Oncology Lecture[1]

8/8/2019 Oncology Lecture[1]

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Oncology Dead Mans partyDead Mans party

Biology of abnormal cells

Cancer grading and stages

Cancer statistics

Chemotherapeutic agents

Radiation treatments

Bone Marrow and Stem Cell transplantsOnco-gene therapy


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Oncology Objectives

1. Identify thedifferent phases of cancercellreplication.

2. Compare the features of a benign versusmalignant tumor

3. Recognize the TNM stage and grading system of

cancertumors. 4. Discuss therole of oncogenes and suppressorgenes

in cancerdevelopment.

5. Identify behaviors with corresponding primaryand secondary nursing prevention forrisks of cancer

development 6. Recognize thedifferent classes of chemotherapies. 7. Create appropriate nursing interventions fora case

study of a patient with cancer.


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Oncology Objectives 8. Identify appropriate testing forcancer patients. 9. Recognize signs and symptoms of chemotherapy side

effects.

10. Recognize signs and symptoms ofradiation therapy. 11. Prioritize nursing interventions fora patient with

neutropenia. 12. Prioritize nursing interventions fora patient with

thrombocytopenia.

13. Prioritize nursing interventions fora patient receivingbone marrow orstem cell transplant.


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Oncology Objectives 14. List 4risk factors forthedevelopment of leukemia.

15.CompareLeukemia andLymphoma pathophysiology,

etiology and clinical manifestations.


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Cellular Review

Evolve3DCellularDifferentiation on website


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Oncology

Biology of abnormal cancer cells

They have continuous orinappropriate, usuallyfastergrowth orlargergrowth patterns

They have no specific morphology and often donot resemble theirparent cells = anaplastic

They do not respond to signals forapoptosis =programmed cell death


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Oncology


Have a large nuclear cytoplasmic ratio; thenucleus may occupy most of the cell area

They lose some orall of theirnormal cellfunctions

They do not makefibronectin, and thus cannotconnect easily and break offeasily


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Oncology


They are able to migrate throughout the body =metastasis

They invade othertissues and types of cells.

They are not controlled by contact

They have more orless chromosomes than the

parent cells = aneuploidora mutation of the genes


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Oncology

Cancer development

Initiation there are many theories as towhen the genes in the cells aredamaged,

maybe in utero, from physical orchemical

exposure, latent oncogenes, viruses, ora

lack of suppressorgenes from ourparents,

and at this point the cell is not dividing.


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Oncology kin cells


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Oncology Cancer development Promotion - the stage when the abnormal

cell starts to divide, may be stimulated by

environmental changes, hormones, drugs, orirritants


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Oncology

Cancer development

Progression the phase when the abnormalcells have continued to grow into a Primary

tumor, may produceangiogenesis factorswhich supply blood and vascularnourishment to the tumor. The tumormayhave subcolonies of cells with different

genes and features


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Oncology

Cancer development

Metastasis

the movement of cancercells into otherorgans of the body, thus creating new tumor

sites.


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Oncology

Cancer grading and staging Canceris graded upon theresemblance to normal cells

= G(The higherthe number, the worse the grade of cancer) i.e. G1,

G2, G3, G4

Staging is based upon the presence of a primary tumor = T

involvement in lymph nodes = N

and appearance ofmetastasis = M Numbers of the stagerange from

x = none to 3 or4 foreach letter


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Oncology

Is this a high grade orlow grade cancer?

Case study

Julie has a breast lump in herright breast, and

has also found one in herright armpit. Biopsyand lumpectomy were performed. The tumor

was graded G3, T2, N2, M1.


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Is this a high grade or low grade

cancer?

High Lo

w

0%0%

1. High

2. Low


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Oncology

Julie opted to have a lymphectomy of herright arm lymph nodes, and startedradiation

treatment right away. Herdoctoralso

suggested that she start Adriamycin IVchemotherapy to get any cells that the

radiation might miss.


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Oncology

Cancer Risks

#1 = advancing age

#2 = smoking tobacco

Hormones Prempro caused a substantial increasein breast canceron theHERS trial

Genetic inheritance of oncogenes and autoimmunediseases

Environmental exposure Excessive intake ofdietary fats


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Oncology

Cancer risks High alcohol consumption

Low dietary vegetables and fiber(sources

of antioxidants) Previous Viral infections:

Hepatitis B orC

Herpes viruses

Papilloma viruses (HPV)

Retrovirus HTLV I


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Oncology

Types of cancer cells are named for their site oforigin:

Adenocarcinoma

Carcinoma in situ (CIS)

Squamous

Basal cell

Astrocytomas

Melanomas Sarcomas

Lymphomas


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Oncology

Symptoms of Cancer Cachexia weight loss,unexplained

Anorexia

Anemia Impaired immuneresponse

Pain when the canceris largeenough tocompress nerves ororgans

Lymphadema when the tumorblocks lymph orcirculatory flow

Motororsensory deficits


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Oncology The 60 year old client with small cell lung cancer is concerned that

his grown children also might develop the disease. What is the

nurses best response?

A. This disease is a random eventand there is no way to prevent it.

B. Because this disease is inherited as adominant trait, your children have a 50% riskfor developing it.

C. Cigarette smoking is the main cause of thisdisease, and helping your children not to

smoke will decrease their risk. D. Lung cancer can be avoided by decreasing

dietary intake of fats and increasing theamount of regular aerobic exercise.


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Oncology

Cancer statistics

The top fourcancers found in the UnitedStates are:

Lung

Breast

Prostate

Colorectal

C


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Oncology

Cancer statistics

Prostate canceris the most common site ofcancerand the2nd most common cause of

cancerdeath in the UnitedStates

The first cause ofdeath in males is LungCancer


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Oncology


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Oncology

Cancer statistics Lung cancer has annual

new cases (incidence)

of 173,770 peopleper year: 93,110 males and

80,660 females

Annual mortality: 160,440peryear

consisting of92,000 males and68,510 females


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Oncology

Cancer statistics 28% of all cancer deaths are due to lung cancer

This is the leading cause of cancer death inboth men and women

There are more deaths from lung cancer thanprostate, breast, and colorectal cancerscombined


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Oncology

Cancer statistics

Risks for lung cancer:

Smoking (75-8

0% of cases) Occupational exposure

Nutrition/Diet

Genetic factors


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Oncology

Cancer statistics

Prostate canceris numbertwo cause of cancerin

men

Breast Canceris numbertwo cause of cancerinwomen

Most common non-malignant ornon-fatal canceris non-melanoma type skin cancers


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Oncology The client says that she has heard that the origin of mostcancers is genetic. What is the nurses best response?

A. The development of most cancers ispredetermined and not affected by

environmental factors. B. Cancers arise in cells that have been

damaged,which may be in the genes.

C. The majority of cancers are inherited

D. Cancer is more common among males than

females.


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Oncology

Lab tests for cancer Ultrasounds to determine size CT scan with contrast the golden standard Genetic markers BRCA 1 and BRCA 2

Tumormarkers:CEA general carcinogenic antigen

PSA prostate antigen

CA-125 ovarian

CA-25,27 breast

HER 2 NEU breast tissue needed


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Oncology

Lab tests for cancer

Liverfunction tests

CBC with diff

Renal function tests

PET scan looks formetastasis using aradioactive glucose solution

PT, PTT, Fibrinogen, Fibrin levels


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Oncology

Lab tests for cancer Pathology slide of tumor:(Should be kept fora period of years)

Determines type of tumor Source of tumor Aggression of tumor whetherfast growing,

differentiated, or non-differentiated

Used to determine tumorgrowth factors andsusceptibility to certain chemotherapies


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Oncology

Chemotherapy Prevention chemotherapy forhigh risk

patients, precancerous lesions, orhistory of

cancer Antioxidants, vitamins

Aldara cream 3x weekly forprecancerousskin lesions

Aspirin

Protease inhibitors


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Oncology

Chemotherapy - typically started aftersurgical dissection of tumor, unless the tumoris

non-operative

Usually given by a long term venous accessdevice, i.e.PICC line, implanted ports, ordirect

catheratization to the tumor.

Chemotherapy is usually potent and horribly

scarring on normal veins


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Oncology

Chemotherapy Biochemotherapy used as in-patient oroutpatient

settings forcancer, MS, and viral treatments:

Alpha interferon (IFN)- Alpha 2a,

Roferon, Intron-A-

used forleukemias, AIDS, Hep-C

Beta interferon Beta 1b

used forrenal carcinoma, melanoma,AIDS, MS, Hepatitis A, B


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Oncology

Chemotherapy/Biochemotherapy

Interleukin I (IL-1)

Interleukin 2 (IL-2), Proleukinstimulates

growth of T-cells and NK cytotoxic cells used investigationally formelanoma in StageII

to StageIV cases on a monthly basis with a 80%

non-recurrencerate


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Oncology


Tumor necrosis factor (TNF) selectively targetsabnormal cells, in nature is produced by NK cells


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Oncology


Vaccines

HPV vaccine forcervical cancer

Melanoma vaccine- forstageII only at this time,ormalignant melanoma


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Oncology

Chemotherapy/Biochemotherapy Monoclonalantibodies used fortreatment of cancer,rheumatoid arthritis, transplants, and otherautoimmunediseases. Can be used to stimulateimmuneresponse orsuppress it.

Rituximab Treatment ofCD20 positive non-Hodgkins B-cell lymphoma

Gentuzumab treatment ofCD33 positive AMLin first relapse in patients who are not candidates

forreg. chemo.


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Oncology Chemotherapy/Biochemotherapy Monoclonal

antibodies

Adalimumab Humira

new treatment forsevererheumatoid arthritis,given s.qevery otherweek

Alemtuzumab Campath

- treatment of B-cell lymphoma who have failedtraditional chemotherapy with fludarabine

BasilixamabSimulect- immunosuppressive monoclonal antibody forrenal transplants


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Oncology

Chemotherapy Alkylating agents

Bisulfan oral

Carboplatin (CBDCA) IV

Chlorambucil (leukeran) oral Cisplatin IV

Cyclophosphamide(Cytoxan)IV orPO

Melphalan (Alkeran) oral

Ifosfamide IV

Thiotepa IV orPO


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Oncology

Chemotherapy/Antibioticsgiven IV as chemotherapy

Adriamycin (Doxirubicin)

Bleomycin

Dactinomycin

Daunorubicin (actinomycin D)

Idarubicin (idomycin)

Mitomycin C

Mithramycin


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Oncology

Chemotherapy anti-metabolites Cytorubine (Cytosar) IV

Floxuridine (FUDR) IA orSQ

Flourourcil (5FU) IV

Fludara IV

Hydroxyurea PO orIV

Methotrexate IV orIM

6MP PO IRESSA PO

Xeloda PO


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Oncology Chemotherapy- Hormones

Progestins uterine cancer

Estrogens

Testosterone - myelodysplasias Anti-hormones block hormonal activity inhormone sensitive cancers:

Leupron

Eulexin Tamoxifen/Nolvadex

Arimedex/Arista


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Oncology Chemotherapy Plant alkaloids

Vinblastine (Velban) IV

Vincristine (Oncovin) IV

Vindesine IV

Eldisine IV

The first doses of this are usually given in ahospital setting, are vesicants, and neurotoxic.

Nurses must wearprotective gear!


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Which of the following are appropriate protective gear for

the nurse when hanging chemotherapy?

Splash

goggles

Latexgloves

Rubbergloves

Paper

gown

Special

biohazardba

gsf..

Lead

apron

0% 0% 0%0%0%0%

1. Splash goggles

2. Latex gloves

3. Rubbergloves

4. Papergown

5. Special biohazardbags fordisposal

6. Lead apron


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Oncology

Chemotherapy Antimitotics Dacarbazine (DTIC Dome) IV

Leukovorin PO orIV

Paclitaxol (Taxol) IV

Topotecan IV

Gemzar IV

Docetaxol IV

Camptothecan (CPT-11) IV

Taxotere (Ormaplatin) IV


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Oncology

Side effects of Chemotherapy Alopecia Fatigue Anemia

Leukopenia Thrombocytopenia Always Nausea,Vomiting, Diarrhea Neurotoxicity & neuropathies

Capillary leakage Headaches Fluid andelectrolyte imbalances


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Oncology

Side effects of Chemotherapy Anorexia change in taste buds Back aches Joint aches

Blood clots Oral mucositis (reduced significantly by L-

glutamine amino acids orally)

Supra opportunistic infections

Septic DIC Tumorlysis syndrome Edema orpulmonary edema


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Oncology

Chemotherapy Nursing Interventions Evaluate and assess sites of chronic chemotherapy,

ports, veins, skin area

AccurateI & Os

Monitorforfluid overload ordehydration Monitorlab electrolytes before and afterinfusion

MonitorBUN andCreatinine

MonitorCBC with differential during the time ofNadir

MonitorPT, PTT


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Oncology

Cancer Nursing Interventions

Nutritional assessment and weights

Dentition oral checks

Monitorforsigns of suprainfection, low gradetemperatures, rash, etc

Vital signs before, during, and aftertreatments

Assess bowel status Assess pain level


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Oncology

Cancer Nursing Interventions

Educate patients and family members:

sideeffects of treatments, meds

care of port andIV sites

oral hygiene

symptoms to report, i.e. shortness of breath orsigns

of infection Increase fluid intake, suck on hard candies to reduce

chemotherapy metallic tastes


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Oncology

Nursing Diagnoses Disturbance in selfesteem, body image

Altered nutrition, less than body requirements

Risk forfluid volumeexcess ordeficit Impaired skin integrity

Pain, chronic

Decreased cardiac output

Self-caredeficit Sexual dysfunction


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Oncology

Nursing Diagnoses Alteration in tissue perfusion

Knowledgedeficit

Risk forinjury Impaired physical mobility

Sensory perception alterations

Alterations in bowel patterns

Alterations in mucous membranes

Anxiety and Fear


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Oncology

Nursing Diagnoses Depression

Grief

Respiratory compromise

Ineffective coping

Spiritual distress

Impaired social interactions Sleep pattern disturbance

Altered family roles


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Oncology

Pharmacological interventions Megace, Marinol forappetite stimulation Premedications fornausea, vomiting, edema,

headaches: usually on the protocol forchemo

Antiemetics;Zofran 24 hourcontrol

Tigan, Kytril, ativan, anzamet, Compazine,benadryl, reglan

Corticosteroids


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Oncology

Pharmacological interventions Analgesics IVelectrolytes and fluidreplacement Stool softeners to counteract constipation from

opioids GSF forWBCs Epogen/Procrit for anemia Leukine/Prokine forleukopenia

Neupogen forneutrophilia Neumega forthrombocytopenia Diuretics foredema


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Oncology

Non-Pharmacological interventions

Massage

Reflexology

AccupunctureMusical therapy

Prayer

MeditationDiversional acitivities

Dietary counselling


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Oncology

Radiation therapy

All types of cells are injured ordestroyedby concentratedradiation. Rapidly dividing

cells are the most sensitive.


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Oncology Radiation therapy

Types :Gamma knife

Local beam treatment

Local seedingARC stereotactic

Radioimmunotherapy

Fractionation

Total body irradiationParticle beam therapy, i.e. proton

orneutron therapy


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Oncology

Radiation therapy side effects

Sideeffects depend on the amount and areabeing irradiated

Fatigue Nausea and vomiting

Mild anemia

Leukopenia

Diarrhea

Pain


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Oncology

Radiation therapy side effects: Erythema/burns

Fatigue

Pneumonitis Esophagitis

Dysphasia

(Pleaseeducate yourpatients on

these as doctors are notoriously

bad at pre-educating theirpatients).


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What side effects of radiation therapy would youexpect to see in a 48-year-old woman with breast

cancer?

Debilit

atingfatigu

e

Mucositis

hairloss

nausea

andvomiting

0% 0%0%0%

1. Debilitating fatigue

2. Mucositis3. hair loss

4. nausea and

vomiting


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What are some of the educational issues for

patients receiving radiation treatment

Burns

Anemia

Skincare

Diet

Allo

fthe

abo

ve

0% 0% 0%0%0%

1. Burns

2. Anemia

3. Skin care

4. Diet

5. All of the above


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Oncology

Nursing interventions for radiation TX

Assess incidence and severity of sideeffects

Maximizeradiation protection, all wastes will be

radioactive if isotopes are injected

Shielding forstaff


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Oncology

Malignant Lymphomas 2 types Hodgkin's Lymphoma most common cancerin

10 to 20 yearolds (young adults). Associated withan inflammatory process related to +EBV/mono

infection. Diagnosis: Classic Reed-Steinberg cell with two

mirrored nuclei, CT scan

Symptoms: Extreme fatigue, enlarged lymph nodesthat are painless. May progress to weight lossfevers, night sweats


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Oncology

Malignant Lymphomas 2 types

Hodgkin's Lymphoma

Treatment combinedradiation andchemotherapy, stem cell transplants if

resistant type orrecurring

85% curable

(90% in some institutions)


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Oncology


Non-Hodgkins Lymphoma 3 times morecommon than Hodgkins lymphoma, can eitherbe

T-cell lymphomas, orB-cell lymphomas

Can be low grade orhigh gradedisease. B-celllymphomas = 50% and usually are more aggressive

tumors. Since they grow faster, they are also more

sensitive to radiation and chemotherapy


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Oncology Malignant Lymphomas 2 types

Non-Hodgkins Lymphoma Diagnosis: bone marrow biopsy, CT scan,

lymphoma panel with CD markers

Symptoms- adenopathy, spleenomegaly with vague

abdominal pain, back pain, and since immunity B orT-cell function is affected- the patient is more proneto infections.Subcutaneous T-cell lymphoma is aclassic discoidrash on the upperbody and trunk thatdoes not respond to steroids orcreams.

NHL can progress rapidly to leukemia if untreated.


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Oncology


Non-Hodgkins Lymphoma

Treatments: Monoclonal antibodies,chemotherapy with Fludara/Fludarabine,

radiation therapy, and bone marrow implants


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Leukemiahematopoeitic cancerof thestem cells. These stem cells proliferate into

non-functional immature white cells.

More children get leukemia than any othertype of cancerand it is the#1 cause ofdeath

in children.

Anyone can get leukemia at any age.

Oncology


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Oncology

Leukemia -4 types

Acute lymphoblastic leukemia (ALL)

Acute myelogenous leukemia (AML) Chronic Lymphocytic leukemia (CLL)

Chronic myelogenous leukemia (CML)

Anagram ALLAniMals are CLearLy

CaMeLs


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Oncology Leukemia ALL suspected cause is a T-cell virus

(HTLV-1) 85% is seen in children, 25% in adults

30-to-40 y.o.

Diagnosis: peripheral blood smearafterabnormally high white count, bone marrow biopsy

shows lymphoblasts >50%m may havedecrease in

platelets.Lumbarpuncture to determineCSFinvolvement


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Oncology Leukemia ALL Symptoms fatigue, anorexia, malaise, weight

loss, bleeding, infections, headaches, adenopathy,spleenomegaly, gingival hypertrophy,hepatomegaly, bone orjoint pain

Treatment: completeresponse is a bone marrowaspirate with < 5% blasts.Chemotherapy vincristine, prednisone, danorubicin, methotrexate,

Maintenance therapy 6 weeks of

6-mercaptopurine and methotrexate low dosetherapy


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Oncology

Leukemia AML more common in patientswith chromosomal genetic disorders, exposure tobenzene orradiation. Use of alkylating agents forbreast, ovarian, ormyeloma are associated with alatermalignancy of this type.

Symptoms- are likeALL with the additions ofanemia, thrombocytopenia, visual disturbances,epistaxis (nosebleeds), headache with vomiting,dysphagia, papilladema, menorrhagia (lots more

bleeding problems)


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Oncology Leukemia AML

Diagnosis:peripheral blood smearshowsAuerbodies (rods), platelets less than

20,000/mm3,bone marrow biopsy

Prognosis poorprognosis if patient hasalready receivedradiation orchemotherapy,orhas a WBC >100,000


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Oncology

Leukemia AML

Treatment: Cytaribine chemotherapy incombination therapy with Danorubicin or

doxirubicin, works 65% of the time. Bone marrow transplant orstem cell

transplant.


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Oncology

Leukemia CLL staged 0-5

chronic diseases have more mature cells, majorityof CLL is B-cellproliferation 95%. Only 5%

are T-cells, more common in people withautoimmunediseases, i.e.SJogrens, SLE,

hemolytic anemia

Symptoms: skin andrespiratory infections,

fatigue, thrombocytopenia, anemia,spleenomegaly


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Oncology

Leukemia CLL Diagnosis-peripheral blood smear, bone

marrow biopsy

Treatments: Gleevac drug of choice;chemotherapy in combinations,

spleenectomy, radiation therapy to spleen,

bone marrow transplant, stem cell

transplants


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Oncology Leukemia CML (last is theCaMeL)

- More common afterradiation exposure, benzeneexposure, less common than the othertypes ofleukemia, and occurs most often between 50-60 y.o.

Diagnosis: hallmark is the presence of the

Philadelphia Chromosome, Chromosome#22 ismissing part of the long arm which is translocated toChromosome#9. This is present in 95% of thosepatients with CML.

WBC >100,000 with proliferation of all types ofmature and immature white cells.

Bone marrow biopsy


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OncologyLeukemia CML Symptoms: same as otherleukemias with chronic

fever, sternal tenderness anddyspnea usuallydue to severe anemias

Treatments: chemotherapy with Bisulfan andhydroxurea, othercombination chemos,

Interferon alpha 2b to suppress theexpression ofthePhiladelphia chromosome.

Bone marrow transplant orstem cells


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Oncology

Bone marrow and stem cell implantsNew treatments for:Acute myelogenous leukemias (AML)

Acute lymphoblastic leukemias (ALL)

Myelodysplasia syndromes (MDS)Chronic myelogenous leukemias that do not respond tochemotherapy (CML)

Blast crisis

Pediatric acute leukemiasNon-Hodgkins lymphoma

Large B-Cell lymphoma

Multiple myelomas


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Bone marrow and stem cell implants


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Oncology

Bone marrow and stem cell implants Procedure= multiple punctures Marrow acquisition from donororwhen patient

is in remission, or stem cells from umbilicalblood of a matching sibling orfamily member

Marrow is filtered to purge tumorcells, fat andbone particles, then place in a blood bag forcryopreservation.


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Oncology Bone marrow and stem cell implantsPreparing Recipient:

Marrow recipient is given high dose chemotherapy

alone orin combination with radiation to suppressimmune system, open spaces in the marrow, andkill remaining cancercells.

Bone marrow is thawed and infused through a

central venous catheter


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Oncology Bone marrow and stem cell implantsPreparing Recipient:

Stem cells are infused afterthawing Post-procedure:

Patient is supported through the period ofaplasia,10 to 30days, while in reverse isolation and ongraft immunosuppressants,

Observed forsigns ofGraft-versus-host disease

and/orinfection


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Oncology

The waves of the future:

Stem Cell Research

Oncogene therapy now that cancercells are

being genetically tagged, we can tell which growthfactors are present, and which enzymes turn offthe gene. Soon all gene markers will have a pillthat matches theenzyme, i.e.IRESSA is atyramine kinase inhibitor, and stops the tumors

growth that use tyramine kinase


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Oncology

Stem Cell Induction there are new drugs outforstem cell induction to immunosuppress the

patient, even in deadly cancers, i.e. Multiple

Myeloma.Recently, the combination oflenalidomide(Revalamid), bortezomib

(Velcade) anddexamethasone produced a

98

%responserate in patients


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Oncology

The waves of the future:

Cancer vaccines

Oncology is the science of cancerandtreatment of all cancerpatients. It is one ofthe most demanding andrewarding fields in

medicine.

The future is open fora cure.

O l


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Oncology

Oncology Lecture[1]

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Transcript of Oncology Lecture[1]