NCLEX: Cancer care

Cancer care: Colorectal cancer

Focus topic: Cancer care

Colorectal cancer is the third most common cause of cancer deaths in the United States. It affects men and women equally. Nearly all colorectal cancers are adenocarcinomas. About 50% are rectosigmoid lesions that adhere closely to the mucosal surface (called sessile). The rest are polyps.

Slow to spread, easier to cure

Focus topic: Cancer care

Because colorectal cancer spreads slowly, it’s potentially curable with early diagnosis. The 5-year survival rate for colon and rectal cancers caught in the early stages is 91%. After the cancer spreads regionally, survival drops to 70%.

What causes it
The cause of colorectal cancer remains unknown. Studies show, however, that it’s prevalent in areas of higher economic development. This suggests it’s linked to a high-fat diet.
Other factors that increase the risk for this disease include:
• age over 50
• inflammatory bowel disease
• history of polyps
• inherited tendency toward colon polyps
• sedentary lifestyle and obesity
• heavy alcohol use
• diet high in red meat
• family history of colorectal cancer, especially before age 60.

Pathophysiology
Most lesions of the large bowel are moderately differentiated adenocarcinomas. Tumors tend to grow slowly and remain asymptomatic for long periods.

Stretching the circumference

Focus topic: Cancer care

Tumors in the sigmoid and descending colon grow circumferentially and constrict the intestinal lumen. At diagnosis, tumors in the ascending colon are usually large and palpable on physical examination.

What to look for
Signs and symptoms of colorectal cancer include malaise and fatigue. Other findings result from local obstruction and, in later stages, from direct extension to adjacent organs (such as the bladder, prostate, ureters,vagina,and sacrum)or from distant metastasis (usually to the liver).
Later signs and symptoms include:
• weight loss
• pain
• pallor
• bloody stools
• cachexia (malnutrition, weakness, and emaciation)
• ascites (buildup of serous fluid in the abdominal cavity)
• hepatomegaly (liver enlargement)
• lymphangiectasis (widening of the lymphatic vessels).

What tests tell you
• Only a tumor biopsy can verify colorectal cancer, but other tests help detect it. For women and men age 50 and older, the ACS recommends one of the following tests: fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year, flexible sigmoidoscopy every 5 years, FOBT or FIT every year plus flexible sigmoidoscopy every 5 years, colonoscopy every 10 years, or double-contrast barium enema every 5 years.
• DRE detects nearly 15% of colorectal cancers. It can be used to detect suspicious rectal and perianal lesions.
• FOBT and FIT detect blood in stools, a warning sign of rectal cancer.
• Proctoscopy or sigmoidoscopy permits visualization of the lower GI tract and can detect up to two-thirds of colorectal cancers.

Photographing the evidence

Focus topic: Cancer care

• Colonoscopy allows visual inspection (and photographs) of the colon up to the ileocecal valve. It also provides access for polypectomy and biopsy of suspected lesions.
• MRI uses magnetic fields to obtain detailed images of body structures.
• Carcinoembryonic antigen testing, although not specific or sensitive enough for early diagnosis, helps monitor the patient before and after treatment to detect metastasis or recurrence.

How it’s treated
Surgery seeks to remove the cancerous tumor and adjacent tissues as well as lymph nodes that may contain cancer cells. The type of surgery depends on tumor location.

Cancer care

Surgical options
• For tumors of the cecum or ascending colon, right hemicolectomy for advanced disease may include resection of the terminal segment of the ileum, cecum, ascending colon, and right half of the transverse colon with corresponding mesentery.
• For tumors of the proximal and middle transverse colon, right colectomy includes transverse colon and mesentery corresponding to midcolonic vessels. Alternatively, the surgeon may perform segmental resection of the transverse colon and associated midcolonic vessels.
• For sigmoid colon tumors, surgery is usually limited to the sigmoidcolon and mesentery.
• Upper rectum tumors usually call for anterior or low anteriorresection. A newer method using a stapler allows resections muchlower than were previously possible.
• For tumors in the lower rectum, abdominoperineal resectionand permanent sigmoid colostomy are usually performed.

Better living through chemotherapy

Focus topic: Cancer care

Chemotherapy may be used as adjuvant therapy or for patients with metastasis, residual disease, or recurrent inoperable tumors.
Commonly used drugs include:
• 5-fluorouracil, with or without leucovorin
• irinotecan (Camptosar)
• oxaliplatin (Eloxatin)
• capecitabine (Xeloda).
Researchers are developing new therapies that target the genes and proteins that lead to cancer.

Radiation
Radiation therapy may induce tumor regression and may be used before and after surgery.

What to do
• If the patient will have colorectal surgery, monitor his diet and give laxatives, enemas, and antibiotics, as ordered (to clean the bowel and minimize abdominal and perineal cavity contamination during surgery).
• Evaluate the patient. He should verbalize an understanding of the treatment regimen, including ostomy care, and the need for long-term follow-up.

Cancer care

Cancer care: Hodgkin disease

Focus topic: Cancer care

Hodgkin disease is a lymphatic cancer marked by painless, progressive enlargement of the lymph nodes, spleen, and other lymphoid tissue. Left untreated, it follows a variable but progressive and ultimately fatal course.

Promising odds

Focus topic: Cancer care

However, recent advances in therapy make Hodgkin disease potentially curable, even in advanced stages. Appropriate treatment yields long-term survival in about 85% of patients.

What causes it
The exact cause of Hodgkin disease is unknown, although indirect evidence suggests it may involve a virus. The disease is most common in young adults.

Pathophysiology
Enlargement of the lymph nodes, spleen, and other lymphoid tissues results from proliferation of lymphocytes, histiocytes, eosinophils, and Reed-Sternberg cells. The latter cells are hallmarks of the disease.

What to look for
Usually, the first sign is painless swelling in a cervical lymph node (or, occasionally, in a lymph node in another area). Other signs and symptoms include pruritus (itching), persistent fever, night sweats, fatigue, weight loss, and malaise. Late-stage signs and symptoms include facial and neck edema, jaundice, nerve pain, enlarged retroperitoneal lymph nodes, and nodular infiltration of the spleen, liver, and bones.

What tests tell you
• Lymph node biopsy reveals abnormal histologic proliferation, nodular fibrosis, necrosis, and Reed-Sternberg cells. Lymph node biopsy is also used to determine lymph node and organ involvement.
• Blood tests show mild to severe normocytic anemia (anemia with RBCs of normal size); normochromic anemia (marked by normal hemoglobin amounts) in 50% of cases; an elevated, normal, or reduced WBC count; and WBC differential showing any combination of neutrophilia (excessive neutrophil levels), lymphocytopenia (deficient lymphocyte levels), monocytosis (excessive monophil levels), and eosinophilia (excessive eosinophil levels).
• Serum alkaline phosphatase levels may be elevated, indicating liver or bone involvement.
• A staging laparotomy is necessary for patients under age 55 and for those without obvious advanced disease (stages III or IV), lymphocyte predominance histology, or medical contraindications.
• Computed tomography (CT) scans evaluate the extent of the disease.

How it’s treated
Depending on the disease stage, treatment may include chemotherapy, radiation, or both. Choice of therapy depends on careful physical examination, accurate histologic interpretation, and proper clinical staging. Correct treatment prolongs survival and induces an apparent cure in many patients.

A favorable outlook

Focus topic: Cancer care

Patients with favorable prognoses may benefit from a combination of targeted radiation and chemotherapy. Commonly used chemotherapy combinations include:
• doxorubicin, bleomycin, vinblastine, and dacarbazine
• cyclophosphamide, doxorubicin, etoposide, oncovin, bleomycin, procarbazine, and prednisone.

What to do
• Monitor the patient closely for indications of toxicity caused by chemotherapy or radiation. As appropriate, manage symptoms to help prevent the need for a treatment hiatus or reduction.
• Provide emotional support and offer appropriate counseling and reassurance.
• Evaluate the patient. He should understand and comply with the self-care regimen for radiation and chemotherapy. He should know how to recognize adverse effects of treatment and know when to notify the practitioner. He should also be able to control weight loss and remain free from infection.

Cancer care

Cancer care: Lung cancer

Focus topic: Cancer care

Although largely preventable, lung cancer is the most common cause of cancer deaths in men and women. It usually develops within the wall or epithelium of the bronchial tree.

Histologic headings

Focus topic: Cancer care

There are two major types of lung cancer:
• Small cell lung cancer—also called oat cell cancer—accounts for 10% to 15% of lung cancers. It usually starts in the bronchi and spreads widely.
• Non–small cell lung cancer accounts for 85% to 90% of lung cancers and includes squamous cell cancers, adenocarcinomas, and large-cell (undifferentiated) carcinomas.

Gloomy forecast

Focus topic: Cancer care

Prognosis varies with cell type and extent of spread at the time of diagnosis. Only 15% of patients with later-stage lung cancer survive 5 years after diagnosis.

What causes it
Tobacco smoking accounts for approximately 90% of lung cancers and is closely associated with all histologic types. Other risk factors include genetic predisposition and exposure to carcinogenic industrial or air pollutants (such as asbestos, uranium, arsenic, nickel, iron oxides, chromium, radioactive dust, and coal dust). Some people without any risk factors develop lung cancer.

Pathophysiology
Lung tumors show bronchial epithelial changes progressing from squamous cell changes or metaplasia (abnormal changes in adult cells) to carcinoma in situ. Tumors originating in the bronchi produce more mucus.
Tumor growth causes partial or complete airway blockage, resulting in collapse of lung lobes distal to the tumor.

Thoracic sprawl

Focus topic: Cancer care

Early metastasis occurs to other thoracic structures, such as the hilar lymph nodes and mediastinum. Distant metastasis may involve the brain, liver, bone, and adrenal glands.

What to look for
Because early-stage lung cancer tends to have a gradual onset, the disease is usually well developed by the time it’s diagnosed. With small cell cancer and squamous cancers, late-stage respiratory findings include smoker’s cough, hoarseness, wheezing, dyspnea, hemoptysis (expectoration of blood), and chest pain. With non–small cell cancer and adenocarcinoma, findings include fever, weakness, weight loss, anorexia, and shoulder pain.

Hormonal disharmony

Focus topic: Cancer care

Sometimes, lung cancer causes hormone-related changes, including:
• gynecomastia, or breast enlargement in males (with non–small cell cancer)
• bone and joint pain (with non–small cell cancer and adenocarcinoma)
• signs or symptoms of Cushing’s syndrome, such as central obesity, round face, supraclavicular fat pads, muscle atrophy, edema, and emotional changes (with small cell cancer)
• signs or symptoms of carcinoid syndrome, such as flushing, diarrhea, cramps, skin lesions, labored breathing, and palpitations (with small cell cancer)
• signs or symptoms of hypercalcemia, such as muscle pain and weakness.

Spreading signs

If lung cancer spreads, signs and symptoms vary. With bronchial obstruction, metastatic signs and symptoms include hemoptysis, atelectasis (lung tissue collapse), pneumonitis (lung inflammation), and dyspnea.
With recurrent nerve invasion, findings may include vocal cord paralysis. With chest wall invasion, the patient may have piercing chest pain, increasing dyspnea, and severe shoulder pain radiating down the arm. With local lymphatic spread, expect cough, hemoptysis, stridor (a harsh sound on expiration), and pleural effusion.

What tests tell you
• A chest X-ray usually shows an advanced lesion, but can detect a lesion up to 2 years before symptoms appear. It also defines tumor size and location.
• Bronchoscopy can locate the tumor site. Bronchoscopic washings provide material for cytologic and histologic examination. Using a flexible fiberoptic bronchoscope increases test effectiveness.
• Needle biopsy uses biplane fluoroscopic visual control to detect peripheral tumors, allowing firm diagnosis in 80% of patients.
• Tissue biopsy of accessible metastatic sites includes supraclavicular and mediastinal node and pleural biopsy.
• Thoracentesis (removal of fluid from the chest cavity) allows chemical and cytologic examination of pleural fluid.
• Tests to detect metastasis include bone scan (a positive scan may lead to bone marrow biopsy; bone marrow biopsy is also recommended for patients with small cell cancer); CT scan of the brain; liver function studies; and gallium scan (noninvasive nuclear scan) of the liver, spleen, and bone.

How it’s treated
Treatment involves combinations of surgery, radiation, and chemotherapy. Although treatment may improve prognosis and prolong survival, it’s largely palliative because most cancers are diagnosed at an advanced disease stage.

Surgery
Surgery is the main treatment for non–small cell cancer—unless the tumor is nonresectable or other conditions (such as cardiac disease) rule out surgery. Surgery may involve partial removal of a lung (as in wedge resection and lobectomy) or total lung removal (as in pneumonectomy and radical pneumonectomy).

Radiation therapy
Preoperative radiation therapy may reduce tumor bulk to allow surgical resection, but its value is questionable. Radiation therapy is generally recommended for early-stage (stage I and stage II) lesions if surgery is contraindicated and as an adjunct to surgery (either preoperatively or postoperatively).
Prophylactic cranial irradiation may be used to prevent or slow brain metastasis in small cell lung cancer. Some patients undergo radiation to control cancer-related symptoms or to prolong their functional lives.

Chemotherapy
Chemotherapy for small cell lung cancer uses a combination of drugs such as:
• cisplatin (Platinol) and etoposide
• carboplatin and etoposide
• cisplatin and irinotecan (Camptosar).
For non–small cell cancers, cisplatin, carboplatin, paclitaxel (Abraxane), and docetaxel (Taxotere) are among the drugs used.

Other treatments
Other possible treatment methods include radiofrequency ablation, photodynamic therapy, and laser therapy.

What to do
• Provide comprehensive supportive care and patient teaching to minimize complications and promote recovery from surgery, radiation, or chemotherapy.
• Evaluate the patient. He should experience an uneventful recovery from surgery, radiation, or chemotherapy. He and his family should verbalize an understanding of risk factors and alter their smoking behavior as appropriate. The patient should follow the treatment regimen and understand the need for good pulmonary hygiene and follow-up. He should also recognize signs and symptoms of respiratory tract infection and understand the need to report these immediately.

Cancer care

Cancer care: Malignant melanoma

Focus topic: Cancer care

The most lethal form of skin cancer, malignant melanoma remains uncommon but is increasing at a rate of about 4% per year. An estimated 68,000 new cases develop each year, with about 8,700 deaths. Peak incidence occurs from ages 45 to 55.
The four types of melanoma are:
• superficial spreading melanoma
• nodular melanoma
• acral-lentiginous melanoma
• lentigo maligna melanoma.

What causes it
The cause of malignant melanoma is unknown. Risk factors include a family tendency, a history of melanoma or dysplastic nevi, excessive sun exposure, a history of severe sunburns, and fair skin.

Ancestral affliction

Most people who develop melanoma have blond or red hair, fair skin, and blue eyes; are prone to sunburn; and are of Celtic or Scandinavian ancestry. Other risk factors are immunosuppressant therapy and psoralen UVA treatment for psoriasis.

Pathophysiology
Melanoma arises from melanocytes (cells that synthesize the pigment melanin). In addition to the skin, melanocytes are less commonly found in the meninges (membranes of the brain and spinal cord), eyes, mouth, and vagina.

When melanoma goes mobile

Melanoma spreads through the lymphatic and vascular systems to the regional lymph nodes, skin, liver, lungs, and central nervous system. Prognosis varies with tumor thickness. Typically, superficial lesions are curable, whereas deeper lesions tend to metastasize and carry a poorer prognosis.

What to look for
Suspect melanoma when any skin lesion or nevus enlarges, changes color, becomes inflamed or sore, itches, ulcerates, bleeds, changes texture, or shows signs of surrounding pigment regression (halo nevus or vitiligo).

Superficial spreading melanoma
Features of superficial spreading melanoma, the most common type, include:
• a red, white, and bluish tinge over a brown or black background
• irregular, notched margins
• an irregular surface
• a small, elevated nodule that may ulcerate and bleed
• horizontal growth pattern.

Nodular malignant melanoma
Nodular malignant melanoma usually grows vertically, invades the dermis, and metastasizes early. It commonly appears as a polyp and has uniformly dark discoloration; sometimes, it’s grayish, resembling a blackberry. Occasionally, it matches the patient’s skin color. Pigment flecks may appear around the lesion’s base, which may be inflamed.

Acral-lentiginous melanoma
Acral-lentiginous melanoma occurs mainly on the palms and soles—especially on the tip of a finger or toe or in the nail fold or bed; sometimes, it’s seen on mucosal surfaces, such as the vulva or vagina. It appears as an irregular, enlarging black macule and has a prolonged nonvinvasive stage. Although relatively rare, it’s the most common melanoma type in nonwhite persons.

Lentigo malignant melanoma
Lentigo malignant melanoma, a relatively rare type, develops over many years from a lentigo maligna (a black or brown, mottled, slowly enlarging lesion with irregular borders) on an exposed skin surface. Usually diagnosed between ages 60 and 70, the lesion looks like a flat, large (2.5 to 6.5 cm) freckle.

A neutral palette

The lesion may be tan, brown, black, white, or slate; and may have scattered black nodules on the surface. Eventually, it may become ulcerated.

Cancer care

What tests tell you
• A skin biopsy with histologic examination distinguishes malignant melanoma from a benign nevus, seborrheic keratosis, or pigmented basal cell epithelioma. It also determines tumor thickness.
• Chest X-ray aids staging.
• Blood studies may show anemia and an elevated erythrocyte sedimentation rate. With metastasis, these tests may also reveal an abnormal platelet count and abnormal liver function studies.

How it’s treated
Wide surgical resection is imperative in treating malignant melanoma. The extent of resection depends on the size and location of the primary lesion. Surgery may include regional lymphadenectomy.

Chemotherapy and biotherapy
Deep primary lesions may merit adjuvant chemotherapy with dacarbazine and nitrosureas carmustine (BCNU) and cisplatin ( Platinol). Biotherapy with interferons, interleukin-2, tumor necrosis factor, and vaccine therapy is being studied.

Radiation therapy
Radiation therapy is usually reserved for metastatic disease. It doesn’t prolong survival but may reduce tumor size and relieve pain. Prognosis depends on tumor thickness.

What to do
• After surgery, take steps to prevent infection. Check the wound often for excessive drainage, foul odor, redness, and swelling. If surgery involved lymphadenectomy, minimize lymphedema by applying a compression stocking and instruct the patient to keep the extremity elevated.
• During chemotherapy, know which adverse reactions to expect and do what you can to minimize these. For instance, give an antiemetic as ordered to reduce nausea and vomiting.
• For advanced metastatic disease, control and prevent pain by giving an analgesic around the clock. Don’t wait until pain begins to initiate pain relief.
• Provide psychological support to help the patient cope with anxiety. Encourage him to express his fears. Answer his questions honestly without destroying hope.
• Evaluate the patient. He should recover uneventfully from surgery. He should also understand risk factors for melanoma and the importance of getting careful treatment follow-up, preventing sun exposure, and performing monthly skin self-examinations.

Cancer care

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