Abstract
Glioblastoma is a type of cancer that affects thousands of people across the world. This cancer is a tumor that grows rapidly in the brain. This can be a genetically inherited process or a spontaneous cancer in a person with no cancer history. There is not a treatment that guarantees successful remission or eradication at this time, although chemotherapy, radiation, and surgical removal of the tumors can help prolong life. Most cases end with the death of the patient in less than 2 years post diagnosis. Stem cell therapies and the use of vaccinations are possible routes towards a cure.
Keywords: Glioblastoma, cancer, tumor, chemotherapy, brain, radiation
Case Study of Glioblastoma
L.S., a 67-year-old female with a history of hypertension, obesity, and diabetes mellitus type 2, presented to her physician’s office with complaints of increasing headache that would not go away with over the counter medications. L.S. states that her husband reports that her personality has been changing and that she has been starting to forget “little things”.
Initial tests included a CT of the head, MRI of brain and brain stem, and positron emission tomography (PET scan). The radiologist diagnosed several small tumors in the cerebellum with no metastasis.
The oncologist recommends that the patient proceed aggressively with immediate chemotherapy and radiation while getting a neurosurgeon on the case to move forward with the removal of the tumors. L.S. is frightened but willing to move forward with treatment “for right now”. Meanwhile, the patient was started on glucocorticoids.
Pathophysiology
Cancer cells work differently than normal human cells. Cancer cells are cells that begin to grow uncontrollably (Cooper, 2000). However, that first cell does not always have the abilities that a cancer cell will have at full maturity (Cooper, 2000). The cells are allowed to continue to grow unstopped in a way that allows from mutations from cell to cell (Cooper, 2000). These cells begin to learn and adapt to the environment that they are in. Many cancer cells have decreased demand for growth factors than normal human cells (Cooper, 2000). In fact, many malignant tumors will secrete enzymes that break down cellular matrices and allow for the tumor cells to grow into the cells (Cooper, 2000). For the cancerous tumors to continue to grow past one million cells, the tumor will grow blood vessels to supply the needed nutrients for it to grow (Cooper, 2000). Glioblastoma is a type of cancerous tumor that resides in the brain (Urbańska et al, 2014). According to Urbańska et al, metastasis is rare due to the brain having little to do with the lymphatic system, as this is the general pathway for the spread of cancerous tumors (2014).
Glioblastoma is an aggressive type of brain cancer (de Castro et al, 2017). The central nervous system is primarily affected by this cancer (de Castro et al, 2017). The general age group for people with glioblastoma is the elderly, or people over age 65 (Straube et al, 2017). Treatment, at this current point in time, can prolong life but not cure patients.
Tumors can grow swiftly and remain undetected in the brain for prolonged periods (Urbańska et al, 2014). Metastasis from tumors in the central nervous system is not common (Capriotti & Parker-Frizzell, 2016). Glioblastoma will typically spread through the brain in tumors but does not normally metastasize out of the brain (Capriotti & Parker-Frizzell, 2016).
Pathophysiology of Primary System Affected.
Glioblastoma cells reside in parts of the brain that are hypoxic and prevent chemotherapy treatments from reaching them (Zeniou et al, 2015). The appearance of glioblastomas varies throughout the brain (Hanif et al, 2017). In some parts of the brain, the tumor could appear necrotic, while other tumor could look like irregular lesions (Hanif et al, 2017). Genetic sequencing has shown differences in the transcription process that leads to fusions of fibroblasts and coil containing proteins; alterations in epidermal growth factor receptors, and over expression of platelet (Hanif et al, 2017) Furthermore, glioma cells multiply rapidly and will spread throughout the brain (Kutwin et al, 2017). This type of proliferation corresponds to the malignancy of the cells (Kutwin et al, 2017). There are researchers who have chosen to focus on stopping the mechanism for proliferation instead to finding the “cure” (Kutwin et al, 2017).
Brain tumors have the potential for deadly consequences based on the effects they have on the brain (Capriotti & Parker-Frizzell, 2016). The growth of the tumor can lead towards increased intracranial pressure, which can increase pressure on the brainstem (Capriotti & Parker-Frizzell, 2016). This increased pressure can lead to losses of function or even death (Capriotti & Parker-Frizzell, 2016). The signs and symptoms of glioblastoma are: headache, personality changes, and seizures (Hanif et al, 2017). The build up of pressure in the brain can cause the headache and seizures (Davis, 2016). Depending on the location of the tumor, personality changes can present in forgetfulness, inability to interpret social cues, or even hallucinations (Boele et al, 2015).
Little is known about what causes glioblastoma in patients, but one of the known risk factors is large exposure to radiation (Hanif et al, 2017). The people exposed to the atomic bombs in Nagasaki and Hiroshima, Japan, have been found to have an increased number of brain cancers that included glioblastoma (Hanif et al, 2017). The prolonged sizeable exposure to the radiation fallout seems to have stimulated the growth of cancer cells (Hanif et al, 2017).
Until physicians began to combine various interventions, the median survival rate for a patient who received surgery to remove the glioblastoma was 6 months post diagnosis (Exeli et al, 2018). With the combined treatment of surgery, radiation, and chemotherapy, the patients’ survival rates are 27% at 2 years and 10% at 5 years (Exeli et al, 2018). Unfortunately, studies are showing that some of the newer treatments, while increasing survival rates, place the brainstem, eyes, cerebellum, and more at risk of damage and loss of function (Exeli et al, 2018).
Some researchers are even testing vaccinations used in glioblastoma treatments in addition to surgery and chemotherapy (Inogés et al, 2017). In the cases of tumors returning, patients are being treated with additional radiation therapy and surgical removal of the tumors (Straube et al, 2018). Studies even suggest that use of stem cell therapy may be used in the future against glioblastoma; although at this point, use of stem cells might encourage the growth and spread of glioblastoma (de Castro et al, 2017). There is a possibility that the modified stem cells may cause the glioblastoma cells to become more immune to the effects of therapy (de Castro et al, 2017). Further modification and testing of these stem cell therapies are needed at this time.
Nursing Priorities and Interventions.
The primary nursing interventions for caring for a patient with glioblastoma would be based on patient comfort. Patients enduring chemotherapy would need pain relief, nausea medications, and appetite stimulants. Some patients even experience nausea and vomiting prior to administration of chemotherapy (Dupuis et al, 2017). Patients experience less nausea and vomiting when they receive anticipatory medications to prevent any nausea or vomiting (Dupuis et al, 2017). A combination of opioids for pain control along with corticosteroids, antidepressants, and anticonvulsants are used in the treatment of chemotherapy pain (Shinde et al, 2015). Glucocorticoids are used to decrease swelling in the brain (Capriotti & Parker-Frizzell, 2016).
Patients could possibly need nutrition supplements as well. Some research has even proposed the use of the Ketogenic Diet to treat glioblastomas. This diet is used primarily for weight loss in adults but is used to treat children with epilepsy (Santos et al, 2018). A side effect of glioblastoma includes seizures (Santos et al, 2018). Studies have shown that blood glucose levels are reduced and the tumors are shown to be disappearing in scans (Santos et al, 2018). Researchers have proposed using ketogenic diet in conjunction with chemotherapy, radiation, and surgery (Santos et al, 2018).
Nurses can help a patient maintain dignity by helping them acquire hats for hair loss or keeping them warm during treatment. Encouraging people to attend groups for people with glioblastoma so that they have a safe place to talk about their hardships would help as well. Effective communication between the patients, their families, and the physician has been shown to improve psychological functioning in patients (Young et al, 2015).
Nurses also extend their care into the patient’s family. They can answer questions, provide educational material, and use nursing presence to help a family care for their loved ones. Being transparent with the patients while staying within the nursing scope of practice will help patients feel comfortable with the nurse and build a sense of trust. Any time the nurse cannot answer a question the physician needs to become involved to help the patient. This care might extend to end-of-life care. The patient and family would then need to have a safe and quiet space to remain with their loved ones during their final days.
Advocating for the continued welfare of patients is the duty of the nurse. Nurses must always take into consideration the wishes of the patients and be willing to fight for what the patient desires. If the patient starts to experience symptoms of decline, the nurse should assess the patient for adjunct care such as home care, physical therapy, or hospice.
Impact of Illness
At this time, treatments for glioblastoma cannot cure the patients. Most cases of glioblastoma result in patient death in less than 2 years (Hanif et al, 2017). Treatments provide, at best, several years of continued life. Some of the treatments can also impact the quality of life for the patients. Reports have shown that up to 90% of people who survived after multiple doses of radiation therapy, suffer from cognitive decline that can affect the patient’s ability to complete day-to-day tasks (Exeli et al, 2018).
The combination of chemotherapy and radiation therapy in elderly adults has been shown to be effective; however, physicians may be undertreating due to patients’ ages (Straube et al, 2017). According to Straube et al, aggressive treatment, after the first diagnosis of glioblastoma, is highly beneficial to elderly patients (2017).
Summary
Glioblastoma is a fast acting cancer that has no cure. Despite the use of various treatments, the lifespan of a patient with glioblastoma can be less than 2 years. The unchecked growth and multiplication of the cancer cells allows for the glioblastoma to spread inside the brain. The increasing size or number of the tumors can cause increased pressure inside the brain and lead to death. Many medical advances are being made at this time.
Unfortunately for L.S., despite surgery, chemotherapy, and radiation treatment, she has a poor prognosis. According to the research, L.S. has a 10% chance of living for 5 years after diagnosis but the likelihood is that she will succumb in less than 2 years. The cancer is not likely to spread through her body.
Nursing care will need to be holistic and include the family as much as possible in the care. Patients will fare better if they remain comfortable as much as possible. As such, many of the best treatments will treat the symptoms not the actual glioblastomas. Some of these treatments will help with the after effects of the other treatments, such as chemotherapy. Nurses will need to remain as transparent as possible within their scope of practice and involve the physician if needed to answer questions. Patients will need the support of their families and the care team that is going to be with them for this process.
Combination treatments of chemotherapy, radiation therapy, and surgical removal of tumors in the brain have shown to provide the greatest outcome with the longest survival rates. However, with these treatments come side effects that have detrimental effects towards the patient’s ongoing quality of life. Cognitive decline from ongoing radiation can make the patient unable to complete activities of daily living. Studies are being conducted every day to provide further insight and to work towards a possible cure for Glioblastoma.