The Good.... The Bad...

And The Ugly

OVERVIEW CANCER, TREATMENT MODALITIES, AND SIDE EFFECTS

OBJECTIVES
Upon completion of this session, the learner will be able to:
1. 2. 3. 4. 5. 6. 7. List cancer statistics related to incidence, cases, and deaths. Define cancer. Explain theories of causation, grading, and staging of cancer. Discuss various treatment modalities available for cancer. State principles of cancer treatment. Examine common side effects, complications, and nursing management related to treatment modalities. Review basic solid tumors and hematological malignancies.

Glossary of Terminology
Neoplasm

new plasmaabnormal tissue growth with rapid growth no metastasis

local invasion and destructive growthwicked spread form primary via lymphatic and/or circulatory system

Benign

Malignant

Metastasis

STATISTICS
Cancer

is the second leading cause of death in the United States affects one in three families

Cancer

STATISTICS
Incidence: #1 Skin Male Prostate Lung Colon/Rectum Female Breast Lung Colon/Rectum Colon/Rectum Colon/Rectum Death: Male: Lung Female: Lung

Prostate

Breast

CANCER

THEORIES OF CAUSATION
Environmental (tobacco, occupational, pesticides,
asbestos)

Radiation (UV, radon)

Genetics (BRCA)
Hormonal Imbalances Viral (HIV, H Pylori, HPV)

Stress

DEFINITIONS
1. Cancer is a disease of the cell 2. Large group of diseases characterized by: a. Abnormal cell structure (no differentiation) b. Uncontrolled growth (proliferation)

c. Ability to spread (metastasis)

d. Ability to invade normal tissue (lack contact
inhibition)

Differentiation = Maturation & Proliferation = Division

Cancer cells follow no rules and have the ability to stimulate the growth of a new blood supply

Grading and Differentiation (need tissue diagnosis):

Grade 1 = Well-Differentiated

Grade 2 = Moderately differentiated

Grade 3 = Poorly-differentiated Grade 4 = Undifferentiated

TNM STAGING
T= Tumor T0-T4

N = Node No-N3

M = Metastasis

TREATMENT MODALITIES (THE GOOD)

SURGERY
Curative Prophylactic Diagnostic Staging

Palliative
Adjuvant or Supportive

Reconstructive/Rehabilitative

RADIATION

Highest energy rays that can kill any cell or tissue May be external source (brachytherapy) Curative Palliative 60% will receive XRT Divided into doses or fractions (Preserve normal cellular growth)

CHEMOTHERAPY

CHEMOTHERAPY

Chemotherapy
Cytotoxic drugs that destroy cancer cells or prevent cellular replication by interfering with DNA and RNA and vital cellular proteins

Goal is to reduce the number of cells to a small number that can be (theoretically) handled by the immune system

BIOTHERAPY

Treatment that alters the bodys biological response Uses bodys own immune system to treat cancer Alters the immune system with either stimulatory or suppressive effect Produce anti-tumor activities

HORMONAL THERAPY
used

against hormonally sensitive tumors like breast and prostate unfavorable growth environment

creates

PRINCIPLES OF CANCER TREATMENT

GOALS
CURE

CONTROL PALLIATION

MEASURE TUMOR RESPONSE

Complete Response
Partial Response Stable Disease

SIDE EFFECTS AND MANAGEMENT

(THE BAD)

MYELOSUPPRESSION
NEUTROPENIA
THROMBOCYTOPENIA ANEMIA

NEUTROPENIA

Pathophysiology
Damage to stem cells in bone marrow with decreased ability to make these important cells Hematologic malignancies cause the malignant cells to crowd the bone marrow and therefore difficult to make normal amount of normal cells Solid tumors metastasize to bone marrow with a decreased normal cell production Radiation damages bone marrows ability to make cells

Neutropenia/Leukopenia

Assess risk factors

(Age, renal and liver function, nutrition, bone marrow, other medications, prior chemotherapy and/or radiation)

Manifestations include

fever >38 C or 100.4F (no classic signs)

cough, SOB skin redness or tenderness, (mouth, perianal, rectal)

urinary symptoms (dysuria frequency, hematuria, hesitancy)

indwelling devices (VADs, pain, edema, swelling, induration at site) sepsis (hypotension, agitation, decreased urine)

Neutropenia/Leukopenia
Prevention:

No fresh fruits or vegetables, no pepper, live plants or potting soil No exposure to live vaccines or pet excreta Avoid others with colds Strict hand washing and personal hygiene

Mouth care at least 4 times daily

No trauma or invasive procedures Prevent constipation and pressure sores

Neutropenia/Leukopenia
Management:

BC lines and peripheral, urine, sputum CXR and good physical assessment Antibiotics immediately (broad spectrum coverage) Administer neupogen or leukine Patient education (temperature at least 2 times daily) Vital signs at least every 4 hours or more Assess for chills, SOB, cough, pain

***This is life-threatening for patients and requires immediate attention

BLEEDING & NO CLOTTING = THROMBOCYTOPENIA (NO PLATELETS)

Thrombocytopenia
Management

Institute bleeding precautions <50,000/mm3 Decrease activity and no lifting or straining/Valsalva High fiber, increase fluids, stool softeners No razors, nail clippers, douching, tampons, water-soluble lubricants, no flossing, guiac/hemocult, pad counts Maintain SBP <140mm/Hg No IM injections, apply pressure to all sites, no NSAIDS, administer platelets per protocol Educate patients signs and symptoms

ANEMIA = DECREASED RED BLOOD CELLS

Anemia

Assess for

chemotherapy kidney damage

tumor infiltration of bone marrow, XRT

bleeding, hemorrhage age

Anemia
Management:

Rest, slow position changes Oxygen

Iron
Transfusion Epogen (Hct<30 % or Hbg <9g/dl) @ 40,000u weekly Patient education on signs and symptoms

Neupogen

Leukine

Hematopoietic Growth Factors

Aranesp
Procrit

Neulasta Neumega

they are glycosylated proteins that function to regulate cell reproduction, cell maturation, and cell function of blood cells

GI Symptom Management

Symptom Management

Nausea/Vomiting
***As many as 60% patients experience nausea and vomiting
Patterns Anticipatory (starts and may last several hours to days)

Acute (0-24 hours) Delayed (1-4 days)

NAUSEA AND VOMITING

medications, ICP, SIADH, stress Assess for weight loss, albumin, hydration

Nausea/Vomiting
Seratonin Inhibitors/Antagonists

receptors on vagus nerve and in the CTZ effectiveness may be enhanced by concurrent administration of decadron act by blocking seratonin from binding to receptors in GI tract (not indicated for anticipatory or delayed N&V)

Ondansetron (Zofran) Dolestron (anzemet) Ganisetron (Kytril)

Nausea/Vomiting
Phenothiazines

only mildly useful as single agents better in combination with other antimetics block dopamine receptors in CTZ works well for XRT, and morphine associated nausea

Prochlorperazine (compazine) Chlorpromazine (Thorazine) Promethazine (Phenergan) Thiethylperazine (torecan)

Nausea/Vomiting
Glucocorticosteroids effective with mild emetic drugs may block prostaglandin release from hypothalmus Dexamethasone (decadron) Methylprednisone (solumedrol) prednisone

Nausea/Vomiting
Most effective agent against Cisplatin Do not use with GI obstruction Blocks CTZ and promotes gastric emptying

Metoclopramide (reglan)

Nausea/Vomiting
Cannabinoids effective with some refractory cases Dronabinol (marinol) Butyrophonones Inapsine (droperidol) Haldol

Nausea/Vomiting
Antihistamines good with motion sickness blocks extrapyrammidal effects of other antimetics not effective as single agents

Hydroxyzine (vistaril, atarax) Diphenhydramine (benadryl)

Nausea/Vomiting
Benzodiazepines amnesiac effect in drug combinations blocks short term memory

Diazepam (valium) Lorazepam (ativan)

Nausea/Vomiting
Anticipatory N & V need to mediate the response of the centers in the cerebral cortex which result in anticipatory nausea and vomiting

ativan valium dronabinol

Nausea/Vomiting
ACUTE N&V: mild potential drugs suggested to use phenothiazide =/- steroid or low dose reglan =/steroids moderate potential benefit from po/IV 5-HT3 antagonist =/- steroid or reglan =/- steroid

high potential benefit from po/IV 5-HT3 antagonist PLUS a steroid =/- a benzodiazepine

Nausea/Vomiting
Delayed N&V corticosteroids commonly used in combination with 5HT3 antagonist or reglan

result of unknown mechanism

Other Notable Side Effects

HOW DO WE TREAT ???

Up to 80% develop mouth sores Assess and prevent NSS mouth rinses

Damage is to shaft (thinning and breakage) Damage to roots (complete alopecia)

Loss begins about 2 weeks after treatment

Regrowth may take up to 3-5 months after treatment

50-100%

patients

SKIN REACTIONS
Hypersensitivity Hyper pigmentation Photo sensitivity Radiation recall Radiation enhancement Ulceration Palmar-Planter Erythrodysestheses (PPE)

THE UGLY

Cardiac Toxicity

Pulmonary

Urologic

Renal/Nephrotoxicity

Hepatotoxicity

Neurotoxicity

Ocular Toxicities

???WHICH TREATMENT DO I CHOOSE???

SOLID TUMORS
Neurological:
Brain Spinal Cord

SOLID TUMORS

Head and Neck Bone and Soft Tissues

SOLID TUMORS

LUNG

SOLID TUMORS
Esophageal Gastric Colorectal Pancreatic Hepatocellular

SOLID TUMORS
GU CANCERS
Kidney Bladder Prostate

SOLID TUMORS
GENITALCANCER

Cervical Endometrial Ovarian Testicular Breast

SKIN CANCER

LEUKEMIAS
ACUTE: AML ALL

CHRONIC: CML CLL

LYMPHOMAS
Non-Hodgkins & Hodgkins

MULTIPLE MYELOMA

HEMTOLOGICAL MALIGNANCIES
IDIOPATHIC

THROMBOCYTOPENIC PURPURA (ITP)

HEMTOLOGICAL MALIGNANCIES

THROMBOTIC THROMBOCYTOPENIA

PURPURA (TTP)

HEMTOLOGICAL MALIGNANCIES

APLASTIC ANEMIA

REFERENCES
Fishman, M., & Orlowski, M.M. (Eds.). (1999). Cancer chemotherapyguidelines and recommendations for practice: ONS (2nd ed.). OncologyNursing Press Inc. Groenwald, S.L., Froygl, M.H., Goodman, M., & Yarbo, C.H. (Eds.). (2002). Cancer nursing: Principles and practice (5th ed.). Boston: Jones and Bartlett Publishing

Itano, J.K. & Taoka, K.N. (1998). Core curriculum for oncology nursing (3rd ed.). Philadelphia: W.B. Saunders.