NCLEX: Cancer care

Cancer care: A look at cancer care

Focus topic: Cancer care

Cancer is an umbrella term for a group of disorders in which abnormal cells grow, multiply uncontrollably, and have the ability to invade other tissues and metastasize. Abnormal tissue masses are called solid tumors and may be benign or malignant (cancerous).
Cancer causes more than 560,000 deaths in the United States annually, making it the second-leading killer after cardiovascular disease. The American Cancer Society (ACS) estimates that half of all men and one-third of all women currently living in the United States will eventually develop some form of cancer.

Cancer care:Pathophysiology

Focus topic: Cancer care

In many cases, the exact cause of cancer remains unknown. However, specific factors have been implicated in some types of cancer. They include:
• chemical carcinogens
• ultraviolet (UV) light exposure
• hereditary predisposition
• viruses
• gender.

Where there’s smoke…

Smoking can cause lung cancer and has been strongly implicated in cancers of the mouth, throat, bladder, kidney, and several other organs. Although not everyone who smokes will get cancer, smoking increases the cancer risk. Similarly, high alcohol intake and smokeless (chewing) tobacco increase the risk of oral cancers.

Cancer care: Genetic mutation

Focus topic: Cancer care

Smoking and other risk factors can affect the cell’s genetic material, interfering with normal gene replication before cell division (mitosis) takes place. Such interference can increase the likelihood of a mutation—an abnormal change in some portion of the cell’s gene complement. (See Reviewing cancer risk factors.) Genetic mutation may result from aging; exposure to chemicals, radiation, or hormones; and other factors. Over time, numerous gene mutations may occur in a cell, permitting it to divide and grow in a way that eventually leads to cancer.

Uncontrolled growth

Focus topic: Cancer care

Cancer cells first develop from a genetic mutation in a single cell. This cell grows without the control that characterizes normal cell growth. Also, it fails to mature into the type of normal cell from which it originated. Uncontrolled localized growth follows. Unlike normal cells, cancer cells keep growing and multiplying even after lost cells have been replaced.

Cancer care: Metastasis

Focus topic: Cancer care

In addition to this uncontrolled localized growth, cancer cells may spread from their origin site in a process called metastasis. Cancer cells metastasize in three ways:
• by circulation through the bloodstream and lymphatic system
• by accidental transplantation during surgery or other invasive procedures
• by spreading to adjacent organs and tissues.

Cancer classifications

Focus topic: Cancer care

Cancer is classified by the tissues or blood cells in which it originates. Most cancers derive from epithelial tissues and are called carcinomas.

Cancer care

Cancer care

Cancer care

Other cancers arise from these tissues and cells:
• glandular tissues (adenocarcinomas)
• connective, muscle, and bone tissues (sarcomas)
• brain and spinal cord tissues (gliomas)
• pigmented cells (melanomas)
• plasma cells (myelomas)
• lymphatic tissue (lymphomas)
• leukocytes (leukemia)
• erythrocytes (erythroleukemia).

Cancer care: Cancers

Focus topic: Cancer care

This section discusses the most prevalent cancers of each body system. For each disorder, you’ll find information on causes, assessment findings, diagnostic tests, treatment, nursing interventions, patient teaching, and evaluation criteria.

Cancer care: Acute leukemia

Focus topic: Cancer care

In acute leukemia, cancerous white blood cell (WBC) precursors called blasts proliferate in the bone marrow or lymph tissue and then accumulate in peripheral blood, bone marrow, and body tissues. Untreated, acute leukemia invariably leads to death, usually from complications of leukemic cell infiltration of bone marrow or vital organs.
Acute leukemia ranks 15th as a cause of cancer-related deaths among people of all ages. With treatment, prognosis varies. Among children, acute leukemia is the most common cancer.

Classifying acute leukemia
The most common forms of acute leukemia are:
• acute lymphoblastic leukemia (ALL), marked by abnormal growth of lymphocyte precursors (lymphoblasts)
• acute myelogenous leukemia (AML), characterized by rapid accumulation of myeloid precursors (myeloblasts)
• acute monocytic leukemia, or Schilling’s type, which involves a marked increase in monocyte precursors (monoblasts). Other leukemia variants include acute myelo monocytic leukemia and acute erythroleukemia.

Survival stats

The 5-year relative survival rate for leukemia is over 50%. The survival rate depends on the type of leukemia, age at diagnosis, gender, and race.

What causes it
The cause of acute leukemia is unknown. According to some experts, risk factors include:
• a combination of viruses
• genetic and immunologic factors
• exposure to radiation and certain chemicals.

Pathophysiology
The pathogenesis of acute leukemia isn’t clearly understood. Immature, nonfunctioning WBCs appear to accumulate first in the tissue where they originate (lymphocytes in lymph tissue, granulocytes in bone marrow). These immature WBCs then spill into the bloodstream and infiltrate other tissues. Eventually, they cause organ malfunction from encroachment or hemorrhage.

What to look for
Typical clinical features of acute leukemia include:
• fever and infection
• abnormal bleeding, easy bruising, and petechiae

• fatigue and weight loss
• bone pain
• enlarged lymph nodes.

Be less specific…

Nonspecific signs and symptoms include low-grade fever, pallor, and weakness and lassitude that may persist for months before other signs and symptoms arise. As the disease progresses, the patient may develop dyspnea, fatigue, malaise, tachycardia, palpitations, systolic ejection murmur, and abdominal or bone pain. In meningeal leukemia, early symptoms typically include confusion, lethargy, and headache.

What tests tell you
• Bone marrow biopsy is performed in a patient with typical clinical findings but whose aspirate is dry or free from leukemic cells. Bone marrow aspiration typically shows proliferation of immature WBCs and confirms the diagnosis.
• WBC differential determines cell type.
• Complete blood count (CBC) shows decreased levels of hemoglobin (anemia), platelets (thrombocytopenia), and neutrophils (neutropenia).
• Lumbar puncture detects meningeal involvement.
• Uric acid measurement may be done to detect hyperuricemia.

How it’s treated
Systemic chemotherapy aims to eradicate leukemic cells and induce remission, restoring normal bone marrow function. Chemotherapy varies with the specific leukemia:
• For meningeal leukemia, treatment includes intrathecal instillation of methotrexate (Trexall) or cytarabine (Cytosar-U), along with cranial radiation.
• For ALL, treatment consists of vincristine and prednisone (Deltasone) with intrathecal metho trexate or cytarabine; I.V. asparaginase (Elspar), daunorubicin (DaunoXome), and doxorubicin; and maintenance with mercaptopurine (Purinethol) and methotrexate.
• For AML, treatment consists of a combination of I.V. daunorubicin or doxorubicin, cytarabine, and oral thioguanine. If these agents fail to induce remission, the patient may receive a combination of cyclophospha mide (Cytoxan), vincristine, prednisone, or methotrexate; high-dose cytarabine alone or with other drugs; amsacrine; mitoxantrone (Novantrone); or maintenance with additional chemotherapy.

Other treatments
Treatment may also include antibiotics, antifungals, and antivirals (given along with granulocyte injections to control infection andplatelet transfusions to prevent bleeding). Red blood cell (RBC)transfusions may be given to prevent anemia. For some patients,bone marrow transplantation is an option.

What to do
• Control infection by placing the patient in a private room and imposing reverse isolation, if necessary. (Benefits of reverse isolation are controversial.) Coordinate care so the patient doesn’t come in contact with staff members who also care for patients with infections or infectious diseases. Avoid using indwelling catheters and giving intramuscular injections, which can pave the way for infection. Screen staff members and visitors for contagious diseases. Watch for and report signs and symptoms of infection.

Fending off fever

• Monitor the patient’s vital signs every 2 to 4 hours. A temperature over 101º F (38.3º C) accompanied by a decreased WBC count calls for prompt antibiotic therapy.
• Watch for bleeding. If it occurs, apply ice compresses and pressure, and elevate the affected extremity. Avoid giving aspirin and aspirin-containing drugs. Also avoid taking rectal temperatures, giving rectal suppositories, and performing digital rectal examinations (DRE).

Supine for safety

• Watch for signs and symptoms of meningeal leukemia. If these occur, provide care after intrathecal chemotherapy. After instillation, place the patient in the Trendelenburg position for 30 minutes. Give plenty of fluids, and keep him supine for 4 to 6 hours. Check the lumbar puncture site often for bleeding.
• If the patient has received cranial radiation, teach him about potential adverse effects, and try to minimize them.
• Take steps to prevent hyperuricemia—a possible result of rapid chemotherapy-induced leukemic cell lysis. Give the patient about 2 qt (2 L) of fluids daily, and administer acetazolamide (Diamox), sodium bicarbonate tablets, and allopurinol (Zyloprim), as ordered. Check urine pH often—it should be above 7.5. Watch for rash and other hypersensitivity reactions to allopurinol.
• Control mouth ulcers by checking often for obvious ulcers and gum swelling and by providing frequent mouth care and saline solution rinses.

• Check the rectal area daily for induration, swelling, erythema, skin discoloration, and drainage.
• Minimize stress by providing a calm, quiet atmosphere that promotes rest and relaxation.
• Provide psychological support by establishing a trusting relationship with the patient. Allow him and his family to express their anger, anxiety, and depression. Encourage them to participate in patient care as much as possible. Refer them to a local chapter of the Leukemia Society of America.
• For a patient with terminal disease that resists chemotherapy, provide supportive care directed at promoting comfort; managing pain, fever, and bleeding; and offering emotional support. Provide the opportunity for spiritual counseling if appropriate. Discuss the option of home or hospice care.

• Evaluate the patient. He and his family should understand the rationale for treatment and potential complications of chemotherapy. They should also know how to recognize signs and symptoms of infection and understand that they must notify the practitioner if these occur. They should be able to discuss treatment options and verbalize concerns about a poor prognosis.

Cancer care

Cancer care

Cancer care: Breast cancer

Focus topic: Cancer care

Breast cancer is the most common cancer among females in the united States and the second-leading cause of cancer deaths in women ages 35 to 54. Breast cancer also occurs in men, although it’s rare.
Thanks to earlier diagnosis and expanded treatment options, the 5-year survival rate for patients with localized breast cancer has improved from 78% in 1940 to 92% today.

Surviving in situ

For noninvasive cancer in situ (confined to the origin site without invading neighboring tissue), the survival rate is near 100%. If the cancer has spread regionally, the survival rate is 71%. With distant metastasis, it falls to 20%.

What causes it
Although the exact cause of breast cancer is unknown, certain risk factors exist. Primary risk factors include:
• gender (more than 90% of breast cancers occur in women)
• age (risk increases after age 50)
• personal history of the disease (15% of women develop breast cancer in the opposite breast)
• family history of the disease (women who have a first-degree relative with breast cancer have a twofold to threefold increased risk).

Secondary risk factors
Secondary risk factors for breast cancer include:
• never having given birth
• giving birth to a first child after age 30
• prolonged hormonal stimulation (menarche before age 12 and menopause after age 50)
• atypical hyperplasia (abnormal cell multiplication) on a previous breast biopsy
• exposure to excessive ionizing radiation (as in Hodgkin disease treatment)
• history of endometrial, ovarian, or colon cancer.

The discovery of specific genes linked to breast cancer, called BRCA1 and BRCA2, indicates that the disease can be inherited. Someone who inherits either gene has roughly an 80% lifetime chance of developing breast cancer.

Pathophysiology
Breast cancer is more commonly found in the left breast than the right. It’s also more common in the upper outer quadrant.  Growth rates vary. Theoretically, slow-growing breast cancer may take up to 8 years to become palpable at 1 cm in size.

Spread pattern

Breast cancer spreads via the lymphatic system and bloodstream, through the right side of the heart to the lungs, and may spread to the other breast, chest wall, liver, bone, and brain.

What to look for
Signs and symptoms of breast cancer include:
• painless lump or mass in the breast
• changes in breast symmetry or size
• changes in breast skin, such as dimpling (called peau d’orange), edema, or ulcers
• changes in nipples; for instance, itching, burning, erosion, retraction, or discharge
• skin temperature changes (a warm, hot, or pink area).
If you detect any of these changes, suspect cancer in a nonlactating woman past childbearing age until proven otherwise. Investigate spontaneous discharge of any kind in a non–breast-feeding, nonlactating woman.

Signs and symptoms of metastasis
Metastatic disease may cause shoulder, hip, or pelvic pain; cough; anorexia; persistent dizziness; or enlarged axillary or supraclavicular lymph nodes.

What tests tell you
• Detection of a breast lump or tumor on breast self-examination, clinical breast examination, or mammography suggests breast cancer.

• Diagnosis hinges on biopsy and pathologic evaluation of the suspicious tissue. The staging workup may include chest X-rays as well as liver and bone scans.
• A hormonal receptor assay of tumor tissue obtained by biopsy can determine whether the tumor’s growth is stimulated by estrogen (estrogen-dependent) or progesterone (progesteronedependent). Such determination guides therapeutic decisions.

Cancer care

Cancer care

How it’s treated
Treatment may include one or any combination of the following options.

Chemotherapy
Chemotherapy for breast cancer may involve various cytotoxic drug combinations. In patients with axillary lymph node involvement but no evidence of distant metastasis, chemotherapy may be adjuvant (used after the primary tumor has been removed) or neoadjuvant (used as a preliminary therapy preceding a necessary second treatment modality).

If metastasis has occurred, chemotherapy may be done as primary therapy based on such factors as the patient’s premenopausal or postmenopausal status.

Chemo combos

Commonly used drug combinations include:
• cyclophosphamide, methotrexate, and fluorouracil (Adrucil)
• doxorubicin and cyclophosphamide
• cyclophosphamide, doxorubicin, and fluorouracil.

Other drug treatments
Paclitaxel and docetaxel (Taxotere) are used to treat recurrent or metastatic breast cancer. Herceptin is a monoclonal antibody used to treat metastatic breast cancer in patients with an over-expression of Her-2/neu, a protein associated with a more aggressive tumor. About 30% of breast cancer patients are candidates for herceptin therapy. New drug treatments continue to be developed.

Radiation therapy
Primary external-beam radiation therapy typically begins 2 to 4 weeks after surgery, when incisions have healed. It may be given before, during, or after chemotherapy. Radiation therapy may also be used as adjunctive therapy for tumors that are located near the chest wall or are locally advanced or recurrent as well as for inflammatory breast cancer. If cancer has spread to the bone, radiation therapy may be targeted to specific bone sites to reduce pain.

Surgery
Lumpectomy, or tumor excision, usually is the initial surgery. It also provides biopsy material to determine tumor cell type. Typically, lumpectomy is performed on an outpatient basis. For some patients—especially those with small tumors and no evidence of axillary node involvement—it’s the only surgery required. However, lumpectomy is commonly combined with radiation therapy.
Lumpectomy is performed in two stages. First, the surgeon removes the lump and confirms malignancy. Then he discusses treatment options with the patient.

Other operation options

Other surgical procedures for breast cancer include:
• lumpectomy with sentinel node biopsy or axillary lymph node dissection, which removes the tumor and axillary lymph nodes while leaving the breast intact

• simple mastectomy, which removes the breast but not axillary lymph nodes or pectoral muscles
• modified radical mastectomy, which removes the breast and axillary nodes
• radical mastectomy (rare), which removes the breast, pectoralis major and minor muscles, and axillary nodes.

Rebuilding the breast

Postmastectomy reconstructive surgery can create a breast mound if the patient desires it, which may help her to cope with changes in her body image.

Other methods
Other breast cancer treatments may include:
• estrogen, progesterone, or androgen therapy
• antiandrogen therapy with aminoglutethimide
• antiestrogen therapy.
Antiestrogen therapy involves administration of tamoxifen, a drug with few adverse effects that inhibits deoxyribonucleic acid synthesis. In postmenopausal women, aromatase inhibitors such as anastrozole (Arimidex) effectively combat estrogen- dependent tumors.

What to do
• Obtain a patient history. Assess the patient’s feelings and knowledge about her diagnosis, and determine her expectations.
• Explain treatment options at the patient’s level of understanding.
• Evaluate the patient. With effective treatment, she should recover uneventfully from surgery, radiation, chemotherapy, or other treatments. She should perform appropriate exercises and understand postoperative safety precautions for the affected arm. Also, she should correctly demonstrate breast self-examination.

Cancer care

Cancer care: Cervical cancer

Focus topic: Cancer care

The third most common cancer of the female reproductive system (after uterine and ovarian cancer), cervical cancer may be preinvasive or invasive. With early detection and proper treatment, the preinvasive form has a high cure rate.

Unwelcome invasion

If untreated (and depending on the exact cancer form), the disease
may progress to become invasive. Invasive cervical cancercauses 4,000 deaths annually in the United States. Rare before age 20, it usually occurs between ages 30 and 50.

What causes it
The cause of cervical cancer is unknown. However, the most
important risk factor is infection by human papillomavirus (HPV).
HPV is responsible for about 70% of cervical cancer cases. HPV
recombinant vaccine (Gardasil or Cervarix) is recommended for
women and girls ages 9 to 26 to protect against cervical cancer.

Other risk factors include:
• chlamydia infection
• immunosuppression
• poor diet and obesity
• early pregnancy and multiple pregnancies
• cigarette smoking.

Pathophysiology
Preinvasive cervical cancer ranges from minimal cervical dysplasia, in which the lower third of the epithelium contains abnormal cells, to carcinoma in situ, which involves the full thickness of epithelium.

No basement bargains

In invasive cancer, cancer cells penetrate the basement membrane and may spread directly to adjacent pelvic structures or to distant sites via the lymph system.

What to look for
Preinvasive cervical cancer is asymptomatic. Abnormal vaginal bleeding, persistent vaginal discharge, and postcoital pain and bleeding may signal early invasive disease. Advanced disease may cause pelvic pain or vaginal leakage of urine and feces from a fistula, along with anorexia, weight loss, and fatigue.

What tests tell you
• A Papanicolaou (Pap) test can detect cervical cancer before symptoms arise. The ACS recommends annual Pap tests starting about 3 years after the initiation of sexual intercourse but no later than age 21. Women ages 30 to 70 with three or more consecutive satisfactory examinations with normal findings should have a Pap test every 2 to 3 years. For women age 70 and older with three or more consecutive satisfactory examinations and no abnormal Pap tests in the past 10 years, screening may stop.
• The HPV DNA test is recommended to detect HPV in women older than age 30 who have had abnormal Pap tests.
• Colposcopy (examination of the vaginal and cervical epithelium using a colposcope) can reveal the presence and extent of preclinical lesions.
• Biopsy and histologic examination confirm the diagnosis.
• Additional studies, such as lymphangiography, cystography, and scans, can detect metastasis.

How it’s treated
Effective treatment is tailored to the cancer stage. Preinvasive lesions may warrant total excisional biopsy, cryosurgery, laser destruction of the tumor, conization (removal of a cone-shaped section of the cervix) with frequent Pap test follow-up or, rarely, hysterectomy. Invasive squamous cancer may require radical hysterectomy and radiation therapy (internal, external, or both).

What to do
• Provide comprehensive patient teaching and emotional and psychological support. • If the patient will receive internal radiation, determine if the radioactive source will be inserted while she’s in the operating room (preloaded) or at the bedside (afterloaded). Remember that safety precautions—time, distance, and shielding—must start as soon as the radioactive source is in place. Tell the patient she’ll require a private room.
• Check the patient’s vital signs every 4 hours. Watch for skin reactions, vaginal bleeding, abdominal discomfort, and evidence of dehydration.

Within arm’s reach

• Make sure she can reach everything she needs without stretching or straining. Assist her in range-of-motion arm exercises; be aware that leg exercises and other body movements could dislodge the radiation source.
• Organize the time you spend with the patient to minimize your radiation exposure. Inform visitors of safety precautions, and hang a sign listing these precautions on the patient’s door.
• Evaluate the patient. When assessing her response to treatment, note how well she tolerates the therapy. She should understand that it won’t impair her ability to have sex. She should also understand the importance of complying with the treatment regimen.

Cancer care

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