Oncology Dead Man’s partyDead Man’s partyOncology Dead Man’s partyDead Man’s party

Biology of abnormal cellsCancer grading and stages

Cancer statisticsChemotherapeutic agents

Radiation treatmentsBone Marrow and Stem Cell

transplantsOnco-gene therapy

Biology of abnormal cellsCancer grading and stages

Cancer statisticsChemotherapeutic agents

Radiation treatmentsBone Marrow and Stem Cell

transplantsOnco-gene therapy

Oncology Objectives• 1. Identify the different phases of cancer

cell replication.• 2. Compare the features of a benign versus

malignant tumor• 3. Recognize the TNM stage and grading

system of cancer tumors.• 4. Discuss the role of oncogenes and

suppressor genes in cancer development.• 5. Identify behaviors with corresponding

primary and secondary nursing prevention for risks of cancer development

• 6. Recognize the different classes of chemotherapies.

• 7. Create appropriate nursing interventions for a case study of a patient with cancer.

Oncology Objectives• 8. Identify appropriate testing for cancer

patients.• 9. Recognize signs and symptoms of

chemotherapy side effects.• 10. Recognize signs and symptoms of radiation

therapy.• 11. Prioritize nursing interventions for a patient

with neutropenia.• 12. Prioritize nursing interventions for a patient

with thrombocytopenia.• 13. Prioritize nursing interventions for a patient

receiving bone marrow or stem cell transplant.

Oncology Objectives

• 14. List 4 risk factors for the development of leukemia.

• 15.Compare Leukemia and Lymphoma pathophysiology, etiology and clinical manifestations.

Cellular Review

• Evolve 3D Cellular Differentiation on web site

Oncology• Biology of abnormal cancer cells• They have continuous or inappropriate,

usually faster growth or larger growth patterns

• They have no specific morphology and often do not resemble their parent cells = anaplastic

• They do not respond to signals for apoptosis = programmed cell death

Oncology• Biology of abnormal cancer cells• Have a large nuclear – cytoplasmic

ratio; the nucleus may occupy most of the cell area

• They lose some or all of their normal cell functions

• They do not make fibronectin, and thus cannot connect easily and break off easily

Oncology

• Biology of abnormal cancer cells• They are able to migrate throughout the

body = metastasis• They invade other tissues and types of

cells.• They are not controlled by contact• They have more or less chromosomes

than the parent cells = aneuploidor a mutation of the genes

Oncology

• Cancer development• Initiation – there are many

theories as to when the genes in the cells are damaged, maybe in utero, from physical or chemical exposure, latent oncogenes, viruses, or a lack of suppressor genes from our parents, and at this point the cell is not dividing.

Oncology• Skin cells

Oncology• Cancer development• Promotion - the stage when the

abnormal cell starts to divide, may be stimulated by environmental changes, hormones, drugs, or irritants

Oncology• Cancer development• Progression – the phase when

the abnormal cells have continued to grow into a Primary tumor, may produce angiogenesis factors which supply blood and vascular nourishment to the tumor. The tumor may have subcolonies of cells with different genes and features

Oncology• Cancer development• Metastasis

the movement of cancer cells into other organs of the body, thus creating new tumor sites.

Oncology• Cancer grading and staging• Cancer is graded upon the resemblance to

normal cells = G(The higher the 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 of metastasis = M• Numbers of the stage range from x = none to 3 or 4 for each letter

Oncology• Is this a high grade or low grade

cancer?• Case study

Julie has a breast lump in her right breast, and has also found one in her right armpit. Biopsy and lumpectomy were performed. The tumor was graded G3, T2, N2, M1.

Is this a high grade or low grade cancer?

0%0%

1. High2. Low

Oncology• Julie opted to have a lymphectomy

of her right arm lymph nodes, and started radiation treatment right away. Her doctor also suggested that she start Adriamycin IV chemotherapy to get any cells that the radiation might miss.

Oncology• Cancer Risks• #1 = advancing age• #2 = smoking tobacco• Hormones – Prempro caused a

substantial increase in breast cancer on the HERS trial

• Genetic inheritance of oncogenes and autoimmune diseases

• Environmental exposure• Excessive intake of dietary fats

Oncology• Cancer risks• High alcohol consumption• Low dietary vegetables and fiber

(sources of antioxidants)• Previous Viral infections:

Hepatitis B or CHerpes virusesPapilloma viruses (HPV)Retrovirus HTLV –I

Oncology

• Types of cancer cells are named for their site of origin:

• Adenocarcinoma• Carcinoma in situ (CIS)• Squamous• Basal cell• Astrocytomas• Melanomas• Sarcomas• Lymphomas

Oncology

• Symptoms of Cancer• Cachexia – weight loss,unexplained• Anorexia• Anemia• Impaired immune response• Pain – when the cancer is large enough

to compress nerves or organs• Lymphadema – when the tumor blocks

lymph or circulatory flow• Motor or sensory deficits

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 event

and there is no way to prevent it.”– B. “Because this disease is inherited as a

dominant trait, your children have a 50% risk for developing it.”

– C. “Cigarette smoking is the main cause of this disease, 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 the amount of regular aerobic exercise.”

Oncology

• Cancer statistics• The top four cancers found in the

United States are:• Lung• Breast• Prostate• Colorectal

C

Oncology• Cancer statistics• Prostate cancer is the most

common site of cancer and the 2nd most common cause of cancer death in the United States

• The first cause of death in males is Lung Cancer

Oncology

Oncology•Cancer statistics• Lung cancer has annual

new cases (incidence) of 173,770 people per year: 93,110 males and 80,660 females

• Annual mortality: 160,440 per year consisting of 92,000 males and 68,510 females

Oncology

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

lung cancer • This is the leading cause of cancer

death in both men and women

• There are more deaths from lung cancer than prostate, breast, and colorectal cancers combined

Oncology• Cancer statistics• Risks for lung cancer:• Smoking (75-80% of cases)• Occupational exposure• Nutrition/Diet• Genetic factors

Oncology• Cancer statistics

• Prostate cancer is number two cause of cancer in men

• Breast Cancer is number two cause of cancer in women

• Most common non-malignant or non-fatal cancer is non-melanoma type skin cancers

Oncology• The client says that she has heard that the

origin of most cancers is “genetic”. What is the nurse’s best response?– A. “The development of most cancers is

predetermined 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.”

Oncology• Lab tests for cancer• Ultrasounds to determine size• CT scan with contrast– the golden

standard• Genetic markers – BRCA 1 and BRCA 2• Tumor markers:

CEA – general carcinogenic antigen

PSA – prostate antigenCA-125 – ovarianCA-25,27 – breastHER 2 NEU – breast tissue needed

Oncology

• Lab tests for cancer• Liver function tests• CBC with diff• Renal function tests• PET scan – looks for metastasis

using a radioactive glucose solution

• PT, PTT, Fibrinogen, Fibrin levels

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

• Determines type of tumor• Source of tumor• Aggression of tumor – whether fast

growing, differentiated, or non-differentiated

• Used to determine tumor growth factors and susceptibility to certain chemotherapies

Oncology• Chemotherapy• Prevention chemotherapy – for

high risk patients, precancerous lesions, or history of cancer

• Antioxidants, vitamins• Aldara cream 3x weekly for

precancerous skin lesions• Aspirin• Protease inhibitors

Oncology• Chemotherapy - typically started

after surgical dissection of tumor, unless the tumor is non-operative

• Usually given by a long term venous access device, i.e. PICC line, implanted ports, or direct catheratization to the tumor.

• Chemotherapy is usually potent and horribly scarring on normal veins

Oncology• Chemotherapy• Biochemotherapy – used as in-patient or

outpatient settings for cancer, MS, and viral treatments:

Alpha interferon – (IFN)- Alpha 2a,Roferon, Intron-A-used for leukemias, AIDS, Hep-CBeta interferon – Beta 1b

– used for renal carcinoma, melanoma, AIDS, MS, Hepatitis A, B

Oncology• Chemotherapy/Biochemotherapy• Interleukin I (IL-1)• Interleukin 2 (IL-2), Proleukin–

stimulates growth of T-cells and NK cytotoxic cells

• – used investigationally for melanoma in Stage II to Stage IV cases on a monthly basis with a 80% non-recurrence rate

Oncology• Chemotherapy/Biochemotherapy• Tumor necrosis factor (TNF) –

selectively targets abnormal cells, in nature is produced by NK cells

Oncology• Chemotherapy/Biochemotherapy• Vaccines

HPV vaccine for cervical cancerMelanoma vaccine - for stage II only at this time, or malignant melanoma

Oncology• Chemotherapy/Biochemotherapy

Monoclonal antibodies – used for treatment of cancer, rheumatoid arthritis, transplants, and other autoimmune diseases. Can be used to stimulate immune response or suppress it.Rituximab – Treatment of CD20 –positive non-Hodgkins B-cell lymphomaGentuzumab – treatment of CD33 positive AML in first relapse in patients who are not candidates for reg. chemo.

Oncology• Chemotherapy/Biochemotherapy

Monoclonal antibodies

• Adalimumab – Humira –new treatment for severe rheumatoid arthritis, given s.q every other week

• Alemtuzumab – Campath- treatment of B-cell lymphoma who have failed traditional chemotherapy with fludarabine

• Basilixamab – Simulect - immunosuppressive monoclonal antibody for renal transplants

Oncology• Chemotherapy – Alkylating agents• Bisulfan oral• Carboplatin (CBDCA) IV• Chlorambucil (leukeran) oral• Cisplatin IV• Cyclophosphamide(Cytoxan) IV or PO• Melphalan (Alkeran) oral• Ifosfamide IV• Thiotepa IV or PO

Oncology

• Chemotherapy/ Antibioticsgiven IV as chemotherapy

• Adriamycin (Doxirubicin)• Bleomycin• Dactinomycin• Daunorubicin (actinomycin D)• Idarubicin (idomycin)• Mitomycin C• Mithramycin

Oncology• Chemotherapy – anti-metabolites• Cytorubine (Cytosar) IV• Floxuridine (FUDR) IA or SQ• Flourourcil (5FU) IV• Fludara IV• Hydroxyurea PO or IV• Methotrexate IV or IM• 6MP PO• IRESSA PO• Xeloda PO

Oncology• Chemotherapy- Hormones• Progestins – uterine cancer• Estrogens• Testosterone - myelodysplasias• Anti-hormones – block hormonal

activity in hormone sensitive cancers:• Leupron• Eulexin• Tamoxifen/Nolvadex• Arimedex/Arista

Oncology• Chemotherapy – Plant alkaloids• Vinblastine (Velban) IV• Vincristine (Oncovin) IV• Vindesine IV• Eldisine IV

• The first doses of this are usually given in a hospital setting, are vesicants, and neurotoxic. Nurses must wear protective gear!

Which of the following are appropriate protective gear for the nurse when hanging

chemotherapy?

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

1. Splash goggles2. Latex gloves3. Rubber gloves4. Paper gown5. Special

biohazard bags for disposal

6. Lead apron

Oncology

• Chemotherapy –Antimitotics• Dacarbazine (DTIC – Dome) IV• Leukovorin PO or IV• Paclitaxol (Taxol) IV• Topotecan IV• Gemzar IV• Docetaxol IV• Camptothecan (CPT-11) IV• Taxotere (Ormaplatin) IV

Oncology• Side effects of Chemotherapy• Alopecia• Fatigue• Anemia• Leukopenia• Thrombocytopenia• Always – Nausea,Vomiting, Diarrhea • Neurotoxicity & neuropathies• Capillary leakage• Headaches• Fluid and electrolyte imbalances

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• Tumor lysis syndrome• Edema or pulmonary edema

Oncology• Chemotherapy Nursing Interventions• Evaluate and assess sites of chronic

chemotherapy, ports, veins, skin area• Accurate I & O’s• Monitor for fluid overload or dehydration• Monitor lab electrolytes before and after

infusion• Monitor BUN and Creatinine• Monitor CBC with differential during the

time of Nadir• Monitor PT, PTT

Oncology

• Cancer Nursing Interventions• Nutritional assessment and weights• Dentition – oral checks• Monitor for signs of suprainfection, low

grade temperatures, rash, etc…• Vital signs before, during, and after

treatments• Assess bowel status• Assess pain level

Oncology• Cancer Nursing Interventions• Educate patients and family members:• side effects of treatments, meds• care of port and IV sites• oral hygiene• symptoms to report, i.e. shortness of

breath or signs of infection• Increase fluid intake, suck on hard candies

to reduce chemotherapy metallic tastes

Oncology• Nursing Diagnoses• Disturbance in self esteem, body image• Altered nutrition, less than body

requirements• Risk for fluid volume excess or deficit• Impaired skin integrity• Pain, chronic• Decreased cardiac output• Self-care deficit• Sexual dysfunction

Oncology• Nursing Diagnoses• Alteration in tissue perfusion• Knowledge deficit• Risk for injury• Impaired physical mobility• Sensory perception alterations• Alterations in bowel patterns• Alterations in mucous membranes• Anxiety and Fear

Oncology• Nursing Diagnoses• Depression • Grief• Respiratory compromise• Ineffective coping• Spiritual distress• Impaired social interactions• Sleep pattern disturbance• Altered family roles

Oncology• Pharmacological interventions• Megace, Marinol – for appetite

stimulation• Premedications for nausea, vomiting,

edema, headaches: usually on the protocol for chemoAntiemetics;Zofran – 24 hour controlTigan, Kytril, ativan, anzamet, Compazine, benadryl, reglanCorticosteroids

Oncology• Pharmacological interventions• Analgesics• IV electrolytes and fluid replacement• Stool softeners to counteract

constipation from opioids• GSF for WBC’s• Epogen/Procrit for anemia• Leukine/Prokine for leukopenia• Neupogen for neutrophilia• Neumega for thrombocytopenia• Diuretics for edema

Oncology• Non-Pharmacological interventions

– Massage– Reflexology– Accupuncture– Musical therapy– Prayer– Meditation– Diversional acitivities– Dietary counselling

Oncology

• Radiation therapy• All types of cells are injured or

destroyed by concentrated radiation. Rapidly dividing cells are the most sensitive.

Oncology• Radiation therapy• Types :Gamma knifeLocal beam treatmentLocal seedingARC – stereotacticRadioimmunotherapyFractionationTotal body irradiationParticle beam therapy, i.e.

proton or neutron therapy

Oncology• Radiation therapy side effects• Side effects depend on the amount

and area being irradiated• Fatigue• Nausea and vomiting• Mild anemia• Leukopenia• Diarrhea • Pain

Oncology • Radiation therapy side effects:• Erythema/burns• Fatigue• Pneumonitis• Esophagitis• Dysphasia

• (Please educate your patients on these as doctors are notoriously bad at pre-educating their patients).

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

cancer?

0% 0%0%0%

1. Debilitating fatigue

2. Mucositis3. hair loss4. nausea and

vomiting

What are some of the educational issues for patients receiving radiation treatment

0% 0% 0%0%0%

1. Burns2. Anemia3. Skin care4. Diet5. All of the above

Oncology• Nursing interventions for radiation

TX• Assess incidence and severity of side

effects• Maximize radiation protection, all

wastes will be radioactive if isotopes are injected

• Shielding for staff

Oncology• Malignant Lymphomas – 2 types• Hodgkin's Lymphoma – most common

cancer in 10 to 20 year olds (young adults). Associated with an inflammatory process related to +EBV/mono infection.

• Diagnosis: Classic Reed-Steinberg cell with two mirrored nuclei, CT scan

• Symptoms: Extreme fatigue, enlarged lymph nodes that are painless. May progress to weight loss fevers, night sweats

Oncology• Malignant Lymphomas – 2 types• Hodgkin's Lymphoma• Treatment – combined radiation

and chemotherapy, stem cell transplants if resistant type or recurring

• 85% curable • (90% in some institutions)

Oncology• Malignant Lymphomas – 2 types• Non-Hodgkins Lymphoma – 3 times

more common than Hodgkin’s lymphoma, can either be T-cell lymphomas, or B-cell lymphomas

• Can be low grade or high grade disease. B-cell lymphomas = 50% and usually are more aggressive tumors. Since they grow faster, they are also more sensitive to radiation and chemotherapy

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 or T-cell function is affected- the patient is more prone to infections. Subcutaneous T-cell lymphoma is a classic discoid rash on the upper body and trunk that does not respond to steroids or creams.

• NHL can progress rapidly to leukemia if untreated.

Oncology• Malignant Lymphomas – 2 types• Non-Hodgkins Lymphoma• Treatments: Monoclonal

antibodies, chemotherapy with Fludara/Fludarabine, radiation therapy, and bone marrow implants

• Leukemia– hematopoeitic cancer of the stem cells. These stem cells proliferate into non-functional immature white cells.

• More children get leukemia than any other type of cancer and it is the #1 cause of death in children.

• Anyone can get leukemia at any age.

Oncology

Oncology• Leukemia -4 types

• Acute lymphoblastic leukemia (ALL)• Acute myelogenous leukemia (AML)• Chronic Lymphocytic leukemia (CLL)• Chronic myelogenous leukemia (CML)• Anagram – ALL AniMals are CLearLy

CaMeLs

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 smear after abnormally high white count, bone marrow biopsy shows lymphoblasts >50%m may have decrease in platelets. Lumbar puncture to determine CSF involvement

Oncology• Leukemia –ALL• Symptoms – fatigue, anorexia,

malaise, weight loss, bleeding, infections, headaches, adenopathy, spleenomegaly, gingival hypertrophy, hepatomegaly, bone or joint pain

• Treatment: complete response is a bone marrow aspirate with < 5% blasts. Chemotherapy – vincristine, prednisone, danorubicin, methotrexate,

• Maintenance therapy – 6 weeks of • 6-mercaptopurine and methotrexate

low dose therapy

Oncology• Leukemia – AML – more common in

patient’s with chromosomal genetic disorders, exposure to benzene or radiation. Use of alkylating agents for breast, ovarian, or myeloma are associated with a later malignancy of this type.

• Symptoms- are like ALL with the additions of anemia, thrombocytopenia, visual disturbances, epistaxis (nosebleeds), headache with vomiting, dysphagia, papilladema, menorrhagia (lots more bleeding problems)

Oncology• Leukemia – AML• Diagnosis: peripheral blood

smear shows Auer bodies (rods), platelets less than 20,000/mm3,

bone marrow biopsy• Prognosis – poor prognosis if

patient has already received radiation or chemotherapy, or has a WBC >100,000

Oncology• Leukemia – AML• Treatment: Cytaribine

chemotherapy in combination therapy with Danorubicin or doxirubicin, works 65% of the time.

• Bone marrow transplant or stem cell transplant.

Oncology• Leukemia – CLL – staged 0-5 • chronic diseases have more mature

cells, majority of CLL is B-cell proliferation – 95%. Only 5% are T-cells, more common in people with autoimmune diseases, i.e. SJogren’s, SLE, hemolytic anemia

• Symptoms: skin and respiratory infections, fatigue, thrombocytopenia, anemia, spleenomegaly

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

Oncology• Leukemia – CML (last is the CaMeL)

- More common after radiation exposure, benzene exposure, less common than the other types of leukemia, and occurs most often between 50-60 y.o.

• Diagnosis: hallmark is the presence of the Philadelphia Chromosome, Chromosome #22 is missing part of the long arm which is translocated to Chromosome #9. This is present in 95% of those patients with CML.

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

• Bone marrow biopsy

OncologyLeukemia – CML• Symptoms: same as other leukemias

with chronic fever, sternal tenderness and dyspnea – usually due to severe anemias

• Treatments: chemotherapy with Bisulfan and hydroxurea, other combination chemos,

• Interferon alpha 2b to suppress the expression of the Philadelphia chromosome.

• Bone marrow transplant or stem cells

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 to chemotherapy (CML)Blast crisisPediatric acute leukemiasNon-Hodgkins lymphomaLarge B-Cell lymphomaMultiple myelomas

Bone marrow and stem cell implants

Oncology• Bone marrow and stem cell

implants• Procedure= multiple punctures• Marrow acquisition from donor or

when patient is in remission, or stem cells from umbilical blood of a matching sibling or family member

• Marrow is filtered to purge tumor cells, fat and bone particles, then place in a blood bag for cryopreservation.

Oncology• Bone marrow and stem cell

implantsPreparing Recipient:• Marrow recipient is given high dose

chemotherapy alone or in combination with radiation to suppress immune system, open spaces in the marrow, and kill remaining cancer cells.

• Bone marrow is thawed and infused through a central venous catheter

Oncology• Bone marrow and stem cell

implantsPreparing Recipient:• Stem cells are infused after thawing• Post-procedure:• Patient is supported through the period

of aplasia, 10 to 30 days, while in reverse isolation and on graft immunosuppressants,

• Observed for signs of Graft-versus-host disease and/or infection

Oncology• The waves of the future:• Stem Cell Research• Oncogene therapy – now that cancer

cells are being genetically tagged, we can tell which growth factors are present, and which enzymes turn off the gene. Soon all gene markers will have a pill that matches the enzyme, i.e. IRESSA is a tyramine kinase inhibitor, and stops the tumors growth that use tyramine kinase

Oncology• Stem Cell Induction – there are new

drugs out for stem cell induction to immunosuppress the patient, even in deadly cancers, i.e. Multiple Myeloma. Recently, the combination of lenalidomide(Revalamid), bortezomib (Velcade) and dexamethasone produced a

98% response rate in patients

Oncology• The waves of the future: • Cancer vaccines• Oncology is the science of cancer

and treatment of all cancer patients. It is one of the most demanding and rewarding fields in medicine.

• The future is open for a cure.

Oncology