Week Six Flashcards
What are risk factors for breast cancer?
- Gender
- Increasing age = >50 years
- Exposure to chest radiation at a young age
- Smoking
- Personal or family history of breast cancer
- History of benign breast disease
- Hormonal influences that promote breast maturation (HRT)
What should you watch out for breast cancer?
- A lump or mammographic abnormality in the breast, most often in the upper, outer quadrant of the breast
- If palpable, usually hard and may be irregularly shaped, poorly delineated, non-mobile and non-tender
- Presence of mastalgia
- Nipple changes or discharge
- Inflammatory breast cancer may make the breast look red, warm and gives it a thickened appearance
- Breast develops ridges and small bumps that look like hives
- Strong family history of breast Ca
What are indications for a referral for breast cancer?
- Distinct breast mass
- Persisting asymmetrical breast nodularity
- Nipple discharge, particularly if over 50 years old
- Severe mastalgia (becoming increasing noted as an independent risk factor)
- Nipple changes
- Strong family history of breast or ovarian cancer
What occurs after a breast cancer referral?
- Clinical assessment (medical history, risk factors and physical examination)
- Radiology (ultrasound +/- mammography)
- Pathology (fine needle aspiration cytology (FNA); core biopsy or open surgical biopsy are sometimes required)
What are the grades for tumour?
- Grade 1: Well differentiated
- Grade 2: Moderately differentiated
- Grade 3: Poorly to very poorly differentiated
- Grade 4: Very poorly differentiated
What is nursing management for the peri-diagnosis phase?
Assess the client concerning:
- Coping with her need for the procedure
- Ability to process information about the procedure
- The possible implications of the results
- Anxiety and fear level
- Psychosocial support
- Knowledge about the diagnosis and treatment options
- Fear of any adverse effects of treatment
What are nursing diagnoses for breast cancer?
- Risk for ineffective coping r/t ….
- Anxiety r/t…
- Fear r/t …
- Deficient knowledge about: e.g. procedure/diagnosis of breast conditions/treatment options
- Acute pain r/t…
- Impaired skin integrity r/t…
- Risk for infection r/t….
- Risk for impaired adjustment r/t…
- Deficient knowledge about pain management, exercises, complications, etc
What is treatment for breast cancer?
- Surgery
- Chemotherapy
- Radiation therapy
- Hormonal therapy (Tamoxifen)
- Herceptin
- Antiglycolytic therapy
What is the first option treatment for breast cancer?
Surgery:
- Total mastectomy and axillary clearance
- Partial mastectomy, axillary clearance and radiotherapy (breast conservation treatment)
- Sentinel node biopsy helps decide if axillary dissection may be avoided
What consists of breast reconstruction following a mastectomy?
- Transverse rectus abdominis myocutaneous flap (TRAM flap)
- Latissimus dorsi flap
- Expandable prosthesis
- Breast prosthesis
What is nursing care following breast surgery?
- Pain management
- Wound care (flap care, infection)
- Lymphoedema
- Impaired body image
- Risk for developing post-operative complications
What is adjuvant therapy?
- Radiotherapy (DCIS after excision)
- Hormone/Endocrine Therapy:
1. Aromatase inhibitor
2. Tamoxifen
What does an aromatase inhibitor do?
Stop the male hormone to turn into oestrogen
What does Tamoxifen do?
Block estrogen, hormone therapy
What are types of chemotherapy?
- Systemic therapy
- Monoclonal antibodies/Immune Therapy
What is an example of systemic therapy?
- Taxane: Paclitaxel (Taxol);
- Docetaxel (Taxotere)
What is an example of Monoclonal antibodies / Immune Therapy?
Trastuzumab: Herceptin – binding to HER2 protein
What is nursing management for the peri-treatment phase?
Nursing assessment: - History taking - Physical discomfort - Self-care ability - Psychosocial aspects - Supportive care Nursing diagnoses: - Physiological concerns as a result of treatment - Psychosocial and emotional needs - Functional impairment
What can go wrong with the prostate?
- Non cancerous enlargement (BPH)
- An inflammation or Infection (Prostatitis)
- Prostate Cancer
What are symptoms of prostate problems?
- Needing to urinate more often, especially at night
- Needing to rush to the toilet
- Difficulty starting to pass urine
- Straining or taking a long time to finish passing urine
- A weaker flow
- A feeling that the bladder has not emptied properly
- Dribbling urine
- Pain when passing urine or with ejaculation
- Blood in semen (rare)
Why are symptoms a poor indicator of cancer?
80% of cancers are found in the peripheral zone, away from the urethra
What are predisposing factors for prostate cancer?
- Age
- Family history
- Ethnicity
What are benefits of prostate cancer testing?
- Men can be reassured prostate cancer is unlikely to be present if PSA and DRE normal
- If testing indicates that cancer is present it is likely to be early stage, meaning chance of cure is greater
- If a man is found to have localised, low risk prostate cancer he has the option of entering an active surveillance programme
What are risks of prostate cancer testing?
- PSA and DRE testing can produce false positives due to calcifications on the prostate, prostatitis, UTI, BPH, recent ejaculation and cycling
- PSA testing can also produce false negatives when the prostate cancer releases no or low PSA
What are risks of prostate biopsy?
- False negatives
- Infection / sepsis
- Transient haematuria
- Transient haematospermia
What does an abnormal PSA test indicate?
Does not confirm prostate cancer, it merely means further diagnostic testing is required
What are risks of curative treatments for prostate cancer?
- All curative treatments have a risk of ED
- Prostatectomy also carries risk of incontinence
- External Beam Radiotherapy carries risk of rectal bleeding, LUTS and radiation induced second malignancy (1-3%)
- The incidence and degree of these treatment side effects are affected by co-morbidities including diabetes, obesity, respiratory problems and cardiovascular disease
What is screening for prostate cancer?
- Digital Rectal Examination (DRE)
- PSA Blood Test
What is Digital Rectal Examination (DRE)?
- Sensitivity ~ 60%; i.e. negative DRE does not exclude cancer, positive DRE does not confirm cancer
- Abnormal DRE requires referral to urology (nodule/ asymmetry) regardless of PSA
What is PSA blood test?
PSA is:
- Produced only by epithelial cells in the prostate gland
- Appears to have a role in liquifying semen
- An imperfect screening test
Why is PSA an imperfect screening test?
- Significant biological ‘daily’ variation
- Other causes of transient elevation (prostatitis, UTI, IDC, infarct, BPH, ejaculation)
What is the criteria for PSA results needing investigation?
- Men aged below 70 years with a score greater than 4.0
- Men aged 71-75 years with a score greater than 10.0
- Men aged greater than 76 years with a score greater than 20.0
How to get a diagnosis for prostate cancer?
Tissue from Biopsy or TURP tissue
What is the nurses role during the biopsy process?
- Communication (aim to put at ease)
- Education (what to expect during and after procedure)
- Assessment (pt. risk factors, audit)
- Referrals (e.g. Infectious Diseases, cardiology opinion)
What is Gleason scoring for prostate cancer?
Calculated by Score (/10) = most common pattern (/5) + highest grade of cancer(/5):
- Gleason Grade 3 - cells lose defined borders and clump together
- Gleason Grade 4 - loss of normal cell structure,
pronounced clumping
- Gleason Grade 5 - most normal cell
characteristics have gone
What is ISUP grading?
- Epstein grade 1 is similar to any Gleason score of 6 or less
- Epstein grade 2 is similar to a Gleason score of 3 + 4 = 7
- Epstein grade 3 is similar to a Gleason score of 4 + 3 = 7
- Epstein grade 4 is similar to a Gleason score of 4 + 4 = 8
- Epstein grade 5 is similar to a Gleason score of 9 or 10
What are stages of prostate cancer?
- Localised - (T1 and T2) organ confined
- Locally advanced- (T3 and T4) without evidence of distant metastases – may include positive lymph nodes
What are treatment paths of prostate cancer?
- Active Surveillance
- Surgery (Radical Prostatectomy)
- External Beam Radiotherapy
- Brachytherapy
- Watchful waiting
What are factors that influence decisions around treatments for prostate cancer?
- Risk of progression
- Cancer control
- Salvage therapy options
- Side effects of treatments
What guides treatment decisions around prostate cancer?
- Stage
- Gleason grade
- PSA
- Number of positive cores
- % of cores that contain cancer
- Imaging results - CT, Bone scan, ? PSMA scan
Also: - Life expectancy
- Abdominal girth
- Urinary Symptoms/Bowel Habit
- Health Insurance (bank balance)
- Personality/travel/previous experiences
What is active surveillance for prostate cancer?
- Deferred treatment with the expectation to intervene if cancer shows signs of progressing
- PSA <10, Gleason 6, T1- T2a
- Involves regular PSA /DRE/ re-biopsy every 18 months or so
- Move towards using MRI scans in combination with repeat biopsies
- 14-42% of men go on to have treatment due to cancer progression or anxiety
What is the nursing role in active surveillance?
- Communication
- Assessment
- Education
- Referrals
What is a radical prostatectomy?
- Removal of entire prostate and some surrounding tissue including seminal vesicles
- Enables immediate assessment of histology
- Can combine with post operative radiotherapy
- Provides relief of outflow obstruction
- Risk of acute and long term or late side effects
- Results in an unrecordable PSA (> 0.05ug/l)
What is external beam radiotherapy?
- None of the risks of surgery. Can be given when you are unsuitable or unfit for surgery
- 6-7 weeks of treatment; can carry on with many of usual activities
- Often combined with hormone therapy
- Risk of acute and long term or late side effects, including bowel problems
- Results in low PSA but not unrecordable
What are long-term complications of a radical prostatectomy and external beam radiotherapy?
For both treatments: - Erectile dysfunction - Incontinence - Infertility For Radiotherapy: - Bowel and bladder changes
What occurs with erectile dysfunction?
- Cancer predominant in patients mind
- Nerve sparing procedure at time of RRP- 50-60% potency rates
- Outcome age dependent (90% <50 years; 25 % > 70 years)
- Once cancer cure, erectile enquiries occur
- Radiotherapy – 40% of men will get ED, can take two years to occur
- Loss of ejaculation, fertility
- Major quality of life issue
What is the nursing role in erectile dysfunction?
Communication Assessment Referrals Education: - Share our knowledge of ED journey from literature and practice - Treatments available and/or funded - Self administration of intracavernosal injections - Optimal use of PDE5 inhibitors - Management of treatment side effects
What occurs with incontinence?
- Stress incontinence < 10%
- Total incontinence < 1%
- Can be a combination of stress and urge
- Will improve with time and at 3 months most patients are better
- Bladder neck stenosis either early or late with RRP
What is the nursing role in incontinence?
Communication Assessment: - Symptom history (urgency vs. stress) - Bladder diary - Pad weights Referrals – physio, continence CNS Education: - Product purchase and use - Pelvic floor exercises
What is brachytherapy?
- Radioactive seed implants into prostate tissue
- Private sector treatment
- Costs approx $25,000
When is brachytherapy used?
- PSA 10 or less
- Gleason 6 (sometimes 3+4)
- Stage T1 to T2a
- Not suited to big prostates, men with obstructive urinary symptoms
What are advantages of brachytherapy?
Less damage to surrounding areas from radiation therefore less urinary, bowel and erectile side effects, but can still occur
What is watchful waiting for prostate cancer?
- Monitoring of prostate cancer that is generally suitable for men who may not benefit from treatments such as surgery or radiotherapy
- This may include men who have other serious health problems who maybe less able to cope with treatment
What is treatment for metastatic disease?
Hormone therapy: also called Androgen Deprivation Therapy (ADT) is the first line treatment
What is Androgen Deprivation Therapy (ADT)?
- ADT has been a mainstay of treatment against high grade, locally invasive and metastatic prostate cancer
- It delays cancer progression, prevents complications and palliates symptoms
What are the two major classes of pharmacological hormonal therapy for prostate cancer?
- LHRH agonists
- Anti-androgens
What do pharmacological hormonal therapy for prostate cancer do?
Work to block the effect of testosterone on prostate cancer cells, but differ in their mechanism of action
What are examples of LHRH agonists?
- Goserelin Acetate (Zoladex)
- Leuprorelin (Lucrin and Eligard)
What are examples of Anti-androgens?
- Cyproterone acetate
- Flutamide, Bicalutamide
What do LHRH agonists do?
- Initially LHRH agonists stimulate LH production, which in turn causes a surge of testosterone and DHT for 5 to 12 days before inhibition of LH. This surge of male hormones can cause a flare reaction
- The goal of LHRH therapy is to achieve castrate levels of testosterone (ideally 0.7nmol/l)
What is castrate resistant prostate cancer (CRPC)?
- CRPC is a nearly universal outcome after a period of ADT
- CRPC is when prostate cancer growth is reactivated despite low castrate levels of testosterone
What is second line treatment and further treatment options for prostate cancer?
- More hormone therapy like bicalutamide
- Steroids- prednisone, dexamethasone
- Chemotherapy – Docetaxel
- Abiraterone- funded (special criteria)
- Enzalutamide/ Apalutamide- not yet funded
- Zoledronic Acid- funded (special criteria)
- Ketoconazole
- Denosumab - not funded
- Clinical Trials
What are possible complications after a lumpectomy?
- Moist desquamation
- Haematoma
- Seroma
- Infection
- Fibrosis
- Lymphoedema
- Myositis
- Pneumonitis
- Rib fractures
What position should a patient be placed in post lumpectomy?
Semi-Fowler position with the arm on the affected side elevated on a pillow
When should exercised begin post lumpectomy?
- Flexing and extending the fingers should begin in the recovery room with progressive increases in activity encouraged
- Postoperative arm and shoulder exercises are instituted gradually at the surgeon’s direction
An increase in the number of new cells in an organ or tissue that is reversible when the stimulus for production of new cells is removed is termed
a. hypertrophy
b. hyperplasia
c. neoplasia
d. atrophy
b. hyperplasia
An adult client is receiving radiotherapy. The nurse is teaching the client about signs of radiation-induced thrombocytopenia, which include
a. fatigue
b. shortness of breath
c. elevated temperature
d. a tendency to bruise easily
d. a tendency to bruise easily
During which step of cellular carcinogenesis do cellular changes exhibit increased malignant behaviour?
a. promotion
b. initiation
c. prolongation
d. progression
d. progression
An adult is receiving cancer chemotherapy and demonstrates alteration in her oral mucous membranes. Which of the following should be included in her plan of care?
a. Bland, mechanical, soft diet until mucous membranes have healed.
b. Brushing teeth and flossing after every meal and at bedtime.
c. Using normal saline mouth rinses every 2 hours while awake.
d. No use of dentures until mucous membranes have healed.
a. Bland, mechanical, soft diet until mucous membranes have healed
Which of the following terms refers to cells that lack normal cellular characteristics and differ in shape and organisation with respect to their cells of origin?
a. hyperplasia
b. dysplasia
c. anaplasia
d. neoplasia
c. anaplasia
A woman is receiving internal radiation therapy for cancer of the cervix. Which statement indicates to the nurse that the client understands precautions necessary during her treatment?
a. “I should get out of bed and walk around in my room at least every other hour.”
b. “I’ll try not to cough, because the force might make me expel the applicator.”
c. “My seven-year-old twins should not come to visit me while I’m receiving treatment.”
d. “I know that my primary nurse has to wear rubber gloves when emptying the bedpan.”
c. “My seven-year-old twins should not come to visit me while I’m receiving treatment.”
A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: T1 N0 M0. What does this classification mean?
a. no evidence of primary tumour, no abnormal regional lymph nodes and no evidence of distant metastasis
b. carcinoma in situ, no abnormal regional lymph nodes, no evidence of distant metastasis
c. can’t assess tumour or regional lymph nodes and no evidence of metastasis
d. carcinoma in situ, no demonstrable metastasis of the regional lymph nodes and ascending degrees of distant metastasis
b. carcinoma in situ, no abnormal regional lymph nodes, no evidence of distant metastasis
A client in the final stages of terminal cancer tells his nurse: “I wish I could just be allowed to die. I’m tired of fighting this illness. I have lived a good life. I only continue my chemotherapy and radiation treatment because my family wants me to.” What is the nurse’s best response?
a. “Would you like to talk to a psychologist about your thoughts and feelings?”
b. “Would you like to talk to your minister about the significance of death?”
c. “Would you like to meet with your family and your physician about this about this matter?”
d. “I know you are tired of fighting this illness, but death will come in due time.”
c. “Would you like to meet with your family and your physician about this about this matter?”
A woman loses most of her hair as a result of cancer chemotherapy. The nurse understands that which of the following is TRUE about chemotherapy-induced alopecia?
a. The hair loss is temporary.
b. New hair will be grey.
c. Avoid the use of wigs.
d. Pre-chemo hair texture will return.
a. The hair loss is temporary.
The nurse is caring for a client who is receiving radiotherapy. Which activity by the client indicates he does NOT understand the side effects of radiotherapy?
a. Using electric razor.
b. Taking his children to see Santa at the mall.
c. Eating a high protein diet.
d. Calling the doctor for a temperature of 38.3 ¬o C
b. Taking his children to see Santa at the mall.
What is the prostate and where is it located?
A gland surrounding the neck of the bladder in males that releases a fluid component of semen
What is the epidemiology of prostate cancer in New Zealand?
- Mostly develops in men over the age of 65
- Higher risk if there is a family history
What are some of the signs and symptoms of prostate cancer?
- Can have no symptoms
- Painful or burning sensation during urination or ejaculation
- Frequent urination, particularly at night
- Difficulty stopping or starting urination
- Sudden erectile dysfunction
- Blood in urine or semen
Prostatitis and Benign Prostatic Hypertrophy/Hyperplasia are two terms that are often confused and used interchangeably by people. Differentiate between the two?
- Prostatitis is swelling and inflammation of the prostate gland and is usually reversible
- Benign prostatic hyperplasia is the enlargement of the prostate gland and is non-cancerous and non-reversible
Are all prostate cancers operated on or treated? Why?
No, some are inoperable and have spread, some the risks out weigh the benefits.
How is prostate cancer described with reference to its stages?
- Tumour (indicates the size or involvement of a malignant tumour)
- Node (indicates whether lymph nodes have cancer cells in them)
- Metastasis (indicates whether cancer has spread to other parts of the body)
What is the 1234 or ABCD system of scoring prostate cancer?
- Stage A/1: tumour is confined to the prostate gland only and cannot be felt during a prostate examination via the rectum. If found at all, it is usually found by chance during treatment for BPH, prostatitis, or some other prostate problem
- Stage B/2: tumour is located within the prostate only but can be felt during a prostate examination via the rectum. The man may or may not have symptoms. Blood levels of PSA are usually increased
- Stage C/3: tumour has spread from the prostate to other nearby tissues The seminal vesicles, the glands that produce semen, may have cancer in them. Difficulty in passing urine is a common symptom
- Stage D/4: tumour has spread to other parts of the body, most often the lymph nodes, bones, liver or lungs. Difficulty in passing urine, bone pain, weight loss and tiredness are common symptoms
