Approach to Cancer Care

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Staging is the process of finding out how much cancer there is in the body and where it is located. It is how the doctor learns the stage of a person’s cancer. Doctors use this information to plan treatment and to help predict a person’s outlook (prognosis). Cancers with the same stage tend to have similar outlooks and are often treated the same way. The cancer stage is also a way for doctors to describe the extent of the cancer when they talk with each other about a person’s case. Doctors need to know the amount of cancer and where it is in the body to be able to choose the best possible treatment.

For example, the treatment for early stage breast cancer may be surgery and radiation, while a more advanced stage of breast cancer may need to be treated with chemotherapy, too. Doctors also use the stage to help predict the course a cancer is likely to take. For most cancers, the stage is based on 3 main factors, T, N, and M: ·T: is based on the size of the original (primary) tumor and whether or not it has grown into nearby tissues ·N: whether or not the cancer has spread to the nearby lymph nodes ·M: whether or not the cancer has spread to distant areas of the body Not all cancers are staged this way.

Often this is because they grow and spread in a different way than most tumors. For example, leukemias (cancers of the blood) affect the blood and bone marrow throughout the body, and so are not staged based on these factors. Cancers in or around the brain are also not staged using the TNM system, since these cancers tend to spread to other parts of the brain and not to lymph nodes or other parts of the body. Doctors gather different types of information about a cancer to figure out its stage. Depending on where the cancer is located, the physical exam may give some clue as to the extent of the cancer.

Imaging tests like x-rays, CT scans, MRIs, ultrasound, and PET scans may also provide information about how much and where cancer is in the body. Often, biopsy is needed to confirm the diagnosis of cancer, and to find out if an abnormal spot on an imaging test is really cancer spread. A biopsy involves taking out tumors or pieces of tumors and looking at them under the microscope. Samples can be removed either during surgery or during less invasive biopsy procedures. The different techniques used to remove and examine samples are described in our Surgery document.

All staging is done at the time of diagnosis, before any treatment is given. There are 2 major types of staging. This is an estimate of how much cancer there is based on the physical exam, imaging tests (x-rays, CT scans, etc. ), and tumor biopsies. For some cancers, the results of other tests, such as blood tests, are also used in staging. The clinical stage is a key part of deciding the best treatment to use. It is also the baseline used for comparison when looking at the cancer’s response to treatment.

Pathological staging (also called surgical staging) relies on information obtained during surgery. Often this is surgery to remove the cancer and nearby lymph nodes, but sometimes surgery may be done to look at how much cancer is in the body and remove tissue samples. In some cases, the pathologic stage may be different from the clinical stage (for example, if the surgery shows the cancer has spread more than it was thought to have spread before surgery). The pathological stage gives the health care team more precise information that can be used to predict treatment response and outcomes (prognosis).

At one time there were many different systems used to stage cancers, and sometimes different systems were used to stage the same type of cancer. But many of these systems did not give doctors very useful information. The American Joint Committee on Cancer (AJCC) developed the TNM classification system as a tool for doctors to stage different types of cancer based on certain standards. It has replaced many of the older staging systems. In the TNM system, each cancer is assigned a T, N, and M category. The T category describes the original (primary) tumor.

The tumor size is usually measured in centimeters (2 and 1/2 centimeters is about 1 inch) or millimeters (10 millimeters = 1 centimeter). ·TX means the tumor can’t be measured. ·T0 means there is no evidence of primary tumor (it cannot be found). ·Tis means that the cancer cells are only growing in the most superficial layer of tissue, without growing into deeper tissues. This is also known as in situ cancer or pre-cancer. ·The numbers T1, T2, T3, and T4 describe the tumor size and/or level of invasion into nearby structures.

The higher the T number, the larger the tumor and/or the more it has grown into nearby tissues. The N category describes whether or not the cancer has spread into nearby lymph nodes. ·NX means the nearby lymph nodes cannot be evaluated. ·N0 means nearby lymph nodes do not contain cancer. ·The numbers N1, N2, and N3 describe the size, location, and/or the number of lymph nodes involved. The higher the N number, the more the lymph nodes are involved. The M category tells whether there are distant metastases (spread of cancer to other parts of body). ·MX means metastasis can’t be evaluated.

·M0 means that no distant metastases were found. ·M1 means that distant metastases were found (the cancer has spread to distant organs or tissues). Each cancer type has its own version of this classification system, so letters and numbers don’t always mean the same thing for every kind of cancer. For example, for some cancers, classifications may have subcategories, such as T3a and T3b, while others may not have an N3 category. Once the values for T, N, and M have been determined, they are combined, and an overall stage is assigned. For most cancers, the stage is a Roman numeral from I to IV.

Sometimes stages are subdivided as well, using letters such as A and B. For example, a T1, N0, M0 breast cancer would mean that the primary breast tumor is less than 2 cm across (T1), does not have lymph node involvement (N0), and has not spread to distant parts of the body (M0). This would make it a stage I cancer. Stage 0 is carcinoma in situ for most cancers. This means the cancer is at a very early stage, is only in the area where it first developed, and has not spread. Not all cancers have a stage 0. Stage I cancers are the next least advanced and often have a good prognosis (outlook for survival).

As the stage number goes up the cancers are more advanced (bigger and more widespread), but in many cases they can still be treated. Cancer and its treatment can cause several complications and side effects from treatments including: ·Pain. Pain can be caused by cancer or by cancer treatment. Most cancer-related pain can be treated effectively. ·Fatigue. Fatigue in people with cancer has many causes, but it can often be managed. Fatigue associated with chemotherapy or radiation therapy treatments is common, but it’s usually temporary. ·Difficulty breathing.

Cancer or cancer treatment may cause a feeling of being short of breath. Treatments may bring relief. ·Nausea. Certain cancers and cancer treatments can cause nausea. Your doctor can sometimes predict if your treatment is likely to cause nausea. Medications and other treatments may help you prevent or cope with nausea. ·Diarrhea or constipation. Cancer and cancer treatment can affect your bowels and cause diarrhea or constipation. ·Unusual immune system reactions to cancer. In some cases the body’s immune system may react to the presence of cancer by attacking healthy cells.

Called paraneoplastic syndromes, these unusual reactions can lead to a variety of signs and symptoms, such as difficulty walking and seizures. Many cancer survivors experience pain during their treatment. Most find ways to manage it with the help of their health care team. However, there are some who may continue to have pain after their treatments have ended. Their chronic (also called persistent) pain may be mild or severe and may affect the quality of life. The good news is that there are now many ways to treat pain that can greatly reduce or even eliminate most pain.

Not every survivor will experience chronic pain. However, some do, and the cause may vary. For example, chronic pain can result from treatment of cancer or because the cancer has metastasized or spread to other parts of the body. Survivors who had breast, prostate, lung or colorectal cancer may have pain because cancer has spread to the bones. Bony metastases are the most common cause of pain in advanced cancer. Peripheral neuropathy, due to injury to nerves, may result from treatment with chemotherapeutic agents. This can cause pain, tingling, burning, numbness or weakness that usually begins in the hands or feet.

Most of the time, the pain caused by peripheral neuropathy will go away when cancer treatment stops. However, if the nerves become permanently damaged, the pain will persist. Chemotherapy medications may cause peripheral neuropathy such as Taxol, Vincristine, Taxotere, and Cisplatin. Steroids taken as part of cancer treatment may bring a risk for chronic bone pain. They can cause the bones to grow weaker leading to osteoporosis that may lead to fractures that can cause pain. Talk with your health care team if you took steroids during your cancer treatment to find out if you might be at risk of chronic pain.

Radiotherapy and surgery can also lead to a variety of acute and chronic pain problems. Studies have shown that unrelieved acute postoperative pain is a major risk factor for delayed recovery and the development of chronic pain problems. Stress can make pain worse. It can also lessen the effect of medications. Sometimes a doctor may recommend counseling to help a patient cope. This may lessen the pain. It may also help improve the effectiveness of the pain medication. Other types of treatment may be used along with pain medications to provide relief.

These methods are called complementary, alternative or holistic medicine. They include massage, acupuncture, biofeedback or hypnosis. Cancer pain is often treated with one or more medications. If you have concerns about taking certain treatments, discuss these with your doctor and pharmacist. Your health care team will want to address your concerns while effectively treating your pain. There are many medications to treat pain. Work with your doctor to find the best treatment for your situation. Ask about long-term usage and side effects such as an allergy or other reaction.

The following list provides examples of how varying levels of pain may be treated with medications: ·For mild pain, medications such as acetaminophen (such as Tylenol) or non-steroidal anti-inflammatory drugs (NSAIDs) may provide relief. Some of these drugs such as ibuprofen or naproxen can be purchased without a prescription. ·For moderate pain, medications that combine an opioid (sometimes called a narcotic) such as hydrocodone or oxycodone with acetaminophen or aspirin may be needed. Vicodin and Percocet are examples of these combination drugs.

The dose of these combination drugs is limited by the toxicity of the acetaminophen or aspirin. ·For severe pain, medications that contain an opioid only (sometimes called a narcotic) such as morphine, oxycodone, fentanyl or methadone are usually needed. ·Adjuvant medications may be important for the treatment or management of neuropathic pain that is generally caused by a problem (such as a lesion) in the nervous system. These are medications with primary uses for other conditions, but are sometimes effective for certain kinds of pain. Examples include the antidepressants Elavil and Cymbalta.

Always talk with your doctor about the possible side effects of medications. Pain medications are almost always needed when pain levels are moderate or severe. However, other treatments can bring comfort and reduce the stress that can actually make the pain experience worse. For some types of pain, heating pads, hot or cold packs, and massage may be soothing and help reduce the pain level. Biofeedback is a method that uses the mind to help with pain. Breathing exercises, relaxation, visualization, meditation, or imagery may also be effective.

Sometimes, talking with friends, laughing, or listening to music might be a helpful distraction from pain. For severe pain, a technique called a nerve block is sometimes considered. This procedure may involve injecting a substance, such as alcohol, directly into or around a nerve or around the spine. This to block the nerves from sending pain signals to the brain so that the pain will not be felt. Extreme cold or heat is now sometimes used in nerve blocks instead of drugs or chemicals. A nerve block can cause temporary muscle paralysis or numbness in the affected or surrounding area.

Nerve blocks may work to control pain for people who have advanced cancer or very painful nerve conditions. However, there may sometimes be serious complications. Nerve blocks are not recommended for people with certain medical conditions. Talk with your doctor about the benefits and risks before any treatment to decide what is best for your situation. Every survivor is different and each responds differently to pain management strategies. Open communication with your health care team can help you decide together what will work best to manage your pain.

Reference: Ackley, B. J. & Ladwig, G. B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care. St. Louis: Mosby Elsevier. McCance, L. , Huether, S. , Brashers, L. , & Rote, N. (2010). Pathophysiology: The biologic basis for disease in adults and children. Maryland Heights, MO: Mosby Elsevier. Lewis, S. , Heitkemper, M. , Dirksen, S. , O’Brien, P. , & Bucher, L. (2007). Medical-surgical nursing: Assessment and management of clinical problems (pp. 1049-1050). St. Louis: Mosby Elsevier.

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