Cancer Stats Did you know

159,900 new cases of cancer will occur in Canada and 72,700 deaths will occur (2007) 39% of women and 44% of men will develop cancer during their lifetimes Cancer is the leading cause of premature or early death in Canada Lung cancer is the overall leading cause of cancer death in Ontario (men and women) Colorectal is the second overall highest cause of death There is wide variation in incidence between countries, and by race within countries for both sexes.

What is Cancer?
Cancer occurs when cells in a part of the body begin to grow out of control. Also known as a neoplasm - An abnormal new growth of tissue in animals or plants; a tumor. Normal cells divide and grow in an orderly fashion, but cancer cells do not. Cancer cells grow and crowd out normal cells. Although there are many kinds of cancer, they all have in common this out-of-control growth of cells.

7 Warning Signs of Cancer CAUTION

Change in bowel/bladder habits A sore that does not heel Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty swallowing Obvious change in mole/wart Nagging cough or hoarseness

What is Metastasis?
Sometimes cancer cells break away from a tumor and spread to other parts of the body through the blood or lymph system. They can settle in new places and form new tumors. When this happens, it is called metastasis. Cancer that spreads in this way is called metastatic cancer. Many cancers have specific sites of metastsis (i.e. Lung liver, brain, bone)

Metastatic Mechanisms
Lympathic spread tumor cells are transported via lymphatic circulation. The tumor enters the lymph channels by way of interstitial fluid that communicates with the lymphatic fluid. Malignant cells also may penetrate lymphatic vessels by invasion Hematogenous spread malignant cells are passed through the bloodstream and is related to vascularity of the tumor. Angiogenesis malignant cells induce growth of new capillaries to meet their needs for nutrients and oxygen.

Staging and Grading of Tumour

Staging determines the size and the existence of metastasis TNM system refers to: T=Tumor (T0, TX, T1-4) N=Node involvement (NX, N, N13), M=metastasis (MX, M0, M1) Grading refers to the classification of the tumor. Grade I IV. See page 325 in Med Surg Test

What is Cancer Recurrence?

When cancer has spread to a new place in the body, it is still named after the part of the body where it started. For example, if prostate cancer spreads to the bones, it is still called prostate cancer. If breast cancer spreads to the lungs, it is still breast cancer. When cancer comes back in a person who appeared to be free of the disease after treatment, it is called a recurrence.

Trends in Incidence and Mortality Rates in Ontario 1964-2001 Male/Female

Males have a higher incidence and mortality rate For all cancers as compared to females

Pancreatic cancer is the most fatal cancer in Ontario, with a 5-year relative survival rate of 9%. All of the cancers shown in the graph, with the exception of lung cancer, occur infrequently, each with about 1,000 or fewer new cases diagnosed in Ontario per year. Lung cancer is one of the most common cancers and is also highly fatal, with a survival of only 16%.

Skin Cancer the Most Common Type of CA

Skin cancer alone accounts for about 1/3 of all cancers diagnosed in Ontario. About 1 in every 7 Canadians will get some form of skin cancer - basal cell carcinoma, squamous cell carcinoma or melanoma - during their lifetime.

Risk Factors
More than half of all fatal cancers are attributable to tobacco (30%) and diet/obesity/physical inactivity (30%). Occupation/environment (7%), family history (5%), biological agents (5%), perinatal effects/growth (5%), alcohol (3%) and reproductive factors (3%) are the next most common causes. Radiation/sunlight (2%) accounts for some of the remainder, with about 10% of fatal cancers attributable to unknown risk factors.

Cancer Detection Guidelines

Breast Yearly mammograms starting at age 40 Clinical breast exams (CBE) should be part of a periodic health exam, about every three years for women in their 20s and 30s and every year for women 40 and over. Women should report any breast change promptly to their health care providers. Breast self-exam (BSE) is an option for women starting in their 20s. Women at increased risk (e.g., family history, genetic tendency, past breast cancer) should talk with their doctors about additional tests like ultrasonography, digital mammography and MRI.

The Best Strategy for Cancer Survival

Early detection is the key to having a positive outcome and survival

Cancer Detection Guidelines

Colon and Rectal Cancer Beginning at age 50, both men and women at average risk for developing colorectal cancer should follow one of these five testing schedules:  yearly fecal occult blood test (FOBT)* or fecal immunochemical test (FIT)  flexible sigmoidoscopy every 5 years  yearly FOBT* or FIT plus flexible sigmoidoscopy every 5 years  double-contrast barium enema every 5 years  colonoscopy every 10 years

Cancer Detection Guidelines

Cervical Cancer Pap screening for cervical cancer should begin about 3 years after vaginal intercourse, but no later than when they are 21 years old. Screening should be done every year with the regular Pap test or every 2 years using the newer liquid-based Pap test. At age 30, women who have had 3 normal Pap test results in a row may get screened every 2 to 3 years with either the conventional (regular) or liquid-based Pap test. Annual screening for certain at risk females. Women who have had a hysterectomy without removal of the cervix should continue screening. Another reasonable option for women over 30 is to get screened every 3 years (but not more frequently) with either Pap test, plus the HPV DNA test. Women 70 years of age or older who have had 3 or more normal Pap tests in a row and no abnormal Pap test results in the last 10 years may choose to stop having cervical cancer screening. Women who have had a total hysterectomy may stop having cervical cancer screening, unless the surgery was done as a tx for cervical cancer or precancer.

Cancer Detection Guidelines

Prostrate Cancer PSA blood test and digital rectal examination (DRE) should be offered annually, beginning at age 50, to men who have at least a 10year life expectancy. Men at high risk (African-American men and men with a strong family of one or more first-degree relatives (father, brothers) diagnosed at an early age) should begin testing at age 45. Men at even higher risk, due to multiple first-degree relatives affected at an early age, could begin testing at age 40. Depending on the results of this initial test, no further testing might be needed until age 45.

WHAT IS CHEMOTHERAPY?
Chemotherapy is the use of drugs or medications to treat disease. Chemo means chemical and therapy means treatment Cancer chemotherapy may involve one drug or a group of drugs (combination chemotherapy) Adjunctive chemotherapy is used to destroy cancer cells that remain after surgery or radiation

How the Drugs Work?

Chemo therapy disrupts the cancer cells ability to grow and multiply Can be given by mouth, IM or IV May affect cells that are rapidly dividing such as bone marrow, GI tract, reproductive and hair follicles (alopecia).

Goals of Treatment
Destroy cancer cells combination chemotherapy Shrink cells before surgery or radiation neoadjuvant chemo Destroy cancer cells after treatment after surgery or radiation adjuvant chemo High doses are given to destroy bone marrow prior to transplantation ablative chemo Given to reduce pain and symptoms palliative chemo

Treatment
Regimes are geared to type of cancer may occur od, weekly, monthly may have rest periods to recover Combination therapy uses two or more meds in combination Clinical trials are used with randomized controls tests to determine efficacy of treatment Some patient are given the drug being investigated while others are given a placebo

Types of Agents
See handout Alkylating agents nitrosureas, antimetabolites, antitumor antibiotics, plant alkaloids, hormonal agents and miscellaneous agends The mechanism of action and cell cycle specificity are unique to each drug

Side Effects of Chemotherapy

Unique to the drug and drug regime being used Fatigue Alopecia Urine colour changes N&V (Ondasetron, Metoclopramide) Muscle weakness and nerve pain Skin problems dry and wet desquamation (dry, peel, red, itchy, rashes) Anorexia (eating problems, swallowing, heartburn, changes in taste, etc.) Diarrhea Constipation Depression Anxiety

Side Effects of Chemotherapy

Stomatitis/Mucositis and Xeristoma Myelosuppression Neutropenia (dec. in WBC predisposing to infection). Anemia (lack of oxygen to all parts of the body fatigue, dizzy, chilly or SOB) Thrombocytopenia (lack of platelets bleed or bruise) Women and sexuality drive does not decrease, absence of menses, hot flashes Men and sexuality may become infertile (sperm banking may be an option) Hand/Foot Syndrome redness, tenderness, peeling of hands and soles cold and moisturers, vit. B6 or dexamethasone Cardiac Toxicities (dunorubicin and doxorubicin)

Nursing Care
Monitor vitals (T for fever) Monitor blood work (WBC and diff) Obtain blood cultures Avoid people with infections Avoid rectal and vaginal products that can lead to bleeding Electric razor Nutrition (small meals, fluids) Complete sterile technique Observe oral cavity for redness, white patches, lesions pain Discuss hair loss Encourage rest for fatigue Provide anti nauseants Support family as a unit

Radiation Therapy
Is the use of certain types of energy (radiation) from x-rays, gamma rays, electron, linear accelerators, kilovoltage therapy and other sources to destroy cancer cells IORT Intraoperative radiation therapy is used when the tumor is open during surgery Radiation in high doses destroys cells in the area being treated by damaging the DNA in the cells making it impossible to grow and divide Damage occurs to healthy and cancer cells, healthy cells regenerate

Types of Radiation
External Beam Radiation radiation is directed at the cancer and surrounding tissue from a machine will need planning and treatment sessions marking with permanent marker and treatment od x 30 minutes per session Brachytherapy internal radiation (implanted) prostrate, cervix, esophagus may be temporary or permanent (seed implant) Systemic Radiation given a radioactive drink or injection and travels through the body

Goals of Radiation Therapy

Destroy the cancer Given after surgery or chemo to destroy cancer cells that remain Relieve symptoms including pain, ICP, SVCS, Shrink the tumor before chemotherapy or surgery

Care of Patient with Internal Radiation

Limit exposure Staff use dosimeter badges Patient in private room Limit visitors to 30 minutes Must stay 6 feet away No pregnant staff or visitors to attend patient Room is marked as radioactive

Managing Side Effects of Radiation

Anxiety and Depression Changes in Appetite Xeristoma Fatigue Hair loss (alopecia) Rad to brain (earaches, hearing loss, N&V, swelling of brain tissue) Rad to head/neck (dry mouth, mouth sores, difficulty swallowing, changes to teeth and gums) Rad to chest cough, difficulty swallowing Rad to breast skin changes Rad to stomach N&V, diarrhea Rad to pelvis bladder and rectal irritation, infertility, menopausal symptoms

Skin Care with Radiation

May have dry or itchy skin (purities) Wet desquamation (do not disrupt blisters) (Use Silver Sufadiazine) Dry desquamation Watch skin on exit area Do not rub, scrub or scratch sensitive spots Do not use powders, creams, salves because they may interfere with rad. Baby oil dry skin Cornstarch if excess moisture Red or sunburned in the treated areas Avoid sun exposure No soaps or deodorants Use electric razor No cold or heating products

Side Effects of Treatment

Anorexia Breathlessness or Dyspnea Constipation Diarrhea Dysuria/Nocturia/Hematuria Fatigue Fever Nausea and Vomiting Oral Stomatitis Pain Skin Alteration Skin Reaction from Radiation

Oncological Emergencies
May include: Spinal Cord Compression Superior Vena Cava Syndrome Extravasation Hypercalcemia Tumor Lysis Syndrome DIC - Disseminated Intravascular Coagulation Pericardia Effusion and Cardiac Tamponade

Spinal Cord Compression

Spinal cord compression is the second commonest neurological emergency of cancer after cerebral metastasis and this most often is due to extradural spread from vertebral metastases. Failure to recognize this oncological emergency results in severe disability with paraplegia and incontinence. Patient may not be able to get out of a chair after being seated The dorsal cord is the commonest site of compression with most frequent primary sites being breast, lung, prostate and kidney. Clinical features suggestive of spinal pain and backache should be assumed to be due to spinal metastases in a cancer patient unless proved otherwise. Urgent neurological investigations and neurosurgical consultation is required.

Signs and Symptoms

Back pain - The first symptom is usually any unexplained back pain which may be mild to begin with, and which lasts for more than one or two weeks. The pain may feel like a 'band' around the chest or abdomen, and can sometimes radiate over the lower back into the buttocks or legs. Numbness or pins and needles in toes and fingers, or over the buttocks. Feeling unsteady on your feet, difficulty walking or your legs are giving way. Problems passing urine These may include difficulty controlling your bladder, passing very little urine or none at all. Constipation or problems controlling your bowels.

Spinal Cord Compression Treatment

X-ray examination Bone scan MRI (cervical, thoracic lesions) CT myelogram (lumbar lesions) Neurosurgery consult Radiotherapy consult Surgical decompression laminectomy Steroids Pain management Check voiding and bowels Assess stabilization of the spine Pain is the initial symptom, weakness, heaviness, paresthesias, local pain in the vertebral column

Spinal Cord Compression Treatment

Neurosurgery is undertaken if there is no definite diagnosis and there is a rapidly progressive neurological picture. Laminectomy decompression is sufficient to relieve tumours However, the prognosis following surgery has not been shown to be superior to that following radiotherapy. The majority of patients are usually treated urgently with corticosteroids and radiotherapy. Radiotherapy must include the entire extent of the tumour, which is best delineated by MRI. Emergency chemotherapy may be very effective in certain tumor types like lymphomas, neuroblastomas and Ewing's sarcomas.

Remember: Confusion +Nausea+constipation = Check Ca+

Hypercalemia
Commonest life-threatening metabolic disorder associated with malignancy. The prevalence of hypercalcemia is 1020% Normal serum calcium is usually 8.7-10.4, with mild hypercalcemia defined as 12 and severe hypercalcemia as 14 or greater. Clinical features include N&V, thirst, polyuria, lethargy, constipation, weakness headache or mental confusion. The severity of symptoms may not be directly r/t the degree of elevation of serum calcium. Hypercalcemia may often occur in the absence of bone disease. Symptomatic hypercalcemia is usually due to carcinoma of lung, breast, bronchus, kidney or due to myeloma or lymphoma. Also malignancy due to osteolytic activity. Monitor I & O, hydrate Use bisphosphates and steroids

Pathological Bone Fractures

Patients may experience a pathological fracture as the first sign that their cancer has metastasized to bone. A pathological # is a break in a bone due to problems within the bone itself rather than by external factors, such as force. Pathological fractures are caused when the cancer destroys enough bone that the skeleton will no longer support the body. Bisphosphonate drugs, a newer approach to treatment for bone metastases, can effectively prevent loss of bone that occurs from metastatic lesions, reduce the risk of fractures, and decrease pain. Bisphosphonate drugs inhibit bone resorption, or break-down eg. Zometa and Aredia.

Myoclonus
Recognition and management of the symptoms of myoclonus. MYO = muscle CLONUS = jerks Central nervous system excitability. Sudden, brief muscular contractions often seen at higher doses of strong opioids, however may be seen at lower doses of opioids. Opioid rotation may help Rehydrate if appropriate SQ, PO, IV Lower opioid dose by analyzing pain and adding adjuvant medications Drugs that may be ordered based on symptoms: Anti-convulsants (Clonazepam) Anti-anxiety (Lorazepam) Muscle relaxant (Diazepam)

Disseminated Intravascular Coagulation DIC

Disorder of coagulation or fibrinolysis which results in thrombosis or bleeding Associated with hematologic cancer, prostate, GI and lungs Clots are depositied in the microvasculature Patients at increased risk for hemorrhage Watch for bleeding May need to administer blood products

Dyspnea
Reasurrance Elevate arms on pillows Conserve energy Suctioning can be distressing use scopolamine and glycopyrolate Fan Oxygen therapy Nebulized morphine ??? Decrease anxiety and panic with benzodiazepines

Delirium
Is a distrubance of consciousness with reduced ability to focus, sustain or shiftt, hyperarousal) or hypoactive symptoms (sleepy, withdrawn, slowed) Symbolic experience, lights, hearing or seeing loved ones, warmth and softness, signs of impending death May require sedation, terminal sedation with Versad (Medazolam) Antianxioloytics may make it worse Use atypical anti-psychotics, Zyprexia, Resperidone

Nausea/Vomiting
Nausea is a sensation with a need to vomit with associated autonomic symptoms including pallor, cold sweat, salivation, tachycardia and diarrhea Vomiting is the forceful expulsion of gastric contents through the mouth. It is a complex reflex process controlled by the vomiting centre . Involves contraction of the diaphragm, chest wall and abdo muscles Caused by rectal, bowel impaction Vestibular movement induced motion sickness, migraine, ICP CNS olfactory, pain, fear Visceral involving internal organs Inflammation, obstruction, gastric stasis, gastric irritation

Management of N&V
Cool room, well ventilated Remove vomitus quickly Mouth Care Small frequent servings Offer sips of fluid (Gatorade, flat gingerale, popsicles) Rice pasta, starchy foods Avoid high fat spicy foods Elevated HOB, avoid lying down for 2 hours after eating Deep breathing, cool compressed Drugs, Maxeran, Haldol, Stematil, Domperidone/Motillium, Phenergan, Anticholinergics, Antihistamines, Ondasetron, Granisetron, Dolansetron (for chemo related N&V) Losec, Famotidine, Ranitidine, Desamethasone

Hemoptysis
Blood expectoration arising from the oral cavity, larynx, trachea, bronchi or lungs, Streaking to massive bleeding IV opiods and benzodiazepines Dark towels may have massive bleed

Sleep Disturbances and Skin Breakdown

Remember wound odour control and use kitty litter, charcoal, Metronidiazole Flagyl If odour is a concern for the patient, they have to live with it 24/7 Tricyclic, Benzos and Neuroleptics for sleep disorders due to fear, anxiety and grief of impending death

Bowel Obstruction
Intensinal obstruction due to blockage of the lumen of the intestine. N&V, colicky abdo pain and bloating, increased bowel sound early, loose stools then no bowel sounds and constipation Due flat plate of abdo Continuous sc infusion, maxeran to be avoided, scopolamine and glycopyrrolate decreased peristalsis, Octreotide (Sandostatin) to slow motility

Febrile Neutropenia
Prompt recognition, reporting and intervention for the symptoms related to a low WBC. A fever with a low white blood count. A patient with bone marrow infiltration by malignant cells, recent chemo or radiation, usually within the last 7-10 days. CBC Cultures Antibiotic therapy Tylenol prn for fever Chest X-ray Precaution: if low WBC no suppositories, rectal exams, or enemas great chance for bleeding

Superior Vena Cava Syndrome SVCS

Impedance of venous return from the head, upper extremities and upper thorax to the heart as a consequence of obstruction of blood flow through SVC vena cava The underlying mechanism may be invasive disease process in the superior mediastinum including extrinsic compression, invasion and thrombosis. This syndrome commonly presents with characteristic features of facial swelling, chest pain and cough with or without dysphagia. Distension of neck, superficial thoracic veins and conjunctival edema are common. able. In extreme conditions proptosis with cerebral edema may occur leading to altered consciousness.

Superior Vena Cava Syndrome SVCS

Lung cancers (75%) & mediastinal lymphomas (15%) account all cases of superior vena caval syndromes. Palliative emergency radiotherapy and corticosteroids are advised for Tx. Patients should be positioned with the HOB o. BP readings should be taken from legs. Physical activity should be limited to essential ADLs with education to avoiding heavy lifting or valsalva. Monitor the patient for any increased difficulty with respiration to provide appropriate care, which may include positioning, energy conservation, physician notification, adaptive equipment, and oxygen

Tumor Lysis Syndrome

Because of the lysis (death of cells by bursting) of a large number of cells in a short period of time large amounts of potassium, phosphate, and uric acid are released resulting in acute renal failure. Tumor Lysis Syndrome also can occur with some solid tumors (ie, hepatic tumors). Symptoms usually arise from 6 to 72 hours after the initiation of chemotherapy. Oncologists are proactive in treating patients with hydration and allopurinol (which blocks uric acid production), and patients are monitored closely for urine output, daily weights, and lab values. Patients often complain of muscle weakness and cramping in skeletal muscles from TLS.

Tumor Lysis Syndrome

The health care team should identify which patients are at risk for developing TLS (high-grade lymphomas/ALL). Recognition of classic symptoms such as muscle cramping, arrhythmias, and oliguria (decreased urine output) are essential. Watch for CNS signs or arrhythmias (decreased BP, tachycardia, irregular HR) during activity.

Extravasation
Is a complication of cancer chemotherapy administration Occurs when a vesicant is administered outside the vein when a cannula causing infusion into the surrounding tissue Symptoms include: swelling, discomfort or burning, and blanching at the IV site Nursing Care: stop IV infusion, aspirate blood, apply warm or cold packs, administer ordered antidote drug, watch for necrosis and ulceration Plastic Surgery Consult Antidote is specific for drug of extravasation; doxorubicin, daunorubicin, idarubicin, mitomycin, actinomycin - cold DMSO; vincristine, vinblastine, vinorelbine - hyaluronidase and heat; mechlorethamine - sodium thiosulfate; streptozocin - cold

Always Remember Psychosocial Care Use the Team

Remember disturbances in body image and self esteem Change in roles Sexuality Issues Relaxation Support for families, individual through hospice Spiritual Care