Stuff for Nurses

1. Carrington College
Summer 2012
N254

2. Terminology to know
 All key terms on page 260  Overall Survival (OS)
in Lewis et al  Quality of Life (QOL)
 Prevalence  Benign
 Incidence  Malignant
 Mortality  Node
 Morbidity  Biopsy
 Survival  Cachexia
 Progression Free Survival  Cure
(PFS)  Control
 Disease Free Survival (DFS)  Palliation
 Adjuvant  Hospice

3. Who gets cancer?
 Men – Prostate, Lung, Colon/rectum, Bladder, NHL,
melanoma, Head and neck
 Women – Breast, Lung, Colon/rectum, Uterus, NHL,
Thyroid, Melanoma, Ovary
 Adult age variables – the older the person, the higher the
risk of cancer
 Children – very specific childhood cancers, significant
genetic components
 Ethnicity variables – page 261
 US and rest of the world
 Developing nations – very different issues

4. How do people get cancer?
Risk factors
 Age, Gender
 Environmental influences – carcinogens
 Chemical/Radiation/Smoke/Smog/ Water Quality/
Infections/Food Processing
 Genetics – 10-15% have genetic link
 New research increasing our ability to detect links
 Behaviors
 Smoking
 Dietary
 Exercise
 ETOH

5. Statistics

7. Classification
 Anatomic site
 Histology
 Solid/Blood
 Origin
 Can have breast cancer in the brain, for example

8. Staging
 T – Primary Tumor
 is: in situ, x: can’t be found, 0: no evidence of primary tumor
 1 – 4: Ascending size
 N – Node
 0: no evidence of disease, x: unable to assess
 1 – 4: Ascending degrees of nodal involvement
 M – distant metastases
 0: no evidence of distant mets, x: cannot be determined
 1 – 4: Ascending degrees of metastatic involvement
 Staging related to the formula for the TNM
 Stage 0 – 4: the higher the number, the more serious the
disease
 Guides decision making about treatment, advises about
prognosis

9. Grading
 Grade 1
 Differ slightly from normal cells – low grade
 Grade 2
 Moderate differentiation – intermediate grade
 Grade 3
 Severe differentiation – high grade
 Grade 4
 Immature and primitive
 The cells of Grade 1 tumors resemble normal cells, and tend to
grow and multiply slowly.
 Conversely, the cells of Grade 3 or Grade 4 tumors do not look
like normal cells of the same type. Grade 3 and 4 tumors tend to
grow rapidly and spread faster than tumors with a lower grade.

10. Diagnostic tests to ID cancer
 Routine screening
 Mammogram
 Colonoscopy
 PAP Smear
 Others not as established – Lung CT, Specific blood
tests
 Issues are often r/t cost, insurance coverage, controversy
 See ACS website for complete list of screening guidelines

11. Example of screening guidelines

12. Diagnostic tests to ID cancer
 Labs
 CBC, Chem Panel, Liver studies
 Some cancer specific tests, called tumor markers (PSA, CA 125,
CEA, etc)
 Genetic markers – (BRCA, etc)
 Diagnostic tests
 Imaging – Ultrasound, CT, MRI, PET CT, Endoscopy, Radio-
isotope scans
 Often biopsy done with Imaging guidance
 Often require a series of tests, and the entire time, the
patient is anxiously waiting!

15. Biopsy
 Definitive identification of histological type of cancer
 Determines type of treatment necessary
 Role of Tumor Board
 Role of Clinical Trials

16. Tumor Board
 Group meets, usually weekly
 MDs - Radiologist, Pathologists, Medical Oncologists,
Surgeons, Radiation Oncologists, Geneticists, Psychiatrists,
Palliative Care, Hospice, Primary Care
 Psychologists, Social workers, Nurse Navigators, Infusion
Room nurses, Radiation Therapy staff and nurses,
Nutrition, Physical and Occupational Therapy, Surgical
and Oncology nurses, Research nurses, Cancer Registry
staff
 Others: Medical and Nursing Students – have to sign
confidentiality agreement
 If you get a chance to go, do it! Fascinating stuff!

17. Tumor Board
 Present all Imaging results
 Present all lab results, including biopsy
 Present patient’s H & P
 Compare to National standards and guidelines
 Discuss cancer and best therapy for that patient
 Recommend treatment options, including clinical
trials and referrals to other facilities (UCSF, Stanford)
 ALL participants discuss, all cite evidence and research
 Often lively discussion and debate about
recommendations

18. Clinical Trials
 Variety of trials available – prevention, screening,
diagnostic, treatment, QOL, genetics
 Patient may leave clinical trial at any time
 Some trials have been stopped abruptly
 Significant negative outcomes
 Significant positive outcomes
 Nurse has huge role in Clinical Trials
 Assisting people in finding appropriate trial
 Data collection and monitoring
 Clinical follow-up
 Examples of CT/research in Reno

20. Surgery
 Goal – removal of as much of tumor as possible
 Other goals:
 Placement of treatment devices
 Cure
 Control
 Support/Palliative
 Rehab

22. Surgery side effects
 Loss of function/motion
 Altered body image
 Altered sexuality
 Social isolation
 Infection

23. Chemotherapy
 Huge number of chemicals that we can give to people –
more being developed all the time.
 Cure
 Control
 Support/palliative

24. Types of chemo administration
 Oral
 IV – most common today
 Usually given in cycles, sometimes RTC
 Peripheral
 Central
 Intracavity or into organ
 Intrathecal or into ventricles

25. Issues r/t chemo
 Toxicity
 Patient
 Nurse safety
 Side effects
 Long therapies
 Cycles
 Continuous infusions
 More and more chemo given in outpatient setting
 Chemo in all patient waste for 2-3 days or longer

26. Biologic and Targeted Therapy
 Alter or modify the relationship between the host and
tumor
 Classic example – hormone therapy for prostate, breast
cancers
 Many of the newer targeted therapies are specific for one
type of cancer, or have only been tested with one type of
cancer
 Many are still under patent, and quite expensive
 Examples:
 Gleevec for CML: $6-7K/month for rest of life
 Herceptin for breast cancer: $54K/year x 1 year
 Patient assistance programs
 Patients may reach lifetime maximum of insurance quickly

28. Side effects of chemo
 Immediate  Skin and nail changes
 N&V  N & V – up to 2 weeks
 Stomatitis, mucousitis after chemo
 Fluid shifts  Bowel changes
 Falls  Peripheral neuropathy
 Delayed  Cognitive changes
 Bone marrow
 Cachexia
suppression  FATIGUE
 Alopecia – about 2
weeks after chemo

29. Side effects of chemo
 Long term  People who had chemo
 Infertility as children now are
 Cardiac dealing with a variety of
 Secondary cancers
issues – need to continue
to see MD for follow-up
 Permanent skin and
hair changes  Emerging area of study
 Some chemos cause
chronic cardiac and/or
pulmonary changes

30. Mitigating side effects
 N&V
 RBCs
 WBCs
 Mouth care
 Fatigue
 Cachexia
 Physical changes

31. Nausea and vomiting
 Much research on this with medications and
complementary therapies
 Multiple reasons that people are nauseated/vomit
 Anticipatory – “Elevator vomiting”
 Immediate
 Delayed
 Long term
 Currently, meds include:
 High doses of steroids
 Anti-emetics – many specific to cancer therapy

32. Nausea and vomiting
 Complementary therapies that have been shown to be
effective:
 Acupressure
 Acupuncture
 Guided imagery
 Music therapy
 Muscle relaxation
 Psychoeducational support and information
 Many more are being researched and may show
effectiveness

33. RBCs and WBCs and platelets
 RBCs
 Transfusions
 Erythropoietin
 Oxygen
 WBCs
 GCSF – Granulocyte Colony Stimulating Factor
 Often given right after chemo, so that patient never has nadir
 Platelets
 Transfusion uncommon
 Often simply put on bleeding precautions until platelets rise
 Meds in the works, so far have not been effective

34. Mouth care
 Prevention of mouth sores is crucial for many reasons:
 Impaired comfort, Impaired nutrition, Impaired body
image, Impaired communication, Risk for infection and
bleeding to name a few!
 Frequent mouth care crucial, but a challenge
 Soft toothbrush, no alcohol mouthwash, careful
attention to dentist visits, flossing, avoiding irritating
foods

35. Radiation Therapy
 Local
 Internal
 Brachytherapy
 External
 Systemic very rarely used
 Cure
 Control
 Support/Palliation
 Rehab

38. Side effects of radiation
 Immediate
 Rare
 With head and neck – Skin issues, N&V, mouth sores
 Delayed
 Usually begin to manifest during treatment to end of
treatment and several weeks beyond
 Skin burns, fatigue
 GI issues if getting radiation to belly

39. Side effects of radiation
 Long term
 Chronic fibrous changes in lungs, heart
 Prostate – incontinence, impotence
 Scar tissue

40. Mitigating side effects
 Skin – creams and lotions
 Mouth – special rinses and meticulous care
 N&V – anti emetics
 Fatigue – exercise during and after radiation!
 Prostate – Urinary exercises, Kegels, Viagra

41. Combination therapies
 Surgery, chemo and radiation may all be used,
sometimes at the same time
 These patients are very ill, often with a compounded
bunch of side effects
 Biggest risks/concerns:
 Infection leading to sepsis
 N&V leading to severe dehydration
 Anorexia leading to severe malnutrition
 Pain from cancer itself, as well as side effects of
treatment

42. Stem cell transplantation/ Bone
marrow transplantation
 Used to treat variety of cancers often blood tumors
 Patient receives “induction” chemo to eliminate cancer cells
 Cells harvested from patient or donor
 If patient cells, they are treated to remove any remaining
cancer cells
 Patient usually gets more chemotherapy/ sometimes
radiation
 Receives stem cells which proliferate and form new cells
that are cancer free
 Very intensive process with many risks
 Significant long term issues

44. Complementary Therapies
 Used with western medicine – best treatments are evidence
based, have had clinical trials
 Effective for cancer treatments:
 Pet therapy
 Healing touch
 Music therapy
 Support groups
 Exercise
 Imagery
 Ongoing study
 Nutrition
 Herbal supplements

46. Alternative Therapies
 Used instead of western medicine
 Hallmarks:
 Cash payments
 No clinical trials
 Often ingredients not revealed
 Anecdotal or celebrity evidence
 Many of the practitioners do not have hospital privileges
or board certifications, may not be physicians
 Doesn’t mean they don’t work, but no data collected
on them – can’t tell if they work or not

47. Advanced Cancers
 Diagnosed late – Stage 3 or 4
 Usually already have metastasis from primary cancer
 Often treatable, can often give significant DFS or PFS
 Lance Armstrong – example
 Recurrence – originally, was the end
 Now, often treatable and can give significant PFS
 Some patients on their 3rd or 4th recurrence, related to
aggressive and newer chemos
 Secondary cancer
 Problem is often that the patient can’t have as much chemo or
radiation – has reached lifetime limit of one or the other or
both, so surgery may be only option available

50. Common cancers and the
treatments commonly used
 Lung (p. 560-564)  Breast (p. 1311-1326) Lotsa pages!
 Leading cause of cancer deaths in  Most frequently occurring cancer in
US at present, expected to continue women
to rise for women  Screening – mammogram, breast
 New screening may diagnosis at exam
earlier stage – improve survival  Hallmarks:
 Hallmarks:  Usually found in screening
 Worsening cough with sputum, mammograms, or small lump
weight loss, fatigue, chest pain palpated – usually no symptoms
 Treatments include surgery, chemo,  Highly treatable, very often curable
sometimes radiation  Treatments include surgery, chemo,
 Issues include shortness of breath, radiation and hormone therapy
fear and anxiety  Issues include fatigue and body
 In 2011, @226,000 diagnosed and image
@160,000 died with lung cancer  In 2011, @ 288,480 diagnosed,
@40,000 died with breast cancer

51. Common cancers and the
treatments commonly used
 Prostate (p. 1386-1391) 5 pages  Colon/rectum (p. 1035 - 1038)
 Most frequently occurring cancer in  Screening test: Colonoscopy, FOBT
men  Hallmark:
 Screening test Exam, PSA  Abdominal pain, change in bowel
 Hallmark: Similar to BPH – pattern, blood in stool, anemia
problems urinating or change in  Treatment includes surgery,
urination patterns chemotherapy, radiation
 Treatment – varies according to  Issues include body image, change
stage – sometimes watch and wait in bowel habits, pain
 Other treatments include surgery,  In 2011, @ 143,000 diagnosed and
radiation, hormonal therapy @51,000 died with colon/rectal
 Issues include impotence cancer
incontinence
 In 2011, @ 241,000 diagnosed with
and @ 28,000 died with prostate
cancer

52. Common cancers and the
treatments commonly used
 Leukemias (p. 694-697)  Lymphomas (p. 699-703)
 Screening – not done.  Screening - not done
 Hallmark: fatigue, patient presents  Hallmark: Often few symptoms
with infection, has very abnormal until substantial lymph node
labs, esp. WBC involvement. Sometimes patient
 Treatments include chemo, rarely presents with infection or chest
radiation, and transplant. pain, and abnormal labs are found.
 Some of the new treatments are oral Fever, night sweats and weight loss –
and VERY effective – hold out a lot indicate poorer prognosis.
of promise. Incredibly expensive as  Treatments are chemo, radiation
well. and for some, bone marrow or stem
 Issues include infections, fear, cell transplants
anxiety and post transplant  Issues include fear, anxiety and post
problems transplant problems
 In 2011, @ 47,000 diagnosed and  In 2011, @79,ooo diagnosed and
23,000 died of leukemias @20,000 died with lymphomas

54. Common cancers and the
treatments commonly used
 Multiple Myeloma (p. 703-704)  Skin cancers – specifically
 Screening – not done Malignant Melanoma (p. 451 – 453)
 Hallmark: bone destruction,  Screening – annual skin inspection
skeletal pain  Other than MM – surgical removal,
 One “new” drug is thalidomide – usually not a problem
significant patient education  MM – Hallmark – VERY rapid
necessary growth and metastasis
 Problems with calcium and uric acid  Requires wide excision, lymph node
– may lead to renal failure excision and aggressive
 Emphasis on preventing chemotherapy
complications from bone damage  Issues with body image, VERY
 Issues with pain, fractures difficult treatment (some new
 In 2011, @ 21,000 diagnosed,
meds on the way, but cost is
@10,ooo died of multiple myeloma concern)
 In 2011, @ 76,000 diagnosed, @9000
died of malignant melanoma

55. Common cancers and the
treatments commonly used
 Liver cancer (p. 1086-1087)
 Pancreatic cancer (p. 1094-1095)
 In the US, rarely a primary site for cancer,  Screening not done
in other nations, a common primary site  Hallmarks are abdominal pain and
 Screening – not done unexplained weight loss, sometimes
jaundice if bile duct blocked
 Hallmarks: History of cirrhosis, Hep B
 Surgery done sometimes, usually
or Hep C, jaundice, anorexia, nausea, chemo, sometimes radiation for
vomiting palliation
 Treatment is directed toward primary  Issues include pain, fear
site  In 2011, @ 43,000 diagnosed, @
37,000 died with pancreatic cancer –
 If liver is primary, surgery, chemo just have not made a lot of headway
transplantation sometimes an option on this cancer yet, because the
 New technique of radiofrequency and/ cancer has often metastasized by
the time of diagnosis
or chemoablation may be more effective
 Issues include pain, fear
 In 2011, @ 28,000 were diagnosed and
@20,000 died with Liver cancer

56. Complications of cancer
 Nutritional issues
 Infections
 Cancer emergencies
 Pain
 Skin Integrity
 Financial

57. Nutritional issues
 Some cancers and some  Some cancers are treated
treatments are hard on the with high doses of steroids
GI system that make a person
 People often need more REALLY hungry, and they
nutrition during and after gain water and food weight
treatment, but they are not during treatment. They
hungry, don’t want to cook get bloated, striae, and feel
or eat. lousy.
 Nutritional supplements  They need to eat healthy
necessary, sometimes G frequent small meals, with
tubes even. an emphasis on high
nutrition and low salt.
Right.

58. Infections
 We create new openings:
 Surgical sites
 IV sites
 We give meds/treatments that decrease the immune
response
 We give meds/treatments that may mask symptoms of
infection
 These are people who have a fever of 100.5, feel lousy
and turn out to be septic.
 End up in hospital on IV broad spectrum antibiotics.

59. Cancer Emergencies
 There are many of these – I do a whole 2 hour lecture
on them, if you would like to see it.
 Suffice to say, most need to be addressed immediately,
and vary with the type of cancer and the type of
treatment.
 Oncology nurses and doctors will give patients
information about the ones for which they are at
highest risk. Patients need to CALL if they have these
symptoms.

60. Cancer Emergencies – a few
 Malignant pleural effusion
 Cardiac tamponade
 Superior vena cava syndrome
 Bone metastases and fractures
Spinal cord compression
 Increased intracranial pressure
 DVTs

61. Pain
 Cancer pain is no different than other pain IMHO – it
is just more persistent and feared
 Related to either cancer itself occupying space, or
rubbing against something, or treatment side effects
 Very treatable with appropriate methods
 ATC meds are the best for some pain BUT!
 Examples:
 Surgery, chemo and radiation all can be used to reduce
pain
 Pains specialists can be called in to do nerve blocks,
ablations to reduce pain

62. Skin integrity
 Serious concern, as any open lesions predispose for
infection
 Many treatments dry skin out (some chemos), damage
hair and nails (chemo) and may cause nerve damage,
decreasing the ability to feel
 Radiation may cause skin damage, and although it is
temporary, it can be very problematic
 Skin folds, pannus, neck, mouth, face, perineum –
breakdown is a serious problem
 May need wound consult

63. Financial
 People without insurance
 Limited options for treatment
 Depend on charity
 Meds may be donated by drug companies
 Patient may choose not to have treatment at all
 People with insurance
 May need to continue working to keep insurance
 Co pays and deductibles may be very high
 Billing very confusing at best!
 Insurance may refuse some treatments, need to appeal
 Insurance may have cap on treatment costs
 Other costs – non-reimbursable
 Time off work
 Travel
 Meals out
 What else?
 Many people, even with insurance, end up declaring medical bankruptcy
 Try getting individual policy type life insurance after having had cancer – not
happening

64. Psychosocial impact of cancer
 Fear
 Pain
 Death
 Long treatment regimen
 Unknown
 Coping mechanisms
 Support groups
 Navigators
 Cancer Survival Toolbox/Stress thermometer
 Entire family needs assistance, not just patient

65. Fear
 Diagnosis of cancer very stressful for patient and family
 Often comes at the end of several stressful weeks of
diagnostic tests
 Unfamiliar doctors, unfamiliar terms, scary treatments
 Radiation
 Chemotherapy
 Cutting
 Cannot promise that treatment will work!
 Significant time between beginning and end of treatment,
so chronic stressor

66. Fear of pain
 Common concern
 Media and others have told of severe, unrelievalbel
cancer pain
 Need to address this head on and right away
 Need to assess beliefs about pain
 Not inevitable
 Treatable
 Will not make patient an addict
 What else?

67. Fear of death
 People do die of cancer, no doubt about it
 Some cancers are very deadly – which ones did you
identify in this talk?
 Need to address this head on as well
 Ask questions
 Help with advanced directives
 Talk about options if needed (Hospice, refusal of
treatment, etc.)

68. Fear of long treatment regimen
 Compare with heart attack
 Chest pain – go to ER – go to cath lab – go to OR – recovery
and cardiac rehab. First line can all happen within one day.
 Breast cancer – get a routine mammo – get called to come
back for more mammos – get called to come back for a biopsy
– go to MD for diagnosis – presented to Tumor Board – have a
lumpectomy – wait for results – go to oncologist – discuss
treatment options – start treatment. Treatment may take up
to 4 months for chemo, then 2 months for radiation, with a
month off in between. So all of the above can take over a year!
At which point the oncologist says “Well it’s all gone, so we
are good for now. Come back and see me in 3 months.”

69. Fear of unknown
 How many words have I used so far today that were
new to you?
 You don’t have cancer!
 Think how hard it would be to hear these words if you
were also dealing with a new diagnosis!
 No wonder that people say “The doctor didn’t tell me
anything.” What they meant was “I didn’t hear
anything.”

70. Coping – Support Groups
 Research and surveys have indicated that this is VERY
helpful for some people
 Some people find on-line groups better than face-to-
face, or that may be only choice for some
 Caregiver support groups are very beneficial as well, to
help family and loved ones cope with the changes that
cancer, its treatment and its ramifications bring
 Usually led by a nurse or social worker, to guide group
and make sure information is accurate

71. Coping - Navigators
 Research and surveys indicate that patients with
navigation are seen faster, more likely to complete
treatment and more satisfied with their experience
than others.
 Issues:
 Navigators do not generate revenue for hospitals, and
may in fact cost money
 Hard to quantify the work
 Probably will be required in the future to get
accreditation by American College of Surgeons and
other groups

72. Coping – Cancer Survival Toolbox
 Series of CDs or downloadable talks that address the
common issues that cancer patients and their families
experience
 Developed by Oncology Nurses and Oncology Social
Workers
 Highly regarded by professional groups as helpful and
accurate
 Currently developing more on specific cancers
 Go to web site!

73. Coping – Stress Thermometer
 See handouts
 Great tool to quickly ID issues and or problems that
you can address each visit
 Monitor whether things are getting better or worse
 Clearly indicates (if you use and follow through!) that
you know how stressful the cancer treatment is
 Provides you with suggestions for referrals
 Fact G sheet – similar tool, but takes longer

74. Fact-G Use and Referral Guidelines for Nurse Navigators
All Cancer Center patients have FACT-G completed
w/in 2 mos of initial contact w Nurse Navigator
Physical Social/Family Emotional Functional
T Score >50 T Score >50 T Score >50 T Score >50
No referral required No referral required No referral required No referral required
T Score <50 T Score <50 T Score <50 T Score <50
Nurse Navigator assesses specific issues contributing to low score
Intensify Nurse Intensify Nurse
Navigator contact Navigator contact
Referral if appropriate to:
Referral if appropriate to: Referral if appropriate to:
Referral if appropriate to: • Med Onc / Rad Onc for
• Med Onc / Rad Onc for • Support Groups
• Support Groups symptom mgmt
symptom mgmt • Individual Counseling
• Individual Counseling • PT / Cancer Rehab for
• PT / Cancer Rehab for • Spiritual Care
• Spiritual Care functional issues
fatigue •Physician if medication
• Financial Counseling • Nutrition if related to issues
• Nutrition if related to issues possibly needed
• Support groups
Repeat FACT-G w/in 1 month end of tx and at 6 mos post-tx if contact continues
Draft 8/9/11 Powerpoint Presentations – Flowchart Fact-G Use

75. Psychosocial impact of cancer
 Family issues
 Patient advocacy
 Lifestyle changes
 Valley of the Shadow of Death

76. Family issues
 Guilt, blame, shame
 Body image changes affect the whole family
 Role changes within the family may be significant
 Not unusual to have a family member not able to deal
with diagnosis
 Can bring some family conflicts to the forefront,
especially related to end of life issues

77. Patient advocacy
 Nurses need to advocate for patients:
 Physicians
 Pharmacy
 Insurance
 Sometimes family!
 Sometimes employers
 Tale of two breast cancer patients
 “What can we do for Kelly.”
 “Take all the time you want – you’re fired.”

78. Lifestyle changes
 Examples:
 Patient who scuba dives + new colostomy
 Patient with breast cancer + clothes don’t fit
 Patient with pancreatic cancer + well meaning friends
who suggest alternative therapy
 Patient who is newly married + prostate cancer and
possible impotence
 Patient with stem cell transplant who needs to live in a
very clean environment + has chickens he loves (Has to
get rid of them)

79. Valley of the Shadow of Death
 We take people, some of whom have few or no
symptoms, and put them through a terrible ordeal. It
is truly amazing that they usually trust us!
 You have seen, or will see, people in the hospital with
terrible complications from the treatments:
 Neutropenia with fever
 Awful mouth sores that bleed constantly
 Dehydration from ongoing nausea and vomiting or
uncontrollable diarrhea
 Malnutrition from anorexia and fatigue

80. Survivorship
 Begins the day person is diagnosed
 Whole family/group is survivor
 http://www.cancer.org/Cancer/News/ExpertVoices/po
st/2012/06/14/ACS-releases-new-data-on-
survivorship.aspx

81. Death and Cancer
 Still kills a lot of folks.
 However:
 Cancer gives you time
 Usually we can give you wide awake, alert pain-free
quality time
 Opportunity for spiritual growth

82. So why be a cancer nurse?
 Always changing, new info
 Improvements every day in care
 Research opportunities
 Autonomy of practice
 People teach you how to live/how to die – personal
growth
 Advanced degrees, certifications

84. Emerging issues
 Genetic testing
 Survivorship – beyond 5 years
 Mitigation of risk factors – ex. Gardisil
 Increasing use of aggressive regimens, especially on
elders
 When to stop – 1st recurrence? 2nd recurrence? 3rd
recurrence?
 Some cancer becoming chronic illnesses
 Incredible cost of care, especially new drugs

86. Sources of reliable information
 American Cancer Society http://www.cancer.org/
 American Society of Clinical Oncology
http://www.asco.org/
 Oncology Nursing Society - research and evidence based
guidelines for nursing care http://www.ons.org/
 National Cancer Institute http://www.cancer.gov/
 National Coalition of Cancer Survivorship
http://www.canceradvocacy.org/
 National Comprehensive Cancer Network – guidelines for
all types of cancer – updated at least yearly
http://www.nccn.com/