Cancer 2

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Cancer Cancer is unregulated growth of cells; Carcinogens are agents capable of producing cellular alterations. II. Complications of Cancer, Radiation and Chemotherapy A. Hematopoietic System (Nadir) o Very low in RBC, WBC & platelets = Nadir o Lowest point someone can be @ once we have damaged good & bad cells 1. Anemia- reduction in RBC’s a) Gas Exchange Impairment b) Dyspnea- Shortness of Breath c) Activity Intolerance d) Low WBC, impaired immune system e) Platelets, No clotting, would bleed/may bleed to death − Nursing care for depressed red cells: o Give O2 o Alternate Rest and Activity (RBC, normal 4-6 million Low RBC = low Hgb) o CSF- Colony Stimulating Factor  Procrit and epogen (exogenous erythropoietin) stimulate the bone marrow to produce RBC’s  Iron, Administer Blood o End up having to back up off the treatment, we try to manage the symptoms, cause we don’t want to have to back off 2. Leukopenia/ granulocytopenia/ neutropenia-  WBC − Penia = decreased − At risk for infection (High Risk) − 5,000 – 10,000 = normal level − May give granulocytes − Nursing care for depressed white cells: o No Flowers o No Catheter – can introduce bacteria o Reverse or protective isolation o S/Sx of infection (Assess very carefully for infection) o Sputum o Urine – Should be clear yellow o Assess puncture sites for any sign or warmth or redness o Breath sounds I.

o

Temperature or 99.4

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101.0 normally, for these patients 99.2

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B. GI

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o Should Avoid raw & fresh fruits or vegetables, everything needs to be cooked. o Need to drink bottled water o Nupagen & Neulasta may help make more WBC, but may cause bone pain o **ANY SLIGHT CHANGE NOTIFY DR. ** Thrombocytopenia = Low Platelets Risk for bleeding 150,000 – 300,000 to 400,000 = Normal 20,000- High risk for bleeding (hemorrhage) Less than 10,000 Fatal Colony stimulating factors Neumega Give platelets Nursing Care of depressed platelets: o Very Careful Oral Care, Do not Floss, may not even use a toothbrush o First signs of bleeding in:  Urine, gums, or puncture site o Stool softeners to prevent strain – can cause BV to burst in brain, may also rupture a hemorrhoid o Do not dig out fecal impactions or insert rectal thermometer, could poke a hole into something o Electric razors only o Falls (remove rugs) Safety o No Catheters o No Dental work o Avoid medications that decrease platelet aggregation  Aspirin  Excedrin  Beyer  BC Powder  Goodies o Administer Blood Products – platelets - Neumega System − cells rapidly proliferate, thus affected by chemo & radiation Chemo will have systemic effect and radiation will affect area radiated Oral Cavity a) Stomatitis − Inflammation of the Stoma (mouth) − could be ulceration in mouth − Yeast infection of the mouth

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b)

Teeth- become loose and fall out = difficulty eating

c)

Salivary Glands (Xerostomia—very dry mouth) − Saliva becomes thick and ropey – difficult to spit out − can give artificial salvia to thin and moisten mouth

Taste Buds- can be impacted i. Hypogeusia (Hypo-goo-zea) − alteration in or loss of taste sensation due to radiation damage to tongue ii. Dysgeusia (Dis-goo-zea) − an unpleasant, usually metallic taste iii. Aguesia (A-goo-zea) − absence of taste sensation 2. Esophagitis- inflammation of exophagus − May avoid eating, It’s quite painful − Yeast Infections in the mouth, thrush, ulcers − Viscas xelecane- numb mouth and esophagus to help with intake − Antifungals to remove yeast infection of the mouth − Nystatin – treats thrush – Swish & Swallow NURSING CARE when upper GI affected: 1. Avoid commercial mouth was (alcohol base) 2. Viscas (thickened) xelecane – numb mouth & esophagus, given prior to meals 3. Oral care ac & pc – Baking Soda to a pint of water or 1 tsp salt to 1 pint of water 4. Artificial salvia 5. High protein, High Carb, High cal Diet (promide – protein supplement) High Vitamins 6. Avoid Temp extremes 7. Determine preferred foods and drinks 8. Vitamin C, E, Zinc- helps with healing process, will get lots 9. Small frequent meals, may do better than 3 big meals 10. Tube feedings (NG, PEG Tube) may need 11. Total Parenteral Nutrition (TPN orHyperalamentation) IV Fluid that has amino acids, electrolytes, and glucose through a central line. (Procalamine – milder not hypotonic) through a central line or a PICC line 12.Antibiotic and pain meds 3. Abdomen a) Nausea and Vomiting- earliest most common SE − Steroid treatments- anti-inflammatory − Can get Acute gastritis d)

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− High Risk for Aspiration Abdominal cramping and diarrhea − Low residue diet – residue = Avoid salads & Fiber foods − Drugs- lomotil- slow GI motility − Loose a lot of bicarb = metabolic acidosis c) Constipation − Due to low intake − Hypokalemia- taking in little fluids −  activity − Fluids & fiber d) Cachexia − severe wasting ( HIV patients, End stage renal failure, Alzheimer’s patients) They are extremely thin, thay are literally starving to death e) Intestinal obstructions − NG Tubes, Suction after eating − NURSING CARE for GI: 1. Antiemetics (around the clock as ordered) normally 1 hour before chemo, BE PROACTIVE 2. Nonirritating low residue diets 3. Maintain fluids (Oral/IV) 4. I and O’s 5. Seitz bath (raw butt, from diarrhea) zinc oxide (couple a times a day) 6. Do not wear irritating fragrances around patient 7. Frequent weights, monitor weights to keep patient supplemented so that they don’t loose weight 8. Steroids (anti-inflammatory) given to prevent N/V, N/v is a SE from inflammation in GI tract, so therefore we now can give steroids 4. Skin Toxicity a) Hyperpigmentation-  stimulation of the melanin in the cells (color change) discolorations on their skin b) Photosensitivity--acceleration of the tanning process caused by the sun = they burn quickly c) Erythematous skin rashes--due to dilation of blood vessels in the skin − Red Rashes d) Desquamation due to radiation: i. Dry desquamation − Dry, flaky, itchy, irritated areas − Keep moist with unscented, non-alcohol lotion ii. Moist desquamation b)

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− Skin breaks down and skin becomes leaky − Keep clean & dry iii. * Keep both clean – Normal saline- Peroxide solution 1:1 mixture, use with a sterile sponge e) Radiation recall − Burn and shrink tumors − Radiation burns skin but it eventually heals & they are put on chemo and the skin breaks down again − Chemo can cause it to recall − Pain, high risk for infection f) Alopecia − Hair loss − After therapy hair will grow back − They need to determine what they will do about their hair before it is gone (wigs, scarf’s, etc…) g) Tissue Extravasation (more later) − Chemo (drug) has infiltrated and going into tissue − Causes severe tissue damage − Vesicant Chemo(will cause necrosis & death in tissues) - Never given in a peripheral line, Needs to be given in a central line − Central Lines 1. PIC Line- Midline - anticubital space 2. PICC Line - much longer − NURSING CARE OF SKIN PROBLEMS: a) Protect from extremes of temperature b) Don’t want pressure or trauma to area c) Don’t massage area d) Avoid the sun e) Avoid products with alcohol & perfume f) Loose Soft clothing g) Tissue extravasation method 5. Head − Cerebral edema − Caused by Radiation − Keep head of bed elevated – enhance venous flow away from head − Superior vena cava syndrome – Tumor in neck, head or upper chest, it impairs blood flow away from the superior vena cava = swelling, puffy face, changes in LOC 6. Chest − Esophagitis, Pneumonitis (Inflamed lungs), pulmonary fibrosis (Hardening of the lungs)

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− Impaired compliance & elastic recoil − NURSING CARE: a) Turn, Deep breath, and Cough (Incentive Spirometer) b) Fluids (Oral) c) Antitussive- Judiciously d) May need O2 (FIO2) e) Alternate Rest and Activity f) Steroids/Bronchodilators g) Expectorants 7. Pelvis − Cervix, endometrium, prostate, bladder, rectum − External beam and internal implants utilized; − SE include diarrhea, cystitis, vaginal, urethral, & rectal stenosis, sexual dysfunction as a result of bowel, bladder, & gonad irritation. − Sexual Function--radiation to pelvis whether by external beam or internal implant can: a) Narrow the walls of the vagina (teach about vaginal dilator and encourage continuing sexual intercourse, if desired, to keep vaginal walls open and flexible) b) Decrease vaginal secretions (teach to use lubricants) c) Inflame and scar vagina d) Partial or permanent sterility in males (sperm banking also in females so egg banking) e) Ovarian function can be eradicated totally f) Premature menopause g) Loss of libido h) Fatigue and weakness − NURSING CARE for Pelvic Complications: a) Shielding, can use shield if you’re trying to radiate b) Birth control while on chemo or radiation & up to 5 years after c) May need sperm bank or egg banking if treatment can make them sterile 8. Renal Toxicity − Risk for Hyperkalemia − Uric acid levels elevated- Gout − * Zyloprim (Allopurinol) help reduce uric acid levels − A lot of drugs are nephrotoxic −  uric acid with breakdown = Gout 9. Tumor Lysis Syndrome − Caused by breaking down cells

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− needs lots of hydration − * Manatole- hypertonic – then give diuretic to draw it back off 10.Neurotoxicity − damaged nerves − Impaired coordination- Safety Issue – Can’t walk straight − Paresthesia- numbness and tingling − Bowel and bladder atonia- inability to urinate normally or bowel problems − Proprioception is off (close eyes and touch nose, this pt may not be able to do it 11.Cardiotoxicity − B/c of chemo − kill cancer but now cardio in trouble − Damage heart with treatment, we did it to kill the cancer 12.Pain − Pain meds − Tolerance builds up − On unbelievable doses of pain meds, takes that much to keep them comfortable 13.Body Image − Impaired o Breast removal o Hair Loss o Colostomy o Amputations 14. Superior vena cava syndrome (SVCS) − Blood returns to heart − Tumor somewhere high in chest or neck and inhibits blood from returning to the heart − Altered mental status − Swelling in neck o Elevate head of bed o Seizure precaution 15.Spinal cord compression − Numbness − Inability to use extremities − Impaired coordination − Paralysis − * Debulking- reduce in size 16.Third spacing of fluids − Comes from Liver damage you develop impaired protein synthesis

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 COP – Liver cancer − Person stops eating and drinking have low protein 17.Paraneoplastic syndrome − Tumor secretes substances that mimic other hormones − Aldosterone, parathormone, ADH −

18.Second Malignancies − Had cancer years later on down the road they develop another kind of malignance in response to first chemo treatment − * CEA − * Lifelong monitoring 19.Death − Hospice care − Cancer Kills − Not qualified until 6 Months Left III. Theories of the Etiology of Cancer (there are many--these are only 2) A. Cellular Transformation and Derangement (crazy cells, altered cell growth) 1. Theory: Can occur from the cells changing into Cancer Cells 2. Agents: Some Drugs can cause cancer or Sun damage = skin cancer o Kaposis sarcoma tumor that people with HIV get o Hep B can cause Liver cancer o Factories = cancer o Asbestos = type of lung cancer o Birth Control pills lead to cancer o Smoking = lung cancer B. Immune Response Failure (The old gray mare she ain’t what she used to be) 1. Theory: The immune system surveys what is you and what isn’t you and whatever isn’t you the body is trained to attack! o We are living longer so we see more cancer 2. Immune response can be repressed by: − Immunosupressors: Transplant patients − Aging − Smoking and alcohol − Poor nutrition (good protein intake) − Chronic steroids

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− Stress IV. Basic Principles A. Differentiation is process where cells diversify and acquire specific structural and functional characteristics and mature. * Cancer cells lack differentiation!!! B. Cell cycle − life of the cell − Normal cells- go through normal cell life − Cancer cells- Do not go through normal cell life, do weird strange things, don’t follow the rules C. Contact inhibition − Normal cells have − Cancer cells do not − * When crowding occurs production of cells slow down, not in the case of cancer cells they just keep growing. D. Benign (spreads locally) − not recurrent or aggressive; does not metastasize; does not cause systemic symptoms or death unless it interferes with vital functions due to location, i.e. brain tumor (acoustic neuroma) E. Malignant (spreads far away) − undifferentiated, immature cells; invade, erode, & spread 1. Implantation- Local spreading 2. Cells can travel by vascular system 3. Lymphatic system F. TNM Classification System (Tumor, Node, Metastasis) − Also see chapter on breast cancer −

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T--tumor size (describes primary tumor) o T O (no evidence of tumor) o T IS (in situ) o T 1 (< or equal to 2 cm) o T2 (> 2 but not > 5 cm) o T3 (> 5 cm) o T4 (extension to chest wall, inflammation) N--degree of spread to nodes o N 0 (no evidence of lymph node involvement) o N 1-4 (ascending degree of node involvement) o N X (regional lymph nodes unable to be assessed clinically) M—metastasis o M 0 (no evidence of distant metastasis) o M 1 - 4 (ascending degree of metastasis)

3 Stages of cancer cell growth 1. Initiation--something causes cell’s genetic structure to change a. Chemical Carcinogens--Drugs, Chemicals, Diet

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b.

Physical Carcinogens i. Ionizing radiation--secondary cancer from radiation to primary cancer ii. UV radiation--short rays of sun worse iii. Foreign bodies—asbestos iv. Certain DNA and RNA viruses--oncogenic--can transform cells i.e., HIV ------>Kaposi's Sarcoma Hep B------->Liver cancer

2. Promotion − 2 mutations are required for cancer to develop in a cell; Proliferationof cells with first mutation leads to a population of cells where a 2nd mutation can occur. Some promoters are specific to specific cancers-Alcohol---->GI tract cancer Smoking--->Lung cancer Some carcinogens can initiate and promote cancer—ex: smoke 3. Progression − includes increased growth rate, invasiveness & metastasis. As tumor increases in size, it develops own blood supply--tumor angiogenesis. V. Prevention and Early Detection Very Important--Major role for nursing A. Seven Warning Signs a. b. c. d. e. f. g. B.

C-- Change in bowel or bladder habits A--A sore that does not heal U--Unusual bleeding or discharge T--Thickening or lump in breast or elsewhere I--Indigestion or difficulty swallowing O--Obvious change in wart or mole N--Nagging cough or hoarseness

Education 1. Diet high in vegetables, fruits, whole grains, vitamins A and C; Limit salt-cured, smoked, nitrite-cured foods, alcohol, fats 2. Avoid smoking, obesity, sunlight 3. Regular Physical Exam (Yearly after age 40) 4. Screening for all a. Skin inspection for changes b. Annual rectal exam after age 40 c. Annual stool for occult blood after age 50 d. Annual oral exam 5. Screening for women:

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Monthly breast self-examination after age 20 Mammogram every 1 - 2 years between 40 and 49, then yearly c. Regular (every 1 -3 years) Pap smear and Pelvic Exam Screening for men a. Testicular self-examination monthly b. Yearly rectal exam for prostate cancer a. b.

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VI. Treatment Modalities for Cancer A. Surgery 1. Diagnostic procedures (cytology specimens, needle biopsy, incisional biopsy, excisional biopsy) 2. Prophylactic 3. Curative--if believed can get it all 4. Palliative--done to help if benefit outweighs risk (debulking) (male less in size , makes things better but won’t cure a) To reduce pain b) To relieve obstructions (GI, GU, Resp, spinal cord, etc.) c) To prevent hemorrhage d) To remove infected and ulcerating tumors or drain abscesses 5. Reconstructive − restoration of form and function to improve quality of life B. Radiation Therapy (RT) 1. Goal: destroy cancer cells with minimized damage to other tissues; Destroys cancer cell's replication by damaging DNA. Cells that divide rapidly are more radiosensitive. Also, normal cells are more capable of repairing the DNA damage done by radiation. 2. Types of Radiation a) External RT—Teletherapy − Mark the site with a permanent marker, teach clients not to scrub it off, it needs to stay on − People go in- Radiation beams shot into them at certain level and depth − Not at risk to anyone else − Special making so radiation Therapist knows where to shot them − Can leave after therapy

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* Fractionation- breaks up into smaller livable doses of radiation, go in 5 days a week for a couple of weeks, damage bad cells & save good cells − *Alternate ports of entry, shoot them from different angles to try & spare good tissue b) Internal RT − Radiation into them − Risk for contaminating those around them/Are a danger to others − Two types of Internal RT: i. Sealed-Source RT (Brachytherapy) − have radiation placed inside of them in something sealed a) Intracavity − Capsule inserted in a cavity − Ex. Vagina − Foul smelling vaginal drainage = dead tissue − Need to be in a private room with lead lined walls − If it falls out you wouldn’t put it back in − Keep in Supine position AAT − You can get radiation from being near them − Typically don’t go home with these b) Interstitial (in the tissue) − Beads placed in knee (look like Mardi Gras Beads) − May go home with these o Must sleep in different bedrooms o Can’t hold grandchildren o Can’t hold grandchildren ii. Unsealed-Source RT − Floating around in them − Oral/IV − Body absorbs it − Vomit/Urine- does contain radiation o Gloves, eyewear, protective clothing o Flush toilet a couple of times iii. Radiation Safety −

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Time – 30 min per 8hr shift with them not @ one time b) Distance- Further away you are the better, do as much as you can from the door c) Shielding- lead lined apron d) Standards--safety officer, film badges (dosimetry badge) C. Chemotherapy - Antineoplastic drugs. 1. Goal: destroy malignant cells with minimal damage to others; disrupts development and reproduction of cells. Interferes with good and bad cells, thus a major limitation. Cells that are the most active and rapidly dividing are most sensitive (thus GI cells, hematopoietic system, and hair follicles are affected). One dosing does not kill all the cancer cells, thus takes repeat therapy. a)

2. Classification of Chemotherapeutic Agents − Classified according to pharmacological action and effect on cell cycle − Cell cycle specific--drugs that affect the cell during certain phases − Cell cycle nonspecific--drugs that do not require the cell to be in a specific phase to be effective − Combination therapy—enhances effectiveness 3. Administration Safety a) Safe Preparation and handling − Gloves − Eyewear − Gown b) Safe Disposal − excretions could be dangerous − Test Question: Person getting chemo actively vomiting what should you wear? EYEWEAR, GLOVES, GOWN − Urinate in bed? WEAR GOWN/GLOVES − Double flush, clean toilet after with bleach after they have used it 4. Chemotherapy Administration Routes--must know if vesicant or not a) Intravenous 1.Peripheral Access--peripheral line or PIC (midline)

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EXTRAVASATION MANAGEMENT: (Infiltration) i. Stop Drug Infusion ii. Take all fluid down disconnect IV lineLeave Iv Cath in iii. Syringe/Aspirate on IV Cath try to aspirate back as much fluid as you can iv. Find out antidote- Bicarbonate v. Inject/Deliver antidote in cath, will go into the tissue vi. D/C cath vii. Apply cold compress to vasoconstrict Typically, unless it’s a vincadrug = warm compress viii. Elevate Extremity to stop swelling ix. Check ups – asses very often & document findings, VERY OFTEN (maybe every 0 minutes) If possible take a picture of it right after it happens − If not a vescant can put in a peripheral line − Flush line to check patency − Can give a vesicant through a PICC, but not a PIC 2. Central Vascular Access a) Central venous catheter − Central line − PICC – subclavian or juglar central line, have to be flushed periodically, o NS & then Heparin behind it, must do site care o @ risk for infection o use sterile technique b)Implanted Venous Port--Venous Access Device (VAD) − Example is a Port-a-Cath or Bard Implanted Port on chest or Omaya Reservoir under scalp (Mediport) 3. Other less common routes − Topical, oral, SQ, IM, or − Intrathecal (lumbar puncture to get to brain and spinal cord) − Intraarterial (into an artery that feeds a tumor) − Intrapleural (into intrapleural space of lungs) −

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− Intraperitoneal − Intravesicle (bladder empties first, then must retain 1 - 3 hours) 4. Outpatient Chemo Administration − Nurse must teach client: o SE to expect o Safe Storage o How to handle equipment o Double flushing, cleaning toilet with Clorox o Washing contaminated linens once by themselves & then with other things D. Bone Marrow Transplantation (BMT)--goal is cure. − 3 Types of Bone Marrow Donors: a) Autologous – Self, saved & stored, can take out own BM b/f treatment & if cancer isn’t in BM, they can then put back in their own healthy BM b) Syngeneic – Twin, someone just like them c) Allogenic – Parent, Brother, Sister & Family Member − Stem Cell transplantation o Take from someone else & inject it into you & it ends up in the Bone Marrow Graft (gift)-versus-Host Disease (GVHD) o Normally worry about body rejecting the graft, where the body realizes that it’s not a part of you, so it starts to attack it. o With this the Graft ends up attacking the host  Someone who is immunocompromised the healthy graft ends up attacking the sick tissue o Will see N/V/D, skin rashes, jaundice & fever o Give steroids or immune suppressants to suppress the graft − STEM CELLS IN BONE MARROW 1. Myeloid Cells a. Erythrocytes: RBCs b. Thrombocytes: Platelets c. Leukocytes: WBCs − Monocytes: − Phagocytic − Only 4-8 % of WBCs −

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2nd response

2. Granulocytes a. Neutrophils − Phagocytic − 50-70% of WBCs − 1st response b. Basophils − Release histamine and heparin in allergic response < 2 % of WBCs c. Eosinophils − Neutralize histamine − Defend against parasites − 2-4 % of WBCs E. Biologic Response Modifiers − Biotherapy, obtained through genetic engineering a) Purpose is to strengthen and manipulate the immune system. b) Examples of Biologic Response Modifiers: 1. Monoclonal antibodies (MoAbs)--used diagnostically to identify tumor cells, as a delivery agent of radioisotopes to tumor site, and to deliver immunotoxins to tumor site 2. Interferons (IFN)--small proteins with cellular activity in three areas: antiviral immunomodulatory, and antiproliferative 3. Interleukins--produced by lymphocytes and function to promote normal hematopoiesis. Responsible forgrowth of T cells. Side effects as well as desirable effects. (Ex: capillary leak syndrome leading to edema.) 4. Colony stimulating factors (CSF)--do not treat cancer but help with negative effects of treatment A. Erythropoietin (EPO)--FDA approved; affects erythrocyte production; Also used in clients with anemia in end stage renal failure. o Procrit or Epogen B. Neupogen – makes WBC o Neumega makes platelets 5. Tumor necrosis factor (TNF)