Lung Cancer
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Outline
Overview
- Two Types
- Small Cell (Oat Cell)
- Non-Small Cell (NSCLC)
- Multiple Treatment Modalities
- Radiation
- Surgery
- Chemotherapy
- Symptom Management
- Survivorship
Nursing Points
General
- NSCLC
- Vast majority of Lung Cancers
- Staging of disease drives treatment options
- Small Cell/Oat Cell
- Aggressive growth
- Spreads early on
- Incurable at late-stage
- Symptom management/palliative care a priority
- Smoking Cessation
- Largest modifiable risk factor
- Quitting exponentially decreases risk of lung cancer
- Screening
- High Risk: Spiral CT
- Low Risk: No routine screening
- Treatment
- Radiation
- Local, focused treatment
- As frequently as 5x/week
- Chemotherapy
- Systemic treatment
- Indicated in metastatic disease
- Side Effects
- Dependent on treatment regimen
- Regimens change frequently
- NCCN guidelines are excellent resource
- Surgery
- Wedge
- Partial lobe removed
- Smaller tumor burden
- Lobectomy
- Total lobe removed
- Moderate tumor burden
- Pneumonectomy
- Removal of total lung
- Largest tumor burden
- Immediate Rehabilitation
- Early ambulation
- Cough and deep breathing
- Treated similarly to an open heart patient
- Multiple chest tubes
- Splinting with cough
- Cardiac monitoring
- Wedge
- Depending on stage of disease, any treatment may be palliative or curative
- Patient education key
- Conversation between MD and patient
- Radiation
- Causes
- Tobacco use
- Second hand smoke exposure
- Asbestos exposure
- Genetics
Assessment
- Initial presentation can be non-specific
- Symptoms
- Shortness of breath
- Productive Cough
- Bloody or pink-tinged sputum
- Activity intolerance
- Anxiety
- Rule out other cardiac/respiratory issues
- Chest x-ray
- Chest CT if concerning for cancer
- Lab work
- Symptoms
- Functional capacity
- Ability to perform ADLs
- Appetite
- Activity tolerance
- All predictors of how patient will tolerate treatments
- Smoking cessation
- Obtain honest history from patient
- More pack years = higher risk
- The sooner they stop, the lower the risk of cancer they will see
- Ongoing treatment
- Monitor for chemotherapy drug-specific symptoms
- Cardiac & respiratory toxicities
- Decreased appetite
- Weight loss
- Monitor respiratory status
- Decline common
- Patient may need supplemental oxygen
- Serious cases of activity intolerance may require home health or other assistance to complete ADLs
- Advanced Care Planning
- Discussion and decision point between patient and provider regarding patient’s end of life wishes
- Can be prompted by RN to MD
- Risk vs. benefit analysis
- Symptom management
- Air hunger / shortness of breath
- Pain
- Nausea / vomiting
- Chemotherapy side effects
- Monitor for chemotherapy drug-specific symptoms
Therapeutic Management
- Driven by type of lung cancer – often multimodal
- NSCLC: Stage I & II – Surgical, Medical
- NSCLC: Stage III & IV – Medical, Palliative (which may include palliative surgery)
- Oat Cell / Small Cell: Medical & Palliative
- Not all interventions are curative
- Chemotherapy
- Determined by:
- Disease progression
- Patient presentation
- ADLs
- Chronic conditions
- Nutrition status
- Genetic mutations
- NCCN guidelines
- Length of chemotherapy plan driven by patient tolerance and disease response to treatment
- Determined by:
- Radiation
- Target therapy
- 5 days/week
- Monitor for signs of skin irritation or infection
- Ensure patient has transportation to appointments
Nursing Concepts
- Coping
- Any cancer diagnosis will affect patient’s ability to cope
- Has profound impact on family/support system
- Health promotion
- Smoking is a modifiable risk factor
- Oxygenation
- Impacted by disease process
- Can impair patient comfort
Patient Education
- Smoking cessation
- Imperative at time of diagnosis
- Life threatening if on home oxygen
- Chemotherapy precautions
- Protect family members from body fluids
- Avoid sick individuals
- Palliative medicine
- Different from hospice care
- Goal-directed quality of life and symptom management driven care
- Contact oncologist
- If admitted to hospital for any reason
- If primary care provider suggests any medication changes
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ADPIE Related Lessons
Related Nursing Process (ADPIE) Lessons for Lung Cancer
Transcript
Hey there, it’s Meg again. Today we are going to talk all about lung cancer. Now oncology nursing is my true area of passion and of expertise. So I want to make sure that I tell you all of the most important things that you need to know about taking care of these patients. So what is lung cancer? I think we all probably have a general idea, but you do need to know that there are two main types of lung cancer. We have small cell and we have what we call non small cell lung cancer. Now combined patients with either type of lung cancer are four times more likely to die than from any other cancer. So lung cancer is so important and we have a modifiable risk factor for lung cancer, which is smoking cessation. It is never too late to stop smoking. I’m going to stress that throughout this entire lesson.
Next, we have treatment modalities. So when we talk about lung cancer, it is one of the ones that we can have surgery, we can have chemo, we can have radiation. And so depending on the type of lung cancer, the location, and what our patient looks like, they could go under all three or only one. And then finally, survivorship. A patient is a cancer survivor at the time of diagnosis. It is never too late for them to change risk factors. It’s never too late to empower a patient and it is never too early to start managing their symptoms.
So lung cancer is the leading cause of death related to cancer in the United States. But unlike some other cancers, our primary risk factor is actually modifiable. That means we can empower our patients to stop smoking and know that it will make a big difference in either preventing lung cancer from the start or in impacting their outlook for the rest of their lives. So it is so important. Let’s talk more about risk factors and prevention now. So by now we all know that smoking causes lung cancer, but it is never ever, ever too late for a patient to stop smoking. The interesting thing about lung cancer is that only in the last 10 years did we actually begin screening for it. We never really had a tool that risk benefit, um, was effective enough to be worth exposing the patient to radiation. But now we have what we call a spiral CT scan.
So this is a low dose radiation, um, CT scan and this has decreased the death rate in our high risk patients by almost 20%. So we are going to do a spiral CT in anyone that has a 30 pack year history. Now this, because it’s only come about in the last decade, not a lot of patients are aware of this. So it is so important that we’re getting an actual accurate history from our patients and how much and how long they’ve smoked because it can make them a candidate for this and we might be able to catch it early. And then of course we know that secondhand smoke is also a risk factor. We know that genetics is a risk factor as it is with any cancer. And then also some environmental exposures, um, such as if a patient lives in a city that’s heavily polluted or they’ve been exposed to as best as those sort of things. But in general when we’re talking about preventing lung cancer, smoking is our key preventative tool.
So let’s talk a little bit more about the way that a patient with lung cancer is going to look. Now from the top, I’m going to tell you that all of these are pretty nonspecific symptoms. Uh, the other thing is that when we’re talking about a patient who smokes, those patients are probably going to have shortness of breath. They’re probably going to have a productive cough and they might also be anxious because smoking deprives your body of oxygen. So when we’re talking about these symptoms in a patient, we have concern for lung cancer. We’re talking about things that are worse than usual or that have recently changed when we talk about shortness of breath. Um, is it preventing ATLs or is it just worse than usual? Do they have a productive cough? Well, what does the cost look like? Is it blood tinge? Is it black?
Is it different than the way that it normally looks? And then finally, anxiety. As a nurse, we can never ever, ever, ever, ever, ever discount the way that our patients feel. And so if the patient is feeling anxious or they’re feeling like something is wrong with their body, that is something we need to take seriously 100% of the time. Okay. So let’s talk a little bit more about the two main types of lung cancer. So we have small cell, which is also called outsell. And that is only about 15% of our patients that get lung cancer. The thing to know about small cell cancer is that it spreads fast. And because of that, it is nonsurgical. When we’re talking about surgical intervention, we are looking to go in, remove the cancer, and then maybe do chemo or radiation to just make sure we kill all of the cancer cells.
So it’s a targeted therapy. The problem with small cell cancer is that it spread so fast that if we went in to take out the main tumor of small cell lung cancer, it has already spread everywhere else to the point that the surgery is no longer beneficial to the patient. So a patient with small cell, they’re probably gonna get chemo and they’re probably gonna get radiation. Um, and then palliative care. We also want this to be a discussion with these patients. So we need to know what are the patient’s goals, what are their expectations, and most importantly, what are their symptoms, how are they feeling? And then the other piece of palliative care, it’s important to remember in cancer patients is that sometimes this chemo and radiation is actually palliative. So often with small cell we are not going for a cure. We are going to palliate those patient’s symptoms and to optimize their quality of life.
Then we have non small cell. So this is the vast majority of our patients with lung cancer say 85%. So the treatment for this is going to be completely dependent on phase. So these patients could get surgery, chemo, radiation, all three to one completely dependent on the patient, what the patient looks like, where the tumor is, those sorts of things. The thing to remember about non-small-cell though is if we are in a later phase, so we’re talking stage four non small cell lung cancer, these treatments can all still be palliative. Um, so really any treatment for any cancer patient can be palliative. Uh, the important thing to remember about palliative care is it is driven by patient, um, expectations, uh, and patient choice. So we always need to be encouraging our patients to be their own advocates and advocating for them when they’re not sure what the next step is.
So let’s talk a little bit about surgical approaches. Any surgery that goes on in a patient’s thoracic cavity is a big deal. And so we really want to remove as little of the patient’s lung as we possibly can because we want to maximize their remaining long volume. When we talk about a wedge procedure, we are talking about a part of a lobe. When we say a lobectomy, it’s the entire lobe. And then in a pneumonectomy it’s the entire lung. So whenever we can, we want to be doing this wedge procedure because that allows the patient to have some remaining lung capacity left. So if we’re talking about a wedge, a lot of times we can actually do this laparoscopically. Um, and it is what it sounds like. We’re going to go in with a wedge, there’s probably gonna be a camera. And like I said, it’s often a laparoscopic surgery.
Now pretty much all of these patients are gonna end up getting chest tubes and you can take that to the bank. So even though it’s a quote unquote small long surgery, it’s still a very big deal. Then we have lobectomy. So maybe we’re just gonna re remove, um, the bottom lobe from our patient’s lung. That’s a lobectomy. And then sometimes the patient requires a pneumonectomy. This is a huge surgery. We are cutting the patient’s lung capacity by 50%. And so we’re doing that for a good reason. A lot of times that means that either the tumor has taken up so much of the lung, um, that it’s not possible to just remove one lobe and have that do the trick. But then a lot of times it also involves blood vessels. So that’s another big reason that we would have to take out the entire lung.
But as you can imagine, if we’re only leaving patient with one lung, the postoperative nursing care just becomes that much more important. So when we’re talking about postoperative care for a patient, like I said, we’re probably going to have chest tubes. Early. Ambulation is key. All of the thoracic surgeons I have worked with expect that our patients will be out of the bed into the chair like two hours after they get to their room after surgery. So days zero ambulation is so important. We also want to cough and deep breathe and then we are above all, we are preventing pneumonia because this can kill patients after any sort of thoracic or long procedure or any, any procedure for that matter. We are maximizing lung capacity, which means preventing pneumonia. All right, so now let’s talk more about chemotherapy and radiation. Now that we’ve talked about surgery, uh, there’s an entire course or an entire lesson, excuse me, focused only on chemotherapy.
So we’re just going to breeze over this really quickly. Chemotherapy is a systemic treatment. It glow, it goes into your bloodstream. So it is touching every cell in your patient’s body except maybe the Bryan if it doesn’t cross the blood brain barrier, brain barrier. Um, so our patients need to have a, some sort of functional capacity to be a candidate for this because it affects the entire body. So when we talk about functional capacity, they need to be able to complete ADLs. They need to have a good nutrition status, that sort of thing. And then because it’s a systemic treatment, the side effects are systemic as well. And that is why a patients undergoing chemotherapy often feel so crummy is because the chemotherapy is affecting their entire body. Okay. And then we have radiation, which is the opposite of chemotherapy. And then it is a localized or targeted, excuse my handwriting, a targeted treatment.
The thing to know about radiation is it is often five times a week. So it’s sort of like a full time or a part time job for these patients. And they can do this for upwards of a month. The thing to remember is if we have a patient with a lower socioeconomic status or living in an urban environment, making sure that patient has transportation that is timely and reliable is so important because we want to make sure that our patient is actually getting to their treatments five times a week. It’s a big commitment. And then skin rashes, this is probably the worst side effect that affects all radiation treatments regardless of where it is, these skin rashes can be, they can limit the treatment. If a rash gets bad enough, I’ve actually seen them pause radiation treatment until it improves. And these radiation oncology nurses are absolute experts in managing these rashes and they take such wonderful care of these patients.
All right. Then we have ongoing treatment. So after a patient has their chemo, their radiation or surgery, um, these can have lifelong toxicities, um, especially cardiac and respiratory. And then with any patient with lung cancer, we’re also wanting to manage their respiratory status. So are they able to do their ADLs? Do they maybe need home OT too? All things that we need to consider. And then we have advanced care planning. This is, we want to be prompting this as early as we possibly can. We want to know what does quality of life look like for our patient? What other expectations are we all on the same page? Important questions to ask and then symptom management. This is so important and this is really, this is for any oncology patient. We’re always wanting to do risk benefit when we’re talking about advanced care planning, but we always want to be asking our patients the right questions to make sure that we are meeting their needs and that there’s not some nursing intervention we can do to make them feel better.
Okay, so we have our nursing concepts for a patient with lung cancer. First coping, any cancer diagnosis is difficult for a patient and their family to handle. So when we’re talking about coping that only do we want the patient coping. We want the family coping too because nine times out of 10 if the family isn’t coping, the patients noticing that and it’s just making it harder on them. Then we have health promotion because our biggest risk factor for lung cancer is modifiable. It is never, ever, ever, ever, ever too late for a patient to stop smoking. And then finally oxygenation. This is severely impacted not only by the disease process, but often by the way that we treat lung cancer. We are altering the patient’s oxygenation. So we need to make sure that we’re managing that and assessing it effectively.
Okay. Our key points, number one, smoking cessation. It is never too late to stop smoking. And then we have treatment approaches. So depending on the type of lung cancer, small cell or non small cell, the patient might be getting surgery, chemotherapy, radiation, or a mixture of the three symptom management essential in any oncology patient, especially when we’re talking about respiratory status, managing air hunger and making sure our patients aren’t too short of breath. And then finally we have advanced care planning. What are our patient’s goals of care? Do they have the same expectations that the treatment team has? These are important conversations to have at every encounter with a patient.
Okay, so that’s all for our lesson on lung cancer. I know it’s a lot, but like I said, oncology. Nursing is my passion and I want to share all of it with you that I can. So remember, it is never too late to stop smoking, but it’s better if you never start now, go out, be your best selves today. And as always, happy nursing.
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