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Epidemiology
Affects every age group - Most > 65 yo > in men than women > industrialized sectors & nations. > 1.5 million Americans diagnosed each year > 560,000 die annually of malignant process Men - Lung, prostate, colorectal Women - Lung, breast, colorectal 5 year survival rate
NEOPLASIA
Any new or continued cell growth not needed for normal development or for replacement of dead and damaged tissues Neoplasia is always abnormal The new cells could be benign or malignant Neoplastic cells develop from normal cells
Pathophysiology
Hypertrophy is cell growth that causes tissue to increase in size by enlarging each cell Hyperplasia is growth that causes tissue to increase in size by increasing the number of cells Neoplasia is any new or continued cell growth not needed for normal development or replacement of dead and damaged tissues
Key Concepts
Primary prevention of cancer involves avoiding exposure to know causes of cancer Secondary prevention of cancer involves screening for early detection Tobacco use is a causative or permissive factor in 30% of all malignant neoplasms Tumors that metastasize from the primary site into another organ are still designated as tumors of the originating tissue
Cell Characteristics
Normal Cell No rapid division Contact inhibited Adhere tightly together Do not break loose or migrate Differentiated and have specific function Malignant Cell Rapid growth Do not recognize or respect tissue borders Break off and migrate Lose differentiation Reproduction out of control
Metastasis
Metastasis occurs through a progression of steps: Extension into surrounding tissue Blood vessel penetration Release of tumor cells Invasion Local seeding Bloodborne metastasis Lymphatic spread
Cancer Classification
Cancer grading and staging help standardize diagnosis, treatment, and prognosis Grading on the basis of cell appearance and activity compares the cancer cell with its normal parent tissue
Staging classifies clinical aspects of the cancer and determines exact location and degree of metastasis at diagnosis
Cancer Development
Carcinogenesis takes years and depends on several tumor and client factors. Three interacting factors influence cancer development: Chemical carcinogenesis Dietary factors Personal factors
Cancer Development
Viral Carcinogenesis Only a few viruses are proven to be carcinogenic, there are many more that are suspected to play major roles in cancer development When viruses infect body cells, they break the DNA chain and insert their own genetic material into the DNA chain
Cancer Prevention
Avoidance of known of potential carcinogens
Modification of associated factors
Diagnosis
Diagnosis of cancer requires a tissue biopsy
Types: Needle, incisional & excisional
Tumor Staging
TNM system of the American Joint Committee on Cancer is preferred for solid tumors T = The extent of the tumor Characteristics of a given tumor N = The extent of spread to the lymph nodes Presence or absence of involved nodes M = Presence or absence of metastases
Tumor Markers
Biochemical indicators of neoplastic activity found in the blood Alpha-fetoprotein (AFP) Carcinoembryonic antigen (CEA) Colon, rectum, pancreas, stomach, lung, breast & ovary CA 125 Epithelial ovarian neoplasms, breast, colorectal CA 19-9 Colorectal, pancreas, stomach, liver Human chorionic gonadotropin (HCG) testicular teratoma Prostate-specific antigen (PSA) Adenocarcinoma of prostate
Teratoma
Principles Of Therapy
Major treatment modalities Surgery Radiation therapy Chemotherapy Hormonal therapy
Palliative Tx
Given when the disease is not curable Survival time is limited To alleviate symptoms Improve quality of life
Adjuvant Therapy
The use of a therapy, usually chemotherapy, along with another treatment modality Adjuvant therapy is given with curative intent
Chemotherapy is classified according to the pharmacologic action of effect on cellular reproduction Cell-cycle specific Cell-cycle nonspecific drugs See Table Antineoplastic Agents
Treatment Issues
Drug dosagecalculated according to the type of cancer and the clients size Drug scheduleregular basis and are timed to maximize cancer cell kill and minimize damage to normal cells. The entire planned schedule is the course of chemotherapy Drug administrationmostly IV due to rapid effects and agents are irritating and damaging to tissues
Radiation Therapy
Goal is to destroy tumor cells while sparing normal cells
Radiation is delivered from a distance by a machine OR close to the patient via an implanted or injected radioactive source (Brachytherapy Internal Radiation)
Nursing Care
Pain management Pain may result from a variety of stimuli Careful assessment is critical in order to identify the physical causes and psychosocial factors that modulate pain intensity & its perception
Cancer Pain
Bone Metastasis Nerve compression Lymphatic or venous obstruction Ischemia Organ obstruction Skin inflammation, ulceration, infection, necrosis
Nutritional Support
Protein-calorie malnutrition Occurs when this macronutrient intake cannot meet the bodys metabolic needs From 40 80 % of all cancer patients experience some degree of malnutrition
Nursing Care
Decreasing fatigue Improving body image & self-esteem Grieving Potential complications
Infection Septic shock Bleeding & hemorrhage
CYBER KNIFE
A form of radiation therapy Non invasive alternate to surgery Delivers high dose radiation Uses a Robotic radiosurgery system No simulation necessary prior to treatment Method of painting the tumor Shorter treatment time Minimal side effects
Hormonal Manipulation
Some hormones make hormone-sensitive tumors grow more rapidly Some tumors require specific hormones to divide, therefore decreasing the amount to these hormones to hormone-sensitive tumors can slow the cancer growth rate and increase survival time
Gene Therapy
Experimental as a cancer treatment Renders tumor cells more susceptible to damage or death by other treatments Injection into tumor cells, enabling the immune system to better recognize cancer cells as foreign and kill them Targeted therapycombine biologic therapy and gene therapy Side effect allergic reaction
Palliative Care
Terminology Palliative care Broad concept of care that focuses on the comfort of the patient Hospice care Dying is a normal process and should not be hastened or postponed End-of-life care
Role of Nurses
Nursing role Establish trust Work with interdisciplinary team Focus on quality of life, control symptoms Be available, nonjudgmental, and nonthreatening Listen, advocate, empower Support the caregivers
Types of Loss
Concrete or tangible Death Removal of a body part Changes in physical health Divorce or separation Property loss Relocation or job layoff
Types of Loss
Psychological, symbolic or intangible Ones prestige, power, dreams, plans, ambition, confidence, security & pride
Grieving Process
A number of authors have described stages or phases of grieving Grieving is manifested in thoughts, feelings, and behaviors There is no one timetable by which a person progresses through the grief process
continuum
Higher levels of education Living in a smaller/supportive community
Legal-Ethical Responsibilities
Euthanasia - implies that under some circumstances death is preferable to life Passive - Removing support or withholding Rx Active - An act of commission
Living will
Advance Directives
documentation.
Required by law when: Person dies with 24 hours of admission to hospital Suicide Homicide Unknown cause Suspected child abuse Criminal activity
Specific Cancers
Bone Cancer
Malignant bone tumors may be primary or secondary Primary tumors of the prostate, kidney, thyroid and lung often metastasize to the bone Metastatic tumors greatly outnumber primary malignant bone tumors
Bone Cancer
Osteosarcoma or osteogenic sarcoma
Ewings Sarcoma
Bone Cancer
Chondrosarcoma typically affects the pelvis and proximal femur Fibrosarcoma an uncommon; slow growing tumor that can metastasize to the lungs
Breast Cancer
Leading cause of death in women in the US Considered non-invasive when it remains within the duct Classified as invasive when it penetrates the tissue surrounding the duct and grows in an irregular pattern
Breast Cancer
Heredity or genetically related susceptibility Hormone regulation
Sex hormones may act as tumor promoters
Hormone replacement therapy
Increasing age increases risk Most women who develop breast cancer have none of the identifiable risk factors
Breast Cancer
Medullary carcinoma Colloid carcinoma Inflammatory carcinoma Common site of metastatic disease are bone, lungs, brain, and liver
Breast Cancer
Risk factors for breast cancer include Age Nulliparity Early menarche Late menopause Family history of breast cancer Exposure to ionizing radiation History of benign breast disease First birth after age 30 A high alcohol and fat intake may increase the risk for breast cancer
Cervical Cancer
A reproductive cancer can be preinvasive or invasive Preinvasive cancer Invasive cancer Metastasis is usually confined to the pelvis Risk factors Low socioeconomic status Early age at first sexual contact or first pregnancy Multiple sex partners Intrauterine exposure to DES (diethylstilbestrol) PAP test for screening
Colorectal Cancer
Cancer of the colon develops as a multistep process Tumors occur in all areas of the colon Tumors spread by direct invasion Risk factors Genetic predisposition Personal risk factors such as age and presence of adenomatous polyps Dietary factors related to high intake of foods such as red meat and animal fat, refined carbohydrates, or fried or broiled red meats and fish Black individuals have an increase incidence
Liver Cancer
Primary hepatic carcinoma is rare in the US Usually develops as a metastatic process from primary cancer site Symptoms Epigastric or RUQ abdominal pain Fatigue Anorexia Jaundice Ascites Bleeding Detected by nuclear radioisotope liver scan, needle biopsy confirms
Lung Cancer
Metastasize by direct extension through the blood and invading lymph glands and vessels 4 major types of lung cancer Small cell lung cancer (SCLC) Epidermiod (squamous cell) Adenocarcinoma Large cell carcinoma The last 3 types are referred to as non-small cell lung cancers (NSCLCs) because of their similar response to treatment Lung cancers occur as a result of repeated exposure to inhaled substances that cause chronic tissue irritation or inflammation
Ovarian Cancer
Leading cause of death from female reproductive organ malignancies The most common is the serous adenocarcinoma Grows rapidly, spreads quickly, and are often bilateraly, with the worst prognosis of all epithelial tumors
Spreads by 1. Peritoneal seeding 2. Direct spread to other organs in the pelvis 3. Distal spread through the lymphatic drainage
Pancreatic Cancer
Highly malignant Primary tumors are generally adenocarcinomas Grow rapidly and spread to surrounding organs (stomach, duodenum, gallbladder, and intestine) May result from metastasis
Renal Cancer
Referred to as adenocarcinoma of the kidney Systemic effects include anemia, erythrocytosis, hypercalcemia, liver dysfunction with elevated liver enzymes, increased sedimentation rate, hypertension, and other hormonal effects Metastasis through the bone or lymph to the liver, lungs, and long bones
Skin Cancer
Overexposure to sunlight is the major cause of skin cancer The most common skin cancers include; Actinic or solar keratoses common in chronic sun damaged skin and may progress to squamous cell carcinoma Squamous cell carcinoma Predisposed by sun exposure and chronic epithelial damage form repeated injury or irritation
Skin Cancer
Basal cell carcinomas Arising primarily form ultraviolet light, radiation exposure, genetic predisposition, and chronic irritation
Melanomas Risk factors include genetic predisposition and precursor lesions, which resemble unusual moles
Stomach Cancer
Malignant neoplasms found in the stomach Adenocarcinomas are the most common type, followed by lymphomas and sarcomas In advanced disease, invasion extends to the stomach muscle or beyond
Thyroid Cancer
There are 4 types of thyroid cancers Papillary carcinoma A slow growing tumor Good prognosis if localized Follicular carcinoma Primarily affects older clients Invades blood vessels and metastasizes Can adhere to the trachea, neck muscles, great vessels, and skin resulting in dysphagia and dyspnea Fair prognosis if metastasis is minimal
Thyroid Cancer
Medullary carcinoma Primarily affects clients over 50 years of age Involves metastasis that occurs via regional lymph nodes and invades surrounding structures Anaplastic carcinoma A rapidly growing, extremely aggressive tumor Directly invades adjacent structures, causing stridor, hoarseness, and dysphagia Poor prognosis
Pediatric cancers
Neuroblastoma
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Solid tumor found only in infants and children Most common tumor in children located outside the cranium Embryonal tumor arising from neural crest cells Boys > girls, white > incidence Peak age 22 mos Approx. 80% present with metastasis
Neuroblastoma
About 50% of neuroblastomas develop in the adrenal gland. Symptoms also result from the tumor spreading to different parts of the body. Neuroblastoma may spread to bone, bone marrow, liver, skin and lymph nodes.
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Neuroblastoma
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Prognosis is based on childs age and staging of the tumor Process of classifying tumors w/respect to: Degree of differentiation Potential for responding to treatment Patient prognosis Children < 1 yr have a better prognosis
Neuroblastoma
Etiology and pathophysiology Cause is unknown
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Although environmental factors Prenatal drug exposure, is implicated Tumor is often silent leading to late diagnosis and poor prognosis
Neuroblastoma - Diagnosis
CT Bone marrow aspiration Urine testing
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Neuroblastoma - Treatment
Depends on staging
Surgery is used for tumor removal following biopsy Radiation therapy
In more advanced cases
And may be palliative w/metastasis
Chemotherapy
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Neuroblastoma - Prognosis
Age at diagnosis important indicator < 1 year better Stage I/II 80% - 90% Disseminated disease & > 1 yr 10% - 30%
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Usually asymptomatic Most frequent admitting symptom is an abdominal mass; parent often finds the mass, which is located to one side of the midline of the abdomen Pain and hematuria may be present HTN is present approx. 25%, because of > renin production
Wilms Tumor
Nephroblasoma
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Encapsulated tumor of kidney Unilateral or bilateral Originates from renal parenchyma and extends into surrounding tissues Grow rapidly Peak incidence 3 to 4 years Prognosis depends on stage at time of dx Metastasis to lungs and liver Often assoc. with congenital anomalies
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Osteosarcoma
Most common bone cancer in children Peak incidence between 10-25 yrs of age Associated w/rapid growth spurt of adolescence Most frequently affects the distal portion of femur; also the humerus, tibia, jaw and phalanges Localized pain in affected site Often relived by flexing the extremity Progressive, insidious or intermittent pain at tumor site Limping, limited ROM, palpable mass, eventually pathological fracture Frequently metastasizes to the lungs
Osteosarcoma
Diagnosis Ct or MRI to detect areas of metastasis X-rays following traumatic injury may be first indication of disease
Femur has a large mass involving the metaphysis of bone. Tumor has destroyed the cortex.
Therapeutic Management
Goals Remove tumor and prevent spread of disease Treatment may include radical resection and amputation Depending on location and/or surgeon may try limb-salvaging procedures w/prosthetic replacement Chemotherapy before and after surgery Thoracotomy if metastasis to the lung Cure rate 75% without metastasis
Nursing Care
Comfort, pain management Phantom limb pain if amputation Utilize straightforward approach when amputation is indicated Allow for verbal expression for feelings Emotional support pre and post-operative important Body image concerns Especially in teens Encourage early interaction with peers