Lung Cancer

By Holly Winn and Cathy Mac Donald

ObjectivesObjectivesTo provide a general overview of lung physiologyTo provide a general overview of lung physiologyTo explore the types and classifications of lung cancerTo explore the types and classifications of lung cancerTo provide causes and risk factors of lung cancerTo provide causes and risk factors of lung cancerTo present the signs and symptoms of lung cancer in To present the signs and symptoms of lung cancer in

throughout its progressionthroughout its progressionTo explore assessment and diagnostic information of lung To explore assessment and diagnostic information of lung

cancercancerTo introduce diagnostic staging specific to lung cancerTo introduce diagnostic staging specific to lung cancerTo discuss treatments and side effects of lung cancer To discuss treatments and side effects of lung cancer To present post-op complications for clients with lung To present post-op complications for clients with lung

cancercancerTo explore the nurses role and nursing interventions for a To explore the nurses role and nursing interventions for a

client with lung cancerclient with lung cancerTo explain preventive health strategies regarding lung To explain preventive health strategies regarding lung

cancercancerTo present appropriate nursing diagnoses for clients living To present appropriate nursing diagnoses for clients living

with lung cancerwith lung cancerTo provide and critically discuss a case studyTo provide and critically discuss a case study

General Overview of Lung General Overview of Lung Physiology: Breathing Physiology: Breathing

Healthy lung tissueHealthy lung tissue

Diseased Lung TissueDiseased Lung Tissue

Types of Lung CancerTypes of Lung Cancer

Two main Types of Lung CancerTwo main Types of Lung Cancer::

Small Cell Lung Cancer Small Cell Lung Cancer (20-25% of all lung (20-25% of all lung cancers)cancers)

Non Small Cell Lung CancerNon Small Cell Lung Cancer (most common (most common ~80%)~80%)

Small Cell Lung CancerSmall Cell Lung Cancer

Non-small cell lung cancerNon-small cell lung cancer

• 1. Squamous cell carcinoma1. Squamous cell carcinoma

• 2. Adenocarcinoma2. Adenocarcinoma

• 3. Large cell carcinomas3. Large cell carcinomas

Squamous cell carcinomaSquamous cell carcinoma

• Moderate to poor differentiationModerate to poor differentiation• makes up 30-40% of all lung cancersmakes up 30-40% of all lung cancers• more common in malesmore common in males• most occur centrally in the large bronchimost occur centrally in the large bronchi• Uncommon metastasis that is slow effects the Uncommon metastasis that is slow effects the

liver, adrenal glands and lymph nodes.liver, adrenal glands and lymph nodes.• Associated with smokingAssociated with smoking

• Not easily visualized on xray (may delay dx)Not easily visualized on xray (may delay dx)

• Most likely presents as a Pancoasts tumorMost likely presents as a Pancoasts tumor

AdenocacinomaAdenocacinoma

• Increasing in frequency. Most common type of Lung cancer (40-50% of all lung cancers).

• Clearly defined peripheral lesions (RLL lesion)

• Glandular appearance under a microscope

• Easily seen on a CXR

• Can occur in non-smokers

• Highly metastatic in nature – Pts present with or develop brain, liver, adrenal or bone metastasis

Large cell carcinomasLarge cell carcinomas

• makes up 15-20% of all lung cancersmakes up 15-20% of all lung cancers

• Poorly differentiated cellsPoorly differentiated cells

• Tends to occur in the outer part (periphery) of lung, Tends to occur in the outer part (periphery) of lung, invading sub-segmental bronchi or larger airwaysinvading sub-segmental bronchi or larger airways

• Metastasis is slow BUTMetastasis is slow BUT

• Early metastasis occurs to the kidney, liver organs as Early metastasis occurs to the kidney, liver organs as well as the adrenal glandswell as the adrenal glands

http://www.youtube.com/watch?v=3wzjqbhbesI. .

Lung Cancer Re-capLung Cancer Re-cap

Small Cell Lung Cancer Non-Small-Cell Lung Cancer

Squamous cell Adenocarinoma

Causes and Risk factors of Causes and Risk factors of Lung CancerLung Cancer

Signs and Symptoms of Signs and Symptoms of Lung CancerLung Cancer

• Sometimes lung cancer does not cause any symptoms and Sometimes lung cancer does not cause any symptoms and is only found in a routine x-ray. is only found in a routine x-ray.

• If a person with lung cancer does have symptoms, they will If a person with lung cancer does have symptoms, they will depend on the location of the tumour in their lung. depend on the location of the tumour in their lung.

• It is also imperative to note that the same symptoms can It is also imperative to note that the same symptoms can be caused by other conditions, so may not necessarily be caused by other conditions, so may not necessarily mean cancer.mean cancer.

• Therefore it is important to consult a doctor when Therefore it is important to consult a doctor when symptoms are present. symptoms are present. 

• Signs and symptoms also depend upon the location, size of Signs and symptoms also depend upon the location, size of the tumor, degree of obstruction and existence of the tumor, degree of obstruction and existence of metastasesmetastases

Signs and Symptoms of Lung Signs and Symptoms of Lung Cancer Cancer

There are two types of signs and There are two types of signs and symptoms of lung cancer:symptoms of lung cancer:

1) Localized – involving the lung.1) Localized – involving the lung.

2) Generalized – involves other areas 2) Generalized – involves other areas throughout the body if the cancer throughout the body if the cancer has spread.has spread.

Localized Signs and Localized Signs and Symptoms Symptoms CoughCoughBreathing Problems, SOB, stridorBreathing Problems, SOB, stridorChange in phlegmChange in phlegmLung infection, hemoptysisLung infection, hemoptysisHoarseness, HiccupsHoarseness, HiccupsWt lossWt lossChest Pain and tightnessChest Pain and tightnessPancoats SyndromePancoats SyndromeHorner’s SyndromeHorner’s SyndromePleural EffusionPleural EffusionSuperior Vena Cava SyndromeSuperior Vena Cava SyndromeFatigueFatigue

Generalized Signs and Generalized Signs and Symptoms Symptoms • Bone pain Bone pain

• Headaches, mental status changes or Headaches, mental status changes or neurologic findingsneurologic findings

• Abdominal pain, elevated liver function Abdominal pain, elevated liver function tests, enlarged liver, gastrointestinal tests, enlarged liver, gastrointestinal disturbances (anorexia, cachexia), disturbances (anorexia, cachexia), jaundice, hepatomegaly jaundice, hepatomegaly r/t liver r/t liver involvementinvolvement

• Weight lossWeight loss

Early/late Signs and Symptoms Early/late Signs and Symptoms Of Lung CancerOf Lung Cancer

Early Signs Late signs

Cough/chronic cough Bone pain, spinal cord compression

Dyspnea Chest pain/tightness

Hemoptysis Dysphagia

Chest/shoulder pain Head and neck edema

Recurring temperature Blurred vision, headaches

Recurring respiratory infections

Weakness, anorexia, weight-loss, cachexia

Pleural effusion

Liver metastasis/regional spread

Diagnostic TestsDiagnostic Tests

• CXRCXR

• CT ScansCT Scans

• MRIMRI

• Sputum cytologySputum cytology

• Fibreoptic bronchoscopyFibreoptic bronchoscopy

• Transthoracic fine needle aspirationTransthoracic fine needle aspiration

Laboratory TestsLaboratory Tests

Blood TestsBlood Tests *CBC-to check red/white blood cell & platelets*CBC-to check red/white blood cell & platelets

-to check bone marrow and organ -to check bone marrow and organ functionfunction

*Blood Chemistry Test-to assess how organs *Blood Chemistry Test-to assess how organs are functioning such as liver and kidneyare functioning such as liver and kidney

Biopsy-to determine if the tumor is cancer or Biopsy-to determine if the tumor is cancer or notnot

-to determine the type of cancer-to determine the type of cancer -to determine the grade of cancer -to determine the grade of cancer

(slow(slow or fast)or fast)

BiopsyBiopsy

EndoscopyEndoscopy

• BronchoscopyBronchoscopy• MediastinoscopyMediastinoscopy• VATS (video assisted thoracoscopic VATS (video assisted thoracoscopic

surgery)surgery)

BronchoscopyBronchoscopy

MediastinoscopyMediastinoscopy

VATS (video assisted VATS (video assisted thoracoscopic surgery)thoracoscopic surgery)

Nursing Management for post Nursing Management for post endoscopic proceduresendoscopic procedures

Bronchoscopy Mediastinoscopy VATS

Monitor V/S; NPO status maintained until return of gag reflex.

Fever up to 101F can be expected afterwards

Monitor VS; potential for bleeding, infection and dyspnea; NPO status until return of gag reflex

Monitor V/S; potential for bleeding, infection and dyspnea; NPO status until return of gag reflex

Post-op complications for Post-op complications for those with lung cancerthose with lung cancer• Airway obstruction, dyspnea, hypoxemia, respiratory failureAirway obstruction, dyspnea, hypoxemia, respiratory failure

• Anesthesia side effects (N/V)Anesthesia side effects (N/V)

• Bleeding (hypotension, cardiogenic shock)Bleeding (hypotension, cardiogenic shock)

• Cardiac dysthymias, CHF, fluid overloadCardiac dysthymias, CHF, fluid overload

• Fever, sepsisFever, sepsis

• PneumoniaPneumonia

• PneumothoraxPneumothorax

• Pulmonary embolusPulmonary embolus

• Wound dehiscenceWound dehiscence

• Prolonged hospitalizationProlonged hospitalization

• DeathDeath

Nursing pulmonary post-op Nursing pulmonary post-op considerations/interventionsconsiderations/interventions• Positioning in bed, Monitor V/SPositioning in bed, Monitor V/S

• Prevention of respiratory complicationsPrevention of respiratory complications– Early ambulation, DB&C, incentive spirometer, Early ambulation, DB&C, incentive spirometer,

managing dyspneamanaging dyspnea

Prevention of deep vein thrombosisPrevention of deep vein thrombosis– Early ambulationEarly ambulation

• Pain managementPain management

• Infection controlInfection control

Educating the patientEducating the patient

• Inform the patient what to expect, from administration of Inform the patient what to expect, from administration of anesthesia to thoracotomy and the likely use of chest tubes anesthesia to thoracotomy and the likely use of chest tubes and a drainage system postoperatively.and a drainage system postoperatively.

• Tell the patient about the administration of oxygen Tell the patient about the administration of oxygen postoperatively and the possible use of a ventilator.postoperatively and the possible use of a ventilator.

• Explain the importance of frequent turning to promote Explain the importance of frequent turning to promote drainage of lung secretions.drainage of lung secretions.

• Instruct the proper use of an incentive spirometry and how to Instruct the proper use of an incentive spirometry and how to perform diaphragmatic and pursed-lip breathing techniques.perform diaphragmatic and pursed-lip breathing techniques.

• Teach the patient to splint the incision site with hands, a Teach the patient to splint the incision site with hands, a pillow or a folded towel to avoid discomfortpillow or a folded towel to avoid discomfort

Cancer StagingCancer Staging

Clinical Staging Pathological

• based on findings gathered by the doctor

• used to plan the initial therapy

• may be modified by additional information found during pathological examination

• Based on the examination of the tissue samples obtained from the primary tumor, nodes or metastasis

• Helpful in planning additional treatment and follow-up

Cancer Staging SystemsCancer Staging Systems

• The most common staging system for The most common staging system for lung cancer is the TNM System lung cancer is the TNM System developed by the International Union developed by the International Union Against Cancer (UICC). Against Cancer (UICC).

• Guides best course of treatment Guides best course of treatment

• Estimates prognosisEstimates prognosis

• It is only useful in stagingIt is only useful in staging

NSCLC, when surgery is NSCLC, when surgery is

considered.considered.

TMN Staging system for Lung TMN Staging system for Lung CancerCancer

TT= Tumors : tumor size, = Tumors : tumor size, (local invasion) (local invasion)

NN= Node : node = Node : node involvement (size and involvement (size and type)type)

MM= Metastasis : general = Metastasis : general involvement in organs involvement in organs and tissuesand tissues

Lung Cancer Staging Lung Cancer Staging ContinuedContinued

• T: Tx, T0, Tis, T1-T4 T: Tx, T0, Tis, T1-T4 (T3-tumors greater (T3-tumors greater than 7cm, T4 is a than 7cm, T4 is a tumor of any size)tumor of any size)

• N: N0, N1, N2, N3N: N0, N1, N2, N3

• M: M0, M1a, M1bM: M0, M1a, M1b

Medical ManagementMedical Management

The three main cancer The three main cancer treatments are:treatments are:

*surgery (lung resections)*surgery (lung resections)

*radiation therapy*radiation therapy

*chemotherapy*chemotherapyOther types of treatment that Other types of treatment that

are used to treat certain cancers are used to treat certain cancers are hormonal therapy, biological are hormonal therapy, biological therapy or stem cell transplant.therapy or stem cell transplant.

Side effects of treatmentsSide effects of treatments

Surgery Radiation Chemotherapy

Pain fatigue Anemia, thrombocytopenia

Hemotomas Decreased nutritional intake

Fatigue

Hemmorhage Radiodermatitis Alopecia, SOB

Altered respiratory function

Decreased hematopoietic function

Cold, pale

Risk for atelectasis, pneumonia, hypoxia

Risk for Pneumonitis, esophagitis, cough

Tingling

Risk for DVT N/V Irritable

Grief Dizzy, weak

Lung resectionsLung resections

• LobectomyLobectomy: a single lobe of lung is removed: a single lobe of lung is removed

• BilobectomyBilobectomy: 2 lobes of the lung are removed (only on : 2 lobes of the lung are removed (only on R side)R side)

• Sleeve resectionSleeve resection: cancerous lobe is removed and : cancerous lobe is removed and segment of the main bronchus is resectedsegment of the main bronchus is resected

• PneumonectomyPneumonectomy: removal of entire lung: removal of entire lung

• SegmentectomySegmentectomy: a segment of the lung is removed: a segment of the lung is removed

• Wedge resectionWedge resection: removal of a small, pie-shaped area : removal of a small, pie-shaped area of the segmentof the segment

• Chest wall resection with removal of cancerous lung Chest wall resection with removal of cancerous lung tissuetissue: for cancers that have invaded the chest wall: for cancers that have invaded the chest wall

Complimentary TherapiesComplimentary Therapies

• Includes acupuncture and massage and pharmacological Includes acupuncture and massage and pharmacological approaches such as vitamins and herbal medicine.approaches such as vitamins and herbal medicine.

• One study showed that herbal medicine is used by One study showed that herbal medicine is used by approximately 48% of lung cancer patients in China.approximately 48% of lung cancer patients in China.

• These herbal therapies combined with chemotherapy These herbal therapies combined with chemotherapy increases survival in non-small-cell lung cancer by up to increases survival in non-small-cell lung cancer by up to 42%, compared with chemotherapy alone.42%, compared with chemotherapy alone.

Complimentary Therapies Complimentary Therapies cont’dcont’d

• Foods: Green tea, N-acetyl cysteine, Foods: Green tea, N-acetyl cysteine, Curcumin, Garlic, Fish Oil, Curcumin, Garlic, Fish Oil, Lactobacillus, ginseng rootLactobacillus, ginseng root

Complimentary Therapies Complimentary Therapies cont’dcont’d

• Mind-body: Mind-body: help to reduce anxiety, mood disturbance, or chronic pain in cancer patients (audiotapes, videotapes, books, music, relaxation, yoga, meditation).

• AcupunctureAcupuncture

• HypnosisHypnosis

• Massage therapyMassage therapy

Prognostic FactorsPrognostic Factors

The best estimate on how a patient will do based on:The best estimate on how a patient will do based on:

*type of cancer cells*type of cancer cells*grade of the cancer*grade of the cancer*size or location of the tumor*size or location of the tumor*stage of the cancer at the time of diagnosis*stage of the cancer at the time of diagnosis*age of the person*age of the person*gender*gender*results of blood or other tests*results of blood or other tests*a persons specific response to treatment*a persons specific response to treatment*overall health and physical condition*overall health and physical condition

Prevention: PrimaryPrevention: Primary

• Avoid the use of tobacco smoke• Personal and family hx are important risk factors• Know environmental carcinogens that increase

risk• Chemoprevention:– Consuming carotenoids, Vit A, retinoids Vit E, selenium, Vit

C, fat

Prevention: SecondaryPrevention: Secondary

• Aim is to early diagnose high risk Aim is to early diagnose high risk populations via screeningpopulations via screening

• CXR, MRI, CT scans, sputum cytologyCXR, MRI, CT scans, sputum cytology

Prevention: TertiaryPrevention: Tertiary

• Targeted at people who survived a Targeted at people who survived a cancer diseasecancer disease

• Assists them to retain an optimal Assists them to retain an optimal level of functioning regardless of level of functioning regardless of their potential debilitating diseasetheir potential debilitating disease

Nurse’s Role with clients with Nurse’s Role with clients with lung cancerlung cancer

• Coping with diagnosisCoping with diagnosis

• Pre/post treatment educationPre/post treatment education

• Education on managing breathlessnessEducation on managing breathlessness

• Referrals for ‘stop smoking advisor’Referrals for ‘stop smoking advisor’

• Referring to services such as hospice care, dietitian, Referring to services such as hospice care, dietitian, massage therapy, counselorsmassage therapy, counselors

• Advocate for appointments, scans etc.Advocate for appointments, scans etc.

• Educate client and family about disease process, Educate client and family about disease process, treatment options and S/Etreatment options and S/E

• Provide resources for support groups and where Provide resources for support groups and where information and be sought information and be sought

Nursing InterventionsNursing Interventions

• Management of N/V, weakness, fatigue, wt loss, appetite loss, Management of N/V, weakness, fatigue, wt loss, appetite loss, altered tastealtered taste

• Pain management, education to avoid concern about addiction, Pain management, education to avoid concern about addiction, pharmacological and non-pharmacologicalpharmacological and non-pharmacological

• Elevate HOBElevate HOB

• Splinting to aid in coughingSplinting to aid in coughing

• Teach breathing exercises to Teach breathing exercises to ↑ diaphragmatic excursion and ↓ ↑ diaphragmatic excursion and ↓ WOBWOB

• DB&CDB&C

• Provide a vaporizerProvide a vaporizer

• Relaxation techniques to ↓ anxiety r/t SOBRelaxation techniques to ↓ anxiety r/t SOB

• Encourage energy conservationEncourage energy conservation

• Encourage small amts of high-calorie and Pn foods freq.Encourage small amts of high-calorie and Pn foods freq.

Nursing DiagnosesNursing Diagnoses• Ineffective breathing pattern r/t loss of adequate ventilationIneffective breathing pattern r/t loss of adequate ventilation• Impaired gas exchange r/t excessive or thick secretions 2 to Impaired gas exchange r/t excessive or thick secretions 2 to

smoking; r/t decreased passage of gases between alveoli of smoking; r/t decreased passage of gases between alveoli of lungs and vascular systemlungs and vascular system

• Chronic pain related to Stage IV NSCLC diagnosis as Chronic pain related to Stage IV NSCLC diagnosis as evidenced by client reporting “pain in right chest and lower evidenced by client reporting “pain in right chest and lower ribs”.ribs”.

• Risk of infection related to altered immune system secondary Risk of infection related to altered immune system secondary to effects of cytotoxic drugs.to effects of cytotoxic drugs.

• Risk for disturbed self concept related to changes in lifestyle.Risk for disturbed self concept related to changes in lifestyle.• Nausea related to effects of chemotherapy as evidenced by Nausea related to effects of chemotherapy as evidenced by client reporting feeling nauseated.client reporting feeling nauseated.• Risk for deficient fluid volume related to gastrointestinal fluid Risk for deficient fluid volume related to gastrointestinal fluid

loss secondary to vomiting.loss secondary to vomiting.• Fatigue related to chemotherapy secondary to stage IV Fatigue related to chemotherapy secondary to stage IV

NSCLC as evidenced by client reporting he “ no longer has NSCLC as evidenced by client reporting he “ no longer has the energy to play with his grandchildren or visit his friends”.the energy to play with his grandchildren or visit his friends”.

Case Study & QUESTIONS Case Study & QUESTIONS John is a 44 year old man from NFLD. He worked in a machine shop John is a 44 year old man from NFLD. He worked in a machine shop

since he was 18. He was laid off for 6 months, has a new girlfriend since he was 18. He was laid off for 6 months, has a new girlfriend and custody of 3 kids from a previous marriage. They live in a low and custody of 3 kids from a previous marriage. They live in a low SES neighborhood and is stressed about not having work to support SES neighborhood and is stressed about not having work to support his family. He can’t afford to move out west and doesn’t want to his family. He can’t afford to move out west and doesn’t want to leave his children. Both of his parents have passed away. (Mum leave his children. Both of his parents have passed away. (Mum from lung cancer and father from prostate cancer). Smoking helps from lung cancer and father from prostate cancer). Smoking helps to manage his stress. He has smoked about a pack a day since he to manage his stress. He has smoked about a pack a day since he was 16. Growing up, both of Johnathan’s parents smoked as well as was 16. Growing up, both of Johnathan’s parents smoked as well as most of his aunts and uncles. His girlfriend is always complaining at most of his aunts and uncles. His girlfriend is always complaining at him because he is coughing and is sick all of the time. He says its him because he is coughing and is sick all of the time. He says its “just from the smokes”. Johnathan also noticed that he is becoming “just from the smokes”. Johnathan also noticed that he is becoming short of breath and can’t play with his kids like he used too. The short of breath and can’t play with his kids like he used too. The past 4 months he has coughed up blood in the sink but attributes past 4 months he has coughed up blood in the sink but attributes that to getting older and coughing “too hard”. that to getting older and coughing “too hard”.

ReferencesReferences

• Carpenito-Moyet, L.J. (2009). Carpenito-Moyet, L.J. (2009). Nursing Diagnosis; Application to clinical Nursing Diagnosis; Application to clinical practice practice (13(13thth ed.). Philadelphia, P.A.: Lippincott Williams & Wilkins ed.). Philadelphia, P.A.: Lippincott Williams & Wilkins

• Cassileth, B., Deng, G., Gomez, J., Johnstone, P., Kumar, N., Vickers, Cassileth, B., Deng, G., Gomez, J., Johnstone, P., Kumar, N., Vickers, A.A.

• Day, R.A., Paul, P., Williams, B. Smeltzer, S.C., Bare, B. (2010). Day, R.A., Paul, P., Williams, B. Smeltzer, S.C., Bare, B. (2010). Brunner & Suddarth’s Textbook of Canadian Medical-Surgical NursingBrunner & Suddarth’s Textbook of Canadian Medical-Surgical Nursing (2(2ndnd ed.). Philadelphia, P.A.: Lippincott ed.). Philadelphia, P.A.: Lippincott Williams & Wilkins.Williams & Wilkins.

• Otto, S. (2001). Otto, S. (2001). Oncology NursingOncology Nursing (4 (4thth ed.). St. Louis, Missouri: Mosby ed.). St. Louis, Missouri: Mosby Inc.Inc.

• http://nursingcrib.com/nursing-notes-reviewer/lung-cancer/http://nursingcrib.com/nursing-notes-reviewer/lung-cancer/

• http://news.bbc.co.uk/2/hi/health/7130216.stm

• http://news.bbc.co.uk/2/hi/health/7130216.stmhttp://news.bbc.co.uk/2/hi/health/7130216.stm

• www.cancer.cawww.cancer.ca