Chapter 11
Oncology: Nursing management in cancer care
275
substandard or suboptimal treatment (Bouchardy et al., 2007).
Access to quality cancer care for older patients may be limited
by discriminatory or fatalistic attitudes of healthcare providers,
caregivers and patients themselves. Issues such as the gradual
loss of supportive resources, declining health or loss of a spouse,
and unavailability of relatives or friends may result in limited
access to care and unmet needs for assistance with activities of
daily living. In addition, the economic impact of healthcare
may be difficult for those living on fixed incomes.
It is not uncommon for older patients to delay reporting
symptoms, attributing them to ‘old age’. Many older people
do not want to report illness for fear of losing their inde-
pendence or financial security. Sensory losses (e.g. hearing
and visual losses) and memory deficits are considered when
planning patient education because they may affect the
patient’s ability to process and retain information. In such
cases, the nurse acts as a patient advocate, encouraging inde-
pendence and identifying resources for support when indi-
cated. Nurses must be aware of the special needs of the ageing
population and work collaboratively with other disciplines to
address identified needs.
Cancer survivorship
Cancer survivorship refers to a distinct phase of cancer care
that follows primary treatment for cancer and lasts until cancer
recurrence or end of life (Hewitt, Greenfield & Stovall, 2006).
Although individuals vary and there are many types of cancers
and treatments, the acute, long-term and late effects of cancer
and its treatment may have multiple physical and psychosocial
consequences.
Approaches to survivorship care are often based on expert
opinion and experiences rather than evidence-based interven-
tions. Knowledge regarding survivorship concerns continues
to evolve. Four components of survivorship care have been
identified (Hewitt et al., 2006) and are listed in Table 11-11.
growing numbers of older adults with cancer (Lynch, Marcone
& Kagan, 2007). Nurses working with the elderly population
must understand the normal physiological changes that occur
with ageing and the implications for the patient with cancer
(Table 11-10). These changes that affect all body systems may
ultimately influence elderly patients’ responses to cancer treat-
ment (Lichtman, 2006). In addition, many elderly patients
have other chronic diseases requiring multiple medications.
The existence of comorbidities and multiple medications may
contribute to drug interactions and toxicities in older patients
(Extermann & Hurria, 2007).
The understanding of the effects and tolerance of chemo-
therapy, biotherapy and radiation in older people is limited
because there have been few studies of the effects of cancer
treatments in this population (Lichtman, 2006). In addition,
older people have been underrepresented in oncology clinical
trials (Lichtman et al., 2007). Potential chemotherapy-related
toxicities, such as renal impairment, myelosuppression, fatigue
and cardiomyopathy, may increase as a result of declining
organ function and diminished physiological reserves. The
recovery of normal tissues after radiation therapy may be
delayed, and older patients may experience more severe
adverse effects, such as mucositis, nausea and vomiting, and
myelosuppression. Older patients are slower to recover from
surgery because of impaired healing and declining pulmonary
and cardiovascular functioning. Older patients are also at
increased risk for complications such as atelectasis, pneumonia
and wound infections.
Several studies have shown that when compared to younger
patients, some older patients with cancer have received
Table 11-10 Age-Related Changes and Their
Effects On Patients With Cancer
Age-related changes
Implications
Impaired immune system Use special precautions to avoid
infection; monitor for atypical signs
and symptoms of infection.
Altered drug absorption,
Mandates careful calculation of
distribution, metabolism
chemotherapy and frequent
and elimination
assessment for drug response and side
effects.
Increased prevalence of
Monitor for effect of cancer or its
other chronic diseases
treatment on patient’s other
chronic diseases; monitor patient’s
tolerance for cancer treatment.
Diminished renal,
Be proactive in prevention of
respiratory and cardiac
decreased renal function,
reserve
atelectasis, pneumonia and
cardiovascular compromise.
Decreased skin and tissue
Prevent pressure ulcers secondary to
integrity; reduction in
immobility.
body mass; delayed
Monitor skin and mucous membranes
healing
for changes related to radiation or
chemotherapy.
Prevent wound infection.
Decreased musculoskeletal
Prevent falls; encourage use of hip
strength
protectors if indicated.
Decreased neurosensory
Provide teaching and instructions
functioning: loss of vision,
modified for patient’s hearing and
hearing and distal
vision loss; provide instruction
extremity tactile senses
concerning safety and skin care for
distal extremities.
Potential changes in
Provide teaching and support
cognitive and emotional
modified for patient’s level of
capacity
functioning.
Table 11-11 Components of Cancer
Survivorship
Component
Examples of care
Prevention and detection of
• Mammography (per ACS
new and recurrent cancer
guidelines)
• Papanicolaou (Pap) smears
(per ACS guidelines)
• Smoking cessation programs
• Nutrition counselling
Surveillance for cancer spread,
• Colonoscopy post–colon cancer
recurrence or second cancers • Mammography post–breast cancer
• Liver function tests post–colon
cancer
• Prostate specific antigen
post–prostate cancer
Intervention for consequences
• Lymphoedema therapy
of cancer and its treatments
• Pain management
• Enterostomal therapy
• Fertility care
Coordination between
• Care for comorbidities (e.g.
specialists and primary
diabetes)
care providers to meet
• Influenza vaccination
health needs
• Bone densitometry
ACS, American Cancer Society.
From Hewitt, M., Greenfield, S. & Stovall, E. (Eds). (2006).
From cancer patient to
cancer survivor.
Washington, DC: Institute of Medicine and National Research Council.
The National Academies Press. Components of survivorship care provided by the
Institute of Medicine report on cancer survivorship.
