Cancer Treatments & Care – Flashcards

Diagnosis (biopsy) Cure and Control. Treatment & staging. Supportive and Palliation. Prophylactic. Rehabilitative. Surgery may be done as treatment alone or in conjunction with other modalities to control submicroscopic spread. In the past the thought was that radical surgical with a wide excision was the best option. However analysis of treatment results showed that this did not have an impact ion tumors recurring. Theory now is that tumor cells shed continually into the systemic circulation so that local therapies (Sx & Rad) must be combined with systemic treatments

At least 50% of people with cancer will receive a course of radiotherapy (RT) Treatment goals: Curative (~50%) Adjuvant with chemo and/or surgery pre/postop. Palliative (reasonable response with minimal side effects.) Prolong survival. Curative: radiation is a primary treatment ex. Skin cancer, early breast & prostrate. Adjuvant-given in conjunction with chemo to treat site not accessible to systemic chemo (ie brain). Chemo can also be given as a radio-sensitizer - enhances the effects of RT on cells. Example - infusion of %FU during radiation therapy kills cells in S phase which are radioresistant. Pre-op: colorectal cancer- decrease tumor bulk. Post-op: lung cancer, kill residual cells Intraoperative is completed at some research centers. Rad. Is administered directly to the tumor site during surgery Ex small cell ca lung. Palliative: relieve of compression tumors, relief of pain bone mets, intestinal obstruction, spinal cord compression, - short intensive radiation want rapid results.

Radiation Tx uses ionizing radiation to interrupt cellular growth. It affects DNA directly by splitting the helix and indirectly by ionizing nearby molecules like water, forming free radicals. Cells that are rapidly dividing and undifferentiated are more sensitive to radiation.Cells most sensitive to radiation during M & G2 phases.The amount of time that is required for the manifestations of radiation damage is determined by the miotic rate of the tissue. EX GI tract cells& bone marrow (rapidly divide) will die fast & exhibit early responses to radiation whereas tissues like bone, & kidneys manifest late responses to radiation Cells treated in the M & G2 phase are more likely to suffer lethal damage.Dose: In the past radiation was delivered in large doses over a short time - resulting in permanent and often severe late side-effects. Now the standard is multifraction treatments once or twice a day, every weekday over several weeks. Prolonging the time of radiation delivery allows tumor cells to move into the sensitive phases of the cell cycle. The DNA damage caused by radiation can cause cell death or loss of ability to reproduce The effects of radiation depends on dose, overall period of treatment and number of sessions of radiotherapy.

Repair - appropriate fractionation allows this Repopulation -of cells between fractions Reassortment - prolonging the time of radiation delivery allows tumor cells to move into radiosensitive phases (G2 and M) resulting in more tumor kill. Reoxygenation of hypoxic cores of tumors -oxygen enhances the damaging effects of radiation.

Precisely locate the target, Hold the target still, Accurately aim the radiation beam, Shape the radiation beam to the target Deliver a radiation dose that damages abnormal cells yet spares normal cells

Tumor location & type. Oxygen effect. Extent of tumor. Patient health. Therapeutic ratio (dose tolerated/curative dose). Dose tolerated. The effect of radiation depends on the radiosensitivity of cancer cells. Histological type of cell: cells in the resting phase of cell are less sensitive to radiation than those in active in cellular division.Oxygen effect: well O2 tissue are more sensitive to rad due to oxygen being needed to form free radicals. A tumor is considered radiosensitive when radiation destroys the cancer cells with moderate doses while doing minimal damage to surrounding areas.The effects of radiation depends on dose, overall period of treatment and number of sessions of radiotherapy. The therapeutic ratio is the ratio of the maximally tolerated dose of a drug to the minimally curative or effective dose.

Dosage is expressed by gray (Gy) or centigray (cGy) 1 centigray = 1 rad 1 gray = 100 rads Radiation absorbed dose (rad) Unit of absorbed dose of radiation 1 rad = 0.01 joules per kilogram of tissue

FRACTIONATION: Administering radiation in divided doses rather than single doses to minimize side effects by allowing normal cells to recover. Dividing the total dose of radiation into small frequent doses.Fractionation allows normal cells time to repair. Increases chance of getting the cells in the vulnerable G2 & M phases. FRACTIONATION: refers to dividing the total radiation doses into small frequent doses to minimize side effects and allow normal cells to recover. Also increases the probability that tumor cells will be in a vulnerable phase of cell cycle.

A part of radiation treatment planning used to determine the optimal treatment method Focuses on size and orientation of radiation beams Permits maximum treatment of tumour with minimal damage to normal tissue Uses immobilization devices to help client maintain a stable position.

Variety of imaging techniques: Physical examination and surgical reports. Marks placed on skin to outline treatment field. Critical normal structures in treatment field are protected

Using a radiotherapy simulator, the patient is placed in the treatment position and the areas of interest are imaged Reference 'markings' or tattoos are placed on the skin Immobilization devices may be required. Accurate targeting of small volumes of tumor Head frame fixed to skull. Use of CT and MRI Markings or tattoos indicating the precise location for the XRT is also done during simulation

Delivered externally or internally Externally = Teletherapy (radiation is at a distance to cancer) Internally = Brachytherapy (radiation is in or close to cancer)

(teletherapy) Most common radiation treatment Client exposed to radiation from a megavolt machine Cobalt 60 machine—gamma rays Cyclotron— produces neutrons or protons Linear accelerator—produces ionizing radiation

Emit external beam radiation that creates high energy x-ray beams Deep-seated tumors - the higher the energy produced by the machine the greater the depth of penetration of radiation beam. "Skin sparing" effect: allow deeper penetration and less superficial tissue damage.

(brachytherapy) Implantation or insertion of radioactive materials into or close to tumour Minimal exposure to healthy tissue Used in combination with teletherapy. Delivers a high dose of radiation to a localized area (distance btw tumor & radiation is short) The specific radioisotope is chosen on the basis of its half-life May be implanted by means of needles, seeds, beads, or catheters into body cavities, tissues or on surface (uterus, abdomen, prostate, pleural space). May be given orally or IV (thyroid cancer) Client is emitting radioactivity Limit amount of time near clients being treated Clients should understand needs for time and distance restrictions on health care providers

ALARA Principle (as low as reasonably achievable) Pregnant nurses should not care for clients receiving radiation. TIME: longer time of exposure, greater amount of radiation absorbed DISTANCE :intensity of radiation decreases as distance from source increases. SHIELDING: % of radiation penetration decreases as the shield thickness increases.

Minimize time spent in close proximity to the client. Organize care prior to entering room. Assemble all equipment prior to room entry In room place supplies/equipment within easy quick access. Post time guidelines on door.

The greater the distance from the rad source, the less the exposure dose. Interventions: Teach client self-care & rationale for isolation. Limit client care by individual caregiver Use communication devices outside room when possible

When used properly, lead shielding can provide added protection from radiation. Institutions with high volume radiation implants rooms have leaded shielded walls. NB pregnant nurses should not care for radiation clients.Shielding: use of shielding devices whenever possible reduces rad exposure. Ex the dose of x-rays and gamma rays is reduced as the thickness of the lead shield increased.. Ex. Shielding wearing a lead vest for an x-ray

Sealed:Interstitial, Intercavity Intraluminal Unsealed: IV or ingesting radioactive substance

SEALED - Radioisotope is completely enclosed by nonradioactive material, thus it cannot circulate thru the body or contaminate excreta, therefore not radioactive unless direct contact-i.e. touching the container with bare hands or from lengthy exposure. Sealed intracavity therapy may last as long as 24-72 hours. For example, uterine or cervical cancer Intracavity—an applicator is inserted into a body cavity-now have afterloading devices in which hollow applicators are surgically placed and then the radioactive source is placed in this applicator for certain periods of time. These afterloading devices decrease the amount of exposure for nurses but increase the total time required to treat the patient. Interstitial---radioisotope placed in needles, beads, seeds, ribbons and catheters and implanted directly into the tumor. May be temporary or permanent

UNSEALED—Injected SYSTEMICALLY IN SOME MANNER OR INGESTED. Colloid suspensions that come into contact with the body tissues. Thus it circulates through the body. Urine, sweat, vomitus, blood are all radioactive. Example = Iodine 131 which is used to treat thyroid cancer.

Unsealed brachytherapy will render client and ALL bodily fluids, including sweat and urine radioactive. No young children or pregnant women will be allowed to visit client. Client will need to stay in hospital for this treatment which usually means for 3 or 4 days. Treatment will be supervised by the Nuclear Medicine department Client will be given the preparation and then asked not to eat or drink for the next 2 hours, to allow the iodine to be absorbed. After this s/he can eat as normal and are encouraged you to drink plenty of water to flush any excess iodine from your body. This will render the patient and ALL your bodily fluids, including sweat and urine radioactive. Before going you will have a total body scan.You will be given information regarding avoiding crowded places, pregnant women and children. This is usually for 2-3 weeks.

Afterloading is best described as a treatment whereby the radioactive sources are inserted manually into the previously inserted applicator. Remote afterloading has replaced the use of radium and manual afterloading. To minimize the radiation exposure of personnel, an electro-mechanical loading device for radioactive sources is developed. The Remote Afterloader automatically places the radioactive source at predetermined positions within the applicator and stores the source between treatments. While the patient is being treated, the personnel is able stay ouside the treatment room to avoid radiation exposure. Brachytherapy with afterloading involves temporarily placing a small source of radioactive material in the patient's body using applicators or other placement devices. After the treatment, the source is retracted into its shielded safe in the remote afterloader. Brachytherapy with after loading allows the tumor to be irradiated to a high dose, while greatly limiting exposure to surrounding normal tissue. The remote afterloader resembles a short "Star Wars" robot. The radioactive source of Iridium-192 is about the size of a very small seed, and is stored in a shielded safe in the "head" of the robot. This source is laser welded to a flexible steel cable wound on a drum inside the machine. There are several ways the source can be placed in position at the treatment site. For some treatments, a narrow tube called an applicator is placed within a body cavity and directed to the treatment site. This applicator is then connected to the "nose" of the afterloader. The source is driven out of the afterloader on its steel cable and through the applicator to predetermined positions within the patient's body. Since the lengths of both the cable and the applicator are known, the source can be stopped at precisely calculated positions for maximum benefit to the patient. Other placement devices are used when an applicator is not appropriate. These include needles or, for gynecological cases, specialized insertion devices. Tumors that will be treated with HDR brachytherapy include cancer of the lung, esophagus, rectum, head and neck, prostate and gynecologic organs.

Emits continuous low energy Ex: Seeds in this case for 1 year. May develop symptoms of irritation or problems voiding (swelling)Seeds have a short half-life so that the dose received by the pt. is limited Radioactive isotope decays over a period of time to a specific element.

Post specific laundry and housekeeping instructions Radioactive material sign Wear dosimeter No pregnant staff Visitors limited to 30 mins per day Visitors are restricted and must remain at 6 feet distance Private room with bathroom: due to risk of implant dislodging & exposure to others Rooms have leaded shields lining the walls Rooms located at end of halls lessening chance of exposure. Clients with radioactive inserts in the abd cavity remain in bed, have a foley & low-fiber diet after insertion of implant to prevent BM before device removed. Dosimeter: monitoring device worn personnel who are exposed to rad. During course of work. Ex pocket dosimeter, film badge. Dose summed over three month period 30 MSV /3 mon (max) 50MSV 1 year(safety standards). Never take dosimeter to beach sun and do not use any one else. All dressings & linens saved until implant removed- then can be disposed of in usual manner once source is removed & accounted for. DISLODGEMENT: never touch with hands notify radiation officer & tech. LEAD CONTAINER & LONG HANDLED FORCEPS,LEAD GLOVES KEPT IN ROOM IN EVENT OF DISLODGEMENT; if dislodged pick it up with forceps and place in lead container, notify safety officer, radiation therapist and they will retrieve and secure the source. Large institutions have radiation safety officers and radiation specialists who advise in areas of care and safety. All body secretions are radioactive. All surfaces and floor covered with paper or protective coverings. Trash & linens left in room until discharge and upon d/c the client is scanned by safety officer to determine decrease and safe radiation level to go home. Precautions for room continue post d/c until cleared by safety officer. Beds only changed when linen soiled to reduce contaimination Limited visitors-Everyone entering the room wear a new booties each time Wear gloves to avoid exposure to bodily fluids Vomit after ingested oral isotope cover pad and call safety officer Follow hospital policies everyone has a film badge to measure whole body exposure.

Reusable personal radiation dosimeter for UV or radioactive radiation.

The risk and level of permanent organ damage depends on the volume of organ exposed to radiation. Retreatment to same area has higher risk of permanent side effects and may be less effective

Compounds used to increase the radio-sensitivity of tumor cells or protect normal cells from the effects of radiotherapy.Radiosensitizer or radioprotectors Examples include:Pilocarpine: radioprotector decreases xerostomia from salivary gland dysfunction related to head/neck radiation. Decreases chance of mucosistis, infections, ulcers of mouth

Are the result of damage to normal healthy tissue, generally rapidly proliferating cells. Are more severe with higher doses or concomitant use of chemotherapy; body site irradiated, extent of body area treated, method of radiation delivery, age of client, age & general health of client, radiosensitivity of tissue/organ treated.

to destroy the cancer while keeping the dosages within the normal tissue tolerance to avoid harming surrounding normal tissues. Certain normal tissues are more sensitive and may incur permanent damage: skin, epithelial lining of GI tract, spinal cord, bone marrow. Dose and technique for administration is very important Side effects are related to the total dose 3. Size of field will affect the amount of dose and what can be tolerated. 4. Method in terms of systemic local etc will impact on side-effects experienced. (depth of penetration) 5/6 both affect the client's ability to tolerate RT. 7. Person receiving chemo may experience increased side effects due to overlapping or synergistic effects. 8 greatest effect on rapidly dividing cells Make sure that potential side effects are explained to patient and family prior to initiating treatment!The goal of RT is to destroy the cancer while keeping the dosages within the normal tissue tolerance to avoid harming surrounding normal tissues. - Certain normal tissues are more sensitive and may incur permanent damage: spinal cord, GI, integumenatry. Dose and technique for administration is very important - Side effects are related to the total dose - Size of field will affect the amount of dose and what can be tolerated. - Method in terms of whether is systemic, local etc will impact on side-effects experienced.(depth of penetration) - Person receiving chemo may experience increased side effects due to overlapping or synergistic effects. - Greatest effect on rapidly dividing cells

Body site irradiated Dosage of radiation and fractionation. Extent of body area treated. Method of radiation delivery. Age of client. General health of client. Previous surgeries & chemotherapy. Radiosensitivity of tissue/organ treated.

Early (acute): occurs within weeks and resolves 4-6 weeks post radiation. Late Phase: may occur months/years later and usually result from damage to the micro-circulation. The risk and level of permanent organ damage depends on the volume of organ exposed to radiation. Retreatment to same area has higher risk of permanent side effects and may be less effective Acute: occurs within weeks and resolve 4-6 weeks post radiation. Usually temporary and effects tissue with rapidly dividing cells (skin, mucous membranes) Late Phase: may occur months/years later and usually result from damage to the micro-circulation. Permanent damage can affect organs such as: lungs, heart, central nervous system and bladder.

Acute: fatigue, anorexia, decreased libido, hair loss, mucositis, bone marrow depression, skin changes, (erythema), GI effects . Late: radiation pneumonitis, fistulas, fibrosis, necrosis, edema, secondary neoplasms. Acute: subside over a few weeks Late: are not reversible

Fatigue Skin reactions GI effects: nausea/vomiting, diarrhea, anorexia Ocular symptoms ( edema, dryness, photophia) Oral mucositis, radiation caries, xerostomia Alopecia Cystitis, reproductive dysfunction Stomatitis, mucositis, esophagitis, dysphagia Bone marrow suppression In general skin reactions and fatigue may occur with RT to any site but many other side effects depend on the specific areas involved in the treatment field

Can be classified as acute or chronic Acute: begin about 2 weeks after start of treatment and resolve over next 3-6 weeks. Reactions include erythema, dry desquamation, wet desquamation, pigmentation change Chronic: may occur years later and include atrophy, pigment changes, fibrosis and telangiectasia. With external radiation, the beam must penetrate the skin. Because of the rapid turnover of cells in the skin, skin reactions and changes to the skin over the area are common. Factors affecting skin reactions include: Total radiation dose Type and energy of radiation (high energy xrays have skin sparing effects) Site of body (skin folds, head & neck, chest wall) Patient-related factors Concurrent treatment (chemo) Erythema: redness of the skin

Begins within 7-10 days of treatment Result of partial loss of the epidermal layer Erythema that may progress to dry, itchy skin. May be scaling, flaking, peeling.

Result of complete destruction of the basal cell layer Blister, vesicles, and serous oozing Pain may occur if nerve endings are exposed Occurs more often in areas of friction & moisture (skin fold, groins) Increased risk of infection (may require break in treatment)

shedding of epithelial cells in scales or sheets

Shower or bathe with lukewarm water, soft cloth and mild soap Pat dry - do not rub or scrub the area Avoid ointment, lotion , or powder unless approved by radiation oncologist Wear soft clothing over radiation site (cotton) Avoid belts, straps & tight clothing Avoid sun exposure No sunscreen during and until reaction has resolved Avoid direct sun. Cover area with protective clothing such as long sleeves and hats Do not use tape over site

Cystitis (usually occurs 1-2 weeks post XRT and subsides 2 weeks after XRT complete Lhermitte's syndrome - after spinal cord radiation Vaginal stenosis - after XRT to pelvis Radiation pneumonitis - after XRT to lungs Other complications radiation treatment depend on area of body radiated for example Cystitis if bladder is included in treatment field Lhermitte's syndrome, temporary condition resulting in shock-like sensation down the spine and limbs on flexion of the neck - after spinal cord radiation- due to demyelination of the sensory neurons from radiation Vaginal stenosis - after XRT to pelvis Radiation fibrosis - after XRT to lungs symptoms usually develop 1-3 months post-treatment. Symptoms mimic infection but do not respond to antibiotics, but often responds to steroids

Use of chemicals as treatment for cancer Antineoplastic drugs are agents which are either cytotoxic or cytostatic to cancer cells. They kill tumor cells by interfering with cellular functions and reproduction Generally a systemic therapy rather than localized therapy such as surgery or radiation.