Definitions	Percentage	Criteria
Able to carry on normal activity and to work; no special care needed	100	Normal; no complaints; no evidence of disease
	90	Ability to carry on normal activity; minor signs or symptoms of disease
	80	Normal activity with effort; some signs or symptoms of disease
Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed	70	Ability to care for self; inability to carry on normal activity or do active work
	60	Occasional assistance necessary but ability to care for most needs
	50	Considerable assistance and frequent medical care necessary
Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly	40	Disabled; special care and assistance necessary
	30	Severely disabled; indication for hospitalization although death not imminent
	20	Very sick; hospitalization necessary; active supportive treatment necessary
	10	Moribund; fatal processes progressing rapidly
	0	Dead

The Karnofsky Performance Scale Index allows patients to be classified as to their functional impairment. This can be used to compare effectiveness of different therapies and to assess the prognosis in individual patients. The lower the Karnofsky score, the worse the survival for most serious illnesses.

eTABLE 16-2

KATZ INDEX OF INDEPENDENCE IN ACTIVITIES OF DAILY LIVING

Activities	Independence	Dependence
Points (1 or 0)	(1 Point) NO supervision, direction, or personal assistance	(0 Points) WITH supervision, direction, personal assistance, or total care
Bathing	(1 POINT) Bathes self completely or needs help in bathing only a single part of the body such as the back, genital area, or disabled extremity.	(0 POINTS) Needs help with bathing more than one part of the body, getting in or out of the tub or shower. Requires total bathing.
points:_______
Dressing	(1 POINT) Gets clothes from closets and drawers and puts on clothes and outer garments complete with fasteners. May have help tying shoes.	(0 POINTS) Needs help with dressing self or needs to be completely dressed.
points:_______
Toileting	(1 POINT) Goes to toilet, gets on and off, arranges clothes, cleans genital area without help.	(0 POINTS) Needs help transferring to the toilet or cleaning self, or uses bedpan or commode.
points:_______
Transferring	(1 POINT) Moves in and out of bed or chair unassisted. Mechanical transferring aides are acceptable.	(0 POINTS) Needs help in moving from bed to chair or requires a complete transfer.
points:_______
Continence	(1 POINT) Exercises complete self-control over urination and defecation.	(0 POINTS) Is partially or totally incontinent of bowel or bladder.
points:_______
Feeding	(1 POINT) Gets food from plate into mouth without help. Preparation of food may be done by another person.	(0 POINTS) Needs partial or total help with feeding or requires parenteral feeding.
points:_______
TOTAL POINTS = _______ 6 = High (patient independent) 0 = Low (patient very dependent)

Slightly adapted from Katz S, Down TD, Cash HR, et al: Progress in the development of the index of ADL, Gerontologist 10:20, 1970.

eTABLE 16-3

SCREENING GUIDELINES FOR EARLY DETECTION OF CANCER IN ASYMPTOMATIC PEOPLE

Site	Recommendation
Breast	• Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health. • Clinical breast examination (CBE) about every 3 years for women in their 20s and 30s and every year for women 40 and over. • Women should know how their breasts normally look and feel and report any breast change promptly to their health care providers. • Breast self-examination (BSE) is an option for women, starting in their 20s. • Some women—because of their family history, a genetic tendency, or certain other factors—should be screened with MRI in addition to mammograms. (The number of women who fall into this category is small: less than 2% of all the women in the United States.) Talk with your health care provider about your history and whether you should have additional tests at an earlier age.
Colon and rectum	Beginning at age 50, both men and women should follow one of these testing schedules.
	Tests That Find Polyps and Cancer • Flexible sigmoidoscopy every 5 years,* or • Colonoscopy every 10 years, or  • Double contrast barium enema every 5 years,* or   • CT colonography (virtual colonoscopy) every 5 years *
	Tests That Primarily Find Cancer • Fecal occult blood test (gFOBT) every year,† or • Fecal immunochemical test (FIT) every year †
	The tests that are designed to find both early cancer and polyps are preferred if these tests are available to you and you are willing to have one of these more invasive tests. Talk to your health care provider about which test is best for you. Some people should be screened using a different schedule because of their personal history or family history. Talk with your health care provider about your history and what colorectal cancer screening schedule is best for you.
Cervix	• Cervical cancer screening (testing) should begin at age 21. Women under age 21 should not be tested. • *Women between ages 21 and 29* should have a Pap test every 3 years. Now there is also a test called the HPV test. HPV testing should not be used in this age group unless it is needed after an abnormal Pap test result. • *Women between the ages of 30 and 65* should have a Pap test plus an HPV test (called “co-testing”) every 5 years. This is the preferred approach, but it is also OK to have a Pap test alone every 3 years. • *Women over age 65* who have had regular cervical cancer testing with normal results should not be tested for cervical cancer. Once testing is stopped, it should not be started again. Women with a history of a serious cervical precancer should continue to be tested for at least 20 years after that diagnosis, even if testing continues past age 65. • *A woman who has had her uterus removed (and also her cervix)* for reasons not related to cervical cancer and who has no history of cervical cancer or serious precancer should not be tested. • *A woman who has been vaccinated against HPV* should still follow the screening recommendations for her age group. • Some women—because of their history—may need to have a different screening schedule for cervical cancer.
Endometrium	• The American Cancer Society recommends that at the time of menopause, all women should be informed about the risks and symptoms of endometrial cancer. Women should report any unexpected bleeding or spotting. • Some women—because of their history—may need to consider having a yearly endometrial biopsy. Please talk with your health care provider about your history.
Prostate	• The American Cancer Society recommends that men make an informed decision with their health care provider about whether to be tested for prostate cancer. Research has not yet proven that the potential benefits of testing outweigh the harms of testing and treatment. The American Cancer Society believes that men should not be tested without learning about what we know and don’t know about the risks and possible benefits of testing and treatment. • Starting at age 50, men should talk to a health care provider about the pros and cons of testing so they can decide if testing is the right choice for them. If they are African American or have a father or brother who had prostate cancer before age 65, men should have this talk starting at age 45. If men decide to be tested, they should have the PSA blood test with or without a rectal exam. How often they are tested will depend on their PSA level.

^*Colonoscopy should be done if test results are positive.

^†For FOBT or FIT used as a screening test, the take-home multiple sample method should be used. An FOBT or FIT performed during a digital rectal examination in the health care provider’s office is not adequate for screening.

Source: American Cancer Society Guidelines for the early detection of cancer. Available at www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer.

TABLE 16-4

FOUR Rs OF RADIOBIOLOGY

The principles of radiotherapy dosing and fractionation are guided by the biologic dynamics of cellular response to radiation.

Principle	Description
Repair	• Refers to the ability of cells to repair sublethal damage in the time interval between fractions. • Dictates that an adequate amount of time between fractions must be allowed for healthy cells to recover (e.g., at least 6 hours).
Repopulation	• Observation of accelerated cellular proliferation in response to radiation injury. • Risk of tumor regrowth during periods of treatment interruption after therapy has been initiated.
Reassortment (redistribution)	• Shifting of more cells within the population from asynchronous cell cycle phases to more synchronous cell cycle phases. • These more sensitive cells in the proliferative phases are preferentially killed by radiation.
Reoxygenation	• Refers to the redistribution of blood flow and oxygen to hypoxic cells as better oxygenated cells are preferentially killed. • Presence of oxygen within the nucleus of the cell at the time radiation is delivered is necessary for the generation of free radicals that induce cell death. • Tumor cells may have varying degrees of oxygenation, with many cells being relatively hypoxic for several reasons, including tumor burden, vascular supply, or metabolic state.

eTABLE 16-5

USES OF RADIATION THERAPY

Use	Description
Definitive or primary therapy	• Used as an independent treatment modality with curative intent (e.g., for cancers of the lung, prostate, bladder, and head/neck)
Neoadjuvant therapy	• Given (with or without chemotherapy) preoperatively to minimize tumor burden and improve the likelihood of complete surgical resection • A previously inoperable tumor (such as one adjacent to a critical structure) can be made operable (e.g., lung, esophageal, or colorectal cancers)
Adjuvant therapy	• Administered following surgery or chemotherapy to improve local control of disease and reduce risk of local disease recurrence (e.g., glioblastoma, cancers of the breast, lung, rectum, pancreas)
Prophylaxis	• Administered to high-risk areas to prevent future cancer development (e.g., prophylactic cranial irradiation to prevent brain metastasis secondary to small-cell lung cancer)
Disease control	• Limiting tumor growth to extend the symptom-free period as much as possible
Palliation	• Given to prevent or relieve distressing symptoms such as pain (bone metastasis) or shortness of breath (obstructing bronchial tumor) • Given to preserve neurologic function (brain metastasis or spinal cord compression)

eTABLE 16-6

PRECAUTIONS TO MINIMIZE RISKS FROM NEUTROPENIA

Personal Hygiene

• Wash hands often with an antibacterial soap, especially before eating, after using the washroom, and shaking hands.

• Bathe daily, and lightly pat the skin dry.

• Use moisturizer to prevent dry skin.

• Clean rectal area thoroughly after bowel movements. Women: Clean perianal area front to back.

• Be careful with grooming (e.g., cutting nails). Do not tear or cut cuticles; use cuticle cream and remover.

• Use a clean electric razor instead of a disposable or safety razor.

• Do not squeeze or scratch blemishes.

• Women: Use sanitary napkins, not tampons, to reduce infection risk. Avoid vaginal douche, bubble baths, and bath salts.

Safety

• Avoid people with colds, flu, open sores, or any type of infection.

• Avoid crowded, enclosed public areas.

• Avoid sunburn.

• Wear shoes to prevent cuts.

• Protect hands from cuts or burns.

• Avoid rectal thermometers or suppositories.

• Discuss vaccination with your physician. People receiving chemotherapy should avoid contact with anyone who has recently received a live vaccine.

Household

• Have everyone remove their shoes when entering your home.

• Avoid contact with animal stool or urine as well as stagnant water (e.g., vases, humidifiers, denture cups).

• Have furnace and ducts cleaned once or twice a year, as required; have filters replaced monthly.

• Dry-clean outerwear frequently.

Nutrition

• A proper diet is important. Ensure that food is cooked adequately.

• Avoid constipation; follow a diet with plenty of fiber.

Oral and Dental Hygiene

• Always use a soft toothbrush to prevent cuts in your mouth.

• Do not use dental floss.

• Rinse mouth often and well. Avoid commercial mouthwashes (very drying) and products that contain alcohol.

• Clean dentures with fresh water.

• Discuss any required or scheduled dental work first with your physician before proceeding.

• Antibiotic treatment is also recommended before and after any dental work or cleaning.

Lifestyle

• Exercise regularly and get plenty of rest. Limit activities that tire you easily.

• Learn how to deal with your stress. Discuss your fears and feelings with family, support groups, and health care professionals.

• Learn as much as you want to know about your disease. Remember that knowledge is the best enemy of fear.

Source: Neutropenia Support Association. Available at http://www.neutropenia.ca/about/living.html.

eTABLE 16-7

DRUG THERAPY
Biologic and Targeted Therapy (Enhanced)

Drug	Mechanism of Action	Indications	Side Effects
α-interferon (Roferon-A, Intron A)	Inhibits DNA and protein synthesis Suppresses cell proliferation Increases cytotoxic effects of natural killer (NK) cells	Hairy cell leukemia, chronic myelogenous leukemia, malignant melanoma, renal cell carcinoma, ovarian cancer, multiple myeloma, Kaposi sarcoma	Flu-like syndrome (fever, chills, myalgia, headache), cognitive changes, fatigue, nausea, vomiting, anorexia, weight loss
interleukin-2 (aldesleukin [Proleukin])	Stimulates proliferation of T and B cells Activates NK cells	Metastatic renal cell cancer, metastatic melanoma	Same as above; capillary leak syndrome resulting in hypotension; bone marrow suppression
BCG vaccine (TheraCys)	Induces an immune response that prevents angiogenesis of tumor	In situ bladder cancer	Flu-like syndrome, nausea, vomiting, rash, cough
Epidermal Growth Factor Receptor (EGFR)—Tyrosine Kinase (TK) Inhibitors
cetuximab (Erbitux)	Inhibits EGFR	Colorectal cancer, head and neck cancer	Rash, infusion reactions, interstitial lung disease
panitumumab (Vectibix)	Inhibits EGFR	Colorectal cancer	Pulmonary fibrosis, severe skin rash complicated with infections, infusion reactions, interstitial lung disease
erlotinib (Tarceva)	Inhibits EGFR-TK	Non–small cell lung cancer, advanced pancreatic cancer	Rash, diarrhea, interstitial lung disease
gefitinib (Iressa)	Inhibits EGFR-TK	Non–small cell lung cancer	Rash, diarrhea, interstitial lung disease
lapatinib (Tykerb)	Inhibits EGFR-TK and binds receptor HER-2	Advanced breast cancer that is HER-2 positive	Cardiotoxicity, diarrhea, rash, nausea, vomiting, hand-foot syndrome
BCR-ABL Tyrosine Kinase Inhibitors
imatinib (Gleevec)	Inhibits BCR-ABL tyrosine kinase	Chronic myeloid leukemia, GI stromal tumors (GIST)	Nausea, diarrhea, myalgia, fluid retention
nilotinib (Tasigna)	Inhibits BCR-ABL tyrosine kinase	Chronic myeloid leukemia	Neutropenia, thrombocytopenia, bleeding, nausea, fatigue, elevated lipase level, fever, rash, pruritus, diarrhea, pneumonia
dasatinib (Sprycel)	Inhibits BCR-ABL tyrosine kinase	Chronic myeloid leukemia	Myelosuppression, CNS or GI hemorrhage, fever, pleural effusion, pneumonia, cardiac failure, fluid retention, abdominal pain
CD20 Monoclonal Antibodies
rituximab (Rituxan)	Binds CD20 antigen, causing cytotoxicity	Non-Hodgkin’s lymphoma (B cell)	Fever, chills, nausea, headache, urticaria
ofatumumab (Arzerra)	Binds CD20 antigen, causing cytotoxicity	Chronic lymphocytic leukemia	Increased risk for infection
ibritumomab tiuxetan/yttrium-90 (Zevalin)	Binds CD20 antigen, causing cytotoxicity and radiation injury	Non-Hodgkin’s lymphoma (B cell)	Bone marrow suppression, fatigue, nausea, chills
tositumomab/¹³¹I tositumomab (Bexxar)	Binds CD20 antigen, causing immune attack and radiation injury	Non-Hodgkin’s lymphoma (B cell)	Bone marrow suppression, fever, chills, nausea, headache
Angiogenesis Inhibitors
bevacizumab (Avastin)	Binds vascular endothelial growth factor (VEGF), thereby inhibiting angiogenesis	Colorectal cancer, non–small cell lung cancer, and renal cell carcinoma	Hypertension, colon bleeding and perforation, impaired wound healing, thromboembolism, diarrhea
pazopanib (Votrient)	Same as above	Advanced renal cell carcinoma	Diarrhea, hypertension, hair dyspigmentation, nausea, anorexia, vomiting
Proteasome Inhibitors
bortezomib (Velcade)	Inhibits proteasome activity, which functions to regulate cell growth	Multiple myeloma	Bone marrow suppression, nausea, vomiting, diarrhea, peripheral neuropathy, fatigue
carfilzomib (Kyprolis)	Same as above	Multiple myeloma	Fatigue, low blood cell count and blood platelet levels, shortness of breath, diarrhea and fever; heart failure
Other Targeted Therapies
alemtuzumab (Campath)	Binds CD52 antigen (found on T and B cells, monocytes, NK cells, neutrophils)	Chronic lymphocytic leukemia (B cell), GIST	Bone marrow suppression, chills, fever, vomiting, diarrhea, fatigue
trastuzumab (Herceptin)	Binds human epidermal growth factor receptor 2 (HER-2)	Breast cancer (HER-2 positive)	Cardiotoxicity
pertuzumab (Perjeta)	Same as above	Breast cancer (HER-2 positive)	Cardiotoxicity
sorafenib (Nexavar)	Inhibits several tyrosine kinases	Advanced renal cell carcinoma	Rash, diarrhea, hypertension; redness, pain, swelling, or blisters on hands/feet
sunitinib (Sutent)	Inhibits several tyrosine kinases	Advanced renal cell carcinoma, GIST	Fatigue, heart failure, hypertension
temsirolimus (Torisel)	Inhibits a specific protein known as the mammalian target of rapamycin (mTOR)	Advanced renal cell carcinoma	Hyperlipidemia (specifically triglycerides), hyperglycemia, interstitial lung disease, renal failure, rash, nausea, fatigue
everolimus (Afinitor)	Same as above	Advanced renal cell carcinoma, advanced breast cancer	Mucositis, diarrhea, anorexia, edema, anemia, shortness of breath, coughing, nausea, vomiting, rash, fever
vemurafenib (Zelboraf)	Inhibits BRAF serine threonine kinase	BRAF V600E mutated metastatic melanoma	Hypersensitivity reactions, skin reactions including Stevens-Johnson syndrome, Q-T prolongation, elevated liver enzymes, photosensitivity, uveitis
ipilimumab (Yervoy)	Binds with CTLA-4 causing an anti-tumor mediated immune response	Metastatic melanoma or unresectable melanoma	Severe or life-threatening colitis, dermatitis, hepatotoxicity, and other organ reactions can occur
crizotinib (Xalkori)	Inhibits ALK tyrosine kinase	Locally advanced or metastatic non–small cell lung cancer that is ALK positive	Hepatotoxicity, pneumonitis, prolonged Q-T interval, N/V, diarrhea, edema, vision disorders

Overall the incidence of cancer has been declining since the 1990s. The mortality rate for the most common cancers (prostate, breast, lung, and colorectal) is also declining.² The incidences of many cancers, such as colorectal, lung, breast, and oropharyngeal cancers, have declined largely as a result of preventive efforts. However, the incidence of other types of cancers, such as leukemia, liver cancer, and skin cancers, has been on the rise. Notably, the incidence of melanoma rose faster than that for any other malignancy in the United States.¹

Cancer incidence overall is higher in men than women. Gender differences in incidence and in death rates for specific cancers are presented in Tables 16-1 and 16-2 and the Gender Differences box. Although mortality rates from all cancers combined are on the decline, cancer is still the second most common cause of death in the United States (heart disease is the most common). However, in people less than 85 years of age, cancer is the leading cause of death. Annually about 580,350 Americans are expected to die as a result of cancer, which is more than 1500 people per day.¹

TABLE 16-1

CANCER INCIDENCE BY SITE AND GENDER *

Male		Female
Type	%	Type	%
Prostate	28	Breast	29
Lung	14	Lung	14
Colon/rectum	9	Colon/rectum	9
Urinary bladder	6	Uterus	6
Melanoma	5	Thyroid	6
Kidney and renal pelvis	5	Non-Hodgkin’s lymphoma	4
Non-Hodgkin’s lymphoma	4	Melanoma	4
Oropharynx	3	Ovary	3

^*Numbers are estimates excluding basal and squamous cell skin cancers and carcinoma in situ.

Source: American Cancer Society: Cancer facts and figures, Atlanta, 2012, The Society. Retrieved from www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-036845.pdf.

TABLE 16-2

CANCER DEATHS BY SITE AND GENDER *

Male		Female
Type	%	Type	%
Lung and bronchus	28	Lung and bronchus	26
Prostate	10	Breast	14
Colon/rectum	9	Colon/rectum	9
Pancreas	6	Pancreas	7
Liver and intrahepatic bile ducts	5	Ovary	5
Liver and intrahepatic bile ducts	5	Leukemia	4
Leukemia	4	Non-Hodgkin’s lymphoma	3
Esophagus	4	Uterus	3
Urinary bladder	3	Liver and intrahepatic bile ducts Brain and other nervous system	2 2
Non-Hodgkin’s lymphoma	3
Kidney and renal pelvis	3

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Nov 17, 2016 | Posted by admin in NURSING | Comments Off

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