CASTE STUDY ONE: ONCOLOGY
Patient Background
Mr. Bob, is a 71-year-old African American 5 foot 9 inches’ tall male. He reported to his
primary care physician due to increasing shortness of breath, persistent cough that began 5
months ago, and increasing chest pain over the last three weeks. He recently has been seen for
reoccurring bronchitis over the course of the past year, although his cough was not as prominent
as it is now. He was given a bronchial steroid inhaler BID, Albuterol. He also took
antihistamines for his seasonal allergies. He has no other known allergies or disease/illness
diagnosis. Over the course of his diagnosis of bronchitis he has lost 15 lbs, bringing his weight to
200lbs (90kg), when previously was 215lbs (97kg).
Mr. Bob retired six year ago as a civil engineer, and spent 8-10 hours per day 5-6 days
per week sitting at a desk. He lived a sedentary lifestyle, and still does not perform much
physical activity upon retiring and continues to live a sedentary lifestyle. He has been smoking
cigarettes for the past 30 years, approximately 1 pack every 2-3 days. He has a frequency of
increasing his smoking when he is consuming alcohol. Socially, he would consume 3-5 beers
once or twice a week with some old friends. He never consumed alcohol on his own. His sister,
Linda, was diagnosed with adenocarcinoma lung cancer 5 years ago, and she has no previous
history of smoking, although she has been around Mr. Bob’s second hand cigarette smoke. There
is no other family history of diseases or illnesses. He frequently enjoys carry out meals from
various restaurants, causing him to eat elevated calories, and often does not consume the proper
macronutrients necessary. He has turned to carry out food since his wife passed away ten years
ago, and he isn’t a fan of cooking himself.
The reoccurring bronchitis brought concern to the primary care physician, which raised
concern for pneumonia or atelectasis to occur. The physician ordered a chest radiology imaging
CASTE STUDY ONE: ONCOLOGY
(x-ray) to examine the lungs, and a sputum cytology to be performed. After examination of the
images and sputum sample, it was confirmed that Mr. Bob has non-small cell lung cancer
(NSCLC), or specifically squamous cell carcinoma (SCC). The images displayed “tumors
located centrally near the hila and project into bronchi” (McCance & Huether, 2019).
Lung Cancer Background
“Primary lung cancers arise from cells that line the bronchi and are therefore called
bronchogenic carcinomas. The development of lung cancer involves a multistep process of
genetic, epigenetic, and environmental interactions resulting in the dysregulation of oncogenes
and tumor suppressor genes with activation of cancer related signaling pathways. Although there
are many types of lung cancers, they are divided into two major categories based on cell
histology: non-small cell lung carcinoma and neuroendocrine tumors. NSCLC can be subdivided
into three common types of lung cancers: squamous cell carcinoma, adenocarcinoma, and large
cell undifferentiated carcinoma” (McCance & Huether, 2019). The primary risk factor is
cigarette smoking. In addition, environmental smoke exposure, exposure to asbestos dust,
arsenic, chromium, mustard gas, coal products, and more increase the likelihood of diagnosis.
“Adenonocarcino (AdCa) was the most prevalent subtype in never smokes and in women.
Squamous cell carcinoma (SqCC) predominated in male smokers… Lung cancer is a leading
cause of death, where the proportion of cases attributable to smoking has reached up to 90% in
countries with a history of tobacco consumption” (Pesch et al, 2011). Individuals over the age of
40-years-old or have pre-existing chronic obstructive pulmonary disease are at an increased risk
of developing lung cancer. Signs and symptoms may also include increasing breathlessness,
coughing up blood-stained phlegm, hoarse voice, dull ache or sharp pain when coughing or
taking deep breaths, loss of appetite and loss of weight, difficulty swallowing, and increased
CASTE STUDY ONE: ONCOLOGY
fatigue. “There are many cancers that start in other organs and spread (metastasize) to other
organs. The lungs are the most common place to which other primary cancers spread,
particularly melanoma and cancer of the breast, colon, bladder, testicle, esophagus and kidney. If
primary lung cancer metastasizes it most commonly spreads to the brain, liver, bones, and lymph
nodes” (Holdstock, 2010).
Early detection of lung cancer is very challenging to diagnosis. Lung cancer is commonly
diagnosed in individuals >70 years or older. Physical examination and patient history can be
used to assist in determining signs and symptoms of lung cancer. To screen for lung cancer
periodic chest X-ray films and sputum cytologic analysis can be conducted. Low-dose spiral
computed tomography has also been used in place of chest X-rays. “Treatment of lung cancer
consists of chemotherapy, surgery, radiotherapy, targeted therapy, or combined therapy and
requires a prolonged process during which patients continuously experience uncertainty
regarding curability and prognosis. In particular, during the terminal stages of cancer, patients
may face a fear of death and feel hopelessness” (Suh et al., 2017). Newer treatments also include
gene therapy and immunotherapy. “Between 2001 and 2009, several improvements occurred in
clinical care for lung cancer; for example, increased use of video-assisted thoracic surgery,
intensity-modulated radiation therapy, and targeted therapy, also referred o as precision or
personalized treatment” (Richards, 2017). The time of diagnosis affects the treatment and
survival rates. The typical 1-year survival rate is 44%, and the 5-year survival rate is 17%.
(McCance & Huether, 2019). The 5-year survival rate was lower among blacks than among
whites and ranged by state (Richards et. al., 2017).
CASTE STUDY ONE: ONCOLOGY
Plan of Care
Upon diagnosis of squamous cell carcinoma lung cancer, a plan of care was established.
The first priority was the patient’s well-being. Mr. Bob was in denial when he first received the
diagnosis. He stated he was aware of the risks of smoking, although when he began smoking it
helped calm him down during work due to high stress levels while performing the job. He had
slight anxiety when diagnosed due to lack of support system because of his wife passing ten
years ago. He did not have a spiritual presence and did not wish to speak with Father Marks
within the hospital premise. The patient was first given instruction to quit smoking cigarettes.
Discussion was had to find a hobby or activity that could decrease anxiety and stress when the
patient feels it is elevated. Nutritional information was provided with simple healthy recipes for
the patient to cook while he is at home. The patient was given instruction to enroll in an exercise
program to begin adding physical activity to his lifestyle and advised to limit the amount of carry
out food he eats. “Palliative care focuses on relief of symptoms across the physical and
psychosocial domains and promotes shared decision-making.” The promotion of physical
activity is recommended before, during, and after cancer therapy. “Positive benefits include
cancer-related fatigue severity, emotional well-being, functional status, and overall quality of
life” (Chandrasekar, Tribett, & Ramchandran, 2016). The patient was recommended to also
participate in a yoga or flexibility training regimen to help clear the mind, and allow the body to
relax upon completion of any physical activity and increase range of motion. Due to the lack of
support system at all, he was also given information on local support groups at the hospital to
allow for conversations with other individuals who are facing the same struggles.
CASTE STUDY ONE: ONCOLOGY
Discussions were had with Mr. Bob about how to manage the pain occurring from the
lung cancer. The use of non-steroidal anti-inflammatory drugs were the first line of medication.
Additional options may include weak opioid analgesics or strong opioid analgesics such as
morphine, oxycodone, or fentanyl. If opioids are prescribed it is also recommended for the
patient to take a laxative to avoid constipation. Currently, the patient opted for the NSAIDS, and
wanted to avoid opioids unless the pain became too unbearable. To assist with the patient’s
respiratory dysfunctions, oxygen therapy will be provided to allow for decreases in shortness of
breath. The oxygen therapy should especially not be used around cigarette smoking, which
increases the emphasize of the patient quitting use.
Mr. Bob was made aware of the recommended treatment options. One recommended
treatment involves a video assisted thoracoscopic surgery to view the cancer between the lungs
and the chest wall. This can assist in determining what stage the cancer is in. Resection of the
cancer is the physician top recommendation. He was made aware of possible risks of surgery
which included stroke, bleeding, transfusion of blood products, infection, pulmonary
dysfunction, organ failures, neurological dysfunction, death, and more. Lymph nodes may also
be removed and examined to determine if the cancer has spread. Resection could involve a small
part of the lung, one lobe of the lung, or the entire lung based on how the cells have spread.
Because the patient is diagnosed with squamous cell carcinoma the use of chemotherapy or
radiation may not be affective.
Mr. Bob was also made aware of the necessary commitments and compliances following
surgery and treatments which will involve regular medical check-ups. He was given
approximately 2-3 years of survival, but he stated he wanted to try and fight his diagnosis. He
was very willing to be a part of medical trials to allow for assistance in future treatments. He
CASTE STUDY ONE: ONCOLOGY
Sources
Chandrasekar, D., Tribett, E., & Ramchandran, K. (2016). Integrated Palliative Care and
Oncologic Care in Non-Small-Cell Lung Cancer.ICurrent Treatment Options in Oncology,I17(5).
doi:10.1007/s11864-016-0397-1
Holdstock, Ruth,B.M., G.P. (2010). Lung cancer: The journal for nurses in general practice the
journal for nurses in general practice.Practice Nurse,40(8), 17-20.
McCance, K. L., & Huether, S. E. (2019).IPathophysiology: The biologic basis for disease in
adults and children. St. Louis, MO: Elsevier.
Pesch, B., Kendzia, B., Gustavsson, P., Jöckel, K., Johnen, G., Pohlabeln, H., . . . Brüning, T.
(2011). Cigarette smoking and lung cancer-relative risk estimates for the major histological types
from a pooled analysis of case-control studies.IInternational Journal of Cancer,I131(5), 1210-
1219. doi:10.1002/ijc.27339
Richards, T. B., Henley, S. J., Puckett, M. C., Weir, H. K., Huang, B., Tucker, T. C., &
Allemani, C. (2017). Lung cancer survival in the United States by race and stage (2001-2009):
Findings from the CONCORD-2 study.ICancer,I123, 5079-5099. doi:10.1002/cncr.31029
Suh, W. N., Kong, K. A., Han, Y., Kim, S. J., Lee, S. H., Ryu, Y. J., . . . Chang, J. H. (2017).
Risk factors associated with treatment refusal in lung cancer.IThoracic Cancer,I8(5), 443-450.
doi:10.1111/1759-7714.12461
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