Presentation on theme: "Oncology Dead Man’s party"— Presentation transcript:
1Oncology Dead Man’s party Biology of abnormal cellsCancer grading and stagesCancer statisticsChemotherapeutic agentsRadiation treatmentsBone Marrow and Stem Cell transplantsOnco-gene therapy
2Oncology Objectives1. Identify the different phases of cancer cell replication.2. Compare the features of a benign versus malignant tumor3. Recognize the TNM stage and grading system of cancer tumors.4. Discuss the role of oncogenes and suppressor genes in cancer development.5. Identify behaviors with corresponding primary and secondary nursing prevention for risks of cancer development6. Recognize the different classes of chemotherapies.7. Create appropriate nursing interventions for a case study of a patient with cancer.
3Oncology Objectives8. Identify appropriate testing for cancer patients.9. Recognize signs and symptoms of chemotherapy side effects.10. Recognize signs and symptoms of radiation therapy.11. Prioritize nursing interventions for a patient with neutropenia.12. Prioritize nursing interventions for a patient with thrombocytopenia.13. Prioritize nursing interventions for a patient receiving bone marrow or stem cell transplant.
4Oncology Objectives14. List 4 risk factors for the development of leukemia.15.Compare Leukemia and Lymphoma pathophysiology, etiology and clinical manifestations.
5Cellular ReviewEvolve 3D Cellular Differentiation on web site
6Oncology Biology of abnormal cancer cells They have continuous or inappropriate, usually faster growth or larger growth patternsThey have no specific morphology and often do not resemble their parent cells = anaplasticThey do not respond to signals for apoptosis = programmed cell death
7Oncology Biology of abnormal cancer cells Have a large nuclear – cytoplasmic ratio; the nucleus may occupy most of the cell areaThey lose some or all of their normal cell functionsThey do not make fibronectin, and thus cannot connect easily and break off easily
8Oncology Biology of abnormal cancer cells They are able to migrate throughout the body = metastasisThey invade other tissues and types of cells.They are not controlled by contactThey have more or less chromosomes than the parent cells = aneuploidor a mutation of the genes
9Oncology Cancer development Initiation – there are many theories as to when the genes in the cells are damaged, maybe in utero, from physical or chemical exposure, latent oncogenes, viruses, or a lack of suppressor genes from our parents, and at this point the cell is not dividing.
11Oncology Cancer development Promotion - the stage when the abnormal cell starts to divide, may be stimulated by environmental changes, hormones, drugs, or irritants
12Oncology Cancer development Progression – the phase when the abnormal cells have continued to grow into a Primary tumor, may produce angiogenesis factors which supply blood and vascular nourishment to the tumor. The tumor may have subcolonies of cells with different genes and features
13Oncology Cancer development Metastasis the movement of cancer cells into other organs of the body, thus creating new tumor sites.
14Oncology Cancer grading and staging Cancer is graded upon the resemblance to normal cells = G(The higher the number, the worse the grade of cancer) i.e. G1, G2, G3, G4Staging is based uponthe presence of a primary tumor = Tinvolvement in lymph nodes = Nand appearance of metastasis = MNumbers of the stage range fromx = none to 3 or 4 for each letter
15Oncology Is this a high grade or low grade cancer? Case study Julie has a breast lump in her right breast, and has also found one in her right armpit. Biopsy and lumpectomy were performed. The tumor was graded G3, T2, N2, M1.
17OncologyJulie opted to have a lymphectomy of her right arm lymph nodes, and started radiation treatment right away. Her doctor also suggested that she start Adriamycin IV chemotherapy to get any cells that the radiation might miss.
18Oncology Cancer Risks #1 = advancing age #2 = smoking tobacco Hormones – Prempro caused a substantial increase in breast cancer on the HERS trialGenetic inheritance of oncogenes and autoimmune diseasesEnvironmental exposureExcessive intake of dietary fats
19Oncology Cancer risks High alcohol consumption Low dietary vegetables and fiber (sources of antioxidants)Previous Viral infections:Hepatitis B or CHerpes virusesPapilloma viruses (HPV)Retrovirus HTLV –I
20Oncology Types of cancer cells are named for their site of origin: AdenocarcinomaCarcinoma in situ (CIS)SquamousBasal cellAstrocytomasMelanomasSarcomasLymphomas
21Oncology Symptoms of Cancer Cachexia – weight loss,unexplained AnorexiaAnemiaImpaired immune responsePain – when the cancer is large enough to compress nerves or organsLymphadema – when the tumor blocks lymph or circulatory flowMotor or sensory deficits
22OncologyThe 60 year old client with small cell lung cancer is concerned that his grown children also might develop the disease. What is the nurses best response?A. “This disease is a random event and there is no way to prevent it.”B. “Because this disease is inherited as a dominant trait, your children have a 50% risk for developing it.”C. “Cigarette smoking is the main cause of this disease, and helping your children not to smoke will decrease their risk.”D. “ Lung cancer can be avoided by decreasing dietary intake of fats and increasing the amount of regular aerobic exercise.”
23Oncology Cancer statistics The top four cancers found in the United States are:LungBreastProstateColorectalC
24Oncology Cancer statistics Prostate cancer is the most common site of cancer and the 2nd most common cause of cancer death in the United StatesThe first cause of death in males is Lung Cancer
26Oncology Cancer statistics Lung cancer has annual new cases (incidence)of 173,770 peopleper year: 93,110 males and80,660 femalesAnnual mortality: 160,440 per year consisting of 92,000 males and68,510 females
27Oncology Cancer statistics 28% of all cancer deaths are due to lung cancerThis is the leading cause of cancer death in both men and womenThere are more deaths from lung cancer than prostate, breast, and colorectal cancers combined
28Oncology Cancer statistics Risks for lung cancer: Smoking (75-80% of cases)Occupational exposureNutrition/DietGenetic factors
29Oncology Cancer statistics Prostate cancer is number two cause of cancer in menBreast Cancer is number two cause of cancer in womenMost common non-malignant or non-fatal cancer is non-melanoma type skin cancers
30OncologyThe client says that she has heard that the origin of most cancers is “genetic”. What is the nurse’s best response?A. “The development of most cancers is predetermined and not affected by environmental factors.”B. “Cancers arise in cells that have been damaged,which may be in the genes”.C. “ The majority of cancers are inherited”D. “Cancer is more common among males than females.”
31Oncology Lab tests for cancer Ultrasounds to determine size CT scan with contrast– the golden standardGenetic markers – BRCA 1 and BRCA 2Tumor markers:CEA – general carcinogenic antigenPSA – prostate antigenCA-125 – ovarianCA-25,27 – breastHER 2 NEU – breast tissue needed
32Oncology Lab tests for cancer Liver function tests CBC with diff Renal function testsPET scan – looks for metastasis using a radioactive glucose solutionPT, PTT, Fibrinogen, Fibrin levels
33Oncology Lab tests for cancer Pathology slide of tumor: (Should be kept for a period of years)Determines type of tumorSource of tumorAggression of tumor – whether fast growing, differentiated, or non-differentiatedUsed to determine tumor growth factors and susceptibility to certain chemotherapies
34Oncology Chemotherapy Prevention chemotherapy – for high risk patients, precancerous lesions, or history of cancerAntioxidants, vitaminsAldara cream 3x weekly for precancerous skin lesionsAspirinProtease inhibitors
35OncologyChemotherapy - typically started after surgical dissection of tumor, unless the tumor is non-operativeUsually given by a long term venous access device, i.e. PICC line, implanted ports, or direct catheratization to the tumor.Chemotherapy is usually potent and horribly scarring on normal veins
37Oncology Chemotherapy Biochemotherapy – used as in-patient or outpatient settings for cancer, MS, and viral treatments:Alpha interferon – (IFN)- Alpha 2a,Roferon, Intron-A-used for leukemias, AIDS, Hep-CBeta interferon – Beta 1b– used for renal carcinoma, melanoma, AIDS, MS, Hepatitis A, B
38Oncology Chemotherapy/Biochemotherapy Interleukin I (IL-1) Interleukin 2 (IL-2), Proleukin– stimulates growth of T-cells and NK cytotoxic cells– used investigationally for melanoma in Stage II to Stage IV cases on a monthly basis with a 80% non-recurrence rate
39Oncology Chemotherapy/Biochemotherapy Tumor necrosis factor (TNF) – selectively targets abnormal cells, in nature is produced by NK cells
40Oncology Chemotherapy/Biochemotherapy Vaccines HPV vaccine for cervical cancerMelanoma vaccine - for stage II only at this time, or malignant melanoma
41OncologyChemotherapy/Biochemotherapy Monoclonal antibodies – used for treatment of cancer, rheumatoid arthritis, transplants, and other autoimmune diseases. Can be used to stimulate immune response or suppress it.Rituximab – Treatment of CD20 –positive non-Hodgkins B-cell lymphomaGentuzumab – treatment of CD33 positive AML in first relapse in patients who are not candidates for reg. chemo.
42Oncology Adalimumab – Humira Chemotherapy/Biochemotherapy Monoclonal antibodiesAdalimumab – Humira–new treatment for severe rheumatoid arthritis, given s.q every other weekAlemtuzumab – Campath- treatment of B-cell lymphoma who have failed traditional chemotherapy with fludarabineBasilixamab – Simulect- immunosuppressive monoclonal antibody for renal transplants
43Oncology Chemotherapy – Alkylating agents Bisulfan oral Carboplatin (CBDCA) IVChlorambucil (leukeran) oralCisplatin IVCyclophosphamide(Cytoxan) IV or POMelphalan (Alkeran) oralIfosfamide IVThiotepa IV or PO
44Oncology Chemotherapy/ Antibiotics given IV as chemotherapy Adriamycin (Doxirubicin)BleomycinDactinomycinDaunorubicin (actinomycin D)Idarubicin (idomycin)Mitomycin CMithramycin
45Oncology Chemotherapy – anti-metabolites Cytorubine (Cytosar) IV Floxuridine (FUDR) IA or SQFlourourcil (5FU) IVFludara IVHydroxyurea PO or IVMethotrexate IV or IM6MP POIRESSA POXeloda PO
46Oncology Chemotherapy- Hormones Progestins – uterine cancer Estrogens Testosterone - myelodysplasiasAnti-hormones – block hormonal activity in hormone sensitive cancers:LeupronEulexinTamoxifen/NolvadexArimedex/Arista
47Oncology Chemotherapy – Plant alkaloids Vinblastine (Velban) IV Vincristine (Oncovin) IVVindesine IVEldisine IVThe first doses of this are usually given in a hospital setting, are vesicants, and neurotoxic. Nurses must wear protective gear!
48Special biohazard bags for disposal Which of the following are appropriate protective gear for the nurse when hanging chemotherapy?Splash gogglesLatex glovesRubber glovesPaper gownSpecial biohazard bags for disposalLead apron
49Oncology Chemotherapy –Antimitotics Dacarbazine (DTIC – Dome) IV Leukovorin PO or IVPaclitaxol (Taxol) IVTopotecan IVGemzar IVDocetaxol IVCamptothecan (CPT-11) IVTaxotere (Ormaplatin) IV
50Oncology Side effects of Chemotherapy Alopecia Fatigue Anemia LeukopeniaThrombocytopeniaAlways – Nausea,Vomiting, DiarrheaNeurotoxicity & neuropathiesCapillary leakageHeadachesFluid and electrolyte imbalances
51Oncology Side effects of Chemotherapy Anorexia – change in taste buds Back achesJoint achesBlood clotsOral mucositis – (reduced significantly by L-glutamine amino acids orally)Supra opportunistic infectionsSeptic DICTumor lysis syndromeEdema or pulmonary edema
52Oncology Chemotherapy Nursing Interventions Evaluate and assess sites of chronic chemotherapy, ports, veins, skin areaAccurate I & O’sMonitor for fluid overload or dehydrationMonitor lab electrolytes before and after infusionMonitor BUN and CreatinineMonitor CBC with differential during the time of NadirMonitor PT, PTT
53Oncology Cancer Nursing Interventions Nutritional assessment and weightsDentition – oral checksMonitor for signs of suprainfection, low grade temperatures, rash, etc…Vital signs before, during, and after treatmentsAssess bowel statusAssess pain level
54Oncology Cancer Nursing Interventions Educate patients and family members:side effects of treatments, medscare of port and IV sitesoral hygienesymptoms to report, i.e. shortness of breath or signs of infectionIncrease fluid intake, suck on hard candies to reduce chemotherapy metallic tastes
55Oncology Nursing Diagnoses Disturbance in self esteem, body image Altered nutrition, less than body requirementsRisk for fluid volume excess or deficitImpaired skin integrityPain, chronicDecreased cardiac outputSelf-care deficitSexual dysfunction
56Oncology Nursing Diagnoses Alteration in tissue perfusion Knowledge deficitRisk for injuryImpaired physical mobilitySensory perception alterationsAlterations in bowel patternsAlterations in mucous membranesAnxiety and Fear
57Oncology Nursing Diagnoses Depression Grief Respiratory compromise Ineffective copingSpiritual distressImpaired social interactionsSleep pattern disturbanceAltered family roles
58Oncology Pharmacological interventions Megace, Marinol – for appetite stimulationPremedications for nausea, vomiting, edema, headaches: usually on the protocol for chemoAntiemetics;Zofran – 24 hour controlTigan, Kytril, ativan, anzamet, Compazine, benadryl, reglanCorticosteroids
59Oncology Pharmacological interventions Analgesics IV electrolytes and fluid replacementStool softeners to counteract constipation from opioidsGSF for WBC’sEpogen/Procrit for anemiaLeukine/Prokine for leukopeniaNeupogen for neutrophiliaNeumega for thrombocytopeniaDiuretics for edema
61Oncology Radiation therapy All types of cells are injured or destroyed by concentrated radiation. Rapidly dividing cells are the most sensitive.
62Oncology Radiation therapy Types : Gamma knife Local beam treatment Local seedingARC – stereotacticRadioimmunotherapyFractionationTotal body irradiationParticle beam therapy, i.e. proton or neutron therapy
63Oncology Radiation therapy side effects Side effects depend on the amount and area being irradiatedFatigueNausea and vomitingMild anemiaLeukopeniaDiarrheaPain
64Oncology Radiation therapy side effects: Erythema/burns Fatigue PneumonitisEsophagitisDysphasia(Please educate your patients onthese as doctors are notoriouslybad at pre-educating their patients).
65Debilitating fatigue Mucositis hair loss nausea and vomiting What side effects of radiation therapy would you expect to see in a 48-year-old woman with breast cancer?Debilitating fatigueMucositishair lossnausea and vomiting
66Burns Anemia Skin care Diet All of the above What are some of the educational issues for patients receiving radiation treatmentBurnsAnemiaSkin careDietAll of the above
67Oncology Nursing interventions for radiation TX Assess incidence and severity of side effectsMaximize radiation protection, all wastes will be radioactive if isotopes are injectedShielding for staff
68Oncology Malignant Lymphomas – 2 types Hodgkin's Lymphoma – most common cancer in 10 to 20 year olds (young adults). Associated with an inflammatory process related to +EBV/mono infection.Diagnosis: Classic Reed-Steinberg cell with two mirrored nuclei, CT scanSymptoms: Extreme fatigue, enlarged lymph nodes that are painless. May progress to weight loss fevers, night sweats
69Oncology Malignant Lymphomas – 2 types Hodgkin's Lymphoma Treatment – combined radiation and chemotherapy, stem cell transplants if resistant type or recurring85% curable(90% in some institutions)
70Oncology Malignant Lymphomas – 2 types Non-Hodgkins Lymphoma – 3 times more common than Hodgkin’s lymphoma, can either be T-cell lymphomas, or B-cell lymphomasCan be low grade or high grade disease. B-cell lymphomas = 50% and usually are more aggressive tumors. Since they grow faster, they are also more sensitive to radiation and chemotherapy
71Oncology Malignant Lymphomas – 2 types Non-Hodgkins Lymphoma Diagnosis: bone marrow biopsy, CT scan, lymphoma panel with CD markersSymptoms- adenopathy, spleenomegaly with vague abdominal pain, back pain, and since immunity B or T-cell function is affected- the patient is more prone to infections. Subcutaneous T-cell lymphoma is a classic discoid rash on the upper body and trunk that does not respond to steroids or creams.NHL can progress rapidly to leukemia if untreated.
72Oncology Malignant Lymphomas – 2 types Non-Hodgkins Lymphoma Treatments: Monoclonal antibodies, chemotherapy with Fludara/Fludarabine, radiation therapy, and bone marrow implants
73OncologyLeukemia– hematopoeitic cancer of the stem cells. These stem cells proliferate into non-functional immature white cells.More children get leukemia than any other type of cancer and it is the #1 cause of death in children.Anyone can get leukemia at any age.
75OncologyLeukemia –ALL suspected cause is a T-cell virus (HTLV-1) – 85% is seen in children, 25% in adults 30-to-40 y.o.Diagnosis: peripheral blood smear after abnormally high white count, bone marrow biopsy shows lymphoblasts >50%m may have decrease in platelets. Lumbar puncture to determine CSF involvement
76Oncology Leukemia –ALL Symptoms – fatigue, anorexia, malaise, weight loss, bleeding, infections, headaches, adenopathy, spleenomegaly, gingival hypertrophy, hepatomegaly, bone or joint painTreatment: complete response is a bone marrow aspirate with < 5% blasts. Chemotherapy – vincristine, prednisone, danorubicin, methotrexate,Maintenance therapy – 6 weeks of6-mercaptopurine and methotrexate low dose therapy
77OncologyLeukemia – AML – more common in patient’s with chromosomal genetic disorders, exposure to benzene or radiation. Use of alkylating agents for breast, ovarian, or myeloma are associated with a later malignancy of this type.Symptoms- are like ALL with the additions of anemia, thrombocytopenia, visual disturbances, epistaxis (nosebleeds), headache with vomiting, dysphagia, papilladema, menorrhagia (lots more bleeding problems)
78Oncology Leukemia – AML Diagnosis: peripheral blood smear shows Auer bodies (rods), platelets less than 20,000/mm3,bone marrow biopsyPrognosis – poor prognosis if patient has already received radiation or chemotherapy, or has a WBC >100,000
79Oncology Leukemia – AML Treatment: Cytaribine chemotherapy in combination therapy with Danorubicin or doxirubicin, works 65% of the time.Bone marrow transplant or stem cell transplant.
80Oncology Leukemia – CLL – staged 0-5 chronic diseases have more mature cells, majority of CLL is B-cell proliferation – 95%. Only 5% are T-cells, more common in people with autoimmune diseases, i.e. SJogren’s, SLE, hemolytic anemiaSymptoms: skin and respiratory infections, fatigue, thrombocytopenia, anemia, spleenomegaly
81Oncology Leukemia – CLL Diagnosis- peripheral blood smear, bone marrow biopsyTreatments: Gleevac – drug of choice; chemotherapy in combinations, spleenectomy, radiation therapy to spleen, bone marrow transplant, stem cell transplants
82Oncology Leukemia – CML (last is the CaMeL) - More common after radiation exposure, benzene exposure, less common than the other types of leukemia, and occurs most often between y.o.Diagnosis: hallmark is the presence of the Philadelphia Chromosome, Chromosome #22 is missing part of the long arm which is translocated to Chromosome #9. This is present in 95% of those patients with CML.WBC >100,000 with proliferation of all types of mature and immature white cells.Bone marrow biopsy
83Oncology Leukemia – CML Symptoms: same as other leukemias with chronic fever, sternal tenderness and dyspnea – usually due to severe anemiasTreatments: chemotherapy with Bisulfan and hydroxurea, other combination chemos,Interferon alpha 2b to suppress the expression of the Philadelphia chromosome.Bone marrow transplant or stem cells
84Oncology Bone marrow and stem cell implants New treatments for: Acute myelogenous leukemias (AML)Acute lymphoblastic leukemias (ALL)Myelodysplasia syndromes (MDS)Chronic myelogenous leukemias that do not respond to chemotherapy (CML)Blast crisisPediatric acute leukemiasNon-Hodgkins lymphomaLarge B-Cell lymphomaMultiple myelomas
86Oncology Bone marrow and stem cell implants Procedure= multiple puncturesMarrow acquisition from donor or when patient is in remission, or stem cells from umbilical blood of a matching sibling or family memberMarrow is filtered to purge tumor cells, fat and bone particles, then place in a blood bag for cryopreservation.
87Oncology Bone marrow and stem cell implants Preparing Recipient: Marrow recipient is given high dose chemotherapy alone or in combination with radiation to suppress immune system, open spaces in the marrow, and kill remaining cancer cells.Bone marrow is thawed and infused through a central venous catheter
88Oncology Bone marrow and stem cell implants Preparing Recipient: Stem cells are infused after thawingPost-procedure:Patient is supported through the period of aplasia, 10 to 30 days, while in reverse isolation and on graft immunosuppressants,Observed for signs of Graft-versus-host disease and/or infection
89Oncology The waves of the future: Stem Cell Research Oncogene therapy – now that cancer cells are being genetically tagged, we can tell which growth factors are present, and which enzymes turn off the gene. Soon all gene markers will have a pill that matches the enzyme, i.e. IRESSA is a tyramine kinase inhibitor, and stops the tumors growth that use tyramine kinase
90OncologyStem Cell Induction – there are new drugs out for stem cell induction to immunosuppress the patient, even in deadly cancers, i.e. Multiple Myeloma. Recently, the combination of lenalidomide(Revalamid), bortezomib (Velcade) and dexamethasone produced a98% response rate in patients
91Oncology The waves of the future: Cancer vaccines Oncology is the science of cancer and treatment of all cancer patients. It is one of the most demanding and rewarding fields in medicine.The future is open for a cure.