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Cancer
− Group of more than 200 diseases
− Characterized by uncontrolled and unregulated growth of cells
− Declining due to preventive efforts: colorectal, lung, oral, pharyngeal cancers
− Rising: non-Hodgkin’s lymphoma, skin cancer, especially MELANOMA (due to genetic
predisposition and sun exposure)
− Mostly >55 years, but ALL age groups can be affected
− Men > women
− African American > whites and other minority group
− Yet, differences in survival from cancer are attributed primarily to a combination of several
factors:
o Poverty
o Difficult access to health care
o More comorbid conditions
o Differences in tumor biology
− Nurses position – lead efforts at changing attitudes and behaviors about cancer
o Goal : implement educational interventions that will assist individuals to
Understand, reduce, or eliminate their risk of cancer development
Comply with cancer management regimens
Cope with effects of cancer and related treatment
Biology of Cancer
Cancer encompasses a broad range of diseases of multiple causes that can arise in ANY CELL of the
body capable of evading regulatory controls over proliferation and differentiation.
o Two major dysfunction:
1) Defect in cellular Proliferation
2) Defective cellular differentiation
Development of Cancer
− Likely to be multifactorial
− Common belief: development of cancer is rapid, haphazard event
− Natural history of cancer: Occurs over a period of time by an orderly process comprising
several stages.
− Stages include: initiation promotion progression
1st Stage : Initiation Stage (Irreversible)
− Mutation in the cell’s genetic structure potential for developing into a clone of neoplastic
cells (NOT ALL go on to establish a tumor b/c many undergo apoptosis)
o Caused by inherited mutation (an error that occurs during DNA replication, OR
o Exposure to a chemical, radiation, or viral agent.
− Does not have the ability to self-replicate and grow therefore, NOT A TUMOR CELL YET
o May remain undetected throughout lifetime unless further events stimulate the tumor to
develop
Carcinogens : cancer-causing agents capable of producing cellular alterations
− Many are detoxified by protective enzymes and harmlessly excreted
But, if protective mechanism fails carcinogens enter cell’s nucleus and alter DNA
− Some cells die or repair itself
But if not before cell division cell replicates into daughter cells, each with same genetic
alteration
− Characteristics : irreversible and additive
Chemical Certain chemicals (identified as cancer causing agents in later eighteenth century by
Carcinoge Percival Pott) Ex; soot scrotum cancer
ns o Later on..evidence indicated that people who are exposed to certain chemicals
over time had a higher incidence of getting cancer than others.
Certain drugs
o that interacts with the DNA are identified as carcinogens. Ex; Pts w/ HL or NHL
or Multiple myeloma treated with alkylating agents either alone or
w/radiation therapy (cyclophosphamide[cytoxan] and nitrogen mustard) &
immunosuppressive agents increased incidence of acute myelogenous
leukemia (Secondary leukemia)
Secondary Leukemia
o Relatively refractory to induction of remission with combination chemotherapy
o Also been observed in those who had transplant surgery and taking
immunosuppressive drugs.
Radiation − Ionizing radiation can cause cancer in almost any human body tissue.
− When cells are exposed, one or both strands of DNA are damaged.
− Certain malignancies correlates w/radiation as a carcinogenic agent:
o Hiroshima and Nagasaki atomic bomb explosions ↑leukemia, lymphoma,
thyroid cancer, and other cancers.
o Certain occupations such as radiologists, radiation chemists, and uranium
miners ↑incidence of bone cancer
o Those who received radiation to head and neck area for treatment such as
acne, tonsillitis, sore throat, or enlarged thyroid gland ↑ incidence in thyroid
cancer
o Children exposed to radiation during fetal life ↑ incidence of childhood
cancers
o UV radiation melanoma and squamous and basal cell carcinoma of the skin
(skin cancer is poorly responsive to systemic treatment)
Viral − Certain DNA and RNA viruses (called oncogenic)
Carcinoge transforms cells that they infect
ns induce malignant transformation.
o Epstein-Barr virus (EBV) in vitro Burkitt’s lymphoma and infectious
mononucleosis
− why an infectious dz in some persons and lymphoma in others is not
known
o AIDS ↑ incidence of Kaposi sarcoma
o Hepatitis B virus hepatocellular carcinoma
o human papillomavirus ↑lesions that progress to squamous cell
carcinomas, such as cervical cancers
Genetic − Cancer-related genes ↑ individual’s susceptibility to development of certain
susceptibil cancers
ity − Ex; those who carries genes BRCA1 or BRCA 2 has a 40% to 80% risk of
developing breast cancer in her lifetime. But, in reality, 95% of wome who develop
breast cancer do not have these genes.
− it is believed that ONLY 10% of cancers have a strong genetic link
Oncofetal Antigens
o Oncofetal Antigens: type of tumor antigen
− Found on both the surfaces and inside of cancer cells, found on fetal cells as well.
− Expression of the shift of cancerous cells to a more IMMATURE METABOLIC PATHWAY
(expression usually associated with embryonic or fetal periods of life)
− Reappearance of fetal cells is not well understood. However, it is believed to occur for the cell
regaining its embryonic capability to differentiate into many different types of cells.
− Examples:
Carcinoembryonic antigen (CEA)
o Found on normal fetal cells in gut, liver, and pancreas
o normally disappears during the last 3 months of fetal life.
o Malignant conditions: Also found on surface of cancer cells derived from GI tract (originally
isolated from colorectal cancer cells)
o Nonmalignant conditions: ↑CEA have been found in cirrhosis of liver, ulcerative colitis, and heavy
smoking
• PRESENTLY, major value of CEA is NOW used as an INDICATOR OF THE SUCCESS OF CANCER
TREATMENT – so MONITOR
− Ex; persistence of elevated preoperated CEA titers post surgery tumor is not completely
removed
− Ex; rise in CEA post chemo or radiation therapy recurrence or spread of the cancer.
a-fetoprotein (AFP)
o Produced by fetal liver cells
o Malignant conditions: Also produced by malignant liver cells
− Has diagnostic value in primary cancer of the liver (hepatocellular cancer)
− Also produced when metastatic liver growth occurs.
o Nonmalignant conditions: testicular carcinoma, viral hepatitis, and nonmalignant liver disorders
• Detection of AFT is of value in tumor detection & determination of tumor progression
Oncofetal antigens curreintly being studied
o CA-125: found in ovarian carcinoma
o CA-19-9: found in pancreatic and gallbladder cancer
o Prostate-specific antigen(PSA): found in prostate cancer
Classification of Cancer
Classified according to
1. Anatomic site
2. Histology (grading)
3. Extent of disease (staging)
Tumor classification provide a standardized way to
1. Communicate the status of the cancer to members of health care team
2. Assist in determining the most effective treatment plan
3. Evaluate the treatment plan
4. Factor in determining the prognosis
5. Compare like groups for statistical purposes
Histologic Classification
Pathologically evaluating the APPEARANCE of cells and the degree of DIFFERENTIATION.
4 grades used to evaluate abnormal cells based on the degree to which they resemble the tissue
of origin.
• Grade I: Cells differ slightly from normal cells (mild dysplasia) and are well differentiated.
• Grade II: Cells are more abnormal (moderate dysplasia) and moderately differentiated
• Grade III: Cells are very abnormal (severe dysplasia) and poorly differentiated.
• Grade IV: Cells are immature and primitive (anaplasia) and undifferentiated; cell of
origin is difficult to determine. NOT GOOD NEWS!
• REMEMBER: tumors that poorly differentiated (undifferentiated) have a worse
prognosis than those that are closer in appearance to the normal tissue of origin.
o TNM Classification System (Represents the AJCC modification of clinical staging (originally
developed by the International Union Against Cancer (UICC))
− Made to achieve consistency w/American medical practice
− Used to determine anatomic extent of disease involvement according to three
parameters:
Primary Tumor (T) : Tumor size and invasiveness
T0 No evidence of primary tumor
Tis Carcinoma in situ (has all the histologic characteristics of cancer except invasion – primary feature of
T1-4 TNM)
Tx Ascending degrees of increase in tumor size and involvement
Tumor cannot be measure or found
Regional Lymph Nodes (N) : presence or absence of regional spread to the lymph nodes
N0 No evidence of disease in lymph nodes
N1-4 Ascending degrees of nodal involvement
Nx Regional lymph nodes unable to be assessed clinically
Distant Metastases (M) : metastasis to distant organ sites
M0 No evidence of distant metastases
M1-4 Ascending degrees of metastatic involvement of the host, including distant nodes
Mx Cannot be determined
• TNM cannot be applied to all malignancies (ex; NO for leukemia since not a solid tumor)
PUBLIC EDUCATION
GOAL of public education: motivate learners to change their negative health behavior patterns to
achieve and maintain an optimal state of health.
− Care should be taken to minimize fear and anxiety
− Reinforce w/ large-type prints including graphics and key concepts increases success of
educational efforts for elderly who may have visual and hearing deficits or difficulty
processing info, or those who has English is a second language.
TEACH – Nursing Implementation
1. Reduce or avoid exposure to carcinogens and cancer-promoting agents (ex; cigarette smoke &
sun exposure)
2. Eat balanced diet including vegetables, freshfruits, whole grains, adequate amounts
of fiber. Reduce amount of fat, preservatives, including smoked and salt-cured meats
containing high nitrite concentrations.
3. Participate in regular exercise regimen (ex; ≥ 30minutes moderate physical activity 5
times weekly)
4. Obtain adequate, consistent periods of rest (at least 6 to 8 hrs /night)
5. Have health examination on a regular basis including health history, physical examination,
specific diagnostic tests for common cancers in accordance with the guidelines published by the
American Cancer Society
6. Eliminate, reduce, or change perceptions of stressors and enhance the ability to effectively cope
w/stressors
7. Know seven warning signs of cancer (actually detect fairly advanced disease)
7 WARNINGS SIGN OF CANCER
− Change in bowel or bladder habits
− A sore that doesn’t heal
− Unusual bleeding/discharge from an orifice
− Thicking or lump in beast or elsewhere
− Indigestion or difficulty swallowing
− Obvious chage in wart or mole
− Nagging cough or hoarseness
8. Learn & practice recommended cancer screenings on a timely basis (ex; colonoscopy in average-
risk people beginning at age 50 and every 10yrs thereafter)
9. Learn & practice self-examination (ex; DO testicular self-exam & SBE starting from EARLY
20’s)
10. Seek immediate medical care if notice any change in what is normal for you and if cancer is
suspected.
• Remember! Early detection of cancer has positive impact on prognosis!
DIAGNOSIS OF CANCER
− When pt has a possible diagnosis of cancer,,,
o Stressful time for pt and family
o Fear of the unknown.
Nursing Implementation
− Be available to actively listen to concerns and skilled in techniques that will engage the in
discussion about their cancer-related fear.
− Recognize that their anxiety may arise from myths and misconceptions about cancer (ex;
cancer is a “death sentence”, cancer treatment is worse than the illness) correcting
misconceptions will ↓anxiety
− Nurses should learn to recognize their own discomfort when discussing about cancer.
o AVOID closed communication patterns that may shut off further communication
o AVOID false reassurance that everything will be all right (ex; it’s probably nothing)
o AVOID redirecting the discussion (let’s discuss that later)
o AVOID generalizing (everyone feels this way)
− Pt may need repeated explanations of diagnostic workup due to HIGH ANXIETY &
FEAR. Clear and repeated/reinforced explanations may be necessary. (written info is
helpful for reinforcement)
− Diagnositic plan for those cancer is suspected : includes health hx, identifying risk factors,
physical exam, specific diagnostic studies
o Health history: emphasis on risk factors such as
family or personal history of cancer
Exposure to or use of known carcinogens (exl cigarette smoking, exposure to
occupational pollutants or chemicals)
Disease characterized by chronic inflammation (exl ulcerative colitis)
Drug ingestion (ex; hormone therapy, previous anticancer therapies)
Dietary habits, ingestion of alcohol
Lifestyle
patterns and degree of coping w/ perceived stressors
o Physical examination
Should be thorough
Particular attention should be given to
• respiratory system GI system (including colon, rectum and liver),
• lymphatic system (including spleen),
• breasts,
• skin,
• reproductive system (testes and prostate gland in men; cervix, uterus,
and ovaries in women), and
• musculoskeletal and neurologic system
o Diagnostic studies
Studies to be performed on will depend on the suspected primary or metastatic
site(s) of the cancer
Examples of studies or procedures:
• Cytology studies (ex; Papanicolaou[Pap] test, bronchial washings)
• Tissue biopsy
• Chest x-ray
• CBC, chemistry profile
• Sigmoidoscopy or colonoscopy exam (include guaiac test for occult blood)
• LFT (ex; aspartate aminotransferase[AST])
• Radiologic studies (ex; mammography, ultrasound)
• Radioisotope scans (ex; bone, lung, liver, brain)
• CT scan (ex; spiral)
• Positron emission tomography (PET) scan
• Presence of tumor markers (ex; CEA, AFP, PSA, CA-125) or genetic
markers (ex; BRCA-1, BRCA-2)
• Bone marrow examination (if hematolymphoid malignancy is suspected or
to document metastatic dz)
Biopsy
o The only definitive means of diagnosing cancer
o Essential in planning a treatment plan
o Involves surgical acquisition of tissue from suspicious area for histologic examination by a
pathologist
Will determine whether tissue is benign or malignant
The anatomic tissue from which tumor arises
Degree of cellular differentiation
o Needle or aspiration biopsy: used to obtain cells and tissue fragments through a large-bore
needle that is guided into tissue in question (ex; bone marrow aspiration; core biopsy of
prostate gland, breast, liver, and kidney tissues)
− To determine the presence of tumor,, cytologic analysis is performed
o Incisional biopsy: performed w/ scalpel or dermal punch
− Common technique for obtaining a tissue sample for making a diagnosis of cancer
o Excisional biopsy: involves removal of entire tumor
− Used for small tumors (smaller than 2 cm), skin lesions, intestinal polyps, and breast
masses
− Considered therapeutic as well as diagnostic
− If not easily accessible major surgical procedure such as laparotomy, thoracotomy,
craniotomy, is necessary to obtain a piece of tumor tissue.
o Endoscopic procedures: biopsy specimens of GI, respiratory, and GU systems
Collaborative Care
Goals and Modalities
• GOAL of cancer treatment : CURE, CONTROL, or PALLIATION
o Factors that determine therapeutic approach are:
Tumor cell type
Location
Size
And systemic extent of dz.
o Other important considerations
Pt’s physiologic status (ex; presence of comorbid illness)
Psychologic status
Personal desires (ex; active treatment versus palliation of symptoms)
o American Society of Clinical Oncologists (ASCO) and the National Comprehensive Cancer Network
(NCCN)
Developed evidence-based cancer treatment guidelines to guide the formulation of
appropriate treatment recommendations for individual patients.
CURE is •
Treatment is expected to have the greatest chance of disease eradication.
the GOAL Treatment may involve:
o
Local therapies (surgery or radiation) alone or in combination
With or without periods of adjunctive systemic therapy (ex; chemotherapy)
− Ex; basal cell carcinoma of skin cured by surgical removal OR by several
weeks of radiation therapy
− Ex; Acute promyelocytic leukemia in adults administration of several
chemotherapy over 6 months to several years in sequential phases known as
remission induction, remission consolidation, and maintenance therapy
− Head and neck cancers cured with combination of surgery and pre-or
postoperative radiation, with or without chemotherapy
o In general, it appears that risk for recurrent disease is HIGHEST following
treatment completion, and gradually decreases the longer the pt. remains
disease free following treatment.
− Ex; pt with rapid mitotic rate is considered cured if not detected in a 2 year time
span
− Slower mitotic rate needs 20 or more dz-free years before she can be considered
cured
CONTROL • Cannot be completely eradicated but are responsive to anticancer therapies
is the • And as with other chronic illnesses such as diabetes mellitus and heart failure, can
GOAL be maintained for long periods of time with therapy.
− Ex; multiple myeloma, certain lung cancers, and chronic lymphocytic leukemia
1. Pts undergo initial treatment,
2. followed by maintance therapy for as long as the dz is responding OR until
adverse drug effects warrant discontinuation. (pts are often treated with variety
of regimens in a sequential pattern)
3. Evidence of tumor resistance (such as dz progression) consider to change to
alternate therapy
o Pts are followed closely for signs and symptoms of recurrence or progression and
the cumulative effects of therapy.
PALLIATI • Relief or control of symptoms and the maintenance of a satisfactory quality
ON is the of life
GOAL − Ex; pain from bone metastasis or discomforts associated with
lymphedemaradiation therapy or chemotherapy are given to reduce tumor size
and relieve pain
− May be in effect for months to years
o 4 treatment modalities for cancer
Surgery
Radiation therapy
Chemotherapy
Biologic and targeted therapy
• For many cancers, “multimodality therapy” or “combined modality therapy” are used to
achieve the goal of cure or control for long period of time
• More effective but often increased toxicity.
Surgical Therapy
o Oldest form of local cancer treatment
o Was the only effective method of cancer diagnosis and treatment in the early days
o For many years, removing the cancer w/ surrounding tissue as much as possible was treatment of
choice
o This approach did not consider the ability of malignant cells traveling to other locations
o Made surgical cure possible only when tumor was localized and relatively small
o TODAY, surgery is employed to meet a variety of goals b/c
Surgical techniques improved
Expanded knowledge of tumor metastasis patterns
Availability of alternate therapies
Prevention
− Prophylactic removal of nonvital organs - used to eliminate or reduce risk of cancer
development who have underlying conditions that ↑risk of developing cancer. (Must weigh risk
vs. benefits)
o Ex; total colostomy to those who have adenomatous familial polyposis to prevent
colorectal cancer
o Ex; prophylactic mastectomy to those who have genetic mutations of BRCA-1 or BRCA-2
and a strong family hx of early-onset breast cancer prevent breast cancer
Rehabilitative Care
− Cancer surgery can produce a change in body image and function. Conjunction with the
diagnosis itself may be difficult for the pt to cope with these changes.
− Patient must be able to accept and cope with their altered body image and functional
deficit on a daily basis in order to maintain its quality of life.
− The emphasis of rehabilitative role of surgery is greatly increasing to increase the quality of
life.
1. Creation of a bladder reservoir at the time of cystectomy
2. Breast reconstruction after mastectomy
3. Spinal or joint stabilizing rods insertion to facilitate function
4. Create ostomies to facilitate function
Chemotherapy
Effect on Cells
Chemotherapy effects is at the cellular level : relationship to the cell cycle.
2 major categories of chemotherapeutic drugs: (often administered in combo to maximize
effectiveness)
1) Cell cycle phase-nonspecific chemotherapeutic drugs: effect on the cells during all
phases of cell cycle
− (include cellular replication & proliferation & those in resting phase(G0)
2) Cell cycle phase-specific chemotherapeutic drugs: most significant effects during
specific phases of cell cycle
− (process of cellular replication or proliferation during G1, S1, G2, or M)
When cancer first develops, most cells are actively dividing most chemoagents are most
effective against dividing cells.
As tumor increases, more cells become inactive and convert to resting state (G0) during
chemo, cells can escape death by staying in the G0 phase. Therefore, a major problem is the
presence of drug-resistant resting and noncycling cells.
Methods of Administration
Intravenous (IV) routes - most common
IV Peripherally Nursing implementation
o Major concerns w/ IV administration o MONITOR for extravasation
Venous access difficulties o Promptly recognize symptoms
Device-or catheter-related infection swelling
Extravasation (infiltration of drugs into tissues redness
surrounding the infusion site) causing local tissue presence of vesicles on the skin,
damage & PAIN w/out pain
o immediately turn OFF infusion
o IRRITANTS – damage the intima of the vein, causing o protocols for drug-specific
phlebitis and sclerosis and limiting future peripheral extravasation to minimize further
venous access tissue damange
- BUT WILL NOT CAUSE TISSUE DAMAGE IF
INFILTRATED IV push
Fresh IV run w/ open saline bag
o VESICANTS – if extravasation or infiltrated into skin Aspirate q few seconds and see flashback
(W/OUT PAIN) may cause severe local tissue of blood..If seen, it is okay
breakdown, ulceration & necrosis (or third But if not seen blood or if pain stop
degree burn) potential to progress to a deep, Give Antidote intradermally
wide crater that warrants closure with skin
grafts
Central vascular access device (CVAD)
o Advantages: (can give over 4 hrs)
To minimize associated physical discomforts, emotional distress and risks of infection and
infiltration. (still IV)
Using large blood vessels and permit frequent, continuous, or intermittent administration of
chemotherapy
Can also be used to administer additional fluids, and electrolytes, blood products, parenteral
nutrition, other meds (antiemetics) and for venous sampling
Avoiding multiple venipunctures for vascular access
↓risk for extravasation injury – but still can occur if displacement or damage to particular
device used for central venous access
Facilitation of supportive therapies
o Disadvantages:
Risk of systemic infection (if pt becomes immunosuppressed during therapy)
− Write down what site looks like, or any signs of infection
o Used for:
Those with limited vascular access
Intensive chemotherapy
Repetitive or continous infusion of vesicant agents
Projected long-term need for vascular access
Tunneled Catheter
Single-, double-, or triple lumen o MUST VERIFY accurate placement
Approximately 90 cm in length using CHEST-X-RAY before using
catheter
Ranging from 1 to 2 mm in internal diameters
o care requirements
− Inserted with local or general anesthesia through Cap chage
a central vein Cleansing
− Tip rests in distal end of superior vena cava OR right Heparin flush
atrium of the heart Dressing change
− Other end is tunneled through subcu tissue and exits o complications - MONITOR
through incision on chest or abdominal wall Occlusion
Sepsis
o DACRON cuff : serves to stabilize catheter and may Bleeding
↓incidence of infection by impeding bacteria
Venous thrombosis
migration along the catheter beyond the cuff
o Groshong catheter : special tube of tunneled cath Technical problems
− Closed ended with a slit valve(pressure activated Local infection at exit site
valve) on the side of the distal end
− Therefore, this valves opens w/infusion, flushing,
or aspirating blood. When not used, valve closes,
preventing backflow of blood or entry of air
− Does not need heparin flushing or clamping
Peripherally inserted Central Venous Catheters o Complications - MONITOR
(PICCs) Catheter occlusion – thrombolytic
-only MD or specially trained nurse can place agent can be used to lyse
these obstructions
Single-, or double-lumen Phlebitis – usually appears within 7
Up to 60 cm in length to 10 days following insertion
Ranging from 24 to 16 guages • Signs
Nontunneled − Redness
Polymer catheters − Edema
− Tenderness along track
− Inserted at or just above the antecubital fossa of catheter line
− Tip ending in the distal 1/3 of superior vena cava • If sign present
− Use guide wire or forceps to advance the line. − Remove catheter
− Primarily used in cancer care for immediate central − Must culture tip of
venous access OR for infusion therapy that is beyond catheter
the capacity of pt’s existing, long-term venous
access device. • Arm in which PICC is in place should
NOT BE USED FOR BP or blood
o Used for drawings
− short term IV therapy – can be in place for up to 6
mons
− frequent administration of blood products
− frequent blood drawing
− intermittent or continuous drug infusions
Implanted Infusion Ports
− Consists of central venous catheter connected to an o Care requirements
implanted, single or double subcu injection port Regular flushing
− Placed into desired vein and other end is connected o Complications
to a port that is sutured to the chest wall muscle Clotting
− Surgically implanted in a subcu pocket on the chest Catheter migration
wall Infection
Bleeding
− Port consists of metal sheat w/ self-sealing silicon
septum
Thrombosis
− Accessed via septum w/special Huber Point Needle
Air embolism
that has a deflected tip to prevent coring of the Infection at the exit site or in the
septum pocket
− Available w/ 90degree tips for longer invusions Formation of “sludge” –
accumulation of clotted blood and
drug precipitate may also occur
within port septum
Infusion Pumps
− Used primarily for continous infusion of o Flow rate can be affected by
chemotherapy by IV, subcutaneous, intraarterial, Drug concentration
and epidural rountes Length and diameter of Silastic
− Pumps worn externally or implanted surgically Catheter
Implanted pumps are used primarily for Pt’s body temp; dose alterations
intraarterial administrations – continous infusion may be required if pt has change
directly to the tumor while ↓systemic effects of in temperature or travels to higher
the drug altitutdes
2nd septum can be used for bolus medication
administration o Complications
− Most commun use: Infection
Hepatic artery infusion for liver metastasis Thrombosis
usually from primary colorectal cancer Clotting of catheter
Pump malfunction
− Catheter is attached to a pump apparatus consisting
two chambers
Inner chamber: serves as the drug reservoir
Outer chamber: contains vapor pressure
providing source of power for the pump
− Pump is implanted surgically in a subcutaneous
pocket
− Access to pump via a silicone septum with a Huber-
point needle
Intraarterial Chemotherapy
o Delivers drug to the tumor via arterial vessel supplying the tumor
o Method: surgical placement of a catheter connected to an external infusion pump or an implanted
infusion pump
o Treatment used for
osteogenic sarcoma
Cancers of head and neck,Bladder,Brain,Cervix
Melanoma
Primary liver cancer
Metastatic liver disease
o reduced systemic toxicity
type of toxicity experienced by pt depends on the site of tumor being treated
Intraperitoneal Chemotherapy – PERITONEAL METASTASES
o Delivery of drug to peritoneal cavity.
− Generally infused into peritoneum in 1 to 2 L of fluid and allowed to “dwell” in the
peritoneum for a period of 1 to 4 hrs. Following the “dwell time,” the fluid is drained from
the peritoneum.
o Method: temporary Silastic catheters (Tenckhoff, Hickman, and Groshong) are percutaneously or
surgically placed into peritoneal cavity for short-term administration.
Alternate method: implanted port can be used to administer chemotherapy intraperitoneally
o Treatment used for
Peritoneal metastases from primary colorectal and ovarian cancers
Malignant ascites
o Complications
Abdominal pain
catheter occlusion, dislodgement, and migration
infection
Intrathecal or Intraventricular Chemotherapy - CNS
o Cancers that metastasize to CNS are difficult to treat b/c of BBB often prevents distribution of
chemotherapy to this area (ex; common in breast, lung, GI tumors, leukemia, and lymphoma)
o Method used to treat metastasis to the CNS
Intrathecal chemotherapy:
− involves lumbar puncture and injection of chemotherapy into subarachnoid space.
− However, results in incomplete distribution of the drug in CNS, particularly to the
cisternal and ventricular areas
Intraventricular Chemotherapy:
− Ommaya reservoir, Silastic, dome-shaped disk with an extension catheter that is
surgically implanted through the cranium into a lateral ventricle, is inserted to ensure
more uniform distribution of chemotherapy to the cisternal and ventricular areas
− Also precludes the use of repeated, painful lumbar punctures
o Complications of both
HA, N/V, fever, nuchal regidity
Intravesical Bladder Chemotherapy - BLADDER
o Instillation of chemotherapy into bladder via urinary catheter and retained for 1 to 3 hrs.
− Promotes destruction of cancer cells and reduces incidence of recurrent disease
− Reduces urinary and sexual dysfunction
o Complications
Dysuria
Urinary frequency
Hematuria
Bladder spasms
Treatment Plan
o Single-drug can be and sometimes prescribed
− Combining agents– proved to be more effective in managing most cancers.
o Choosing agents with different MOA and Varying toxicity profiles
− Avoids tumor cell resistance and minimizes s/e
o Drug regimens are selected based on evidence used in specific cancers, and are sometimes
customized for individual pts
o Chemotherapy is most effective when
Tumor burden is Low
Therapy is not interrupted
Pt receives the intended dose
• REMEMBER~! Each drug is carefully calculated according to pt’s body surface area (ex; based
on body weight & height) – FOLFOX treatment