Presentation on theme: "Cancer Lake Sumter Community College Irene Owens MSN, FNP Fall 2010."— Presentation transcript:
Cancer Lake Sumter Community College Irene Owens MSN, FNP Fall 2010
2 Cancer Statistics (NCI, 2003 a; WHO, 2003) Cancer rates will increase by 50% to 15 million new cases in The three leading cancer killers worldwide are lung, stomach, and liver cancers. Industrial nations with the highest overall cancer rates Developing countries with the lowest cancer rates Overall cancer incidence and mortality Statistics for mortality and incidence of all cancers vary by race, socioeconomic disparities and unequal access to medical car. Cancer rates vary relative to select demographic variables.
2005 Estimated US Cancer Cases* *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, Men 710,040 Women 662,870 32%Breast 12%Lung & bronchus 11%Colon & rectum 6%Uterine corpus 4%Ovary 4%Non-Hodgkin lymphoma 4%Melanoma of skin 3%Thyroid 2%Pancreas 2%Urinary bladder 20%All Other Sites Prostate33% Lung & bronchus13% Colon & rectum11% Urinary bladder6% Melanoma of skin4% Non-Hodgkin lymphoma4% Kidney3% Oral Cavity3% Leukemia3% Pancreas2% All Other Sites18%
2005 Estimated US Cancer Deaths* ONS=Other nervous system. Source: American Cancer Society, Men 295,280 Women 275,000 25%Lung & bronchus 15%Breast 10%Colon & rectum 6%Ovary 6%Pancreas 4%Leukemia 3%Non-Hodgkin lymphoma 3%Uterine corpus 2%Multiple myeloma 2%Brain/ONS 24% All other sites Lung & bronchus32% Prostate10% Colon & rectum10% Pancreas5% Leukemia5% Non-Hodgkin4% lymphoma Esophagus4% Liver & intrahepatic3% bile duct Urinary bladder3% Kidney3% All other sites21%
Cancer Death Rates*, by Race and Ethnicity, *Per 100,000, age-adjusted to the 2000 US standard population. † Hispanic is not mutually exclusive from whites, African Americans, Asian/Pacific Islanders, and American Indians. Source: Surveillance, Epidemiology, and End Results Program, , Division of Cancer Control and Population Sciences, National Cancer Institute, 2003.
9,000 new cases of childhood cancer 1,500 deaths One third die from leukemia 5 year survival for childhood cancer is 75% 10 year survival approaches 70%
Changing Cancer Statistics Aging –Elderly will double from 1.3 to 2.6 million from Diversifying –25% Hispanic –25% African American, Asian American and Native Americans –50% population ethnically and culturally diverse
Cancer Survival Increasing 9.3 million Americans have a cancer history Represents 3.4 % US population 14% diagnosed over 20 years ago
Development of Cancer Cellular Immunologic Genetic Environmental
Cancer Development Environmental Factors ----Chemical: Tobacco, alcohol, asbestos, pesticides, hair dyes, preservatives, etc. ----Physical: radiation, chronic irritation, sunlight ----Viral: HPV
Cancer Development Personal factors: age, immune factor, genetic risks, host susceptibility, lifestyle, risky health practices, gender, socioeconomic factors, race Psychosocial Factors: Socioeconomic Factors: Barriers to access, poverty, no insurance, lack of education, lack of early detection
Normal Cells vs. Cancer Cells Normal vs Cancer Cells Page 402 in Iggy
Characteristics of Cancer Cells Lack of contact inhibition Inability to differentiate Cancer cells derive from a single cell Abnormal cellular proliferation Local tumor formation Invasion of surrounding tissue Ability to metastasize
Pathophysiology of Cancer Development Initiation: Normal cell exposed to any carcinogen ( initiator), the normal cell’s DNA can be damaged or mutated. A carcinogen is any chemical, physical, or genetic agent that can irreversibly alter cellular DNA, causing abnormal cells to be produced. Promotion: substance that promote or enhance growth of initiated cancer cell such as hormones, drugs or chemicals Progression- develops own blood supply
Promotion - Oncogenes Oncogenes are genes that encode proteins to promote cellular proliferation Oncogenes are derived from normal proto-oncogene –A proto-oncogene is essential for growth, proliferation, differentiation, apoptosis Results in uncontrolled growth and replication of cells Mutations in proto-oncogene yields uncontrolled growth- stimulatory proteins (deregulation)
Progression Cancer cells divide uncontrollably Tumors form and invade surrounding structures Tumors form new blood vessels (angiogenesis) Cancer cells can form new colonies (metastasis)
Tumor-Suppressor Genes Normal braking signal to stop cellular division Defect in tumor suppressor gene Mutation causes inactivation or deletion of tumor- suppressor gene Changes in –cell adhesion, signal transduction, nuclear transcription and cell cycle
Apoptosis – Programmed Cell Death Unscheduled apoptosis occurs in Parkinson’s, Alzheimer’s and autoimmune disease Defect in apoptosis occurs with cancer
Angiogenesis Important in normal growth and development –wound healing and pregnancy Cancer - critical for growth and spread of most cancers by forming new blood vessels Target of anti-angiogenic therapy is normal endothelial cell rather than unstable tumor cell
Angiogenesis in Primary and Metastatic Tumors
Tumor Angiogenesis and Neovascularization
Comparison of Normal and Tumor Neovasculature From Konerding et al. In Molls and Vaupel, eds. Blood Perfusion and Microenvironment of Human Tumors, 2002, with permission. Normal colorectal mucosa Nearby colorectal cancer
Metastasis Cells detach from original tumor Cells spread through blood, lymphatics, or seeding Cells establish new colony in distant site
Routes of Tumor Spread Direct Metastatic Lymphatic
Common Sites of Metastasis Bone Lung Liver Brain
Nursing Assessment Risk Factors Lifestyle Factors Family History Signs/symptoms of Cancer (7 warning signs)
7 Warning Signs of Cancer 1. C 2. A 3. U 4. T 5. I 6. O 7. N
Prevention of Cancer Lifestyle Changes –DO NOT SMOKE! –STOP SMOKING!! –Minimize sun exposure –Avoid risky behaviors: ETOH abuse, multiple sex partners
Health Behaviors Dietary changes - 5 fruits/vegetables a day Exercise Know the 7 warning signs Control weight Decrease stress Practice self exam Stop or prevent smoking
Breast Cancer Screening and Early Detection –Baseline mammogram by age 40 –Mammogram annually after 50 –Clinical Breast Exam every 3 years –Breast self-exam every month –High risk women need increased surveillance
Breast Cancer 211,000 new cases Most frequently diagnosed cancer in women Second leading cause of cancer death 40,480 expected deaths Risk factors – advancing age, family history of breast cancer, atypical hyperplasia, long menstrual history, obesity after menopause
Screening Guidelines for the Early Detection of Breast Cancer, American Cancer Society Yearly mammograms are recommended starting at age 40. A clinical breast exam should be part of a periodic health exam, about every three years for women in their 20s and 30s, and every year for women 40 and older. Women should know how their breasts normally feel and report any breast changes promptly to their health care providers. Breast self- exam is an option for women starting in their 20s. Women at increased risk (e.g., family history, genetic tendency, past breast cancer) should talk with their doctors about the benefits and limitations of starting mammography screening earlier, having additional tests (i.e., breast ultrasound and MRI), or having more frequent exams.
Screening Guidelines for the Early Detection of Cervical Cancer, American Cancer Society Screening should begin approximately three years after a women begins having vaginal intercourse, but no later than 21 years of age. Screening should be done every year with regular Pap tests or every two years using liquid-based tests. At or after age 30, women who have had three normal test results in a row may get screened every 2-3 years. However, doctors may suggest a woman get screened more frequently if she has certain risk factors, such as HIV infection or a weakened immune system. Women 70 and older who have had three or more consecutive Pap tests in the last ten years may choose to stop cervical cancer screening. Screening after a total hysterectomy (with removal of the cervix) is not necessary unless the surgery was done as a treatment for cervical cancer.
Prostate Cancer Screening & Early Detection –Digital rectal exam every year after age 50 –PSA every year after age 50 –Increased surveillance of high risk men particularly African Americans
Prostate Cancer 220,900 new cases and 28,900 deaths in 2003 Early prostate cancer has no symptoms Risk factors: age, AA, family history Treatment: surgery, radiation, hormone therapy, watchful waiting
Screening Guidelines for the Early Detection of Prostate Cancer, American Cancer Society The prostate-specific antigen (PSA) test and the digital rectal examination (DRE) should be offered annually, beginning at age 50, to men who have a life expectancy of at least 10 years. Men at high risk (African-American men and men with a strong family history of one or more first-degree relatives diagnosed with prostate cancer at an early age) should begin testing at age 45. For men at average risk and high risk, information should be provided about what is known and what is uncertain about the benefits and limitations of early detection and treatment of prostate cancer so that they can make an informed decision about testing.
Lung Cancer The American Cancer Society’s Estimates In the United States during 2008: –215,020 new cases of lung cancer will be diagnosed. –161,840 deaths will occur as the result of this disease.
Lung Cancer Persistent cough, blood- streaked sputum, chest pain Cigarette smoking most common cause
Colorectal Cancer 105,500 colon; 42,000 rectal; 57,100 deaths 3 rd most common cancer No symptoms in early stages Hereditary Non-polyposis colorectal cancer and NPC (non-polyposis) are hereditary)
Screening Guidelines for the Early Detection of Colorectal Cancer, American Cancer Society Beginning at age 50, men and women should follow one of the following examination schedules: A fecal occult blood test (FOBT) every year A flexible sigmoidoscopy (FSIG) every five years Annual fecal occult blood test and flexible sigmoidoscopy every five years* A double-contrast barium enema every five years A colonoscopy every ten years *Combined testing is preferred over either annual FOBT or FSIG every 5 years alone. People who are at moderate or high risk for colorectal cancer should talk with a doctor about a different testing schedule
Testicular Cancer The American Cancer Society estimates that about 8,090 new cases of testicular cancer will be diagnosed during 2008 in the United States. It is estimated that 380 men will die of testicular cancer in The rate of testicular cancer has been increasing in many countries, including the United States.
Testicular Exams The best time to examine is after a shower. Hold the penis out of the way and examine each testicle separately. Hold the testicle between your thumbs and fingers with both hands and roll it gently between the fingers. Look and feel for any hard lumps or nodules (smooth rounded masses) or any change in the size, shape, or consistency of the testes.
Diagnosis The ideal is to find early ( a few cells) ---Detectable at 1 cm ( 10 billion cells)
Diagnosis of Cancer Cytology Studies CXR CBC Sigmoidoscopy or colonoscoy LFT Radiologic studies Radioisotpoe scans CT MRI CEA, AFP, CA-27-29, BRCA-1 BRCA-2 Bone Marrow Biopsy
Biopsy Definitive means of diagnosing –Benign or malignant, the anatomic tissue, the degree of cellular differentiation of the cancer cells present. Differentiate needle vs incisional vs. excisional biopsy
TNM Classification System Table 23-7 Staging of Cancer Grading of Cancer Table 23-6 Staging vs. Grading
Staging of Cancer TNM System for major solid tumors T umor –size of T umor N odes –presence of N odes M etastasis –presence of M etastasis Duke’s staging for colorectal cancer Cancer is best treated in the early stages
Nursing Interventions during Assessment Phase Variability of Distress --- Depends on Psychological make-up Family and Social support system Specific disease Self Concept Effects Physical Changes Changes in Roles Changes in Body Function Lengthy diagnostic period
You’ve been diagnosed with Cancer… What do want to know? Is it curable? How long do I have to live? Will disabilities be temporary or permanent? What types of physical impairment will occur? What are side effects of treatment? When can I return to work? What will it cost? Other????
Assessment How is your client coping? –Well…………….. Is he or she able to confront reality? Remain flexible? Accept support? Remain hopeful and optimistic? –Poorly……………..Use avoidance, feel hopeless, pessimistic, inflexible??
Medical Interventions Goals of intervention ---- Treat patient effectively –With appropriate therapy – For sufficient duration CURE With minimal functional & structural impairment If can’t cure Prevent further metastasis, relieve symptoms, maintain highest quality of life as long as possible Choice of treatment depends on… tumor type, extent of disease and clients’ physical status
Cancer Treatment & Goals Surgery Radiation therapy Chemotherapy Targeted Therapy Cure Control Palliation
Clinical Implications Prevention Screening and early detection Diagnosis and staging Treatment selection Targeted therapy
Surgical Interventions For diagnosis For staging For treatment For cure Palliative…. Debulking, reduce pain, relieve airway, urinary, GI, Respiratory obstructions and relieve pressure on brain and spinal cord
HER/2neu Oncogene Encodes transmembrane receptor, tyrosine kinase Over-expressed in 25-30% breast and ovarian cancers Over-expression is associated with rapid proliferation and metastasis Associated with poorer survival
Cancer Surgery Oldest cancer treatment Local control Used for Local control of disease Single therapy: small tumors Adjuvant therapy with XRT & chemotherapy Supportive/palliative therapy
61 Principles of Surgery (Rosenberg, 2001) Surgery treatment of choice for malignant tumors Removes malignant tumor and a margin of adjacent normal tissue Removes malignant tumor with attention to postprocedure quality of life issues Type and extent of surgical procedure Surgical procedures include strategies to decrease local and systemic spread (Cady, 2001).
62 Principles of Surgery (cont’d) Role of surgery (Frogge & Cunning, 2000; Rosenberg, 2001) –Establish tissue diagnosis. –Determine stage of disease. –Treat disease (Jennings, 2001; Mintzer, 1999). –Place therapeutic and supportive hardware. –Assess response to treatment by “second-look” procedures. –Reconstruct affected body parts.
63 Principles of Surgery (cont’d) Types and classifications of surgery (cont’d) –Cryosurgery –Chemosurgery –Laser –Stereotactic surgery (Chang & Adler, 2001) –Laparoscopic resection (Bickert & Frickel, 2002) –Endoscopy (Carrion & Seigne, 2002) –Radiofrequency ablation (Iannitti et al., 2002; Zagoria et al., 2002) Safety measures in delivery of surgery –Aseptic technique reduce risk of infection –Anesthesia –Electrical hazards Informed consent obtained Client prepared for surgery
64 Assessment: Surgery (Frogge & Cunning, 2000; Marek & Boehnlein, 2003; Pfifer, 2001) Pertinent personal history –Factors that may increase complications of surgery –Factors that may influence discharge planning Physical examination –Cardiovascular –Pulmonary –Renal –GI –Mobility –Nutrition –Comfort level
65 Assessment: Surgery (cont’d) Psychosocial examination –Explore client’s and family’s concerns. –Assess client’s and family’s current level of coping. Critical laboratory and diagnostic data –Cardiovascular—ECG –Hematologic—complete blood count, prothrombin time, partial thromboplastin time –Hepatic—liver function studies –Renal—urinalysis, blood urea nitrogen, creatinine, electrolytes –Pulmonary—chest x-ray examination –Nutritional—serum albumin
70 Interventions: Surgery (Boehnlein & Marek, 2003; Frogge & Cunning, 2000; Lefor, 1999) Maximize safety for client and family. –Implement preoperative medical preparation regimen as ordered. Decrease incidence and severity of complications unique to surgery. –Teach turning, coughing, and deep breathing (TCDB); schedule activities after surgery; use incentive spirometer; assist client to remove mucus or sputum. –Turn and shift positions in bed every 2 hours; massage uninjured areas; mattress overlays for high-risk clients; change surgical dressing; protective film, hydrocolloid barriers, and/or collection devices around drains or tubes with drainage; early ambulation.
71 Interventions: Surgery (cont’d) (Boehnlein & Marek, 2003; Frogge & Cunning, 2000; Lefor, 1999) Decrease incidence and severity of complications unique to surgery (cont’d). –Splint incision during TCDB or movement; non- pharmacologic methods for pain control; analgesic and antiemetic medications –Client and family discuss feelings, fears, and concerns; client and family teaching; encourage coping strategies; referrals for physical and psychosocial support; adequate rest periods
72 Interventions: Surgery (cont’d) Monitor for unique complications of surgery. –Assess respiratory effort, rate, and rhythm and subjective responses to breathing; inspect chest wall for symmetric movement, use of accessory muscles, diaphragmatic breathing, and sternal retraction; auscultate lungs. –Assess incision site for redness, swelling, increased drainage, discomfort, and approximation of surgical margins; assess bony prominences for reddened areas. –Assess for bowel sounds; assess for signs of dehydration; assess fluid loss and intake and output ratio, daily weights and progressive diet; monitor nutritional status.
73 Interventions: Surgery (cont’d) Enhance adaptation and rehabilitation. Implement postoperative teaching plan and include multidisciplinary team in discharge planning. Involve client and family in assessment, planning, and evaluation of care; instruct client and family about rehabilitation programs; refer client and family in support programs; refer to professional counselor as indicated.
74 Nursing Diagnoses: Surgery Acute Pain Impaired Skin Integrity Deficient Knowledge related to type of and rationale for surgical procedure, potential immediate and long- term complications of surgery Anxiety Ineffective Airway Clearance Imbalanced Nutrition: Less Than Body Requirements
Radiation Therapy Used for local control Used for local control of disease Most often used in adjuvant setting Used in palliation of pain, obstruction, & bleeding Goal is to destroy cancer cells with minimal exposure of the normal cells to the damaging radiation actions of radiation
Radiation Therapy High energy ionizing rays that destroy cell’s ability to reproduce Damages cell’s DNA Cells damaged by radiation either die outright or become unable to divide. Three different types of energy or rays Table 28-5 page 488
Radiation Therapy Teletherapy External beam or radiation Client is not radioactive & poses no exposure threat to caregivers Fractionation divided total dose into small frequent doses to decrease damage to surrounding cells Patient Preparation Marking's/tattoo’s for location Forms/molds to keep precise positioning Teaching
Brachytherapy Means short or close therapy The radiation source is in the client thus the patient emits radiation for a period of time and is hazard to others.
Brachytherapy Sealed Patient emits radiation while implant in place ( waste products not radioactive) temporary or permanent Intracavity: in cavity hours, ribbons catheters or needles Interstitial: Beads, seeds implanted in tumor
Brachytherapy Unsealed Systemic IV or PO or instilled into cavity Enter body fluids/waste products are radioactive Isolate 3-4 days, flush toilet several times for a few days Example: iodine to treat thyroid cancers
Sealed Implants Caregiver Precautions 3 Principles of Distance, Time and Shielding Private Room/private bath Caution sign on door Dosimeter film badge No pregnant women or child under 16 Limit visitors to ½ hour per day ( 6 feet away) Lead container and long forceps Chart 24-1, 24-2
Teletherapy Adverse Effects Determined by: Size of field Area treated Total dose of radiation In General –Localized skin changes and alopecia –Fatigue –Anorexia, taste disturbances –Skin reaction 2 weeks into treatment –Highest risk for damage for damage are tissues that divide quickly such as bone marrow, mucosal lining of the GI and GU tract, hair follicles, ovaries and testes
General Nursing Interventions Assess for: patterns of fatigue, EXERCISE may reduce fatigue, asses for infections and bleeding Monitor CBC for anemia, neutropenia and thrombocytopenia Assure adequate pain management if needed Skin care with mild soap and water, pat dry, no lotions See Chart 24-2 Assure adequate nutrition..hi calorie, hi protein
Adverse Effects of Radiation System Specific Chest Abdominal Pelvis Brain
Chemotherapy Classification of Chemotherapy Drugs Table Methods of Administration Table 24-3 Nursing Management
86 Principles of Antineoplastic Therapy Cancer chemotherapy (Chu & DeVita, 2001) Cellular kinetics –Cell cycle (Vermeulen et al., 200 –Cell-cycle time –Growth fraction of tumor –Tumor burden
87 Principles of Antineoplastic Therapy (cont’d) Approaches to chemotherapy –Single-agent chemotherapy –Combination chemotherapy –Regional chemotherapy –High-dose chemotherapy Factors influencing the response to antineoplastic agents –Characteristics of the tumor –Characteristics of the client –Administration schedule
88 Principles of Antineoplastic Therapy (cont’d) Roles of chemotherapy –Cure Single-treatment modality Combined-treatment modality –Control Extend length and quality of life when cure is not realistic –Palliation Improve comfort when neither cure nor control is possible Relief of tumor-related symptoms (Chu & DeVita, 2001)
89 Antineoplastic Therapy: Types and Classifications Phase of action during cell cycle: cell cycle–specific and cell cycle–nonspecific agents Mechanism of action, biochemical structure, and physiologic action –Alkylating agents –Antimetabolites –Antitumor antibiotics –Plant alkaloids –Hormonal agents –Miscellaneous agents
91 Assessment: Neoplastic Therapy Pertinent personal and family history –Type of cancer and phase of cancer trajectory –Previous cancer therapy and time interval since last therapy –Dietary intake –Alternative and complementary therapy use –Knowledge of rationale for and goals of treatment; agents to be given; potential side effects; and relative risks and benefits of treatment
92 Assessment: Neoplastic Therapy (cont’d) Physical examination –Renal—intake and output, color of urinary output, patterns of urinary elimination –GI system –Hematologic system –Neurologic system –Pulmonary system –Performance status
93 Assessment: Neoplastic Therapy (cont’d) Psychosocial assessment –Previous responses to stressors and effective coping mechanisms used –Level of independence and responsibility, desire, and ability for self-care –Support systems and personnel available to client and family
94 Assessment: Neoplastic Therapy (cont’d) Laboratory and diagnostic data –Complete blood count with differential –Creatinine, BUN, and liver function tests –Electrolyte levels (Brown et al., 2001; Goodman, 2000; Gullatte, 2001) –Other pertinent data specific to chemotherapy agents
95 Potential Side Effects of Chemotherapy Hematopoietic –Neutropenia –Thrombocytopenia: avoid ASA and ASA containing products, check for bruising –Anemia Gastrointestinal –Anorexia –Nausea and vomiting –Mucositis –Stomatitis –Diarrhea and constipation –Pancreatitis –Hepatic toxicity
96 Potential Side Effects of Chemotherapy (cont’d) Integumentary –Dermatitis –Hyperpigmentation –Alopecia –Nail changes –Radiation recall –Rash and urticaria Genitourinary –Cystitis and hemorrhagic cystitis –Acute renal failure –Chronic renal insufficiency
Immunotherapy Biological Response Modifiers Interleukins --Help immune system cells recognize & destroy abnormal body cells Interferons ---Slow down tumor cell division Colony Stimulating Facotrs ---induce rapid recovery of bone marrow
103 Rationale Theory of immune surveillance –An intact immune system is able to recognize cancer cells as different from normal cells and can destroy cancer cells. –Cancer cells are constantly produced by the body and destroyed by the functioning immune system. –Cancer develops when the immune system does not function properly or is unable to recognize cancer cells as foreign (Brown et al., 2001).
105 Nursing Diagnoses: Antineoplastic Therapy Deficient Knowledge related to chemotherapy protocol, names of agents, potential side effects Imbalanced Nutrition: Less Than Body Requirements Risk for Infection Impaired Oral Mucous Membrane Sexual dysfunction Fatigue Disturbed Body Image Constipation Diarrhea Nausea
Bone Marrow Suppression Nursing Interventions Chart 28-7 and Chart 28-8 page 497 Chart 28-9 page 497 Remember Fever in client with neutropenia is a medical emergency Chart Page 498
Bone Marrow Suppression Medications Epoetin Alfa (Epogen, Procrit): stimulates RBC’s Filgrastim ( Neupogen): Prevent infection Oprelvekin (Neumega): Stimulates production of platelets
Gastrointestinal Adverse Effects Nursing Interventions Stomatitis (oral Mucositis) Gentle cleansing soft toothbrush, brushing all tooth surfaces for at least 90 seconds and at least twice a day. Floss at least every day Bland rinses ( normal saline, sodium bicarbonate, or a combo.) 4 times per day Artificial saliva if dry Topical Anesthetics Avoid hot/cold or spicy foods, citrus Eat soft foods Avoid alcohol, tobacco, and irritating foods use water based moisturizers to protect lips Maintain adequate hydration January 2008 ONS Connect Evidence base practice
Gastrointestinal Adverse Effects Nursing Interventions Antiemetics 6-12 hours before chemo and every 4- 6 hours after chemo for 24 hours at least If uncontrolled can lead to anorexia, malnutrition and dehydration Diarrhea… low residue or liguid diet monitor electrolytes and I&O’s, antidiarrheals, nutmeg, apples and bananas slow, A&D ointment to rectum after washing
Alopecia Is Temporary Not always confined to just the head Color and Texture may change with re-growth Loss depends on drug used Select wigs, hats, turbans, before loss Instruct patient to not wash their hair every day/ avoid use of hairdryers