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Chapter 11

Oncology: Nursing management in cancer care

stimulate the immune system or assist in preventing tumour growth. The antitumour effects are dependent on the type of IFN and the disease for which the IFN is being used. IFNs enhance both lymphocyte and antibody production. They also facilitate the cytolytic or cell destruction role of macrophages and natural killer cells. Additionally, IFNs can inhibit cell multiplication by increasing the duration of various phases of the cell cycle. The effects of IFN have been demonstrated in a variety of malignancies. IFN- α has been approved by the TGA, MEDSAFE, FDA and PHARMAC for treating hairy-cell leukaemia, Kaposi’s sarcoma, chronic myeloge- nous leukaemia, high-grade non-Hodgkin’s lymphoma and melanoma. Other positive responses have been seen in hae- matological malignancies and renal carcinomas. IFN α , IFN β , and IFN- γ have been approved by the TGA for the treatment of several non-malignant diseases. IFN is administered through sub­cutaneous, intramuscular, intravenous and intracavitary routes. Efforts are underway to establish the effectiveness of IFN for various malignancies in combination with other treat- ment regimens. Interleukins.  Interleukins are a subgroup of cytokines known as lymphokines and monokines because they are primarily produced by lymphocytes and monocytes. About 25 different interleukins have been identified. They act by signalling and coordinating other cells of the immune system. The TGA has approved interleukin-2 (IL-2) as a treatment option for renal cell cancer and metastatic melanoma in adults. Originally referred to as T-cell growth factor, IL-2 is known to stimu- late the production and activation of several different types of lympho­cytes. In addition, IL-2 enhances the production of other types of cytokines and plays a role in influencing both humoral and cell-mediated immunity. Side effects of ILs include flu-like symptoms, fatigue and anorexia as well as seri- ous side effects (e.g. profound diarrhoea, pulmonary oedema, hypotension and oliguria). When combined with other cyto- kines, IL-2 can cause hypersensitivity reactions or cardiac dysrhythmias and hypotension (Tyre & Quan, 2007). Clinical trials are being conducted on the role of ILs in treating other cancers. Some early-stage clinical trials are assessing the effects of interleukins in combination with chemo­therapy. In addition, interleukins are being investigated for their role as growth factors for treating myelosuppression after the use of some forms of chemotherapy. Retinoids Retinoids are vitamin A derivatives (retinol, all- trans retinoic acid, and 13- cis -retinoic acid) that play a role in growth, reproduction, epithelial cell differentiation and immune function. Retinoids have many important and diverse func- tions throughout the body including roles in vision, regula- tion of cell proliferation and differentiation, growth of bone tissue, immune function and activation of tumour suppressor genes. Retinoids are being tested for treating both haemato- logical cancers and solid tumours and for preventing a variety of cancers such as prostate and brain cancers (Wilkes & Barton-Burke, 2007). Cancer vaccines Cancer vaccines are used to mobilise the body’s immune response to recognise and attack cancer cells. Cancer vaccines contain either portions of cancer cells alone or portions of cells

in combination with other substances (adjuvants) that can augment or boost immune responses. Autologous vaccines are made from the patient’s own cancer cells, which are obtained during diagnostic biopsy or surgery. The cancer cells are killed and prepared for injection back into the patient. Allogeneic vaccines are made from cancer cells that are obtained from other people who have a specific type of cancer. These cancer cells are grown in a laboratory and eventually killed and prepared for injection. Prophylactic vaccines are given to prevent disease. Quad­ rivalent human papilloma virus (HPV) recombinant vaccine (Gardasil) protects against HPV types 6, 11, 16 and 18 associ- ated with common genital warts (types 6 and 11) and develop­ ment of cervical cancer (types 16 and 18). It is administered over a series of three doses to females aged 9 to 26 (McLemore, 2006). Therapeutic vaccines are given to kill existing cancer cells and to provide long-lasting immunity against further cancer development. Challenges to the therapeutic activity of cancer vaccines include the size of the tumour burden, the mecha- nisms that allow tumour cells to avoid recognition as ‘non-self’ by the immune system, and immune tolerance as the result of previous exposure to the tumour antigens. Multiple clinical trials are being conducted to develop therapeutic vaccines for cancers of the prostate, breast, kidney and lung, as well as for melanoma, myeloma and lymphoma (Schlom, Arlen & Gulley, 2007). Nursing management in biological response modifier therapy Patients receiving BRM therapy have many of the same needs as cancer patients undergoing other treatment approaches. However, some BRM therapies are still investigational and considered a last-chance effort by many patients who have not responded to standard treatments. Consequently, it is essen- tial that the nurse assess the need for education, support and guidance for both the patient and family and assist in planning and evaluating patient care. Monitoring therapeutic and adverse effects.  Nurses need to be familiar with each agent given and the potential effects. Adverse effects, such as fever, myalgia, nausea and vomiting, as seen with IFN therapy, may not be life-threatening. However, nurses must be aware of the impact of these side effects on the patient’s quality of life. Other life-threatening adverse effects (e.g. capillary leak syndrome, pulmonary oedema and hypotension) may occur with IL-2 therapy. Nurses must work closely with doctors to assess and manage potential toxicities of BRM therapy. Because of the investigational nature of many of these agents, the nurse will be administering them in a research setting. Accurate observations and careful docu- mentation are essential components of patient assessment and data collection. Promoting home- and community-based care Teaching patients self-care. Some BRMs, such as IFN, EPO and G-CSF, can be administered by the patient or family in the home. Nurses educate patients and families, as needed, about how to administer these agents through subcutaneous injec- tions. They provide instructions about side effects and assist patients and families to identify strategies to manage many of the common side effects of BRM therapy, such as fatigue, anorexia and flu-like symptoms.