Page 21 Complete Your CE Test Online - Click Here ● ● Reconstructive surgery: Surgery is used to help restore the patient’s appearance or function after cancer surgery. It is important that the patient understand the goal of surgery beforehand, and have an idea of postoperative expectations and management. People who still smoke should be offered ways to quit before surgery. Even though many people want to believe that there is no need to quit smoking after they are diagnosed with cancer, it is well documented that wound healing after surgery is slowed in smokers. Studies have shown that continued smokers also have a higher risk of cancer recurrence [194]. Surgical techniques to manage solid tumors are continuously evolving as new procedures are added. Robotic or robot-assisted surgery is common now, in which laparoscopic surgery is performed using robotic arms to control the instruments [5]. Some cancer surgeries have become less invasive as surgeons use laparoscopic surgery and endoscopy to remove cancerous lesions; some are even conducted on an outpatient basis. However, it is important to know that studies have not validated the equivalence of laparoscopic surgery in every instance, and that the surgeon’s experience with that particular type of surgery will affect outcomes. Initial cancer surgery for cancer in which multiple organs can be affected, like ovarian cancer, for example, often has two goals: to debulk the cancer, and to stage it. This calls for a surgeon with experience in oncologic debulking, who has expertise in finding and delicately removing abnormal tissue from multiple organs [36]. Open surgeries are typically required for debulking situations. There are also laser surgeries, cryosurgeries, electrosurgeries such as radiofrequency ablation, and other techniques. These procedures do not use a scalpel, but they use other types of energy (lasers, cold, or electricity) to cut or destroy tumor tissue [5]. Nursing management: After cancer surgery, as with other types of surgery, pain management, safety, and infection control are the first priorities. There is also the need to teach the patient about wound care, activities of daily living during recovery, and any specific procedures that will be needed after discharge (e.g. drain maintenance). There may also be body image issues, especially concerning for head and neck cancer, breast cancer, and any cancer surgery in which the results are publicly visible. Patients with mastectomy often need special instruction and exercise for range of motion in the affected upper extremity. Lymphedema is a possibility, especially if a full lymph node dissection was done. For many types of cancer surgery, the patient will want to know if the procedure “got it all,” and this may require a discussion between the patient and the surgeon. Sometimes the patient will need support and educational reinforcement in coping with the operative findings. Often, the outcome of the surgery will include more complete information on the stage of the cancer, although there may still be some delay for the biopsy (pathology) report, which is needed for the final stage grouping (see also “Cancer Staging”). The final staging information often shapes the plan for further treatment as well as prognosis. Depending on the outcome, this can be overwhelming to the patient as s/he may be looking forward to an uneventful recovery or preparing for a long chemotherapy or radiation treatment, or starting hospice care. Radiation therapy Radiation, in high doses, kills or slows the growth of cancer cells, but also causes damage to normal cells. Radiation therapy is used with the following goals: ● ● Curative intent. ● ● Slow or stop the growth of cancer cells, to shrink a tumor before or during other types of cancer treatment. ● ● To kill remaining cancer cells after surgery or other treatment, to prevent recurrence. ● ● Palliative care (shrink tumors to treat pain, pressure, gut blockage or other symptoms). Radiation therapy does not kill cancer cells right away. It takes days or weeks of treatment before cancer cells begin dying and cancer cells keep dying for weeks or months after radiation therapy ends [188]. Nursing consideration: Helping patients understand the intent and goals of their radiation, chemotherapy, or surgical treatments can help them make better decisions about their preferences. This becomes critically important in advanced or refractory cancer and near the end of life. External beam radiation therapy External beam radiation therapy typically comes from a linear accelerator machine (also called a linac) that aims beams of ionizing radiation toward the cancer from different angles and locations on the body. Radiation is a local treatment but it affects skin and other organs and tissues in its path and can cause some systemic side effects [188]. Intraoperative radiation is an option for some; it is one large dose given during surgery so that radiation does not have to pass through skin [188]. External beam radiation therapy begins by the patient meeting with the radiation oncologist for the treatment planning process. Planning begins with imaging of the tumor area and its surrounding tissue. CT scanning, MRI, PET, or ultrasounds may be used for this. This first meeting involves a simulation of the radiation treatment, during which time, body molds, face masks, and other devices are constructed to help hold the patient still and in the proper position during treatments. The radiation oncologist calculates the total radiation dose that will be delivered to the tumor and how much will be allowed to hit normal tissues around it as well as the paths that will be used. Temporary skin marks or tattoos may be used mark radiation ports (i.e. entry points on the skin with which beam radiation is aligned) throughout the course of treatment [188]. It is important to offer patients who smoke help in quitting before radiation treatments begin. In a study of patients with advanced head and neck cancer who underwent radiation therapy, patients who continued to smoke during radiation therapy suffered mucositis for a longer time (23.4 weeks) than patients who quit at the time of radiation therapy (13.6 weeks) or patients who did not smoke for at least a month after treatment (18.3 weeks) [252]. People who continue smoking heal more slowly and are more likely to have additional cancer(s) in the future [194]. Most people have external beam radiation therapy with the same dose of radiation once a day, five days a week, on an outpatient basis. Treatment lasts up to six weeks, depending on the type of cancer and the treatment goal [188]. Sometimes, the radiation dose or schedule is changed to reach the total dose of radiation more quickly. This can be done in one of these ways [188]: ● ● Accelerated fractionation, which gives the half of the usual daily dose of radiation twice each day. ● ● Hyperfractionation, which is a smaller than usual daily dose of radiation given twice each day. ● ● Hypofractionation, which is a larger than usual daily dose of radiation given once a day for up to three weeks. Teach patients to avoid removal of radiation markings until after treatment, or let them know if the mark is tattooed and permanent. Patients will need to cover irradiated skin to protect from sunlight for at least a year after treatment. If the site cannot be covered and sun exposure is unavoidable, they can try a gentle, fragrance-free broad- spectrum sunscreen of 30 SPF or higher. Teach the patient to clean irritated skin very gently with mild soaps, avoid shaving if possible, and to use an electric razor if they must, and to protect the site from rubbing, pressure or irritation by wearing loose, soft fabrics next to the skin. Avoid alcohol-containing liquids, aftershave lotions, powders, depilatories, deodorants, tape, and extreme heat or cold to the area [57]. If skin becomes dry, most treatment centers recommend twice-daily use of moisturizing creams without fragrances, such as Aquaphor, Cetaphil, Eucerin, Vanicream, and Cerave, which are available over the counter at drugstores [129,222]. Radiation therapy can cause acute and chronic side effects, a lot of which depend on the body part being irradiated and the radiation dose. Common acute side effects of radiation, regardless of site, are fatigue and nausea. Depending on the site, the patient may also have: ● ● Erythematous or pruritic, tender, dry, or weeping skin at the radiation port. ● ● Alopecia at the treatment site, which can become permanent.