A. Breast Cancer: Surgery

Claire Maurice G.
Juanero
BSN III-C
A. BREAST CANCER
PATHOPHYSIOLOGY
Breast cancers arise from a sequence that begins with an increase in the number of
breast cells to the emergence of atypical breast cells followed by carcinoma in situ and
finally invasive cancer. Breast cancer occurs due to interaction between the
environment and a defective gene. When cells became cancerous they lost ability to
stop dividing, to attach to other cells and to stay where they belong. Some mutations
can cause cancer such as p-53, BRCA1 and BRCA2. These mutations are either
inherited or acquired after birth. Other mutations also cause breast cancer which is
deterring the P13K/AKT pathway; these are helpful in ‘apoptosis’ so that the pathway is
stuck in the on position and cancer cells do not commit suicide.
Breast cancers are many types which are mainly invasive (infiltrating) breast cancer,
non-invasive(ductal, lobular), estrogen fueled, inflammatory and metastatic breast
cancer, in these types ductal carcinoma and invasive breast cancers are more common
types accounting for about 15% and 80% respectively.
SURGERY
Surgery is the removal of the tumor and some surrounding healthy tissue during an
operation. Surgery is also used to examine the nearby axillary lymph nodes, which are
under the arm. A surgical oncologist is a doctor who specializes in treating cancer with
surgery. Learn more about the basics of cancer surgery.
Generally, the smaller the tumor, the more surgical options a patient has. The types of
surgery for breast cancer include the following:
 Lumpectomy. This is the removal of the tumor and a small, cancer-free margin
of healthy tissue around the tumor. Most of the breast remains. For invasive
cancer, radiation therapy to the remaining breast tissue is often recommended
after surgery, especially for younger patients, patients with hormone receptor
negative tumors, and patients with larger tumors. For DCIS, radiation therapy
after surgery may be an option depending on the patient, the tumor, and the type
of surgery. A lumpectomy may also be called breast-conserving surgery, a partial
mastectomy, quadrantectomy, or a segmental mastectomy. Women
with BRCA1 or BRCA2 gene mutations who have been newly diagnosed with
breast cancer may be eligible to receive breast-conserving surgery. So may
women with newly diagnosed breast cancer who carry a moderate-risk gene
mutation, like CHEK2 or ATM. Your genetic mutation status alone should not
determine which course of treatment may be best for you.
 Mastectomy. This is the surgical removal of the entire breast. There are several
types of mastectomies. Talk with your doctor about whether the skin can be
preserved, called a skin-sparing mastectomy, or whether the nipple can be
preserved, called a nipple-sparing mastectomy or total skin-sparing mastectomy.
A nipple-sparing mastectomy may be a treatment option for certain women with
a BRCA1 or BRCA2 gene mutation or for women with a moderate-risk gene
mutation, like CHEK2 or ATM. Your doctor will also consider how large the tumor
is compared to the size of your breast in determining the best type of surgery for
you.
CHEMOTHERAPY
Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer
cells from growing, dividing, and making more cells. It may be given before surgery to
shrink a large tumor, make surgery easier, and/or reduce the risk of recurrence, called
neoadjuvant chemotherapy. It may also be given after surgery to reduce the risk of
recurrence, called adjuvant chemotherapy.
A chemotherapy regimen, or schedule, usually consists of a combination of drugs given
in a specific number of cycles over a set period of time. Chemotherapy may be given on
many different schedules depending on what worked best in clinical trials for that
specific type of regimen. It may be given once a week, once every 2 weeks, once every
3 weeks, or even once every 4 weeks. There are many types of chemotherapy used to
treat breast cancer. Common drugs include:
 Docetaxel (Taxotere)
 Paclitaxel (Taxol)
 Doxorubicin (available as a generic drug)
 Epirubicin (Ellence)
 Pegylated liposomal doxorubicin (Doxil)
 Capecitabine (Xeloda)
 Carboplatin (available as a generic drug)
 Cisplatin (available as a generic drug)
 Cyclophosphamide (available as a generic drug)
 Eribulin (Halaven)
 Fluorouracil (5-FU)
 Gemcitabine (Gemzar)
 Ixabepilone (Ixempra)
 Methotrexate (Rheumatrex, Trexall)
 Protein-bound paclitaxel (Abraxane)
 Vinorelbine (Navelbine)
A patient may receive 1 drug at a time or a combination of different drugs given at the
same time. Research has shown that combinations of certain drugs are sometimes
more effective than single drugs for adjuvant treatment. ASCO does not
recommend routinely adding platinum chemotherapy (cisplatin or carboplatin) to
anthracycline (doxorubicin or epiribicin) or taxane (paclitaxel or docetaxel)
chemotherapy to treat people with inherited BRCA mutations before or after surgery.
The following drugs or combinations of drugs may be used as adjuvant therapy for
early-stage and locally advanced breast cancer:
 AC (doxorubicin and cyclophosphamide)
 EC (epirubicin, cyclophosphamide)
 AC or EC followed by T (paclitaxel or docetaxel), or the reverse)
 CAF (cyclophosphamide, doxorubicin, and 5-FU)
 CEF (cyclophosphamide, epirubicicyclophospham
 CMF (cyclophosphamide, methotrexate, and 5-FU)
 TAC (docetaxel, doxorubicin, and cyclophosphamide)
 TC (docetaxel and cyclophosphamide)
Therapies that target the HER2 receptor may be given with chemotherapy for HER2-
positive breast cancer (see "Targeted therapy," below). An example is the antibody
trastuzumab. Combination regimens for early-stage HER2-positive breast cancer may
include:
 AC-TH (doxorubicin, cyclophosphamide, paclitaxel or docetaxel, trastuzumab)
 AC-THP (doxorubicin, cyclophosphamide, paclitaxel or docetaxel, trastuzumab,
pertuzumab)
 TCH (paclitaxel or docetaxel, carboplatin, trastuzumab)
 TCHP (paclitaxel or docetaxel, carboplatin, trastuzumab, pertuzumab)
 TH (paclitaxel, trastuzumab)
The side effects of chemotherapy depend on the individual, the drug(s) used, whether
the chemotherapy has been combined with other drugs, and the schedule and dose
used. These side effects can include fatigue, risk of infection, nausea and vomiting, hair
loss, loss of appetite, diarrhea, constipation, numbness and tingling, pain, early
menopause, weight gain, and chemo-brain or cognitive dysfunction. These side effects
can often be very successfully prevented or managed during treatment with supportive
medications, and they usually go away after treatment is finished. For hair loss
reduction, talk with your doctor about whether they do cold cap techniques. Rarely,
long-term side effects may occur, such as heart damage, permanent nerve damage, or
secondary cancers such as leukemia or lymphoma.
Many patients feel well during chemotherapy and are actively taking care of their
families, working, and exercising during treatment, although each person’s experience
can be different. Talk with your health care team about the possible side effects of your
specific chemotherapy plan, and seek medical attention immediately if you experience a
fever during chemotherapy.
RADIATION THERAPY
Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer
cells. A doctor who specializes in giving radiation therapy to treat cancer is called a
radiation oncologist. There are several different types of radiation therapy:
 External-beam radiation therapy. This is the most common type of radiation

treatment and is given from a machine outside the body. This includes whole
breast radiation therapy and partial breast radiation therapy, as well as
accelerated breast radiation therapy, which can be several days instead of
several weeks.
 Intra-operative radiation therapy. This is when radiation treatment is given
using a probe in the operating room.
 Brachytherapy. This type of radiation therapy is given by placing radioactive
sources into the tumor.
Although the research results are encouraging, intra-operative radiation therapy and
brachytherapy are not widely used. Where available, they may be options for a patient
with a small tumor that has not spread to the lymph nodes. Learn more about the basics
of radiation therapy.
A radiation therapy regimen, or schedule (see below), usually consists of a specific
number of treatments given over a set period of time, such as 5 days a week for 3 to 6
weeks. Radiation therapy often helps lower the risk of recurrence in the breast. In fact,
with modern surgery and radiation therapy, recurrence rates in the breast are now less
than 5% in the 10 years after treatment or 6% to 7% at 20 years. Survival is the same
with lumpectomy or mastectomy. If there is cancer in the lymph nodes under the arm,
radiation therapy may also be given to the same side of the neck or underarm near the
breast or chest wall.
Radiation therapy may be given after or before surgery:
 Adjuvant radiation therapy is given after surgery. Most commonly, it is given
after a lumpectomy, and sometimes, chemotherapy. Patients who have a
mastectomy may or may not need radiation therapy, depending on the features
of the tumor. Radiation therapy may be recommended after mastectomy if a
patient has a larger tumor, cancer in the lymph nodes, cancer cells outside of the
capsule of the lymph node, or cancer that has grown into the skin or chest wall,
as well as for other reasons.
 Neoadjuvant radiation therapy is radiation therapy given before surgery to
shrink a large tumor, which makes it easier to remove. This approach is
uncommon and is usually only considered when a tumor cannot be removed with
surgery.
ASCO recommends that, when appropriate, adjuvant radiation therapy should be
offered to women with breast cancer with BRCA1 or BRCA2 mutations. Women with
a TP53 mutation are at higher risk of complications from radiation therapy, and
therefore should undergo mastectomy instead of lumpectomy and radiation. Those with
an ATM mutation or other related mutations should talk with their doctor about whether
adjuvant radiation therapy is right for them. Currently, there is not enough data to
recommend avoiding radiation therapy in all women with ATM mutations.
Radiation therapy can cause side effects, including fatigue, swelling of the breast,
redness and/or skin discoloration, and pain or burning in the skin where the radiation
was directed, sometimes with blistering or peeling. Your doctor can recommend topical
medication to apply to the skin to treat some of these side effects.
Very rarely, a small amount of the lung can be affected by the radiation therapy, causing
pneumonitis, a radiation-related swelling of the lung tissue. This risk depends on the
size of the area that received radiation therapy, and it tends to heal with time.
In the past, with older equipment and radiation therapy techniques, women who
received treatment for breast cancer on the left side of the body had a small increase in
the long-term risk of heart disease. Modern techniques, such as respiratory gating,
which uses technology to guide the delivery of radiation while a patient breathes, are
now able to spare the vast majority of the heart from the effects of radiation therapy.
Many types of radiation therapy may be available to you with different schedules (see
below). Talk with your doctor about the advantages and disadvantages of each option.
BIOTHERAPY
Immunotherapy, also called biologic therapy, is designed to boost the body's natural
defenses to fight the cancer. It uses materials made either by the body or in a laboratory
to improve, target, or restore immune system function. The following drugs are used for
advanced or metastatic breast cancer.
 Atezolizumab (Tecentriq). The FDA approved a combination of atezolizumab
plus protein-bound paclitaxel (see Chemotherapy, above) for locally advanced
triple-negative breast cancer that cannot be removed with surgery and metastatic
triple-negative breast cancer. In addition, it is only approved for breast cancers
that test positive for PD-L1 (see Diagnosis).
 Pembrolizumab (Keytruda). This is a type of immunotherapy that is approved
by the FDA to treat metastatic cancer or cancer that cannot be treated with
surgery. These tumors must also have a molecular alteration called microsatellite
instability-high (MSI-H) or DNA mismatch repair deficiency (dMMR)
(see Diagnosis). In addition, it is approved in combination with a few different
chemotherapy drugs to treat metastatic or locally recurrent triple-negative breast
cancer that cannot be treated with surgery and that tests positive for PD-L1.
Different types of immunotherapy can cause different side effects. Common side effects
include skin rashes, flu-like symptoms, diarrhea, and weight changes. Other severe but
less common side effects can also occur. Talk with your doctor about possible side
effects of the immunotherapy recommended for you. Learn more about the basics
of immunotherapy.
DIAGNOSTIC PROCEDURES
Tests and procedures used to diagnose breast cancer include:
 Breast exam. Your doctor will check both of your breasts and lymph nodes in
your armpit, feeling for any lumps or other abnormalities.
 Mammogram. A mammogram is an X-ray of the breast. Mammograms are
commonly used to screen for breast cancer. If an abnormality is detected on a
screening mammogram, your doctor may recommend a diagnostic mammogram
to further evaluate that abnormality.
 Breast ultrasound. Ultrasound uses sound waves to produce images of
structures deep within the body. Ultrasound may be used to determine whether a
new breast lump is a solid mass or a fluid-filled cyst.
 Removing a sample of breast cells for testing (biopsy). A biopsy is the only
definitive way to make a diagnosis of breast cancer. During a biopsy, your doctor
uses a specialized needle device guided by X-ray or another imaging test to
extract a core of tissue from the suspicious area. Often, a small metal marker is
left at the site within your breast so the area can be easily identified on future
imaging tests.
Biopsy samples are sent to a laboratory for analysis where experts determine whether
the cells are cancerous. A biopsy sample is also analyzed to determine the type of cells
involved in the breast cancer, the aggressiveness (grade) of the cancer, and whether
the cancer cells have hormone receptors or other receptors that may influence your
treatment options.
 Breast magnetic resonance imaging (MRI). An MRI machine uses a magnet
and radio waves to create pictures of the interior of your breast. Before a breast
MRI, you receive an injection of dye. Unlike other types of imaging tests, an MRI
doesn't use radiation to create the images.
Other tests and procedures may be used depending on your situation.
MEDICAL MANAGEMENT
Systemic therapy is the use of medication to destroy cancer cells. Medications circulate
through the body and therefore can reach cancer cells throughout the body. Systemic
therapies are generally prescribed by a medical oncologist, a doctor who specializes in
treating cancer with medication.
Common ways to give systemic therapies include an intravenous (IV) tube placed into a
vein using a needle, an injection into a muscle or under the skin, or in a pill or capsule
that is swallowed (orally).
The types of systemic therapies used for breast cancer include:
 Chemotherapy
 Hormonal therapy
 Targeted therapy
 Immunotherapy
Each of these therapies are discussed below in more detail. A person may receive 1
type of systemic therapy at a time or a combination of systemic therapies given at the
same time. They can also be given as part of a treatment plan that includes surgery
and/or radiation therapy. The medications used to treat cancer are continually being
evaluated. Your doctor may suggest clinical trials that are studying new ways to treat
breast cancer.
Talking with your doctor is often the best way to learn about the medications that can be
prescribed for you, their purpose, and their potential side effects. It is also important to
let your doctor know if you are taking any other prescription or over-the-counter
medications or supplements. Herbs, supplements, and other drugs can interact with
cancer medications.
NURSING MANAGEMENT
 Monitor for adverse effects of radiation therapy such as fatigue, sore throat, dry
cough, nausea, anorexia.
 Monitor for adverse effects of chemotherapy; bone marrow suppression, nausea
and vomiting, alopecia, weight gain or loss, fatigue, stomatitis, anxiety, and
depression.
 Realize that a diagnosis of breast cancer is a devastating emotional shock to the
woman. Provide psychological support to the patient throughout the diagnostic
and treatment process.
 Involve the patient in planning and treatment.
 Describe surgical procedures to alleviate fear.
 Prepare the patient for the effects of chemotherapy, and plan ahead for alopecia,
fatigue.
 Administer antiemetics prophylactically, as directed, for patients receiving
chemotherapy.
 Administer I.V. fluids and hyperalimentation as indicated.
 Help patient identify and use support persons or family or community.
 Suggest to the patient the psychological interventions may be necessary for
anxiety, depression, or sexual problems.
 Teach all women the recommended cancer-screening procedures.
SUPPORTIVE MANAGEMENT
Palliative care is specialized medical care that focuses on providing relief from pain and
other symptoms of a serious illness. Palliative care specialists work with you, your
family and your other doctors to provide an extra layer of support that complements
your ongoing care. Palliative care can be used while undergoing other aggressive
treatments, such as surgery, chemotherapy or radiation therapy.
When palliative care is used along with all of the other appropriate treatments, people
with cancer may feel better and live longer.
Palliative care is provided by a team of doctors, nurses and other specially trained
professionals. Palliative care teams aim to improve the quality of life for people with
cancer and their families. This form of care is offered alongside curative or other
treatments you may be receiving.
Alternative medicine
No alternative medicine treatments have been found to cure breast cancer. But
complementary and alternative medicine therapies may help you cope with side effects
of treatment when combined with your doctor's care.
Alternative medicine for fatigue

Many breast cancer survivors experience fatigue during and after treatment that can
continue for years. When combined with your doctor's care, complementary and
alternative medicine therapies may help relieve fatigue.
Talk with your doctor about:
 Gentle exercise. If you get the OK from your doctor, start with gentle exercise a
few times a week and add more if you feel up to it. Consider walking, swimming,
yoga or tai chi.
 Managing stress. Take control of the stress in your daily life. Try stress-reduction
techniques such as muscle relaxation, visualization, and spending time with
friends and family.
 Expressing your feelings. Find an activity that allows you to write about or
discuss your emotions, such as writing in a journal, participating in a support
group or talking to a counselor.
Coping and support

A breast cancer diagnosis can be overwhelming. And just when you're trying to cope
with the shock and the fears about your future, you're asked to make important
decisions about your treatment.
Every person finds his or her own way of coping with a cancer diagnosis. Until you find
what works for you, it might help to:
 Learn enough about your breast cancer to make decisions about your
care. If you'd like to know more about your breast cancer, ask your doctor for the
details of your cancer — the type, stage and hormone receptor status. Ask for
good sources of up-to-date information on your treatment options.
Knowing more about your cancer and your options may help you feel more
confident when making treatment decisions. Still, some women may not want to
know the details of their cancer. If this is how you feel, let your doctor know that,
too.
 Talk with other breast cancer survivors. You may find it helpful and
encouraging to talk to others in your same situation. Contact the American
Cancer Society to find out about support groups in your area and online.
 Find someone to talk about your feelings with. Find a friend or family member
who is a good listener, or talk with a clergy member or counselor. Ask your
doctor for a referral to a counselor or other professional who works with cancer
survivors.
 Keep your friends and family close. Your friends and family can provide a
crucial support network for you during your cancer treatment.
As you begin telling people about your breast cancer diagnosis, you'll likely get many
offers for help. Think ahead about things you may want assistance with, whether it's
having someone to talk to if you're feeling low or getting help preparing meals.
 Maintain intimacy with your partner. In Western cultures, women's breasts are
associated with attractiveness, femininity and sexuality. Because of these
attitudes, breast cancer may affect your self-image and erode your confidence in
intimate relationships. Talk to your partner about your insecurities and your
feelings.
B.PROSTATE CANCER
PATHOPHYSIOLOGY
The prostate is roughly 3 centimeters long, about the size of a walnut, and weighs
approximately 20 grams. Its function is to produce about a third of the total seminal fluid.
The prostate gland is located in the male pelvis at the base of the penis. It is below
(inferior) to the urinary bladder and immediately anterior to the rectum.
The prostate surrounds the posterior part of the urethra, but this can be misleading. The
posterior urethra, prostatic urethra, and proximal urethra all describe the same anatomy
as there is no difference between the internal lining of the prostate and the urethra; they
are the same entity.
The prostate is primarily made up of glandular tissue which produces fluid that
constitutes about 30% to 35% of the semen. This prostatic portion of the semen
nourishes the sperm and provides alkalinity which helps maintain a high pH. (The
seminal vesicles produce the rest of the seminal fluid.)
The prostate gland requires androgen (testosterone) to function optimally. This is why
hormonal therapy (testosterone deprivation) is so effective. Castrate resistant tumors
are thought to generate intracellular androgens.
Cancer begins with a mutation in normal prostate glandular cells, usually beginning with
the peripheral basal cells.
Prostate cancer is most common in the peripheral zone which is primarily that portion of
the prostate that can be palpated via digital rectal examination (DRE).
 Prostate cancer is an adenocarcinoma as it develops primarily from the glandular
part of the organ and shows typical glandular patterns on microscopic
examination.
 The cancer cells grow and begin to multiply, initially spreading to the immediately
surrounding prostate tissue forming a tumor nodule.
 Such a tumor may grow outside the prostate (extracapsular extension) or may
remain localized within the prostate for decades.
 Prostate cancer commonly metastasizes to the bones and lymph nodes.
 Metastases to the bone are thought to be at least partially a result of the prostatic
venous plexus draining into the vertebral veins.
The prostate accumulates zinc and produces citrate. However, increased dietary or
supplemental zinc and citrate do not appear to have any influence on prostatic health or
the development of prostate cancer.
SURGERY
Surgery involves the removal of the prostate and some surrounding lymph nodes during
an operation. A surgical oncologist is a doctor who specializes in treating cancer using
surgery. For prostate cancer, a urologist or urologic oncologist is the surgical oncologist
involved in treatment. The type of surgery depends on the stage of the disease, the
man’s overall health, and other factors.
 Radical (open) prostatectomy. A radical prostatectomy is the surgical removal
of the entire prostate and the seminal vesicles. Lymph nodes in the pelvic area
may also be removed. This operation has the risk of affecting sexual function.
Nerve-sparing surgery, when possible, increases the chance that a man can
maintain his sexual function after surgery by avoiding surgical damage to the
nerves that allow erections and orgasm to occur. Orgasm can occur even if some
nerves are cut because these are separate processes. Urinary incontinence is
also a possible side effect of radical prostatectomy. To help resume normal
sexual function, men can receive drugs, penile implants, or injections.
Sometimes, another surgery can fix urinary incontinence.
 Robotic or laparoscopic prostatectomy. This type of surgery is less invasive
than a radical prostatectomy and may shorten recovery time. A camera and
instruments are inserted through small keyhole incisions in the patient’s
abdomen. The surgeon then directs the robotic instruments to remove the
prostate gland. In general, robotic prostatectomy causes less bleeding and less
pain, but the sexual and urinary side effects are similar to those of a radical
(open) prostatectomy. Talk with your doctor about whether your treatment center
offers this procedure and how it compares with the results of the radical (open)
prostatectomy.
 Bilateral orchiectomy. Bilateral orchiectomy is the surgical removal of both
testicles. It is described in detail in “Systemic treatments” below.
 Transurethral resection of the prostate (TURP). TURP is most often used to
relieve symptoms of a urinary blockage, not to treat prostate cancer. In this
procedure, with the patient under full anesthesia, which is medication to block the
awareness of pain, a surgeon inserts a narrow tube with a cutting device called a
cystoscope into the urethra and then into the prostate to remove prostate tissue.
Before surgery, talk with your health care team about the possible side effects from the
specific surgery you will have. Typically, younger or healthier men may benefit more
from a prostatectomy. Younger men are also less likely to develop permanent erectile
dysfunction and urinary incontinence after a prostatectomy than older men.
CHEMOTHERAPY
cells from growing, dividing, and making more cells.
Chemotherapy may help those with advanced or castration-resistant prostate cancer
and those with newly diagnosed or hormone-sensitive metastatic prostate cancer. A
chemotherapy regimen, or schedule, usually consists of a specific number of cycles
given over a set period of time.
There are several standard drugs used for prostate cancer. In general, standard
chemotherapy begins with docetaxel (Taxotere) combined with prednisone.
Cabazitaxel (Jevtana) is approved to treat metastatic castration-resistant prostate
cancer that has been previously treated with docetaxel. It is a microtubule inhibitor.
Recent research shows adding docetaxel chemotherapy to testosterone suppression
therapy in those with newly diagnosed or hormone-sensitive metastatic prostate cancer
significantly helps people live longer and stops the disease from growing and spreading.
The side effects of chemotherapy depend on the individual, the type of chemotherapy
received, the dose used, and the length of treatment, but they can include fatigue, sores
in the mouth and throat, diarrhea, nausea and vomiting, constipation, blood disorders,
nervous system effects, changes in thinking and memory, sexual and reproductive
issues, appetite loss, pain, and hair loss. The side effects of chemotherapy usually go
away after treatment has finished. However, some side effects may continue, come
back, or develop later. Ask your doctor which side effects you may experience, based
on your treatment plan. Your health care team will work with you to manage or prevent
many of these side effects.
RADIATION THERAPY
Radiation therapy is the use of high-energy rays to destroy cancer cells. A doctor who
specializes in giving radiation therapy to treat cancer is called a radiation oncologist. A
radiation therapy regimen, or schedule, usually consists of a specific number of
treatments given over a set period of time.
External-beam radiation therapy. External-beam radiation therapy is the most
common type of radiation treatment. The radiation oncologist uses a machine located
outside the body to focus a beam of x-rays on the area with the cancer. Some cancer
centers use conformal radiation therapy (CRT), in which computers help precisely map
the location and shape of the cancer. CRT reduces radiation damage to healthy tissues
and organs around the tumor.
One method of external-beam radiation therapy used to treat prostate cancer is called
hypofractionated radiation therapy. This is when a person receives a higher daily dose
of radiation therapy given over a shorter period instead of lower doses given over a
longer period.
According to recommendations from ASCO, American Society for Radiation Oncology,
and American Urological Association, hypofractionated radiation therapy may be an
option for the following people with early-stage prostate cancer that has not spread to
other parts of the body:
 Men with low-risk prostate cancer who need or prefer treatment instead of active
surveillance.
 Men with intermediate or high-risk prostate cancer receiving external-beam
radiation therapy to the prostate but not to the pelvic lymph nodes.
People who receive hypofractionated radiation therapy may have a slightly higher risk of
some short-term side effects after treatment compared with those who receive regular
external-beam radiation therapy. This may include gastrointestinal side effects. Based
on current research, people who receive hypofractionated radiation therapy are not at a
higher risk of side effects in the long term. Talk with your health care team if you have
questions about your risk for side effects.
Brachytherapy. Brachytherapy, or internal radiation therapy, is the insertion of
radioactive sources directly into the prostate. These sources, called seeds, give off
radiation just around the area where they are inserted and may be left for a short time
(high-dose rate) or for a longer time (low-dose rate). Low-dose-rate seeds are left in the
prostate permanently and work for up to 1 year after they are inserted. However, how
long they work depends on the source of radiation. High-dose-rate brachytherapy is
usually left in the body for less than 30 minutes, but it may need to be given more than
once.
Brachytherapy may be used with other treatments, such as external-beam radiation
therapy and/or testosterone suppression therapy. ASCO recommends the following
brachytherapy options:
 Men with low-risk prostate cancer who need or choose an active treatment may
consider low-dose-rate brachytherapy. Other options include external-beam
radiation therapy or a radical prostatectomy.
 Men with intermediate-risk prostate cancer who choose external-beam radiation
therapy (with or without testosterone suppression therapy) should be offered
either a low-dose-rate or high-dose-rate brachytherapy boost in addition to the
external-beam radiation therapy. For a brachytherapy boost, a lower dose of
radiation is given for a shorter period of time. Some men with intermediate-risk
prostate cancer may be able to receive only brachytherapy without external-
beam radiation therapy or testosterone suppression therapy.
 Men with high-risk prostate cancer who are receiving external-beam radiation
therapy and testosterone suppression therapy should be offered a low-dose-rate
or high-dose-rate brachytherapy therapy.
Intensity-modulated radiation therapy (IMRT). IMRT is a type of external-beam
radiation therapy that uses CT scans to form a 3D picture of the prostate before
treatment. A computer uses this information about the size, shape, and location of the
prostate cancer to determine how much radiation is needed to destroy it. With IMRT,
high doses of radiation can be directed at the prostate without increasing the risk of
damaging nearby organs.
Proton therapy. Proton therapy, also called proton beam therapy, is a type of external-
beam radiation therapy that uses protons rather than x-rays. At high energy, protons
can destroy cancer cells. Current research has not shown that proton therapy provides
any more benefit to men with prostate cancer than traditional radiation therapy. It is also
more expensive.
IMMUNOTHERAPY
to improve, target, or restore immune system function.
For some men with castration-resistant metastatic prostate cancer who have no or very
few cancer symptoms and generally have not had chemotherapy, vaccine therapy with
sipuleucel-T (Provenge) may be an option.
Sipuleucel-T is adapted for each patient. Before treatment, blood is removed from the
patient in a process called leukapheresis. Special immune cells are separated from the
patient’s blood, modified in the laboratory, and then put back into the patient. At this
point, the patient’s immune system may recognize and destroy prostate cancer cells.
When this treatment is used, it is difficult to know if the treatment is working to treat the
cancer because treatment with sipuleucel-T does not lead to lower PSA levels,
shrinking of the tumor, or keeping the cancer from getting worse. However, results from
clinical trials have shown that treatment with sipuleucel-T can lengthen lives by about 4
months in men with metastatic castration-resistant prostate cancer with few or no
symptoms.
Different types of immunotherapy can cause different side effects. Common side effects
include skin reactions, flu-like symptoms, diarrhea, and weight changes. Talk with your
doctor about possible side effects for the immunotherapy recommended for you.
TARGETED THERAPY
Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the
tissue environment that contributes to cancer growth and survival. This type of
treatment blocks the growth and spread of cancer cells and limits damage to healthy
cells.
Not all tumors have the same targets. To find the most effective treatment, your doctor
may run tests to identify the genes, proteins, and other factors in your tumor. This helps
doctors better match each patient with the most effective treatment whenever possible.
In addition, research studies continue to find out more about specific molecular targets
and new treatments directed at them.
Targeted therapy for prostate cancer includes:
Olaparib (Lynparza). Olaparib is a type of targeted therapy called a PARP inhibitor. It
is approved for patients with metastatic castration-resistant prostate cancer whose
disease has continued to grow and spread during treatment with abiraterone and/or
enzalutamide and who have homologous recombination repair (HRR) gene defects,
which may be inherited or in the tumor. HRR gene defects make it harder for cancer
cells to repair damaged DNA. Certain genes, such as BRCA1, BRCA2, and several
others, are linked with HRR gene defects, and the presence of any of these can allow
treatment with olaparib. The FDA has also approved 2 specific tests to select patients
for treatment with olaparib.
Rucaparib (Rubraca). Rucaparib is another PARP inhibitor approved to treat
metastatic castration-resistant prostate cancer in patients whose disease has not been
stopped by treatment with abiraterone and/or enzalutamide and chemotherapy, and
who have a BRCA1 or BRCA2 mutation that is either inherited or in the tumor.
Talk with your doctor about possible side effects for a specific medication and how they
can be managed.
HORMONE THERAPY
Hormone therapy is treatment to stop your body from producing the male hormone
testosterone. Prostate cancer cells rely on testosterone to help them grow. Cutting off
the supply of testosterone may cause cancer cells to die or to grow more slowly.
Hormone therapy options include:
 Medications that stop your body from producing testosterone. Certain

medications — known as luteinizing hormone-releasing hormone (LHRH) or
gonadotropin-releasing hormone (GnRH) agonists and antagonists — prevent
your body's cells from receiving messages to make testosterone. As a result,
your testicles stop producing testosterone.
 Medications that block testosterone from reaching cancer cells. These
medications, known as anti-androgens, usually are given in conjunction
with LHRH agonists. That's because LHRH agonists can cause a temporary
increase in testosterone before testosterone levels decrease.
 Surgery to remove the testicles (orchiectomy). Removing your testicles reduces
testosterone levels in your body quickly and significantly. But unlike medication
options, surgery to remove the testicles is permanent and irreversibbef
Hormone therapy is often used to treat advanced prostate cancer to shrink the cancer
and slow its growth.
Hormone therapy is sometimes used before radiation therapy to treat cancer that hasn't
spread beyond the prostate. It helps shrink the cancer and increases the effectiveness
of radiation therapy.
Screening for prostate cancer
Testing healthy men with no symptoms for prostate cancer is controversial. There is
some disagreement among medical organizations whether the benefits of testing
outweigh the potential risks.
Most medical organizations encourage men in their 50s to discuss the pros and cons of
prostate cancer screening with their doctors. The discussion should include a review of
your risk factors and your preferences about screening.
You might consider starting the discussions sooner if you're a Black person, have a
family history of prostate cancer or have other risk factors.
Prostate screening tests might include:
 Digital rectal exam (DRE). During a DRE, your doctor inserts a gloved,
lubricated finger into your rectum to examine your prostate, which is adjacent to
the rectum. If your doctor finds any abnormalities in the texture, shape or size of
the gland, you may need further tests.
 Prostate-specific antigen (PSA) test. A blood sample is drawn from a vein in
your arm and analyzed for PSA, a substance that's naturally produced by your
prostate gland. It's normal for a small amount of PSA to be in your bloodstream.
However, if a higher than usual level is found, it may indicate prostate infection,
inflammation, enlargement or cancer.
Diagnosing prostate cancer
If prostate cancer screening detects an abnormality, your doctor may recommend
further tests to determine whether you have prostate cancer, such as:
 Ultrasound. During a transrectal ultrasound, a small probe, about the size and
shape of a cigar, is inserted into your rectum. The probe uses sound waves to
create a picture of your prostate gland.
 Magnetic resonance imaging (MRI). In some situations, your doctor may
recommend an MRI scan of the prostate to create a more detailed
picture. MRI images may help your doctor plan a procedure to remove prostate
tissue samples.
 Collecting a sample of prostate tissue. To determine whether there are cancer
cells in the prostate, your doctor may recommend a procedure to collect a
sample of cells from your prostate (prostate biopsy). Prostate biopsy is often
done using a thin needle that's inserted into the prostate to collect tissue. The
tissue sample is analyzed in a lab to determine whether cancer cells are present.
MEDICAL MANAGEMENT
Some people never need treatment because the cancer grows slowly and doesn’t
spread. With treatment, most prostate cancer is highly curable. Treatment options
include:
 Active surveillance: With this approach, you get screenings, scans and biopsies
every one to three years to monitor cancer growth. Active surveillance works best
if the cancer is only in the prostate, slow-growing and not causing symptoms.
 Watchful Waiting: Watchful waiting sounds similar to active surveillance, but is
often used in older or frailer patients. Similar to active surveillance, this approach
does not involve definitive treatment at diagnosis. However, the testing is much
less frequent, and focuses on symptom management.
 Brachytherapy: A form of internal radiation therapy, brachytherapy involves
placing radioactive seeds within the prostate. This approach helps preserve
surrounding healthy tissue.
 External beam radiation therapy: With external beam radiation therapy, a
machine delivers strong X-ray beams directly to the tumor. Intensity-modulated
radiation therapy is a form of external radiation therapy that delivers powerful
doses of radiation to the disease site.
 Systemic therapies: Your provider may recommend systemic therapies if
cancer has spread outside of the prostate gland. These therapies include
chemotherapy, androgen deprivation hormone therapy and immunotherapy
 Focal therapy: Focal therapy is a newer form of treatment focusing on treating
only the area of the prostate affected by cancer. You may be able to try this
treatment if cancer hasn’t spread. Focal therapy options include high-intensity
focused ultrasound (HIFU), cryotherapy, laser ablation and photodynamic
therapy.
 Prostatectomy: This surgical procedure removes the diseased prostate gland.
Surgeons can perform laparoscopic prostatectomy and robotic radical
prostatectomy through small abdominal incisions. These procedures are less
invasive than an open radical prostatectomy, which requires a larger abdominal
incision, although both are effective in cancer removal.
NURSING MANAGEMENT
 Nurses are often the key workers for patients with prostate cancer, and are
responsible for maintaining continuity of care (NICE, 2004). Key nursing roles are
providing information and supporting men in making treatment decision.
 Patients often expect doctors to recommend a treatment and can find it
distressing to have to make a choice, particularly as there is a great deal of
uncertainty about disease progression (NICE, 2014). Using a decision aid, such
as the Localised Prostate Cancer Decision Aid (NHS, 2012), can be help guide
them through the process while ensuring their own beliefs and values are
considered; for example, remaining potent might be a key factor.
 Patients should be given as much or as little information as they want and nurses
should be aware that needs may vary with age, culture and sexual orientation.
 After treatment, nurses need to assess patients for side-effects and offer formal
assessment and treatment for troubling symptoms. Patients should be asked
regularly whether their side-effects are troubling, as their views and quality of life
may change over the years.
 Treatments for prostate cancer affect masculinity, as side-effects include erectile
dysfunction, testicular shrinkage, breast development and loss of strength. While
some men joke about their feminisation, this may mask psychological distress.
Nurses should be alert to cues and offer patients referral to professionals for help
with psychosexual issues (NICE, 2014).
No complementary or alternative treatments will cure prostate cancer. However,
complementary and alternative prostate cancer treatments may help you cope with the
side effects of cancer and its treatment.
Nearly everyone diagnosed with cancer experiences some distress at some point. If
you're distressed, you may feel sad, angry or anxious. You may experience difficulty
sleeping or find yourself constantly thinking about your cancer.
Several complementary medicine techniques may help you cope with your distress,
including:
 Art therapy
 Dance or movement therapy
 Exercise
 Meditation
 Music therapy
 Relaxation techniques
 Spirituality
Discuss your feelings and concerns with your doctor. In some cases, treatment for
distress may require medications.
When you receive a diagnosis of prostate cancer, you may experience a range of
feelings — including disbelief, fear, anger, anxiety and depression. With time, each
person finds his own way of coping with a prostate cancer diagnosis. Until you find what
works for you, try to:
 Learn enough about prostate cancer to feel comfortable making treatment
decisions. Learn as much as you need to know about your cancer and its
treatment in order to understand what to expect from treatment and life after
treatment. Ask your doctor, nurse or other health care professional to
recommend some reliable sources of information to get you started.
 Keep your friends and family close. Your friends and family can provide support
during and after your treatment. They may be eager to help with the small tasks
you won't have energy for during treatment. And having a close friend or family
member to talk to can be helpful when you're feeling stressed or overwhelmed.
 Connect with other cancer survivors. Friends and family can't always understand
what it's like to face cancer. Other cancer survivors can provide a unique network
of support. Ask your health care providers about support groups or community
organizations that can connect you with other cancer survivors. Organizations
such as the American Cancer Society offer online chat rooms and discussion
forums.
 Take care of yourself. Take care of yourself during cancer treatment by eating a
diet full of fruits and vegetables. Try to exercise most days of the week. Get
enough sleep each night so that you wake feeling rested.
 Continue sexual expression. If you experience erectile dysfunction, your natural
reaction may be to avoid all sexual contact. But consider touching, holding,
hugging and caressing as ways to continue sharing sexuality with your partner.
C.BRONCHOGENIC CANCER
PATHOPHYSIOLOGY
Bronchogenic carcinoma tends to form an intraluminal mass which may partially
or completely obstruct the bronchus. The neoplasm also may compress or invade local
structures such as aorta, esophagus, superior vena cava or cervical sympathetic chain.
Bronchogenic carcinoma may present with a variety clinical manifestations but the
major findings are cough, weight loss, chest pain and dyspnea. These neoplasms also
have the capacity to secrete hormones or hormone-like substances which have a
variety of clinical effects.
SURGERY
During surgery, your surgeon works to remove the lung cancer and a margin of healthy
tissue. Procedures to remove lung cancer include:
 Wedge resection to remove a small section of lung that contains the tumor
along with a margin of healthy tissue
 Segmental resection to remove a larger portion of lung, but not an entire lobe
 Lobectomy to remove the entire lobe of one lung
 Pneumonectomy to remove an entire lung
If you undergo surgery, your surgeon may also remove lymph nodes from your chest in
order to check them for signs of cancer.
Surgery may be an option if your cancer is confined to the lungs. If you have a larger
lung cancer, your doctor may recommend chemotherapy or radiation therapy before
surgery in order to shrink the cancer. If there's a risk that cancer cells were left behind
after surgery or that your cancer may recur, your doctor may recommend chemotherapy
or radiation therapy after surgery.
CHEMOTHERAPY
Chemotherapy uses drugs to kill cancer cells. One or more chemotherapy drugs may be
given through a vein in your arm (intravenously) or taken orally. A combination of drugs
usually is given in a series of treatments over a period of weeks or months, with breaks
in between so that you can recover.
Chemotherapy is often used after surgery to kill any cancer cells that may remain. It can
be used alone or combined with radiation therapy. Chemotherapy may also be used
before surgery to shrink cancers and make them easier to remove.
In people with advanced lung cancer, chemotherapy can be used to relieve pain and
other symptoms.
RADIATION THERAPY
Radiation therapy uses high-powered energy beams from sources such as X-rays and
protons to kill cancer cells. During radiation therapy, you lie on a table while a machine
moves around you, directing radiation to precise points on your body.
For people with locally advanced lung cancer, radiation may be used before surgery or
after surgery. It's often combined with chemotherapy treatments. If surgery isn't an
option, combined chemotherapy and radiation therapy may be your primary treatment.
For advanced lung cancers and those that have spread to other areas of the body,
radiation therapy may help relieve symptoms, such as pain.
TARGETED DRUGS or IMMUNOTHERAPY

Targeted drugs are those that work only for certain genetic mutations or specific types
of lung cancer. Immunotherapy drugs help your body’s immune system recognize and
fight cancer cells. These treatments may be used for advanced or recurrent lung
cancer.
People with lung cancer often experience signs and symptoms of the cancer, as well as
side effects of treatment. Supportive care, also known as palliative care, is a specialty
area of medicine that involves working with a doctor to minimize your signs and
symptoms.
Your doctor may recommend that you meet with a palliative care team soon after your
diagnosis to ensure that you're comfortable during and after your cancer treatment.
In one study, people with advanced non-small cell lung cancer who began receiving
supportive care soon after their diagnosis lived longer than those who continued with
treatments, such as chemotherapy and radiation. Those receiving supportive care
reported improved mood and quality of life. They survived, on average, almost three
months longer than did those receiving standard care.
Testing healthy people for lung cancer
People with an increased risk of lung cancer may consider annual lung cancer
screening using low-dose CT scans. Lung cancer screening is generally offered to
people 55 and older who smoked heavily for many years or who have quit in the past 15
years.
Discuss your lung cancer risk with your doctor. Together you can decide whether lung
cancer screening is right for you.
Tests to diagnose lung cancer
If there's reason to think that you may have lung cancer, your doctor can order a
number of tests to look for cancerous cells and to rule out other conditions.
Tests may include:
 Imaging tests. An X-ray image of your lungs may reveal an abnormal mass or
nodule. A CT scan can reveal small lesions in your lungs that might not be
detected on an X-ray.
 Sputum cytology. If you have a cough and are producing sputum, looking at the
sputum under the microscope can sometimes reveal the presence of lung cancer
cells.
 Tissue sample (biopsy). A sample of abnormal cells may be removed in a
procedure called a biopsy.
Your doctor can perform a biopsy in a number of ways, including bronchoscopy, in
which your doctor examines abnormal areas of your lungs using a lighted tube that's
passed down your throat and into your lungs.
Mediastinoscopy, in which an incision is made at the base of your neck and surgical
tools are inserted behind your breastbone to take tissue samples from lymph nodes is
also an option.
Another option is needle biopsy, in which your doctor uses X-ray or CT images to guide
a needle through your chest wall and into the lung tissue to collect suspicious cells.
A biopsy sample may also be taken from lymph nodes or other areas where cancer has
spread, such as your liver.
Careful analysis of your cancer cells in a lab will reveal what type of lung cancer you
have. Results of sophisticated testing can tell your doctor the specific characteristics of
your cells that can help determine your prognosis and guide your treatment.
Tests to determine the extent of the cancer
Once your lung cancer has been diagnosed, your doctor will work to determine the
extent (stage) of your cancer. Your cancer's stage helps you and your doctor decide
what treatment is most appropriate.
Staging tests may include imaging procedures that allow your doctor to look for
evidence that cancer has spread beyond your lungs. These tests include CT, MRI,
positron emission tomography (PET) and bone scans. Not every test is appropriate for
every person, so talk with your doctor about which procedures are right for you.
The stages of lung cancer are indicated by Roman numerals that range from 0 to IV,
with the lowest stages indicating cancer that is limited to the lung. By stage IV, the
cancer is considered advanced and has spread to other areas of the body.
MEDICAL MANAGEMENT
 Oxygen through nasal cannula based on level of dyspnea.
 Enteral or total parenteral nutrition for malnourished patient who is unable or
unwilling to eat.
 Removal of the pleural fluid (by thoracentesis or tube thoracostomy) and
instillation of sclerosing agent to obliterate pleural space and fluid recurrence.
 Radiation therapy in combination with other methods.
NURSING MANAGEMENT
 Elevate the head of the bed to ease the work of breathing and to prevent fluid
collection in upper body (from superior vena cava syndrome).
 Teach breathing retraining exercises to increase diaphragmatic excursion and
reduce work of breathing.
 Augment the patient’s ability to cough effectively by splinting the patient’s chest
manually.
 Instruct the patient to inspire fully and cough two to three times in one breath.
 Provide humidifier or vaporizer to provide moisture to loosen secretions.
 Teach relaxation techniques to reduce anxiety associated with dyspnea. Allow
the severely dyspneic patient to sleep in reclining chair.
 Encourage the patient to conserve energy by decreasing activities.
 Ensure adequate protein intake such as milk, eggs, oral nutritional supplements;
and chicken, fowl, and fish if other treatments are not tolerated – to promote
healing and prevent edema.
 Advise the patient to eat small amounts of high-calorie and high-protein foods
frequently, rather than three daily meals.
 Advise the patient to eat small amounts of high-calorie and high-protein foods
frequently, rather than three daily meals.
 Suggest eating the major meal in the morning if rapid satiety is the problem.
 Change the diet consistency to soft or liquid if patient has esophagitis from
radiation therapy.
 Consider alternative pain control methods, such as biofeedback and relaxation
methods, to increase the patient’s sense of control.
 Teach the patient to use prescribed medications as needed for pain without
being overly concerned about addiction.
Lifestyle and home remedies

Coping with shortness of breath
Many people with lung cancer experience shortness of breath at some point in the
course of the disease. Treatments such as supplemental oxygen and medications are
available to help you feel more comfortable, but they aren't always enough.
To cope with shortness of breath, it may help to:
 Try to relax. Feeling short of breath can be scary. But fear and anxiety only make
it harder to breathe. When you begin to feel short of breath, try to manage the
fear by choosing an activity that helps you relax. Listen to music, imagine your
favorite vacation spot, meditate or say a prayer.
 Find a comfortable position. It may help to lean forward when you feel short of
breath.
 Focus on your breath. When you feel short of breath, focus your mind on your
breathing. Instead of trying to fill your lungs with air, concentrate on moving the
muscles that control your diaphragm. Try breathing through pursed lips and
pacing your breaths with your activity.
 Save your energy for what's important. If you're short of breath, you may become
tired easily. Cut out the nonessential tasks from your day so that you can save
your energy for what needs to be done.
Tell your doctor if you experience shortness of breath or if your symptoms worsen, as
there are many other treatments available to relieve shortness of breath.
Complementary and alternative lung cancer treatments can't cure your cancer. But
complementary and alternative treatments can often be combined with your doctor's
care to help relieve signs and symptoms.
The American College of Chest Physicians suggests people with lung cancer may find
comfort in:
 Acupuncture. During an acupuncture session, a trained practitioner inserts
small needles into precise points on your body. Acupuncture may relieve pain
and ease cancer treatment side effects, such as nausea and vomiting, but there's
no evidence that acupuncture has any effect on your cancer.
 Hypnosis. Hypnosis is typically done by a therapist who leads you through
relaxation exercises and asks you to think pleasing and positive thoughts.
Hypnosis may reduce anxiety, nausea and pain in people with cancer.
 Massage. During a massage, a massage therapist uses his or her hands to
apply pressure to your skin and muscles. Massage can help relieve anxiety and
pain in people with cancer. Some massage therapists are specially trained to
work with people who have cancer.
 Meditation. Meditation is a time of quiet reflection in which you focus on
something, such as an idea, image or sound. Meditation may reduce stress and
improve quality of life in people with cancer.
 Yoga. Yoga combines gentle stretching movements with deep breathing and
meditation. Yoga may help people with cancer sleep better.
Coping and support

A diagnosis of cancer can be overwhelming. With time you'll find ways to cope with the
distress and uncertainty of cancer. Until then, you may find it helps to:
 Learn enough about lung cancer to make decisions about your care. Ask your
doctor about your lung cancer, including your treatment options and, if you like,
your prognosis. As you learn more about lung cancer, you may become more
confident in making treatment decisions.
 Keep friends and family close. Keeping your close relationships strong will help
you deal with your lung cancer. Friends and family can provide the practical
support you'll need, such as helping take care of your home if you're in the
hospital. And they can serve as emotional support when you feel overwhelmed
by cancer.
 Find someone to talk with. Find a good listener who is willing to listen to you talk
about your hopes and fears. This may be a friend or family member. The concern
and understanding of a counselor, medical social worker, clergy member or
cancer support group also may be helpful.
Ask your doctor about support groups in your area. Or check with local and national
cancer organizations, such as the National Cancer Institute or the American Cancer
Society.
PHARMACOLOGIC INTERVENTION
 Expectorants and antimicrobial agents to relieve dyspnea and infection.
 Analgesics given regularly to maintain pain at tolerable level. Titrate dosages to
achieve pain control.
 Chemotherapy using cisplatin in combination with a variety of other agents and
immunotherapy treatments may be indicated.
D.BRAIN TUMOR
PATHOPHYSIOLOGY
A brain tumor is an overgrowth of cells that creates a mass of tissue within the brain. As
it grows, this compresses the brain tissue, causing symptoms ranging in severity from
minor headaches to brain death. Symptoms will vary based on the size and location of
the tumor.
SURGERY
operation. It is usually the first treatment used for a brain tumor. It is often the only
treatment needed for a low-grade brain tumor. Removing the tumor can improve
neurological symptoms, provide tissue for diagnosis and genetic analysis, help make
other brain tumor treatments more effective, and, in many instances, improve the
prognosis of a person with a brain tumor.
A neurosurgeon is a doctor who specializes in surgery on the brain and spinal column.
Surgery to the brain requires the removal of part of the skull, a procedure called a
craniotomy. After the surgeon removes the tumor, the patient's own bone will be used to
cover the opening in the skull.
There have been rapid advances in surgery for brain tumors, including the use of
cortical mapping, enhanced imaging, and fluorescent dyes.
 Cortical mapping allows doctors to identify areas of the brain that control the
senses, language, and motor skills.
 Enhanced imaging devices give surgeons more tools to plan and perform
surgery. For example, computer-based techniques, such as Image Guided
Surgery (IGS), help surgeons map out the location of the tumor very accurately.
However, this is a very specialized technique that may not be widely available.
 A fluorescent dye, called 5 aminolevulinic acid, can be given by mouth the
morning before surgery. This dye is taken up by tumor cells. Doctors can use a
special microscope and light to see the cells that have taken up the dye during
the surgery. This helps doctors safely remove as much of the tumor as possible.
For a tumor that is near the brain’s speech center, it is increasingly common to perform
the operation when the patient is awake for part of the surgery. Typically, the patient is
awakened once the surface of the brain is exposed. Then, special electrical stimulation
techniques are used to locate the specific part of the brain that controls speech. This
approach can help avoid causing damage while removing the tumor.
In addition to removing or reducing the size of the brain tumor, surgery can provide a
tissue sample for biopsy analysis, as explained in Diagnosis. For some tumor types, the
results of this analysis can help determine if chemotherapy or radiation therapy will be
useful. For a cancerous tumor, even if it cannot be cured, removing it can relieve
symptoms from the tumor pressing on the brain.
Sometimes, surgery cannot be performed because the tumor is located in a place the
surgeon cannot reach, or it is near a vital structure. These tumors are called inoperable
or unresectable. If the tumor is inoperable, the doctor will recommend other treatment
options that may also include a biopsy or removal of a portion of the tumor.
Before surgery, talk with your health care team about the possible side effects from the
specific surgery you will have.
MEDICAL MANAGEMENT
CHEMOTHERAPY
Chemotherapy is the use of drugs to destroy tumor cells, usually by keeping the tumor
A chemotherapy regimen, or schedule, usually consists of a specific number of cycles
given over a set period of time. A patient may receive 1 drug at a time or a combination
of different drugs given at the same time. The goal of chemotherapy can be to destroy
tumor cells remaining after surgery, slow a tumor’s growth, or reduce symptoms.
As explained above, chemotherapy to treat a brain tumor is typically given after surgery
and possibly with or after radiation therapy, particularly if the tumor has come back after
initial treatment.
Some drugs are better at going through the blood-brain barrier. These are the drugs
often used for a brain tumor.
 Gliadel wafers are a way to give the drug carmustine. These wafers are placed in
the area where the tumor was removed during surgery.
 For people with glioblastoma and high-grade glioma, the latest standard of care
is radiation therapy with daily low-dose temozolomide (Temodar). This is followed
by monthly doses of temozolomide after radiation therapy for 6 months to 1 year.
 A combination of 3 drugs, lomustine (Gleostine), procarbazine (Matulane), and
vincristine (Vincasar), have been used along with radiation therapy. This
approach has helped lengthen the lives of patients with grade III
oligodendroglioma with a 1p/19q co-deletion (see also, "Biogenetic markers" in
the Grades and Prognostic Factors section) when given either before or right
after radiation therapy. It has also been shown to lengthen lives of patients after
radiation therapy for a low-grade tumor that could not be completely removed
with surgery. Clinical trials on the use of chemotherapy to delay radiation therapy
for patients with low-grade glioma are ongoing.
Patients are monitored with a brain MRI every 2 to 3 months while receiving active
treatment. Then, the length of time between MRI scans increases depending on the
tumor’s grade. Patients often have regular MRIs to monitor their health after treatment is
finished and the tumor has not grown. If the tumor grows during treatment, other
treatment options will be considered.
The side effects of chemotherapy depend on the individual and the dose used, but they
can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite and
diarrhea. These side effects usually go away after treatment is finished. Rarely, certain
drugs may cause some hearing loss. Others may cause kidney damage. Patients may
be given extra fluid by IV to protect their kidneys.
RADIATION THERAPY
Radiation therapy is the use of high-energy x-rays or other particles to destroy tumor
cells. Doctors may use radiation therapy to slow or stop the growth of a brain tumor. It is
typically given after surgery and possibly along with chemotherapy. A doctor who
specializes in giving radiation therapy to treat a tumor is called a radiation oncologist.
The most common type of radiation treatment is called external-beam radiation therapy,
which is radiation given from a machine outside the body. When radiation treatment is
given using implants, it is called internal radiation therapy or brachytherapy. A radiation
therapy regimen, or schedule, usually consists of a specific number of treatments given
over a set period of time.
External-beam radiation therapy can be directed at a brain tumor in the following ways:
Conventional radiation therapy. The treatment location is determined based on
anatomic landmarks and x-rays. In certain situations, such as whole brain radiation
therapy for brain metastases, this technique is appropriate. For more precise targeting,
different techniques are needed. The amount of radiation given depends on the tumor’s
grade.
3-dimensional conformal radiation therapy (3D-CRT). Using images from CT and
MRI scans (see Diagnosis), a 3-dimensional model of the tumor and healthy tissue
surrounding the tumor is created on a computer. This model can be used to aim the
radiation beams directly at the tumor, sparing the healthy tissue from high doses of
radiation therapy.
Intensity modulated radiation therapy (IMRT). IMRT is a type of 3D-CRT (see above)
that can more directly target a tumor. It can deliver higher doses of radiation to the
tumor while giving less to the surrounding healthy tissue. In IMRT, the radiation beams
are broken up into smaller beams and the intensity of each of these smaller beams can
be changed. This means that the more intense beams, or the beams giving more
radiation, can be directed only at the tumor.
Proton therapy. Proton therapy is a type of external-beam radiation therapy that uses
protons rather than x-rays. At high energy, protons can destroy tumor cells. Proton
beam therapy is typically used for tumors when less radiation is needed because of the
location. This includes tumors that have grown into nearby bone, such as the base of
skull, and those near the optic nerve.
Stereotactic radiosurgery. Stereotactic radiosurgery is the use of a single, high dose
of radiation given directly to the tumor and not healthy tissue. It works best for a tumor
that is only in 1 area of the brain and certain noncancerous tumors. It can also be used
when a person has more than 1 metastatic brain tumor. There are many different types
of stereotactic radiosurgery equipment, including:
 A modified linear accelerator is a machine that creates high-energy radiation by
using electricity to form a stream of fast-moving subatomic particles.
 A gamma knife is another form of radiation therapy that concentrates highly
focused beams of gamma radiation on the tumor.
 A cyber knife is a robotic device used in radiation therapy to guide radiation to
the tumor, particularly in the brain, head, and neck regions.
Fractionated stereotactic radiation therapy. Radiation therapy is delivered with
stereotactic precision but divided into small daily doses called fractions and given over
several days or weeks, in contrast to the 1-day radiosurgery. This technique is used for
tumors located close to sensitive structures, such as the optic nerves or brain stem.
With these different techniques, doctors are trying to be more precise and reduce
radiation exposure to the surrounding healthy brain tissue. Depending on the size and
location of the tumor, the radiation oncologist may choose any of the above radiation
techniques. In certain situations, a combination of multiple techniques may work best.
Short-term side effects from radiation therapy may include fatigue, mild skin reactions,
hair loss, upset stomach, and neurologic symptoms, such as memory problems. Most
side effects go away soon after treatment is finished. Also, radiation therapy is usually
not recommended for children younger than 5 because of the high risk of damage to
their developing brains. Longer term side effects of radiation therapy depend on how
much healthy tissue received radiation and include memory and hormonal problems
and cognitive (thought process) changes, such as difficulty understanding and
performing complex tasks.
TARGETED THERAPY
In addition to standard chemotherapy, targeted therapy is a treatment that targets the
tumor’s specific genes, proteins, or the tissue environment that contributes to a tumor’s
growth and survival. This type of treatment blocks the growth and spread of tumor cells
and limits the damage to healthy cells.
Not all tumors have the same targets, and some tumors may have more than 1 target.
To find the most effective treatment, your doctor may run tests to identify the genes,
proteins, and other factors in your tumor. This helps doctors better match each patient
with the most effective treatment whenever possible. In addition, research studies
continue to find out more about specific molecular targets and new treatments directed
at them.
For a brain tumor, there are 2 types of targeted therapy that may be used:
 Bevacizumab (Avastin, Mvasi) is an anti-angiogenesis therapy used to treat
glioblastoma multiforme when prior treatment has not worked. Anti-angiogenesis
therapy is focused on stopping angiogenesis, which is the process of making
new blood vessels. Because a tumor needs the nutrients delivered by blood
vessels to grow and spread, the goal of anti-angiogenesis therapy is to “starve”
the tumor.
 Larotrectinib (Vitrakvi) is a type of targeted therapy that is not specific to a certain
type of tumor but focuses on a specific genetic change called an NTRK fusion.
This type of genetic change is found in a range of tumors, including some brain
tumors. It is approved as a treatment for some brain tumors that are metastatic or
cannot be removed with surgery and have worsened with other treatments.
Talk with your doctor about the possible side effects for a specific medication and how
they can be managed.
If it's suspected that you have a brain tumor, your doctor may recommend a number of
tests and procedures, including:
 A neurological exam. A neurological exam may include, among other things,
checking your vision, hearing, balance, coordination, strength and reflexes.
Difficulty in one or more areas may provide clues about the part of your brain that
could be affected by a brain tumor.
 Imaging tests. Magnetic resonance imaging (MRI) is commonly used to help
diagnose brain tumors. In some cases a dye may be injected through a vein in
your arm during your MRI study
A number of specialized MRI scan components — including functional MRI,
perfusion MRI and magnetic resonance spectroscopy — may help your doctor
evaluate the tumor and plan treatment.
Sometimes other imaging tests are recommended, including computerized
tomography (CT). Positron emission tomography (PET) may be used for brain
imaging, but is generally not as useful for creating images of brain cancer as it is for
other types of cancer.
 Tests to find cancer in other parts of your body. If it's suspected that your
brain tumor may be a result of cancer that has spread from another area of your
body, your doctor may recommend tests and procedures to determine where the
cancer originated. One example might be a CT or PET scan to look for signs of
lung cancer.
 Collecting and testing a sample of abnormal tissue (biopsy). A biopsy can
be performed as part of an operation to remove the brain tumor, or a biopsy can
be performed using a needle.
A stereotactic needle biopsy may be done for brain tumors in hard to reach areas or
very sensitive areas within your brain that might be damaged by a more extensive
operation. Your neurosurgeon drills a small hole into your skull. A thin needle is then
inserted through the hole. Tissue is removed using the needle, which is frequently
guided by CT or MRI scanning.
The biopsy sample is then viewed under a microscope to determine if it is cancerous
or benign. Sophisticated laboratory tests can give your doctor clues about your
prognosis and your treatment options.
NURSING MANAGEMENT
 Administer antiepileptic drugs
 Administer other medication therapy as ordered
 Place the patient in seizure precautions
 Frequent neuro checks (q1-2h)
 Perform interventions to minimize ICP:
Maintain HOB 30-45°
Decrease stimuli
Avoid valsalva maneuvers
 Monitor respiratory status & protect airway as needed
 Prepare patient for possible craniotomy
 Educate patients on the importance of medication compliance.
REHABILITATION AFTER TREATMENT

Because brain tumors can develop in parts of the brain that control motor skills, speech,
vision and thinking, rehabilitation may be a necessary part of recovery. Depending on
your needs, your doctor may refer you to:
 Physical therapy to help you regain lost motor skills or muscle strength
 Occupational therapy to help you get back to your normal daily activities,
including work, after a brain tumor or other illness
 Speech therapy with specialists in speech difficulties (speech pathologists) to
help if you have difficulty speaking
 Tutoring for school-age children to help kids cope with changes in their memory
and thinking after a brain tumor
Little research has been done on complementary and alternative brain tumor
treatments. No alternative treatments have been proved to cure brain tumors. However,
complementary treatments may help you cope with the stress of a brain tumor
diagnosis. Some complementary treatments that may help you cope include:
 Acupuncture
 Art therapy
 Exercise
 Meditation
 Music therapy
 Relaxation exercises
Talk with your doctor about your options.
Coping and support

A diagnosis of a brain tumor can be overwhelming and frightening. It can make you feel
like you have little control over your health. But you can take steps to cope with the
shock and grief that may come after your diagnosis. Consider trying to:
 Learn enough about brain tumors to make decisions about your care. Ask
your doctor about your specific type of brain tumor, including your treatment
options and, if you like, your prognosis. As you learn more about brain tumors,
you may become more confident in making treatment decisions.
you deal with your brain tumor. Friends and family can provide the practical
support you'll need, such as helping take care of your house if you're in the
by cancer.
 Find someone to talk with. Find a good listener who is willing to listen to you
talk about your hopes and fears. This may be a friend or family member. The
concern and understanding of a counselor, medical social worker, clergy member
or cancer support group also may be helpful.
E. Thyroid Cancer
Pathophysiology
Thyroid cancer begins in the follicular cell of the thyroid gland. There are 2 types of cells
located within the thyroid parenchyma: the follicular cells and the supporting cells (also
called the C cells). Cancers derived from follicular cells are generally differentiated
thyroid carcinomas (DTC). Although these cancers are not usually aggressive, they can
eventually mutate into more aggressive variants.
Thyroid cancer progresses according to a well-defined tumor progression model (Figure
1).3 Approximately 85% of patients present with DTC, and they have an excellent
prognosis following treatment. Between 10% and 15% of tumors will mutate into more
aggressive variants of thyroid carcinoma (Figure 2). These tumors may present with tall-
cell features or as tall-cell thyroid carcinoma, and they have a biologic behavior that
requires more aggressive surgical intervention and adjuvant therapy. Notably, these
patients could be candidates for novel therapies if their disease is unresectable or
refractory to radioactive iodine (RAI).
When the same stimulus that initiated the cancer continues, the tumors may mutate into
poorly differentiated carcinomas. Approximately 10% of thyroid cancers may present
with these features, and they carry a worse prognosis requiring more aggressive
interventions, both surgically and nonsurgically. These cancers are generally refractory
to RAI and have a higher risk of cause-specific mortality.
Fewer than 2% of thyroid cancers present as anaplastic carcinomas.4 Most mortality in

thyroid cancer occurs in patients with anaplastic carcinoma. It is a uniformly fatal
cancer.
Thyroidectomy
Thyroidectomy is surgery to remove the thyroid gland. It is the most common surgery for
thyroid cancer. As with lobectomy, this is typically done through an incision a few inches
long across the front of the neck. You will have a small scar across the front of your
neck after surgery, but this should become less noticeable over time.
If the entire thyroid gland is removed, it is called a total thyroidectomy. Sometimes the
surgeon may not be able to remove the entire thyroid. If nearly all of the gland is
removed, it is called a near-total thyroidectomy.
After a near-total or total thyroidectomy, you will need to take daily thyroid hormone
(levothyroxine) pills. But one advantage of this surgery over lobectomy is that your
doctor will be able to check for recurrence (cancer coming back) afterward using
radioiodine scans and thyroglobulin blood tests.
Lymph node removal

If cancer has spread to nearby lymph nodes in the neck, these will be removed at the
same time surgery is done on the thyroid. This is especially important for treatment of
medullary thyroid cancer and for anaplastic cancer (when surgery is an option).
For papillary or follicular cancer where only 1 or 2 enlarged lymph nodes are thought to
contain cancer, the enlarged nodes may be removed and any small deposits of cancer
cells that may be left are then treated with radioactive iodine. (See Radioactive Iodine
[Radioiodine] Therapy.) More often, several lymph nodes near the thyroid are removed
in an operation called a central compartment neck dissection. Removal of even more
lymph nodes, including those on the side of the neck, is called a modified radical neck
dissection.
Chemotherapy
Chemotherapy is rarely used to treat thyroid cancer, but it's sometimes used to treat
anaplastic thyroid carcinomas that have spread to other parts of the body.
It involves taking powerful medicines that kill cancerous cells. It does not cure thyroid
cancer, but it may help to control the symptoms.
After treatment
After your treatment has finished you may need to continue taking medicine to reduce
the risk of further problems.
You'll also be advised to have regular check-ups to look for signs of the cancer coming
back.
Radioactive iodine (radioiodine) therapy

The thyroid absorbs almost all iodine that enters a body. Therefore, a type of radiation
therapy called radioactive iodine (also called I-131 or RAI) can find and destroy thyroid
cells not removed by surgery and those that have spread beyond the thyroid. Doctors
who prescribe radioactive iodine therapy are usually endocrinologists or nuclear
medicine specialists.
Radioactive iodine treatment is an option for some people with papillary, follicular, and
Hurthle cell thyroid cancer. Radioactive iodine is used to treat people with differentiated
thyroid cancers that have spread to lymph nodes or to distant sites. A small test dose
may be given before full treatment to be sure that the tumor cells will absorb the I-131.
Patients with MTC or anaplastic thyroid cancer should not be treated with I-131.
I-131 therapy is given in either liquid or pill form. Patients who receive I-131 to destroy
cancer cells may be hospitalized for 2 to 3 days, depending on several factors, including
the dose given. Patients are encouraged to drink fluids to help the I-131 pass quickly
through the body. Within a few days, most of the radiation is gone. Talk with your doctor
about ways to limit radiation exposure to other people, including children, who may be
around you during this treatment and the days following it.
In preparation for I-131 therapy after surgery, patients are usually asked to follow a low-
iodine diet for 2 to 3 weeks beforehand. In addition to the low-iodine diet, patients will be
asked to either stop taking thyroid hormone replacement pills temporarily or to receive
injections of recombinant TSH (Thyrogen) while taking the hormone replacement. If the
hormone therapy is stopped during the preparation period, the patient will likely
experience the side effects of hypothyroidism (see above).
It is important to discuss the possible short-term and long-term effects of I-131 therapy
with your doctor. On the first day of treatment, patients may experience nausea and
vomiting. In certain circumstances, pain and swelling can occur in the areas where the
radioactive iodine is collected. Because iodine is concentrated in salivary gland tissue,
patients may experience swelling of the salivary glands. This may result in xerostomia,
sometimes called dry mouth.
Large or cumulative doses of radioactive iodine may cause infertility, which is the
physical inability to have a child, especially in men. It is recommended that women
avoid pregnancy for at least 1 year after I-131 treatment. There is a risk of secondary
cancer with the use of I-131 (see Follow-up Care). Occasionally, patients may require
repeated treatments over time. However, there is a maximum total dose of radioactive
iodine allowed over time, and once reached, this may prevent further use of this
treatment.
Immunotherapy
Immunotherapy is a treatment that uses the patient’s immune system to fight cancer.
Substances made by the body or made in a laboratory are used to boost, direct, or
restore the body’s natural defenses against cancer. This type of cancer treatment is
also called biotherapy or biologic therapy. Immunotherapy is being studied as a
treatment for thyroid cancer.
Diagnosis
Typically, thyroid cancer is diagnosed after intrathyroid nodules are discovered on
routine imaging (eg, on an MRI performed for a whiplash injury or an ultrasound
performed on carotid arteries). The majority of such patients with thyroid cancer have no
symptoms at the time of initial diagnosis. When symptoms do arise, they are usually
caused by invasion of an adjacent structure by the primary tumor or metastatic
progression to a lateral neck lymph node. A minority of patients present with locally
advanced thyroid cancer (often poorly differentiated or anaplastic carcinoma). These
patients may present with either symptoms of a mass in the neck, a feeling of pressure
in the neck, or a choking sensation. Occasionally, patients present with hoarseness
caused by paralysis of the vocal cords resulting from invasion of the recurrent laryngeal
nerve. Some patients may also experience hemoptysis or airway obstruction from
tumors growing into the trachea and compromising the airway. In some patients, the
only symptom is a lump in the neck that turns out to be a metastatic lymph node.
A series of tests can be performed to diagnose and assess the primary tumor. The tests
most relevant to decision-making in this disease are an ultrasound of the thyroid gland
and a fine-needle aspiration biopsy. All other tests are relatively peripheral and
subsequent to the establishment of the diagnosis of cancer.
Following confirmation of the diagnosis, and depending on the size and extent of the
tumor, further radiologic workup may be necessary. Anatomic imaging studies, such as
CT or MRI, are usually required in those patients who have an extensive primary tumor
(such as a T3 or a T4 primary tumor) with invasion of adjacent structures or in patients
who present with extensive nodal metastases.
Some clinicians believe that a CT scan should not be performed with the contrast dye.
Use of iodine-containing contrast dye for imaging studies will delay the administration of
RAI treatment, but this delay is not necessarily detrimental to the long-term outcome of
the patient. In fact, detailed and accurate anatomic assessment of the primary tumor
and its invasion to local structures is crucial for the surgeon to be able to perform a
definitive and complete operation and achieve an R0 resection. Thus, when necessary,
contrast dye should be used to obtain a good structural study.
Coping and support

A diagnosis of thyroid cancer can be frightening. You might feel as if you aren't sure
what to do next.
Everyone eventually finds his or her own way of coping with a cancer diagnosis. Until
you find what works for you, consider trying to:
 Find out enough about thyroid cancer to make decisions about your
care. Write down the details of your thyroid cancer, such as the type, stage and
treatment options. Ask your doctor where you can go for more information. Good
sources of information to get you started include the National Cancer Institute,
the American Cancer Society and the American Thyroid Association.
 Connect with other thyroid cancer survivors. You might find comfort in talking
with people in your same situation. Ask your doctor about support groups in your
area. Or connect with thyroid cancer survivors online through the American
Cancer Society Cancer Survivors Network or the Thyroid Cancer Survivors'
Association.
 Control what you can about your health. You can't control whether or not you
develop thyroid cancer, but you can take steps to keep your body healthy during
and after treatment. For instance, eat a healthy diet full of a variety of fruits and
vegetables, get enough sleep each night so that you wake feeling rested, and try
to incorporate physical activity into most days of your week.
Nursing Management
Observe patient for signs of pain both verbal and nonverbal
Teach and encourage patients to use relaxation techniques
Administer analgesic as ordered (for pain, if needed)
Monitor respiratory frequency, depth of breathing; Auscultate breath sounds and
record a Ronchi
Assess for dyspnea, stridor and cyanosis
Provide oxygen therapy if necessary
Determine the patient’s ability to chew, swallow and taste food. Evaluate teeth,
gums, note denture fit for oral health as they may affect ingestion and/or
digestion of nutrients.
Promote a pleasant, relaxing environment, including socialization when possible
to enhance intake.
Encourage patient to choose foods or have the family member bring foods that
seem appealing to simulate the appetite.
Give several small meals and snacks daily to relieve dysphagia.
Promote adequate and timely fluid intake to reduce possibility of early satiety.
Periodically examine the function of speech of patient
Keep communication simple
Provide a suitable alternative method of communication if patient is having
difficulty of speaking
Anticipate patient needs as possible
Psychosocial and Behavioral Interventions

A wide variety of therapies have been developed for addressing the psychosocial
aspects of cancer. A meta-review of psychological interventions identified 79 distinct
modalities of psychosocial therapies,42 ranging from education to breathing exercises.
However, reviewers have not appraised the details of psychosocial therapies in terms of
their individual components and activities, methods of delivery or duration of the
interventions.42 Health researchers have been recommended to pay attention to the
aforementioned details of psychosocial therapies in recently provided recommendations
for reviewing complex interventions: assessment and trials implementation of services
(COMPASS).42,43
Thyroid cancer and its treatment cause physical symptoms and side effects, as well as
emotional, social, and financial effects. Managing all of these effects is called palliative
care or supportive care. It is an important part of your care that is included along with
treatments intended to slow, stop, or eliminate the cancer.
Palliative care focuses on improving how you feel during treatment by managing
symptoms and supporting patients and their families with other, non-medical needs. Any
person, regardless of age or type and stage of cancer, may receive this type of care.
And it often works best when it is started right after a cancer diagnosis. People who
receive palliative care along with treatment for the cancer often have less severe
symptoms, better quality of life, and report they are more satisfied with treatment.
Palliative treatments vary widely and often include medication, nutritional changes,
relaxation techniques, emotional and spiritual support, and other therapies. You may
also receive palliative treatments similar to those meant to get rid of the cancer, such as
chemotherapy, surgery, or radiation therapy.
Before treatment begins, talk with your doctor about the goals of each treatment in the
treatment plan. You should also talk about the possible side effects of the specific
treatment plan and palliative care options.
During treatment, your health care team may ask you to answer questions about your
symptoms and side effects and to describe each problem. Be sure to tell the health care
team if you are experiencing a problem. This helps the health care team treat any
symptoms and side effects as quickly as possible. It can also help prevent more serious
problems in the future.
Prevention
Doctors aren't sure what causes most cases of thyroid cancer, so there's no way to
prevent thyroid cancer in people who have an average risk of the disease.
Prevention for people with a high risk
Adults and children with an inherited gene mutation that increases the risk of medullary
thyroid cancer may consider thyroid surgery to prevent cancer (prophylactic
thyroidectomy). Discuss your options with a genetic counselor who can explain your risk
of thyroid cancer and your treatment options.
Prevention for people near nuclear power plants
A medication that blocks the effects of radiation on the thyroid is sometimes provided to
people living near nuclear power plants. The medication (potassium iodide) could be
used in the unlikely event of a nuclear reactor accident. If you live within 10 miles of a
nuclear power plant and are concerned about safety precautions, contact your state or
local emergency management department for more information.
Complications
Thyroid cancer that comes back
Despite treatment, thyroid cancer can return, even if you've had your thyroid removed.
This could happen if microscopic cancer cells spread beyond the thyroid before it's
removed.
Thyroid cancer may recur in:
 Lymph nodes in the neck
 Small pieces of thyroid tissue left behind during surgery
 Other areas of the body, such as the lungs and bones
Thyroid cancer that recurs can be treated. Your doctor may recommend periodic blood
tests or thyroid scans to check for signs of a thyroid cancer recurrence.
Targeted therapy
Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the
tissue environment that contributes to cancer growth and survival. This type of
treatment blocks the growth and spread of cancer cells while limiting damage to normal
cells. Learn more about the basics of targeted therapy.
Not all tumors have the same targets. To find the most effective treatment, your doctor
may run tests to identify the genes, proteins, and other factors in your tumor. This helps
doctors better match each patient with the most effective treatment whenever possible.
In addition, research studies continue to find out more about specific molecular targets
in the different types of thyroid cancer and new treatments directed at them.
For papillary and follicular thyroid cancer, the U.S. Food and Drug Administration (FDA)
has approved 2 targeted therapies:
 In 2013, the FDA approved a targeted therapy called sorafenib (Nexavar) for
later-stage or recurrent differentiated thyroid cancer when I-131 therapy (see
above) has not worked. Common side effects of sorafenib include hand-foot skin
reactions or other skin problems, diarrhea, fatigue, weight loss, and high blood
pressure.
 In 2015, the FDA approved a targeted therapy called lenvatinib (Lenvima, E7080)
for later-stage differentiated thyroid cancer when surgery, I-131 treatment, or
both have not worked. The side effects of lenvatinib include high blood pressure,
diarrhea, decreased appetite, decreased weight, and nausea.
For MTC, there are 2 other FDA-approved targeted therapy options:
 In 2011, the FDA approved vandetanib tablets (Caprelsa, zd6474), which is a
type of targeted therapy known as a tyrosine kinase inhibitor. Specifically,
vandetanib is now a standard treatment for adults when MTC cannot be removed
surgically, if the disease is worsening, or if MTC has spread to other parts of the
body.
The medication is given as a daily pill. The typical daily dose of vandetanib is 300
mg. Common side effects include diarrhea and colon inflammation, skin rash,
nausea, high blood pressure, headache, fatigue, loss of appetite, and stomach
pain. Additionally, more serious side effects such as respiratory and heart
problems can occur. Blood tests, including measurement of serum potassium,
calcium, magnesium, and TSH levels, may be done regularly to monitor the
body’s reaction to this medication.
 In 2012, the FDA approved another tyrosine kinase inhibitor for metastatic MTC
called cabozantinib (Cometriq, Cabometyx, XL184). The recommended dose is
140 mg, taken in pill form once daily. Side effects may include constipation,
stomach pain, high blood pressure, hair color changes, fatigue, nausea, and
swelling, in addition to serious colon problems.
For anaplastic thyroid cancer, there is 1 targeted therapy combination approved by the
FDA:
 In 2018, the FDA approved the first treatment for anaplastic thyroid cancer in
almost 50 years. This treatment is a combination of 2 targeted therapies,
dabrafenib (Tafinlar), a BRAF inhibitor, and trametinib (Mekinist), a MEK inhibitor,
for people with anaplastic thyroid cancer with a specific genetic change, or
mutation, in the BRAF gene.
The approval was based on data released in 2018 from a clinical trial that
included 16 people with tumors with a BRAF gene mutation. All of these people
had already been treated with radiation therapy, surgery, chemotherapy, or a
combination of these treatments. Of those in the study, 69% of the cancers
stopped growing or shrunk because of the treatment combination. The
researchers were not able to determine whether the treatment would help people
live longer, a clinical end point called “overall survival,” when they released the
study data, but they estimated that at least 80% of people with tumors that
responded to the treatment would benefit from the combination. The dabrafenib
and trametinib combination is now a standard of care for anaplastic thyroid
cancer that cannot be removed surgically or has spread to distant areas. Side
effects of this combination therapy may include fever, rash, headache, joint pain,
cough, nausea, vomiting, diarrhea, muscle pain, dry skin, decreased appetite,
high blood pressure, and difficulty breathing.
Before any targeted treatment begins, talk with your doctor about possible side effects
for each specific medication and how they can be managed.
F. Bladder Cancer
Pathophysiology
The wall of the bladder has many several layers. Each layer is made up of different
kinds of cells.
Most bladder cancers start in the innermost lining of the bladder, which is called the
urothelium or transitional epithelium. As the cancer grows into or through the other
layers in the bladder wall, it has a higher stage, becomes more advanced, and can be
harder to treat.
Over time, the cancer might grow outside the bladder and into nearby structures. It
might spread to nearby lymph nodes, or to other parts of the body. (When bladder
cancer spreads, it tends to go to distant lymph nodes, the bones, the lungs, or the liver.)
Surgery
One of the following types of surgery may be done:
 Transurethral resection (TUR) with fulguration: Surgery in which a cystoscope (a
thin lighted tube) is inserted into the bladder through the urethra. A tool with a
small wire loop on the end is then used to remove the cancer or to burn
the tumor away with high-energy electricity. This is known as fulguration.
 Radical cystectomy: Surgery to remove the bladder and any lymph nodes and
nearby organs that contain cancer. This surgery may be done when the bladder
cancer invades the muscle wall, or when superficial cancer involves a large part
of the bladder. In men, the nearby organs that are removed are the prostate and
the seminal vesicles. In women, the uterus, the ovaries, and part of
the vagina are removed. Sometimes, when the cancer has spread outside the
bladder and cannot be completely removed, surgery to remove only the bladder
may be done to reduce urinary symptoms caused by the cancer. When the
bladder must be removed, the surgeon creates another way for urine to leave the
body.
 Partial cystectomy: Surgery to remove part of the bladder. This surgery may be
done for patients who have a low-grade tumor that has invaded the wall of the
bladder but is limited to one area of the bladder. Because only a part of the
bladder is removed, patients are able to urinate normally after recovering from
this surgery. This is also called segmental cystectomy.
 Urinary diversion: Surgery to make a new way for the body to store and pass
urine.
After the doctor removes all the cancer that can be seen at the time of the surgery,
some patients may be given chemotherapy after surgery to kill any cancer cells that are
left. Treatment given after surgery, to lower the risk that the cancer will come back, is
called adjuvant therapy.
Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types
of radiation to kill cancer cells or keep them from growing. External radiation
therapy uses a machine outside the body to send radiation toward the area of the body
with cancer.
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells,
either by killing the cells or by stopping them from dividing. When chemotherapy is
taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and
can reach cancer cells throughout the body (systemic chemotherapy). When
chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a
body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas
(regional chemotherapy). For bladder cancer, regional chemotherapy may
be intravesical (put into the bladder through a tube inserted into the urethra). The way
the chemotherapy is given depends on the type and stage of the cancer being
treated. Combination chemotherapy is treatment using more than one anticancer drug.
Immunotherapy
Immunotherapy is a treatment that uses the patient’s immune system to fight cancer.
Substances made by the body or made in a laboratory are used to boost, direct, or
restore the body’s natural defenses against cancer. This type of cancer treatment is
also called biotherapy or biologic therapy.
There are different types of immunotherapy:
 Immune checkpoint inhibitors block proteins called checkpoints that are made by
some types of immune system cells, such as T cells, and some cancer cells. PD-
1 is a protein on the surface of T cells that helps keep the body’s immune
responses in check. PD-L1 is a protein found on some types of cancer cells.
When PD-1 attaches to PD-L1, it stops the T cell from killing the cancer cell. PD-
1 and PD-L1 inhibitors keep PD-1 and PD-L1 proteins from attaching to each
other. This allows the T cells to kill cancer cells.
o Pembrolizumab and nivolumab are types of PD-1 inhibitors.
o Atezolizumab, avelumab, and durvalumab are types of PD-L1 inhibitors.
 BCG (bacillus Calmette-Guérin): Bladder cancer may be treated with an

intravesical immunotherapy called BCG. The BCG is given in a solution that is
placed directly into the bladder using a catheter (thin tube).
Targeted therapy
Targeted therapy is a type of treatment that uses drugs or other substances to identify
and attack certain cancer cells. Targeted therapies may cause less harm to normal cells
than chemotherapy or radiation therapy do.
The following targeted therapies are approved for patients with bladder cancer that is
locally advanced or has spread to other parts of the body:
 Enfortumab vedotin is a monoclonal antibody linked to an anticancer drug. This is
called an antibody-drug conjugate. It may be used in patients whose cancer has
become worse after treatment with an immune checkpoint inhibitor and
chemotherapy (cisplatin or carboplatin-based therapy).
 Erdafitinib is a tyrosine kinase inhibitor. It may be used in patients with bladder
cancer that has certain mutations in the FGFR genes and which has become
worse after treatment with chemotherapy (cisplatin or carboplatin-based therapy).
Diagnosis
Diagnosing bladder cancer
Tests and procedures used to diagnose bladder cancer may include:
 Using a scope to examine the inside of your bladder (cystoscopy). To
perform cystoscopy, your doctor inserts a small, narrow tube (cystoscope)
through your urethra. The cystoscope has a lens that allows your doctor to see
the inside of your urethra and bladder, to examine these structures for signs of
disease. Cystoscopy can be done in a doctor's office or in the hospital.
 Removing a sample of tissue for testing (biopsy). During cystoscopy, your
doctor may pass a special tool through the scope and into your bladder to collect
a cell sample (biopsy) for testing. This procedure is sometimes called
transurethral resection of bladder tumor (TURBT). TURBT can also be used to
treat bladder cancer.
 Examining a urine sample (urine cytology). A sample of your urine is analyzed
under a microscope to check for cancer cells in a procedure called urine
cytology.
 Imaging tests. Imaging tests, such as computerized tomography (CT) urogram
or retrograde pyelogram, allow your doctor to examine the structures of your
urinary tract.
During a CT urogram, a contrast dye injected into a vein in your hand eventually flows
into your kidneys, ureters and bladder. X-ray images taken during the test provide a
detailed view of your urinary tract and help your doctor identify any areas that might be
cancer.
Retrograde pyelogram is an X-ray exam used to get a detailed look at the upper urinary
tract. During this test, your doctor threads a thin tube (catheter) through your urethra
and into your bladder to inject contrast dye into your ureters. The dye then flows into
your kidneys while X-ray images are captured.
Determining the extent of the cancer
After confirming that you have bladder cancer, your doctor may recommend additional
tests to determine whether your cancer has spread to your lymph nodes or to other
areas of your body.
Tests may include:
 CT scan
 Magnetic resonance imaging (MRI)
 Positron emission tomography (PET)
 Bone scan
 Chest X-ray
Your doctor uses information from these procedures to assign your cancer a stage. The
stages of bladder cancer are indicated by Roman numerals ranging from 0 to IV. The
lowest stages indicate a cancer that's confined to the inner layers of the bladder and
that hasn't grown to affect the muscular bladder wall. The highest stage — stage IV —
indicates cancer that has spread to lymph nodes or organs in distant areas of the body
Bladder cancer grade
Bladder cancers are further classified based on how the cancer cells appear when
viewed through a microscope. This is known as the grade, and your doctor may
describe bladder cancer as either low grade or high grade:
 Low-grade bladder cancer. This type of cancer has cells that are closer in
appearance and organization to normal cells (well differentiated). A low-grade
tumor usually grows more slowly and is less likely to invade the muscular wall of
the bladder than is a high-grade tumor.
 High-grade bladder cancer. This type of cancer has cells that are abnormal-
looking and that lack any resemblance to normal-appearing tissues (poorly
differentiated). A high-grade tumor tends to grow more aggressively than a low-
grade tumor and may be more likely to spread to the muscular wall of the bladder
and other tissues and organs.
Pharmacologic Intervention
 Chemotheraphy with a combination of methotrexate, 5-fluorouracil (5-FU),

vinblastine, doxorubicin (Adriamycin), and cisplatin (M-VAC) and new agents
gemcitabine and taxane, possibly by topical chemotheraphy applied directly to
the bladder wall
 Intravesical BCG (effective with superficial transitional cell carcinoma)
 Cytotoxic agent infusions through the arterial supply of the involved organ
 Formalin, phenol, or silver nitrate instillations to achieve relief of hematuria and
strangury (slow and painful discharge of urine) in some patients
Nursing Intervention
For patients who require radical cystectomy with urinary diversion, offer support and
reinforcement of the information. Be sure what to expect. Involve another family
member in the preoperative education. If it is needed, arrange a preoperative visit by
someone who has adjusted well to a similar diversion.
If any type of stoma is to be created, arrange for a preoperative visit from the
enterostomal therapist. The enterostomal therapist can assist in the selection and
marking of the stoma site (although the stoma site is somewhat contingent upon the
type of urinary diversion to be performed) and can introduce the patient to the external
urine collection pouch and related care.
Preoperative interventions
1. Administer bowel preparation as prescribed, which may include a clear liquid
diet, laxatives and enemas, and antibiotics to lower the bacterial count in the
bowel.
2. Assist the surgeon and the enterostomal nurse in selecting an appropriate skin
site for creation of the abdominal stoma.
3. Encourage the client to talk about his or her feelings related to the stoma
creation.
Postoperative interventions
1. Monitor Vital signs.
2. Assess incision site.
3. Assess stoma (should be red and moist) every hour for the first 24 hours.
4. Monitor for edema in the stoma, which may be present in the immediate
postoperative period.
5. If the stoma appears dark and dusky, notify the physician immediately because
this indicates necrosis
6. Monitor for prolapse or retraction of the stoma.
7. Assess for return of bowel function; monitor for peristalsis, which will return in 3
to 4 days.
8. Maintain NPO status as prescribed until bowel sounds return.
9. Monitor urine flow, which is continuous (30 to 60 mL per hour) following surgery.
10. Notify the physician if the urine output is less than 30 mL an hour or if no urine
output occurs for more than 15 minutes.
11. Ureteral stents or catheters may be in place for 2 to 3 weeks or until healing
occurs; maintain stability with catheters to prevent dislodgment.
12. Monitor urinary output closely and irrigate catheter (if present ) gently to prevent
obstruction, as prescribed, with 60 mL of NS.
13. Monitor for hematuria.
14. Monitor for signs of peritonitis.
15. Monitor for bladder distention following a partial cystectomy.
16. Monitor for shock, hemorrhage, thrombophlebitis, and lower extremity
lymphedema following a radical cystectomy.
17. Monitor the urinary drainage pouch for leaks, and check skin integrity.
18. Monitor the pH of the urine (do not place the dipstick in the stoma) because
strong alkali urine can cause skin irritation and facilitate crystal formation.
19. Instruct the client regarding the potential for urinary tract infection or the
development of the calculuses.
20. Instruct the client to assess the skin for irritation and to monitor the urinary
drainage pouch for any leakage.
21. Encourage the client to express feelings about changes in body image,
embarrassment, and sexual dysfunction.
Coping and support

Living with the concern that your bladder cancer may recur can leave you feeling as if
you have little control over your future. But while there's no way to ensure that your
bladder cancer won't recur, you can take steps to manage the stress.
Over time you'll find what works for you, but until then, you might:
 Get a schedule of follow-up tests and go to each appointment. When you
finish bladder cancer treatment, ask your doctor to create a personalized
schedule of follow-up tests. Before each follow-up cystoscopy exam, expect to
have some anxiety. You may fear that cancer has come back or worry about the
uncomfortable exam. But don't let this stop you from going to your appointment.
Instead, plan ways to cope with your concerns. Write your thoughts in a journal,
talk with a friend or use relaxation techniques, such as meditation.
 Take care of yourself so that you're ready to fight cancer if it comes
back. Take care of yourself by adjusting your diet to include plenty of fruits,
vegetables and whole grains. Exercise for at least 30 minutes most days of the
week. Get enough sleep so that you wake feeling rested.
 Talk with other bladder cancer survivors. Connect with bladder cancer
survivors who are experiencing the same fears you're feeling. Contact your local
chapter of the American Cancer Society to ask about support groups in your
area.
Prevention
Although there's no guaranteed way to prevent bladder cancer, you can take steps to
help reduce your risk. For instance:
 Don't smoke. If you don't smoke, don't start. If you smoke, talk to your doctor
about a plan to help you stop. Support groups, medications and other methods
may help you quit.
 Take caution around chemicals. If you work with chemicals, follow all safety
instructions to avoid exposure.
 Choose a variety of fruits and vegetables. Choose a diet rich in a variety of
colorful fruits and vegetables. The antioxidants in fruits and vegetables may help
reduce your risk of cancer.
Possible Complications
Bladder cancers may spread into the nearby organs. They may also travel through the
pelvic lymph nodes and spread to the liver, lungs, and bones. Additional complications
of bladder cancer include:
 Anemia
 Swelling of the ureters (hydronephrosis)
 Urethral stricture
 Urinary incontinence
 Erectile dysfunction in men
 Sexual dysfunction in women
G. Colorectal Cancer
Most colorectal cancers start as a growth on the inner lining of the colon or rectum.
These growths are called polyps.
Some types of polyps can change into cancer over time (usually many years), but not all
polyps become cancer. The chance of a polyp turning into cancer depends on the type
of polyp it is. There are different types of polyps.
 Adenomatous polyps (adenomas): These polyps sometimes change into
cancer. Because of this, adenomas are called a pre-cancerous condition. The 3
types of adenomas are tubular, villous, and tubulovillous.
 Hyperplastic polyps and inflammatory polyps: These polyps are more
common, but in general they are not pre-cancerous. Some people with large
(more than 1cm) hyperplastic polyps might need colorectal cancer screening with
colonoscopy more often.
 Sessile serrated polyps (SSP) and traditional serrated adenomas
(TSA): These polyps are often treated like adenomas because they have a
higher risk of colorectal cancer.
Other factors that can make a polyp more likely to contain cancer or increase
someone’s risk of developing colorectal cancer include:
 If a polyp larger than 1 cm is found
 If more than 3 polyps are found
 If dysplasia is seen in the polyp after it's removed. Dysplasia is another pre-
cancerous condition. It means there's an area in a polyp or in the lining of the
colon or rectum where the cells look abnormal, but they haven't become cancer.
How colorectal cancer spreads
If cancer forms in a polyp, it can grow into the wall of the colon or rectum over time. The
wall of the colon and rectum is made up of many layers. Colorectal cancer starts in the
innermost layer (the mucosa) and can grow outward through some or all of the other
layers (see picture below).
When cancer cells are in the wall, they can then grow into blood vessels or lymph
vessels (tiny channels that carry away waste and fluid). From there, they can travel to
nearby lymph nodes or to distant parts of the body.
The stage (extent of spread) of a colorectal cancer depends on how deeply it grows into
the wall and if it has spread outside the colon or rectum. For more on staging,
Surgery
operation. It is often called surgical resection. This is the most common treatment for
colorectal cancer. Part of the healthy colon or rectum and nearby lymph nodes will also
be removed. While both general surgeons and specialists may perform colorectal
surgery, many people talk with specialists who have additional training and experience
in colorectal surgery. A surgical oncologist is a doctor who specializes in treating cancer
using surgery. A colorectal surgeon is a doctor who has received additional training to
treat diseases of the colon, rectum, and anus. Colorectal surgeons used to be called
proctologists.
In addition to surgical resection, surgical options for colorectal cancer include:
 Laparoscopic surgery. Some patients may be able to have laparoscopic
colorectal cancer surgery. With this technique, several viewing scopes are
passed into the abdomen while a patient is under anesthesia. Anesthesia is
medicine that blocks the awareness of pain. The incisions are smaller and the
recovery time is often shorter than with standard colon surgery. Laparoscopic
surgery is as effective as conventional colon surgery in removing the cancer.
Surgeons who perform laparoscopic surgery have been specially trained in that
technique.
 Colostomy for rectal cancer. Less often, a person with rectal cancer may need
to have a colostomy. This is a surgical opening, or stoma, through which the
colon is connected to the abdominal surface to provide a pathway for waste to
exit the body. This waste is collected in a pouch worn by the patient. Sometimes,
the colostomy is only temporary to allow the rectum to heal, but it may be
permanent. With modern surgical techniques and the use of radiation therapy
and chemotherapy before surgery when needed, most people who receive
treatment for rectal cancer do not need a permanent colostomy.
 Radiofrequency ablation (RFA) or cryoablation. Some patients may have
surgery on the liver or lungs to remove tumors that have spread to those organs.
Other ways include using energy in the form of radiofrequency waves to heat the
tumors, called RFA, or to freeze the tumor, called cryoablation. Not all liver or
lung tumors can be treated with these approaches. RFA can be done through the
skin or during surgery. While this can help avoid removing parts of the liver and
lung tissue that might be removed in a regular surgery, there is also a chance
that parts of tumor will be left behind.
Radiation therapy
Radiation therapy is the use of high-energy x-rays to destroy cancer cells. It is
commonly used for treating rectal cancer because this tumor tends to recur near where
it originally started. A doctor who specializes in giving radiation therapy to treat cancer is
called a radiation oncologist. A radiation therapy regimen, or schedule, usually consists
of a specific number of treatments given over a set period of time.
External-beam radiation therapy. External-beam radiation therapy uses a machine to
deliver x-rays to where the cancer is located. Radiation treatment is usually given 5
days a week for several weeks. It may be given in the doctor's office or at the hospital.
Stereotactic radiation therapy. Stereotactic radiation therapy is a type of external-
bean radiation therapy that may be used if a tumor has spread to the liver or lungs. This
type of radiation therapy delivers a large, precise radiation dose to a small area. This
technique can help save parts of the liver and lung tissue that might otherwise have to
be removed during surgery. However, not all cancers that have spread to the liver or
lungs can be treated in this way.
Other types of radiation therapy. For some people, specialized radiation therapy
techniques, such as intraoperative radiation therapy or brachytherapy, may help get rid
of small areas of cancer that can not be removed with surgery.
 Intraoperative radiation therapy. Intraoperative radiation therapy uses a single,
high dose of radiation therapy given during surgery.
 Brachytherapy. Brachytherapy is the use of radioactive "seeds" placed inside
the body. In 1 type of brachytherapy with a product called SIR-Spheres, tiny
amounts of a radioactive substance called yttrium-90 are injected into the liver to
treat colorectal cancer that has spread to the liver when surgery is not an option.
Limited information is available about how effective this approach is, but some
studies suggest that it may help slow the growth of cancer cells.
Radiation therapy for rectal cancer. For rectal cancer, radiation therapy may be used
before surgery, called neoadjuvant therapy, to shrink the tumor so that it is easier to
remove. It may also be used after surgery to destroy any remaining cancer cells. Both
approaches have worked to treat this disease. Chemotherapy is often given at the same
time as radiation therapy, called chemoradiation therapy, to increase the effectiveness
of the radiation therapy.
Chemoradiation therapy is often used in rectal cancer before surgery to avoid colostomy
or reduce the chance that the cancer will recur. One study found that chemoradiation
therapy before surgery worked better and caused fewer side effects than the same
radiation therapy and chemotherapy given after surgery. The main benefits included a
lower rate of the cancer coming back in the area where it started, fewer patients who
needed permanent colostomies, and fewer problems with scarring of the bowel where
the radiation therapy was given.
Radiation therapy is typically given in the United States for rectal cancer over 5.5 weeks
before surgery. However, for certain patients (and in certain countries), a shorter course
of 5 days of radiation therapy before surgery is appropriate and/or preferred.
A newer approach to rectal cancer is currently being used for certain people. It is called
total neoadjuvant therapy (or TNT). With TNT, both chemotherapy and chemoradiation
therapy are given for about 6 months before surgery. This approach is still being studied
to determine which patients will benefit most.
Chemotherapy
A chemotherapy regimen, or schedule, usually consists of a specific number of cycles
given over a set period of time. A patient may receive 1 drug at a time or a combination
of different drugs given at the same time.
Chemotherapy may be given after surgery to eliminate any remaining cancer cells. For
some people with rectal cancer, the doctor will give chemotherapy and radiation therapy
before surgery to reduce the size of a rectal tumor and reduce the chance of the cancer
returning.
Many drugs are approved by the U.S. Food and Drug Administration (FDA) to treat
colorectal cancer in the United States. Your doctor may recommend 1 or more of them
at different times during treatment. Sometimes these are combined with targeted
therapy drugs (see “Targeted therapy” below).
 Capecitabine (Xeloda)
 Fluorouracil (5-FU)
 Irinotecan (Camptosar)
 Oxaliplatin (Eloxatin)
 Trifluridine/tipiracil (Lonsurf)
Some common treatment regimens using these drugs include:
 5-FU alone
 5-FU with leucovorin (folinic acid), a vitamin that improves the effectiveness of 5-
FU
 Capecitabine, an oral form of 5-FU
 FOLFOX: 5-FU with leucovorin and oxaliplatin
 FOLFIRI: 5-FU with leucovorin and irinotecan
 Irinotecan alone
 XELIRI/CAPIRI: Capecitabine with irinotecan
 XELOX/CAPEOX: Capecitabine with oxaliplatin
 Any of the above with 1 of the following targeted therapies (see below):
cetuximab (Erbitux), bevacizumab (Avastin), or panitumumab (Vectibix). In
addition, FOLFIRI may be combined with either of these targeted therapies (see
below): ziv-aflibercept (Zaltrap) or ramucirumab (Cyramza).
Immunotherapy
to improve, target, or restore immune system function.
Checkpoint inhibitors are an important type of immunotherapy used to treat colorectal
cancer. Learn more about the basics of immunotherapy.
 Pembrolizumab (Keytruda). Pembrolizumab targets PD-1, a receptor on tumor
cells, preventing the tumor cells from hiding from the immune system.
Pembrolizumab is used to treat unresectable or metastatic colorectal cancers
that have a molecular feature called microsatellite instability (MSI-H) or mismatch
repair deficiency (dMMR). Unresectable means surgery is not an option.
 Nivolumab (Opdivo). Nivolumab is used to treat people who are 12 or older and
have MSI-H or dMMR metastatic colorectal cancer that has grown or spread after
treatment with chemotherapy with a fluoropyrimidine (such as capecitabine and
fluorouracil), oxaliplatin, and irinotecan.
 Nivolumab and ipilimumab (Yervoy) combination. This combination of
checkpoint inhibitors is approved to treat patients who are 12 or older and have
MSI-H or dMMR metastatic colorectal cancer that has grown or spread after
treatment with chemotherapy with a fluoropyrimidine, oxaliplatin, and irinotecan.
Physical, emotional, and social effects of cancer

Cancer and its treatment cause physical symptoms and side effects, as well as
emotional, social, and financial effects. Managing all of these effects is called palliative
care or supportive care. It is an important part of your care that is included along with
treatments intended to slow, stop, or eliminate the cancer.
Palliative care focuses on improving how you feel during treatment by managing
symptoms and supporting patients and their families with other, non-medical needs. Any
person, regardless of age or type and stage of cancer, may receive this type of care.
And it often works best when it is started right after a cancer diagnosis. People who
receive palliative care along with treatment for the cancer often have less severe
symptoms, better quality of life, and report they are more satisfied with treatment.
Palliative treatments vary widely and often include medication, nutritional changes,
relaxation techniques, emotional and spiritual support, and other therapies. You may
also receive palliative treatments similar to those meant to get rid of the cancer, such as
chemotherapy, surgery, or radiation therapy.
Before treatment begins, talk with your doctor about the goals of each treatment in the
treatment plan. You should also talk about the possible side effects of the specific
treatment plan and palliative care options.
During treatment, your health care team may ask you to answer questions about your
symptoms and side effects and to describe each problem. Be sure to tell the health care
team if you are experiencing a problem. This helps the health care team treat any
symptoms and side effects as quickly as possible. It can also help prevent more serious
problems in the future.
Therapies using medication

Systemic therapy is the use of medication to destroy cancer cells. This type of
medication is given through the bloodstream to reach cancer cells throughout the body.
Systemic therapies are generally prescribed by a medical oncologist, a doctor who
specializes in treating cancer with medication.
Common ways to give systemic therapies include an intravenous (IV) tube placed into a
vein using a needle or in a pill or capsule that is swallowed (orally).
The types of systemic therapies used for colorectal cancer include:
 Chemotherapy
 Targeted therapy
 Immunotherapy
Each of these types of therapies is discussed below in more detail. A person may
receive 1 type of systemic therapy at a time or a combination of systemic therapies
given at the same time. They can also be given as part of a treatment plan that includes
surgery and/or radiation therapy.
The medications used to treat cancer are continually being evaluated. Talking with your
doctor is often the best way to learn about the medications prescribed for you, their
purpose, and their potential side effects or interactions with other medications. It is also
important to let your doctor know if you are taking any other prescription or over-the-
counter medications or supplements. Herbs, supplements, and other drugs can interact
with cancer medications.
Therapeutic Intervention / Medical Management

Treatment of cancer depends on stage of disease and related complications.
Obstruction is treated with intravenous fluids and nasogastric suction and with blood
therapy if bleeding is significant. Supportive therapy and adjuvant therapy (e.g.,
chemotherapy, radiation therapy, immuno therapy) are included.
Pharmacologic Intervention
 Narcotic analgesic is often administered as patient-controlled anesthesia to

manages surgical pain or pain from metastasis
Nursing Intervention
 Administer chemotherapy agents as ordered, provide care for the client receiving
chemotherapy.
 Provide care for the client receiving radiation therapy.
 Provide care for the client with bowel surgery.
Prevention
Screening colon cancer
Doctors recommend that people with an average risk of colon cancer consider colon
cancer screening around age 50. But people with an increased risk, such as those with
a family history of colon cancer, should consider screening sooner.
Several screening options exist — each with its own benefits and drawbacks. Talk
about your options with your doctor, and together you can decide which tests are
appropriate for you.
Lifestyle changes to reduce your risk of colon cancer
You can take steps to reduce your risk of colon cancer by making changes in your
everyday life. Take steps to:
 Eat a variety of fruits, vegetables and whole grains. Fruits, vegetables and
whole grains contain vitamins, minerals, fiber and antioxidants, which may play a
role in cancer prevention. Choose a variety of fruits and vegetables so that you
get an array of vitamins and nutrients.
 Drink alcohol in moderation, if at all. If you choose to drink alcohol, limit the
amount of alcohol you drink to no more than one drink a day for women and two
for men.
 Stop smoking. Talk to your doctor about ways to quit that may work for you.
 Exercise most days of the week. Try to get at least 30 minutes of exercise on
most days. If you've been inactive, start slowly and build up gradually to 30
minutes. Also, talk to your doctor before starting any exercise program.
 Maintain a healthy weight. If you are at a healthy weight, work to maintain your
weight by combining a healthy diet with daily exercise. If you need to lose weight,
ask your doctor about healthy ways to achieve your goal. Aim to lose weight
slowly by increasing the amount of exercise you get and reducing the number of
calories you eat.
Colon cancer prevention for people with a high risk
Some medications have been found to reduce the risk of precancerous polyps or colon
cancer. For instance, some evidence links a reduced risk of polyps and colon cancer to
regular use of aspirin or aspirin-like drugs. But it's not clear what dose and what length
of time would be needed to reduce the risk of colon cancer. Taking aspirin daily has
some risks, including gastrointestinal bleeding and ulcers.
These options are generally reserved for people with a high risk of colon cancer. There
isn't enough evidence to recommend these medications to people who have an average
risk of colon cancer.
If you have an increased risk of colon cancer, discuss your risk factors with your doctor
to determine whether preventive medications are safe for you.
Possible Complications
Complications may include:
 Blockage of the colon, causing bowel obstruction
 Cancer returning in the colon
 Cancer spreading to other organs or tissues (metastasis)
 Development of a second primary colorectal cancer
H. Liver Cancer
Pathophysiology
Although ngene sequencing studies have described multiple genes associations with
hepatocellular carcinoma, most of the initiating genetic events that incite hepatocellular
carcinoma remain unknown. Genomic instability, including chromosomal or single
nucleotide polymorphism, could be the force of tumorigenesis in liver cancer.
Recurrently somatic mutated genes (e.g., TERT promoter, TP53, CTNNB1, ARID1A,
FGF) with implicated signaling pathways (JAK/STAT, WntB-catenin, PI3K-AKT-mTOR)
have been identified as major drivers of the development of hepatocellular carcinoma.
No potential driver or targeted therapy has emerged likely due to the genomic
heterogeneity of hepatocellular carcinoma. The classical prognostic biomarkers of
hepatocellular carcinoma include Ki-67 protein expression and TP53 gene mutation,
which has repeatedly been demonstrated to correlate with poor prognosis.
The most important pathologic issue is the distinction between fibrolamellar variant with
tumor encapsulation that presents in younger individuals. These lesions are more likely
to be resectable, less frequently related to viral infection or cirrhosis, accompany normal
AFP levels and an overall better prognosis, or the traditional hepatocellular cancer
presenting in the older population with a chronic disease and less than 25% resectable
cases.
Surgery
Operations used to treat liver cancer include:
 Surgery to remove the tumor. In certain situations, your doctor may
recommend an operation to remove the liver cancer and a small portion of
healthy liver tissue that surrounds it if your tumor is small and your liver function
is good.
Whether this is an option for you also depends on the location of your cancer within the
liver, how well your liver functions and your overall health.
 Liver transplant surgery. During liver transplant surgery, your diseased liver is
removed and replaced with a healthy liver from a donor. Liver transplant surgery
is only an option for a small percentage of people with early-stage liver cancer.
Radiation therapy
This treatment uses high-powered energy from sources such as X-rays and protons to
destroy cancer cells and shrink tumors. Doctors carefully direct the energy to the liver,
while sparing the surrounding healthy tissue.
Radiation therapy might be an option if other treatments aren't possible or if they haven't
helped. For advanced liver cancer, radiation therapy might help control symptoms.
During external beam radiation therapy treatment, you lie on a table and a machine
directs the energy beams at a precise point on your body.
A specialized type of radiation therapy, called stereotactic body radiotherapy, involves
focusing many beams of radiation simultaneously at one point in your body.
Immunotherapy
Immunotherapy uses your immune system to fight cancer. Your body's disease-fighting
immune system may not attack your cancer because the cancer cells produce proteins
that blind the immune system cells. Immunotherapy works by interfering with that
process.
Immunotherapy treatments are generally reserved for people with advanced liver
cancer.
Chemotherapy
Chemotherapy uses drugs to kill rapidly growing cells, including cancer cells.
Chemotherapy can be administered through a vein in your arm, in pill form or both.
Chemotherapy is sometimes used to treat advanced liver cancer.
Supportive (palliative) care
Palliative care is specialized medical care that focuses on providing relief from pain and
other symptoms of a serious illness. Palliative care specialists work with you, your
family and your other doctors to provide an extra layer of support that complements
your ongoing care. Palliative care can be used while undergoing other aggressive
treatments, such as surgery, chemotherapy or radiation therapy.
When palliative care is used along with all of the other appropriate treatments, people
with cancer may feel better and live longer.
Palliative care is provided by a team of doctors, nurses and other specially trained
professionals. Palliative care teams aim to improve the quality of life for people with
cancer and their families. This form of care is offered alongside curative or other
treatments you may be receiving.
Coping and support

Learning you have any life-threatening illness can be devastating. Each person finds his
or her own ways of coping with a diagnosis of liver cancer. Although there are no easy
answers for people dealing with liver cancer, the following suggestions may be of help:
 Learn enough about liver cancer to make decisions about your care. Ask
your doctor about your liver cancer, including the stage of your cancer, your
treatment options and, if you like, your prognosis. As you learn more about liver
cancer, you may become more confident in making treatment decisions.
you deal with your liver cancer. Friends and family can provide the practical
support you'll need, such as helping take care of your house if you're in the
by cancer.
 Find someone to talk with. Find a good listener with whom you can talk about
your hopes and fears. This may be a friend or family member. The support of a
counselor, medical social worker, clergy member or cancer survivors group also
may be helpful.
Ask your doctor about support groups in your area. Or check your phone book, library or
a cancer organization, such as the National Cancer Institute or the American Cancer
Society.
 Make plans for the unknown. Having a life-threatening illness, such as cancer,
requires you to prepare for the possibility that you may die. For some people,
having a strong faith or a sense of something greater than themselves makes it
easier to come to terms with a life-threatening illness.
Ask your doctor about advance directives and living wills to help you plan for end-of-life
care, should you need it.
Prevention
Reduce your risk of cirrhosis
Cirrhosis is scarring of the liver, and it increases the risk of liver cancer. You can reduce
your risk of cirrhosis if you:
 Drink alcohol in moderation, if at all. If you choose to drink alcohol, limit the
amount you drink. For women, this means no more than one drink a day. For
men, this means no more than two drinks a day.
 Maintain a healthy weight. If your current weight is healthy, work to maintain it
by choosing a healthy diet and exercising most days of the week. If you need to
lose weight, reduce the number of calories you eat each day and increase the
amount of exercise you do. Aim to lose weight slowly — 1 or 2 pounds (0.5 to 1
kilograms) each week.
Get vaccinated against hepatitis B
You can reduce your risk of hepatitis B by receiving the hepatitis B vaccine. The vaccine
can be given to almost anyone, including infants, older adults and those with
compromised immune systems.
Take measures to prevent hepatitis C
No vaccine for hepatitis C exists, but you can reduce your risk of infection.
 Know the health status of any sexual partner. Don't engage in unprotected
sex unless you're certain your partner isn't infected with HBV, HCV or any other
sexually transmitted infection. If you don't know the health status of your partner,
use a condom every time you have sexual intercourse.
 Don't use intravenous (IV) drugs, but if you do, use a clean needle. Reduce
your risk of HCV by not injecting illegal drugs. But if that isn't an option for you,
make sure any needle you use is sterile, and don't share it. Contaminated drug
paraphernalia is a common cause of hepatitis C infection. Take advantage of
needle-exchange programs in your community and consider seeking help for
your drug use.
 Seek safe, clean shops when getting a piercing or tattoo. Needles that may
not be properly sterilized can spread the hepatitis C virus. Before getting a
piercing or tattoo, check out the shops in your area and ask staff members about
their safety practices. If employees at a shop refuse to answer your questions or
don't take your questions seriously, take that as a sign that the facility isn't right
for you.
Nursing Interventions: Liver Cancer

1. Give analgesics as ordered and encourage the patient to identify care measures
that promote comfort.
2. Provide patient with a special diet that restricts sodium, fluids, and protein and
that prohibits alcohol.
3. To increase venous return and prevent edema, elevate the patient’s legs
whenever possible.
4. Keep the patient’s fever down.
5. Provide meticulous skin care.
6. Turn the patient frequently and keep his skin clean to prevent pressure ulcers.
7. Prepare the patient for surgery, if indicated.
8. Provide comprehensive care and emotional assistance.
9. Monitor the patient for fluid retention and ascites.
10. Monitor respiratory function.
11. Explain the treatments to the patient and his family, including adverse
reactions the patient may experience.
Complications
Liver cancer can result in a number of complications. They may result from the pressure
of a tumor on the bile duct or other organs, hormones produced by the cancer cells,
liver dysfunction that results in the build-up of toxins in the body, or other mechanisms.
Some potential complications include:
Anemia
Anemia, a low red blood cell count, is a very common complication of liver cancer 3 and
may occur due to a few mechanisms, including a lack of clotting factors in the blood
leading to bleeding. Anemia can be insidious at first, and it frequently causes symptoms
such as fatigue, shortness of breath, a rapid heart rate, pale skin, and lightheadedness.
Since liver cancer can sometimes result in erythrocytosis (increased red blood cell
production) as well, these effects sometimes cancel each other out.
Bile Duct Obstruction
Bile is made in the liver. Several ducts ensure that it gets transported to the
small intestine, either via the gallbladder or directly. Liver tumors or bile duct tumors can
grow within a duct or exert pressure near one, resulting in bile duct obstruction.
When a duct is obstructed for either reason, it usually results in the rapid onset of
severe and constant pain in the right upper abdomen, nausea, vomiting, jaundice, and
itching.
Bleeding
The liver is responsible for making proteins (clotting factors) that help your blood clot.
When a large percentage of your liver has been overtaken by cancer, these factors are
no longer produced in sufficient numbers. The result is that bleeding may occur (even
with a normal number of platelets) and anemia may ensue. The first sign is often
bleeding when you brush your teeth or frequent nosebleeds. More serious bleeding,
such as internal hemorrhage, may occur when the cancer is advanced.
Portal Hypertension
Liver cancer (and other liver diseases) can lead to bleeding from the digestive tract in
another way as well. A tumor within the liver can make it difficult for blood to flow
through the small veins in the organ that lead to the large portal vein. The resulting
pressure on the vein (portal hypertension) causes increased pressure in blood vessels
upstream, such as those in the esophagus.
These veins are weaker than the larger portal vein and can develop into varicose veins,
much like you see on people's legs, or on the abdomen at times with liver disease.
When these varicosities rupture, it can result in massive bleeding into the esophagus
(esophageal variceal bleeding, which can be life-threatening if not treated rapidly.
Bleeding may occur in the stomach and intestines as well due to the same mechanism.
High Blood Calcium (Hypercalcemia)
Liver cancer may result in a high calcium level in the blood (hypercalcemia of
malignancy) through a few different mechanisms. This may cause nausea and vomiting,
extreme muscle weakness, and confusion, which can progress to coma and even death
if not treated.
Hepatorenal Syndrome
Hepatorenal syndrome is a condition in which liver disease leads to kidney disease due
to changes in blood vessels and reduced blood flow to the kidneys. Hepatorenal
syndrome is very common with liver cancer and other forms of liver disease, and it's
estimated that 40 percent of people who have cirrhosis will develop the syndrome within
five years.4 Unfortunately, it is usually irreversible in these individuals unless liver
transplantation is performed.
Hepatic Encephalopathy
Hepatic encephalopathy can be a frightening complication of liver cancer but is actually
a reversible cause of symptoms that can look like Alzheimer's disease.
Toxins that the liver is unable to remove travel to the brain. This can result in memory
loss, disorientation, personality changes, and severe confusion. Symptoms may begin
mildly with difficulty doing math-centered tasks, like balancing a checkbook. Other
symptoms may include breath that has a sweet odor and flapping of the arms when they
are held out straight in front of a person. There are ways to treat the encephalopathy,
but the prognosis usually depends on the extent of the tumor.
Rehabilitation
Exercise is recommended for patients with various diseases including cancer. Walking
as well as resistance training has been reported to improve physical function and
skeletal muscle mass in patients with cancer. In accordance with the American College
of Sports Medicine guidelines, exercise training is a key recommendation to maintain
activity even in cancer patients. Cancer rehabilitation (CR), a new multidisciplinary
intervention for cancer patients, consists of nutritional and physical therapy. CR
improves fatigue, pain, physical function, and quality of life in patients with cancer.
I. Leukemia
Pathophysiology
As with many malignancies, the precise aetiology of childhood leukaemia remains
unknown. It is clearly a multi-factorial condition, with infection, genetic predisposition
and numerous environmental exposures all playing a potential role in its development.
Disruptions in the regulation and proliferation of lymphoid precursor cells in the bone
marrow leads to excessive production of immature “blast” cells and a subsequent
drop in numbers of functional red blood cells, white blood cells and platelets.
Children with certain genetic diagnoses, such as trisomy 21, are known to be at
increased risk of leukaemia.
Chemotherapy
Chemotherapy is the administration of drugs that kill rapidly dividing cells such as
leukemia or other cancer cells. Chemotherapy may be taken orally in pill or tablet form,
or it may be delivered via a catheter or intravenous line directly into the bloodstream.
Combination chemotherapy is usually given, which involves a combination of more than
one drug. The drugs are given in cycles with rest periods in between.
Sometimes, chemotherapy drugs for leukemia are delivered directly to the cerebrospinal
fluid (known as intrathecal chemotherapy). Intrathecal chemotherapy is given in
addition to other types of chemotherapy and can be used to treat leukemia in the brain
or spinal cord or, in some cases, to prevent spread of leukemia to the brain and spinal
cord. An Ommaya reservoir is a special catheter placed under the scalp for the delivery
of chemotherapy medications. This is used for children and some adult patients as a
way to avoid injections into the cerebrospinal fluid.
Side effects of chemotherapy depend on the particular drugs taken and the dosage or
regimen. Some side effects from chemotherapy drugs include hair
loss, nausea, vomiting, mouth sores, loss of appetite, tiredness, easy bruising or
bleeding, and an increased chance of infection due to the destruction of white blood
cells. There are medications available to help manage the side effects of chemotherapy.
Some adult men and women who receive chemotherapy sustain damage to the ovaries
or testes, resulting in infertility. Most children who receive chemotherapy for leukemia
will have normal fertility as adults, but depending on the drugs and dosages used,
some may have infertility as adults.
Biological therapy
Biological therapy is any treatment that uses living organisms, substances that come
from living organisms, or synthetic versions of these substances to treat cancer. These
treatments help the immune system recognize abnormal cells and then attack them.
Biological therapies for various types of cancer can include antibodies, tumor vaccines,
or cytokines (substances that are produced within the body to control the immune
system). Monoclonal antibodies are antibodies that react against a specific target that
are used in the treatment of many kinds of cancer. An example of a monoclonal
antibody used in the treatment of leukemia is alemtuzumab, which targets the CD52
antigen, a protein found on B-cell chronic lymphocytic leukemia (CLL) cells. Interferons
are cell signaling chemicals that have been used in the treatment of leukemia.
Side effects of biological therapies tend to be less severe than those of chemotherapy
and can include rash or swelling at the injection site for IV infusions of the therapeutic
agents. Other side effects can include headache, muscle aches, fever, or tiredness.
Radiation therapy
Radiation therapy uses high energy radiation to target cancer cells. Radiation therapy
may be used in the treatment of leukemia that has spread to the brain, or it may be
used to target the spleen or other areas where leukemia cells have accumulated.
Radiation therapy also causes side effects, but they are not likely to be permanent. Side
effects depend on the location of the body that is irradiated. For example, radiation to
the abdomen can cause nausea, vomiting, and diarrhea. With any radiation therapy,
the skin in the area being treated may become red, dry, and tender. Generalized
tiredness is also common while undergoing radiation therapy.
Supportive treatments
Because many of the treatments for leukemia deplete normal blood cells, increasing the
risk for bleeding and infection, supportive treatments may be needed to help prevent
these complications of treatment. Supportive treatments may also be needed to help
minimize and manage unpleasant side effects of medical or radiation therapy.
Types of supportive and preventive treatments that can be used for patients undergoing
treatment for leukemia include the following:
 Vaccines against the flu or pneumonia
 Blood or platelet transfusions
 Anti-nausea medications
 Antibiotics or antiviral medications to treat or prevent infections
 White blood cell growth factors to stimulate white blood cell production (such as
granulocyte-colony stimulating factor [G-CSF], made up
of filgrastim [Neupogen] and pegfilgrastim [Neulasta] and granulocyte
macrophage-colony stimulating growth factor [GM-CSF], made up
of sargramostim [Leukine])
 Red cell growth factors to stimulate red blood cell production (darbepoetin alfa
[Aranesp] or epoetin alfa [Procrit])
 Intravenous injections of immunoglobulins to help fight infection
What are complications of leukemia?

Many of the challenges of leukemia relate to the depletion of normal blood cells as well
as the side effects of treatments as described in the previous section, such as frequent
infections, bleeding, and GVHD in recipients of stem cell transplants. Weight loss
and anemia are further complications of leukemia and its treatment. Complications of
any leukemia also include a relapse or a progression of the disease after a remission
has been achieved with treatment.
Other complications of leukemia relate to the specific type of leukemia. For example, in
3% to 5% of cases of CLL, the cells change characteristics and transform into
an aggressive lymphoma. This is known as a Richter transformation. Autoimmune
hemolytic anemic, in the body attacks and destroys red blood cells, is another potential
complication of CLL. People with CLL are also more likely to develop second cancers
and other blood disorders and blood cancers.
Tumor lysis syndrome is a condition caused by the rapid death of cancer cells during
acute treatment. It can occur in almost any type of cancer, and it is seen with some
cases of leukemia, particularly when large numbers of leukemia cells are present such
as with AML or ALL. The rapid destruction of the leukemia cells leads to the release of
large amounts of phosphate, which further causes metabolic abnormalities and can lead
to kidney failure.
Children who receive therapy for ALL may experience late adverse effects including
central nervous system (CNS) impairment, slowing of growth, infertility, cataracts, and
an increased risk for other cancers. The incidence of these late effects varies depending
upon the age at treatment and the type and strength of therapies.
Coping and support

A diagnosis of leukemia may be devastating — especially for the family of a newly
diagnosed child. With time you'll find ways to cope with the distress and uncertainty of
cancer. Until then, you may find it helps to:
 Learn enough about leukemia to make decisions about your care. Ask your
doctor about your leukemia, including your treatment options and, if you like, your
prognosis. As you learn more about leukemia, you may become more confident
in making treatment decisions.
o The term "leukemia" can be confusing because it refers to a group of
cancers that aren't all that similar except for the fact that they affect the
bone marrow and blood. You can waste a lot of time researching
information that doesn't apply to your kind of leukemia. To avoid that, ask
your doctor to write down as much information about your specific disease
as possible. Then narrow your search for information accordingly.
o Write down questions for your doctor before each appointment, and look
for information in your local library and on the internet.
you deal with your leukemia. Friends and family can provide the practical support
you'll need, such as helping take care of your house if you're in the hospital. And
they can serve as emotional support when you feel overwhelmed by cancer.
 Find someone to talk with. Find a good listener who is willing to listen to you
talk about your hopes and fears. This may be a friend or family member. The
concern and understanding of a counselor, medical social worker, clergy member
or cancer support group also may be helpful.
Ask your doctor about support groups in your area. Or check your phone book, library or
a cancer organization, such as the National Cancer Institute, the American Cancer
Society or the Leukemia & Lymphoma Society.
 Take care of yourself. It's easy to get caught up in the tests, treatments and
procedures of therapy. But it's important to take care of yourself, not just the
cancer. Try to make time for yoga, cooking or other favorite diversions.

Prevention
There is no known way to prevent leukemia, but avoiding tobacco and exposure to
pesticides and industrial chemicals might help.
Rehabilitation
The following are some of the oncology rehabilitation therapies you may incorporate into
your leukemia treatment:
 Physical therapy: This type of oncology rehab combines range-of- motion training
with light resistance exercises to help alleviate breathing problems, improve
appetite, relieve constipation, reduce stress and increase energy.
 Occupational therapy: These therapies can help you perform daily living
activities, such as grooming, dressing, showering and eating, so you can
continue to live as independently as possible.
 Auriculotherapy: This non-invasive technique, which involves an electrical
stimulation to the external ear, can help alleviate side effects, such as balance
problems, nausea, shortness of breath and fatigue.
 ReBuilder: This form of oncology rehab involves an electronic stimulation to an
affected area (such as the hands and feet) to increase tactile sensory and
awareness, can help improve peripheral neuropathy.
 Massage therapy: This type of touch therapy can help restore a sense of
harmony, relaxation and well-being during leukemia treatment.
 Interactive metronome: This series of computer-generated sounds to measure a
rhythmic beat and response can be used to increase concentration and improve
balance, function and cognition during leukemia treatment.
 Speech and language pathology: Some leukemia treatments may cause dry
mouth or difficulty swallowing, which can limit your ability to eat. A speech
therapist will work with other members of your care team to address these
problems.
Nursing Interventions and Rationales

 Initiate bleeding precautions

Clotting factors are impaired and patients are at a higher risk of bleeding and bruising

 Assess and manage pain appropriately
o Massage
o Positioning
o Cool/heat therapy
o Aromatherapy
o Guided imagery
o Medications as necessary

Pain can be difficult to control and manage and medications may be scheduled with
PRN measures for breakthrough pain. Make sure the intervention is appropriate for the
patient and avoid extra stressors such as movement. Encourage patient to try non-
pharmacological interventions and balance those with medication for more
comprehensive pain control.

 Monitor for signs / symptoms of infection or sepsis

Especially during treatment, patients are at higher risk of developing sepsis. Monitor
closing for signs and symptoms and notify MD as necessary.

 Promote normothermia

Progressive hyperthermia may occur as the body’s response to disease and effects of
treatment. Monitor temperature closely, especially during chemotherapy.

 Anticipate needs

Time pain and nausea medications at their peak according to therapy, chemo and meal
times to increase their effectiveness

 Monitor Intake & Output and signs/symptoms of dehydration
o Skin turgor
o Dry mucous membranes
o Capillary refill

Dehydration and kidney compromise is a potential complication of disease and
treatment. Encourage hydration and monitor closely.

 Patient and family education
o Symptoms and disease process
o Infection prevention
o Plan of care

Patients and family members must be knowledgeable of process and what to expect to
help reduce anxiety and be prepared for complications as they arise. Educate family
members and caregivers of the importance to help reduce risk of infection for the patient
by practicing good hand hygiene.

 Avoid risk of infection from procedures:
o Foley catheter insertion
o Injections
o Lines and tubes

Lack of sufficient white blood cells damages the immune system and patients are more
prone to infections. Weight risk versus benefit.

 Promote self care, independence and ADLs

Fatigue is a common symptom and can prevent the patient from participating in self
care. Provide assistance with ADLs as needed and cluster care to reduce fatigue and
promote rest. Prioritize activities to help conserve energy for self care.

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 External-beam radiation therapy. This is the most common type of radiation

Alternative medicine for fatigue

Coping and support

 Medications that stop your body from producing testosterone. Certain

TARGETED DRUGS or IMMUNOTHERAPY

Lifestyle and home remedies

Coping and support

REHABILITATION AFTER TREATMENT

Coping and support

Fewer than 2% of thyroid cancers present as anaplastic carcinomas.4 Most mortality in

Lymph node removal

Radioactive iodine (radioiodine) therapy

Coping and support

Psychosocial and Behavioral Interventions

o Atezolizumab, avelumab, and durvalumab are types of PD-L1 inhibitors.

 BCG (bacillus Calmette-Guérin): Bladder cancer may be treated with an

 Chemotheraphy with a combination of methotrexate, 5-fluorouracil (5-FU),

Coping and support

Physical, emotional, and social effects of cancer

Therapies using medication

Therapeutic Intervention / Medical Management

 Narcotic analgesic is often administered as patient-controlled anesthesia to

Coping and support

Nursing Interventions: Liver Cancer

What are complications of leukemia?

Coping and support

Nursing Interventions and Rationales

o Dry mucous membranes

o Lines and tubes

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