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Chapter 11

Oncology: Nursing management in cancer care

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

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.

Table 11-11  Components of Cancer Survivorship Component Examples of care Prevention and detection of

• Mammography (per ACS guidelines) • Papanicolaou (Pap) smears (per ACS guidelines) • Smoking cessation programs • Nutrition counselling

  new and recurrent cancer

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.

  atelectasis, pneumonia and cardiovascular compromise. Prevent pressure ulcers secondary to Monitor skin and mucous membranes   for changes related to radiation or   chemotherapy. Prevent wound infection. Prevent falls; encourage use of hip Provide teaching and instructions   modified for patient’s hearing and   vision loss; provide instruction   concerning safety and skin care for distal extremities. Provide teaching and support   modified for patient’s level of   immobility.   protectors if indicated.

Decreased skin and tissue integrity; reduction in

body mass; delayed

healing

Decreased musculoskeletal

strength

Decreased neurosensory

functioning: loss of vision, hearing and distal extremity tactile senses

Potential changes in

cognitive and emotional

capacity

  functioning.