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GI

MALIGNANCIES

Trisha Marsolini RN, BS, OCN, CMSRN Overlake Hospital Medical Center March 2014

Objectives

Review pathophysiology of GI systems Esophagus Colon Pancreas

Discuss risk factors

Discuss presenting signs and symptoms

Discuss and Identify current treatment options

Review side effects and nursing management

2010 Estimated US Cancer Cases

3 Source: American Cancer Society, 2010

Men

789,620

Women

739,940

27% Breast

14% Lung & bronchus

9% Colon & rectum

6% Uterine corpus

4% Non-Hodgkin lymphoma

4% Melanoma of skin

4% Thyroid

3% Kidney & renal pelvis

3% Ovary

3% Pancreas

22% All Other Sites

Prostate 25%

Lung & bronchus 15%

Colon & rectum 9%

Urinary bladder 7%

Melanoma of skin 5%

Non-Hodgkin 5% lymphoma

Kidney & renal pelvis 5%

Leukemia 3%

Oral cavity 3%

Pancreas 3%

All Other Sites 19%

2010 Estimated US Cancer Deaths

4

ONS=Other nervous system.

Source: American Cancer Society, 2010.

Men

299,200

Women

270,290

26% Lung & bronchus

15% Breast

9% Colon & rectum

7% Pancreas

5% Ovary

4% Non-Hodgkin lymphoma

3% Leukemia

3% Uterine corpus

2% Liver & intrahepatic bile duct

2% Brain/ONS

25% All other sites

Lung & bronchus 30%

Prostate 9%

Colon & rectum 9%

Pancreas 6%

Leukemia 4%

Liver & intrahepatic 4% bile duct

Esophagus 4%

Urinary bladder 3%

Non-Hodgkin 3% lymphoma

Kidney & renal pelvis 3%

All other sites 25%

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GI Malignancies Worldwide

Type Diagnosed Cases

Deaths US cases

Esophageal

482,300 406, 800 17, 460

Stomach

989,600 738,000 21,320

Pancreatic # fall under other

800,230 43, 920

Colorectal

1,167,020 602,958 143,460

Combined: 25% of all diagnosis and 32% of deaths

worldwide

•Numbers are based data collected by ACS in 2008

http://blogs.abcnews.com

Esophageal

Cancer

Anatomy and Function

Located behind the trachea, at the hypopharynx

Starts at thoracic inlet, ending at GE junction

muscular tube 10-13 inches long Facilitates swallowing and moves food and fluids

Movement controlled by sphincters and peristalsis

Esophageal Anatomy

Mucosa – two components

• Epithelial layer – squamous cells

• Lamina layer – connective tissue

Sub mucosa

• Glandular layer

Muscularis Propria

• Muscle layer

Adventia

• Connective tissue layer

Lymph Nodes

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•Types of Esophageal Cancer

Squamous cell carcinoma (SCC)

Originate from mucosal layer

Usually occurs from mid to upper esophagus

90% used to be SCC now < 30%

More common in black men

Types of Esophageal Cancer

• Adenocarcinoma

• Does anyone remember where this type originates from?

• Originate from glandular cells of sub mucosa

• Squamous cells are replaced by glandular cells

• Usually occurs near the stomach

• Increasing about 1% a year in white men

Incidence of Esophageal Cancer

2% of U.S. cancer deaths

17, 460 estimated new cases - 2012 US

15,070 estimated deaths – 2012 US

8th most common cancer Worldwide

7th most common cancer death Worldwide

3 to 4 higher in men than women

startoncology.net

• Stats from 2004

Highest incidence :

•South Africa

•China

•Malawi

•Mongolia

•These areas have 20

to 30 times higher

than US

Worldwide Incidence 2008

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Risk Factors for Esophageal Cancer

Age - most cases occur > 65

Male – 3 to 4x higher than women

Tobacco

44X risk more significant in SCC

Alcohol – heavy

Synergic relationship with smoking

Obesity/ High BMI

More significant in adenocarcinoma

Risk Factors for Esophageal Cancer

HPV – predisposes to adenocarcinoma

Diet Diet low in fruits and vegetables Drinking hot fluids frequently Diet high in processes meats (high salt), pickled

vegetables

Decline of h. pylori in esophagus In squamous cell

Presenting Signs & Symptoms

Asymptomatic in early stage Late Symptoms

• circumference of esophagus less than 13mm –Difficulty/painful swallowing –Weight loss – Chest or Epigastric Pain –Hoarse Voice –Hiccups –Hematemesis –Melena

No screening tests available in US

Risk Factors for Esophageal Cancer

Barrett’s Esophagus

10% of people with GERD have Barrett’s

GERD asst with high BMI

Squamous cells replaced with glandular cells

30-125 times increased risk of adenocarcinoma

Cancer risk higher when there is dysplasia

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Case Study

Jim a 67 yr old

Hx: HTN, Hyperlipidemia, DM, GERD, obese and Barrett’s

Progessive dyspaghia for last 4 to 6 weeks

Previous 2 weeks only eating soft food

50 pd weight loss last 6 mo.

Previous EGD 2 yrs ago – WNL

3/26 Had EGD

Obstructing mass distal esophagus

Biopsy

High grade poorly differentiated adenocarcinoma

Diagnostic Work-up

Initial diagnostic exams

Baruim Swallow

Endoscopy and Biopsy

Staging exams

CT chest and abdomen

Bronchoscopy

PET scan

MRI

Bone scan

Laparoscopy

Diagnostic Work-up

Endoscopic Ultrasound

Identifies unseen

tumors and depth of

tumors

Can do biopsies

Even of lymph nodes

http://www.barrettsadvice.com

Case Study

4/4 CT/PET

Obstructing mass distal esophagus and junction

Enlarged perigastric node

Bulky upper R mediastinum/paratracheal node

No distant mets

Family Hx

Dad passed from esophageal ca

Brother passed from a brain tumor

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Metastatic Patterns

Local Spread through esophageal layers

Lymph Nodes

Surrounding organs

Distant Metastases

Liver

Lung & Pleura

Stomach

Peritoneum

NCCN Esophageal Staging

TNM used

Plus add Grade

Makes difference in early stages

Squamous Vs Adenocarcinoma

Squamous staging

adds location

TNM Staging - Squamous TNM staging - Adenocarcinoma

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Staging TX Primary tumor cannot be assessed.

T0 No evidence of primary tumor.

Tis High-grade dysplasia.c

T1 Tumor invades lamina propria, muscularis mucosae, or submucosa.

T1a Tumor invades lamina propria or muscularis mucosae.

T1b Tumor invades submucosa.

T2 Tumor invades muscularis propria.

T3 Tumor invades adventitia.

T4 Tumor invades adjacent structures.

T4a Resectable tumor invading pleura, pericardium, or diaphragm.

T4b Unresectable tumor invading other adjacent structures, such as aorta, vertebral body, trachea, etc.

Nodes

Nx = unable to

assess LN

N0 = no LN

N1= 1-2 LN

N2 = 3-6 LN

N3 = >7 LN

Esophageal tumor

5 Year Survival Rates

Localized disease survival rate is 37%

Regional staged is 19%

Distant metastasis 3%

Survival rates doubled last 40 years but remain poor

NCCN Treatment Guidelines

Surgery alone

Early Stage - rare

Chemotherapy

Pre and postoperative

Chemoradiation – Primary treatment

Used alone in locally advanced SCC

Combined with surgery in adenocarcinoma

Radiation –

Alone if tumor is locally advanced

Palliative for symptom management

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Case Study

Jim is not a surgical candidate

Why?

4/9 Port placed and chemo started

Carboplatinum, taxotere and 5-FU

4/14 admitted to onc unit

Dehydration, diarrhea and stomatitis/esophagitis

WBC 8.8

HCT 34.6

Crt 1.7

Stopped 5-FU 8 hrs early

Time frame in general early for SE

NCCN Treatment Guidelines Combination Chemotherapies most common

Xeloda or 5-FU paired with Cisplatin Irinotecan Oxaliplatin Carboplatin Pacilataxel Docetaxel

Herceptin in locally advanced or metastatic setting

2 drug regimens most common with Radiation 3 drug regimens most common when Radiation is not

indicated

Ongoing trials to find the best chemo and radiation combo

Trials ongoing with radiosensitizers

NCCN Treatment Guidelines

Surgery Esophago-gastrectomy

Less invasive approaches Thoracoscopy with limited laparotomy or laparoscopy & possible cervical incision

More invasive approaches Thoracotomy with laparotomy & possible cervical incision

NCCN Treatment Guidelines

Tumor can be unresectable – due to location

Close to cricopharyngeaus – cervical area

Extensive EGJ involved

Bulky tumor that involves surrounding organs

Bulky lymphadenopthy

Distant mets

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Nursing Management

Post Surgical care

Pneumonia Obstruction or paralytic ileus Bleeding Anastomosis Leakage Blood clots Infection Pain management Recurrent laryngeal nerve paralysis (cervical

sites)

Nursing Management

Later phase surgical issues

Slow emptying and chronic nausea/vomiting Strictures Heartburn

Patient are going to have to learn to eat different

Nutrition Consult

Case Study

Jim is not a surgical candidate

Why?

4/9 Port placed and chemo started

Carboplatinum, taxotere and 5-FU

4/14 admitted to onc unit

Dehydration, diarrhea and stomatitis/esophagitis

WBC 8.8

HCT 34.6

Crt 1.7

Stopped 5-FU 8 hrs early

Time frame in general early for SE

Case Study

4/17 Labs

WBC 2.2

HCT 25.1

Treatment

2 units PRBCs

GCSF

Next treatment dosed reduced

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Palliative Therapy

Esophageal Dilatation

Esophageal Stents

PEG or PEJ placement

Photodynamic Therapy

Laser Endoscopy

Treatment

Photodynamic Therapy

Used on superficial and mucosal lesions Procedure Given photosensitizing agent

Wait a few days

Via endoscopy Special laser is pointed at cancer

cells causing cell death

Little harm to normal cells Patients need to stay inside for 4- 6 weeks

Case Study

5/22 CT showed

Mild improvement in obstructing mass

Dysphagia improved – Reg diet

Creatinine climbing 2.7

No more GCSF

Stopped chemo except 5-FU

6/1 palliative radiation started

Total 25 treatments

Case Study 6/9 admitted

increased confusion, dehydration, weakness

Mucositis/dysphagia

Currently on 5-FU CADD pump

Labs

Crt 2.06

K 3.1

BS 388

Finished 5-FU took a few days off Radiation TX

7/8 last dose of 5-FU

7/26 finished radiation

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Case Study

8/4 CT

T12 compression fx

New bulky distal esophageal adenopathy

8/9 started rad tx to new area

8/20 admitted LBP compression L-5 and constipation

IV narcotics for pain control

Kyphoplasty – pain not improved after

Relistor relieved constipation

Summary – Esophageal cancer

Overall 5 yrs survival is 11 to 18%

Males much higher risk than women

Tobacco significant risk in SCC

GERD significant risk in Adenocarcinoma

Healthy weight and active lifestyle best defense

Adenocarcinoma increasing in white men

SCC decreasing in US but still significant problem worldwide

Colorectal Cancer

Colon Anatomy •Primary Function is water and mineral absorption and stool formation.

•70% of tumor occurrences are in the colon and 30% are in the rectum.

•Colon is approx. 5 to 6 ft long

•Rectum is 10 to 12 inches long

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45

Normal to Adenoma to Carcinoma Human colon carcinogenesis

progresses by the dysplasia/adenoma to carcinoma pathway

•How long do you think this pathway takes?

Genetic Model of Colon Cancer

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p53

Late Adenoma

Optimum phase for early detection

Many

decades

APC

K-ras

Mutation

Courtesy of Barry M. Berger. MD, FCAP EXACT Sciences

Late Cancer

Early Cancer

Adenoma Norma l Epithelium

Dwell Time: 2-5

years

2-5

years

1 in 19 men and 1 in 20 women lifetime risk

143, 460 new cases - 2012 US

51,690 death – 2012 US

3rd leading cause of cancer death men and women

World-wide incidence similar in developed countries

African Americans have 20% higher incidence, 45% higher mortality

Colon cancer has decreased 15 years due to screening

1 million survivors of colorectal cancer in the US

Incidence of Colorectal Cancer

47

World-wide Incidence 2008

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Risk Factors

Age over 50

Obesity - especially abdominal obesity

High fat and red meat

Type II Diabetes

Smoking

Inflammatory Bowel Disease: Crohns, Ulcerative colitis

Previous cancerous polyps

Family history – 20% of all CRC

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Risks Factors

Familial Adenomatous Polyposis (FAP)

1% of CRC

Adenomatous polyposis coli (APC) gene mutation

Hundreds of polyps by age 39

Not necessarily just located in colon and rectum

100% lifetime risk of CRC

Autosomal dominant

Risks Factors

Hereditary Nonpolyposis Colorectal Cancer (HNPCC)

• 3-5% of CRC

• Also known as Lynch Syndrome

• Mismatch repair gene mutation

• Average age of onset is 44

• 70-80% lifetime risk of CRC

• Women have very high risk of endometrial cancer

• Increased risk of other cancers

Presenting Symptoms - Generalized

Persistent abdominal discomfort

Changes in bowel habits (over several weeks)

Rectal bleeding/Blood in the stool

A feeling that your bowel doesn't empty completely

Unexplained weight loss

Fatigue

Anemia

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Presenting Symptoms – Location

Ascending Descending

Large bulky tumor

Palpable mass uncommon

Dull pain

Tarry dark stool Late Symptoms:

Transverse Palpable mass

Occult blood in stool

Obstruction

Maroon colored in stool

Incomplete stool evacuation

Obstruction

Tenesmus

Sigmoid Constipation

Pencil-like stool

Tenesmus

Presenting Symptoms - Rectal

Mucous discharge/diarrhea

Bright red rectal bleeding (most common)

Tenesmus – spasmodic contraction

Sense of incomplete evacuation

Late Symptoms:

Feeling of rectal fullness

Constant ache

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Screening

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American Cancer Society-Screening Guidelines

Screening should begin at the age of 45 to 50 If there is no previous history of polyps or cancer

Tests that find polyps and cancer Flexible sigmoidoscopy every 5 years*, or Colonoscopy every 10 years, or Double-contrast barium enema every 5 years*, or CT colonography (virtual colonoscopy) every 5 years*

Tests that primarily find cancer Yearly fecal occult blood test (gFOBT)**, or Yearly fecal immunochemical test (FIT) every year**, or Stool DNA test (sDNA), interval uncertain** * If the test is positive, a colonoscopy should be done. ** The multiple stool take-home test should be used. One test done by the doctor in the office is

not adequate for testing. A colonoscopy should be done if the test is positive.

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Colon Polyps Colon Cancers

Diagnostic & Lab Procedures

Barium Enema

CAT Scan/PET Scan

Colonoscopy, Sigmoidoscopy, Protoscopy

MRI

Hematocrit

Liver Function Tests

Carcinoembryonic Antigen (CEA) Monitor for response to therapy and recurrence – not presence

of cancer

Case Study

Jane 33 weeks of pregnancy

CT showed large obstructing mass in rectum and liver mets.

Flex sig showed innumerable polyps.

She was to have a C-Section at 36 weeks

contractions at 35 weeks

C-section = healthy boy

Pathology from flex sig

Familial Adenomatous Polyposis (FAP)

She has 10 other children at home.

What are their risk of getting FAP?

50/50

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Case Study

CEA (Reference Range: 0-3 NG/ML)

Jan. 23 Result: 2126.94

Feb. 25 Result: 4176.6

After delivery sent home

Return to hospital 1 week later in terrible pain

After about a week had to have a debulking surgery Diverting ileostoy

TPN

PCA, frequent large boluses and pain consult

DC home about 2 weeks later

Metastatic Patterns

Local extension through penetration of layers of bowel

Invasion of submucosal layer: direct access to vascular and

lymphatic system

Distant metastasis

most frequent in liver, then the lungs Less frequent in brain, bone and adrenal glands

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Staging for Colon Cancer TNM – Staging

System

Tumor Nodes Metastasis 5 yr Survival

Stage 0 - Polyp Tis N0 M0

Stage I Tumor involves the inner lining of the intestine.

T1

T2

N0

N0

M0

M0 93%

Stage IIA Tumor invades muscle wall of the intestine but no LN.

T3 N0 M0 85%

Stage IIB T4 N0 M0 72%

Stage IIIA Lymph nodes are involved.

Any T N1 M0 83%

Stage IIIB Any T N2 M0 64%

Stage IIIC Any T N3 M0 44%

Stage IV Tumor spread to other organs.

Any T Any N M1

8%

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NCCN Treatment Guidelines

Recommendations for treatment by stage

Surgery

Primary treatment 75% of colorectal cancers goal being cure!

Chemotherapy

Monoclonal antibodies/Targeted Agents

Radiation – Rectal cancer mostly

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Treatment: Chemotherapy

Used in combination with surgery in colon cancer

Can be adjuvant or neoadjuvant

Fluorouracil (5-FU)/Xeloda and Leucovorin remains mainstay

Other agents:

Irinotecan (Camptosar)

oxaliplatin (Eloxatin),

Cisplatin

Targeted therapy

Avastin – k-ras mutation

Erbitux

Vectibix

Treatment- Radiation

Used in combination with chemo in rectal cancer

Endocavitary radiation

• Early rectal cancers in low-rectal and mid-rectal regions

• Early anal cancers

External Beam radiation

• Can be before or after surgery in rectal cancer

• Limited use in colon cancer

• Not used in metastatic setting

• Palliative – symptom management

Treatment: Surgery Colon

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Right Hemicolectomy Left Hemicolectomy

•Laproscopic-assited colectomy – early stage colon cancer

•Hemicolectomy - sometimes many need temporary colostomy -rarely are

the permanent

•Debulking – pallative/symptom management – often ends up with

colostomy

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Treatment: Surgery Rectum

Early stage surgeries

Transanal endoscopic microsurgery

Local Transanal Resection

Surgical procedure determined by location

Lower Anterior Resection – lesion in upper third of the rectum

temporary ileostomy may be neccessary

Treatment: Surgery Rectum

Colo-anal Anastomosis – lesion in the middle and lower third of the rectum

J-pouch and temporary ileostomy

Abdominoperineal (AP) Resection – lesion in the middle and lower third of the rectum, large and bulky

Permanent colostomy

Nursing Management – Post Op

Post Surgical care

Pneumonia

Obstruction or paralytic ileus

Bleeding

Anastomosis Leakage

Stoma complications

TPN

Discharge teaching

Ostomy Care

Self image

New and Exciting Treatments

Immunotherapy Using patients T-cells to attack antigens on the surface

of the colorectal cancer cells

Her-2/neu expression in GI

Malignancies

Vit D is being studied in recurrent

disease

An Aspirin a day may decrease risk of developing

recurrent colorectal cancer

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Case study

Jane started chemo 4 weeks after surgery

5Fu. Leucovorin and oxaliplatin

Tolerated treatment for many months

CEA started to rise in November

Added Avastin

Early on too much bleeding worry

April following year tumor began to progress

Passed way in August

Summary – Colon cancer

3rd leading cause of cancer death

Most significant risk age & smoking!

Early detection SO IMPORTANT!

Get your colonoscopy

Stage is most significant prognostic indicator

Surgery is primary treatment

Cure is the goal!

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Pancreatic Cancer Anatomy of Pancreas

Pear shaped dual-function gland

6 in long/about 15 cm

Located between stomach and

spine

3 Parts

• Head

• Body

• Tail

Approximately 75%of tumors occur in the head

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Function of the Pancreas

Endocrine Function Islets of Langerhans –

produce insulin and glucagon

Neuroendocrine tumors originate here

1% of pancreatic cancers

Exocrine Function Comprised of ducts and acini

Enzymes help in digestion

95% pancreas

95% are adenocarcinomas

Incidence of Pancreatic Cancer

10th most common cancer

4th leading cause of cancer deaths

43, 920 new cases – 2012 US

37,330 deaths – 2012 US

Lifetime risk 1 in 72

Higher incidence in African Americans

At time of diagnosis > 50% have distant mets

Incidence the same worldwide – developed countries

World-wide incidence Risk Factors

Age – 55 and greater

Smoking – 2 to 3x greater risk Obesity Type 2 diabetes

Cirrhosis of the Liver Chronic pancreatitis – often related to smoking Helicobacter pylori (H. pylori) infection Genetic Syndromes

10% of pancreatic cancers

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Presenting Signs & Symptoms

Abdominal and back pain

• Dull and constant

• Radiates to mid or upper back

• Worse while supine

Weight Loss and Poor Appetite

Blockage of digestive enzymes

• Pale, bulky, greasy stool that may float

Nausea and vomiting

Presenting Signs & Symptoms

Jaundice – usually painless

DVT/PE – paraneoplastic syndrome

Fatigue

Depression

Ascites ♦ Once there are signs and symptoms the disease is already

advanced!!!

Diagnostic Procedures

CT

ERCP -No mass on CT

Stent obstruction

biopsies

Endoscopic Ultrasound (EUS)

• MRCP- If ERCP can’t be done

• Total Bilirubin

• CA 19-9 – not pancreas specific

• Liver Enzymes

• PET scan

• Laparotomy

• Jill healthy 60 yr old was admitted Nov. 2011 with painless jaundice

• HCT 24.2

• Total Bilirubin 8.8 (0.1-1.5)

• Alkaline Phosphate 444 (20-140)

• CA 19-9 = 125, 328

• EGD -showed bleeding duodenal mass

ERCP not possible D/T mass

• CT – mass at head of pancreas obstructing of biliary system and mets to the liver

• IR – biopsy done with biliary stent placement

Case Study

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Metastatic Pattern

Local spread/invasion to surrounding tissue and organ

• Small bowel, CBD, Stomach

Most common distant metastatic sites

• Liver

• Lungs

• Peritoneum/abdominal cavity

Staging/TNM Classification

TNM Tumor Nodes Metastasi

s

5 YR Survival

Stage 0 Tis N0 M0

Stage IA T1 N0 M0 37%

Stage IB T2 N0 M0 21%

Stage IIA T3 N0 M0 12%

Stage IIB T1 N1 M0 6%

T2 N1 M0

T3 N1 M0

Stage III T4 Any N M0 2%

Stage IV Any T Any N M1 1%

Staging •T1 is a tumor < 2cm

•T2 is a tumor > 2cm

•T3 tumor beyond pancreas, major arteries or veins

not involved

•T4 tumor involves major arteries and veins

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NCCN Treatment Guidelines

Chemotherapy – usually at all stages

• Gemcitabine and 5FU/Xeloda– Gold standard • proven to be chemo-resistant

Others you may see Xeloda, cisplatin, irinotecan,CPT-11, Taxol,

docetaxol, oxaliplatin

Targeted Therapy

• Erlotinib

Radiation – limited use

• After surgery to help prevent recurrence

• Tumor too large for surgery

Intra-operative Radiation

Clinical trials

Surgery

– Whipple Procedure (Pancreaticoduodenectomy) – Cancer much be contained with in the pancreas –Only potential cure and only 1 and 10 case

A series of three anastomoses are created Gastrojejunostomy tube

5 year survival even with surgery is 20%

Surgery

Gastrojejunostomy

Bypass tumor and attach stomach

to jejunum

Second anastomoses done

from biliary systemt to if possible

A palliative procedure for symptom management

Nursing Management Post operative care

Pneumonia

Bleeding

Infection

Anastomotic leaking

Blood sugar and electrolyte imbalances

TPN

Ileus

Dumping Syndrome

• Pain control

• Insulin Dependence – surgically induced

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Nursing Management

Malnourishment/Malabsorption

• Anorexia

• Nausea

• Pancreatic insufficiency

• Blockage

Interventions

• Pancreatic enzyme tablets

• Nutritional consult

• Feeding tube

Palliation treatment

Biliary obstruction – in IR or by ERCP

• Permanent biliary stent

• Percutaneous biliary

stent with drain

Gastric outlet obstruction

• Enteral stent

• PEG/PEJ tube

• Gastrojejunostomy

Case Study

• Jill was admitted in January for N/V and weakness

• Current Treatment

• Gemcitabine and Xeloda

CA 19-9 = 513,626 (125, 328)

Received bowel rest and IV hydration

• After several day N/V started again

Upper GI series showed gastric outlet obstruction

Laprascopic Gastrojejunostomy with Moss tube placement and cholecystectomy

Summary – Pancreatic cancer

Overall 5 yr survival is 3%

Smoking increases risk 3 to 4 fold

One of the most lethal cancers – in US

Median survival is 9-12 months

After resection 15-19 months

Treatment for majority pain and symptom management

Pancreatic cancer has proven to be fairly chemo resistant

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Chemotherapy Side Effects

Side effect Management Drug

Mucositis Good Oral Care Magic Mouthwash

5 –Fu

Diarrhea Anti-diarrheal Hydration

Irinetecan 5-FU

Hand Foot Syndrome Monitor Patient education

5-FU/Xeloda Targeted therapies

Acne like rash Monitor Creams/antibotics

Erlotinib Oxaliplatin

Thrombocytopenia Patient Education on risk and signs and symptoms

Gemcitabine

Neurotoxicity (tingling/numbness)

Monitor Patient education

Oxaliplatin

Cold Sensitivity No cold food Scarf in cold weather

Oxaliplatin

Patient Education -Chemotherapy

Nausea & Vomiting

• Antiemetic, keeping hydrated and when to call

Myelosuppression

• Growth factors, blood transfusion, hand hygiene

Fatigue

> than 99% of patients complaining of fatigue

• Encourage mild exercise and energy conservation

Decreased libido

Patient Education - Radiation

Inflammation of bowel or bladder

Blood in stool or urine

Ulceration of GI mucosa – pain

Necrosis of GI tract

Skin irritation/burns

Changes in sexual activity

Please refer to your handouts for nursing and patients resources.

Thankyou!

Q & A