Patient Care Exam 2

Identify expected acute and late side effects for: colon

- acute: abdominal cramping, diarrhea - late: fibrosis, diarrhea

Identify expected acute and late side effects for: prostate

- acute: diarrhea, tenesmus, rectal bleeding, erectile dysfunction - late: persistent bowel, incomplete bowel, changes of diarrhea, fistula formation

Identify expected acute and late side effects for: bladder

- acute: dysuria, hematuria, incontinence - late: hematuria from mucosal inflammation/ telangiectasia

Identify expected acute and late side effects for: lung

- acute: increasing cough, hoarseness, esophagitis - late: pneumonitis, fibrosis, esophageal stricture

Identify expected acute and late side effects for: breast

- acute: radiodermatitis, breast pain, tenderness, swelling - late: firmness, fibrosis, shrinkage, telangiectasias

Cell Kill Hypothesis

-Explains how chemotherapy agents theoretically kill cancer cells - Based on the belief that a given dose of chemotherapy will kill a percentage rather than a given number of cancer cells -Never getting to ZERO

Roles of surgery: reconstruction

-Improve function or cosmetic appearance after extensive cancer surgery

Describe why combination chemotherapy (multiple chemotherapy agents) is used to treat certain cancers.

-Includes drugs with non-overlapping side effects -Each drug has been shown to be effective as a single agent -Long term remission often achieved -Attack cells in different phases -Prevention of drug resistance -Tolerable side effects with maximal doses -Additive effects increase response rates -High-dose, intermittent therapy most effective.

Mitosis

-Parent cell divides into two identical "daughter" cells -Very short, lasts ~ one hour

Roles of surgery: supportive care

-Patients undergoing chemo may have a port surgically implanted in their chest to provide an access point for delivery of the chemotherapy

Describe several uses and limitations of radiation therapy for the treatment of cancer.

-Primary/Definitive Therapy -Neoadjuvant therapy -Adjuvant therapy -Prophylaxis -control -palliation -emergency

Gap 1 (G1)

-RNA and protein synthesis -Lasts several hours -Length of G1 influences rate of cell proliferation

immunosuppressant therapy

-Treatment that lowers the activity of the body's immune system -Poses risks because it reduces the body's ability to fight infections and other diseases -Its used to keep a person from rejecting a bone marrow or organ transplant.

Gap 0

-True resting or dormant phase; cell is not actively involved in cell division -Varies in length -Cells can be "recruited" back into G1 as needed

Define components of tumor staging and the severity of each rating.

-Used to determine whether the disease has spread from the original site of the tumor to other parts of the body—determines the extent of the disease -Lower stages are more localized -Lower stages are more easily controlled with surgery

incisional biopsy

-use- diagnosis -removal of a piece of the tumor -tumors usually greater than 3cm

Identify conditions/diseases that may indicate a bone marrow transplant as part of the treatment regimen.

Breast cancer and brain cancer- in which high doses of radiation therapy and chemo are required to reduce or eradicate the tumor which often results in severe toxic effects on bone marrow

Synthesis (S)

DNA replication -lasts 10-30 hours

Roles of surgery: Diagnostic:

Diagnosis depends on biopsy. Biopsy confirm diagnosis, determine specific type of cancer present. Technique used based on type, size, shape

Describe the use of chemotherapy for cancer treatment.

Goals: · Cure (primary/definitive therapy) · Control (limit growth of cancer cells) · Palliation (symptom management/focus is quality of life) · Prophylaxis (prevent spread to high risk areas)

Know examples of biotherapy treatment medicines. Monoclonal Antibody Therapy

Monoclonal Antibody Therapy- Use antibodies made from cell lines to react with certain antigens for specific types of cells. May be joined (tagged) with drugs, toxins, radioisotopes to destroy cancer cells.

Know examples of biotherapy treatment medicines: Non-Specific Immunotherapies and Adjuvants

Non-Specific Immunotherapies and Adjuvants- Cytokines—Promote regulate growth and activity of immune system cells. Can help bone marrow produce new blood cells and can destroy cancer cells, ex. interferons and interleukins.

Know examples of biotherapy treatment medicines. Vaccinces

Vaccines- Cancer cells, parts of cells, or pure antigens that cause the body to produce antibodies

The _______ agents are plant alkaloids made from the periwinkle plant

Vinca

Define Nadir.

When blood counts hit rock bottom

Define antigen.

a toxin or other foreign substance that induces an immune response in the body, especially the production of antibodies.

Neo-adjuvant

given before another treatment

Understand the importance of diagnostic evaluation and its role in cancer treatment.

• A diagnostic evaluation is used to determine: - Is malignant or benign? - Tissue Type (Histology) - Primary Site - Extent of Disease - Biologic characteristics

Sexual dysfunction

•Some types of radical cancer surgeries can cause sexual dysfunction and/or urinary incontinence •Examples include: -radical prostatectomy for prostate cancer -Radical cystectomy for bladder cancer -Abdominoperineal resection for removal of the lower colon and rectum for colon cancer

Anti-tumor Antibiotics

- Cell Cycle nonspecific, except bleomycin (G2) -Similar actions to alkylating agents

Antimetablites

- Cell cycle specific to S phase -Damage cells by substituting normal metabolites essential for DNA synthesis

common side effects associated with biologic therapy

- Flu-like symptoms - Allergic reactions - Fever, Chills, Weakness, Headache, Nausea, Vomiting, Diarrhea, Fatigue, Hypotension, Rash, Leukopenia, & Thrombocytopenia

Briefly describe the bone marrow transplant process.

- High doses of radiation (sometimes along with chemo) is given to kill any cancer cells; this also kills (ablates) healthy bone marrow -Patient is then given new, healthy stem cells - Radiation not only kills the cancer cells but it also suppresses the recipient's immune system and help prevent rejection of the bone marrow/stem cell transplant from donor (leaves them immunocompromised and susceptible to infections) -Delivered as Total Body Irradiation (TBI)

routes of administration for Chemo:

- IV (vein) - Oral (mouth) - Intraperitoneal (abdominal cavity) - Intrathecal (spinal canal via a lumbar puncture) - Intraventricular (ventricles of the brain) - Intra-arterial (artery) - Intravesicalar (bladder via urinary catheter) - Intrapleural (pleural cavity via a chest tube)

Doxirubicin

- anti-tumor antibodies, -cardio-toxicity

Late effects associated with cancer surgery

- renal effects -lymphedema -Sexual Dysfunction

Stereotactic Radiosurgery (SRS)

- •Delivers a large dose of radiation to a very specific target within the brain, while delivering only a small dose of radiation to surrounding normal brain structures -Used to treat some brain tumors, can be delivered in one treatment, normally 5-10. Extremely cautious, lots of people involved. It's a LOT of rad, so we need to be VERY careful. Strict requirements- majority don't qualify. Not surgery candidates cause of location of tumor, size is big factor, tumors need to be less than 3 cm to qualify. SBRT- used to treat cancer outside, like abdomen. Similar to external beam.

5-FU

-5-fluorouracil, -antimetabolic, -Radiosensitizing agent—used in conjunction with radiation to sensitize the tumor to the radiation

Mitotic Inhibitors

-Cell Cycle specific to M phase - Arrest cells in mitosis

Topoisomerase Inhibitors

-Cell cycle specific to S phase - Prevents DNA from replicating

Roles of surgery: palliative treatment

-Goal is to minimize the symptom of the disease, enhance the patient's comfort, and optimize overall quality of life -Not intended to be curative

Acute Graft-vs.-Host Disease

-Primary and Secondary Graft failure - Failure of the host to accept bone marrow either right away (primary) or after initial acceptance (secondary) -Graft rejection—most common chronic post transplantation complication -Infection (most common early side effect of transplant) -Veno-Occlusive - liver, lung complications due to Radiation or Chemotherapy - Relapse

Gap 2

-Second Phase of RNA and protein synthesis -Mitotic spindle forms -Lasts 1 - 12 hours

Cell cycle:

-Sequence of steps through which normal and malignant cells grow and divide -G1, Synthesis, G2, Mitosis, G0

Nitrosureas *cross the blood brain barrier

-cyclophosphamide (cytoxan) -cisplatin -carmustine (BCNU) -Lomustine( CCNU) -Pacarbazine (DTIC) -Carboplatin (CBDCA)

Type of bone marrow transplant: Allogeneic

-non-self donating; hematologic malignancies (leukemia), and nonmalignant diseases such as sickle cell, severe combined immunodeficiency syndrome, osteogenesis imperfecta, Wiskott-Aldridge syndrome, & aplastic anemia

Needle localization biopsy

-use- diagnosis and treatment -needle placed by stereotactic guidance to mark the tumor, then tumor is excised -tumor usually nonpalpable but seen as radiographic abnormality. -commonly used for breast cancer

•Excisional Biopsy

-use- diagnosis and treatment -removal of the whole tumor with an effort to obtain clean margins -most commonly used biopsy method -tumor usually less than 3 cm and accessible

laparotomy

-use- diagnosis, staging, treatment -exploratory surgery used to rule out metastases to other organs. -all types of biopsies can be performed

laparoscopy

-use- diagnosis, staging, treatment -tumor visualized through laparoscope and a specimen can be taken using one or more techniques (incisional, excisional, scraping, or peritoneal washing).

endoscopy

-use- diagnosis, treatment -tumor visualized through endoscope and a piece of the tumor removed with forceps. -commonly used for tumors of GI, GU, and respiratory tracts -can be incisional or excisional.

Needle Aspiration Biopsy-

-use-diagnosis -needle inserted into tumor -percutaneous or during surgery -sample may be fluid or tissue -fine needle (21-22 gauge) or core needle (cutting needle)

Leucovorin:

-used as an antidote for MTX (called Leucovorin Rescue); prevents MTX toxicity -enhances anticancer effects of 5-FU

Nursing Measures to manage RT Side effects: Oral Stomatitis

=inflammation of the mouth •Patient should brush teeth after each meal and floss teeth once a day to get rid of bacteria that could irritate the mouth •Rinse with warm saline every 1-2 hours or as needed •Eat soft, non-irritating foods and fluids; avoid alcohol •May use topical anesthetic or analgesics before meals to make eating more comfortable •Offer smoking cessation programs

Differentiating Agents

Act on the cancer cells to make them mature into normal cells

Type of bone marrow transplant: Unrelated Donor

Another type

Acute responses RT: Lung

Dyspnea—shortness of breath •Esophagitis—inflammation of the esophagus

Neoadjuvant Therapy

RT used before the definitive tx

Adjuvant Therapy

RT used in addition to another tx modality

Cell Cycle Specific (CCS)

agents work at a specific point in the cycle, but are not effective against G0. Most work for S or M phase.

Cell Cycle Non-Specific (CCNS)

agents work regardless of the cycle phase. G0 are just as vulnerable as dividing cells

Nitrosureas

can cross blood-brain barrier

Primary/Definitive Therapy

cure

List of 8 roles of surgery

diagnostic, staging, definitive treatment, preventive treatment, reconstruction, palliative treatment, supportive care, emergency treatment

Palliation

goal is to improve quality of life

Type of bone marrow transplant: Syngeneic

identical twin

Adjuvant

in addition to another treatment, not necessarily at the same time.

control

limit growth of cancer cells

Type of bone marrow transplant: Human Leukocyte Antigen (HLA)

matched sibling (6 matches)

Antitumor antibodies Vesicants:

o Dactinomycin o Daunorubicin o Doxorubicin o Idarubicin

Alkylating agents vesicants:

o Mechlorethamine o Mitomycin C o Menogaril o Mitoxantrone

Type of bone marrow transplant: HLA

o Mismatched Family 3-4 matches

Plant (vinca) Alkaloids vesicants:

o Vinblastine o Vincristine o Vinorelbine o Teniposide

Cisplatin

platinum compound, anti-cancer agent

miscellaneous vesicants:

plicamycin

Prophylaxis

prevent spread to high risk areas

Emergency

save patient's life or prevent/reverse paralysis

Type of bone marrow transplant: Autologous

self donating; nonhematologic malignancies (solid tumors)

Hormonal Agents

sex hormones, or hormone-like drugs, that change the action or production of female or male hormones

Interferons

slow growth or angiogenesis; leukemia and lymphoma

Interleukins

stimulate growth and activities of certain WBCs; metastatic renal cell and metastatic melanoma

Extravasation

the leakage of intravenously infused, and potentially damaging, medications into the extravascular tissue around the site of infusion.

Concurrent chemo and rad

two of them together.

sentinel node biopsy

use- diagnosis - injection of blue dye and/or radioactive substance into area of tumor to identify lymph node closest to the tumor site, which is removed and examined

Roles of surgery: emergency treatment

used to relieve symptoms and improve quality of life

Induction-

very high dose of chemo before to wipe as much out as possible, then a more definitive treatment after.

Vincristine-

vinca alkaloids, - treats: leukemia, lymphoma

Vinblastine-

vinca alkaloids, - treats: testicular, breast, lymphomas, some sarcomas

Alkylating Agents/Platinum Agents

· Crosslink DNA and RNA strands in abnormal ways · Cell cycle nonspecific

Define chemotherapy.

· Defined as the use of chemical agents in the treatment or control of disease

Describe the different types of radiation treatment modalities

• External Beam Radiation Therapy (EBRT) • Brachytherapy (internal therapy) • Intraoperative Radiation Therapy (IORT) • Stereotactic Radiosurgery (SRS)

• External Beam Radiation Therapy (EBRT)

•Administered with machines that deliver high-energy megavoltage radiation •Most external beam machines used today are linear accelerators (Linacs) •Most clinics today have MLCs (instead of poured blocks) to shape the field and spare normal structures when treating with photons

Nursing Measures to manage RT Side effects: Fatigue

•Assess level of fatigue and possibly hemoglobin/hematocrit levels •Suggest rest periods throughout the day •Provide resources for help with transportation, chores, and meals •Ensure proper nutrition

•Obstacles to clinical trial participation

•Availability • - Affordability • - Access • - Acceptability

Nursing Measures to manage RT Side effects: Cystitis

•Classic symptoms are frequent, urgent urination and pain and burning when urinating •Assess patient for possible bladder infection •Encourage fluid intake •Encourage use of antispasmodics/analgesics as ordered

Acute Responses RT: Ovary/ vagina

•Dyspareunia—painful intercourse

Acute Responses RT: Bladder

•Dysuria—painful urination Hematuria—blood in the urine

Acute Responses RT: Skin

•Erythema—skin reddening •Dry desquamation—dry, peeling skin •Moist desquamation—moist, peeling skin •Alopecia—hair loss

Acute responses RT: Oral cavity

•Mucositis—inflammation of mucous membranes lining the digestive tract •Stomatitis—sore mouth •Xerostomia—dry mouth •Pharyngitis—inflamed pharynx

Intraoperative Radiation (IORT)

•One time treatment, while patient is in surgery. High dose of electrons to area. Can use boost before or after main treatment Used to deliver a concentrated dose of electron external beam radiation directly to the tumor or tumor bed during the course of surgery •Delivered while the patient is under anesthesia •May be used to kill microscopic disease or provided an added boost •Requires a special machine, typically kept in surgery

Lymphedema

•Patients who have undergone a lymph node dissection of the groin, pelvis, or axilla are at risk for development of lymphedema •Lymphedema = swelling as the result of lymph fluid build-up •Caused by damage to the lymph nodes or vessels during surgery which impairs the body's ability to transport lymph fluid, causing an accumulation of fluid in the affected extremity.

Nursing Measures to manage RT Side effects: Xerostomia

•Patients with dry mouth usually have decreased saliva—this can cause infections and cavities •Patients may need to use saliva substitutes as needed •Recommend soft and moistened food •Suggest fluids with meals and snacks

Roles of surgery: preventive treatment

•Preventative (prophylactic) surgery may be used to lower the incidence of certain diseases and possibly prevent occurrence of cancer.

Nursing Measures to manage RT Side effects: Diarrhea

•Recommend a low-residue (low-fiber) diet •Encourage use of anti-diarrheal medication as needed •Monitor hydration status (biggest issue) •Assess perianal tissues for chafing

Nursing Measures to manage RT Side effects: Cough

•Recommend cough medicine or possibly antibiotics if caused by bacteria •Encourage fluid intake as tolerated •Encourage warm saline gargles as needed to help prevent/decrease coughing

Nursing Measures to manage RT Side effects: Dysgeusia )Taste Changes

•Recommend experimenting with a variety of foods to find ones that provide some satisfying taste •Suggest performing mouth care before meals to make eating more tolerable

Nursing Measures to manage RT Side effects: Pharyngitis and Esophagitis

•Recommend soft, non-irritating foods •Encourage use of topical anesthetics or analgesics before meals •Avoid drinking alcohol Offer smoking cessation programs

Renal Effects

•Surgery for gynecologic, prostate, or bladder cancer can result in recurrent urinary tract infections, hydronephrosis, renal stones, stress incontinence, and urgency, all of which, over time, can lead to renal (kidney) impairment

Roles of surgery: definitive treatment

•Surgery may be used as a definitive cancer therapy, a treatment plan designed to potentially cure cancer •Surgery that involves removal of the entire tumor, a margin of normal tissue, and has patient cure as its goal is referred to as the Primary Treatment- most important treatment •Surgery and Radiation Therapy are both primary treatments for localized disease. •

Acute Responses RT: Prostate

•Tenesmus—feeling of incomplete defecation •Proctalgia—rectal pain

Nursing Measures to manage RT Side effects: Nausea and Vomiting

•Use antiemetics (anti-nausea medicine) as needed •Monitor hydration status (biggest issue) and encourage fluids to stay hydrated •Encourage small, frequent meals, as tolerated •Encourage resting after meals Suggest relaxation techniques

Nursing Measures to manage RT Side effects: Radiodermatitis (Skin Reaction)

•Use only tepid water and a soft washcloth when washing the treated area •Avoid soaps, deodorants, powders, perfumes, cosmetics, and heavily scented lotions in the treatment area •Skin care products for treatment of the affected area will vary among facilities •Wear loose-fitting, cotton clothing •Do not expose the treatment area to extreme temperatures Protect area from sun, wind, and cold

Roles of surgery: staging

•Used to determine whether the disease has spread from the original site of the tumor to other parts of the body—determines the extent of the disease •Appropriate treatment is determined in part by the stage of disease •In general: -Lower stages are more localized -Lower stages are more easily controlled with surgery

Principles of Cancer Surgery

•Well-differentiated, slow growing, well confined tumors are most amenable to surgical treatment. •Initial surgery is more successful than secondary surgery for recurrence. •Diagnosis •Staging •Tumor and lymph node excision •Reconstruction and rehabilitation •Benefits vs. impairments

Brachytherapy

•radioactive isotopes implanted in body, delivers rad in very close proximity very close to tumor or inserted into tumor. Implants provide rad to very minimal area. Uses radioactive isotopes for either temporary or permanent implants •Unlike EBRT, brachytherapy delivers radiation in close proximity to the tumor •The radioisotopes are placed in body cavities or inserted directly into tissues with an applicator •HDR and LDR brachytherapy •Radioisotopes used depend on the type of cancer, but may include: cesium, radium, iodine, palladium, and others