Lung Cancer

      

Also called bronchogenic cancer. It is a malignant tumor of the lung arising within the bronchial wall or epithelium. Bronchogenic cancer is classified according to cell type: epidermoid (squamous cell most common), adenocarcinoma, small cell (oat cell) carcinoma, and large cell (undifferentiated) carcinoma. The lung is also a common site of metastasis from cancer elsewhere in the body through venous circulation or lymphatic spread. The primary predisposing factor in lung cancer is cigarette smoking. Lung cancer risk is also high in people occupationally exposed to asbestos, arsenic, chromium, nickel, iron, radioactive substances, isopropyl oil, coal tar products, and petroleum oil mists. Complications include superior vena cava syndrome, hypercalcemia (from bone metastasis), syndrome of inappropriate antidiuretic hormone (SIADH), pleural effusion, pneumonia, brain metastasis, and spinal cord compression.

ASSESSMENT New or changing cough, dyspnea, wheezing, excessive sputum production, hemoptysis, chest pain (aching, poorly localized), malaise, fever, weight loss, fatigue, or anorexia.  Decreased breath sounds, wheezing, and possible pleural friction rub (with pleural effusion) on examination.

DIAGNOSTIC EVALUATION Chest X-ray may be suspicious for mass; CT or position emission tomography scan will be better visualize tumor.  Sputum and pleural fluid samples for cytologic examination may show malignant cells.  Fiberoptic bronchoscopy determines the location and extent of the tumor and may be used to obtain a biopsy specimen.  Lymph node biopsy and mediastinoscopy may be ordered to establish lymphatic spread and help plan treatment.  Pulmonary function test, which may be combined with a split-function perfusion scan, determines if the patient will have adequate pulmonary reserve to withstand surgical procedure.


PHARMACOLOGIC INTERVENTIONS Expectorants and antimicrobial agents to relieve dyspnea and infection.  Analgesics given regularly to maintain pain at tolerable level. Titrate dosages to achieve pain control.  Chemotherapy using cisplatin in combination with a variety of other agents and immunotherapy treatments may be indicated.


SURGICAL INTERVENTIONS Resection of tumor, lobe, or lung.

THERAPEUTIC INTERVENTIONS Oxygen through nasal cannula based on level of dyspnea. Enteral or total parenteral nutrition for malnourished patient who is unable or unwilling to eat. Removal of the pleural fluid (by thoracentesis or tube thoracostomy) and instillation of sclerosing agent to obliterate pleural space and fluid recurrence.  Radiation therapy in combination with other methods.
  

NURSING INTERVENTIONS 1. Elevate the head of the bed to ease the work of breathing and to prevent fluid collection in upper body (from superior vena cava syndrome). 2. Teach breathing retraining exercises to increase diaphragmatic excursion and reduce work of breathing. 3. Augment the patients ability to cough effectively by splinting the patients chest manually. 4. Instruct the patient to inspire fully and cough two to three times in one breath. 5. Provide humidifier or vaporizer to provide moisture to loosen secretions. 6. Teach relaxation techniques to reduce anxiety associated with dyspnea. Allow the severely dyspneic patient to sleep in reclining chair. 7. Encourage the patient to conserve energy by decreasing activities. 8. Ensure adequate protein intake such as milk, eggs, oral nutritional supplements; and chicken, fowl, and fish if other treatments are not tolerated to promote healing and prevent edema. 9. Advise the patient to eat small amounts of high-calorie and high-protein foods frequently, rather than three daily meals. 10. Suggest eating the major meal in the morning if rapid satiety is the problem. 11. Change the diet consistency to soft or liquid if patient has esophagitis from radiation therapy. 12. Consider alternative pain control methods, such as biofeedback and relaxation methods, to increase the patients sense of control. 13. Teach the patient to use prescribed medications as needed for pain without being overly concerned about addiction.

BREAST CANCER
      

Is the leading type of cancer in women.Most breast cancer begins in the lining of the milk ducts, sometimes the lobule. The cancer grows through the wall of the duct and into the fatty tissue. Breast cancer metastasizes most commonly to auxiliary nodes, lung, bone, liver, and the brain. The most significant risk factors for breast cancer are gender (being a woman) and age (growing older). Other probable factors include nulliparity, first child after age 30, late menopause, early menarche, long term estrogen replacement therapy, and benign breast disease. Controversial risk factors include oral contraceptive use, alcohol use, obesity, and increased dietary fat intake. About 90% of breast cancers are due not to heredity, but to genetic abnormalities that happen as a result of the aging process and life in general.

A womans risk of breast cancer approximately doubles if she has a first-degree relative (mother, sister, daughter) who has been diagnosed with breast cancer. About 20-30% of women diagnosed with breast cancer have a family history of breast cancer.

ASSESSMENT A firm lump or thickness in breast, usually painless; 50% are located in the upper outer quadrant of the breast.  Spontaneous nipple discharge; may be bloody, clear or serous.  Asymmetry of the breast may be noted as the woman changes positions; compare one breast with the other.  Nipple retraction or scalliness, especially in Pagets disease.  Enlargement of auxiliary or supraclavicular lymph nodes may indicate metastasis.


DIAGNOSTIC EVALUATION Mammography (most accurate method of detecting non-palpable lesions) shows lesions and cancerous changes, such as microcalcification. Ultrasonography may be used to distinguish cysts from solid masses.  Biopsy or aspiration confirms diagnosis and determines the type of breast cancer.  Estrogen or progesterone receptor assays, proliferation or S phase study (tumor aggressive), and other test of tumor cells determine appropriate treatment and prognosis.  Blood testing detects metastasis; this includes liver function tests to detect liver metastasis and calcium and alkaline phosphatase levels to detect bony metastasis.  Chest x-rays, bone scans, or possible brain and chest CT scans detect matastasis.

PHARMACOLOGIC INTERVENTIONS 1. Chemotherapy is the primary used as adjuvant treatment postoperatively ; usually begins 4 weeks after surgery (very stressful for a patient who just finished major surgery).  Treatments are given every 3 to 4 weeks for 6 to 9 months. Because the drugs differ in their mechanisms of action, various combinations are used to treat cancer.  Principal breast cancer drugs include cyclosphosphamide, methotrexate, fluorouracil, doxorubicin, and paclitaxel.  Additional agents for advanced breast cancer include docetaxel, vinorelbine, mitoxantrone, and fluorouracil.  Herceptin is a monoclonal antibody directed against Her-2/neu oncogene; may be effective for patients who express this gene 2. Indications for chemotherapy include large tumors, positive lymph nodes, premenopausal women, and poor prognostic factors. 3. Chemotheraphy is also used as primary treatment in inflammatory breast cancer and as palliative treatment in metastatic disease or recurrence. 4. Anti-estrogens, such as tamoxifen, are used as adjuvant systemic therapy after surgery. 5. Hormonal agents may be used in advanced disease to induce remissions that last for months to several years. SURGICAL INTERVENTIONS 1. Surgeries include lumpectomy (breast-preventing procedure), mastectomy (breast removal), and mammoplasty (reconstructive surgery). 2. Endocrine related surgeries to reduce endogenous estrogen as a palliative measure. 3. Bone marrow transplantation may be combined with chemotherapy.

NURSING INTERVENTIONS 1. Monitor for adverse effects of radiation therapy such as fatigue, sore throat, dry cough, nausea, anorexia. 2. Monitor for adverse effects of chemotherapy; bone marrow suppression, nausea and vomiting, alopecia, weight gain or loss, fatigue, stomatitis, anxiety, and depression. 3. Realize that a diagnosis of breast cancer is a devastating emotional shock to the woman. Provide psychological support to the patient throughout the diagnostic and treatment process. 4. Involve the patient in planning and treatment. 5. Describe surgical procedures to alleviate fear. 6. Prepare the patient for the effects of chemotherapy, and plan ahead for alopecia, fatigue. 7. Administer antiemetics prophylactically, as directed, for patients receiving chemotherapy. 8. Administer I.V. fluids and hyperalimentation as indicated. 9. Help patient identify and use support persons or family or community. 10. Suggest to the patient the psychological interventions may be necessary for anxiety, depression, or sexual problems. 11. Teach all women the recommended cancer-screening procedures.

PROSTATE CANCER
 

  

Is the second leading cause of carcinoma in men older than age 65. The cause of the prostate cancer is unknown; there is an increased risk for people with a family history of the disease, and the influence of dietary fat, serum testosterone, vasectomy, and industrial toxins is under investigation. Most prostate cancers are adenocarcinoma and are palpable on rectal examination because they are arise form the posterior portion of the gland. Prostate cancer usually multifocal, slow growing, and can spread by local extension, by lymphatics or through the bloodstream. Complications include bone metastasis leading to vertebral collapse, spinal cord compression, and pathologic fractures, or spread to urinary tract to pelvic lymph nodes.

Assessment 1. First symptoms are caused by obstructed urinary flow, including hesitancy and straining on voiding, frequency, nocturia, reduced size and force of urinary stream. 2. A firm to hard nodule may be felt on rectal examination of the prostate. 3. Pain in lumbosacral area radiating to hips and down leg (from bone metastases). 4. Perineal and rectal discomforts. 5. Anemia, weight loss, weakness, nausea, oliguria (from uremia). 6. Hematuria 7. Low extremity edema occurs when pelvic node metastases compromise when venous return. Diagnostic Evaluation 1. Needle biopsy (through anterior rectal wall or through perineum) for histologic study of biopsy tissue or aspiration for cytologic study. 2. Transrectal ultrasonography delineates tumor. 3. Prostate-specific antigen (PSA)

4. Metastatic workup may include skeletal x-ray, bone scan, and CT or MRI to detect local extension, bone, and lymph node involvement. Therapeutic Interventions 1. In many patients older than age 70, no treatment may be indicated because the cancer may be slow growing and will not be the cause of death. Instead, the patients should be followed closely with periodic serum PSA testing and examined for evidence of metastasis. 2. In advanced prostatic cancer not responsive to treatment, palliative measures include analgesics and opioids to relieve pain, short course of radiation therapy and transurethral resection of the prostate. 3. Extreme beam radiation using linear accelerator focused on the prostate. 4. Interstitial radiation (brachytherapy). Pharmacologic Interventions 1. Hormone manipulation deprives tumor cells of androgens or their by products and thereby alleviates symptoms and retards progress of disease. 2. Analogs of luteinizing hormone-releasing hormone (LNRH), such as leuprolide, reducetestosterone levels. 3. Antiandrogen drugs that blocks androgen action directly at the target tissues and block androgen synthesis within the prostate gland. 4. Combination therapy with LHRH analogs and flutamide blocks the action of all circulating androgen. 5. Complications of hormonal manipulation include hot flashes, nausea, and vomiting, gynecomastia, and sexual dysfunction. Surgical Interventions 1. Radical prostatectomy removal of entire prostate gland, prostatic capsule, and seminal vesicles, may include pelvic lymphadenectomy. 2. Cryosurgery freezes prostate tissue, killing tumor cells without prostatectomy. 3. Bilateral orchiectomy (removal of testes) result in reduction of the major circulating androgen, testosterone, as a palliative measure to reduce symptoms and progression. Nursing Interventions 1. Assess pain control. Make sure that the patient is not undermedicated. 2. Teach relaxation techniques such as imagery, music therapy, and progressive muscle relaxation as adjunct to pain control. 3. Employ safety measures to prevent pathologic fractures, such as prevention of falls if bone metastasis is present. 4. To reduce anxiety, give repeated explanations of diagnostic tests and treatment options, and help the patient gain some feeling of control over disease and decisions. 5. To help achieve optimal sexual function, give the patient the opportunity to communicate his concerns and sexual needs. 6. Inform the patient that decreased libido expected after hormonal manipulation therapy, and that impotence may result from some surgical procedures and radiation. 7. Suggest options such as sexual counseling, learning other options of sexual expression, and consideration of penile implant. 8. Emphasize the importance of follow-up for check of PSA levels and evaluation for disease progression. 9. Teach the patient to administer hormonal agents intramuscularly or subcutaneously as indicated. 10. If bone metastasis has occurred, encourage safely measures around the home to prevent pathologic fractures, such as removal of throw rugs, using handrail on stairs, and using nightlights.

11. Advise the patient to report symptoms of worsening urethral obstruction, such as increased frequency, urgency, hesitancy, and urinary retention. 12. Encourage all men to seek medical screening for prostate cancer.