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78 Cards in this Set

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Incidence and Epidemiology
-Major health problem in US: More than 8 million Americans are living with cancer
-Incidence rises with age. Most cases affect adults in mid-life and beyond with 77% Dx. after age 55.
-Second most common cause of death with half occurring before 65
Epidemiology
1940's-5 year survival rate: 40%
2000 - 5 year survival rate: 62%
1 out of every 4 deaths in US is from cancer
Epidemiology
-2004 data shows:
Mortality rates for the 4 most common cancers: lung, breast, prostate and colorectal have decreased.
-Reasons for decrease:
Better methods of detection and increased knowledge of prevention
Effective treatment approaches
Cost
-NIH Estimate: 171.6 billion in 2002
-17% of Americans under 65 years have no health insurance
-27% of Americans over 65 have only Medicare coverage (not enough to cover cancer pt.)
What is Cancer?
-A series of cellular, genetic aberrations which result in abnormal cell growth
-Unchecked growth allows invasion of surrounding tissue
-Ability to spread (metastasize) to sites distant to original growth
What is Cancer?
-More than 200 diseases characterized by unregulated cell growth.
-Cellular proliferation may be defective
-Cellular differentiation may be defective
Normal Cellular Proliferation
-Population of predetermined undifferentiated cells
-Characterized by programmed cell death
-The number of cells proliferating equals the number of cells dying
Cellular Differentiation
-This is an orderly process
-Cells differentiate to perform their preprogrammed function
Cellular Differentiation
-Protooncogenes: normal cellular genes promote and regulate cell
-Tumor suppressor genes: suppress cellular growth
-Mutations may alter these genes and influence the development of cancer
Characteristics of Normal Cells
-Have limited cell division
-Specific morphology (shape and look)
-Small nuclear cytoplasmic ratio
-Perform specific differentiated functions
-Adhere tightly together
-Are non-migratory
-Grow in orderly, regulated manner
-Are contact inhibited
Characteristics of Benign Cells
-Continuous/inappropriate cell growth
-Specific morphology
-Small nuclear cytoplasmic ratio
-Perform differentiated functions
-Adhere tightly together
-Are non-migratory
-Grow in orderly manner
Characteristics of Malignant Cells
-Rapid or continuous cell division
-Anaplastic morphology (don't look normal)
-Large nuclear cytoplasmic ratio
-Lose some or all diff. functions
-Adhere loosely together
-Are able to migrate
-Grow by invasion
-Are not contact inhibited
Cancer Cell Characteristics
-Immortal
-Able to divide without anchorage
-Capable of angiogenesis
-Accelerated use of nutrients
-Able to invade other tissues
Histological Analysis Classification: Grading
Grade I -- Cells differ slightly from normal cells and are well differentiated: Mild dysplasia
Grade II -- Cells are more abnormal and moderately differentiated: Moderate dysplasia
Grade III -- Cells are very abnormal and poorly differentiated: Severe dysplasia
Grade IV -- Cells are immature and primitive and undifferentiated: Anaplasia
Basic Clinical Staging
(How much cancer does this person have?)
Stage 0 -- Carcinoma insitu
Stage I -- Localized tumor growth, limited to tissue of origin (clear, clean margins)
Stage II -- Limited local spread
Stage III -- Extensive local and regional spread (spread to lymph nodes)
Stage IV -- Metastatic disease, distant spread
"TNM" Classification
T = tumor size
N = degree of regional spread or lymph nodal status
M = metastatic spread
Staging
T1 N2 M0 = small tumor, 2 lymph nodes, no metastasis
T2 N0 Mx = larger tumor, no lymph nodes, unknown metastasis
T2 N2 M1 = large tumor, 2 lymph nodes, metastasis
Cancer Development
Carcinogenesis/oncogenesis

Malignant transformation
Biology of Cancer
Initiation
-Irreversible alteration in the cells genetic structure (DNA)
Chemical Physical Genetic
Promotion
-Reversible proliferation of the altered, initiated cell
-Latent period - the time between initial genetic alteration and clinical evidence of cancer. (1-40 years)
Progression
-Increased growth rate of the tumor and increased invasiveness and metastasis
Biology of Cancer
-Metastasis can occur early or late
-follows a somewhat predictable pattern (example: lung cancer check bone and brain for site of metastasis)
-Angiogenesis: the ability to establish a blood supply and directly invade tissues.
Extrinsic Factors
-Environmental carcinogens
-Chemical
-Physical
-Viral
-Dietary
Intrinsic Factors (Non-Modifiable)
-Immune function
-Age
-Genetic predisposition
-Geographic location
-Stress
-Gender
Warning Signs of Cancer
C-change in bowel/bladder habits
A-sore that doesn't heal
U-unusual bleeding or discharge
T-thickening or lump in breast
I-indigestion or difficulty swallowing
O-obvious change in wart or mole
N-nagging cough or hoarseness
Unintentional weight loss
Role of the Immune System
-Tumor Associated Antigens (TAA's) Antigens found on tumors resulting in cell surface antigen changes
Role of the Immune System
-Initiate a response to foreign substances
-Respond to Tumor Associated Antigens
-Immune surveillance
Escape Mechanisms
-Cell surface antigens are weak
-Overwhelming antigen exposure
-Blocking factors
Oncofetal Antigens
-Type of tumor antigen found on the surfaces and inside cancer cells and fetal cells
-These antigens have been the focus of recent cancer therapies
Tumor Surface Antigens
(measures how active cancer is, also called Tumor Markers)
-Alpha-fetoprotein (AFP)
-CA-125
-CA-15-3
-Human chorionic Gonadotropin (HCG)
-Carcinoembryonic Antigen (CEA) colon cancer
-Prostate Specific Antigen (PSA)
Different Kinds of Cancer
Some common carcinomas
-Lung
-Breast
-Colon
-Bladder
-Prostate
Leukemias
-Bloodstream
Lymphomas
-Lymph nodes
Some common sarcomas
-Fat
-Bone
-Muscle
Naming Cancers
Prefix: adeno
gland
Naming Cancers
Prefix: chondro-
cartilage
Naming Cancers
Prefix: erythro-
red blood cell
Naming Cancers
Prefix: hemangio-
blood vessels
Naming Cancers
Prefix: hepato-
liver
Naming Cancers
Prefix: lipo-
fat
Naming Cancers
Prefix: lympho-
lymphocyte
Naming Cancers
Prefix: melano-
pigment cell
Naming Cancers
Prefix: myelo-
bone marrow
Naming Cancers
Prefix: myo-
muscle
Naming Cancers
Prefix: osteo-
bone
Naming Cancers
Tissue of Origin: Epithelium
Malignancy: Adenocarcinoma
Naming Cancers
Tissue of Origin:
Connective Tissue
Malignancy: Sarcoma
Naming Cancers
Tissue of Origin:
Endothelial Tissue
Malignancy: Hemangiosarcoma
Naming Cancers
Tissue of Origin: Neural Tissue
Malignancy: Glioblastoma, Medulloblastoma
Naming Cancers
Origin of Tumor: Bone
Name: -sarcoma
Naming Cancers
Origin of tumor: Bone
Name: Osteo
Naming Cancers
Origin of tumor: Cartilage
Name: Chondro
Naming Cancers
Origin of tumor: Fat
Name: Lipo
Naming Cancers
Origin of tumor: Skeletal Muscle
Name: Rhabo
Naming Cancers
Origin of tumor: Smooth Muscle
Name: Leiomyo
Goals and Principals of Cancer Therapies
-Cure: A complete response that is durable
-Control: An extension of life when we do not expect cure
-Palliation: Comfort and reduction in tumor burden that may be causing symptoms
Adjuvant Therapy
-"Added therapy" usually follows definitive treatment
-Therapy may be chemotherapy, radiation therapy, hormonal therapy or immunotherapy
-Requires careful evaluation of risk vs benefit.
-"Added therapy" usually follows definitive therapy
Treatment Modalities: Surgery
-Preventive: removal of precancerous lesion or suspicious area with cells that are likely to become cancer
Examples: suspicious moles, prophylactic mastectomy, colon polypectomy
Surgery
-Curative, the goal is the removal of the tumor to cure the disease. The trend has been to remove as little tissue as possible and include examination of the lymph nodes
Surgery: Diagnostic and staging
-Biopsy
-Staging
-Endoscopic
"second look" - make sure we removed all the cancer
Surgery
-Palliative
-Restorative (ex: breast reconstruction)
-Removal of metastasis
-Supportive surgery, may include g tubes, or ports
Surgery
-Cytoreductive Surgery
a.k.a. debulking
Remove as much of a cancer as possible, then treat with chemotherapy or radiation therapy
-Undertaken when there is a good chance radiation and chemo will be able to destroy residual cancer
Radiation Therapy a.k.a. XRT
-Radiation disrupts the replication process of dividing cells
-The goals of radiation therapy are similar to those of surgery or chemotherapy
-Kills cancer cells and non-cancer (healthy) cells
Radiation
-1895-First discovered by Wm. Roentgen
-1896-Radium discovered by Madame Marie Curie and Pierre Curie
-1960's-Beginning of research/improved technology and equipment
-Today approx. 60% of cancer patients will receive radiation therapy to treat their disease
Goals of Radiation Therapy
-Achieve maximum tumor kill while minimizing injury to surrounding tissue
*Cure
*Control
*Palliation
*Adjuvant
Types of Radiation Therapy
-External beam: radiation is directed from an outside source into the body also referred to as teletherapy (given in divided doses)
-Brachytherapy: could also be called internal therapy, the radioactive source is placed inside the body, near the cancer.
Radiation Therapy
-Usually daily treatment over 2-8 weeks depending on total dose = fractionalization
-Curative course longer than palliative
-Given by Fractionalization-goal to give large dose over time, decreasing toxicity, increasing cell kill
-Requires simulation = CT Scans (mark field with skin markers or tatoos. Nurse must know not to remove).
Simulation
-Meeting with radiation oncologist and physicist to determine dose, location and methods to be used.
-Client is positioned where mock treatment is to be performed
-Skin markings used to mark treatment field-DO NOT WASH OFF! (May even be a tattoo).
Brachytherapy
-Radiation delivered directly by implant or insertion of radioactive source directly into tumor or nearby the tumor
-Treatment usually over short period
-Maximum effect to local area with minimal damage to surrounding area
Example: Brachytherapy for Prostate Cancer
Brachytherapy-Sealed Sources
-Placed into tumor (interstitial) or body cavity (intracavity)
-Body fluids not contaminated
-Notify Radiation Oncologist if dislodged, never touch with bare hands!
-Need lead container/forceps in room for accidental dislodgement
Brachytherapy-Sealed Sources (cont)
-Safety issues: private room, usually lead-lined walls
-Caregivers wear dosimeter to monitor radiation exposure
-Minimal contact with client
-Follow agency protocol re: linens, dressings and dispose of accordingly
Brachytherapy, Unsealed source
-Systemic radioisotope that concentrates in high activity area (ie, the tumor), given IV or PO
-Safety issues: client and potentially body fluids are radioactive up to 3-4 days
-Excreted in saliva, sweat, urine, emesis, stool
Brachytherapy, Unsealed source (cont)
-Due to contamination issues, attention must be given to avoiding oral contact with others, wash eating utensils/dishes separately.
-Flush toilet twice, reduces contamination.
-Practice good hand hygiene.
-Wash clothes separately
-Know your agency protocol
Time, Distance, Shielding
-Time: Dose of radiation received based on time near source
-Nursing Implication: Cluster care, organize supplies prior to entering room
-Health care provider: 1/2 hour in 8 hour shift
-Visitor: no more then 1/2 hour per day
-No pregnant persons - either visitors or staff
Time, Distance, Shielding (cont)
-Distance: Dose of radiation received determined by amount or space between source and care giver.
-Nursing implication: The further the distance, the less exposure.
-Stand several feet away from client on opposite side as source.
-Visit from door rather than entering.
-The radiation safety officer may be involved in planning the distance allowable. (How close can I be to the patient?)
Time, Distance, Shielding (cont)
-Shielding: involves placing protective device between source and caregiver.
-Most often used is lead, ie. lead-lined walls or containers
-Note: lead aprons NOT advised as don't shield all rays.
Will I be radioactive?
-External Beam: there is NO potential radiation exposure to caregivers or families.
-Internal Radiation: when the source of radiation is an enclosed implant patients are hospitalized in a lead-shielded room to protect others from exposure to the minimal amounts of radiation emitting.
Will I be radioactive? (cont)
-Prostate implants: the amount of radiation to the patient and others is considered safe. Answer: NO
-Radioactive Iodine: patients are isolated from children and from physical contact with others until the iodine is flushed from the body. Answer: YES, need instruction when they leave hospital
Radiation Side Effects
-Fatigue (3-4 weeks into treatment)
-GI symptoms-nausea, vomiting, anorexia, altered taste, diarrhea
-Alteration in skin integrity
-Bone marrow suppression
-Genitourinary tract - cystitis, nephrotoxicity, reproductive dysfunction
-Pneumonitis-acute and delayed (pleural effusion need to think about what's in the field)
Radiation Side Effects (cont)
-Fatigue: occurs 3-4 weeks into therapy, may be complicated by depression, anemia or nausea
Nursing Interventions
-Education re: energy conservation
-Assessment of symptoms
-Education re: exercise
Radiation Side Effects (cont)
-Bone marrow surression: occurs relatively soon after beginning therapy, may be worse when client is receiving combination therapy
Nursing Interventions: education related to infection prevention, energy conservation, thrombocytopenia precautions
Radiation Side Effects (cont)
-Local effects will be noted as a result of exposure of the tissues to the radiation. An example would be, pneumonitis (SOB), diarrhea or xerostomia (dry mouth)
Xerostomia and Mucositis
-May be related to radiation or chemotherapy
-May compromise nutritional status
-Mucositis may involve the entire GI tract
Treatment for mucositis: saliva substitutes, vitamin E tablets