Textbook of Medical-Surgical Nursing 3e

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Chapter 11

Oncology: Nursing management in cancer care

some instances, the aspiration biopsy does not yield enough tissue to permit accurate diagnosis. A needle core biopsy uses a specially designed needle to obtain a small core of tissue. Most often, this specimen is sufficient to permit accurate diagnosis. Surgery as primary treatment When surgery is the primary approach in treating cancer, the goal is to remove the entire tumour or as much as is feasible (a procedure sometimes called debulking) and any involved surrounding tissue, including regional lymph nodes. Two common surgical approaches used for treating primary tumours are local and wide excisions. Local excision is war- ranted when the mass is small. It includes removal of the mass and a small margin of normal tissue that is easily accessible. Wide or radical excisions (en bloc dissections) include removal of the primary tumour, lymph nodes, adjacent involved struc- tures and surrounding tissues that may be at high risk for tumour spread (Szopa, 2005). This surgical method can result in disfigurement and altered functioning. Wide excisions are considered, however, if the tumour can be removed completely and the chances of cure or control are good. In some situations, video-assisted endoscopic surgery is replacing surgeries associated with long incisions and extended recovery periods (Swanson et al., 2007). The surgical instru- ments are inserted into the surgical field through one or two additional small incisions, each about 3 centimetres long. The camera in the endoscope transmits the image of the involved area to a monitor so the surgeon can manipulate the instruments to perform the necessary procedure. This type of procedure is now being used for many thoracic and abdominal surgeries. Salvage surgery is an additional treatment option that uses an extensive surgical approach to treat the local recurrence of the cancer after a less extensive primary approach is used. A mastectomy to treat recurrent breast cancer after primary breast conserving surgery and radiation is an example of salvage surgery. In addition to the use of surgical blades or scalpels to excise the mass and surrounding tissues, several other types of surgical interventions are available (Table 11-5). Electrosurgery makes use of electrical current to destroy the tumour cells. Cryosurgery uses liquid nitrogen to freeze tissue to cause cell destruction. Chemosurgery uses combined topical chemotherapy and layer- by-layer surgical removal of abnormal tissue. Laser surgery ( l ight a mplification by s timulated e mission of r adiation) makes use of light and energy aimed at an exact tissue location and

depth to vaporise cancer cells. Stereotactic radiosurgery (SRS) treats the tumour with a precise delivery of a single, high dose of radiation in a 1-day session. Focused radiation beams are delivered to a specific area used in some types of brain, head and neck cancers. SRS is limited to the head and neck, because these areas can be immobilised with skeletal fixation devices that completely restrict the head’s movement, permitting the most precise and accurate treatment. This type of radiation has such a dramatic effect on the target area that the changes are considered to be comparable to more traditional surgical approaches (International Radiosurgery Association, 2010). (Radiation therapy is discussed later in this chapter.) A multidisciplinary approach to patient care is essential during and after any type of surgery. The effects of surgery on the patient’s body image, self-esteem and functional abilities are addressed. If these effects are anticipated, a plan for post­operative rehabilitation is made before the surgery is performed. The growth and dissemination of cancer cells may have produced distant micrometastases by the time the patient seeks treatment. Therefore, attempting to remove wide margins of tissue in the hope of ‘getting all the cancer cells’ may not be feasible. This reality substantiates the need for a coordinated multidisciplinary approach to cancer therapy. Once the surgery has been completed, one or more addi- tional (or adjuvant) modalities may be chosen to increase the likelihood of destroying the cancer cells. However, some cancers that are treated surgically in the very early stages are considered to be curable (e.g. skin cancers, testicular cancers). Prophylactic surgery Prophylactic surgery involves removing non-vital tissues or organs that are likely to develop cancer. The following factors are considered when doctors, nurses, patients and families discuss possible prophylactic surgery: • Family history and genetic predisposition • Presence or absence of symptoms • Potential risks and benefits • Ability to detect cancer at an early stage • Patient’s acceptance of the postoperative outcome Colectomy, orchidectomy, mastectomy and oopho­rectomy are examples of prophylactic surgical procedures. Recent develop­ments in the ability to identify genetic markers indic- ative of a predisposition to develop some types of cancer may play a role in decisions concerning prophylactic surgeries. Some controversy, however, exists about adequate justification

Table 11-5  Selected Techniques Used to Remove or Destroy Tumours Type of procedure Description Examples of use Electrosurgery Use of an electric current to destroy tumour cells

Basal and squamous cell skin cancers Cervical and prostate cancers

Cryosurgery

Use of liquid nitrogen or a very cold probe to freeze tissue

  and cause cell destruction

Chemosurgery

Use of chemicals or chemotherapy applied directly to

Intraperitoneal chemotherapy for ovarian cancer   involving the abdomen and peritoneum Dyspnoea associated with endobronchial obstructions

  tissue to cause destruction

Laser surgery

Use of light and energy aimed at an exact tissue location

  and depth to vaporise cancer cells (also referred to as   photocoagulation or photoablation) Photodynamic therapy Intravenous administration of a light-sensitising agent

Palliative treatment of dysphagia associated with   oesophageal and dyspnoea associated with

  (haematoporphyrin derivative [HPD]) that is   taken up by cancer cells, followed by exposure to laser   light within 24–48 hours; causes cancer cell death Uses localised application of thermal energy that destroys   cancer cells through heat: temperatures exceed 50 8 C

  endobronchial obstructions

Radiofrequency   ablation (RFA)

Non-resectable liver tumours, pain control with bone

  metastasis