Nursing Care for a person with Cancer

• Differentiate the three phases of cancer development:

  • Latent: time that elapses between the first genetic alteration and actual clinical evidence (includes both the initiation and promotion stages)
  • Initiation: mutations in cell genetic structure
  • Promotion: mutations lead to an increase in altered cells due to reversible proliferation
  • Progression: increased growth rate, invasiveness, and metastasis
• Describe the role of the immune system in the recognition and destruction of tumor cells:

  • Cancer cells develop in our bodies but usually eliminated by our immune system
  • Cancer cells have altered cell surface antigens
• Immunological Escape:

  • Cancer cells can and do evade the immune system
  • Cancer cells can mutate which weakens their surface antigens and make them less visible to the immune system
  • Cancer can create cytokines which confuse the immune system and interfere with its communication systems
  • Cancer cells can create proteins which turn off immune cells
  • checkpoint proteins
• Sentinel Lymph Node:

  • First lymph node to which cancer cells are most likely to spread from primary tumor
  • Sentinel lymph node biopsy (SLNB): determines if cancer cells have spread to lymphatic system
  • Routinely used for people with breast cancer and melanoma
  • If sentinel node is negative it means that lymph nodes distal are not removed
• Anatomical Site can determine the status of Cancer:

  • Named according to the organ where they originated (most common sites are the skin, lungs, female breasts, prostate, colon and rectum, uterus).
  • Are also based on the type of tissue affected (major categories include carcinoma, sarcoma, myeloma, leukemia, lymphoma)
• Anatomical Sites:

  • Carcinoma: malignant cancer of epithelial origin
  • Squamous Cell: originates in squamous epithelium and occurs in many areas of the body
  • Adenocarcinoma: develops in mucous-producing (glandular) cells
  • Sarcoma: originates in the connective tissue (bones, cartilage, fibrous tissue, muscle, fat)
  • Lymphoma: cancer that originates in the lymphatic system
  • Leukemia: cancer of bone marrow origin
  • Myeloma: cancer that originates in plasma cells in the bone marrow
• Histology Grading:

  • Grade 1: cells differ slightly from normal cells (mild dysplasia) and are well differentiated (low grade)
  • Grade 2: cells are more abnormal (moderate dysplasia) and are moderately differentiated (intermediate grade)
  • Grade 3: cells are very abnormal (severe dysplasia) and poorly differentiated (high grade)
  • Grade 4: cells are immature and primitive (anaplasia) and undifferentiated (high grade- cell origin is difficult to determine)
  • Grade 5: grade cannot be processed
• Clinical Staging:

  • Stage 0: abnormal cells that could grow into cancer are present but have not spread to nearby tissue
  • pre cancer: carcinoma in situ
  • Stage 1: Cancer is present but has not spread
  • early stage cancer
  • Stage 2: Cancer has spread into nearby tissue
  • Stage 3: Cancer has spread further, tumor is larger
  • Stage 4: Cancer has spread to distant parts of the body
  • advanced/metastatic cancer
• TNM Classification System:

  • T: size of the tumor and extent of tumor invasion into tissue
  • N: spread to nearby lymph nodes
  • M: spread to distant tissue/organs
• Surgery: used for prevention, cure or control, and supportive/palliative care
• Chemotherapy: use of chemicals as systemic therapy

  • Can control cure, or offer palliative relief
  • Primarily disrupts the cell cycle and kills rapidly dividing cells
  • cancer cells
  • bone marrow, mucous membranes, integumentary system (skin, hair, nails)
• Radiation Therapy: energy is emitted from an external source and travels to the intended treatment field to damage the cancer cell's DNA and destroy their ability to grow and divide

  • Used for both curative and palliative treatment of cancer
  • More than half are treated with this
  • Two types: External Beam Radiation, Brachytherapy
• External Beam Radiation:

  • A machine called a linear accelerator is used to deliver photon external beam radiation therapy
  • First session is simulation session to map out exactly where the radiation needs to be delivered
• Brachytherapy:

  • Implantation or insertion of radioactive materials directly into the tumor or near the tumor
  • Used for treatment of cervical, breast, prostate, and head and neck cancers
  • Intracavity for cervical cancer allows for higher dose of radiation to the cervix while sparing surrounding tissue
  • Visitors need to limit visiting time and stay 6ft or more away from patient
• Immunotherapy: boosts the immune system to help the body find and destroy cancer cells
• Types of Immunotherapy:

  • Non-specific immunotherapies
  • cytokines: Interferon Alfa
  • Immune Checkpoint Inhibitors
  • Pembrolizumab (Keytruda)
  • T-cell Transfer Therapy
  • CAR T therapy for leukemia and lymphoma
• Side effects of Immunotherapies

  • Tend to be mild but can be severe
  • Include flu like symptoms, rash, diarrhea, fatigue, liver toxicity
• Targeted Therapy: drugs designed to destroy cancer cells by focusing on a specific protein or mutation in the cancer cell that is allowing it to grow and multiply

  • examples: Trastuzumab (Herceptin) - HER2 inhibitor and Imatinib (Gleevec)
  • side effects: same as immunotherapy
• • Methods of Administration: Chemotherapy
  • Intravenous: Central venous access device
  • Chemo drugs are often vesicant can cause tissue necrosis if infused into tissue surrounding a vein
  • Oral
  • Subcutaneous, intramuscular, topical
  • Regional
  • Intracavitary: into a CAVITY
  • Intrathecal: into the CEREBRAL SPINAL FLUID
  • Intravesical: into the BLADDER
• • Chemotherapy Side Effects:
  • Acute Toxicity: during or right after administration
  • Anaphylactic or hypersensitivity reaction, GI upset, cardiac dysrhythmias
  • Delayed Effects: within days to weeks of administration
  • GI upset, mucositis, alopecia, rashed, bone marrow suppression
  • Chronic Toxicity: long-term effects, last several months to years after administration
  • Heart, lung, kidney damage; neuropathy; skin changes; infertility
• • Radiation Side Effects: 
  • Acute Radiation Effects:
  • Dryness, itching, blistering, wet sores, peeling of skin
  • N/V & Diarrhea
  • Fatigue - Severe
  • Bone marrow suppression
  • Late Radiation Effects:
  • Can occur weeks - months after; can be permanent
  • Damage to heart, lung scarring, cystitis & infertility
• Chemotherapy & Radiation Therapy:

  • Common side effects include bone marrow suppression, fatigue, GI disturbances, skin and mucosal reactions, and pulmonary and reproductive effects
• Bone Marrow Suppression

  • Monitor CBC
  • If neutropenic, do infection measures and monitor temp
  • If thrombocytopenia, monitor for signs of hemorrhage
  • If anemia, give RBC growth factors
• Fatigue:

  • Assess for reversible causes of fatigue, such as anemia, hypothyroidism, depression, anxiety, insomnia, dehydration, or infection
  • Help them recognize this is normal, teach energy conservation strategies, encourage them to be active
  • Encourage rest when fatigued and moderate exercise when tolerated
• GI Effects:

  • Nausea and Vomiting
  • Diarrhea
  • Mucositis
  • Anorexia
• GI effects: Nausea and Vomiting

  • Aggressive emesis control (giving prophylactic antiemetic and anti anxiety meds 1 hour before treatment is recc. – may also give a light meal)
  • Assess for dehydration and metabolic alkalosis
• GI effects: Diarrhea

  • Recommend a diet low in fiber and residue before chemo
  • Limit fruit, veggies, seeds, nuts
  • Also avoid fried, fatty, seasoned foods
  • May also cause lactose intolerance, so avoid milk
  • Hydration and electrolyte supp. are recc.
  • Lukewarm sitz baths may ease discomfort cleanse area
  • Maintain skin integrity
• GI effects: Mucositis

  • Oral assessments, implement standard oral care protocols
  • Pain can be eased by systemic and/or topical analgesics and antibiotics if infection is present
• GI effects: Anorexia

  • Monitor weight 
  • Try small, frequent meals of high protein, high cals
  • May try nutritional supp.
  • Enteral or parenteral nutrition may be needed if severely malnourished
  • Manage other symptoms that are interfering with appetite
  • May recommend journal for recording intake
• Skin Reactions

  • Radiation Therapy 
  • Prevent infection and promote wound healing
  • With dry reactions, lubricate dry skin with lotion 
  • With wet reactions, keep tissues clean with normal saline compresses or modified burow’s solution soaks and protect skin with dressings or gauze (if wet = keep wet)
  • Do not use heating pads, ice packs, and hot water bottles
  • Avoid constricting garments
  • Chemotherapy
  • Psychosocial support and patient education about potential skin changes 
  • Avoid sun exposure and unnecessary irritants 
  • Scalp cooling and cold caps for alopecia
• Cardiovascular and Pulmonary

  • Monitor left ventricular function during treatment with ECGs
  • Also monitor ejection fraction and blood pressure often
  • Antidysrhythmic meds
• Cognitive and Reproductive

  • Monitor level of consciousness
  • Encourage discussion and work with patient to keep brain active and be involved
  • Use testicular or ovarian shieling
  • Address fertility preservation before therapy (pretreatment harvesting)
• Immunotherapy and Targeted Therapy Effects:

  • Effects occur more acutely and are dose limited
  • Monitor vital signs and temperature, planning for periods of rest, assist with ADLs, and monitor for adequate oral intake
  • If needed...
  • Give acetaminophen (before and every 4 hours after) and give fluids for flu like symptoms
  • IV meperidine has been used to control chills or rigors