The Moran article presents an excellent summary of the malignancies
associated with HIV. The diagnosis of an HIV-related malignancy
places additional stress on an already compromised immune system.
Neoplasms arising in AIDS patients tend to be aggressive, and
because of the immunocompromised state of these patients, they
are unable to tolerate the side effects of the various modalities
used in treatment.
The strategy for treating AIDS and cancer is threefold. Health-care
professionals must treat the cancers associated with HIV while
trying to maintain or reconstitute a weakened immune system and
deal with the physical, psychological, and social issues associated
with these diseases. Nursing plays a vital role in the assessment
and management of patients with the dual diagnosis of AIDS and
Each AIDS-related malignancy poses its own unique challenges for
nursing management. Nurses must attend to the physical, psychological,
and social needs of their patients. Treatments for neoplasms associated
with AIDS cause an already compromised immune system to be taxed
further. Also, these therapies often cause an increased incidence
of opportunistic infections. These opportunistic infections are
physically and psychologically difficult for the patient to tolerate.
The medications used to treat these complications often cause
additional symptoms that are difficult to control. Nurses must
be flexible and innovative when caring for these patients, altering
their approach based on individual patient's needs.
Since non-Hodgkin's lymphoma (NHL) is an aggressive malignancy
and AIDS is a disease characterized by multiple problems, this
combination is particularly challenging to manage (Table 1). Current
efforts at treating AIDS-related lymphomas are designed to aggressively
treat the underlying disease and ameliorate the myelosuppression
associated with extensive chemotherapy. Chemotherapy administered
to AIDS patients can severely test an already compromised immune
system and provide increased opportunity for opportunistic infections
The response of AIDS-associated NHL to standard chemotherapy regimes
is poorer than those seen in non-AIDS lymphomas. A complete response
occurs in approximately 50% of all patients. These complete responses
tend to be of relatively short duration, with relapses into the
central nervous system (CNS) frequently. Median survival is approximately
6 to 8 months.
A history of opportunistic infections, especially Pneumocystis
carinii pneumonia (PCP), is a poor prognostic indicator. Opportunistic
infections are a common cause of death in patients receiving therapy.
Treatment includes aggressive chemotherapy regimens, with prophlactic
chemotherapy administered intrathecally to prevent relapse of
the lymphoma into the CNS. Concurrent prophylaxis against PCP
is also administered. Granulocyte-macrophage colony stimulating
factor (GMCSF) (molgramostim [Leucomax], sargramostim [Leukine,
Prokine]) or granulocyte colony stimulating factor (GCSF) [Neupogen]
is given to decrease the patient's neutropenic period and to reduce
the incidence of opportunistic infections. Antiretroviral therapy
is given concurrently as well.
A major factor limiting the use of chemotherapy in AIDS-related
NHL is hematologic toxicities or bone marrow suppression. This
is a particular problem in patients who have depleted marrow reserves
from long-term zidovudine (Retrovir) therapy (see Table 1).
Tumor Lysis Syndrome--Non-Hodgkin's lymphoma is associated
with rapid tumor proliferation, a large tumor burden, and acute
sensitivity to chemotherapy agents. These three factors place
the patient at risk for the tumor lysis syndrome. In this syndrome,
the necrotized tumor releases its intracellular contents into
the circulatory system. Metabolic abnormalties can be severe and
lethal. They include hyperkalemia, hyperuricemia, hyperphosphatemia,
hypocalcemia, and xan- thinuria. The clearance of the products
of tumor lysis depend on hepatic metabolism, the extent of the
patient's renal dysfunction, and the process of phagocytosis.
Patients at greatest risk have the predisposing condition of renal
insufficiency and/or a large tumor burden.
Nursing case of the patient with AIDS-related NHL involves
the administration of intensive medical therapies and the provision
of complex, innovative physical care. Consistent attention and
support must also be focused on the psychosocial, ethical, and
spiritual needs of the patient. Patients need assistance in dealing
with the complexity of two life-threatening disease processes
and in coming to terms with their probable death. Nurses play
an important role in advocating for the patient with the health-care
team, the family, and friends, and helping the patient address
the issue of advance directives.
Kaposi's sarcoma (KS) is a multifocal disease that ranges from
cutaneous lesions to disseminated disease involving the internal
organs. The physical appearance of someone affected by KS has
caused some persons to equate it with wearing a scarlet letter.
This perception causes persons with HIV to be fearful of any lesion
that appears and to become reclusive if the KS is visible.
Nurses can discuss KS with their patients and talk about the options
that patients have to cope with the skin lesions. These include
using make-up, altering their style of dressing, and joining a
support group to learn other ways persons have found to cope.
The nurse needs to take a holistic approach to treating patients
with KS. These patients have complex physical and psychosocial
needs, which require time and creative solutions. The most important
thing that a nurse can do is acknowledge patients' lesions. Touching
patients and talking with them will make them feel less alone
and isolated. Laughter and compassion are important tools to help
the patient continue to be a part of their social environment.
Giving a patient a make-up lesson or arranging for a friend to
assist in purchasing clothes that will hide the lesions can make
a significant difference.
Also, health-care professionals can play an important role in
advocating for and addressing the ethical needs of these patients.
Nurses are in an excellent position to explore their patients'
feelings, values, and knowlege concerning quality of life and
medical interventions in the face of health, chronic illness,
or irreversible disease. Discussing quality-of-life issues with
patients ultimately promotes patient autonomy.
Invasive Squamous Cell Cervical Carcinoma
Invasive squamous cell carcinoma of the cervix has begun to be
studied in several clinical trials, which should lead to new knowledge
about the disease. Women are beginning to be studied to determine
the effects of the HIV virus on their systems.
The impact of cancer and AIDS on women and their families has
significant ethical and legal ramifications. A large proportion
of women with AIDS and cancer have families to care for. The children
may or may not be HIV-positive, and arranging care for them while
the mother is ill and after she dies is a critical issue--one
that is just being faced by many families.
Nurses can assist their patients by allowing them to talk about
their fears and concerns. They can also direct patients and families
to family services that can help them make these difficult decisions.
It is imperative that women receive appropriate care for themselves,
as well as provide care for their families. Nurses must work with
the health-care team to help these women find the resources to
assist them in obtaining care. Services should be identified by
all members of the health-care team. Prior planning for patient
referrals is essential to optimize care.
The Moran article provides a thorough look at the cancers associated
with AIDS. In addition to providing medical care, health-care
professionals must address the psychosocial and legal ramifications
of these diseases in order to provide holistic care to their patients.
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