Nursing 151 Cancer notes

1 She starts with the most common types of cancer, bottom of page 1 - just the first couple for both men and women, they don’t include skin cancer terms top of page 2 stem cells: embryonic stem cells, these are what there is so much controversy about but also stem cells in many tissues of our body, called mature or adult stem cells there’s a theory that cancer wants to attack stem cells proliferation, reproduction or multiplication of cells, important with cancer because cancer causes cells to go haywire and then they proliferate, often at an increased rate Differentiation specialized, specialization, such as in an embryo, cells begin to specialize in to what will be lung tissue, skin tissue, organs, specification of a stem cell, purpose and function, they become a specific part of the body again important when a cell is attacked by a carcinogen and there is a mutation in the cell, there’s a change in the ability of that cell to differentiate, to continue to look like the mother cell poorly differentiated, on the chart, means that the cells in the tumor have gone through so many mutations that they no longer look like or function like the original tissue, example: uterine carcinoma, they don’t look or function like the original cells of the uterus more importantly it means they do not respond to treatment well, resistant to treatment so poorly differentiated is a bad thing

malignancy and benign both are tumors, or excessive cell growth benine: hasn’t spread or encroached on surrounding tissue, hasn’t gone through the lymph node system or the blood system and metastasized to other parts of the body, its contained, often encapsulated malignancy: it has infiltrated surrounding tissue, may have infiltrated the lymph or blood systems and gone to other parts of the body and of course the usual, malignant is usually classified as cancerous, benign as noncancerous neoplastic or neoplasm: uncontrolled cell growth, both benign and malignant are neoplastic, benign just has not metastasized metaplasia: change of cells to another type of cell due to outside stimulus, such as smoking causing a cancer on the lip dysplasia: bizarre cell growth, often in reference to the cervix and cervical dysplasia in women anaplasia or anaplastic: low degree of differentiation, poorly differentiated more stuff on the top of page 9

How cancer affects the cells of the body, there has to be some carcinogen on the nucleus of a cell that impacts the DNA of the cell, the DNA mutates and is rearranged in a cell loses its properties and divide indiscriminately contact inhibition: normal cells start encroaching on other cells and kind of stopped growing, they respond to the boundaries of other tissues or other cells, one theory is that cancer cells lose the property of contact inhibition which would stop them from spreading to other organs, then they continue to mutate and divide indiscriminately, grow more rapidly than other cells or tissue part of cellular proliferation

another theory is cellular differentiation (bottom of page 2) proto-oncogene: a lock or gene that keeps the cells functioning the way they’re supposed, these are a good thing, what keeps ourselves abiding by the program, doing what they’re supposed to do but when the cell is confronted by a carcinogen and mutates the genes are converted to oncogenes: tumor inducing genes, they allow for the growth of the tumor cells can show properties similar to those in fetal development, so in lab tests from body fluids they can get CEA: carcino embryonic antigen, a protein, also found in fetal development but disappears when the baby is delivered, so if they find it in the blood or fluids it’s a pretty good indicator of cancer AFP, alpha fetal protein, similar to CEA, usually found in fetal development, disappears after birth, also an indicator of cancer is found in fluids

Stages of cancer: initiation, promotion, progression mutation in the cell’s genetic structure may be inherited, an error during DNA replication, or exposure to a carcinogen

carcinogen: something that causes cancer, may be a chemical, physical element, inherited Chemical/drugs: radioactive chemicals, soot (chimney sweeps) developed a lot of scrotal cancer that progressed into lung cancer some chemotherapy drugs can initiate another type of cancer, usually some type of leukemia hormone replacement therapy can initiate breast cancer or uterine cancer at first we said asbestos but later she clarified to classify that as a foreign body physical: the sun (UV radiation) - basal cell or squamous cell carcinoma, one blistering sunburn as a child doubles your risk for cancer x-ray - ionizing radiation, gamma rays genetic: certain types of cancer, breast cancer, uterine cancer, colon cancer, leukemia (in identical twins) viruses: Epstein-Barr can lead to lymphoma, AIDS can lead to capose’s (?) sarcoma, HPV can lead to cervical cancer, other spontaneous viruses

Wrapping up the initiation can be an error in DNA or a carcinogen there’s a latency period between exposure and when the cancer appears up to four years

Promotion promotion is reversible, initiation is not, there’s things we can do to diminish promotion dietary fat: a high-fat diet can contribute to the development of cancer, breast cancer, gallbladder cancer low fiber contributes to colon cancer protein deficiency, especially for patients already with cancer, develop anorexia, can go into a negative proteins status, makes it easier for the cancer to overtake the body, want to look at proteins stores and pre-albumin levels fresh vegetables help to resist cancer, want green, yellow, and orange vegetables: sweet potatoes, carrots, red yellow green and orange peppers, corn, spinach, squash, broccoli, broccoli, broccoli alcohol consumption, oral cancer, esophageal, liver, when combined with smoking a greater incidence of head, neck, esophageal and bladder cancer “Lightly” educate the patient, don’t want to scare them stress, severe and prolonged stress, not like the regular stress of nursing school, such as with abdominal surgery, and then they dehisce, and won’t heal, and go into surgery after surgery, or from a trauma that will take multiple surgeries over a year to put them back together complete carcinogen, they can initiate, promote, and progress cancer, smoking is a complete carcinogen

Progression increase in growth rate of the tumor, increased invasiveness and metastasis cancer may not be identified until it reaches this stage, silent cancers like ovarian, usually very advanced once it’s discovered tumor angiogenesis: tumor develops its own blood supply, they’re working on drugs to counteract this, to diminish the tumor by depriving it of oxygen and nutrients, then use other treatments to finish it off

Immune system immunologic surveillance: there are antigens or proteins on all of the cells of the body called cell surface antigens, cancer will cause a change in these antigens to a TAA - tumor associated antigen, lymphocytes and other cells identify the TAA and attack the cell, done through the T cells (lymphocytes are divided into T cells and B cells), they work to kill off the cells she came back and made a note that TAA is on the cell instead of the normal cell surface antigen, the immune system identifies these and kills the cell off using T cells, natural killer cells, macrophages natural killer cells: also try to destroy those cells, lyse tumor cells macrophages: engulf/lyse the cells B lymphocytes: build anti-bodies against the cancer producing cells T cells produce cytokines, proteins, two types are interleukin-2 and y interferons, kind of like a biofeedback, the immune surveillance system identifying an abnormal cell, initiates increased production of T cells, T cells increase production of interleukin-2 and y interferons, which stimulate more T cells, natural killer cells, b lymphocytes, macrophages later she came back to say interleukin-1 (I think that should be interleukin -2) and y interferons stimulates T cells (check out the interleukin 1 vs. 2) Important to maintain a strong, healthy immune system stuff on page 6, middle TNF: tumor necrosis factor, make sure you know that, causes hemorrhagic necrosis of tumor cells macrophages also secrete colony stimulating factors (CSF), this is fabulous, regulate and produce the cells in our blood system, can initiate the production and maturation of WBC’s, RBCs and platelets, all which are impacted by chemotherapy and radiation therapy, and macrophages stimulate the production of these, these can now be produced synthetically and injected into patients (I think she means the CSFs) macrophages also secrete cytokine, interleukin-1 (IL-1) which stimulates T-cell production a wonderful wonderful system

Role of the nurse, teaching and prevention stuff on the bottom of page 6 vitamin A: protects the immune system and contributes to cell differentiation, counters cancer which wants to undifferentiate cells, vitamin A tries to keep the cell going with the program and to stay specified and differentiated foods with vitamin A: carrots, dark green leafy veggies, eggs, whole milk, pumpkin, sweet potatoes, liver, spinach (be sure you can identify that) exercise: 30 minutes or 10,000 steps per day rest: patients don’t get to sleep very well in the hospital, one reason for quick discharge

seven warning signs of cancer (caution) change in bowel or bladder habits: constipation or diarrhea, difficulty having a BM, change in size, pencil like, changing color, over a period of time, usually an obstruction, some type of tumor, difficulty urinating, difficulty maintaining a stream of urine (prostate), blood in urine or stool many developed rectal fissures, a store near the rectum that bleeds, it’s like go unchecked can contribute to cancer a sore that constantly weeps, doesn’t heal, over a series of weeks obvious change in a wart, mole, or freckle, evaluate monthly

from example, risks for ovarian cancer hormone replacement therapy, history, family history, overweight, not having kids, age

Diagnosing cancer can take some time and usually involves a biopsy but they also look at family history (ovarian cancer on the mother’s side, colon cancer on the farther side), exposure to carcinogens (agent orange or radiation if in the service, what kind of house you live in for lead paint), chronic inflammation, fisher that went unattended, medications such as hormones, prednisone can cause cancer, dietary habits, high-fat diet associated with breast cancer, physical exam and diagnostic studies CBC can be elevated due to a tumor, angiogenesis increases the blood supply which increases blood counts SGOT refers to liver enzymes, elevated may indicate liver cancer CA125, normal is 35 or below, elevated may indicate ovarian cancer, may be clear up in the thousands CA 19-9, indicator for pancreatic and hepitobiliary (?) cancer PSA, prostate specific antigen, for prostate cancer, normal is 0 to 4, this is very important, risk of prostate cancer increases with age, many many many elderly men develop prostate cancer, unusual at younger ages and will be treated very aggressively and follow them the rest of their lives cytology testing: insert a needle into the site and draw some of the cells, view them under a microscope fiber-optic scopes for colonoscopies, etc.

biopsy the most definitive diagnosis specimen is taken, fine needle aspiration, large bore aspiration, incisional (may remove entire tumor) info on benine versus malignant top of page 9

early detection Self breast exams, should be done roughly one week after period, men can examine their breasts as well mammogram, if no history usually done around age 40, then every 2 to 3 years until 50, then every year testicular, started age 40, earlier if you suspect, self exams feeling for lumps should be done monthly after puberty, feels like a pea, rectal and prostate starting at age 50 unless suspicious Pap smears start at age 18 or when they become sexually active if younger skin inspection should be done monthly

skin cancer basal cell carcinoma: least invasive, can be cured if detected early, arises from the lowest layer of skin, the basal layer, shiny, pearly, raised area on the skin, can also look like a reddish scaly patch on the skin, but more likely the shiny pearly raised bump, can be from sun exposure, on the back of the hands, back of the ears, face, these will be excised (removed) or frozen, usually under local anesthesia, not likely to spread squamous cell carcinoma: more invasive, harder to treat, especially if not detected early, looks angry, may have a crater, back in the hands, ears, edge of the lips, head, neck, upper back, also especially if exposed to sun, red scaly itchy and weep, doesn’t heal (the sore that doesn’t heal), can spread to other parts of the body, spreads through the lymph nodes and bloodstream to other organs and tissues if basal cell and swami cell are caught early they rarely result in death malignant melanoma: least common type of skin cancer but the most lethal, can arise on a normal patch of skin anywhere on the body, under the nail bed, between the toes, perineal area, these do metastasize and spread to other parts of the body

Detection of melanoma: ABCD, looking at existing freckle or mole asymmetry is bad borders, notched or irregular, uneven is bad color, red, blue, black, brown, beige, differentiate and color, not all one color is bad diameter, quarter inch, size of an eraser is bad

staging and grading Once diagnosed, want to identify the primary site, where did it originate (grading), has it metastasized, how big is it (staging) start with a baseline at diagnosis, before treatment use numbers, 1 to 4, how large it is, whether or not it’s metastasized, degree that it resembles the primary tumor, higher number means there’s been more mutations in that it doesn’t really resemble or function like the original tissue, so essentially grade 4 is poorly differentiated

TNM classification: top of page 11 Tumor, Nodes (lymph nodes), Metastasis all on 0 to 4 scale

Cancer management about 65% now live beyond five years, if not cured then controlled like a chronic illness, otherwise then palliative care, how to maintain comfort and quality of life for the patient

treatment modalities: bottom of page 11, surgery, radiation, chemotherapy, biologic response modifiers, synthetically developed drugs, colony stimulating factors, promote the growth of RBCs, WBCs, and platelets, she sees them as rescue drugs to help the body catch back up after chemotherapy, radiation etc. may use one or all four, may be in different sequences, may want to shrink the tumor with radiation or chemo before taking it out with surgery, or they may do the surgery and follow it up with chemo and/or radiation debulking: go in and take as much of the tumor out as possible, but some will be left behind, have to follow-up with radiation or chemo, they didn’t get all of the cancer, “the word debulking is significant, remember it, underline it” laparoscopic surgery: exploratory, go in with a scope and look around, through a hole with a tube and a light laparotomy: usually cut open, open it up and look at everything, pulling organs out, biopsies, they have to recover from surgery before starting with chemo or radiation

Radiation therapy uses gamma rays that break the chemical bonds of DNA, then the cancer cells cannot survive mitosis, results and cellular death at the time of cell division, however it can’t distinguish between cancer cells and normal cells so the normal cells in that area will be impacted as well, the radiation physician have to consider where the cancer is located and how the dose of radiation will impact normal cells, then determine the number of minutes and days of the week three tissues of the body that multiply divide and replicate very quickly: hair follicles, epithelial lining of the GI tract, bone marrow, these things are easily impacted by radiation, especially a problem in areas like the pelvis with a lot of bone, results in bone marrow suppression external radiation: teletherapy, there is a distance between the emission of radiation in the site, they will x-ray and marked a specific area, there may be a form that holds it in a specific place, want to narrow the field as close as they can, want to make sure to hit the exact same site every time, can be done outpatient, usually five times a week and rest over the weekend, the patient is not emitting any radiation to others outside of treatment, no safety issue to others internal radiation: brachytherapy (close therapy) the nurse really gets involved with this one insert a catheter or tube into the tumor or near it, temporary - insert a radioactive substance that remains for a period of hours or days, high-dose temporary versus low-dose temporary high-dose temporary: insert a ribbon of radiation, possibly through a large number of catheters, remains several minutes, then the ribbons are removed, repeated every day, we may have very specific instructions for turning and repositioning, or we may not be able to move them so that the catheters stay in place, the patient is no longer radioactive when they come back to the room

internal temporary low dose: they insert the catheter in the radioactive substance which remains in them when they come back to the room, they are radioactive to their environment, important principles of time, distance and shielding 1. they have to be in a private room, 2. The radiation officer has to check that the road has lead walls, 3. All the nurses that help with that patient where a radiation uptake badge, only allowed to have exposure to the patient 30 minutes per shift, can’t take care of more than two patients with low dose radiation in one shift (two patients in one shift, 30 minutes each) visitors are not allowed more than one hour per day, per 24 hours, no one under 18 or pregnant should enter the room, the door should be kept closed, these patients are usually not up and moving but if so they should not go into the hallway, they feel very isolated if the substances in the abdomen, the nurse should perform their assessment from the head of the bed, use the shield if you get close change sheets only when absolutely necessary, avoid bed baths, double flush

Permanent internal implant radioactive seeds are inserted, usually left in place, radiation exposure to others is very low, period of time where children should not sit on their lap, can’t have intercourse, double flush, radiation diminishes over time

Side effects of radiation therapy fatigue, the tumor releases a substance that causes fatigue in the muscles loss of appetite, anorexia, two important lab values, know these, albumin and pre-albumin, normal albumin is 3.5 to 5, half-life of 21 days, so its value reflects what’s been going on for almost a month, normal pre-albumin is 15 to 36, half-life of 1.9 days, a snapshot of the nutrition right now, we’ll get both when we start TPN to see how they’re progressing teaching: explain that it can occur, proper nutrition, light exercise, short naps, perhaps began walking as exercise, walking releases endorphins which decreases depression and anxiety, also know that three drugs to stimulate appetite and to decrease N&V
Magace: hormone, stimulates appetite, can also be used as a chemotherapeutic agent, given orally
Marinol: synthetic marijuana, increases sensation of well-being and appetite
Reglan: helps the stomach to empty, diminishes the feeling of fullness when the patient first starts to eat,

review Reglan: unique characteristic, increases gastric emptying, remember that risk of bone marrow suppression from radiation therapy and greater risk from chemotherapy, RBCs, WBCs and platelets are all formed in the bone marrow

WBCs: turnover rate (life span of) is 1 to 2 weeks, decreased WBCs causes risk of infection, neutropenia is a big risk factor platelets: turnover rate of 2 to 3 weeks, low platelet count is thrombocytopenia, normal range is 150,000 to 400,000, they’ll let it go very low for chemotherapy or radiation therapy it may go down to 50,000 and they won’t change dosages etc., but in the 50,000 to 90,000 range the patient is really at risk of bleeding, probably more so with chemo than with radiation signs and symptoms of bleeding: petechiae (pinpoint red dots, usually on the thorax), so do a really good thorasic assessment when they have low platelets, bruising, gums from brushing teeth, stool - maybe orders for occult blood (she said it’s a little hard to see blood in the urine, has to be pretty frank??), oozing from an IV site, stiff distended abdomen, tell the physician about any of these treatment for thrombocytopenia: platelet transfusion, would not have them on Coumadin or heparin at this point, may give them a biologic response modifier to promote platelet production RBCs: anemia, live 2 to 3 months, normal level is 4.0 to 6.1, as it declines looking for signs of anemia, poor tissue perfusion, capillary refill shortness of breath, hemoglobin hemoglobin: want it to be 10 or above, want well oxygenated cells, radiation therapy is more effective against well oxygenated cells really watch the test questions for external versus internal radiation therapy, if it’s internal is it permanent like the seeds or temporary with a catheter in place, then also high-dose temporary or low-dose temporary, study them all carefully and note the differences

External radiation has to go through the skin, so the skin at the site will be impacted dried desquamation, what you’ll probably see first, itching redness and flaking, very dry, the outer cells - epidermis -is being destroyed, hopefully the cells can recuperate especially over the weekend, it progresses becomes wet desquamation wet desquamation: when the outer epidermis is more fully deteriorated and there is oozing and weeping and risk of infection, vesicles, painful, lower levels of skin are impacted, don’t wash off the markings (but then after Erin asked she said the markings are tattoos and won’t wash off anyway, whatever)

Oral or esophageal radiation dry mouth, mucositis, swelling of the glands that produce saliva, very difficult to eat with a dry mouth, difficulty swallowing, like they’ve got a lump in her throat, loss of taste, cavities encourage lots of fluids, cleansing (saliva also protects us from infections) gargling with solution of 1 L water and a teaspoon of salt, add baking soda (sodium bicarbonate) if they’re having mouth odor problems from dry mouth and sores big concern becomes nutrition, if they don’t eat, fluids, electrolytes, protein, same as with chemo they may not want to use TPN because it can feed the tumor and make it grow

Pulmonary effects of radiation can be more of a factor because there aren’t other tissues to help absorb it loss of surfactant, causes alveolar collapse, SOB, cough, SOB and cough is what brings most lung cancer patients into the hospital, so they may think it’s bad in that they are relapsing, we have to explain that it’s a normal reaction to the radiation also inflammation of lung, pain, fatigue they’ll need antibiotics, expectorants to help them get the fluids out, repositioning, elevate HOB, O2 /// stopped here for flashcards
GI tract and radiation GI cells are highly proliferative (rapid turnover rate), means they will be impacted by the radiation or chemo, means it will knock out the good GI cells along with the tumor, results in nausea and vomiting, serotonin is released by the GI tract and sends a signal to the chemo receptor triggers of the brain, causes extreme N&V, can also develop severe diarrhea, so bad that they can’t leave the house, rectum gets very red and painful, SIDS bath can help to relieve and heal, will give anti-spasmodics and antidiarrheals educate them to call immediately, not to wait a day or two

Reproductive organs in the abdomen uterus, cervix, testicles, sperm production women are the stronger sex, uterus and cervix can tolerate higher doses of radiation than the testicles can cause fissures or fistulas to develop, recto vaginal fistulas - can have stool coming through the vaginal canal, can be the result of the nature of tumors in this area, especially for women in the reproductive organs, they can be very silent until they have progressed

Coping with radiation therapy may have to take it five days a week, may be fatigue, changes in blood counts, creates new demands on the family, dealing with side effects nurses often the one evaluating the patient, following up, all of the teaching

Chemotherapy most effective when the tumor has a high mitotic rate, it’s proliferating, the cells are undergoing mitosis, this is usually occurring in smaller tumors and younger tumors, and larger tumors the cells have gone through a self cycle and end up in a resting stage, no longer going through mitosis, once they’re in the resting stage chemotherapy can’t do much to them the larger the tumor (tumor burden ) the harder it is to eradicate, along with the resting state they may have gone through more mutations so they’re not responsive to the usual treatment

first line regimen/therapy the drug of choice, regimen based on what’s been shown to work the best looking to see if the cancer is responsive to the first line therapy see if the cancer has progressed which means it’s not working second line regimen the next option if the first line doesn’t work adjunct treatment
Also concern if they chemo agent will reach the tumor many do not cross the blood brain barrier but they’re developing good ones for this
Nonresistance cells: the ones that have mutated or are in a resting state less responsive to treatment (does this make sense? Aren’t they actually resistant)

Psychological and physiologic response of the patient if they embrace the treatment, do what they need to do, have a positive outlook, can have a positive impact

Methods of chemo administration basically anything you can imagine, middle of page 16 intraperitoneal catheter: into the abdomen, 2 L of fluid put in with the chemo agent, dwells for four hours, bring it back out Ommaya reservoir: in the brain, insert a catheter and insert the chemo agent directly at the site intrathecal: into the spinal column Oral, intramuscular, IV
IV: Central line: PICC, Hickman, porta cath is the most common, usually a dedicated line just for chemo with IV it’s a vesicant (damages tissue), “if the chemo infiltrates out of the vein into the tissue it’s going to cause necrosis of the tissue, death of tissue ”, the infiltration is called an extravisation, this is why we want to use a dedicated Central line Hickman: tunneled under the skin into the subclavian, advantage that everything is under the skin, then the patient can work with the catheter, access it, hook things up, fluids or TPN, can do it all themselves at home, many do a lot of their care at home

Extravasation stop the pump immediately if we suspect an extravasation (similar to a PCA and RR is