Test #2 Flashcards
Where is colon cancer
In the large intestine
What cancer is the 2nd leading cause of cancer deaths and the 3rd most common form of cancer
Colorectal cancer
What are the majority of causes of Colorectal cancer
DNA mutations are more common (inheriting the cancer is less common)
What are risk factors for Colorectal cancer (a lot)
- Having a first degree relative with colorectal cancer and/or inflammatory bowel disease, such as Crohn’s, ulcerative colitis or polyps.
- Increase in age
- Having a relative who was diagnosed under 50
- Having two or more family members diagnosed with Colorectal cancer
- Family history of lynch syndrome
- Having an abnormal (mutation) KRAS gene (gene helps control growth, under normal function)
- Familial adenomatous polyposis (family member with Colorectal cancer)
- Minority groups are often diagnosed in later stages (access to care)
- Smoking
- Obesity
- Processed meats like salami and low fiber diet (processed meats can be carcinogenetic, and fiber is needed to help clear these out)
- Two or more alcoholic drinks per day.
What is the most common type of Colorectal cancer and what causes it
Adenocarcinoma caused by adenomatous polyps
Where are the most common sites of metastasis for adenocarcinoma 5
- Regional lymph nodes
- Liver
- Lungs
- Bones
- Brain
What are some common clinical manifestations of Colorectal cancer 6
- Change in bowel habits like diarrhea or constipation, snake like bowel movements, because stool is trying to pass through the cancer
- Feeling like you need to evacuate after you’ve already gone poop
- Bright red rectal bleeding or dark, tarry stools (so acute and chronic bleeding)
- Abdominal cramping or pain
- Weakness and fatigue
- Unintended weight loss
If Colorectal cancer is in the ascending colon, what might be some symptoms 4
- Pain
- Mass
- Change in bowel habits
- Anemia
If Colorectal cancer is in the Transverse colon, what might be some symptoms 4
- Pain
- Obstruction
- Change in bowel habits
- Anemia
If Colorectal cancer is in the descending colon, what might be some symptoms
- Pain
- Change in bowel habits
- Bright red blood in stool
- Obstruction 4
If Colorectal cancer is in the rectum, what might be some symptoms 3
- Blood in stool
- Change in bowel habits
- Rectal discomfort
What ages should you be screened for colorectal cancer
45-75.
75-85 decide between you and your doctor if you need the screenings.
85 and older, no screenings.
What types of screenings might they do
- Flexible sigmoidoscopy every 5 years (only goes into the sigmoid colon)
- Colonoscopy every 10 years
- Double-contrast barium enema every 5 years
- CT colonography every 5 years
- Test of blood in the stool using a high sensitivity fecal occult blood test (FOBT) yearly or fecal immunochemical test (FIT) yearly
Who are going to need earlier screenings for colorectal cancer before the age of 45 2
- If they have a first degree relative who was diagnosed with colorectal cancer before age 60
- If they have two or more first degree relatives with colorectal cancer
How can we diagnosis colorectal cancer
Perform a diagnostic colonoscopy and obtain a tissue biopsy during the colonoscopy (may also remove a polyp during the colonoscopy).
What illness do we often find with colorectal cancer? Why?
Anemia, because they usually have bleeding in their colon. (check CBC)
When evaluating a patient with colorectal cancer, what function test do we want to look for? What levels should this be at?
Liver function test - because it often metastases to the liver.
AST: 7-56
ALT: 5-40
What does a tumor marker tell us? What is the name of the tumor marker that can indicate that a person has colorectal cancer?
They can tell us if cancer is happening. It is called carcinoembryonic antigen (CEA).
Why are tumor markers not a good screening method
Because there are a large number of false positives - biopsy is the only definitive tool to diagnosis.
What are the other types of diagnostic studies we can use to help diagnosis and monitor cancer? 5
- CT guided needle biopsy to help guide to get a biopsy (can help detect in lymph nodes, liver and lungs)
- Ultrasound (look at abdominal endorectal, intraoperative (liver))
- MRI (Liver, brain, spinal cord)
- Chest xray (lungs)
- Angiography (shows arteries that supply the tumor)
What scan is not routinely done for colorectal cancer
PET scan
Why is it so important to get colorectal cancer screenings?
Because in the early stages it is often asymptomatic (usually symptoms will appear, like rectal bleeding, in the later stages)
What are the stages of colorectal cancer
0: cancer has not grown beyond the inner layer of the colon wall
1: cancer has grown to the outer layer
2: tumor is through the wall, but has not spread to lymph nodes
3: cancer has spread to lymph nodes
4: cancer has spread to distant sites in the body
What is one of the biggest interventions for colorectal cancer
Surgery
What are the surgical goals for colorectal cancer 5
- Take out the tumor
- Explore the abdomen to make sure all of the cancer is out
- Look to see if the cancer has metastasized
- Remove lymph nodes that drain the area
- Restore the bowel so the patient can still have GI function
What is a polypectomy
Removing a polyp during a colonoscopy
When will they do a polypectomy 3
- The area around the polyp is free from cancer
- The cancer is well differentiated
- No apparent involvement of lymphatic or blood vessels of the cancer
What is it called when they remove the right or the left side of the bowel
Hemicolectomy
How does a hemicolectomy work
Will be done laparoscopically where they remove the right or left side of the bowel, depending on where the cancer is located, and then sew up the cancer-free ends.
With a hemicolectomy, at what stages would they perform it
- Stage 1: remove the tumor and at least 5cm of surrounding intestine and nearby lymph nodes
- Stage 2 (low risk): wide resection and reanastomosis (reattaching colon back together)
- Stage 2 (high risk): same as low risk, but with chemo
- Stage 3: Surgery and chemo
- Stage 4: Surgery is palliative, chemo and radiation used to control spread and help with pain
What are the two surgical options if the cancer is in the rectum
- Abdominal-perineal resection (APR) with a permanent colostomy (entire rectum was removed with the tumor)
- Low anterior resection (LAR) to preserve sphincter function (may have temporary colostomy or ileostomy, and then a takedown to remove colostomy or ileostomy so they can have control of their bowels)
What are 3 reasons why someone might have a temporary colostomy after colorectal cancer surgery
- Perforation (in surgery)
- Peritonitis (inflammation)
- Hemodynamic instability
What is a J-pouch
If all or a large portion of a person’s large intestine is removed, then a pouch can be created from the ilium (which is at the end of the small intestine) and can be attached to the sphincter, so that person can still have bowel movements.
What is a coloplasty
Can be used for someone with colorectal cancer, where a pouch is made from a portion of the large intestine that wasn’t removed. This portion is stretched so a new pouch can be made to carry stool.
For someone with a j-pouch or coloplasty, what might they experience
Urgency and frequency to have a bowel movement as the new pouch stretches
What are the 3 reasons to have chemo if you have colorectal cancer
- Neoadjuvant (shrink tumor before surgery)
- Adjuvant (shrink tumor following resection)
- Palliative
What does targeted therapy do 3
- Angiogenesis inhibitors block the blood supply to the tumor(s)
- Also block epidermal growth factor (blocks proteins that help the cancer grow)
- BRAF inhibitors attack the BRAF protein to shrink or slow cancer growth
When we are getting a past health history from a patient, what things are we looking for that might indicate a risk for colorectal cancer 5
- Previous breast or ovarian cancer
- Familial polyposis
- Villous adenoma
- Adenomatous polyps
- Inflammatory bowel disease
What specific tx can lead to colorectal cancer
Treatment for breast cancer
When assessing our patient for potential colorectal cancer, what do we want to ask 6
- What medications they’re taking
- If they’ve had any weakness or fatigue
- Have they had a change in bowel habits
- Have they been eating a high calorie, high fat, low fiber diet
- Have they had increased flatus
- Do they have feelings of incomplete evacuation
What prep should be done prior to a colonoscopy 4
- Low fiber diet 72 hours prior.
- Clear or full liquid diet 24 hours prior.
- Evening before drink half of the cleansing solution
- 4-6 hours before drink the remaining.
What is prostate cancer? What type of cancer causes it?
It’s a mostly slow growing androgen-dependent cancer caused by adenocarcinoma (which is cancer living in glands)
How does prostate cancer spread
- Direct extension (touching something) involves seminal vesicles, urethreal mucosa, bladder wall and external sphincter
- Through lymph nodes
- Through the bloodstream via the axial skeleton (pelvic bone, head of femur, lower lumbar spine, liver and lungs).
What are risk factors for prostate cancer a lot
- Age, typically after 50
- Higher incidence in African Americans and Caribbean men of African ancestry
- More common in North America, NW Europe, Australia and Caribbean islands
- Can be inherited but usually occurs without family history
- Mutations can raise the risk but occurrence is a small percentage
- Common with mutations in same genes that cause breast cancer like BRCA 1 and 2 genes (hereditary breast and ovarian cancer syndrome)
- Lynch syndrome.
- Diet (dairy products, excessive calcium intake)
- Obesity
- Environment (agent orange, firefighters)
- 3 or more first-degree relatives with prostate cancer
- prostate cancer in 3 generations on the same side of the family
- 2 or more close relatives on the same side diagnosed with prostate cancer before age 55
Is there a single gene known to cause prostate cancer? Are there genetic tests to be done to see if you are at risk for prostate cancer?
No and No
What are the 3 ways that someone can have prostate cancer
- Sporadic (damage to genes occurs by chance after a person is born - most common)
- Familial (genetics and environment)
- Hereditary (gene passed down - very rare)
If you are trying to prevent prostate cancer, what supplement should you not take unless indicated by your provider
Calcium supplements (dairy products and calcium can cause an increase in risk)
What does having hereditary breast and ovarian cancer (HBOC) syndrome due to mutations in the BRCA 1 and 2 genes put men and women at increased risk for
- Men: increased risk for breast and prostate cancer
- Women: increased risk for breast and ovarian cancer
What are manifestations of prostate cancer 3
- May be no symptoms in the early stages
- Eventually patient may experience LUTS symptoms similar to BPH
- ED
What are signs that prostate cancer has spread 2
- Pain in lumbosacral area that radiates down to hips or legs in combination with urinary symptoms
- Numbness/weakness in legs/feet and/or loss of bowel or bladder function (caused by spinal cord compression from tumor)
What are LUTS (lower urinary tract) symptoms that may indicate prostate cancer (similar to BPH) 6
- Urgency
- Hematuria (bloody urine)
- Nocturia
- Retention
- Interruption of urinary stream
- Inability to urinate
What are the 2 ways that we can diagnosis prostate cancer
- Digital rectal exam
- PSA test (prostate-specific antigen) is a glycoprotein produced by the prostate gland (primary screening)
What are normal PSA levels
0-4. Above 4 may indicate prostate cancer or other problems. (if above 4 they will do a biopsy to confirm) (4-10 may or may not have it). (above 10 is 50% chance they may have it)
What is interesting about prostate cancer
Most men live with prostate cancer, but will not die from it (if it’s super slow-growing, it may not even be treated)
When should screenings start for prostate cancer 3
- Start at the age of 50 for average risk
- Start at the age of 45 for higher risk (African American men and men who have a first degree relative with prostate cancer at an early age)
- Start at 40 for even higher risk (more than one 1st degree relative who had prostate cancer at an early age)
After you’ve been initially screened, what are your need screening recommendations for prostate cancer 2
- Screened every 2 years if PSA was less than 2.5
- Screened yearly if PSA was higher than 2.5
Does elevated PSA levels indicate prostate cancer? If not, what can elevated PSA levels indicate?
No - elevated PSA levels do not necessarily indicate prostate cancer, it may due to
- Aging
- BPH (enlarged prostate)
- Recent ejaculation
- Constipation
- Acute or chronic prostatitis
- After long bike rides (causes inflammation of the prostate)
- Certain urologic procedures
- Some medications
How might we obtain a biopsy for prostate cancer 2
- Transrectal ultrasound procedure
- MRI/ultrasound fusion biopsy
Will we continue to monitor PSA levels after a patient has been diagnosed with prostate cancer
Yes, PSA levels are used to monitor treatment success and recurrence of cancer. (a rising or detectable PSA, may indicate recurrence)
Besides PSA, what is another indicator of prostate cancer
- Increase in PAP (prostatic acid phosphatase), especially if cancer has spread
What tests will they perform to determine the location and extent of metastasis in prostate cancer 6
- Transrectal ultrasound (TRUS)
- Bone scan
- CT scan
- MRI using an endorectal probe
- Lymph node biopsy
- Biopsy during surgery
What two medications may be used to reduce the chance of needing surgery for prostate cancer
Finasteride and dutasteride (which are used to treat BPH)
What are the 2 ways that prostate cancer is staged and graded
- TNM system (0-4 stages)
- Gleason scale (tumors are graded from 1, which is well-differentiated to 5, which is undifferentiated. Grades are given to the two most common patterns of cells and are added together. Scores range from 2-10). (the higher the number, the worst prognosis)
What is the surgical option for prostate cancer
Radical prostatectomy (where they remove the prostate)
- Entire gland, seminal vesicles and part of the bladder neck are removed
- Retroperineal lymph node dissection is done for men at a higher risk for metastasis
- Not indicated for advanced stages, unless it’s to relieve obstruction, because the cancer has spread all over
What is our post-op care after a patient has a radical prostatectomy 3
- Pt will have an indwelling catheter with possible continuous bladder irrigation
- Surgical site drain
- 1-3 day hospital stay
What are major/common complications from a radical prostatectomy
- ED
- Incontinence/urinary retention
- Hemorrhage
- Infection
- Wound dehiscence
- DVTs or PEs
If we want to help a man regain their bladder function, what can we suggest.
Kegels (like you’re trying to stop your stream - don’t do during urination)
Can cryotherapy help to treat prostate cancer
Yes, you can use very cold temperatures to freeze and kill prostate cancer cells
(not a first line treatment - probably done after chemo or radiation fail)
(probe goes into the rectum to freeze the prostrate, warm salt water goes into the urethra to keep that from freezing)
What might be some complications after cryotherapy 8
- Damage to the urethra
- Urethrorectal fistula
- Urethrocutaneous fistula
- Tissue sloughing
- ED
- Urinary incontinence
- Prostatitis
- Hemorrhage
What is the most common type of radiation used
External beam radiation
What is external beam radiation used to treat for prostate cancer
When the cancer is confined to the prostate and/or surrounding tissue (not if it has spread all over)
What is interesting about external beam radiation and a radical prosectomy
Cure rates are about the same
What are common side effects of radiation
- Skin irritation, burns
- Urinary issues (painful, difficult, leakage, blood in urine)
- Frequent urination
- Diarrhea
- Painful, bowel movements
- Frequent bowel movements
- Bloody stool
- Fatigue
- ED
- Secondary cancers to that area
What is another type of radiation where they implant radioactive seeds into the prostate gland
Brachytherapy
What is the benefit of bracytherapy
It spares the surrounding tissue, as opposed to external beam radiation
When is brachytherapy administered
Early stages of the prostate cancer
What are common side effects of brachytherapy
- ED
- Irritative or obstructive urinary problems (frequency, bloody, etc)
- Issues with bowels.
(basically the same urinary and bowel symptoms as external beam radiation)
What might brachytherapy be offered with
In combination with external beam radiation for advanced tumors
What are treatment options for advanced or metastatic prostate cancer
- Androgen deprivation therapy (ADT) (androgens, like testosterone supply the cancer. So lowering these androgens will help shrink or cause the cancer to grow more slowly over time)
- Chemo
- Combination
What is interesting about the transgender population and hormone therapy to treat cancer
There is a possibility that transgender male to female, taking estrogen, may decrease prostate cancer risk. (but taking estrogen increases breast cancer risk for both men and women)
When is chemo primarily used for prostate cancer
- Used when the cancer is not responding to changes in hormones (like blocking testosterone)
What is the most common chemo for prostate cancer
Docetaxel
When might radiotherapy, radium-223 dichloride be used to treat prostate cancer and when not?
For patients with:
- Castration-resistant prostate cancer (not responding to low T levels)
- Symptomatic bone metastases (given for metastases in the bone)
- Not given if known visceral metastatic disease (like in liver lungs, etc)
How does an orchiectomy (surgical removal of the testes) help to fight prostate cancer? What are the benefits? Is it commonly performed?
- Causes androgen deprivation (reduces androgens - basically starve the cancer from testosterone)
- Very low cost
- Facilitates cancer control and rapid relief of bone pain in advanced stages
- Rarely performed today because it has horrible side effects (depression, fatigue, low muscle mass, etc - just not good for men)
When screening for prostate cancer, what medications should we be concerned that a patient is taking 5
- Testosterone supplements
- Morphine (can increase risk)
- Anticholinergics
- Monoamine oxidase inhibitors (MAOIs) (can disrupt androgen receptor signaling)
- Tricyclic antidepressants (can increase prostate cancer risk)
Is low back pain radiating to legs or pelvis, bone pain symptoms of prostate cancer metastasis
Yes
Why is smoking so bad for you 3
- Contains 60 carcinogens that interfere with cell development
- There are 7,000 chemicals in cigarette smoke
- Causes a change in bronchial epithelium
If you quit smoking, after 10-15 years, how much is your risk of lung cancer decreased
By half for a person who is still smoking
What are the risks for lung cancer 7
- Total number of cigarettes smoked
- Age of smoking onset
- Depth of inhalation
- Use of unfiltered cigarettes
- Second hand smoke
- Maybe vaping
- Other carcinogens (pollution, radiation, asbestos, nickel, uranium, chromium, formaldehyde, arsenic)
What is the pathophysiology of lung cancer 4
- Arise from mutated epithelia cells
- Tumor development is promoted by epidermal growth factor
- It takes 8-10 years for a tumor to reach 1cm (which will let it be detectable on xray) (can have cancer for a long time before they even can tell)
- Occur primarily in segmental bronchi and upper lobes
What are the 2 main categories of lung cancer
- Non-small cell lung cancer
- Small-cell lung cancer
What are the 3 categories of non-small cell lung cancer
- Adenocarcinoma
- Large cell
- Squamous cell
Describe adenocarcinoma 4
- Moderate growing
- Most common lung cancer in nonsmokers
- Surgery may be available
- Does not respond well to chemo
Describe large-cell carcinoma 4
- Highly metastatic by lymph node and blood
- No surgery due to high rate of metastasis
- Rapid growing
- Tumors may be radiosensitive but often reoccur
Describe squamous cell carcinoma 3
- Early symptoms include cough, hemoptysis
- Does not have a strong tendency to metastases
- Surgery may be tried, with chemo and radiation
Describe small-cell lung cancer 7
- Very rapid growth
- Most malignant
- Early metastasis (lymph and blood stream(
- Associated endocrine disorders
- Surgery is not generally an option
- Can have chemo and radiation
- Poor prognosis
How is lung cancer metastasized 3
- Direct extension
- Blood circulation
- Lymph system
Where does lung cancer go 5
- Lymph nodes
- Liver
- Brain
- Bones
- Adrenal glands
What is paraneoplastic syndrome associated with lung cancer
Immune system is attacking the tumor, tumor begins secreting hormones, cytokines and enzymes, which then start attacking the patient’s healthy cells.
What is the issue with diagnosing lung cancer early
Lung cancer is often masked by a chronic cough, so someone with COPD may not even realize that something is wrong
Besides a chronic cough, what are other early symptoms of lung cancer 6 (symptoms depend on what type and where the lung cancer is located)
- Pneumonitis (presents as chest pain)
- Sputum with cough
- Hemoptysis
- Dyspnea
- Wheezing
- Chest pain
What are later symptoms of lung cancer 10
- Anorexia
- Fatigue
- Weight loss
- N/V
- Hoarseness
- Unilateral paralysis of diaphragm
- Dysphagia
- Superior vena cava obstruction
- Palpable lymph nodes
- Mediastinal involvement
How can we diagnosis lung cancer and metastasis (a lot)
- Chest xray
- CT scan
- Sputum cytology (rarely used)
- Lung biopsy for definitive diagnosis
- Pleural fluid analysis
- Bone scans
- CT scans of brain, pelvis, abdomen
- CBC with differential
- Chemistry panel
- Liver, renal, and pulmonary function tests
- MRI
- PET scan
How is non-small lung cancer staged
Uses the TNM system
What does TNM stand for
T: tumor size, location and degree of invasion
N: indicates regional lymph node invasion
M: represents presence/absence of distant metastases
What are the 4 stages of non-small cell lung cancer
Stage 1: tumor is small and localized, no lymph node involvement.
Stage 2: Tumor has increased in size, greater than 5cm, and has some lymph node involvement
Stage 3: Tumor has spread to nearby tissues
Stage 4: Distant metastasis
How do they stage small cell lung cancer
- TNM is not useful
- It’s an aggressive cancer that is always considered systemic
- Staged as limited or extensive
When do we screen for lung cancer? How do we screen?
- Annually in people aged 50-80 with good health and currently smoke or have quit smoking in the past 15 years
- Annually in people who have at least a 20 pack smoking history
(both are completed with a low dose CT)
How do we find a persons pack year smoking
Number of packs of cigarettes smoked per day multiplied by the number of years smoked.
What is the early treatment of choice for early staged non small lung cancer
Surgery (not indicated for small cell, because you’re not going to be able to find all of the sites of metastasis in the lungs)
What are the 4 surgical options for lung cancer (for stages 1-3)
- Wedge resection (removal of a little triangle chunk)
- Lobectomy (removal of a lobe)
- Segmental resection (part of the lobe)
- Pneumonectomy (removing one of the lungs)
If a patient cannot tolerate surgery for lung cancer, what is our next option
Radiation therapy (can be curative, palliative or adjuvant)
What is stereotactic radiotherapy 3
- Works to target the area without minimal impact to surrounding tissue
- Doesn’t kill the cancer, but kills the DNA of the tumor, which then causes the tumor to lose it’s ability to reproduce and then it shrinks)
- Given over 1-3 days
What is the primary treatment for small cell lung cancer
Chemo
How can targeted therapy work on lung cancer
Blocks tumor growth and proteins responsible for growth and development
What are our 3 types of inhibitors for targeted therapy
- Tyrosine kinase inhibitors (blocks growth signals)
- Kinase inhibitors (inhibits protein that help cancer grow and develop)
- Angiogenesis inhibitors (blocks cancer cells from making own blood supply)
What are 3 other therapies for lung cancer
- Prophylactic cranial therapy used for small cell lung cancer to prevent cerebral metastasis (because most chemos don’t cross the blood brain barrier)
- Bronchoscopic laser therapy to remove obstructing tumors in the airway
- Photodynamic therapy used in very early stage lung cancers in outer layers of airways using light
To help control symptoms caused by airway obstructions from lung cancer, what can be done
Airway stenting, which can help relieve dyspnea, cough, or respiratory insufficiency
What is radiofrequency ablation
Using an electrical current to heat and destroy tumor cells for non small lung cancer
What medications might indicate a possible lung cancer diagnosis
Someone who has been taking cough medicines or other respiratory medications because they are treating the symptoms
What objective data might indicate lung cancer when performing our physical assessments 8
- Fever, chills
- Lymphadenopathy (swollen lymph nodes)
- Paraneoplastic syndrome
- Jaundice
- Edema
- Clubbing
- Adventitious lung sounds
- Pleural effusions
What are other problems that may be associated with lung cancer 5
- Pericardial effusion
- Dysrhythmias
- Unsteady gait
- Pathologic fractures
- Muscle wasting
What are the screening guidelines for breast cancer (for women who have an average risk)
- Women 40-44 have the option to start having a mammogram every year
- Women 45-54 should get a mammogram every year
- Women 55 and older can switch to every other year or continue to have one every year (continue screenings if a woman is in good health and is expected to live at least 10 years)
Should women only use breast self exams as a screening
No, they need to do them in conjunction with mammograms
What screenings should a woman get if she is at an increased risk? And at what age?
At age 30, start having mammograms and breast MRIs
How do mammograms work
- Take the first image and compare it each year to your next mammogram
- Can detect breast cancer before it’s felt
Do mammograms detect all breast cancers
No, about 10-15% cannot be seen, and will need a follow-up palpitation, ultrasonography, MRI or biopsy
What type of mammogram might a younger woman have
A digital mammogram, as they are more accurate in younger women
What are the different breast cancer biopsies
- Fine needle aspiration (taking a small amount of tissue)
- Core needle (for larger samples
- Surgery (excisional)
- Lymph node biopsy
What are nonmodifiable risk factors for breast cancer
- Females are at high risk
- Age 55-60
- Genetics
- Family history (especially if you have a father or brother with breast cancer)
- Personal history of breast cancer (can develop a different type)
- Race (white women are slightly higher risk)
- Being taller
- Having dense breast tissue (difficult to see on mammogram)
- Having certain benign breast conditions
- Early menarche and late menopause (being exposed to estrogen longer)
What are modifiable risk factors for breast cancer
- Alcohol
- Obesity (having more fatty tissue after menopause - estrogen can store here)
- Sedentary lifestyle
- Not bearing children (stop producing estrogen during pregnancy)
- Not breastfeeding (stop producing estrogen during breastfeeding)
- Hormonal birth control
- Hormonal therapy after menopause
- Smoking
- Dietary fat intake
- Environmental factors
- Breast implants
What are breast cancer risk factors for men 3
- Hyperestrogenism (testicular tumor, hyperthyroidism, liver disease, adrenal disease)
- Family history of breast cancer
- Radiation exposure to chest area
What if a man finds out that they have the BRCA mutation
- They should have breast and prostate screenings yearly starting at age 35 (this mutation also increases risk for prostate cancer)
Do men get mammograms
No
If you find out that you are at high risk for developing breast cancer, such as having the BRCA 1 and 2 mutations, what can be done?
You can have prophylactic oophorectomy (removing ovaries) and a mastectomy, which can decrease your risk of breast and ovarian cancer
Why would it be beneficial to remove your ovaries before menopause?
Because they are the main source of estrogen
Does removing your ovaries after menopause decrease breast cancer risk
No
What are the two main categories of breast cancer
- Ductal carcinoma (affects milk ducts)
- Lobular carcinoma (affects milk-producing glands
Besides ductal carcinoma and lobular carcinoma, what are 3 other categories of breast cancer
- Inflammatory
- Paget’s disease
- Phyllodes
What are the 4 types of ductal carcinoma
- In situ vs invasive
- Medullary
- Tubular
- Colloid (mucinous)
What is ductal carcinoma in situ 4
- About 1 in every 5 new breast cancers
- Pre-invasive
- Nearly all women can be cured if it’s found early
- Cells that line the ducts have turned into cancer, but have not spread
What is invasive ductal carcinoma 3
- Most common type of breast cancer
- About 8-10 invasive cancer
- Start in cells that line the ducts and breakthrough to nearby tissue, lymph system and then into the blood stream
What is medullary ductal carcinoma 4
- Rare subtype of invasive
- Called medullary because the tumor develops soft tissue that looks like the medulla of the brain
- Does not grow quickly
- Usually does not spread outside of breast or lymph nodes, making it easier to treat
What is tubular carcinoma 2
- Subtype of invasive carcinoma
- Called this, because the cancer are tube like structures
What is colloid (mucinous) ductal carcinoma
- Abnormal cells float in a pool of mucous
What lobular carcinoma 5
- Can become invasive
- Start in lobules (milk producing glands)
- Can spread to other parts of the body
- Harder to detect
- 1 in 5 women will have cancer in both breasts
What is inflammatory breast cancer 7
- Rare
- Invasive
- Blocks lymph vessels
- Causes skin to look inflamed
- Breast will be swollen, purple, red in color, dimpling in color that makes it look like orange peel
- Usually in advanced stage 3 when it is found, because cancer has grown into the skin
- Has the worse prognosis
What is Paget’s disease 4
- Rare
- Skin and nipple areola
- Usually on one side
- Usually found with ductal carcinoma
What is Phyllodes disease 2
- Rare
- Affects connective tissue of the breast
Once we get a biopsy, how can we test those cells
We will look to see if they have estrogen or progesterone receptors, as receptors can help fuel the cancer
What are the 4 different types of hormone receptor statuses
- Estrogen receptor positive (ER positive) (these breast cancers have estrogen receptors)
- Estrogen receptor negative
- Progesterone receptor positive (PR positive)
- Progesterone receptor negative
Besides checking for estrogen and progesterone receptors, what is another receptor we want to check for
HER-2
Why do we not want progesterone and estrogen to attach to cancer cells
These two hormones can help the cancer grow
What is nice if your cancer is positive for estrogen receptors, and progesterone receptors
We can use hormonal therapy to block these receptors
Can we use hormone therapy on cancers that are ER negative or PR negative
No, because they do not have receptors for us to block
What does HER-2 stand for? What is it?
Human epidermal growth factor. It’s a growth protein located on the outside of a cancer’s cell wall
What if you are HER-2 positive? What’s the bright side?
Your cancer will likely grow and spread faster than other cancers. We can use treatments to target this HER-2 protein.
What is the difference between triple positive receptors and triple negative receptors
- Triple positive cancers have both estrogen and progesterone receptors, as well as the HER-2 protein, which makes them easier to treat
- Triple negative cancers don’t have any of these, which can make them difficult to stop (these are usually more aggressive, spread easier and come back after treatment)
Who is at an increased risk for triple negative cancer 3
- African American and Hispanic women
- Premenopausal women (younger than 50)
- People with BRCA 1 mutation
What is the typical treatment for triple negatives
- Surgery in the earlier stages
- Chemo in the later stages
What are clinical manifestations of breast cancer
- Lump or thickening of breast tissue
What area of the breast are we more likely to find breast cancer
Upper, outer quadrant
What might a breast cancer lump feel like 5
- Hard
- Irregularly shaped
- Poorly lined
- Non-mobile
- Non-tender
What might nipple symptoms be of breast cancer 3
- Discharge (can be bloody)
- Nipple retraction
- Dimpling pulling in
What does metastatic breast cancer most commonly spread 4
- Bones
- Liver
- Lungs
- Brain
What factors affect prognosis of breast cancer 5
- Tumor size
- Axillary node involvement
- Tumor differentiation
- Estrogen and progesterone receptor status
- HER-2 receptors
What test can help predict the risk of cancer recurrence
An axillary lymph node analysis
What is an axillary lymph node analysis 3
- One of the most important prognostic factors in breast cancer
- It can tell you how many lymph nodes are involved (the more lymph nodes = greater risk for recurrence
- Perform a sentinel lymph node biopsy
What is a sentinel lymph node biopsy 2 (sentinel lymph nodes are the first lymph nodes with cancer cells)
- Helps identify which lymph nodes are the sentinel lymph nodes which drain first from the tumor site (basically help you identify the closes lymph nodes to the cancer that are involved)
- May indicate the need for a complete axillary lymph node dissection
What does a positive sentinel lymph node biopsy indicate
That cancer is present in the sentinel lymph nodes, which may indicate that the cancer has spread to other parts of the body.
What other tools can we use to predict recurrence of cancer 4
- Tumor size
- Estrogen and progesterone receptor status
- Cell-proliferative indices (measure the number of cells in the tumor that are dividing and proliferating, which can tell us how fast the tumor is growing)
- Genetic/genomic assays
What can a tumor tell us 3
- The larger the tumor, the poorer the prognosis.
- The more well differentiated the tumor is, the less aggressive it will be.
- A poorly differentiated tumor appears morphologically disorganized and are more aggressive
What do tumors that are estrogen and progesterone receptor positive tell us 3
- They are well-differentiated
- Lower chance of recurrence
- Respond well to hormonal therapy
What do tumors that are negative for estrogen and progesterone receptors tell us 3
- They are poorly differentiated
- They frequently recur
- They are unresponsive to hormonal therapy
What does a genomic assay tell us about prognosis
- This means the tumor is HER-2 positive
Leads to: - unusually aggressive tumor growth
- Greater risk for recurrence
- Poorer prognosis
What can genetic tests tell us
- Use a sample of breast cancer tissue to analyze activity of a group of genes that an affect how a cancer is likely to behave and respond to treatment (looking at genes to guess how a tumor is going to behave)
Review the stages of breast cancer on page 1199. Or look on PowerPoint.
Review prostate staging on page 1264
At what stage in breast cancer is there always lymph node involvement
Stage 3 and 4
What are the different surgery options for breast cancer 4
- Lumpectomy - removing the cancerous breast tissue as well as tissue around the cancer, this preserves the rest of the breast as well as sensation.
- Simple mastectomy - removes whole breast, may also remove some lymph nodes under the arm.
- Radical mastectomy - remove the breast, pectoral muscle and all of the underarm lymph nodes.
- Modified radical mastectomy - same as above, but leaves the pectoral muscle.
Since there are a ton of lymph nodes in the axillary region, what is an issue if you get them all removed
You will have poor drainage in that area, which can cause lymphedema
What is lymphedema 3
- Where lymph nodes have been removed near the site of the breast, and cannot remove fluid in that area.
- Fluid accumulates in the arm, hands or breast
- Causes obstructive pressure on veins and venous return
If someone has had lymph nodes removed, what should you not do
Take BPs, put in IVs, do injections, get blood draws from that side (this fluid build up causes pain, and it can cause an infection risk, because that fluid just stays in there and collects)
After breast surgery, what can people have
- Neuropathic pain - in the chest wall, armpit or arm that doesn’t go away.
- Can feel like pain, tingling, aching, burning, numbness, itchiness, and have edema.
- Can be mild to debilitating.
How can we treat this pain after surgery
- NSAIDs, low dose antidepressants, EMLA (topical anesthetics like lidocaine, antiseizure drugs.
- Use PT, guided imagery, biofeedback, counseling.
Besides having neuropathic pain after breast surgery, what other pain can you have
Phantom breast pain (where the brain continues to send signals to nerves in the breast area that were cut out during surgery)
How can we treat phantom breast pain
Treat like any other pain (don’t not treat it)
What can we use to help prevent cancer recurrence after breast cancer surgery
Radiation therapy - to make sure there aren’t any cancer cells floating around that might cause recurrence.
What can external beam radiation be used for
- Performed after breast cancer surgery to help decrease the risk of recurrence
- But it does not prevent distant metastasis
What are side effects of external beam radiation for breast cancer 3
- Fatigue
- Skin changes
- Breast edema
How can brachytherapy be used with breast cancer 3
- Uses internal radiation
- Delivers directly into the cavity after a lumpectomy
- Only takes 5 days
How is brachytherapy administered for breast cancer
Uses a mammostie (tube looking thing), insert it into the breast, inflate a little balloon in there, and then insert the radiation seeds.
- These seeds and the mammosite are only during treatment and are removed after each session.
With breast cancer surgery, neoadjuvant or adjuvant therapy may be given. What does this mean?
- Neoadjuvant therapy may be given to help shrink the tumor prior to surgery
- Adjuvant therapy may be given after surgery to help decrease the risk of recurrence
What are two reasons why chemo is often given with a combination of drugs
- One drug may need to be given in high doses, but it can be very toxic, so if we offer other cancer fighting drugs with it, then we might be able to decrease the dose of that toxic chemo.
- Also, helps to hit the cancer at different parts of the cell cycle
How long is chemo usually given
3-6 months
What are common chemo drugs for breast cancer
- Methotrexate
- Doxorubicin
- 5FU
- Paclitaxel
- Docetaxel
- Cyclophosphamide
- Epirubicin
What are side effects of chemo 4
- GI issues (n/v, anorexia, weight loss)
- Bone marrow loss (causes anemia)
- Alopecia
- Chemo brain
How does hormone therapy work
- If cancer is ER positive and/or PR positive (this means the tumor needs estrogen or progesterone to grow), we can use hormone therapy to block these receptors and suppress the body from making these two hormones
What test can we use to determine if hormone therapy is an option for someone’s cancer
Use receptor assays (basically test whether this treatment will work using a tissue sample)
What is ovarian ablation? What is the purpose?
Basically stopping the ovaries from making estrogen and progesterone
- Can be accomplished through removing the ovaries, radiation or using drugs to lower hormone levels.
What is the most common form of hormone therapy for beast cancer
Estrogen receptor blockers (either lower estrogen or stop estrogen from acting on cancer cells)
What is the number one drug of choice for ER positive women during all stages of breast cancer
Tamoxifen
What is another reason we might give a woman tamoxifen, even if they don’t have breast cancer
To prevent breast cancer in high risk women
What are some side effects of tamoxifen 7
- hot flashes
- mood swings
- vaginal discharge and dryness
- clots
- endometrial cancer
- cataracts
- stroke
(side effects of not having estrogen)
What type of drugs might we give for postmenopausal women with breast cancer
Aromatase inhibtors
What are our aromatase inhibitors
- Anastrozole (most common)
- Letrozole
- Exemestane
How do aromatase inhibitors work
Interfere with aromatase, which is an enzyme needed for the synthesis of estrogen
Do aromatase inhibitors block ovarian estrogen production
No
Can you give aromatase inhibitors to premenopausal women
No
What are side effects of aromatase inhibitors 6
- osteoporosis/bone fractures
- night sweats
- nausea
- arthralgias
- myalgias
What drug is a monoclonal antibody that can inhibitor the growth factor HER-2
Trastuzumab (Herceptin)
When we’re performing an assessment on someone who may have breast cancer, what are we looking for 5
- Presence of nipple discharge
- Pain
- Rate a lump is growing
- Breast asymmetry (pretty key - sometimes only thing that can indicate a problem)
- Correlation with menstrual cycle (having menstrual cycles at an early age)
When someone had breast cancer surgery, what can make the pain worse
Removal of the pectoral muscle can make their pain even worse
What are good ways to prevent or decrease lymphedema
- No BP readings, venipunctures or injections on the affected arm
- Arm should not remain in a dependent position for lengthy periods of time (usually have arm in a sling up)
What can we do for acute lymphedema 5
- Decongestive therapy (using massage, which helps mobilize subcutaneous fluid accumulation)
- Compression bandaging
- Pneumatic compression sleeve (like SCDs)
- Elevation of arm (level with the heart)
- Isometric exercises
Basically, what is leukemia 3
- Cancer affecting the blood and blood-forming tissue, which include bone marrow, lymph system and spleen.
- Immature/abnormal/functionless WBCs are produced that are unable to fight against the infection
- These bad WBCs obstruct the production and crowd out normal functioning cells
What are the 4 different types of leukemia
Acute lymphocytic leukemia (ALL)
Acute myelogenous leukemia (AML)
Chronic myelogenous leukemia (CML)
Chronic lymphocytic leukemia (CLL)
REVIEW: symptoms of leukemia
Fever, lymphadenopathy, lethargy
Pallor, jaundice, petechiae, ecchymoses
CV - tachycardia, systolic murmurs
GI - oral lesions or bleeding, herpes or infection, hepatomegaly, splenomegaly
Seizures, disorientation, confusion
Muscle wasting, bone or joint pain
REVIEW: Diagnostics of leukemia
WBC may be normal or abnormal
Anemia
↓ Hct and Hgb
Thrombocytopenia
Philadelphia chromosome (in CML)
Hypercellular bone marrow aspirate or biopsy used to diagnosis
Is there an actual “cure” of leukemia
No, but they can go into and remain in remission (can’t get every single tiny cancer cell out)
What are the 3 different types of remission
- Complete (absence of active disease and no evidence by imaging or biopsy)
- Partial (decrease in cancer in the body and the response to treatment)
- Molecular (no evidence of disease in blood cells or bone marrow using sensitive PCR test)
What is the main tx for leukemia
Chemo
What are the 3 stages of chemo
- Induction
- Postinduction or postremission (consolidation)
- Maintenance
What is induction chemo
- We want to cause remission
- Do so by destroying leukemic cells in tissues, peripheral blood, and bone marrow
What sucks about induction therapy
It is a very aggressive chemo, where a pts bone marrow will become severely depressed.
What chemo drugs do they use for induction therapy (probably don’t need to memorize - notice how induction treatment is only for the acute leukemias)
- AML: cytarabine and daunorubicin
- ALL: daunorubicin, vincristine, prednisone, asparaginase and sometimes cyclophosphamide
When is someone considered to be in remission after induction therapy 2
- Biopsy shows no persistent leukemia
- Blood counts return to normal
After induction therapy shows possible remission, what tx might follow? Why?
Postinduction or postremission chemo or consolidation therapy. Because there could still be leukemic cells floating around in the body, that we weren’t able to detect.
What consists of postinduction or postremission chemo
It’s an intensification therapy
- Give high-dose therapy
- Use drugs that work in a different way than those used in induction therapy (basically trying to kill it multiple different ways)
What is consolidation therapy
- May include several cycles of chemo or several months of chemo
- Started after remission is achieved
What will maintenance therapy consist of
Low dose of the same drugs given every 3-4 weeks (basically after treatment, you will still need to take chemo)
Once in remission, how often will a pt have a blood test
Once a month
During maintenance therapy, which type of leukemia may let a person return to work
ALL
What are the benefits of giving chemo drugs in combination 3
- Can decrease drug resistance
- Can decrease drug toxicity (because you’re using multiple drugs at typically lower doses)
- Interrupt cell growth at multiple points
Besides chemo, what are other txs for leukemia 3
- Corticosteroids (help shrink tumor)
- Radiation (can be total body to prepare for a bone marrow transplant or area specific like liver or spleen to relieve pain/discomfort)
- Immunotherapy and targeted therapy
How does a stem cell transplant work
We basically eradicate the pts hematopoietic stem cells through radiation, and then replace them with a match (or even their own cells that were taken out prior)
REVIEW: lymphoma
Cancers originating in bone marrow and lymphatic structures
Result in proliferation of lymphocytes
Two major types
Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma (NHL)
How many cycles of chemo will someone receive with Hodgkin’s lymphoma
Depends on how advanced their cancer is
- Early stage: 2-4 cycles of chemo
- Unfavorable early state: 4-6 cycles
- Advanced: 6-8 cycles
What is scary about Hodgkin’s lymphoma
It is an aggressive treatment, and may cause life-threatening problems
Will someone have maintenance therapy for Hodgkin’s lymphoma once remission has been achieved
No, because maintenance chemo has not shown to contribute to increased survival once remission has been achieved
Is radiation the main tx option for hodgkin’s
No - it is only supplemental (chemo is the number one tx)
Once remission is achieved for Hodgkin’s, what might we do to try and get this person cured
Give intensive chemo and perform an autologous or allogeneic stem cell transplant
What is nice about hodgkin’s lymphoma
They have an overall better prognosis than many other cancers
What sucks after having tx for hodgkin’s
They can cause secondary cancer after 10 years (most common - lung and breast)
What tx do we use for non-hodgkin’s
- Chemo
- Radiation
What’s nice but doesn’t sound nice about non-hodgkin’s
It is usually more aggressive, but this also makes it easier to treat and cure
What are the txs for non-hodgkin’s
- Hematopoietic stem cell transplant
- Rituximab (probably the only med we need to know for this)
- Ibritumomab tiuxetan
- Phototherapy (cutaneous T cell lymphoma - uses ultraviolet light to decrease inflammation in the skin)
- Interferon
- Bexarotene
- Vorinostat
What should we monitor if someone is taking rituximab
Monitor for severe hypersensitivity infusion reactions, especially with the first infusion
For non-hodgkin’s, do we expect complete remission
No, complete remission is uncommon, however, improvement in symptoms is expected
What can cause spinal cord compression from cancer and what can this lead to
A tumor, which can cause irreversible paralysis (tumor can spread through direct extension or metastasis)
What cancers are more common to cause spinal cord compression
Cancers that are known to metastasize
- lung
- breast
- prostate
- kidney
- lymphomas
- myelomas
- sarcomas
What are symptoms of spinal cord compression
- Pain in back or neck (often in thoracic region described as feeling like a tight band around the chest) (90% of patients have pain - other 10% do not have pain)
- Changes in mobility and sensation
- New incontinence (change in bowel/bladder)
- Numbness around peri area
What is the issue with spinal cord compression
They can be hard to diagnosis if pain is the only symptom.
What is the first treatment option you should do for a spinal cord compression? Why? What specific drug?
Use corticosteroids to reduce the spinal edema. Dexamethasone.
What is superior vena cava syndrome
Compression of the SVC caused by a tumor (by the sternum region)
What type of cancer most commonly causes superior vena cava syndrome
Lung cancer
What are common symptoms of superior vena cava syndrome 7
- Facial and arm swelling
- Distended neck and chest veins
- Facial plethora (red face)
- SOB
- Cough
- Hoarseness
- Syncope
What is it called when cancer causes a high leukemic WBC count (greater than 100,000)
Leukostasis
What can Leukostasis cause
Thickening blood (hyperviscositiy), which can lead to clots and damage your brain, lungs and other organs
What type of cancers are more likely to cause Leukostasis
The acute leukemias
What type of cancers are more likely to cause Leukostasis
The acute leukemias
What is the tx for Leukostasis
- Hydration
- Removing WBCs
- Removing blood
- Hydroxyurea
- Leukopheresis
What 3 oncologic emergencies are caused my tx
- Sepsis
- TLS (tumor lysis syndrome)
- Hypercalcemia
How does sepsis occur
A person who is receiving cancer tx can cause them to become immunosuppressed (neutropenic), and then they can get an opportunistic infection.
Which cancer is at the highest risk for sepsis? Why?
Bone marrow transplant patients, because their immune system is wiped out.
Besides antibiotics/antifungals/antivirals, what else will a cancer pt be given for sepsis
GSF (Granulocyte-colony stimulating factor) which can help cause rapid leukocyte recovery.
What is tumor lysis syndrome (TLS)
- Associated with leukemia and lymphoma, but can be from any cancer
- As tx destroys cancer cells, metabolites from these destroyed cancer cells enter into the bloodstream and cause kidney failure. (what we’re worried about when someone has a large or lot of tumors)
What lab results would we see for TLS 3
- Hypercalcemia
- Hyperuricemia
- Hyperphosphatemia
What is the tx for TLS 5
- Hydration
- Loop diuretics
- Anti-gout meds like alopurinol to decrease uric acid
- Hemodialysis if kidneys are already affected
- Restrictive diet, phosphate binders (to treat hyperphosphatemia)
Why does hypercalcemia occur from cancer (teacher says from tx, I don’t think tx causes it?)
- Bones are breaking down and are releasing too much calcium into the blood stream and kidneys can’t excrete it enough
- Caused by pretty advanced cancers
What is the tx for hypercalcemia
- Replace fluids (helps kidneys work better so they can remove the calcium from the blood)
- Diuretics
- Bisphosphonates (stops body from breaking down the bones and helps strengthen the bones)
- Calcitonin (hormone to help stop calcium from being broken down)
- Dialysis if needed
- Biggest thing is to help treat the malignancy in the first place!
What is the biggest thing to remember about the heart and cancer
That a lot of cancer drugs carry life time maximums, because high life-time amounts can damage the heart
What temperature are we worried about for neutropenic patients
100.4 = deadly (sometimes this elevated temp is their only sign of infection)
Why would we give granulocyte-stimulating factor? What are these two drugs?
To help stimulate the growth of WBCs. Filgrastim (Neupogen) and pegfilgrastim.
What is a good way to remember humoral immunity
This one has antibodies and immunoglobulins (humor the goblins)
What is cell-mediated immunity
Immune system responds with cells, like our T cells, macrophages and NK cells.
What can cause lupus 6
Their are multiple factors, can be a combination of the ones below (some of these can also cause flare ups):
- Genetic component
- Hormonal (onset and flare ups may occur after the start of menses, with the use of oral contraceptives, and during and after pregnancy)
- Environmental (sun exposure, chemical exposure, etc)
- Immunologic (overreactive immune system)
- Coming into contact with a virus or bacteria
- Certain medications like procainamide, hydralazine and quainidine.
What gender and ethnicity is more likely to develop lupus
- Women of childbearing years
- Other races besides whites
What happens when our immune system is overactive
Antibodies that are fighting our DNA are deposited into capillary membranes in the kidneys, heart, skin, brain and joints, where they cause inflammation, which leads to tissue destruction.
What are clinical manifestations of lupus (there are a bunch)
- Red and dry eyes
- Mouth can have ulcers
- Brain is affected causing FATIGUE, memory loss, psychosis, seizures and fevers.
- Photosensitivity
- Butterfly rash
- Discoid rash (misshaped rash usually on areas of the skin that have been exposed to sunlight)
- Alopecia
- Heart failure (basically lupus causes inflammation in the heart, weakening it)
- Chest pain/pericarditis (remember that lupus is causing inflammation - so it pretty much causes anything that ends in “itis”)
- Murmurs
- Infections like pneumonic or pleuritis
- Lupus nephritis (damage to the nephrons that filter the urine)
- Protein in the urine (kidneys are not working)
- Retain fluid (kidneys are not working)
- Hypertension (kidneys are not working)
- Renal failure (kidneys are not working)
- Increases risk for infections (immune system is not working)
- Blood clots
- Antiphospholipid syndrome (immune system causes the body to clot more)
- Swollen, painful joints
- Muscle aches and pain
- Raynaud’s syndrome (bluish/pale fingers or toes when exposed to the cold)
- Can increase risk of blood clots if pregnant
- Anemia
Why does lupus increase your susceptibility to infections 3
- Defects in the ability to phagocytize invading bacteria
- Deficiency producing antibodies
- Medications you’re taking for lupus may cause immunosuppression
What is a major cause of death of lupus
Infection
In regards to infection, what should we tell lupus pts
No live vaccines to pts on corticosteroids or cytotoxic drug
How do we diagnosis lupus 4
No specific test but we can use the following tests to help determine a diagnosis:
- Antinuclear antibodies are present in 97% of people with lupus (so this is our main indicator)
- Anti-Smith antibodies are found in 30-40% of people with lupus
- Xrays of joints and chest
- ECG
What 2 lab tests might we run to check or monitor inflammation
ESR and CRP(C-reactive protein that measures inflammation)
When caring for an acute pt with lupus, what should we be doing 5
- Monitor Is and Os (at risk for fluid retention due to poor heart and kidneys)
- 24 hour urine sample to monitor for protein in the urine and creatinine clearance
- Watch for signs of bleeding due to medications that they might be on
- Watch for neruo status
- Watch for psychosis (may be from corticosteroids)
What is our normal creatinine clearance
88-137
What are drug therapy options for lupus 5
- NSAIDs for mild joint pain (watch for GI bleeding and renal toxicity)
- Steroid-sparing drugs like methotrexate
- Antimalarial drugs like hydroxychloroquine and chloroquine to treat fatigue and skin and joint problems and help reduce the occurrence of flare ups (watch for retinopathy - have frequent eye exams)
- Corticosteroids for severe lupus (don’t want to give for long periods of time though)
- Immunosuppressive drugs like azathioprine and cyclophosphamide to help suppress the immune system and reduce organ damage
What is some good pt teaching (that isn’t obvious) 3
- Try to avoid stress
- Wear sunscreen and avoid the sun from 11-3
- Plan for pregnancy (want to be in remission for at least 6 months before becoming pregnant)
What is RA
Autoimmune disease, where there is inflammation of connective tissue in synovial joints.
How does incidence work with RA
Increases with age and peaks between 30-50
What gender is more affected by RA
Women
What causes RA:
Exact cause is unknown, most likely caused by a combination of genetics and the environment, where an individual who likely has a predisposition genetically for RA comes into contact with an antigen from a bacteria or virus, which triggers an immune response. This antigen causes the body to make abnormal IgG, where autoantibodies develop called Rheumatoid Factor. Both IgG and the Rheumatoid Factor then combine to form an immune complex and deposit into the synovial joints. This triggers WBCs to come and release things that cause inflammation and enzymes that eat this cartilage.
What happens in Stage 1 of RA 3
- Synovitis (inflammation at synovial joints)
- Increased number of WBCs in synovial fluid
- Xray (not a lot of changes - possibly see some swelling, osteoporosis, no joint destruction yet)
What happens in Stage 2 of RA 3
- Increased joint inflammation
- Gradual destruction in joint cartilage
- Narrowing joint space from loss of cartilage
What happens in Stage 3 of RA 2
- Formation of synovial pannus (inflamed joint lining, where there could be bone on bone)
- Xray may show extensive cartilage loss, erosion of joint margins and possible deformities
What happens in Stage 4 of RA 3
- Inflammatory process subsides
- But there is massive loss of joint function
- Formation of subcutaneous nodules
What are manifestations of RA a lot
Onset of symptoms is usually subtle
- Fatigue
- Anorexia/wt loss
- joint stiffness after periods of inactivity
- Spindle shaped fingers early due to hypertrophy of knuckles
- Joints are tender, painful and warm to the touch
- Joint pain increases with activity
- Nodules may develop, where basically parts of the bone are sticking out
- Sjogren’s syndrome where lacrimal glands can be damaged, which can cause dry eye
What makes RA different from osteoarthritis (a lot)
- RA can happen in the young to middle age
- Loss of weight
- Has exacerbations and remissions
- Small joints are affected first and occur symmetrically
- Stiffness lasts 1hr to all day
- Has nodules
- WBC will be elevated
What are 4 common deformities that we see with RA
A. Ulnar drift
B: boutonniere deformity
C: Hallux valgus
D: swan neck deformity
What sucks if you have higher levels of biomarkers, like RF
You are more likely to have extraarticular manifestations of RF like carpal tunnel syndrome, nodules, peripheral neuropathy, sjogren’s syndrome, etc.
What kind of lab tests will we see for RA 6
- CBC (looking at WBCs)
- ESR (tells us if there is active inflammation)
- CRP (tells us if there is active inflammation)
- Titer to look for an increase in antinuclear antibody (increase may indicate RA, because it shows that there is an autoimmune reaction going on in the body)
- Test for antibodies to Anti-citrullinated peptide (anti-CCP) which is a more specific indicator for RA and can be found 5-10 years before RA symptoms occur
- Testing for RF
What other diagnostic tests can we perform to check for RA besides lab tests 3
- Test the synovial fluid (An enzyme, MMP-3 in the fluid can be an indicator of joint damage)
- Xrays can show changes to the joint
- Bone scans will be better than xrays
For RA, what type of drug is prescribed to help slow down the disease
Disease-modifying antirheumatic drugs (DMARDs)
What is the preferred early treatment for RA
Methotrexate
What should we know about methotrexate 4
- Lower risk of toxicity than other drugs
- Rare side effects include bone marrow suppression (because we’re trying to stop the immune response) and hepatotoxicity
- Must frequently monitor CBC
- Effects should be seen in 4-6 weeks
If DMARDs aren’t working, what is another class of drugs that we can use
Biologic Response Modifiers (BRMs)
What should we know about BRMs 4
- Used for moderate to severe RA
- Used to slow the progression
- Can be used in combo with a DMARD
- Includes TNF inhibitor drugs, where TNF is inhibited to stop an immune response
What are examples of the TNF inhibitors (just look over) 5
- Etanercept
- Infliximab
- Adalimumab
- Certolizumab
- Golimumab
What should we monitor for RA patients using drug therapy 2
- Monitor for signs infection
- Monitor for signs of bleeding
Before starting RA drugs, what should we check first
Check for TB and get an xray before the start of therapy
Can you get live vaccines if you are on RA drugs
NO (because these drugs are working to suppress your immune system, which can lead you vulnerable to infection)
Which is more risky, receiving sex from an infected partner or giving sex to an infected partner
Receiving, because you’re coming into contact with their semen
What body fluids can HIV spread through 4
- Blood
- Semen
- Vaginal secretions
- Breast milk
Can HIV spread from an infected mother to her baby during pregnancy, delivery or breastfeeding?
Yes
What can help decrease the risk that a baby will contract HIV from their mother
By giving the mother antiretroviral therapy (ART)
What is the pathophys with HIV 4
- Ribonucleic acid virus
- Called a retrovirus because it replicates backwards, going from RNA to DNA
- It targets and lives inside CD4+ T cells, which is a type of lymphocyte
- This causes the number of CD4+ T cells to drop
What is the normal range of CD4+T cells, and what number can cause serious problems
Normal should be between 800-1200, anything below 200 creates severe problems
What happens when you are first infected with HIV
- You have an acute infection which occurs 2-4 weeks after infection, that might feel like the flu or mono
- You are also highly contagious with HIV
After you get over the acute infection phase of HIV, what happens in the next phase
- Asymptomatic infection, may have slight symptoms though, but for the most part you probably won’t notice anything wrong
- If HIV goes untreated, a diagnosis of AIDS is usually made 10 years after the initial infection
In which phase is an HIV infected person more contagious, the acute phase or the asymptomatic phase? What sucks about this?
Acute phase, because this is when their viral load is the highest. Sucks because the HIV test won’t show you’re positive until after your acute infection phase and health care people can think your flu like symptoms are actually from the flu and not HIV.
When does HIV start to turn to an active phase, where your body is no longer able to keep infections at bay
When the CD4 T cell count gets closer to 200
What infections might we see appear when CD4 levels get closer to 200 7
- Oropharyngeal candidiasis (thrush)
- Shingles (because you had chicken pox as a kid, your body can’t keep shingles from coming up)
- Vaginal candidal infections
- Outbreaks of oral or genital herpes
- Bacterial infections
- Kaposi sarcoma
- Oral hairy leukoplakia
What infections might we see appear when CD4 levels get closer to 200
- Oropharyngeal candidiasis (thrush)
- Shingles (because you had chicken pox as a kid, your body can’t keep shingles from coming up)
- Vaginal candidal infections
- Outbreaks of oral or genital herpes
- Bacterial infections
- Kaposi sarcoma
- Oral hairy leukoplakia
When HIV advances to a more active stage, what basic symptoms might we see 5
- Fever
- Frequent night sweats
- Chronic diarrhea
- Recurrent headaches
- Severe fatigue
When is it determined that a pt has AIDS 4
When one of the following conditions has been met:
1. CD4 T cell count drops below 200
2. Develop an opportunistic infection
3. Develop an opportunistic cancer (like Kaposi sarcoma)
4. Wasting syndrome, where they have lost 10% of body mass
What is the window period? What do we use to test?
- Can take 3 weeks to test positive for HIV (dangerous because you can be out spreading it and not even know you have it)
- Use blood or saliva to test for antibodies and/or antigens
If your viral load is “undetectable” can you still transmit the virus
Yes
If an HIV pt is in the hospital and susceptible to infection, what type of room pressure might they have
Positive pressure (we want the pressure high, so we can keep the bad stuff from getting in)
What should people use PrEP with
Other prevention techniques like condoms, clean needles, etc…
Who should receive PrEP
Adults who are at an increased risk for sexually transmitted HIV
What happens if you know you may have been exposed to HIV
You should take PEP (postexposure prophylaxis) in combination with ART, which can significantly decrease your risk for infection. You’ll take for about 28 days after contact.
When asking a pt their health history, in regards to blood transfusions and clotting factors, what date should we ask if they received one before?
Ask if they received a blood transfusion or clotting factors before 1985.
What does the CDC recommend for routine testing regarding HIV? What if you are high risk?
That everyone between the ages of 13-64 should get tested at least once during routine health care
If you’re high risk, get tested at least once a year.
What are the goals of ART 5
- Decrease viral load (can significantly decrease viral load)
- Maintain/increase CD4T cells
- Prevent HIV related symptoms and opportunistic infections
- Delay disease progression
- Prevent transmission
What is a big issue with ART
If people don’t take the right doses and at the right time, they can develop drug resistance
Will you be on ART for the rest of your life
Yes
What are common side effects of HIV tx 5
- Diarrhea
- Peripheral neuropathy
- Pain
- N/V
- Fatigue
What disorders do we see occur when pts have been on ART for a long time 8
Metabolic disorders
- Lipodystrophy (adipose redistribution)
- Hyperlipidemia (check their HDLs)
- Insulin resistance (oral glucose tolerance test)
- Hyperglycemia
- Bone disease
- Lactic acidosis
- Renal disease
- Cardiovascular disease
Basically, what is palliative care
Providing relief of their symptoms (doesn’t have to be only when they’re dying)
What are the benefits of palliative care 3
- Improve quality of life
- Decreases costs of healthcare
- Alleviates the burden of care
What are barriers to palliative care 3
- Expectations for cure (thinking there is a cure when there isn’t one)
- Hesitancy to imitate discussions about prognosis (like from the doctor, or from the pt)
- Cultural issues
What are potential barriers to care in vulnerable populations 5
- Veterans
- Homeless
- Impoverished
- Disabled
- Institutionalized
(can be hard to have 24/7 care, because hospice does not provide 24/7 care - they would have to pay for another service, difficult to get medical supplies, family might be stealing their meds)
What are the two criterias to go on hospice
- Pt must want the service
- Pt must be eligible for the service (2 drs have to agree that pt has 6 months or less to live, insurance has to agree to cover it)
When does death occur 2
- Irreversible loss of all brain functions including the brainstem
- Cerebral cortex stops functioning or is destroyed
What are musculoskeletal system symptoms at EOL 5
- Activity level will decline
- Trouble speaking
- Loss of gag reflex
- Swallowing will be difficult
- Sagging of jaw towards the very end
What is the last sense to lapse before death
Hearing
What are GI/GU symptoms at EOL 8
- Decreased desire for food/drink
- Digestive tract slows down
- Accumulation of gas
- Distention and nausea
- Loss of sphincter control
- BM may occur before imminent death or at the time of death
- Decrease in urinary output
- Incontinent of urine or unable to urinate
Vitals at EOL 5
- Loss of ability to regulate temp
- Might have increased HR first, and then lowering
- Decreased BP
- Pulse is slow and weak
- Body may not absorpb IM or SQ drugs (due to decreased circulation)
What does skin look like at EOL 5
- Mottling on hands, feet, arms and legs (looks like white spots with red around it)
- Cold, clammy skin
- Cyanosis of nails, nose and knees
- “wax like” skin
- Kennedy ulcer (caused by lack of nutrients, can just get a pressure ulcer that suddenly irrupts, just try to manage symptoms)
Respiratory EOL symptoms
- Cheyne-stokes (take a breath, then they stop, and then they breath again)
- “Death rattle” (basically secretions that are stuck in their throat - repositioning can help drain out the secretions - doesn’t bother the pt, bothers the family)
Sensory EOL symptoms
- Decreased sensation
- blurring vision
- absent blinking reflex
- pt appears to star
- eyelids remain halfopen
- decreasesd sense of taste and smell
- can have illusions/hallucinations
- near death awareness
Typical medications given for hospice pts 5
- Morphine
- Lorazepam
- Haloperidol
- Senna/bisacodyl supp
- Promethazine
How long is bereavement available to family in the hospice setting after a pt has died
13 months
What are the 5 stages of grief from kubler ross
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
(doesn’t have to be in this order)
What is the grief wheel
- Shock
- Protest
- Disorganization
- Reorganization (get life back together)
- New normal
What is anticipatory grief
Begin to grieve long before the actual death (this can be by family and/or pt)
What is adaptive grief
- Healthy process
- You accept the reality of death (working through the grief process)
- Remember the “good times”
What is dysfunctional grief (complicated grief)
Extended and intense mourning
- Recurrent and severe distressing emotions
- Intrusive thoughts about the loss
- Self-neglect (increase for illness, etc)
- Denial of the loss for greater than 6 months
Can you provide grief support before the pt has past away
Yes, especially for high risk family and pts
Can you provide grief support before the pt has passed away
Yes, especially for high risk family and pts
What is nice about spirituality at EOL
It can help decrease despair (“know they are safe with God”)
When can the organ and tissue donation decision be made
Decided by a pt before death or with family permission after death.
What is an advanced directive
What a pt wants as far a medical care if something happens (includes your POA, living will, and wishes regarding resuscitation and intubation)
When should you update your advanced directive 3
- New diagnosis
- New marriage (new POA)
- Every 10 years
Who can make decisions in Oregon (look up)
- Legal guardian
- Spouse
- Children
What is a POLST
Have in your home which is a “snapshot” of what you do and do not want done (used for emergency personnel when they come to your home)
Is it good to have family present during CPR
Yes - it can help the family decide when to stop CPR, can help them have a sense of closure, family has less PTSD if they see it
Is it legal to give a pt a med that is going to cause their death
No - the pt has to take the medication themself
Is it legal to give a pt a med that is going to cause their death
No 0 the pt has to take the medication themself
Can nurses participate in active euthanasia
No - it is against ANA, we can support the pts autonomous decision and provide resources
Is palliative sedation the same as physican assisted eath
No - palliative sedation is just relieveing their symptoms and to help with pain and suffering
What goes into the physician assisted death
- Pt must be at least 18 years old
- Pt must be able to make their own decision
- Pt must do 2 separate requests for the medication in a written request, 15 days apart, have to have 2 witnesses present
- Prescribing physician and consulting physician have to give the pt a 6 month or less diagnosis, and determine that the pt is ok to make the decision, they must also provide alternatives (like comfort care and hospice care and pain control), - - pharmacist must be informed on the use of the medication and they have the right or not to give the medication,
- no one is under requirement to participate
- Usually give Barbiturates - slow down the brain, which tells the body to stop breathing
What is the difference between POLST and advanced directive
- POLST is for home use
- Advanced directive has more information and should be brought to the hospital instead of the POLST
Are we concerned about addiction (people getting addicted to the morphine when onEOL)
No - because they are more likely to die before they become addicted
What are the main 4 fears of pts
- Pain
- SOB
- Loneliness and abandonment
- Meaninglessness
What is the double-effect principle
Giving morphine even when the pt is having decreased respirations - It’s ok to give that last dose of morphine, even though it might hasten their death, we want to make them comfortable
What is the double-effect principle
It’s ok to give that last dose of morphine, even though it might hasten their death, we want to make them comfortable
What is our gold standard for SOB
Morphine - it doesn’t cure the SOB, but it takes away the pt feeling the SOB (so they’re not scared or anxious)
What should be included in postmortem care
- Close pts eyes and jaw (if possible- can use a rolled up washcloth)
- Replace dentures
- Remove jewelry and glasses
- Wash and position the body
- Comb hair
- Remove lines if appropriate and dressings
- Leave pillow under head so blood doesn’t pool in the head
- Place incontinence pad to absorb any urine or bowel
(family may want to do some of these)
