Blood Cancer Flashcards
WHAT IS BLOOD CANCER?
- Cancer arising from cells responsible for blood formation or immune function
- Commonly occurs in your bone marrow where stem cells are located and mature
- In the bone marrow, normal cell production is interrupted and abnormal cells begin to grow
WHAT IS BONE MARROW?
- Bones are made up of 3 main parts:
— Compact bone
— Spongy bone
— Bone marrow - Red marrow
- Yellow marrow
UNDERSTANDING BLOOD CELL FORMATION
UNDERSTANDING BLOOD CELL FORMATION 2
LEUKEMIA BASICS
- Four main types
— Acute Lymphoblastic (Lymphocytic) Leukemia (ALL)
— Acute Myeloid (Myelogenous) Leukemia (AML)
— Chronic Lymphocytic Leukemia (CLL)
— Chronic Myeloid Leukemia (CML) - All begin in the bone marrow
— Myeloid stem cell line
— Lymphoid stem cell line - ALL and AML are made of immature blasts
- CLL and CML have few to no blasts
- Each major type has its own subtypes
- acute leukemias are more aggressive and need timely treatment
- chronic leukemias are slower growing and might not need treatment
MYELODYSPLASTIC SYNDROMES (MDS)
- Sometimes called “pre-leukemia”; affects myeloid cell line, where 5-19% blasts are present
- Bone marrow doesn’t make enough healthy blood cells
MYELODYSPLASTIC SYNDROMES (MDS)
Risk factors
- Male gender, white
- Older age (60+, typically)
- No risks known for de novo (Latin for “from the beginning”) MDS
- Secondary MDS may be due to previous cancer treatment
- can progress to AML
MYELODYSPLASTIC SYNDROMES (MDS)
Symptoms
- Possible to have none
- Cytopenias (anemia, neutropenia, thrombocytopenia)
LYMPHOMA BASICS
Hodgkin Lymphoma (HL)
Abnormal lymphocytes accumulate and form masses (tumors) in the lymphatic system
- Classical Hodgkin Lymphoma (95%)
- Nodular Lymphocyte Predominant Hodgkin Lymphoma (5%)
-
- was initially named Hodgkins disease, this was later changed to Hodgkin lymphoma
- Is a B cell lymphoma
- Distinguished from other lymphoma by the presence of the Reed-Sternberg cell
- Hodgkin lymphoma is most likely to be diagnosed in young adults, but then becomes more common again after age 65
- most forms are curable
LYMPHOMA BASICS
Non-Hodgkin Lymphoma (NHL)
- B-cell lymphomas ~85% of all NHLs
- T-cell and NK-cell lymphomas ~15% of all NHLs
- 70–90 subtypes
- graded on behavior: Aggressive or indolent, sometimes intermediate
- Stage I –IV
LYMPHOMA STAGING
Often time a letter follows the stage number
- ex. Stage 3b, stage 2a
- A: no symptoms present
- B: unexplained fevers, Drenching night sweats, unexplained weight loss of 10% or more in last 6 months,
- E: involvement of organs or tissues beyond the lymph system
MYELOMA BASICS
- Cancer of the plasma cells (product of B lymphocytes)
- Can be a single tumor – “plasmacytoma,” asymptomatic and slow growing – “smoldering,” or
- diffuse throughout the body – “multiple myeloma”
- CRAB criteria are important to the diagnosis:
— Calcium is increased
— Renal (kidney) failure or insufficiency
— Anemia
— Bone lesions
MYELOPROLIFERATIVE NEOPLASMS (MPNS)
- Myelo – of the bone marrow
- Proliferative – to grow or reproduce quickly
- Neoplasm – abnormal growth of cells
- Many subtypes, but three are considered “classic”:
— Polycythemia vera (PV) – too many red blood cells are made
— Essential Thrombocythemia (ET) – too many platelets are made
— Myelofibrosis (MF) – scarring of the bone marrow after it has “exhausted” itself or as a primary disease
CANCER MOLECULAR PROFILING
- ## Identifies DNA, RNA, or protein molecules associated with certain diseases
- Examples of types of tests:
— Immunohistochemistry/Flow cytometry - antibodies/antigens
— FISH - Fluorescence in situ Hybridization
— NGS - Next-Generation Sequencing
— qPCR - Quantitative Polymerase Chain Reaction
HOW IS BLOOD CANCER TREATED?
- Cellular Therapy
- Clinical Trial
- Palliative Care
- Chemotherapy
- Radiation Therapy
- Targeted Therapy
- Immunotherapy
HOW IS BLOOD CANCER TREATED? 2
- Treatment varies greatly based on key factors:
— What type of blood cancer
— Leukemia vs. Lymphoma
— Acute vs. Chronic
— Myeloid vs. Lymphoid - Molecular/genetic changes?
— BCR/ABL mutation (Philadelphia chromosome) CML, ALL
— FLT3, IDH1/2 - Comorbidities of patient
— Heart, kidney, liver function OK to withstand chemotherapy
CHEMOTHERAPY
- Stops the growth of dividing cells
- Used in combinations to make other treatments more effective
- Can be used with surgery or radiation
- Can be given by many different routes
— PO, IV, IM, IT, IP
CHEMOTHERAPY SIDE EFFECTS
- Fatigue
- Alopecia
- Neuropathy/Confusion
- Mouth sores
- Nausea/Diarrhea
- Cytopenias - Neutropenia, Anemia, Thrombocytopenia
— Infection
— Bleeding - Skin and nail changes
- Mood changes
- Infertility and changes in libido
RADIATION THERAPY
- Works by damaging DNA of cancer cells so that they cannot replicate
- Types
— Internal: put inside the target, ie: brachytherapy
— External: comes from a machine, targets certain area of your body - Used in combination with chemotherapy and surgery
RADIATION THERAPY SIDE EFFECTS
- Fatigue
- Localized skin changes
- Specific side effects related to the area being treated:
— Lung: fatigue, SOB, cough
— Brain: fatigue, hair loss, nausea/vomiting
— GI: nausea/vomiting, diarrhea, abdominal pain, bladder, fertility
— Head/neck: sore throat, dry mouth, taste alteration, hair loss
TARGETED THERAPY
- Specifically targets the changes found in cancer cells’ DNA which makes it become cancerous
- Types:
— Monoclonal antibodies
— Cancer growth inhibitors:
—- Tyrosine kinase inhibitors: dasatinib, imatinib, nilotinib
—- Proteasome inhibitors: bortezomib
—- PI3K inhibitors: idelalisib
—- HDAC inhibitors: panobinostat, vorinostat
—- mTOR inhibitors: sirolimus, everolimus
—- Hedgehog pathway inhibitors: glasdegib
TARGETED THERAPY SIDE EFFECTS
- Diarrhea
- Liver abnormalities- increased LFTs, hepatitis
- Skin and nail changes
- High blood pressure
- Alterations in blood clotting
IMMUNOTHERAPY
- Harnesses your immune system to fight the cancer
- Types:
— Monoclonal or Bispecific antibodies
—- Rituximab, Obinutuzumab
—- Blinatumomab - Checkpoint inhibitors
— Nivolumab, pembrolizumab - Vaccines
— Antigen, whole cell, dendritic cell - Cytokines
— Interferon and interleukin
IMMUNOTHERAPY SIDE EFFECTS
- Fever/chills
- Weakness/fatigue
- Blood pressure abnormalities
- Shortness of breath
- Nausea/vomiting
- Swelling/fluid retention
- Organ inflammation
— Colitis
— Hepatitis
— Pneumonitis
CELLULAR THERAPY
- Hematopoietic Stem Cell Transplant
- Adoptive Cell Therapy
HEMATOPOIETIC STEM CELL TRANSPLANT
- Allows patient to receive high doses of chemotherapy to eradicate disease but then recover normal hematopoietic cell function
- Types :
— Autologous
— Allogeneic
— Umbilical Cord Blood
ADOPTIVE CELL THERAPY
- Therapies that use body’s own defense system to fight cancer
- Tumor-infiltrating lymphocytes (TILs)
— Penetrate the environment around the tumor
— Mostly used in solid tumor - T-cell receptors (TCRs)
— T cells engineered to express a specific T-cell receptor which can recognize cancer antigens
— Mostly used in solid tumor - Chimeric Antigen Receptor T cells (CAR T)
— T cells taken from patient, engineered to produce chimeric antigen receptors and then injected back into the patient which then recognizes specific antigen on tumor cells
CHIMERIC ANTIGEN RECEPTOR T-CELL THERAPY
CAR T-CELL THERAPY SIDE EFFECTS
- Cytokine release syndrome (CRS)
— T cells naturally release cytokines, however in CRS there is a massive amount released which cause fever, hypotension
— Anti-IL6 antibody: tocilizumab - Neurotoxicity
— Confusion, headache, seizure, cerebral edema - B cell aplasia
— Normal B cells often killed by infused CAR T cells since they express same targets
— Patients will go on to receive immunoglobulin therapy
ADOPTIVE CELL THERAPY
- Since 2017, there have been three approved CAR T-cell products
- Yescarta (axicabtagene ciloleucel)
- Kymriah (tisagenlecleucel)
- Tecartus (brexucabtagene autoleucel)
- Adoptive-cell therapy continues to be highly studied with many new and exciting therapies coming down the pipeline
CLINICAL TRIALS
- Carefully controlled research studies conducted by doctors to improve the care and treatment of people with cancer or other illnesses
- Key step in advancing all cancer treatments
- Cancer clinical trials are 40–50% of all trials conducted in the US
- Trials available for all stages of cancer journey - newly diagnosed, relapsed/refractory
- Can be very difficult to navigate available trials
BENEFITS OF CLINICAL TRIALS
- Contribution to present and the future
- Financial access to new treatments
- Early access to new therapies
- Access to physicians with extensive experience in the type of cancer
- Followed closely
RISKS OF CLINICAL TRIALS
- Possibility the treatment may not work
- Unknown/fear of side effects
- Randomized trials - risk of being in the standard of care arm
- Increase time away from home, work and family
ONCOLOGY NURSES ROLE WITH BLOOD CANCER PATIENTS AND CAREGIVERS
What to discuss with the patient and caregiver before and throughout treatment
- Disease and Treatment Education
— Understand specifics of disease
— Learn patient wishes and goals of care
— Be the patient advocate
- Fertility – treatment implications, preservation
- Potential Side Effects
— Recognize adverse effects of treatment and stress the importance of communicating with the healthcare team
— What are “normal” side effects and what needs immediate attention
— What to do for fever and emergency management
24-hour access to providers - who to contact and best method of communication
ONCOLOGY NURSES ROLE WITH BLOOD CANCER PATIENTS AND CAREGIVERS
- What to discuss with the patient and caregiver before and throughout treatment
- Nutrition
— Food safety guidelines are key
— Small, frequent mini-meals and smart snacks
— Real Food > Supplements
— Eat a variety of foods
— Be open to new foods, flavors and tastes
— Keep a stable body weight
— Stick to what you know
— Ask about any dietary restrictions
— Discuss side effects and changes in appetite/intake
— Use trusted sources of oncology nutrition information
— Ask for a referral to an oncology registered dietitian
ONCOLOGY SOCIAL WORKER’S ROLE WITH BLOOD CANCER PATIENTS AND CAREGIVERS
Phases of Cancer Care:
- Prevention and Screening
- Diagnosis
- Palliative Care
- Treatment
- Survivorship
- End of Life
- Bereavement
PSYCHOSOCIAL CONSIDERATIONS WHEN WORKING WITH ONCOLOGY PATIENTS AND THEIR CAREGIVERS
- Physical concerns
— Diagnosis, physical symptoms or side effects, fertility planning, intimacy, and treatment planning - Emotional concerns
— Stress, fear, worry, anxiety, anger, frustration - Financial concerns
— Insurance, medical and prescription costs, employment, daily living expenses - Practical concerns
— Transportation, housing, childcare, school, daily tasks
WHAT TO CONSIDER: PSYCHOSOCIAL NEEDS:
For the pt
- Awareness of ethnic, cultural, and spiritual beliefs
- May live alone, be unable to care for self or others
- Concerns about how their cancer affects family members
- Financial and employment concerns
- Physical and cognitive side effects of treatment
- May be predisposed to or develop mental health concerns
- Emotional concerns
- Self-care practices and positive coping strategies
WHAT TO CONSIDER: PSYCHOSOCIAL NEEDS: For the caregiver:
- Awareness of ethnic, cultural, and spiritual beliefs
- Balancing employment and caregiver roles
- Balancing family responsibilities
- Traveling for treatment
- May be predisposed to or develop mental health concerns
- Emotional concerns
- Self-care practices and positive coping strategies
RELIABLE RESOURCES
- The Leukemia & Lymphoma Society – LLS.org
- National Cancer Institute – cancer.gov
- American Cancer Society – cancer.org
- CancerCare – cancercare.org
- Cancer Support Community – cancersupportcommunity.org
- Triage Cancer – Triagecancer.org
- PubMed.gov
- OncLive.com
WHAT TO CONSIDER: CANCER & COVID-19
- The Pandemic has brought on many concerns for all; even more for cancer patients. Fears are multiplied for immunocompromised patients and those undergoing treatments. Encourage patients to ask their doctor specific concerns; many factors need to be considered and the doctor would have information to determine next steps.
- LLS offers support and guidance for blood cancer patients and caregivers to navigate both cancer & COVID-19. COVID-19 and blood cancer related updates and support resources on the LLS website:
— https://www.lls.org/public-health/coronavirus o
— https://www.cdc.gov/coronavirus/2019-ncov/index.html o
— https://www.cdc.gov/coronavirus/2019-ncov/vaccines/index.html
Acute lymphoblastic leukemia (ALL)
- Most common cancer seen in children
- Risk peaks between one – four, then decreases until about age 55
- May also see Philadelphia chromosome - more common in adults (25% of cases versus 3% four pediatric ALL)
Acute Myeloid Leukemia (AML)
- Most common acute leukemia in adults
- Has many subtypes based on differences in biomarkers
Chronic Lymphocytic Leukemia (CLL)
- most common type of leukemia in adults in western countries
- Can progress slowly or quickly, depending on the forms it takes
- Some patients may have CLL for years and not need treatment, their doctor monitors them under “ watch & wait” some patients referred to as “watch & worry”
Chronic Myeloid Leukemia (CML)
- has three phases
— chronic
— accelerated
— blast (often called “ blast crisis”) - Diagnosis of CML REQUIRES oral treatment upon diagnosis to prevent it from becoming aggressive
DX for leukemia
Bone marrow aspiration
