Chapter 15

Cancer

Copyright © 2020 by Elsevier, Inc. All rights reserved.

 Cancer (1 of 5)
 Group of diseases characterized by uncontrolled
and unregulated growth of cells
 Occurs in people of all ages
➢ Most cases are diagnosed in those over age 55

Copyright © 2020 by Elsevier, Inc. All rights reserved. 2

 Cancer (2 of 5)
 Both the incidence and mortality rate of cancer has
been declining
➢ Incidences of lung, colorectal, breast, and oral cancer
have decreased
➢ Other cancers have increased

Copyright © 2020 by Elsevier, Inc. All rights reserved. 3

 Cancer (3 of 5)
 Higher in men than women
 Second most common cause of death in United
States after heart disease
➢ Leading cause of death in people 40 to 79 years of
age

Copyright © 2020 by Elsevier, Inc. All rights reserved. 4

 Cancer (4 of 5)
 Greater than 14.5 million Americans are alive today
who have a history of cancer
➢ Disease free
➢ In remission
➢ Under treatment

Copyright © 2020 by Elsevier, Inc. All rights reserved. 5

 Cancer (5 of 5)
 Statistics cannot describe the combined
physiologic, psychologic, and social impact of
cancer on individual patients, their caregivers,
and families.

(©Comstock/Thinkstock)

Copyright © 2020 by Elsevier, Inc. All rights reserved. 6

 Biology of Cancer
 Two major dysfunctions in the process of cancer
development:
1. Defective cell proliferation (growth)
2. Defective cell differentiation

Copyright © 2020 by Elsevier, Inc. All rights reserved. 7

 Defect in Cellular Differentiation
(1 of 3)
 Two types of genes that can be affected by mutation
are
➢ Protooncogenes
• Regulate normal cellular processes such as promoting
growth
➢ Tumor suppressor genes
• Suppress growth

Copyright © 2020 by Elsevier, Inc. All rights reserved. 8

 Defect in Cellular Differentiation
(2 of 3)
 Protooncogenes
➢ Genetic locks that keep cells functioning normally
➢ Mutations that alter their expression can activate
them to function as oncogenes

Copyright © 2020 by Elsevier, Inc. All rights reserved. 9

 Defect in Cellular Differentiation
(3 of 3)
 Tumor suppressor genes
➢ Function to regulate cell growth
• Prevent cells from going through the cell cycle
➢ Mutations make them inactive
• Result in loss of suppression of tumor growth

Copyright © 2020 by Elsevier, Inc. All rights reserved. 10

 Development of Cancer (1 of 11)
 Initiation
➢ First stage
➢ Mutation of cell’s genetic structure
• Any change in usual DNA sequence

Copyright © 2020 by Elsevier, Inc. All rights reserved. 11

 Gene Mutations
 Inherited
➢ About 5% to 10% of all cancers or predisposition to
cancers are inherited
➢ Lead to a very high risk for cancer
 Acquired
➢ Most cancers are acquired

Copyright © 2020 by Elsevier, Inc. All rights reserved. 12

 Carcinogens
 Cancer-causing agents capable of producing cell
alterations
➢ Many are detoxified by protective enzymes and are
harmlessly excreted
➢ Failure of protective mechanisms allows them to enter
cell’s nucleus and alter DNA

Copyright © 2020 by Elsevier, Inc. All rights reserved. 13

 Development of Cancer (2 of 11)
 Carcinogens may be
➢ Chemical
➢ Radiation
➢ Viral

Copyright © 2020 by Elsevier, Inc. All rights reserved. 14

 Development of Cancer (3 of 11)
 Chemical carcinogens
➢ Many chemicals have been identified as carcinogens
over the years
• Benzene
• Arsenic
• Formaldehyde

Copyright © 2020 by Elsevier, Inc. All rights reserved. 15

 Development of Cancer (4 of 11)
 Radiation
➢ Radiation can cause cancer in almost any human
tissue
➢ Damage occurs to DNA
➢ Ultraviolet radiation is associated with melanoma and
squamous and basal cell carcinoma
• Sunlight is main source of UV exposure

Copyright © 2020 by Elsevier, Inc. All rights reserved. 16

 Development of Cancer (5 of 11)
 Viral carcinogens
➢ Epstein-Barr virus (EBV)
• Burkitt’s lymphoma
➢ Human immunodeficiency virus (HIV)
• Kaposi sarcoma
➢ Hepatitis B virus
• Hepatocellular carcinoma
➢ Human papillomavirus (HPV)
• Squamous cell carcinomas

Copyright © 2020 by Elsevier, Inc. All rights reserved. 17

 Development of Cancer (6 of 11)
 Promotion
➢ Characterized by reversible proliferation of altered
cells
➢ Activities of promotion are reversible
• Obesity
• Smoking
• Alcohol use
• Dietary fat

Copyright © 2020 by Elsevier, Inc. All rights reserved. 18

 Development of Cancer (7 of 11)
 Latent period
➢ May range from 1 to 40 years
➢ Length of latent period associated with mitotic rate of
tissue of origin and environmental factors
➢ For disease to be clinically evident, tumor must reach
a critical mass that can be detected

Copyright © 2020 by Elsevier, Inc. All rights reserved. 19

 Development of Cancer (8 of 11)
 Progression
➢ Characterized by
• Increased growth rate of tumor
• Invasiveness
• Metastasis

Copyright © 2020 by Elsevier, Inc. All rights reserved. 20

 Main Sites of Metastasis

Fig. 15-3

Copyright © 2020 by Elsevier, Inc. All rights reserved. 21

 Development of Cancer (9 of 11)
 Progression
➢ Metastasis process begins with rapid growth of
primary tumor
• Develops its own blood supply
 Tumor angiogenesis
• Tumor cells can detach and invade surrounding tissues

Copyright © 2020 by Elsevier, Inc. All rights reserved. 22

 Development of Cancer (10 of 11)
 Progression
➢ Metastasis process
• Detached cells can invade lymph nodes and vascular vessels
to travel to distant sites
• Most mobile tumor cells do not survive
• Surviving tumor cells must create an environment conducive
to growth and development

Copyright © 2020 by Elsevier, Inc. All rights reserved. 23

 Development of Cancer (11 of 11)
 Progression
➢ Sentinel lymph node
• First node confronted as tumor cells spread through the
lymphatic system
• Biopsy can help determine extent of cancer
➢ Skip metastasis
• When tumor cell travel to distant nodes

Copyright © 2020 by Elsevier, Inc. All rights reserved. 24

 Role of Immune System (1 of 8)
 Immune response is to reject or destroy cancer cells
➢ May be inadequate as cancer cells arise from normal
human cells
 Some cancer cells have changes on their surface
antigens
➢ Tumor-associated antigens (TAAs)

Copyright © 2020 by Elsevier, Inc. All rights reserved. 25

 Benign Versus Malignant
Neoplasms
 Tumors can be classified as benign or malignant
 Ability of malignant tumor cells to invade and
metastasize is major difference between benign
and malignant neoplasms

Copyright © 2020 by Elsevier, Inc. All rights reserved. 26

 Classification of Cancer (1 of 13)
 Tumors can be classified by
➢ Anatomic site
➢ Histology
• Grading severity
➢ Extent of disease
• Staging

Copyright © 2020 by Elsevier, Inc. All rights reserved. 27

 Classification of Cancer (2 of 13)
 Classification systems provide a standardized way
to
➢ Communicate with health care team
➢ Prepare and evaluate treatment plan
➢ Determine prognosis
➢ Compare groups statistically

Copyright © 2020 by Elsevier, Inc. All rights reserved. 28

 Classification of Cancer (3 of 13)
 Anatomic site classification
➢ Identified by tissue of origin
➢ Carcinomas originate from
• Embryonal ectoderm (skin, glands)
• Endoderm (mucous membrane of respiratory tract, GI
and GU tracts)

Copyright © 2020 by Elsevier, Inc. All rights reserved. 29

 Classification of Cancer (4 of 13)
 Anatomic site classification
➢ Sarcomas originate from
• Embryonal mesoderm (connective tissue, muscle,
bone, and fat)
➢ Lymphomas and leukemias originate from
• Hematopoietic system

Copyright © 2020 by Elsevier, Inc. All rights reserved. 30

 Classification of Cancer (5 of 13)
 Histologic classification
➢ Appearance of cells and degree of differentiation are
evaluated to determine how closely cells resemble
tissue of origin
➢ Poorly differentiated tumors have a poorer prognosis
than those closer in appearance to normal cells

Copyright © 2020 by Elsevier, Inc. All rights reserved. 31

 Classification of Cancer (6 of 13)
 Four grades of abnormal cells
➢ Grade I
• Cells differ slightly from normal cells and are well
differentiated
➢ Grade II
• Cells are more abnormal and moderately differentiated

Copyright © 2020 by Elsevier, Inc. All rights reserved. 32

 Classification of Cancer (7 of 13)
 Four grades
➢ Grade III
• Cells are very abnormal and poorly differentiated
➢ Grade IV
• Cells are immature and primitive and undifferentiated
• Cell of origin is difficult to determine

Copyright © 2020 by Elsevier, Inc. All rights reserved. 33

 Classification of Cancer (8 of 13)
 Clinical staging classifications
➢ 0: Cancer in situ
➢ I: Tumor limited to tissue of origin; localized tumor
growth
➢ II: Limited local spread
➢ III: Extensive local and regional spread
➢ IV: Metastasis

Copyright © 2020 by Elsevier, Inc. All rights reserved. 34

 Classification of Cancer (9 of 13)
 TNM classification system
➢ Anatomic extent of disease is based on three
parameters:
• Tumor size and invasiveness (T)
• Spread to lymph nodes (N)
• Metastasis (M)

Copyright © 2020 by Elsevier, Inc. All rights reserved. 35

 Classification of Cancer (10 of 13)
 Staging
➢ Performed initially and at several evaluation points
• Clinical staging
• Surgical staging

Copyright © 2020 by Elsevier, Inc. All rights reserved. 36

 Classification of Cancer (11 of 13)
 Clinical staging
➢ Done at completion of diagnostic workup to guide
effective treatment selection
• Bone and liver scans, ultrasonography, CT, MRI, PET
scans

Copyright © 2020 by Elsevier, Inc. All rights reserved. 37

 Classification of Cancer (12 of 13)
 Surgical staging
➢ Determined by surgical excision, exploration, and/or
lymph node sampling
➢ Exploratory surgical staging is being used less
frequently

Copyright © 2020 by Elsevier, Inc. All rights reserved. 38

Classification of Cancer (13 of 13)
 Stage classification is not changed once
established
 Retreatment staging is done if additional
treatment is needed or if treatment fails
➢ (rTNM)

Copyright © 2020 by Elsevier, Inc. All rights reserved. 39

 Diagnoses of Cancer (1 of 8)
 Patient may experience fear and anxiety
➢ Actively listen to patient’s concerns
➢ Manage your own discomfort
➢ Give clear explanations; repeat if necessary
➢ Give written information for reinforcement
➢ Refer to oncology team when possible

Copyright © 2020 by Elsevier, Inc. All rights reserved. 40

 Diagnoses of Cancer (2 of 8)
➢ Manage your own discomfort
• Avoid
 Communication patterns that may hinder exploration of
feelings
 Use of overly technical language
• Encourage patients to share the meaning of their
experience
• Listening is an important skill at this time

Copyright © 2020 by Elsevier, Inc. All rights reserved. 41

 “Caring” Questions
 What can you do if you are uncomfortable
discussing patient’s fears and concerns about
cancer?
 Do you believe that it’s possible to “fix” patient’s
fears by avoiding them?

Copyright © 2020 by Elsevier, Inc. All rights reserved. 42

 Diagnoses of Cancer (3 of 8)
 Diagnostic plan includes
➢ Health history
• History of present illness
➢ Identification of risk factors
➢ Physical examination
➢ Specific diagnostic studies

Copyright © 2020 by Elsevier, Inc. All rights reserved. 43

 Diagnoses of Cancer (4 of 8)
 Indicated diagnostic studies depend on site of
cancer
➢ Cytology studies
➢ Chest x-ray
➢ CBC, chemistry profile
➢ Liver function studies
➢ Endoscopic examinations

Copyright © 2020 by Elsevier, Inc. All rights reserved. 44

 Diagnoses of Cancer (5 of 8)
 Indicated diagnostic studies depend on site of
cancer
➢ Radiographic studies
➢ Radioisotope scans
➢ PET scan
➢ Tumor markers
➢ Genetic markers

Copyright © 2020 by Elsevier, Inc. All rights reserved. 45

 Diagnoses of Cancer (6 of 8)
 Indicated diagnostic studies depend on site of
cancer
➢ Molecular receptor status
➢ Bone marrow examination
➢ Biopsy

Copyright © 2020 by Elsevier, Inc. All rights reserved. 46

 Diagnoses of Cancer (7 of 8)
 Biopsy involves histologic examination by a
pathologist of a piece of tissue
➢ Tissue may be obtained by
• Needle or aspiration
• Incisional procedure
• Excisional procedure

Copyright © 2020 by Elsevier, Inc. All rights reserved. 47

 Diagnosis of Cancer (8 of 8)
 Pathologic evaluation of a tissue sample is only
definitive means to diagnose cancer
➢ Benign or malignant
➢ Histology
➢ Histologic grade

Copyright © 2020 by Elsevier, Inc. All rights reserved. 48

 Prevention is Key
 The war on cancer will not be won with drugs or
radiation therapy
 A stronger emphasis on prevention is needed
 Nurses have an essential role

Copyright © 2020 by Elsevier, Inc. All rights reserved. 49

 Education Is Essential
 Goals of public education
➢ Motivate people to recognize and modify behaviors
that may negatively affect health
➢ Encourage awareness of and participation in health-
promoting behaviors

Copyright © 2020 by Elsevier, Inc. All rights reserved. 50

 Prevention and Detection of
Cancer (1 of 3)
 Lifestyle habits to reduce risks
➢ Practice recommended cancer screenings
➢ Practice self-examination
➢ Know “7 Warning Signs of Cancer”
➢ Seek medical care if cancer is suspected

Copyright © 2020 by Elsevier, Inc. All rights reserved. 51

 Prevention and Detection of
Cancer (2 of 3)
 Lifestyle habits to reduce risks
➢ Avoid or reduce exposure to known or suspected
carcinogens
• Cigarette smoke, excessive sun exposure
➢ Eat a balanced diet
➢ Limit alcohol use
➢ Exercise regularly

Copyright © 2020 by Elsevier, Inc. All rights reserved. 52

 Prevention and Detection of
Cancer (3 of 3)
 Lifestyle habits to reduce risks
➢ Maintain a healthy weight
➢ Get adequate rest
➢ Eliminate, reduce, or cope with stress
➢ Have a regular health examination
• Be familiar with your family history
• Know your risk factors

Copyright © 2020 by Elsevier, Inc. All rights reserved. 53

Interprofessional Care and
Complications

Copyright © 2020 by Elsevier, Inc. All rights reserved. 54

 Cancer Treatment (1 of 3)
 Goals
➢ Cure
➢ Control
➢ Palliation

Copyright © 2020 by Elsevier, Inc. All rights reserved. 55

 Cancer Treatment (2 of 3)
 Curative therapy
➢ Surgery alone or periods of adjunctive systemic
therapy
➢ Timeframe to “cure” may differ according to the tumor
and its characteristics
 Control treatment
➢ Initial course and maintenance therapy

Copyright © 2020 by Elsevier, Inc. All rights reserved. 56

 Cancer Treatment (3 of 3)
 Palliation goal
➢ Relief or control of symptoms
➢ Maintain quality of life
 Palliative care and treatment are not mutually
exclusive and can take concurrently

Copyright © 2020 by Elsevier, Inc. All rights reserved. 57

 Personalized Cancer Medicine
(1 of 4)
 Genetic information is used to customize decisions
about
➢ Prevention
➢ Diagnosis
➢ Treatment

Copyright © 2020 by Elsevier, Inc. All rights reserved. 58

 Personalized Cancer Medicine
(2 of 4)
 Targeted therapy
➢ Aims at a cancer’s specific genes or proteins that
contribute to cancer growth and survival
➢ Biopsy can help determine whether a tumor has the
specific target

Copyright © 2020 by Elsevier, Inc. All rights reserved. 59

 Cancer Treatment
Surgical Therapy (1 of 4)
 Surgery
➢ Oldest form of cancer treatment
➢ Meets a variety of goals
➢ Trend is toward less radical surgeries

Copyright © 2020 by Elsevier, Inc. All rights reserved. 60

 Cancer Treatment
Surgical Therapy (2 of 4)
 Prevention
➢ Surgery used to eliminate or reduce risk of cancer in
at-risk patients
• Prophylactic removal of nonvital organs has been
successful in reducing the incidence of some cancers
• Usual sites of regional spread may be removed

Copyright © 2020 by Elsevier, Inc. All rights reserved. 61

 Cancer Treatment
Surgical Therapy (3 of 4)
 Cure and control
➢ Remove only as much tissue as necessary and spare
normal tissue
➢ Debulking procedure may be used if tumor cannot be
completely removed
• Followed by chemotherapy or radiation therapy

Copyright © 2020 by Elsevier, Inc. All rights reserved. 62

 Cancer Treatment
Surgical Therapy (4 of 4)
 Supportive and palliative care
➢ Cure or control not possible
➢ Supportive care includes
• Insertion of gastric feeding tube
• Placement of central venous access device
• Prophylactic surgical fixation of bones at risk for
pathologic fracture

Copyright © 2020 by Elsevier, Inc. All rights reserved. 63

 Chemotherapy (1 of 2)
 Antineoplastic therapy
➢ Use of chemicals given as a systemic therapy for
cancer
➢ Mainstay for most solid tumors and hematologic
cancers
➢ Can offer cure, control, or palliative care

Copyright © 2020 by Elsevier, Inc. All rights reserved. 64

 Goals of Chemotherapy

Fig. 15-10
Copyright © 2020 by Elsevier, Inc. All rights reserved. 65
 Chemotherapy
Classification of Drugs
 Classified by
➢ Molecular structure
➢ Mechanism of action
 Two major categories
➢ Cell cycle phase nonspecific
➢ Cell cycle phase specific
 Typically given in combination

Copyright © 2020 by Elsevier, Inc. All rights reserved. 66

 Preparation and Handling of
Chemotherapy Agents
 May pose an occupational hazard
 Drugs may be absorbed through
➢ Skin
➢ Inhalation during preparation, transportation, and
administration
 Only properly trained personnel should handle
cancer drugs

Copyright © 2020 by Elsevier, Inc. All rights reserved. 67

 Chemotherapy
Methods of Administration (1 of 2)
 Oral
➢ More available options today
➢ Storage and side effects
 IM
 IV (most common)
➢ Central venous access device (CVAD)

Copyright © 2020 by Elsevier, Inc. All rights reserved. 68

 Chemotherapy
Methods of Administration (2 of 2)
 CVAD administration
➢ Placement in large blood vessels
➢ Frequent, continuous, or intermittent administration
➢ Can be used to administer other fluids (blood,
electrolytes, etc.)

Copyright © 2020 by Elsevier, Inc. All rights reserved. 69

 Chemotherapy
Regional Administration (1 of 3)
 Delivery of drug directly into
tumor site
 Higher concentrations of drug can be delivered
with less systemic toxicity

Copyright © 2020 by Elsevier, Inc. All rights reserved. 70

 Chemotherapy
Regional Administration (2 of 3)
 Types of regional delivery methods
➢ Intraarterial
• Delivers drug through arteries supplying tumor
➢ Intraperitoneal
• Delivers drug to peritoneal cavity for treatment of peritoneal
metastases

Copyright © 2020 by Elsevier, Inc. All rights reserved. 71

 Chemotherapy
Regional Administration (3 of 3)
 Types of regional delivery methods
 Intrathecal or intraventricular
• Involves lumbar puncture and injection of
chemotherapy into subarachnoid space
➢ Intravesical bladder
• Agent added to bladder by urinary catheter and
retained for 1 to 3 hours

Copyright © 2020 by Elsevier, Inc. All rights reserved. 72

 Chemotherapy
Effects on Normal Tissue (1 of 2)
 Chemotherapy agents cannot distinguish
between normal and
cancer cells
 Side effects are result of destruction of normal
cells

Copyright © 2020 by Elsevier, Inc. All rights reserved. 73

 Chemotherapy
Effects on Normal Tissue (2 of 2)
 General and drug-specific adverse effects are
classified
➢ Acute
➢ Delayed
➢ Chronic

Copyright © 2020 by Elsevier, Inc. All rights reserved. 74

 Chemotherapy
Treatment Plan
 Drugs given in combination
➢ Dosages are carefully calculated according to body
surface area
➢ Regimens involve drugs with different mechanisms of
action and varying toxicity profiles

Copyright © 2020 by Elsevier, Inc. All rights reserved. 75

 Nursing Management
Chemotherapy
 Mutation of cancer cells can result in resistance to
chemotherapy
➢ Multiple drugs that work at different places in cell
cycle can more effectively kill cancer cells

Copyright © 2020 by Elsevier, Inc. All rights reserved. 76

 Cancer Treatment
Radiation Therapy (1 of 11)
 One of the oldest nonsurgical methods of cancer
treatment
 50% of all cancer patients will receive radiation
therapy at some point in their treatment

Copyright © 2020 by Elsevier, Inc. All rights reserved. 77

 Cancer Treatment
Radiation Therapy (2 of 11)
 Radiation is emission of energy from a source
and travels through space or some material
 Different types of ionizing radiation are used to
treat cancer
 Technologic advances

Copyright © 2020 by Elsevier, Inc. All rights reserved. 78

 Cancer Treatment
Radiation Therapy (3 of 11)
 Low-energy beams
➢ Expend energy quickly
➢ Penetrate a short distance
➢ Useful for skin lesions
 High-energy beams
➢ Greater depth of penetration
➢ Suitable for optimal dosing of internal targets while
sparing skin

Copyright © 2020 by Elsevier, Inc. All rights reserved. 79

 Cancer Treatment
Radiation Therapy (4 of 11)
 Historically, the radiation dose was expressed in
units called rads (radiation absorbed doses)
 Current nomenclature is gray (Gy) or centigray
(cGy)
 A centigray is equivalent to 1 rad and 100
centigray equals 1 gray

Copyright © 2020 by Elsevier, Inc. All rights reserved. 80

 Cancer Treatment
Radiation Therapy (5 of 11)
 Total doses divided into fractions
 Typically delivered once a day for 5 days a week for
2 to 8 weeks
➢ Standard fractionation
 Certain tumors are more susceptible to the effects of
radiation than others

Copyright © 2020 by Elsevier, Inc. All rights reserved. 81

 Cancer Treatment
Radiation Therapy (6 of 11)
 Simulation
➢ A process by which radiation treatment fields are
defined, filmed, and marked out on skin
➢ Radiation oncologist specifies dose and volume of
area to be treated

Copyright © 2020 by Elsevier, Inc. All rights reserved. 82

 Cancer Treatment
Radiation Therapy (7 of 11)
 Simulation
➢ Target tumor defined using
• Variety of imaging techniques
• Physical examination and surgical reports
➢ Marks placed on skin to outline treatment field

Copyright © 2020 by Elsevier, Inc. All rights reserved. 83

 Cancer Treatment
Radiation Therapy (8 of 11)
 Radiation is used to treat a carefully defined area of
the body
➢ Not a primary treatment for systemic disease
➢ May be used by itself or with chemotherapy or
surgery
• To treat primary tumors
• For palliation of metastatic lesions

Copyright © 2020 by Elsevier, Inc. All rights reserved. 84

 Cancer Treatment
Radiation Therapy (9 of 11)
 External radiation (teletherapy)
➢ Most common radiation treatment
➢ Patient exposed to radiation from a megavolt machine
• Gamma knife technology—Cobalt
• Cyclotron—Neutrons or protons
• Linear accelerator—Ionizing radiation

Copyright © 2020 by Elsevier, Inc. All rights reserved. 85

 Cancer Treatment
Radiation Therapy (10 of 11)
 Internal radiation (brachytherapy)
➢ Implantation or insertion of radioactive materials into
or close to tumor
➢ Minimal exposure to healthy tissue
➢ Commonly used in combination with external
radiation

Copyright © 2020 by Elsevier, Inc. All rights reserved. 86

 Cancer Treatment
Radiation Therapy (11 of 11)
 Internal radiation
➢ Patient is emitting radioactivity
➢ Limit amount of time near patients being treated
• Organize care
• Use shielding
• Wear film badge to monitor exposure

Copyright © 2020 by Elsevier, Inc. All rights reserved. 87

 Nursing Management
Nursing Implications (1 of 11)
 Common side effects
➢ Bone marrow suppression
➢ Fatigue
➢ GI problems
➢ Integumentary and mucosal reactions
➢ Pulmonary effects
➢ Reproductive effects

Copyright © 2020 by Elsevier, Inc. All rights reserved. 88

 Nursing Management
Nursing Implications (2 of 11)
 Bone marrow suppression
➢ Myelosuppression: most common side effect of
chemotherapy
➢ Treatment-induced reductions in RBCs and WBCs
can result in
• Infection
• Hemorrhage
• Overwhelming fatigue

Copyright © 2020 by Elsevier, Inc. All rights reserved. 89

 Nursing Management
Nursing Implications (3 of 11)
 Fatigue
➢ Encourage conservation strategies
• Rest before activity
• Get assistance with activity
• Remain active during periods of time patients feel
better
➢ Maintain nutritional and hydration status
➢ Assess for reversible causes of fatigue

Copyright © 2020 by Elsevier, Inc. All rights reserved. 90

 Nursing Management
Nursing Implications (4 of 11)
 Gastrointestinal (GI) effects
➢ Prophylactic administration of antiemetics
➢ Assess for signs and symptoms of
• Alkalosis, dehydration, and I and O
➢ Nonirritating, low-fiber,
high-calorie, high-protein diet

Copyright © 2020 by Elsevier, Inc. All rights reserved. 91

 Nursing Management
Nursing Implications (5 of 11)
 GI effects
➢ Antidiarrheal, antimotility, and antispasmodic
medications
➢ Anorexia
• Monitor carefully to avoid weight loss
 Weigh twice weekly
• Recommend small, frequent, high-protein,
high-calorie meals
• Involve dietitian before treatment begins

Copyright © 2020 by Elsevier, Inc. All rights reserved. 92

 Nursing Management
Nursing Implications (6 of 11)
 Skin reactions
➢ Occur in radiation treatment field
➢ Acute or chronic
• Develop 1 to 24 hours after treatment
• Generally progressive as treatment dose accumulates

Copyright © 2020 by Elsevier, Inc. All rights reserved. 93

 Dry Desquamation

Fig. 15-14
Copyright © 2020 by Elsevier, Inc. All rights reserved. 94
 Wet Desquamation

Fig. 15-15
Copyright © 2020 by Elsevier, Inc. All rights reserved. 95
 Nursing Management
Nursing Implications (7 of 11)
 Skin reactions
➢ Prevent infection
➢ Facilitate wound healing
➢ Protect irritated skin temperature extremes
➢ Avoid constricting garments, harsh chemicals, and
deodorants
➢ Help patients deal with hair loss (alopecia)

Copyright © 2020 by Elsevier, Inc. All rights reserved. 96

 Nursing Management
Nursing Implications (8 of 11)
 Pulmonary effects
➢ May be progressive and irreversible
➢ Cough, dyspnea, pneumonitis, pulmonary edema
➢ Treatment
• Bronchodilators
• Expectorants/cough suppressants
• Bed rest
• Oxygen

Copyright © 2020 by Elsevier, Inc. All rights reserved. 97

 Nursing Management
Nursing Implications (9 of 11)
 Cardiovascular effects
➢ Patients with preexisting coronary artery disease are
more vulnerable
➢ Baseline and periodic echocardiograms are often
done

Copyright © 2020 by Elsevier, Inc. All rights reserved. 98

 Nursing Management
Nursing Implications (10 of 11)
 Cognitive effects
➢ “Chemo” brain
➢ Often described as mental cloudiness or fog
➢ Can last for a short time or for years
➢ Can be severe

Copyright © 2020 by Elsevier, Inc. All rights reserved. 99

 Nursing Management
Nursing Implications (11 of 11)
 Reproductive effects
➢ Inform patient of expected sexual side effects
➢ Use appropriate shielding
➢ Encourage discussion of issues related to
reproduction and sexuality
➢ Refer to counseling if needed

Copyright © 2020 by Elsevier, Inc. All rights reserved. 100

 Late Effects of Radiation and
Chemotherapy
 Most at risk are patients treated with alkylating
agents and high-dose radiation
➢ May be progressive
➢ Generally permanent
 Secondary cancers
➢ Leukemia, angiosarcoma, skin cancer

Copyright © 2020 by Elsevier, Inc. All rights reserved. 101

 Immunotherapy
 Immunotherapy uses the immune system to fight
cancer
 Some types called biologic therapy
 Boost or manipulate the immune system and
create an environment not conducive for cancer
cells to grow
 Attack cancer cells directly

Copyright © 2020 by Elsevier, Inc. All rights reserved. 102

 Targeted Therapy (1 of 2)
 Interferes with cancer growth by targeting specific
cell receptors and pathways that are important in
tumor growth
➢ Does less damage to normal cells
➢ Agents that target specific oncogenes are being
developed

Copyright © 2020 by Elsevier, Inc. All rights reserved. 103

 Immunotherapy and Targeted
Therapy (1 of 3)
 Side effects
➢ Flulike symptoms
➢ Anorexia/weight loss
➢ Fatigue, malaise, weakness
➢ Nausea/vomiting
➢ Photosensitivity

Copyright © 2020 by Elsevier, Inc. All rights reserved. 104

 Immunotherapy and Targeted
Therapy (2 of 3)
 Tachycardia and orthostatic hypotension are
common
 CNS system effects
 Hepatotoxicity
 Renal system effects

Copyright © 2020 by Elsevier, Inc. All rights reserved. 105

 Immunotherapy and Targeted
Therapy (3 of 3)
 Nursing Management
➢ Side effects occur more acutely and are dose limited
➢ Can influence patient decision to continue therapy
➢ May not be reported for fear treatment may be
stopped

Copyright © 2020 by Elsevier, Inc. All rights reserved. 106

 Hormone Therapy
 Sex hormones
➢ Can stop the growth of cancer cells
 Corticosteroids
➢ Used in combination with drug regimens to help curb
side effects

Copyright © 2020 by Elsevier, Inc. All rights reserved. 107

 Hematopoietic Growth Factors
 Colony-stimulating factors
➢ Glycoproteins that stimulate production, maturation,
regulation, and activation of cells in hematologic
system
➢ May hasten recovery from bone marrow depression
or reestablish bone marrow function

Copyright © 2020 by Elsevier, Inc. All rights reserved. 108

 Hematopoietic Stem Cell
Transplantation (HSCT) (1 of 7)
 Bone marrow transplant (BMT)
 Peripheral stem cell transplantation (PSCT)
 Allows high doses for treatment
➢ Failing to respond to standard doses of chemotherapy
or radiation
➢ Develop resistance (refractory)

Copyright © 2020 by Elsevier, Inc. All rights reserved. 109

 Hematopoietic Stem Cell
Transplantation (HSCT) (2 of 7)
 Procedure with many risks, including death
 Highly toxic
 Overall cure rates are steadily increasing
 Tumor cells are eradicated and bone marrow is
rescued by infusing healthy cells

Copyright © 2020 by Elsevier, Inc. All rights reserved. 110

 Hematopoietic Stem Cell
Transplantation (HSCT) (3 of 7)
 HSCT may be categorized as
➢ Allogeneic, syngeneic, and autologous
 Sources of cells include
➢ Bone marrow
➢ Peripheral blood
➢ Umbilical cord blood

Copyright © 2020 by Elsevier, Inc. All rights reserved. 111

Autologous Stem Cell Transplant

Fig. 15-17

Copyright © 2020 by Elsevier, Inc. All rights reserved. 112

 Hematopoietic Stem Cell
Transplantation (HSCT) (4 of 7)
 Stem cells from bone marrow
➢ Procedure is performed in OR under general or spinal
anesthesia
➢ Multiple aspirations are carried out to obtain adequate
number of stem cells
• Usually from iliac crest or sometimes from sternum

Copyright © 2020 by Elsevier, Inc. All rights reserved. 113

 Hematopoietic Stem Cell
Transplantation (HSCT) (5 of 7)
 Stem cells from bone marrow
➢ Marrow is processed to remove bone fragments
➢ Cells are cryopreserved until infused

Copyright © 2020 by Elsevier, Inc. All rights reserved. 114

 Hematopoietic Stem Cell
Transplantation (HSCT) (6 of 7)
 Stem cells from peripheral blood
➢ Outpatient procedure
➢ Cell separation equipment sorts stem cells out, and
other cells are returned to donor
➢ Procedure takes 2 to 4 hours
➢ Multiple collections may be needed

Copyright © 2020 by Elsevier, Inc. All rights reserved. 115

 Hematopoietic Stem Cell
Transplantation (HSCT) (7 of 7)
 Stem cells from cord blood
➢ Umbilical cord blood can be HLA-typed and
cryopreserved
➢ May have insufficient numbers of stem cells to permit
transplant to adults
➢ Research is ongoing

Copyright © 2020 by Elsevier, Inc. All rights reserved. 116

 Posttransplant Complications
 Bacterial, viral, and fungal infections are common
➢ Prophylactic antibiotic therapy
 Graft-versus-host disease
➢ T cells from donor (graft) marrow recognize recipient
(host) as foreign
➢ Attacks organs such as skin, liver, and GI tract

Copyright © 2020 by Elsevier, Inc. All rights reserved. 117

 Gene Therapy
 Experimental therapy
➢ Genetic material is introduced into cells to fight
disease
➢ Investigational

Copyright © 2020 by Elsevier, Inc. All rights reserved. 118

 Complications of Cancer
 Patients with cancer may develop complications
from
➢ Continual growth of the cancer into normal tissue
➢ Side effects of treatment

Copyright © 2020 by Elsevier, Inc. All rights reserved. 119

 Complications of Cancer
Nutritional Problems (1 of 2)
 Malnutrition
➢ Fat and muscle depletion
➢ Nutritional counseling
• When 5% weight loss is noted
• Patient has potential for protein and calorie malnutrition

Copyright © 2020 by Elsevier, Inc. All rights reserved. 120

 Complications of Cancer
Nutritional Problems (2 of 2)
 Altered taste sensation (dysgeusia)
➢ Physiologic basis of altered taste is unknown
➢ Teach patient to
• Avoid foods they dislike
• Experiment with spices and seasonings to mask
alterations

Copyright © 2020 by Elsevier, Inc. All rights reserved. 121

 Cancer Cachexia
 Wasting syndrome
➢ Anorexia and/or unintended loss of weight and
appetite
• Generalized tissue wasting
• Skeletal muscle atrophy
• Immune dysfunction
• Metabolic abnormalities

Copyright © 2020 by Elsevier, Inc. All rights reserved. 122

 Complications of Cancer
Infection (1 of 2)
 Primary cause of death
 Usual sites of infection
➢ Lungs
➢ Genitourinary tract system
➢ Mouth, rectum
➢ Peritoneal cavity
➢ Blood

Copyright © 2020 by Elsevier, Inc. All rights reserved. 123

 Complications of Cancer
Infection (2 of 2)
 Occurs due to
➢ Ulceration
➢ Compression of vital organs by tumor
➢ Neutropenia caused by disease or treatment

Copyright © 2020 by Elsevier, Inc. All rights reserved. 124

 Complications of Cancer
Oncologic Emergencies
 Life-threatening
 Occur as the result of disease or treatment
 Emergencies can be
➢ Obstructive
➢ Metabolic
➢ Infiltrative

Copyright © 2020 by Elsevier, Inc. All rights reserved. 125

 Cancer Pain (1 of 2)
 Patient report should always be believed and
accepted as primary source for pain assessment
data
 Drug therapy should be used to control pain

Copyright © 2020 by Elsevier, Inc. All rights reserved. 126

 Cancer Pain (2 of 2)
 Undertreatment of pain causes
➢ Needless suffering
➢ Decreased quality of life
➢ Increased burden on family caregivers
 Inadequate pain assessment is single greatest
barrier to effective cancer pain management

Copyright © 2020 by Elsevier, Inc. All rights reserved. 127

 Managing Cancer Pain
 Fear of addiction is unwarranted
 Numerous drug options for pain management
 Nonpharmacologic interventions, including
relaxation therapy and imagery, can be used
effectively

Copyright © 2020 by Elsevier, Inc. All rights reserved. 128

Coping With Cancer and Treatment
(1 of 6)
 Nursing assessment and support are key
➢ Pervasive anxiety and fear
• Fears of dependency
• Loss of control
• Family relationship stress
• Financial burden
• Fear of death

Copyright © 2020 by Elsevier, Inc. All rights reserved. 129

Coping With Cancer and Treatment
(2 of 6)
 Many factors influence coping
➢ Demographics
➢ Prior coping skills and strategies
➢ Social support
➢ Religious and spiritual beliefs

Copyright © 2020 by Elsevier, Inc. All rights reserved. 130

Coping With Cancer and Treatment
(3 of 6)
 Be available, especially during difficult times
 Exhibit caring
 Actively listen
 Provide symptom relief
 Provide accurate information

Copyright © 2020 by Elsevier, Inc. All rights reserved. 131

Coping With Cancer and Treatment
(4 of 6)
 Build trust
 Use touch
 Assist setting realistic goals
 Support usual lifestyle patterns
 Maintain hope
 Reassure of ongoing support

Copyright © 2020 by Elsevier, Inc. All rights reserved. 132

Coping With Cancer and Treatment
(5 of 6)
 Offer support from survivors
 Provide phone contact between visits
 Assist with planning for
➢ Transportation
➢ Nutrition

Copyright © 2020 by Elsevier, Inc. All rights reserved. 133

Coping With Cancer and Treatment
(6 of 6)
 Care for the caregiver and other family members
➢ Education
➢ Support
➢ Psychosocial intervention
➢ Resource information

Copyright © 2020 by Elsevier, Inc. All rights reserved. 134

 Cancer
Gerontologic Considerations
 Clinical manifestations may be mistaken for age-
related changes
 More vulnerable to complications of cancer and
cancer therapy
 Functional status should be considered when a
treatment plan is selected

Copyright © 2020 by Elsevier, Inc. All rights reserved. 135

 Cancer Survivorship (1 of 2)
 Cancer survivors continue to increase
➢ Aging and growth of the population
➢ Improvement in early detection and treatment
➢ Greater than 14.5 million in the United States

Copyright © 2020 by Elsevier, Inc. All rights reserved. 136

 Cancer Survivorship (2 of 2)
 Be aware of late and long-term effects of cancer
➢ Secondary cancer
➢ Cognitive changes
➢ Cardiovascular/sexual dysfunction
➢ Psychosocial effects

Copyright © 2020 by Elsevier, Inc. All rights reserved. 137

Culturally Competent Care: Cancer
 Underserved populations are at risk for late-stage
disease at time of diagnosis
 You need to know how to
➢ Assess for cultural differences
➢ Identify barriers to care
➢ Adapt care to meet specific cultural needs

Copyright © 2020 by Elsevier, Inc. All rights reserved. 138