Cancer Care (Nursing and Health Survival Guides), 1e

Cancer treatment

Successful treatment depends on:

• early detection of the disease

• careful staging and grading assessing the extent of the cancer

• prompt intervention

• appropriate support

• medical and technological advances

Cancer can be treated in different ways depending on the type of cancer, where it is in the body and if it has spread. Knowing more about what the treatments involve can help the nurse care competently and confidently for the person with cancer and their family.

Cancer treatment aims to:

• cure

• control the disease process

• offer palliation of symptoms

These goals may overlap and people are often given more than one type of treatment for their cancer. Treatment for cancer may be through:

• surgery

• chemotherapy

• radiotherapy

• biotherapy

• hormonal therapy

• bone marrow and stem cell transplants

Treatment options will be discussed with the patient and at multidisciplinary team meetings and relate to tumour staging and grading. The goals of treatment are:

• eliminating the tumour or malignant cells

• preventing metastases from developing

• reducing cellular growth and tumour burden

• promoting independence, functional abilities and providing pain relief to those whose disease has not responded to treatment

Images SURGERY

Surgery is used for the diagnosis and staging of most cancers. It is also considered for reconstruction (in breast cancer) and prophylactically. As a primary treatment for cancer, the objective is to eradicate the whole tumour, a clear margin of unaffected surrounding tissue and if lymph nodes are suspicious these are also removed. On occasion surgical intervention results in injury to the body and the formation of new structures to take over the function of structures lost during surgery; for example, in the removal of the distal sigmoid colon and rectum, an alternative means of providing elimination is required, the remaining segment of healthy colon is brought out through a created opening, a stoma on to the abdominal wall resulting in a permanent colostomy.

Side effects

• Destruction of nerves.

• Loss of normal functioning; for example, surgery on the prostate gland can lead to incontinence and erectile dysfunction.

• Surgical removal of diseased regional lymph nodes may lead to long-term lymphoedema; lymphoedema of the arm can occur after surgery for breast cancer.

When the tumour is inoperable or there is widespread metastases, surgery may be palliative:

• allowing the involved organs to function for as long as possible

• to relieve pain and provide comfort

• to bypass an obstruction

Surgery can help to reduce the bulk of the tumour enhancing the ability to control the residual disease through other treatment options, such as chemotherapy and radiotherapy. Often surgery is used in combination with other treatments to effect a cure.

Radiotherapy can be used before surgery to reduce the size of the tumour prior to being removed.

Exploratory laser technology is being considered for use in different types of cancer surgery, this:

• minimises blood loss

• decreases deformity

• enhances the accuracy of tissue resection

• promotes healing

In prostate cancer there has been an increase in laser use to preserve urinary continence and sexual functioning.

The nurse has a responsibility to help prepare the person physically, psychologically and legally for the proposed surgery; the role extends to the post-operative period teaching the person what to expect. The person should be given the opportunity to ask questions and discuss concerns and fears. There may be some instances where the person may wish to discuss alternative treatment options. In this case, the person must be listened to and their decision respected. It is imperative that the person makes an informed decision.

Images CHEMOTHERAPY

Chemotherapy is the treatment of cancer using anti-cancer drugs, cytotoxic drugs.

• Chemotherapeutic drugs can prevent cancer cells dividing and reproducing.

• The drugs are transported in the blood stream and can reach cancer cells anywhere in the body.

• They can also be taken up by some healthy cells.

• Healthy cells can repair the damage caused by chemotherapy but cancer cells cannot; they eventually die.

A number of new anti-cancer drugs are becoming available; these are known as targeted treatments. Cytotoxic drugs affect the growth of cancer cells and normal cells: the newer drugs are specifically targeted against certain parts of the cancer cells.

Cytotoxic drugs are still the most widely used form of chemotherapy. Chemotherapy agents act in a number of ways. They are:

• phase-specific, working at specific points of the cell cycle

or

• non-phase-specific; working throughout the entire cell cycle

Chemotherapeutic agents are commonly used in combination to increase the potential cell kill because tumours are made up of cells replicating at different rates, therefore, a combination of drugs affecting the cell at different points in the cell cycle has a better chance of being effective. Combinations of drugs are used when a cancer shows signs of drug resistance which develops when cells mutate rapidly.

Chemotherapy drugs can cause unpleasant side effects, as they affect some of the healthy cells in the body. Damage to the healthy cells is usually temporary: most side effects will disappear once treatment is over. Healthy cells in certain parts of the body are especially sensitive to chemotherapy drugs, including:

• bone marrow

• hair follicles

• lining of the mouth

• digestive system

It is usual for chemotherapy to be given as a series of sessions of treatment, with each session followed by a rest period: a cycle of treatment. A series of cycles make up a course of treatment. With each session of chemotherapy more of the cancer cells are destroyed; the rest period allows the normal cells and tissues to recover.

There are over 50 different cytotoxic chemotherapeutic drugs available. Combination chemotherapy can be used. The kind of chemotherapy treatment given depends on a number of things, including:

• type of cancer

• primary site

• cancer grade

• metastatic spread

Chemotherapy can also be used with other types of treatment, for example:

• surgery

• radiotherapy

• hormonal therapy

• biological therapies

or

• a combination of these

Classes of chemotherapeutic drugs

Chemotherapeutic agents can be classified either by the effects of the agent on the cell or its pharmacological properties. Usually they are grouped as:

• alkylating agents

• antimetabolites

• anti tumour antibiotics

• mitotic inhibitors

CLASSIFICATION

ACTION

Alkylating Agents

The oldest class of agents used and are either:

• Mono-functional; targeting one part of DNA formation

• Bi-functional; there are two opportunities in the cell cycle of working

Used to treat leukaemias, lymphomas and solid cancers

Affect stem cells and may lead to infertility; other side effects are nephrotoxicity and haemorrhagic cystitis

Antimetabolites

Phase specific drugs, interfering with the making of DNA causing cells to die. Side effects occur when high levels of the drug are administered; affecting rapidly dividing cells, for example, those in the gastrointestinal tract, the hair, skin and white blood cells. Examples are: folic acid analogues (methotrexate – treats breast cancer), pyrimidine analogues (5-fluorouracil) – treats colorectal and pancreatic cancers, cytosine arabinoside (ARA-C) – treats acute myeloid leukaemia, gemcitabine – used for pancreatic cancer and purine analogues (6-mercaptopurine) – used for lymphomas and leukaemias

Anti tumour antibiotics

Originally derived from natural sources, generally too toxic to be used as antibacterial agents. They are not phase specific, acting in several ways:

• Disrupting DNA replication and RNA transcription

• Creating free radicals, generating breaks in DNA

• Interfering with DNA repair

• Binding to cells, killing them

They also damage the cardiac muscle, limiting the amount and duration of treatment. Examples include actinomycin D, doxorubicin, bleomycin, mitomycin-C, and mithramycin.

Mitotic inhibitors

Act to prevent cell division, include the plant alkaloids and taxoids.

Plant alkaloids are extracted from plant sources:

• Vinca alkaloids (e.g., vincristine and vinblastine)

• Etoposide

Side effects associated are:

• Depression of deep tendon reflexes

• Pain and altered sensation

• Motor weakness

• Cranial nerve disruptions

• Paralytic ileus

Etoposide may cause bone marrow suppression, nausea and vomiting. The most common toxic effect is hypotension when the intravenous administration is too rapid.

Taxoids act by inhibiting cell division. Paclitaxel is used for the treatment of Kaposi’s sarcoma and metastatic breast and ovarian cancer. Side effects include alopecia, bone marrow depression, and severe hypersensitivity reactions, e.g. hypotension, dyspnoea and urticaria.

Side effects

Side effects vary depending on the drug used and the length of treatment. Most of the drugs act on fast-growing cells, side effects impact on normally rapidly dividing cells. Tissues usually affected by cytotoxic drugs include:

• mucous membranes of the mouth, tongue, oesophagus, stomach, intestine and rectum

• hair cells, resulting in alopecia

• bone marrow depression affecting most blood cells, results in impaired ability to respond to infection, diminished ability to clot blood and severe anaemia

• organs, such as heart, lungs, bladder, kidneys

• reproductive organs, resulting in impaired reproductive ability or altered foetal development

• nerve damage causing neuropathies and loss of sensation in the soles and palms

You must be aware of the side effects so supportive treatment can be provided; this will include physical and psychological care. You must provide patients with a safe environment, for example, ensuring risks associated with infection are reduced.

Images RADIOTHERAPY

Many patients choose to receive radiotherapy as part of treatment. This can be given as:

• External radiotherapy – high energy x-rays are used from outside of the body, normally given as a series of short, daily treatments using equipment similar to a large x-ray machine.

• Internal radiotherapy – a radioactive material is placed internally – inside the body and is used primarily to treat cancers of the head and neck, cervix, uterus, prostate gland or skin.

Treatment is given in one of two ways:

• Brachytherapy – solid radioactive material is placed close to or inside the tumour for a limited period of time.

• Radioisotope treatment – radioactive liquid is administered either as a drink or as an intravenous injection.

Radiotherapy works by destroying cancer cells in the area treated. However, healthy normal cells may also become damaged by radiotherapy, usually repairing themselves. Radiotherapy can cure some cancers and may also reduce the risk of a cancer recurring after surgery. It may also be used to alleviate symptoms caused by cancer.

There are specific nursing interventions required after radiotherapy:

• provision of psychological and physical support

• the site to be treated is usually marked on the skin with a semi permeable marker: this should not be washed off, otherwise all the measurements for positioning of the radiotherapy beam will have to be recalculated

The nurse should also advise the patient:

• not to wash the treated area with soap or apply creams, talcum powder or other topical preparations, as this may lead to skin damage

• avoid rubbing, scratching, shaving or exposing the area to sunlight

• not to apply hot or cold packs to the area

• to wear loose cotton clothing

• to check the skin condition daily, reporting any changes

Images BIOLOGICAL THERAPIES

Biological therapies (immunotherapy) use substances occurring naturally in the body to destroy cancer cells. There are several types of treatment:

• monoclonal antibodies

• cancer growth inhibitors

• vaccines

• gene therapy

Images BONE MARROW AND STEM CELL TRANSPLANTS

Bone marrow transplantation (BMT) is an accepted treatment, stimulating a non-functioning marrow or to replace marrow. BMT is given as an intravenous infusion of bone marrow cells from a donor to the person. Most commonly used in leukaemias, this therapy is being expanded to include treatment of other cancers including melanoma and testicular cancer.

Images HORMONES AND HORMONE ANTAGONISTS

Hormonal therapies act by changing the production or activity of specific hormones in the body, and are most commonly used to treat breast and prostate cancers. The type of hormone therapy given depends on the type of cancer being treated. There are a number of types of hormonal therapy.

Hormone antagonists work with hormone-binding tumours of the breast, prostate and endometrium, blocking the hormone’s receptor site on the tumour, preventing it from receiving normal hormonal growth stimulation. These drugs do not cure, but cause regression of the tumour in approximately 40% of breast and endometrial tumours and in 80% of prostate tumours.

Side effects can impair healing and may also lead to:

• hyperglycaemia

• hypertension

• osteoporosis

• hirsutism

Images SECTION SUMMARY

Broadly cancer treatment may be through:

• surgery

• chemotherapy

• radiotherapy

• biotherapy

• hormonal therapy

• bone marrow and stem cell transplants

There is no single treatment for cancer: a number of options are available and decisions are based on an individual assessment. Often a combination of several types of treatment are required ensuring greatest effect, taking into account a variety of factors, including the patient’s age, history and lifestyle. At all times the patient should be at the centre of the decision making process. High quality care means that the patient is cared for in a holistic manner.

Surgery may be indicated with the aim of removing the cancer. Chemotherapy may be required before or after surgery. There may be a need for radiotherapy or other forms of treatments.

All forms of treatment have side effects, some more tolerable than others. The nurse has to provide as much information as possible to the patient so he/she is able to make a truly informed decision about care management proposals.

Take some time and think about the various types of treatment listed below and think of the potential side effects. When you have done this begin to think of ways in which the nurse can help the patient address the issues identified.

TREATMENT

POTENTIAL SIDE EFFECTS

ALLEVIATING NURSING INTERVENTIONS

Chemotherapy

   

Radiotherapy

   

Brachytherapy

   

Hormone therapy

   
  

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