ONCOLOGY NURSING

Prepared by Crisanto Christopher B. Sanares

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THEORIES OF PATHOGENESIS A. CELLULAR TRANSFORMATION AND DERANGEMENT THEORY 1. THERE ARE NO CANCER CELLS in the body. It only develops when we are EXPOSED to carcinogens (nicotine, nitrates, etc.) 2. Environmental cause B. FAILURE OF THE IMMUNE RESPONSE THEORY 1. THERE ARE CANCER CELLS IN THE BODY but are inactive because of a well functioning immune system. When the IMMUNE SYSTEM GOES DOWN, cancer cells develop or activate. 2. Physiological cause RISK FACTORS R Race I Immunologic factor S Sex [gender, sexual activity, STD] K genetiKs F A C T O R S Food [fats, alcohol, smoked meats, nitrates/nitrites, high calorie] Age Chemicals Toxins [Bilirubin, Lead, Ammonia, Carbon monoxide, Ketones] Others [Hormones, Occupation (miners, gasoline boy/girl, radiation technician, commercial sex workers), Lifestyle, Microorganisms (Virus EBV, HPV, HBV, HIV; Bacteria H. pylori; Parasites Schistosoma haematobium), Stress] Radiation Sunlight; Smoking

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III. PATTERNS OF CELL GROWTH A. HYPERPLASIA increase in the number of cells B. METAPLASIA conversion of one type of mature cell into another type of cell C. DYSPLASIA bizarre cell growth resulting in cells that differ in size, shape, or arrangement from other cells of the same type of tissue D. ANAPLASIA lack of differentiation; cells that lack normal cellular characteristics and differ in shape and organization with respect to their cells of origin; usually malignant E. NEOPLASIA uncontrolled cell growth that follows no physiologic demand IV. MALIGNANCY A. CARCINOMA epithelial cells B. SARCOMA connective tissues C. LYMPHOMA lymph nodes D. LEUKEMIA blood-forming tissues E. ADENOCARCINOMA glandular organs V. CARCINOGENESIS = Malignant transformation A. INITIATION 1. Carcinogens (chemicals, physical factors, biologic agents) alter genetic structure of the DNA 2. It could lead to cellular programmed suicide (APOPTOSIS), permanent cellular mutations, or it may be reversed B. PROMOTION 1. PROTO-ONCOGENES on cell growth 2. CANCER SUPPRESSOR GENES off cell growth 3. Mutations from Initiation damages cancer suppressor genes and turns the proto-oncogenes on C. PROGRESSION 1. Malignant behaviors of cells affected during initiation and promotion CANCER CELLS unpredictable undifferentiated no faster parasites MALIGNANT CELLS faster undifferentiated no capsule systemic / metastasizes infiltrative / not movable may recur

VI. NORMAL CELLS VS. CANCER CELLS NORMAL CELLS LIFE CYCLE predictable DIFFERENTIATION well differentiated CONTACT INHIBITION yes GROWTH RATE slower FUNCTION for well-being VII. BENIGN CELLS VS. MALIGNANT CELLS BENIGN CELLS GROWTH RATE slower DIFFERENTIATION somehow differentiated CAPSULE encapsulated LOCATION local GROWTH TYPE expansive / movable RECURRENCE rare VIII. METASTATIC MECHANISMS A. Lymphatic spread most common B. Hematogenous spread C. Angiogenesis

IX. TUMOR STAGING AND GRADING A. STAGING 1. Determining size of tumor and presence of metastasis 2. TNM Classification System a. Tumor size Tx = tumor cannot be assessed T0 = no evidence of tumor T1 = less than 2 cm T2 = > 2 cm but < 5 cm T3 = > 5 cm, no metastasis T4 = any size, with metastasis b. Nodal involvement Nx = nodes cant be assessed N0 = no evidence of nodal involvement N1 = 1 node involved N2 = 2 nodes involved N3 = 3 or more involved c. Metastasis Mx = metastasis cant be assessed M0 = no evidence of metastasis M1 = metastasis, site specified M+ = metastasis, site unspecified 3. Stages of Cancer a. Stage I T1 N0 M0 localized tumor surgery 70%-90% survival b. Stage II T2 N1 M0 local spread plus 1 node surgery, chemo, rad 45%-55% survival c. Stage III T3 N2 M0 local and regional spread chemo, rad 15%-25% survival d. Stage IV T4 N3 M+(1) distant metastasis palliation < 5% survival B. GRADING 1. Classification of tumor cells 2. Defines type of tissue from which the tumor originated and the degree to which tumor cells retain the functional and histologic characteristics of tissue of origin 3. Grade I: cells differ slightly from normal cells and are well differentiated (mild dysplasia) 4. Grade II: cells are more abnormal and are moderately differentiated (moderate dysplasia) 5. Grade III: cells are very abnormal and are poorly differentiated (severe dysplasia) 6. Grade IV: cells are immature (anaplasia) and undifferentiated; cell of origin is difficult to determine X. LEVELS OF PREVENTION LEVEL CLIENT Primary Healthy Secondary Tertiary High risk CA patient GOALS Promote health Early detection Treatment and Rehab SIGN & SYMPTOM Asymptomatic Early symptomatic Late symptomatic ACTIVITIES Diet, smoking cessation, promotional activities Diagnostic tests and tumor markers Treatment modalities (chemo, rad)

XI. DIAGNOSTIC TESTS A. BREAST CLINICAL EXAM (BCE) 1. Starts at 20 years old and done every 3 years thereafter. 2. A clinical breast examination (CBE) is a physical examination of the breast done by a health professional. Clinical breast examinations are used along with mammograms to check women for breast cancer. 3. Breast implants do not change a woman's chance of getting breast cancer, so women with breast implants should also have regular clinical breast examinations. 4. You may want to have your examination 1 to 2 weeks after your menstrual period ends, if you are still menstruating; your breasts are less likely to be tender at that time. 5. A clinical breast examination is done by a health professional. You will need to take off your clothes above the waist. You will be given a gown to wear during the examination. 6. First, your health professional will ask you questions about any problems you may have, your medical history, and your risk factors for breast cancer. Talk to your health professional about any areas of your breasts you may be concerned about. 7. Your health professional will then examine each breast, underarm, and collarbone area for changes in breast size, skin changes, or signs of injury or infection, such as bruising or redness. You may be asked to lift your arms over your head, put your hands on your hips, or lean forward and press your hands together to tighten the muscle beneath each breast during this part of the examination. You may also lie flat on the table and put your arm behind your head while your health professional checks your breast tissue. 8. Your health professional will feel (palpate) each breast for any unusual or painful areas or for a dominant lump. A dominant lump in the breast is any lump that is new, larger, harder, or different in any other way from other lumps or the rest of the breast tissue. 9. Your health professional will gently press on the breast tissue from about 1in. below the breast up to the collarbone. He or she also will examine your armpit (axillary area) and your neck for swollen glands (lymph nodes). Your health professional will likely press gently on your nipple to check for any discharge. 10. After the examination, your health professional may teach you how to examine your own breasts (breast self-examination) and help you practice doing it. Regular breast self-examination has not been shown to be helpful for finding early breast cancers. 11. A clinical breast examination normally does not cause any discomfort unless your breasts are tender. B. BREAST SELF-EXAM (BSE) 1. Most women notice increased tenderness and lumpiness before their menstrual period; therefore, BSE is best performed after menses (day 5 to day 7, counting the first day of menses as day 1), when less fluid is retained. 2. For postmenopausal women, BSE is optimally timed once monthly. 3. Step 1: a. Stand before a mirror.

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b. Check both breasts for anything unusual. c. Look for discharge from the nipple, puckering, dimpling, or scaling of the skin. 4. Step 2: a. Watch closely in the mirror as you clasp your hands behind your head and press your hands forward. b. Note any change in the contour of your breasts. 5. Step 3: a. Next, press your hands firmly on your hips and bow slightly toward the mirror as you pull your shoulders and elbows forward. b. Note any change in the contour of your breasts. 6. Step 4 (some women do the next part of the exam in the shower. Your fingers will glide easily over soapy skin, so you can concentrate on feeling for changes inside the breast.): a. Raise your left arm. b. Use 3 or 4 fingers of your right hand to feel your left breast firmly, carefully, and thoroughly. c. Beginning at the outer edge, press the flat part of your fingers in small circles, moving the circles slowly around the breast. d. Gradually work toward the nipple. e. Be sure to cover the whole breast. f. Pay special attention to the area between the breast and the underarm, including the underarm itself. g. Feel for any unusual lumps or masses under the skin. h. If you have any spontaneous discharge during the month whether or not it is during your BSE see your doctor. i. Repeat the examination on your right breast. 7. Step 5: a. Step 4 should be repeated lying down. b. Lie flat on your back with your left arm over your head and a pillow or folded towel under your left shoulder. (This position flattens your breast and makes it easier to check.) c. Use the same circular motion described above. d. Repeat on your right breast. MAMMOGRAPHY 1. Breast-imaging technique that can detect nonpalpable lesions (less than 1 cm) and assist in diagnosing palpable masses. 2. Takes about 20 minutes, the breast is mechanically compressed from top to bottom and side to side. 3. Started at the 40 years of age then done annually thereafter. 4. Baseline mammogram should be obtained after the age of 35 years and by the age of 40. TESTICULAR SELF-EXAM (TSE) 1. Begins during adolescence since testicular cancer occurs most often in young adults (15-40 years of age). 2. Done monthly, usually after a warm bath or shower when the scrotum is more relaxed. 3. Use both hands to palpate the testis. The normal testicle is smooth and uniform in consistency. 4. With the index and middle fingers under the testis and the thumb on top, roll the testis gently in a horizontal plane between the thumb and fingers. 5. Feel for any evidence of a small lump or abnormality. 6. Follow the same procedure and palpate upward along the testis. 7. Locate and palpate the epididymis, a cord-like structure on the top and back of the testicle that stores and transports sperm. Also locate and palpate the spermatic cord. 8. Repeat the examination for the other testis, epididymis, and spermatic cord. It is normal to find that one testis is larger than the other. 9. If you find any evidence of a small, pea-like lump or if the testis is swollen (possibly from an infection or tumor), consult your physician. DIGITAL RECTAL EXAM (DRE) 1. Done for every man older than 40 years of age. 2. DRE enables the examiner to assess the size, shape, and consistency of the prostate gland. 3. Tenderness of the prostate gland on palpation and the presence and consistency of any nodules are noted. PAP SMEAR 1. Starts at 18 years of age for women who are sexually active 2. Performed for 3 consecutive years, annually 3. Screens for cervical cancer 4. Once the woman tests negative after 3 years, Pap smear is performed according to doctors order or recommendation 5. It is performed annually for women 50 years and above 6. Class I result normal 7. Class II result indicates inflammation (cervicitis) 8. Class III result mild dysplasia 9. Class IV result probably malignant 10. Class V result definitively malignant FECAL OCCULT BLOOD TEST (FOBT) 1. Tests for GI bleeding tests for the presence of HEME, the iron-containing portion of the hemoglobin molecule that is altered during transit through the intestines. 2. HIGH FIBER DIET for 2-3 days before 3. NO red meat, liver, poultry, fish (salmons, sardines), turnips, broccoli, cauliflower, melons, horseradish within 7 days before testing cause false positive result (they contain a chemical with PEROXIDASE properties, which immediately breaks down hydrogen peroxide in the absorbent paper in the slide) 4. WITHHOLD aspirin, iron, steroids, NSAIDs, chemotherapeutic agents, anticoagulants, colchicine for 48 hours cause false positive result 5. Dont give Vitamin C from supplements or food or citrus fruits causes false negative result 6. THREE stool specimens (3 consecutive days) COLONOSCOPY 1. Adequate cleansing of the colon 2. CLEAR LIQUID DIET at noon on the day before the test 3. NPO after midnight on the day of the test 4. IV Midazolam (Versed) for sedation 5. Left side lying position with knees drawn up to the chest

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6. Continuously monitor for cardiac and respiratory function (monitor vital signs) during the test 7. Bed rest until alert after the test 8. Monitor for bowel perforation and report any bleeding to the physician after the test. BARIUM ENEMA 1. LOW FIBER DIET 1-2 days before the test. 2. CLEAR LIQUID DIET and laxative the evening before the test. 3. NPO post midnight the day of the test 4. Cleansing enema on the morning of the test 5. Barium sulfate is given per rectum 6. Give laxatives or enemas as ordered after the test to facilitate excretion of barium sulfate. 7. Increase oral fluid intake after the test 8. Inform patient that stools will turn white for 1-3 days after the test. 9. Observe for distention and constipation after the procedure. BIOPSY

XII. TUMOR MARKERS or TUMOR-SPECIFIC ANTIGENS A. Proteins found on cell membranes of malignant cells B. Develop as cells become less differentiated over time C. Examples: 1. Carcinoembryonic Antigen (CEA) Colorectal CA 2. Bence Jones Protein Multiple Myeloma 3. Prostate-Specific Antigen (PSA) Prostate CA 4. Acid phosphatase 5. Alkaline Phosphate XIII. TREATMENT MODALITIES A. SURGERY 1. Diagnostic surgery = BIOPSY a. Excisional b. Incisional c. Needle 2. Surgery as primary treatment a. Local Excision removal of mass and a small margin of normal tissue that is easily accessible b. Wide excisions (en bloc dissections) removal of primary tumor, lymph nodes, adjacent involved structures, and surrounding tissues that may be at high risk for tumor spread c. Video-assisted endoscopic surgery d. Salvage surgery uses extensive surgical approach to treat the local recurrence of the cancer after a less extensive approach is used (ex. mastectomy to treat recurrent breast CA after primary lumpectomy and radiation) e. Electrosurgery makes use of electric current f. Cryosurgery uses liquid nitrogen to freeze tissue to cause cell destruction g. Chemosurgery combined topical chemotherapy and layer-by-layer surgical removal of abnormal tissue h. Laser surgery (Light Amplification by Stimulated Emission of Radiation) uses light and energy aimed at an exact tissue location and depth to vaporize CA i. Stereotactic radiosurgery (SRS) single and highly precise administration of high-dose radiation therapy used in some types of brain, head and neck cancers 3. Prophylactic surgery a. Removing non-vital tissues or organs that are likely to develop cancer b. Examples: colectomy, mastectomy, oophorectomy 4. Palliative surgery a. Relieves complications of cancer like ulcerations, obstructions, hemorrhage, pain, and malignant effusions b. Examples: colostomy / ileostomy for bowel obstruction, pleural drainage tube placement for pleural effusions 5. Reconstructive surgery a. For breast, head, neck, and skin cancers B. RADIATION 1. Types of ionizing radiation: a. Electromagnetic rays x-rays, gamma rays b. Particles electrons, protons, neutrons, alpha particles 2. Cells most vulnerable to radiation during DNA synthesis and mitosis (early S, G2, or M phase) 3. External Radiation a. The higher the energy of radiation the deeper the penetration into the body b. Using X-rays Kilovoltage therapy device deliver maximal radiation dose to superficial lesions, such as of the skin and breast Linear accelerators and betatron machines produce higher energy x-rays and deliver their dosage to deeper structures with less harm to the skin and less scattering of radiation within the body tissues c. Using Gamma rays Gamma rays are produced from spontaneous decay of naturally occurring radioactive elements such as Cobalt 60 Delivers radiation dose beneath skin surface, sparing skin tissue from adverse effects d. Using Neutrons, heavy ions Particle-beam radiation therapy used for more hypoxic and radiation-resistant tumors; aka high linear energy transfer radiation; damages target cells as well as cells in its pathway e. Intraoperative radiation therapy (IORT) Delivers a single dose of high-fraction radiation therapy to the exposed tumor bed while the body cavity is open during surgery Gastric, pancreatic, colorectal, bladder, cervical cancers, and sarcomas

Minimized toxicity since radiation is precisely targeted to the diseased areas and exposure to overlying skin and structures is avoided f. Client education: Wash the irradiated area gently each day with warm water alone or with mild soap and water. Use your hand rather than a washcloth to be more gentle. Rinse soap thoroughly from your skin. Take care not to remove the markings that indicate exactly where the beam of radiation is to be focused. Dry the irradiated area with patting motions rather than rubbing motions; use a clean, soft towel or cloth. Use no powders, ointments, lotions, or creams on your skin at the radiation site unless they are prescribed by your radiologist. Wear soft clothing over the skin at the radiation site. Avoid wearing belts, buckles, straps or any type of clothing that binds or rubs the skin at the radiation site. Avoid exposure of the irradiated area to the sun. Avoid heat exposure. 4. Internal radiation a. Unsealed radiation source Administration is via the oral or IV route or by instillation into body cavities The source is not confined completely to one body area, and it enters body fluids and eventually is eliminated via various excreta, which are radioactive and harmful to others. Most of the source is eliminated from the body within 48 hours; then neither the client nor the excreta is radioactive or harmful. b. Sealed radiation source A sealed, temporary or permanent radiation source (solid implant) is implanted within the tumor target tissues. The client emits radiation while the implant is in place, but the excreta are not radioactive. Care of the client with sealed radiation source: o Place the client in a private room with a private bath. o Place a caution sign on the clients door o Organize nursing tasks to minimize exposure to the radiation source. o Nursing assignments to a client with a radiation implant should be rotated. o Limit time to 30 minutes per care provider per shift. o Wear a dosimeter film badge to measure radiation exposure. o Wear a lead shield to reduce the transmission of radiation. o A nurse should never care for more than one client with a radiation implant at one time. o Do not allow a pregnant nurse to care for the client. o Do not allow children younger than 16 years or a pregnant woman to visit the client. o Limit visitors to 30 minutes per day; visitors should be at least 6 feet from the source. o Save bed linens and dressings until the source is removed; then dispose of in the usual manner. o Other equipment can be removed from the room at any time. Dislodged radiation source: o Do not touch a dislodged radiation source with bare hands. o If the radiation source dislodges, use long-handled forceps to place the source in the lead container kept in the clients room, and call the physician. o If unable to locate the radiation source, prohibit visitors and notify the physician. Removal of sealed radiation source: o The client is no longer radioactive. o Inform the client that sexual partners cannot catch cancer. o Inform the female client that she may resume sexual intercourse after 7 to 10 days if the implant was cervical or vaginal. o Provide a povidone-iodine douche, if prescribed, if implant was placed into the cervix. o Administer a Fleet enema if prescribed. o Advise the client who had a cervical or vaginal implant to notify the physician if nausea, vomiting, diarrhea, frequent urination, vaginal or rectal bleeding, hematuria, foul-smelling vaginal discharge, abdominal pain or distention, or fever occurs. C. CHEMOTHERAPY 1. Cell cycle a. G0 phase resting/dormant phase b. G1 phase RNA and CHON synthesis c. S phase DNA synthesis d. G2 phase premitotic phase; mitotic spindles e. M phase cell division occurs 2. Cell cycle-specific agents a. Miscellaneous agents target G1 phase Ex. asparaginase has been associated with anaphylaxis; given with epinephrine Prednisone is given to combat airway swelling procarbazine b. Antimetabolites target S phase Ex. cytarabine (DepoCyt) 5-Fluorouracil (Adrucil) hydroxyurea (Hydrea) methotrexate (Rheumatrex) causes bleeding Can decrease folic acid; given with Leucovorin c. bleomycin (Blenoxane) only antitumor antibiotic that is cell cycle-specific; targets G2 phase d. Vinca alkaloids target M phase Ex. vinblastine sulfate (Velban) vincristine sulfate (Oncovin)

Taxanes target M phase Ex. docetaxel (Taxotere) paclitaxel (Taxol) 3. Cell cycle-nonspecific agents a. Alkylating agents Ex. busulfan (Myleran) chlorambucil (Leukeran) increases uric acid levels cisplatin (Platinol) nephrotoxic cyclophosphamide (Cytoxan) causes hemorrhagic cystitis melphalan (Alkeran) b. Nitrosureas Ex. carmustine (Gliadel) lomustine (CeeNu) streptozocin (Zanosar) c. Antitumor antibiotics Ex. dactinomycin (Cosmegen) doxorubicin (Adriamycin) daunorubicin (DaunoXome) d. Hormonal agents Ex. Estrogens diethylstilbestrol Antiestrogens raloxifene (Evista), tamoxifen citrate (Nolvadex) Androgens testosterone Antiandrogens flutamide (Eulexin), nilutamide (Nilandron) Progestins medroxyprogesterone (Depo-Provera) 4. Vinca alkaloids, alkylating agents, and antitumor antibiotics are Vesicant drugs. Vesicant drugs can cause tissue necrosis. 5. Protective gears: goggles, mask, gown, gloves 6. Chemotherapeutic agents are light-sensitive; store them in dark containers D. BONE MARROW TRANSPLANTATION 1. Bone marrow transplantation (BMT) and peripheral blood stem cell transplantation (PBSCT) are procedures that replace stem cells that have been destroyed by high doses of chemotherapy and/or radiation therapy. 2. BMT and PBSCT are most commonly used in the treatment of leukemia and lymphoma, but are also used to treat other cancers, such as neuroblastoma and multiple myeloma. 3. The goal of treatment is to rid the client of all leukemic or other malignant cells through treatment with high doses of chemotherapy and whole-body irradiation. 4. Because these treatments are damaging to bone marrow cells without the replacement of blood-forming stem cell function through transplantation, the client would die of infection or hemorrhage. 5. Types of donor stem cells: a. ALLOGENEIC stem cell donor is usually a sibling, parent with a similar tissue type, or a person who is not related to the client (unrelated donor). b. SYNGENEIC stem cell is from an identical twin c. AUTOLOGOUS most common type; the client receives his or her own stem cells; stem cells are harvested during disease remission and are stored frozen to be reinfused later. 6. Procedure: a. Harvest The stem cells used in PBSCT come from the bloodstream in a 4- to 6-hour process call apheresis or leukapheresis (the blood is removed through a central venous catheter and an apheresis machine removes the stem cells and returns the remainder of the blood to the donor). In BMT, marrow is harvested through multiple aspirations from the ILIAC CREST to retrieve sufficient bone marrow for the transplant. Marrow is filtered for residual cancer cells. Allogeneic marrow is transfused immediately; autologous marrow is frozen for later use (cryopreservation). Harvesting is done before the initiation of the conditioning regimen. b. Conditioning refers to an immunosuppression therapy regimen used to eradicate all malignant cells, provide a state of immunosuppression, and create space in the bone marrow for the engraftment of the new marrow. c. Transplantation: Stem cells are administered through the clients central line in a manner similar to that for a blood transfusion. Stem cells may be administered by IV infusion or by IV push directly into the central line. d. Engraftment: The transfused stem cells move to the marrow-forming sites of the recipients bones Engraftment occurs when the white blood cell, erythrocyte, and platelet counts begin to rise. When successful, the engraftment process takes 2 to 5 weeks. 7. Post-transplantation period a. The client remains without any natural immunity until the donor stem cells begin to proliferate and engraftment occurs. b. Infection, bleeding, or neutropenia and thrombocytopenia are major concerns until engraftment occurs. 8. Complications: a. Failure to engraft: If the transplanted stem cells fail to engraft, the client will die unless another transplantation is attempted and is successful. b. Graft-versus-host disease (GVHD) in allogeneic transplants Although the recipient cannot recognize the donated stem cells as foreign or non-self because of the total immunosuppression, the immune competent cells of the donor recognize the recipients cells as foreign and mount an immune offense against them. GVHD is managed with immunosuppressive agents cautiously to avoid suppressing the new immune system to the extent that the client becomes more susceptible to infection, or the transplanted cells to stop engrafting. c. Veno-occlusive disease

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 The disease involves occlusion of the hepatic venules by thrombosis or phlebitis. Signs include RUQ abdominal pain, jaundice, ascites, weight gain, and hepatomegaly. Early detection is critical because there is no known way to open the hepatic vessels. The client will be treated with fluids and supportive therapy. E. HYPERTHERMIA THERAPY 1. Aka Thermal Therapy 2. Generation of temperatures greater than physiologic fever range (> 41.5C) by use of radiowaves, ultrasound, microwaves, magnetic waves, hot water baths, hot-wax immersions 3. Operates through this mechanisms: a. Malignant cells lack repair mechanisms necessary to repair cell damage by elevated temperatures b. Most malignant cells lack adequate blood supply to provide oxygen during periods of increased cellular demand c. Cancerous cells lack blood vessels of adequate size for dissipation of heat d. Bodys immune system may be indirectly stimulated when hyperthermia is used 4. Most effective when used with radiation therapy, chemotherapy or biologic therapy a. Heat damages tumor cells so that they cannot repair themselves after radiation therapy b. Hyperthermia alters cellular membrane permeability when used with chemotherapy, allowing for an increased uptake of the chemotherapeutic agents. F. BIOLOGIC RESPONSE MODIFIERS (BRM) Use of naturally occurring or recombinant (reproduced through genetic engineering) agents or treatment methods that can alter the immunologic relationship between the tumor and the cancer patient to provide a therapeutic benefit 1. Nonspecific BRM a. Acts as antigen and thus STIMULATES IMMUNE RESPONSE (the stimulated immune system will eradicate malignant cells) b. Examples: Bacillus Calmette-Guerin (BCG), corynebacterium parvum 2. Monoclonal antibodies (MoAbs) a. How monoclonal antibodies? Tumor cells injected to mice (acts as antigen) antibodies formed in spleen cells of mice antibody-producing spleen cells are fused with cancer cells hybridomas are formed monoclonal antibodies are harvested purified, and prepared for diagnostic or therapeutic use b. Examples: rituximab (Rituxan), trastuzumab (Herceptin), alemtuzumab (Campath) 3. Cytokines Substances produced by cells of immune system a. Inteferons produced by leukocytes (IFN-), fibroblasts (IFN-), lymphocytes (IFN-) Has antiviral and antitumor properties Given SC, IM, IV, or intracavitary b. Interleukins produced by lymphocytes (lymphokines) and monocytes (monokines) signals and coordinates other cells of the immune system c. Hematopoietic growth factors (Colony-stimulating factors) Hormone-like substances Regulates production of all cells in the blood, including neutrophils, macrophages, monocytes, RBCs, platelets Do not treat underlying malignancy Targets effects of myelotoxic cancer therapies Examples: GM-CSF, G-CSF, IL-11, EPO (Epogen) d. Tumor Necrosis Factor produced by macrophages, lymphocytes, astrocytes, and microglial cells of the brain Stimulates other cells of the immune response or has direct tumor-killing activity 4. Retinoids vitamin A derivatives which play a role in growth, reproduction, epithelial cell differentiation, and immune function Examples: retinol, retinoic acids G. PHOTODYNAMIC THERAPY 1. Aka Phototherapy 2. Uses photosensitizing agents like porfimer (Photofrin) 3. Administered IV retained in higher concentrations in malignant tissue than in normal tissue activated by a light source (usually laser light) which penetrates body tissues light-activated agent crates activated oxygen molecules that are cytotoxic or harmful to body tissue cells 4. Side-effect: photosensitivity for 4-6 weeks after therapy H. GENE THERAPY 1. Corrects genetic defects or manipulate genes to induce tumor cell destruction using Somatic Cells (p53 tumor suppressor gene) I. UNPROVEN / UNCONVENTIONAL THERAPIES 1. Machines and devices electrical gadgets decorated with elaborate lights and dials and which produces vibrations or other sensations 2. Drugs and biological medicinal agents, herbs (Echinacea, ginseng, green tea, pau darco), proteins (such as shark cartilage), megavitamins (Vit. C therapy), immune therapy, vaccines, enzymes, hydrogen peroxide 3. Metabolic and dietary regimens emphasize the ingestion of only natural substances (grape diet, carrot juice diet, garlic, onions, various teas, raw liver intake) 4. Mystical / Spiritual approaches psychic surgery, faith healing, prayer groups, invocation of mystical universal powers to kill cancerous growth XIV. ONCOLOGIC EMERGENCIES A. Superior Vena Cava Syndrome (SVCS) 1. Compression or invasion of the superior vena cava by tumor, enlarged lymph nodes, intraluminal thrombus that obstructs venous circulation, or drainage of the head, neck, arms, and thorax. 2. Typically associated with lung cancer; may also occur with lymphoma and metastases. 3. May lead to cerebral anoxia, laryngeal edema, bronchial obstruction, and death 4. Signs and symptoms: a. Progressive shortness of breath (dyspnea), cough, and facial swelling b. Edema of the neck, arms, hands, and thorax and reported sensation of skin tightness and difficulty swallowing c. Possibly engorged and distended jugular, temporal, and arm veins d. Dilated thoracic vessels causing prominent venous patterns on the chest wall e. Increased ICP, associated visual disturbances, headache, and altered mental status.

Management: a. Radiation therapy to shrink tumor size and relieve symptoms b. Chemotherapy for radiation-resistant tumor c. Anticoagulant or thrombolytic therapy for intraluminal thrombosis d. Surgery vena cava bypass graft (synthetic or autologous) e. Supportive measures: oxygen, corticosteroids, diuretics f. Monitor cardiopulmonary, neurologic, fluid volume status. g. Facilitate breathing by positioning the patient properly and promote energy conservation to minimize shortness of breath. B. Spinal Cord Compression 1. Potentially leads to permanent neurologic impairment and associated morbidity and mortality. 2. 70% of compressions occur at the thoracic level, 20% in the lumbosacral level, and 10% in the cervical region. 3. Associated with metastatic cancers: breast, lung, kidney, prostate, myeloma, lymphoma 4. Signs and symptoms: a. Local inflammation, edema, venous stasis, and impaired blood supply to nervous tissues b. Local or radicular pain along the dermatomal areas innervated by the affected nerve root (eg, thoracic radicular pain extends in a band around the chest or abdomen) c. Pain exacerbated by movement, coughing, sneezing, or the Valsalva maneuver d. Neurologic dysfunction, and related motor and sensory deficits (numbness, tingling, feelings of coldness in the affected area, inability to detect vibration, loss of positional sense) e. Motor loss ranging from subtle weakness to flaccid paralysis f. Bladder and/or bowel dysfunction depending on level of compression (above S2, overflow incontinence; from S3 to S5, flaccid sphincter tone and bowel incontinence) 5. Management: a. Radiation therapy to reduce tumor size to halt progression and corticosteroid therapy to decrease inflammation and swelling at the compression site. b. Surgery only if symptoms progress despite radiation therapy or if vertebral fracture leads to additional nerve damage. c. Chemotherapy as adjuvant to radiation therapy for patients with lymphoma or small cell lung cancer. d. Note: despite treatment, patients with poor neurologic function before treatment are less likely to regain complete motor and sensory function; patients who develop complete paralysis usually do no regain all neurologic function. e. Perform ongoing assessment of neurologic function to identify existing and progressing dysfunction. f. Control pain with pharmacologic and non-pharmacologic measures. g. Prevent complications of immobility resulting from pain and decreased function (eg, skin breakdown, urinary stasis, thrombophlebitis, and decreased clearance of pulmonary secretions). h. Maintain muscle tone by assisting with range-of-motion exercises in collaboration with physical and occupational therapists. i. Institute intermittent urinary catheterization and bowel training programs for patients with bladder or bowel dysfunction. C. Hypercalcemia 1. Potentially life-threatening metabolic abnormality resulting when the calcium released from the bones is more than the kidneys can excrete or the bones can reabsorb. 2. It may result from: a. Bone destruction by tumor cells and subsequent release of calcium b. Production of prostaglandins and osteoclast-activating factor, which stimulate bone breakdown and calcium release c. Tumors that produce parathyroid-like substances that promote calcium release d. Excessive use of vitamins and minerals and conditions unrelated to cancer, such as dehydration, renal impairment, primary hyperparathyroidism, thyrotoxicosis, thiazide diuretics, and hormone therapy 3. Signs and symptoms: a. Fatigue, weakness, confusion, decreased level of responsiveness, hyporeflexia, nausea, vomiting, constipation, polyuria, polydipsia, dehydration, and dysrhythmias 4. Management: a. Treat underlying cause (chemo for malignancy or partial parathyroidectomy for hyperparathyroidism) b. Increase patient mobility c. Increase fluid intake (sodium-containing fluids unless contraindicated) d. Adequate fiber to offset constipation e. Safety measures especially with mental symptoms f. Monitor ECG changes, especially in patients taking digitalis g. Pharmacologic therapy: IV 0.9% NaCl furosemide (Lasix) is usually used in conjunction with NSS IV phosphate Calcitonin useful in patients with heart disease or renal failure who cannot tolerate large Na loads skin test first (calcitonin derived from salmon is commonly used) injected IM rather than SC Biphosphonates Pamidronate (Aredia) Etidronate (Didronel) Mithramycin h. Encourage patients to consume 2 to 3 L of fluid daily unless contraindicated by existing renal or cardiac disease. i. Explain the use of dietary and pharmacologic interventions such as stool softeners and laxatives for constipation. j. Advise patients to maintain nutritional intake without restricting normal calcium intake. k. Discuss antiemetic therapy if nausea and vomiting occur. l. Promote mobility by emphasizing its importance in preventing demineralization and breakdown of bones. D. Pericardial Effusion and Cardiac Tamponade 1. Cardiac tamponade is an accumulation of fluid in the pericardial space. The accumulation compresses the heart and thereby impedes expansion of the ventricles and cardiac filling during diastole. As ventricular volume and cardiac output fall, the heart pump fails, and circulatory collapse develops.

5.

2.

E.

F.

With gradual onset, fluid accumulates gradually, and the outer layer of the pericardial space stretches to compensate for rising pressure. Large amounts of fluid accumulate before symptoms of heart failure occur. 3. With rapid onset, pressures rise too quickly for the pericardial space to compensate. 4. Lung, esophageal, breast cancers, and cancer treatment are the most common causes of cardiac tamponade. 5. Untreated pericardial effusion and cardiac tamponade lead to circulatory collapse and cardiac arrest. 6. Signs and symptoms: a. Neck vein distention during inspiration (Kussmauls sign) b. Pulsus paradoxus (SBP decrease exceeding 10 mmHg during inspiration; pulse gets stronger on expiration) c. Distant heart sounds, rubs and gallops, cardiac dullness d. Compensatory tachycardia (heart beats faster to compensate for decreased cardiac output) e. Increased venous and vascular pressures f. Shortness of breath and tachypnea g. Narrow pulse pressure h. Weakness, chest pain, orthopnea, anxiety, diaphoresis, lethargy, and altered consciousness from decreased cerebral perfusion 7. Management: a. Pericardiocentesis (the aspiration or withdrawal of the pericardial fluid by a large-bore needle inserted into the pericardial space). In malignant effusions, pericardiocentesis provides only temporary relief; fluid usually reaccumulates. Windows or openings in the pericardium can be created surgically as a palliative measure to drain fluid into the pleural space. Catheters may also be placed in the pericardial space and sclerosing agents (such as tetracycline, talc, bleomycin, 5-fluorouracil, or thiotepa) injected to prevent fluid from reaccumulating. b. Radiation therapy or antineoplastic agents, depending on how sensitive the primary tumor is to these treatments. In mild effusions, prednisone and diuretic medications may be prescribed and the patients status carefully monitored. c. Assess and monitor vital signs, oxygen saturation, pulsus paradoxus, ECG tracings, ABG, electrolytes, heart and lung sounds, neck vein filling, LOC, respiratory status, and skin color and temperature d. Elevate the head of the patients bed to ease breathing. e. Minimize patients physical activity to reduce oxygen requirements; administer supplemental oxygen as prescribed. f. Reposition and encourage the patient to cough and take deep breaths every 2 hours. Disseminated Intravascular Coagulation (DIC, also called Consumption Coagulopathy) 1. Complex disorder of coagulation or fibrinolysis (destruction of clots), which results in thrombosis or bleeding. 2. DIC is most commonly associated with hematologic cancers (leukemia); cancer of prostate, GIT, and lungs; chemotherapy (methotrexate, prednisone, L-asparaginase, vincristine, and 6-mercaptopurine), and disease processes, such as sepsis, hepatic failure, and anaphylaxis. 3. Blood clots form when normal coagulation mechanisms are triggered. Once activated, the clotting cascade continues to consume clotting factors and platelets faster than the body can replace them. Clots are deposited in the microvasculature, placing the patient at great risk for impaired circulation, tissue hypoxia, and necrosis. In addition, fibrinolysis occurs, breaking down clots and increasing the circulating levels of anticoagulant substances, thereby placing the patient at risk for hemorrhage. 4. Signs and symptoms: a. Chronic DIC: few or no observable symptoms or easy bruising, prolonged bleeding from venipuncture and injection sites, bleeding of the gums, and slow GI bleeding b. Acute DIC: life-threatening hemorrhage and infarction; clinical symptoms of this syndrome are varied and depend on the organ system involved in thrombus and infarction or bleeding episodes c. Prolonged prothrombin time (PT or protime) d. Prolonged partial thromboplastin time (PTT) e. Prolonged thrombin time (TT) f. Decreased finbrinogen, platelet, clotting factors, hemoglobin, hematocrit 5. Management: a. Chemotherapy, biologic response modifier therapy, radiation therapy, or surgery is used to treat the underlying cancer. b. Antibiotic therapy is used for sepsis. c. Anticoagulants, such as heparin or antithrombin III, decrease the stimulation of the coagulation pathways. d. Transfusion of FFP or cryoprecipitates (which contain clotting factors and fibrinogen), PRBC, and platelets may be used as replacement therapy to prevent or control bleeding. e. Monitor vital signs, and measure and document intake and output. f. Assess skin color and temperature; lung, heart, and bowel sounds; LOC, headache, visual disturbances, chest pain, decreased urine output, and abdominal tenderness. g. Inspect all body orifices, tube insertion sites, incisions, and body excretions for bleeding. h. Minimize physical activity to decrease injury risks and oxygen requirements. i. Prevent bleeding; apply pressure to all venipuncture sites, and avoid nonessential invasive procedures; provide electric rather than straight-edged razors; avoid tape on the skin and advise gentle but adequate oral hygiene. j. Assist the patient to turn, cough, and take deep breaths every 2 hours. Syndrome of Inappropriate Antidiuretic Hormone (SIADH) 1. The continuous, uncontrolled release of ADH, produced by tumor cells or by the abnormal stimulation of the hypothalamic-pituitary network, leads to increased ECF fluid volume, water intoxication, hyponatremia, and increased excretion of urinary sodium. As fluid volume increases, stretch receptors in the right atrium respond by releasing a second hormone, atrial naturetic factor (ANF). The release of ANF causes increased renal excretion of sodium, which worsens hyponatremia. 2. The most common cause of SIADH is cancer, especially small cell cancers of the lung. 3. Antineoplastics vincristine, vinblastine, cisplatin, and cyclophosphamide and morphine also stimulate ADH secretion, which promotes conservation and reabsorption of water by the kidneys. As more fluid is absorbed, the circulatory volume increases, ANF is released, and sodium is actively excreted by the kidneys in compensation. 4. Signs and symptoms: a. Serum sodium levels below 120 mEq/L (Hyponatremia): personality changes, irritability, nausea, anorexia, vomiting, weight gain, fatigue, muscular pain (myalgia), headache, lethargy, and confusion. b. Serum sodium levels below 110 mEq/L: seizure, abnormal reflexes, papilledema, coma, and death. Edema is rare. 5. Management: a. Fluid intake range limited to 500 to 1,000 mL/day to increase the serum sodium level and decrease fluid overload. b. Demeclocycline to interfere with the antidiuretic action of ADH and ANF.

When neurologic symptoms are severe, parenteral sodium replacement and diuretic therapy are indicated. Electrolyte levels are monitored carefully to detect secondary magnesium, potassium, and calcium imbalances. After the symptoms of SIADH are controlled, the underlying cancer is treated. If water excess continues despite treatment, pharmacologic intervention (urea and furosemide) may be indicated. Maintain intake and output measurements. Assess LOC, lung and heart sounds, vital signs, daily weight, and urine specific gravity; also assess for nausea, vomiting, anorexia, edema, fatigue, and lethargy. i. Minimize the patients activity; provide appropriate oral hygiene; maintain environmental safety; and restrict fluid intake if necessary. G. Tumor Lysis Syndrome 1. Potentially fatal complication associated with radiation- or chemotherapy-induced cell destruction of large or rapidly growing cancers such as leukemia, lymphoma, and small cell lung cancer. The release of intracellular contents from the tumor cells, leads to electrolyte imbalances hyperkalemia, hypocalcemia, hyperphosphatemia, and hyperuricemia because the kidneys can no longer excrete large volumes of the released intracellular metabolites. 2. Signs and symptoms: a. Clinical manifestations depend on the extent of metabolic abnormalities. b. Neurologic: fatigue, weakness, memory loss, altered mental status, muscle cramps, tetany, paresthesias (numbness and tingling), seizures c. Cardiac: elevated BP, shortened QT complexes, widened QRS waves, dysrhythmias, cardiac arrest d. GI: anorexia, nausea, vomiting, abdominal cramps, diarrhea e. Renal: flank pain, oliguria, anuria, renal failure, acidic urine pH 3. Management: a. To prevent renal failure and restore electrolyte balance, aggressive fluid hydration is initiated 48 hours before and after the initiation of cytotoxic therapy to increase urine volume and eliminate uric acid and electrolytes. Urine is alkalinized by adding sodium bicarbonate to IV fluid to maintain a urine pH or 7 or more; this prevents renal failure secondary to uric acid precipitation in the kidneys. b. Diuretic therapy, with a carbonic anhydrase inhibitor or acetazolamide, to alkalinize the urine c. Allopurinol therapy to inhibit the conversion of nucleic acids to uric acid d. Administration of a cation-exchange resin, such as sodium polystyrene sulfonate (Kayexelate) to treat hyperkalemia by binding and eliminating potassium through the bowel e. Administration of hypertonic dextrose and regular insulin temporarily shifts potassium into the cells and lowers serum potassium levels. f. Administration of phosphate-binding gels, such as aluminum hydroxide, to treat hyperphosphatemia by promoting phosphate excretion in the feces. g. Hemodialysis when patients are unresponsive to the standard approaches for managing uric acid and electrolyte abnormalities. h. Institute essential preventive measures (eg, fluid hydration and allopurinol)

c. d. e. f. g. h.