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The oldest form of cancer treatment. Can be a primary treatment or used with a combination of chemo or radiation therapies.

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Surgical Therapy

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Surgical intervention can be used to eliminate or reduce the risk of development. Prophylactic removal of non-vital organs for those who have high probability for development has proven to be successful in reducing cancer incidence for selected malignancies.

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Prevention

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Objective is to remove all or as much tumor as possible while sparing normal tissue. Small tumor size, surrounding tissue margins free of disease, and absence of node involvement relate to good prognosis.

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Cure and Control

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When cure and control are not possible, focus shifts to keeping quality of life at highest level possible.

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Supportive and Palliative Care

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1. insertion of feeding tube to maintain nutrition 2. Creation of a colostomy for patient advanced prostate cancer 3.Suprapubic cystostomy for advanced prostate cancer 4.Placement of venous access device to deliver chemo agents, medications, parental nutrition, blood products, and other supplements. 5.Removal of metastic liver lesions in a person with colorectal cancer

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Supportive and Palliative Care Examples

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Local treatment modality for cancer. One of the oldest methods along with surgery. Causes damage to both normal healthy cells as well as unhealthy cells.

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Radiation Therapy

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Part of radiation treatment planning used to accurately localize the tumor and ensure setup position reproducibility. A tattoo or a marker may be used to mark the area to be used during radiation therapy.

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Simulation

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External beam therapy which is the most common delivery. A linear accelerator may be used to deliver different types of treatment techniques.

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Teletherapy

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Close or internal radiation treatment. Implantation or insertion of radioactive materials directly to the tumor or close in proximity adjacent to the tumor which allows for direct dose delivery to the target with minimal exposure to surrounding healthy tissue.

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Brachytherapy

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Be aware patient is emitting radiation after undergoing therapy. Those with internal radiation are constantly emitting only during the time source is in place. Time, distance, and shielding are essential for those taking care of these patients. Make sure to inform patient of interventions which limit one care persons continuous care of patient.

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Direct Care of Radiation Patient

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Teach patients about their treatment regimen, supportive care options(antiemetic, antidiarrheal) and what to expect during the course of treatment to help decrease fear and anxiety, encourage adherence, and guide self-management.

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Radiation and Chemo Nursing management

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Nursing Management of Problems by Chemo & Radiation therapy

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*Asses oral mucosa daily and teach patient to do this. *Encourage nutritional supplements (Ensure, Carnation instant breakfast) if intake is decreasing *Be aware that eating, swallowing, and talking may be difficult(analgesic may be required) *Instruct in diet modifications as necessary. Selection of moist bland softer foods *Keep oral cavity clean and moist with saline or salt & soda solution *Discourage alcohol and tobacco *Apply topical anesthetics *NO DENTAL FLOSS!!!!

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Stomatitis, Mucositis, Esophagitis ( Epithelial cells are destroyed by chemo or radiation treatment when in located field of treatment. Inflammation and ulceration occur due to rapid cell destruction)

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*Teach to eat and drink when not N *Administer antiemetic's prophylactically before and PRN *Use diversion activities

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N&V

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*Monitor weight *Encourage small frequent high protein high cal foods *Gently encourage to eat without nagging *Serve food in pleasant environment

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Anorexia

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*Give antidiarrheal agents PRN *Encourage low fiber low residue diet *Encourage fluid intake of at least 3 L *Avoid milk products

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Diarrhea

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*Monitor liver function

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Hepatotoxicity (Toxic effect from chemo drugs)

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*Monitor H&H levels (Normal M Hb 14-18 F 12-16, Hemat M 40-54% F 36-48%) *Administer iron supplements and darbepoetin,epoetin. Transfusion may be necessary. *Encourage intake of foods that promote RBC production

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Anemia ( Bone marrow depressed secondary to therapy. Malignant infiltration of bone marrow by cancer)

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*Monitor WBC count especially neutrophils *Teach report of temp elevation and other infection manifestations *Teach avoid large crowds and people with infections *This is a medical emergency due to the fact that WBC are diminished from disease and therapy.

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Leukopenia ( Depression of bone marrow. Infection most frequent cause of morbidity and death in cancer patients. Res and genitourinary system usual sites of infection.)

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*Observe for bleeding signs *Monitor platelet counts

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Thrombocytopenia ( Bone marrow depressed. Malignant infiltration of bone marrow that crowds out normal marrow. Spontaneous bleeding

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*Encourage increased fluids 24-72hr after treatment as tolerated *Monitor manifestations such as urgency, frequency, and hematuria *Administer cytoprotectant agent(mensa) and hydration *Administer supportive care agents (Urimax,flavoxate)

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Hemorrhagic Cystitis ( Cells lining bladder destroyed from therapy. Side effect of radiation when located in field.)

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* Monitor BUN and Creatinine (BUN 7-20, Creatn0.6-1.2) *Avoid potentiating drugs *Alkalinize the urine with sodium bicarb and administer allopurinol or rasburicase for TLS prevention

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Nephrotoxicity (Direct renal cell damage due to exposure to nephrotox agents. Precipitation of metabolites of cellular breakdown(tumor lysis syndrome)

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*Use of detailed daily planner *Get enough sleep and rest *Exercise brain *Focus on one thing don't multitask

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Cognitive changes (CHEMO BRAIN)

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*Monitor uric acid levels *Allopurinol may be given as a prophylactic measure *Encourage increased fluids

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Hyperuricemia (increased uric acid levels from cell destruction. Can cause secondary gout and obstructive uropathy)

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*Assess for reversible causes and address them as indicated *Reassure that its common side effect of therapy *Encourage rest when fatigued, to maintain usual lifestyle patterns as close as possible, and to pace activities in accordance with energy levels *Encourage moderate exercise as tolerated such as walking programs which helps improve mood and avoid the debilitating cycle of fatigue-depression-fatigue that can occur. *Maintaining good nutritional and hydration status and managing other symptoms

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Fatigue

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*Avoid use of perfumes, smelling deodorants soaps *Gently cleanse skin treatment field using mild soap (dove, Ivory), tepid water, a soft cloth, and gentle patting motion rinsing thoroughly and pat dry *Apply nonperfumed moisturizing lotion or cream(aloe, aquaphor, biafine) OTC Hydrocortisone cream. *Rinse saline solution. Expose to air often. Use astringent for copious drainage and nonadhesive absorbent dressings. Observe daily for infection *Avoid tight fitting clothing *Avoid harsh fabrics(wool). Use cotton light weight if possible *Use dreft or ivory snow to wash clothing *Avoid direct sunlight hat and sunscreen should be worn *Avoid excessive heat and cold *Avoid swimming *Avoid shaving area, using all medications deodorants perfumes powders cosmetics, tape dressings and adhesive bandages

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Skin Reactions

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*Assess emotional status and Use Encouragement, feelings of hope *Depression anxiety with radiation as may need to be isolated during treatment *Refer to group therapy

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Coping with Therapy

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Three ways agents affect host-tumor response 1.Have direct antitumor effects 2.Restore,augment,or modulate host immune system mechanism 3.Have other biologic effects such as interfering w/cancer cell's ability to metastasize or differentiate

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Biological Therapy (Agents that modify relationship between host and tumor by altering biologic response of host to the tumor.)

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Interferes with cancer growth by targeting specific cellular receptors and pathways important for growth. Target therapies work at sites that are on the cell surfaces, at the intracellular level, or in the extracellular domain. They are able to kill cancer cells with less damage to normal cells compared to Chemo

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Targeted Therapy

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Drugs used for Target/Biological Therapy

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*Inhibits DNA & protein synth/ Suppress cell prolif/ *Indications-Hairy cell leuk, chron myleogen leuk, malig melanoma, renal cell carcin, ovian cancer, multi myeloma,

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a-interferon (Roferon-A, INteron A)

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Flue like symp cog changes Fatigue N&V Anorexia Weight loss *Administration of Acetaminophen often reduces flue like symptoms

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interferon side effects

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*Stim cell prolif of T & B cells Activates NK cells *indications-Metast renal cell cancer/ melanoma

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interleukin-2 (aldesleukin, Proleukin)

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Flu like Cog changes Fatigue N&V Anorexia Weight loss capillary leak syndrome resulting in hypotension bone marrow suppression *Tachycardia and Orthostatic hypotension commonly reported

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Interleukin-2 side effects

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Inhibit BCR-ABL tyrosine kinase Indications- Chron myeloid leuk, GIST

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Tyrosine Kinase Inhibitors

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*imatinib(N D myalgia Fluid retention) *nilorinb(Neutropenia* Thrombocytopenia* Bleeding* N FD) *dasatinib(Myleosupression* CNS GI hemorrhage* Pleural Effusion)

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Examples of TKI

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Binds CD20 antigen causing cytotox Indications- Non Hodge lymph (B) Chron lymph leuk (Arzerra)

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Monoclonal Antibodies

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Fever Chills Infection(Arzerra) Marrow suppression(Zevalin, Bexxar)

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Monoclonal Antibodies side effects

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Allogeneic transplantation Syngeneic transplantation Autologous transplantation

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Hematopoietic Stem Cell Transplants

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Stem cells are acquired from a donor who through human leukocyte antigen tissue typing has ben determined to be HLA matched to the recipient. Often it is a family member. Common indications for this transplant are certain leukemia's, multiple myeloma, and lymphoma

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Allogeneic transplantation

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Type of allogeneic transplantation that involves obtaining stem cells from one identical twin and infusing them into the other. Neither the graft-versus-host tumor effect occurs

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Syngeneic Transplantation

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Patient receives their own stem cells back following myeloablative (destroying bone marrow) chemo. This aim is purely rescue. Restoration usually takes 4-6 weeks depending.

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Autologous Transplantation

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Complications From Cancer

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Suggest foods high calorie high protein. Suggest need for supplementation to care provider as soon as 5% weight is lost. *Milk (whole, Double strength powder added to whole, milk shake, yogurt) *Eggs, cheese, Pork, chicken, fish, tuna

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Malnutrition

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Tell patient to experiment with spices and other seasonings. Lemon juice, onion, mint, basil, and fruit juice marinades. Bacon bits, onion, and ham pieces may enhance veggies. Tell to try foods previous didn't like

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Altered taste

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Usual sites of infection *Lungs, GU, mouth, rectum, peritoneal cavity, and blood Watch for elevated temp 100.5

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Infection

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------------------------------------------------------------------------

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Oncological Emergences

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*Manifestations- facial edema, periorbital edema, distention of veins of head neck chest, headache, seizures *Most common causes-Lung cancer, Non Hodge lymph, and metastic breast cancer *Management- radiation therapy to site obstructed. Chemo may be administered.

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Superior Vena Cava Syndrome

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*Most common causes-Breast, lung, prostate, GI, Renal. Melanoma *Manifestations-Back pain intense localized and persistent accompanied by Valsalva maneuver; motor weakness and dysfunction; sensory parsthesia and loss; and autonomic dysfunction *Radiation therapy in conjunction with prompt initiation of corticosteroids. Surgery if not subjective to radiation.

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Spinal cord compression

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*Results form abnormal or sustained production of ADH with resultant H2O retention and hyponatremia *Most common cause carcinoma of the lung *Symptoms include weight gain without edema, weakness, A N V, personality changes, seizures, oliguria, coma *Treatment is treat underlying problem, restrict intake if needed, use of 3% NaCl in extreme

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Syndrome of Inappropriate Antidiuretic Hormone Secretion

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*Most frequent Lung, breast, kidney, colon, ovarian, or thyroid cancers. *Manifestations-apathy, depression, fatigue, muscle weakness, ECG changes, polyuria, nocturia, N V A, Serum levels 12+ life threatening *Treat with infusion of Zometa or Aredia

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Hypercalcimia

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* Acute TLS is metabolic complications characterized by rapid release of cellular components in response chemo *Metabolic abnormalities and concentrated uric acid lead quickly to acute renal failure if not treated early *Four hallmark signs- Hyperuricemia, Hypophosphatemia, Hyperkalemia, Hypocalcaemia *Symptoms- Weakness, muscle cramps, D N&V *Treat imbalance and prevent Renal Failure

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Tumor Lysis Syndrome (Usually occurs 24-48 hrs after initiation of chemo)(persistence of 5-7 days)

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*What told pain is on scale is what it is *Addiction is not a problem for acute pain in cancer patients *Control with the least side effects is key

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Pain

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