A brief Introduction to Oncology: Part I

Since graduating in September last year I’ve been working in Oncology, it’s been a steep learning curve and there’s still so much more to learn but I thought I’d share a few bits and pieces that might be useful background reading for anyone with an oncology placement coming up! Skip to the bottom of the page for a list of useful resources and a glossary of oncology terms.


Cell Biology Basics

Cancer can be defined as malignant uncontrolled growth from abnormal cell division. Before any new placement I found it useful to recap the relevant anatomy and physiology beforehand, therefore I thought it might be useful to include a mini recap of the basics of the cell cycle. If your oncology placement has a particular sub-speciality, for example haematology or gynaecology, you may also find it useful to revise the relevant body system.

cell cycle

Mitosis can be subdivided into 4 stages, prophase, metaphase, anaphase and telophase. G1 is when cellular contents (excluding chromosomes) are duplicated, S phase is where DNA is synthesised and duplicated and the G2 phase is when checking for errors in chromosome repair occurs, then the cells divide to produce two daughter cells. From G1, some cells may enter G0, a resting phase when cell division ceases.

Different cytotoxic drugs act on different parts of the cell cycle. As such you may find that different types of chemotherapy are given in combination to have a synergistic effect.

hallmarkswheel

The Hallmarks of Cancer, as described by Hanahan and Weinberg, illustrates the different types of mutations within carcinogenesis that enable survival and uncontrolled growth of cancer cells in tumours. Researchers can use these hallmarks as a focus for mechanisms of cytotoxic drugs. For example; Bevacizumab (Avastin), prevents angiogenesis so it slows the growth of new blood vessels, preventing the growth of this new vasculature supplying the tumour.

Cancer Staging

TNM staging is the most widely used clinical staging tool for solid tumours (does not apply to CNS tumours or haematological malignancies). It categorises the stage of the cancer with three simple alphanumeric codes corresponding to the categories of the primary tumour, involvement of lymph nodes and whether the cancer has metastasised. Prefixes and codes for additional modifiers can be added to give additional clinical information including details such as resection margins or specific histology of samples.

TNM staging

A number of disease group specific staging classifications are also used, a few you may come across are: Dukes (colorectal), Clarke & Breslow (melanoma), Lugano classification (lymphoma), Gleason score (prostate), and Robson staging system (renal cell carcinoma).

Communication

As with any placement area, communication is key! The following tools may be useful to recap  before starting your next placement.

SBAR

For acute situations the SBAR handover tool is great to clearly handover key clinical information. It provides structure to help you provide clear and concise information.

When exploring broader concerns with patients and relatives the Sage & Thyme communication tool can be really useful to help gather information and respond with empathy. Developed at UHSM in 2006 it can provide structure to responses in emotive situations, actively listening with the patient guiding the solution. (I’d also strongly recommend going on this course if you ever get the opportunity to go while on placement or in your future career.)

If you’re dealing with patients or relatives who wish to make a complaint the LASTED mnemonic can be useful to help structure a response but in your role as a student it’s best to escalate the situation to a member of staff; Listen, Acknowledge, Solve, Thank, Explain, Document.

IMG_5761

Source: Learning aid from Critical Care Department at Manchester Royal Infirmary

Body language, although non-verbal is an important communication tool. SOLER, SURETY and other similar models help illustrate the key components in effective non-verbal communication.

Last but not least, always remember to introduce yourself to patients and ask their permission before performing or observing any procedure! #hellomynameishello-my-name-is-logo-web

Palliative Care

From the latin Palliare, meaning ‘to cloak’, palliative care is essentially the relief of pain and associated symptoms without treating the underlying cause of the condition. You may come across this as ‘Best Supportive Care’ in a move away from negative connotations of palliative care in the media.

Dame Cecily Saunders was the founder of the hospice movement and a pioneer in palliative medicine. As increasing numbers of people began to die in a hospital environment rather than at home, she recognised the inadequacy of care and the fears of patients. Particularly regarding a terminal cancer diagnosis, where pain relief was insufficient due to the prevailing medical beliefs surrounding opiates. She led an evidence based medical and social change to provide holistic care encompassing physical, spiritual and psychological well-being in the last days of life.

Within palliative care you’ll gain exposure to pain management, controlling nausea and secretions, as well as learning how to manage other issues such as, constipation, terminal restlessness and spiritual distress. This will be in cases where a patient’s primary cancer has spread to other organs and is no longer considered curable, some patients may have a longer prognosis and better quality of life and others will have a much more limiting diagnosis so there can be a wide spectrum within palliative care, therefore care should accordingly be holistic and individual. It’s also imperative to discuss a patient’s preferred place of care and preferred place of death as part of the holistic assessment and Advance Care Planning, you may find the 5 Stages of Grief (Denial, Anger, Bargaining, Depression and Acceptance) by Elisabeth Kubler-Ross a useful resource as a framework to understand the grieving process.

Despite a life limiting metastatic cancer diagnosis there can still be treatment options sometimes this will include palliative intervention such as chemotherapy, radiotherapy and also surgeries. Sometimes hormone therapies or receptor specific SACT (for example, Trastuzumab (Herceptin) in HER2 positive breast cancer). In these cases the aim will be to prolong life and improve remaining quality of life. In these cases it’s important for the medical team proposing the treatment to have sensitive but frank discussions with the patient to ensure there are no misconceptions around the purpose of any proposed treatments.

On that note, remember that oncology isn’t all doom and gloom!! You may find that some people may comment that they think it must be a depressing job but it can be a really rewarding  and holistic environment. Cancer is a very emotive topic and most people will have a friend or family member who has been affected by cancer.

Although the prevalence of cancer may have increased in recent years, the overall incidence of cancer has remained fairly stable . This is due to an increase in overall life expectancy leading to an older demographic of patients with cancer who, some decades ago would likely have died of other comorbidities. Recent developments in anti-cancer therapies has led to an increase in patients living with cancer, including conditions which would have historically been untreatable.

However, as with any areas of nursing there you will experience end of life care and care of the deceased person. It’s important to remember that most people have had very limited experience with death and it can sometimes be hard to process difficult situations that your peers can’t relate to.

Remember if you’re struggling or feeling upset it’s absolutely okay to take yourself off to a quiet corner to collect yourself if you need to, you are supernumerary! Don’t underestimate the benefits of a debrief with your preceptor and remember that your AA and the PEF are always available. If you want to talk to somebody out of office hours the Greater Manchester Nightline listening and information service is open from 8pm-8am during term time.

ECOG Performance Score

This grading tool is commonly used in all areas of oncology to assess disease progression and how this impact’s on a patient’s activities of daily living. Created by the Eastern Cooperative Oncology Group, this 0-5 scale is something you will come across on any oncology placements, familiarising yourself with the descriptions of these categories will help you understand the impact of performance status on patient’s day to day experiences.

Grade 0 : Fully active, able to carry on all pre-disease performance without restriction
Grade 1 : Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
Grade 2 : Ambulatory and capable of all self care but unable to carry out any work activities, up and about more than 50% of waking hours
Grade 3 : Capable of only limited self care, confined to bed or chair more than 50% of waking hours
Grade 4 : Completely disabled, cannot carry on any self care, totally confined to bed or chair
Grade 5 : Dead

Specific side effects are graded primarily using the CTCAE (Common Terminology Criteria for Adverse Events) database. You can view this online here.

Neutropenic Sepsis

Neutropaenia is defined as having a Neutrophil count of less than 1. Chemotherapy can cause a drop in Neutrophil count, some patients on cytotoxic treatment will often be given a Granulocyte Stimulating Factor (GCSF) prophylactically to prevent neutropaenia.

Sepsis

The nadir (lowest point) of a patient’s white cell count usually occurs 7-10 days after chemotherapy. It’s important to consider this if you suspect sepsis.

Sepsis is a life threatening immune response to infection. Make sure that you escalate your concerns quickly to your mentor or another nurse if you think a patient may have sepsis, then they can begin treatment within the hour to improve outcomes. You can find out more information about the Sepsis Six campaign here: www.sepsistrust.org 

Metastatic Spinal Cord Compression

MSCC is an oncological emergency, it occurs when the pressure from a tumour site begins to compress the spinal cord and pain and neurological symptoms occur. This can happen from either a tumour within the CNS system growing within the spinal cord itself, from a tumour pressing on the vertebrae or from vertebrae collapsing and pressing upon the cord as they are weakened by metastases within the bone (bony metastases are more common in progressive Prostate, Lung and Breast cancers).

A ‘red flags’ early warning system has been developed to help quickly identify symptoms that can indicate cord compression. If you suspect a patient may have MSCC it’s important to act quickly and escalate this. The longer the symptoms occur the worse the prognosis can become for the patient and paralysis can become permanent.

MSCC

Its also important to consider these red flags in other clinical settings, such as A&E because ~25% of patients who present with MSCC do not have a diagnosed primary cancer. MSCC is a palliative condition as the cancer has already spread and mestastasized to other sites but it’s still really important to diagnose and treat to prevent paralysis. Even if patients aren’t having active treatment and are being managed with best supportive care, communication is really important as early treatment can mean improved quality of life, but patients may be reluctant to have a hospital admission if their preferred place of care at the end of life is at home.

Chemotherapy Induced Nausea & Vomiting

CINV is one of the main worries of patients undergoing chemotherapy. Since the first chemotherapy treatments were used in the 1940s, antiemetics have come along a long way. Although some drugs, such as Cisplatin, are still highly emetogenic, CINV is able to be better managed through use of anti-sickness medications since it was first licensed for use in 1979. However, due to the portrayal of chemotherapy in films and television, CINV is often a source of great worry for patients. Therefore it’s important to communicate well with your patients to provide information and reassurance and assess the effectiveness of their anti-emetics.

The main causes of CINV are sensitivity of the GI mucosal lining, stimulation of the 5HT3 receptors and direct stimulation of the chemoreceptor trigger zone, although some pathways are unknown. Some common categories of antiemetics are listed below: Most can be given by a variety of routes of administration, you can check these in the BNF, on Medusa (an online injectable medicines guide) or the electronic medicines compendium. 💉💊

Antihistamines- Cyclizine: H1 receptor antagonist. Main side effect: drowsiness but also has anti-muscarinic properties causing xerostomia (dry mouth), blurred vision and urinary retention. Most commonly used for drug induced N&V but also useful in pregnancy as cyclizine is non teratogenic. Hepatic metabolism, half life approximately 20 hours. Note that cyclizine and metoclopramide can’t be given together.

Antimuscarinic- Hyoscine: main mechanism of action is competitive inhibition at M1 receptor. Classic side effects of antimuscarinic drugs may be present- dry mouth, blurred vision and urinary retention.

Dopamine receptor antagonists- Domperidone:  A pure dopamine receptor antagonist, domperidone is often used for drug induced N&V and postoperatively. Metoclopramide: At higher doses metoclopramide also acts as a 5-HT receptor antagonist, this dual action makes it especially effective in CINV. It also has prokinetic effects- this means the rate of gastric emptying is increased alongside an increase in muscle tone of the gastroesophageal sphincter. They are both metabolised in the liver and have significant first pass metabolism.

5-HT receptor antagonsists- Ondansetron, Palonosetron, Granisetron: These drugs all act on 5HT3 receptors within the gut but also in the chemoreceptor trigger zone within the brain. Ondansetron is very commonly given with emetogenic chemotherapies, it’s important to note that for patients  over 65 years old, it should be administered in a bag infused over 15 mins to reduce risk of long Q-T syndrome but if given as a bolus should be given slowly to avoid vein irritation- “Zofran Flare”. Constipation is a common side effect. Palonosetron has similar properties but is longer lasting.

Neurokinin receptor antagonists- Aprepitant: Also known as Emend, it acts in the CNS on NK1 receptors. Aprepitant also has a secondary effect of increasing the effects of 5-HT receptor antagonists and corticosteroids. It is absorbed in the GI tract and metabolised by the liver. Aprepitant can interact with Warfarin, decreasing its effect.

Corticosteroids- Dexamethasone is an example of a corticosteroid given for CINV, in itself it only has weak antiemetic effects but has an additive effect when given with 5-HT receptor antagonists.

Other antiemetic compounds- There have also been recent studies into the use of herbal compounds such as ginger which was previously used in traditional Chinese medicine and mint to investigate their antiemetic properties.

You can browse other side effects from chemotherapy on the Common Terminology Criteria for Adverse Events (CTCAE) database.

 

Alternative Therapies

As with all nursing specialities, it’s important to ensure that we provide evidence based practice. Some patients may have queries about alternative therapies they have heard about. This can include things like dietary advice such as eating peach stone extract and can be quite dangerous (http://scienceblog.cancerresearchuk.org/2017/11/01/alternative-cancer-therapies-the-potential-impact-on-survival/). Even some over the counter remedies from health food shops, such as St. John’s wort, can have adverse interactions with medication so it’s always best for patient’s to consult their medical team before taking any additional supplements. Patients may also decline treatment in favour of unregulated and unproven therapies if they are worried about side effects, which reiterates the importance of effective and empathetic communication to address patients concerns and allow them to make informed decisions about their care.

The benefits of complementary therapy alongside conventional treatment should not be understated. Relaxation techniques can be beneficial for needlephobic patients during cannulation or for claustrophobic patients requiring scans or radiotherapy using molded masks. Research has also been done into acupuncture to help prevent peripheral neuropathy.


More topics to follow in An Introduction to Oncology: Part II, including an overview of Central Venous access devices, Scalp cooling, Immunotherapy treatments, Radiotherapy and other palliative care emergencies such as hypercalcaemia and arterial bleeds, watch this space! If there’s any other topics you’d like to be included or to give feedback, please use the form below!

Many thanks to my fantastic preceptor Laura for all your advice and support in helping me survive my first year being qualified and also for proofreading this article!


Useful Resources:

I’d also really recommend The Emperor of all Maladies: A biography of Cancer, by Siddhartha Mukherjee if you’re interested in oncology and a bookworm like me!

Glossary:

Adjuvant Therapy- Treatment (usually hormone therapy, chemotherapy or radiotherapy) given after surgery to ‘mop-up’ any remaining cancerous cells.

Brachytherapy- Radioactive seeds planted within a patients tumour, often used in prostate, cervical and endometrial cancers.

Cancer of Unknown Primary- See also Malignancy of Undefined Origin. True CUP is a very small percentage of MUO patients and has implications for treatment options if the primary cell line is unknown. Provisional CUP is the terminology used until a primary diagnosis has been made or confirmed as a true CUP.

Carcinogen- Substances known to cause cancer.

Carcinoma- Cancers which originate from tissues that line internal organs or the skin.

Clinical Oncology- Medical specialty focussing on the treatment of cancer with radiotherapy.

Concurrent- Different modalities of treatment given at the same time, for example chemotherapy alongside radiotherapy.

Cytotoxic- A substance toxic to living cells.

Emetogenic- A substance with the capacity to introduce vomiting (emesis) and nausea.

Dysplasia- The presence of an abnormal cell type, whose growth may be a precursor to cancerous tissue.

In Situ- A Carcinoma In Situ means the tumour has not spread from its original location.

Local Therapy- Treatment specific to the affected area such as surgery or radiotherapy.

Malignancy of Undefined Origin- The term used until a CUP is diagnosed or a primary site is discovered either through scans or histology from biopsies.

Medical Oncology- Medical specialty focussing on the treatment of cancer with drugs.

Metastasis- The spread of cancer from a primary site to other organs of the body either via the bloodstream or lymphatic system or through direct infiltration of adjacent organs by the tumour.

Neo-Adjuvant- Anti-Cancer therapies given to shrink the tumour initially before second stage treatment, usually surgery so the tumour is easier to resect.

SACT- Systemic Anti Cancer Therapy. This encompasses both chemotherapy and immunotherapy.

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Prostate Cancer Awareness Month

If you had asked me a month ago what I knew about prostate cancer, I would have said “didn’t that fictional character Adrian Mole have it?”, and then quickly add that it was mentioned in an A&P lecture- so I’m not an expert. If a patient or relative had asked me, it would have been an awkward moment for everyone. So as March is prostate cancer awareness month, maybe its time to spread the knowledge! As the most common cancer for men, its key for any budding student nurse to know their stuff.

My pathway of prostate cancer knowledge began with an afternoon shadowing a specialist Urology nurse. I sat and watched the patients come and go, lapping up the constant information that was being thrown at me.

Firstly, you have to identify the cancer through a PSA (prostate specific antigen) blood test (which should be performed regularly for men over 50!). PSA is a protein produced by cancer cells, so can help early detection. There’s loads more information about the tests available here, the same information from the leaflet I was given on placement!

PSA test

The next step is treatment. I had no idea that the usual first action to prevent the cancer from spreading is steroid injections. These prevent the production of Testosterone, which would otherwise fuel the cancerous cell growth. With this treatment, you can carry on a relatively normal life! I met a patient who was diagnosed quite young and carried on working.

The last, and most important step, is support. Cancer does change your life, so its super important to be able to talk to people in similar situations. Talking is some of the best treatment you can get. The nurse I was shadowing was a keen champion of support groups, and made sure that every patient knew where there closest one was.

So that’s your whistlestop tour of prostate cancer! For more information, Prostate Cancer UK and Macmillan are amazing and very informative.

 

 

World Cancer Day 2016

Today is WORLD CANCER DAY, I write you an experience I had coming into contact with a patient who was diagnosed with cancer. I hope it may inspire some of you to choose the oncology path, will keep it short and sweet.

Nurses who have chosen the path of oncology have my utmost respect. For those who are thinking “what is she babbling on about oncology?” well an oncology nurse is someone who provides care for patients who are suffering from cancer as well as monitoring those who are at risk of developing cancer. These nurses become part of the person’s life, see them throughout this difficult and distressing time and not only are they there for the patients but are also there for the family.

To protect his right to confidentiality, let’s call him, Mr Andrews, he was 82 years old. During my shift I was asked to monitor Mr Andrews, whilst I was recording his observations the doctor came in with the results of his biopsy. As a first year student, I thought this would be a great learning experience, so I stayed and listened. The doctor informed Mr Andrews that unfortunately his cancer had returned, it was aggressive and all they could do was hope for the best after more chemo-radiotherapy. After the doctor had finished his chat with Mr Andrews and left, I wanted to know what was going on in Mr Andrews head. I asked him, how he was feeling and if he wanted me to call anyone. He took my hand and remained in silence for a long time. I wasn’t sure what my role was in this situation and what I was supposed to do. So I sat with him, in silence. After a while, he said that he didn’t want any more treatment. He was done. He had 82 good years, a loving family and now it was time for him to go. I wasn’t sure how to respond, so I asked why he felt that way. He responded by saying the staff that had previously took care of him were absolute “angels”, they stood by him when he was in agony and crying with pain. He had seen so much in those 82 years. He felt, cancer coming back was nature’s way of telling him, enough. He didn’t want that last few months of his life to be spent suffering from side-effects. He wanted to go home, see his grandchildren and be at peace on his own terms.

At the end of my shift, I was thinking about Mr Andrews and tried to gather all my thoughts together. He had cancer. Again. He was dying. It cannot be cured. He was not sad. He was not shocked by the results. He was not in much pain. He had a loving family. He wanted to die with dignity. With his family around him. He was loved by many. It was his choice. After that, all I could think was how brave he was, he fought the cancer twice already and third time round he decided enough was enough. He was a happy man and he wanted to end life like that. I should be okay with that.

In short, caring for patients who are suffering from cancer requires you to listen attentively. Respect their choices and support them from the moment they come into contact with you. You having a presence, holding their hand, smiling, bringing them a cup of tea, all the little things one may think is a simple task leads to you making their last moments be at peace. You make a difference, even if you sit in silence holding their hand.

Why don’t you save a life today and hop on over to Cancer Research UK and make a donation to transform the lives of people who are currently suffering from cancer: http://www.cancerresearchuk.org

Further Reading:

  1. Rieger PT, Yarbro CH. Role of the Oncology Nurse. In: Kufe DW, Pollock RE, Weichselbaum RR, et al., editors. Holland-Frei Cancer Medicine. 6th edition. Hamilton (ON): BC Decker; 2003.Available from: http://www.ncbi.nlm.nih.gov/books/NBK13570/
  2. Cancer.Net. (2015).Types of Oncologist.Available: http://www.cancer.net/navigating-cancer-care/cancer-basics/cancer-care-team/types-oncologists. Last accessed 04 Feb 2016.