medical mgmt of CA Flashcards
how can drs Identify when a tumour is primary or secondary
When they look at the cells in the secondary site they can often identify by the cell str where the site of origin was
in general what is the cause of CA in young vs old
In young people cancers tend to be the result of a cell that has genetic issue during regen. For older people its often env toxins
if you have lung CA and it mets to the brain how do you describe this
Metastasis to a new tissue is still the same cancer, e.g. Lung cancer that metastasizes to bone is “lung cancer with bone metastasis”
what are the categories of causes of CA
Viral/Bacterial Physical (X-rays, UV rays) Chemical Genetic Dietary Hormonal
how do incidence of CA and age correlate? who is the following found in brain tumours testicular CA leukemia
Most CA is in those over 65 but can occur in any age group
Testicular CA in young men
Leukemias and brain tumours in kids
what are the SPECIFIC s/s of CA
how does it present in early stages
signs and symptoms vary widely
Can be vague in early stages –
t or f CA is sometimes detected before s/s appear
T Is sometimes detected before signs appear
at what point in CA is pain experienced
Pain is usually not experienced until the cancer is well-developed
other than using Screening tests for detection of cancer before it causes signs and symptoms what is it used for
Some of the screening tests are good for seeing how treatment is going
what kinds of CA can have a genetic link?
what can genetic testing lead to?
Genetic testing – can help identify people with specific susceptibility
Some breast cancers, ovarian, colon have genetic links
Genetic testing can lead to some preventative severe measures (radical mastectomy if many indicators of BR CA)
she probably taught us these for our own benefit but how do you do BR self exam and TSE?
what is done to investigate colon? cervix?
BSE: do in wk after menstrual cycle every month so you get used to it, good to put hand behind head, start up in axilla, press firmly, check nipple for puckering and pulling
TSE: start at the top of the scrotum as they are often there.
Colonography or colonoscopy to screen for colon cancer; pap test
At age 40 you start mammograms. When 50 they start doing stool tests.
what are blood tests looking for/helping to detect
Blood tests –
Tumour markers, leukemias, lymphomas
many types of imaging may be used to detect suspected cancer
which diagnostic imaging is cheap and often used for finding tumours because results are received quickly
Imaging –
MRI, CT scan, fluoroscopy, ultrasound, endoscopy, nuclear med images, PET scan
Often U/S to check for tumours as theyre cheaper and results are received quickly
why can biopsy be so challenging for pt
Biopsy-the pt may have to be opened for this. The pt can receive local anaesthetic for the biopsy which is the painful part.
The technician/nurse explaining the procedure before hand can dec anxiety for pt and help them through process
why is tumour grading and staging done
Done prior to treatment:
for baseline data
to help identify the best treatment options
to aid in prognosis
if a tumour is a low grade is it more or less responsive to tx?
The lower the grade (the less aggressive the cell) the more responsive to Tx it may be!!!!!!!!!!
t or f rapidly proliferating cells can be very responsive to tx
sometimes the very rapidly proliferating cells are very responsive to tx as long as we get it in time
what is the TNM system for?
what is it based on?
which type of tumours is TNM good for and what will this not work on?
TNM system - for classifying how far a tumour has spread
Based on imaging and/or biopsy
Solid tumours only, not CNS or blood cancers
T = extent (or size) of primary tumour, N = lymph node involvement, M = extent of metastasis
E.G. a colon tumour may be referred to as T1 N0 M0
how is tumor staging done
biopsy specimens,
surgical excision of the tumour or part of the tumour
tissue scrapings (Pap test)
body fluids (CSF)
secretions or washings (bronchial)
The lower the grade, the more responsive to treatment it may be
what does Tx mean
what does T1 vs T 4 mean
N0- what number
M0- what number
tx-means primary tumour cant be assessed
t1 hasnt invaded through mucosa
t4 has invaded surrounding organs
N0-3
M 0-1
grading
purpose
from what to what?
where
o Seek to define type of tissue from which T originated + degree to which T cells retain functional and histological characteristics of origin (differentiation)
o Samples come from tissue scrapings, body fluids, secretions, biopsy, washings, sx
o Graded I-IV
o Grade I: well-differentiated T, closely resembles tissue of origin
o Grade IV: poorly or undifferentiated; are more aggressive, less response to tx
what would examples of primary prevention of CA be
- Concerned with reducing risks of disease through health promotion
- Majority of risk factors for CA modifiable
- Avoid carcinogens, dietary mods, lifestyle – smoking cess, dec caloric intake, inc physical activity
- Clinical trials being done on meds that help prevent occurrence
examples of secondary prevention
o Colon/rectum fecal occult blood test q 2yr
o Prostate PSA testing + DRE (afte 50 or 40yrs for those at risk)
o Skin watch skin changes
o Testicles TSE regularly after 15yrs
o Breast clinical breast exam, breast self exam (BSE), mammography (after 50 yrs q 2yrs)
o Cervical PAP q1-3yrs, those who are/have been sexually active
if pt has suspected CA what kind of evaluativ process will they go through
1) Determine presence and extent of tumour
2) Identify possible spread (mets) or invasion of other body tissues
3) Evalfx of involved and uninvolved body systems + organs
4) Obtain tissues and cells for analysis, including T stage + grade
what are the 3 general differing goals of CA tx
Cure
Prolong survival
Palliation (to relieve symptoms)
what is biologic response modifier therapy addressing
-the issue is that the CA is our own cels and body is slow to address it. This med helps the body to recog CA cells as unique.
what is the most form of CA tx
sx
what are the various goals of sx
- diagnosis (for biopsy only)
- prevention (removal of breasts when BRCA-1 gene is present)
- Cure (excision of the entire tumour)
- symptom relief (pain, obstruction by large tumour)
- reconstructive (breast, limbs)
what is the advantage of a needle biopsy
how do they perform needle biopsy
Done in outpatient unit, easy, use only local anesthetic
Minimally disrupts surrounding tissue – less risk of seeding
Aspiration to get small sample
from slides: Needle biopsy may be assisted by fluoroscopy, CT, U/S, MRI to help find the mass
what is debulking
o Debulking = removing as much T as possible
o Goal is remove whole T or as much as is feasible and any involved surrounding tissues (including regional lymph nodes)
how do local vs wide excisions differ
o Two common strategies for treating primary T’s = local and wide excisions
Local = for small T, done on outpatient basis; removal of mass and small margin of normal tissue
Wide (aka radical) = removal of T, lymph nodes, adjacent involved structures, surrounding tissues that may have high risk of tumour spread;
-considered if chances of cure or control good but higher risk of causing functional issues from taking other tissues
what do negative vs positive margins indicate
basically (from class) you take a cell sample and roll it in dye, if ositive margins it means that a part of that sample is cancerous and further treatment is necesary
which mental health focused role can nurses fill for pts going through CA tx
we are supports
we dec anxiety
we use those lived exp of CA principles
we also do all reg postop etc care
what is radiation as tx
• 2 types of ionizing radiation lead to tissue destruction: electromagnetic radiation (xray, gamma rays) and particulate radiation
from slides: Ionizing Radiation: Breaks the strands of DNA in the tumour cells
Causes cell death or inability to multiply
how systemic is radiation
its LOCAL-only those tissues inside treatment field are affected
which tissues/tumours are sensitive to radiation and are not sensitive
- Tissues that undergo rapid cell proliferation most responsive to radiation b/c acts well during DNA synthesis + mitosis = bone marrow, lymphatic tissue, GI epithelium, hair cells + gonads
- T’s that are better oxygenated are more responsive to radiation
- Radiation sensitivity also enhanced in small tumours that are rapidly proliferating and poorly differentiated (no longer look like tissue of origin)
o Muscles, cartilage, connective tissue more radioresistent
what is the most common form of radiation
what system is highly affected by this
External Beam Radiation : (in our notes it is known as teletherapy)
Most common
The radiation beam can be directed at deep or shallow tissues
Recent technology minimizes effects of radiation in surrounding or more shallow tissues, but skin reactions fairly common
Doses of radiation are measured and aimed precisely for maximum tumour kill and minimum effects on surrounding tissue
why are chemo and radiation of ten used together
• Chemo drugs sensitize O2-poor T’s to effect of radiation therefore good in combo
other than teletherapy what forms of radiation admin are there
Brachytherapy = internal radiation
Systemic = radioisotopes
Contact and surface moulds
what is bracytherapy
precautions
other routes
implantation of devices that hold radioactive “seeds” for a few days
in a body cavity such as vagina,
Or interstitially near prostate, for example
Patient is “radioactive” while the radioactive source is in place.
Or administered orally – radioactive iodine for thyroid cancer. Patient is radioactive for a few days beyond the half-life of the radioactive iodine
what are antineoplastic drugs more useful for in comparison to sx and radiaition
more effective for systemic or metastatic disease (most effective against actively multiplying cells)
radiation and surgery are most effective with localized lesions
because of the harshness of chemo what can you advocate for?
where should hemo NOT be given
routes of chemo admin
they are vesicants. advocate for CVC
o Vesicant chemo drugs should never be given in hand or wrist peripheral veins
IV oral Subcut intrathecally (spinal) intracavitary (e.g.- bladder), others
how does chemo cause nausea
because of the emetic potential of chemo what drugs will you give
other less invasive measures of controlling symptoms
o Mechanisms responsible for nausea incl action of CTZ zone in medulaa, stimulation of periperal + autonomic + vestibular pathways, cognitive stimulation or combo of these
a mix of corticosteroids, phenothiazines, sedatives, antihistamines, anxiolytics, serotonin blockers (Ondansetron)
o Relaxation, imagery, acupuncture, small frequent meals, bland foods + comfort foods also helpful
is chemo generally a single agent or multiple? how long is txx with this?
can be single agent but is most often a combination of multiple drugs
over a series of days
at intervals over a few months to maximize tumour death
because antineopastic agents are excreted via emesis, stool, urine how long must precautions be in place for
58hrs
because of chemo pts altered immune response what should they be taught to do and what steps can be taken to protect them
Neutropenia/ Reduced WBC / Altered Immune Response:
Monitor WBC and neutrophil count daily
Thorough head to toe assessments
Monitor S&S of infection, report immediately
Take steps to minimize infection – private room, avoid crowds, or anyone with infection even if it’s a cold
Avoid those who’ve recently been immunized
Careful hand hygiene
concerns for chemo pt in priority order
is this systemic or local
Chemo (in priority order) Caution: renal toxicity and cardiac toxicity!!!!!
Allergy
Fever/neutropenia
N, V
GI (mouth ulcers stomatitis, diarrhea or constipation)Loss of appetite or anorexia, pain, diff swallowing
Integumentary: focus on IV site, pruritus, rash, swelling in hands and joints, tingling or numbness
Resp (SOB, cough (is worrisome)
ALOPECIA IST LIFE THREATENING BUT COMMON (this can also occur with radiation if targeting head)
This is systemic
this wasnt on her list but she said this earlier:
Myelosuppression (neutropenia, thrombocytopenia, anemia)theyre vulnerable to infection, hih risk of bleeds, anemic
if pt is getting radiation for brain tumour what s/s should mean an immed trip to emerg
Radiation is used for brain tumours! (nausea and vomiting) nausea and vomiting can indicate a brain issue. This pt should report to emerg immediately. Worsening headache and any seizure activity means they must go to emerg
radiation side effects from class
Very very common and pt often thinks its d/t disease is fatigue!
Skin irritation/fragility (dry/flakey, wet seeping serous)—this is unique to radiation
Radiation is localized. Side effects are site specific
the fatigue may also be d/t anemia from myelosuppression
which diagnostics would you do that are specific to chemo
VS particularly temperature
Check WBC, RBC (Hg), platelets
Renal fx (BUN, creatinine, creatinine clearance)
Sometimes from cell lysis syndrome K levels inc
Radiation
Site specific
CBC (if blood or bone is being targeted in any way)
GIfluids and lytes
what would be very concerning signs if pt is on chemo
VS?
GI?
pulm?
Fever (subtle) anything >37.5 (they can mount lg response) Chemo pt must not eat raw veggies
>6x vomiting/24h
No BMx4 days
Cough and SOB
what would be concerning signs if pt is on radiation
1 systemic
1 r/t radiation to brain
If radiation to brain (N and V, dec hearing) Extreme fatigue (cant get out of bed)
what is the nadir point
what can be given to counter this
o Count (of WBC, platelets) lowest 7-14 days post chemo admin = nadir point o Colony stimulating factors given after chemo admin to sitmualte bone marrow prod of WBCs o EPO to simulate RBC (RBC nadir is after the above as they live longer)
what kind of skin rxns could radiation cause?
chemo?
interventions to address these? what to avoid and what to do
Skin reactions (to radiation) - erythematous desquamation, irritations are possible
Some chemo drugs can cause skin rashes or palmar erythema
Avoid using any lotions, ointments or powder in the radiated area; wash gently as recommended by the radiation specialists (usually lukewarm water)
what other sensitive tissue might a CA pt receiving radiation and chemo get irritated and inflamed
radiation mucositis if the mouth is in the radiated area
Teach meticulous mouth care – plaque removal essential - soft tooth brush, flossing, saline and bicarb mouth rinse q2h,
Assess for and treat candida infections;
Lip lubricants
(they are at ris of bleeding!)
Mucositis also common after chemotherapy
does radiation, chemo or both cause diarrhea
Diarrhea- radiation induced, if the rectum is in the radiated area
Some chemotherapy drugs can cause diarrhea
what is alopecia
how long after tx does it start?
precaution?
Alopecia
Ensure pt is aware of this effect.
starts about 2 weeks after chemo or radiation
They may choose to cut off long hair before that time.
Wigs, scarves, etc may be preferred
Protect scalp from sunburn (maybe photosensitive due to treatment too)
nursing diagnoses for CA pt (seems like theyre related more to meds than CA itself)
Impaired oral mucous membrane Impaired tissue integrity Alopecia Altered nutrition due to anorexia, cachexia, nausea, vomiting Chronic pain Anticipatory grieving Fatigue Disturbed body image
although there were some parts of notes woven in now they are solely from notes and the ppt is done
how long can nausea last for after chemo
o Nausea most common – persists up to 48hrs after admin (or up to 1 week)
does chemo cause sterility? what should be done surrouding family planning
o Testicular + ovarian fx impacted
o Early menopause or permanent sterility may result
o Men recommended to bank sperm before tx
o Pt needs to know to remain on birth control, sterility not necessarily case
why is renal damage occuring
o Damage results d/t direct effecs during excretion + accum of end products of cell lysis
o T cell lysis increases urinary excretion of uric acid possible renal damage
hyperthermia as CA tx? not touched on in class…
• Used for many years as tx for CA
• Generation of temperatures greater than physiological fever range
• Works in multiple ways:
o Malignant cells more sensitive than normal cells to temperatures
o M cells lack mechaisms necessary to rpair damage caused by these temps
o Most M cells lack adequate O2 supply to meet inc metb demands that accompany inc temp
o Most tumour lack blood vessels to dissipate heat
• Most effective when combined with other treatments
• Can be done at systemic or localized levels
gene therapy as CA tx. not touched on in class
o Includes approaches that correct genetic defects of manipulate genes to induce tumour cell destruction n hopes of preventing or combating CA
o Some use vectors to introduce the genetic material…viruses seen as ideal candidates (but have short term effect because of IR
physical exam findings of child with CA
what issues indicate what CA
probly too much detail
Swollen lymph glands (Hogkin’s) Headache (brain tumor) N + V (brain tumour) Wight loss Ecchymotic marks (leukemia) Eye deviations (brain tumour, retinoblastoma) Pain + swelling in large large joint Palpapble mass in abdomen
what might take the innocence of the illness away (the parents may have been denying it in terms of dx
concerns with this
• Biopsy – used to confirm malignancy…don’t treat this lightly! Is thing that takes away sense of “innocent” illness in child that parents may be trying to convince themselves of
o If sedation + gen anesthesia used, are risks there too
o Anxious parent may need reteaching post-op
as the child is getting radiation while growing what effects could this cause
- Long term side effects: asymmetrical and other irregular bone growth, hormone abnormalities (esp if head and neck irradiated, affects thyroid, pituitary, etc or reproductive organs); effects on CNS (demyelination of brain resulting in sleepiness, seizures…), chronic pneumonitis, pericardial thickening + other effects on heart + lungs, nephritis…alopecia..,impaired growth of teeth…
- Child will need dental consult prior to radiation of head b/c may impair future healing if tooth extraction
if kid is older what could you do to help them be distracted during radiaiton
• In older child, can give mental task like selecting 10 people to take on camping trip during procedure so active mind but still body
which medications could interact with chemo?
what should not be taken during chemo d/t the dec IR?
which med should parents not use with their kids?
- Caution parent not to give aspirin – risk for Reye syndrome, also interferes with blood coag (which may exacerbate existing risk from low thrombocyte levels) – use Tylenol or ibuprofen instead
- Parent must consult w physician if want to give vitamins – can interfere
- Live vaccines NOT to be given while having chemo – immunocompromised so may get disese
