Cancer: Interprofessional Care and Complications

Cancer: Interprofessional Care and Complications 150 150 Tony Guo

Cancer: Interprofessional Care and Complications

 

Cancer treatment goals

  • Goals
    • Cure therapy 
      • Surgery alone or periods of adjunctive systemic therapy
      • Timeframe to “cure” may differ according to the tumor and its characteristics
    • Control therapy 
      • Initial course and maintenance therapy
    • Palliation therapy
      • Palliation goal 
        • Relief or control of symptoms 
        • Maintain quality of life
      • Palliative care and treatment are not mutually exclusive and can take concurrently

Personalized cancer medicine

  • Genetic information is used to customize decisions about
    • Prevention
    • Diagnosis
    • Treatment
  • Targeted therapy
    • Aims at a cancer’s specific genes or proteins that contribute to cancer growth and survival
    • Biopsy can help determine whether a tumor has the specific target
  • Pharmacogenomics
    • Study of genomic variation associated with drug responses
  • Not all types of cancer have personalized treatment options
    • Costly
    • Time-consuming
    • Not covered by insurance

Cancer treatment 

  • Surgical therapy
    • Oldest form of cancer treatment
    • Meets a variety of goals
    • Trend is toward less radical surgeries
  • Role of surgery in cancer treatment
  • Prevention
    • Removal of non-vital organs to prevent cancer
  • Diagnosis
    • Biopsy
  • Palliation of symptoms
    • Relief of pain
    • Obstruction
    • Hemorrhage
  • Rehabilitation
    • Reconstructive surgery
  • Determine the diagnostic and treatment plan 
    • Clinical staging
  • Cure and/or control of cancer
    • Removal of localized cancer tissue
      • Primary site
      • Site of metastasis
  • Supportive care
    • Insertion of therapeutic devices (e.g., feeding tubes, suprapubic catheter)

 

Chemotherapy

  • Antineoplastic therapy
    • Use of chemicals given as a systemic therapy for cancer
    • Mainstay for most solid tumors and hematologic cancers
    • Can offer cure, control, or palliative care
      • Cure
        • Burkitt’s lymphoma
        • Wilms’ tumor
        • Neuroblastoma
        • Acute lymphocytic leukemia
        • Hodgkin’s lymphoma
        • Testicular cancer
      • Control
        • Breast cancer
        • Non-Hodgkin’s lymphoma
        • Small cell lung cancer
        • Ovarian cancer
      • Palliation
        • Relieve pain
        • Relieve obstruction
        • Improve the sense of well-being
  • Effect on cells
    • Effective against dividing cells, so cancer cells escape death by staying in G0 phase (resting phase)
    • Problem: Presence of drug-resistant resting and non-cycling cells
    • As tumors get bigger, more cells become inactive and convert to G0
    • Chemotherapy agents cannot distinguish between normal and
      cancer cells
    • Side effects are result of destruction of normal cells
  • Nursing management

 

Etiology Effects Nursing managements
Gastrointestinal System 
Stomatitis, Mucositis, Esophagitis Epithelial cells are destroyed by chemotherapy or radiation treatment when located in field (e.g., head and neck, stomach, esophagus).

Inflammation and ulceration occur due to rapid cell destruction.

Assess oral mucosa daily and teach patient to do this.

Encourage nutritional supplements (e.g., Ensure, Carnation Instant Breakfast) if intake decreasing.

Be aware that eating, swallowing, and talking may be difficult (may require analgesics).

Instruct in avoidance of irritating spicy or acidic foods or too hot or too cold food (extremes in temperature).

Instruct on how to select moist, bland, and softer foods.

Encourage patient to keep oral cavity clean and moist by performing frequent oral rinses with saline or salt and soda solution.

Encourage patient to use artificial saliva to manage dryness (radiation).

Discourage use of irritants such as tobacco and alcohol.

Apply topical anesthetics (e.g., viscous lidocaine, oxethazaine)

Nausea and Vomiting Release of intracellular breakdown products stimulates vomiting center in brain.

Drugs also stimulate vomiting center in brain

GI lining destroyed with radiation and chemotherapy.

Encourage patient to eat and drink when not nauseated.

Administer antiemetics pro phylactically before chemotherapy and also on as-needed basis.

Instruct patient to take antiemetics on a scheduled basis for 2-3 days after highly emetogenic chemotherapy.

Use diversional activities (if appropriate).

Anorexia Release of TNF and IL-1 from macrophages has appetite-suppressant effect.

Therapy-induced GI effects (mucositis, nausea and vomiting, bowel disturbances) and anxiety reduce appetite.

Monitor weight.

Encourage patient to eat small, frequent meals of high-protein, high-calorie foods.

Gently encourage patient to eat, but avoid nagging.

Recommend keeping a food diary to track daily calories and fluids.

Serve food in pleasant environment

Diarrhea From denuding of epithelial lining of intestines.

Side effect of chemotherapy.

Follows radiation to abdomen, pelvis, and lumbosacral areas.

Give antidiarrheal drugs as needed.

Encourage low-fiber, low-residue diet.

Encourage fluid intake of at least 3 L/day.

Constipation Decreased intestinal motility is related to autonomic nervous system dysfunction.

Caused by neurotoxic effects of plant alkaloids (vincristine, vinblastine).

Instruct patient to take stool softeners as needed, eat high-fiber foods, and increase fluid intake.

Instruct patient to increase activity (e.g., walking) if tolerated.

Hepatotoxicity Toxic effects from chemotherapy drugs (usually transient and resolve when drug is stopped). Monitor liver function tests. 
Hematologic System
Anemia Bone marrow depressed secondary to therapy.

Malignant infiltration of bone marrow by cancer.

Monitor hemoglobin and hematocrit levels.

Administer iron supplements and erythropoietin.

Encourage intake of foods that promote RBC production

Leukopenia Depression of bone marrow secondary to chemotherapy or radiation therapy.

Infection most frequent cause of morbidity and death in cancer patients.

Respiratory and genitourinary system usual sites of infection.

Monitor WBC count, especially neutrophils.

Tell patient to report temperature elevation and any other manifestations of infection.

Teach patient to avoid large crowds and people with infections.

Administer WBC growth factors

Thrombocytopenia Bone marrow depressed secondary to chemotherapy.

Malignant infiltration of bone marrow crowds out normal marrow.

Spontaneous bleeding can occur with platelet counts ≤20,000/μL.

Observe for signs of bleeding (e.g., petechiae, ecchymosis).

Monitor platelet counts.

Integumentary System
Alopecia Destruction of hair follicles by chemotherapy or radiation to scalp.

Hair loss usually is temporary with chemotherapy, but usually permanent in response to radiation.

Suggest ways to cope with hair loss (e.g., hair pieces, scarves, wigs).

Cut long hair before therapy.

Avoid excessive shampooing, brushing, and combing of hair.

Avoid use of electric hair dryers, curlers, and curling rods.

Discuss impact of hair loss on self-image.

Radiation skin changes (dry to moist desquamation) Radiation damages skin
Chemotherapy-Induced Skin Changes Hyperpigmentation.

Telangiectasia.

Photosensitivity.

Acneiform eruptions.

Acral erythema.

Alert patient to potential skin changes.

Encourage patient to avoid sun exposure.

Implement symptomatic management as needed depending on specific skin effect (e.g., application of lotions, benzoyl peroxide for acne, corticosteroid creams

Genitourinary Tract
Hemorrhagic Cystitis Cells lining bladder are destroyed by chemotherapy (e.g., cyclophosphamide, ifosfamide).

Side effect of radiation when located in treatment field.

Encourage increased fluid intake 24-72 hr after treatment as tolerated.

Monitor manifestations such as urgency, frequency, and hematuria.

Administer cytoprotectant agent (mesna [Mesnex]) and hydration.

Administer supportive care agents to manage symptoms (e.g., lavoxate [Urispas]).

Reproductive Dysfunction Cells of testes or ova are damaged by therapy. Discuss possibility with patients before treatment initiation.

Offer opportunity for sperm and ova banking before treatment for patients of childbearing age.

Nephrotoxicity Direct renal cell damage from exposure to nephrotoxic agents (cisplatin and high-dose methotrexate).

Precipitation of metabolites of cell breakdown (tumor lysis syndrome [TLS]).

Monitor BUN and serum creatinine levels.

Avoid potentiating drugs.

Alkalinize the urine by adding sodium bicarbonate to IV infusion and administer allopurinol (Zyloprim) or rasburicase for TLS prevention

Nervous System
Intracranial Pressure May result from radiation edema in central nervous system. Monitor neurologic status.

May be controlled with corticosteroids.

Peripheral Neuropathy Paresthesias, arelexia, skeletal muscle weakness, and smooth muscle dysfunction can occur as a side effect of plant alkaloids, taxanes, and cisplatin Monitor for these manifestations in patients on these drugs.

Consider temporary chemotherapy dose interruption or reduction until symptoms improve.

Anti-seizure drugs (e.g., gabapentin [Neurontin]) may be considered.

Cognitive Changes (“chemo brain”) Occur during and after treatment (especially with chemotherapy).

Difficulties in concentration, memory lapses, trouble remembering details, taking longer to finish tasks.

May happen quickly and last a short time. Sometimes people have mild long-term effects

Teach patients to do the following:

Use detailed daily planner.

Get enough sleep and rest.

Exercise brain (learn something new, do word puzzles).

Focus on one thing (no multi-tasking) 

Respiratory System
Pneumonitis Radiation pneumonitis develops 2-3 months after start of treatment.

After 6-12 months, fibrosis occurs and is evident on x-ray.

Side effect of some chemotherapy drugs.

Monitor for dry, hacking cough; fever; and exertional dyspnea.
Cardiovascular System
Pericarditis and Myocarditis Inflammation secondary to radiation injury.

Complication when chest wall is irradiated. May occur up to 1 yr after treatment.

Side effect of some chemotherapy drugs

Monitor for clinical manifestations of these disorders (e.g., dyspnea)
Cardiotoxicity Some chemotherapy drugs (e.g., anthracyclines, taxanes) can cause ECG changes and rapidly progressive heart failure Monitor heart with ECG and cardiac ejection fractions.

Drug therapy may need to be modified for symptoms or deteriorating cardiac function studies

Biochemical
Hyperuricemia Increased uric acid levels due to chemotherapy-induced cell destruction.

Can cause secondary gout and obstructive uropathy

Monitor uric acid levels.

Allopurinol may be given as a prophylactic measure.

Encourage increased fluid intake

Psychoemotional
Fatigue Anabolic processes result in accumulation of metabolites from cell breakdown. Assess for reversible causes of fatigue, and address them as indicated.

Reassure patient that fatigue is a common side effect of therapy.

Encourage patient to rest when fatigued, to maintain usual lifestyle patterns as much as possible, and to pace activities in accordance with energy level.

Encourage moderate exercise as tolerated

 

  • Preparation and handling of chemotherapy agents
    • May pose an occupational hazard
    • Drugs may be absorbed through 
      • Skin 
      • Inhalation during preparation, transportation, and administration
    • Only properly trained personnel should handle cancer drugs
  • Chemotherapy methods of administration
    • Oral
      • More available options today
      • Storage and side effects 
    • IM – Intramuscular
    • IV – Intravenous (most common)
      • Central venous access device (CVAD)
    • CVAD administration
      • Placement in large blood vessels
      • Frequent, continuous, or intermittent administration
      • Can be used to administer other fluids (blood, electrolytes, etc.)
  • Regional administration
    • Delivery of drug directly into
      tumor site
    • Higher concentrations of drug can be delivered with less systemic toxicity
    • Types of regional delivery methods
      • Intraarterial 
        • Delivers drug through arteries supplying tumor
      • Intraperitoneal
        • Delivers drug to peritoneal cavity for treatment of peritoneal metastases
      • Intrathecal or intraventricular
        • Involves lumbar puncture and injection of chemotherapy into subarachnoid space
      • Intravesical bladder
        • Agent added to bladder by urinary catheter and retained for 1 to 3 hours
  • Effects on normal tissue
    • General and drug-specific adverse effects are classified
      • Acute
      • Delayed
      • Chronic
  • Radiation therapy
    • One of the oldest nonsurgical methods of cancer treatment
    • 50% of all cancer patients will receive radiation therapy at some point in their treatment
    • Radiation is emission of energy from a source and travels through space or some material 
    • Different types of ionizing radiation are used to treat cancer
    • Technologic advances
      • Low-energy beams 
        • Expend energy quickly 
        • Penetrate a short distance 
        • Useful for skin lesions
      • High-energy beams 
        • Greater depth of penetration 
        • Suitable for optimal dosing of internal targets while sparing skin
    • Total doses divided into fractions 
    • Typically delivered once a day for 5 days a week for 2 to 8 weeks
      • Standard fractionation

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