Incidence and Trends of Cancer

Cancer is the second leading cause of death, ♥ dis is 1st

#1 ca in males = prostate= 25% of new cases

#1 ca in females= breast= 25% of new cases

#2 ca = lung/bronchus

#3 = colon/rectal

5yr survival rate is 66% (1996-2003)

Cancer Trends

5 yr survival rate

5 yr survival rate from date of dx/66%= those pts who are

disease free

in remission (leukemia, lymphoma, breast ca)

under treatment

**% does not include pts who are "cured of cancer"

Main Cancers in Children

Leukemia

Neuroblastoma (brain)

Wilm's Tumor (kidney)

Survival Rates in Children

5 yr survival rate <1970 = <50%

5 yr survuval rate 1996-2003 = 80%

Survival rates is dependent on type of ca

Late effects are common = organ malfunction, 2dary ca, cognitive impairments

Cancer is the transformation of a normal cell to an UNREGULATED cell

(defective mitosis in parts of cell cycle, combination therapy is used to achieve an ↑ chance of survival)

Normal cells (of the kidneys, lungs, etc.) have specific functions and an orderly process of progressing from immaturity to maturity.

The daughter cells resemble the mother cells and are differentiated from other cells

Two major dsyfunctions present in the process of cancer development

1 defective cell proliferation (growth)= cells divide abnormally & DNA is substituted or permenantly deranged

2 defective cell differentiation = process is interuppted  & cells remains immature

Proto-onco gene = important regulator of cellular progress promoting cell growth

Tumor Suppressor gene = suppresses growth & makes mutations occur in gene

1. Adhesion = cells stick together

2. Contact Inhibition = still prolierate - not inhibited by adhesion

3. Apoptosis = cell death/ divide & die

Defects in Cellular Proliferation

1. Loss of Adhesion (where body system allows metastisis /lymph & bone marrow)=allows cells to break off from main tumor and move thru bld vesl & tissue (mets)

2. Loss of Contact Inhibition=cells grow on top of each other and on top & between norml cells

3. Loss of apoptosis = ca cells respond diferently than normal cells to intracellular signals regulating equilibrium, divide indicriminately, & are immortal

Proto- Onco Genes = regulate nml cell process & promote growth

Tumor Suppressor Genes = suppress growth

Defect in Differentiation

lose appearance and function of parent cell

Proto-onco genes to oncogenes

Tumor suppressor genes are rendered inactive

Benign Neoplasm

Malignant Neoplasm

Neoplasm = new growth

well differentiated

Encapsulated (usually)

expansive mode of growth

similar to parent cell

metastisis is absent

rarely recur

ranges from well differentiated to undifferentiated

able to metastisize

infiltrative & expansive growth

frequent reoccurrence

moderate to marked vascularity

rarely encapsulated (allowing them to metastisize more quickly)

becomes less like the parent cell

1. Initiation of Cells

2. Promotion = (aboout 1/2 deaths in US related to ) Tobacco, inactivity, obesity, poor diet

3. Progression

Immune system rejects or destroys cancer cell (may be inadequate as ca cells arise from normal human cells)

Some ca cells have changes on their surface antigens =TAA=tumor assoc'd antigens

TAA= responsible for the development of tumors

Genetic (ex: colon, breast)

Chemical

Environmental

Viral (infectious mono)

Immunologic

Tumor Markers:

Confirm Diagnosis

Assess Response to Therapy

Predict Prognosis (high levels of tumor markers = high mortality rate)

Ca-125 = ovarian cancer

Ca-19-9= pancreatic & gallbladder cancer

PSA (prostate specific antigen) = prostate cancer

AFP (alpha fetoprotein) = malignant liver cells

CEA (carcinoembryonic antigen) = cancers of the GI tract

Breast Exam = clinical (CBE) 1xyr self (SBE) monthly/7d prior to cycle

Mammography @ 40yrs and after

MRI

PAP

HPV 26yrs & under

PSA

FOBT/FIT (fecal occult blood test / fecal immunochemical test)

Double contrast Barium Enema, Sigmoidoscopy, Colonoscopy, DRE

Biopsy= definitive means to diagnosis

Needle (aspirate contents from tumor)

Incisional (incision to bx a piece of tissue)

Excisional (removal of tumor itself)

Imaging

Blood Studies=CBC shows immature cells (differential, enzymes, bilirubin, LFT)

Bone Marrow aspiration - leukemia, lymphoma , done in hip or sternum

Oscopies

classification defines by the :

appearance of cells and the degree of differentiation

**poorly differentiated tumors have worse prognosis than those who are closer in appearance to normal cells

grade 1 = cells differ slightly from nml cells and are well differentiated

grade 2 = cells more abnormal and moderately differentiated

grade 3 = cells very abnormal and poorly differentiated

grade 4 = cells immature, primitive and undifferentiated/the cell of origin is difficult to determine

Anatomical Classification of Cancer / Clinical Staging

Stage 0 = cancer in situ

stage 1 = tumor limited to tissue of origin; localized tumor growth

stage 2 = limited local spread

stage 3 = extensive local and regional spread

stage 4 = metastisis

TNM classification represents the anatomic extent of the cancer and is based on three parameters.

T = tumor size and invasiveness

N = spread to lymph node

M = metastisis

Cure = total tumor kill or irradication

Control = Slowing or Arresting growth w/o cure

Palliation = Relieve symptoms, pain, bleeding & obstructions/when cure & control not obtainable, help w/ psychological well being, hospice

Surgery = can be used for cure, control a/o palliation, #1 tx, oldest form and primary tx for solid tumors/ eveidence of micrometastasis in 70% of all tumors/sx complemented by radiation, chemotherapy, & biological tx

Radiation Therapy = may be done prior to sx to decrease chance of micrometastasis tumors

Chemotherapy

Biological and Targeted Therapies

diagnosis/biopsy

determine diagnositic and tx plan/clinical staging

cure a/o control, removal of local ca tissue (primary or met site)

supportive care / prophylactic (masectomy, colon polyp removal)

rehabilitation reconstructive therapy

palliation of symptoms

Is tumor made of solid tissue/slow growing & confined to a specific area?

Can a small area of surrounding tissue (nml) be removed w/o causing loss of function or physical limitation?

What is the individuals pre-surgical function?

ability to safely remove surrounding malignant tissue to decrease risk of tumor recurrence or spread

obtaining detailed informed consent including potential for physical dysfunction or impairment (physician responsibility)

prioritizing patient wishes

Bone Marrow Transplant (BMT) = performed in OR, can be done w/ most ca, extensive radiation prior to BMT to get rid of CA cells, possibly chemo as well

Peripheral stem cell transplantation (PSCT) or (PBSCT)

Categories:

Allogeneic (different species)

Syngeneic (same species)

Autologous (self)

Sources:

Bone Marrow

Peripheral Blood

Umbilical Cord Blood (insuff #stem cells for adults/good for children)

1. Bone Marrow

2. Peripheral Blood

3. Umbilical Cord (can be stored and used later)

is performed if ca is resistant to chem & radiation tx (non hodgkins & hodgkins, immune deficiency syndrome, acute myologous syndrome, stage 4 neuroblastomas, chronic aplastic anemia

BMT is standard protocol w/ children w/ ALL after first remission

Complications include:

bacterial, viral, and fungal infections:

prophylactic abx tx/ pt can become septic , can occur 20-100 days after transplant or histocompatibility or triggered by CMV, epstein barr

Graft-versus- host disease:

T lymphocytes from donor stem cells recognize recipient as foreign

attcks organs such as skin, liver, and GI tract

reduce chance to develop graft vs host by using stem cells from cord blood

Uses: Curative, Control, Adjunctive, Palliative

High-Energy Ionizing radiation to kill: breaks DNA, rapid division, nml cells

Delivered: externally or Internally (cervical, oral, & prostate ca)

Radiation Care = 

Time = limit time around patient to 30 minutes

Distance = Remain 12-18 inches away from radiation site

Shielding = lead apron if working w/ radiation, wear badges to calculate amount of radiation exposed to / No care to pt if you are pregnant/ pt should be in private room

External = pt is NOT radioactive

Internal = pt IS radioactive

implantation or insertion of radioactive materials into or close to tumor

minimal exposure to healthy tissue

used in combination w/ teletherapy (external beam radiation) 

pt is emitting radioactivity

Dry Desqamation= do not apply anything to skin, can wash & dry only/do not wash off radiation markings

Wet Desquamation = deep underlying tissue burns

Chemotherapy = different chemo agents work at diff phases of the cell cycle and are classified as cell specific cycle chemo (G1 & G2)& cell non-specific chemo (all phases of repro cycle)

drugs are given in combination (better chance of arresting ca)

dosages are calculated to BSA

selection of drugs w/ diff modes of action minimizes occurrences and severity of adverse side effects (does & kill more ca cells @ diff phases of cell cycle)

Neutropenic Precautions

Neutropenia= <2000 WBC

pt needs:

reverse isolation/private room

limit visitors

no children visitors

no fresh fruit or vegetables 

no pepper

no fresh flowers or plants

mask for care

Neupogen to help increase WBC

Respiratory System: Pneumonitis, Pulmonary Edema, pleural effusion

Cardiovascular: Pericarditis, Cardiotoxicity (drug Andriamycin causes ♥ problems, cardiomyopathy

Psychoemotional: Fatigue, Anxiety

Hematologic System: Anemia, Leukopenia, thrombocytopenia

Genitourinary Tract: Hemorrhagic Cystitis, Reproduction Dsyfunction

Nephrotoxicity

Monoclonal Antibodies (MoAb)

Inhibitors

Rituxan (rituximab) s/e rigors/ inpt only/ binds B cell / non hodgkins lymphoma

Herceptin (Trastuzumab) breast ca / binds Her2+

Avastin (Bevacizumab) colorectal ca / prevents vascularization of tumor

Cachexia: breakdown of tissue, ↓ albumin, ↓ wgt

Anorexia: ↓ appetite

Xerostomia: ↓ dry mouth

Provide good mouth care, cold foods, smooth foods, little or no chewing is better, more frequent small meals. popsicles

Biologic Response Modifier Therapies

Immonotherapy: Boost immune system/major focus is MODULATION of the immune sys

Biotherapy/Biological Therapy: agents used are capable of multiple actions No PO/Proteins

Targeted Therapy: agents that interfere w/ specific molecules involved in carcinogenesis & tumor growth/ kill tumor cells w/o damaging healthy cells No PO/proteins /IM

Hematopoietic Growth Factors

Epogen = RBC

Procrit = RBC

Aranesp = RBC

Neupogen = WBC

Neulasta = WBC

Neumega = Platelets

Blood Transfusions (for any blood product)

1 of 2

******check chart for order & consent***************************

IV access must be 18 or 20 gauge or larger

VS - TPR & BP

Hang blood asap (should be transfused w/in 4hr of recvg from blood bank)

Unsafe to put in refrigerator

ID Check w/ 2 RN's or RN & Doc

Use Y Tubing

NSS only***NO Dextrose

no other meds via line

transfuse slowly. stay 1st 15 minutes

lasix may be ordered to follow infusion

hem <9 = transfusion, if ren failure hem ++lower for transfusion

Blood Transfusion

2 of 4

Assess for Reactions  =

***febrile (fever, chills, h/a)response to foreign prot/Tylenol most often given/continue w/ transfusion

***hemolytic (fever, chills, h/a, flushed face, low back pain)/can cause renal failure, STOP transfusion, take down blood, send to blood bank & send blood & urine specime to lab

*** Allergic (hives, itching, anaphylaxsis) STOP transfusion

Targeted Therapies

Tyrosine Kinase Inhibitors

Tarceva (Erlotinib)

Gleevec (Imatinib) = transduction & angiogenesis  inhibitors

Biotherapy Side Effects

Flu like symptoms

liver toxicity

capillary leaks syndrome w/ difficulty breathing

anorexia

infusion reactions (caused by injections) infiltrates=necrosis=stop IV no Flush no Remove

SKIN RASH

HTN

Skin fissures (paronychia)

diarrhea

neurotoxicity, lethary, & atigue

mouth ulcers

Blood Transfusions 3 of 3

Prep = to help avoid severe reaction> Tylenol, Benadryl, & Prednisone

Reaction to Transfusion > STOP transulsion STAT>KVO w/ NSS> call dr>treat symptoms per protocol

No Reactions > ^ rate after 15min>infuse 4hr or less, ck VS per protocol, monitor for other reactions: fluid volume excess > when transfusion complete flush line w/ NSS

Pain

Pain is what the patient says it is!

Causes :

Cancer (bone invasion, nerve compression, & GI obstruction)

Treatments:(surgery, diagnostic tests, chemo & radiation)

Pain Management

Goals: relief from pain, comfort & quality of life

Measures:

Pharmacologic (analgesics, opioid, non-opioid)(adjuvants)

Non-pharmacologic (comfort measures, surgery, radiation)

Analgesics the mainstay of pain management

Acute Pain (break the pain cycle)

Chronic Pain (begin with non-narcotics)(use adjuvants)

Routes (PO, SQ, IM, IV, topical)

Schedule ATC = best pain control method

PRN = for breakthrough pain 

Analgesics

Narcotics: MC Contin, Fentanyl patch, Morphine infusion (hospice phase - titrate morphine to relieve them of pain), Dilaudid

Other techniques: PCA Pump, Epidural Infusion, TENS

Pediatric = frequently undermedicated, assess carefully

Elderly = more susceptible to s/e, drug interactions

Nurse's Role in Pain Management

Assess pain and communicate with other health care providers

Ensure initiation of adequate pain relief measures

Evaluate effectiveness of interventions *reassess to see if pain med working

Advocate for those in pain

Management of Cancer Pain

Patient report should always be believed and accepted as primary source for pain assessment data

Drug therapy should be used to control pain

Fear of addiction is unwarranted

Non-pharmacologic interventions including relaxation therapy and imagery can be effectively used

Extravasation

Leakage of fluid into tissues rather than into vein

Differentiation

Kidney cells do not look like liver cells

Teletherapy

The use of ionizing radiation from an external source such as linear accelerator

Hyperplasia

Increase in the number of normal cells in a tissue or organ

Cell Cycle

Complete circle of replication

Benign

Tumor that is generally well differentiated, slow growing, encapsulated and does not metastasize

Brachytherapy

Use of high energy radioactive materials placed into or directly on the body to treat disease

Doubling Time

The time for the tumor mass to double in size

BRM

Biological Response Modifier

Substances that stimulate and boost the patient's own immunologic response

Nadir

The lowest point immunosuppression of RBC's and WBC's

Metastasis

Cancerous Cells are no longer localized

Hemolytic

Potential life-threatening transfusion reaction

Carcinogen

A substance that can cause changes in the structure and function of  cell that can lead to cancer

Bone Marrow Suppression

acheived through high dose chemotherapy and/or radiation prior to bone marrow transplant

Radiation

Energy that is transmitted in the form of waves or particles; used a treatment for cancer

Vesicant

Chemotherapy agent that can cause tissue necrosis and sloughling if infiltration occurs

Tumor Marker

Used to confirm a diagnosis, asses a response to therapy, predict or confirm relapse and assess prognosis

Dysplasia

An alteration in size, shape and organization of cells; strongly associated with neoplastic changes

Malignant

Poorly differentiated cells that grow rapidly, invade adjacent tissue and typically metastasize