NRSG 3200 Unit 11 Cancer Treatment

Stem Cell Retrieval

Peripheral blood stem cell collection using the process of apheresis. The cells are specially processed and infused into the patient. Safer and more cost effective than harvesting bone marrow. Stem cells can also be collected from umbilical cord blood.

Each time a tumor is exposed to chemotherapy, a percentage of the tumor cells (20%-99%, depending on dosage and agent) are destroyed. _____ of chemotherapy are necessary over a prolonged period to achieve regression of the tumor.

Repeated doses

______ transplants result in less incidence of GVHD and graft rejection; however, there is also less graft-versus-tumor effect to fight the malignancy. For this reason, even when an identical twin is available, another matched sibling or unrelated donor may be more suitable.

Syngeneic

_____ involves the use of antineoplastic drugs in an attempt to destroy cancer cells by interfering with cellular functions, including replication and DNA repair.

Chemotherapy

Autologous HSCT

Considered for patients with disease of the bone marrow who do not have a suitable donor or for patients who have healthy bone marrow, but require bone marrow-ablative doses of chemo to cure aggressive malignancy. Stem cells are collected from the patient and preserved for reinfusion; if necessary, they are treated to kill any malignant cells within the marrow, called purging. The patient is then treated with ablative chemotherapy and possibly total-body irradiation to eradicate any remaining tumor. The stem cells are then reinfused. No immunosupressant medications are needed afterwards because the patient does not receive foreign tissue.

Clinical manifestations of acute GVHD include...

Diffuse rash progressing to blistering and desquamation similar to second-degree burns. Mucosal inflammation of the eyes and the entire GI tract. Diarrhea that may exceed 2L/day. Biliary stasis with abdominal pain, hepatomegaly, and elevated liver enzymes progressing to obstructive jaundice.

Nonablative AlloHSCT

The chemotherapy doses are lower and aimed at destroying malignant cells (without completely eradicating the bone marrow), thus suppressing the recipient's immune system to allow engraftment of donor stem cells. The lower dose of chemo is associated with less organ toxicity and infection, and can be used for older patients or for those with underlying organ dysfunction. After engraftment, it is hoped that the donor cells will create a graft-versus-tumor effect.

Chemotherapy Dosage

The dosage of chemotherapeutic agents is based primarily on the patient's total body surface area, weight, previous exposure and response to chemotherapy or radiation therapy, and function of major organ systems. Dosage is determined to maximize cell kill while minimizing impact on healthy tissues and subsequent toxicities. Modification of dosage is often required if critical lab values or the patient's symptoms indicate unacceptable or dangerous toxicities. Some chemotherapeutic agents have a maximum lifetime dose limit that must be adhered to because of the danger of long term irreversible organ complications.

Surgery as Primary Treatment

The goal is to treat the cancer by removing the entire tumor or as much as possible, as well as any involved surrounding tissue, including regional lymph nodes.

During the first 30 days after the conditioning regimen, AlloHSCT patients are at risk for developing _____

hepatic sinusoidal obstructive syndrome (HSOS) (s/s- weight gain, hepatomegaly, increased bilirubin, and ascites)

To prevent GVHD, patients receive ______ drugs.

immunosuppressant

Surgical care is _____ according to age, organ impairment, specific deficits, comorbidities, cultural implications, and altered immunity.

individualized

Before engraftment, patients are at high risk for....

infection, sepsis, and bleeding.

The use of injectable dyes and nuclear medicine imaging can help identify the sentinel lymph node or the ________

initial lymph node to which the primary tumor and surrounding tissue drain.

Hematopoietic stem cell transplantation is a standard of care for patients with....

malignant myeloma, acute leukemia, and non-Hodgkin lymphoma

Chemotherapeutic agents may be classified by their....

mechanism of action, cell cycle specificity, and chemical group

The consequences of extravasation range from mild discomfort to severe tissue destruction, depending on whether the agent is classified as a ____, ____, or ____.

nonvesicant; irritant; vesicant

Radiation therapy may be given prophylactically to...

prevent local recurrence or spread of microscopic cells from the primary tumor to a distant area.

Approximately 60% of patients with cancer receive _____ at some point during treatment.

radiation therapy

A _____ tumor is one that can be destroyed by a dose of radiation that still allows for cell repair and regeneration in the surrounding normal tissue.

radiosensitive

Neoadjuvant radiation therapy, with or without chemotherapy, is used to....

reduce tumor size in order to facilitate surgical resection.

Palliative radiation therapy is used to....

relieve the symptoms of locally advanced or metastatic disease, especially when the cancer has spread to the brain, bone, or soft tissue, or to treat oncologic emergencies, such as superior vena cava syndrome, bronchial airway obstruction, or spinal cord compression.

The radiation dosage depends on the....

sensitivity of the target tissues to radiation, the size of the tumor, radiation tolerance of the surrounding normal tissues, and critical structures adjacent to the tumor target.

In external-beam radiation therapy, the total radiation dose is delivered over ____ ____ in daily doses called ____.

several weeks; fractions

Radiation sensitivity is enhanced in tumors that are...

smaller in size and that contain cells that are rapidly dividing (highly proliferative) and poorly differentiated (no longer resembling the tissue of origin).

Chemotherapy is used primarily to treat _____ disease rather than localized lesions that are amenable to surgery or radiation.

systemic

An advantage of AlloHSCT (allogeneic hematopoietic stem cell transplantation) is....

the transplanted cells should not be immunologically tolerant of a patient's malignancy and should cause a lethal graft-versus-tumor effect in which the donor cells recognize the malignant cells and act to eliminate them.

Radiation may be used to cure cancer, as in _____, _____, and cancers of the _____.

thyroid carcinomas, localized cancers of the head and necks, cervix

Eradication of 100% of the tumor is almost impossible; the goal of chemotherapy treatment is.....

eradication of enough of the tumor so that the remaining malignant cells can be destroyed by the body's immune system.

GVHD may be acute, occurring within the ____ 100 days, or chronic, occurring ____ 100 days.

first; after

Electrosurgery

Use of an electric current to destroy tumor cells

Chemosurgery

Use of chemicals or chemotherapy applied directly to tissue to cause destruction

Laser surgery

Use of light and energy aimed at an exact tissue location and depth to vaporize cancer cells.

Cryoablation

Use of liquid nitrogen or a very cold probe to freeze tissue and cause cell destruction.

Hyperthermia

Use of temperatures greater than physiologic fever range (greater than 106.7F) to destroy cancerous tumors. Most effective when combined with radiation, chemo, or biologic therapy. May be local or whole body. Side effects: burns, fatigue, hypotension, peripheral neuropathies, thrombophlebitis, nausea, vomiting, diarrhea, and electrolyte imbalances.

Excisional biopsy

Used for small, easily accessible tumors of the skin, upper or lower gastrointestinal and upper respiratory tracts. In many cases, the surgeon can remove the entire tumor as well as the surrounding marginal tissues. This approach provides the pathologist with the entire tissue specimen for the determination of stage and grade; also decreases the chance of seeding tumor cells.

Core needle biopsy

Uses a specially designed needle to obtain a small core of tissue that permit histologic analysis. Usually this specimen is sufficient to permit accurate diagnosis.

Radiofrequency ablation (RFA)

Uses localized application of thermal energy that destroys cancer cells through heat; temperatures exceed 50C (122F)

_____ are those agents that, if deposited into the subcutaneous or surrounding tissues (extravasation), cause inflammation, tissue damage, and possibly necrosis of tendons, muscles, nerves, and blood vessels.

Vesicants

Palliative surgery

When surgical cure is not possible, the goals of surgical interventions are to relieve symptoms, make the patient as comfortable as possible, and promote quality of life as defined by the patient and family. Performed in an attempt to relieve symptoms, such as ulceration, obstruction, hemorrhage, pain, and malignant effusions. Honest and informative communication is necessary to avoid false hope and disappointment.

Classes of Chemotherapeutic Agents

Alkalating agents Nitrosoureas Antimetabolites Antitumor antibiotics Topoisomerase inhibitors Plant alkaloids Hormonal agents Miscellaneous agents

Types of Hematopoietic Stem Cell Transplantation

Allogeneic- from a donor other than the patient Autologous- from the patient Syngeneic- from an identical twin Myeloablative- consists of giving patients high dose chemo and, occasionally, total-body irradiation. Nonmyeloablative- also called mini-transplants; does not completely destroy bone marrow cells.

Acute Toxicities of Radiation (Begin within 2 weeks)

Altered skin integrity Alopecia Radiation dermatitis Erythema and dry desquamation (flaking of skin) Erythema and wet desquamation (skin oozing fluid) Ulceration Stomatitis Decreased salivation Dry mouth Change in or loss of taste Mucositis Chest pain Dysphagia Anorexia Nausea Vomiting Diarrhea Anemia Leukopenia Thrombocytopenia Fatigue Malaise

Nursing Care for Radiation

Anticipate, prevent, and work collaboratively with other providers to manage symptoms associated with radiation therapy in order to promote healing, patient comfort, and quality of life. Consider factors that may be predictive of radiation toxicities or radiosensitivity of tissues. Assess the patient's skin regularly. Assess nutritional status and general feelings of well-being regularly. Educate about symptoms- explain they are a result of the treatment and not indicative of a deterioration or progression of the disease.

Internal Radiation

Includes localized implantation or systemic radionuclide administration.

Fine-needle aspiration

Involves aspirating cells rather than intact tissue through a needle that is guided into a suspected diseased area. This type of specimen can only be analyzed by cytological examination (viewing only cells, not tissue). Often, x-ray, CT, ultrasound, or MRI is used to help locate the suspicious area and guide placement of the needle. Does not always yield enough material to permit accurate diagnosis, necessitating additional biopsy procedures.

Prophylactic surgery

Involves removing non-vital tissues or organs that are at increased risk of developing cancer. Factors considered when discussing this type of surgery: Family history and genetic predisposition Presence or absence of signs and symptoms Potential risks and benefits Ability to detect cancer at an early stage Alternative options for managing increased risk The patient's acceptance of the postoperative outcome Examples: colectomy, mastectomy, oophorectomy

Administration of Chemotherapy

It is only given by those who have the knowledge and established competencies for vesicant and extravasation management. Vesicant chemotherapy should never be given in peripheral veins involving the hand or wrist. Peripheral administration is only for short-duration infusions, and the IV should be placed in the forearm. Frequent or prolonged infusions should be given through PICC lines, central lines, ports, etc. Keep extravasation kit at the bedside with antidote.

Reconstructive surgery

May follow curative or extensive surgery in an attempt to improve function or obtain a more desirable cosmetic effect. It may be performed in one operation or in stages. May be indicated for breast, head and neck, and skin cancers.

Advantages of minimally invasive surgery

Minimization of surgical trauma. Decreased blood loss. Decreased incidence of wound infection and other complications associated with surgery. Decreased surgical time and requirement for anesthesia. Decreased postoperative pain and limited mobility. Shorter periods of recovery.

Nursing Management for HSCT- during treatment

Monitor closely for acute toxicities associated with the high-dose chemotherapy and total-body irradiation. Provide symptom management. Monitor vital signs Assess for adverse effects, such as fever, chills, shortness of breath, chest pain, cutaneous reactions, nausea, vomiting, hypotension, hypertension, anxiety, and taste changes. Provide strategies for symptom control. Provide ongoing support and patient education. Enforce a neutropenic diet. Assess for signs of tumor lysis syndrome and acute tubular necrosis.

External Radiation

Most commonly used form of radiation therapy. The energy utilized is generated either from a linear accelerator or from a unit that generates energy directly from a core source of radioactive material such as a GammaKnife unit. Through computerized software programs, both approaches are able to shape an invisible beam of highly charged photons or gamma rays to penetrate the body and target the tumor with pinpoint accuracy.

Chemotherapy Protecting Caregivers

Nurses must be familiar with their institutional policies and procedures regarding PPE, handling and disposal of the chemotherapeutic agent and supplies, and management of accidental spills or exposures. Emergency spill kits should be readily available. Educate patients, families, caregivers, assistive personnel, and housekeepers about precautions. While handling bodily fluids wear gown and double glove. After disposing of patient's urine or vomit in the toilet, flush twice. Bedding and clothing are bagged in yellow bags. Chemo gowns and gloves are disposed in yellow containers or Hazard-waste receptacle. Sharps are disposed in yellow sharps container. If there is a chemo spill, then notify the charge nurse and follow institution policy.

Replicating cells are most vulnerable to radiation. Therefore, those body tissues that undergo frequent cell division are most sensitive to radiation therapy. These tissues include:

bone marrow, lymphatic tissue, epithelium of the GI tract, hair follicles, and gonads.

Radiation therapy may also be used to ____ ____ when a tumor cannot be removed surgically or when local nodal metastasis is present.

control cancer

In certain regimens, additional medications are given with chemotherapy agents to...

enhance activity or protect normal cells from injury.

The lethal tumor dose is defined as the dose that will...

eradicate 95% of the tumor yet preserve normal tissue.

Nursing Management for HSCT- before treatment

Nutritional assessments Extensive physical examinations Organ function tests Psychological evaluations Blood work (assessing past infectious antigen exposure- hepatitis, CMV, herpes, HIV, syphilis, etc) Evaluate the patient's support system, financial, and insurance resources Informed consent and patient education about the procedure are done

Nursing Management for HSCT- after treatment

Ongoing nursing assessments during follow-up visits to detect late effects of therapy. Psychosocial assessments must be ongoing and a priority. Assess the family and other caregivers' needs and provide education, support, and information about resources.

Radiation Protecting Caregivers

Patient must be in a private room. Appropriate notices and radiation safety precautions must be posted. Staff members must wear dosimeter badges. Pregnant staff members should not be assigned to the patient. Prohibit visits by children or pregnant women. Limit visits from others to 30 minutes/day. Visitors must maintain a 6 foot distance from the patient. Patients with seed implants can generally go home due to the minimal risk of exposure to others.

Incisional biopsy

Performed if the tumor mass is too large to be removed. A wedge of tissue from the tumor is removed for analysis. The cells of the tissue wedge must be representative of the tumor mass so the pathologist can provide an accurate diagnosis.

Diagnostic Surgery

Performed to obtain a tissue sample for histologic analysis of cells suspected to be malignant. Example: biopsy

Needle biopsy

Performed to sample suspicious masses that are easily and safely accessible, such as some masses in the breast, thyroid, lung, liver, and kidney. Mostly performed on an outpatient basis. They are typically fast, relatively inexpensive, easy to perform, and may require only local anesthesia. The patient experiences only slight and temporary physical discomfort. The surrounding tissues are minimally disturbed, thus decreasing the likelihood of seeding cancer cells.

Nursing Care- Surgical

Provide the patient and family with verbal and written information about the surgical procedure as well as other interventions that may take place intraoperatively. Provide instructions concerning prophylactic antibiotic requirements, diet, and bowel preparation. Serve as the patient advocate Encourage the patient and family to take an active role in decision making. Explain and clarify information. Assess patient responses to surgery. Monitor the patient for complications, such as infection, bleeding, thrombophlebitis, wound dehiscence, fluid and electrolyte imbalance, and organ dysfunction. Provide postoperative education about wound care, pain management, activity, nutrition, and medication information. Encourage patients and families to use community resources as needed for support and information.

______ surgery is an additional treatment option that uses an extensive surgical approach to treat the local recurrence of cancer after the use of a less extensive primary approach.

Salvage

Local excision

Surgical approach for treating primary tumors. Often performed on an outpatient basis. Warranted when the mass is small. Removal of the mass and a small margin of normal tissue that is easily accessible.

Wide or radical excision

Surgical approach for treating primary tumors. Removal of the primary tumor, lymph nodes, adjacent involved structures, and surrounding tissues that may be at high risk for tumor spread. May result in disfigurement and altered functioning, necessitating rehabilitation, reconstructive procedures, or both. Considered if the tumor can be removed completely and the chances of cure or control are good.

Late Toxicities of Radiation (6+ months after treatment)

Fibrosis Atrophy Ulceration Necrosis Dysphagia Incontinence Cognitive impairment Sexual dysfunction

Nursing Management for Chemotherapy

Frequently monitor lab values and assess the patient prior to, during, and after chemo treatment. Assess fluid/electrolyte status. Encourage adequate fluid and dietary intake. Assess cognitive status. Inform patients and families of the possibility of cognitive impairment. Decrease risk of infection and bleeding. Administer the chemotherapy. Educate the importance of adhering to the premedication and reporting signs and symptoms. Educate about signs and symptoms that warrant medication administration or emergency transport to the hospital. Monitor for extravasation. Keep an extravasation kit and antidote at bedside. Evaluate the patient and make appropriate referrals for occupational or rehabilitative therapies. Prevent nausea and vomiting by identifying contributing factors and administering antiemetic regimens. Manage cognitive changes by recommending exercise, natural restorative environmental intervention, and cognitive training programs. Assist patients to address factors, such as fluid/electrolyte imbalances, nutrition deficits, fatigue, pain, and infection to minimize their contribution to cognitive impairment. Work with the patient and other team members to identify effective approaches for fatigue management.

Toxicities of Chemotherapy

GI- nausea, vomiting, stomatitis, mucositis, diarrhea. Hepatopoietic- myelosuppression (leukopenia, neutropenia, anemia, thrombocytopenia), increased risk of infection and bleeding. Renal- SIADH, decreased renal perfusion, interstitial nephritis, hemorrhagic cystitis, hematuria, electrolyte imbalance from tumor lysis syndrome. Cardiopulmonary- cardiotoxicity, alveolar damage, bronchospasm, penumonitis, pulmonary fibrosis, capillary leak syndrome, pulmonary edema, dyspnea, cough, respiratory distress/failure. Reproductive- sterility, early menopause. Neurologic- sensory alterations in the extremities, loss of deep tendon reflexes, muscle weakness, loss of balance and coordination, paralytic ileus, paresthesias. Cognitive- difficulty remembering things or focusing, motor and behavioral changes, impaired memory (chemo brain) Fatigue- expected, but it is distressing for the patient and affects their quality of life.

_______, a major cause of morbidity and mortality in 30-50% of the allogenic transplant population, occurs when the donor lymphocytes initiate an immune response against the recipient's tissues (skin, GI tract, liver) during the beginning of engraftment.

Graft-versus-host disease (GVHD)

______ reactions are a subgroup of adverse drug reactions that are unexpected and associated with mild or progressively worsening signs and symptoms, such as rash, urticaria, fever, hypotension, cardiac instability, dyspnea, wheezing, throat tightness, and syncope.

Hypersensitivity

Photodynamic therapy

IV administration of a light-sensitizing agent (hematoporphyrin derivative HPD) that is taken up by cancer cells, followed by exposure to laser light within 24-48 hours; causes cancer cell death.

_____ hypersensitivity reactions appear within 1 hour of an infusion, while ____ hypersensitivity reactions may occur hours afterward.

Immediate; delayed

Brachytherapy

The placement of radioactive sources within or immediately next to the cancer site in order to provide a highly targeted, intense dose of radiation beyond a dose that is usually provided by EBRT. Helps spare exposure to normal surrounding tissue. Radiation source can be implanted by means of needles or rods, seeds, beads, ribbons, or catheters placed into the body. Imaging techniques are used to guide placement. Temporary applications are delivered as high-dose radiation (HDR) for short periods of time, while low-dose radiation (LDR) is delivered over a more extended period of time.

Ablative AlloHSCT

The recipient receives high doses of chemotherapy and possibly total-body irradiation to completely eradicate the bone marrow and any malignant cells and help prevent rejection of the donor stem cells. The stem cells are then infused into the patient where they produce bone marrow and establish themselves through the process of engraftment. Once engraftment is complete (2-4 weeks), the new bone marrow becomes functional and begins producing RBCs, WBCs, and platelets.