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Chapter 28

Cancer

Risk for developing cancer increases with age.

Adults over the age of 65 account for 60% of all new cancer diagnosis.

Most common cancers in older adults are: (1) lung cancer, (2) prostate and breast cancers, and (3) colon and rectal cancers.

Introduction

The number of new cases in a given time period, usually a year, in general population

Leading types of cancer in men are lung, prostate, and colorectal.

Leading types of cancer in women are lung, breast, and colorectal.

Many persons survive cancer.

Some cancers have relatively high incidence rates and relatively low death rates.

Cancer Incidence

Racial and ethnic group age cohorts demonstrate different patterns of cancer incidence.

Examination of patterns of cancer among racial or ethnic groups should include age and environmental considerations.

Race and ethnicity are highly correlated with socioeconomic status.

Racial and Ethnic Patterns

Cancer is a disease of aging.

Cancer develops from “genetic mutations that are either inherited or acquired through errors in DNA replication and environmental insults.”

Cancer results from cancer stem cells (CSCs) that retain their ability to proliferate repeatedly without losing their ability to initiate uncontrolled growth, leading to cancer.

Aging and Relationship to Cancer

Process of cancer growth is believed to occur in four steps: tumor initiation, tumor promotion, malignant conversion, and tumor progression.

Oncogenes are genes that produce abnormal codes for growth-regulating substances and are believed to play a role in the development of cancers because, once activated, they interfere with normal physiologic regulation of cell growth.

Oncogenes can cause improper regulation of cell growth, leading to cancerous transformation in normal cells.

Cancer Growth and Development

The study of what genes do and their interaction with each other

Cancer genome research studies the differences in genes found in tumors to understand which ones cause development and proliferation of a tumor.

Different genes are involved in different tumor types.

Learning which genes cause certain cancer has led to improvements in detecting, diagnosing, and treating cancer.

Researchers hope to develop drugs that target mutations on specific genes to stop the cancer’s growth.

Genomics

Aging increases the duration of exposure to substances that may act as promoting agents.

Aging cells demonstrate a tendency toward abnormal growth.

Once an aged cell is damaged by a carcinogen, it is more difficult to repair.

Oncogene activation might be increased in older persons.

Decreased immune surveillance may contribute to increased cancers development and progression.

How Aging Process Influences Cancerous Transformation of cells

Cancer risk is similar for a given birth cohort within specific environmental boundaries.

Older adults should be encouraged to consume the recommended daily requirements of fruits and vegetables because dietary habits may be beneficial in halting the cancer process.

Evaluation of environmental risk factors can lead to specifically targeted education and screening programs among selected high-risk cohorts.

Aging and Cancer Prevention

Most common type of cancer and leading cause of cancer death in both men and women

Lung cancer-related deaths have declined across all races and genders, but black men and women are at higher risk.

Lung Cancer

Cigarette smoking: the greatest lifetime cumulative exposure to cigarette smoking occurs between ages 70 and 80.

The risk of lung cancer decreases over time for ex-smokers.

Exposure to certain industrial substances

Long-term exposure to air pollution

Radiation exposure

Lung Cancer Risk Factors

One quarter of individuals have no signs and symptoms, or vague symptoms.

Classic clinical presentation is persistent cough, sputum streaked with blood, chest pain, fatigue and weight loss, recurring respiratory infections, shortness of breath, and hoarseness.

Lung Cancer Signs and Symptoms

Low-dose spiral computed tomography (LDCT) screening of current or former (quit within 15 years) smokers between the ages 55 and 74, who have at least a 30 pack year smoking history has been shown to reduce lung cancer mortality by about 20%.

Lung Cancer Early Detection

Options for treatment include surgery, radiotherapy, and chemotherapy, depending on the type and stage of disease.

Non–small-cell lung cancer (NSCLC) surgery is the treatment of choice, sometimes with chemotherapy, other times with radiation.

Advanced NSCLC, treatment is with chemotherapy and targeted drugs.

Small cell lung cancer (SCLC), chemotherapy is used, alone or combined with radiation.

Lung Cancer Treatment

Most common neoplasm in women, increasing in incidence with advancing age

Is the leading cause of cancer-related death in women ages 55–74

The primary presenting symptom is a lump in the breast.

Breast cancer is more common in Caucasian women than in other racial or ethnic groups.

African American women of all ages have the highest mortality rates from breast cancer.

Breast Cancer

Duration and intensity of exposure to estrogen, early menarche, late menopause, lengthy exposure to postmenopausal estrogen, recent use of oral contraceptives, and never having given birth or having first given live birth at a late age

Personal or family history of breast cancer, history of benign breast disease or dense breast tissue, excessive alcohol use, and smoking

Genetic basis: BRCA1 and BRCA2

Breast Cancer Risk Factors

Malignant lumps are hard and fixed, with irregular borders, and are sometimes described as frozen peas.

Nipple retraction or elevation

Skin dimpling may be present.

Localized erythema and warmth may be present.

Characteristically, edema appears as “orange peel” skin.

Breast Cancer Signs and Symptoms

Women should be familiar with how their breasts normally look and feel and report any changes to a health care provider right away.

Mammography is able to detect breast tumors before they present physical findings.

The American Cancer Society (ACS) recommends mammography screening every year for women after the age of 40, until age 54; those over age 55 may change to biennial mammography and should continue as long as overall health is good and life expectancy is 10 or more years.

Breast Cancer Early Detection

Surgery either lumpectomy or modified radical mastectomy for removal of primary tumor

Radiation after breast-conserving surgery or following mastectomy for large tumors or when cancer has spread to the lymph nodes

Lymph nodes should be evaluated.

Treatment may also involve chemotherapy, hormone therapy, and/or targeted therapy.

5-year survival rate for localized breast cancer, when caught early, is 99% and for regional breast cancer, it is 90%.

Breast Cancer Treatment

Average age at diagnosis is 66.

Although prostate cancer is serious, most men do not die from it.

Is usually adenocarcinoma that develops slowly in the gland cells of the prostate

Disease of aging

Risk factors include a family history of prostate cancer (before the age of 65), occupational exposure to carcinogens and smoking

Prostate Cancer

Asymptomatic in early stages

Signs and symptoms related to the increased growth of the prostate: weak or interrupted urine flow, difficulty or inability to begin urine flow, difficulty stopping urine flow, and urinary frequency, especially at night

As the cancer progresses: Pain in the hips, spine, and ribs (from bony metastases), impotence, weakness or numbness in the lower extremities, and bowel and bladder incontinence

Prostate Cancer Signs and Symptoms

Routine prostate cancer screening for men at average risk is not recommended due to concerns about the high rate of over diagnosis leading to potential for serious side effects associated with prostate cancer treatment.

Men age 50, with average risk and who have a life expectancy of at least 10 years, should discuss risks and benefits of screening with doctor.

Men at high risk (black men, or close relative diagnosed with prostate) should have this discussion beginning at age 45.

Prostate Cancer Early Detection

Active surveillance, surgery, external beam radiation, or radioactive seed implants used alone or in combination

Hormonal therapy may be used with surgery or radiation in advanced cases or used alone in patients who cannot have surgery or radiation.

Treatment choice is determined by age, comorbidities, stage and grade of the tumor, the likelihood of a cure, and what the patient wants.

Chemotherapy may be used for metastasis.

Prostate Cancer Treatment

Colorectal cancer is the third most common cancer.

Early screening with polyp removal, early diagnosis and treatment leading to cure, and improvements in treatment account for the declining rates.

Risk factors: Personal or family history of colorectal cancer, polyps, or inflammatory bowel disease and type 2 diabetes, diet, obesity, and sedentary lifestyle

Colorectal Cancer

Early stages: may not have symptoms

As disease advances: A change in bowel habits or stool shape, the feeling that the bowel is not completely empty, abdominal cramping or pain, decreased appetite, and weight loss

Early detection: Starting at age 50, both men and women should have yearly guaiac-based fecal occult blood tests; flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years, or double-contrast barium enema every 5 years, or computed tomography (CT) colonography every 5 years

Colorectal Cancer Signs and Symptoms

Cancer stage guides treatment, but surgery is the treatment of choice

Permanent colostomy is seldom needed

Radiation therapy prior to surgery to shrink the size of tumor, or after surgery to reduce the chance of recurrence

Chemotherapy after surgery is used with cancer that has spread to the lymph nodes or cancer that has penetrated the bowel wall

Targeted therapies are used for treating advanced colorectal cancer

Colorectal Cancer Treatment

Older adults have had a lifetime of exposure to risk factors; changing lifestyles is advantageous, but changes may not reverse effects of exposure.

Detection of cancer at an early stage may greatly improve survival rates.

Screening guidelines vary greatly among different national organizations due to the lack of cancer screening trials that include older adults.

Screening and Early Detection Issues for Older Adults

Taking into account the older adult’s personal preference and health should be used rather than relying only on age guidelines.

Decision to screen or not to screen should be an active one; with input from a multidisciplinary health care team considering screening guidelines, individual circumstances, potential complications of aggressive evaluation workups, and associated costs

Decision Making Process in Screening

Is based on following factors:

Individualize the decision

Estimate life expectancy

Assess risk of cancer screening

Ascertain patient preferences

Consult various cancer screening guidelines

U.S. Preventive Services Task Force (USPSTF)

American Cancer Society and American Geriatric Society

Walter and Covinsky’s Framework for Cancer Screening

The nurse is teaching a group of older adults about health promotion, and cancer prevention. The nurse includes which of the following?

Lung cancer is the most common cancer and can be screened for by yearly chest x-ray.

Women who have never given birth or had late menopause are less likely to get breast cancer.

Since prostate cancer is slow growing, men should discuss getting screened with their physician.

To detect colon cancer early, colonoscopy should be done every 5 years.

Quick Quiz!

ANS: C

Answer to Quick Quiz

The nurse should teach older adults the following:

Change in bowel or bladder habits

A sore that does not heal

Unusual bleeding or discharge

Thickening or lump in the breast or elsewhere

Indigestion or difficulty swallowing

Obvious change in a wart or mole

Nagging cough or hoarseness

Early Warning Signs of Cancer

Five types of cancer treatment: (1) surgery, (2) radiation therapy, (3) chemotherapy, (4) targeted therapy, and (5) immunotherapy

Type of treatment is determined by the type and stage of cancer, unique biophysiologic characteristics of cancer cells, and patient’s overall health status at the time of diagnosis.

Major Treatment Modalities

Cure—elimination of disease

Control or minimization of disease

Palliation—relief of symptoms

Adjuvant therapies to standard therapies have been developed that include angiogenesis inhibition, gene therapy, hyperthermia, laser therapy, and photodynamic therapy.

Cancer Therapies

Functional status reported to be a more important pretreatment variable, influencing both the decision to treat and type of treatment

Number of comorbid conditions is a significant predictor of outcome of an older adult receiving cancer treatment.

Nurses should be sure patients and families have accurate information and a clear understanding of treatment options offered.

Patient Considerations in Treatment

Indicated for most solid tumors

Surgery also used: helps diagnose the disease, palliative care, placement of treatment-related devices, rehabilitation or restorative purposes

Not a treatment of choice for disseminated disease (metastasis)

Curability of cancer in older adults is largely predicted by an individual’s ability to tolerate major surgery.

Surgery

Priority: Preventing respiratory complications and promoting cardiac and renal function

Because of the overall reduced compensatory reserves in these systems, older adults are susceptible to many serious complications, including congestive heart failure, electrolyte imbalances, hypoxia, dehydration, and venous thromboembolism.

Stress of surgery and medications predisposes to delirium, paralytic ileus, and constipation.

Other possible complications include paralytic ileus and constipation and pressure ulcers.

Postoperative Concerns

May be curative for the treatment of several cancers

As adjuvant therapy prevents recurrence, controls cancers, shrinks the tumor, provides palliative care, relieves pain, and prevents pathologic fractures

Can also result in less disability and disfigurement than some extensive surgeries

Radiation therapy may involve external or internal techniques.

Age cannot be used as a predictor for how patients will respond to treatment.

Radiotherapy

Is systemic use of drugs to destroy cancer cells

Kills cancer cells either by damaging DNA, interfering with DNA synthesis, or inhibiting cell division

Combination chemotherapy is necessary to provide a better chance of long-term, disease-free survival.

Objectives of chemotherapy include cure, control, and palliation.

Chemotherapy

Pharmacokinetics refers to the movement of drugs throughout the body, including absorption, distribution, metabolism, and excretion.

Age-related changes in liver may result in reduced hepatic chemotherapy drug clearance.

Dosage of chemotherapeutic agents may need to be adjusted to account for age-related changes in the kidneys.

Pharmacodynamics refers to the interactions between the chemotherapeutic agents and their cellular targets.

All drugs act at the cellular level and their mechanisms of action varies, therefore nurses should understand the specific actions and side effects of individual chemotherapeutic agents.

Pharmacokinetics and Pharmacodynamics

Targeted cancer therapies are drugs that block the growth and spread of cancer by interfering with specific molecules (molecular targets) that are involved in the growth, progression, and spread of cancer.

They are a form of medicine that uses information about a person’s genes and proteins to prevent, diagnose, and treat disease.

Targeted Therapy

Type of cancer treatment designed to help the immune system fight cancer

Is a type of biological therapy treatment that uses substances made from living organisms to treat cancer

Includes monoclonal antibodies, adoptive cell transfer, cytokines, and vaccines

Immunotherapy

Most treatment pharmacodynamics includes the prevention of cell division; actively dividing cell types are particularly vulnerable.

Actively dividing cell types most likely to exhibit side effects: hematopoietic tissue, the gastrointestinal tract, and hair follicles

Chemotherapy side effects are specific to the type of agent, dosage, and duration of use.

Radiation-related side effects depend on location of radiation field, intensity of dose, and duration of therapy.

Common Physiologic Complications

The 85-year-old patient just received news that she has colon cancer in her sigmoid colon. The patient has severe COPD, CHF, and osteoarthritis in her hands. The nurse is reviewing the options the physician presented to the patient and the family at their request. The nurse includes which of the following to help them decide on a treatment modality? (Select all that apply.)

Although surgery is the treatment of choice, the patient has to be able to tolerate the procedure and post-op recovery.

The patient may have difficulty with self-care if a colostomy is performed.

The patient will most likely be able to tolerate chemotherapy without any problems.

Radiation therapy does not pose as much risk to the older adult patient.

Quality of life needs to be taken into consideration when choosing treatment.

Quick Quiz!

ANS: A, B, E

Answer to Quick Quiz

Is a decrease in the ability of the bone marrow to manufacture hematopoietic stem cells which differentiate into the red blood cells, white blood cells, and platelets that the body

Can result in anemia, neutropenia, and thrombocytopenia which may cause fatigue, lightheadedness, pallor, shortness of breath, and tachycardia, symptoms of infection and bleeding

Bone Marrow Suppression

Anemia—should improve after chemotherapy is completed; medication to stimulate red blood cell production and iron supplements; sometimes blood transfusions may be necessary

Neutropenia—avoid situations that could result in infection and medications to prevent infection or stimulate the production of white blood cells

Thrombocytopenia—platelet transfusion or medications to stimulate the bone marrow to make more platelets may be prescribed if bleeding is present

Bone Marrow Suppression Management

Wash hands properly.

Call the health care provider with any signs of infection (fever >100.5°F, coughing, chills, shortness of breath, or pain with urination).

Rest when tired and stand up slowly after resting.

Avoid aspirin and ibuprofen and take care to avoid situations where injuries may occur.

Bone Marrow Suppression Patient Teaching

Most distressing side effect

Not all chemotherapeutic agents cause nausea and vomiting.

Monitor for dehydration and electrolyte imbalances and renal failure

Current pharmacologic management includes corticosteroids, serotonin antagonists, dopamine antagonists, neurokinin 1 (NK1) receptor antagonists, cannabinoids, and anti-anxiety drugs.

Chemotherapy-Induced Nausea and Vomiting (CINV)

Destruction of rapidly proliferating mucosal cells in oral cavity resulting in inflammation, ulceration, pain, and bleeding

Teach patients good oral hygiene and avoiding products with alcohol.

Gargling with a solution of one quart of water, with half teaspoon of salt and half teaspoon of baking soda may sooth mucus membranes

Prescription products are also available.

Intravenous fluid administration may be necessary with severe mucositis.

Chemotherapy-Induced Oral Mucositis

General loss of appetite

Contributing factors: chemotherapeutic agents; radiotherapy, pain medications, and mucositis

Leads to decreased caloric intake and weight loss, which is linked to poor outcomes

Dietary consultation and frequent weight monitoring are necessary.

Anorexia

Results from destruction of actively dividing epithelial cells of the gastrointestinal tract

Absorption of nutrients is decreased, and patients are at risk for dehydration and malnutrition.

Can aggravate perirectal problems such as hemorrhoids and can cause pain, bleeding, and infection

Assessment includes number of stools per day, consistency, and color.

To control diarrhea, instructed patients to eat low fiber foods, small frequent meals, and to avoid coffee, tea, alcohol, sweets, fried, greasy, or spicy foods as well as milk and milk products

Diarrhea

Hair loss may range from thinning of scalp hair to total body hair loss, including eyelashes, eyebrows, and pubic hair.

Occurs rapidly and becomes apparent over a 2–3-week period after initiation of treatment

Hair begins to grow back slowly when treatment is completed.

The emotional distress can be enormous.

Wigs and hair pieces should be purchased before total hair loss occurs.

Alopecia

The patient is receiving chemotherapy and is experiencing several side effects, including myelosuppression, nausea and vomiting, diarrhea, and mucositis. The nurse provides which of the following interventions? (Select all that apply.)

Give antiemetic medication prior to meals.

Monitor for fluid and electrolyte imbalance.

Offer frequent oral hygiene with mouthwash.

Provide a high-fiber diet.

Administer blood and platelet transfusions as ordered.

Offer frequent small meals.

Quick Quiz!

ANS: B, E, F

Answer to Quick Quiz

For an older adult experiencing cancer in the context of a life mostly lived, quality is a very—if not the most—important consideration.

It is a multidimensional concept that includes not only functional status and severity of symptoms but also the patient’s ideas about psychologic development, sociocultural issues, ethical issues, economic issues, and spirit.

Quality of Life (1 of 2)

Evaluation is relevant to both curative and palliative care.

Curative care: information obtained from assessment can guide the selection of therapeutic strategies leading to a more normal life

Palliative care: assessment can provide insight into areas that may require intervention, such as family counseling, financial planning, and management of depression

Quality of Life (2 of 2)

Depressive symptoms may result from side effects of medications used to control cancer.

Understand how experience of cancer affects such things as feelings of well-being, interpersonal relationships, and self-fulfillment

Older patients and family members should be encouraged to discuss the effects of cancer on family functioning.

Individual evaluation of depressive symptoms is needed if the older person is suspected of experiencing depression.

Depression

An older adult being treated for cancer may experience multiple losses: loss of energy, loss of a body part, loss of functional ability, loss of self-esteem, and loss of control.

Intensity of grief is determined by the meaning an individual places on the loss.

Nurses should support older patients and families by patiently repeating information when asked, validating what the family has heard, and determining what the information means to them as individuals and as a family unit.

Grief and Loss

The sense of being cut off from people and things of importance, is an experience commonly described by older adults with cancer

Social isolation can have negative consequences on psychological health.

Risk factors: physical disability or illness, frailties associated with advanced age, psychological or neurologic disorders, and environmental constraints

Social isolation may be voluntary (i.e., a person seeks disengagement from social interaction) or involuntary (i.e., imposed by others or by circumstances).

Social Isolation

An important component to nursing care of older adults is awareness of resources and referrals to appropriate agencies or support groups.

Nurses should have up-to-date listings for the groups in their areas.

Web resources are also being used by older persons.

Resources and Support