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International symposium on cancer nursing
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International symposium on cancer nursing Rose Marie Lee, RN Nurse editor
he key to cancer nursing is understanding, Rachel Ayers, RN, MS, told an audience of 1,561 nurses attending an international symposium on cancer nursing Sept 3-5 in New York City. She said cancer touches the lives of all of us at sometime. "In every instance, nurses must be there. They have a role to play if people are to have that unique component of oncology nursing-understanding. It is a difficult task, and it takes a lot of care. But caring is what nursing is all about.'' Mrs Ayers is assistant vice president and chairman, department of nursing, Memorial Hospital for Cancer and Allied Diseases, New York City. She was one of about 85 members of the center's interdisciplinary team of nurses, physicians, social workers, physical therapists, and dietitians who spoke at the symposium. Attendees represented nearly all of the United States, and seven of Canada's ten provinces. Some of the other countries represented were Australia, Egypt, England, Israel, Jamaica, Japan, New Zealand, Panama, Puerto Rico, Sweden, Switzerland, Thailand, and Venezuela. The symposium was sponsored by Memorial Sloan-Kettering Cancer Center (MSKCC), a comprehensive cancer center that includes a new $50 million, 565-bed referral hospital and the Sloan-Kettering Institute for Cancer Research, founded in 1945 to complement research being carried out at Memorial Hospital. Today, it is the largest privately operated cancer research operation in the country. The new hospital opened in 1973 and replaces the old Memorial Hospital building and the James Ewing Pavilion. It represents the realization of an idea that dates back to 1884 when Memorial Hospital was founded to provide a special institution to treat cancer patients. It was the first hospital in the country based on the idea that cancer could best be treated in a hospital whose entire staff and resources were mobilized to subdue and eradicate it. About 5,000new cancer cases are seen each year at Memorial with about 75% of the patients coming from the New York metropolitan area. "Memorial probably has the sickest patients of any hospital in the United States,"
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says Edward J Beattie, Jr, MD. He is general director and chief executive officer, Memorial Hospital for Cancer and Allied Diseases. Its staff of 4,500 includes about 550 registered nurses. The theme of the center-sponsored conference was the emerging specialty of oncology nursing. "Without question, oncology nursing is on the move as a viable specialty," Mrs Ayers said, pointing out that because there are so many diseases of cancer, the spectrum of treatment modalities is becoming increasingly complex for nurse practitioners. "Just as there are growing numbers of medical oncology subspecialists, nurse specialists of both professional and technical nature are appearing on the scene at a breathtaking rate," Mrs Ayers said. Some of these specialists at MSKCC include the family nurse practitioner, nurse epidemiologist, total parenteral nutrition (TPN) nurse, chemospecialist who administers chemotherapeutic drugs and monitors the patient's reaction, mental health specialist, stoma nurse, dialysis nurse, analgesic studies nurse, immunotherapy research nurse who procures blood samples and prepares them for research studies to isolate antigens, advanced nurse practitioners, clinical instructor, pediatric nurse practitioner, clinical nurses in specialty areas such as transplantation, and nurses who work in the special procedures department of diagnostic radiology or therapeutic radiation where the badge, "bald is beautiful," is popular with pediatric patients. Mrs Ayers pointed out that oncology nurses include not only those who work in major oncology centers as part of an interdisciplinary team of specialists but also individual nurses in community hospitals who care for the cancer patient along with other patients who may have diabetes, hypertension, or any number of surgical diseases. "There are many lonely artists facing up to the complex, intense, unique demands that cancer presents to all of us,'' she said. One problem nursing must face, Mrs Ayers said, is the "disparity of service" provided around the world. "It is true that cancer centers and health care/teaching institutions with major oncology programs have resources that include an impressive array of highly specialized nurse practitioners. But what
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Nurse's attitude toward pain affects approach The word cancer brings to mind pain, although some cancers are not in themselves associated with pain. But oncology nurses know only too well the debilitating physical and psychological effect pain can have. For the nurse, probably more than any of the other health professionals who deal with pain, has the most direct daily contact with the patient in pain. It is he or she, for example, who shares the long nights that seem endless for the patient in pain. It is the nurse who knows when too little or too much pain medication is prescribed. And it is the nurse who often sees how anxiety, fear, boredom, and fatigue can potentiate pain. "Sometimes the nurse feels hindered and often helpless in facing human suffering," Linda Zelski, RN, said at a special interest
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session on pain at the cancer nursing symposium. “It may be impossible to alleviate the cause of pain, especially in cancer, but nurses can offer patients some relief of pain and general comfort,” she said optimistically. Ms Zelski is a clinical instructor, medical service, Memorial Hospital for Cancer and Allied Diseases. Kathleen M Foley, MD, pointed out that the management of intractable pain requires a multidisciplinary approach for successful therapy. The first line of treatment, according to Dr Foley, is detailed diagnostic studies to assess the nature of pain and prescribe specific therapy. Dr Foley is assistant attending physician, neuropsychiatric service, Memorial Hospital for Cancer and Allied Diseases. Dr Foley believes analgesics should be employed early for the temporary relief of pain. “Initially we place the patient on aspirin or Tylenol to see what his response is. Commonly, there is no response so we immediately move to short-acting narcotic analgesics such as Percodan or Demerol. If these are not holding the patient or they need more sustaining drugs, we give LevoDromoran or methadone.” She said she prefers methadone to Levo-Dromoran because it does not have the sedative effect and enables patients to be awake, ambulatory, and in pain control. “We use tranquilizers and psychotropins as needed and increase drug intake as tolerance develops,” Dr Foley explained. “Too often,” Ms Zelski said, “the only nursing intervention in pain is administration of analgesics.” She explained that measures to relieve pain, such as back rubs, position changes, splinting incisions and encouraging fluid intake to make coughing easier, insuring that patients receive rest, efforts to counteract boredom, and decreasing noxious stimuli are often not even tried. She said the nurse’s attitude toward pain may affect her approach to pain in her patients. For example, if he or she values emotional control and stoicism, he or she finds crying and complaining of pain unacceptable. Attitude, too, may affect the way analgesics are administered. On the one hand, the nurse may withhold narcotics fearing the patient may become addicted. “This
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Intractable pain: A case study The following case study is about Sol, a 41 -year-old lawyer, who has intractable pain associated with bladder cancer metastasis. It was related by Nessa Coyle, RN, nurse clinician, neurology service, Memorial Hospital for Cancer and Allied Diseases, at a session on pain. The time span of the study is about two years, from the time Sol was first diagnosed to three subsequent hospital admissions, and finally, to predying care in a nursing home. Ms Coyle explained that Sol presented, as many patients at Memorial, a complex nursing problem that, along with the progression of his disease and his pain and anxiety, taxed the ingenuity of the nursing staff. “His mounting problems were like a constant reproach giving us a sense of inadequacy and failure. It was very important that a multidisciplinary team work closely to arrive at an understanding of Sol’s physical and emotional problems,” she said. In July 1973, Sol underwent partial cystectomy for cancer of the bladder. Four months later cystoscopy revealed numerous lesions, and he was informed his prognosis was guarded. Seven months later, he developed pain along the lateral aspect of his left leg. The pain was unrelated to position or movement and at first was relieved by Darvon. Gradually, it became worse, requiring strong analgesics, and the resulting exhaustion from persistent pain made it difficult for him to work. Despite drug manipulation, psychotherapy, acupuncture, and transcutaneous stimulation, the pain persisted. Finally, 13 months after his original surgery, he was seen as an outpatient in the pain clinic at Memorial. Initially, Sol was depressed and angry because no cause for his pain was found. He was given analgesics and Elavil, 50 mg, at HS to help him sleep. His primary concern was the pain in his leg and not the fact he had cancer. About a month later when he began to talk of suicide, he and his wife literally demanded he be admitted to Memorial to evaluate his
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disease and control his pain. A laparotomy revealed bladder cancer had invaded the left lumbar plexis. Thus disease progression was the cause of his leg pain. In recounting the case, Ms Coyle said though it was difficult to communicate with Sol at this time, we had to be firm and demand he cooperate to avoid further complications and promote rehabilitation. We set new goals for him daily and offered positive feedback for his efforts. He was medicated before ambulation and postop exercises to keep discomfort to a minimum. To improve his appetite, Ms Coyle said, we gave him antiemetics, but also served him small portions of his favorite foods. Throughout his ordeal, Sol was concerned about Barbara, his wife of 14 years. Barbara had been under intermittent psychiatric care since she was 17 and described herself as needing someone to lean on. Sol talked to the nurses about his wife and children, two daughters, 13 and 11, and both he and Barbara expressed concern that he would not be able to care for them. Radiation therapy was begun following surgery. This made Sol feel something positive was being done and confident that it would enable him to return to normal activities. Once he knew the cause of his pain, he seemed to tolerate its presence with more ease. He was sent home on Percodan and only required about 45 tablets daily. For two months he continued to receive radiation therapy as an outpatient and returned to part-time work in a law partnership. He then developed left foot weakness and increasing pain in his left knee and ankle. A bone scan revealed metastasis. Efforts at this time to control the disease included radiation therapy to his foot, knee, and ankle and chemotherapy with 5-Fluorouracil and Cytoxan. He was seen in the outpatient department for eight months. His leg pain became increasingly severe requiring several changes in analgesics. The systemic disease had spread to his lung, liver, spleen, and skeletal system. Finally, in July 1975, he was admitted to
Memorial for the third time. He had lost 15 kg (33 pounds) since his previous admission and had a wizened appearance. He talked about the aloneness of pain. He knew he was dying and said he'd thought about suicide. In addition to pain and anxiety, he had numerous other nursing needs including loss of appetite, edematous left back, constipation, and delusions and confusion due to increased calcium. After several -days on a low calcium diet, his confusion cleared but returned periodically. He was encouraged to be up and about and take at least 2,000 cc fluids per day. It had been hoped that Sol could return home, but because of his deteriorating condition and periodic confusion, it was apparent he could be managed better in a nursing home. He was upset by this and felt abandoned not only by his wife, but by the hospital because it could do nothing more for him. Barbara was realistic and realized she could not care for him at home, but she felt guilty about asking him to go to a nursing home. We felt inadequate in dealing with Sol's feeling of abandonment, so we asked the family rabbi who frequently visited Sol and Barbara to help them. With the rabbi's understanding and counseling, Sol realized that his physical needs were too much for Barbara to manage. Barbara began to attend weekly family meetings conducted by the hospital's department of social work. Group members listened to her concerns and gave her support by identifying many of her problems as similar to their own. This seemed to help her realize she wasn't alone in her fears of cancer and death, although she wondered about the futility of his life being prolonged. Before Sol went to the nursing home, Barbara visited it, and we discussed his care with its nursing staff. At the time of his transfer, he was accompanied by a written nursing care plan. When Sol returned to the neurology clinic at Memorial for an appointment, Barbara visited us on the ward. She said Sol seemed to be adjusting to the nursing home, his pain was being controlled, and he was sleeping through the night.
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Photos by Rose M Lee, RN
William S Howland, M D
Kathleen M Foley, M D attitude causes many cancer patients to suffer needlessly,” Ms Zelski said. Or, the nurse may go to the other extreme and give an analgesic every four hours whether the patient needs it or not. “A more rational approach,” suggests Ms Zelski, “is to consider each complaint separately.” Dr Foley said she occasionally finds it necessary to order regularly scheduled narcotics around the clock. Several nurses from the audience questioned this practice. Dr Foley explained she “also disagreed” with having to regularly schedule medication around the clock but ”found this to be the only acceptable way of delivering medication to the patient when he is having pain.” She pointed out that a patient may request pain medication at 330 pm, but because of shift change, reports, and so forth, the patient may not receive it until 1 to 11/2 hours later. ”The patient in pain is not the primary problem of the nurse at that time,” Dr Foley said. “The only way to get around this . . . is to let patients have pain meds at the bedside. There’s no reason why they can‘t control these meds in the hospital as well as they do at home. This is a goal we will work
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for. Right now, there are legal problems associated with narcotics being so widely dispersed in the hospital,” she explained. Ms Zelski said, “It is unfortunate that pain meds sometimes have to be scheduled to be given every four hours around the clock.” She pointed out that the nurse must still use her judgment in administering the order. As an example, she said, “If the patient is obviously lethargic and not complaining of pain, the drug may be withheld. Or if the patient is in pain, the next dose may be given before the time period is up.” “The rigid adherence to a schedule of narcotics for patients with intractable pain is unfortunate,” Jerome B Posner, MD, said. He is chief, neuropsychiatric service, and attending physician, department of medicine, Memorial Hospital for Cancer and Allied Diseases. “If there is a q4h prn order written and the patient begins to develop pain in 3112 hours, the nurse should dispense the medication and get the order rewritten. Either the medication has to be changed or the time interval at which it’s given is going to have to be shorter. There is ample evidence that once pain gets severe . . . it requires a greater dosage to relieve. This is the reason
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Linda Zelski. RN patients are awakened in the middle of the night and given their analgesic so they don’t wake up later with severe intractable pain.” According to Dr Posner, “Nurses often fail to take responsibility in administering analgesics. They simply take the med to the bedside and say, ‘This is what the doctor ordered.’ They don’t use the flexibility their profession requires. As far as we physicians are concerned, if you come to us and say, ‘That drug needs to be given more often,’ or ‘You‘ve got to change drugs,’ or ‘You’ve got to increase the dose,’ those orders should be written immediately. Yes, indeed, you should make the decisions, Dr Posner asserted, “but you should tell us about it because legally we have to write the order.” Pain at Memorial is controlled chiefly by narcotic analgesics, William S Howland, MD, said, pointing out that marked advances in tumor therapy have decreased the need for the anesthetic approach to pain. Dr Howland is deputy general director and chairman of the department of anesthesiology at Memorial Hospital for Cancer and Allied Diseases. But occasionally peripheral nerve blocks or subarachnoid blocks are employed for intractable pain. “Initially, we start with short-
acting drugs like lidocaine, then if that doesn’t relieve the pain, we use alcohol and phenol. With a good nerve block,” Dr Howland said, “narcotics are not needed and you don’t have the classical withdrawal symptoms.” He said that, in general, one out of four patients treated with alcohol and phenol will have no pain relief. On a pessimistic note, Dr Howland predicted that the threat of malpractice will “drive us out of this field.” Most of the relief of cancer pain will probably be in the field of chemotherapy and more and improved narcotics, he said. Dr Foley explained that acupuncture and hypnosis are being considered at Memorial as possible adjuvant therapy for relief of cancer pain. “To date, we have not found acupuncture a successful tool in treating cancer pain,” she said, explaining that it was tried in 38 outpatients. In general, it worked only in patients whose pain was ill defined (commonly not associated with their cancer and secondary to other problems) and in patients who were highly suggestible to any means of pain control.
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chemotherapy treat osteogenic cancer Aggressive chemotherapy and a surgical technique to replace cancerous bone with a metal, femur has given 17 youngsters at Memorial Hospital for Cancer and Allied Diseases, New York City, a fighting chance against osteogenic sarcoma. Previously, the only hope was amputation with a cure rate of about 17% or one out of six patients. Now, instead of amputation, the femur, knee joint, and upper tibia are removed in most cases and replaced with a Vitallium (cobalt-chromium) prosthesis. The key to the technique is an aggressive attack on the cancer with potent drugs to attack the sarcoma in various stages of its life cycle. Chemotherapy is begun before surgery to kill as many cancer cells as possible and continued after surgery to kill off any lingering cells. Development of the chemotherapy protocol was begun late in 1971 by Pediatrician Gerald Rosen, MD. The first femur replacement took place in December 1973. The new metal femur and the operation used at Memorial were designed by Ralph C Marcove, MD, associate attending surgeon and acting chief, bone service. Preliminary results of the therapy have led Memorial physicians to predict five out of six patients are expected to be cured. Osteogenic sarcoma is a relatively rare disease in the United States with about 500 Americans, almost all teenagers, stricken each year. It is the third most common cancer among adolescents. One of the big problems in treating osteogenic sarcoma is metastasis, Edward J Beattie, Jr, MD, said at the cancer nursing symposium. He is general director and chief
executive officer of Memorial Hospital, and chairman, department of surgery, and a member of the hospital's interdisciplinary team treating osteogenic sarcoma. Dr Beattie explained that in certain situations the primary tumor can be removed successfully, but within a year after amputation, eight out of ten patients develop lung metastases and die six to nine months later. The use of prophylatic chemotherapy is giving encouraging early results in that about 80% of patients treated are free of disease. "Dr Rosen's promising results with chemotherapy prompted us to combine aggressive surgical removal with aggressive chemotherapy in treating patients with pulmonary metastases," Dr Beattie explained, adding that the rationale is to remove gross tumors and treat residual disease with systemic chemotherapy. He described several cases including one in which a patient has undergone six thorocotomies to remove disease. "We know from our experience that many more tumor nodules can be found by the surgeon at thorocotomy than are seen in chest x-ray," he said. He pointed out that studies at Memorial have shown that over 25% of patients can be salvaged by aggressive surgical removal of pulmonary metastases if the metastases are not too numerous. He said the percentage of long-term survival in the group treated with thoracic surgery combined with chemotherapy is not yet known. "But, to date, the early referral of the osteogenic sarcoma patient for adjuvant therapy after surgery offers the most promising course for lengthening survival," Dr Beattie said. He said the approach used in treating patients with osteogenic sarcoma is an "ideal example" of an aggressive interdisciplinary approach. This includes chemotherapy to eliminate gross disease and reduce the size of the tumor in the leg thus decreasing the need for extensive surgery; surgical resection of the primary tumor and replacement with prosthesis; thoracic surgery to remove mestastastic lesions, and the subsequent use of chemotherapy to keep the disease in remission. Dr Beattie emphasized that this therapy can only be done in a center where the patient receives the needed supportive
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care during the devastatingly toxic chemotherapy. “This approach shows what can be done with the tools at hand even if we don’t know what causes cancer,” Dr Beattie said. “What has been done with osteogenic sarcoma, to my way of thinking, shows there is no reason why it can’t be done with other kinds of cancers in children and adults. It remains to be proven, but I do think it’s absolutely possible. With this kind of approach and early diagnosis, we don’t have to wait for the day after tomorrow when we have an understanding of the underlying mechanism of cancer.” The age of patients undergoing femur replacement at Memorial has ranged from 11 to 31 years. Nancy Strafford, RN, pointed out that many of the patients are hospitalized at a time when he or she has attained independence, or if an adolescent (on the periphery of adulthood) at about the time they would naturally be seeking it. A clinical nurse on the pediatric service at Memorial Hospital, Ms Strafford said frustration is inevitable as the patient faces the long confinement of hospitalization, the pain of chemotherapy, and the threat to his image and self-identity by loss of hair and loss of or diminution of limb function. The prospect of failure-the procedure is experimental and the possibility of failure does exist-and of possible death is frightening, Ms Strafford said. “Nursing intervention can provide optimum growth and development and make hospitalization a constructive experience for the adolescent and his family,” Ms Strafford said. She stressed truthfulness in establishing a trusting relationship with the patient. “He‘ll ask questions that reflect the extent of the answers he wants,” she said. In the period before surgery patients undergo one or more 38-day cycles of chemotherapy consisting of vincristine sulfate, high-dose Methotrexate with citrovorum factor rescue, Adriamycin and Cytoxan, Dr Rosen explained. Methotrexate, one of the oldest cancerfighting drugs, is a folic acid antagonist that inhibits DNA synthesis. Once inside the cancer cell, it prevents the cell from dividing and multiplying and eventually kills it. Because Methotrexate is given in doses
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high enough to destroy normal cells as well, citrovorum factor (folinic acid), the active form of folic acid, is given. It acts as an antidote to “rescue” normal cells from the cytotoxic onslaught of Methotrexate. Adriamycin is an antitumor antibiotic and inhibits RNA formation. Dose-related side effects include nausea and vomiting, hair loss, leukopenia, stomatitis, bone morrow depression, and cardiotoxicity. Cytoxan is given to help control the disease and allow continuation of chemotherapy. Its side effects include nausea and vomiting, alopecia, diarrhea, skin rash, and bone morrow depression. Toxicity signs include pancytopenia, hemorrhagic cystitis, and fluid retention. At Memorial Hospital the effect of chemotherapy is confirmed by osseous arteriography directed by R Caird Watson, MD, attending roentgenologist and chairman, diagnostic radiology. The AP and lateral arteriograms provided by Dr Watson enable Dr Marcove to see the size of the tumor and its location in relation to adjacent blood vessels, and to choose an optimum site for biopsy. (The diagnosis of osteogenic sarcoma is confirmed by open biopsy.) It takes about three to four months for the prosthesis to be manufactured. Scanogram measurements to match the patient’s femur with the prosthesis permit up to a millimeter of accuracy, Dr Marcove explained. The patient is scheduled for femur replacement upon completion of chemotherapy and return of the patient’s blood count and nutritional status to a satisfactory level. The patient is introduced preoperatively to equipment and techniques to be used in his postoperative treatment, explained Cathy Bagnal, RN, clinical nurse, pediatric service. “For example, he is shown how to use blow bottles to increase his vital capacity and strengthen respiratory muscles. It is explained that a closed suction drainage system will be used to drain isotonic saline and plasma accumulating in the third space, the area vacated by removal of muscle and diseased bone. The patient is told he will have a Foley catheter in place for a few days postoperatively and antibiotics will be administered intravenously until his wound heals. He will be on complete bed rest for four to six
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weeks so he is taught how to use the bed trapeze to ease movement in bed and prepare his arms for crutch walking. He is also shown how the bed is made with him in it. It is explained that the head of his bed will be lower than his feet to prevent tension on the new femur. And, he is fitted for the hip belt and brace he will wear after surgery to fixate the limb,” Ms Bagnal explained. The surgical procedure takes about 10 hours. The femur, knee, and upper tibia are removed en bloc along with overlying muscle. The sciatic nerve, femoral vessles, abductor muscles, and lymph vessels are carefully preserved. The eight-inch stem of the prosthesis is inserted into the medullary cavity of the tibia and fixed with methyl methacrylate cement. One continuous envelope is formed by suturing the gluteus medius muscle and the tensor fascia lata over the prosthesis to the fascia lata and the outer thigh muscle. The remaining thigh fascia are sutured around the prosthesis. Following surgery, the patient spends his first night in the recovery room. The primary concern there, according to Ms Bagnal is fluid and electrolyte balance and maintenance of the patient’s cardiovascular and respiratory status. Symptoms of loss of isotonic saline and plasma into the third space include decreased central venous pressure, decreased blood pressure, and increased pulse. This requires replacement with plasma of up to one-fourth of the patient’s total blood volume for two to three days postoperatively, Ms Bagnal explained. Due to the lengthy anesthesia and intubation, the patient is prone to develop respiratory complications. He is encouraged to cough and deep breath and use blow bottles to clear his airway and decrease the possibility of developing atelectasis and pneumonia. Medication is given as needed for pain, and the affected leg is elevated on two pillows and externally rotated and slightly abducted to prevent hip dislocation. Foot drop is prevented by placing the patient’s foot in a neutral position and encouraging him to wiggle his toes as much as possible. Upon transfer from the recovery room, nursing care aims deal primarily with preventing complications of the respiratory, gastroin-
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testinal, cardiovascular, urinary or integumentary systems; preventing sepsis of the wound or other structures such as the bladder or lungs; and preventing physiological or psychological stress. The ultimate goal in the hospital is enabling the patient to progress from bed rest to walking with a cane.
Lung cancer, Ieading kiIIer , is curable in early stage In the past 40 to 50 years there has been a
2,000% increase in lung cancer in males, and today, this largely preventable disease is the leading cancer killer of United States men. It is the third leading cancer killer in women surpassing uterine cancer. Cigarette smoking, alone, is the cause of 80% of lung cancer deaths. Those statistics were cited by Nael Martini, MD, director of intramural education and attending surgeon and chief, thoracic service, Memorial Hospital for Cancer and Allied Diseases, in a speech on lung cancer at the recent international cancer nursing symposium in New York City. Dr Martini pointed out that with early detection one-half of early lung cancer is curable by present day therapy. “Without early detection, however, 10% of patients with lung cancer are alive five years hence. Unfortunately,” he said, “both early detection and early diagnosis continue to lag behind in that it takes three to four months for a symptomatic patient with lung cancer to seek medical advice, and an additional three to four months for a diagnosis to be established. By this time far too many have disease that is advanced beyond the scope of cure.” Lung cancer cells may be rapid or slow
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growing, Dr Martini explained. Slow-growing types include epidermoid (comprises 85% of lung cancer) and adenocarcinoma (29% incidence). An aggressive and rapid growing cell that occurs in 15% of cases is the small oat cell. It is "uniformly fatal and difficult to control," he said He pointed out that the use of fiberoptic bronchoscope has increased the chance of tissue diagnosis (to confirm and classify tumor types) 65% to 70%. "In many instances, however, confirmatory diagnosis must be made by thorocotomy," Dr Martini stated. There is no universal screening test for lung cancer but Dr Martini suggested that an effective way of saving more lives may be achieved by identifying high-risk groups and providing them with periodic checkup. The high-risk group, according to Dr Martini, includes males 45 and over and females 55 to 64 who have smoked at least one pack of cigarettes per day for the last 20 years. In the absence of symptoms, sputum cytology and chest x-ray are the only two methods available for early detection. Dr Martini said it is now possible to determine some cases with sputum cytology in the absence of visible abnormality on chest x-ray. Prognosis of cure is 60% to 70% in patients undergoing localized resection with early positive sputums cytology, no visible abnormality on chest x-ray, and no involvement of regional lymph nodes He said that at Memorial coin, or radiographically visible, lesions are picked up by chest x-ray in about one-third of the patients who have no chest symptoms. He said there is a potential five-year cure rate in 40% to 50% of lesions that are visible on chest x-ray but confined to the lung parenchyma without invasion of adjacent structures. He emphasized that all disease must be removed at the time of surgery. He said external irradiation alone has limited curative value. "In instances where tumors are not resectable because of their precarious locationnear major vessels or the spine-it is possible to seed the tumor at thoroctomy with a radioactive substance. Thus, internal radiation permits a 10% five-year survival rate in
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Study nursing not nurses "Too many nursing studies focus on nurses rather than nursing; on the needs of nurses rather than the needs of patients." Thus contends Marilyn Oberst, RN, EdD, director of nursing practice, Memorial Hospital for Cancer and Allied Diseases. Speaking at the cancer nursing conference, she said, "The focus of clinical research must be on patients and the care they receive." She explained that much of current nursing knowledge is based on medical knowledge, and changes in nursing care are based on medical action. "Bold new nursing knowledge needs to be developed by nurse clinicians and researchers who have failed in the past by not documenting outcomes in terms of patient response to their action." According to Ms Oberst, practitioners and clinicians in the field are in the best position to design, test, and conduct the research. Her two-fold challenge: to get research out into the clinical setting and to get nurses involved in research. these otherwise nonresectable lesions," Dr Martini explained. Chemotherapy is mainly used for advanced or disseminated disease, he said, explaining that "Recently, efforts are underway to combine systemic chemotherapy with surgery and irradiation when disease is still localized with the hope of improving overall results." He said, immunotherapy is evolving as an important fourth form of cancer therapy. "Although it is in use as part of an interdisciplinary approach to treatment," Dr Martini said, "it is too early yet to comment on its relative merits."
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Cancer research links levels of science If you want a glimpse of what may lie ahead in cancer research, one of the places to watch most closely is a comprehensive cancer center, says a physician who lives in one. He is Lewis Thomas, MD, president of Memorial Sloan-Kettering Cancer Center. He spoke on the progress of cancer research at the recent cancer nursing symposium in New York City. Dr Thomas explained that the center is primarily a "scientific center" and "its business is to find new answers to the problem of cancer." Its science may be arbitrarily divided into today's science, tomorrow's science, and the science of the day after tomorrow, he said, explaining that in this classification, a day is a "finite period of time, but not by any means a 24-hour period." "Everything that is done must be related to one or another of these relatively separate levels of science," he said, pointing out that success depends on linking the levels so they become one coherent whole. Today's science. According to Dr Thomas, today's science is what goes on in the hospital. Its problem is to treat cancer by the removal or destruction of cancer tissue with the least possible damage to other tissues. He said the central question of today's science is which technique is the best for a given type of cancer and what is the evidence for a decision of this kind. "It may come as a surprise to some of you to hear the term science used for the everyday, day-to-day patient care functions of a hospital, and yet this is exactly what goes on," Dr Thomas said. The day-to-day work of the hospital is "proper clinical science," the
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"careful assembly of large amounts of hard data, long patient observation, meticulous clinical judgment, and a good sense of scientific balance." According to Dr Thomas, it is this level of science that enables surgeons, such as Edward J Besttie, Jr, MD, to say "with certainty" that the 20-year survival of patients with breast cancer who come in with small, localized cancers and have a radical mastectomy is about 90%. "He has solid data to show precisely how this high survival rate is affected when patients are seen later in the disease or subjected to other forms of treatment," Dr Thomas said. When modalities such as radiation and chemotherapy are evaluated, clinical science becomes even more complex and demanding, he said. He pointed out that the early diagnosis of cancer is itself a scientific effort and "obviously an important one." Today's science represents an enormous amount of effort and money. Dr Thomas continued, "Sometimes the payoff is great, as in the treatment of childhood cancer. At other times, the gains are slower in coming and only marginal in effect." He said clinical science is "itself remarkable and even more remarkable for what it says about the relationship between good science and good clinical care." In the public mind, good science is often equated with an obsession with cold facts. "A cancer hospital stands as living disproof of this," Dr Thomas said. "I have never known a hospital where so many of the staff workers are so deeply and emotionally concerned with the welfare of the patients as individual human beings . . . even though I can't explain it, the science doesn't interfere with compassion, and I rather suspect that the two support each other in a strange way that I've not seen in other institutions." Tomorrow's science. The key question posed by this second level of research is, Are there ways of getting at, and destroying selectively, cancer cells in human beings, which are quite different from today's techniques of surgery, radiation, and chernotherapy? In this new territory, Dr Thomas said, the research laboratory is the main source of
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ideas and techniques, but "the hospital remains the proving ground." At the moment, immunology is the most "promising approach," Dr Thomas said, explaining that "irnmunotherapy derives from the idea . . . that the same immunological defense apparatus that we use for defense against invasion of bacteria and viruses ought . . . to protect us against cancer cells. At the root of this . . . is another essential notion that cancer cells are themselves somehow foreign, and their foreignness ought to be recognizable by the cells of the immune system." Dr Thomas said there is now "good evidence" that this is so. But the problem of how to turn the immunological response on and direct it against cancer cells is unimaginably complicated. "Almost everything we need to know is still ahead of us waiting to be found out." Dr Thomas said his "own private hunch . . . is that this is going to work." He predicted that immunotherapy will someday provide a "completely new technology" that will be "exquisitely selective, precise, and totally destructive of cancer cells." He pointed out that clinical and basic scientists have already learned that cancer patients tend to have defects in their general immune responsiveness and patients with a poor prognosis have the poorest responses. "Efforts to bring about nonspecific stimulation of the immune response are . . . beginning to yield promising results . . . ," he said. Science of the day after tomorrow, The cancer science for the day after tomorrow seeks an understanding of the underlying process of cancer, Dr Thomas said, explaining that "we are profoundly ignorant about the real nature of a cancer cell." He said viruses may be "centrally involved" and the basic processes of cell differentiation and membrane labeling are "surely involved." Fieids for inquiry include cellular genetics, molecular biology, immunological recognition systems, the regulators of growth and differentiation, and "perhaps even influences of the nervous system. "We have come far enough along in the biological revolution to know . . . that the problem of cancer is an approachable and soluble biological problem even though none of us would dare predict whether we will
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reach it in this decade or in the next century," he said. Dr Thomas has predicted that "at the end of the line" when the underlying mechanism of cancer is understood, the hospital may be transformed by changes in cancer therapy. He said he has a "hunch" that therapeutic measuies will probably be "simpler, more direct and decisive than we can imagine today." He believes the cost of treating cancer will be reduced "just as the cost of treating lobar pneumonia was reduced by penicillin or typhoid by chloromycetin." In the immediate future he foresees drastic changes in cancer treatment. "We will be living in an environment of change as the result of both clinical and basic research," he predicted. He said that nursing and medicine must become symbiotic or jointly involved at "every stage" if clinical research and the extension and application of research findings to patient care in general are to succeed. Dr Thomas referred to nursing and medicine as synergetic professions. "Neither can exist alone nor have its life taken over by the other; whatever happens to change the strength and productivity of either, for good or illl will surely and quickly have corresponding effects on the other. Linked together, they can accomplish considerable more than the simple sum of the two parts." Because of the symbiotic relationship between nursing and medicine, the role of nursing in the national cancer program is of special significance, Dr Thomas said. "Never before in human society has such a grandscale effort been mounted to rid ourselves of a single disease, and it is obvious that nursing, side by side with medicine, has a crucial part to play in this."
AORN Journal. December 1975, Vol22, No 6
International symposium on cancer nursing Rose Marie Lee, RN Nurse editor
he key to cancer nursing is understanding, Rachel Ayers, RN, MS, told an audience of 1,561 nurses attending an international symposium on cancer nursing Sept 3-5 in New York City. She said cancer touches the lives of all of us at sometime. "In every instance, nurses must be there. They have a role to play if people are to have that unique component of oncology nursing-understanding. It is a difficult task, and it takes a lot of care. But caring is what nursing is all about.'' Mrs Ayers is assistant vice president and chairman, department of nursing, Memorial Hospital for Cancer and Allied Diseases, New York City. She was one of about 85 members of the center's interdisciplinary team of nurses, physicians, social workers, physical therapists, and dietitians who spoke at the symposium. Attendees represented nearly all of the United States, and seven of Canada's ten provinces. Some of the other countries represented were Australia, Egypt, England, Israel, Jamaica, Japan, New Zealand, Panama, Puerto Rico, Sweden, Switzerland, Thailand, and Venezuela. The symposium was sponsored by Memorial Sloan-Kettering Cancer Center (MSKCC), a comprehensive cancer center that includes a new $50 million, 565-bed referral hospital and the Sloan-Kettering Institute for Cancer Research, founded in 1945 to complement research being carried out at Memorial Hospital. Today, it is the largest privately operated cancer research operation in the country. The new hospital opened in 1973 and replaces the old Memorial Hospital building and the James Ewing Pavilion. It represents the realization of an idea that dates back to 1884 when Memorial Hospital was founded to provide a special institution to treat cancer patients. It was the first hospital in the country based on the idea that cancer could best be treated in a hospital whose entire staff and resources were mobilized to subdue and eradicate it. About 5,000new cancer cases are seen each year at Memorial with about 75% of the patients coming from the New York metropolitan area. "Memorial probably has the sickest patients of any hospital in the United States,"
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says Edward J Beattie, Jr, MD. He is general director and chief executive officer, Memorial Hospital for Cancer and Allied Diseases. Its staff of 4,500 includes about 550 registered nurses. The theme of the center-sponsored conference was the emerging specialty of oncology nursing. "Without question, oncology nursing is on the move as a viable specialty," Mrs Ayers said, pointing out that because there are so many diseases of cancer, the spectrum of treatment modalities is becoming increasingly complex for nurse practitioners. "Just as there are growing numbers of medical oncology subspecialists, nurse specialists of both professional and technical nature are appearing on the scene at a breathtaking rate," Mrs Ayers said. Some of these specialists at MSKCC include the family nurse practitioner, nurse epidemiologist, total parenteral nutrition (TPN) nurse, chemospecialist who administers chemotherapeutic drugs and monitors the patient's reaction, mental health specialist, stoma nurse, dialysis nurse, analgesic studies nurse, immunotherapy research nurse who procures blood samples and prepares them for research studies to isolate antigens, advanced nurse practitioners, clinical instructor, pediatric nurse practitioner, clinical nurses in specialty areas such as transplantation, and nurses who work in the special procedures department of diagnostic radiology or therapeutic radiation where the badge, "bald is beautiful," is popular with pediatric patients. Mrs Ayers pointed out that oncology nurses include not only those who work in major oncology centers as part of an interdisciplinary team of specialists but also individual nurses in community hospitals who care for the cancer patient along with other patients who may have diabetes, hypertension, or any number of surgical diseases. "There are many lonely artists facing up to the complex, intense, unique demands that cancer presents to all of us,'' she said. One problem nursing must face, Mrs Ayers said, is the "disparity of service" provided around the world. "It is true that cancer centers and health care/teaching institutions with major oncology programs have resources that include an impressive array of highly specialized nurse practitioners. But what
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Nurse's attitude toward pain affects approach The word cancer brings to mind pain, although some cancers are not in themselves associated with pain. But oncology nurses know only too well the debilitating physical and psychological effect pain can have. For the nurse, probably more than any of the other health professionals who deal with pain, has the most direct daily contact with the patient in pain. It is he or she, for example, who shares the long nights that seem endless for the patient in pain. It is the nurse who knows when too little or too much pain medication is prescribed. And it is the nurse who often sees how anxiety, fear, boredom, and fatigue can potentiate pain. "Sometimes the nurse feels hindered and often helpless in facing human suffering," Linda Zelski, RN, said at a special interest
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session on pain at the cancer nursing symposium. “It may be impossible to alleviate the cause of pain, especially in cancer, but nurses can offer patients some relief of pain and general comfort,” she said optimistically. Ms Zelski is a clinical instructor, medical service, Memorial Hospital for Cancer and Allied Diseases. Kathleen M Foley, MD, pointed out that the management of intractable pain requires a multidisciplinary approach for successful therapy. The first line of treatment, according to Dr Foley, is detailed diagnostic studies to assess the nature of pain and prescribe specific therapy. Dr Foley is assistant attending physician, neuropsychiatric service, Memorial Hospital for Cancer and Allied Diseases. Dr Foley believes analgesics should be employed early for the temporary relief of pain. “Initially we place the patient on aspirin or Tylenol to see what his response is. Commonly, there is no response so we immediately move to short-acting narcotic analgesics such as Percodan or Demerol. If these are not holding the patient or they need more sustaining drugs, we give LevoDromoran or methadone.” She said she prefers methadone to Levo-Dromoran because it does not have the sedative effect and enables patients to be awake, ambulatory, and in pain control. “We use tranquilizers and psychotropins as needed and increase drug intake as tolerance develops,” Dr Foley explained. “Too often,” Ms Zelski said, “the only nursing intervention in pain is administration of analgesics.” She explained that measures to relieve pain, such as back rubs, position changes, splinting incisions and encouraging fluid intake to make coughing easier, insuring that patients receive rest, efforts to counteract boredom, and decreasing noxious stimuli are often not even tried. She said the nurse’s attitude toward pain may affect her approach to pain in her patients. For example, if he or she values emotional control and stoicism, he or she finds crying and complaining of pain unacceptable. Attitude, too, may affect the way analgesics are administered. On the one hand, the nurse may withhold narcotics fearing the patient may become addicted. “This
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Intractable pain: A case study The following case study is about Sol, a 41 -year-old lawyer, who has intractable pain associated with bladder cancer metastasis. It was related by Nessa Coyle, RN, nurse clinician, neurology service, Memorial Hospital for Cancer and Allied Diseases, at a session on pain. The time span of the study is about two years, from the time Sol was first diagnosed to three subsequent hospital admissions, and finally, to predying care in a nursing home. Ms Coyle explained that Sol presented, as many patients at Memorial, a complex nursing problem that, along with the progression of his disease and his pain and anxiety, taxed the ingenuity of the nursing staff. “His mounting problems were like a constant reproach giving us a sense of inadequacy and failure. It was very important that a multidisciplinary team work closely to arrive at an understanding of Sol’s physical and emotional problems,” she said. In July 1973, Sol underwent partial cystectomy for cancer of the bladder. Four months later cystoscopy revealed numerous lesions, and he was informed his prognosis was guarded. Seven months later, he developed pain along the lateral aspect of his left leg. The pain was unrelated to position or movement and at first was relieved by Darvon. Gradually, it became worse, requiring strong analgesics, and the resulting exhaustion from persistent pain made it difficult for him to work. Despite drug manipulation, psychotherapy, acupuncture, and transcutaneous stimulation, the pain persisted. Finally, 13 months after his original surgery, he was seen as an outpatient in the pain clinic at Memorial. Initially, Sol was depressed and angry because no cause for his pain was found. He was given analgesics and Elavil, 50 mg, at HS to help him sleep. His primary concern was the pain in his leg and not the fact he had cancer. About a month later when he began to talk of suicide, he and his wife literally demanded he be admitted to Memorial to evaluate his
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disease and control his pain. A laparotomy revealed bladder cancer had invaded the left lumbar plexis. Thus disease progression was the cause of his leg pain. In recounting the case, Ms Coyle said though it was difficult to communicate with Sol at this time, we had to be firm and demand he cooperate to avoid further complications and promote rehabilitation. We set new goals for him daily and offered positive feedback for his efforts. He was medicated before ambulation and postop exercises to keep discomfort to a minimum. To improve his appetite, Ms Coyle said, we gave him antiemetics, but also served him small portions of his favorite foods. Throughout his ordeal, Sol was concerned about Barbara, his wife of 14 years. Barbara had been under intermittent psychiatric care since she was 17 and described herself as needing someone to lean on. Sol talked to the nurses about his wife and children, two daughters, 13 and 11, and both he and Barbara expressed concern that he would not be able to care for them. Radiation therapy was begun following surgery. This made Sol feel something positive was being done and confident that it would enable him to return to normal activities. Once he knew the cause of his pain, he seemed to tolerate its presence with more ease. He was sent home on Percodan and only required about 45 tablets daily. For two months he continued to receive radiation therapy as an outpatient and returned to part-time work in a law partnership. He then developed left foot weakness and increasing pain in his left knee and ankle. A bone scan revealed metastasis. Efforts at this time to control the disease included radiation therapy to his foot, knee, and ankle and chemotherapy with 5-Fluorouracil and Cytoxan. He was seen in the outpatient department for eight months. His leg pain became increasingly severe requiring several changes in analgesics. The systemic disease had spread to his lung, liver, spleen, and skeletal system. Finally, in July 1975, he was admitted to
Memorial for the third time. He had lost 15 kg (33 pounds) since his previous admission and had a wizened appearance. He talked about the aloneness of pain. He knew he was dying and said he'd thought about suicide. In addition to pain and anxiety, he had numerous other nursing needs including loss of appetite, edematous left back, constipation, and delusions and confusion due to increased calcium. After several -days on a low calcium diet, his confusion cleared but returned periodically. He was encouraged to be up and about and take at least 2,000 cc fluids per day. It had been hoped that Sol could return home, but because of his deteriorating condition and periodic confusion, it was apparent he could be managed better in a nursing home. He was upset by this and felt abandoned not only by his wife, but by the hospital because it could do nothing more for him. Barbara was realistic and realized she could not care for him at home, but she felt guilty about asking him to go to a nursing home. We felt inadequate in dealing with Sol's feeling of abandonment, so we asked the family rabbi who frequently visited Sol and Barbara to help them. With the rabbi's understanding and counseling, Sol realized that his physical needs were too much for Barbara to manage. Barbara began to attend weekly family meetings conducted by the hospital's department of social work. Group members listened to her concerns and gave her support by identifying many of her problems as similar to their own. This seemed to help her realize she wasn't alone in her fears of cancer and death, although she wondered about the futility of his life being prolonged. Before Sol went to the nursing home, Barbara visited it, and we discussed his care with its nursing staff. At the time of his transfer, he was accompanied by a written nursing care plan. When Sol returned to the neurology clinic at Memorial for an appointment, Barbara visited us on the ward. She said Sol seemed to be adjusting to the nursing home, his pain was being controlled, and he was sleeping through the night.
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Photos by Rose M Lee, RN
William S Howland, M D
Kathleen M Foley, M D attitude causes many cancer patients to suffer needlessly,” Ms Zelski said. Or, the nurse may go to the other extreme and give an analgesic every four hours whether the patient needs it or not. “A more rational approach,” suggests Ms Zelski, “is to consider each complaint separately.” Dr Foley said she occasionally finds it necessary to order regularly scheduled narcotics around the clock. Several nurses from the audience questioned this practice. Dr Foley explained she “also disagreed” with having to regularly schedule medication around the clock but ”found this to be the only acceptable way of delivering medication to the patient when he is having pain.” She pointed out that a patient may request pain medication at 330 pm, but because of shift change, reports, and so forth, the patient may not receive it until 1 to 11/2 hours later. ”The patient in pain is not the primary problem of the nurse at that time,” Dr Foley said. “The only way to get around this . . . is to let patients have pain meds at the bedside. There’s no reason why they can‘t control these meds in the hospital as well as they do at home. This is a goal we will work
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for. Right now, there are legal problems associated with narcotics being so widely dispersed in the hospital,” she explained. Ms Zelski said, “It is unfortunate that pain meds sometimes have to be scheduled to be given every four hours around the clock.” She pointed out that the nurse must still use her judgment in administering the order. As an example, she said, “If the patient is obviously lethargic and not complaining of pain, the drug may be withheld. Or if the patient is in pain, the next dose may be given before the time period is up.” “The rigid adherence to a schedule of narcotics for patients with intractable pain is unfortunate,” Jerome B Posner, MD, said. He is chief, neuropsychiatric service, and attending physician, department of medicine, Memorial Hospital for Cancer and Allied Diseases. “If there is a q4h prn order written and the patient begins to develop pain in 3112 hours, the nurse should dispense the medication and get the order rewritten. Either the medication has to be changed or the time interval at which it’s given is going to have to be shorter. There is ample evidence that once pain gets severe . . . it requires a greater dosage to relieve. This is the reason
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Linda Zelski. RN patients are awakened in the middle of the night and given their analgesic so they don’t wake up later with severe intractable pain.” According to Dr Posner, “Nurses often fail to take responsibility in administering analgesics. They simply take the med to the bedside and say, ‘This is what the doctor ordered.’ They don’t use the flexibility their profession requires. As far as we physicians are concerned, if you come to us and say, ‘That drug needs to be given more often,’ or ‘You‘ve got to change drugs,’ or ‘You’ve got to increase the dose,’ those orders should be written immediately. Yes, indeed, you should make the decisions, Dr Posner asserted, “but you should tell us about it because legally we have to write the order.” Pain at Memorial is controlled chiefly by narcotic analgesics, William S Howland, MD, said, pointing out that marked advances in tumor therapy have decreased the need for the anesthetic approach to pain. Dr Howland is deputy general director and chairman of the department of anesthesiology at Memorial Hospital for Cancer and Allied Diseases. But occasionally peripheral nerve blocks or subarachnoid blocks are employed for intractable pain. “Initially, we start with short-
acting drugs like lidocaine, then if that doesn’t relieve the pain, we use alcohol and phenol. With a good nerve block,” Dr Howland said, “narcotics are not needed and you don’t have the classical withdrawal symptoms.” He said that, in general, one out of four patients treated with alcohol and phenol will have no pain relief. On a pessimistic note, Dr Howland predicted that the threat of malpractice will “drive us out of this field.” Most of the relief of cancer pain will probably be in the field of chemotherapy and more and improved narcotics, he said. Dr Foley explained that acupuncture and hypnosis are being considered at Memorial as possible adjuvant therapy for relief of cancer pain. “To date, we have not found acupuncture a successful tool in treating cancer pain,” she said, explaining that it was tried in 38 outpatients. In general, it worked only in patients whose pain was ill defined (commonly not associated with their cancer and secondary to other problems) and in patients who were highly suggestible to any means of pain control.
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chemotherapy treat osteogenic cancer Aggressive chemotherapy and a surgical technique to replace cancerous bone with a metal, femur has given 17 youngsters at Memorial Hospital for Cancer and Allied Diseases, New York City, a fighting chance against osteogenic sarcoma. Previously, the only hope was amputation with a cure rate of about 17% or one out of six patients. Now, instead of amputation, the femur, knee joint, and upper tibia are removed in most cases and replaced with a Vitallium (cobalt-chromium) prosthesis. The key to the technique is an aggressive attack on the cancer with potent drugs to attack the sarcoma in various stages of its life cycle. Chemotherapy is begun before surgery to kill as many cancer cells as possible and continued after surgery to kill off any lingering cells. Development of the chemotherapy protocol was begun late in 1971 by Pediatrician Gerald Rosen, MD. The first femur replacement took place in December 1973. The new metal femur and the operation used at Memorial were designed by Ralph C Marcove, MD, associate attending surgeon and acting chief, bone service. Preliminary results of the therapy have led Memorial physicians to predict five out of six patients are expected to be cured. Osteogenic sarcoma is a relatively rare disease in the United States with about 500 Americans, almost all teenagers, stricken each year. It is the third most common cancer among adolescents. One of the big problems in treating osteogenic sarcoma is metastasis, Edward J Beattie, Jr, MD, said at the cancer nursing symposium. He is general director and chief
executive officer of Memorial Hospital, and chairman, department of surgery, and a member of the hospital's interdisciplinary team treating osteogenic sarcoma. Dr Beattie explained that in certain situations the primary tumor can be removed successfully, but within a year after amputation, eight out of ten patients develop lung metastases and die six to nine months later. The use of prophylatic chemotherapy is giving encouraging early results in that about 80% of patients treated are free of disease. "Dr Rosen's promising results with chemotherapy prompted us to combine aggressive surgical removal with aggressive chemotherapy in treating patients with pulmonary metastases," Dr Beattie explained, adding that the rationale is to remove gross tumors and treat residual disease with systemic chemotherapy. He described several cases including one in which a patient has undergone six thorocotomies to remove disease. "We know from our experience that many more tumor nodules can be found by the surgeon at thorocotomy than are seen in chest x-ray," he said. He pointed out that studies at Memorial have shown that over 25% of patients can be salvaged by aggressive surgical removal of pulmonary metastases if the metastases are not too numerous. He said the percentage of long-term survival in the group treated with thoracic surgery combined with chemotherapy is not yet known. "But, to date, the early referral of the osteogenic sarcoma patient for adjuvant therapy after surgery offers the most promising course for lengthening survival," Dr Beattie said. He said the approach used in treating patients with osteogenic sarcoma is an "ideal example" of an aggressive interdisciplinary approach. This includes chemotherapy to eliminate gross disease and reduce the size of the tumor in the leg thus decreasing the need for extensive surgery; surgical resection of the primary tumor and replacement with prosthesis; thoracic surgery to remove mestastastic lesions, and the subsequent use of chemotherapy to keep the disease in remission. Dr Beattie emphasized that this therapy can only be done in a center where the patient receives the needed supportive
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care during the devastatingly toxic chemotherapy. “This approach shows what can be done with the tools at hand even if we don’t know what causes cancer,” Dr Beattie said. “What has been done with osteogenic sarcoma, to my way of thinking, shows there is no reason why it can’t be done with other kinds of cancers in children and adults. It remains to be proven, but I do think it’s absolutely possible. With this kind of approach and early diagnosis, we don’t have to wait for the day after tomorrow when we have an understanding of the underlying mechanism of cancer.” The age of patients undergoing femur replacement at Memorial has ranged from 11 to 31 years. Nancy Strafford, RN, pointed out that many of the patients are hospitalized at a time when he or she has attained independence, or if an adolescent (on the periphery of adulthood) at about the time they would naturally be seeking it. A clinical nurse on the pediatric service at Memorial Hospital, Ms Strafford said frustration is inevitable as the patient faces the long confinement of hospitalization, the pain of chemotherapy, and the threat to his image and self-identity by loss of hair and loss of or diminution of limb function. The prospect of failure-the procedure is experimental and the possibility of failure does exist-and of possible death is frightening, Ms Strafford said. “Nursing intervention can provide optimum growth and development and make hospitalization a constructive experience for the adolescent and his family,” Ms Strafford said. She stressed truthfulness in establishing a trusting relationship with the patient. “He‘ll ask questions that reflect the extent of the answers he wants,” she said. In the period before surgery patients undergo one or more 38-day cycles of chemotherapy consisting of vincristine sulfate, high-dose Methotrexate with citrovorum factor rescue, Adriamycin and Cytoxan, Dr Rosen explained. Methotrexate, one of the oldest cancerfighting drugs, is a folic acid antagonist that inhibits DNA synthesis. Once inside the cancer cell, it prevents the cell from dividing and multiplying and eventually kills it. Because Methotrexate is given in doses
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high enough to destroy normal cells as well, citrovorum factor (folinic acid), the active form of folic acid, is given. It acts as an antidote to “rescue” normal cells from the cytotoxic onslaught of Methotrexate. Adriamycin is an antitumor antibiotic and inhibits RNA formation. Dose-related side effects include nausea and vomiting, hair loss, leukopenia, stomatitis, bone morrow depression, and cardiotoxicity. Cytoxan is given to help control the disease and allow continuation of chemotherapy. Its side effects include nausea and vomiting, alopecia, diarrhea, skin rash, and bone morrow depression. Toxicity signs include pancytopenia, hemorrhagic cystitis, and fluid retention. At Memorial Hospital the effect of chemotherapy is confirmed by osseous arteriography directed by R Caird Watson, MD, attending roentgenologist and chairman, diagnostic radiology. The AP and lateral arteriograms provided by Dr Watson enable Dr Marcove to see the size of the tumor and its location in relation to adjacent blood vessels, and to choose an optimum site for biopsy. (The diagnosis of osteogenic sarcoma is confirmed by open biopsy.) It takes about three to four months for the prosthesis to be manufactured. Scanogram measurements to match the patient’s femur with the prosthesis permit up to a millimeter of accuracy, Dr Marcove explained. The patient is scheduled for femur replacement upon completion of chemotherapy and return of the patient’s blood count and nutritional status to a satisfactory level. The patient is introduced preoperatively to equipment and techniques to be used in his postoperative treatment, explained Cathy Bagnal, RN, clinical nurse, pediatric service. “For example, he is shown how to use blow bottles to increase his vital capacity and strengthen respiratory muscles. It is explained that a closed suction drainage system will be used to drain isotonic saline and plasma accumulating in the third space, the area vacated by removal of muscle and diseased bone. The patient is told he will have a Foley catheter in place for a few days postoperatively and antibiotics will be administered intravenously until his wound heals. He will be on complete bed rest for four to six
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weeks so he is taught how to use the bed trapeze to ease movement in bed and prepare his arms for crutch walking. He is also shown how the bed is made with him in it. It is explained that the head of his bed will be lower than his feet to prevent tension on the new femur. And, he is fitted for the hip belt and brace he will wear after surgery to fixate the limb,” Ms Bagnal explained. The surgical procedure takes about 10 hours. The femur, knee, and upper tibia are removed en bloc along with overlying muscle. The sciatic nerve, femoral vessles, abductor muscles, and lymph vessels are carefully preserved. The eight-inch stem of the prosthesis is inserted into the medullary cavity of the tibia and fixed with methyl methacrylate cement. One continuous envelope is formed by suturing the gluteus medius muscle and the tensor fascia lata over the prosthesis to the fascia lata and the outer thigh muscle. The remaining thigh fascia are sutured around the prosthesis. Following surgery, the patient spends his first night in the recovery room. The primary concern there, according to Ms Bagnal is fluid and electrolyte balance and maintenance of the patient’s cardiovascular and respiratory status. Symptoms of loss of isotonic saline and plasma into the third space include decreased central venous pressure, decreased blood pressure, and increased pulse. This requires replacement with plasma of up to one-fourth of the patient’s total blood volume for two to three days postoperatively, Ms Bagnal explained. Due to the lengthy anesthesia and intubation, the patient is prone to develop respiratory complications. He is encouraged to cough and deep breath and use blow bottles to clear his airway and decrease the possibility of developing atelectasis and pneumonia. Medication is given as needed for pain, and the affected leg is elevated on two pillows and externally rotated and slightly abducted to prevent hip dislocation. Foot drop is prevented by placing the patient’s foot in a neutral position and encouraging him to wiggle his toes as much as possible. Upon transfer from the recovery room, nursing care aims deal primarily with preventing complications of the respiratory, gastroin-
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testinal, cardiovascular, urinary or integumentary systems; preventing sepsis of the wound or other structures such as the bladder or lungs; and preventing physiological or psychological stress. The ultimate goal in the hospital is enabling the patient to progress from bed rest to walking with a cane.
Lung cancer, Ieading kiIIer , is curable in early stage In the past 40 to 50 years there has been a
2,000% increase in lung cancer in males, and today, this largely preventable disease is the leading cancer killer of United States men. It is the third leading cancer killer in women surpassing uterine cancer. Cigarette smoking, alone, is the cause of 80% of lung cancer deaths. Those statistics were cited by Nael Martini, MD, director of intramural education and attending surgeon and chief, thoracic service, Memorial Hospital for Cancer and Allied Diseases, in a speech on lung cancer at the recent international cancer nursing symposium in New York City. Dr Martini pointed out that with early detection one-half of early lung cancer is curable by present day therapy. “Without early detection, however, 10% of patients with lung cancer are alive five years hence. Unfortunately,” he said, “both early detection and early diagnosis continue to lag behind in that it takes three to four months for a symptomatic patient with lung cancer to seek medical advice, and an additional three to four months for a diagnosis to be established. By this time far too many have disease that is advanced beyond the scope of cure.” Lung cancer cells may be rapid or slow
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growing, Dr Martini explained. Slow-growing types include epidermoid (comprises 85% of lung cancer) and adenocarcinoma (29% incidence). An aggressive and rapid growing cell that occurs in 15% of cases is the small oat cell. It is "uniformly fatal and difficult to control," he said He pointed out that the use of fiberoptic bronchoscope has increased the chance of tissue diagnosis (to confirm and classify tumor types) 65% to 70%. "In many instances, however, confirmatory diagnosis must be made by thorocotomy," Dr Martini stated. There is no universal screening test for lung cancer but Dr Martini suggested that an effective way of saving more lives may be achieved by identifying high-risk groups and providing them with periodic checkup. The high-risk group, according to Dr Martini, includes males 45 and over and females 55 to 64 who have smoked at least one pack of cigarettes per day for the last 20 years. In the absence of symptoms, sputum cytology and chest x-ray are the only two methods available for early detection. Dr Martini said it is now possible to determine some cases with sputum cytology in the absence of visible abnormality on chest x-ray. Prognosis of cure is 60% to 70% in patients undergoing localized resection with early positive sputums cytology, no visible abnormality on chest x-ray, and no involvement of regional lymph nodes He said that at Memorial coin, or radiographically visible, lesions are picked up by chest x-ray in about one-third of the patients who have no chest symptoms. He said there is a potential five-year cure rate in 40% to 50% of lesions that are visible on chest x-ray but confined to the lung parenchyma without invasion of adjacent structures. He emphasized that all disease must be removed at the time of surgery. He said external irradiation alone has limited curative value. "In instances where tumors are not resectable because of their precarious locationnear major vessels or the spine-it is possible to seed the tumor at thoroctomy with a radioactive substance. Thus, internal radiation permits a 10% five-year survival rate in
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Study nursing not nurses "Too many nursing studies focus on nurses rather than nursing; on the needs of nurses rather than the needs of patients." Thus contends Marilyn Oberst, RN, EdD, director of nursing practice, Memorial Hospital for Cancer and Allied Diseases. Speaking at the cancer nursing conference, she said, "The focus of clinical research must be on patients and the care they receive." She explained that much of current nursing knowledge is based on medical knowledge, and changes in nursing care are based on medical action. "Bold new nursing knowledge needs to be developed by nurse clinicians and researchers who have failed in the past by not documenting outcomes in terms of patient response to their action." According to Ms Oberst, practitioners and clinicians in the field are in the best position to design, test, and conduct the research. Her two-fold challenge: to get research out into the clinical setting and to get nurses involved in research. these otherwise nonresectable lesions," Dr Martini explained. Chemotherapy is mainly used for advanced or disseminated disease, he said, explaining that "Recently, efforts are underway to combine systemic chemotherapy with surgery and irradiation when disease is still localized with the hope of improving overall results." He said, immunotherapy is evolving as an important fourth form of cancer therapy. "Although it is in use as part of an interdisciplinary approach to treatment," Dr Martini said, "it is too early yet to comment on its relative merits."
AORN Journal, December 1975, Vol22, No 6
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Cancer research links levels of science If you want a glimpse of what may lie ahead in cancer research, one of the places to watch most closely is a comprehensive cancer center, says a physician who lives in one. He is Lewis Thomas, MD, president of Memorial Sloan-Kettering Cancer Center. He spoke on the progress of cancer research at the recent cancer nursing symposium in New York City. Dr Thomas explained that the center is primarily a "scientific center" and "its business is to find new answers to the problem of cancer." Its science may be arbitrarily divided into today's science, tomorrow's science, and the science of the day after tomorrow, he said, explaining that in this classification, a day is a "finite period of time, but not by any means a 24-hour period." "Everything that is done must be related to one or another of these relatively separate levels of science," he said, pointing out that success depends on linking the levels so they become one coherent whole. Today's science. According to Dr Thomas, today's science is what goes on in the hospital. Its problem is to treat cancer by the removal or destruction of cancer tissue with the least possible damage to other tissues. He said the central question of today's science is which technique is the best for a given type of cancer and what is the evidence for a decision of this kind. "It may come as a surprise to some of you to hear the term science used for the everyday, day-to-day patient care functions of a hospital, and yet this is exactly what goes on," Dr Thomas said. The day-to-day work of the hospital is "proper clinical science," the
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"careful assembly of large amounts of hard data, long patient observation, meticulous clinical judgment, and a good sense of scientific balance." According to Dr Thomas, it is this level of science that enables surgeons, such as Edward J Besttie, Jr, MD, to say "with certainty" that the 20-year survival of patients with breast cancer who come in with small, localized cancers and have a radical mastectomy is about 90%. "He has solid data to show precisely how this high survival rate is affected when patients are seen later in the disease or subjected to other forms of treatment," Dr Thomas said. When modalities such as radiation and chemotherapy are evaluated, clinical science becomes even more complex and demanding, he said. He pointed out that the early diagnosis of cancer is itself a scientific effort and "obviously an important one." Today's science represents an enormous amount of effort and money. Dr Thomas continued, "Sometimes the payoff is great, as in the treatment of childhood cancer. At other times, the gains are slower in coming and only marginal in effect." He said clinical science is "itself remarkable and even more remarkable for what it says about the relationship between good science and good clinical care." In the public mind, good science is often equated with an obsession with cold facts. "A cancer hospital stands as living disproof of this," Dr Thomas said. "I have never known a hospital where so many of the staff workers are so deeply and emotionally concerned with the welfare of the patients as individual human beings . . . even though I can't explain it, the science doesn't interfere with compassion, and I rather suspect that the two support each other in a strange way that I've not seen in other institutions." Tomorrow's science. The key question posed by this second level of research is, Are there ways of getting at, and destroying selectively, cancer cells in human beings, which are quite different from today's techniques of surgery, radiation, and chernotherapy? In this new territory, Dr Thomas said, the research laboratory is the main source of
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ideas and techniques, but "the hospital remains the proving ground." At the moment, immunology is the most "promising approach," Dr Thomas said, explaining that "irnmunotherapy derives from the idea . . . that the same immunological defense apparatus that we use for defense against invasion of bacteria and viruses ought . . . to protect us against cancer cells. At the root of this . . . is another essential notion that cancer cells are themselves somehow foreign, and their foreignness ought to be recognizable by the cells of the immune system." Dr Thomas said there is now "good evidence" that this is so. But the problem of how to turn the immunological response on and direct it against cancer cells is unimaginably complicated. "Almost everything we need to know is still ahead of us waiting to be found out." Dr Thomas said his "own private hunch . . . is that this is going to work." He predicted that immunotherapy will someday provide a "completely new technology" that will be "exquisitely selective, precise, and totally destructive of cancer cells." He pointed out that clinical and basic scientists have already learned that cancer patients tend to have defects in their general immune responsiveness and patients with a poor prognosis have the poorest responses. "Efforts to bring about nonspecific stimulation of the immune response are . . . beginning to yield promising results . . . ," he said. Science of the day after tomorrow, The cancer science for the day after tomorrow seeks an understanding of the underlying process of cancer, Dr Thomas said, explaining that "we are profoundly ignorant about the real nature of a cancer cell." He said viruses may be "centrally involved" and the basic processes of cell differentiation and membrane labeling are "surely involved." Fieids for inquiry include cellular genetics, molecular biology, immunological recognition systems, the regulators of growth and differentiation, and "perhaps even influences of the nervous system. "We have come far enough along in the biological revolution to know . . . that the problem of cancer is an approachable and soluble biological problem even though none of us would dare predict whether we will
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reach it in this decade or in the next century," he said. Dr Thomas has predicted that "at the end of the line" when the underlying mechanism of cancer is understood, the hospital may be transformed by changes in cancer therapy. He said he has a "hunch" that therapeutic measuies will probably be "simpler, more direct and decisive than we can imagine today." He believes the cost of treating cancer will be reduced "just as the cost of treating lobar pneumonia was reduced by penicillin or typhoid by chloromycetin." In the immediate future he foresees drastic changes in cancer treatment. "We will be living in an environment of change as the result of both clinical and basic research," he predicted. He said that nursing and medicine must become symbiotic or jointly involved at "every stage" if clinical research and the extension and application of research findings to patient care in general are to succeed. Dr Thomas referred to nursing and medicine as synergetic professions. "Neither can exist alone nor have its life taken over by the other; whatever happens to change the strength and productivity of either, for good or illl will surely and quickly have corresponding effects on the other. Linked together, they can accomplish considerable more than the simple sum of the two parts." Because of the symbiotic relationship between nursing and medicine, the role of nursing in the national cancer program is of special significance, Dr Thomas said. "Never before in human society has such a grandscale effort been mounted to rid ourselves of a single disease, and it is obvious that nursing, side by side with medicine, has a crucial part to play in this."
AORN Journal. December 1975, Vol22, No 6