NCLEX: Cancer care

Cancer care: Prostate cancer

Focus topic:Cancer care

The most common cancer in men over age 50, prostate cancer is the second-leading cause of cancer deaths among males. Incidence is highest among Blacks and men with blood type A and lowest in Asians. Incidence isn’t affected by socioeconomic status or fertility.

Testing, testing

Focus topic:Cancer care

Both DRE and serum prostate-specific antigen (PSA) testing are used to screen for prostate cancer. There are limits to screening, however, and the ACS recommends that patients discuss screening with their practitioners.

Prognoses and predictions

Focus topic:Cancer care

When prostate cancer is treated in its localized form, the 5-year survival rate is 84%. After metastasis occurs, the rate drops below 35%. Death typically results from widespread bone metastasis.

What causes it
The cause of prostate cancer is unknown. Risk factors may include:
• age over 40
• diet high in saturated fats
• hormonal factors (testosterone may initiate or promote prostate cancer).

Pathophysiology
Prostate cancer grows slowly. When primary lesions spread beyond the prostate, they invade the prostatic capsule and spread along the ejaculatory ducts in the space between the seminal vesicles.

What to look for
Signs and symptoms of prostate cancer appear only in advanced disease stages and may include:
• difficult urination
• urinary dribbling
• urine retention
• unexplained cystitis (urinary bladder inflammation)
• hematuria (blood in the urine), a rare sign
• back or pelvic pain.
DRE may reveal a hard nodule, which may be felt before other signs and symptoms develop.

What tests tell you
• PSA testing may be used to detect cancer.
• Transrectal prostatic ultrasonography can detect a mass.
• Biopsy confirms the diagnosis.

• Serum acid phosphatase levels are elevated in two-thirds of patients with metastasized prostate cancer. Successful therapy restores a normal enzyme level; a subsequent rise points to cancer recurrence.
• Increased alkaline phosphatase levels and a positive bone scan suggest bone metastasis. However, routine bone X-rays don’t always show evidence of metastasis.

How it’s treated
Treatment varies with each disease stage, but generally includes:
• radiation
• prostatectomy (prostate removal)
• orchiectomy (removal of one or both testes) to decrease androgen production
• cryoablation (tumor removal by freezing)
• hormone therapy with synthetic estrogen (diethylstilbestrol [DES]) or leuprolide (Lupron) and flutamide (Eulexin).

Radical measures

Focus topic:Cancer care

For localized lesions with no evidence of metastasis, radical prostatectomy (removal of the prostate with its capsule, seminal vesicles, ductus deferens, some pelvic fasciae and, sometimes, pelvic lymph nodes) is usually effective.

Radiation therapy
Radiation therapy is used in the early stages to relieve bone pain from metastatic skeletal involvement, or prophylactically for patients with regional lymph node tumors.

Planting a seed

Focus topic:Cancer care

Alternatively, implantating radioactive seeds (brachytherapy) focuses radiation on the prostate while minimizing exposure of surrounding tissue.

Chemotherapy
If hormone or radiation therapy and surgery can’t be done or prove ineffective, chemotherapy may be tried. Common combinations include vinblastine, doxorubicin, estramustine (Emcyt), paclitaxel (Abraxane), and vindesine.

What to do
• Provide supportive care if the patient is scheduled for prostatectomy, along with good postoperative care and symptomatic treatment of radiation and postsurgical complications.

• If incontinence or erectile dysfunction follows treatment, the patient and his significant other should be informed about corrective techniques and educational and support groups. Encourage the patient to contact the ACS for information.
• If the patient has received radiation or hormonal therapy, watch for and treat nausea, vomiting, dry skin, and alopecia. Also watch for adverse effects of DES (such as gynecomastia, fluid retention,nausea, and vomiting) and thrombophlebitis (such as pain, tenderness, swelling, warmth, and redness in a calf).
• Evaluate the patient. He should understand the treatment regimen and be aware of adverse reactions that require immediate medical attention (such as thrombophlebitis). He should also express his feelings about potential sexual dysfunction.

Cancer care

Cancer care: Squamous cell carcinoma

Focus topic:Cancer care

Squamous cell carcinoma is an invasive tumor with metastatic potential that arises from squamous cells—thin, flat cells on the outer layer of the skin. The disease commonly develops on sun-damaged areas.
Except for those on the lower lip and the ears, lesions on sun-damaged skin are less likely to metastasize as readily as lesions arising on unexposed skin. With treatment, prognosis is excellent for well-differentiated lesions on sun-damaged areas.

What causes it
Squamous cell carcinoma may result from overexposure to UV rays, radiation, chronic skin irritation and inflammation, ingestion of herbicides containing arsenic, and exposure to local carcinogens (such as tar and oil).

Sunbathing sequelae

Focus topic:Cancer care

Risk factors for squamous cell carcinoma include:
• being white, male, and over age 60
• having an outdoor job
• living in a sunny, warm climate
• premalignant lesions
• such hereditary diseases as xeroderma pigmentosum or albinism
• psoriasis or chronic discoid lupus erythematosus
• smallpox vaccination.

Pathophysiology
Transformation from a premalignant lesion to squamous cell carcinoma may start with hardening and inflammation of a preexisting lesion. When the disease arises from normal skin, the nodule grows slowly on a firm, hardened base. If untreated, this nodule eventually ulcerates and invades underlying tissues.

What to look for
Physical findings may include lesions on the face, ears, or backs of the hands and forearms as well as on other sun-damaged skin areas. Lesions may be scaly and keratotic (marked by excessive growth of horny skin tissue), with raised, irregular borders.

Powder and crust

Focus topic:Cancer care

In late disease, lesions grow outward from the epithelium, are friable (easily reduced to powder), and tend toward chronic crusting. What tests tell you Excisional biopsy of the lesion confirms the diagnosis.

How it’s treated
Depending on the lesion, treatment may consist of wide surgical excision or electrodesiccation (destruction by electrical current) followed by curettage (tissue removal). These procedures offer good cosmetic results for smaller lesions. Radiation therapy is usually used for older or debilitated patients. Mohs’ surgery (serial excision and histologic analysis of cancerous tissues) may also be indicated.

What to do
• Disfiguring lesions may be distressing to the patient. Try to accept him as he is, develop strategies to increase his self-esteem, and project a caring relationship.
• Develop a consistent care plan for changing the patient’s dressings. A standard routine helps the patient and his family learn how to care for the surgical wound. Keep the wound dry and clean. Try to control odor with balsam of Peru, yogurt flakes, oil of cloves, or other odor-masking substances (although they’re usually ineffective for long-term use). Topical or systemic antibiotics also temporarily control odor and eventually alter the lesion’s bacterial flora.
• Evaluate the patient. He should recover from surgery uneventfully. He should also demonstrate an understanding of sun protection methods and the importance of follow-up care.

Cancer care

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