Nursing Challenges of Caring for Patients with HIV-Related Malignancies
Nursing Challenges of Caring for Patients with HIV-Related Malignancies
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 cancer.
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 to develop.
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.
Baird SB: Decision Making in Oncology Nursing. Toronto, Decker, 1988.
Brown MH: Standards of Oncology Nursing Practice, New York, John Wiley, 1991.
Chase M: Increasing incidence of a lymph cancer seen among long-term AIDS survivors. Wall Street Journal, June 11, 1990.
Devita V: AIDS, 2nd ed. Philadelphia, JB Lippincott, 1991.
Dorr RT: Cancer Chemotherapy Handbook. New York, Elsevier, 1980.
Knowles DM: Lymphoid neoplasia associated with the acquired immunodeficiency syndrome (AIDS). Ann Intern Med 108:744-753, 1988.
Oncology: Programmed Modules for Nurses. Types of Cancer, vol 3, no. 6. New York, LP Communications, 1990.
Pluda JT: Development of non-Hodgkin lymphoma in a cohort of patients with severe human immunodeficiency virus (HIV) infection on long-term antiretroviral therapy. Ann Intern Med 113:276-282, 1990.
Pluda JT: The occurrence of opportunistic non-Hodgkin's lymphomas in the setting of infection with the human immunodeficiency virus. Ann Intern Med 2(suppl 2):191-200, 1991.
Wittes RE: Oncologic Therapeutics. Philadelphia, JB Lippincott, 1989/1990.