1. Carrington College Summer 2012 N254

2. Terminology to know All key terms on page 260 Overall Survival (OS)in Lewis et al Quality of Life (QOL) Prevalence Benign Incidence Malignant Mortality Node Morbidity Biopsy Survival Cachexia Progression Free Survival Cure(PFS) Control Disease Free Survival (DFS) Palliation Adjuvant Hospice 3. Who gets cancer? Men Prostate, Lung, Colon/rectum, Bladder, NHL,melanoma, Head and neck Women Breast, Lung, Colon/rectum, Uterus, NHL,Thyroid, Melanoma, Ovary Adult age variables the older the person, the higher therisk of cancer Children very specific childhood cancers, significantgenetic components Ethnicity variables page 261 US and rest of the world Developing nations very different issues 4. How do people get cancer?Risk factors Age, Gender Environmental influences carcinogens Chemical/Radiation/Smoke/Smog/ Water Quality/ Infections/Food Processing Genetics 10-15% have genetic link New research increasing our ability to detect links Behaviors Smoking Dietary Exercise ETOH 5. Statistics 6. Classification Anatomic site Histology Solid/Blood Origin Can have breast cancer in the brain, for example 7. Staging T Primary Tumor is: in situ, x: cant be found, 0: no evidence of primary tumor 1 4: Ascending size N Node 0: no evidence of disease, x: unable to assess 1 4: Ascending degrees of nodal involvement M distant metastases 0: no evidence of distant mets, x: cannot be determined 1 4: Ascending degrees of metastatic involvement Staging related to the formula for the TNM Stage 0 4: the higher the number, the more serious the disease Guides decision making about treatment, advises about prognosis 8. Grading Grade 1 Differ slightly from normal cells low grade Grade 2 Moderate differentiation intermediate grade Grade 3 Severe differentiation high grade Grade 4 Immature and primitive The cells of Grade 1 tumors resemble normal cells, and tend togrow and multiply slowly. Conversely, the cells of Grade 3 or Grade 4 tumors do not looklike normal cells of the same type. Grade 3 and 4 tumors tend togrow rapidly and spread faster than tumors with a lower grade. 9. Diagnostic tests to ID cancer Routine screening Mammogram Colonoscopy PAP Smear Others not as established Lung CT, Specific blood tests Issues are often r/t cost, insurance coverage, controversy See ACS website for complete list of screening guidelines 10. Example of screening guidelines 11. Diagnostic tests to ID cancer Labs CBC, Chem Panel, Liver studies Some cancer specific tests, called tumor markers (PSA, CA 125, CEA, etc) Genetic markers (BRCA, etc) Diagnostic tests Imaging Ultrasound, CT, MRI, PET CT, Endoscopy, Radio- isotope scans Often biopsy done with Imaging guidance Often require a series of tests, and the entire time, the patient is anxiously waiting! 12. Biopsy Definitive identification of histological type of cancer Determines type of treatment necessary Role of Tumor Board Role of Clinical Trials 13. Tumor Board Group meets, usually weekly MDs - Radiologist, Pathologists, Medical Oncologists,Surgeons, Radiation Oncologists, Geneticists, Psychiatrists,Palliative Care, Hospice, Primary Care Psychologists, Social workers, Nurse Navigators, InfusionRoom nurses, Radiation Therapy staff and nurses,Nutrition, Physical and Occupational Therapy, Surgicaland Oncology nurses, Research nurses, Cancer Registrystaff Others: Medical and Nursing Students have to signconfidentiality agreement If you get a chance to go, do it! Fascinating stuff! 14. Tumor Board Present all Imaging results Present all lab results, including biopsy Present patients H & P Compare to National standards and guidelines Discuss cancer and best therapy for that patient Recommend treatment options, including clinicaltrials and referrals to other facilities (UCSF, Stanford) ALL participants discuss, all cite evidence and research Often lively discussion and debate aboutrecommendations 15. Clinical Trials Variety of trials available prevention, screening,diagnostic, treatment, QOL, genetics Patient may leave clinical trial at any time Some trials have been stopped abruptly Significant negative outcomes Significant positive outcomes Nurse has huge role in Clinical Trials Assisting people in finding appropriate trial Data collection and monitoring Clinical follow-up Examples of CT/research in Reno 16. Surgery Goal removal of as much of tumor as possible Other goals: Placement of treatment devices Cure Control Support/Palliative Rehab 17. Surgery side effects Loss of function/motion Altered body image Altered sexuality Social isolation Infection 18. Chemotherapy Huge number of chemicals that we can give to people more being developed all the time. Cure Control Support/palliative 19. Types of chemo administration Oral IV most common today Usually given in cycles, sometimes RTC Peripheral Central Intracavity or into organ Intrathecal or into ventricles 20. Issues r/t chemo Toxicity Patient Nurse safety Side effects Long therapies Cycles Continuous infusions More and more chemo given in outpatient setting Chemo in all patient waste for 2-3 days or longer 21. Biologic and Targeted Therapy Alter or modify the relationship between the host andtumor Classic example hormone therapy for prostate, breastcancers Many of the newer targeted therapies are specific for onetype of cancer, or have only been tested with one type ofcancer Many are still under patent, and quite expensive Examples: Gleevec for CML: $6-7K/month for rest of life Herceptin for breast cancer: $54K/year x 1 year Patient assistance programs Patients may reach lifetime maximum of insurance quickly 22. Side effects of chemo Immediate Skin and nail changes N&V N & V up to 2 weeks Stomatitis, mucousitis after chemo Fluid shifts Bowel changes Falls Peripheral neuropathy Delayed Cognitive changes Bone marrow Cachexia suppression FATIGUE Alopecia about 2 weeks after chemo 23. Side effects of chemo Long term People who had chemo Infertilityas children now are Cardiacdealing with a variety of Secondary cancersissues need to continueto see MD for follow-up Permanent skin and hair changes Emerging area of study Some chemos cause chronic cardiac and/or pulmonary changes 24. Mitigating side effects N&V RBCs WBCs Mouth care Fatigue Cachexia Physical changes 25. Nausea and vomiting Much research on this with medications andcomplementary therapies Multiple reasons that people are nauseated/vomit Anticipatory Elevator vomiting Immediate Delayed Long term Currently, meds include: High doses of steroids Anti-emetics many specific to cancer therapy 26. Nausea and vomiting Complementary therapies that have been shown to be effective: Acupressure Acupuncture Guided imagery Music therapy Muscle relaxation Psychoeducational support and information Many more are being researched and may show effectiveness 27. RBCs and WBCs and platelets RBCs Transfusions Erythropoietin Oxygen WBCs GCSF Granulocyte Colony Stimulating Factor Often given right after chemo, so that patient never has nadir Platelets Transfusion uncommon Often simply put on bleeding precautions until platelets rise Meds in the works, so far have not been effective 28. Mouth care Prevention of mouth sores is crucial for many reasons: Impaired comfort, Impaired nutrition, Impaired body image, Impaired communication, Risk for infection and bleeding to name a few! Frequent mouth care crucial, but a challenge Soft toothbrush, no alcohol mouthwash, carefulattention to dentist visits, flossing, avoiding irritatingfoods 29. Radiation Therapy Local Internal Brachytherapy External Systemic very rarely used Cure Control Support/Palliation Rehab 30. Side effects of radiation Immediate Rare With head and neck Skin issues, N&V, mouth sores Delayed Usually begin to manifest during treatment to end of treatment and several weeks beyond Skin burns, fatigue GI issues if getting radiation to belly 31. Side effects of radiation Long term Chronic fibrous changes in lungs, heart Prostate incontinence, impotence Scar tissue 32. Mitigating side effects Skin creams and lotions Mouth special rinses and meticulous care N&V anti emetics Fatigue exercise during and after radiation! Prostate Urinary exercises, Kegels, Viagra 33. Combination therapies Surgery, chemo and radiation may all be used,sometimes at the same time These patients are very ill, often with a compoundedbunch of side effects Biggest risks/concerns: Infection leading to sepsis N&V leading to severe dehydration Anorexia leading to severe malnutrition Pain from cancer itself, as well as side effects oftreatment 34. Stem cell transplantation/ Bonemarrow transplantation Used to treat variety of cancers often blood tumors Patient receives induction chemo to eliminate cancer cells Cells harvested from patient or donor If patient cells, they are treated to remove any remainingcancer cells Patient usually gets more chemotherapy/ sometimesradiation Receives stem cells which proliferate and form new cellsthat are cancer free Very intensive process with many risks Significant long term issues 35. Complementary Therapies Used with western medicine best treatments are evidencebased, have had clinical trials Effective for cancer treatments: Pet therapy Healing touch Music therapy Support groups Exercise Imagery Ongoing study Nutrition Herbal supplements 36. Alternative Therapies Used instead of western medicine Hallmarks: Cash payments No clinical trials Often ingredients not revealed Anecdotal or celebrity evidence Many of the practitioners do not have hospital privilegesor board certifications, may not be physicians Doesnt mean they dont work, but no data collectedon them cant tell if they work or not 37. Advanced Cancers Diagnosed late Stage 3 or 4 Usually already have metastasis from primary cancer Often treatable, can often give significant DFS or PFS Lance Armstrong example Recurrence originally, was the end Now, often treatable and can give significant PFS Some patients on their 3rd or 4th recurrence, related to aggressive and newer chemos Secondary cancer Problem is often that the patient cant have as much chemo or radiation has reached lifetime limit of one or the other or both, so surgery may be only option available 38. Common cancers and thetreatments commonly used Lung (p. 560-564) Breast (p. 1311-1326) Lotsa pages! Leading cause of cancer deaths in Most frequently occurring cancer inUS at present, expected to continuewomento rise for women Screening mammogram, breast New screening may diagnosis at examearlier stage improve survival Hallmarks: Hallmarks: Usually found in screening Worsening cough with sputum,mammograms, or small lumpweight loss, fatigue, chest pain palpated usually no symptoms Treatments include surgery, chemo, Highly treatable, very often curablesometimes radiation Treatments include surgery, chemo, Issues include shortness of breath,radiation and hormone therapyfear and anxiety Issues include fatigue and body In 2011, @226,000 diagnosed andimage@160,000 died with lung cancer In 2011, @ 288,480 diagnosed, @40,000 died with breast cancer 39. Common cancers and thetreatments commonly used Prostate (p. 1386-1391) 5 pages Colon/rectum (p. 1035 - 1038) Most frequently occurring cancer in Screening test: Colonoscopy, FOBTmen Hallmark: Screening test Exam, PSA Abdominal pain, change in bowel Hallmark: Similar to BPH pattern, blood in stool, anemiaproblems urinating or change in Treatment includes surgery,urination patternschemotherapy, radiation Treatment varies according to Issues include body image, changestage sometimes watch and waitin bowel habits, pain Other treatments include surgery, In 2011, @ 143,000 diagnosed andradiation, hormonal therapy @51,000 died with colon/rectal Issues include impotencecancerincontinence In 2011, @ 241,000 diagnosed withand @ 28,000 died with prostatecancer 40. Common cancers and thetreatments commonly used Leukemias (p. 694-697) Lymphomas (p. 699-703) Screening not done. Screening - not done Hallmark: fatigue, patient presents Hallmark: Often few symptomswith infection, has very abnormal until substantial lymph nodelabs, esp. WBCinvolvement. Sometimes patient Treatments include chemo, rarelypresents with infection or chestradiation, and transplant.pain, and abnormal labs are found. Some of the new treatments are oral Fever, night sweats and weight loss and VERY effective hold out a lot indicate poorer prognosis.of promise. Incredibly expensive as Treatments are chemo, radiationwell. and for some, bone marrow or stem Issues include infections, fear,cell transplantsanxiety and post transplant Issues include fear, anxiety and postproblemstransplant problems In 2011, @ 47,000 diagnosed and In 2011, @79,ooo diagnosed and23,000 died of leukemias@20,000 died with lymphomas 41. Common cancers and thetreatments commonly used Multiple Myeloma (p. 703-704) Skin cancers specifically Screening not doneMalignant Melanoma (p. 451 453) Hallmark: bone destruction, Screening annual skin inspectionskeletal pain Other than MM surgical removal, One new drug is thalidomide usually not a problemsignificant patient education MM Hallmark VERY rapidnecessary growth and metastasis Problems with calcium and uric acid Requires wide excision, lymph node may lead to renal failure excision and aggressive Emphasis on preventingchemotherapycomplications from bone damage Issues with body image, VERY Issues with pain, fractures difficult treatment (some new In 2011, @ 21,000 diagnosed,meds on the way, but cost is@10,ooo died of multiple myelomaconcern) In 2011, @ 76,000 diagnosed, @9000died of malignant melanoma 42. Common cancers and thetreatments commonly used Liver cancer (p. 1086-1087) Pancreatic cancer (p. 1094-1095) In the US, rarely a primary site for cancer, Screening not donein other nations, a common primary site Hallmarks are abdominal pain and Screening not done unexplained weight loss, sometimesjaundice if bile duct blocked Hallmarks: History of cirrhosis, Hep B Surgery done sometimes, usuallyor Hep C, jaundice, anorexia, nausea, chemo, sometimes radiation forvomitingpalliation Treatment is directed toward primary Issues include pain, fearsite In 2011, @ 43,000 diagnosed, @37,000 died with pancreatic cancer If liver is primary, surgery, chemo just have not made a lot of headwaytransplantation sometimes an option on this cancer yet, because the New technique of radiofrequency and/cancer has often metastasized bythe time of diagnosisor chemoablation may be more effective Issues include pain, fear In 2011, @ 28,000 were diagnosed and@20,000 died with Liver cancer 43. Complications of cancer Nutritional issues Infections Cancer emergencies Pain Skin Integrity Financial 44. Nutritional issues Some cancers and some Some cancers are treatedtreatments are hard on thewith high doses of steroidsGI system that make a person People often need moreREALLY hungry, and theynutrition during and aftergain water and food weighttreatment, but they are not during treatment. Theyhungry, dont want to cookget bloated, striae, and feelor eat. lousy. Nutritional supplements They need to eat healthynecessary, sometimes Gfrequent small meals, withtubes even. an emphasis on highnutrition and low salt.Right. 45. Infections We create new openings: Surgical sites IV sites We give meds/treatments that decrease the immuneresponse We give meds/treatments that may mask symptoms ofinfection These are people who have a fever of 100.5, feel lousyand turn out to be septic. End up in hospital on IV broad spectrum antibiotics. 46. Cancer Emergencies There are many of these I do a whole 2 hour lectureon them, if you would like to see it. Suffice to say, most need to be addressed immediately,and vary with the type of cancer and the type oftreatment. Oncology nurses and doctors will give patientsinformation about the ones for which they are athighest risk. Patients need to CALL if they have thesesymptoms. 47. Cancer Emergencies a few Malignant pleural effusion Cardiac tamponade Superior vena cava syndrome Bone metastases and fracturesSpinal cord compression Increased intracranial pressure DVTs 48. Pain Cancer pain is no different than other pain IMHO itis just more persistent and feared Related to either cancer itself occupying space, orrubbing against something, or treatment side effects Very treatable with appropriate methods ATC meds are the best for some pain BUT! Examples: Surgery, chemo and radiation all can be used to reducepain Pains specialists can be called in to do nerve blocks,ablations to reduce pain 49. Skin integrity Serious concern, as any open lesions predispose forinfection Many treatments dry skin out (some chemos), damagehair and nails (chemo) and may cause nerve damage,decreasing the ability to feel Radiation may cause skin damage, and although it istemporary, it can be very problematic Skin folds, pannus, neck, mouth, face, perineum breakdown is a serious problem May need wound consult 50. Financial People without insurance Limited options for treatment Depend on charity Meds may be donated by drug companies Patient may choose not to have treatment at all People with insurance May need to continue working to keep insurance Co pays and deductibles may be very high Billing very confusing at best! Insurance may refuse some treatments, need to appeal Insurance may have cap on treatment costs Other costs non-reimbursable Time off work Travel Meals out What else? Many people, even with insurance, end up declaring medical bankruptcy Try getting individual policy type life insurance after having had cancer nothappening 51. Psychosocial impact of cancer Fear Pain Death Long treatment regimen Unknown Coping mechanisms Support groups Navigators Cancer Survival Toolbox/Stress thermometer Entire family needs assistance, not just patient 52. Fear Diagnosis of cancer very stressful for patient and family Often comes at the end of several stressful weeks ofdiagnostic tests Unfamiliar doctors, unfamiliar terms, scary treatments Radiation Chemotherapy Cutting Cannot promise that treatment will work! Significant time between beginning and end of treatment,so chronic stressor 53. Fear of pain Common concern Media and others have told of severe, unrelievalbelcancer pain Need to address this head on and right away Need to assess beliefs about pain Not inevitable Treatable Will not make patient an addict What else? 54. Fear of death People do die of cancer, no doubt about it Some cancers are very deadly which ones did youidentify in this talk? Need to address this head on as well Ask questions Help with advanced directives Talk about options if needed (Hospice, refusal oftreatment, etc.) 55. Fear of long treatment regimen Compare with heart attack Chest pain go to ER go to cath lab go to OR recovery and cardiac rehab. First line can all happen within one day. Breast cancer get a routine mammo get called to come back for more mammos get called to come back for a biopsy go to MD for diagnosis presented to Tumor Board have a lumpectomy wait for results go to oncologist discuss treatment options start treatment. Treatment may take up to 4 months for chemo, then 2 months for radiation, with a month off in between. So all of the above can take over a year! At which point the oncologist says Well its all gone, so we are good for now. Come back and see me in 3 months. 56. Fear of unknown How many words have I used so far today that werenew to you? You dont have cancer! Think how hard it would be to hear these words if youwere also dealing with a new diagnosis! No wonder that people say The doctor didnt tell meanything. What they meant was I didnt hearanything. 57. Coping Support Groups Research and surveys have indicated that this is VERYhelpful for some people Some people find on-line groups better than face-to-face, or that may be only choice for some Caregiver support groups are very beneficial as well, tohelp family and loved ones cope with the changes thatcancer, its treatment and its ramifications bring Usually led by a nurse or social worker, to guide groupand make sure information is accurate 58. Coping - Navigators Research and surveys indicate that patients withnavigation are seen faster, more likely to completetreatment and more satisfied with their experiencethan others. Issues: Navigators do not generate revenue for hospitals, andmay in fact cost money Hard to quantify the work Probably will be required in the future to getaccreditation by American College of Surgeons andother groups 59. Coping Cancer Survival Toolbox Series of CDs or downloadable talks that address thecommon issues that cancer patients and their familiesexperience Developed by Oncology Nurses and Oncology SocialWorkers Highly regarded by professional groups as helpful andaccurate Currently developing more on specific cancers Go to web site! 60. Coping Stress Thermometer See handouts Great tool to quickly ID issues and or problems thatyou can address each visit Monitor whether things are getting better or worse Clearly indicates (if you use and follow through!) thatyou know how stressful the cancer treatment is Provides you with suggestions for referrals Fact G sheet similar tool, but takes longer 61. Fact-G Use and Referral Guidelines for Nurse NavigatorsAll Cancer Center patients have FACT-G completedw/in 2 mos of initial contact w Nurse Navigator PhysicalSocial/Family Emotional Functional T Score >50T Score >50T Score >50T Score >50No referral required No referral required No referral required No referral requiredT Score