Page 17 Complete Your CE Test Online - Click Here Regional lymph nodes (N) ● ● NX: Cancer in nearby lymph nodes cannot be measured. ● ● N0: There is no cancer in nearby lymph nodes. ● ● N1, N2, N3: Refers to the number and location of lymph nodes that contain cancer. Distant metastasis (M) ● ● MX: Metastasis cannot be measured. ● ● M0: Cancer has not metastasized to other parts of the body. ● ● M1: Cancer has metastasized to other parts of the body. Stage grouping The TNM system describes the cancer in great detail. But the TNM information can also be grouped into five less-detailed stages, called stage groupings. Table 4 summarizes the TNM information in a specific way that alludes to prognosis and treatment. Table 4. The TNM system description of cancer Stage Summary Stage 0 Abnormal cells are present but have not spread to nearby tissue. It is not cancer but might develop into cancer. Also called carcinoma in situ, or CIS. Stage I, II, or III Cancer is present. The higher the number, the larger the cancer tumor and the more it has spread into nearby tissues. Stage IV The cancer has metastasized to distant parts of the body. Another staging system that is used for many types of cancer groups the cancer into one of five main categories. This staging system is more often used by cancer registries than by oncologists. It is an alternate way to describe stages and may also be used informally: 1. In situ: Abnormal cells are present but have not spread to nearby tissue. 2. Localized: Cancer is limited to where it started, no signs of metastasis. 3. Regional: Cancer has metastasized to nearby lymph nodes, tissues, or organs. 4. Distant: Cancer has metastasized to distant parts of the body. 5. Unknown: Insufficient information to determine stage. Cancer Treatment: Pretreatment Assessment Health history, current illnesses, and future plans Health and family history Before starting any cancer treatment, a full health history and summary of current medical conditions are required. These are important to review even though the patient may have completed questionnaires and forms. Nurses report often that the patient does not always understand the terminology and gives different answers when the questions are asked in everyday language. This is a good time to ask if patients have had recent vaccines, surgery, dental problems, or other health issues. Follow up on details about any family history of cancer, especially in first-degree relatives (parent, sibling, child). It is especially important to know if the person has ever had cancer before and, if so, when and what type it was and how it was treated at that time, or if the person has had radiation therapy. This may require getting release of information forms signed because most patients cannot provide enough detail. A cancer history can affect treatment choices because radiation and medications with cumulative dose toxicity might not be available for use because of concerns about effects on certain organs from past drug or radiation treatment. Comorbid conditions can also affect cancer treatment choices and drug doses. Given that many people with cancer are older, there is greater likelihood of comorbidities. Problems like cardiac arrhythmias, prolonged QT interval, congestive heart failure, lung disease, hypertension, diabetes, kidney disease, HIV, hepatitis B or C, and frequent heartburn or reflux can affect treatment. Drug allergies and intolerances can indicate possible issues with future cancer treatments. Medications and drug use This assessment must also include daily meds plus a listing of p.r.n. medications, herbs, supplements, and recreational drugs the patient takes must be elicited. Drinking habits and smoking are important too, as these can sometimes affect drug metabolism. Continuing to smoke can slow healing and increase certain toxicities of cancer treatment. If the patient smokes, this is a good time to assess the person’s readiness to quit. Nursing consideration: To improve success and reduce side effects of cancer treatment, encourage patients to quit smoking before cancer treatment begins. Smoking cessations works best when the patient has emotional support with the mental part and pharmaceutical assistance to reduce withdrawal symptoms. It is essential that the professional nurse take such histories in a private location and in a nonjudgmental fashion, especially when moving into a discussion of amounts of alcohol used each week and use of illegal or nonprescribed drugs. This full drug/substance listing can be used, along with the treatment plan, in a drug interaction evaluation. Pregnancy and childbearing plans It is important to ask about possible pregnancy and pregnancy risk in premenopausal women because cancer treatment can cause birth defects, fetal wasting, and other harmful effects in the embryo. Men and premenopausal women should also be asked about any plans or thoughts about having children in the future. Patients will need to know that cancer treatment can sometimes cause infertility, and options become much more limited after treatment is started. Knowledge For informed consent purposes, this is a good time to check the patient’s understanding of her diagnosis, prognosis, and plan of care, and to correct any misconceptions. By this time, there will be a treatment plan of some sort though it may be subject to changes. Most patients have had a chance to come up with concerns and questions (see also “Informed consent” and “Resources for Patients”). Teaching Tell the patient that he should let the nurse and the doctor know about any changes he makes in the drugs or supplements he is taking. This necessitates the updating of the drug list and repetition of the drug interaction evaluation as well as any time before medication regimens are changed or when side effect management medications are to be added. It is helpful to explain to the patient that there are many drugs, including over-the-counter medicines and supplements, that interact with each other in the body in very predictable ways. Some drugs interact with grapefruit and starfruit or with herbs like St. John’s wort. Some of these interactions can be enough to cause problems with cancer drug treatments, such as subtherapeutic drug levels or unexpected toxicities because of the high levels of drug in the body. It is a good time to ask the patient about supplements and herbs, and let her know that grapefruit can cause problems with a lot of medicines. There are other kinds of interactions, including physical ones that patients may need to understand, for example, that a calcium supplement or calcium-based antacid cannot be taken within a certain number of hours of a drug dose because the calcium in the stomach prevents the drug’s absorption. The action of some drugs causes problems with other drugs; for instance, some drugs requiring an acidic environment in the stomach, such as erlotinib, will not dissolve or absorb well when a person is taking stomach acid inhibitors, like proton pump inhibitors, which raise the pH of the stomach for many hours. Interactions with foods are generally much better known because food in the stomach can help some drugs absorb but keep others from being absorbed.