NSG210 Hinkle Ch. 12: Management of Patients With Oncologic Disorders

Source: Hinkle & Cheever, Brunner & Suddarth’s Medical-Surgical Nursing 15e, Chapter 12, pp. 301-364 (textbooks/HINKLE_MS_CH12.pdf, also in textbooks/exam03/). Week 09 reading (cancer, lung cancer and chest tubes, non-Hodgkin lymphoma); on Exam 3. The syllabus chapter number matches the 15th edition here.

Learning Outcomes

1. Differentiate benign and malignant tumors.
2. Discuss the nurse’s role in prevention and management of cancer.
3. Compare the goals of cancer care: prevention, diagnosis, cure, control, palliation.
4. Describe surgery, radiation, chemotherapy, HSCT, immunotherapy, and targeted therapy.
5. Use the nursing process across the cancer trajectory, from diagnosis to survivorship and end of life.

I. Epidemiology and Pathophysiology

• Cancer is the 2nd leading cause of death in the US; leading cancer deaths: lung, prostate, colorectal (men); lung, breast, colorectal (women); 80% of diagnoses at 55 or older
• Disparities: non-Hispanic Black patients have higher death rates for most cancers; Hispanic patients have twice the rate of infection-related cancers (liver)
• Cancer begins with DNA mutations (inherited or acquired); clone escapes growth controls and immune surveillance, invades, and metastasizes through blood and lymph

A. Benign vs malignant (Table 12-1)

B. Carcinogenesis

• Three steps: initiation (carcinogen damages DNA), promotion (repeated exposure to promoters; REVERSIBLE if promoter removed - focus of prevention), progression (angiogenesis, invasion, metastasis)
• Proto-oncogenes are “on switches” (EGFR, KRAS); tumor suppressor genes are “off switches”
• Complete carcinogens both initiate and promote (cigarette smoke, asbestos)

C. Etiology

• Viruses: HPV (cervical, head and neck), hepatitis B (liver), EBV (Burkitt, nasopharyngeal); bacteria: H. pylori (stomach)
• Physical: UV light (skin), ionizing radiation, radon (lung), chronic irritation
• Chemical: tobacco is the single most lethal carcinogen (about 30% of cancer deaths, 12 cancer types); secondhand smoke raises lung cancer risk 20-30%; smokeless tobacco (oral, pancreatic, esophageal); occupational (asbestos, benzene, arsenic, vinyl chloride)
• Genetic: 5-10% hereditary; hallmarks of a hereditary syndrome: two or more first-degree relatives, onset under 50, same cancer in several relatives, multiple primaries in one person, rare cancer; BRCA1/2, Lynch, MEN; take a 3-generation family history
• Lifestyle: obesity, alcohol, red/processed meat, inactivity (second only to smoking as modifiable risk)
• Hormonal: menses before 12, menopause after 55, nulliparity, first birth after 30 raise breast cancer risk; estrogen alone raises endometrial cancer risk; combined HRT raises breast cancer risk
• Immune: immunosuppressed patients (transplant, AIDS - Kaposi sarcoma) have more cancer; tumors evade by hiding antigens and using PD-L1 to switch off T cells

D. Classification by tissue (Table 12-2)

• Carcinoma: epithelial, 80-90% of cancers (adenocarcinoma - glandular; squamous cell)
• Sarcoma: connective tissue (osteosarcoma, liposarcoma, mesothelioma - asbestos)
• Myeloma (plasma cells), lymphoma (lymphocytes), leukemia (marrow cells)

II. Prevention and Detection

• Primary: risk reduction - HPV vaccine (cervical, head and neck), hepatitis B vaccine (liver), ACS nutrition and activity guidelines (Chart 12-2): healthy weight, 150 min moderate or 75 min vigorous exercise per week, at least 2.5 cups fruits and vegetables a day, limit red and processed meat, alcohol no more than 1 drink a day for women or 2 for men
• Secondary: screening and early detection
• Tertiary: surveillance for recurrence and second cancers in survivors (about 16.9 million US survivors)

ACS screening guidelines (Table 12-3)

III. Diagnosis, Staging, Grading

• Diagnostic workup: history, exam, imaging (CT, MRI, PET - shows metabolic activity), tumor markers, endoscopy, biopsy
• Nursing: explain tests and sensations, encourage fears to be voiced, clarify provider information
• TNM staging (Chart 12-3): T = primary tumor size (Tis = in situ; T1-T4 increasing size); N = regional nodes (N0 none; N1-N3 increasing); M = distant metastasis (M0 none, M1 present)
• Anatomic stage I-IV (increasing severity)
• Grading I-IV: grade I well differentiated (resembles tissue of origin, better prognosis); grade IV poorly differentiated/undifferentiated (aggressive, poorer prognosis)
• Treatment goals: cure, control (prolonged survival), palliation (relief of symptoms and quality of life)

IV. Surgery

• Diagnostic biopsy:
  • Excisional: whole small tumor plus margins; least risk of seeding
  • Incisional: wedge of a large tumor; a negative result does not rule out cancer if sample not representative
  • Needle: fine-needle aspiration (cells only - cytology) or core needle (tissue - histology)
  • Sentinel lymph node biopsy: maps the first draining node; replaces full node dissection in breast cancer and melanoma (less lymphedema)
• Primary treatment: local excision or wide/radical (en bloc) excision; debulking; minimally invasive and robotic surgery (less pain, bleeding, infection, faster recovery); salvage surgery for local recurrence
• Prophylactic: colectomy, mastectomy, oophorectomy for high genetic risk (BRCA)
• Palliative: relieve obstruction, pain, bleeding, effusions (stents, ostomies, drainage tubes, nerve block, cordotomy) - be honest about goals to avoid false hope
• Reconstructive: breast, head and neck, skin
• Nursing: perioperative care plus higher risk of infection, poor healing, VTE when combined with chemo/radiation; consistent information; early discharge planning

V. Radiation Therapy

• About 60% of patients receive it; used to cure (thyroid, head and neck, cervix), control, neoadjuvant (shrink before surgery), prophylactic, or palliative (bone, brain, oncologic emergencies like SVCS, spinal cord compression)
• Kills by breaking DNA directly or by free radicals; most sensitive: rapidly dividing tissues (marrow, lymph, GI epithelium, hair follicles, gonads); radiation is localized - only tissue in the field is affected
• Fractionation: daily doses over weeks lets normal tissue repair and reoxygenates tumor
• External beam (EBRT): linear accelerator; IMRT, IGRT, SBRT (1-5 days of high-dose treatment), proton therapy (spares tissue behind the tumor), GammaKnife stereotactic radiosurgery
• Brachytherapy: sealed sources in or next to tumor (prostate seeds, intracavitary cervical, intraluminal); HDR short outpatient vs LDR inpatient over days
• Systemic: radioactive iodine I-131 (thyroid cancer), radium-223 (prostate bone metastases)

Toxicity

• Acute (begins within 2 weeks) in rapidly dividing tissue in the field:
  • Skin: radiodermatitis from erythema to dry desquamation (flaking) to moist/wet desquamation (oozing) to ulceration; hyperpigmentation at 2-4 weeks
  • Head and neck: stomatitis, xerostomia, taste loss; thoracic: esophagitis and dysphagia; abdominal: nausea, vomiting, diarrhea
  • Marrow in field (iliac crest, sternum): anemia, leukopenia, thrombocytopenia
  • Systemic: fatigue (up to 99%), malaise, anorexia - explain it does NOT mean disease progression; aerobic exercise is the best intervention
• Late (6 months to years): fibrosis, atrophy, ulceration, necrosis of lungs, heart, CNS, bladder

Skin care during radiation (Chart 12-6)

• Lukewarm water only; no soaps, perfumes, powders, lotions on the field (non-aluminum deodorant on intact skin is acceptable)
• No rubbing, scratching, straight razors, heating pads, ice, adhesive tape; avoid sun and cold; loose cotton clothing
• Wet desquamation: do not break blisters, avoid frequent washing, nonadhesive absorbent dressing, report blistering

Protecting caregivers from internal radiation (brachytherapy)

• Time, distance, shielding; private room; posted signs; dosimeter badges
• No pregnant staff; no children or pregnant visitors; visitors limited to 30 minutes a day and 6 feet from the source
• Patients with permanent seed implants usually go home; exposure to others is minimal

VI. Chemotherapy

• Systemic treatment; neoadjuvant (before surgery), adjuvant (after surgery), or primary (leukemia, lymphoma)
• Each dose kills a percentage of cells, so repeated cycles are needed; actively dividing cells are most sensitive
• Cell cycle: G1 (RNA, protein synthesis), S (DNA synthesis), G2 (premitotic), M (mitosis)
• Cell cycle-specific (S phase: antimetabolites, topoisomerase inhibitors; M phase: vinca alkaloids, taxanes) vs cell cycle-nonspecific (alkylating agents, antitumor antibiotics)
• Combination chemotherapy: different mechanisms and toxicities, prevents resistance
• Dosing by body surface area, weight, organ function; lifetime limits (doxorubicin 550 mg/m2 because of cardiomyopathy)
• Leucovorin: enhances fluorouracil and “rescues” normal cells from high-dose methotrexate

Extravasation of vesicants

• Vesicants (doxorubicin, daunorubicin, dactinomycin, mitomycin, nitrogen mustard, vinblastine, vincristine) cause tissue necrosis if they leak; irritants cause inflammation without lasting damage
• Never give vesicants in hand or wrist veins; peripheral only for short infusions under 1 hour in the forearm with a soft plastic catheter; prolonged or frequent infusions through a central line (tunneled right atrial catheter, implanted port with Huber needle, PICC)
• Signs: no blood return, resistance to flow, burning, pain, swelling, redness
• If suspected, STOP the infusion immediately; follow agent-specific antidote protocol (extravasation kit); notify provider; document

Hypersensitivity reactions

• Within 5 minutes to 6 hours; risk rises with repeated exposure; carboplatin, oxaliplatin, asparaginase (IgE); rituximab, cetuximab (cytokine release)
• Rash, urticaria, fever, hypotension, wheezing, throat tightness - stop the drug and start emergency protocol; premedicate as ordered

Toxicities by system

• GI: nausea and vomiting (acute within 24 hours, peak 5-6 hours; delayed 24 hours to 7 days, peak 48-72 hours; anticipatory - conditioned); give antiemetics (serotonin blockers plus steroids) BEFORE chemo and for a week at home; stomatitis 3-14 days after antimetabolites and antitumor antibiotics
• Hematologic: myelosuppression is usually the dose-limiting toxicity; nadir 7-14 days after chemo; G-CSF/GM-CSF shorten neutropenia; erythropoietin for anemia
• Renal: cisplatin, methotrexate, mitomycin; SIADH; tumor lysis; hydrate and give allopurinol; hemorrhagic cystitis with cyclophosphamide and ifosfamide - aggressive hydration and frequent voiding
• Cardiac: anthracyclines cumulative cardiotoxicity (at 400 mg/m2); dexrazoxane is cardioprotective; monitor ejection fraction
• Pulmonary: bleomycin (fibrosis), busulfan, carmustine; capillary leak with cytarabine
• Reproductive: infertility, early menopause, azoospermia - offer sperm banking or egg/embryo freezing BEFORE treatment; use birth control (agents are teratogenic) and do not assume infertility
• Neurologic: vincristine and taxanes - cumulative peripheral neuropathy, loss of reflexes, paralytic ileus; cisplatin - hearing loss; oxaliplatin - cold-triggered throat and lip dysesthesia (avoid cold drinks and cold exposure for 3-4 days)
• Cognitive impairment (“chemo brain”); cancer-related fatigue

Safe handling (Chart 12-5)

• Prepare in a class II or III biologic safety cabinet with closed-system transfer devices
• Double chemo-rated powder-free gloves (inner under cuff, outer over), disposable long-sleeve impermeable gown, face shield if splash risk
• Body fluids and linens of patients on chemo are hazardous (drug excreted in urine and stool)
• Dispose in labeled puncture-proof hazardous containers; spill kits wherever chemo is given; wash hands after gloves off

VII. Hematopoietic Stem Cell Transplantation (HSCT)

• Used mainly for hematologic cancers (myeloma, leukemia, lymphoma); cells usually collected by apheresis of peripheral blood (also marrow or umbilical cord blood)
• Allogeneic: HLA-matched donor; graft-versus-tumor effect (good) but risk of graft-versus-host disease (GVHD) - needs immunosuppressants (cyclosporine, tacrolimus, methotrexate)
• Autologous: patient’s own cells; no GVHD, no immunosuppressants; risk that tumor cells are reinfused; used for lymphoma and myeloma
• Syngeneic: identical twin; less GVHD but less graft-versus-tumor
• Myeloablative (high-dose chemo plus total-body irradiation) vs nonmyeloablative “mini” transplant (older or sicker patients)
• Engraftment takes 8-10 days or more; until then the patient is at highest risk of death from sepsis and bleeding
• GVHD: acute within 100 days - rash progressing to blistering and desquamation, diarrhea that can exceed 2 L/day, jaundice and elevated liver enzymes; chronic after 100 days
• Hepatic sinusoidal obstruction syndrome (veno-occlusive disease) in first 30 days: weight gain, hepatomegaly, rising bilirubin, ascites
• Engraftment syndrome: fever, rash, weight gain, pulmonary infiltrates; responds to steroids
• During infusion: watch vital signs, SpO2, reactions to DMSO preservative
• Late effects: infections (zoster), pulmonary disease, infertility, cataracts, chronic GVHD; donors also need emotional support

VIII. Immunotherapy and Targeted Therapy

• Nonspecific: BCG bladder instillation (flulike symptoms, bladder burning, blood-tinged urine for 2-3 days); interferons and IL-2 (capillary leak, hypotension, pulmonary edema)
• Monoclonal antibodies (“-mab,” IV, act on cell surface): trastuzumab (HER2), rituximab (CD20); can be conjugated with radioisotopes; risk of infusion reactions
• Checkpoint inhibitors (take the “brakes” off T cells): ipilimumab (CTLA-4); nivolumab, pembrolizumab (PD-1); atezolizumab, durvalumab (PD-L1)
  • Immune-related adverse events, often delayed: rash, diarrhea/colitis, pneumonitis, nephritis, hepatitis, thyroiditis, hypophysitis - report early; treated with corticosteroids
• Cancer vaccines: HPV vaccines (Gardasil-9, both sexes, prevention); sipuleucel-T (therapeutic, prostate)
• CAR T-cell therapy: patient’s T cells collected, engineered to target CD19, reinfused (tisagenlecleucel, axicabtagene)
  • Cytokine release syndrome (CRS): fever is the hallmark; tachycardia, hypotension, hypoxia
  • Neurologic toxicity from headache and confusion to cerebral edema
• Small-molecule targeted drugs (“-nib,” oral, act inside cells): imatinib (tyrosine kinase, BCR-ABL), erlotinib (EGFR - lung), axitinib (VEGF - kidney), sorafenib (multikinase), bortezomib (proteasome)
  • Toxicities: rash (acneiform - doxycycline, hydrocortisone cream, sunscreen), diarrhea, hypertension, impaired wound healing, cardiotoxicity, hepatotoxicity
• Oral chemo adherence (Table 12-8): pill boxes, alarms, diaries, pill counts, financial assistance, 14-point font for older adults; ask about all OTC drugs and supplements
• Complementary therapies: ask about them; herbs may interact; no deep massage with thrombocytopenia, VTE, anticoagulants, or radiodermatitis

IX. Nursing Care of the Patient With Cancer

A. Stomatitis and mucositis

• Develops 3-14 days after stomatotoxic chemo; up to 100% with HSCT, 90% with head and neck radiation
• Assess the mouth daily with the same scale
• Prevention: soft toothbrush with nonabrasive paste for 90 seconds after meals and at bedtime; floss only if already a habit; bland rinses (saline, sodium bicarbonate) 4 times a day; NO alcohol mouthwash or tobacco; water-based lip lubricant; hydration; oral ice chips during infusion (cryotherapy); palifermin for HSCT; low-level laser
• Mild: saline rinses every 1-4 hours, remove dentures except meals, soft foods
• Severe: culture lesions, check gag reflex, rinses with antifungal and topical anesthetic (viscous lidocaine), liquid or pureed diet, systemic analgesics, monitor for dehydration

B. Alopecia

• Starts 1-3 weeks after chemo begins; regrowth usually within 8 weeks after the last treatment (may change color or texture)
• Cut long hair beforehand, mild shampoo, no dryers or curling irons, wide-tooth comb, sunscreen or hat
• Buy a wig before hair loss (matching easier); ACS donated wigs
• Scalp cooling reduces hair loss but NOT used in leukemia or lymphoma (cells may be in scalp)

C. Nutrition

• Anorexia from taste changes (metallic, “mouth blindness”), early satiety, nausea, distress
• Cancer-related anorexia-cachexia syndrome (CACS): increased energy expenditure plus decreased intake; loss of fat and skeletal muscle; up to 86% at end of life
• Interventions: small frequent high-calorie, high-protein meals; cold foods; limit fluids at meals; oral care before meals; megestrol acetate or short-term corticosteroids for appetite; metoclopramide for early satiety; PEG tube placed before head and neck radiation; parenteral nutrition only if GI tract fails
• Do not let family nag the patient to eat

D. Pain

• Up to 52% with advanced disease; often chronic
• Give analgesics around the clock (long-acting) rather than as needed, premedicate before painful activities; address fear of addiction; use pain scale before and after; coanalgesics (tricyclics, anticonvulsants, steroids) for neuropathic pain
• Pain 0-3 nonopioid; 4-6 opioid like oxycodone; 7-10 strong opioid like morphine

E. Fatigue

• Most distressing symptom; not relieved by rest; can last months to years
• Correct causes (anemia, electrolytes, pain, depression, sleep); exercise is most effective; schedule activity during peak energy; delegate chores

F. Body image, sexuality, grief, distress

• Address body image and sexuality openly; fertility preservation before therapy
• Grief is normal; screen for psychosocial distress; refer to mental health as needed

G. Infection

• Fever may be the ONLY sign in neutropenia (no pus, redness, or swelling)
• ANC = (percent segs + percent bands) x WBC; example (25% + 25%) x 6,000 = 3,000
• ANC under 1,500 increased risk; under 500 severe risk; nadir 7-14 days
• Neutropenic fever: single temp 38.3 C (101 F) or 38 C (100.4 F) for 1 hour or more, with ANC under 500 (or under 1,000 and expected to fall)
• Response: cultures (blood from peripheral and central line, urine, sputum, wounds) and chest x-ray, then broad-spectrum antibiotics promptly
• Precautions: private room if ANC under 1,000; hand hygiene; avoid sick contacts and recent vaccine recipients; no rectal temperatures, suppositories, enemas, tampons, or IM injections; avoid urinary catheters; stool softeners; electric razor; change water pitchers daily; avoid animal excreta; safe food handling (raw-food restriction has no evidence); teach G-CSF injections
• Most common organisms: gram-positive (Staph, Strep), gram-negative (E. coli, Klebsiella, Pseudomonas), Candida
• Septic shock: neutropenic and hematologic cancer patients at highest risk - ICU care

H. Bleeding and thrombocytopenia

• Thrombocytopenia: platelets under 100,000; bleeding risk under 50,000; spontaneous bleeding under 20,000 (platelet transfusion threshold) and especially under 10,000
• Watch for petechiae and ecchymoses (early signs), bleeding gums, blood in urine/stool/emesis, altered mental status (intracranial bleed), hypotension, tachycardia
• Precautions: soft toothbrush, electric razor, emery board, no aspirin or NSAIDs, no rectal temps or suppositories, no IM injections (smallest needle if needed), pressure 5 minutes or more on puncture sites, one daily venipuncture for all labs, stool softeners, fluids 3 L/day, water-based lubricant, no forceful nose blowing, supervise ambulation; premedicate platelet transfusions (diphenhydramine, hydrocortisone)

I. VTE

• Common in cancer; risk from chemo, surgery, immobility, central lines; teach DVT/PE symptoms; prophylaxis per guidelines

X. Gerontologic Considerations

• 55% of cancer cases and 70% of cancer deaths at 65 or older
• Decreased renal, cardiac, pulmonary reserve; altered drug metabolism; comorbidities and polypharmacy; atypical signs of infection; slower healing; more mucositis and myelosuppression

XI. Survivorship and Advanced Cancer

• Survivorship care plan: treatment summary, surveillance for recurrence and second cancers, late effects, rehabilitation, psychosocial support, coordination with primary care
• Advanced cancer: palliative goals, around-the-clock long-acting analgesics, energy conservation, honor wishes; hospice when cure and control are no longer possible

XII. Oncologic Emergencies (Table 12-13)

High-Yield Numbers

• Tobacco: about 30% of cancer deaths; secondhand smoke raises lung cancer risk 20-30%
• Hereditary cancers 5-10% of adult cancers
• Carcinomas 80-90% of all cancers
• Screening: mammogram 45 annually; Pap at 21; colorectal at 45; lung CT 55-74 with 30 pack-years
• Radiation used in about 60%; acute effects start within 2 weeks; late effects after 6 months
• Brachytherapy visitors: 30 minutes a day, 6 feet away
• Doxorubicin lifetime limit 550 mg/m2
• Chemo nadir 7-14 days; delayed nausea peaks 48-72 hours
• ANC under 1,500 risk; under 500 severe; neutropenic fever 38.3 C once or 38 C for 1 hour
• Platelets: under 50,000 bleeding risk; under 20,000 spontaneous bleeding; under 10,000 high risk
• Stomatitis 3-14 days after chemo; alopecia 1-3 weeks after start; regrowth within 8 weeks after end
• GVHD acute within 100 days; engraftment 8-10 days
• Peripheral vesicant infusion under 1 hour, forearm only
• Hypercalcemia: calcium over 10.4 mg/dL; fluids 3-4 L/day

Priority Nursing Actions and Red Flags

• Neutropenic patient with fever: cultures then broad-spectrum antibiotics immediately; fever may be the only sign
• Suspected extravasation: stop the infusion first
• Hypersensitivity reaction during infusion: stop the drug, start emergency protocol
• Check blood return before and during vesicant administration
• SVCS: facial swelling and dyspnea; elevate head; no BP or IV in arms
• New back pain in a patient with cancer: suspect spinal cord compression; check motor, sensory, bowel, bladder
• Confusion, constipation, polyuria in myeloma or breast/lung cancer: check calcium
• Within days of starting chemo for leukemia or lymphoma: watch potassium, phosphate, calcium, uric acid, urine output (TLS)
• CAR T-cell: fever means cytokine release syndrome; watch BP, O2 sat, neuro status
• Checkpoint inhibitor: new diarrhea, cough, or rash may be immune-related - report early
• Radiation fatigue is expected; skin care with lukewarm water and no lotions on the field
• Wear chemo PPE for drugs and for patient body fluids
• Thrombocytopenia: no IM injections, rectal temps, aspirin; pressure on puncture sites

Medications

Related

• nsg210-hinkle-ch30-hematologic-neoplasms - leukemia, lymphoma, myeloma (same week)
• nsg210-hinkle-ch19-chest-lower-respiratory-disorders - lung cancer and chest tubes (same week)
• INDEX - NSG210 chapter index
• nsg210-textbook-chapter-crosswalk