Management of Cancer: SURGERY

Existing premalignant condition

Oncology: nursing management in cancer care

Known family history

Different Treatment Modalities for Cancer:

Example: prophylactic mastectomy

1. surgery

2. radiation therapy

3. chemotherapy

4. immunotherapy / biologic therapy

5. bone marrow transplant

6. stem cell therapy

7. pain management

General Treatment Goals:

CURE

CONTROL

PALLIATION

Control Surgery removal of a large portion (bulk) of a

locally invasive tumor

Should be performed before the start of chemotherapy

whenever possible

Curative Surgery removal of the primary site of

malignancy and any lymph nodes to which the neoplasm
has extended

Most widely used CA treatment

SURGERY
Surgical removal of the cancerous mass or tumor
Most IDEAL and FREQUENTLY USED
Indicated to diagnose, stage, and treat CA

Types of Surgery and Their Purposes:

Diagnostic Surgery obtain tissue for analysis

Example: oopharectomy of a locally invasive

advanced ovarian CA

3 COMMON APPROACHES

I.

1. LOCAL OR MARGINAL EXCISION removal of

small mass and small margin of normal tissue

2. WIDE EXCISION removal of the lump with

some surrounding healthy tissue

3. RADICAL EXCISION removal of primary tumor,

lymph nodes, adjacent involved structures, and
surrounding tissues that may be at high risk for
tumor spread
-

Can result in DISFIGUREMENT and

ALTERED FUNCTIONING

May necessitate rehabilitative or

reconstructive surgery

Example: biopsy

Prophylactic / Preventative Surgery removal of

nonvital tissues or organs

- performed in clients with:

Other Approaches:

4. ENDOSCOPIC SURGERY uses an endoscope with

attached minicamera inserted into the body through a small
incision

Attempts to relieve complication

Cure is NOT possible

Examples: pleural effusion pleural drainage

tube placement

- advantages:

Bowel obstruction colostomy

a. Minimally invasive
b. Shorter recovery time
c. Does not compromise surgical outcomes
-

5. LASER SURGERY laser beam vaporizes the water of

the malignant cells then destroy them

Pain nerve block

General side effects of surgery:

Loss or loss of function of a specific body part

Reduced function as a result of organ loss

a. pinpoint precision

Scarring or disfigurement

b. minimal bleeding

Grieving about altered body image or imposed change in

lifestyle

c. decreased risk of infection

- 6. SALVAGE SURGERY an additional treatment option that
uses an extensive surgical approach AFTER the use of a less
extensive primary approach

General Nursing Management:

General perioperative nursing care

Complete or thorough preoperative assessment, diagnosis,

planning, implementation, and evaluation of a patient who
will undergo / has undergone surgery

Provide honest and informative communication and health

education

Provide support (emotional) by assessing needs (px and

family) and by discussing fears and coping mechanism

Reinforce information conveyed by the physician

Post operatively:

- example: lumpectomy mastectomy

Rehabilitative / Reconstructive surgery may follow
curative or radical surgery

- performed in one generation or stages;

- performed early or delayed
- best outcome depends on the CANCER SITE and the EXTENT
OF SURGERY

Breast CA oopharectomy

- advantages:

Palliative surgery is performed to improve quality of life

during the survival time

a. assess pxs response to surgery

b. monitor for possible complications

c. provide px comfort

3. to provide relief of neurologic dysfunction and brain

metastasis
RADIATION THERAPY

d. health teaching
e. plan
- discharge

USE OF HIGH ENERGY IONIZING RADIATION TO INTERRUPT

THE GROWTH OF MALIGNANT CELLS

2 TYPES OF IONIZING RADIATION

- rehabilitative program

A. ELECTROMAGNETIC RADIATION

- follow up treatment, check up / visits

B. PARTICULATE RADIATION

- home care instructions

EFFECTIVE ON TISSUES DIRECTLY WITHIN THE PATH OF THE

RADIATION BEAM

HAVE BOTH AN IMMEDIATE AND DELAYED EFFECT

- possible complications monitoring and

interventions

EFFECTS OF IONIZING RADIATION:

MANAGEMENT OF CANCER: RADIATION THERAPY

A. IMMEDIATE

PURPOSES OF RADIATION THERAPY:

Damage cell membrane immediately

a. CURATIVE used as localized tx for solid tumor

Cell Lysis;
Decomposition of the cell

GOAL: to eradicate ALL disease

b. CONTROL
GOAL: to prolong and improve
eradication

CELL DEATH
survival without disease

c. PROPHYLACTIC
GOAL: to prevent spread of primary CA to distant sites
d. PALLIATIVE

2. Formation of FREE
RADICALS

B. DELAYED

1. Direct alteration of DNA molecule

Breaking of DNA

strands

Cells
will NOT die UNLESS
it attempts to replicate and divide

GOALS:
1. to relieve s/sx of metastatic disease
2. to treat oncologic emergencies

Irreversible DNA damage

Impaired DNA repair
Cell death
Apoptosis

Therefore,
the IMMEDIATE and DELAYED effects of radiation cause

TUMOR SHRINKAGE
eventually leading to
TUMOR DESTRUCTION.

PRINCIPLES OF RADIATION THERAPY:

I.

GOAL: to destroy malignant cells with minimal exposure of

normal cells to the damaging effects of radiation

- REMEMBER! RT is a LOCALIZED TX.

example: external beam radiation

Advantages:

Radiation dose calculated by physicist-physician

- Depends on the following factors:

1. Sensitivity of the target tissues

-

Cells are most vulnerable during the DNA synthesis; cell kill
is most effective during cell mitosis

Rate of cell mitosis determine whether the effect of

radiation will occur in days, months, or years

radioresistance is the lack of tumor response to

radiation

Therefore, the number of CA cells destroyed (cell kill) is

maximal if radiation is delivered when most tumor cells
are cycling through the cell cycle.

3. the location of the tumor

- tissue tolerance of the surrounding normal tissues and the
critical organs adjacent to the tumor target

Units of measuring radiation absorption:

1. Gray (Gy) unit to measure absorbed dose

Achieves greater cell kill

- lethal tumor dose dose that will eradicate 95% of the tumor
yet preserve normal tissues

- the smaller the size & more poorly differentiated

enhanced radiosensitivity

Allows repair of healthy cells

Allow the periphery of the tumor to be reoxygenated

repeatedly

radiosensitivity degree and speed of response of cells

to radiation

2. the size of the tumor

- irradiated person or area receiving radiation therapy

II. FRACTIONED DOSES : delivery of optimum dosage of radiation
with the least amount of effects to normal tissues

1 Gy = 100 rads
2. rad (radiation absorbed dose) previously used to measure
radiation dosage
3. Joules/kg used to measure absorbed dose
1 J/kg = 1 Gy

Unit of exposure
1. Roentgen (R) standard unit of exposure
2. Radiation dose equivalent (rem) unit of measure that
relates to biologic effectiveness; roentgen equivalent in
human beings
- According to the ICRP Standards

5 rems recommended MPD for radiation workers

for persons >18yo

1.2 rems maximum dose for women of

reproductive capacity

III. Role of Oxygen

-

Oxygen must be present at the time of radiations maximal

killing effect radiosensitizer

IV. Chemical and Thermal Modifiers of Radiation

Cellular response can be modified by:

d.) usual schedule is weekdays

e.) actual therapy lasts minutes, most time is spent on positioning
Computerized treatment plans are devised

a.) lead blocks are made to shape

b.) immobilization devices are designed to ensure accurate
positioning
c.) skin markings are applied to define the target and portal
Sources Of Radiation
Linear accelerator- produce a voltage many times higher
than machines used for diagnoses
Radioactive or substance

a. changing the dose rate

b. manipulating the process of cell repair
c. recruiting cells into replication cycle
d. using hyperthermia

radiosensitization is the use of medications to enhance

sensitivity of the tumor cells

TWO TYPES OF RADIATION THERAPY DELIVERY

Radioprotectors promote repair of normal tissues

Hyperthermia / Thermal therapy (above 104F / 41.5C)
combined with RT to destroy CA tumors
TREATMENT PLANNING:

Accurate diagnosis is established by biopsy and extent of

disease is determined

Goal of therapy is decided

All patients undergo simulation and treatment planning

a.) Target volume is identified by PE and imaging studies

b.) treatment unit is selected
c.) the design and pattern of delivery, total dose to be
administered, time and dose per day determined

External radiation therapy or teletherapy

The source of radiation is outside the pt.
Administer through an XR machine
Internal radiation therapy or brachetherapy
The source of radiation is a radioactive element or
substance that has been:
a) Implanted or sealed radiation therapy
b) Injected into the body or taken orally( unsealed
radiation therapy)
- Administered into the body (IV or PO)
- When caring pt. be careful to excreta, saliva,
tears ectc. Are radioactive
Administer within or near the pt.

FACTORS AFFECTING ADMINISTRATION

a) Source of radiation
b) Location of the tumor
c) Type of cancer targeted
TYPES:
a) TELETHERAPY ( external body radiation therapy
Descriptions:

 Source is external
Most commonly used
FORMS OF EBRT:

Intensity modulated radiation therapy

Image-guide radiation therapy
Gamma rays
Stereotactic body radiation therapy(SBRT)
Proton therapy

1. IMRT- direct different increased energy levels at different

angles directed
Advantage: tumor cells receives increase radiation than the
normal cells
- Given daily or hyperfraction radiation dose (2x/day)
2. IGRT- the tumors are viewed in CT scan/UTZ, the machine is
automatic to move with tumor cells
Used continuous monitoring and tumor with CT scan/UTZ
during tx to allow for automatic adjustment of the target as
the tumor changes shape and position
To spare normal tissue.g. respiratory breathing
3. Gamma rays- a unit is put, a radioactive
Used in one time high dose treatment (e.g. cobalt 60)
4. SBRT- it uses high dose of radiation to penetrate very
deeply into the body to control deep seated tumor that
cannot be treated by other approaches
Usually 1-5 days
5. Proton therapy- it utilizes the charged protons as the
radiation to ancer cells
Advantage: do not penetrate to cancer cells causing not targeting
the behind organs or normal tissues
ADVANTAGES OF EBRT:
a) More beneficial and less harmful- because of pinpoint
accuracy
b) Improvements in tumor localization
c)
d) Efficient planning

e) Advances
TEACHING GUIDELINES REGARDING EBRT
1. Painless
2. Lie very still: special position
3. Usually lasts for a minute; sounds of the machine may be
heared
4. Remain in the room alone as safety precaution
5. Technologist is outside room,primary
6. No residu. Radioactivity after radiation therapy; may resume
ADL
7. Teach pt. about s/s and active part in its management
COMMON SIDE EFFECTS

Head and neck ( increased intracranial pressure, dizziness,

dysphagia, indigestion, loss of appetite, oral pain,
mucocytis)
Risk of infection
Chest
Abdomen( diarrhea, N/V, anorexia)
Pelvis (diarrhea, cystitis, sexual dysfunction,urethral and
rectal stenosis)
General side effects( fatigue, depressed immune function,
leucopenia, anemia, thrombocytopenia)
Skin-most affected

NURSING INTERVENTION:
Maintaining optimal skin care
1. Wash indicated area gently with warm water only / mild
soap and water
2. Use hands not wash cloth
3. Rinse it thoroughly
4. Dont remove marking
5. Dry using patting motion
6. No vigorous or rubbing friction/scratching
7. No powder, lotions, creams or any cosmetics cornstarch may
be used
8. Wear soft, cotton clothing
9. Avoid tight clothing, belt and straps
10. Avoid exposure to extreme temperature
11. Avoid lying on area

12. Avoid shaving on area

13. Protect skin from injury& allow to heal
14. Dont apply adhesives/ tapes on skin
15. Observe early signs of skin irritations
Provide health teaching:
a) Allow pt. time assemble the information given to him and
adjust to whatever changes he might
b) Provide written info before they leave the clinic

Internal radiation implantation ( administered by placing it

into a sealed container and will be put either distal from the
tumor or directly into the tumor)
Place temporarily or permanently

Low dose radiation brachetherapy- longer periods of time

require hospitalization
High dose radiation brachetherapy- given short period of
time ; emitting radiation the excreta, of pt. are not radioactive
Advantage of HDR brachetherapy:

BRACHYTHERAPY

The radiation source is usually radiation therapy

Radioactive element is used
It involves introduction into the body so the radiation
therapy is within the pt.
It involves sealed and unsealed source

Radiaoctive elements: ( unstable and decompose easily and

naturally which emits radiation which can be dangerous to normal
living

Isotopes- increase no. in neutrons;when the elements are

are increase in neutrons the elements are unstable
Some elements that is naturally occurring:
Radium-half-life of 1800 years
Uranium

*half life- is the length of time of certain elements to lose life

- iodine- 8 days
Phosphorus- 14 days

Radioactive ( not natural)

Cobalt and iodine

Forms of internal radiation therapy

1. Sealed radiation source

a) Treatment is shorter
b) Reduced of exposure to personnel
c) Performed on an outpatient procedure or basis

2. Unsealed radiation source

ROUTES OF IR IMPLANTATION:
1.

2.

Intraluminal brachetherapy
Insertion of hallow tubes at the lumen
Tumor are inoperable
E.g. obstruction lesion of lungs, esophagus
Intracavitary brachetherapy
Used in gynecological cancer
It may be dislodged
Insertion of applicator the container of the isotopes will be
placed distal of the tumor
Confirmed by x-ray
Can deliver HDR and LDR
3. Interstitial brachetherapy
Can be in form of: seeds, needles, wires, small catheter,
inflatable balloons
Inflatable balloons- less shorter of exposure to normal
cells/tissue; minimal radiation; mammosite; minimize skin
reaction
4. Contact of surface brachetherapy
Principles of radiation protection:

a) The distance between the pt. and the nurse(6feet away from
the pt.)
b) Amount of time spent in actual proximity to the pt.( 5
minutes each and maximum of 30 min. exposure within 8
hours)
c) The degree of shielding provided(wear dosimeter
badge,made up of lead)
*for lead sheet: 1 cm thick- 5 cm of concrete and 30 cm of wood
Radiation Dosimeter badge
Caring for client with sealed radiation source
1. Private room
2. Caution sign in the pt.s door
3. Organize task
4. Observe principles of DTS
5. Nursing assignment are rotated
6. Dosimeter badge
7. Never care for more than 1 client with radiation implant
8. No pregnant nurse
9. No children less than 16 y.o. or pregnant woman as visitors
10. Do not linger longer than necessary in giving care
11. Limit visitors: 30 min. daily at least 6 feet from source
12. Save bed linens and dressings until source is removed and
then the disease according to hospital policy
13. Avoid standing near the part of the pt.s body where the
radioactive element is located
14. Other equipment can be removed from the room at any time
15. Follow instruction precaution sheet on pt.s chart
16. Be alert for loosened implants
17. Notify the radiation therapist of any implant that been
moved out of the position
18. Always wear gloves and do careful handling of
gown/dressing, linens, and utensils
19. Most pt. are placed in bed rest for 72 hours
Disloged radiation source:
1. Do not touch with barehands
2. If source is dislodged but has not fallen out of pt.s body,
notify the XR radiation

3. If the source has fallen out pick it up with long handle

forceps in tongs and place in a lead container
4. If unable to locate source, prohibit visitors and notify the
physician
5. Do not discard any linens or dressings unless safe that are
no radioactive source is present
Pt. may be log rolled

Combination of these factors

Factors:
1. Anticipatory- has condition response ; associate in
chemotherapy
2. Acute pattern nausea and vomiting- takes place from 0-24
hours after the administration
3. Delayed pattern nausea and vomiting- occur 1-4 days after
administration
Nursing interventions:

SIDE EFFECTS OF CHEMOTHERAPY

GI SYSTEM

Nausea and vomiting- because multiple pathways causes:

o Stimulation of vagus nerve by the serotonin
release of the upper tract
o Activation of the receptor found
o Stimulation of peripheral and vestibular pathways
o Cognitive stimulation in CTZ( medulla)

Administer anti emetics

Given prior to administering chemo agents
Given routine schedule rather than PRN
e.g. serotonin blockers- ondasetron(zofran); dula setron;
gramisetron (kytril)
dopaminergic blockers- metochlopromide; haloperidol;
prochlorperazine
neurokin 1 recepto antagonist (blocks the substance P
potent neurotransmitter that
involves stimulating
N/V(e.g. apropitant-emend)
Effective if combined to other medications:
o
o
o
o

Corticosteroid
Antihistamine
Sedative
phenothiazines