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Course: Oncology Nursing

Topic: Cancer Treatment Planning

The Nurses International Community

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NI Privacy Policy and Terms of Use.

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Module Goals

Learners will be able to:

Describe how classification of tumors influence treatment planning.
Describe the individual related factors that influence cancer treatment planning.
Discuss the influence and use of cancer clinical trials in cancer treatment planning.
Identify the principles for facilitating decision making by people affected by cancer.
Define evidence-based guidelines.
Identify evidence-based guidelines for cancer treatment planning.

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Cancer Grading and Staging

Disease Staging:

Following a cancer diagnosis, the person undergoes a series of investigations to determine the characteristics of the tumor tissue and the extent of spread of disease in the body.

This is commenced before treatment begins

Edcan Cancer Australia, 2016

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Classification and Treatment Planning in Cancer

Three factors that are essential for planning cancer treatment are:

The site of origin of the cancer:

Example: breast, prostate, colon.

The histologic/biologic characteristics:

The microscopic examination of tumor tissue.
Cellular genetic changes and the degree of mitotic activity within a tumor tissue specimen are some of the properties examined in the laboratory.

The anatomical extent of the cancer:

The anatomical extent for cancer is the TNM Classification.

UICC, 2021

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Exams and Tests to Stage Cancer

American Cancer Society, 2020

Different types of exam and tests to stage cancer include:

Physical exams
Imaging tests (x-rays, CT scans)
Endoscopy exams
Biopsies
Blood tests

The clinical stage is often a key part of deciding the best treatment options

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Exams and Tests to Stage Cancer

American Cancer Society, 2020

Physical Exams:

Feel the area of body for lumps that may indicate cancer
Look for abnormalities in skin colors or enlargement of an organs that may indicate cancer

Blood Tests:

In people with leukemia, complete blood count may reveal an unusual number or type of white blood cells

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Exams and Tests to Stage Cancer

Imaging tests:

X-rays, CT scans, MRIs, ultrasound, and PET scans also give information about how much and where cancer is in the body

Endoscopy Exams:

An endoscope, which is a thin, lighted tube is put inside the body to look for cancer

Biopsy:

Often needed to confirm cancer diagnosis
Removes pieces of a tumor to be looked at in the lab.
Some are done during surgery or may also be done using a thin, hollow needle or through an endoscope

American Cancer Society, 2020

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Classification and Treatment Planning in Cancer

UICC,2021

TNM classification:

Major determinant of cancer treatment and planning

T: describes the primary tumor site
N: describes the regional lymph node involvement
M: describes the presence or otherwise of distant metastatic spread

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Classification and Treatment Planning in Cancer

The primary tumor (T category)

The T category can be assigned a letter or a number:

TX means it can’t be measured
T0 means no evidence of a primary tumor
Tis means cancer cells are only growing in the layer of cells where they started, without growing into deeper layers (also called in situ cancer or pre-cancer)
T1, T2, T3, or T4: describe the tumor size and or amount of spread into nearby structures

The higher the T number, the larger the tumor

American Cancer Society, 2020

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Classification and Treatment Planning in Cancer

The lymph nodes (N category):

NX: means there’s no information about the nearby lymph nodes, or they can’t be assessed.
N0: means nearby lymph nodes do not contain cancer
N1, N2, or N3: describe the size, location, and/or the number of nearby lymph nodes affected by cancer.
The higher the N number, the greater the cancer spread to nearby lymph nodes

American Cancer Society, 2020

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Classification and Treatment Planning in Cancer

Metastasis (M category)

M0: no distant cancer spread has been found
M1: cancer has been found to have spread to distant organs or tissues

Example for Treatment Planning:

Treatment for an early-stage cancer may be surgery or radiation
A more advanced-stage cancer may need treatments such as chemotherapy, targeted drug therapy, or immunotherapy

American Cancer Society, 2020

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Case Study/Critical Thinking Question/What would the nurse do?

Miss Sharma has a painless lump in the abdominal region, abdominal pain and weight loss. When she got admitted to a hospital, she was diagnosed with Sarcoma. What would be the three things that Oncologists would consider before starting the treatment?

Answer:

__________
__________
__________

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Principles of Treatment Planning in Cancer

The aim of treatment for cancer may be:

Cure
Control and prolongation of life
Palliation of symptoms

Factors taken into account when determining a treatment plan are:

Tumor factors
Treatment factors
Individual factors

EdCan Cancer Australia, 2016

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Principles Treatment Planning in Cancer

EdCan Cancer Australia, 2016

Tumor factors:

Tumor size
Anatomic location
Histology
Sensitivity to antineoplastic agents or radiation
Natural history and related survival statistics are also considered
Prognostic and risk factors identified in staging can determine the need for standard approaches

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Principles Treatment Planning in Cancer

EdCan Cancer Australia, 2016

Treatment factors:

Treatment decisions may vary in complexity depending on disease types
Evidence of treatment effectiveness
Affordability of a client

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Principles Treatment Planning in Cancer

EdCan Cancer Australia, 2016

Individual factors:

Choice of therapy can be influenced by a person's:

General health
Age
Performance status
Preferences, values, and beliefs

Important in ensuring a health care approach which is sensitive to the needs and expectations of the person affected by cancer

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Principles Treatment Planning in Cancer

Older People with Cancer:

Physiological changes that occur with ageing, as well as multiple comorbidities, can complicate management of types of cancer in older persons

Example: Increased susceptibility to therapeutic complications:

Severe myelosuppression
Mucositis
Increased risk of cardiomyopathy
Central and peripheral neuropathy

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Principles Treatment Planning in Cancer

EdCan Cancer Australia, 2016

Older People with Cancer:

Domains that need to be considered in determining a treatment plan for the older person include:

Mental and emotional status
Activities of daily living
Home environment
Social support
Comorbidities
Nutrition
Polypharmacy

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Principles Treatment Planning in Cancer

Children and young people with cancer:

Survival outcomes and impact of toxicities also differ according to age

Example: radiotherapy is avoided in children aged under three because of associated long term effects

Differences in cancer treatment for children compared with adults are:

Increased intensity
Toxicities may have more significant and lasting effects

Consider treatment and supportive care strategies:

Example: During treatment with radiotherapy, the child may be required to remain still for up to 25 minutes

EdCan Cancer Australia, 2016

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Cancer Clinical Trials

“Clinical trials are research studies where doctors find new ways to improve treatments and the quality of life for people with diseases.”

The purpose is to evaluate:

the safety, effectiveness and toxicities of new agents and combinations of agents or interventions in humans

Researchers design cancer clinical trials to test new ways to:

Treat cancer
Find and diagnose cancer
Prevent cancer
Manage symptoms of cancer and side effects from its treatment

National Cancer Institute, 2020

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Cancer Clinical Trials

Phases of Clinical Trials:

Phase I trials: involves determination of safe drug levels and/or schedules of a new drug using human subjects.
Phase II trials: involves determination of therapeutic efficacy when applied to clients with various diagnoses.
Phase III trials: are used once efficacy is established to compare the drug to an existing effective standard therapy for the same diagnosis.
Phase IV trials: involve utilization as standard therapy to determine optimal use of the drug with large client populations.

EdCan Cancer Australia, 2016

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Cancer Clinical Trials

Treatment trials are designed to answers questions such as:

What is a safe dose of the new treatment?
How should the new treatment be given?
Does the new treatment help people with cancer live longer?
Can the new treatment shrink tumors or prevent them from growing and spreading to new places in the body?
What are the new treatment side effects?
Does the new treatment allow a better quality of life with fewer side effects?
Does the new treatment help prevent the cancer from coming back once treatment is finished?

EdCan Cancer Australia, 2016

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Cancer Clinical Trials

Nurse's role in research and clinical trials: Cancer nurses can contribute to many aspects of the clinical trial process including:

Conceptualizing and designing studies as part of a multidisciplinary team providing information to people affected by cancer
Assessing and monitoring people involved in clinical trials
Implementing treatments as part of a clinical trial protocol
Ensuring adherence to ethical principles associated with clinical trials

EdCan Cancer Australia, 2016

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Case Study/Critical Thinking Question/What would the nurse do?

In a cancer clinical trial, among the four phases, which phase indicates the determination of therapeutic efficacy of the treatment to clients with different diagnoses?

Answer:

_________________________________________

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Decision Making Criteria in Oncology

Decision making criteria used in Oncology : Three categories

Decision maker-related characteristics(Both the physician and the patient): Attributes, such as capabilities, confidence, self-efficacy, emotions, frames of reference, and degree of expertise, also influence decision making
Decision-specific criteria: These involve classical clinical criteria, such as performance status, age, presence of comorbidities, cancer stage, biomarkers, or expected treatment toxicity

Glatzer, 2020

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Decision Making Criteria in Oncology

Contextual factors:

The patient’s socioeconomic status
The health care system
Treatment costs
Influence from the pharmaceutical industry

Patient physician interaction is important for decision making in cancer care

Glatzer, 2020

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Conceptual Model of Decision Making Criteria

Decision maker-related criteria

Decision-specific criteria

Contextual factors

Decision-making process

Personal belief system

Age

Clinical trials

Quality of life

Motivation

Physicians time constraints

Position within department

Compliance

Adherence to treatment

Experience

Disease-related symptoms

Professional background

(e.g., urologist vs. radiation)

Professional Interaction

Marketing

Financial situation

Advocacy groups

Socioeconomic status

Government policies

Experience

Influences of family

Access to resources/information (literature, conferences)

Cultural/religion

Practice organganization

Comorbidities

Emotional stress

Tumor stage

Treatment toxicity

Performance status

Gender

Time pressure

Morphological/histological cancer characteristics

Treatment intent

Biomarkers, laboratory values

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Principles Facilitating Decision Making by Cancer People

Communication:

Communication is identified as an important element of treatment decision making
A tool kit to support decision making and assist in effective communication for health professionals and people affected by cancer include:

Principle 1: Good communication between healthcare consumers and healthcare professionals has many benefits.
Principle 2: Healthcare consumers vary in how much participation in decision making they desire.

EdCan Cancer Australia, 2016

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Principles Facilitating Decision Making by Cancer People

Principle 3: Good communication depends on recognizing and meeting the needs of healthcare consumers.
Principle 4: Perception of risks and benefits are complex, and priorities may differ between healthcare consumers and healthcare professionals.
Principle 5: Information on risks and benefits needs to be comprehensive and accessible.

EdCan Cancer Australia, 2016

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Evidence Based Practice

Definition:
“Evidence-based clinical practice guidelines are systematically developed statements that assist the practitioner and person affected by cancer to make decisions about appropriate health care for specific clinical circumstances.”
They collate the best available evidence to underpin scientifically valid recommendations for the prevention, diagnosis, and treatment of cancer

EdCan Cancer Australia, 2016

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Evidence Based Practice

Evidence-based clinical guidelines have been developed by the National Health and Medical Research Council (NHMRC) and the Australian Cancer Network (ACN) in cancer control

In addition to the clinical guidelines for the treatment of specific cancers, several valuable sources provide evidence-based approaches to inform core domains of practice for nurses working in cancer settings

Examples include:

Oncology Nursing Society(ONS) resources
National Comprehensive Cancer Centre (NCCN) guidelines
NHMRC guidelines on supportive care

EdCan Cancer Australia, 2016

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Importance of Evidence Based Practice

Evidence Based Practices (EBP) helps to:

Make a well-founded decision
Can be updated with the new medical treatment protocol for patient care
Provide the most effective care that is available
Have better patient outcomes

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Case Study/Critical Thinking Question/What would the nurse do?

A nurse has been working in an Oncology ward. How does EBP help nurses in this area of practice? Select all that apply:

Helps nurses provide effective care
Helps nurse to make appropriate decision
Improve patient outcomes
Keep updated about the new treatment protocol

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Reference:

American Cancer Society (2020). Treatment and Support: How Treatment Is Planned and Scheduled. Retrieved from: https://www.cancer.org/treatment/understanding-your-diagnosis/staging.html

EdCan Cancer Australia (2016).Module Four – Cancer Treatment Principles. Retrieved from: https://www.edcan.org.au/sites/default/files/EdCaN-Specialty-Module-Four-Cancer-Treatment-Principles_1.pdf

Glatzer M, Panje C, M, Sirén C, Cihoric N, Putora P, M: Decision Making Criteria in Oncology. Oncology 2020;98:370-378. doi: 10.1159/000492272 Retrieved from: https://www.karger.com/Article/Fulltext/492272

Contact info: info@nursesinternational.org

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Reference:

National Cancer Institute (2020). About Cancer: What Are Clinical Trials. Retrieved from: https://www.cancer.gov/about-cancer/treatment/clinical-trials/what-are-trials

UICC (2021). TNM classification of Malignant Tumor: What is the TNM cancer staging system. Retrieved from: https://www.uicc.org/resources/tnm

Contact info: info@nursesinternational.org

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