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Principles of Cancer Treatment

• Aims to prevent cancer from spreading locally or recurring/ relapsing at sites distant from the original location.

Treatments
• • • • • • • • Surgery Radiation Therapy Hormonal Therapy Targeted Therapy Antibodies Cancer Vaccines Complimentary and Alternative Medicines Chemotherapy

Treatment Modalities
A. Loco- Regional Treatment 1. Surgery 2. Radiation Therapy B. Systemic Treatment 1. Cytotoxic Chemotherapy 2. Hormonal, Biologic Therapy

I. Loco- Regional Treatment

I. SURGERY
• A local treatment used to remove visible tumors. Purposes:
– Diagnosis – Cure – Control – Palliation

Types of Treatment
• Local Excision- simple surgery with small margin of normal tissue surrounding tumor.

• En bloc Dissection- removal of tumor, tissues, and any contiguous structures.

Surgery on Cancer in Situ
• Electrosurgery- application of electrical current to cancerous cells • Cryosurgery- deep freezing with liquid nitrogen • Chemosurgery- applied chemotherapeutic agents layer by layer with surgical incision. • Co2 laser- use of laser for laser excision.

II. Radiation Therapy
• The use of high- energy ionizing rays to treat a variety of cancers. • Destroys the cell’s ability to reproduce by damaging the cell’s DNA. • Rapidly dividing cells are more vulnerable to radiation than are slower dividing cells.

Biological Effects of Radiation on living cells
• Cells experience DNA damage and are able to detect and repair the damage. • Cells experience DNA damage and are unable to repair the damage. These cells may go through the process of programmed cell death, thus eliminating the potential genetic damage from the larger tissue. • Cells experience a nonlethal DNA mutation that is passed on to subsequent cell divisions. This mutation may contribute to the formation of a cancer.

Pre- operative Radiation Therapy
• It can kill tumor cells at margins of the tumor site. • It can keep the cancer under control and prevent metastases, and also convert technically inoperable tumors into operable ones.

Postoperative Radiation
• It can destroy cancer cells still present around the margins after a tumor has been surgically removed.

Types Of Radiation Therapy
1. External Radiation Therapy 2. Internal Radiation Therapy

External Radiation
• It utilizes a machine to deliver radiation to the tumor. • This therapy is primarily an outpatient treatment. • Series of daily radiation exposure as patient is left alone in a room. • Also called as Teletherapyexternal source of radiation. ( machine is a distance from client)

External Radiation: Nursing Care
• • • • Marks must not remove Keep the skin dry Talcum and Lotions are contraindicated Avoid strong sunlight, extremes temperature, constricting clothes. • No Eating (NPO) • Patient is not the SOURCE of Radiation after the procedure.

Internal Radiation
• Is the process of implanting radioactive material onto or near the tumor or placing radioactive sources into the body. • Implantation of radioactive substance within a client. • It can be temporary or permanent. • Also called Brachytherapy

Types of Internal Radiation Therapy
Sealed Source RT ( Brachytherapy) Un Sealed- Source RT

Sealed- Source RT
• Sealed radiation source is placed in a cavity or adjacent to cancer. • Ex: Radium, Iridium, Cesium

Sealed- Source RT
• INTRACAVITARY Therapy
• Radioisotope is placed into an applicator, then placed into the body cavity for a carefully calculated time (usually 24 – 72 H)

Ex: Radioisotopes: Celsium 137 Radium 226

Sealed – Source of RT
INTERSTITIAL THERAPY • Radioisotope of choice is placed into needles, beads, seeds, ribbons or catheters and then implanted directly into the tumor. • Implants may be left in the tumor temporarily or permanently. • Ex: Iridium 192, Iodine 125, Celsium 137, Gold 198, Radon 222

UNSEALED –SOURCE RT
• Used in Systemic therapy. • Source of Radiation is given orally, intravenously. • PO Administration: Low dose: Graves Disease
131I High Dose: Thyroid Ca

• IV Administration: 32p Treats Polycythemia Vera

Nursing Care Highlight Care of the Client with Sealed Implants of Radioactive Sources

• Assign the client to a private room, with private bath. • Place “Caution: Radioactive Material” sign on the door of the clients room. • Pregnant nurses should not care for these clients; do not allow children younger than 16 and pregnant women to visit.

• Limit each visitor to ½ hour per day • Never touch the radioactive material with bare hands • Save all dressings and bed linens until after the radioactive source is removed.

RADIATION SAFETY

Three factors which determine the total exposure one receives in a given radiation field are:

1. Time of exposure. 2. Distance from Source. 3. Amount of shielding present.

TIME
The Shortest Possible Time

• The less time you spend near a source, the less radiation you will receive

DISTANCE
• As far as possible ( can spend more time at a distance of 20 feet) • The farther you get from a source, the less radiation you will receive.

SHIELDS
Protective Lead Apron
• The more shielding you have, the less radiation you will receive.

II. SYSTEMIC TREATMENT
HORMONAL THERAPY • Fights cancer by • altering the amounts of hormones in the body. • BIOLOGIC TREATMENTS Referred to by many terms including: Immunologic therapy, Immunotherapy, biotherapy. (Interferon, Interleukin) Often used to help restore the functioning of the immune system. • Stimulates the disease- fighting ability of the body.

CHEMOTHERAPY
• The use of powerful drugs to:
– Kill Cancer Cells – Control their Growth – Relieve Pain Symptoms

CHEMOTHERAPY
• A systemic treatment. • Directly or indirectly disrupts reproduction of cells by altering essential biochemical processes. • The desired outcome is control or eradication of all malignant cells.

Types of Chemotherapy

1. Primary Chemotherapy The use chemotherapy alone for the cure of a specific tumor. 2. Adjuvant Chemotherapy The use of chemotherapy after primary, loco –regional treatment, with the intent of decreasing the relapse rate and improving survival.

3. Neo- adjuvant Chemotherapy The use of chemotherapy before locoregional treatment with the intent of decreasing tumor size enhancing chances for resectability and preservation of normal structures. 4. Concurrent Chemotherapy The use of chemotherapy combined with radiotherapy in order to increase local response and control systemic spread.

5. Palliative Chemotherapy The use of chemotherapy in advanced malignancies, the intent of which is not cure but control of the disease and tumor related symptoms.

Types of Chemotherapy Drugs
• • • • Antimetabolites Genotoxic Drugs Spindle Inhibitors Other Chemotherapy Agents

Anti- Metabolites
• Drugs that interfere with the formation of key bio-molecules within the cell including nucleotides, the building blocks of DNA. • These drugs ultimately interfere with DNA replication and therefore cell division.

Types of Anti- metabolites
• Folate Antagonists • Purine Antagonists • Pyrimidine Antagonists

Folate Antagonist
• also known as antifolates • It inhibit dihydrofolate reductase (DHFR), an enzyme involved in the formation of nucleotides. • When this enzyme is blocked, nucleotides are not formed, disrupting DNA replication and cell division • Methotrexate and Pemetrexed

Purine Antagonists
• It function by inhibiting DNA synthesis • 6-Mercaptopurine, Dacarbazine, Fludarabine

Pyrimidine Antagonists
 act to block the synthesis of pyrimidine containing nucleotides (C and T in DNA; C and U in RNA).  The drugs used to block the construction of these nucleotide have structures that are similar to the natural compound.

• By acting as 'decoys', these drugs can prevent the production of the finished nucleotides. They may exert their effects at different steps in that pathway and may directly inhibit crucial enzymes.
– – – – – 5-fluorouracil Arabinosylcytosine Capecitabine Gemcitabine Decitabine

Genotoxic Drugs
• Drugs that damage DNA. By causing DNA damage, these agents interfere with DNA replication, and cell division • 3 Treatments:
– Alkylating Agents – Intercalating Agents – Enzyme Inhibitors

The genotoxic chemotherapy treatments include:
Alkylating agents: • The first class of chemotherapy agents used. These drugs modify the bases of DNA, interfering with DNA replication and transcription and leading to mutations

Intercalating agents • These drugs wedge themselves into the spaces between the nucleotides in the DNA double helix. They interfere with transcription, replication and induce mutations. Enzyme inhibitors • These drugs inhibit key enzymes, such as topoisomerases, involved in DNA replication inducing DNA damage.

Spindle Inhibitors
• These agents prevent proper cell division by interfering with the cytoskeletal components that enable one cell to divide into two. • Vinca Alkaloids Paclitaxel (Taxol®) Docetaxel (Taxotere®) Ixabepilone (Ixempra®)

Additional Chemotherapy Agents
• Drugs that work through mechanisms that do not neatly fit into one of thecategories. • Arsenic trioxide (Trisenox®) Bleomycin Hydroxyurea Streptozocin

Chemotherapeutic Administration
• • • • • • • Oral IM/ SQ IV Central Venous Catheter Venous Access Devices (VAD) Intraarterial Route Intraperitoneal Route

Chemo Drugs Doxurubicin Cyclophosphamide Vincristine

Major Side Effects Cardiotoxicity Hemorrhagic Cystitis Peripheral Neuropathy

Nursing Interventions Monitor VS & HR Encourage OFI, unexpected bleeding, hematuria or dysuria. Tell the client to report numbness or tingling in finger and toes.

F- Asparaginase

Allergic Reactions

Skin test to assess allergic reaction before first use. Watch for signs of anaphylactic shock.

Terms related to Chemotherapy Drugs
IRRITANTS Drugs that are capable of producing pain at the IV site or along the vein, with or without inflammatory reaction. EXTRAVASATION Escape of agents from a vein to a tissue

NON VESICANTS Drugs that can be given by IV bolus through the side arm of free flowing IV containing no additives. VESICANTS Drugs that are capable of causing blister formation and tissue destruction.

STEM CELL TRANSPLANTATION

STEM CELLS
• Stem cells are able to grow into other blood cells that mature and function as needed in the body. • Stem cells create the three main types of blood cells:
– red blood cells – white blood cells – platelets

Where are stem cells located?
• Bone marrow (the spongy center of the bone where blood cells are made) • Peripheral blood (found in blood vessels throughout the body) • Cord blood (found in the umbilical cord and collected after a baby’s birth)
Stem cells for transplantation are obtained from any of these three places.

STEM CELL TRANSPLANT
• Is a process that takes healthy stem cells from a donor and gives them to the patient through a central line.

Types of Stem Cell Transplants
• Bone marrow transplants are those that are obtained from the bone marrow • Peripheral blood stem cell (PBSC) transplants are obtained from the peripheral blood. • Cord blood transplants refer to transplants where the stem cells are obtained from umbilical cord blood.

Stem cell transplants are further categorized based on the donor who provides the stem cells. Autologous stem cell transplants (autografts) - It refer to stem cells that are collected from an individual and given back to that same individual.

Allogeneic stem cell transplants (allografts)
• It refer to stem cells that are taken from one person and given to another.

Syngeneic Stem Cell Transplants
• It refer to stem cells that are taken from an identical twin of the recipient. These types of transplants are quite rare

Transplant Care

THE CANCER PAIN PROBLEM

PAIN
In cancer is the most feared and distressing symptom of the disease.

THE CANCER PAIN PROBLEM
• WHO reveals that everyday at least 4 million people suffer from cancer pain. • 30 – 50% of cancer patients undergoing treatment, and up to 95% of patients with advanced disease, suffer from pain. • More than 50% of patients still suffered from unrelieved cancer pain.

WHO: 3 Step Analgesic Ladder For Cancer Pain Management Basic Principles: • BY THE MOUTH If the patient can swallow, oral administration is the route of choice.

• BY THE CLOCK Analgesics should be given regularly and prophylactically. • BY THE LADDER Use a few drugs well than many badly.

3 Medications for Pain Ladder
• Non- Opoid Analgesics • Opoid Analgesics • Adjuvant Drugs

• “There is an UPPER LIMIT to how effective they are.” • “DO NOT have an upper limit of effectiveness.”

• Step I For patients with mild to moderate pain, the use of non-opioids is the treatment of choice. These may or may not be combined with adjuvant drugs (drugs that are used to hasten or add to the primary mode of treatment). • Step II For patients with moderate pain, who did not feel relief after using only non-opioids, a combination of opioids and non-opioids should be tried. Again, adjuvants may or may not be used. • Step III For moderate to severe pain, opioids should be used, with or without non-opioids, and with or without adjuvants.

WHO Three-Step Analgesic Ladder

Cancer : Management
• • • • • • C – Comfort A- Altered Body Image N – Nutrition C – Chemotherapy E- Evaluate the Response in Treatment R - Rest

SUMMARY
• Early detection and screening of high risk individuals play significant roles in treating cancer. • Patient and family caregivers should be involved in all aspects of nursing care. • Various treatment modalities are available to cure, control and palliate cancer.

• Safety Standards of treatment must always implemented. • Life long surveillance for recurrence after treatment.

THANK YOU!

• If pain occurs, there should be prompt oral administration of drugs in the following order: nonopioids (aspirin and paracetamol); then, as necessary, mild opioids (codeine); then strong opioids such as morphine, ntil the patient is free of pain. To calm fears and anxiety, additional drugs – “adjuvants” – should be used. To maintain freedom from pain, drugs should be given “by the clock”, that is every 36 hours, rather than “on demand” This three-step approach of administering the right drug in the right dose at the right time is inexpensive and 80-90% effective. Surgical intervention on appropriate nerves may provide further pain relief if drugs are not wholly effective.