Cancer Nursing Care Management and Study Guide for Nurses

Cancer touches every body system and every phase of care, from screening to end of life. At the bedside your work is concrete: protect the patient from the predictable harms of the disease and its treatment (infection, bleeding, malnutrition, pain, skin breakdown) and catch the dangerous complications early. Know the physiology behind the cell, and the treatments and their toxicities follow logically.

Epidemiology

Cancer incidence is higher in men than women and higher in industrialized regions and nations. More than 1.4 million Americans are diagnosed each year. Cancer is second only to cardiovascular disease as a leading cause of death in the United States. Although cancer deaths have fallen slightly, more than 560,000 Americans were expected to die from a malignant process in 2008. The leading causes of cancer death, in order of frequency, are lung, prostate, and colorectal cancer in men, and lung, breast, and colorectal cancer in women. Across all cancer sites, African American men have a 15% higher incidence rate and a 38% higher death rate than Caucasian men, while African American women have a 9% lower incidence rate but an 18% higher death rate than Caucasian women.

Pathophysiology

Cancer begins when an abnormal cell is transformed by a genetic mutation of cellular DNA. These malignant neoplasms show uncontrolled growth that follows no physiologic demand (neoplasia).

Malignant cells are undifferentiated and often bear little resemblance to normal cells. They grow at the periphery and send out processes that infiltrate and destroy surrounding tissue. Their growth rate varies with the level of differentiation. They gain access to blood and lymphatic channels and metastasize, cause generalized effects such as anemia, weakness, and weight loss, and produce extensive tissue damage that causes death unless growth is controlled.

Malignant disease spreads by invasion (growth of the primary tumor into surrounding host tissue) and metastasis (dissemination of malignant cells from the primary tumor to distant sites). Carcinogenesis, the malignant transformation, runs through initiation (initiators such as chemicals, physical factors, and biologic agents escape normal enzymatic mechanisms and alter the cellular DNA), promotion (repeated carcinogen exposure causes expression of the mutant genetic information), and progression (the altered cells show increasingly malignant behavior). The immune system can detect and destroy malignant cells before growth becomes uncontrolled; clinical cancer develops when it fails to do so.

Detection and Prevention

Nurses and physicians have traditionally focused on tertiary prevention, the care and rehabilitation of patients after diagnosis and treatment. The American Cancer Society, the National Cancer Institute, clinicians, and researchers also emphasize primary and secondary prevention. Primary prevention reduces disease risk through health promotion. Secondary prevention promotes screening and early detection, such as breast and testicular self-examination and Papanicolaou (Pap) tests.

Diagnosis

A cancer diagnosis rests on physiologic and functional changes plus diagnostic evaluation. Tumor marker identification analyzes substances in tissue, blood, or other fluids made by the tumor or by the body in response to it. Genetic profiling looks for mutations in genes found in tumors or tissue. Mammography uses x-ray images of the breast. MRI uses magnetic fields and radio-frequency signals to create sectioned images. CT uses narrow-beam x-ray to scan successive tissue layers for a cross-sectional view. Fluoroscopy uses x-rays to identify contrasts in tissue density and may use contrast agents. Ultrasonography uses high-frequency sound waves echoing off tissue, converted to images, to assess deep structures. Endoscopy directly visualizes a body cavity or passageway and allows biopsy, fluid aspiration, and excision of small tumors. Nuclear medicine imaging injects or ingests radioisotopes, then images tissues that concentrate them. PET uses a tracer to image biologic activity rather than structure. PET fusion combines a PET and CT scanner in one machine for anatomic detail with functional metabolic data. Radioimmunoconjugates are monoclonal antibodies labeled with a radioisotope and injected intravenously.

Tumor Staging and Grading

A complete evaluation identifies the stage and grade of the tumor. Staging determines tumor size and the presence of local invasion and distant metastasis. The TNM system is used frequently: T is the extent of the primary tumor, N is the absence or presence and extent of regional lymph node metastasis, and M is the absence or presence of distant metastasis. Grading classifies tumor cells by the tissue of origin and by how closely the cells retain that tissue's functional and histologic characteristics. Grade I tumors (well-differentiated) closely resemble the tissue of origin in structure and function; Grade IV tumors do not clearly resemble it.

Management of Cancer

Treatment is chosen by the goals set for each specific cancer type.

Surgery

Surgical removal of the entire cancer remains the ideal and most frequently used treatment.

Diagnostic surgery (biopsy). Biopsy obtains a tissue sample to analyze cells suspected of being malignant. The three most common methods are excisional, incisional, and needle biopsy. Excisional biopsy is used most often for accessible tumors of the skin, breast, upper and lower GI tract, and upper respiratory tract. Incisional biopsy is used when the mass is too large to remove. Needle biopsy samples accessible suspicious masses such as growths in the breast, thyroid, lung, liver, and kidney.

Surgery as primary treatment. The goal is to remove the entire tumor or as much as feasible along with involved surrounding tissue, including regional lymph nodes. Local excision, often done outpatient, is warranted for small accessible masses and removes the mass with a small margin of normal tissue. Wide or radical excisions remove the primary tumor, lymph nodes, adjacent involved structures, and surrounding tissue at high risk for spread. Video-assisted endoscopic surgery inserts an endoscope with intense lighting and a multichip mini-camera through a small incision. Salvage surgery is an extensive approach to treat local recurrence after a less extensive primary approach. Electrosurgery destroys tumor cells with electric current. Cryosurgery freezes tissue with liquid nitrogen or a very cold probe. Chemosurgery applies chemicals or chemotherapy directly to tissue. Laser surgery vaporizes cancer cells with light and energy at an exact location and depth. Photodynamic therapy gives an IV light-sensitizing agent taken up by cancer cells, followed by exposure to laser within 24-48 hours. Radiofrequency ablation destroys cancer cells with localized thermal energy.

Prophylactic surgery removes nonvital tissues or organs at increased risk of developing cancer, such as colectomy, mastectomy, and oophorectomy. It is offered selectively and discussed thoroughly with patients and families.

Palliative surgery is performed to relieve complications of cancer when cure is not possible. Honest, informative communication about the goal is essential to avoid false hope.

Reconstructive surgery may follow curative or radical surgery to improve function or cosmetic effect, and may be indicated for breast, head and neck, and skin cancers.

Radiation Therapy

More than half of cancer patients receive radiation at some point. It may cure cancer (as in thyroid carcinomas, localized head and neck cancers, and cancer of the uterine cervix), control disease when a tumor cannot be removed surgically or when local nodal metastasis is present, or be used neoadjuvantly. Two types of ionizing radiation can disrupt tissue: electromagnetic radiation (x-rays and gamma rays) and particulate radiation (electrons, beta particles, protons, neutrons, and alpha particles).

Dosage. Dosage depends on the target tissue's radiosensitivity, tumor size, tolerance of surrounding normal tissue, and critical structures adjacent to the target. The lethal tumor dose eradicates 95% of the tumor while preserving normal tissue. In external beam radiation, the total dose is delivered over several weeks in daily doses called fractions. Repeated fractionated treatments let the periphery of the tumor reoxygenate as the tumor shrinks from the outside inward.

Administration. Teletherapy (external beam) is the most common form: energy levels are matched to tumor size, shape, and location to produce a shaped beam that destroys the tumor while sparing healthy tissue. Brachytherapy (internal radiation) delivers a high dose to a localized area through needles, seeds, beads, or catheters placed into body cavities (vagina, abdomen, pleura) or interstitial compartments (breast, prostate).

Toxicity. Altered skin integrity is common and can include alopecia. Oral effects include stomatitis, xerostomia, change and loss of taste, and increased salivation. Because bone marrow cells proliferate rapidly, including a marrow site in the radiation field can cause anemia, leukopenia, and thrombocytopenia.

Nursing management. Assess the skin and oropharyngeal mucosa regularly when those areas are treated, along with nutritional status and general well-being. When systemic symptoms like weakness and fatigue occur, explain that they result from treatment and do not signal disease progression. Brachytherapy safety precautions include a private room, posted radiation-safety notices, dosimeter badges for staff, no pregnant staff assigned to the patient, no visits by children or pregnant visitors, visits from others limited to 30 minutes daily, and visitors kept 6 foot from the radiation source.

Chemotherapy

Antineoplastic agents destroy tumor cells by interfering with cellular functions including replication. The goal is to eradicate enough tumor that the body's immune system can destroy the rest. Actively proliferating cells are most sensitive to chemotherapy; nondividing cells capable of future proliferation are least sensitive and therefore potentially dangerous. Cell cycle-specific agents destroy actively reproducing cells, most affecting the S phase by interfering with DNA and RNA synthesis. Cell cycle-nonspecific agents act independently of cycle phase and have a prolonged effect leading to cellular damage and death.

Agents are also classified by chemical group. Alkylating agents alter DNA structure by misreading the code, breaking the DNA molecule, and cross-linking strands. Nitrosoureas are similar but cross the blood-brain barrier. Topoisomerase I inhibitors bind topoisomerase I to break the DNA strand and prevent division. Antimetabolites interfere with the biosynthesis of metabolites or nucleic acids needed for RNA and DNA synthesis. Antitumor antibiotics bind DNA to interfere with synthesis and prevent RNA synthesis. Mitotic spindle poisons arrest metaphase by inhibiting mitotic tubular formation and DNA and protein synthesis. Hormonal agents bind hormone receptor sites to alter growth, block estrogen binding, inhibit RNA synthesis, and suppress aromatase of the P450 system.

Nursing management. Anorexia, nausea, vomiting, altered taste, mucositis, and diarrhea put patients at risk for nutritional and fluid-electrolyte disturbances. Marrow and immune suppression is expected and often guides dosing, but it raises the risk of anemia, infection, and bleeding. Observe closely during administration for extravasation, especially of vesicant agents. Follow institutional policy on personal protective equipment, handling and disposal of agents and supplies, and management of spills or exposures.

Bone Marrow Transplantation

Bone marrow transplantation (BMT) is used for malignant and some nonmalignant diseases. By donor source: allogeneic comes from a related or matched unrelated donor; autologous comes from the patient; syngeneic comes from an identical twin.

Nursing management. Before transplant, conduct nutritional assessments, physical exams, organ function and psychological evaluations, and blood work including past antigen exposure, and assess the patient's support system and financial and insurance resources. During marrow or stem cell infusion, monitor vital signs and oxygen saturation and watch for fever, chills, shortness of breath, chest pain, cutaneous reactions, nausea, vomiting, hypotension or hypertension, tachycardia, anxiety, and taste changes, while providing support and teaching. After transplant, ongoing assessment (including psychosocial assessment at followup) detects late effects, which occur 100 days or more after the procedure; donors also need support to keep realistic expectations of themselves and the patient.

Targeted Therapies

Targeted therapies disrupt specific cancer cell functions (malignant transformation, cell communication, growth and metastasis, genetic coding) to spare healthy tissue.

Biologic response modifiers (BRM) use naturally occurring or recombinant agents to alter the immunologic relationship between tumor and host. Nonspecific agents such as bacillus Calmette-Guérin (BCG) and Corynebacterium parvum act as antigens to stimulate an immune response against malignant cells. Monoclonal antibodies (MoAbs) destroy cancer cells while sparing normal cells. Cytokines, made by immune cells to enhance immune function, are a focus of research. Retinoids (vitamin A derivatives) act through retinoid-dependent nuclear receptors to affect growth, reproduction, apoptosis, epithelial differentiation, and immune function. Cancer vaccines mobilize the immune response to recognize and attack cancer cells.

For BRM therapy, know each agent and its effects and their impact on quality of life. Teach the patient and family to give BRMs by subcutaneous injection, explain side effects, and help them develop strategies to manage common ones.

Gene therapy corrects genetic defects or manipulates genes to induce tumor cell destruction. A central challenge is the multiple somatic mutations involved in cancer, which makes the best approach hard to identify. Viral vectors that carry a gene into a target cell include retroviruses, adenoviruses, vaccinia virus, fowlpox, herpes simplex viruses, and Epstein-Barr viruses. Three general approaches are used, with adenoviruses showing promise in each: tumor-directed therapy introduces a therapeutic gene (a suicide gene) into tumor cells to destroy them; active immunotherapy administers genes that invoke the immune system's antitumor response; and adoptive immunotherapy administers genetically altered lymphocytes programmed to cause tumor destruction.

Complementary and Alternative Medicine

Many patients use complementary and alternative therapies alongside conventional medicine. CAM covers diverse systems, practices, and products not currently part of conventional medicine. Because of possible herb-vitamin-drug interactions, biologicals and dietary supplements are a concern; they are not regulated by the FDA or subjected to rigorous scientific evaluation. Unconventional treatments are those without scientific evidence of curing or controlling cancer. Patients seek them out of hopelessness, desperation, unmet needs, lack of factual information, and family and social pressure.

The best protection against fraudulent cures is a trusting relationship, supportive care, and realistic hope. Answer questions about unproven methods truthfully and without judgment to ease the patient's and family's fear and guilt. Teach them the common characteristics of fraudulent therapies so they can evaluate other "therapies" cautiously. Encourage the patient to tell their physicians about any therapies used to prevent interactions with prescribed treatment.

Nursing Care of Patients with Cancer

Maintaining tissue integrity. Assess the patient's subjective experience along with the oropharyngeal tissues and teeth; for oral mucositis, palifermin (Kepivance), a synthetic human keratinocyte growth factor, may be given. For radiation skin reactions, maintain skin integrity, cleanse the skin, promote comfort, reduce pain, prevent further trauma, and prevent and manage infection. For alopecia, give information about hair loss and support coping with body-image change. For malignant skin lesions, cleanse the skin, reduce surface bacteria, control bleeding, reduce odor, protect from trauma, and relieve pain.

Promoting nutrition. Anorexia may occur because the patient feels full after eating little. Surgery can change peristalsis, alter GI secretions, and reduce absorptive surface, causing malabsorption. Assess patients at risk for altered intake so measures start before nutritional decline (cachexia).

Relieving pain. Assess the source and site of pain and the factors that worsen the patient's perception of it. Combine opioid and nonopioid medications and adjuvants using the World Health Organization three-step ladder. Educate and support the patient to correct fears and misconceptions about opioid use.

Decreasing fatigue. Assess physiologic and psychological stressors that add to fatigue, using tools such as a visual analog scale. Exercise is a supported intervention. Pharmacologic options include antidepressants for depression, anxiolytics for anxiety, hypnotics for sleep disturbance, and psychostimulants for some patients with advanced cancer or refractory fatigue.

Improving body image and self-esteem. Identify threats to body image and assess the patient's ability to cope with the assaults of disease and treatment. When sexual or communication difficulties arise, help the patient seek specialized evaluation and intervention.

Assisting in the grieving process. Assess psychological and mental status and the emotional reaction to diagnostic results and prognosis. Grieving is a normal response to these fears and to actual or potential losses.

Monitoring and managing complications. Monitor lab studies for early changes in WBC counts (infection). For septic shock, perform neurologic assessments, monitor fluid and electrolyte status, arterial blood gases, and pulse oximetry, and administer IV fluids, blood, and vasopressors. For bleeding and hemorrhage, IL-11 (FDA-approved to prevent severe thrombocytopenia) may be given, along with additional medications for coagulation disorders.

Promoting home and community-based care. Followup visits and phone calls help identify problems and reassure the patient and family. Home care responsibilities include assessing the home environment and suggesting modifications to meet the patient's physical needs.

Cancer Screening Guidelines

Cancer rarely announces itself early. The World Health Organization reported that in 2012 there were 14 million new cancer cases and 8.2 million cancer-related deaths, 60% of new cases from Africa, Asia, and parts of America. In the United States, an estimated 1.6 million new cases were projected for 2016, with deaths reaching about half a million. Early detection raises the chance of survival, so know these screening guidelines from the American Cancer Society and the U.S. Preventive Services Task Force.

Breast. About 70% of women have no known predisposing factors, but established risk factors include age 65 and above, two first-degree relatives diagnosed at an early age, high breast tissue density, and factors affecting circulating hormones (late menopause, long-term hormone replacement therapy, obesity). Screening uses mammography, clinical breast examination (CBE), and breast self-examination (BSE). Mammography (x-ray of the breast) is done yearly for women age 40 and above, and may start at age 30 for women at increased risk. CBE is done every 2-3 years for women 20-39 years and annually after 40. Teach BSE to women 20 years and above, performed 5-7 days after menstruation when the breasts are not swollen and tender; women with irregular cycles should pick a fixed monthly date.

Cervical. The screening test is the Pap smear. Under the 2012 American College of Obstetricians and Gynecologists (ACOG) guideline, first screening is at age 21. For women age 21 to 39, screen every 3 years. Up to age 60, screen with cytology if the Pap smear is positive or the patient is high-risk on HPV testing. Routine screening is discontinued after hysterectomy for benign reasons, and for women age 65 and above after 3 consecutive negative Pap smears.

Ovarian. There is no effective screening test. Risk factors include a family history of breast or ovarian cancer and BRCA1 or BRCA2 mutations. A pelvic exam is done at checkup, with ultrasound and MRI as needed.

Testicular. Monthly testicular self-examination (TSE) is recommended for men, done after a warm shower when the skin is relaxed; report any painless nodule or lump to the doctor.

Lung. Annual low-dose CT is recommended for adults age 55-80 years with a 30 pack-year smoking history or who quit within 15 years. Screening stops once the person has not smoked for at least 15 years.

Liver. The American Cancer Society has no current screening recommendation. The two most commonly requested tests are ultrasound and the alpha-fetoprotein (AFP) blood test.

Colorectal. Screening options include fecal occult blood test (FOBT), sigmoidoscopy, and colonoscopy. Assess risk factors (polyps, a first-degree relative with colorectal cancer, personal history of ulcerative colitis) beginning at age 20. For those not at high risk, routine screening runs between 50 and 75 years. FOBT is annual; alternatively, sigmoidoscopy every 5 years with FOBT every 3 years, or colonoscopy every 10 years.

Prostate. Prostate cancer is the leading cancer among men in the U.S. and the second leading cause of cancer death. Risk factors include age, family history, and African American ethnicity. Screening uses digital rectal examination (DRE) and prostate-specific antigen (PSA), though neither is highly accurate: DRE can miss 25-35% of tumors with a sensitivity of only 59%, and PSA's detection rate is only 28-35%. Combine both for men above 50 years; start at age 40 for men with risk factors.

Skin. There is not enough evidence to recommend routine screening for early detection. Fair-skinned individuals aged 65 and older are at increased risk for melanoma, as are those with atypical moles or more than 50 moles.