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Unit 3
Applying concepts from the nursing process
which are stimulated by many biological agents (van der Zee
& van Rhoon, 2006).
Heat can be produced by using radiowaves, ultrasound,
microwaves, magnetic waves, hot-water baths or even hot
wax immersions. Hyperthermia may be local or regional, or it
may include the whole body. Local or regional hyperthermia
may be delivered to a cancerous extremity (for malignant
melanoma) by regional perfusion, in which the affected
extremity is isolated by a tourniquet and an extracorporeal
circulator heats the blood flowing through the affected part.
Hyperthermia probes may also be inserted around a tumour in
a local area and attached to a heat source during treatment.
Chemotherapeutic agents, such as melphalan (Alkeran), may
also be heated and instilled into the region’s circulating blood.
Local or regional hyperthermia may also include infusion of
heated solutions into cancerous body organs. Whole-body
hyperthermia to treat disseminated disease may be achieved
by extracorporeal circulation, immersion of patients in heated
water or paraffin, or enclosure in heated suits (Bruner et al.,
2006; van der Zee & van Rhoon, 2006).
Side effects of hyperthermic treatments include skin burns
and tissue damage, fatigue, hypotension, peripheral neuro
pathies, thrombophlebitis, nausea, vomiting, diarrhoea and
electrolyte imbalances. Resistance to hyperthermia may
develop during the treatment because cells adapt to repeated
thermal insult. Research into the effectiveness of hyper
thermia, methods of delivery and side effects is ongoing.
Nursing management in hyperthermia
Although hyperthermia has been used for many years, many
patients and their families are unfamiliar with this cancer
treatment. Consequently, they need explanations about the
procedure, its goals and its effects. The patient is assessed for
adverse effects, and efforts are made to reduce the occurrence
and severity. Local skin care at the site of the implanted hyper-
thermic probes is also required.
Targeted therapies
Recent scientific advances have led to an improved under-
standing of cancer development. Traditional therapies such
as chemotherapy and radiation affect all actively proliferating
cells. As a result, both healthy cells and malignant cells are
subject to harmful systemic effects of treatment.
Targeted ther-
apies
seek to minimise the negative effects on healthy tissues
by disrupting specific cancer cell functions such as malignant
transformation, cell communication pathways (called signal
transduction), processes for growth and metastasis, and genetic
coding. Actions of targeted therapies include stimulation or
augmentation of immune responses through the use of biolog-
ical response modifiers, targeting of cancer cell growth factors,
promotion of apoptosis and genetic manipulation through gene
therapy (Khoukaz, 2006; Rieger, 2006). Most of the currently
available targeted therapies are categorised as either mono
clonal antibodies or small molecule tyrosine kinase inhibitors.
Biological response modifiers
Biological response modifier (BRM) therapy
involves the
use of naturally occurring or recombinant (reproduced through
genetic engineering) agents or treatment methods that can alter
the immunological relationship between the tumour and the
cancer patient (host) to provide a therapeutic benefit. Although
the mechanisms of action vary with each type of BRM, the goal
is to destroy or stop the malignant growth. BRM treatment
chemotherapy agents used in the conditioning regime or
those used to treat infection (aminoglycosides). Tumour lysis
syndrome and acute tubular necrosis are also risks after BMT.
GVHD requires skilful nursing assessment to detect early
effects on the skin, liver and gastrointestinal tract. VOD result-
ing from the conditioning regimes used in BMT can result in
fluid retention, jaundice, abdominal pain, ascites, tender and
enlarged liver, and encephalopathy. Pulmonary complications,
such as pulmonary oedema, interstitial pneumonia, and other
pneumonias, often complicate the recovery after BMT (Saria
& Gosselin-Acomb, 2007).
Providing posttransplantation care
Caring for recipients.
Ongoing nursing assessment in
follow-up visits is essential to detect late effects of therapy
after BMT, which occur 100 days or more after the procedure.
Late effects include infections (e.g. varicella zoster infection),
restrictive pulmonary abnormalities and recurrent pneumonias.
Sterility often results due to total body irradiation as part of
the ablative regime. Chronic GVHD involves the skin, liver,
intestine, oesophagus, eyes, lungs, joints and vaginal mucosa.
Cataracts may also develop after total body irradiation.
Psychosocial assessments by nursing staff must be ongoing.
In addition to the stressors affecting patients at each phase
of the transplantation experience, marrow donors and family
members also have needs that must be addressed.
Caring for donors.
Like BMT recipients, donors need nursing
care. They commonly experience mood alterations, decreased
self-esteem and guilt from feelings of failure if the transplanta-
tion fails. Family members must be educated and supported to
reduce anxiety and promote coping during this difficult time.
Family members must also be assisted to maintain realistic
expectations of themselves as well as of the patient.
As BMT becomes more prevalent, many moral and ethical
issues become apparent, including those related to valid
(informed) consent, allocation of resources and quality of life.
Hyperthermia
Hyperthermia (thermal therapy), the generation of tempera-
tures greater than physiological fever range (above 41.5°C),
has been used for many years to destroy tumours. Malignant
cells may be more sensitive than normal cells to the harmful
effects of high temperatures for several reasons.
Malignant cells lack the repair mechanisms necessary to
repair cell damage by elevated temperatures. Most tumour cells
lack an adequate blood supply to provide needed oxygen during
periods of increased cellular demand, such as during hyper
thermia. Cancerous tumours lack blood vessels of adequate size
for dissipation of heat. In addition, the body’s immune system
may be indirectly stimulated when hyperthermia is used.
Hyperthermia is most effective when combined with radi-
ation therapy, chemotherapy or biological therapy. Hyper
thermia and radiation therapy are thought to work well
together because hypoxic tumour cells and cells in the ‘S’ phase
of the cell cycle are more sensitive to heat than radiation; the
addition of heat damages tumour cells so that they cannot
repair themselves after radiation therapy. Hyperthermia is
thought to alter cellular membrane permeability when used
with chemotherapy, allowing for an increased uptake of the
chemotherapeutic agent. Hyperthermia may enhance function
of immune system cells, such as macrophages and T cells,
