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135 Cards in this Set
- Front
- Back
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what do patients with suspected cancer undergo testing for
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Presence and extent of the tumor
Identify Metastasis Evaluate the function of the organs involved Obtain biopsy for staging and grading |
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what does staging do
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Determines the size of the tumor and the existence of local invasion and distant metastasis.
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what is used for the staging of cancer
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TNM
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what does TMN stand for
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tumor, nodal involvement, metastasis,
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what is Tx
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primary tumor cannot be assessed
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what is T0
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no tumor found
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what is Tis
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carcinoma found in situ
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what is the T scale range from
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Tx-T4
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what does the N class range from
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N1-N3
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what does the M class range from
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M0-M1
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what are the treatment options for cancer
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Cure
Control Palliation |
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what are the therapeutic treatments for cancer
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Surgery
Radiation Chemotherapy Biologic therapies Phototherapy or Photodynamic Therapy |
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what are the types of biopsies
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Excisional
Incisional Needle aspirations Sentinel lymph node biopsy |
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what are the types of surgery for cancer
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Primary
Prophylactic Palliative Reconstructive |
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how is radiation therapy used palliatively
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Prophylactically usage relieve cough, pain, chest pain, hemoptysis , bone and liver pain
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what are complications of radiation therapy
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burns, pneumonitis, pericarditis, esophagitis, radiation lung fibrosis
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how does radiation therapy work
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Uses high energy x-rays or other types of radiation to kill cancer cells
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what is external radiation therapy
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uses a machine to send radiation toward the cancer
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what is internal radiation therapy
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uses radioactive substance in seeds, needles, wires or catheters
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what are the types of internal radiation
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Brachytherapy
Intracavity radioisotopes MammoSite Systemic Brachytherapy |
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what are the signs of radiation toxicity
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Alopecia
Xerostomia Stomatitis Anorexia, Nausea Vomiting Thrombocytopenia Skin burns |
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what is chemotherapy used for
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non-resectable tumors or as adjunct to surgery. Used to alter the growth of tumor cells
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How does chemotherapy destroy the tumor
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by interfering with the cellular functioning including replication
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what are the most sensitive cells to chemo
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Proliferating cells within a tumor
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what are the complications of chemo
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Peripheral Neuropathy
N/V Alopecia Nutrition and weight loss concern Extravasion Cardiac toxicities Sterility CNS Fatigue Bone Marrow Suppression Leukopenia sepsis Anemia Thrombocytopenia |
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what does biological therapy do
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Alters the biologic response of the host toward the tumor cells
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how is biological therapy used
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as an adjuvant
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what can be used for biological therapy
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Interferon
Interleukins Monoclonal Antibodies Growth factors |
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what does YAG do
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Shrinks the tumor as a result of thermal necrosis
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how does phototherapy work
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Porfimer injected IV concentrates in tumor cells, is activated by laser light, destroys tumor cells by producing a toxic form of oxygen
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what are preoperative nursing interventions
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Patient Teaching
TCDB/ Incentive spirometry Incisional Splinting Mobility Pain Management Ivs/ Foleys |
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what is included in the initial post operative assessment
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VS including O2 sats and Oxygen ordered
Pain assessment Wound Dressings , Drains, tubes |
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what is included in the Family and patient unit orientation
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Introduction
Call bell Restrooms |
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what are postoperative nursing interventions
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Prevent respiratory Complication
Relieving Pain Encouraging ambulation if ordered Manage wounds/ Change dressings daily or as ordered Care for drains: check often, note color, amount and odor of drainage JP, Hemavac, Promote Bowel Function Manage Voiding TEDS/Seds |
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what is palliative care
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Comprehensive symptom management, psychosocial care and spiritual support to enhance quality of life.
Interdisciplinary collaboration |
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what is hospice
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Interdisciplinary services provided by professional caregivers and trained volunteers to patients with serious progressive illness that are not responsive to cure.
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what are the principles of hospice
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Death must be accepted
Interdisciplinary Team who communicates Pain and other symptoms are managed Patient and Family are treated Home care of dying is necessary Bereavement care provided to family Research and education should be ongoing. |
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what are the risk factors of breast cancer
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Age
Hereditary Familial Genetic Prior history Benign breast disease Age at menarche |
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what is the familial risk factor
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Four or more women who have had breast or ovarian cancer across at least two generations
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what is the heredity risk factor for breast cancer
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BRCA1and BRCA2
mutation increases risk of breast cancer by 6.0-14.0 |
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In Whom Should Testing for Breast Cancer Gene Mutation be Considered?
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Individual member of a family with known BRCA 1 or BRCA 2 mutation
Breast and ovarian cancer in a single family member 2 or more family members with breast cancer under age 50 Male breast cancer Ashkenazi ancestry and one family member with breast cancer under age 50 or ovarian cancer at any age |
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what is the prior history risk factors
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Breast Biopsy
Atypical Hyperplasia Hyperplasia |
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what are estrogen risk factors for breast cancer
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Exposure to estrogen over prolonged durations results in increased risk.
Menarche- small relative risk under 12 protective over 15 Menopause – After 54 First pregnancy – Early 40’s |
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what are other risk factors for breast cancer
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HRT, Obesity/Anthropometric Factors
Alcohol Smoking – no effect? Breast Implants – no effect? Environmental Toxins – Which and how much? |
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what should you do for normal risk prevention
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Based on solid evidence, The Women’s Health Initiative Study, obesity is associated with increased breast cancer risk
Post-menopausal women just 44 pounds overweight double their risk of breast cancer. Strenuous exercising more than 4 hours per week is associated with reduced breast cancer risk. Insulin-like growth factor-1, or IGF- 1 |
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what can be used for high risk prevention
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The Breast Cancer Prevention Trial showed that tamoxifen, a selective estrogen-receptor modulator, reduced the incidence of breast cancer in healthy women determined to be at high risk.
4 years, tamoxifen reduced the incidence of breast cancer by 49% compared with placebo (P<.00001). |
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what can be done to detect breast cancer
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Self breast exam
Clinical exam Mammography Breast lump |
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what are the screening guidelines for breast cancer
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Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health.
A clinical breast exam should be part of a periodic health exam, about every three years for women in their 20s and 30s, and every year for women 40 and older. Women should know how their breasts normally feel and report any breast changes promptly to their health care providers. Women at increased risk (e.g., family history, genetic tendency, past breast cancer) should talk with their doctors about starting mammography screening earlier. |
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what does a mammogram do and when should it be started
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Lower the chance of dying from breast cancer by 35% in women over the age of 50
Ages 40 – 50 – Baseline and then annually |
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what do you do for an evaluation of a palpable mass
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Can wait through menstrual cycle
The role of mammography is not to visualize a palpable mass. Best evaluated by biopsy Fine needle aspiration core biopsy |
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what are the types of non-invasive breast cancer
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DCIS
LCIS |
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what are the types of invasive breast cancer
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Adenocarcinomas
Ductal carcinomas Lobular Medullary Tubular Inflammatory |
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what is inflammatory breast cancer
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Less than 1%-2% of breast cancers, but most malignant – very aggressive
Breast looks red, swollen, feels warm Cancer cells block the lymph vessels in the skin Skin may look like the skin of an orange (peau d’orange) Can be confused as infection Can occur at any age, can be misdiagnosed |
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what are the types of breast surgery
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Mastectomy –
Modified radical Total Mastectomy Wide local excision – excisional biopsy, lumpectomy, segmental mastectomy Breast Reconstruction |
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what are the reconstruction surgerys
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TRAM, implants
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what is TRAM
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Transfer of rectus abdominal muscle
Involves transfer of tissue from another part of the body Long, involved surgery Longer hospitalization and longer recovery time Must be in good health and nonsmoker Leave hospital with breasts |
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what are implants
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Following skin sparing mastectomy
Tissue expander – not the same as cosmetic implants Usually replaced by more permanent implant later on Placed on top of pectoral muscle Takes weeks to months for result |
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what are the prognostic markers
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C-erb2/Her-2/neu
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what is a theraputic option for the prognositc markers
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herceptin
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how do you test the risk of recurrance
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using biomarkers
The TAILORx trial is underway to determine the validity of the Oncotype DX results |
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how do you check lymph node involvement
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sentinel node biopsy
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what are the lymph node status categorizations
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N0 No involved nodes
N1 Involved node or nodes N2 Involved nodes that are fixed to one another N3 Represents cancer in the lymph nodes within breast tissue |
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what are the metastasis categorizations
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M0 no metastasis
M1 metastasis has occurred |
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what is pre-op nursing care for breast cancer
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Teach turning, coughing and deep breathing, IS
Teach post op exercises Type of surgery Emotional support Explain pain control |
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what is post-op nursing care
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Turn, cough, deep breath, IS
Exercises Pain control Emotional support S/S infection Ambulation Nutrition |
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what are discharge instructions for cancer patients
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Signs and symptoms of infection
Ambulation and exercises Wound care Follow up appointments, plan Support groups Pain control |
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what are the arm exercises after lymph node dissection
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Perform slowly and gently
Goal is Full ROM Perform 4 times/day Open and close hand Sitting crawl up and down thigh Bend and extend elbow With your arm extended at side twist hand/wrist and lower arm Shrug shoulders Hand on shoulder make circles “wing” “Wall climbing” Gradual improvement |
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what is breast cancer staging
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Stage 1
Tumor <=2 cm with no lymph node metastasis Stage 2 Tumor >2 cm or positive lymph nodes Stage 3 Locally advanced (Skin or Chest wall) Stage 4 Metastatic (Lung, Liver, Bones, Brain) |
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what are Adjuvant Treatment Decisions
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Protocol/Algorithm Driven
Hormone Chemotherapy Radiation Herceptin Watchful waiting |
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what is the treatment plan for breast cancer
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Must take into consideration type of cancer, disease stage and treatment goals
Chemotherapy: neoadjuvant, adjuvant, palliative, prevention Radiation Surgery Clinical Trials |
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what is Adjuvant Systemic Therapy
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Premenopausal
Postmenopausal Chemotherapy Dose Dense High dose therapy Neoadjuvant therapy Standard Chemotherapy |
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what is a mammosite
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Partial Breast Irradiation (PBI)
Targeted to specific area of breast Only takes 5 days compared to weeks Recurrence rate 1-3% lower Balloon placed at time of surgery – catheter outside of body Radioactive seed place inside balloon Removed following treatment |
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what are the effects of chemotherapy
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Adriamycin –
Hair Loss, Infertility, Heart Failure Cytoxan Immunosuppressive Taxanes Myalgias, weight gain |
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what is targeted therapy
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Trastuzumab Herceptin
Now for Her2+ women One year of therapy |
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what are the types of Adjuvant Hormonal Therapy
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Premenopausal
Tamoxifen Postmenopausal Aromatase Inhibitors ATAC Trial,2003 |
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what are the effects of hormone therapy
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Weight gain?
Hot flashes Myalgias Depression/fatigue? Vaginal Dryness |
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what must be done with hormone therapy
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Exercise
Low fat diet Use birth control Annual gyne exams Can discuss local estrogen for vaginal dryness Symptom Cluster |
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what is the follow up schedule for breast cancer
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History and Physical every 4-6 months for 5 years and then annually
Mammogram annually On Tamoxifen – Gynecologic exam annually On AI – Gyne + Bone density baseline and every 2 years. |
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what are some nursing diagnosis for breast cancer
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Anxiety related to fear of diagnosis of breast cancer
Powerlessness related to decisional conflict and informational overload regarding breast cancer treatment options and plan of care Risk for injury related to surgical wound healing and impaired lymph drainage secondary to breast cancer surgery, complicated by failure to view and care for wound/drains Anxiety related to fear of side effects of additional treatment with chemotherapy or radiation therapy and to impact on resumption of usual activities in social and family life Impaired social interaction Anticipatory grieving, related to possible losses, including death |
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what is the Treatment of Recurrent New Primary
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Begin over again
Staging Treatment as per disease severity |
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what is the treatment of Treatment of Metastatic Disease
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Depends on Previous Treatment
Weekly therapies Herceptin+/- chemotherapy Hormonal manipulation Tamoxifen Aromatase Inhibitors Other anti-estrogen options |
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what are the types of metastatic disease
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Bone alone
Visceral Disease Options |
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what are the ovaries and what are their function
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Walnut-sized (premenopausally)
Lie below the fallopian tubes on each side of the uterus Produce ripe eggs about once a month Egg is walled off from rest of the ovary in a cyst (normal) At ovulation, the egg is released and picked up by fallopian tube, & cyst bursts |
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what are the types of ovarian cancer
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Epithelial (outside layer of cells covering the surface of the ovary) – 85-90% of all ovarian cancers
Germ cell malignancies - arising from the ova (most common in teens & 20’s) – rare, aggressive, but curable; 70% diagnosed at Stage I. Stromal tumors (connective tissue within ovary)– rare low grade cancers; 70% diagnosed at Stage I. 75-90% have long-term survival |
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what are the risk factors for ovarian cancer
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Age
Family history/Genetics Infertility/No children Personal history of cancer |
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what is the Median age at diagnosis
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63
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what is the Single greatest risk factor for ovarian cancer
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family history
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what heredity fact places a patient at most risk for lifetime chance of getting ovarian cancer
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Known BRCA1 or BRCA2 germline mutation
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who passes along the BRCA1 and BRCA 2 mutation
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both men and women
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what does BRCA1 mutation increase
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lifetime risk or breast and ovarian cancer and colon cancer
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which causes more heredity ovarian cancers BRCA1 or 2
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BRCA1
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what does BRCA2 do to people
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increases women's life time risk of developing breast cancer and ovarian cancer. Men have increased risk of breast cancer
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what kind of inheritance is the BRCA gene
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Autosomal dominate
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who has a hereditary risk for ovarian cancer
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History of 2 or more individuals from the same side of the family (including yourself) with premenopausal breast or ovarian cancer at any age
A male relative with breast cancer A male or female relative known to carry the BRCA1 or BRCA2 mutations |
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what personal history risk factors are there for ovarian cancer
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Personal history of breast, colon, or uterine (endometrial) cancers
Women with personal history of breast cancer have a 4 x risk for ovarian cancer |
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what can women with a high risk of developing ovarian cancer do?
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Consider q 6 month screening with Ca-125 & trans-vaginal ultrasound for very high risk women**
Use of oral contraceptives Prophylactic oopherectomy should also be considered for those 35 years and older and not considering future childbearing |
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what is CA 125
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Tumor marker
Function not fully understood Elevated in the blood in >80% of advanced epithelial ovarian cancers Can be used to monitor progression of disease in known ovarian cancer patients |
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how high is CA 125 elevated in stage 1 cancers
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Elevated in only 25-50% Stage I cancers
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what is a risk factor with no children for developing ovarian cancer
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Unexplained infertility, no pregnancies & no history of birth control pill usage
One theory: uninterrupted ovulation |
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what heritage is a risk factor for ovarian cancer
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Ashkenazi Jewish descent and people living in industrialized countries
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what are factors that reduce the risk of developing ovarian cancer
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Removal of ovaries
Oral contraceptives Pregnancy/breast feeding Bilateral tubal ligation (Hysterectomy) diet and exercise |
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what are facts on birth control pills and decreasing the risk of ovarian cancer?
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Oral contraceptives reduce the risk for ovarian cancer; the benefit is immediate.
Average risk decreases 10-12% for those who have used oral contraceptives for 1 year. Average risk halved for those who have used oral contraceptives for > 5 years. |
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what does pregnancy do to reduce ovarian cancer risk
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First full-term pregnancy < age 25
Number of pregnancies Breast-feeding |
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what surgeries can be done do reduce the risk of ovarian cancer
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Bilateral tubal ligation
Risk reduction of 33% Hysterectomy Risk reduction of 67% Removal of ovaries Risk reduction of 95% |
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how can diet and exercise decrease the risk of ovarian cancer
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Body Mass
Increased body mass a/w increased risk* Diet Low-fat milk Vitamin-rich foods Decrease fat Exercise Women who work out > 6 hours/wk had a 27% lower risk than those with <1hr/wk |
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what is early detection important of ovarian cancer
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70% of ovarian cancers are diagnosed at advanced stage (III and IV)
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what don't pelvic exams work to detect ovarian cancer
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do not detect early stages
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why don't pap smears work to detect ovarian cancer
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Sensitivity of only 10-30% - High false negatives
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when is a routine CA 125 screen used
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used for following course of disease after diagnosis
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what is test sensitivity
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The extent to which a test can find a cancer that is there. Low sensitivity = high rate of false negatives
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what is test specificity
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Extent to which test is able to determine no cancer when there is none. Low specificity = high rate of false positives.
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whats wrong with diagnostic ultrasounds
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lots of false positives
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what are the screening recommendations for ovarian cancers
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Comprehensive family history on all patients
All women Annual rectovaginal pelvic exam 2 or more family members Genetic counseling Annual rectovaginal pelvic exam, CA125, transvaginal ultrasound Consider clinical trial participation |
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what are symptoms of ovarian cancer
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Pelvic or abdominal pain or discomfort
Frequency and/or urgency of urination Pelvic and/or abdominal swelling, bloating and/or feeling of fullness Vague but persistent gastrointestinal upsets such as nausea & indigestion; early satiety |
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what should you do if you have persistence of symptoms
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If you experience a new onset of these symptoms which persist for > 2 weeks, seek evaluation from your gynecologist.
Aske gyn to put ovarian cancer on the differential. Bi-manual recto-vaginal pelvic exam Transvaginal ultrasound |
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what is done to diagnose ovarian cancer
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Rectovaginal pelvic exam
Transvaginal ultrasound and/or CT scan CA 125 If diagnosis uncertain, laparoscopy may be useful Surgery may be needed for diagnosis |
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what is wrong with diagnosing ovarian cancer
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No exam or test is perfect for diagnosing ovarian cancer
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what is treatment of ovarian cancer in stage 1A and 1B
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Total abdominal hysterectomy and bilateral salpingo-oopherectomy with omentectomy
In patients who wish to maintain fertility, unilateral salpingo-oopherectomy can be considered |
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what is the problem with stage 1C ovarian cancer
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chance of relapse
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what is the treatment of stage 1C ovarian cancer
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Add chemotherapy, or watchful waiting
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what is stage 2 ovarian cancer treatment
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TAH-BSO with omentectomy and tumor debulking
If residual disease remains in pelvis, combination chemo should be used: Most common front-line therapy Paclitaxel (Taxol) + Cisplatin or Carboplatin IV or IV +IP |
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what is stage 3 and 4 ovarian cancer treatment
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TAH-BSO with omentectomy + cyto-reductive surgery (optimal debulking)
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who does ovarian cancer surgery
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gynecologic oncologist
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what is the ovarian cancer surgery
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TAH-BSO with omentectomy
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what is the staging procedure for ovarian cancer surgery
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Undersurface of diaphragm
Pelvic and abdominal peritoneal biopsies Pelvic and para-aortic lymph node biopsies Peritoneal washings |
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what is optimal debunking
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Volume of disease left at end of 1° surgery is related to patient survival
39 months vs. 17 months |
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what are the first line chemotherapies for ovarian cancer
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Platinum compounds up to “optimal dose-intensity”
I.V. and I.P. routes Current efforts focusing on optimally combining platinums with other active drugs (paclitaxel, docetaxel, cyclophosphamide) |
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what is used with optimal debunking patients
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IP chemotherapy (cisplatin or paclitaxel) has favorable outcomes over standard therapy for Stage III with optimal debulking.
IV paclitaxel on day 1, IP cisplatin on day 2, and IP paclitaxel on day 8 x 4-6 courses. <50% tolerate full course. Still 16 month survival advantage |
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what do we do for nausea and vomiting
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it is prophylactic. Corticosteroid (dexamethasone)
5-HT3 antagonist: Ondansetron, granisitron, dolasetron Given pre-chemo and on schedule for 2-3 days post chemo |
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what is used with optimal debunking patients
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IP chemotherapy (cisplatin or paclitaxel) has favorable outcomes over standard therapy for Stage III with optimal debulking.
IV paclitaxel on day 1, IP cisplatin on day 2, and IP paclitaxel on day 8 x 4-6 courses. <50% tolerate full course. Still 16 month survival advantage |
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what is important in therapy completion and recurrence
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interval of time between the two
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what do we do for nausea and vomiting
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it is prophylactic. Corticosteroid (dexamethasone)
5-HT3 antagonist: Ondansetron, granisitron, dolasetron Given pre-chemo and on schedule for 2-3 days post chemo |
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what is important in therapy completion and recurrence
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interval of time between the two
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what should you do if the interval is greater than 5 months
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retreat with platinum. Positive prognostic indicator.
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what should you do if the interval is less than 5 months or patient doesn't respond to platinum
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consider paclitaxel. Negative prognostic indicator.
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