Oncology

Dead Mans party

Biology of abnormal cells Cancer grading and stages Cancer statistics Chemotherapeutic agents Radiation treatments Bone Marrow and Stem Cell transplants Onco-gene therapy

Oncology Objectives
1. Identify the different phases of cancer cell replication. 2. Compare the features of a benign versus malignant tumor 3. Recognize the TNM stage and grading system of cancer tumors. 4. Discuss the role of oncogenes and suppressor genes in cancer development. 5. Identify behaviors with corresponding primary and secondary nursing prevention for risks of cancer development 6. Recognize the different classes of chemotherapies. 7. Create appropriate nursing interventions for a case study of a patient with cancer.

Oncology Objectives
8. Identify appropriate testing for cancer patients. 9. Recognize signs and symptoms of chemotherapy side effects. 10. Recognize signs and symptoms of radiation therapy. 11. Prioritize nursing interventions for a patient with neutropenia. 12. Prioritize nursing interventions for a patient with thrombocytopenia. 13. Prioritize nursing interventions for a patient receiving bone marrow or stem cell transplant.

Oncology Objectives
14. List 4 risk factors for the development of leukemia. 15.Compare Leukemia and Lymphoma pathophysiology, etiology and clinical manifestations.

Cellular Review
Evolve 3D Cellular Differentiation on web site

Oncology
Biology of abnormal cancer cells They have continuous or inappropriate, usually faster growth or larger growth patterns They have no specific morphology and often do not resemble their parent cells = anaplastic They do not respond to signals for apoptosis = programmed cell death

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Biology of abnormal cancer cells Have a large nuclear cytoplasmic ratio; the nucleus may occupy most of the cell area They lose some or all of their normal cell functions They do not make fibronectin, and thus cannot connect easily and break off easily

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Biology of abnormal cancer cells They are able to migrate throughout the body = metastasis They invade other tissues and types of cells. They are not controlled by contact They have more or less chromosomes than the parent cells = aneuploid or a mutation of the genes

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Cancer development Initiation there are many theories as to when the genes in the cells are damaged, maybe in utero, from physical or chemical exposure, latent oncogenes, viruses, or a lack of suppressor genes from our parents, and at this point the cell is not dividing.

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Skin cells

 Cancer development Promotion - the stage when the abnormal cell starts to divide, may be stimulated by environmental changes, hormones, drugs, or irritants

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Cancer development Progression the phase when the abnormal cells have continued to grow into a Primary tumor, may produce angiogenesis factors which supply blood and vascular nourishment to the tumor. The tumor may have subcolonies of cells with different genes and features

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Cancer development Metastasis the movement of cancer cells into other organs of the body, thus creating new tumor sites.

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Cancer grading and staging Cancer is graded upon the resemblance to normal cells = G
(The higher the number, the worse the grade of cancer) i.e. G1, G2, G3, G4

Staging is based upon the presence of a primary tumor = T involvement in lymph nodes = N and appearance of metastasis = M Numbers of the stage range from x = none to 3 or 4 for each letter

Oncology
Is this a high grade or low grade cancer? Case study Julie has a breast lump in her right breast, and has also found one in her right armpit. Biopsy and lumpectomy were performed. The tumor was graded G3, T2, N2, M1.

1. High 2. Low

Is this a high grade or low grade cancer?

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Julie opted to have a lymphectomy of her right arm lymph nodes, and started radiation treatment right away. Her doctor also suggested that she start Adriamycin IV chemotherapy to get any cells that the radiation might miss.

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Cancer Risks #1 = advancing age #2 = smoking tobacco Hormones Prempro caused a substantial increase in breast cancer on the HERS trial Genetic inheritance of oncogenes and autoimmune diseases Environmental exposure Excessive intake of dietary fats

Oncology
Cancer risks High alcohol consumption Low dietary vegetables and fiber (sources of antioxidants) Previous Viral infections: Hepatitis B or C Herpes viruses Papilloma viruses (HPV) Retrovirus HTLV I

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Types of cancer cells are named for their site of origin: Adenocarcinoma Carcinoma in situ (CIS) Squamous Basal cell Astrocytomas Melanomas Sarcomas Lymphomas

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Symptoms of Cancer Cachexia weight loss,unexplained Anorexia Anemia Impaired immune response Pain when the cancer is large enough to compress nerves or organs Lymphadema when the tumor blocks lymph or circulatory flow Motor or sensory deficits

Oncology
The 60 year old client with small cell lung cancer is concerned that his grown children also might develop the disease. What is the nurses best response? A. This disease is a random event and there is no way to prevent it. B. Because this disease is inherited as a dominant trait, your children have a 50% risk for developing it. C. Cigarette smoking is the main cause of this disease, and helping your children not to smoke will decrease their risk. D. Lung cancer can be avoided by decreasing dietary intake of fats and increasing the amount of regular aerobic exercise.

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Cancer statistics The top four cancers found in the United States are: Lung Breast C Prostate Colorectal

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Cancer statistics Prostate cancer is the most common site of cancer and the 2nd most common cause of cancer death in the United States The first cause of death in males is Lung Cancer

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Oncology Cancer statistics

Lung cancer has annual new cases (incidence) of 173,770 people per year: 93,110 males and 80,660 females Annual mortality: 160,440 per year consisting of 92,000 males and 68,510 females

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Cancer statistics
28% of all cancer deaths are due to lung cancer This is the leading cause of cancer death in both men and women There are more deaths from lung cancer than prostate, breast, and colorectal cancers combined

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Cancer statistics Risks for lung cancer: Smoking (75-80% of cases) Occupational exposure Nutrition/Diet Genetic factors

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Cancer statistics
Prostate cancer is number two cause of cancer in men Breast Cancer is number two cause of cancer in women Most common non-malignant or nonfatal cancer is non-melanoma type skin cancers

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The client says that she has heard that the origin of most cancers is genetic. What is the nurses best response?
A. The development of most cancers is predetermined and not affected by environmental factors. B. Cancers arise in cells that have been damaged,which may be in the genes. C. The majority of cancers are inherited D. Cancer is more common among males than females.

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Lab tests for cancer Ultrasounds to determine size CT scan with contrast the golden standard Genetic markers BRCA 1 and BRCA 2 Tumor markers: CEA general carcinogenic antigen PSA prostate antigen CA-125 ovarian CA-25,27 breast HER 2 NEU breast tissue needed

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Lab tests for cancer Liver function tests CBC with diff Renal function tests PET scan looks for metastasis using a radioactive glucose solution PT, PTT, Fibrinogen, Fibrin levels

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Lab tests for cancer
Pathology slide of tumor: (Should be kept for a period of years) Determines type of tumor Source of tumor Aggression of tumor whether fast growing, differentiated, or nondifferentiated Used to determine tumor growth factors and susceptibility to certain chemotherapies

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Chemotherapy Prevention chemotherapy for high risk patients, precancerous lesions, or history of cancer Antioxidants, vitamins Aldara cream 3x weekly for precancerous skin lesions Aspirin Protease inhibitors

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Chemotherapy
- typically started after surgical dissection of tumor, unless the tumor is nonoperative Usually given by a long term venous access device, i.e. PICC line, implanted ports, or direct catheratization to the tumor. Chemotherapy is usually potent and horribly scarring on normal veins

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Chemotherapy Biochemotherapy used as in-patient or outpatient settings for cancer, MS, and viral treatments: Alpha interferon (IFN)- Alpha 2a, Roferon, Intron-Aused for leukemias, AIDS, Hep-C Beta interferon Beta 1b used for renal carcinoma, melanoma, AIDS, MS, Hepatitis A, B

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Chemotherapy/Biochemotherapy Interleukin I (IL-1) Interleukin 2 (IL-2), Proleukin stimulates growth of T-cells and NK cytotoxic cells used investigationally for melanoma in Stage II to Stage IV cases on a monthly basis with a 80% nonrecurrence rate

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Chemotherapy/Biochemotherapy Tumor necrosis factor (TNF) selectively targets abnormal cells, in nature is produced by NK cells

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Chemotherapy/Biochemotherapy Vaccines HPV vaccine for cervical cancer Melanoma vaccine - for stage II only at this time, or malignant melanoma

 Chemotherapy/Biochemotherapy Monoclonal antibodies used for treatment of cancer, rheumatoid arthritis, transplants, and other autoimmune diseases. Can be used to stimulate immune response or suppress it. Rituximab Treatment of CD20 positive non-Hodgkins B-cell lymphoma Gentuzumab treatment of CD33 positive AML in first relapse in patients who are not candidates for reg. chemo.

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Chemotherapy/Biochemotherapy Monoclonal antibodies

Adalimumab Humira new treatment for severe rheumatoid arthritis, given s.q every other week Alemtuzumab Campath - treatment of B-cell lymphoma who have failed traditional chemotherapy with fludarabine Basilixamab Simulect - immunosuppressive monoclonal antibody for renal transplants

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Chemotherapy Alkylating agents Bisulfan oral Carboplatin (CBDCA) IV Chlorambucil (leukeran) oral Cisplatin IV Cyclophosphamide(Cytoxan) IV or PO Melphalan (Alkeran) oral Ifosfamide IV Thiotepa IV or PO

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Chemotherapy/ Antibiotics given IV as chemotherapy Adriamycin (Doxirubicin) Bleomycin Dactinomycin Daunorubicin (actinomycin D) Idarubicin (idomycin) Mitomycin C Mithramycin

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Chemotherapy anti-metabolites Cytorubine (Cytosar) IV Floxuridine (FUDR) IA or SQ Flourourcil (5FU) IV Fludara IV Hydroxyurea PO or IV Methotrexate IV or IM 6MP PO IRESSA PO Xeloda PO

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Chemotherapy- Hormones Progestins uterine cancer Estrogens Testosterone - myelodysplasias Anti-hormones block hormonal activity in hormone sensitive cancers: Leupron Eulexin Tamoxifen/Nolvadex Arimedex/Arista

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Chemotherapy Plant alkaloids Vinblastine (Velban) IV Vincristine (Oncovin) IV Vindesine IV Eldisine IV

The first doses of this are usually given in a hospital setting, are vesicants, and neurotoxic. Nurses must wear protective gear!

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1. Splash goggles 2. Latex gloves 3. Rubber gloves 4. Paper gown 5. Special biohazard bags for disposal 6. Lead apron

Which of the following are appropriate protective gear for the nurse when hanging chemotherapy?

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Chemotherapy Antimitotics
Dacarbazine (DTIC Dome) Leukovorin Paclitaxol (Taxol) Topotecan Gemzar Docetaxol Camptothecan (CPT-11) Taxotere (Ormaplatin) IV PO or IV IV IV IV IV IV IV

Oncology
Side effects of Chemotherapy Alopecia Fatigue Anemia Leukopenia Thrombocytopenia Always Nausea,Vomiting, Diarrhea Neurotoxicity & neuropathies Capillary leakage Headaches Fluid and electrolyte imbalances

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Side effects of Chemotherapy Anorexia change in taste buds Back aches Joint aches Blood clots Oral mucositis (reduced significantly by L-glutamine amino acids orally) Supra opportunistic infections Septic DIC Tumor lysis syndrome Edema or pulmonary edema

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Chemotherapy Nursing Interventions Evaluate and assess sites of chronic chemotherapy, ports, veins, skin area Accurate I & Os Monitor for fluid overload or dehydration Monitor lab electrolytes before and after infusion Monitor BUN and Creatinine Monitor CBC with differential during the time of Nadir Monitor PT, PTT

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Cancer Nursing Interventions Nutritional assessment and weights Dentition oral checks Monitor for signs of suprainfection, low grade temperatures, rash, etc Vital signs before, during, and after treatments Assess bowel status Assess pain level

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Cancer Nursing Interventions Educate patients and family members: side effects of treatments, meds care of port and IV sites oral hygiene symptoms to report, i.e. shortness of breath or signs of infection Increase fluid intake, suck on hard candies to reduce chemotherapy metallic tastes

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Nursing Diagnoses
Disturbance in self esteem, body image Altered nutrition, less than body requirements Risk for fluid volume excess or deficit Impaired skin integrity Pain, chronic Decreased cardiac output Self-care deficit Sexual dysfunction

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Nursing Diagnoses
Alteration in tissue perfusion Knowledge deficit Risk for injury Impaired physical mobility Sensory perception alterations Alterations in bowel patterns Alterations in mucous membranes Anxiety and Fear

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Nursing Diagnoses
Depression Grief Respiratory compromise Ineffective coping Spiritual distress Impaired social interactions Sleep pattern disturbance Altered family roles

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Pharmacological interventions Megace, Marinol for appetite stimulation Premedications for nausea, vomiting, edema, headaches: usually on the protocol for chemo Antiemetics; Zofran 24 hour control Tigan, Kytril, ativan, anzamet, Compazine, benadryl, reglan Corticosteroids

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Pharmacological interventions Analgesics IV electrolytes and fluid replacement Stool softeners to counteract constipation from opioids GSF for WBCs Epogen/Procrit for anemia Leukine/Prokine for leukopenia Neupogen for neutrophilia Neumega for thrombocytopenia Diuretics for edema

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Non-Pharmacological interventions
Massage Reflexology Accupuncture Musical therapy Prayer Meditation Diversional acitivities Dietary counselling

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Radiation therapy All types of cells are injured or destroyed by concentrated radiation. Rapidly dividing cells are the most sensitive.

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Radiation therapy Types : Gamma knife Local beam treatment Local seeding ARC stereotactic Radioimmunotherapy Fractionation Total body irradiation Particle beam therapy, i.e. proton or neutron therapy

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Radiation therapy side effects Side effects depend on the amount and area being irradiated
Fatigue Nausea and vomiting Mild anemia Leukopenia Diarrhea Pain

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Radiation therapy side effects:
Erythema/burns Fatigue Pneumonitis Esophagitis Dysphasia

(Please educate your patients on these as doctors are notoriously bad at pre-educating their patients).

What side effects of radiation therapy would you expect to see in a 48-year-old woman with breast cancer?

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1. Debilitating fatigue 2. Mucositis 3. hair loss 4. nausea and vomiting

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What are some of the educational issues for patients receiving radiation treatment

1. Burns 2. Anemia 3. Skin care 4. Diet 5. All of the above

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Nursing interventions for radiation TX Assess incidence and severity of side effects Maximize radiation protection, all wastes will be radioactive if isotopes are injected Shielding for staff

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Malignant Lymphomas 2 types Hodgkin's Lymphoma most common cancer in 10 to 20 year olds (young adults). Associated with an inflammatory process related to +EBV/mono infection. Diagnosis: Classic Reed-Steinberg cell with two mirrored nuclei, CT scan Symptoms: Extreme fatigue, enlarged lymph nodes that are painless. May progress to weight loss fevers, night sweats

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Malignant Lymphomas 2 types Hodgkin's Lymphoma Treatment combined radiation and chemotherapy, stem cell transplants if resistant type or recurring 85% curable (90% in some institutions)

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Malignant Lymphomas 2 types Non-Hodgkins Lymphoma 3 times more common than Hodgkins lymphoma, can either be T-cell lymphomas, or B-cell lymphomas Can be low grade or high grade disease. B-cell lymphomas = 50% and usually are more aggressive tumors. Since they grow faster, they are also more sensitive to radiation and chemotherapy

 Malignant Lymphomas 2 types Non-Hodgkins Lymphoma Diagnosis: bone marrow biopsy, CT scan, lymphoma panel with CD markers Symptoms- adenopathy, spleenomegaly with vague abdominal pain, back pain, and since immunity B or T-cell function is affected- the patient is more prone to infections. Subcutaneous T-cell lymphoma is a classic discoid rash on the upper body and trunk that does not respond to steroids or creams. NHL can progress rapidly to leukemia if untreated.

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Malignant Lymphomas 2 types Non-Hodgkins Lymphoma Treatments: Monoclonal antibodies, chemotherapy with Fludara/Fludarabine, radiation therapy, and bone marrow implants

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Leukemia hematopoeitic cancer of the stem cells. These stem cells proliferate into non-functional immature white cells. More children get leukemia than any other type of cancer and it is the #1 cause of death in children. Anyone can get leukemia at any age.

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Leukemia -4 types
Acute lymphoblastic leukemia (ALL) Acute myelogenous leukemia (AML) Chronic Lymphocytic leukemia (CLL) Chronic myelogenous leukemia (CML) Anagram ALL AniMals are CLearLy CaMeLs

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Leukemia ALL suspected cause is a T-cell virus (HTLV-1) 85% is seen in children, 25% in adults 30-to-40 y.o. Diagnosis: peripheral blood smear after abnormally high white count, bone marrow biopsy shows lymphoblasts >50%m may have decrease in platelets. Lumbar puncture to determine CSF involvement

 Leukemia ALL Symptoms fatigue, anorexia, malaise, weight loss, bleeding, infections, headaches, adenopathy, spleenomegaly, gingival hypertrophy, hepatomegaly, bone or joint pain Treatment: complete response is a bone marrow aspirate with < 5% blasts. Chemotherapy vincristine, prednisone, danorubicin, methotrexate, Maintenance therapy 6 weeks of 6-mercaptopurine and methotrexate low dose therapy

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Leukemia AML more common in patients with chromosomal genetic disorders, exposure to benzene or radiation. Use of alkylating agents for breast, ovarian, or myeloma are associated with a later malignancy of this type. Symptoms- are like ALL with the additions of anemia, thrombocytopenia, visual disturbances, epistaxis (nosebleeds), headache with vomiting, dysphagia, papilladema, menorrhagia (lots more bleeding problems)

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Leukemia AML Diagnosis: peripheral blood smear shows Auer bodies (rods), platelets less than 20,000/mm3, bone marrow biopsy Prognosis poor prognosis if patient has already received radiation or chemotherapy, or has a WBC >100,000

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Leukemia AML Treatment: Cytaribine chemotherapy in combination therapy with Danorubicin or doxirubicin, works 65% of the time. Bone marrow transplant or stem cell transplant.

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Leukemia CLL staged 0-5
chronic diseases have more mature cells, majority of CLL is B-cell proliferation 95%. Only 5% are Tcells, more common in people with autoimmune diseases, i.e. SJogrens, SLE, hemolytic anemia Symptoms: skin and respiratory infections, fatigue, thrombocytopenia, anemia, spleenomegaly

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Leukemia CLL Diagnosis- peripheral blood smear, bone marrow biopsy Treatments: Gleevac drug of choice; chemotherapy in combinations, spleenectomy, radiation therapy to spleen, bone marrow transplant, stem cell transplants

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Leukemia CML (last is the CaMeL) - More common after radiation exposure, benzene exposure, less common than the other types of leukemia, and occurs most often between 50-60 y.o. Diagnosis: hallmark is the presence of the Philadelphia Chromosome, Chromosome #22 is missing part of the long arm which is translocated to Chromosome #9. This is present in 95% of those patients with CML. WBC >100,000 with proliferation of all types of mature and immature white cells. Bone marrow biopsy

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Leukemia CML Symptoms: same as other leukemias with chronic fever, sternal tenderness and dyspnea usually due to severe anemias Treatments: chemotherapy with Bisulfan and hydroxurea, other combination chemos, Interferon alpha 2b to suppress the expression of the Philadelphia chromosome. Bone marrow transplant or stem cells

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Bone marrow and stem cell implants New treatments for: Acute myelogenous leukemias (AML) Acute lymphoblastic leukemias (ALL) Myelodysplasia syndromes (MDS) Chronic myelogenous leukemias that do not respond to chemotherapy (CML) Blast crisis Pediatric acute leukemias Non-Hodgkins lymphoma Large B-Cell lymphoma Multiple myelomas

Bone marrow and stem cell implants

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Bone marrow and stem cell implants Procedure= multiple punctures
Marrow acquisition from donor or when patient is in remission, or stem cells from umbilical blood of a matching sibling or family member Marrow is filtered to purge tumor cells, fat and bone particles, then place in a blood bag for cryopreservation.

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Bone marrow and stem cell implants
Preparing Recipient: Marrow recipient is given high dose chemotherapy alone or in combination with radiation to suppress immune system, open spaces in the marrow, and kill remaining cancer cells. Bone marrow is thawed and infused through a central venous catheter

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Bone marrow and stem cell implants Preparing Recipient: Stem cells are infused after thawing Post-procedure: Patient is supported through the period of aplasia, 10 to 30 days, while in reverse isolation and on graft immunosuppressants, Observed for signs of Graft-versushost disease and/or infection

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The waves of the future: Stem Cell Research Oncogene therapy now that cancer cells are being genetically tagged, we can tell which growth factors are present, and which enzymes turn off the gene. Soon all gene markers will have a pill that matches the enzyme, i.e. IRESSA is a tyramine kinase inhibitor, and stops the tumors growth that use tyramine kinase

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Stem Cell Induction there are new drugs out for stem cell induction to immunosuppress the patient, even in deadly cancers, i.e. Multiple Myeloma. Recently, the combination of lenalidomide(Revalamid), bortezomib (Velcade) and dexamethasone produced a 98% response rate in patients

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The waves of the future: Cancer vaccines Oncology is the science of cancer and treatment of all cancer patients. It is one of the most demanding and rewarding fields in medicine. The future is open for a cure.

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