Cancer Care
Cancer is second only to cardiovascular disease as a leading cause of death in the United States. The most common types in the United States are prostate, breast, lung, and colorectal cancers.
Cancer results from malignant transformation, or carcinogenesis, of normal cells, causing them to enlarge and divide more rapidly than normal and to serve no useful purpose. Cancer cells characteristically grow uncontrollably and independently and spread quickly from the primary site to other tissues, where they establish secondary foci called metastases. The cells spread, or metastasize, in several ways: They can be carried throughout the body by the blood or lymphatic systems, they can be accidentally transplanted from one site to another during surgery, and they can extend, or grow, locally into a neighboring area.
According to researchers, cancer has numerous origins, including genetics, reactions to carcinogens (radiation and other environmental elements), potentially carcinogenic viruses (such as Epstein-Barr), and dietary intake. Other factors that interact to increase susceptibility to cancer include immunologic competence, age, nutritional status, and response to stress.
Careful assessment for cancer is crucial. In most cancers, the earlier the detection, the more effective the treatment and the better the prospect for cure. To perform the assessment, you’ll need to learn about the patient’s risk factors, such as cigarette smoking and hazardous working conditions. You’ll also need to be alert for cancer’s warning signs. (See Cancer signs, page 134.)
Patient assessment for cancer should include a thorough health history and physical examination. Both are useful for detecting cancer in the early stages. (See Cancer assessment, pages 135 and 136.)
Diagnostic tests
Useful tests for detecting early cancerous lesions include X-rays; lymphangiography; mammography; endoscopy; barium studies; and isotope, computed tomography, and magnetic resonance imaging scans. The single most important diagnostic tool is a biopsy for direct histologic study of tumor tissue. Although it doesn’t confirm a diagnosis by itself, a tumor marker—carcinoembryonic antigen—can signal cancer that affects the large bowel, stomach, pancreas,
lungs, or breasts, and sometimes sarcomas, such as leukemias and lymphomas as well. Alpha-fetoprotein, a fetal antigen rare in adults, can suggest testicular, ovarian, gastric, pancreatic, and primary lung cancers. Beta-human chorionic gonadotropin may point to testicular cancer or choriocarcinoma. The test for prostate-specific antigen helps detect and evaluate prostatic cancer, whereas CA125 is useful for monitoring ovarian cancer.
lungs, or breasts, and sometimes sarcomas, such as leukemias and lymphomas as well. Alpha-fetoprotein, a fetal antigen rare in adults, can suggest testicular, ovarian, gastric, pancreatic, and primary lung cancers. Beta-human chorionic gonadotropin may point to testicular cancer or choriocarcinoma. The test for prostate-specific antigen helps detect and evaluate prostatic cancer, whereas CA125 is useful for monitoring ovarian cancer.
Cancer signs
Use CAUTION, the American Cancer Society’s mnemonic device, to assess for the following cancer signs in your patients:
C hange in bowel or bladder habits
A sore that doesn’t heal
U nusual bleeding or discharge
T hickening or lump in the breast or elsewhere
I ndigestion or difficulty swallowing
O bvious change in a wart or mole
N agging cough or hoarseness.
Staging cancer
Choosing effective therapeutic options depends on determining the correct stage of a malignant tumor. Although cancer staging systems vary according to cancer site and pathologists’ preferences, the widely used TNM (tumor, node, metastasis) staging system quantifies cancer and allows reliable comparison of cancer treatments and survival rates among large populations. The TNM system describes the tumor, lymph node involvement, and metastasis to other areas. Another objective way to define a tumor is through grading, which takes into account the resemblance of tumor tissue to normal cells (differentiation) and the tumor’s estimated growth rate. Grading also names the lesion according to corresponding normal cells, such as lymphoid or mucinous lesions.
Procedures
Surgery, radiation, chemotherapy, immunotherapy (biotherapy), and hormone therapy, used independently or in combination, are used to treat cancer. In each patient, treatment depends on the type, stage, localization, and responsiveness of the tumor as well as the patient’s limitations.
Surgery
Once the mainstay of cancer treatment, surgery is now regularly combined with radiation, chemotherapy, and immunotherapy. Surgery removes the bulk of the tumor, and the other treatments discourage residual cell proliferation. Surgery is also used to relieve pain, correct obstruction, and alleviate pressure. Often, less radical surgery (for example, a lumpectomy instead of a radical mastectomy) is more acceptable to patients.
Radiation therapy
This treatment aims to destroy the rapidly dividing cancer cells and, at the same time, do as little damage to normal cells as possible. Treatment approaches include external beam radiation and intracavitary and interstitial implants (requiring personal radiation protection for all staff members who come in contact with the patient). The success of the treatment and damage to normal tissue vary with the radiation’s intensity. Although a large single dose of radiation has greater cellular effects than fractions of the same amount delivered sequentially, a protracted schedule allows time for normal tissue to recover in the intervals between individual sublethal doses.
Radiation may be chosen for palliative therapy to relieve pain, obstructions, malignant effusions, cough, dyspnea, ulcerative lesions, and hemorrhage. It also can promote the repair of pathologic fractures and delay tumor spread. Radiation can give a cancer patient an important psychological lift just by shrinking a visible
tumor. Combining radiation and surgery can minimize radical surgery, prolong survival, and preserve physiologic function.
tumor. Combining radiation and surgery can minimize radical surgery, prolong survival, and preserve physiologic function.
Cancer assessment
Routine assessment can uncover signs and symptoms that can prove to be cancer. A thorough health history and a physical examination are essential precursors to diagnostic testing.
Patient health history
Remember that the patient may be worried that he has cancer, so establish rapport and keep the interview as open as possible. First, obtain biographical information, including the patient’s current and previous occupations, his ethnic background, and his previous places of residence. These factors may inform you about the patient’s exposure to possible carcinogens.
Investigate the patient’s current complaints. What are the symptoms? How long has he had them? What precipitates, exacerbates, or relieves the symptoms?
Examine the patient’s medical history for additional clues. Does he have allergies? Has he undergone medical treatments, been hospitalized, or had surgery? Because of a link with melanoma and other skin cancer, even the removal of a tiny mole may be important. Ask whether he’s had chemotherapy or ionizing radiation, because these procedures are associated with secondary cancers.
Ask the patient about previous drug therapy and any current drug regimen. Some medications, such as phenytoin (an anticonvulsant), azathioprine (an immunosuppressant), and estrogen (a hormone commonly used postmenopausally), may lead to cancer if taken over prolonged periods.
Question the patient about family members’ health histories. Has a family member had breast, colorectal, or lung cancer (suggesting a possible genetic susceptibility)?
Review the patient’s lifestyle for behaviors that predispose him to cancer.
Physical examination
Take the patient’s vital signs. Note whether his temperature is above or below normal. Also note any hypertension, tachycardia or bradycardia, and tachypnea. Keep in mind that intermittent fever occurs in leukemia.
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