial period of recovery ▪ Late Effects o Cataracts: concern primarily in patients receiving TBI o Gonadal dysfunction: women (ovarian failure); men (absent or abnormal spermatogenesis) o Growth failure: children who received TBI, 50% to 60% have decreased growth hormone causing a retardation of both spinal growth and the pubertal growth spurt o Hypothyroidism: thyroid function is affected o Secondary malignancy: TBI, immunosuppression, immunodeficiency, viral infection, chronic immune stimulation, and genetic predisposition are factors that have been identified with increased risk of second malignancy after HSCT Future Directions and Advances in Hematopoietic Stem Cell Transplantation ▪ Future advances will include the: o Use of cord blood stem cells for gene therapy, because they are more efficient at taking up genes than stem cells from other sources o Fetal therapy o Transplanting stem cells in utero for patients with congenital disease such as SCIDS o Expansion of stem cells in the laboratory so fewer stem cells will be needed ▪ Ongoing research will continue to look for better conditioning regimens and more effective treatments for infection and GVHD  Complications of Cancer and Cancer Treatment Oncologic complications occur frequently in patients with cancer and may be a direct result of the disease More frequently an indication of progressive or advancing disease Oncologic complications also occur as a result of treatment for cancer Acute, life-threatening oncologic complications are often referred to as oncologic emergencies Structural Oncologic Complications Cardiac Tamponade ▪ Compression of the cardiac muscle by pathologic fluid accumulation under pressure within the pericardial sac ▪ Beck’s triad has also been considered the hallmark (elevated CVP, distant or muffled heart sounds, and arterial hypotension) ▪ Two clinical findings that are classic features are pulsus paradoxus (weaker pulse during inspiration) and hepatojugular reflux (elevation in JVP by 1 cm or more) ▪ Electrical alternans (alternation of amplitude and direction of P wave and QRS complexes on every other beat) is the most specific abnormality ▪ Treatment: Pharmacologic (corticosteroids and diuretics), fluid removal (pericardiocentesis, pericardiotomy, pericardiectomy, sclerotherapy), radiation therapy, and chemotherapy Increased Intracranial Pressure ▪ Also referred to as Intracranial hypertension ▪ Results when the volume of any of the three components (brain, CSF, and cerebral blood volume) within the skull and meninges are increased ▪ Most common oncologic etiology is brain metastasis ▪ MRI has been found to be the most sensitive tool and is the preferred diagnostic method ▪ Treatment: Pharmacologic (corticosteroids, osmotic diuretics, loop diuretics, anticonvulsants, mechanical hyperventilation), surgery (VP shunt or temporary ventriculostomy, ventricular drain, partial or complete resection of tumor), radiation and chemotherapy Spinal Cord Compression ▪ Neoplasm in the epidural space can encroach on the spinal cord or cauda equina and result in spinal cord compression (SCC) ▪ Metastatic disease is the most common cause ▪ Back pain is the presenting complaint in 96% of patients ▪ Symptomatology is directly related to the location of the compression (lumbosacral – colon and prostate, thoracic – lung and breast) ▪ Diagnostic method of choice is an MRI scan ▪ Treatment: Steroids, radiation therapy, surgery, chemotherapy, and prevention Superior Vena Cava Syndrome ▪ Obstruction of the venous flow through the SVC results in impaired drainage, with engorgement of the vessels from the head and the upper body torso ▪ ¾ of all malignant cases of SVCS are caused by bronchogenic cancer, particularly SCLC ▪ Most frequent symptom is dyspnea occurring in 63% of patients ▪ Diagnosis may be obtained via bronchoalveolar lavage or thoracostomy ▪ Treatment: Radiation therapy, chemotherapy, surgery, and pharmacologic (fibrinolytic therapy) Metabolic Oncologic Complications Disseminated Intravascular Coagulation ▪ Alteration in the blood-clotting mechanism, with abnormal acceleration of the coagulation cascade, resulting in thrombosis ▪ Hemorrhage occurs simultaneously as a result of the depletion of clotting factors ▪ Most common cause of DIC is sepsis ▪ Treatment: o Sepsis is treated with antibiotics o Surgery, chemotherapy, and radiation therapy are used to treat underlying malignancy o Fluid replacement is used to manage hypotension and proteinuria o Blood component therapy (platelets, fresh-frozen plasma, PRBCs, and cryoprecipitate Hypercalcemia ▪ 90% of hypercalcemia caused by primary hyperparathyroidism (65%) or malignancy (35%) ▪ Result of increased bone resorption of calcium, which exceeds renal ability to excrete calcium overload ▪ Clinical manifestations vary tremendously, depending on the level of serum calcium, the rate of onset, the underlying cause, and the patient’s general condition ▪ Treatment: Hydration and diuresis, pharmacologic (bisphosphonates, pamidronate, zolendronic acid, etidronate, gallium nitrate, oral phosphates, NSAIDs, plicamycin, osteoprotegerin), mobilization – immobilization should be avoided, dietary manipulation, and dialysis Hypersensitivity Reaction to Antineoplastic Agents ▪ Severe hypersensitivity reactions (HSRs), or anaphylaxis, is defined as a life-threatening immunologic response to a foreign substance or antigen ▪ Signs and symptoms typically occur within minutes of initiating the agent IV and peak within 15 to 30 minutes ▪ Most common effects include dyspnea, agitation, and hypotension ▪ Treatment: o Prevention – primary treatment o Pharmacologic (epinephrine, diphenhydramine, aminophylline, corticosteroids) Septic Shock ▪ Shock compromises a group of diverse life-threatening syndromes that result from different pathophysiologic circumstances ▪ Three major classifications: 1. Hypovolemic shock is a result of decreased intravascular volume 2. Cardiogenic shock results from the heart’s impaired ability to pump blood adequately 3. Distributive or vasogenic shock is the result of an abnormality in the vascular system ▪ Septic shock is defined as sepsis-induced hypotension (despite fluid resuscitation) and organ perfusion abnormalities ▪ Diagnosis of septic shock depends on astute observations of the patient ▪ Treatment: Identified stage of septic shock will dictate the necessary medical interventions Syndrome of Inappropriate Antidiuretic Hormone Secretion ▪ Endocrine paraneoplastic syndrome that causes a disorder of water balance ▪ Most common malignant disease associated with this syndrome is lung cancer (80%, SCC) ▪ Symptomatology depends on the severity, rapidity, and duration of the hyponatremia and decreased plasma osmolality ▪ Diagnosed from the combination of hyponatremia, decreased plasma osmolality, and increased urine osmolality ▪ Primary treatment of choice for SIADH is to treat tor eliminate the underlying cause ▪ Treatment decisions are based on the severity of the hyponatremia and symptoms of water intoxication Tumor Lysis Syndrome ▪ TLS is an oncologic emergency that occurs with rapid lysis of malignant cells ▪ Resultant metabolic imbalance can quickly lead to fatal renal, cardiac, and neurologic complications ▪ Most commonly results from treatment-related malignant cell death ▪ As malignant cells are lysed, intracellular contents are rapidly released into the bloodstream resulting in high levels of potassium (hyperkalemia), phosphate (hyperphosphatemia), uric acid (hyperuricemia), and a decrease in calcium (hypocalcemia) ▪ Best way to treat TLS is to prevent it by recognizing the patient population who is at risk and initiating prophylactic measures before initiation of antineoplastic therapy  Cancer Clinical Trials Clinical trials have led the transformation of cancer treatment and symptom management over the last 50 years Cancer centers have a scientific agenda that is primarily focused on basic or population sciences or clinical research, or any two of the three components Comprehensive cancer centers integrate research activities across three major areas: laboratory, clinical, and population-based research  Prevention trials – examine ways to reduce the risk, or chance, of developing cancer Drug Development Screening trials – study ways to detect cancer ▪ A successful pharmaceutical clinical trial Diagnostic trials – study focus on procedures that could be requires careful planning and resolution of used to identify cancer or other diseases accurately and at several key issues before implementation an earlier stage ▪ The primary and secondary objectives of Treatment trials – conducted with people who have cancer, the trial should be carefully determined, with and are designed to answer specific questions about, and an estimated number of subjects and time evaluate the effectiveness of, a new treatment or procedure required to achieve these goals Supportive clinical trials – explore ways to improve the quality of life of cancer patients and cancer survivors Genetics studies – focus on how genetic makeup can affect diagnosis, detection, treatment, and symptom management, as well as how genetic disorders affect quality of life Phases of Clinical Trials ▪ Phase I – first attempt at evaluating a new drug or new drug combinations in human beings ▪ Phase II – seeks preliminary evidence of the effectiveness of the treatment, typically using pre- experimental or quasi-experimental designs ▪ Phase III – complete experimental test of the treatment or intervention with the objective of determining whether it is more effective than the standard treatment ▪ Phase IV – occur after the decision to adopt an innovative treatment has been made Research Data Management Ethical Concerns ▪ Discipline that involves data collection, ▪ Vulnerable subjects and inclusion of women storage, retrieval, and quality control of the and minorities, certificates of confidence, data required for evaluating the scientific federal assurance, and informed consent objective of the study Strategies to Improve Patient Accrual Institutional Review Boards (IRBs) ▪ Recruitment and enrollment to clinical trials ▪ Review research projects to ensure that ethical standards are met in relation to protection of the rights of human subjects Evidence-Based Practice (EBP) ▪ EBP involves making clinical decisions on the basis of the best possible evidence Barriers to Enrolling Subjects in Clinical Trials Physician-related Patient-related System-related ✓ Possible effects on the physician- ✓ Financial costs ✓ Poorly designed clinical trials that patient relationship by a require numerous trips to the clinic randomized clinical trial ✓ Concerns of privacy and or physician office confidentiality ✓ Difficulty with the informed ✓ Lack of commitment from consent process ✓ Lack of understanding administration ✓ General dislike of an open ✓ Fear of research ✓ Limited resources such as discussion involving uncertainty inadequate staffing and space, ✓ Family influences poor staff attitudes, and lack of ✓ Perceived conflict between the education roles of scientists and clinician ✓ Anticipated treatment toxicities ✓ Feelings of personal responsibility ✓ Presence of comorbidities that may if the treatments were found to be limit their energy or functional unequal status Cancer Care Supportive Therapies Nutrition ▪ Oral supplementation, the simplest type of support ▪ Enteral and parenteral nutrition may be required for individuals with more severe symptoms and for those with demonstrated physical impairment of the GI tract Skin Integrity ▪ Wound management for patients receiving palliative care may require recognition that treatment goals are not curative ▪ Maintaining patient comfort becomes the primary goal Bone Marrow Suppression ▪ Myelosuppression is the most common dose-limiting side effect related to chemotherapy administration, and it is potentially the most life-threatening side effect of chemotherapy ▪ Resulting clinical conditions associated with myelosuppression include neutropenia, thrombocytopenia, and anemia Oral Mucositis ▪ Inflammation of the mucosal tissue, can occur anywhere in the gastrointestinal tract ▪ Associated with erythema, inflammation, and ulceration that results in pain and dysgeusia (taste changes) that can lead to impaired hydration and nutrition Psychosocial Care ▪ Psychosocial services and psychotherapeutic interventions should be available to cancer patients and families, and directly involved in their care in conjunction with oncologic medical treatment Sexuality ▪ Depending on the type of cancer and therapy used, specific physiologic and psychologic changes can interrupt normal sexual functioning and feelings of femininity or masculinity Functional Status in the Patient with Cancer ▪ Functional status may be broadly defined as a systematic evaluation of the level at which a person is functioning in areas such as physical health, self-maintenance, role activities, intellectual status, social activity, attitude toward the world and toward self, and emotional status ▪ Clinical assessment of function should include two dimensions: o Functional ability, which is defined as the capacity to perform the daily activities and tasks normally expected of individuals to care for themselves and fulfill fundamental needs o Functional performance, which is defined as an individual’s actual performance of activities and tasks associated with life roles Patient Education ▪ The educator of the patient with cancer has to take both factors into account when working with cancer patients and their families ▪ The entire health care team is responsible for teaching, but nurses play a crucial role Palliative Care ▪ Nurses play an important role in assisting patients and families to address their psychosocial and spiritual concerns ▪ Bereavement care is an important component of any palliative care program Family Caregiving ▪ Patients with cancer move through a number of health care settings during the course of their illness ▪ Advance directives, also known as living wills, are legal documents that communicate a person's wishes for health care in the event they are unable to make decisions for themselves ▪ There are two main types of advance directives: o Living will - a person's preferences for medical care, especially end-of-life care o Durable power of attorney for healthcare - a person designates a proxy or surrogate to make decisions about their care and treatment Ethical Considerations ▪ Four major principles in the bioethics literature and many codes of professional ethics: o Autonomy – the right to make one's own decisions and live life according to one's own values, desires, and reasons o Beneficence – moral principle that requires acting in a way that benefits others o Nonmaleficence – to do no harm or to refrain from causing intentional harm to others o Justice – concerned with how people are treated and how benefits and burdens are distributed Symptom Management Fatigue CANCER-RELATED FATIGUE (CRF) Definition ▪ Persistent subjective sense of tiredness related to cancer or cancer treatment (National Comprehensive Cancer Network, 2003) Prevalence ▪ 61% to 100% during diagnosis and treatment and in the year immediately following completion of treatment Risk Factors ▪ Sleep deprivation, electrolyte imbalances, rapid metabolic shifts, fever, pain, infection, and dehydration Etiology ▪ Disease-related factors include tumor growth, metastatic spread, and the side effects from each malignancy-specific presentation ▪ Treatment-related factors can be further subdivided into surgery, chemotherapy, radiation, and biotherapy or immunotherapy ▪ Psychologic distress (anxiety and depression) causing CRF may be experienced by patients at diagnosis, during treatment, following completion of treatment, or as they experience adjustment to life as a survivor ▪ Inactivity CANCER-RELATED FATIGUE (CRF) Effects and Consequences ▪ CRF has mental and physical consequences, and many patients report that CRF is more limiting than nausea and vomiting or pain and is not as well controlled Assessment and Measurement ▪ Brief Fatigue Inventory (BFI) ✓ Designed to measure the intensity and interference of CRF ✓ Uses a scale from 0 (none) to 10 (severe) ▪ The Functional Assessment of Cancer Therapy (FACT-F) ✓ Consists of 28 questions regarding QOL and health-related issues, and 13 questions about CRF in patients with cancer ▪ Piper CRF Scale (PFS) and Revised PFS ✓ Contains 22 items that measure four dimensions of subjective CRF: behavioral severity (six items), sensory (five items), cognitive or mood (six items), and affective meaning (five items) ▪ Multidimensional CRF Inventory (MFI-20) ✓ Tool consisting of 20 statements that assess five dimensions of CRF based on different modes of expressing CRF: (a) general fatigue; (b) physical fatigue; (c) reduced activity; (d) lack of motivation to start any activity; and (e) mental CRF CANCER-RELATED FATIGUE (CRF) Assessment and Measurement ▪ Schwartz Cancer Fatigue Scale (SCFS) ✓ Consisting of 28 items based on an extensive literature review and various self-report instruments ✓ Four dimensions are conceptualized in this scale: physical, emotional, cognitive, and temporal aspects of CRF ▪ Profile of Mood States (POMS) ✓ Contains 65 5-point, adjective rating scales, and measure six identifiable mood states ✓ Shows good reliability when compared with other tools ✓ Several physical items that overlap with either disease-related or treatment-related symptoms ▪ Quick CRF Assessment Scale (QFAS) ✓ Based on five primary symptoms: sleep disturbance, pain, anxiety, vomiting, and depression ✓ 17-item assessment technique designed to provide an efficient method for obtaining descriptive data about a patient’s CRF Interventions ▪ Pharmacologic: ✓ Erythropoietin, psychostimulants, antidepressants ▪ Non-pharmacologic: ✓ Exercise, energy conservation, sleep and rest, restorative activities, stress management, psychosocial support, as well as nutritional support and supplements CANCER-RELATED FATIGUE (CRF) Outcomes ▪ Assessment of CRF in any patient should include attention to possible physiologic, psychosocial, and environmental factors, with interventions geared toward correcting the abnormalities that are discovered ▪ Patients should be educated in advance regarding what to expect by way of CRF as they approach and undergo treatment ▪ Validation that their experiences and the struggle with CRF are real can be reassuring and provide the opportunity for more in- depth assessment of which intervention is best for that particular patient Dyspnea DYSPNEA Definition ▪ Subjectively perceived breathing difficulty or distress that encompasses a variety of unpleasant respiratory sensations and includes the cognitive, affective, and behavioral responses to those sensations Prevalence ▪ Dyspnea is most commonly associated with breast, lung, and colorectal cancers ▪ Prevalence of dyspnea in patients with lung cancer is reported to range from 46% to 73% and even 87% Risk Factors ▪ Direct causes: bronchial or airway obstruction, superior vena cava syndrome, tumor invasion of lung tissue, pleural effusion, ascites, hepatomegaly, or the like ▪ Indirect causes: debilitating nature of the disease, such as anemia, cachexia, pneumonia, electrolyte imbalance, infection, pulmonary embolism, or pulmonary aspiration ▪ Psychologic factors may also increase the risk of dyspnea Etiology ▪ Physiologic mechanism: caused by a dissociation or mismatch between central respiratory motor activity and incoming afferent information from receptors in airways, lungs, and the chest wall DYSPNEA Etiology ▪ Psychologic mechanism: interpretation or meaning of dyspnea influences the patient’s perception of severity Effects and Consequences ▪ Presence of dyspnea results in a reduced QOL that includes a reduction in social, work, and personal care activities Dyspnea Measurement and Patient Assessment ▪ Patient Report Measures ✓ Numeric Rating Scale (NRS) ✓ Graphic or Verbal Rating Scale (GRS) ✓ Visual Analogue Dyspnea Scale (VADS ▪ Dyspnea Descriptors ✓ Words used to describe dyspnea have been shown to vary according to the disease state or cause of dyspnea ▪ Measures that include Multiple Symptoms ✓ Memorial Symptom Assessment Scale ✓ Symptoms Distress Scale (SDS) ✓ Cancer Dyspnea Scale ✓ Breathlessness, Cough, and Sputum Scale DYSPNEA Dyspnea Measurement and Patient Assessment ▪ Measurement of Symptoms from Radiation Therapy ✓ Radiation Therapy Oncology Group and the European Organization for Research in the Treatment of Cancer (RTOG/EORTC) ▪ Quality of Life Measures ✓ Lung Cancer Symptom Scale ▪ Dyspnea in Children ✓ McCorkle and Young’s Symptom Distress Scale Comprehensive Patient Assessment ▪ History ✓ Determine the onset of dyspnea, its duration, and the circumstances under which it occurs, as well as the patient’s prior experience with dyspnea ▪ Pulmonary Function Tests ✓ Not useful in determining dyspnea ▪ Arterial Blood Gases ✓ Important in the assessment of dyspnea and should be taken at rest without supplemental oxygen, if possible ▪ Physical Exam ✓ Assess for accessory muscle use for breathing DYSPNEA Interventions ▪ Non-pharmacologic: ✓ Supplemental oxygen, fan blowing, relaxation techniques, pursed-lip breathing, semi-Fowler’s positioning, activity modification, exercise, and comprehensive nursing intervention ▪ Pharmacologic: ✓ Opiates (respiratory depressant), diuretic medication (decrease the demand on the heart), bronchodilator (bronchospasm), steroids and NSAIDs, benzodiazepines ▪ Palliative radiotherapy can reduce a tumor and decreased dyspnea for a period of time Assessment and Teaching of Caregivers ▪ It is not enough that interventions be effective in relieving dyspnea; they must also meet the needs and acceptance of the family caregivers who are to put them to use Outcomes of Nursing Intervention ▪ Main outcome desired is the reduction or the elimination of dyspnea Considerations for Older Adults/End of Life ▪ Recommended that numeric rating scale is used to assess for dyspnea and directly from the patient Pain PAIN Definition ▪ Unpleasant sensory and emotional experience associated with actual or potential damage Prevalence ▪ 1/3 of persons receiving treatment for cancer and 2/3 of those with advanced malignant disease experience pain Risk Factors ▪ Disease-related: bone metastasis, abdominal visceral pain, and nerve compression or injury ▪ Treatment-related: chemotherapy, radiation, and surgery ▪ Health care provider-related: inadequate knowledge of pain, poor pain assessment; lack of responsibility, fear of patient addiction, concerns of adverse side effects of analgesics, and concerns about patients becoming tolerant to analgesics ▪ Patient- and family-related: fears of addiction or being thought of as an addict Etiology ▪ Acute cancer-related pain ▪ Chronic cancer-related pain Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations Pseudoaddiction is a term that has been used to describe patient behaviors, such as “clock watching” and ”drug seeking,” occurring when pain is undertreated Physical dependence is a state of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood levels of the drug, and/or administration of an antagonist Tolerance is a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug’s effects over time Distress is an unpleasant feeling of a physical, psychological, social, or spiritual nature that interferes with one’s ability to cope Suffering, which is severe distress associated with events that threaten the individual’s perception of wholeness, is identified within the spiritual dimension of quality of life, but it transcends all dimensions, often occurring when health care providers fail to attend to the symptoms of cancer and its treatment PAIN Effects and Consequences ▪ Unrelieved pain has several consequences, such as depressed immune system, impaired cardiac and respiratory systems, decreased gastric and bowel motility, muscle spasms, immobility, which may lead to deep vein thrombosis or pneumonia, and poor quality of life ▪ Pain intensity scores of 4 to 5 out of 10 have demonstrated interference with activities and enjoyment Pain Assessment ▪ Location of pain with cancer may be multiple ▪ Quantify pain with a standard pain intensity scale ▪ Quality of pain can be broadly divided into nociceptive (somatic and visceral) and neuropathic pain ▪ Pattern refers to the persistent nature of pain or breakthrough pain ▪ Precipitating factors are aggravating or alleviating factors ▪ Pain history includes words that are used by the patient to indicate pain, descriptions of the patient’s significant prior pain experiences; and agents or actions that have been effective in relieving the patient’s pain ▪ Medication history provides key information regarding what medications the patient has tried, as does determining their effectiveness or adverse effects ▪ Psychosocial issues, such as the meaning of pain, cultural considerations, and spiritual or religious beliefs may affect the patient’s perception of pain PAIN Pain Assessment ▪ Reassessment of pain occurs regularly with any new report of pain or increased in pain and with changes in the analgesic regimen ▪ Communicate assessment findings to the health care team, including all disciplines involved in the care of the patient Pharmacologic Interventions for Pain Management ▪ Managing opioid side effects: allergic reactions, respiratory depression, sedation, constipation, nausea and vomiting, pruritus, and myoclonus ▪ Route of administration: oral/sublingual, IV, transdermal, oral transmucosal, IM, rectal, topical, and spinal ▪ Co-analgesics: anticonvulsants (carbamazepine, phenytoin), tricyclic antidepressants (amitriptyline, nortriptyline, desipramine, corticosteroids (dexamethasone), local/topical (lidocaine), and antispasmodic agent (Baclofen) ▪ Other pain-relieving therapies: biphophonates (inhibit osteoclast activity and subsequently bone resorption), and radiopharmaceuticals (Strontium-89 and samarium-153) may also be utilized in combination with radiation therapy PAIN Non-Pharmacologic Interventions ▪ Physical techniques include heat, cold, massage, positioning, acupuncture, acupressure, and assistive devices to increase function and independence ▪ Cognitive-behavioral strategies include relaxation techniques, such as music therapy, breathing exercises, guided imagery, distraction, cognitive reframing, support groups, pastoral counseling, and prayer Outcomes ▪ Nurses individualize the pain management plan of care, based on the comprehensive pain assessment findings, and emphasize patient outcomes daily in providing care to patients and their families ▪ Patient education is the cornerstone of cancer pain management, and patient education clarifies the myths and misconception that arise as barriers to effective pain management Sleep Disturbance SLEEP DISTURBANCE Definition ▪ Complex, highly structured activity that is regulated by internal biologic processes such as melatonin, and environmental factors such as amount of daylight ▪ Adult sleep disturbances (disorders) include narcolepsy, sleep apnea, periodic leg movements, restless leg syndrome, and insomnia (most common) Prevalence ▪ 30% to 50% of newly diagnosed or recently treated cancer patients report sleep difficulties (30% to 88% in women with breast cancer, 25% to 52% in patients with lung cancer, and 52% to 62% in patients with solid tumors) ▪ Most prevalent sleep-wake problems reported by cancer patients (mixed diagnoses) were excessive daytime fatigue (44%), insomnia (31%), and excessive daytime sleepiness (28%) Risk Factors ▪ Predisposing factors: ✓ Women report more difficulty sleeping than men across populations ✓ Younger cancer patients reported more sleep disturbances ✓ Hyperarousability trait, family and/or personal history of insomnia, and presence of depression and/or anxiety ✓ Less modifiable predisposing factors: gender, age, history, and personality traits SLEEP DISTURBANCE Etiology ▪ Precipitating factors: ✓ Cancer treatments (surgery, hospitalization) ✓ Radiotherapy ✓ Estrogen deficiency produced by surgical menopause, chemotherapy, and hormonal therapy ✓ Cancer pain ✓ Cancer related fatigue ▪ Perpetuating factors: ✓ Maladaptive sleep habits ✓ Dysfunctional thoughts (faulty beliefs and attitudes about sleep and sleeplessness) Effects and Consequences ▪ Psychologic and behavioral consequences: ✓ Fatigue ✓ Impaired daytime functioning ✓ Mood disturbances ▪ Physiologic consequences: ✓ Headache, diarrhea, gastrointestinal distress, palpitations, and nonspecific pain SLEEP DISTURBANCE Assessment and Measurement ▪ Sleep diary ✓ Most commonly used insomnia assessment instrument ✓ 1- to 2-week prospective diary that the patient fills each day and night (time to bed; time to fall asleep; duration of sleep; number, duration, and cause of night-time awakenings; and daytime functioning) Interventions ▪ Pharmacologic therapies: ✓ Hypnotic medications ▪ Cognitive-behavioral therapies (CBT): ✓ Stimulus control, sleep restriction, and multimodal treatments ✓ Relaxation therapies ✓ Cognitive therapy, focused on reframing the individual’s thoughts about sleep Outcomes ▪ Goal of treatment are to bring the patient’s sleep patterns closer to the recommendations for quality sleep ▪ Recommendations include at least 8 hours’ duration (time asleep), at least 85% efficiency (time asleep/time in bed x 100), and less than 15 minutes latency Nausea NAUSEA Definition ▪ Vomiting or emesis is the forceful expulsion of gastric, duodenal, or jejunal contents through the oral cavity caused by powerful contraction of the abdominal and chest wall muscles ▪ Nausea is a person’s conscious awareness of potential vomiting, characterized by a subjective unpleasant wavelike sensation at the back of the throat, in the epigastrium, or in the abdomen that may or may not culminate in vomiting ▪ Retching is the physical effort to vomit without expulsion of gastric contents ▪ Although nausea, vomiting, and retching are separate phenomena, they usually occur together as a cluster (NVR) Prevalence ▪ The incidence of nausea and vomiting related to cancer and its treatment ranges from 30% to over 80% ▪ Chemotherapy remains the major causal factor to the development of nausea and vomiting in patients with cancer Risk Factors ▪ Patient-specific: age, gender, weight, previous experience of nausea and vomiting, alcohol consumption, anxiety, stress, and responses to chemotherapy ▪ Treatment-specific: emetogenicity of chemotherapeutic agents, radiation ▪ Disease-related: GI conditions, intracranial pressure, and metabolic imbalance ▪ Environmental: clinic atmosphere and family relationship NAUSEA Etiology ▪ Physiology: vomiting or emesis is a complicated process that involves coordination of the emetic or vomiting center (VC) in the lateral reticular formation of the medulla ▪ Pathophysiology: chemotherapy induces nausea and vomiting through direct or indirect stimulation of the CTZ and the VC ▪ Psychosocial contributing factors: anxiety, stress, fear, and pretreatment expectations Effects and Consequences ▪ Distress from inadequately controlled nausea and vomiting can affect patients’ quality of life, functional status, and withdrawal from or interruption of potentially curable treatment ▪ Nausea and vomiting can precipitate potential life-threatening medical complications such as dehydration, electrolyte imbalances, anorexia, nutritional deficit, wound dehiscence, and esophageal tears Assessment and Measurement ▪ Nausea is a subjective phenomenon that can only be assessed and measured subjectively, vomiting can be objectively observed and measured ▪ As a symptom cluster, nausea and vomiting can be assessed through key measurable indicators of occurrence, symptom distress, and symptom experience NAUSEA Interventions ▪ Prevention: optimal intervention ▪ Pharmacologic: currently the mainstay of management ✓ Serotonin 5-HT3-receptor antagonists ✓ NK-1-receptor antagonists ✓ Dopamine-receptor antagonists ✓ Benzodiazepines ✓ Other antiemetic medications (antihistamines, corticosteroids, and cannabinoids) ▪ Nonpharmacologic: used in conjunction with pharmaceutical agents ✓ Diet and environment ✓ Acupressure ✓ Progressive muscle relaxation training (PMRT) ✓ Music therapy and guided imagery ✓ Hypnosis ✓ Massage Outcomes ▪ Expected outcome of nursing interventions is manifested by complete relief from nausea and vomiting in terms of symptom status, improved QOL, and improved functional and cognitive performance Hot Flashes HOT FLASHES Definition ▪ One of the most common symptoms associated with hormone depletion in both men and women ▪ Sudden sensation of intense warmth that begins in the chest area and may rise to the neck and face as well as down to the toes ▪ Manifest as night sweats Prevalence ▪ 65% to 75% in women with a history of cancer ▪ 40% to 80% of men undergoing androgen ablation therapy will experience hot flashes Risk Factors ▪ Postmenopausal ▪ Advanced age ▪ Increased body mass index (BMI) ▪ Currently smoking ▪ Ethnicity (African American) ▪ Socioeconomic status ▪ Lack of physical activity ▪ Receiving treatment for breast cancer HOT FLASHES Etiology ▪ Estrogen deprivation in women and withdrawal of androgens, specifically testosterone, in men Effects and Consequences ▪ Emotional responses: panic, irritation, and being embarrassed or annoyed and distressed ▪ Behavioral responses: major sleep disturbance, bed linen changes, and cold showers Assessment ▪ Begins with obtaining information about the frequency, the severity, and the duration of the hot flashes ▪ Determine what behaviors or other interventions the person has tried previously for hot flash management Measurement ▪ Most symptoms (be it for research or practice) are measured with self-report questionnaires that are validated, reliable tools developed for symptom assessment ▪ These measures generally have time, duration, and severity components as well as interference or impact questions ▪ To date, most studies evaluating hot flash interventions use a prospective diary that is either kept electronically or with pen and paper HOT FLASHES Interventions ▪ Hormonal-related therapies: ✓ Estrogen ✓ Progesterone ✓ Other hormonal agents (androgenic agents) ▪ Nonhormonal therapies: ✓ Serotonin/Norepinephrine reuptake inhibitors (venlafaxine) ✓ Selective serotonin reuptake inhibitors (fluoxetine, paroxetine, sertraline, citalopram, and mirtazapine) ✓ Gabapentin ✓ Clonidine, Bellergal (combination of ergotamine tartrate, levorotatory alkaloids, and phenobarbital) ▪ Nutraceutical therapies: (no compelling evidence to recommend) ✓ Vitamin E, soy, black cohosh (herb) ▪ Behavioral interventions: ✓ Keeping the environment cool with moving air,,, ✓ Paced respirations and applied relaxation ✓ Exercise hypnosis Outcomes ▪ Diminishing hot flashes and their effects will help improve the overall function and quality of a patient’s life