Chapter 8

Care of Patients With Cancer

1
 Impact of Cancer

• A group of diseases that

characteristically grow in an
Cancer uncontrolled manner with the
spread of abnormal cells.

New treatments
have greatly • 68% of patients live 5 years or
improved the longer.
survival of patients
with cancer

2
 Physiology of Cancer
• Replicate only to replace damaged or dead
Normal Cells cells

• An abnormal replication of cells

Neoplasm • May be benign or malignant

Cancer Cells • Reproduce in an uncontrolled way

• Movement of cancer cells from the original

Metastasis cancer site to other areas of the body

3
Normal and Malignant
Skeletal Muscle Cells
 A, From Damjanov I, Linder
J, editors: Anderson’s
pathology, ed 10, St Louis,
1996, Mosby. B, From
Kumar V, Abbas AK, Aster
JC: Robbins and Cotran
pathologic basis of disease,
ed 9, Philadelphia, 2015,
Elsevier; courtesy of Dr.
Trace Worrell, Department
of Pathology, University of
Texas Southwestern
Medical School.

1
 Genetic Factors
All cancer results from
defects in the DNA of
genes. Oncogenes and tumor
• Can be inherited or caused
suppressor genes
by mutation

Carcinogens in external
Immunocompetence and internal
environment

5
Chemical Carcinogens (1 of 2)

Cancer-causing substances

Certain chemicals
Carcinogens in the Sources of radiation
external environment Viruses

Exogenous Hormones
Carcinogens in the Inherited genes
internal environment Advanced age

6
 Chemical Carcinogens (2 of 2)
 Occupational
 Petrofluorocarbons (polychlorinated biphenyls or PCBs)
 Some pesticides (e.g., DDT)
 Pitch, asphalt, crude paraffin, and petroleum products
 Irritating substances in the air
• Tobacco smoke
• Asbestos
• Chemical wastes from industry and automobiles
 Immunosuppressive drugs used to suppress organ transplant rejection are a cause of non-
Hodgkin’s lymphoma.
 Synthetic estrogens are linked to a higher incidence of endometrial cancer; many of the drugs
used to treat cancer affect the immune system and can predispose to other types of cancer.

7
 Cancer Promotion

Alcohol is a Chronic irritation

promoter. • A contributing cause of
Promoters are not • When nicotine is cancer
present, cancers occur • The presence of a
carcinogenic when found at a faster rate in those mole or exposure to
alone, but when they are who are heavy chemical carcinogen or
in the body with a known consumers of alcohol ultraviolet (UV) rays
• It is thought that about
carcinogen, cancer occurs 90% of all head and
faster. neck cancers are
tobacco plus alcohol
related.

8
Physical Carcinogens: Radiation

May originate from x-ray machines, radioactive elements,

or UV rays from the sun

Capable of penetrating certain body tissues and causing the

development of malignant cells in the affected area

People with fair complexions have less protective pigment

and therefore are more likely to develop skin cancer from
UV radiation than are people with darker skin.

9
 Radon Gas
 People who live in areas that have more radon
emission from the earth have a higher incidence
of malignancy in the population than people in
areas that are low in radon.

10
 Viruses (1 of 3)

Experiments involving animals have demonstrated that a

number of cancers can be produced in animals by injecting
them with a filtrate from virus-infected malignant growths.

These viruses are known as oncoviruses because of their

ability to cause cancer.

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 Viruses (2 of 3)

Viruses are capable of introducing new genetic material into a normal

cell and transforming it into a malignant one.

Cell reproduction can be altered when viruses interact with

carcinogens.

Viruses such as the human immunodeficiency virus (HIV) can damage

the immune system and decrease immunocompetence, causing the
body to become more susceptible to the growth of abnormal cells.

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 Viruses (3 of 3)
 The hepatitis B virus is carcinogenic for liver
cancer.
 The Epstein-Barr virus causes Burkitt’s
lymphoma.
 Cases of adult T-cell leukemia and lymphoma
are caused by human T-cell lymphotropic virus.
 Several types of the HPV cause cervical
carcinoma and are related to throat and mouth
cancer in nonsmokers.

13
 Genetic Predisposition

Research is revealing that there is a genetic

predisposition to various types of cancer.

Breast cancer is more likely to occur in women

who have a close female relative who developed
breast cancer before the age of 50 years.

Gene markers have been found for colon cancer,

breast cancer, prostate cancer, pancreatic
cancer, and leukemia.

14
 Cultural Considerations
 Some populations are at a higher risk for certain
types of cancer.
 Of the four types of melanoma, African Americans are
most susceptible to the acral lentiginous type, and
whites are least susceptible to it.
 Lentigo maligna melanoma is found most often in
Hawaii.

15
 Human Genome Project
 Current research is focused on finding genetic
markers, or oncogenes.
 Such markers, or the proteins they produce,
could identify high-risk individuals who then
might undergo more vigorous, regular diagnostic
testing to detect any malignancy in the very
earliest stages.

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Contributing Factors

Age

Intrinsic factors Sex

Dietary factors Race

Disease factors:
Diabetes Mellitus

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 TNM Staging System

T—primary tumor

N—regional nodes

M—metastasis

The number written beside each letter indicates how much the malignancy has
spread and attacked other tissues.

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Measures to Prevent Cancer

Nutrition and exercise

Avoid and limit exposure to carcinogens

Identify high-risk people

19
 Detection of Cancer
 Warning signs
 Unusual bleeding or discharge
 A sore that does not heal
 A change in bowel or bladder habits
 A lump in the breast or other part of the body
 A nagging cough
 An obvious change in a mole
 Difficulty swallowing

20
 Diagnostic Tests

BIOPSY RADIOLOGIC ENDOSCOPY LABORATORY

STUDIES TESTS

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 Screening Guidelines
 pg 158 – review chart
 Breast – all women, all ages – self breast exam
 Mammography – age 40, 45-54 annual, 55 and up-
biannual or annual
 History of breast cancer in family – younger age.
 Cervix – ages 25-65
 pap smear (HPV testing)
 Colorectal – ages 45 – occult blood
 Colonoscopy – age 50, every 10 years unless polyps

22
 Common Therapies, Problems,
and Nursing Care
 Surgery, radiation, and chemotherapy
 Hormone manipulation, immunotherapy with biologic

response modifiers, and bone marrow or stem cell

transplantation
 Each of the modes of treatment may be used singly or in

combination with one or more of the other methods available.

• For example, chemotherapy may be used as an adjuvant

(assisting) treatment after surgical removal of a tumor.

• The methods of treatment are chosen after due consideration

of many factors and are prescribed with the best interest of the
patient in mind.

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 Surgery
Biopsy—obtain specimen

Prophylaxis—preventive treatment

Explorative—determine effectiveness of therapy

Palliative—offer pain relief

Curative—attempt cure

Reconstructive

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 Radiation Therapy
Radiation destroys malignant cells (which are more
sensitive to radiation than are normal cells) without
permanent damage to adjacent body tissues.

The course of radiation is spread over a period of days

to weeks.

The RAD (radiation absorbed dose) is the unit used for

measuring dosages of radiation.

25
 Internal Radiation Therapy

Involves introducing a radioactive element into

the body

The material may be administered in different

ways.
• Placed in a sealed container and inserted into a body cavity
at the site of the tumor or placed directly into the tumor
• Administered in an unsealed form and taken orally or
injected by syringe

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 Principles of Radiation Protection
 The amount of radiation a nurse might receive while caring for a patient
being treated with internal radioactive elements depends on three factors:
 The distance between the nurse and the patient
 The amount of time spent in actual proximity to the patient
 The degree of shielding provided
 Shielding from radiation exposure must take into account the type of
rays being emitted. The denser the shielding material, the less the
possibility of penetration by the rays, and the better the protection. A
lead shield that is 1-cm thick offers the same amount of protection as 5
cm of concrete or 30 cm of wood. Lead aprons give protection from
diagnostic x-rays but do not provide adequate shielding from the gamma
rays emitted by radium, cesium-137, and cobalt-60. Anyone in proximity
to—or in contact with—a source of radiation should wear a radiation
dosimeter badge (Fig. 8.5B). This badge measures the radiation dose
that the individual has received through exposure to the source.

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 Audience Response Question 1
In helping a 40-year-old patient cope with breast cancer,
the nurse should help the patient focus on which aspect(s)
of radiation therapy and care? (Select all that apply.)
1. Complying with scheduled radiation therapies
2. Taking precautions on exposing other family members
3. Protecting the skin by applying lotion
4. Wearing snug-fitting clothing
5. Understanding the therapeutic effects and side effects

1
 Chemotherapy
 Antineoplastic agents
 Decrease the number of malignant cells in a generalized
malignancy (e.g., leukemia) or to reduce the size of a
localized tumor and thereby lessen the severity of
symptoms
 Cytotoxic agents
 Poisonous to cells; however, normal cells do not reproduce
in exactly the same way as malignant cells, so normal cells
are able to repair themselves more rapidly and effectively.
 Steroids often are used in combination with antineoplastic
drugs for cancer treatment. – puts pt at risk for?

29
 Chemotherapy Administration
 Techniques of administration
 Intra-arterial
 Intraperitoneal
 Intraventricular
 Intrathecal (within a space of the spine)
 Intravenous infusion
 Vesicants
 Chemicals causing tissue damage upon direct contact
 Can cause severe local injury if they escape from the
vein into which they are administered

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Nursing Care of Patients Receiving
Chemotherapy
 Toxicity on cells that have a short life span
 Blood cells
 Hair follicles
 Epithelial cells of mucous membranes
 Most chemotherapeutic agents are excreted in body
fluids.
 Most are teratogenic (can cause birth defects).

31
 Side Effects of Chemotherapy
Severe anemia

Reduced immunity

Thrombocytopenia (decreased platelets)

Alopecia (hair loss)

Mucositis (sores in the mouth)

Nausea and vomiting

Constipation or diarrhea

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Hormone Therapy (1 of 2)

Used as an adjunct to other types of cancer

therapy

Can slow tumor growth or prevent cancer

recurrence

When a hormone is added to the body, the

balance of naturally produced hormones changes.

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Hormone Therapy (2 of 2)

Giving large amounts of one hormone prevents the uptake

of other hormones.

If the tumor growth is aided by one type of hormone,

giving another type prevents the uptake of the growth-
promoting hormone and slows the progress of the tumor.

34
 Immunotherapy Using Biologic
Response Modifiers
 Biologic response modifiers
 Interferons and interleukins
 Monoclonal antibodies (MoAbs)
 Targeted therapies
 Bone marrow and stem cell transplantation

35
 Common Problems Related to
Cancer or Cancer Treatment
 Anorexia and malnutrition  Immunosuppression and
 Mucositis and oral care decreased white blood
 Significant weight loss of cells (WBCs)
2 or more pounds per  Anemia
week  Bleeding problems
 Nausea, vomiting, and  Hyperuricemia
diarrhea  Fatigue
 Constipation  Alopecia
 Cystitis  Pain

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 Anorexia

Loss of appetite

Often associated with changes in taste and with

inflammation of the mouth and tongue

Megestrol (Megace) (female hormone) has proven

to work well to stimulate the appetite.

37
 Mucositis

Irritation and inflammation of the mucosa in the

mouth

Nursing interventions and implications that

would assist with this would include?

38
 Weight Loss
 Nursing implications
 Monitor weight.
 Increase protein intake.
 Small, frequent feedings.
 Attend to preferences for foods.
 Provide pleasant and restful environment during
meals.
 Supplement feedings.

39
 Nausea and Vomiting
 Caused by radiation therapy of the abdomen or lower back
often starting 7 to 10 days after the beginning of treatment
 Antiemetics are given before the nausea and vomiting begin.
The nursing priority is to ensure adequate control of CINV.
Teach patients to continue antiemetic drugs even when CINV
appears controlled. When the patient stops taking the drugs,
teach them to start retaking the drugs at the first sign of
nausea to prevent it from becoming uncontrollable .

40
 Diarrhea
 Caused by radiation to the abdomen, lower back, or
pelvis, chemotherapy effect on intestinal mucosa
 Loperamide is recommended for uncomplicated mild to
moderate diarrhea, and octreotide is recommended for
severe diarrhea. Teach the patient to avoid high-fiber
foods that encourage rapid evacuation from the bowel
and to add low-fiber foods such as bananas and cheese
to the diet. Cleansing the rectal area and applying
petroleum jelly, A&D ointment

41
 Constipation

Certain antineoplastic drugs, such as vincristine, vinblastine, and taxol,

cause constipation.

Certain antineoplastic drugs, such as vincristine, vinblastine, and

paclitaxel, cause constipation. Increasing fluids (as allowed), adding fiber
to the diet, administering stool softeners and fiber laxatives, exercise,
and monitoring vigilantly for the beginning signs of constipation are the
usual measures taken. Suppositories or enemas may be necessary.

42
 Cystitis

Caused by Cytoxan and ifosfamide

How would this be treated and nursing

implications and teaching to treat and avoid?

43
 Bone Marrow Suppression
 Major reason that doses of chemotherapy must
be limited
 Slows production of erythrocytes, leukocytes,
and platelets
 Some can cause severe suppression
 Usually is temporary
 Improvement in bone marrow function occurs
within weeks to months of completed therapy

44
 Infection Prevention
 Report the following signs of infection to the
physician immediately.
 Temperature over 100° F (38° C)
 Persistent cough
 Colored or foul-smelling drainage from wound or nose
 Presence of a boil or abscess
 Cloudy, foul-smelling urine or burning on urination

45
 Hyperuricemia
 Caused by antimetabolite destruction of cancer
cells

46
 Fatigue
 Fatigue from immunosuppression treatment
requires an adjustment of lifestyle.
 The patient may feel tired and without energy.
 The patient may be impatient and irritable and
withdraw from social environment.
 A decrease in activity may lead to a decline in
function, that is, irreversible.

47
 Alopecia
 Hair loss (alopecia) resulting from chemotherapy
is temporary.
 Occasionally, radiation therapy to the head
causes permanent hair loss.

48
 Pain (1 of 2)
 For many cancer patients, pain is a daily reality.
 Pain reduces appetite, limits activity, and
interferes with sleep.
 Most cancer pain (90%) can be relieved or at
least controlled by a combination of measures.
 Often, however, the pain of cancer is
undertreated.

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 Pain (2 of 2)
 Pain must be
 Assessed and documented regularly
 Discussed openly with family and the reports of pain
must be believed and understood
 Addressed with options that are appropriate for the
setting and for family
 Treated with interventions in a timely fashion

50
 Nonpharmacologic Interventions
 Nonpharmacologic interventions are combined
with oral, topical, and parenteral analgesia to
achieve relief or good control of pain.

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Fear and Ineffective Coping (1 of 2)
 Assess the patient’s and family’s usual coping
techniques.
 Pay attention to the patient’s partner.
 Be honest about the adverse effects but take a
positive approach.
 Consider psychosocial and spiritual care.
 Assist the patient to use strengths in planning for
fighting the disease.

52
Fear and Ineffective Coping (2 of 2)
 Coordinate family strengths to continue with
daily life.
 Speak with the patient and partner about sexual
concerns.
 Refer to a social worker to coordinate resources.
 Encourage a sense of humor and looking for
little pleasure and enjoyment in life on a daily
basis.

53
 Oncologic Emergencies
 Tumor lysis syndrome, including hyperkalemia
and hypercalcemia
 Hypercalcemia
 Disseminated intravascular coagulation (DIC)
 Pericardial effusion and cardiac tamponade
 Spinal cord compression
 Superior vena cava syndrome

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Caring for the Dying Cancer Patient
 Nurses working with cancer patients need to
understand the process of death and dying, and
grief.
 Need to apply knowledge about these processes
compassionately when caring for cancer
patients and their families.

55
 Grieving
 Kübler-Ross’ stages of dying
 Denial (This can’t happen to me!)
 Anger (Why me?)
 Bargaining (Yes me, but…)
 Depression (It is me. I give up…)
 Acceptance (I’m ready…)

56
 Fear
 Almost all dying patients and families face
varying levels of fear
 A nurse who is compassionate and soothing
provides comfort and strength for the patient.

57
 Palliative Care
 Palliative care (comfort care) is directed at meeting the
needs
 Provide comfort and maintain a high quality of life.
 Anticipatory guidance and stages of dying
 Terminal hydration
 End-stage symptom management
 Pain
 Dyspnea
 Death rattle
 Delirium

58
 Anticipatory Guidance
 Prepare the family and patient by anticipating the
death.
 Give guidance about physical changes, symptoms,
and complications.
 This may also aid the patient and family in deciding
about possible hospice care.
 Two stages of dying
 Pre-active, which may take weeks or months
 Active, which lasts only a few days

59
 Terminal Hydration
 A dying patient gradually reduces fluid intake.
 Dehydration can increase because of the
disease process.
 Dry mouth and thirst may be induced by drugs.

60
End-Stage Symptom Management
 Comfort is the goal of palliative care.
 Administering only oral medications is the preferred
choice, but this may not be possible as death draws
near.
 The goal is to allow a pain-free death.
 In some cases, it may be possible to administer
transdermal or rectal pain medications.

61
 Pain
 Transdermal fentanyl has helped eliminate the
burden of pain at the end of life.
 Sometimes this regimen is supplemented with
rescue doses of morphine.
 Whatever the regimen, studies have shown that
pain relief, either total or at least enough to
make the pain tolerable, is possible 75% to 97%
of the time.

62
 Dyspnea
 When patients are near death, they often
subjectively feel as if they cannot get enough air.
 It is difficult to determine what causes this feeling,
but several measures can be taken.
 Place in Fowler’s position.
 Reduce activities.
 Adjust air temperature.
 Give bronchodilators and morphine to ease breathing.

63
 Death Rattle
 Noisy ventilation is heard when patients can no
longer clear their throats of normal secretions.
 Family members are often alarmed and are
afraid the patient will choke to death.
 In these cases, scopolamine or atropine, drugs
that are known to reduce secretions, may be
used to quiet the patient and bring breathing
back to normal.

64
 Delirium
 Dying patients may experience hallucinations or
altered mental status.
 The nurse must first search for causes such as
pain, positional discomfort, or bladder distention
and address those physical problems.
 The nurse should discuss the delirium with the
patient’s family and encourage the family to talk
to the patient in quiet tones while remaining
calm.

65
 Audience Response Question 2
A terminally ill woman reminiscing about the “good old
days” becomes increasingly confused and talks of seeing
relatives who have died. Which nursing intervention(s)
would be appropriate? (Select all that apply.)
1. Discuss the patient’s behaviors with the family.
2. Force oral fluids.
3. Encourage the family to talk to the patient in quiet tones.
4. Promote a calm environment.
5. Apply physical restraints.