Most cancers occur in people of what age?

Overall, the incidence of cancer is higher in men or women?

For men, what is the leading type of cancer for new cases, and for women?

Which type of cancer attributes for the most deaths?

65 and older

higher in men

Most new cases: men- prostate cancer; women- breast cancer

Most deaths: Lung and bronchus 

Cancer is second only to ______ ______ as a leading cause of death in the U.S.

For persons <85 yrs is the ______ cause of death.

Between caucasian men and women and african american men and women, which groups have the highest incidence rate and the highest death rate?

cardiovascular disease

leading

Incidence rate and death rate is higher in A.A. men than in Caucasian men.

Incidence rate is lower in A.A. women, but death rate is higher than caucasian women 

Characteristics of benign neoplasms

• cell characteristics
• mode of growth
• rate of growth
• metastasis
• general effects
• tissue destruction
• ability to cause death

• well-differentiated, resembling normal cells fr which tumor originated
• tumor grows by expansion and dones not infiltrate surrounding tissues; usually encapsulated
• usually slow
• does not spread by metastasis
• usually localized, not causing generalized effects, unless location interferes with vital functions
• does not usually cause tissue damage unless its location interferes with blood flow
• does not usually cause death unless its location interferes with vital functions

Characteristics of malignant neoplasms

• cell characteristics
• mode of growth
• rate of growth
• metastasis
• general effects
• tissue destruction
• ability to cause death

• cells are undifferentiated and often brear little resemblance to normal cells of the tissue fr which they arose
• grows at the periphery and sends out processes that infiltrate and estroy the surrounding tissue
• rate of growth is variable and depends on lvl of differentiation; the more anaplastic the tumor, the faster its growth
• gains access to the blood and lymph channels and metastasizes to other areas of the body
• often causes generalized effects such as anemia, weakness, and weight loss
• 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 case cell damage
• usually causes death unless growth can be controlled

dissemination of malignant cells via the bloodstream, directly related to vascularity of the tumor

malignant cells that survive transport do so by attaching to _____ and attracting _____, ______, and ____ _____ to seal themselves from immune system surveillance

hematogenous spread

malignant cells that survive transport do so by attaching to endothelium and attracting fibrin, platelets and clotting factors to seal themselves from immune system surveillance

The process of carcinogenesis

1. Single genetic change occurs in normal cell, altering cellular growth, function, or both
2. Repeated exposure to cocarcinogens cause the altered cell to undergo additional malignant changes; cells begin to produce mutant cell populations that differ from their oiginal cellular ancestors
3. the altered cells exhibit increased malignant behavior. The cells can invade adjacent tissues and metastasize

1. initiation
2. promotion
3. progression

Risk factors of Cancer

dietary substances that appear to increase the risk of cancer include:

decrease the risk of cancer:

Endogenous: age, genetic factors, hormonal factors

External: tobacco, radiation, nutrition, inactivity & obesity, infectious organisms

fats, alcohol, salt-cured or smoked meats, nitrate-containing and nitrite-containing foods, and red and processed meats, high caloric dietary intake

Greater consumption of vegetables, fruits

Macrophages and T lymphocytes, Interferon (substance produced by body in response to viral infection, also possesses some antitumor properties), B lymphocytes, and Natural Killer (NK) cells

NK cells are a subpopulation of lymphocytes and act by directly destroying cancer cells or by producing lymphokines and enzymes that assist in cell destruction.

How does Metastasis occur:

1. Mechanisms
2. Modes of dissemination

1. angiogenesis, altered cell adhesion, escape form the immune system
2. Direct extension; permeate into lymp and blood vessels, lodge in lymph notes; diffusion

Educating community a/b cancery risks

Encourage dietary/lifestyles changes: smoking cessation, decreasing caloric intake, increased physical activity

screening and early detection

breast/testicular self exams, Pap tests, blood tests, digital rectal examan (DRE), prostate-speciic antigen (PSA) test

Tumor marker identification (analysis of substances found in body - tissues, blood, other body fluids made by tumor)

genetic profiling

mammography

MRI (createsd sectioned images of body structures)

CT (provides cross-sectional view)

Fluroscopy (xrays w or w/o contrast to determine tissue densities)

Ultrasonography

Endoscopy (allows tissue biopsy, fluid aspiration, and excision of sm tumors)

Nuculear medicine imaging (IV injection or ingestion of radioisotope substances followed by imaging of tissues)

Positron emission tomography (PET) provides images of biologic activity of particular area. used in detection or response to treatment)

Radioimmunoconjegates (visualizes  injected antibodies)

GRADING

describe each grade 0-4

0 - normal tissue

1 - well-differentiated, similar to tissue origin

2 - moderately well differentiated, structural changes fr tissue of origin

3 - poorly differentiated, extensive structural changes

4 - very anaplastic, no resemblance to tissue of origin

STAGING

What does it determine?

How is it staged?

Determines size of tumor and presence of metastasis

TNM: tumor size, Nodal involvement, Metastasis

Combining surgery with other treatment methods, such as radiation and chemotherapy, also contribues to post-op complications, such as:

Postoperatively, the nurse assess the patient's responses to the surgery and monitors the patient for possible complications such as:

Postoperative teaching addresses:

infection, impaired wound healing, altered pulmonary or renal function, and the development of deep vein thrombosis

infection, bleeding, thrombophlebitis, wound dehiscence, fluid and electrolye imbalance, and organ dysfunction

wound care, activity, nutrition, and medication information

1. surgery aimed at removing the entire tumor or as much as is feasible (debulking) and any involved surrounding tissue including regional lymph nodes
2. An additional treatment option that uses an extensive surgical approach to treat the local recurrence of a cancer after the use of a less extensive primary approach (i.e. a mastectomy to treat recurrent breast cancer after primary lumpectomy and radiation)
3. Removing nonvital tissues or organs that are at increased risk to develop cancer
4. When cure is not possible, surgical procedures with goal of making patient as comfortable as possible and to promote quality of life

Choices: salvage, prophylactic, primary, palliative

1. Primary
2. salvage
3. prophylactic
4. palliative

Radiation therapy

Reasons for Radiation therapy

• Curative
• Adjuvant: in combination with surgery and/or chemotherapy
• Prophylactically: to prevent spread of a primary cancer to a distant area
• Palliative: to relieve symptoms of metastatic disease, esp when cancer as spread to brain, bone or soft tissue; to treat oncologic emergencies such as superior vena cava syndrome, bronchail airway obstruction, or spinal cord compression

Radiation therapy causes cell death by:

Cells are most vulnerable to the disruptive efects of radiation during ___ ____ and ______ (specifically the __ phase).

Those body tissues that undergo frequent cell division are most sensitive to radiation therapy. These tissues include:

1. direct damage to DNA molecule w/in cells of tissue. interference with cellular reproduction/ repair

2. DNA synthesis, and mitosis 

3. bone marrow, lymphatic tissue, skin, GI tract

1. sensitivity of the target tissues to radiation
2. size of the tumor
3. tissue tolerance of the surrounding normal tissues
4. critical structures adjacent  to the tumor target

External beam radiation therapy (EBRT) 

1. Is it the most commonly used?
2. Who develops the plan?
3. Patient goes for ________.
4. How is the precise target area marked?
5. Dose is determined and ______.

1. yes
2. radiation oncologist
3. simulation
4. with ink or tattoo
5. fractioned (repeated radiation treatments over time)

Internal Radiation (Brachytherapy)

1. Can be implanted by means of:
2. Sealed: delivers concentrated dose _______; container placed in ____; radioactive substance placed in _______ in pt's room.
3. Unsealed: delivers dose by _____ or ____; excreted in ____ _____; caregive must _____ _______.

1. needles, seeds, beads, or catheters into body cavities (vagina, abdomen, pleura) or interstitial compartments (breast, prostate)
2. SEALED: directly to lesion; OR; container
3. UNSEALED: mouth or IV; body fluids; precautions

• wear dosimetry badge
• room is lead-lined and private
• take turns caring for pt.
• TIME: minimize time spent with pt
• DISTANCE: maximize distance
• SHIELDING: stay behind shield
• prohibiting children or pregnant women
• limiting visits to 30 mins daily
• see that visitors maintain 6ft distance from radiation source

inflammation of the oral tissues

dryness of the mouth

stomatitis

xerostomia

Alterations in oral mucosa secondary to radiation therapy include:

Gastrointestinal symptoms secondary to radiation include:

If sites including bone marrow are included in the radiation field, what may result?

Other common systemic side effects include:

stomatitis (inflammation of oral tissues), dry mouth, change and loss of taste, and decreased salivation

chest pain, dysphagia, anorexia, n/v, diarrhea

anemia, leukopenia (decreased wbc), and thrombocytopenia (decreased platelets)

fatigue, malaise (vague discomfort), and anorexia

• assess skin and oropharyngeal mucose regularly
• nutritional status and general feeling of well being
• trtmt protools for mgmt of toxicities
• explain systemic symptoms being result of treatment
• protect self and caregivers from affects of radioactive implant

CHEMOTHERAPY

1. Antineoplastic agents are used in an attempt to destroy tumor cells by interfering with cellular functions, including ________. 

2. Is used to treat _______ disease rather than localized lesions.

3.  Chemotherapy may be used to treat some forms of _____ or ______.

4. The goals of chemotherapy are  _____, ______, or ________.

1. replication
2. systemic
3. leukemia or lymphoma
4. cure, control, palliation

1. Each time a tumor is exposed to chemotherapy agent, a percentage of tumor cells (___ to ___%, depending on dosage) is destroyed.
2. Chemotherapy is given in ____ doses over a _____ period to acieve ______ of the tumor.
3. T or F: Eradication of 100% of the tumor is almost impossible
4. What is the goal of treatment?

1. 20 - 99%

2. repeated doses over a prolonged period

3. T

4. The goal is to eradicate enough of the tumor so that the immune system can destroy the remaining tumor cells

Like radiation therapy, chemotherapeutic agents are most effective on what type of cells?

Nondividing cells must be destroyed to eradicate a cancer.  How are they targeted?

Actively prolifereating cells within a tumor.  Nondividing cells (during G₀ phase)capable of future proliferation are the least sensitive to antineoplastic meds. 

With repeated cycles of chemotherapy or sequencing of multiple chemotherapeutic agents.  they desroy the nondividing cells as they begin active division.

G1: RNA and protein synthesis occur (8+ hrs)

S Phase: DNA synthesis (6-8 hrs)

G2: premitotic phase; DNA syntheis is complete, mitotic spindle forms

Mitosis: cell devision occurs (prophase, metaphase, anaphase, telophase) 2-5hrs

G0: resting or dormant phase of cells (dangerous phase of cells that are not actively dividing, but have potential for replicating)

topical, oral, intravenous, intreamuscular, subq, arterial, intracavitary, and intrathecal.

Route of admin depends on type of agent; required dose; and type, loc and extent of tumor being treated

1. Irritant agents: induce inflammatory reactions but permanent tissue damange unlikely
2. Vesicants: agents that, if deposited into the subQ tissue, cause tissue necrosis and damage to underlying tendons, nerves, and blood vessels. 
3. Non-vesicants: do not cause tissue necrosis or damage

With extravasation, _______ and ______ of the tissue progresses to tissue ______ and may be so sever that ____ _____ may be necessary.

What are indications of extravasation?

If exravasation is suspected, the medication administered is _______ immediately, and dependent on the drug, an attempt is made to ______ any remaining drug from the site.

sloughing and ulceration; necrosis; skin grafting

Absence of blood return form IV catheter; resistance to flow of IV fluid; burning or pain, swelling or redness at site

stopped; aspirate

Hypersensitivity Reaction

1. Repeated exposure _____ the liklihood of a reaction. 
2. What is the usual chemotherapy hypersensitivity reaction categorized as? 
3. What are symptoms?

1. increases
2. Type 1 immediate, immunogobulin E mediated reaction
3. generalized itching w/localized or generalized urticaria (hives); flusing of the face, hands or feet; chest tightness; agitation; n/v; dyspnea and bronchospasm; diff. speaking; feeling of impending doom; and hypotension

What is the most common side effect of chemothearpy?

How long does it persisit?

What are some other GI side effects?

nausea & vomiting

it persists from 24 to 48 hrs, but can have delayed n/v which may persist for as long as 1 week after chemotherapy

stomatitis, mucositis, and diarrhea

Most chemotherapeutic agents cause myelosuppression (depression of bone marrow function), resulting in decreased production of:

This puts the patient at an increased risk for: 

The nadir point (point at which blood counts are lowest) is usually __ to ___ days after chemotherapy.

WBC (leukopenia), granulocytes (neutropenia) RBC (anemia), platelets (thrombocytopenia)

bleeding and infection

7-14

What can be administered to stimulate the bone marrow to produce WBCs at an accelerated rate, thus decreasing the duration of neutropenia?

What can stimulate RBC production, reducing anemia?

What can stimulate platelet production, reducing thrombocytopenia?

WBCs- G-CSF & GM-CSF

RBC - Erythropoietin (EPO)

Platelets - Interleukin 11 (IL-11)

Rapid tumor cell lysis after chemotherapy results in ______ urinary excretion of _____ _____, which can cause renal damage.

Intracellular contents released into ciculation from tumor lysis, can result in ______, ______, and _______.

How would you prevent side effects?

increased; uric acid

hyperkalemia, hyperphosphatemia, and hypocalcemia

adequate hydration, diuresis, alkalinaztion of the urine to prevent uric acid crystals, and allopurinal

How is the bladder affected by chemotherapy?

What does protection of the bladder focus on?

Renal: hemorrhagic cystitis is bladder toxicity; hematuria; transient irritative urination, dysuria, suprpubic pain; life-threatening hemorrhage. 

aggressive IV hydration, frequent voiding, and diuresis

possible serility

normal ovulation, early menopause, or permanent sterility

Men: temporary or permanent azoospermia

• use biologic safety cabinet for the prep of all chemotherapy agents
• wear surgical gloves when handling anineoplastic agents and the excretions of patients who reveived chemotherapy
• wear disposable, long-sleeved gowns when preping and admin chemotherapy agents
• use Luer-lok fittings on all IV tubing used to deliver chemotherapy
• dispose of all equip used in chemotherapy preparation and amin in appropriate, leak-proof, puncture proof containers
• dispose of all chemotherapy wastes as hazardous materials

1. replace diseased bone marrow
2. rescure healthy bone marrow while giving intensive treatment against solid tumors
3. replace diseased stem cells

Types of bone marrow transplants

1. from a donor othat than the patient - may be related or matched unrelated donor
2. from the patient
3. from an identical twin

1. allogenic
2. autologous
3. syngeneic

an allogenic bone marrow transplant's benefit is that the transplanted cells should not be immunologically tolerant of a patient's malignancy and should cause a lethal ______ vs ____ effect. 

How does this effect work?

graft vs tumor effect

the donor cells recognize the malignant cells and act to eliminate them

In high dose allogenic BMT (_______), the recipiet must under high doses of chemotherapy to destroy all existing ____ _____ and ________ disease. 

The harvested donor marrow or PBSCs are infused IV into the recipients, and they travel to sites in the body where they produce _____ _____ and establish themselves.

Once engraftment is complete (__ to __ weeks, sometimes longer), the new bone marrow becomes functional and begins producing ____, ____, and ______. 

ablative; bone marrow; malignant

bone marrow

2 to 4 wks; RBC, WBC, and platelets

In _________, mini-dose allogenic BMT, the chemotherapy doses are lower and are aimed at suppressing the recipient's ____ _____ to allow  ________ of donor bone marrow or PBSCs.

The lower doses of chemotherapy create less organ toxicity and thus can be offered to _______ patients or those with underlying _____ ______.

nonablative; bone marrow; engraftment

older; organ dysfunction

an immune response initiated by T lymphocytes of donor tissue against the reipients tissues; an indesirable response.  

how is it prevented?

What are the clinical manifestations?

graft-vs-host disease

patients receive immunosuppressant drugs

diffuse rash progressing to blistering and desquamation, mucosal shedding with subsequent diarrhea and may exceed 2L/day; biliary stasis w/abdominal pain, hepatomegaly, and elevated liver enzymes progressing to obstructive jaundice. 

nursing management in bone marrow transplantation

Providing care during treatment

Until engraftment of the new marrow occurs, the pt is at high risk for death from ______ and ______.

What are the symptoms of engraftment syndrome which occurs during neutrophil recovery phase of allogenic and autologous transplants?

sepsis and bleeding

noninfectious fever assoc w/ skin rash, weight gain, diarrhea, pulmonary infiltrates. 

monoclonal antibodies (targeted antibodies are grown and produced to destroy the cancer cells and spare normal cells - uses mice)

epiderman growth factor receptors and tyrosine kinase pahways

vascular endothelial growth factors

Cytokines: interferons, interleukins

Retinoids

Cancer vaccines

Gene Therapy

includes approaches that correct genetic defects or manipulate genes to induce tumor cell destruction in the hope of preventing or combating disease.

_____ serve as vehicles or carriers that transport a gene into the target cell via the cell membrane.

Vectors

currently there are no FDA-approved cancer gene therapies in the U.S.

• asses oral cavity daily
• instruct pt to report oral burning, pain, areas of redness, lesions on lips, pain assoc w/swallowing, or decreased tolerance to temp extremes of food
• encourage and assist in oral hygiene
• advise pt to avoid irritants such as commercial mouthwashes, alcoholic bvgs, & tobacco
• brush w/soft toothbrush; use nonabrasive toothpaste after meals and bedtime; floss q24h unless painful or platelet count below 40,000

• use norm saline mouth rinses q2h while awake; q6h at night
• use soft toothbrush or toothette
• remove dentures except for meals; be sure they fit
• apply water soluble lip lubricant
• aboid foods that are spicy or hard to chew and those w/extreme temps

• obtain tissue sampes for culture and sensitivity tests of areas of infection
• assess ability to chew and swallow; assess gag reflex
• use oral rinses as prescribed or place pt on side and irrigate mouth; have suction ready
• remove dentures
• use toothette or gauze soaked with solution for cleaning
• use water soluble lip lubricant
• provide liquid or pureed diet
• monitor for dehydration
• mouth care as prescribed

• assess for potential for bleeding: monitor platelet count. (mild risk: 50,000-100,000; moderate risk 20,000 - 50,000; severe risk < 20,000)
• assess for bleeding: ecchymosis, decrease in hgg or hct, prolonged bleeding, frank or occult blood in any body excretion, bleeding from any body orifice, altered mental status
• soft toothbrush; avoid commercial mouthwash; electric razor; use emery board for nails; avoid diff to chew foods
• draw all lab work once daily
• avoid rectal temp or suppositories/enemas
• aboid IV injections
• apply pressure to injection sites for min 5 mins
• lubricate lips with petrolatum
• maintain fluid intake of at least 3L per day
• use stool softeners or incrase bulk in diet
• avoid meds interfering with clotting

Superior Vena Cava Syndrome

(Compression or invasion of the superior vena cava by tumor, enlarged lumph nodes, intraluminal thrombus that obstructs venous circulation, or drainage of the head, neck arms, and thorax.)

Clinical Manifestations and Nursing interbentions

Manifestations: dyspnea, cough, hoarseness, chest pain, and facial swelling

Edema of the neck, arms, hands and thorax; skin tightness; diff. swallowing

possibly engorged and distended jugular, temporal, and arm veins

Increased intracranial pressure, assoc visual disturbances, headache, and altered mental staus

Nursing Management

identify those at risk

monitor/report signs of SVCS

monitor cardiopulmonary and neurologic status

avoid upper extremity venipuncture and blood pressure

position properly

promote energy conservation

monitor fluid status, admin fluids cautiously to min edema

assess for dysphagia and esophagitis

monitor for myelosuppression

Spinal Cord Compression

manifestations and nursing mgmt

• Manifestations
• local inflammation, edema, venous stasis, and impaired blood supply to nervous tissues
• local or radicular back or neck pain
• pain exacerbated by movement, supine recumbent position, coughing, sneezing or valsalva maneuver
• neurologic dysfunction & motor/sensory deficits
• motor loss fr subtle weakness to flaccid paralysis
• bladder/bowel dysfunction depending on lvl of compression

Management

• neurologic assessment
• pain control
• prevent complications of immobility
• ROM exercises
• bowel training programs/intermittent urinary catheter

Hypercalcemia

Manifestations and Interventions

Manifestations

• fatigue, weakness, confusion, decreased lvl of responsiveness, hyporeflexia, n/v, constipation, ileus, polyuria, polydipsia (excessive thirst), dehydration, and dysrhythmias

• assess for signs/symptoms
• encourage pts to consume 2-4L of fluid daily
• explain use of laxative/stool softeners
• maintain nutritional intake
• promote movility to prevent demineralization and breakdown of bones
• institute safety precautions for pts with mental and mobiltity impairments

Pericardial Effusion and Cardiac Tamponade

Manifestations and Interventions

Manifestations

• neck vein distention during inspiration (Kaussmauls)
• Pulsus paradoxus
• distant heart sounds, rubs and gallops, cardiac dullness
• compensatory tachycardia
• increased venous and vascular pressures

Interventions

• monitor vitals and SpO2
• assess for pulsus paradoxus
• monitor ECG tracings
• assess heart and lung sounds, neck vein filling, lvl of consciousness, resp status, skin color/temp
• I&O
• review labs
• elevate head of bed
• minimize pt physical activity/ admin oxygen
• provide freq oral hygiene
• reposition and encourage Cough and DB q2h

• superior vena cava syndrome
• spinal cord compression
• hypercalcemia
• pericardial effusion and cardiac tamponade
• disseminated intravascular coagulation (DIC)
• syndrome of inappripriate secretion of antidiuretic hormone
• tumor lysis syndrome