Adult Exam 4 Flashcards
1
Q
Cancer
A
Group of more than 200 diseases
Characterized by uncontrolled and unregulated growth of cells
2
Q
Biology of Cancer
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Two major dysfunctions:
- Defective cell proliferation (growth)
- Defective cell differentiation
3
Q
Defect in Cellular Proliferation
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Characterized by loss of contact inhibition
No regard for cell boundaries, divide indiscriminately and haphazardly
4
Q
Defect in Cellular Differentiation
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Two types of genes that can be affected by mutation are protooncogenes and tumor suppressor genes
5
Q
Protooncogenes
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Regulate normal cellular processes such as promoting growth
Genetic locks that keep cells functioning normally
Mutations can activate them to work as oncogenes
6
Q
Tumor Suppressor Genes
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Function to regulate cell growth
Mutations make them inactive
Result in loss of suppression of tumor growth
7
Q
Stages of Cancer Development
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Initiation, Promotion, Progression
8
Q
Initiation
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Mutation of a cell’s genetic structure
Any change in the usual DNA sequence
May be inherited or acquired
9
Q
Carcinogens
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Cancer-causing agents capable of producing cell alterations
Many are detoxified by protective enzymes and are harmlessly excreted
May be chemical, radiation, or viral
10
Q
Promotion
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Characterized by reversible proliferation of altered cells
Activities of promotion are reversible (obesity, smoking, alcohol, dietary fat)
11
Q
Latent Period of Cancer
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May range from 1-40 years
Length of latent period associated with mitotic rate of tissue of origin and environmental factors
12
Q
Progression
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Characterized by increased growth rate of tumor, invasiveness, and metastasis
13
Q
Main Sites of Metastasis
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Lungs, brain, bone, liver, and adrenal glands
14
Q
Role of Immune System in Cancer
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Immune response is to reject or destroy cancer cells
Some cancer cells have changes on their surface antigens (Tumor-Associated Antigens, TAAs)
Immunologic surveillance (response to TAAs)
Immunologic Escape (mechanism by which cancer cells evade immune system)
Oncofetal antigens
15
Q
Benign Neoplasms
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Similar to tissue of origin
Well differentiated
Slow growth rate
No local invasion, often encapsulated
No metastasis
16
Q
Malignant Neoplasms
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Abnormal cells, poorly differentiated
Slow to rapid growth rate
Local invasion present, infiltrative growth, usually no capsule
Frequent metastasis
Significant harm to host
17
Q
Tumors can be classified by…
A
Anatomic site
Histology (grading severity)
Extent of disease (staging)
18
Q
Anatomic Site Classification
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Carcinomas originate from embryonal ectoderm (skin, glands), endoderm (mucous membranes)
Sarcomas originate from embryonal mesoderm (connective tissue, muscle, bone, fat)
Lymphomas and leukemias originate from hematopoietic system
19
Q
Histologic Classification
A
Appearance of cells and degree of differentiation are evaluated to determine how closely cells resemble tissue of origin
Grade I (cells differ slightly, well differentiated)
Grade II (cells are more abnormal, moderately differentiated)
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)
20
Q
Clinical Staging Classifications
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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
21
Q
TNM Classification System
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Anatomic extent of disease based on three parameters:
Tumor size and invasiveness (T)
Spread to lymph nodes (N)
Metastasis (M)
22
Q
Diagnoses of Cancer
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Cytology studies Chest x-ray CBC, chemistry profile Liver function studies Endoscopic examinations Bone marrow examination Radiographic studies Radioisotope scans PET scan Tumor markers Genetic markers Molecular receptor status
23
Q
Definitive Diagnostic Test
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Biopsy
Tissue may be obtained by needle/aspiration, incisional procedure, excisional procedure
24
Q
7 Warning Signs of Cancer
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C: change in bowel/bladder function A: a sore that does not heal U: unusual bleeding or discharge T: thickening or lump I: indigestion or difficulty swallowing O: obvious change in wart/mole N: nagging cough or hoarseness
25
Primary Factors that Determine what Cancer Treatment Therapy Is Used...
Cell type
Location and size of tumor
Extent of disease
Physiologic and psychologic status
26
Role of Surgery in Cancer Treatment
Consideration of surgical intervention involves assessment of tumor stage, technical feasibility of surgical resection, co-morbidities that may influence surgical risk, and expected postoperative functional outcomes
Objective is to remove all or as much resectable tumor as possible while sparing normal tissue
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Goals of Chemotherapy
Can offer cure for some cancers, control other cancers for long periods of time, and in some instances offer palliative relief of symptoms
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Chemotherapy Effect on Cells
Effective against dividing cells, so cancer cells escape death by staying in G0 phase
Problem: presence of drug-resistant resting and noncycling cells
As tumors get bigger, more cells become inactive and convert to G0
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Classification of Chemotherapy Drugs
Classified by molecular structure and mechanism of action
Two major categories: Nonspecific and cell cycle phase-specific drugs
Typically given in combination
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Cell Cycle Phase Nonspecific Drugs
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Alkylating agents
Nitrosoureas
Platinum drugs
Antitumor antibiotics
Corticosteroids
Hormone therapy
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Cell Cycle Phase Specific Drugs
Antimetabolites
Mitotic inhibitors
Topoisomerase inhibitors
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Chemotherapy Methods of Administration
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Oral
IM
IV (most common)
Intracavitary (intravesical, intraperitoneal)
Intrathecal/Intraventricular
Intraarterial
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Preparation and Handling of Chemotherapy Agents
May pose an occupational hazard
Drugs may be absorbed through skin or inhalation
Only properly trained personnel should handle drugs
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Chemotherapy Effects on Normal Tissue
Chemotherapy agents cannot distinguish between normal and cancer cells
Side effects are the result of the destruction of normal cells
General and drug-specific adverse effects are classified as acute, delayed, and chronic
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Acute Toxicity of Chemotherapy
Occurs during and immediately after drug administration and includes anaphylactic and hypersensitivity reactions, extravasation or a flare reaction, anticipatory nausea and vomiting, and cardiac dysrhythmias
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Delayed Effects of Chemotherapy
Include delayed nausea and vomiting, mucositis, alopecia, skin rashes, bone marrow suppression, and altered bowel function
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Chronic Toxicities of Chemotherapy
Involve damage to organs such as the heart, liver, kidneys, and lungs
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Radiation Therapy
Emission of energy from a source and travels through space or some material
Different types of ionizing radiation are used to treat cancer
Typically delivered once a day for 5 days a week for 2 to 8 weeks
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Low-Energy Beams
Expend energy quickly
Penetrate a short distance
Useful for skin lesions
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High-Energy Beams
Greater depth of penetration
Suitable for optimal dosing of internal targets while sparing the skin
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Hypofractionated
High daily doses of radiation given with fewer fractions
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Hyperfractionated
Lower doses given more than once daily
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Accelerated Fractionation
Standard doses delivered twice daily over a shortened treatment time
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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
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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
Patient emits radioactivity
Limit amount of time near patients being treated
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Common Side Effects of Radiation
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Bone marrow suppression
Fatigue
GI disturbances
Integumentary and mucosal reactions
Pulmonary effects
Reproductive effects
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47
Bone Marrow Suppression
Most common side effect of chemotherapy
Treatment-induced reductions in RBCs and WBCs can result in infection, hemorrhage, and overwhelming fatigue
48
Nursing Management of GI Effects
Prophylactic administration of antiemetics
Assess for signs and symptoms of alkalosis, dehydration, and intake and output
Nonirritating, low-fiber, high-calorie, high-protein diet
Antidiarrheal, antimotility, and antispasmodic medications
Monitor for anorexia
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Dry Desquamation
Erythema is an acute response followed by dry desquamation
Dry reactions are uncomfortable and result in pruritus
Lubricate the skin with a nonirritating lotion emollient
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Wet Desquamation
If the rate of cell sloughing is faster than the ability of the new epidermal cells to replace dead cells, a wet desquamation occurs with exposure of the dermis and weeping of serous fluid
Wet reaction must be kept clean and protected from further damage
Generally produces pain, drainage, and increased risk of infection
51
Nursing Management of Pulmonary Effects
May be progressive and irreversible
Cough, dyspnea, pneumonitis, pulmonary edema
Treatment includes bronchodilators, expectorants/cough suppressants, bed rest, oxygen
52
Nursing Management of Cardiovascular Effects
Patients with preexisting coronary artery disease are more vulnerable
Radiation-induced heart disease is more likely in patients given high doses of radiation and doxorubicin
Herceptin is cardiotoxic
Commonly pericardial effusion
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Nursing Management of Reproductive Effects
Inform patients of expected sexual side effects
Use appropriate shielding
Encourage discussion of issues related to sexuality
Refer to counseling if needed
No way to repair ovarian function
54
Late Effects of Radiation and Chemotherapy
Increased risk for leukemias and other secondary malignancies (multiple myeloma, non-Hodgkins lymphoma, various cancers)
Fibrosarcomas have been reported several years after radiation therapy
Secondary malignancies are usually resistant to therapy
55
Biologic and Targeted Therapy
Effective alone or with surgery, radiation, and chemotherapy
Biologic: agents alter biologic response to tumor cells
Targeted: targets and binds cell receptors important to tumor growth
Include tyrosine kinase inhibitors, monoclonal antibodies, vascular endothelial growth factor receptor inhibitors, proteasome inhibitors
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Targeted Therapy
Works at sites on the cell surface, at the intracellular level, or in the extracellular domain
Interferes with cancer growth by targeting specific cell receptors and pathways that are important in tumor growth
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Tyrosine Kinase Inhibitors
Inhibits tyrosine kinase, the enzyme regulating cell proliferation and survival
Side effects include rash, dry skin, interstitial lung disease, infusion reaction, fatigue, fever, diarrhea
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Monoclonal Antibodies
Capable of binding to specific target cells to ultimately destroy them
Administered by infusion; can experience infusion-related symptoms, capillary leak syndrome, rare anaphylaxis
Fever, chills, urticaria, mucosal congestion, nausea, diarrhea, myalgias
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Angiogenesis Inhibitor
Binds vascular endothelial growth factor
Side effects include hypertension, colon bleeding and perforation, impaired wound healing, thromboembolism, hemorrhage
60
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
Can cause thromboembolic events
61
Proteasome Inhibitor
Inhibits proteasome activity, which regulates cell growth
Side effects include bone marrow suppression, peripheral neuropathy, fatigue, diarrhea, nausea, vomiting
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Side Effects of Biologic and Targeted Therapy
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Flulike symptoms
Anorexia/weight loss
Fatigue, malaise, weakness
Nausea/vomiting
Photosensitivity
Tachycardia and orthostatic hypotension
CNS system effecs
Hepatotoxicity
Renal system side effects
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63
Hematopoietic Stem Cell Transplantation (HSCT)
Bone marrow transplant (BMT)
Peripheral stem cell transplantation (PSCT)
Allows high doses for treatment
Highly toxic, procedure with many risks including death
Tumor cells are eradicated and bone marrow is rescued by infusing healthy cells
Sources of cells include bone marrow, peripheral blood, umbilical cord blood
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Autologous Transplantation
Patients receive their own stem cells back following myeloablative chemotherapy
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Stem Cells from Bone Marrow
Procedure is performed in the OR under general or spinal anesthesia
Multiple aspirations are carried out to obtain adequate number of stem cells
Marrow is processed to remove bone fragments
Cells are cryopreserved until infused
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Stem Cells from Peripheral Blood
Outpatient procedure
Cell separation equipment sorts stem cells out, and other cells are returned to the donor
Procedure takes 2-4 hours
Multiple collections may be needed
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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
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Complications of HSCT
Bacterial, viral, and fungal infections are common
Graft-versus-Host disease: T lymphocytes from donor stem cells recognize recipient as foreign; attacks organs such as skin, liver, and GI tract
Peripheral blood stem cells cause fever and less severe complications
69
Gene Therapy
Experimental therapy
Genetic material is introduced into cells to fight disease or replace missing genes to prevent the development of disease
70
Nutritional Problems of Cancer
Malnutrition
Fat and muscle depletion
Nutritional counseling needed when 5% weight loss is noted
Altered taste sensation
71
Infection Related to Cancer
Primary cause of death
Usual sites of infection include lungs, GU system, mouth, rectum, peritoneal cavity, blood
Occurs due to ulcerations, compression of vital organs by the tumor, neutropenia caused by disease or treatment
72
Oncologic Emergencies
Life-threatening
Occur as the result of disease or treatment
Emergencies can be obstructive, metabolic, infiltrative
73
Superior Vena Cava Syndrome
Obstructive emergency
Obstruction by tumor or thrombosis
Signs include facial/periorbital edema, distention of veins of head neck and chest, seizures, headache
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Spinal Cord Compression
Obstructive emergency
Tumor in epidural space of spinal cord
Signs include intense back pain, motor weakness, sensory paresthesia and loss, change in bowel or bladder function
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Third Space Syndrome
Obstructive emergency
Shifting of fluid from vascular space to interstitial space
Signs of hypovolemia, including hypotension, tachycardia, low central venous pressure, and decreased urine output
Treatment is replacement of fluids, electrolytes, and plasma protein
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Metabolic Oncologic Emergencies
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SIADH
Hypercalcemia
Tumor lysis syndrome
Septic shock
DIC
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Caused by the production of ectopic hormones directly from the tumor or are secondary to metabolic alterations caused by the presence of the tumor or cancer treatment
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SIADH
Abnormal or sustained production
Cancer cells are able to manufacture, store, and release ADH
Treatment includes treating underlying malignancy and measures to correct the sodium-water imbalance, including fluid restriction, isotonic saline, oral salt tablets
Symptoms include weight gain without edema, weakness, anorexia, nausea, vomiting, personality changes, seizures, oliguria, decrease in reflexes, and coma
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Hypercalcemia
Parathyroid hormone-like substance secreted from cancer cells
Signs include apathy, depression, fatigue, weak muscles
Electrocardiogram changes, polyuria, nocturia, anorexia, nausea, vomiting
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Tumor Lysis Syndrome
Triggered by chemotherapy's rapid destruction of large numbers of tumor cells
Increased serum phosphate causes calcium to decrease resulting in hypocalcemia
Can cause biochemical changes resulting in renal failure
Four hallmark signs: hyperuricemia, hyperphosphatemia, hyperkalemia, hypocalcemia
Usually occurs within 24-48 hours after chemotherapy
80
Cardiac Tamponade
Infiltrative oncologic emergency
Fluid accumulation in pericardial sac, constriction of pericardium by tumor, or pericarditis
Management aimed at decreasing fluid around the heart and includes surgical establishment of pericardial window, indwelling pericardial catheter
Manifestations include SOB, tachycardia, cough, dysphagia, hiccups, hoarseness, nausea, vomiting, excessive perspiration, decreased LOC, distant heart sounds, extreme anxiety
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Carotid Artery Rupture
Infiltrative oncologic emergency
Invasion of artery wall by tumor or erosion following surgery or radiation
Bleeding can manifest as minor oozing, spurting of blood
IV fluids and blood administered to stabilize for surgery
82
Cancer Pain
Inadequate pain assessment is the single greatest barrier to effective cancer pain management
Fear of addiction is unwarranted
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Cancer Psychologic Support
Emphasis is placed on maintaining optimal quality of life
Positive attitude of patient, family, and health care providers can have a positive impact on quality of life
Common fears include disfigurement, emaciation, dependency, disruption of relationships, pain, financial depletion, abandonment, death
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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
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Skin Cancer
Most common cancer in the US
Includes both non-melanoma skin cancer and melanoma
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Risk Factors for Skin Cancer
Fair skinned, fair haired
People who sunburn
Chronic sun exposure
Exposure to chemicals
Adults over 50 years old
Males
Scars from severe burns
Chronic skin irritation
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Nonmelanoma Skin Cancers
Actinic Keratosis
Basal Cell Carcinoma
Squamous Cell Carcinoma
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Actinic Keratosis
Premalignant skin lesions
Squamous epithelium or mucous membranes
Irregularly shaped, flat, slightly erythematous papule, indistinct borders, keratotic scale or horn
Appears in sun exposed areas
Treatment is removal or topical agents
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Basal Cell Carcinoma
Most common type of skin cancer
Least deadly
Small, waxy nodule with pearly or translucent borders, may develop ulceration as it grows
Appears in sun exposed areas
Rarely metastasizes
Treatment is removal
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Squamous Cell Carcinoma
Potential to metastasize, more deadly
Firm flesh colored or erythematous papule, becomes ulcerated and painful as it grows
Appears in sun exposed areas
Treatment is removal, chemotherapy
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Melanoma
Skin cancer arising from melanocytes
When lesions confined to epidermis--flat and relatively benign
When lesions penetrate dermis--mix with blood and lymph and metastasize, develop raised or nodular appearance
Prognosis determined by tumor thickness, ulceration, metastasis, site, age, gender
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Melanoma Growth Phases
Radial Growth Phase: initial phase, grows parallel to skin surface, curable
Vertical Growth Phase: penetrates into dermis, grows rapidly, color and shape changes
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Melanoma Precursor Lesions
Dysplastic nevi
Congenital nevi
Lentigo maligna
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Dysplastic Nevi
Weird shaped moles
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Congenital Nevi
Higher likelihood of becoming cancerous because they've been there since birth
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Lentigo Maligna
Flat, kind of like age spots
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ABCDE Rule
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Asymmetry
Border irregularity
Color change
Diameter greater than 6 mm
Evolving in appearance
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Diagnosis of Malignant Melanoma
Shave-biopsied, shave-excised, electrocauterized
MelaFind
Tumor thickness--Breslow measurement (looks at depth), Clark level (looks at how invasive)
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Labs to Evaluate for Melanoma Metastasis
LFT
CBC
Chemistries
CXR
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Collaborative Care for Malignant Melanoma
Treatment determined by site of original tumor, stage of cancer, and patient's age and general health
Includes surgical incision and adjuvant therapy
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Nursing Care for Malignant Skin Disorders
Reassurance and emotional support
Skin/wound care
Prevention measures
Monthly skin exams
Regular checkups
