Cancers in Different Systems

NCM 106 TEAM First Semester 2012-2013

It is the most common cause of cancer death in men and is fast becoming the most common cause in women though its largely preventable.

Risk factors: Any smoker over age 40, especially if he began to smoke before age 15, has smoked a whole pack or more per day for 20 years, or works with or near asbestos

Cancer risk is determined by:

Number of cigarettes smoked daily The deth of inhalation How early in life smoking began The nicotine content of cigarettes

Other factors that increase susceptibility: Exposure to industrial and air pollutants (asbestos, uranium, arsenic nickel, radioactive dust)

Familial susceptibility

> are

round cells that replace injured or damaged cells in the lining (the epithelium) of the bronchi, the major airways.

usually found in the center of the lung, either in a major lobe or in one of the main airway branches They may grow to large sizes and form cavities in the lungs

> are

>estimated to account for 30% to 50% of all lung cancers most common lung cancers in many countries. most common lung cancer in women

>Adenocarcinomas usually arise from the mucus-producing cells in the lung.

>About two-thirds of adenocarcinomas develop in the outer regions of the lung, while one-third develops in the center of the lung

Bronchoalveolar Lung Cancer

a subtype of adenocarcinoma.
develops as a layer of column-like cells on the lung and spreads through the airways, causing great volumes of sputum

> which

makes up about 10% to 20% of lung cancers, includes cancers that cannot be identified under the microscope as squamous cell cancers or adenocarcinomas.

like squamous cells, be derived from reserve cells or other cells in the epithelium. causes between 15% and 25% of all lung cancers; without chemotherapy, very aggressive and is usually rapidly fatal. It requires a different treatment approach from non-small cell lung cancer.

Early stage lung cancer usually produces no symptoms, this disease is often in an advanced state at diagnosis.

The following late-stage symptoms often lead to a diagnosis:

With squamous and small cell carcinomas: Smokers cough, hoarseness, wheezing and chest pain With adenoma and large cell carcinomas: Fever, weakness, weight loss, anorexia, and shoulder pain

Metastatic symptoms vary greatly, depending on the affected structures:

Bronchial obstruction: hemoptysis, atelectasis, dyspnea Recurrent nerve invasion: vocal cord paralysis Chest wall invasion: piercing chest pain, increasing dyspnea, severe shoulder pain radiating down the arm Esophageal compression: dysphagia Vena Caval obstruction: venous distention and facial edema, neck, chest and back

Chemotherapy

For advanced non-small cell lung cancer:

VbP (vinblastine, cisplatin); CAMP 9cyclophosphamide, doxorubicin, methotrexate, procarbazine); MVbP (mitomycin, vinblastine, cisplatin
For small cell lung cancer:

CAV (cyclophosphamide, doxorubicin, vincristine), CEA (cyclosphosphamide, etoposide, doxorubicin); VP-16 +P (etoposide, cisplatin)

Radiation

External Beam, Interstitial/endobrochial bradytherapy with IRIDIUM-192

Obtain pre-op status: Amount and extent of dyspnea, cough, hemoptysis, tachypnea Baseline pulmonary function studies, ABGs ECG, blood counts and chemistry, general nutrition and hydration status.

Encourage patient to stop smoking pre-op

Explain the use of suctioning and chest drainage after surgery

Instruct DBE, coughing exercises, ROM, early ambulation

Closed chest drainage: Note for the fluctuation in the water-seal chamber & drainage tubing near the patient. Assess patient frequently for signs of: airway obstruction, atelectasis, aspiration or impaired gas exchange. Pain management, fluid replacement, exercise (movt. of the shoulder on affected side) and rest.

Observe and record the amount, character of drainage. Check dressing at the entry site of chest tube, skin/wound care.

Segmentectomy: A wedge-shaped section of the affected

lung is removed.

Lobectomy: The affected lobe of the lung is

removed.

Pneumonectomy: The entire affected lung is removed.

Health Teaching
Encourage patient to stop smoking

Instruct the patient and family to notify the physician if the patient experienced any side effects from .medications or signs or recurrence such as shoulder pain, increased coughing or hemoptysis.

Teach patient the name, dose & action, frequency & side effects of meds Encourage eating a diet high in protein and calories

Refers to a group of malignant diseases that commonly occur in the female breast and infrequently in the male breast.

the most common malignancy in women.

One in every nine (9) woman is expected to develop breast cancer.

Gender/Age/Socioeconomic
Status Early menarche <12 and late menopause >55 >30 years old : first full term

pregnancy

Nulliparity
Obesity/High Fat diet Family history of breast cancer

The mass is usually nontender, hard, irregular in shape, and non mobile.
Presentation of 64% to 70% of breast Lets Review the Breast Self Exam cancers, is as a palpable mass found by and examine yourself! the client

A painless mass or thickening in the breast, most often found in the outer quadrant .

Thats why you have to emphasize early detection through BSE and Mammogram

Chest X-Ray Mammogram

Biopsy

15%

48%

17%
6% 11%

This shows the right breast (the breast on the left side) being larger than the left. Look carefully and you can see that the level of the nipples are not the same and the right nipple is pointing downwards.

depression or sunken dip in the skin of the upper part of the left breast, above the nipple. .
(breast to your right) as dimpling of the skin.

Normally when the arms are raised this becomes apparent or more obvious. The right picture shows the dimpling of the skin from the side view.

the breast appears patchy red and thickened. an example of a type of breast cancer that looks as if your breast has an infection. a sign of an inflammatory cancer of the breast.

d r a w n i n w a r d s a n d t h i s i s c a l l e d r e t r a c t i o n o f t h e n i p p l e . T h e p i c t u r e o n

Compare both nipples. The one to your right (the left nipple) is drawn inwards and this is called retraction of the nipple. The picture on the right shows the nipple retraction from the side view.

d r a w n i n w a r d s a n d t h i s i s

nipple retraction, with small lumps on the areola (brownish skin around the nipple). reddening and thickening of the skin around the areola as well.

c a l l e d r e t r a c t i o n o f t h e n i p p l e . T h e p i c t u r e o n

Peau d orange refers to the orange peel skin appearance of skin Sunkist oranges typically have this pitted appearance, due to edema in the skin, akin to water retention. breast on the right is at a more advanced stage of the orange peel skin and the nipple is retracted (drawn inwards)

Very advanced breast cancer ulcerating and involving the whole of the left breast. spread to the left armpit lymph nodes. Even the enlarged lymph nodes are on the verge of breaking through the skin

MALE BREAST CANCER: Breast cancer involving the nipple (ulceration has occurred)

Involves the removal of the cancerous mass & some normal tissue for clean margins. Frequently, the initial excisional biopsy is the Lumpectomy.

Involves the en bloc removal of the breast, axillary lymph nodes, and overlying skin. This is the most commonly performed mastectomy

Involves resection of breast tissue and some skin from the clavicle to the costal margin and form the midline to the latissimus dorsi.

axillary tail and pectoral fascia are also removed.

Axillary nodes are NOT removed. ( rarely used).

Involves the en bloc removal of the breast, overlying skin, pectoral muscles, and axillary nodes.

removes the local lesion and the axillary nodes with wide safety margin of surrounding tissue.

This procedure has declined due to unsatisfactory treatment results and morbidity.

Chemotherapy

Combination chemotherapy: CMF (cyclophosphamide, methotrexate,5fluoracil); CMFVP (CMF with vincristine and prednisone)

Radiation
in combination with lumpectomy or quandrantectomy is an accepted treatment for early stage (stage I & II).

Women who are eligible for these treatment choices are women with:

Lesions less than 5cm No large or fixed ancillary nodes No demonstrable disease Clear surgical margins Breasts that can be easily evaluated mammographically

Nursing Care

Alleviate patients symptoms due to the sideeffects of the treatment

Nursing Care
Post-Mastectomy
Post Mastectomy Exercises Prevent strain on the affected side Elevate arm/affected side using a pillow to minimize edema Increase the number of pillows gradually as edema subsides Allow slow abduction/ adduction few days after surgery, unless contraindicated NO BP taking, IV insertion, compresses on the affected side Monitor color, consistency and volume of drainage Daily wound dressing, or as PRN

Home Care dissection, the affected arm may swell and is less INSTRUCTION
able to fight infection

Because the patient had an axillary node

Avoid burns while cooking or smoking

Wear a long length oven mitt Do not reach into a hot oven with this arm Do not hold cigarette on the affected hand

Avoid sunburn and insect bites

Wear long sleeve shirts or gloves Use sunscreen Use insect repellent to avoid bites or stings

Home Care
INSTRUCTION

Because the patient had an axillary node dissection,

the affected arm may swell and is less able to fight infection

Avoid cuts, pinpricks, and scratches

Wear Gloves when gardening, Do not work near thorny plants. Use an electric razor with narrow head for underarm shaving to reduce risk of nicks or scratches Use a thimble when sewing Never cut or pick at cuticles; use hand cream or lotion Wash cuts promptly, treat them with antibacterial medication and cover them with sterile dressing. Check often for redness, soreness, pus or other signs of infection.

Home Care
INSTRUCTION

Because the patient had an axillary node dissection,

the affected arm may swell and is less able to fight infection

Avoid strong detergents, harsh chemicals, and abrasive compounds

Wear protective gloves when doing dishes and cleaning

Avoid other trauma

Use a lanolin hand cream a few times each day Have all vaccinations, injections, blood samples and BP taken on the unaffected side/other arm Wear a Medic Alert ID tag that cautions no test injections or BP readings on the affected arm Carry handbag and other heavy objects on the other arm Wear watch or jewelry loosely, if worn at the operated arm Avoid elastic cuffs on blouses and nightgowns Wear an elastic sleeve if recommended by the physician

Home Care
INSTRUCTION

Because the patient had an axillary node

dissection, the affected arm may swell and is less able to fight infection

Contact the physician if the arm or hand becomes red, swollen, or feels hot. In the meantime, try to keep your arm over your head and periodically pump your fist.

Epidemiology

2nd most common visceral neoplasm

in the US and Europe Incidence is equally distributed between men and women

ranks just behind the lung cancer as

cause of death most tumors are found in the distal portion of the large bowel, from the sigmoid colon to the anus

Risk factor: Exact cause is unknown,

concentration in areas of higher economic development suggest a relation to diet (excess Animal fat, beef and low fiber) Other factors are: other diseases of the digestive tract, age (over 40), history of ulcerative colitis, familial polyps

Right Colon Pain

umbilicus

Left Colon and Rectum

Weight loss Anorexia Nausea Vomiting Anemia Palpable Mass

Pain

Rectal Bleeding Changed bowel habits Tenesmus Intestinal Obstruction

Pain

Pain

Diagnostics
Digital Rectal Examination can detect almost 15% of colorectal cancer Hemooccult Test (Guaiac) can detect blood in stool Proctoscopy or sigmoidoscopy can detect up to 66% of colorectalcancer Colonoscopy permits visual inspection (& photographs) of the colon up to the ileocecal valve and gives access for polypectomies & biopsies of suspected lesions

Diagnostics
Computed Tomography (CT) scan can detect areas affected by metastases Barium X-ray utilizing a dual contrast with air, can locate lesions that are undetectable manually or visually. This should FOLLOW endoscopy or excretory urography because the barium sulfate interferes with these tests

Carcinoembryonic antigen although not specific or sensitive enough for an early diagnosis, is helpful in monitoring patients before and after treatment to detect metastases or recurrence

Most effective treatment for colorectal cancer, it removes the malignant tumor and adjacent tissues as well as any lymph nodes that may contain cancer cells

Tumor in upper rectum : anterior colectomy Tumor in middle rectum: pull-through procedure Tumor in lower rectum : abdominal perineal resection and colostomy Tumor in right colon : right colectomy or colostomy Tumor in left colon : colectomy or colostomy Tumor in sigmoid colon : sigmoid resection

Chemotherapy
is indicated for patients with metastasis, residual disease, or a recurrent inoperable tumor Drugs for such treatment commonly include fluorouracil with levamisole,leucovorin, methotrexate, or streptozocin

Radiation
Nursing Care
Before Surgery:

induces tumor regression and may be used before or after surgery or combined withchemotherapy, especially fluorouracil show them a diagram of the intestine before and after surgery, stressing how much of the bowel will remain intact prepare the patient for post-op IV infusions , NGT and indwelling urinary catheter discuss the importance of DBE & coughing exercises

monitor the patients diet modifications, laxatives, enemas, and antibiotics if the patient is having a colostomy, teach him and his family about the Procedure

Emphasize the stoma will be red, moist, and swollen and that post-operative swelling will eventually subside

Radiation

induces tumor regression and may be used before or after surgery or combined with chemotherapy, especially fluorouracil

Nursing Care
After Surgery: Explain to the family the importance of their positive reactions to patients Adjustment

Encourage the patient to look at the stoma and participate in its care as soon Inform the patient that a structured, as possible. Teach good hygiene and skin gradually progressive exercise program care. to strengthen abdominal muscles may be instituted under medical supervision If appropriate, instruct the patient with sigmoid colostomy to do his own irrigation inform the patient to avoid heavy lifting as soon as he can after surgery. Advise him to prevent herniation or prolapse to schedule irrigation for the time of day he normally evacuated before surgery

If flatus, diarrhea, or constipation occurs, eliminate suspected food from pts. diet

Second most common neoplasm found in men over age 50. Incidence is highest in blacks and lowest in Asians.

Manifestations of prostatic cancer appear only in the advanced stages Includes difficulty initiating a urinary stream, dribbling, urine retention and unexplained cystitis, rarely hematuria.

Digital Rectal exam for men over age 40 Yearly blood test to detect PSA in men over age 50 UTZ- if abnormal results are found in the prelim Biopsy- confirms the diagnosis MRI, CT Scan , Excretory Urography may also aid the diagnosis

Nursing Care
Explain the after effects of surgery (such as impotence and incontinence) and radiation Teach the pt. to do perineal exercises 1 to 10 times an hour

Radical Prostatectomy, Prostatectomy, orchiectomy to reduce androgen production

Radiation
Radiation is used to cure some locally invasive lesions and to relieve pain from metastatic bone involvement. A single injection of radionuclide Strontium-89 is also used to treat pain caused by bone mets.

Radical Prostatectomy, Prostatectomy, orchiectomy to reduce androgen production

Chemotherapy
Single agents: Cyclophosphamide, 5-FU, doxurubicin, methotrexate, cisplatin, mitomycin, dacarbazine, hormonal therapy, diethylsylvestrol, premarin, estradiol

Nursing Care

Explain the after effects of surgery (such as impotence and incontinence) and radiation Teach the pt. to do perineal exercises 1 to 10 times an hour

Epidemiology: More common among women of lower socioeconomic status, many of whom are black or Hispanic, but all women are at high risk for developing it

Risk Factors: intercourse at a young age, particularly 15-17 yrs old multiple sex partners sexually transmitted diseases multiple pregnancies pregnancies in the teen years

Classified as either preinvasive or invasive carcinoma

Preinvasive ranges from minimal cervical dysplasia, the lower third of the epithelium contains abnormal cells, to carcima in situ the full thickness of epithelium contains abnormally proliferating cells curable 75% to 90% of the time with early detection and proper treatment. If untreated, it may progress to invasive cervical cancer.

Invasive cervical cancer cells penetrate the basement membrane and can spread directly to contiguous pelvic structures or disseminate to distant sites by lymphatic routes. Usually, invasive carcinomas occurs between ages 30 and 50; rarely, under age 20

Signs and symptoms: Preinvasive cervical cancer produces no symptoms or other clinically apparent changes Early invasive cervical cancer causes abnormal vaginal bleeding, persistent vaginal discharge, and post coital pain and bleeding. In advanced stages, it causes pelvic pain, vaginal leakage of urine or stool from a fistula, anorexia, weight loss and anemia

Diagnostics: Papanicoulau Smear (Pap test) can detect cervical cancer before clinical evidence appears Colposcopy being done if there is abnormal cervical cytology, it can detect the presence and extent of preclinical lesions requiring a biopsy and histologic examination Lympangiography, cystography and scans can detect metastases

Nursing Care

Drape the patient and prepare her as for a routine Pap Test and Pelvic Exam if she: 1. needs a biopsy 2. is having cryosurgery Tell the patient to expect a discharge or spotting for about 1 week after an excisional biopsy, cryosurgery, or laser therapy and advise her not to douche, use tampons, or engage in sexual intercourse during this time Tell the patient what to expect postoperatively, if shell have a hysterectomy Watch for signs and symptoms of complications, such as bleeding, abdominal distention, severe pain and breathing difficulties Encourage the patient to perform deep breathing and coughing exercises

Nursing Care
Find out whether the patient is to have internal or external radiation procedure. Internal radiation requires a 2-3 day facility stay, bowel prep, a povidone-iodine vaginal douche, a clear liquid diet, NPO the night before the implantation; it also requires an indwelling catheter Internal radiation procedure is performed in the operating room under general anesthesia and that an applicator containing radioactive material will be implanted Remember that safety precautions time, distance, and shielding begin as soon as the radioactive source is in place. Inform the patient that shell require a private room Encourage the patient to lie flat and limit movement while the implant is in place. If she prefers, elevate the head of bed slightly Assist the patient in ROM arm exercises (leg exercises and other body movements can dislodge the implant). If needed, administer tranquilizer to help the patient relax and remain still. Organize the time you spend with the patient to minimize exposure to radiation.

Epidemiology: Ovarian cancer is the fourth leading cause of death from cancer in woman. Its incidence is increasing faster than the survival rate

Risk Factors: Higher in women with upper socioeconomic levels between the ages of 20 and 54 Includes age at menopause Infertility Celibacy High-fat diet Exposure to asbestos, talc and industrial pollutants Nulliparity Familial tendency History of breast or uterine cancer

Signs and Symptoms

vague abdominal discomfort other mild GI disturbances constipation abdominal distention

Diagnostics

dyspepsia urinary frequency pelvic discomfort weight loss

complete patient history surgical exploration histologic studies complete physical exam including pelvic exam with Pap Smear Other special tests are: Abdominal ultrasonography, ct scan or xray CBC, blood chemistries, electrocardiography Excretory urography for information on renal function Chest X-ray for distant metastases Barium enema Lymphangiography to show lymph node involvement Mammography to rule out primary breast cancer Liver function studies or liver scan Ascites fluid aspiration for identification of typical cells by cytology

Treatment:
Simple Salpingo-oophorectomy Total Abdominal hysterectomy w/ bilateral salpingoooporectomy and partial or complete omentectomy

Radiation

Intracavity Radiation External Radiation

Chemotherapy

Single Agent: Chlorambucil, melphalan, doxorubicin, cyclophosphamide, 5FU, methotrexate, vinblastine, bleomycin, cisplatin, nitrogen mustard, thiotepa, tetracycline Combination Therapy (containing cisplatin)

Nursing Care

Before Surgery: Thoroughly explain all preoperative tests, the expected course of treatment, and surgical and postoperative procedures In pre menopausal women, explain that bilateral oophorectomy artificially induces early menopause, so they may experience hot flashes, headaches, palpitations, insomnia, depression, and excessive perspiration After Surgery: Provide abdominal support, and watch for abdominal distention. Encourage coughing and deep breathing. Reposition the patient often, and encourage her to walk shortly after surgery Monitor and treat adverse effects or radiation and chemotherapy

Thank you for listening