Oncology & Breast Cancer Flashcards
Risk factors
Carcinogen exposure – predisposes a person to DNA destruction, leading to malignancy (i.e. Ionizing radiation, benzene, HPV, sunlight, tobacco)
Other: Environmental, hormonal and lifestyle factors, meds., immune status, nutritional status
Modifiable – Weight, smoking
Non-modifiable – Age, genetics (10%)
Characteristics of normal cells & CA cells
NORMAL CELLS:
1. Contact inhibition: Cells will stop growing when they come in contact with other cells
- Apoptosis: Programmed cell death
- Anchorage dependence: Cells anchor to neighboring or basement cells to remain viable
- Structural and functional characteristics
CA CELLS: Anaplasia (the loss of mature or specialized features)
CA types
Types of CA:
1. SOLID – i.e. Lung CA
- HEMATOLOGIC – Originate from hematopoietic cell lines (RBCs, WBCs, platelets) OR secondary immune organs (Lymph nodes, spleen)
Staging
Dependent on tumor size, burden of disease, and spread
Solid tumor staging:
- Tumor size (T)
- Number of lymph nodes (N)
- Presence of metastasis
Stages: Stage 1 – no spread outside the organ Stage 2 – invasion of deeper tissues and lymph node involvement Stage 3 – locally invasive tumors Stage 4 – metastasis
**All hematologic tumors are stage 4 at diagnosis
Clinical presentation
3 types of symptoms: 1. CAUTION (>2 weeks) C: Changes in bowel or bladder habits A: Sore throat that doesn't heal U: Unusual bleeding or discharge T: Thickening or lump I: Indigestion or difficulty swallowing O: Obvious change in wart or mole N: Nagging cough or hoarseness
- Constitutional – vague symptoms (i.e. Fatigue, unexplained weight loss, fever of unknown etiology, night sweats)
- Malignancy-specific – (1) BREAST CA: Breast mass/lump, axillary node enlargement, disproportionate breasts, and nipple discharge; (2) ESOPHAGEAL CA: Dysphagia and chest discomfort; (3) GASTRIC CA: Indigestion, loss of appetite, abdominal discomfort, and N/V/
Prevention
PRIMARY (reduce the probability of CA development by modifying risk factors):
- Risk factor modification – i.e. Smoking cessation
- Immunization – i.e. HPV is linked with head and neck CA
- Chemoprevention – i.e. Early stage hormonal cancers such as breast and prostate CA
SECONDARY (early CA detection and screening):
- Mammogram
- PAP smear test
TERTIARY (reducing complications and improving quality of life):
1. CA treatment
Diagnosing CA: LABORATORY TESTS
Types of laboratory tests:
1. Blood/serum, or tissue – used to validate malignancy (i.e. PSA is linked to prostate CA; presence is also indicative of inflammation)
- Track response – CBC (i.e. Monitor WBC count)
- Track tumor marker – i.e. CA-125 is linked to ovarian CA
Diagnosing CA: IMAGING
Radiological, sonographical, and other technology are used to detect mass/metastasis that are often undetectable by PE
**Useful in diagnosis and assessment of solid tumor masses (NOT in hematologic, except lymphomas)
Types of imaging:
1. Computerized Tomography (CT scan) – mass locations and vessel involvement
- Positron Emission Tomography (PET scan) – injection of radioactive material that accumulates in areas of increased metabolic activity (hot spots)
- Magnetic Resonance Imaging (MRI) – evaluates changes on brain, joint, and breast tissue
Diagnosing CA: BIOPSY
Types of biopsies:
1. Incisional (cut into mass) – danger in tracking malignant cells through healthy tissue
- Excisional (cut out mass) – clean margin cut
- Fine needle biopsy (if mass is close to surface) – less cells = difficult to analyze
- Bone marrow aspiration/biopsy – used for hematologic malignancies
Diagnosing CA: ENDOSCOPIC PROCEDURES
Visualize structures (i.e. Esophagus, lungs) and allow for tissue access and biopsy
Treatment
Based on: (1) Cell type, (2) Staging, and (3) Markers
GOALS:
1. Cure – disease-free for 5 yrs. (debatable)
- Remission (if not curable) – reduce tumor burden or prevent progression; disease-free as long as meds. are taken (i.e. Hematologic)
- Palliation – alleviation of the burdens of cancer; team-based approach with pt goals
Treatment types
Types of treatment – can be done with one modality or in combination of:
- Surgery
- Radiation
- Medical therapy
Treatment classification:
1. PRIMARY – the definitive (best) treatment in a multimodal therapy
- NEOADJUVANT – administration of therapeutic agents before a main treatment
- ADJUVANT – in addition to the primary or initial therapy to maximize its effectiveness (i.e. Breast CA)
Breast CA
Requires multimodal treatment (surgery, radiation, and medical therapy)
Example of breast CA therapy:
1. Primary: Surgery – removal of malignant tumor
- Neoadjuvant: Chemotherapy – medical therapy to reduce tumor prior to surgery
- Adjuvant: Radiation after surgery – decrease risk of recurrence
Surgery
Preferred, greatest probability of cure; primary modality for solid tumors
Goal: Total excision or tumor debunking (including rerouting of vessels and organs)
Nursing interventions:
1. Understand the pt’s goals, education deficits, treatment plans, and anticipated barriers to post-op recovery
- Include plan for: Monitoring infection, pain, nutrition, reconditioning (and ADLs), and psychological considerations
Radiation
Defined as a localized manner of delivering ionizing radiation to destroy DNA within malignant cells and induce cell death
Types of radiation:
1. EXTERNAL BEAM RADIATION
- INTERNAL RADIATION (BRACHYTHERAPY): Insertion of radioactive implants directly into the tissue
- SYSTEMIC RADIATION: Injecting radioactive substance or taking oral substance
Medical therapy
Antineoplastic agents:
1. CHEMOTHERAPY: Interferes with all dividing cells (It is either cell cycle specific OR cell cycle non-specific); Many routes – IV, intrathecal (spinal), topical, intra-arterial, intraperitoneal, oral
- TARGETED AGENTS: Precision medicine that targets proteins that control how CA cells grow, divide, and spread
- IMMUNOLOGIC AGENTS: Assist the immune system in detecting and destroying abnormal cells (Types: Non-specific immune simulation, T-cell transfer therapy, and immune checkpoint inhibitor)
- HORMONAL AGENTS: Slows or stops the growth of CAs that use hormones to grow (i.e. Breast, prostate CA)
Goals of medical therapy:
- Cure
- Control
- Palliation
- Minimize adverse affects
- Maximize cell kill
Stem cell and bone marrow therapy
Used to replace bone marrow cells that have been destroyed by CA or by antineoplastic drugs
Role of the nurse
Minimize adverse effects with radiation and antineoplastics – GI, hair loss, fatigue, anemia, infection
Supportive care – psychosocial care
GI effects
Adverse effects due to damage to the lining of the stomach and intestines:
1. DIARRHEA – avoid fried foods and high fiber foods, limit dairy, and screen for C. diff and CMV (virus)
- CONSTIPATION – high fiber foods, be active, and drink plenty fluids
- N/V – non-irritating foods, small frequent meals, sit up after eating, ginger, PRN meds (i.e. Zofran), assess PMHX (i.e. Extreme N/ during pregnancy)
- ANOREXIA – meds.
- STOMATITIS – soft foods, avoid hot and spicy food, and “magic” mouthwash (infection prevention)
- FOOD TASTES BAD – rinse before eating, ginger ale
Hair loss
Most disturbing adverse effect
Support via:
- Wigs
- Scarves
- Hair pieces
- DigniCap (cooling cap): minimizes hair loss during chemotherapy treatment
Fatigue
Can lead to distress, interfere with ADLs, and decrease desire to care for oneself
Nursing interventions:
1. Treat the underlying cause (i.e. Anemia)
- Regular exercise, as tolerated – 150 min/week
- Conserve energy when possible
- Stress reduction techniques
- Adequate nutrition and sleep
Anemia
Caused by: CA itself, antineoplastics and radiation, and decreased RBC production
Nursing interventions:
1. Treat the cause of anemia (if possible)
- Monitor RBC, H&H, and platelets
- Raise Hgb level to alleviate symptoms
- Meds. (i.e. Erythropoetin alpha)
Infection
Fever (>38 Celsius or 100.4 Fahrenheit) – Reliable indicator, and often the only sign of infection
MEDICAL EMERGENCY – most common life-threatening complication
Interventions:
1. Monitor neutropenia; Minimal risk = 1,000-1,500 ANC, Moderate = 500-1,000, Severe <500 (wear mask)
- Hygiene and oral health; sterile utensils when eating
- Avoid large crowds; remain away from people with fevers or colds; flu shot
- Electric shaver instead of razor
- No fresh flowers or live plants indoor
- Do not clean litter box
Psychosocial care
Individual:
- Situational demoralization
- Long-term depression
- Body image disturbance
- Depression in survivorship
- Spiritual distress
Family – Caregiver burden
Provide social networking
End of life
PALLIATIVE CARE: Care for adults/children that focuses on relieving symptoms caused by serious illnesses like CA and improving the quality of life of pts and their families
Breast CA
Can occur in the cells of:
- Lobules – milk-producing glands
- Ducts
- Stromal tissue – includes fatty and fibrous connective tissue (less common)
Incidence: 1 in 8 females in the U.S. will develop breast CA over the course of their lifetime
Risk factors: Female, ERT/PRT (especially post-menopause), >50 yrs. old, genetic (BRCA1 or BRCA 2 – 5-10%), FHX (CA), early menarche (<12 yrs. old), first pregnancy after 30, dense breast tissue, weight gain and obesity after menopause
Types:
- Ductal; in situ (non-invasive) – 20%
- Ductal carcinoma (invasive infiltrating) – 70-75%
- Lobular carcinoma (invasive) – 5-10%
Breast CA: Clinical S/S
Clinical signs – Swelling of entire/part of breast, skin irritation/dimpling, nipple or breast pain, nipple turning inward, redness/scaliness/thickening of nipple or breast, discharge, lump in underarm area
Early signs – may not be detectable except via mammogram
Breast CA: Diagnosis/Post diagnosis
Diagnosis – On PE, mammogram, breast MRI, biopsy
Post diagnosis – Axillary node dissection, tumor size, estrogen and progesterone receptor status, HER-2 receptor, DNA content (policy status) correlates with tumor aggression
Breast CA: Staging
Breast CA stages:
Stage I: Tumor <2cm with no lymph node spread, and no distant metastasis
Stage II: Tumor may increase in size with possible spread to nearby lymph nodes, and no distant metastasis
Stage III: Tumor may increase in size with possible spread to lymph nodes, chest wall, or skin; no distant metastasis
Stage IV: Tumor of any size with direct extension to chest wall or skin and with distant metastasis
Breast CA: Surgical options and other therapies
Surgical options:
1. BREAST CONSERVATION (local) – removal of tumor and sentinel lymph node biopsy
- MODIFYING RADICAL MASTECTOMY – removal of entire breast and of axillary lymph nodes
Other therapies:
- Radiation – prevent occurrence after surgery
- Chemotherapy – main treatment for women with hormone receptor negative CAs (HT is NOT helpful)
- Hormone therapy – antiestrogen used in estrogen receptor positive (HR+) CAs
- Targeted therapy – treat tumors that overexpress HER-2 gene (HER+)
Breast CA: Nursing management
Post surgery:
- Prevent infection
- Lymphedema – semi-fowlers, rest arm, and no BP on affected side
- Pneumonia – monitor for PE
Radiation therapy – monitor for skin breakdown, pneumonitis
Psychosocial needs
Follow-up (lab work) – monitor serum HER2/neu test
Talk to family – caregiver burden
Connect to support services
Breast CA: Basic assessments
Monitor for adverse effects related to radiation and antineoplastic meds. (i.e. Infection, VT, mobility, body image)
Collaborate – PT/OT for lymphedema, diet (chemo meal plan), support groups
