Cancer Management
Jill C. Cash and Cheryl A. Glass
Definition
A.Cancer is a disease in which cells in the body divide in an abnormal fashion, invading normal cells and tissues. These abnormal cells proliferate and spread to other parts of the body by means of the blood and of the lymphatic systems. Cancer cells generally begin in one area of the body, causing cancer
in that particular organ of the body. However, with invasion of other tissues/organs, the cancer cells can spread to other organs, causing cancer
in other parts of the body.
Incidence
There are over 100 different types of cancer. The different cancers are broken down into five broad categories.
A.Carcinoma: Cancer of the skin and/or tissue covering major internal organs.
B.Sarcoma: Cancer of the bone, cartilage, muscle, fat, connective tissue, and blood vessels.
C.Leukemia: Cancer of the bone marrow and blood forming tissues.
D.Lymphoma and myeloma: Cancer of the immune system.
E.Central nervous system: Cancer of the brain and spinal cord system.
F.It has been estimated that in the year 2014 there were approximately 1,665,540 new cases of cancer reported, and approximately 585,720 cancer-related deaths expected in the United States. The cancers that are expected to be the most frequent include the following:
1.Bladder cancer.
2.Breast cancer.
3.Lung cancer.
4.Melanoma.
5.Colon/rectal cancer.
6.Non-Hodgkin’s lymphoma.
7.Endometrial cancer.
8.Pancreatic cancer.
9.Kidney (renal cell) cancer.
10.Prostate cancer.
11.Leukemia.
12.Thyroid cancer.
The most common cancers in women are breast, lung, and colorectal cancers. The most common cancers in men are prostate, lung, and colorectal cancers.
Pathogenesis
A.Cell division occurs by the body producing new cell formations in a controlled order, producing the appropriate number of cells to keep the body healthy. Once the cell grows and divides properly, the cell will die, and new cells will replace the old cells. However, when cancer occurs, cell division does not occur properly, and mutations occur that affect normal cell growth and division. The existing cells do not die while new cells are being produced, and the overproduction/accumulation of cells form a mass, which is known as a tumor. Tumors may be benign or malignant. Benign tumors are not hazardous to the body. Malignant tumors are cancerous and may spread to other parts of the body, known as metastasis.
Predisposing Factors
A.Predisposing risk factors for each type of cancer depend on the type of cancer present.
Common Complaints
A.Many complaints and side effects may occur prior to the diagnosis of cancer as well as during cancer treatment. Warning signs of cancer are the following:
1.Change in bowel or bladder habit.
2.A sore that does not heal.
3.Unusual bleeding or discharge.
4.Thickening or lump in breast, testicles, or elsewhere.
5.Indigestion or difficulty swallowing.
6.Obvious change in the size, color, shape, or thickness of a wart, mole, or mouth sore.
7.Nagging cough or hoarseness.
8.Coughing up blood.
9.Persistent headaches.
10.Unexplained loss of weight or appetite.
11.Chronic pain in bones.
12.Persistent fatigue, nausea, or vomiting.
13.Persistent low-grade fever, either constant or intermittent.
14.Repeated instances of infection.
B.Common complaints associated with cancer and treatment side effects:
1.Nausea and vomiting:
2.Constipation.
3.Diarrhea.
4.Fever and neutropenia.
Subjective Data
A.Inquire about onset, duration, and course of presenting symptoms.
B.What measures has the patient used to relieve the symptoms?
C.What makes the symptoms worse or better?
D.What medications, over-the-counter (OTC) or prescription, have been used to treat the symptoms? What were the results?
E.Over the past week, how have symptoms changed?
F.Is patient sleeping well? If not, what has the patient tried to do to assist sleeping?
G.Has patient lost or gained weight over the past few weeks?
H.Is the patient experiencing fever, cough, dyspnea, tightness in the chest, dysuria, diarrhea?
Physical Examination
A.Check temperature, pulse, respirations, blood pressure, and weight.
B.Inspect:
1.Observe overall appearance.
2.Inspect skin for color and hydration.
C.Palpate:
1.If abdominal symptoms exist, palpate abdomen for tenderness and masses.
2.Evaluate for tissue swelling.
D.Percuss:
1.Percuss abdomen.
E.Auscultate:
1.Auscultate heart and lung sounds.
2.Auscultate abdomen for bowel sounds.
F.Neurologic exam:
1.Assess deep tendon reflexes (DTRs) and mental status.
Diagnostic Tests
A.Screening tests for specific cancers:
1.Mammogram starting at age 40 years of age.
2.Colonoscopy every 10 years or flexible sigmoidoscopy or double contrast barium enema every 5 years.
3.Pap smear starting at 21 years of age.
B.Complete blood count (CBC) with differential.
C.Comprehensive metabolic profile (CMP).
D.Bone mineral density (BMD): Consider assessing for osteoporosis in patients who are at risk for fracture. Long-term use of steroids, chemotherapy treatment, and advanced age contribute to an increase risk in bone loss leading to osteoporosis.
Differential Diagnoses
A.Cancer being the primary diagnosis, the secondary diagnosis is made according to the presenting symptoms, which may include the following:
1.Dehydration.
2.Fatigue.
3.Nausea and vomiting.
4.Constipation.
5.Diarrhea.
6.Osteoporosis.
7.Anemia.
8.Neutropenic fever.
Plan
A.General interventions for the common side effects of cancer treatment may include the following:
1.Fatigue (National Comprehensive Cancer Network [NCCN] website, www.nccn.org/professionals/physician_gls/f_guidelines.asp):
a.Advise taking several naps during the day in the chair or bed, whichever is most comfortable.
b.Encourage daily exercise or activities as tolerated. Short periods of exercise and activity help to increase energy levels and also help with anxiety/depression.
c.Encourage the patient to ask family and friends for help when needed. During this time, the patient should not feel guilty for needing help with certain activities.
d.Encourage the patient to keep a schedule and block off times when he or she will need to perform certain activities. Saving energy for these tasks/time blocks will help the patient complete the task and feel better when performing the task.
2.Nausea and vomiting (NCCN website, www.nccn.org/professionals/physician_gls/f_guidelines.asp):
a.Several medications are used to prevent and treat nausea and vomiting. Some medications may be used prior to the start of chemotherapy to prevent nausea and vomiting. If the patient is prescribed around the clock dosing of their antiemetic drug, encourage patient to take even if not experiencing nausea. The medication used may depend on the type of chemotherapy being prescribed. Stress the importance of the patient notifying the oncologist about the severity of nausea/vomiting and treatment success with medications being prescribed.
b.Other suggestions to improve nausea and vomiting include the following:
i.Eat small, frequent meals during the day. Eating meals at a slower pace can also improve symptoms.
ii.Bland foods are best tolerated. Avoid spicy foods, alcohol, and caffeine.
iii.Wear comfortable clothing that does not restrict breathing or interfere with comfort around the abdomen.
iv.Encourage frequent oral hygiene to eliminate bad tastes in the mouth.
v.Eat foods that have ginger in them, such as ginger tea. Ginger has been shown to reduce nausea.
vi.Hydration must be maintained. Encourage the patient to drink plenty of liquids in whatever form the patient is able to tolerate. Water, Gatorade, Pedialyte, and other bland liquids are suggested. Some patients may also tolerate liquids that are cold; however, drinking liquids that are close to room temperature may be easier for some patients to keep down.
3.Constipation/diarrhea:
a.Constipation can be experienced as a side effect of some chemotherapy medications and opioids.
b.Encourage the patient to notify the oncologist if severe constipation is experienced.
c.Encourage good dietary habits, such as increasing liquids, and eating foods high in fiber for prevention/treatment of constipation.
d.Healthy dietary choices include foods high in protein (eggs, meat, fish, poultry, peanut butter, beans), an assortment of fruits and cooked vegetables, and foods low in fat and lactose. Avoid fatty/fried foods, raw vegetables, and dried fruits.
e.Daily exercise is recommended to improve constipation.
f.All patients receiving opioids need to be placed on a stool softener and laxative.
g.Diarrhea may occur as a side effect and can cause dehydration and loss of electrolytes from the body. Hydration should be maintained by drinking plenty of water, Gatorade, or Pedialyte. OTC medications may be used, such as loperamide (Imodium). If medications are needed to control the diarrhea, the primary provider or oncologist should be notified. If diarrhea is not controlled by diet and OTC medications, prescription medications may be given. For severe diarrhea not controlled by dietary changes and oral medications, intravenous (IV) hydration and medications should be prescribed.
4.Bone loss can be a side effect of patients treated with radiation. Radiation breaks down the bone-building cells and increases the risk of fracture. Steroids are given to some patients with cancer. Steroids are known to increase the production of osteoclasts, which are cells that break down bone tissue. Other chemotherapy agents are known to suppress bone marrow growth. Therefore, all patients should have a baseline bone density screening test (dual-energy x-ray absorptiometry [DEXA] scan). Vitamin D and calcium should also be taken daily. Counsel the patient regarding daily weight-bearing activities to increase bone strength. See Chapter 22 for evaluation and treatment of osteoporosis.
5.Anemia should also be evaluated in patients receiving medications for cancer. Anemia can be caused by the cancer, radiation, chemotherapy, iron deficiency, or a combination of these. Symptoms of anemia include fatigue, pale skin, shortness of breath, tachycardia, dizziness, and so on. See section Anemia
of this chapter.
6.Neutropenia occurs when chemotherapeutic agents destroy maturing neutrophils. The patient will be at greatest risk for neutropenia 7 to 14 days after last treatment and the neutrophils usually begin to recover within 21 to 28 days. Preventive measures to reduce the risk of infection include the use of granulocyte colony stimulating factors (G-CSF such as filgrastim), good handwashing, avoiding crowds, and staying away from people who recently received attenuated vaccinations. Immunization recommendations are inactivated influenza vaccine annually. Newly diagnosed adult cancer patients are immunized against pneumococcal infection if never received. Patient receives pneumococcal conjugate vaccine (PCV13) followed by pneumococcal polysaccharide vaccine (PPSV23) 8 weeks later.
Neutropenic fever is defined as a single oral temperature of 38.3°C or a temperature of greater than 38.0ºC sustained for more than 1 hour in the neutropenic patient. Fever requires prompt assessment and intervention/referral. A CBC with differential should be drawn. A chest x-ray and urinalysis are warranted based on clinical presentation. (NCCN website, www.nccn.org/professionals/physician_gls/pdf/infections.pdf ).
B.Caregiver support, advance directives, and palliative care should also be addressed. See Chapter 5 for information on this content.
C.Reference websites for clinicians and patients:
1.The NCCN comprises 25 designated cancer centers that have world-class, state-of-the-art research programs. The National Cancer Institute (NCI) is a U.S. federal agency for cancer research and clinician and family information. NCCN mobile apps are available for free for smartphones and tablets from the App Store for iPad or iPhone (search NCCN) or from the Google Play Store for the Android tablet or smartphone (search NCCN):