GRADES OF ABNORMAL CELLS (p.

333 hinkle and cheever)

- Pathologic classification of tumor cells; also refers to cell division; mitotic rate of the cell
growth
 Grade 1 – cells differ slightly from normal cells (mild dysplasia) well differentiated
 Grade 2 – abnormal (moderate dysplasia); moderately differentiated
 Grade 3 – very abnormal (severe dysplasia); poorly differentiated cells
 Grade 4 – immature; primitive (anaplasia); undifferentiated cells; origin difficult to determine
CLINICAL STAGING CLASSIFICATION
 0 - CA in situ (in natural or original position)
 1 – limited to tissue origin; localized growth
 2 – limited local spread
 3 - extensive local and regional spread
 4 – metastasis
TNM CLASSIFICATION SYSTEM (refer to book p. 335 chart 15-3)
MEDICAL MGT
A. SURGERY
 Diagnostic (biopsy, excisional, incisional needle) – table 9. P. 399, lemone
 Primary tx: debulking (remove entire tumor); (local and wide/radical incisions) (see table 15-5 p 336
for selected techniques used for localized destruction of tumor tissue, hinkle and cheever)
 Prophylactic, preventive or risk reduction surgery: remove tissues or organs that are likely to
develop CA
 Curative – removal of an entire tumor & surrounding lymph nodes
 Reconstructive – improvement of appearance & function of organ affected
 Palliative - relief for distressing s/s or for retardation of metastasis (table 15-6 p 337, hinkle and
cheever)
B. RADIATION THERAPY – use of high-energy ionizing radiation (electromagnetic radiation, xrays and
gamma rays and Particulate radiation, electrons, beta particles, protons, neutrons, alpha particles) to
destroy DNA; spare normal cells from excessive cell death
GOAL – kill tumor, reduce size, decreased pain or relieve obstruction
CATEGORIES
 Primary - only tx used and aims to achieve local cure (e.g. early stage skin CA, Hodgkin’s disease, CA
of cervix, head and neck)
 Neoadjuvant - prior to local definitive tx with or without chemotherapy (used to reduce tumor size
to facilitate surgical resection)
 Adjuvant – done preop or postop to destroy CA cells; used in conjunction with chemotherapy to
enhance destruction of CA cells.
 Prophylactic – prevent local recurrence or spread or primary tumor to a distant area
 Palliative – relieve pain caused by obstruction, pathologic fractures, spinal cord compression and
metastases.
MEASUREMENT FOR RADIATION
 Curie (Ci) – measures number of atoms of a particular radioisotope that disintegrate in 1 sec
 Roentgen - measure of radiation required to produce a standard number of ions in air; a unit of
exposure to radiation
 Rad – measurement of radiation dosage absorbed by tissues
 Rem – measurement of biologic effectiveness of various forms of radiation on human cell (1 rem = 1
rad)
 Gray – (Gy) – 1Gy = 100 rads; 1 antigray (cGy) = 1 rad
TYPES OF RADIATION THERAPY
 External beam radiation therapy (EBRT) or teletherapy
- most common administered through a high energy X-ray or gamma X-ray machine (e.g. linear
accelerator (SBRT), cobalt, betatron or a machine containing radioisotope, proton therapy –
cyclotron)
- radiation delivered from a source at some distance from pt.
- total radiation dose is delievered over several weeks is daily doses called fractions.
Advantages
- skin – sparing effect (effect occurs on tumor deep in the body, not on skin surface)
- no need for isolation (no residual radioactivity)

 Internal Radiation Therapy (Brachytherapy)

- Localized implantation or systematic radionuclide adm.
Sources
Sealed (brachytherapy); localized
- Radioisotope placed within or near tumor enclosed in a sealed container using needles, beads,
seeds, ribbons or catheters and adm through the ff routes:

a. Intracavity RT - radioisotope placed in body cavities (vagina, abdomen, pleura) for 24-72 hours
(cesium 137 or radium 226) e.g. tx of uterine and cervical CA
b. Interstitial therapy – implanted directly into tumor (iridium 192, iodine 125, cesium 137, gold
198 or radium 222) e.g. tx of breast, prostate -----------
c. Intraluminal – lumens within organs e.g. bronchus, esophagus, rectum or blue duck

ADVANTAGES - can’t circulate nor contaminate urine, sweat, blood or vomitus (excretions not
radioactive
DISADVANTAGES – radiation exposure d/t direct contact with sealed radioisotope e.g touching
with bare hands or from lengthy eposure

SOURCES
Unsealed source (systemic) – adm IV (alrontium chloride 89 and radium 223 for prostate CA (for
relief of painful bony metastasis), orally (iodine 131 for grave’s disease and thyroid CA) or by
instillation directly into body cavity.
DISADVANTAGES
- Radioisotope circulates; in body and contaminates urine, sweat, blood and vomitus
HEALTH EDUCATION
 Flush toilet twice after use
 Rinse sink with copious amount of water after toothbrushing
PRINCIPLES OF RADIATION PROTECTION
 Distace (atleast 3ft-6ft)
 Time (limit contact for 5 mins. A total of 30mins per 8 hour of shit)
 Shield (use of lead shield – gloves and apron)
PROTECTION FOR HEALTH CARE PROVIDERS
- Pregnant staff not be assigned to clients receiving internal RT
- Staff should wear dosimeter badge (internal RT) as monitoring device
- For isolated clients maintain contact while keeping distance from radiation exposure; talk form
doorway of room
- For clients with cervical CA & having implants into uterus, the ff. interventions must be
implemented:
 Back turned towards door (minimize exposure of staff to radioisotope when entering room)
 Turn to sides at regular intervals
 CBR (prevent dislodgement of radioisotope)
 Adm. Enema prior to the procedure (bowel movement during procedure may cause
dislodgement of radioisotope)
 Low fiber diet (inhibit defecation during procedure until device is removed 2-3 days (prevent
dislodgement of radioisotope)
 Foley cath. During irradiation of bladder (irradiation of bladder may cause fistula formation
b/w bladder and uterus causing urine to come out from the vagina_
 Long forceps and lead container readily available (use long forceps to pick dislodged
radioisotope and place in lead container)
- For client with unsealed source of RT private room and bath
 All surfaces i.e. floor area client will be waling on must be covered with Chux or paper
 Use disposable plates and utensils
 Trash and linens are kept in room and not removed until discharge linens are not changed
until they are grossly soiled (minimize radiation exposure to caregivers)
 Anyone entering the room wears a new pair of booties each time to prevent tracking the
isotope out into hallway
 Any emesis hat occurs after ingestion of oral radioisotope should be covered with absorbent
pad sand the radiation safety officer must be called immediately.
TEACHING GUIDELINES REGARDING EXTERNAL RADIATION THERAPY
 Painless
 Lie very still and maybe placed in special position (maximize tumor radiation
 Each Tx lasts for a few minutes; may hear sounds of machine being operated, machine may
move during therapy
 Safety precautions for staff; tell client that he will remain alone in Tx room while machine is in
operation
 Technologist stays outside room observing through window or closed-circuit TV, you may
communicate
  No residual radioactivity after RT, safety precautions are necessary only during actual time of RT,
resume ADLs after RT.
CLIENT EDUCATION ON SKIN CARE IN EXTERNAL RADIATION THERAPY
 Keep skin dry
 Don’t wash Tx area until instructed to do so, when permitted, wash treated skin gently with mild
soap, rinse well and pat dry; use warm water or cool water, not hot water
 Don’t remove the lines or ink marks placed on skin (serve as guide on areas to be Tx)
 Avoid using powders, lotions, creams, alcohol and deodorants on Tx skin (prevent skin irritation)
 Wear-----
 Don’t apply tape toTx area if dressings are applied
 Shave with an electric razor; don’t use preshave or after shave lotions
 Protect skin form exposure to direct sunlight, chlorinated swimming pools and temperature
extremes (e.g. hot water bottles, heating pads, ice packs)
 Consult radiation therapist or nurse about specific measures for individual skin reactions
NURSING INTERVENTIONS FOR SIDE EFFECTS OF RADIATION THERAPY
1. Skin reactions
 Erythema, dry/moist desquamation
 Atrophy, telangiectasia, depigmentation, necrotic/ulcerative lesions
Nursing interventions
 Observe for early signs of skin reaction and report to physician
 Keep area dry
 Wash area with water, no soap and pat dry (don’t rub)
 Don’t apply ointments, powders or lotion on area, cornstarch maybe used
 Don’t apply heat, avoid direct sunlight, or cold on area
 Use soft cotton fabrics for clothing (prevent skin irritation)
 Don’t erase markings on skin (guide areas for irradiation)
2. Infection

 Due to bone marrow depression

Nursing Interventions

 Monitor blood counts weekly (WBC)

 Personal hygiene, nutrition, adequate rest
 Teach s/s of infection and report to MD
3. Hemorrhage

 Decreased platelets
Nursing Interventions

 Monitor platelet fount

 Avoid physical trauma or use of aspirin (ASA) and NSAIDS
  Teach s/s of hemorrhage to report (e.g. gum bleeding, epistaxis, melena, menorrhagia,
hematoma)
4. Fatigue
 Increase metabolic demands for tissue repair and toxic waste removal
 Plenty of rest and good nutrition
5. Weight loss: anorexia, pain and effect of CA
6. Stomatitis and xerostomia (dry mouth)
 Ulceration of oral mucous membrane
Nursing interventions
 Administer analgesics before meals as Rx
 Oral hygiene with saline rinses every 2 hrs.
 Bland diet, avoid smoking and alcohol
 Sugarless lemon drops or mint to increase salvation
7. Diarrhea, nausea and vomiting, headache, alopecia and cystitis may also occur
8. Social isolation (fear of contaminating others with radiation)
C. CHEMOTHERAPY

 Use of an antineoplastic agent to destroy cancer cells by interfering with cellular functions.
Including replication and repair
 Tx: for systemic diseases
 Combined with surgery, radiation or both to reduce tumor size preoperatively (neoadjuvant), to
destroy any remaining tumor cells postoperatively (adjuvant) or Tx some forms of leukemia or
lymphoma
 Goals: cure, control or palliation
 Objective” destroy all malignant tumor cells without excessive destruction of normal cells
Characteristics of Chemotherapy
Side effects:
Cells with Rapid Rate of Proliferation

Cells and Generation time Effects of Cell Destruction

Bone marrow stem cell (6-24)
Neutrophils (12hrs)
Epithelial cells lining the GIT (12-24hrs)
Cells of hair follicles (24hrs)
Ova or testes (24-36hrs)
Myelosuppression, infection, bleeding,
anemia
Leukopenia infection
Anorexia, mucositis (e.g. stomatitis,
esophagitis) N/V, diarrhea
Alopecia
Reproductive dysfunction
 Has fraction cell-kill, only certain number of cancer cells are killed with each course of
chemotherapy given in a series
 Cell-cycle specific (CCS)
 Cell-cycle non-specific (CCNS) – may destroy cancer cells at any stage of cell division, combination
chemotherapy destroys more malignant cells and produce fewer side effects because each drug
destroys CA cells at different stages of cell cycle
Classification of Chemotherapeutic Agents (Table 15-7, p. 343 Hinkle & Cheever; Table 10, p. 402,403,
Lemone)
ADMINISTRATION OF CHEMOTHERAPEUTIC AGENTS
Dosage:
Base on total body surface area (TBSA), wt., previous exposure, response to chemotherapy or radiation
therapy, fxn of major organ systems
Routes of administration of chemotherapy
1. IV Chemotherapy
 Vascular access device (VADs) – provides continuous chemotherapy, multiple access, route for
IV fluids, antibiotics & frequent blood testing
 Can be implanted (e.g. Porth-A-Cath), central lines (e.g. tunneled and non-tunnelled),
peripherally inserted central (PICC lines)
 Oral (cyclophosphamide-Cytoxan) & chlorambucil (Leukeran)
 IM (hormones or hormone-blocking agents)
2. Regional chemotherapy - Increased con. of drugs directed to localized tumors
Methods:
a. Topical – Fluorouracil cream may be applied to the skin to Tx actinic keratosis
b. Intra-arterial – Enable major organs or tumor sites to receive maximal exposure with milited
serum levels of mediations
c. Intra-cavity – Instills medication directly into an area i.e. abdmn, bladder or pleural space
d. Intraperitoneal – for CA of intraabdominal area e.g. ovarian CA allows increased concentration
of chemotherapeutic agent to be delivered to actual tumor site with minimal exposure of
healthy tissues
e. Intrathecal – Instilling chemotherapeutic agents into CNS through a reservoir placed in ventricle
via an Omnaya reservoir or via a lumbar puncture, done because most medications given
through the system can’t cross blood-brain barrier
Ommaya reservoir – a quarter-sized soft, plastic, dome-shaped device placed under scalp, connected to
a catheter (thin, flexible tube), placed in one of ventricles of the brain. Ventricles are hollow spaces that
make cerebrospinal fluid (CSF). Which surrounds the brain and spinal cord.
Use of Ommaya reservoir
 Get samples of CSF to check for cancer cells or infections
 Give medications, such as chemotherapy or monoclonal antibodies or antibodies directly into CSF
  this procedure is referred to as an “Ommaya reservoir tap”
Contraindications of Chemotherapy

 Infection
 Recent surgery
 Impaired renal or hepatic function (nephrotoxic and hepatotoxic)
 Recent radiation therapy
 Pregnancy
 Bone marrow depression
Adverse Reactions to Chemotherapy
1. Extravasation – leaking of chemicals from vein into surrounding tissues
S/S:
 Absence of blood return from IV catheter
 Resistance to flow of IV
 Burning or pain, swelling or redness at site
 Vesicants (agents that can cause inflammation tissue damage, necrosis of tendons muscles,
nerves and blood vessels)
 Examples: dactinomycin, daunorubicin, doxorubicin, nitrogen mustard, mitomycin,
vinblastine. Vincristine
 Precaution – should be inserted in central line
Prevention OF Extravasation

 Proper selection of peripheral veins, skilled venipuncture and careful adm of medication
 Peripheral adm (short duration < 1 hr, IV push or bolus) infusions using only a soft, plastic
catheter in forearm
 Central line for continuous infusion > 1 hr or given frequently (right atrial silastic catheter,
implanted venous access device or PICC)

Management
 Stop drug adm immediately
 Leve needle in place & attempt to aspirate any residual drug from tubing, needle & site
 Adm antidote as Rx then remove needle
 Apply warm or cold compress as indicated
 Document appearance of site before & after
2. Hypersensitivity reactions (HSRs)
S/S:
 Pruritus
 Urticaria (wheals)
 Fever
 Hypotension
 Cardiac instability: tachycardia, chest tightness or pain
 Dyspnea
 Wheezing
  Throat tightness
 Syncope
 Anxiety and agitation (jittery, restlessness, uneased)
 Inability to speak
 Nausea
 Rashes
 Cloudy mental status
 Cyanosis
Management
 Stop drug adm stat
 Maintain IV access with 0.5% NS (NaCI)
 Keep an open airway
 Trendelenburg position (elevated 20 to 30 degrees) unless contraindiciated
 Monitor V/S until stable
 Adm epinephrine (or adrenaline), aminophylline (asthmatic drug; allergy drug),
diphenhydramine & corticosteroids as Rx
TOXICITY (ACUTE OR CHRONIC) BODY SYSTEMS AFFECTED
GI SYSTEM
 Early: nausea & vomiting (24-48 hrs); late 48 hrs to 1 wk
 Stomatitis
 Mucositis
 Diarrhea
 Constipation
Management for nausea and vomiting:
Drugs
 Corticosteroifs(e.g. dexamethasone)
 Phenothiazines
 Sedatives
 Histamines
 Serotonin blockers
 Anti-emetics (metochlopramide)
Non-pharmacologic mgt for N/V
 Relaxation techniques
 Imagery
 Acupressure
 Acupuncture
 Small, frequent meals
 Diet, bland, comfort; low-fiber, increase fluid (diarrhea); high fiber and increase fluid
(constipation)
 Comfort foods
  Fluid and electrolytes
HEMATOPOIETIC SYSTEM

 Myelosuppression (leukopenia, neutropenia, anemia, thrombocytopenia); increased risk of

infection and bldng
Management: Anemia
 Monitoring of RBC, hgb and hct
 Erythropoietin (EPO) – stimulate RBC prod.
 Oxygen therapy prn
 BT prn
 Frequent rest periods
Management: Neutropenia
 Adm. Granulocyte colony-stimulating factors (GCSF) and granulocyte-macrophage colony-
stimulating factor (GM-CSF)
 Protect from infection: strict handwashing and hygiene
 Avoid people with infection
 Avoid crowds
 Take daily temperature
 Avoid raw foods
 Avoid foods refrigerated for few days, meals should be freshly cooked
 Single-patient room
 Avoid gardening or cleaning-up after pets
 Limit visitors
 Report fever, chills, diaphoresis, heat, pain, erythema or exudates
 Avoid rectal or vaginal procedure
 Avoid: fresh fruits, raw meat, fish, vegetables, fresh flowers, potted plants
 Fruits that can be peeled are allowed
 Change IV sites every other day
 Change all solutions and IV infusions sets every 48hrs
Management: Thrombocytopenia

 Adm granulocyte colony-stimulating factors (G-CSF) and granulocyte-macrophage colony-

stimulating factor (GM-CSF)
 Protect from trauma
 Avoid ASA, NSAIDs
 Use soft-bristled toothbrush or soft swabs
 No dental flossing
 Use electric razor
 Avoid/minimize injections
 Apply pressure at injection site for 5 mins.
 Avoid straining at stools
 Avoid constipation
Nadir – time (7-14 days) after chemotherapy adm when WBC or platelet count is at its lowest point
RENAL SYSTEM
Drugs that cause renal toxicity: cisplatin, methotrexate, mitomycin
Drugs causing bladder toxicity: cyclophosphamide and ifosfamide
Ss:
 Syndrome of inappropriate secretion of anti-diuretic hormone (SIADH)
 Decreased renal perfusion
 Precipitate end products after cell lysis, (increase excretion of uric acid, hyperkalemia,
hyperphosphatemia, hypocalcemia & obstructive nephropathy)
 Interstitial nephritis
 Urine color changes (harmless)
Management
 Monitoring BUN, serum creatinine, creatinine clearance & serum electrolytes
 Adequate hydration (2-3 liters of fluid/day) diuresis, alkalinization of urine (prevent formation of
uric acid crystals)
 Adm of allopurinol and amifostine
 Mesna (cystitis)
RESPIRATORY SYSTEM
Drugs causing lung toxicity; bleomycin, carmustine, busulfan, mitomycin, paclitaxel/docetaxel
Ss:

 Alveolar damage
 Bronchospasm
 Pneumonitis (2-3mos after Tx)
 Pulmonary fibrosis (6-12 mos after Tx evidenced by x-ray)
 Capillary leak syndrome
Management

 Monitoring of pulmonary function (dry, hacking cough; fever & dyspnea on exertion (DOE)
 Steroids
 Supportive therapies
CARDIOVASCUAR SYSTEM
Drugs causing cardiac toxicity: anthracyclines, taxanes
Ss:
 Pericarditis or myocarditis (inflammatn secondary to irradiation of chest wall, occurs 1 yr after Tx)
 ECG changes leading to heart failure
Management
------------------
REPRODUCTIVE SYSTEM
Women:
 problems with ovulation (cells damaged); early menopause; amenorrhea
 teratogenic
Men
 Temporary or permanent azoospermia (cells damaged)
Management
 Women: freezing of oocytes, embryos or ovarian tissues
 Menses will return after chemotherapy
 Men: sperm banking
NEUROLOGICAL SYSTEM
Drugs causing toxicity: ifosfaide, high-dose methotrexate, and cytarabine, vincristine
Ss:
 Radiation edema (increased ICP)
 Tingling, pricking, numbness of extremities, burning or freezing pain, sharp, stabbing or electric
shock-like pain, extreme sensitivity to touch, loss of DTR, muscle weakness, loss of balance and
coordination
 Paralytic ileus
Management
 Oxaliplatin (avoid cold fluids or going outside with extremities exposed to cold)
 Cisplatin (may cause hearing loss or damage to acoustic nerve)
 Corticosteroids
 Monitor neurologic status
COGNITIVE IMPAIRMENT OR “CHEMO BRAIN”
- Decline in information-handling processes of attention and concentration, executive function,
information processing speed, language visual-spatial skill, psychomotor ability, learning and memory
ss:

 difficulty remembering dates, multitasking, managing numbers and finances, organization, face or
object recognition
 inability to follow directions
 feeling easily directions
 motor and behavioral changes
Management

 Referral for neurocognitive evaluation and intervention

 Exercise, natural restorative environmental intervention, i.e. walking, cognitive training programs
BIOCHEMICAL
- hyperuricemia p0d/t cell destruction causing secondary gout and obstructive uropathy
Management
Monitor uric acid levels
Allopurinol-----------
Chart 15-5 p. 349 safety un handling