Nursing Management in Cancer Care

Larry Santiago, MSN, RN

7 Warning Signs of Cancer

Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty in swallowing Obvious change in a mole or wart Nagging cough or hoarseness

Benign Tumors
Benign Not recurrent or progressive. Opposite of malignant

Pathophysiology of the Malignant Process

Characteristics of Malignant Cells
- All cancer cells share some common cellular characteristics - Cell membrane of malignant cells contain proteins called tumor-specific antigens, such as carcinoembryonic antigen and PSA

Pathophysiology 2
Invasion growth of the primary tumor into the surrounding host tissues Metastasis dissemination or spread of malignant cells from the primary tumor to distant sites

Detection and Prevention of Cancer

Primary Prevention - Use teaching and counseling skills to encourage patients to partipate in cancer prevention and promote a healthy lifestyle

Detection and Prevention of Cancer 2

Secondary Prevention Examples breast and testicular selfexamination, Pap smear

Detection and Prevention of Cancer 3

Tumor Staging and Grading
Staging determines size of tumor and existence of metastasis Grading classifies tumor cells by type of tissue

Cancer ManagementCure, Control, or Palliation

Surgery

Radiation

Chemotherapy

Chemotherapy problems
Myelosuppression Pulmonary or cardiac toxicity Nausea and vomiting Extravasation Hypersensitivity reactions Neuropathy Pain at the injection site Flulike syndrome Hyperglycemia

Cancer ManagementCure, Control, or Palliation

Bone marrow transplantation

Nursing Process: The Patient with Cancer

Risk for Infection Impaired Skin Integrity Impaired Oral Mucous Membrane: Stomatitis Imbalanced Nutrition: Less Than Body Requirements Fatigue Chronic Pain

Leukemia
A neoplastic proliferation of one particular cell type (granulocytes, monocytes, lymphocytes, or megakaryocytes) Common feature is an unregulated proliferation of WBCs in the bone marrow

Acute leukemia
Progresses rapidly; characterized by ineffective, immature cells in the bone marrow pushing out the normal cells. Acute myeloid leukemia (AML)--adults Acute lymphocytic leukemia (ALL)--children Signs and symptoms: Pallor, headache, fatigue, malaise, loss of appetite, weight loss, tachycardia, shortness of breath, petechiae, ecchymosis, splenomegaly, and bone tenderness.

Acute myelogenous leukemia (AML)

Normally, myelogenous line of cells mature into neutro-phils, monocytes, eosinophils, RBCs, and platelets. AML develops when cells commit to one type, typically neutrophils. Diagnosis: Bone marrow biopsy Prognosis: Favorably affected by age under 60 years, spontaneous rather than secondary leukemia, WBC less than 10,000/mm3 and remission after one round of chemotherapy.

AML treatment options

Induction chemotherapy Goal is remission Cytosine arabinoside and an anthracycle Postinduction therapy (consolidation) Goal is to prevent relapse after remission, but effective in only 25% to 35% of patients. High-dose cytarabine has improved duration of first remission in young patients with AML. Options: Standard chemotherapy, autologous stem cells, or human-leukocyte-antigen (HLA) matched sibling or donor (allogenic).

Acute lymphocytic leukemia (ALL)

Rapidly developing immature lymphocytes crowd our normal cells Poor prognostic factors: High WBCs (> 25,000/mm3 at presentation), age over 50 years, and slow first remission (longer than 4 weeks). Treatment - Induction chemotherapy, administered in two phases, followed by maintenance therapy for up to 36 months. Goal is complete remission.

Chronic leukemia
Progresses slowly and rarely affects people under age 20. Chronic myeloid leukemia (CML) strikes ages 40 to 50, more in males. Chronic lymphocytic leukemia (CLL) strikes after age 40 and is most common in older men.

Chronic myeloid leukemia (CML)

Too many neutrophils and the presence of the Philadelphia chromosome. Chronic phase follows an indolent course, mild symptoms, <10% blasts in the marrow. Accelerated phase characterized by spleen enlargement and progressive intermittent fevers, night sweats, and unexplained weight loss. 10% to 30% blasts and promyelocytes. It last 6 to 12 months. Blast phase characterized by transformation to a very aggressive acute leukemia. 30% blasts and premyelocytes; patients die in this phase.

CML treatment options

Kinase inhibitor imatinib (Gleevec) is treatment of choice Interferon alpha reduces growth and division 55% to 60%. Hydroxyurea may prolong the chronic phase. Stem cell transplant--greatest risk of dying in the first 100 days.

Chronic lymphocytic leukemia (CLL)

Average survival is 2.5 years for advanced disease and 14 years for those with earlystage disease. Indolent disease characterized by lymphocytosis, lymphadenopathy and hepatosplenomegaly. Risk of death from infection as the disease advances.

CLL treatment options

Standard chemotherapy, which can produce a remission not a cure and has harsh adverse reactions. Usually delayed till signs and symptoms appear. Chemotherapy, radiation, and Rituximab to enhance the response.

Lymphoma
Neoplastic disease in which lymphocytes undergo malignant changes and produce tumors Classified as Hodgkins disease (accounts for 12% of lymphomas) and non-Hodgkins lymphoma (NHL) Hodgkins disease accounted for 5 % of all cancer diagnoses in 2005; 3% NHL

Stages of lymphoma
Stage I involves a single lymph node or localized involvement Stage II involves two or more lymph node regions on the same side of the diaphragm Stage III involves several lymph node regions on both sides of the diaphragm Stage IV involves extralymphatic tissue, such as the bone marrow

Hodgkins treatment options

Radiation is treatment of choice for stage IA or IIA nonbulky (<9 cm) Hodgkins. Over 95% achieve complete remission and 90% survive beyond 20 years. Chemotherapy is appropriate for stage IIIB or IV, bulky disease. Standard ABVD (adriamycin, bleomycin, vinblastine, dacarbazine) regimen is used.

Non-Hodgkins lymphoma (NHL)

Incidence has increased about 7% annually over 20 years, primarily older adults. Cause is unknown but increased risk: long-term immunosuppressant therapy, bone marrow transplant, inherited immune defects, rheumatoid arthritis, and prior Hodg-kins disease and treatment. Spread through the bloodstream.

NHL Treatment Options

Radiation, chemotherapy, or both Stem cell transplant for recurrent disease

Multiple Myeloma
A malignant disease of the most mature form of B lymphocyte

Multiple Myeloma 2
Clinical Manifestations Bone pain Hypercalcemia Renal failure Anemia Oral hemorrhage Fatigue, weakness

Assessment and Diagnostic Findings

Medical/Nursing Management