Cancer

Disease related consequences: Motor/Sensory deficits

Occur when cancers invade bone or brain or compress nerves Bone Mets • Sites most often affected o Vertebrae o Ribs o Pelvis o Humerus o Scapula o Sternum o Skull o Clavicle • Causes pain, fractures, spinal cord compression, and hypercalcemia (all reduce mobility) Sensory changes • Spinal cord damage • Compressed nerves • Brain (when cancer spreads to brain) o Sensory, motor, and cognitive functions are impaired o Any tumor (benign or malignant) growing in the brain can destroy healthy brain tissue and cause death • Pain o Chronic o Does not always accompany cancer o Major problem for those with terminal cancer

Hypercalcemia

Occurs most often in bone metastasis Cancer in bone causes release of calcium into the bloodstream Decreased mobility and dehydration worsen hypercalcemia Early manifestations • Fatigue, loss of appetite, nausea, vomiting, constipation, increased urine output Serious problems • Severe muscle weakness, loss of deep tendon reflexes, paralytic ileus, dehydration, ECG changes Treatment • Oral hydration • Normal saline • Dialysis can temporarily reduce serum calcium levels when hypercalcemia is life-threatening

Aneuploidy

Abnormal chromosomes Common in cancer cells as they become more malignant Chromosomes are: lost, gained, broken, rearranged, can have more or less than 23

Neoplasia

Any new or continued cell growth not needed for normal development or replacement of dead and damaged tissues Neoplasia cell growth is always abnormal even if it causes no harm Cancer cells were once normal cells but changed to no longer look/grow/function normally. The process of controlling normal growth and function have been lost Whether new cells are benign or cancerous, neoplastic cells develop from normal cells (parent cells)

Clinical staging

Assess the patients clinical manifestation and evaluates clinical signs for tumor size and possible spread

Surgical staging

Assess the tumor size, number, sites, and spread by inspection at surgery

Differential function

Every normal cell has at least one special function it performs to contribute to whole-body function Examples: skin cells make keratin, liver cells make bile, cardiac cells contract, nerve cells conduct impulses, red blood cells make hemoglobin

Specific morphology

Feature in which each normal cell type has a distinct and recognizable appearance, size, and shape

Malignant cell growth

Cancer Without intervention leads to death As a nurse you have vital impact in educating the pubic about cancer prevention and early detection methods

Features of cancer cells

Cancer (malignant) cells are abnormal, serve no function, and are harmful of normal body tissues

Anaphasia

Cancer cells' loss of the specific appearance of their parent cells As cells become more malignant it becomes smaller and rounded (makes diagnosis difficult becuase different types of cancer cells look alike

G0 period

Living cells not actively reproducing are in a reproductive resting state Cells actively carry out their functions but do not divide Normal cells spend most their lives in this state rather than reproductive

Pathologic staging

Most definitive type, determining the tumor size, number, sites, and spread by pathologic examination of tissues obtained at surgery

Nonmigratory

Normal cells do not wander throughout the body (except blood cells) Occurs in normal cells because they are tightly bound together (prevents cell wandering from one tissue to the next)

Euploidy

Normal chromosomes Is a feature of most normal human cells 23 pairs of chomosomes

Small nuclear-to-cytoplasmic ratio

Nucleus of normal cell does not take up much space inside the cell. Nucleus is small compared to cytoplasm

Tight adherence

Occurs by normal cell making proteins that protrude from the membranes, allowing cells to bind closely and tightly together Example: fibronectin Exceptions: blood cells do not usually adhere together; red and white blood cells do not produce fibronectin

Rapid or continuous cell division

Occurs in many types of cancer cells (they re-enter the cell cycle for mitosis almost continuously) Generation time (some short, 2-4 hours; mot are similar to the parent cells) Apoptosis (cells do not respond to signals; most cells have a lot of enzyme telomerase; maintains telomeric DNA resulting in cell not responding to apoptotic signals and have unlimited life span; immortal)

Metastisis

Occurs when cancer cells move from the primary location by breaking off from the original group and establishing remote colonies (called metastatic or secondary tumors) Even though cancer has spread, it is still considered a cancer from the original altered tissue Example: breast cancer spreads to the lungs and bone is still considered breast cancer-not bone cancer-not lung cancer

Advanced aging

Single most important risk factor for cancer Immune protection decreases Carcinogens accumulate Teach elderly to report symptoms such as the seven warning signs of cancer

Blood borne metastasis

Spread to distant organs and tissues Tumor cell release into the blood Most common cause of cancer spread

Contact Inhibition

Stop further rounds of cell division when dividing cell is completely surrounded and toughed by other cells Normal cell division is contact inhibited

Carcinogens

Substances that change the activity of a cell's genes so that the cell becomes a cancer cell (chemicals, physical agents, viruses)

Promotion

The enhancement of growth of a n initiated cell Promoters: Substances that promote or enhance growth of the initiated cancer cell; normal hormones and body proteins (insulin, estrogen)

Mitotic index

The percentage of actively dividing cells within a tumor Smallest detectable tumor (1 cm 1 billion cells) A tumor with mitotic index less than 10% is slow-growing tumor A tumor with a mitotic index 85% or greater is fast growing

Secondary prevention

The use of screening strategies to detect cancer early, at a time when cure or control is more likely Yearly mammography for women older than 40 years Yearly clinical breast examination for women older than 40 years Colonoscopy at age 50 years and then every 10 years Yearly fecal occult blood for adults of all ages Yearly prostate-specific antigen (PSA) test and digital rectal examination (DRE) for men older than 50 years

Primary prevention

The use of strategies to prevent the actual occurrence of cancer. This method of cancer prevention is most effective when there is a known cause for cancer type Avoidance of known or potential carcinogens Modifying associated factors Removal of "at risk" tissues Chemoprevention (Drugs, chemicals, natural nutrients, or other substances to disrupt one or more steps important to cancer development) Vaccination

Latency period

Time between a cell's initiation and the development of an overt tumor Exposure to promoters can shorten this period

Normal cells divide for 2 reasons

To develop normal tissue To replace lost or damaged normal tissue

Loose adherence

Typical because they do not make firbronectin Resulting in: cells easily breaking off from the main tumor

Cancer etiology and genetic risk

When a normal cell is exposed to a carcinogen, the normal cell's DNA can be damaged and mutated The manipulations often damage suppressor genes preventing them from producing proteins that control the expression of oncogenes As a result, the oncogenes are overexpressed and can cause the cells to change from normal cells to cancer cells When oncogenes are overexpressed in a cell, excessive amounts of cyclins are produced and upset the balance between cell growth enhancement and cell growth limitation The effect of these excessive cyclins is greater than the effect of the suppressor gene products, thus allowing uncontrolled cell division

Generation time

amount of time needed for one cell to divide completely into 2 cells

Other names for cancer development

carcinogenesis oncogenesis

Benign

Do not require interventions Most common types: moles, skin tags

Contact inhibition (cancer)

Doesn't occur in cancer cells Persistence of cell division makes the disease difficult to control

Second-look therapy (surgery)

"Rediagnosis" after treatment Purpose is to assess disease status in patients who have been treated and have no symptoms of remaining tumor Results are used to determine whether a specific therapy should be continued/discontinued Most commonly used with ovarian cancer

Complications for IV Chemotherapy

A Serious complication is IV Extravasation (occurs when drug leaks into surrounding issues aka infiltration) Pain/infection/tissue damage and loss

Disease related consequences: altered GI structure

Abdominal tumors may obstruct or compress structures anywhere in the GI tract, reducing the ability to absorb nutrients and eliminate wastes Tumors increase metabolic rate and increase the need for nutrients • Patient has less energy for meal preparation or eating Tumors in the liver • Damage important metabolic functions • Leads to malnutrition and death Anorexia • Interferes with ability to meet energy needs • Cachexia (extreme body wasting and malnutrition) o Develops from imbalance between food intake and energy use (increased catabolism) o Can occur even if nutritional intake appears adequate • Changes in taste from cancer or treatment = reduced appetite Nutritional support • Diet high in protein and carbohydrates to maintain weight and provide nutrients needed for energy and cellular repair • No one nutritional plan meets the needs of all patients with cancer

Radiation: Patient safety

Action Alert • Skin in the radiation path is more sensitive to sunburn and damage. Advise against direct skin exposure to the sun during treatment and for at least 1 year after completing radiation therapy Skin in the path of radiation becomes very dry and may break down. Teaching patients about skin care needs during radiation therapy is a priority nursing intervention • Wash the irradiated area gently each day with either water or a mild soap and water as prescribed by your radiologist • Use your hand rather than a washcloth to be gentler • Rinse soap thoroughly from your skin • If ink or dye markings are present to identify exactly where the beam of radiation is to be focused take care not to remove them. • Dry the irradiated area with patting motions rather than rubbing motions; use a clean, soft towel or cloth • Use only powders, ointments, lotions, or creams on your skin at the radiation site that are prescribed by the radiation oncology department • Wear soft clothing over the skin at the radiation site • Avoid wearing belts, buckles, straps or any type of clothing that binds or rubs the skin at the radiation site • Avoid exposure of the irradiated area to the sun o Protect this area by wearing clothing over it o Try to go outdoors in the early morning or evening to avoid the more intense sun rays o When outdoors, stay under awnings, umbrellas, and other forms of shade during the times when the sun's rays are most intense (10 am to 7 pm) • Avoid heat exposure

Scheduling (chemotherapy)

All about timingmaximizing cancer cell kill and minimizing damage to normal cells Individualized Usually schedule every 3-4 weeks for a specified number of times (on average, 4-12 times)

Surgery: psychosocial support

Anxiety related to the chances of surviving cancer Grieving about the change in appearance or lifestyle Assess the patient's and family's ability to cope with the uncertainty of cancer and its treatment and with the changes in body image and role Some cancer organizations have support groups for patients and separate support groups for patients' spouses and children For patients who have persistent sadness or depression as a result of appearance changes from cancer surgery, a referral to a mental health counselor and drug therapy may be needed

Dose-dense Chemotherapy

Newer protocols of giving higher doses of chemotherapy more often Used for aggressive forms of cancer, especially breast cancer Results in more intense side effects than traditional dosing schedule

Spinal Cord Compression

Occur when a tumor directly enters the spinal cord or when the vertebrae collapse from tumor degradation of the bone • Tumors can begin in the spinal cord or spread from lung, prostate, breast, and colon Early detection and treatment Assess for neurologic changes, including back pain, muscle weakness or a sensation of heaviness in the arms or legs, numbness or tingling in the hands or feet, inability to distinguish hot and cold, and an unsteady gait Depending on how low the compression occurs, constipation, incontinence, and difficulty starting and stopping urination also may be present Treatment • Palliative with high dose corticosteroids (reduce swelling and relieve symptoms) • High-dose radiation (reduce size of tumor) • Surgery (remove tumor or rearrange bony tissue for less pressure on spinal cord)

Two main criteria for choosing chemo agent

1. Tumor sensitivity: 2. Degree of side effects

Chemotherapy: Routes

Most chemotherapy drugs are given IV, although other routes may be used Intrathecal Route: delivers drugs into the spinal canal Intraventricular Route: delivers drug directly into the ventricles of the brain Intraperitoneal Route: instillations place the drugs within the abdominal cavity, most often for ovarian cancer Intravesicular Route: used for bladder cancer, delivers drug directly into the bladder

Chemotherapy: Nursing Interventions

Most important nursing intervention for extravasation is prevention Close monitoring of the access site is critical during chemotherapy administration to prevent leakage of larger volumes (less than 0.5mL can resolve without extensive treatment; larger amount may require surgery)

Radiation: Quality Nursing Care

Assign the patient to a private room with a private bath Place a "Caution: Radioactive Material" sign on the door of the patient's room If portable lead shields are used, place them between the patient and the door Keep the door to the patient's room closed as much as possible Wear a dosimeter film badge at all times while caring for patients with radioactive implants. The badge offers no protection but measures a person's exposure to radiation. Each person caring for the patient should have a separate dosimeter to calculate his or her specific radiation exposure Wear a lead apron while providing care. Always keep the front of the apron facing the source of radiation (do not turn your back toward the patient) Pregnant nurses should not care for these patients; do not allow pregnant women or children younger than 16 years to visit Limit each visitor to ½ hour per day. Be sure visitors stay at least 6 feet from the source Never touch the radioactive source with bare hands. In rare instance that it is dislodged, use a long-handled forceps to retrieve it. Deposit the radioactive source in the lead container kept in the patient's room Save all dressings and bed linens in the patient's room until after the radioactive source is removed. After the source is removed, dispose of dressings and linens in the usual manner. Other equipment can be removed from the room at any time without special precautions and does not pose a hazard to other people

Diagnostic Surgery

Biopsy Removal of all or part of a suspected lesion for examination and testing Provides proof of the presence of cancer

Disseminated Intravascular Coagulation

Caused by sepsis (septicemia)- a condition in which organisms enter the bloodstream and can result in septic shock • Patients with cancer are at risk because their WBCs are low and immune function is impaired Disseminated intravascular coagulation (DIC) is a problem with the blood clotting process • Triggered by severe illnesses (including cancer) • Often caused by gram-negative sepsis by the release of thrombin or thromboplastin (clotting factors) from cancer cells or by blood transfusions • Extensive, abnormal clotting occurs throughout the small blood vessels • Widespread clotting uses up the existing clotting factors and platelets and is followed by extensive bleeding • Clots block blood vessels and decrease blood flow to major body organs and result in pain, stroke-like manifestations, dyspnea, tachycardia, reduced kidney function, and bowel necrosis • Best management of sepsis and DIC is prevention o Strict adherence to aseptic technique o Teach patient/families early symptoms of infection and when to seek assistance o IV antibiotics o Heparin

Surgery: Maintain maximum function

Coordinate with the physical therapist, occupational therapist, and family members to plan strategies individualized to each patient to regain or maintain optimal function Example • Modified radical mastectomy can lead to muscle weakness and reduced arm function on the surgical side • Performing specific exercises after surgery can reduce functional loss • Exercises can be painful and the patient needs encouragement to perform them • Teach the importance of performing and increasing the intensity of the exercises to regain as much function as possible and prevent complications

Alkalating agents

Cross-link DNA, making the 2 DNA strands bind tightly together. This tight binding prevents proper DNA and RNA synthesis, which inhibit cell division

Antitumor antibiotics

Damage the cell's DNA and interrupt DNA or RNA synthesis

Topoisomerase inhibitors

Disrupt an enzyme (Topoisomerase) needed for DNA synthesis and cell division. The enzyme nicks and straightens the DNA helix, allowing the DNA to be copied, and then reattaches together Prevent proper DNA maintenance, causing DNA breakage and cell death

Palliative Surgery

Focuses on improving the quality of life during the survival time, not a cure Example • Removal of tumor tissue that is causing pain, obstruction, or difficulty swallowing Specific procedure used depends on the patient's specific problem

Disease related consequences: reduced immunity

Impaired immune and blood-producing functions occur most often in patients with leukemia and lymphoma but can also occur with any cancer that invades the bone marrow Tumor cells enter the bone marrow and reduce the production of healthy WBCs = increased risk for infection When cancer invades bone marrow, it also causes anemia by decreasing the number of RBCs and causes thrombocytopenia by decreasing the number of platelets Caused by • Cancer itself • Cancer treatment (chemotherapy)

Reconstructive/Rehabilitative Surgery

Increases function Enhances appearance Or both Examples • Breast reconstruction after mastectomy • Replacement of esophagus • Bowel reconstruction • Revision of scars • Placement of penile implants

Tumor Lysis Syndrome

Large numbers of tumor cells are destroyed rapidly. Their intracellular contents, including potassium and purines are released into the bloodstream faster than the body can eliminate them Positive sign that cancer treatment is effective Severe or untreated can cause tissue damage and death Serum potassium levels can increase to the point of hyperkalemia causing cardiac dysfunction Large amounts of purines form uric acid causing hyperuricemia. These uric acid crystals precipitate in the kidney, blocking kidney tubules and leading to acute kidney injury Treatment • Hydration prevents and manages TLS • Instruct patients to drink 3-5 L of fluid the day before, the day of, and for 3 days after treatment • Management becomes aggressive for hyperkalemia or hyperuricemia o Diuretics (osmotic) o Drugs that promote purine excretion (allopurinol, rasburicase, febuxostat) o Enemas for mild hyperkalemia o IV infusions containing glucose and insulin may be given for severe hyperkalemia or dialysis is needed

Radiation: side effects

Limited to the tissues exposed to the radiation Vary according to the site Skin changes and hair loss are local but are often permanent depending on the total absorbed dose Altered taste sensations and fatigue are commonly noted by patients receiving teletherapy, regardless of their site

Side effects of surgery

Loss of a specific body part or its function Any organ loss reduces function • Kidney, lung, breast, testes, leg, tongue Amount of function lost and how much the loss affects patients depend on the location and extent of the surgery Major scarring or disfigurement

Management (extravasation)

Management depends on specific drug. With some drugs, cold compresses to the area are prescribed, for others, warm compresses are used Collaborative care: coordinate with Oncologist and Pharmacist to determine specific antidote needed for extravasated site

Superior Vena Cava Syndrome

Occurs most often in bone metastasis Cancer in bone causes release of calcium into the bloodstream Decreased mobility and dehydration worsen hypercalcemia Early manifestations • Fatigue, loss of appetite, nausea, vomiting, constipation, increased urine output Serious problems • Severe muscle weakness, loss of deep tendon reflexes, paralytic ileus, dehydration, ECG changes Treatment • Oral hydration • Normal saline • Dialysis can temporarily reduce serum calcium levels when hypercalcemia is life-threatening o Superior Vena Cava Syndrome Occurs when the SVC is compressed or obstructed by tumor growth or by clots in the vessel Painful and life-threatening Occurs most often with lymphomas, lung cancer, breast cancer Manifestations • Occur from blockage of venous return from the head, neck, and upper trunk • Early o Occur when patient arises after a night's sleep and include edema of the face (eyes) and tightness of the shirt collar • As compression worsens o Engorged blood vessels and erythema of the upper body, edema in the arms and hands, dyspnea and epistaxis • Late o Hemorrhage, cyanosis, mental status changes, decreased cardiac output, hypotension Treatment • High-dose radiation therapy to the upper chest area may be used to provide temporary relief • Metal stent placed in the vena cava in interventional radiology to reduce swelling (follow-up angioplasty to keep stent open)

Teletherapy

Radiation delivered from a source outside of the patient Because the source is external, the patient is not radioactive and is not hazardous to others

Prophylactic Surgery

Removes "at-risk" tissue to prevent cancer development Patient has premalignant condition or family history that strongly predisposes the person to development of specific cancer Example • Removing benign polyp from the colon before it can develop into colon cancer

Curative Surgery

Removes all cancer tissue Cure rate of 27%-30% when all visible and microscopic tumor is removed

Cancer control/cryoreductive surgery

Removes part of but not the entire tumor Debulking Alone is not a cure Decreases number of cancer cells Increases chances other therapies can be successful

Brachytherapy

Short or close therapy Radiation source comes into direct, continuous contact with the tumor tissues for a specific time period Provides high dose of radiation in tumor tissues and a very limited dose in surrounding normal tissues Uses radioactive isotopes in solid form or within body fluids Radiation source is within the patient and the patient emits radiation for a period of time and is a hazard to others When isotopes are unsealed, they enter body fluids and eventually are eliminated in waste products, which are radioactive and should not be directly touched by other people. After the isotope is completely eliminated from the body, neither the patient nor the body wastes are radioactive Solid or sealed radiation sources are implanted within or near the tumor and can be temporary or permanent While the solid implants are in place, the patient emits radiation but excreta are not radioactive and do not pose a hazard to anyone

Antimetabolites

Similar to normal metabolites needed for vital cell processes Most cell reactions require metabolites in order to begin or continue the reaction. Antimetabolites closely resemble normal metabolites and are "counterfeit" metabolites that fool cancer cells into using the antimetabolites in cellular reactions Because antimetabolites cannot function as proper metabolites, their presence impairs cell division

SIADH

Some tumors make and secrete ADH Some tumors stimulate brain to secrete ADH Drugs often used in patients with cancer (morphine, cyclophosphamide) Mild manifestations • Weakness, muscles cramps, loss of appetite, fatigue, hyponatremia With greater fluid retention • Weight gain, nervous system changes, personality changes, confusion, and extreme muscle weakness Sodium levels <110 mEq/L • Seizures, coma, and death may follow depending on how rapidly the sodium value is lowered Nursing priorities • Patient safety • Restoring normal fluid balance • Providing supportive care Management • Fluid restriction • Increased sodium intake • Drug therapy

Combination therapy

Successful cancer chemotherapy involves giving more than one specific anticancer drug in a timed manner Increase effectiveness in killing cancer cells Con: Increase in side effects and damage to normal tissues

Nadir

Time when bone marrow activity/WBC levels are at their lowest point after giving chemotherapy Occurs at different times for different drugs To reduce immunosuppression, combination chemotherapy avoids using drugs with nadirs that occur at or near the same time

Disease related consequences: reduced oxygenation

Tumors in airways • Cause airway obstruction Involvement of lung tissue • Decreased lung capacity Tumors in chest • Press on blood and lymph vessels • Block blood flow through chest and lungs o Results in pulmonary edema and dyspnea Often results in death

A large nuclear-cytoplasmic ratio

Cause: cancer cell nucleus being larger than that of a normal cell and the cancer cell being small The nucleus occupies much of the space with in the cancer cell, a large nuclear-to-cytoplasmic ratio

7 warning signs of cancer

Caution Changes in bowel habits or bladder habits A sore throat that does not heal Unusual bleeding or discharge Thickening or lump in the breast or elsewhere Indigestion or difficulty swallowing Obvious change in a wart or mole Nagging cough or hoarseness

External factors causing cancer

Chemical: exposure to drugs/chemicals/other products (ex: tobacco/alcohol: mildly carcinogenic need chronic long-term exposure) 30% of cancers diagnosed in North America are related to tobacco use Physical: radiation/chronic irritation (ionizing/ultraviolet light) Viral: infect body cells and break DNA strands; then insert own genetic material in DNA; then can activate/oversuppress oncogenes Oncoviruses (viruses that cause cancer)

Grading

Classifies cellular aspects of the cancer Needed because some cells are more malignant High grade cancer (aggressive and spread rapidly) Compares appearance and activity with normal parent tissue from which it arose Means of evaluation of the patient for prognosis and therapy

Progression

Continued change of a cancer making it more malignant Many processes within the tumor take place before progression (first tumor must develop its own blood supply) Early stages, tumor receives nutrition by diffusion (after 1 cm diffusion is not efficient) Selection advantages (allows certain cancer cells to live and divide no matter how the conditions around them change (more malignant))

Suppressor genes

Controls much of cell cycle by regulation of proteins secreted by these genes

Ploidy

Description of cancer cells by chromosome number and appearance Some specific chromosome changes are associated with specific cancers, and their presence is used for diagnosis and prognosis Example: Philadelphia chromosome abnormality

Staging

Determines the exact location of the cancer and it's degree of metastasis at diagnosis Important because for most cancers the smaller the cancer is at diagnosis and the less it has spread, the greater the chances are treatment will result in a cure Done by clinical staging, surgical staging, pathologic staging

Cancer grading, ploidy, and staging

Developed to help standardize cancer diagnosis, prognosis, and treatment

Initiation

First step in carcinogenesis (normal cells can become cancer cells if their genes promoting cell division (oncogenes) are turned on excessively or overexpressed) Change in gene expression (caused by anything that can penetrate a cell, get into the nucleus, and damage the DNA; the changes activate oncogenes that should have limited expression and damage suppressor genes) Leads to excessive cell division through DNA Damage (results in loss of suppressor gene function; enhancement of oncogene function) Irreversible event that can lead to cancer development (can become a cancer cell if cellular changes that occurred during initiation continue and cell division is not impaired; a cancer cell is not a health threat unless it can divide; if it cannot divide, it cannot form a tumor; if a condition are right metastasis can occur from just one cancer cell)

Activities of the phases of cell cycle

G1: in this phase, the cell is getting ready for division by taking on extra nutrients, making more energy and growing extra membrane; cytoplasm is increased S: because making one cell into tow cells requires twice as much of everything, including DNA, the cell must double its DNA content through DNA synthesis G2: The cell makes important proteins that will be used in actual cell division and in normal physiologic function after cell division is complete M: Single cell splits apart into two cells (actual mitosis) during M phase

Features of benign tumor cells

Growing in the wrong place at the wrong time (moles/skin tags/nasal polyps) Cell division: growth may continue beyond appropriate time; rate of growth is normal. Growth by hyperplastic expansion. It does not invade Normal chromosomes are usually found

Mitosis

Growth of cells and tissue is expected during infancy and childhood, and many human body cells continue to gorw by mitosis (cell division) long after maturation is complete -These cells are located in tissues with consistent wear and tear and have the ability to divide throughout a person's life span. Growth is well controlled -Skin, hair, mucous membranes, bone marrow, lining or organs (lungs, stomach, intestines, bladder, uterus)

Hypertrophy

Growth that causes tissue to increase in size by enlarging each cell

Hyperplasia

Growth that causes tissue to increase in size by increasing the number of cells

Some tissues and organs stop growing by cell division after development is complete

Heart muscle cells (do not divide after fetal life; number of heart muscle cells is fixed at birth) Size increases with growth of person (each cell gets larger; number does not increase)

Cancer

In affluent countries, more than 50% of people diagnosed with cancer are cured and thousands of others live 5 years or longer Regardless of treatment type, cancer always affects a person's physical and psychological functioning

Malignant transformation

Process of changing a normal cell into a cancer cell Occurs through the steps of: initiation, promotion, progression, metastasis

Apoptosis

Programmed cell death Some cells have to die at the appropriate time to ensure optimum body function (each round of cell division, the telomeric DNA at the ends of the cells chromosomes shortens; when DNA is gone, the cell responds to signals for apoptosis) Purpose is to ensure each organ has adequate number of cells at their functional peak

Immune function

Protects the body from foreign invaders and non-self cells Non-self cells include cells that are no longer normal, such as cancer cells Cell mediated immunity (the part of the immune system that protects against cancer; natural killer and helper T-cells provide immune surveillance Immunosuppression (greater risk for development of cancer; organ transplant; immunosuppressive drugs

Cyclins

Proteins that promote cell to enter and complete cell division Produced by oncogenes When activated: allows cells to leave the G0 period and enter the cycle of mitosis

Lymphatic spread

Related to the number, structure and location of lymph nodes and vessels Primary sites that are rich in lymphatics have more early metastatic spread than areas with few lymph nodes

Normal cell division

a balance between the proteins that promote cell division (cyclins) and the proteins that limit cell division (suppressor gene products)

Radiation therapy

o Purpose Destroy cancer cells and have minimal damaging effects on the surrounding normal cells o Local Treatment Effects are seen only in the tissues in the path of the radiation beam o Ionizing radiation Most radiation therapy for cancer is ionizing radiation When cells are exposed to it, particles within the cell's nucleus are rearranged, resulting in tremendous release of intracellular energy Given off by many elements (including radium) and radioactive isotopes of specific elements o Exposure Amount of radiation delivered to a tissue o Radiation dose Amount of radiation absorbed by the tissue Dose is always less than the exposure because some energy is lost as scatter on the way to the tissue o Cell death If the dose of radiation is high enough, all cells are killed immediately Cancer radiation is different • Cells within a tumor absorb the radiation dose slightly differently • Their overall response to the radiation is slightly different • A few cells die immediately, and more die within the next 24 hours as they attempt to divide • Some cells become sterile as a result of single treatment • Other cells repair the radiation-induced damage and recover Radiation is given in a series of divided doses because of the varying responses of all cancer cells within a given tumor

Cancer Management

o Purpose Prolong survival time Improve the quality of life o Types of therapy used depend on Specific type of cancer Whether the cancer has spread Health of the patient o Surgery o Radiation o Chemotherapy o Hormonal manipulation o Photodynamic therapy o Immunotherapy o Targeted therapy

Chemotherapy-Induced peripheral neuropathy

o The loss of sensory or motor function of peripheral nerves associated with exposure to certain anticancer drugs o Most often seen in patients with long-term diabetes, but patients' undergoing chemotherapy with nerve-damaging drugs (especially antimitotics and platinum-based drugs) often have rapid onset o Widespread damage Results of CIPN on function are widespread Most common problems including loss of sensation in the hands and feet, orthostatic hypotension, erectile dysfunction, neuropathic pain, loss of taste discrimination, and severe constipation o Preventing injury Priority nursing care is teaching patient to prevent injury Loss of sensation increases the patient's risk for injury because he/she may not be aware of excessive heat, cold, or pressure o Fall prevention Falls are more likely because the patient cannot feel the change in terrain and because of orthostatic hypotension

Target Therapy

o What is it? Agents used to disrupt the pathway and slow or stop cell division Work only with those cancer cells that have the actual target The signal for turning on cell division genes (oncogenes) does not get through to the cell's nucleus Individualized • Each person's cancer cells are evaluated to determine whether the cells have enough of a target to be affected by targeted therapy

Immunotherapy

o What is it? Biologic response modifiers (BRMs) modify the patient's biologic responses to tumor cells Some agents can stimulate specific immune system cells to attack and destroy cancer cells; other agents block cancer cell access to an essential function Slow tumor cell division Stimulate the growth and activation of NK cells Inducing cancer cells to resume a more normal appearance and function Inhibiting the expression of oncogenes o Supportive therapy Induce more rapid recovery of the bone marrow after suppression by chemotherapy Patients are at less risk for life-threatening infections, anemia, and bleeding Because the growth factors allow more rapid bone marrow recovery, patients can receive their chemotherapy on time and may even be able to tolerate higher doses, improving the curative outcome of chemotherapy o Side effects Generalized and often severe inflammatory reactions Fluid shifts and capillary leak are widespread with edema forming in most tissues Tissue swelling affects the function of all organs and can be life-threatening Fever, chills, rigors, and flu-like general malaise Peripheral neuropathy • Decreased sensory perception, visual disturbances, decreased hearing, unsteady balance and gait, and orthostatic hypotension Skin dryness, itching, and peeling

Hormonal Manipulation

o What is it? Can help control some types of cancer for many years but does not cure the disease If a tumor depends on hormone A for growth and a large quantity of hormone B (similar to A) is given to the patient, hormone B will interfere with the tumor's uptake of hormone A or will limit the amount produced Tumor growth is slowed and survival time increases o Side effects Women: • Androgens and antiestrogen receptor drug cause masculinizing effects o Chest and facial hair may develop o Menstrual period stops o Breast tissue shrinks o Fluid retention o Acne o Hypercalcemia o Liver dysfunction • Estrogens and progestins o Irregular menses o Fluid retention o Breast tenderness o Increased risk for venous thromboembolism Male: • Estrogens, progestins, antiadrogen receptor drugs o Feminine manifestations Facial hair thins or disappears Facial skin is smoother Body fat is redistributed Gynecomastia (breast development in men) Bone loss (increases risk for osteoporosis Testicular and penile atrophy (to some degree)

Photodynamic Therapy

o What is it? Selective destruction of cancer cells through a chemical reaction triggered by types of laser lights Used to: • Destroy some cancers • Reduce the size of tumors and then allow more complete tumor removal by surgery • Shrink tumors in airways or the esophagus to relieve obstruction • Used most often for non-melanoma skin cancers, ocular tumors, GI tumors, and lung cancers o Side effects General sensitivity to light for up to 12 weeks High risk for sunburn and eye pain/damage especially the 48 hours after injection o Patient teaching The priorities for nursing care of the patient receiving PDT are teaching the patient and family to prevent complications and coordinating changes in the care environment for protection of the patient Treatment must begin before the patient comes for the injection Bring clothing, hat, and eye protection to wear on the way home from the injection • Gloves, shirts with long sleeves and high collars, long pants, and socks to prevent burns from exposure to direct or indirect sunlight (including through the window) Use protective measures and be homebound for 1-3 months Even the use of a penlight or the sensor on a pulse oximeter can lead to burns for the patient who has been injected with a photosensitizer

Migration

occurs because cancer cells do not bind tightly together and have many enzymes on their cell surfaces (allows cells to slip thorugh blood vessel walls and between tissues, spreading from the main tumor site to many other body sites Metastasize (ability to spread): unique to cancer cells, major cause of death, cells expand by mitosis and invade other tissues

Primary tumor

original tumor Identified by parent tissue Breast cancer (tumor its self will generally not cause death unless it spreads) Lung cancer (tumor can cause function problems and death in major organs

Specific functions are lost

partially or completely in cancer cells

Chemotherapy-induced nausea and vomiting

• CINV arises from a variety of GI and neural mechanisms • Most chemotherapy drugs are emetogenic (vomiting inducing) to some degree • Prolonged symptoms Symptoms may last up to 7 days after treatment • Treatment Ensuring adequate N/V control PRIOR to start of treatment Many antiemetics are available to relieve nausea and vomiting, one or more antiemetics are usually given before, during, or after chemotherapy, work best when given before the nausea and vomiting are out of control. In any case, these drugs are most effective when used AGGRESSIVELY and on a SCHEDULED BASIS It is crucial to work with the patient and manage the nausea and vomiting before it gets out of control • Non-Pharmacologic Measures Music/muscle relaxation/guided imagery/grape juice before meals/ acupressure

Cognitive Changes (chemotherapy)

• Concentration • Memory • Difficulty Learning new info • Supportive measures • Chemotherapy drugs can induce inflammation and general biochemical changes that could reduce cognitive function, at least temporarily • The problem termed "chemo brain" is reported most often in women undergoing chemotherapy for breast cancer

Oral Chemo Agents

• Convenient Can be taken at home • Toxicity Oral agents are just as toxic as IV agents One of the biggest problems with these oral agents is the perception by patients and non-oncology nurses that these drugs are less toxic than those given IV Just as toxic to the person taking the and the person handling the drug as IV route • Education Increased education due to the role of self-management Patients must be educated about protection, correct administration, adherence, and recognition and management of side effects • Precautions Precautions are just as important (handling/disposing/knowing side effects) Ex: pills cannot be broken/split/crushed/chewed

Chemotherapy

• Damaging DNA/Cell Division: killing effect on cancer cells is related to the ability of chemotherapy to damage DNA and interfere with cell division • Systemic: chemotherapy is useful in treating cancer because its effects are systemic (killing metastatic cancer cells) Drugs used for chemotherapy usually are given systemically and exert their cell-damaging (cytotoxic) effects against healthy cells as well as cancer cells. The normal cells most effected by chemotherapy are those that divide rapidly (skin, hair, intestinal tissue, spermatocytes, and blood-forming cells) • Adjuvant: chemotherapy that is used along with surgery or radiation is termed Adjuvant Therapy • Many of the drug used for Chemotherapy have a potential to induce nausea and vomiting (emetogenic) or to damage surrounding tissue

Chemotherapy: Risk factors and precautions

• Health Care workers who prepare or give chemotherapy drugs are at risk for absorbing them Long-term exposure can affect health Anyone preparing, giving, or disposing of chemotherapy drugs or handling excreta from patients within 48 hours of receiving IV chemotherapy must use extreme caution and wear PPE (eye protection, masks, double gloves or "chemo" gloves, and gown)

Bone Marrow Suppression

• In addition to killing cancer cells, chemotherapy also destroys circulating blood cells and reduces replacement of these cells by suppressing bone marrow function, also known as Myelosuppression • Number of all circulating leukocytes, erythrocytes, and platelets are decreased Reduced leukocyte numbers, especially neutrophils (neutropenia) greatly increases the risk for infection Extreme risk for Sepsis. This critical problem is the major dose-limiting side effect of cancer chemotherapy and can lead to death during treatment • The most common infections are fungal, bacterial, and some residual viral breakthrough Most infections during neutropenia result from overgrowth of patient's own mornal flora • Patient Teaching Report changes in skin and mucous membranes or other health status Report any new pimple/rash/sore/open area Report burning on urination Report a cough Report pain around venous access site or new drainage from any body area Teach the importance of mouth care and washing of the axillary and perianal regions at least every 12 hours • When delegating to UAP, teach them the importance of protecting the neutropenic patient from infection. Stress ways that cross-contamination can occur, and how to avoid this source of infection • At no time is the patient an infection hazard to other people; however, other people can be an infection hazard to the patient • See Charts 24-4, 24-5, 24-6 on Pg. 420 • Infection Prevention is Crucial!! Monitor for signs of infections! • Critical Rescue: consider any temperature elevation in a patient with neutropenia a sign of infection. Report it to the HCP immediately and implement standard precautions. • Pharmacological Treatment Erythropoiesis-stimulating agents (ESA): Epogen/Procrit-can prevent or improve anemia associated with chemotherapy and can reduce the need for transfusion therapy These drugs increase the production of many blood cells, not just erythrocytes, increasing the patient's risk for hypertension, blood clots, strokes, and heart attacks Growth factor treatment for thrombocytopenia is the use of Neumega (increases the production of platelets)

Alopecia

• May occur as whole-body hair loss or may be as mild as only thinning of the scalp hair • Reassure patients that hair loss is temporary. Hair regrowth usually begins about One month after completion of chemotherapy (new hair may differ from original hair) • No known treatment prevents alopecia • The priority nursing interventions for the patient with alopecia are to teach the patient to prevent injury to the scalp and to assist him or her to cope with this body image change Avoid direct sunlight on scalp Wear head covering under helmets, headphones, headsets, and other items that rub the head Wear something on head in cold temperature to prevent hypothermia

Mucositis

• Often develops in the entire GI tract, especially in the mouth • Rapid dividing cells Normally, the lining of the GI tract undergoes rapid cell division and quickly replaces cells; Chemotherapy kills mucous membrane cells more rapidly than they are replaced, resulting in sores Sores are painful and interfere with eating and general quality of life Frequent mouth assessment and oral hygiene are key • Patient teaching Good and frequent oral hygiene/teeth cleaning (soft-bristles)/mouth-washing (avoid heavy alcohol based products) Rinse mouth with plain water or normal saline Gentle flossing once daily Because most patients with Mucositis also have Myelosuppression and are at risk for bleeding...avoid traumatizing oral mucosa • Pharmacological treatment Swish and spit mixtures that contain a local anesthetic combined with anti-inflammatory agents. Remind patients NOT to swallow these mixtures

Side effects of chemotherapy

• Temporary and permanent physical damage can occur • Known problems include: Hemorrhagic cystitis, cardiac muscle damage, and loss of bone density • For some cancer drugs, agents that protect healthy cells (cytoprotectants) are administered ahead of or with chemotherapy drugs to decrease the impact on normal tissues • The side effects for hematopoietic (blood-producing) system can be life-threatening and are the most common reason for changing the dosage or schedule The suppressive effects of blood-forming cells of bone marrow cause anemia, neutropenia (leading to immunosuppression), and thrombocytopenia • Common disturbing side effects include: Alopecia (alopecia cannot be prevented but the patient can be helped to reduce distress from its presence) Mucositis (open sores on mucus membranes) Many skin changes Anxiety Sleep disturbance Altered elimination Impaired cognition These side effects are known as Cancer Therapy Symptom Distress • Non-Pharmacologic Measures Distraction: virtual reality, guided imagery, reading, watching television, and talking with visitors Massage Guided imagery Reiki Aromatherapy