CANCER TYPE	CHAPTER	pages
Bladder (urolithial)	69	1512-1515
Brain	47	1031-1036
Breast	73	1591-1608
Cervical	74	1624-1626
Colorectal	59	1245-1254
Esophageal	57	1211-1217
Head and Neck	31	590-600
Leukemia	42	880-889
Lung	32	632-640
Lymphoma	42	892-894
Ovarian	74	1626-1627
Prostate	75	1637-1642
Renal cell carcinoma	70	1532-1533
Skin	27	502-505
Stomach (gastric)	58	1234-1238

General Disease-Related Consequences of Cancer

Cancer can develop in any organ or tissue and destroys normal tissue, which decreases function of that tissue or organ. Even when cancers occur in nonvital tissues or organs, they can cause death by metastasizing (spreading) into vital organs and disrupting critical physiologic processes (see Chapter 23). Cancers that are left untreated often cause:

• Reduced immunity and blood-producing functions

• Altered GI structure and function

• Motor and sensory deficits

• Decreased respiratory function

These impairments cause great physical and emotional distress. Without intervention, cancer invasion of normal tissues leads to death.

Reduced Immunity and Blood-Producing Functions

Impaired immune and blood-producing functions occur most often in patients with leukemia and lymphoma but also can occur with any cancer that invades the bone marrow. Tumor cells enter the bone marrow and reduce the production of healthy white blood cells (WBCs), which are needed for normal immune function. Thus patients who have cancer, especially leukemia, are at an increased risk for infection.

When cancer invades the bone marrow, it also causes anemia by decreasing the number of red blood cells (RBCs) and causes thrombocytopenia by decreasing the number of platelets (Fitch et al., 2009). These changes may be caused by the cancer itself or by cancer treatment, especially chemotherapy. The patient feels weak and fatigued and is at risk for bleeding.

Altered Gi Structure and Function

Cancer can alter GI function and impair nutrition. Abdominal tumors may obstruct or compress structures anywhere in the GI tract, reducing the ability to absorb nutrients and eliminate wastes. Tumors often also increase metabolic rate and increase the need for nutrients at a time when the patient has less energy for meal preparation or eating.

Tumors that invade the liver profoundly damage this organ, which has many important metabolic functions. Cancer-related reduced liver function leads to malnutrition and death.

Many patients with cancer have anorexia that often interferes with their ability to meet energy needs. Cachexia (extreme body wasting and malnutrition) develops from an imbalance between food intake and energy use (increased catabolism). This problem may occur even when nutritional intake appears adequate (Granda-Cameron et al., 2010). Changes in taste can result from the cancer or the treatment and reduce appetite.

Nutritional support for the patient with cancer, especially one undergoing cancer therapy, is complex. A diet high in protein and carbohydrates is often prescribed to help him or her maintain weight and to provide the nutrients needed for energy and cellular repair. Patients and families often believe cancer can be cured more easily if weight is gained or maintained. Currently no one nutritional plan meets the needs of all patients with cancer.

Motor and Sensory Deficits

Motor and sensory deficits occur when cancers invade bone or the brain or compress nerves. In patients with bone metastasis, the primary cancer started in another organ (e.g., lung, prostate, breast). The bone sites most often affected are the vertebrae, ribs, pelvis, humerus, scapula, sternum, skull, and clavicle. Bone metastasis causes pain, fractures, spinal cord compression, and hypercalcemia, each of which reduces mobility.

Patients may have sensory changes if the spinal cord is damaged or if nerves are compressed. Sensory, motor, and cognitive functions are impaired when cancer spreads to the brain. Any tumor, benign or malignant, growing in the brain can destroy healthy brain tissue and cause death.

The patient with cancer may also have pain, especially chronic pain. Pain does not always accompany cancer, but it can be a major problem for those with terminal cancer. Chapter 5 provides an in-depth discussion of the causes and management of cancer pain. The Concept Map on p. 42 presents nursing care issues related to chronic cancer pain.

Reduced Oxygenation

Cancer can disrupt oxygenation in several ways and often results in death. For example, tumors in the airways cause airway obstruction. If lung tissue is involved, lung capacity is decreased. Tumors can also press on blood and lymph vessels in the chest, blocking blood flow through the chest and lungs, which results in pulmonary edema and dyspnea. Tumors can thicken the alveolar membrane and damage pulmonary blood vessels, reducing gas exchange. With any lung tumor (primary or metastatic), patients have hypoxia and poor tissue oxygenation.

Nclex Examination Challenge

Health Promotion and Maintenance

A client diagnosed with widespread lung cancer asks the nurse why he must be careful to avoid crowds and people who are ill. What is the nurse’s best response?

A. “With lung cancer, you are more likely to develop pneumonia and could pass this on to other people who are already ill.”

B. “When lung cancer is in the bones, it becomes a bone marrow malignancy, which stops producing immune system cells.”

C. “The large amount of mucus produced by the cancer cells is a good breeding ground for bacteria and other microorganisms.”

D. “When lung cancer is in the bones, it can prevent production of immune system cells, making you less resistant to infection.”

Cancer Management

The purpose of cancer management is to prolong survival time or improve quality of life. Without cancer therapy, most patients with cancer would die within months of diagnosis. Cancer therapy includes surgery, radiation, chemotherapy, hormonal manipulation, photodynamic therapy, immunotherapy, and targeted therapy. These therapies may be used separately or in combination to kill cancer cells. The types of therapy used depend on the specific type of cancer, whether the cancer has spread, and the health of the patient. Treatment regimens (protocols) have been established for most types of cancer. These regimens are based on experiments with cancer cells and animals and on experience with other patients with cancer.

Surgery

Overview

Surgery for cancer involves the removal of diseased tissue. If cancer is confined to the removed tissue, surgery alone can result in a “cure” for that cancer. Although many cancers have spread too far at the time of diagnosis for surgery alone to result in a cure, it is often a useful part of diagnosis, treatment, follow-up, and rehabilitation.

Cancer surgery may be used for prophylaxis, diagnosis, cure, control, palliation, assessing therapy effectiveness, and reconstruction. Prophylactic surgery removes “at-risk” tissue to prevent cancer development. It is performed when a patient has either an existing premalignant condition or a family history that strongly predisposes the person to development of a specific cancer. For example, removing a benign polyp from the colon before it can develop into colon cancer is a prophylactic action. Diagnostic surgery (biopsy) is the removal of all or part of a suspected lesion for examination and testing. It provides proof of the presence of cancer. Curative surgery removes all cancer tissue. Surgery alone can result in a cure rate of 27% to 30% when all visible and microscopic tumor is removed or destroyed. Cancer control, or cytoreductive surgery, removes part of but not the entire tumor. It is also known as “debulking” surgery and alone cannot result in a cure. It decreases the number of cancer cells and increases the chances that other therapies can be successful. Palliative surgery focuses on improving the quality of life during the survival time, not on cure. Examples include removal of tumor tissue that is causing pain, obstruction, or difficulty swallowing. The specific procedure used depends on the patient’s specific problem. Second-look surgery is a “rediagnosis” after treatment. The purpose is to assess the disease status in patients who have been treated and have no symptoms of remaining tumor. The results of this surgery are used to determine whether a specific therapy should be continued or discontinued. This type of surgery is most commonly used with ovarian cancer. Reconstructive or rehabilitative surgery increases function, enhances appearance, or both. Examples include breast reconstruction after mastectomy, replacement of the esophagus, bowel reconstruction, revision of scars, and placement of penile implants.

Side Effects of Surgical Therapy

Unlike surgery performed for many other reasons, cancer surgery often involves the loss of a specific body part or its function. Sometimes whole organs are removed, such as the kidney, lung, breast, testes, leg, or tongue. Any organ loss reduces function. The amount of function lost and how much the loss affects patients depend on the location and extent of the surgery. Some cancer surgery results in major scarring or disfigurement. Patients are anxious about the chances of surviving the cancer and also may be grieving about a change in appearance or lifestyle.

Patient-Centered Collaborative Care

The physical care needs of the patient having surgery for cancer are similar to those related to surgery for other reasons (see Chapters 16, 17, and 18). For cancer surgery, two additional priority care needs are psychosocial support and assisting the patient to achieve or maintain maximum function.

Often cancer surgery occurs within days of the diagnosis, before the patient and family have time to adjust. Assess the patient’s and family’s ability to cope with the uncertainty of cancer and its treatment and with the changes in body image and role. For example, surgery involving the genitals, urinary tract, colon, and rectum may permanently damage these organs, resulting in changes in the patient’s means of sexual expression or control of elimination. Procedures to create a urinary or fecal diversion may damage nerves, causing erectile dysfunction in men and painful intercourse in women. Removal of a lung reduces the patient’s respiratory capacity and forever limits his or her ability to engage in physical activities.

Coordinate with the health care team to support the patient. Encourage the patient and family to express their concerns. Help the patient accept changes in appearance or function by encouraging him or her to look at the surgical site, touch it, and participate in dressing changes. Provide information about support groups such as those sponsored by the American Cancer Society (www.cancer.org) or Canadian Cancer Society (www.cancer.ca). Some cancer organizations have support groups for patients and separate support groups for patients’ spouses and children. Discuss having a person who has coped with the same issues come for a visit. Such visits can be valuable in showing the patient that many aspects of life can be the same after cancer treatment. If the patient is open to this type of support, arrange for a visit. For patients who have persistent sadness or depression as a result of appearance changes from cancer surgery, a referral to a mental health counselor and drug therapy may be needed (Weaver, 2009).

Reduced function may be an outcome for some types of cancer surgery. For example, a modified radical mastectomy for breast cancer can lead to muscle weakness and reduced arm function on the surgical side. Performing specific exercises after surgery can reduce functional loss. These exercises can be painful, and the patient needs encouragement to perform them. Teach the patient about the importance of performing and increasing the intensity of the exercises to regain as much function as possible and prevent complications. Coordinate with the physical therapist, occupational therapist, and family members to plan strategies individualized to each patient to regain or maintain optimal function.

Radiation Therapy

Overview

The purpose of radiation therapy for cancer is to destroy cancer cells and have minimal damaging effects on the surrounding normal cells. The effects of radiation are seen only in the tissues in the path of the radiation beam; thus this type of therapy is a local treatment. For example, radiation to the chest for breast cancer or lung cancer causes skin changes and hair loss only on the area of the chest actually being irradiated. The person does not lose his or her scalp hair. Some effects are apparent within days or weeks, whereas other effects on deeper tissues may not be apparent for months to years after radiation therapy is completed.

Most radiation therapy for cancer is ionizing radiation. When cells are exposed to it, particles within the cell’s nucleus are rearranged, resulting in a tremendous release of intracellular energy. Ionizing radiation is given off by many elements, including radium, and radioactive isotopes of specific elements. For example, a radioactive isotope of cobalt is used in radiation therapy for cancer.

As a radioactive element breaks down (decays), radiation energy is released as high energy particles (alpha particles and beta particles) and high energy photons (gamma rays). X-rays are radiation that is generated by machine. X-ray photons and gamma ray photons are identical in their effects on cells.

Cells damaged by radiation either die outright or become unable to divide. Radiation damage can occur anytime a cell is exposed to radiation, not just when it is actively dividing. However, the damage is greater to dividing cells than to non-dividing cells when exposed to radiation.

Three different types of energy, or rays, are produced by radioactive elements: gamma rays, alpha particles, and beta particles. These energies vary in their ability to penetrate tissues and damage cells (Fig. 24-1). Gamma rays are used most commonly for radiation therapy because of their ability to deeply penetrate tissues (Camporeale, 2008). Beta particles are weaker and must be placed within or very close to the cancer cells for cancer therapy (see discussion of brachytherapy on pp. 412-413). Alpha particles are not used as cancer therapy.

FIG. 24-1 Penetrating capacity of different types of radiation.

The amount of radiation delivered to a tissue is called the exposure; the amount of radiation absorbed by the tissue is called the radiation dose. The dose is always less than the exposure because some energy is lost as scatter on the way to the tissue. The three factors determining the absorbed dose are the intensity of exposure, the duration of exposure, and the closeness of the radiation source to the cells (Camporeale, 2008).

The intensity of the radiation decreases with the distance from the radiation source (Fig. 24-2). This factor is known as the inverse square law. For example, the radiation dose received at a distance of 2 meters from the radiation source is only one fourth of the dose received at a distance of 1 meter from the radiation source; the dose of radiation received at 3 meters is only one ninth of the dose received at 1 meter.

FIG. 24-2 The inverse square law of radiation exposure.

If the dose of radiation is high enough, all cells are killed immediately. This does not happen with cancer radiation therapy because cells within a tumor absorb the radiation dose slightly differently. Therefore their overall response to the radiation is slightly different. A few cells die immediately, and more die within the next 24 hours as they attempt to divide. Some cells become sterile as a result of this single treatment. Still other cells repair the radiation-induced damage and recover.

Radiation therapy usually is given as a series of divided doses because of the varying responses of all cancer cells within a given tumor. Most often, small doses of radiation are given on a daily basis for a set time period to allow greater destruction of cancer cells while reducing the damage to normal tissues. Absorbed radiation doses are described in units called gray (gy). (The older term for radiation dose was rad for radiation absorbed dose. One gy is the same as 100 rad.) One gy is equal to one joule of energy absorbed by one kg of a material. The total dose of radiation used depends on tumor size and location and on the radiation sensitivity of the tumor and nearby tissues. Some normal tissues are more sensitive than others to radiation. For example, breast tissue tolerates much higher doses of radiation than the liver does. A total dose of 50 to 60 gy might be prescribed for a breast cancer. However, only 12 gy might be prescribed for a liver tumor, because a higher dose would destroy healthy liver cells as well as the tumor.

Radiation Delivery Methods and Devices

Radiation delivery types for cancer therapy are teletherapy and brachytherapy. The type used depends on the patient’s general health and on the shape, size, and location of the tumor to be irradiated. The ideal radiation dose is one that can kill the cancer cells with an acceptable level of damage to normal tissues (damage to normal tissues cannot be avoided).

Teletherapy is radiation delivered from a source outside of the patient. Because the source is external, the patient is not radioactive and is not hazardous to others.

One newer method of teletherapy is intensity modulated radiation therapy (IMRT). This type of radiation breaks up the single beam into thousands of smaller beams that allow better focus on the tumor.

Another newer method of teletherapy is stereotactic body radiotherapy (SBRT). This method uses three-dimensional tumor imaging to identify the exact tumor location, which allows more precise delivery of higher radiation doses and spares more of the surrounding tissue. Usually, the total dosage is delivered in one to five separate treatment sessions. Currently, this approach is most commonly used for small, localized lung cancers (Smink & Schneider, 2008).

Regardless of the teletherapy delivery method, the exact location of the tumor is determined for therapy accuracy. Once the pattern of radiation delivery is determined, the patient must always be in exactly the same position for all treatments (Camporeale, 2008). Ensure that the patient can get into and maintain this position. Position-fixing devices and markings, either on the patient’s body or on the devices, ensure the proper position each day of treatment. The markings may be small permanent “tattoos,” ink outlines on the skin, or a marked covering laid over the skin during positioning. Position-fixing devices include customized external vacuum-type body molds, foam-based body molds, and fiberglass splints (Smink & Schneider, 2008).

Brachytherapy means “short” or “close” therapy. The radiation source comes into direct, continuous contact with the tumor tissues for a specific time period. This method provides a high dose of radiation in tumor tissues and a very limited dose in surrounding normal tissues.

Brachytherapy uses radioactive isotopes either in solid form or within body fluids. Isotopes can be delivered to the tumor tissues in several ways. With all types of brachytherapy, the radiation source is within the patient. Therefore the patient emits radiation for a period of time and is a hazard to others (Waring & Gosselin, 2010). When the isotopes used are unsealed and suspended in a fluid, they are given by the oral or IV routes or instilled within body cavities. An example of brachytherapy with soluble isotopes is the ingestion or injection of the radionuclide iodine-131 (¹³¹I) (an iodine base with a half-life of 8.05 days) to treat some thyroid cancers. The iodine concentrates in the thyroid gland and destroys the thyroid cancer cells. When the isotopes are unsealed, they enter body fluids and eventually are eliminated in waste products, which are radioactive and should not be directly touched by other people. After the isotope is completely eliminated from the body, neither the patient nor the body wastes are radioactive.

Solid or sealed radiation sources are implanted within or near the tumor. These sources can be temporary or permanent. Most implants emit continuous, low-energy radiation to tumor tissues. Some devices (e.g., seeds or needles) can be placed into the tissues and stay in place by themselves. Some devices are so small and the half-life of the isotope so short that the device is permanently left in place (most often for prostate cancer) and, over time, completely loses its radioactivity. Other devices are removed and reused in other patients. Some sources must be held in place during therapy using special applicators. While the solid implants are in place, the patient emits radiation but excreta are not radioactive and do not pose a hazard to anyone.

Traditional implants deliver “low-dose rates” (LDRs) of radiation continuously and patients are hospitalized for several days. “High-dose rate” (HDR) implant radiation is another delivery type. The patient comes into the radiation therapy department several times a week, and a stronger radiation implant is placed for only an hour or so each time. The patient goes home between treatments and is radioactive only when the implant is in place (Waring & Gosselin, 2010). Chart 24-1 lists the best practices for care of the patient with sealed implant radiation sources and for the safety of the personnel providing the care.

Chart 24-1 Best Practice for Patient Safety & Quality Care

Care of the Patient with Sealed Implants of Radioactive Sources

• Assign the patient to a private room with a private bath.

• Place a “Caution: Radioactive Material” sign on the door of the patient’s room.

• If portable lead shields are used, place them between the patient and the door.

• Keep the door to the patient’s room closed as much as possible.

• Wear a dosimeter film badge at all times while caring for patients with radioactive implants. The badge offers no protection but measures a person’s exposure to radiation. Each person caring for the patient should have a separate dosimeter to calculate his or her specific radiation exposure.

• Wear a lead apron while providing care. Always keep the front of the apron facing the source of radiation (do not turn your back toward the patient).

• Pregnant nurses should not care for these patients; do not allow pregnant women or children younger than 16 years to visit.

• Limit each visitor to one-half hour per day. Be sure visitors stay at least 6 feet from the source.

• Never touch the radioactive source with bare hands. In the rare instance that it is dislodged, use a long-handled forceps to retrieve it. Deposit the radioactive source in the lead container kept in the patient’s room.

• Save all dressings and bed linens in the patient’s room until after the radioactive source is removed. After the source is removed, dispose of dressings and linens in the usual manner. Other equipment can be removed from the room at any time without special precautions and does not pose a hazard to other people.

Side Effects of Radiation Therapy

The immediate and long-term side effects of all types of radiation are limited to the tissues exposed to the radiation. Therefore the side effects vary according to the site (Ruppert, 2011). Skin changes and hair loss are local but are often permanent depending on the total absorbed dose.

Altered taste sensations and fatigue are two common systemic side effects noted by patients receiving teletherapy, regardless of the radiation site. Taste changes are thought to be caused by metabolites released from dead and dying cells. Many patients develop an aversion to the taste of red meats. Fatigue may be related to the increased energy demands needed to repair damaged cells. Regardless of the cause, radiation-induced fatigue can be debilitating and may last for months (Kuchinski et al., 2009).

Radiation damage to normal tissues during cancer therapy can start inflammatory responses that lead to tissue fibrosis and scarring. These effects may appear years after radiation treatment. For example, women who receive HDR therapy for uterine cancer may develop radiation-induced changes in the colon (which also was irradiated) years later, resulting in constipation and obstruction.

Patient-Centered Collaborative Care

Most patients are anxious about radiation and look to the nurse to explain the purpose and side effects of radiation therapy. Accurate, objective information about radiation therapy helps patients cope with the treatment and continue to participate in normal activities.

Skin in the path of radiation becomes very dry and may break down. Teaching patients about skin care needs during radiation therapy is a priority nursing intervention. Chart 24-2 lists skin care and other precautions needed with external radiation therapy. Instruct the patient to not remove any temporary ink markings when cleaning the skin until the entire course of radiation therapy is completed. At one time, patients were told to avoid using lotions or other skin care products within 4 hours of the radiation therapy; however, this practice is not evidence-based and is now controversial (Bieck, Phillips, & Steele-Moses, 2010). Teach patients to follow the radiation-oncology department’s policy regarding the use and timing of skin care products. Use of skin care products designed to manage or protect the skin from radiation damage does reduce the degree of skin problems that develop during a full course of radiation therapy (Gosselin et al., 2010) (see the Evidence-Based Practice box on p. 414).

Chart 24-2 Patient and Family Education

Preparing for Self-Management: Skin Protection During Radiation Therapy

• Wash the irradiated area gently each day with either water or a mild soap and water as prescribed by your radiologist.

• Use your hand rather than a washcloth to be gentler.

• Rinse soap thoroughly from your skin.

• If ink or dye markings are present to identify exactly where the beam of radiation is to be focused, take care not to remove them.

• Dry the irradiated area with patting motions rather than rubbing motions; use a clean, soft towel or cloth.

• Use only powders, ointments, lotions, or creams on your skin at the radiation site that are prescribed by the radiation oncology department.

• Wear soft clothing over the skin at the radiation site.

• Avoid wearing belts, buckles, straps, or any type of clothing that binds or rubs the skin at the radiation site.

• Avoid exposure of the irradiated area to the sun.

• Protect this area by wearing clothing over it.

• Try to go outdoors in the early morning or evening to avoid the more intense sun rays.

• When outdoors, stay under awnings, umbrellas, and other forms of shade during the times when the sun’s rays are most intense (10 AM to 7 PM).

• Avoid heat exposure.

Evidence-Based Practice

Do Skin Care Products Reduce Radiation Skin Effects?

Gosselin, T., Schneider, S., Plambeck, M., & Rowe, K. (2010). A prospective randomized, placebo-controlled skin care study in women diagnosed with breast cancer undergoing radiation therapy. Oncology Nursing Forum, 37(5), 619-626.

Breast cancer is a common cancer among women and is often treated with external beam radiation. The radiation therapy, administered daily for 6 to 7 weeks, can cause skin reactions. At times, patients are told not to use skin care products in the area of irradiation during the treatment period. This study sought to (1) identify the incidence of radiation-induced skin reactions among women undergoing external beam radiation therapy for breast cancer; and (2) compare the effectiveness of three skin care products versus placebo in reducing radiation-induced skin reactions.

A convenience sample of 208 adult women undergoing teletherapy for breast cancer were recruited into the study. Each subject was randomly assigned to one of four groups and asked to use a skin care product on the irradiated area twice daily throughout the radiation therapy period (placebo, product 1, product 2, product 3). The groups and the researchers were blinded to which products were assigned to which groups. The women kept a home journal to describe the skin site and the features of the assigned skin care product. Skin condition was assessed weekly using the Radiation Therapy Oncology Group (RTOG) acute radiation morbidity scoring criteria. Although this tool has no published validity and reliability, it has been used for 25 years as a standard of practice in radiation oncology. The inter-rater reliability for this tool among data collectors in this study was 0.96.

Of the 208 subjects completing the study, 95% experienced a skin reaction, usually by the 4th week of treatment. Although subjects using all skin care products had a slightly reduced skin reaction compared with those in the placebo-control group, the difference did not reach statistical significance.

Level of Evidence: 2

The study method was prospective, randomized, double-blind, and placebo-controlled. The large number of subjects, the random assignment, and double-blinding of the groups added strength to the study, as did objective skin-scoring using an established tool. The statistical evaluation methods were appropriate for the design, and power was adequate.

Commentary: Implications for Practice and Research

The study is important for many reasons. First, it established the incidence of radiation skin reactions for a large group of subjects all receiving radiation to the same tissue area, at the same dosage levels, for the same time period. The study also demonstrated that weekly skin assessment by radiation oncology nurses is a feasible and desirable care intervention. Second, it established that the physical benefits of three different skin care products often prescribed for use during radiation therapy were not statistically significant and had minimal clinical benefit. In fact, the product the women rated as most satisfactory (for ease of use and lifestyle fit) was the product with the poorest performance in protection against radiation skin reactions. Nurses in radiation oncology departments are often the professionals who are asked how to manage the associated skin problems. Some of the recommended products are available by prescription only and have significant cost. Thus nurses can inform patients that use of any skin care product does not prevent radiation skin reactions and that no product is superior to another. Therefore patients should decide what product to use based on ease of use, availability, and cost.

The study defined important areas for future nursing research. Issues include which patient characteristics increase the risk for radiation skin reactions, what are the reliability and validity of the RTOG acute radiation morbidity scoring criteria tool, and did weekly skin assessments by radiation oncology nurses identify problems earlier or increase patient satisfaction with therapy.

Nursing Safety Priority

Action Alert

Skin in the radiation path is more sensitive to sunburn and damage. Advise against direct skin exposure to the sun during treatment and for at least 1 year after completing radiation therapy.

The normal tissues most sensitive to external radiation are bone marrow cells, skin, mucous membranes, hair follicles, and germ cells (ova and sperm). When possible, these tissues are shielded from radiation during therapy. At times, they are in the radiation path and cannot be protected from exposure. Some changes caused by radiation are permanent. The long-term problems vary with the location and dose of radiation received. For example, radiation to the throat and upper chest can cause difficulty in swallowing. Combined with taste alteration, this problem can lead to reduced nutrition. A registered dietitian is part of the radiation oncology team (Gosselin et al., 2008). Head and neck radiation may damage the salivary glands and cause dry mouth (xerostomia), which increases the patient’s lifelong risk for tooth decay. Bone exposed to radiation therapy is less dense and breaks more easily. Teach about the symptoms that might be expected from the location and dose of radiation (see Table 24-1 for the location of this information for different cancer types).

Nclex Examination Challenge

Health Promotion and Maintenance

Which precaution is most important for the nurse to teach a client receiving radiation therapy for head and neck cancer?

A. Avoid eating red meat during treatment.

B. Pace your leisure activities to prevent fatigue.

C. See your dentist twice yearly for the rest of your life.

D. Avoid using headphones or headsets until your hair grows back.

Chemotherapy

Overview

Chemotherapy, the treatment of cancer with chemical agents, is used to cure and to increase survival time. It has some selectivity for killing cancer cells over normal cells. This killing effect on cancer cells is related to the ability of chemotherapy to damage DNA and interfere with cell division. Tumors with rapid growth are most sensitive to chemotherapy.

As described in Chapter 23, cancer cells can separate from the original tumor, spread to new areas, and establish new cancers at distant sites (metastasize). Patients with metastatic cancer will die unless treatment eliminates the metastatic cancer cells along with the original cancer cells. Chemotherapy is useful in treating cancer because its effects are systemic, providing the opportunity to kill metastatic cancer cells that may have escaped local treatment. Chemotherapy used along with surgery or radiation is termed adjuvant therapy.

Drugs used for chemotherapy usually are given systemically and exert their cell-damaging (cytotoxic) effects against healthy cells as well as cancer cells. The normal cells most affected by chemotherapy are those that divide rapidly, including skin, hair, intestinal tissues, spermatocytes, and blood-forming cells. These drugs are classified by the specific types of action they exert in the cancer cell. Table 24-2 lists categories, drugs, and their potential to induce nausea and vomiting (emetogenic) or to damage surrounding tissue.

TABLE 24-2 CATEGORIES OF CHEMOTHERAPEUTIC DRUGS

DRUG	EMETOGENIC POTENTIAL	TISSUE DAMAGE POTENTIAL
Antimetabolites
Azacitidine (Vidaza)	High	Irritant
Capecitabine (Xeloda)	Low	N/A (oral drug)
Cladribine (Leustatin)	Moderate	Bruising
Clofarabine (Clofar)	Low—Moderate	Irritant
Cytarabine (Cytosar, ara-C)	Moderate	Irritant
Decitabine (Dacogen)	Moderate	Irritant
Floxuridine (FUDR)	High	Bruising
5-Fluorouracil (Adrucil, Efudex, Fluoroplex)	Moderate	Irritant
Fludarabine (Fludara, FLAMP)	Low	Bruising
Gemcitabine (Gemzar)	Moderate	Bruising
6-Mercaptopurine (Purinethol)	Low	N/A (oral drug)
Methotrexate (MTX, Mexate)	Low—Moderate	Bruising
Nelarabine (Arranon)	Moderate	Irritant
Pemetrexed (Alimta)	Moderate—High	Bruising
Pentostatin (Nipent)	Low—Moderate	Irritant
6-Thioguanine (Tabloid)	Moderate—High	N/A (oral drug)
Antitumor Antibiotics
Bleomycin (Blenoxane)	Moderate	Irritant
Dactinomycin (Cosmegen)	High	Vesicant
Daunorubicin (Cerubidine, Daunomycin)	High	Vesicant
Doxorubicin (Adriamycin, Rubex)	High	Vesicant
Doxorubicin liposomal (Doxil)	High	Vesicant
Epirubicin (Ellence)	High	Vesicant
Idarubicin (Idamycin)	Moderate—High	Vesicant
Mitomycin C (Mutamycin)	Moderate	Vesicant
Mitoxantrone (Novantrone)	Low	Irritant
Valrubicin (Valstar)	N/A	N/A (intravesicular drug)
Antimitotics
Cabazitaxel (Jevtana)	Moderate	Irritant
Docetaxel (Taxotere)	Moderate	Bruising
Etoposide (VP-16, VePesid)	Low	Irritant
Eribulin mesylate (Halaven)	Low—Moderate	Irritant
Paclitaxel (Taxol)	Moderate	Irritant & potential vesicant
Teniposide (Vumon)	Moderate	Vesicant
Vinblastine (Velban, Velbe, Velsar)	Low—Moderate	Vesicant
Vincristine (Oncovin)	Low	Vesicant
Vinorelbine (Navelbine)	Moderate	Vesicant
Alkylating Agents
Altretamine (Hexalen)	Moderate	N/A (oral drug)
Bendamustine (Treanda)	Moderate	Vesicant
Busulfan (Busulfex)	High	Bruising
Carboplatin (Paraplatin)	High	Irritant
Carmustine (BiCNU; Gliadel)	High	Irritant
Chlorambucil (Leukeran)	High	N/A (oral drug)
Cisplatin (Platinol)	High	Irritant
Cyclophosphamide (Cytoxan, Procytox)	High	Bruising
Dacarbazine (DTIC)	Moderate—High	Irritant
Estramustine (Emcyt, Estracyte)	Moderate	Vesicant
Ifosfamide (Ifex)	High	Bruising
Lomustine (CCNU, CeeNU)	High	N/A (oral drug)
Mechlorethamine (Mustargen)	High	Vesicant
Melphalan (Alkeran) (available in oral or IV form)	High	Vesicant (IV drug)
Oxaliplatin (Eloxatin)	Moderate—High	Vesicant
Streptozocin (Zanosar)	High	Bruising
Temozolomide (Temodar)	Moderate—High	N/A (oral drug)
Thiotepa (Thioplex)	Low	Bruising
Topoisomerase Inhibitors
Irinotecan (Camptosar)	Moderate	Irritant
Topotecan (Hycamtin)	Moderate	Irritant
Miscellaneous Agents
Arsenic trioxide (Trisenox)	Moderate	Not known
Asparaginase (Elspar)	Low	Vesicant
Hydroxyurea (Droxia, Hydrea)	Low	N/A (oral drug)
Ixabepilone (Ixempra)	Low—Moderate	Irritant
Pegaspargase (Oncaspar)	Low	Bruising
Procarbazine (Matulane, Natulan )	High	N/A (oral drug)
Vorinostat (Zolinza)	Moderate	N/A (oral drug)