Patient Summary Patient RAB, 49 y/o male, diagnosed with Non-Small Cell Lung Cancer.

Medical History shows that he had wedge resection last November 2010 and Lobectomy last June 2011 because of Right Adenocarcinoma. He also had a Segmentectomy due to Left Adenocarcinoma last December 2011. PET scan performed last August 2012 reveals hypermetabolic pleural nodules at the Right Lower Lobe. Based on his physical examination done last September 2012, he is negative EGFR (Epidermal Growth Factor Receptor), Vital Signs Stable, Decreased Breath Sounds and NRRR. His initial recommendations are Pemetrexed (Alimta) and Zoledronic Acid (Zometa). Patient undergone 2 cycles of Pemetrexed and shifted to Gemcitabine HCL (Gemzar) last December 3, 2012. Lung Cancer Overview Lung Cancer is a disease characterized by uncontrolled cell growth in tissues of the lung, also known as bronchogenic carcinomas. There are two main types of lung cancer: Non-small Cell Lung Cancer (NSCLC) is the most common type of lung cancer, accounts for 80%. Squamous Cell Carcinoma (Epidermoid Carcinoma) it is the most common type of NSCLC and the most common type of lung cancer in men. This forms in the lining of the bronchial tubes. Adenocarcinoma - the most common type of lung cancer in women and in nonsmokers. It forms in the mucus-producing glands of the lungs. Bronchioalveolar Carcinoma - this type of lung cancer is a rare type of adenocarcinoma that forms near the lungs' air sacs. Large-cell Undifferentiated Carcinoma - a rapidly growing cancer which form near the outer edges or surface of the lungs. This is the least common type of NSCLC. Small Cell Lung Cancer (SCLC) comprises about 20% of lung cancers. This is the most aggressive and rapidly growing of all lung cancers. This is mostly related to cigarette smoking, with only 1% of these tumors occurring in non-smokers.

If the lung cancer is made up of both types, it is called mixed small cell/large cell cancer. If the cancer started somewhere else in the body and spread to the lungs, it is called metastatic cancer to the lung.

CAUSE Smoking Passive Smoking Asbestos Fibers Radon Gas Familial Predisposition Lung Disease (COPD) Air Pollution

SIGNS AND SYMPTOMS Persistent or intense coughing Pain in the chest shoulder, or back from coughing Changes in color of the mucus that is coughed up from the lower airways (sputum) Difficulty breathing and swallowing Hoarseness of the voice Harsh sounds while breathing (stridor) Chronic bronchitis or pneumonia Coughing up blood, or blood in the sputum

INCIDENCE Lung cancer is the deadliest type of cancer for both men and women. Each year, more people die of lung cancer than of breast, colon, and prostate cancers combined. In 2008, there were 1.61 million new cases, and 1.38 million deaths due to lung cancer.

PROGNOSIS The overall prognosis for lung cancer is poor when compared with some other cancers. Survival rates for lung cancer are generally lower than those for most cancers, with an overall five-year survival rate for lung cancer of about 16%

Diagnosing Lung Cancer Medical History and Physical Examination Chest X-ray CT Scan (Computerized Tomography) MRI (Magnetic Resonance Imaging) PET Scan (Positron Emission Tomography) Bone Scan Sputum Cytology Bronchoscopy Needle Biospy Thoracentesis Blood Tests

Staging Lung Cancer The most common cancer staging method is called the TNM system. T (1-4) indicates the size and direct extent of the primary tumor N (0-3) indicates the degree to which the cancer has spread to nearby lymph nodes M (0-1) indicates whether the cancer has metastasized to other organs in the body.

For example, a small tumor that has not spread to lymph nodes or distant organs may be staged as (T1, N0, M0).

For non-small cell lung cancer, TNM descriptions lead to a simpler categorization of stages. These stages are labeled from I to IV, where lower numbers indicate earlier stages where the cancer has spread less. More specifically: Stage I is when the tumor is found only in one lung and in no lymph nodes. Stage II is when the cancer has spread to the lymph nodes surrounding the infected lung. Stage III A is when the cancer has spread to lymph nodes around the trachea, chest wall, and diaphragm, on the same side as the infected lung. Stage III B is when the cancer has spread to lymph nodes on the other lung or in the neck. Stage IV is when the cancer has spread throughout the rest of the body and other parts of the lungs.

Small cell lung cancer has two stages: limited or extensive. In the limited stage, the tumor exists in one lung and in nearby lymph nodes. In the extensive stage, the tumor has infected the other lung as well as other organs in the body. Treatment Surgery Wedge Resection (Segmentectomy) - is a surgical operation where a part of a lung is removed. It is done to remove a localized portion of diseased lung, such as early stage lung cancer. Lobectomy - is a type of lung cancer surgery in which one lobe of a lung is removed. (The right lung has 3 lobes, and the left lung has 2 lobes.) A lobectomy of the lung is performed in early stage non-small cell lung cancer patients. It is not performed on patients that have lung cancer that has spread to other parts of the body. Pneumonectomy - is a type of lung cancer surgery in which an entire lung is removed as a treatment for lung cancer.

Radiation Chemotherapy Chemotherapy utilizes strong chemicals that interfere with the cell division process damaging proteins or DNA - so that cancer cells will commit suicide. These treatments target any rapidly dividing cells (not just cancer cells), but normal cells usually can recover from any chemical-induced damage while cancer cells cannot. Chemotherapy is considered systemic because its medicines travel throughout the entire body, killing the original tumor cells as well as cancer cells that have spread throughout the body. Combination therapies often include multiple types of chemotherapy, and chemotherapy is also given as adjuvant therapy as a complement to surgery and radiation. Adjuvant therapy is designed to reduce the risk of cancer recurrence after surgery and killing any cancer cells that exist after surgery. Chemotherapy can be given before surgery, called neo-adjuvant therapy, to shrink tumors and to make surgery more successful. DRUG STUDY

Pre-Medications RAMOSETRON (Nasea) DOSAGE INDICATIONS

ADVERSE NURSING EFFECTS RESPONSIBILITIES Antiemetic 5 Adult Dosage is Prevention Shock or Monitor BP carefully HT3 Antagonist 300 mcg once a of anaphylactoid during IV day. If a gastrointesti symptoms (ill administration sufficient nal feeling, feeling Monitor for response is not symptoms of chest extrapyramidal achieved, an (nausea and distress, reactions, and consult additional 300 vomiting) dyspnea, physician if they occur. mcg dose may associated wheezing, hot Instruct patient that be given. with antifacial flushes, alcohol, sleep However, the cancer drug redness, remedies, or sedatives ; daily dosage therapy. itching, serious sedation could should not cyanosis and occur. exceed 600 hypotension) mcg. Epileptiform attacks CLASSIFICATION

METOCLOPROMIDE DOSAGE INDICATIONS ADVERSE EFFECTS NURSING RESPONSIBILITIES Monitor BP carefully during IV

CLASSIFICATION Antiemetic

10mg given Prevention of Restlessness, 30 minutes nausea and drowsiness,

before chemother apy.

vomiting associated with emetogenic cancer chemotherapy.

fatigue, insomnia, extrapyramidal reactions

administration Monitor for extrapyramidal reactions, and consult physician if they occur. Instruct patient that alcohol, sleep remedies, or sedatives ; serious sedation could occur.

DEXAMETHASONE DOSAGE 20mg ADVERSE NURSING EFFECTS RESPONSIBILITIES Short term Seizures, Avoid exposure to management of vertigo, infection various headaches, Report unusual weight inflammatory hypertension gain, swelling of the and allergic and peptic or extremities, muscle disorders. esophageal weakness, black tarry ulcer. stools, fever , prolonged sore throat, colds or other infections. INDICATIONS

CLASSIFICATION Corticosteroid

RANITIDINE DOSAGE ADVERSE NURSING EFFECTS RESPONSIBILITIES Inhibiting gastric Headache, Check allergy to acid secretion tachycardia, ranitidine, impaired that it is bradycardia, renal or hepatic stimulated by constipation, function. food, histamine diarrhea, Report sore throat, and cholinergic nausea, unusual bruising or agonists. vomiting and bleeding, tarry stools, abdominal dizziness and severe pain. headache. INDICATIONS

CLASSIFICATION

Histamine2 (H2) 50mg Antagonist

ZOLEDRONIC ACID (Zometa) DOSAGE 4mg INDICATIONS / Prevention ADVERSE NURSING EFFECTS RESPONSIBILITIES of Bone pain, Check allergy to

CLASSIFICATION Biphosphonate

100ml D5W skeletal related for 15 events minutes To reduce and delay bone complications due to multiple myeloma and bone metastases from solid tumors.

nausea, Zometa. fatigue, Monitor patient with anemia, fever, mild to moderate renal vomiting, impairment. It should constipation, be assessed prior shortness of Zometa administration. breath, diarrhea, weakness and muscle pain.

Protocol of Lung Cancer Pemetrexed (Alimta) is antifolate antineoplastic agents which works by blocking the action of a certain substance in the body that may help cancer cells multiply. o In patients treated for non-small cell lung cancer, the recommended dose of ALIMTA is 500 mg / m2 BSA administered as intravenous infusion over 10 minutes on the first day each of each 21-day cycle. o To reduce the incidence and severity of skin reactions, a corticosteroid should be given the day prior to, on the day of, and the day after pemetrexed administration. o This drug can suppress bone marrow function as manifested by neutropenia, thrombocytopenia and anemia. Myelosuppression is usually the dose limiting toxicity. Patients should be monitored for myelosuppression during therapy and Alimta should not be given to patients until absolute neutrophil count (ANC) returns to > 1500 cells/mm3 and platelets returns to > 100,000 cells/mm3. Gemcitabine HCl (Gemzar) is a nucleoside analogue that exhibits antitumor activity. o This medication is given by injection into a vein (intravenous) usually over 30 minutes. It should not be given for longer than 60 minutes or more than once a week because of the risk to increase side effects or toxicity. o Combination Therapy with Gemzar plus Cisplatin in NSCLC 28 day schedule Gemzar 1000 mg/m2 on days 1 , 8 and 15 cisplatin 100 mg /m2 day 1 every 28 days. 21 day schedule Gemzar plus cisplatin: Gemzar 1250 mg/m2 on days 1, and 8 cisplatin 100 mg / m2 on day 1 every 21 days. Currently patient RAB, received Gemzar 1600mg in 250ml PNSS for 30 minutes as ordered by his physician (1st cycle). o The most common side effects are low blood cell counts (red blood cells, white blood cells, and platelets); fever; infection; hair loss; tiredness; nausea; vomiting; constipation; diarrhea; rash; shortness of breath; muscle aches; blood in urine; hearing changes and numbness or tingling in your toes or fingers

Lung Cancer
(Out Patient Oncology)

Submitted by: Krizelle C. Natividad ANSET II Cluster C

Cheats

history and physical examination may reveal the presence of symptoms or signs that are suspicious for lung cancer. In addition to asking about symptoms and risk factors for cancer development such as smoking, doctors may detect signs of breathing difficulties, airway obstruction, or infections in the lungs.Cyanosis, a bluish color of the skin and the mucous membranes due to insufficient oxygen in the blood, suggests compromised function due to chronic disease of the lung. Likewise, changes in the tissue of the nail beds, known as clubbing, also may indicate chronic lung disease. chest X-ray is the most common first diagnostic step when any new symptoms of lung cancer are present. Chest X-rays may reveal suspicious areas in the lungs but are unable to determine if these areas are cancerous. In particular, calcified nodules in the lungs or benign tumors called hamartomas may be identified on a chest X-ray and mimic lung cancer. CT scans - may be performed on the chest, abdomen, and/or brain to examine for both metastatic and lung tumors. A CT scan of the chest may be ordered when X-rays do not show an abnormality or do not yield sufficient information about the extent or location of a tumor. One advantage of CT scans is that they are more sensitive than standard chest X-rays in the detection of lung nodules, that is, they will demonstrate more nodules. MRI - scans may be appropriate when precise detail about a tumor's location is required. PET scanning is a specialized imaging technique that uses short-lived radioactive drugs to produce threedimensional colored images of those substances in the tissues within the body. While CT scans and MRI scans look at anatomical structures, PET scans measure metabolic activity and the function of tissues. PET scans can determine whether a tumor tissue is actively growing and can aid in determining the type of cells within a particular tumor Bone scans are used to create images of bones on a computer screen or on film. Doctors may order a bone scan to determine whether a lung cancer has metastasized to the bones Sputum cytology: The diagnosis of lung cancer always requires confirmation of malignant cells by a pathologist, even when symptoms and X-ray studies are suspicious for lung cancer. The simplest method

to establish the diagnosis is the examination of sputum under a microscope. If a tumor is centrally located and has invaded the airways, this procedure, known as a sputum cytology examination, may allow visualization of tumor cells for diagnosis. This is the most risk-free and inexpensive tissue diagnostic procedure, but its value is limited since tumor cells will not always be present in sputum even if a cancer is present. Also, noncancerous cells may occasionally undergo changes in reaction to inflammation or injury that makes them look like cancer cells.

Bronchoscopy: Examination of the airways by bronchoscopy (visualizing the airways through a thin, fiberoptic probe inserted through the nose or mouth) may reveal areas of tumor that can be sampled (biopsied) for diagnosis by a pathologist Needle biopsy: (FNA) through the skin, most commonly performed with radiological imaging for guidance, may be useful in retrieving cells for diagnosis from tumor nodules in the lungs. Needle biopsies are particularly useful when the lung tumor is peripherally located in the lung and not accessible to sampling by bronchoscopy Thoracentesis: Sometimes lung cancers involve the lining tissue of the lungs (pleura) and lead to an accumulation of fluid in the space between the lungs and chest wall (called a pleural effusion). Aspiration of a sample of this fluid with a thin needle (thoracentesis) may reveal the cancer cells and establish the diagnosis. As with the needle biopsy, a small risk of a pneumothorax is associated with this procedure. Blood tests: While routine blood tests alone cannot diagnose lung cancer, they may reveal biochemical or metabolic abnormalities in the body that accompany cancer. For example, elevated levels of calcium or of the enzyme alkaline phosphatase may accompany cancer that is metastatic to the bones. Likewise, elevated levels of certain enzymes normally present within liver cells, including aspartate aminotransferase(AST or SGOT) and alanine aminotransferase (ALT or SGPT), signal liver damage, possibly through the presence of tumor metastatic to the liver.