Clinical Pharmacy- II

Semester: 10
Batch : 15
PRESENTATION TOPIC: Lungs Cancer
Course Title : Clinical Pharmacy
Submitted To :
Mam Anum Hanif
Submitted By:
UMAIR MAZHAR 1087
WAQAR ASHRAF 1097
MOHSIN RAZA 1100
OSAMA SAEED 1284
Learning Outcomes:
 Respiratory system.
  Organs of respiratiory system
  Normal Physiology Of Respiration
 Lung Cancer
 Definition
 Types of Lung Cancer
 Causes and risk factors
 Patho-physiology
  Signs and Symptoms
 Diagnostic Tests
 Post-op complications for those with lung cancer
 Cancer Staging Systems 
 Medical Management
 Side effects of treatments
 Complimentary Therapies
  Prognostic Factors
 Prevention
 Nursing assessment 
  Nursing Diagnoses 
  Ineffective breathing pattern
  Impaired gas exchange
 References
Respiratory system:
Organs of respiratiory system:

  Upper respiratory tracts

 Nose
 Pharynx
 Larynx
 Trachea
 Lower respiratory tracts
 Two bronchi (one bronchus to each lung) Bronchioles and smaller air passage
 Two lungs and their covering pleura
Normal Physiology Of Respiration:

 Normal respiration begins by inhaling air through the mouth and nose.
 This air flows down into trachea, which divides into the left and right bronchi, and
then to the alveoli.
 The alveoli are responsible for oxygenating the blood for circulation as well as
removing carbon dioxide from the blood.
 Respiratory physiology includes all the processes of gas exchange and transport
between the atmosphere and the body tissues
Lung Cancer:

 Most common cause of cancer death for men and women.

 Tobacco use accounts for 87% of lung cancer.
 Lung cancer affect primarily in 5 or 6th decade of life.
 In 70% of lung cancer patient , disease has spread to distant organs.
 Cancer is a disease in which cells in the body grow out of control. When cancer
starts in the lungs, it is called lung cancer. Lung cancer begins in the lungs and may
spread to lymph nodes or other organs in the body, such as the brain. Cancer from
other organs also may spread to the lungs.
Definition:

 Cancer is an abnormal growth of cells which tend to proliferate in an uncontrolled

way and, in some cases, to metastasize (spread).
 Cancer is not one disease. It is a group of more than 100 different and distinctive
diseases.
 Cancer that begins in the lungs is called primary lung cancer.
 Cancer that spreads to the lungs from another place in the body is known as
secondary lung cancer ..
Healthy Lung Tissue Vs Diseased Lung Tissue:
Types of Lung Cancer:
Two main Types of Lung Cancer:
1. Small Cell Lung Cancer (20-25% of all lung cancers)
2. Non Small Cell Lung Cancer (most common ~80%)
1. Small Cell Lung Cancer:
 Small Cell Lung Cancer is the most aggressive form of lung cancer.
 It usually starts in the bronchi and then effects the whole lung.
 These cancer cells are small and are considered to be quite aggressive in nature and
they have a large growth factors.
 Because of these reasons, at the time of diagnosis, (60% of the time), these tumors
have often metastasize to other parts of the body (brain, liver, and bone marrow) 
SCLC accounts for 20-25% of all lung cancers.
2. Non Small Cell Lung Cancer:
NSCLC is any type of epithelial lung cancer other than small cell lung cancer.
Non-small cell lung Ca usually grows and spreads more slowly than SCLC.
Types of NSCL:
 Squamous cell carcinomas usually arise centrally in larger bronchi
 Adenocarcinoma formed from grandular structure in epithelial tissues (mucus
secreting glands) are often found in the periphery of the lungs
 Large cell carcinomas can occur in any part of the lung and tend to grow and spread
faster than the other two types
Squamous Cell Carcinoma

 Moderate to poor differentiation

 Makes up 30-40% of all lung cancers
 More common in males
 Most occur centrally in the large bronchi
 Uncommon metastasis that is slow effects the liver, adrenal glands and lymph nodes.
 Associated with smoking
 Not easily visualized on x-ray
Adenocacinoma:

 Increasing in frequency.
 Most common type of Lung cancer (40-50% of all lung cancers).
 Clearly defined peripheral lesions
 Glandular appearance under a microscope
 Easily seen on a CXR
 Can occur in non-smokers
 Slow metastatic in nature
 Pts present with or develop brain, Liver, adrenal or bone metastasis
Large Cell Carcinomas

 Makes up 15-20% of all lung cancers

 Poorly differentiated cells
 Tends to occur in the outer part (periphery) of lung, invading sub-segmental bronchi
or larger airways
 Metastasis is slow BUT
 Early metastasis occurs to the kidney, liver organs as well as the adrenal glands.
Causes and risk factors

 Gender
 Smoking history
 Active smoking=85-87%
 Passive smoking=3-5%
 Older age
 Presence of airflow obstruction
 Genetic predisposition.
 Pollution and occupational exposure
 Industry work due to asbestos(heat resistant fibrous).
 Lung Disease like T.B
 family History
 Diet (low in fruits and vegetables)
Patho-physiology:

 Carcinogens like smoking, occupational and environmental agents, genetics. Binds

with cell’s DNA and damage the cells.
 Cellular changes and abnormal cell growth occur.
 Malignant transformation of pulmonary epithelial cells.
 Abnormal proliferation of the lung cell.
 These cells grow slowly and covers the segmental bronchi and lobes of the lung.
 Non specific inflammatory changes with hypersecretion of mucus, desquamation of
the cells.
 Lesions formation in the lung’s tissues involving the bronchi, bronchioles or even
alveoli Bronchogenic carcinoma.
Signs and Symptoms:
•  There are two types of signs and symptoms of lung cancer:
1. Localized – involving the lung.
2. Generalized – involves other areas throughout the body if the cancer has spread.
Localized Signs and Symptoms:
 Cough and fatigue
 Breathing Problems, stridor
 blood in phlegm
 Lung infection, hemoptysis
 Hoarseness, Hiccups
 Weight loss
 Chest Pain and tightness
 Pleural Effusion
2. Generalized Signs and Symptoms
 Bone pain
 Headaches, mental status changes or neurologic findings
 Abdominal pain, elevated liver function tests, enlarged liver, gastrointestinal
disturbances (anorexia, cachexia), jaundice, hepatomegaly
 Weight loss
Early/late Signs and Symptoms Of Lung Cancer:
1. Early Signs:
 Cough/chronic cough
 Dyspnea
 Hemoptysis
 Chest/shoulder pain
 Recurring temperature
 Recurring respiratory infections
2. Late signs:
 Bone pain, spinal cord compression
 Chest pain/tightness
 Dysphagia
 Head and neck edema
 Blurred vision
 headaches
 Weakness, anorexia, weight-loss
 Pleural effusion
 Liver metastasis/regional spread
Diagnostic Tests:
 CXR
 CT Scans
 MRI
 Sputum cytology
 Fibreoptic bronchoscopy
 Transthoracic fine needle aspiration
 Laboratory Tests
1. Blood Tests
CBC- to check red/white blood cell & platelets -to check bone marrow and organ
function
2. Blood Chemistry Test- to assess how organs are functioning such as liver and
kidney
3. Biopsy:
to determine if the tumor is cancer or not -to determine the type of cancer -to determine
the grade of cancer (slow or fast)
 Bronchoscopy:
 Bronchoscopy is a procedure to look directly at the airways in the lungs using a
thin, lighted tube (bronchoscope). The bronchoscope is put in the nose or mouth. It is
moved down the throat and windpipe (trachea), and into the airways.
 Bronchoscopy is most commonly performed using a flexible bronchoscope.
However, in certain situations, such as if there's a lot of bleeding in your lungs or a
large object is stuck in your airway, a rigid bronchoscope may be needed.
 Bronchoscopy can also be used to obtain samples of mucus or tissue, to remove
foreign bodies or other blockages from the airways or lungs, or to provide treatment
for lung problems.
Bronchoscopy:
 Mediastinoscopy
 VATS (video assisted thoracoscopic surgery)
Mediastinoscopy :
 procedure in which a mediastinoscope is used to examine the organs in the area
between the lungs and nearby lymph nodes. A mediastinoscope is a thin, tube-like
instrument with a light and a lens for viewing.
 Mediastinoscopy is a procedure that enables visualization of the contents of the
mediastinum, usually for the purpose of obtaining a biopsy.
 Mediastinoscopy is often done to remove or biopsy lymph nodes in the area
between the lungs to check for cancer or to stage lung cancer. It can also be used in
people with thymoma (tumor of the thymus gland), esophagus cancer, or lymphoma
for the same reasons.
Mediastinoscopy:
VATS (video assisted thoracoscopic surgery):
Post-op complications for those with lung cancer:
 Airway obstruction, dyspnea, hypoxemia, respiratory failure
 Anesthesia side effects (N/V)
 Bleeding (hypotension, cardiogenic shock)
 Cardiac dysthymias, CHF, fluid overload
 Fever, sepsis
 Pneumonia
 Pneumothorax
 Pulmonary embolus
 Wound dehiscence
 Prolonged hospitalization
 Death
Cancer Staging Systems:
 The most common staging system for lung cancer is the TNM System developed by
the International Union Against Cancer (UICC).
 Guides best course of treatment
 Estimates prognosis
 It is only useful in staging NSCLC, when surgery is considered.
TMN Staging system for Lung Cancer :
T= Tumors : tumor size, (local invasion)
N= Node : node involvement (size and type)
M= Metastasis : general involvement in organs and tissues
Tumor size:
 Tx – The tumor size is unknown, or cancer cells are only found in sputum.
 T0 – The tumor is present only in the cells lining the airway
 T1 – Tumors less than or equal to 3 cm
 T2- Tumors size is 4-7 cm.
 T3 – Tumors greater than 7 cm T4 – tumor that invades structures in the chest such
as the heart, major blood vessels near the heart, the trachea, the esophagus.
Nodal involvement:
 N0 – No nodes are involved.
 N1 – The tumor has spread to nearby nodes on the same side of the body.
 N2 – The tumor has spread to nodes farther away, but on the same side of the chest.
 N3 – The tumor has spread to lymph nodes on the other side of the chest from the
original tumor, or has spread to nodes near the collarbone or neck muscles.
Metastasis:
 M0 - The tumor has not spread to distant regions.
M1 includes:
 M1a – The tumor has spread to the opposite lung, to the lung lining
 M1b – The tumor has spread to distant regions of the body, such as the brain or bones.
Staging:
Stage 1:
 Tumor is small and localised to lung, no lymph node involvement
 A-Tumor <3 cm
 B-Tumor >3 cm and invading surrounding local area
Stage 2:
 A-Tumor <3cm with invasion of lymph nodes.
 Tumor >3 cm involving the bronchus and lymph nodes on the same side of chest and tissue of local organs
Stage 3:
 Tumor spread to the nearby structure and regional lymph nodes
 Tumor involving heart, trachea, esophagus, mediastinum and lymph nodes.
Stage 4: distant metastasis
Medical Management
The three main cancer treatments are:
1. surgery (lung resections)
2. Radiation therapy
3. chemotherapy
4. Other types of treatment that are used to treat certain cancers are hormonal therapy,
biological therapy or stem cell transplant.
Surgical treatment:
Lobectomy: a single lobe of lung is removed
Bilobectomy: 2 lobes of the lung are removed (only on R side)
Sleeve resection: cancerous lobe is removed and segment of the main bronchus is
resected
Pneumonectomy: removal of entire lung
Segmentectomy: a segment of the lung is removed
Wedge resection: removal of a small, pie-shaped area of the segment
Chest wall resection with removal of cancerous lung tissue: for cancers that have
invaded the chest wall
Radiation treatment:
 Useful in controlling the neoplasm that can not be surgically removed.
 Used to reduce the size of the tumor
 May help to remove the symptoms like cough, chest pain, dyspnea and hemoptysis etc.
Chemotherapy:
 Is used to alter tumor growth and to treat the patient with metastasis.
Non small cell:
 Two drug regimen.
 Cis/Carbo platin + 1 other (Taxol/Taxotere/Gemcitabine)
Small cell:
 Cisplatin / Etoposide
Other drugs involved like:
 Etoposide
 Paclitaxel
 Cyclophosphamide
 Doxorubicin
 Vinblastin
Side effects of treatments
 Breathing Problems.
 Fatigue.
 Infection, bleeding and anemia (chemotherapy can lower blood counts)
 Stomach problems (nausea, vomiting, diarrhea or constipation)
 Changes in appearance, including hair loss.
 Pain and discomfort.
 Changes in sexual functioning and effects on fertility.
Complimentary Therapies

 Includes ACUPUNCTURE and MASSAGE and pharmacological approaches such

as vitamins and herbal medicine.
 These herbal therapies combined with chemotherapy increases survival in non-
small-cell lung cancer by up to 42%, compared with chemotherapy alone.
 Foods: Green tea, Garlic, Fish Oil, Lactobacillus.
 Mind-body: help to reduce anxiety, mood disturbance, or chronic pain in cancer
patients (audiotapes, videotapes, books, music, relaxation, yoga, meditation).
 Acupuncture
 Hypnosis
 Massage therapy
Prognostic Factors:

The best estimate on how a patient will do based on:

 Type of cancer cells
 Size or location of the tumor
 Stage of the cancer at the time of diagnosis
 Age of the person
 Gender
 Results of blood or other tests
 A persons specific response to treatment
 Overall health and physical condition
Prevention:
 Primary:
 Avoid the use of tobacco smoke
 Know environmental carcinogens that increase risk
 Chemoprevention:
 Consuming Vit. A, Vit E,, Vit C.
 Secondary:
 Aim is to early diagnose high risk populations via screening
 Chest X-Ray, MRI, CT scans, sputum cytology
Tertiary:
 Targeted at people who survived a cancer disease
 Assists them to retain an optimal level of functioning regardless of their potential
debilitating disease.
Nursing assessment:

Subjective data:
 Past health history
 Exposure to smoke, air born carcinogens, any respiratory diseases and pollutants
 Nutritional habbits
 Symptoms like anorexia, nausea , vomiting, cough and hemoptysis
Objective data:
 Vitals monitoring
 Respiratory-assess for wheezing, stridor, hoarseness, pleural effusion
 CVS- assess for cardiac temponade, dysrhythmias, pericardial effusion
 Findings- chest X- ray, MRI, CT scan, CBC.
Nursing Diagnoses:
1) Ineffective breathing pattern r/t loss of adequate ventilation as evidenced by
overexertion of pt. during respiration.
2) Impaired gas exchange r/t excessive or thick secretions or r/t decreased passage of
gases between alveoli of lungs and vascular system as evidenced by decreased
SPo2 level of pt.
3) Chronic pain related to Stage IV NSCLC diagnosis as evidenced by client reporting
“pain in right chest and lower ribs”.
4) Risk of infection related to altered immune system secondary to effects of cytotoxic
drugs as evidenced by side effects of the drug/chemotherapy.
5) Risk for disturbed self concept related to changes in lifestyle.
 Nausea related to effects of chemotherapy as evidenced by client reporting feeling
nauseated.
 Risk for deficient fluid volume related to gastrointestinal fluid loss secondary to
vomiting.
 Fatigue related to chemotherapy secondary to stage IV NSCLC as evidenced by
client reporting he “ no longer has the energy to play with his grandchildren or visit
his friends”.
Ineffective breathing pattern:
 Teach patient about deep breathing exercises
 Encourage alternating activity with rest periods
 Chest physiotherpy
 Suctioning
 Bronchodilator medication
 O2 administration, if required
Impaired gas exchange:

 Instruct the patient to stop smoking

 Semi-fowler position
 Administered antibiotics as prescribed
 Adequate hydration
 Deep breathing exercises
 Nebulisation
 Suctioning, as required
Chronic pain:
 Relaxation techniques
 Diversional therapy
 Frequant massage
 Encourage energy conservation
 Comfortable position
 Education to avoid concern about pharmacological and non- pharmacological therapies
 Medication , as prescribed.
Risk of infection:
 Monitor the client body temp. routinely
 Encourage the patient to do regular ADL like brushing, bathing, eating, toileting
 Provide a high calorie, high protein diet
 Hand washing before and after taking food
 Antibiotics, as prescribed
Risk of disturbed self concept:
 Provide psychological support
 Encourage the family members in caring of the patient
 Encourage the communication with the patient
 Diversional therapy
 Ask the client to identify personal strenght and talent.
Risk of deficit fluid volume:
 Encourage the patient to take fluids (2-3 l/day)
 Small and frequent diet
 I/V fluid administration, if prescribed
 Intake- output charting
 Administer skin care, apply hydrating lotion
 Weight recording
References:

 Brunner and sudderth’s, a textbook of medical- surgical nursing, smeltzer bare, 10th
edition, page no-554-557.
 Lewis’s , a text book of medical surgical nursing, chintamani, 7th edition, page no.
585-588.
 Potter.perry, a text book of fundamental of nursing, 7th edition, page no. 1066, 865.
 Posther KE, Harpole DH. The surgical management of lung cancer. Cancer
Investigation, 2006;24:56–67.
 National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in
Oncology: . Accessed at www.nccn.org/professionals/physician_gls/PDF/nscl.pdf on
March 18, 2013.