Category: Individualised Nursing Care 1 (Part 1)

Cancer treatments can be offered with various aims, depending on which type of cancer, its location, health status, and at what stage and grading it is discovered.

Cancer spreads through lymph nodes. Thus, when cancer is detected, the nearest lymph nodes are checked for signs of cancer, which, if found, would mean that cancer would have started spreading.

Cancer treatments aims include prevention, cure, control (prolonging survival where cure is unattainable), and palliative care (symptom relief), as well as prophylactic care. Active treatment lasts around 8-12 months, however, in some cases, this may take up to 8-10 years.

Cancer treatments include the following options: surgery, chemotherapy, radiotherapy, hormone therapy, targeted therapy, complimentary therapy, bone marrow transplantation, and supportive therapy. Supportive Therapy aims to treat symptoms of cancer through the use of antiemetics, immunotherapy, etc.

The Nurse’s Role in Cancer Treatments

Patient education is a must with regards to patients with cancer. Providing adequate patient education helps minimise risks during cancer treatment. For example, the nurse should teach the patient to avoid areas which are prone to illness if possible, since a patient undergoing certain cancer treatment is considered to be immunocompromised.

A nurse navigator is assigned to patients with cancer, whose role is to look after a patient throughout the whole treatment journey, as well as provide support for both the patient and other family members.

Cancer and its treatment options impact all domains of a patient’s life.

Patient Perspective of Quality Care in Cancer Treatments

Cancer Grading and Staging

Cancer Treatments Responses

Surgery

As one of the options for cancer treatments, surgery can be chosen for the following reasons:

• prevention
• diagnosis and staging
• to prevent further growth and spread
• to reduce the tumour’s size if size becomes a burden to the individual
• to interfere with the tumour’s growth process
• to correct defects caused by the tumour
• to provide pain relief

Factors for consideration prior to surgery include:

• diagnosis
• prognosis
• risks
• health status
• impact of recommended surgical procedure

In patients who are predisposed to breast cancer, blood testing is performed to check for BRCA1 and BRCA2 cancer genes. Genetic predisposition carries a risk factor of 10-12% for breast cancer development. If the patient is found positive for BRCA, a prophylactic mastectomy may be recommended.

With regards to pain relief, surgery may be an option too. For example, if a patient has a tumor which is pressing on a neuropathic nerve, removing it surgically would reduce the pain.

Cancer Surgical Treatment Perioperative Nursing Care

• patient assessment
• provision of health literacy
• enabling decision-making and informed consent – patients have a right to refuse treatment
• providing and/or enabling physical, functional, psychological, social, and spiritual supportive care

Chemotherapy

In chemotherapy, cytotoxic chemicals are used with the aim of eradicating or controlling cancer.

Types of chemotherapy include:

• cytotoxic therapy
• systemic treatment
• neoadjunvant
• adjuvant
• chemoradiation
• first-order kinetics – kills almost all cancer cells through cycle treatments
• primary and secondary tumour resistance

Chemotherapy can be administered via the following routes:

• oral
• intravenous (continuous and bolus)
• intra-arterial
• intrapleural
• intravesical (through the bladder)
• intrathecal/intraventricular (in the subarachnoid space)
• intraperitoneal
• topical

When selecting the ideal chemotherapy for a patient, the following considerations are taken into account:

• therapy which offers the maximum therapeutic effect and with what is considered as acceptable toxicity levels
• assessment of the patient’s physiological and psychosocial status
• benefits vs toxicity
• in multi-drug regimen, the aim is to kill as many tumour cells as possible, reduce toxicity, and reduce drug resistance possibility

Prior to chemotherapy administration, the patient should be evaluated so as to determine whether he/she is healthy enough to receive chemotherapy treatment.

Histology results provide accurate tumor grading information.

Chemotherapy Side Effects

Chemotherapy side effects include:

• myelosuppression – a condition which causes a decrease in bone marrow activity that results in less red blood cells, white blood cells and platelets
• neutropaenia – an abnormal low concentration of neutrophils (white blood cells) in the blood; may lead to febrile neutropaenia which is characterised by a fever and other signs indicating infection
• thrombocytopaenia – low blood platelet count
• anaemia – a deficiency in the number and/or quality of red blood cells
• alopecia – hair loss
• oral mucositis – tissue swelling in the mouth
• fatigue
• nausea and vomiting

Nurse’s Role During Chemotherapy Administration

• patient education – enabling informed consent and establishing reachable goals
• chemotherapy targets cells that multiply fast, hence why it destroys cancer cells as well as other cells in the body which do the same eg. hair cells (causing alopecia with certain chemotherapies), the lining of the digestive system (causing nausea, vomiting, and diarrhoea)
• if patient loses hair following chemotherapy, advise patient that hair will regrow once all chemotherapy sessions are completed, even if the texture and colour may be different
• if patient experiences nausea and vomiting, parameters should be taken so as to check for sepsis; antiemetics may be prescribed so as to reduce side effect; tepid-sponging face and neck may also help the patient feel better; prop up patient so as to avoid aspiration in case of vomiting, as this may cause pneumonia; if patient vomits, encourage oral hygiene since gastric contents would contain chemotherapy, which would lead to the oral mucosa to become damaged – encourage to brush teeth, tongue and gums well with toothpaste, mouthwash, and even rinse throughout the day with a solution made out of 1 tsp baking soda in a cup of water – this balances the acidity in the mouth from gastric content, with the alkaline solution used for rinsing
• if patient experiences fatigue, encourage to rest, but also encourage bed exercises so as to promote mobility and avoid complications (DVT and pneumonia); reassure patient that once chemotherapy is completed, fatigue lessens; teach patient to identify times during the day in which fatigue is lessened, so as to be able to shower and do other tasks at that time; monitor the patient’s haemoglobin level, as if this is very low, a blood transfusion may be needed
• chemotherapy administration & safety – safe handling and disposing of chemotherapy for the benefit of all; spillage protocol; extravasation protocol
• prevention of complications
• management of side effects
• ongoing support

NOTE: Chemotherapy is excreted through bodily fluids including urine. Thus patient should aim to use a different bathroom than other family members, or else clean well after use, since if another person comes in contact with the patient’s bodily fluid, there would be a risk of developing cancer and killing cells (chemotherapy is cytotoxic).

Radiotherapy

Radiotherapy a.k.a. radiation therapy is a cancer treatment that uses high doses of radiation to kill cancer cells and shrink tumors through the use of Ionising Radiation. This is done either through External Beam Radiotherapy (EBRT) which works through linear accelerators that produce high energy x-rays that can treat deep tumours, or as Internal Radiotherapy / targeted therapy eg. radioisotope therapy, brachytherapy etc).

Radiotherapy Side Effects

Radiotherapy side effects are usually related to the area being treated for cancer.

Acute side effects usually show up around 10 days following treatment initiation, with its peak effects showing up around 10 days after the full treatment course.

Late side effects usually develop gradually around 6 months following treatment. These side effects are often permanent.

Side Effects of Radiotherapy for Breast Cancer including Axilla

Acute side effects include skin reactions, pain, and fatigue.

Long-term side effects include Brachial Plexopathy (type of peripheral neuropathy in which damage to the brachial plexus is incurred), Lymphoedema (a condition in which build-up of lymph fluid in the body’s soft tissues causes swelling), Lung Fibrosis (damaged and scarred lung tissue), and Bone Necrosis (death of bone tissue).

Skin Reactions to Radiation Therapy

If skin reactions to radiation therapy are noted:

• use a gentle washing technique with mild soap
• use an electric shaver when shaving
• avoid exposure of affected area to the sun
• promote skin hydration using aqueous cream twice daily
• avoid using deodorants, perfumes and other irritants
• promote adequate hydration
• encourage clothing made of natural fibre

Nurse’s Role During Radiotherapy Administration

• holistic assessment – take into consideration side effect risks
• patient education
• aiming to minimise side effects through continuous patient assessment

Hormone Receptors and Hormone Manipulation Therapy

Hormone Manipulation Therapy is a treatment which adds, blocks or removes hormones with the aim of stopping or slowing down cancer cell growth which require hormones to grow.

Side effects of hormone manipulation therapy may include:

• hot flushes
• sweating
• physical changes
• low libido
• fatigue
• nausea

Targeted Therapy

Targeted Therapy refers to the use of drugs or substances which target particular molecules to stop cancer cells from growing and/or spreading. Targeted Therapy doesn’t cause harm to cells other than the ones targeted – cancer cells.

Immunotherapy

Immunotherapy , which is another type of targeted therapy, stimulates specific components of the immune system and counteracts signals produced by cancer cells that suppress immune responses through checkpoint inhibitors.

Bone Marrow Transplantation

Bone Marrow Transplant (BMT) is a type of cancer (or other diseases) therapy in which cells that are usually found in the bone marrow (eg. stem cells) are filtered and given back to the patient or to another person in need of a bone marrow transplant.

Bone Marrow Transplantation is usually carried out once a patient is in remission. Patient may be sent abroad for this procedure. It is ideal for patients with Leukaemia (the bone marrow is where all blood cells are produced).

Complementary Therapies and Psychological Support for Cancer Patients

• Homeopathy
• Detoxification/Antioxidant
• Nutritional Supplements
• Diet
• Acupuncture
• Aromatherapy
• Reflexology
• Therapeutic Massage
• Reiki / Universal Energy
• Counseling
• Psychotherapy
• Music Therapy
• Meditation/Relaxation Techniques

NOTE: Homeopathy isn’t recommended when pharmacological therapy for cancer is involved. Similarly, it is important that a cancer patient mentions all medicines and supplements (even vitamins) that are being ingested.

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