MEDSURG: CHAPTER 15: MANAGEMENT OF PATIENTS WITH ONCOLOGIC DISORDERS:

Graft-Versus-Host-Disease:

- (GVHD), a major cause of morbidity and mortality in 30% to 50% of the allogeneic transplant population, occurs when the donor lymphocytes initiate an immune response against the recipient's tissues (skin, gastrointestinal tract, liver) during the beginning of engraftment - The donor cells view the recipient's tissues as foreign or immunologically different from what they recognize as "self" in the donor. - To prevent GVHD, patients receive immunosuppressant drugs, such as cyclosporine (Sandimmune), methotrexate, tacrolimus (Prograf), or mycophenolate mofetil (MMF). - GVHD may be acute, occurring within the first 100 days, or chronic, occurring after 100 days - 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 gastrointestinal tract with subsequent diarrhea that may exceed 2 L per day; and biliary stasis with abdominal pain, hepatomegaly, and elevated liver enzymes progressing to obstructive jaundice. - The first 100 days or so after AlloHSCT is crucial for patients; the immune system and blood-making capacity (hematopoiesis) must recover sufficiently to prevent infection and hemorrhage. - Most acute side effects, such as nausea, vomiting, and mucositis, resolve during this period of time. - However, there are some complications that may occur, such as encephalopathy, hemolytic uremia syndrome, hemolytic anemia, and thrombotic thrombocytopenia purpura

Malignant Process: Molecular Process: Initiation:

- - During initiation, carcinogens (substances that can cause cancer), such as chemicals, physical factors, or biologic agents, cause mutations in the cellular DNA. - Normally, these alterations are reversed by DNA repair mechanisms or the changes initiate programmed cellular death (apoptosis) or cell senescence. - Cells can escape these protective mechanisms with permanent cellular mutations occurring, but these mutations usually are not significant to cells until the second step of carcinogenesis.

Diagnosis Of Cancer:

- A cancer diagnosis is based on assessment of physiologic and functional changes and results of the diagnostic evaluation. - Patients with suspected cancer undergo extensive testing to (1) determine the presence and extent of cancer, (2) identify possible disease metastasis, (3) evaluate the function of involved and uninvolved body systems and organs, and (4) obtain tissue and cells for analysis, including evaluation of tumor stage and grade. - The diagnostic evaluation includes a review of systems; physical examination; imaging studies; laboratory tests of blood, urine, and other body fluids; procedures; and pathologic analysis. - Patients undergoing extensive testing may be fearful of the procedures and anxious about possible test results. - Nurses help address the patient's fear and anxiety by explaining the tests to be performed, the sensations likely to be experienced, and the patient's role in the test procedures. - The nurse encourages the patient and family to voice their fears about the test results, supports the patient and family throughout the diagnostic evaluation, and reinforces and clarifies information conveyed by the physician. - The nurse also encourages the patient and family to communicate, share their concerns, and discuss their questions and concerns with one another.

Tumor Staging & Grading:

- A complete diagnostic evaluation includes identifying the stage and grade of the tumor. - This is accomplished prior to treatment to provide baseline data for evaluating outcomes of therapy and to maintain a systematic and consistent approach to ongoing diagnosis and treatment. - Treatment options and prognosis are based on tumor stage and grade. - Staging provides a common language used by health care providers and scientists to accurately communicate about cancer across clinical settings and in research. - These systems also provide a convenient shorthand notation that condenses lengthy descriptions into manageable terms for comparisons of treatments and prognoses.

Carcinogenesis: Genetics & Family Factors:

- Almost every cancer type has been shown to run in families. - This may be due to genetics, shared environments, cultural or lifestyle factors. - Genetic factors play a fundamental role in cancer cell development. - Cancer has been associated with extra chromosomes, too few chromosomes, or translocated chromosomes. - Cancers with these underlying genetic abnormalities include chronic myelogenous leukemia, meningiomas, acute leukemia, retinoblastomas, and Wilms tumor. - In addition, certain syndromes represent a cluster of cancers identified by a specific genetic alteration that is inherited across generations. - In these families, the associated genetic mutation is found in all cells (it is germline and somatic) and represents an inherited susceptibility to cancer for all family members who carry the mutation. - Approximately 5% to 10% of cancers in adults display a pattern of cancers suggestive of a familial predisposition (NCI, 2016). - The hallmarks of families with a hereditary cancer syndrome include cancer in two or more first-degree relatives (the parent, sibling, or child of an individual), onset of cancer in family members younger than 50 years, the same type of cancer in several family members, individual family members with more than one type of cancer, and a rare cancer in one or more family members - There is also evidence of an autosomal dominant inheritance pattern of cancers affecting several generations of a family. - There have been considerable advances in the recognition of inherited cancer susceptibility syndromes and in the ability to isolate and identify the inherited genetic mutations responsible for cancer. - These advances have enabled the appropriate identification of families at risk for certain syndromes. - Examples include hereditary breast and ovarian cancer syndrome (BRCA1 and BRCA2) and multiple endocrine neoplasia syndrome (MEN1 and MEN2) - Other cancers associated with familial inheritance syndromes include nephroblastomas, pheochromocytomas, and colorectal, stomach, thyroid, renal, prostate, and lung cancers

Nonmyeloablative:

- Also called mini-transplants; does not completely destroy bone marrow cells

Hypersensitivity Reactions:

- Although hypersensitivity reactions (HSRs) can occur with any medication, many chemotherapy agents pose a high risk and have been associated with life-threatening outcomes. - HSRs 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 - Immediate HSRs appear within 1 hour of an infusion, while delayed HSRs may occur hours afterward. - Although patients may or may not react to the first infusion of a chemotherapy agent, repeated exposure increases the likelihood of a reaction. - Most immediate HSRs are immunoglobulin E (IgE)-mediated reaction—an allergic reaction. - Examples of agents that may cause an allergic, IgE-mediated response include carboplatin, oxaliplatin (Eloxatin), and L-asparaginase. - However, some HSRs, such as anaphylactoid reactions, are non-IgE-mediated (nonallergic) and a result of cytokine release syndrome - Rituximab and cetuximab are examples of agents associated with non-IgE-mediated (nonallergic) HSRs. - When signs and symptoms of HSR occur, the medication should be discontinued immediately and emergency procedures initiated. - Many institutions have developed specific protocols for responding to HSRs, including standing orders for administration of emergency medications - For some chemotherapeutic agents, especially if they are essential in the treatment plan, desensitization procedures may be possible, and the patient is retreated with the agent at reduced dosages or slower infusion rates. - Premedication regimens are used for certain chemotherapy agents to prevent or minimize reactions.

Nursing Management Toxicity: Assessing Fluid & Electrolyte Status:

- Anorexia, nausea, vomiting, altered taste, mucositis, and diarrhea put patients at risk for nutritional and fluid and electrolyte disturbances. - Therefore, it is important for the nurse to assess the patient's nutritional and fluid and electrolyte status on an ongoing basis and to identify creative ways to encourage an adequate fluid and dietary intake.

Radiation Therapy:

- Approximately 60% of patients with cancer receive radiation therapy at some point during treatment - Radiation may be used to cure cancer, as in thyroid carcinomas, localized cancers of the head and neck, and cancers of the cervix. - Radiation therapy may also be used to control cancer when a tumor cannot be removed surgically or when local nodal metastasis is present. - Neoadjuvant (prior to local definitive treatment) radiation therapy, with or without chemotherapy, is used to reduce tumor size in order to facilitate surgical resection. - Radiation therapy may be given prophylactically to prevent local recurrence or spread of microscopic cells from the primary tumor to a distant area (e.g., irradiating the breast and axilla following lumpectomy or mastectomy for breast cancer).

Carcinogenesis: Lifestyle Factors:

- Approximately one quarter to one third of all cancers in the United States have been linked to lifestyle factors, such as diet, obesity, and insufficient physical activity. - These factors are second only to tobacco use as major risk factors associated with cancer development - The risk of cancer increases with long-term ingestion of carcinogens or co-carcinogens or the absence of protective substances in the diet. - Dietary substances that appear to increase the risk of cancer include fats, alcohol, salt-cured or smoked meats, nitrate- and nitrite-containing foods, and red and processed meats. - Heavy alcohol use increases the risk of cancers of the mouth, pharynx, larynx, esophagus, liver, colon, rectum, and breast - Poor diet and obesity have been identified as contributing factors to the development of cancers of the breast (in postmenopausal women), colon, endometrium, esophagus, and kidney. - Obesity is also associated with an increased risk for cancers of the pancreas, gallbladder, thyroid, ovary, and cervix, and for multiple myeloma, Hodgkin lymphoma, and an aggressive form of prostate cancer. - Multiple studies have long linked sedentary lifestyles and lack of regular exercise to cancer development

Biopsy:

- Biopsy methods include excisional, incisional, and needle biopsy. - The biopsy type is determined by the size and location of the tumor, the type of treatment anticipated if the cancer diagnosis is confirmed, and the need for surgery and general anesthesia. - The biopsy method that allows for the least invasive approach while permitting the most representative tissue sample is chosen. - Diagnostic imaging techniques can be used to assist in locating the suspicious lesion and to facilitate accurate tissue sampling. - The patient and family are provided the opportunity and time to discuss the options before definitive plans are made.

Internal Radiation: Brachytherapy:

- Brachytherapy is 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. - In addition, this form of radiation delivery helps to spare exposure to normal surrounding tissue. - The radiation source can be implanted by means of needles or rods, seeds, beads, ribbons, or catheters placed into body cavities (vagina, abdomen, pleura), lumens within organs, or interstitial tissue compartments (breast, prostate). - Multiple imaging techniques such as ultrasound, CT, or MRI are used to guide placement of radiation sources. - Patients may have many fears or concerns about internal radiation, and the nurse explains the various approaches and safety precautions that will be used to protect the patient, family, and health care staff. - Brachytherapy may be delivered as a temporary or a permanent implant. - 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. - The primary advantage of HDR brachytherapy is that treatment time is shorter, there is reduced exposure to personnel, and the procedure can be performed on an outpatient basis over several days. - HDR brachytherapy can be used for intraluminal, surface, interstitial, and intra-cavitary lesions. - Intraluminal HDR brachytherapy involves the insertion of catheters or hollow tubes into the lumens of organs so that the radioisotope can be delivered as close to the tumor bed as possible. - Lesions in the bronchus, esophagus, rectum, or bile duct can be treated with this approach. - Contact or surface application is used for treatment of tumors of the eye, such as retinoblastoma in children or ocular melanoma in adults. - Interstitial HDR implants, used in treating such malignancies as prostate, pancreatic, or breast cancer, may be temporary or permanent, depending on the site and radioisotope used. - Based on the dose to be delivered (LDR or HDR), the implants may consist of seeds, needles, wires, strands, or small catheters positioned to provide a local radiation source. - Prostate HDR therapy is one form of interstitial brachytherapy, in which radioactive strands or wires are placed, while the patient is under anesthesia, into hollow catheters that have been inserted in the perineum close to the prostate gland - Intracavitary radioisotopes are used to treat gynecologic cancers. In these malignancies, the radioisotopes are inserted into specially positioned applicators within the vagina. - The applicator placement is verified by x-ray. - Treatment can be achieved with either HDR or LDR brachytherapy sources, depending on the extent of disease. - LDR therapy requires hospitalization because the patient is treated over several days. - HDR intraoperative radiotherapy (IORT) has been used as a treatment approach for advanced gynecologic cancer that has spread to the para-aortic area or pelvic wall - Systemic radiotherapy (radiopharmaceutical therapy) involves the intravenous (IV) administration of a therapeutic radioactive isotope targeted to a specific tumor. - Radioactive iodine (I-131) is a widely used form of systemic brachytherapy that is the primary treatment for thyroid cancer - Radium-223 dichloride selectively targets prostate cancer bone metastases with high-energy, short-range alpha particles and is approved for the treatment of patients with symptomatic bone metastases and no known visceral metastatic disease - Radioisotopes are also used as a form of radioimmunotherapy for the treatment of refractory non-Hodgkin lymphoma.

Malignant Process:

- Cancer is a disease process that begins when a cell is transformed by genetic mutations of the cellular deoxyribonucleic acid (DNA). - Genetic mutations may be inherited and/or acquired, leading to abnormal cell behavior - The initial genetically altered cell forms a clone and begins to proliferate abnormally, evading normal intracellular and extracellular growth-regulating processes or signals as well as the immune system defense mechanisms of the body. - Genetic mutations may lead to abnormalities in cell signaling transduction processes (signals from outside and within cells that turn cell activities either on or off) that can in turn lead to cancer development. - Ultimately cells acquire a variety of capabilities that allow them to invade surrounding tissues and/or gain access to lymph and blood vessels, which carry the cells to other areas of the body resulting in metastasis or spread of the cancer

Fatigue Toxicity:

- Cancer-related fatigue has been defined as an unusual, persistent, and subjective sense of tiredness that is not proportional to recent activity and interferes with usual functioning - Fatigue is a distressing side effect for most patients that greatly affects quality of life, during treatment and for months after treatment. - The health care team works together to identify effective pharmacologic and nonpharmacologic approaches for fatigue management.

Primary Tumor (T): Tis:

- Carcinoma in situ

Malignant Cell:

- Cells are undifferentiated and may bear little resemblance to the normal cells of the tissue from which they arose.

Chemotherapy:

- Chemotherapy involves the use of antineoplastic drugs in an attempt to destroy cancer cells by interfering with cellular functions, including replication and DNA repair - Chemotherapy is used primarily to treat systemic disease rather than localized lesions that are amenable to surgery or radiation. - Chemotherapy may be combined with surgery, radiation therapy, or both to reduce tumor size preoperatively (neoadjuvant), to destroy any remaining tumor cells postoperatively (adjuvant), or to treat some forms of leukemia or lymphoma (primary). - The goals of chemotherapy (cure, control, or palliation) must be realistic because they will determine the medications that are used and the aggressiveness of the treatment plan.

Neurologic System Toxicity:

- Chemotherapy-induced neurotoxicity, a potentially dose-limiting toxicity, can affect the central nervous system, peripheral nervous system, and/or the cranial nerves. - Neurotoxicity characterized by metabolic encephalopathy can occur with ifosfamide, high-dose methotrexate, and cytarabine. - With repeated doses, the taxanes and plant alkaloids, especially vincristine, can cause cumulative peripheral nervous system damage with sensory alterations in the feet and hands. - These sensations can be described as tingling, pricking, or numbness of the extremities; burning or freezing pain; sharp, stabbing, or electric shock-like pain; and extreme sensitivity to touch. - If unreported by patients or undetected, progressive motor axon damage can lead to loss of deep tendon reflexes, with muscle weakness, loss of balance and coordination, and paralytic ileus. - Severe peripheral neuropathies may lead to diminished quality of life and functional abilities and result in dose reductions, a change in chemotherapy regimen, or early cessation of treatment - Although often reversible, these side effects may take many months to resolve or persist indefinitely. - Along with the usual paresthesias of the hands and feet, oxaliplatin has a unique and frightening neurotoxicity presentation that is often precipitated by exposure to cold and is characterized by pharyngolaryngeal dysesthesia consisting of lip paresthesia, discomfort or tightness in the back of the throat, inability to breathe, and jaw pain.

Myelobiative:

- Consists of giving patients high-dose chemotherapy and, occasionally, total-body irradiation

Staging:

- Determines the size of the tumor, the existence of local invasion, lymph node involvement, and distant metastasis. - Several systems exist for classifying the anatomic extent of disease. The tumor, nodes, and metastasis (TNM) system

Diagnostic Surgery:

- Diagnostic surgery, or biopsy, is performed to obtain a tissue sample for histologic analysis of cells suspected to be malignant. - In most instances, the biopsy is taken from the actual tumor; however, in some situations, it is necessary to take a sample of lymph nodes near a suspicious tumor. - Many cancers can metastasize from the primary site to other areas of the body through the lymphatic circulation. - Knowing whether adjacent lymph nodes contain tumor cells helps the health care team plan the best therapeutic approach to combat cancer that has spread beyond the primary tumor site. - 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. - Sentinel lymph node biopsy (SLNB), also known as sentinel lymph node mapping, is a minimally invasive surgical approach that in many instances has replaced more invasive lymph node dissections (lymphadenectomy) and the associated complications such as lymphedema and delayed healing. - SLNB has been widely adopted for regional lymph node staging in selected cases of melanoma and breast cancer

Distant Metastasis (M): M1:

- Distant metastasis

Distant Metastasis (M): Mx:

- Distant metastasis cannot be assessed

Metastasis: Benign:

- Does not spread by metastasis

Ability To Cause Death: Benign:

- Does not usually cause death unless its location interferes with vital functions

Tissue Destruction: Benign:

- Does not usually cause tissue damage unless its location interferes with blood flow

Malignant Process: Molecular Process: Progression:

- During progression, the altered cells exhibit increasingly malignant behavior. - These cells acquire the ability to stimulate angiogenesis (growth of new blood vessels that allow cancer cells to grow), to invade adjacent tissues, and to metastasize. - Cellular oncogenes are responsible for vital cell functions, including proliferation and differentiation. - Cellular proto-oncogenes, such as those for the epidermal growth factor receptor (EGFR), transcription factors such as c-Myc, or cell signaling proteins such as Kirsten ras (KRAS), act as "on switches" for cellular growth. - Amplification of proto-oncogenes or overexpression of growth factors, such as epidermal growth factor (EGF), can lead to uncontrolled cell proliferation. - Mutations that increase the activity of oncogenes also deregulate cell proliferation. - Genetic alterations in the gene for KRAS have been associated with pancreatic, lung, and colorectal cancers - Just as proto-oncogenes "turn on" cellular growth, cancer suppressor genes "turn off," or regulate, unneeded cellular proliferation. - When suppressor genes are mutated, resulting in loss of function or expression, the cells begin to produce mutant cell populations that are different from their original cellular ancestors.

Malignant Process: Molecular Process: Promotion:

- During promotion, repeated exposure to promoting agents (co-carcinogens) causes proliferation and expansion of initiated cells with increased expression or manifestations of abnormal genetic information, even after long latency periods. - Promoting agents are not mutagenic and do not need to interact with the DNA. - Latency periods for the promotion of cellular mutations vary with the type of agent, the dosage of the promoter, and the innate characteristics and genetic stability of the target cell. - The promotion phase generally leads to the formation of a preneoplastic or benign (noncancerous) lesion.

External Radiation:

- EBRT is the most commonly used form of radiation therapy. - The energy utilized in EBRT 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 GammaKnifeTM 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. - Advances in computer technology allow multiple imaging modalities (CT, MRI, and PET scans) to be used to provide three-dimensional images of the tumor, neighboring tissues at risk for microscopic spread, and surrounding normal tissues or organs at risk for radiation-induced toxicity. - These images, referred to as volumetric images, allow the radiation oncologist to plan for multiple radiation beams directed from different angles and different planes so that the beams conform precisely around the tumor (referred to as conformal radiation). - The dose of radiation that reaches the surrounding normal tissues is reduced, leading to much less toxicity than in older forms of radiation therapy - Treatment enhancements in EBRT include the ability to control different intensity or energy levels of radiation beams at different angles directed at the tumor, a process known as intensity-modulated radiation therapy (IMRT), which enables higher doses to be delivered to the tumor while sparing the important healthy structures surrounding the tumor -IMRT can be given as standard daily fractions or as "hyperfractionated" twice-daily fractions, which shortens the duration of the patient's treatment schedule. - Image-guided radiation therapy (IGRT) uses continuous monitoring of the tumor with ultrasound, x-ray, or CT scans during the treatment to allow for automatic adjustment of the beams as the tumor changes shape or position in an effort to spare the healthy surrounding tissue and reduce side effects. - Additional treatment enhancements include respiratory gating, where the treatment delivery is actually synchronized with the patient's respiratory cycle, enabling the beam to be adjusted as the tumor or organ moves. - These treatment advancements improve tumor destruction while reducing acute and long-term toxicities - Gamma rays generated from the spontaneous decay of naturally occurring solid source of radioactivity, such as cobalt-60, are one of the oldest forms of EBRT. - With the advent of modern linear accelerators, the use of solid radioactive elements is confined primarily to the GammaKnifeTM stereotactic radiosurgery unit, which is used as a one-time, high-dose delivery of EBRT for treatment of both benign and malignant intracranial lesions. - Stereotactic body radiotherapy (SBRT) is another form of EBRT that uses higher doses of radiation to penetrate very deeply into the body to control deep-seated tumors that cannot be treated by other approaches such as surgery. - SBRT is delivered with considerably higher treatment fraction doses over a short span of time, usually 1 to 5 treatment days, in contrast to daily treatments for 5 days per week for 6 to 8 weeks for conventional EBRT. - Specialized linear accelerators with the capability of robotically moving around the patient are used to deliver SBRT, such as the CyberKnifeTM, TrilogyTM, and TomoTherapyTM delivery systems, which are now more commonly available. - Proton therapy is another approach to EBRT. - Proton therapy utilizes high linear energy transfer (LET) in the form of charged protons generated by a large magnetic unit called a cyclotron. - The advantage of proton therapy is that it is capable of delivering its high-energy dose to a deep-seated tumor, with decreased doses of radiation to the tissues in front of the tumor while virtually no energy exits through the patient's healthy tissue behind the tumor - Proton therapy permits treatment of deep tumors in close proximity to critical structures, such as the heart or major blood vessels.

Ability To Cause Death: Malignant:

- Eventually causes death unless growth can be controlled

Nursing Management Toxicity: Managing Fatigue:

- Fatigue is a common side effect of chemotherapy. - Nurses assist patients to explore the role that the underlying disease processes, combined treatments, other symptoms, and psychosocial distress play in the patient's experience of fatigue. - In addition, nurses work with the patient and other team members to identify effective approaches for fatigue management

Allogeneic HSCT (AlloHSCT):

- From a donor other than the patient (may be a related donor such as a family member or a matched unrelated donor from the National Bone Marrow Registry or Cord Blood Registry)

Synergic:

- From an identical twin

Autologous:

- From the patient

Metastasis: Malignant:

- Gains access to the blood and lymphatic channels and metastasizes to other areas of the body or grows across body cavities such as the peritoneum

Malignant: Mode Of Growth:

- Grows at the periphery and overcomes contact inhibition to invade and infiltrate surrounding tissues

Hematopoietic Stem Cell Transplantation:

- HSCT has been used to treat several malignant and nonmalignant diseases for many years. - The use of HSCT for solid tumors is limited to clinical trials - However, the use of HSCT in the treatment of certain adult hematologic malignancies (i.e., malignant myeloma, acute leukemia, and non-Hodgkin lymphoma) is considered standard of care. - The process of obtaining hematopoietic stem cells (HSCs) has evolved over the years. - Historically, HSCs were obtained in the operating room by harvesting large amounts of bone marrow tissue from a donor under general anesthesia. - However, peripheral blood stem cell collection using the process of apheresis has gained widespread use. - The cells collected are specially processed and ultimately reinfused into the patient. This method of collecting HSCs is a safe and a more cost-effective means of collection than the process of harvesting of marrow - Stem cells can also be collected from umbilical cord blood harvested from the placenta of newborns at birth.

Malignant Cancer Cells:

- Having cells or processes that are characteristic of cancer

Tertiary Prevention Of Cancer:

- Improved screening, diagnosis, and treatment approaches have led to an estimated 14.5 million cancer survivors in the United States - Tertiary prevention efforts focus on monitoring for and preventing recurrence of the primary cancer as well as screening for the development of second malignancies in cancer survivors. - Survivors are assessed for the development of second malignancies such as lymphoma and leukemia, which have been associated with certain chemotherapy agents and the use of radiation therapy - Survivors may also develop second malignancies not related to treatment but genetic mutations related to inherited cancer syndromes, environmental exposures, and lifestyle factors.

Regional Lymph Nodes (N): N1, N2, N3:

- Increasing involvement of regional lymph nodes

Primary Tumor (T): T1, T2, T3, T4:

- Increasing size and/or local extent of the primary tumor

Internal Radiation:

- Internal radiation includes localized implantation or systemic radionuclide administration. - Brachytherapy delivers the dose of radiation to a localized area while systemic radiotherapy relies on strategies for getting the radionuclides closer to the tumor. - The specific radioisotope used is selected on the basis of its half-life, which is the time it takes for half of its radioactivity to decay, and the depth of penetration of the radiation.

Extravasation:

- Intravenously given chemotherapy agents are additionally classified by their potential to damage tissue if they inadvertently leak from a vein into surrounding tissue (extravasation). - The consequences of extravasation range from mild discomfort to severe tissue destruction, depending on whether the agent is classified as a nonvesicant, irritant, or vesicant. - The pH levels of irritant agents (<5 or >9) induce inflammatory reactions but usually cause no permanent tissue damage - Vesicants 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. - Although the mechanism of vesicant actions varies with each drug, some agents bind to cell DNA and cause cell death that progresses to involve neighboring cells, whereas other agents are metabolized into cells and cause a localized, painful reaction that usually improves over time - Sloughing and ulceration of the tissue may progress to tissue necrosis that is so severe that skin grafting becomes necessary. - The full extent of tissue damage may take several weeks to become apparent. - Examples of commonly used agents classified as vesicants include dactinomycin (Cosmegen), daunorubicin (DaunoXome), doxorubicin (Adriamycin), nitrogen mustard (Mustargen), mitomycin (Mutamycin), vinblastine (Velban), and vincristine (Oncovin). - Chemotherapy administration safety standards require the availability of defined extravasation management procedures, including antidote order sets and accessibility of antidotes in all settings where vesicant chemotherapy is given - Chemotherapy is given only by those who have the knowledge and established competencies for vesicant and extravasation management - Prevention and management of extravasation are essential. - Vesicant chemotherapy should never be given in peripheral veins involving the hand or wrist. - Peripheral administration is permitted for short-duration infusions only, and placement of the venipuncture site should be on the forearm area using a soft, plastic catheter. - For any frequent or prolonged administration of antineoplastic vesicants, right atrial silastic catheters, implanted venous access devices, or peripherally inserted central catheters (PICCs) should be inserted to promote safety during medication administration and reduce problems with access to the circulatory system

Secondary Prevention Of Cancer:

- Involves screening and early detection activities that seek to identify precancerous lesions and early-stage cancer in individuals who lack signs and symptoms of cancer. - ACS screening is advocated for many types of cancer - Detection of cancer at an early stage may reduce costs, use of resources, and the morbidity associated with advanced stages of cancer and their associated complex treatment approaches. - Many screening and detection programs target people who do not regularly practice health-promoting behaviors or lack access to health care. - Nurses continue to develop community-based screening and detection programs that address barriers to health care or reflect the socioeconomic and cultural beliefs of the target population - The evolving understanding of the role of genetics in cancer cell development has contributed to prevention and screening efforts. - Many centers offer cancer risk evaluation programs that provide interdisciplinary in-depth assessment, screening, education, and counseling as well as follow-up monitoring for people at high risk for cancer - The NCI provides guidance for cancer risk assessment, counseling, education, and genetic testing

Cancer:

- Is a large group of disorders with different causes, manifestations, treatments, and prognoses. - Because cancer can involve any organ system and treatment approaches have the potential for multisystem effects, cancer nursing practice overlaps with numerous nursing specialties. - Cancer nursing practice covers all age groups and is carried out in various settings, including acute care institutions, outpatient centers, physician offices, rehabilitation facilities, the home, and long-term care facilities. - The scope, responsibilities, and goals of cancer nursing, also called oncology nursing, are as diverse and complex as those of any nursing specialty. - Nursing management of the patient with oncologic disorders includes care of patients throughout the cancer trajectory from prevention through end-of-life care

Precision Medicine:

- Is now possible because of the recent development of biologic databases (e.g., human genome sequencing), technological advances that can identify unique characteristics of individual persons (e.g., genomics, cellular assay tests), and computer-driven systems that can mine and analyze datasets. - This is an exciting time for oncology as the immediate goal of the precision medicine initiative is to focus on preventing and curing cancers

Incisional Biopsy:

- Is performed if the tumor mass is too large to be removed. - In this case, 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 that the pathologist can provide an accurate diagnosis. - If the specimen does not contain representative tissue and cells, negative biopsy results do not guarantee the absence of cancer. - Excisional and incisional approaches are often performed through endoscopy. - However, a surgical procedure may be required to determine the anatomic extent or stage of the tumor. - For example, a diagnostic or staging laparotomy (the surgical opening of the abdomen to assess malignant abdominal disease) may be necessary to assess malignancies such as gastric or colon cancer.

Needle Biopsy:

- Is performed to sample suspicious masses that are easily and safely accessible, such as some masses in the breasts, thyroid, lung, liver, and kidney. - Needle biopsies are most often performed on an outpatient basis. - They are fast, relatively inexpensive, easy to perform, and may require only local anesthesia. - In general, the patient experiences slight and temporary physical discomfort. - In addition, the surrounding tissues are minimally disturbed, thus decreasing the likelihood of seeding cancer cells (disseminating cancer cells to adjacent tissue). - Fine-needle aspiration (FNA) biopsy 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, computed tomography (CT) scanning, ultrasonography, or magnetic resonance imaging (MRI) is used to help locate the suspicious area and guide placement of the needle. - FNA does not always yield enough material to permit accurate diagnosis, necessitating additional biopsy procedures. - A core needle biopsy uses a specially designed needle to obtain a small core of tissue that permits histologic analysis. - Most often, this specimen is sufficient to permit accurate diagnosis.

Grading:

- Is the pathologic classification of tumor cells. - Grading systems seek to define the type of tissue from which the tumor originated and the degree to which the tumor cells retain the functional and histologic characteristics of the tissue of origin (differentiation). - Samples of cells used to establish the tumor grade may be obtained from tissue scrapings, body fluids, secretions, washings, biopsy, or surgical excision. - This information helps providers predict the behavior and prognosis of various tumors. - The grade corresponds with a numeric value ranging from I to IV. - Grade I tumors, also known as well-differentiated tumors, closely resemble the tissue of origin in structure and function. - Tumors that do not clearly resemble the tissue of origin in structure or function are described as poorly differentiated or undifferentiated and are assigned grade IV. - These tumors tend to be more aggressive, less responsive to treatment, and associated with a poorer prognosis as compared to well-differentiated, grade I tumors. - Various staging and grading systems are used to characterize cancers.

Excisionial Biopsy:

- Is 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. - The removal of normal tissue beyond the tumor area decreases the possibility that residual microscopic malignant cells may lead to a recurrence of the tumor. - This approach not only provides the pathologist with the entire tissue specimen for the determination of stage and grade but also decreases the chance of seeding tumor cells (disseminating cancer cells throughout surrounding tissues).

General Affects: Benign:

- Is usually a localized phenomenon that does not cause generalized effects unless its location interferes with vital functions

Virus & Bacteria:

- It is estimated that about 11% of all cancers worldwide are linked to viral infections - After infecting individuals, DNA viruses insert a part of their own DNA near the infected cell genes causing cell division. - The newly formed cells that now carry viral DNA lack normal controls on growth. - Examples of these viruses that are known to cause cancer include human papillomavirus (HPV) (cervical and head and neck cancers), hepatitis B virus (HBV) (liver cancer), and Epstein-Barr virus (EBV) (Burkitt lymphoma and nasopharyngeal cancer) - There is little evidence to support the link of most bacteria to cancer, although chronic inflammatory reactions to bacteria and the production of carcinogenic metabolites are possible mechanisms that continue to be investigated. - Helicobacter pylori is one bacterium identified as a significant cause of gastric cancer

Local Excision:

- Local excision, often performed on an outpatient basis, is warranted when the mass is small. - It includes removal of the mass and a small margin of normal tissue that is easily accessible.

Malignant Process: Molecular Process:

- Malignant transformation, or carcinogenesis, is thought to be at least a three-step cellular process, involving initiation, promotion, and progression. - Agents that initiate or promote malignant transformation are referred to as carcinogens.

Carcinogenesis: Chemical Agents:

- Many cancers are thought to be related to environmental factors - Most hazardous chemicals produce their toxic effects by altering DNA structure. This can occur in body sites distant from that of initial chemical exposure. - Tobacco smoke, thought to be the single most lethal chemical carcinogen, accounts for about one third of cancer deaths - Smoking is strongly associated with cancers of the lung, head and neck, esophagus, stomach, pancreas, cervix, kidney, and bladder and with acute myeloblastic leukemia - Passive smoke (i.e., secondhand smoke) has been linked to lung cancer; nonsmokers who live with a smoker have about a 20% to 30% greater risk of developing lung cancer (HHS, 2014). - There is evidence that passive smoke may be linked with childhood leukemia and cancers of the larynx, pharynx, brain, bladder, rectum, stomach, and breast - Other combustible forms of tobacco such as cigars, pipes, roll-your-own products, and water pipes (or hookah) are also associated with increased cancer risk - Electronic nicotine delivery systems referred to as electronic cigarettes have gained increased popularity as an alternative to tobacco. - Although there are no data regarding the safety of these products, there is great concern about potential negative health effects. - Smokeless tobacco products, such as chewing tobacco and snuff, used most often by young adults aged 18 to 24 years, are associated with an increased risk of oral, pancreatic, and esophageal cancer - Many chemical substances found in the workplace are carcinogens or co-carcinogens. - In the United States, carcinogens are classified by two federal agencies: the National Toxicology Program of the Department of Health and Human Services (HHS) and the Environmental Protection Agency's (EPA) Integrated Risk Information System (IRIS). - The Centers for Disease Control and Prevention (CDC) established the National Institute for Occupational Safety and Health (NIOSH) to provide occupational exposure limits and guidelines for protection of the workforce as regulated by the Occupational Safety and Health Act of 1970. - The extensive list of suspected chemical substances continues to grow and includes aromatic amines and aniline dyes; pesticides and formaldehydes; arsenic, soot, and tars; asbestos; benzene; cadmium; chromium compounds; nickel and zinc ores; wood dust; beryllium compounds; and polyvinyl chloride. - Betel nut and lime, which are chewed as stimulants in some cultures, are also included.

Hematopoietic System Toxicity:

- Many chemotherapy agents cause some degree of myelosuppression (depression of bone marrow function), resulting in decreased WBCs (leukopenia), granulocytes (neutropenia), red blood cells (RBCs) (anemia), and platelets (thrombocytopenia) and increased risk of infection and bleeding. - Depression of these cells is the usual reason for limiting the dose of the chemotherapy. - Myelosuppression is predictable; for most agents, patients usually reach the point at which blood counts are lowest 7 to 14 days after chemotherapy has been given. - During these 2 weeks, nurses anticipate associated toxicities, especially a fever associated with neutrophil count less than 1,500 cells/mm3. Frequent monitoring of blood cell counts is essential, and patients are educated about strategies to protect against infection, injury, and blood loss, particularly while counts are low - Other agents—colony-stimulating factors (granulocyte colony-stimulating factor [G-CSF] and granulocyte-macrophage colony-stimulating factor [GM-CSF])—can be given after chemotherapy to stimulate the bone marrow to produce WBCs, especially neutrophils, at an accelerated rate, thus decreasing the duration of neutropenia. - G-CSF and GM-CSF decrease the episodes of infection and the need for antibiotics and allow for more timely treatment cycles of chemotherapy with less need to reduce the dosage. - Erythropoietin (EPO) stimulates RBC production, thus decreasing the symptoms of treatment-induced chronic anemia and reducing the need for blood transfusions. - Interleukin 11 (IL-11) (oprelvekin [Neumega]) stimulates the production of megakaryocytes (precursors to platelets) and can be used to prevent and treat severe thrombocytopenia but has had limited use because of toxicities, such as HSR; capillary leak syndrome; pulmonary edema; atrial dysrhythmias; and nausea, vomiting, and diarrhea

Cognitive Impairment Toxicity:

- Many patients with cancer experience difficulty with remembering dates, multitasking, managing numbers and finances, organization, face or object recognition, inability to follow directions, feeling easily distracted, and motor and behavioral changes. - Although not completely understood, these are viewed as symptoms of cognitive impairment, defined as a decline in the information-handling processes of attention and concentration, executive function, information processing speed, language, visual-spatial skill, psychomotor ability, learning, and memory - Commonly referred to by patients as "chemo brain," cognitive impairment has been associated with both cancer and cancer treatments, including surgery, radiation, chemotherapy, and targeted agents - The symptoms may be subtle or profound with potential negative effects on functional abilities, employment, independence, quality of life, and psychosocial status. - Comorbidities, age, medications, pain, impaired nutrition, anemia, fatigue, fluid and electrolyte disturbances, organ dysfunction, infection, and hormonal imbalances are factors that may contribute to the experience of cognitive impairment and make it difficult to fully understand. - Underlying mechanisms of cognitive impairment in patients with cancer being explored include neurotoxic effects, oxidative stress, hormonal changes, immune dysregulation, cytokine release, clotting, genetic predisposition, and accelerated aging processes

Distant Metastasis (M): M0:

- No distant metastasis

Primary Tumor (T): T0:

- No evidence of primary tumor

Regional Lymph Nodes (N): N0:

- No regional lymph node metastasis

Benign Cancer Cells:

- Not cancerous; benign tumors may grow but are unable to spread to other organs or body parts

Nurse Management Of Patient During Radiation:

- Nurses 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. - Symptoms that are not appropriately managed may lead to poor outcomes as a result of interruptions, decreased doses, or early cessation of treatment -Ideally, nurses consider factors that may be predictive of radiation toxicities or radiosensitivity of tissues. - In particular, diminished body mass index (BMI) and elevated radiation doses have been associated with greater toxicity and symptoms - The area of the body being irradiated partially guides the focus of nursing assessments. - In patients receiving EBRT, the nurse assesses the patient's skin regularly throughout the course of treatment. In addition, nutritional status and general feelings of well-being are assessed throughout the course of treatment. - Evidence-based protocols for nursing management of the toxicities associated with radiation therapy are used. - If systemic symptoms, such as weakness and fatigue, occur, the nurse explains that these symptoms are a result of the treatment and do not represent deterioration or progression of the disease.

Nursing Management Toxicity: Preventing Nausea & Vomiting:

- Nurses are integral to the prevention and management of CINV. - They collaborate with other members of the oncology care team to identify factors contributing to the experience of CINV and select effective antiemetic regimens that maximize currently available therapies. - Nurses provide education for patients and families regarding antiemetic regimens and care for delayed CINV that may continue at home after the chemotherapy infusion has completed

Protecting Caregivers In Chemotherapy:

- Nurses involved in handling chemotherapeutic agents may be exposed to low doses of the agents by direct contact, inhalation, or ingestion. - Studies suggest that nurses and others preparing chemotherapy agents or handling linens and other materials that are contaminated with body fluids of patients receiving chemotherapy have been unknowingly exposed - Skin and eye irritation, nausea, vomiting, nasal mucosal ulcerations, infertility, low-birth-weight babies, congenital anomalies, spontaneous abortions, and mutagenic substances in urine have been reported in nurses preparing and handling chemotherapy agents - The Occupational and Safety Health Administration (OSHA), the ONS, hospitals, and other health care agencies have developed specific precautions for health care providers involved in the preparation and administration of chemotherapy and for handling materials exposed to body fluids of those who have received these hazardous agents - Nurses must be familiar with their institutional policies and procedures regarding personal protective equipment, handling and disposal of chemotherapy agents and supplies, and management of accidental spills or exposures. - Emergency spill kits should be readily available in any treatment area where chemotherapy is prepared or given. - Precautions must also be taken when handling any bodily fluids or excreta from the patient, as many agents are excreted unaltered in urine and feces. - Nurses in all treatment settings have a responsibility to educate patients, families, caregivers, assistive personnel, and housekeepers concerning precautions.

Nursing Management Toxicity: Administering Chemotherapy:

- Nurses must be aware of chemotherapy and other agents most associated with HSRs, strategies for prevention, signs and symptoms characteristic of HSRs, and the appropriate early and time-sensitive interventions for preventing progression to anaphylaxis. - Nurses provide patient and family education that emphasizes two key points: the importance of adhering to prescribed self-administered premedication before presenting to the infusion center, and recognizing and reporting the signs and symptoms to the nurse once the infusion has started. - Patients and families are also educated about signs and symptoms that may occur at home following discharge from the infusion area that may warrant medication administration or immediate transport to the emergency department for further assessment and treatment. - The local effects of the chemotherapeutic agent are also of concern. - The patient is observed closely during administration of the agent because of the risk and consequences of extravasation. - Prevention of extravasation is essential and relies on vigilant nursing care - Selection of peripheral veins, skilled venipuncture, and careful administration of medications are essential. - Peripheral administration is limited to short duration (less than 1 hour; IV push or bolus) infusions using only a soft, plastic catheter placed in the forearm area. - Continuous infusion of vesicants that takes longer than 1 hour or are given frequently are given only via a central line, such as a right atrial silastic catheter, implanted venous access device, or PICC. - These long-term venous access devices promote safety during medication administration and reduce problems with repeated access to the circulatory system - Indwelling or subcutaneous venous access devices require consistent nursing care. Complications include infection and thrombosis Indications of extravasation during administration of vesicant agents include the following: - Absence of blood return from the IV catheter - Resistance to flow of IV fluid - Burning or pain, swelling, or redness at the site - An extravasation kit should be readily available with emergency equipment and antidote medications, as well as a quick reference for how to properly manage an extravasation of the specific vesicant agent used (although evidence-based data regarding effective antidotes are limited) - Nurses should refer to their organization's policy and procedures for reporting, managing, and documenting extravasation. - Safety standards require the availability of defined extravasation management procedures, including antidote order sets and accessibility of antidotes in all settings where vesicant chemotherapy is given - Recommendations and guidelines for managing vesicant extravasation, which vary with each agent, have been issued by individual medication manufacturers, pharmacies, and the ONS - Difficulties or problems with administration of chemotherapeutic agents are brought to the attention of the primary provider promptly so that corrective measures can be taken to minimize local tissue damage. - The nurse evaluates the patient receiving neurotoxic chemotherapy, communicates findings with the medical oncologist, provides education to patients and families, and makes appropriate referrals for complete neurologic evaluation and occupational or rehabilitative therapies

Nursing Management Toxicity:

- Nurses play an important role in assessing and managing many of the problems experienced by patients receiving chemotherapy. - Chemotherapy agents affect both normal and malignant cells; therefore, their effects are often widespread, affecting many body systems. - Laboratory and physical assessments of metabolic indices and the dermatologic, hematologic, hepatic, renal, cardiovascular, neurologic, and pulmonary systems are critical in evaluating the body's response to chemotherapy. - These assessments are performed prior to, during, and after a course of chemotherapy to determine optimal treatment options, evaluate the patient's response, and monitor toxicity. - Patients are monitored for long-term effects of chemotherapy after active treatment has been completed during the period of survivorship

Nursing Management Toxicity: Assessing Cognitive Status:

- Nurses should assess patients routinely for indications of cognitive impairment. - Prior to the initiation of treatment, patients and families should be informed about the possibility of cognitive impairment. - Nursing assessment plays an important role in determining the need for referral for neurocognitive evaluation and intervention

Tissue Destruction: Malignant:

- Often causes extensive tissue damage as the tumor outgrows its blood supply or encroaches on blood flow to the area; may also produce substances that cause cell damage

General Affects: Malignant:

- Often causes generalized effects, such as anemia, weakness, systemic inflammation, weight loss, and CACS

Palliative Radiation Therapy:

- 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.

Carcinogenesis: Physical Agents:

- Physical factors associated with carcinogenesis include exposure to sunlight, radiation, chronic irritation or inflammation, tobacco carcinogens, industrial chemicals and asbestos. - Excessive exposure to the ultraviolet rays of the sun, especially in fair-skinned people, increases the risk of skin cancers. - Factors such as clothing styles (sleeveless shirts or shorts), the use of sunscreens, occupation, recreational habits, and environmental variables, including humidity, altitude, and latitude, all play a role in the amount of exposure to ultraviolet light. - Exposure to ionizing radiation can occur with repeated diagnostic x-ray procedures or with radiation therapy used to treat disease. Improved x-ray equipment minimizes the risk of extensive radiation exposure. - Radiation therapy used in cancer treatment and exposure to radioactive materials at nuclear weapon manufacturing sites or nuclear power plants in the past have been associated with a higher incidence of leukemia, multiple myeloma, and cancers of the lung, bone, breast, thyroid, and other tissues. - Background radiation from the natural decay processes that produce radon has also been associated with lung cancer. - Ventilation is advised in homes with high levels of trapped radon to allow the gas to disperse into the atmosphere.

Primary Prevention Of Cancer:

- Primary prevention is about reducing the risks of disease through health promotion and risk reduction strategies. - An example of primary prevention is the use of immunization to reduce the risk of cancer through prevention of infections associated with cancer. - The HPV vaccine is recommended to prevent cervical and head and neck cancers - The vaccine to prevent HBV infection is recommended by the CDC to reduce the risk of hepatitis and subsequent development of liver cancer.

Primary Tumor (T): Tx:

- Primary tumor cannot be assessed

Prophylactic Surgery:

- Prophylactic or risk reduction surgery involves removing non-vital tissues or organs that are at increased risk of developing cancer. The following factors are considered when discussing possible prophylactic 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 - Colectomy, mastectomy, and oophorectomy are examples of prophylactic surgeries. - Identification of genetic markers indicative of inherited cancer syndromes or a predisposition to develop some types of cancer plays a role in decisions concerning prophylactic surgeries. - However, what is adequate justification for prophylactic surgery remains controversial. - For example, several factors are considered when deciding to proceed with a prophylactic mastectomy, including a strong family history of breast cancer; positive BRCA1 or BRCA2 findings; an abnormal physical finding on breast examination, such as progressive nodularity and cystic disease; a proven history of breast cancer in the opposite breast; abnormal mammography findings; abnormal biopsy results; and individual factors that may influence the patient's decision-making process - Prophylactic surgery is discussed with patients and families along with other approaches for managing increased risk of cancer development. - Preoperative education and counseling, as well as long-term follow-up, are provided.

Benign: Rate Of Growth:

- Rate of growth is usually slow.

Malignant: Rate Of Growth:

- Rate of growth is variable and depends on level of differentiation; the more anaplastic the tumor, the faster its growth.

Reconstructive Surgery:

- 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. - The surgeon who will perform the surgery discusses possible reconstructive surgical options with the patient before the primary surgery is performed. - - Reconstructive surgery may be indicated for breast, head and neck, and skin cancers. - The nurse assesses the patient's needs and the impact that altered functioning and body image may have on quality of life. - Nurses provide patients and families with opportunities to discuss these issues. - The individual needs of the patient undergoing reconstructive surgery and their families must be accurately recognized and addressed.

Regional Lymph Nodes (N): Nx:

- Regional lymph nodes cannot be assessed

Cardiopulmonary System Toxicity:

- Several agents are associated with cardiac toxicity. - Anthracyclines (e.g., daunorubicin, doxorubicin) are known to cause irreversible cumulative cardiac toxicities, especially when total dosage reaches 300 mg/m2 and 550 mg/m2, respectively - If these agents are given in the presence of thoracic radiation therapy or other agents with cardiotoxicity potential, the cumulative dose limit is lower. - Patients at increased risk for the development of cardiopulmonary toxicities include those older than 70 years, those with a history of preexisting cardiac disease, hypertension, tobacco use, renal or hepatic dysfunction, and longer survival time. - Dexrazoxane (Zinecard) has been used on a limited basis as a cardioprotectant when doxorubicin is needed in individuals who have already received a cumulative dose limit and continuation of therapy is deemed beneficial. - Patients with known cardiac disease (e.g., heart failure) are treated with lower doses or agents not known to be associated with cardiac toxicity. - Cardiac ejection fraction (volume of blood ejected from the heart with each beat) and other signs of heart failure must be monitored closely. - Bleomycin (Blenoxane), carmustine (BCNU), busulfan (Busulfex, Myleran), mitomycin, and paclitaxel/docetaxel, among other agents, have toxic effects on lung function, such as alveolar damage, bronchospasm, pneumonitis, and pulmonary fibrosis. - Therefore, patients are monitored closely for changes in pulmonary function, including pulmonary function test results. - Patients with known lung disease are treated with alternative agents not known to cause pulmonary toxicity. - When pulmonary toxicity occurs, the agent is stopped and patients are treated with steroids and other supportive therapies - Capillary leak syndrome with resultant pulmonary edema is an effect of cytarabine (DepoCyt, Tarabine, Ara-C), mitomycin C, cyclophosphamide, and carmustine. - Subtle onset of dyspnea and cough may progress rapidly to acute respiratory distress and subsequent respiratory failure. - Patients who are at significant risk for capillary leak syndrome are monitored closely.

Renal System Toxicity:

- Some chemotherapy agents damage the kidneys because they impair water secretion, leading to syndrome of inappropriate secretion of antidiuretic hormone (SIADH), decrease renal perfusion, precipitate end products after cell lysis, and cause interstitial nephritis - Cisplatin (Platinol), methotrexate, and mitomycin (Mutamycin) are particularly toxic to the kidneys. - Rapid tumor cell lysis after chemotherapy results in increased urinary excretion of uric acid, which can cause renal damage. - In addition, intracellular contents are released into the circulation, resulting in hyperkalemia, hyperphosphatemia, and hypocalcemia and obstructive nephropathy. - Monitoring laboratory values of blood urea nitrogen (BUN), serum creatinine, creatinine clearance, and serum electrolytes is essential - Adequate hydration, diuresis, alkalinization of the urine to prevent formation of uric acid crystals, and administration of allopurinol (Zyloprim) may be used to prevent renal toxicity. - Amifostine has demonstrated an ability to minimize renal toxicities associated with cisplatin, cyclophosphamide (Cytoxan), and ifosfamide (Ifex) therapy. - Hemorrhagic cystitis is a bladder toxicity that can result from cyclophosphamide and ifosfamide therapy. - Hematuria can range from microscopic to frank bleeding with symptoms ranging from transient irritation during urination, dysuria, and suprapubic pain to life-threatening hemorrhage. - Protection of the bladder focuses on aggressive IV hydration, frequent voiding, and diuresis. - Mesna (Mesnex) is a cytoprotectant agent that binds with the toxic metabolites of cyclophosphamide or ifosfamide in the kidneys to prevent hemorrhagic cystitis.

Metastasis:

- Spread of cancer cells from the primary tumor to distant sites

Nursing Management Toxicity: Modifying Risks For Infection & Bleeding:

- Suppression of the bone marrow and immune system is expected and frequently serves as a guide in determining appropriate chemotherapy dosage but increases the risk of anemia, infection, and bleeding disorders. - Nursing assessment and care address factors that would further increase the patient's risk. - The nurse's role in decreasing the risk of infection and bleeding is discussed further in the Nursing Care of Patients With Cancer section

Surgical Treatment:

- Surgical removal of the entire cancer remains the ideal and most frequently used treatment method. - However, the specific surgical approach may vary for several reasons. - Diagnostic surgery is the definitive method for obtaining tissue to identify the cellular characteristics that influence all treatment decisions. - Surgery may be the primary method of treatment, or it may be prophylactic, palliative, or reconstructive.

Reproductive System Toxicity:

- Testicular and ovarian function can be affected by chemotherapeutic agents, resulting in possible sterility. - Women may develop problems with ovulation or early menopause, whereas men may develop temporary or permanent azoospermia (absence of spermatozoa). - Because treatment may damage reproductive cells, banking of sperm is often recommended for men before treatment is initiated - Options available for women prior to initiation of chemotherapy include freezing (cryopreservation) of oocytes, embryos, or ovarian tissue - Patients and their partners are informed about potential changes in reproductive function resulting from chemotherapy. - In addition, many chemotherapy agents are known or thought to be teratogenic. - Therefore, patients are advised to use reliable methods of birth control while receiving chemotherapy and not to assume that sterility has resulted.

TNM: N:

- The absence or presence and extent of regional lymph node metastasis

TNM: M:

- The absence or presence of distant metastasis - The use of numerical subsets of the TNM components indicates the progressive extent of the malignant disease.

Dosage Of Chemotherapy:

- 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. - Dosages are determined to maximize cell kill while minimizing impact on healthy tissues and subsequent toxicities. - The therapeutic effect may be compromised if modified and inadequate dosing is required due to toxicities. - Modification of dosage is often required if critical laboratory values or the patient's symptoms indicate unacceptable or dangerous toxicities. - Chemotherapy treatment regimens include standard-dose therapy, dose-dense regimens (giving chemotherapy more frequently than standard treatment regimens), and myeloablative therapy for HSCT. - For certain chemotherapeutic agents, there is a maximum lifetime dose limit that must be adhered to because of the danger of long-term irreversible organ complications (e.g., because of the risk of cardiomyopathy, doxorubicin [Adriamycin] has a cumulative lifetime dose limit of 550 mg/m2).

TNM: T:

- The extent of the primary tumor

GI System Toxicity:

- The most common side effects of chemotherapy are nausea and vomiting, which may persist for 24 to 48 hours; delayed nausea and vomiting may occur up to 1 week after administration. - The experience of chemotherapy-induced nausea and vomiting (CINV) may affect quality of life, psychological status, nutrition, fluid and electrolyte status, functional ability, compliance with treatment, and utilization of health care resources - Comorbidities, the underlying malignancy, other treatment approaches, and medications, as well as symptoms (i.e., pain), may contribute to CINV. - Acute CINV is experienced in the first 24 hours after chemotherapy with a maximal intensity after 5-6 hours; delayed CINV occurs 24 hours posttreatment and may last as many as 7 days with a maximal intensity 48-72 hours after drug administration - Anticipatory nausea and vomiting, occurring prior to administration of chemotherapy, may be a conditioned response triggered by a stimulus such as the smell of the infusion setting, the sight of the nurse, or the outpatient center waiting room. - Several mechanisms are responsible for the occurrence of nausea and vomiting, including activation of multiple receptors found in the vomiting center of the medulla, the chemoreceptor trigger zone, the gastrointestinal tract, the pharynx, and the cerebral cortex. - Activation of neurotransmitter receptors in these areas is thought to induce CINV. - Stimulation may originate through peripheral, autonomic, vestibular, or cognitive pathways. - The primary neuroreceptors known to be implicated in CINV are 5-hydroxytryptamine (5-HT or serotonin) and dopamine receptors - The approach for managing CINV is based on the knowledge of the probability of emesis of the chemotherapy agents used. - Algorithms are used to prevent and treat CINV based on national guidelines that consider this classification of chemotherapy agents - Corticosteroids, phenothiazines, sedatives, and histamines are helpful, especially when used in combination with serotonin blockers to provide antiemetic protection - In order to manage delayed nausea and vomiting, antiemetic medications may be combined and are given for the first week at home after chemotherapy. - Nonpharmacologic approaches such as relaxation techniques, imagery, acupressure, or acupuncture can help decrease stimuli contributing to symptoms and may be most helpful for patients with anticipatory nausea and vomiting. - Small, frequent meals, bland foods, and comfort foods may reduce the frequency or severity of symptoms. - Stomatitis is commonly associated with some chemotherapy agents because of the rapid turnover of epithelium that lines the oral cavity. - The entire gastrointestinal tract is susceptible to mucositis (inflammation of the mouth, throat, and gastrointestinal tract) with diarrhea. - Antimetabolites and antitumor antibiotics are the major culprits in mucositis and other gastrointestinal symptoms, which can be severe in some patients.

Toxicity:

- Toxicities associated with radiation therapy are most often localized in the region being irradiated and may be increased if concomitant chemotherapy is given. - Acute or early toxicities most often begin within 2 weeks of the initiation of treatment occur when normal cells within the treatment area are damaged and cellular death exceeds regeneration. - Body tissues most affected are those that normally proliferate rapidly, such as the skin, the epithelial lining of the gastrointestinal tract, and the bone marrow. - Altered skin integrity is common and can include alopecia (hair loss) associated with whole brain radiation. - Other skin reactions, referred to as radiation dermatitis, occur along a continuum ranging from erythema and dry desquamation (flaking of skin) to moist or wet desquamation (dermis exposed, skin oozing serous fluid) to, potentially, ulceration. - Factors that contribute to the severity of radiation dermatitis include the dose and form of radiation, inclusion of skin folds in the irradiated area, increased age and the presence of medical comorbidities - Symptoms of radiation dermatitis may necessitate treatment interruption, delays, or cessation of therapy. Re-epithelialization occurs after treatments have been completed. - Hyperpigmentation, a less severe radiation-associated skin reaction, may develop about 2 to 4 weeks after the initiation of treatment. - Alterations in oral mucosa secondary to radiation therapy in the head and neck region include stomatitis (inflammation of the oral tissues), decreased salivation and xerostomia (dryness of the mouth), and change in or loss of taste. - Depending on the targeted region, any portion of the gastrointestinal mucosa may be involved, causing mucositis (inflammation of the lining of the mouth, throat, and gastrointestinal tract). - For example, patients receiving thoracic irradiation for lung cancer may experience acute esophageal irritation—associated chest pain and dysphagia. - Anorexia, nausea, vomiting, and diarrhea may occur if the stomach or colon is in the radiation field. - Symptoms subside and gastrointestinal re-epithelialization occurs after treatments have been completed. - Bone marrow cells proliferate rapidly, and if sites containing bone marrow (e.g., the iliac crest or sternum) are included in the radiation field, anemia, leukopenia (decreased white blood cells [WBCs]), and thrombocytopenia (a decrease in platelets) may result. - The patient is then at increased risk for infection and bleeding until blood cell counts return to normal. - One medication, amifostine (Ethyol), is occasionally used in patients with head and neck cancers to reduce acute and chronic xerostomia while preserving antitumor efficacy of the necessary radiation dose - Systemic side effects are commonly experienced by patients receiving radiation therapy. - These include fatigue, malaise, and anorexia that may be secondary to substances released when tumor cells are destroyed. - Early effects tend to be temporary and most often subside within 6 months of the cessation of treatment. - Late effects (approximately 6 months to years after treatment) of radiation therapy may occur in body tissues that were in the field of radiation. - These effects are chronic, usually a result of permanent damage to tissues, loss of elasticity, and changes secondary to a decreased vascular supply. - Severe late effects include fibrosis, atrophy, ulceration, and necrosis and may affect the lungs, heart, central nervous system, and bladder. - With advances in treatment planning and the accuracy of treatment delivery, the occurrence of late toxicities has diminished. - However, late or chronic symptoms, such as dysphagia, incontinence, cognitive impairment, and sexual dysfunction, may persist for several years with implications for survivors' overall health and quality of life

Management Of Cancer:

- Treatment options offered to patients with cancer are based on treatment goals for each specific type, stage, and grade of cancer. - The range of possible treatment goals includes complete eradication of malignant disease (cure), prolonged survival and containment of cancer cell growth (control), or relief of symptoms associated with the disease and improvement of quality of life (palliation). - Treatment approaches are not initiated until the diagnosis of cancer has been confirmed and staging and grading have been completed. - The health care team and the patient and family must have a clear understanding of the treatment options and goals. - Open communication and support are vital as those involved periodically reassess treatment plans and goals when complications of therapy develop or disease progresses. - Multiple modalities are commonly used in cancer treatment. - Various approaches, including surgery, radiation therapy, chemotherapy, hematopoietic stem cell transplantation (HSCT), hyperthermia, and targeted therapy, may be used together or at different times throughout treatment. - Understanding the principles of each and how they interrelate is important in understanding the rationale and goals of treatment.

Benign: Mode Of Growth:

- Tumor grows by expansion and does not infiltrate the surrounding tissues; usually encapsulated.

Carcinogenesis: Hormonal Factors:

- Tumor growth may be promoted by disturbances in hormonal balance, either by the body's own (endogenous) hormone production or by administration of exogenous hormones. - Cancers of the breast, prostate, and uterus are thought to depend on endogenous hormonal levels for growth. - Prenatal exposure to diethylstilbestrol (a synthetic form of the female hormone estrogen) has long been recognized as a risk factor for clear cell adenocarcinoma of the lower genital tract. Hormonal changes related to the female reproductive cycle are also associated with cancer incidence. - Early onset of menses before age 12 and delayed onset of menopause after age 55, null parity (never giving birth), and delayed childbirth after age 30 are all associated with an increased risk of breast cancer. - Increased numbers of pregnancies are associated with a decreased incidence of breast, endometrial, and ovarian cancers. - Women who take estrogen after menopause appear to have an increased risk of ovarian cancer. - Combination estrogen and progesterone therapy is linked to a higher risk of breast cancer. - The longer the combined therapy is used, the higher the risk. - However, within 3 years of stopping the hormones, the risk returns to that of a woman who never used this therapy. - Women who have taken hormonal therapy appear to have a lower risk of getting colorectal cancer, but when cancers are found it may be more advanced (more likely to have spread to lymph nodes or distant sites) than the cancers found in women not taking hormones

Benign Cell:

- Well-differentiated cells resemble normal cells of the tissue from which the tumor originated.

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. - Palliative surgery is performed in an attempt to relieve symptoms, such as ulceration, obstruction, hemorrhage, pain, and malignant effusions - Honest and informative communication with the patient and family about the goal of surgery is essential to avoid false hope and disappointment.

Protecting Caregivers:

- When the patient has a radioactive implant in place, the nurse and other health care providers need to protect themselves, as well as the patient, from the effects of radiation. - Patients receiving internal radiation emit radiation while the implant is in place; therefore, contact with the health care team is guided by principles of time, distance, and shielding to minimize exposure of personnel to radiation. - Specific instructions are provided by the radiation safety officer from the radiology department and specify the maximum time that can be spent safely in the patient's room, the shielding equipment to be used, and special precautions and actions to be taken if the implant is dislodged - Safety precautions used in caring for a patient receiving brachytherapy include assigning the patient to a private room, posting appropriate notices about radiation safety precautions, having staff members wear dosimeter badges, making sure that pregnant staff members are not assigned to the patient's care, prohibiting visits by children or pregnant visitors, limiting visits from others to 30 minutes daily, and seeing that visitors maintain a 6-foot distance from the radiation source. - Patients with seed implants typically are able to return home; radiation exposure to others is minimal. Information about any precautions, if needed, is provided to the patient and family members to ensure safety. - Depending on the dose and energy emitted by a systemic radionuclide, patients may or may not require special precautions or hospitalization - The nurse should explain the rationale for these precautions to keep the patient from feeling unduly isolated.

Wide Excision:

- Wide or radical excisions (en bloc dissections) include removal of the primary tumor, lymph nodes, adjacent involved structures, and surrounding tissues that may be at high risk for tumor spread. - This surgical method may result in disfigurement and altered functioning, necessitating rehabilitation, reconstructive procedures, or both. - However, wide excisions are considered if the tumor can be removed completely and the chances of cure or control are good.

Which type of surgery is being done when lesions that are removed are likely to develop into cancer? A.Diagnostic B.Palliative C.Prophylactic D.Reconstructive

C.Prophylactic - Rationale: The type of surgery being done when lesions that are removed are likely to develop into cancer is called prophylactic surgery. Diagnostic surgery such as a biopsy is usually performed to obtain a tissue sample for analysis of cells suspected to be malignant. Palliative surgery is performed in an attempt to relieve complications of surgery. Reconstructive surgery is carried out in an attempt to improve function or obtain a more desirable cosmetic effect

Which specific agents or factors are associated with the etiology of cancer? A.Dietary and genetic factors B.Hormonal and chemical agents C.Viruses D.All of the above

D.All of the above - Rationale: Specific agents or factors associated with the etiology of cancer include: viruses and bacteria, physical factors, sunlight, radiation, chronic irritation, chemical agents, tobacco, asbestos, genetic and familial factors, diet, hormones

Is the following statement true or false? Malignant tumors spread by way of blood and lymph channels to other areas of the body

True - Rationale: Malignant tumors spread by way of blood and lymph channels to other areas of the body. Cells bear little resemblance to the normal cells of the tissue from which they arose