Exam 4 Flashcards
(155 cards)
1
Q
Cancer risk factors
A
smoking, alcohol, obesity, oral contraceptive use, diet high in fat and low in fiber, uncontrolled DM, frequent sun exposure
2
Q
Cancer prevention-primary
A
diet high in fruits and vegetables and complex carbohydrates, exercise, smoking cessation, control weight, stay out of the sun during peek hours and use sunscreen daily, PPE at work
3
Q
Cancer prevention-secondary
A
Self examination practices: skin(annually by provider), oral cavity(dippers), lymph nodes, breasts(Once a month after period)/chest walls, testicles(in shower, once a month), penis
4
Q
Cancer prevention-tertiary
A
Screening test:
Mammogram, PSA levels, prostate exams, papsmear (21 y/o and every 3 hours if normal)
5
Q
When is primary cancer prevention started?
A
ASAP- young age
6
Q
When is secondary cancer prevention started?
A
ASAP-never too young
7
Q
When is tertiary cancer prevention started?
A
Mammogram at 40 and then annually (high risk individuals= 35), PSA at 50 and then every 2-3 years (high risk at 40), prostate exam 55-69 y/o
8
Q
Lung cancer review
A
If not a smoker, radon is #1 cause
Heavy smokers= small cell carcinoma (oat-cell(
Non-small-cell carcinoma(bronchogenic carcinoma)= most common type of malignant lung cancer
9
Q
Lung cancer S/S
A
Persistent cough, change in usual cough, dyspnea, hemoptysis, frequent respiratory infection , CP, hoarseness, weight loss, anemia, fatigue
10
Q
Bladder cancer S/S
A
Painless hematuria= 1st sign
Abnormal urine color, frequency, dysuria, UTI’s, back or abd pain
11
Q
Bladder cancer risk factors
A
Advancing age, men, Caucasians, working with chemicals, smoking, excessive use of analgesics, experiencing recurrent UTIs, long-term catheter placement, chemotherapy, radiation
12
Q
Bladder cancer tx
A
Surgical removal, radiation, chemotherapy, immunologic agents
13
Q
Breast cancer S/S
A
Most common malignancy in women, second leading cause of cancer death in women
-asymptomatic, mass in breast or Axillary that is hard, uneven edges, usually painless, change in size, shape, feel of breast in nipple, nipple drainage that may be bloody, clear to yellow, green, or purulent
14
Q
Breast cancer risk factors
A
Rates higher in Caucasian women, African American women more likely to die
Age, early onset of menstruation, family Hx, genetic predisposition (BRCA1,BRCA2), obesity, chest wall radiation, excessive alcohol cosumption, exogenous estrogen exposure
15
Q
Breast cancers are
A
Estrogen dependent (mostly), originate in duct system, may arise in lobules, early the tumor is freely moving, tumor becomes fixed as cancer progresses
Metastasis occur to nearby lymph nodes, lungs, brain, bone and liver
16
Q
Skin cancer risk factors
A
Males, Caucasian, fair complexion, family Hx, UV exposure (natural or artificial)= most significant risk factor
17
Q
Skin cancer types
A
Basal cell carcinoma (most common), rarely metastasizes
Squamous cell carcinoma (middle layer of epidermis)
Melanoma (melanocytes), least common type but most serious, often metastasizes
18
Q
Skin cancer appearance
A
Small, shiny, waxy, scaly, rough, firm, red, crusty, bleeding
-asymmetry, border irregularity, color variations, diameter larger than 6mm, any skin growth that bleeds or will not heal, any skin growth that changes in appearance over time
19
Q
Prostate cancer
A
Most common cancer in men, particularly African Americans
-slow growing with unknown cause, obstructs urethra
20
Q
Prostate cancer risk factors
A
History of STI’s, family Hx, high-fat diets, androgen hormone replacement, African american
21
Q
Prostate cancer S/S
A
Urinary difficulties, erectile dysfunction, bloody semen, hematuria
22
Q
Acute myeloid leukemia (AML)
A
Unknown cause, rarely occurs before 40, peaks at 67 y/o
-immature myeloblasts in bone marrow
-WBC may be low, normal, high
Prognosis depends on pt
23
Q
S/S AML
A
Result from insufficient blood cells
-fever and infection (neutropenia)
-fatigue and weakness (anemia)
-bleeding tendencies (thrombocytopenia)
-painful enlarged liver/spleen(engorgement)
-hyperplasia of gums
-bone pain (expansion of marrow)
24
Q
AML Dx and tx
A
CBC: dec RBC and PLT
BMA: excessive immature blast cells sitting in marrow
Tx: induce remission
Aggressive- cytarabine
Elderly pts can take hydroxyurea
BMT last resort
25
Tumor Lysis syndrome
Complication of cancer treatment
large amounts of tumor cells destroyed and components in blood stream
-hyperuricemia,hyperkalemia,hyperphosphatemia, hypocalcemia
Nurse role:
Monitor for bleeding, infections, pain, end of life issues
26
Chronic leukemia
Less likely to be terminal
Two types:
Chronic lymphocytic leukemia
Chronic myelogenous leukemia
27
Chronic leukemia…
Progresses more slowly
-longer life expectancy
-cells better differentiated
-unknown cause
Link between Epstein Barr virus
Predisposition in families
28
Chronic lymphocytic leukemia
Older person (>72 usually)
-malignant transformation of B cells
“B symptoms”: fevers, night sweats, unintentional weight loss, and infections
29
CLL S/S
Weak, fatigue, painful lymphadenopathy
Anemia
Thrombocytopenia (depending on stage)
Enlarged spleen
Elevated WBC
30
CLL Dx and tx
Bone marrow biopsy
Tx not started until S/S appear severe
Not curable, only induce periods of remission
-combo therapy
-radiation to thymus, spleen, entire body
-older person have heightened risk of second malignancy with radiation
31
CLL progression requires…
Nutritional support, pain control ,skin care, emotional support
32
Chronic myelogenous leukemia
Overproduction of abnormal myeloid/blast
-uncontrolled proliferation of granulocytes
-causes bone marrow and organs to enlarge (pain)
Risk dramatically increases with age, if in chronic stage life expectancy >5 yrs
No known cause except ionizing radiation
33
CML S/S
Philadelphia chromosome- good Dx marker in 95% pts
-asymptomatic with leukocytes is
Classic chronic symptoms:
-fatigue, weakness, anorexia, weight loss, splenomegaly
-SOB, confusion with high leukocyte counts
-hepatomegaly, but functional
-fever and adenopathy in blast stage
WBC 15,000-500,000
34
Tx CML
Therapeutic blood draws to draw out some WBCs (dec blood viscosity)
Goal= control proliferation of WBC/induce remission
-bone marrow transplants
-leukophoresis (>300,000)
-hydroxurea
35
Nursing care for pts with leukemia
Know potential effects of leukemia and of tx and assess
-manage mucositis
-control pain and discomfort
- risk of dehydration
-weakness and fatigue (fall risk)
-rest between activities
-assist with self care
- anxiety/grieg
-hospice/ home health
36
Hodgikin’s lymphoma
More common in immunosuppressant pts
Reed-sternburg cells
37
Hodgkin’s lymphoma S/S
First sign= enlarged cervical node
-one or more enlarged painless lymph node(s)
“B” symptoms
-fatigue, pruritus, early mild anemia then worsens and accompanies with weight loss (poor prognosis)
-inc ESR, leukocytosis eosinophilia, leukopenia, PLT normal
-impaired cellular immunity so dec response to skin testing
38
Multiple myeloma
Worst cancer, most aggressive
5 year survival for new Dx pts
Infiltrates bone marrow and aggregates into tumor masses in skeletal system
39
MM presentation
Bone pain , bone lesions (destruction of bone tissue, inc calcium form reabsorption of bone by osteoclasts)
RF secondary to hypercalcemia
Anemia d/T inhibited erythropoiesis
40
MM S/S
Pathological fx
Back pain/ribs pain
Repeated infection form suppressed humoral response (pneumonia/phyelonephritis)
-fever wight loss, night sweats, breakdown of bone can lead to RF
41
Dx of multiple myeloma
Blood test, sudden inc in protein in blood/urine
CRAB
C=elevated calcium (bone breakdown )
R=renal insufficiency
A=anemia
B=bone lesion
BMA
X-ray
Nuclear bone scan
42
tx of MM
No cure, poor prognosis
Chemo-treat immediate and high grade
Radiation
Plasmapheresis-when blood viscosity is high
-mostly end of life care
43
Caution-cancer
Things to look out for
C=change in bowel and bladder habits
A= A sore that does not heal
U= Unusual bleeding or discharge (women after menopause should NOT bleed)
T= thickening or a lump in breast or elsewhere
I= Indigestions or difficulty swallowing
O= Obvious change in wart or mole
N=nagging cough or hoarseness
44
Major treatment modalities- chemo
Systemic form of tx->destroys greatest number of cancer cells (goal= w/o irreversible damage to normal cells)
- destroys rapidly growing cells; interferes w/ cell growth and division
-nurse must be educated to administer
-same nurse who prepares dose does not administer
-another nurse must check MD order and IV contents
45
Major treatment modalities-radiation
Damage cancer cells during different phases of cell division
-duration= once/day for 5 days for 2-8 weeks (must give cancer cells time to reoxygenate)
-internal/external
Markings made on skin (with marker to mark location-most precise)
46
External radiation
Treat superficial lesions and deeper structures
Skin care: inspect for redness, ask about changes in sensation
No lotions, ointment, powders, or soaps
Do not wash off skin marking
47
internal radiation
Brachytherapy- high dose to localized area via implants, needles, seeds, beads, catheters
Pt=reverse isolation- protect pts and visitors (pt emits radiation)
48
S/e of tx- neutropenia
Depleted WBC, high risk of infection
-chemo not given if ANC= <1,500/cmm
-precautions for ANC= <1,000/cmm
-avoid animal contact
-no rectal exams/procedures
-no fresh flowers
-private room desirable
-use fresh ground pepper
-low microbial diet
- reverse isolation if ANC= <500
-STRICT HANDWASHING BY ALL STAFF AND FAMILY
49
S/e of tx of thrombocytopenia
Depleted platelets, high risk of bleeding
-chemo not given if PLT= <100,000cmm
-hold all sticks for 5 min
-use electric razors only
-no rectal temps, enemas, suppositories, or examinations
-no IM injections
-use stool softeners (avoid straining)
-no aspirin or aspirin-containing products/anticoagulants
-observe daily for petechia, ecchymosis, hematuria and inc ICP
50
Common physiologic complications-superior vena cava syndrome
Most often associated with lung cancer, lymphoma, metastases
-compression.invasion of SVC by tumor, enlarged lymph nodes
51
SVCS
Superior vena cava syndrome-oncologic emergency
52
S/S SVCS
Progressive SOB, cough, facial swelling, edema of neck, arms, hands, thorax, tightness and difficulty swelling, engorged and distended jugular
53
management of SVCS
Radiation-shrink tumor and relieve symptoms
-chemotherapy, oxygen therapy, anticoagulant therapy, diuretics
54
Nursing care for SVCS
Identify at risk pts
-check CV and neuro status
-position for easier breathing, minimize energy expenditure
-watch fluid balance, admin fluids with caution
-assess for dysphagia, esophagitis r/t radiation
55
Common physiologic complications-tumor lysis syndrome
Develops when cytotoxic therapies (chemo/irradation) cause destruction (lysis) of large number of rapidly dividing malignant cells
-lysis of fast growing cells is greater than the body’s capacity to excrete the end-products of cell death
56
What is released when cells die
Potassium,phosphorus, nucleic acids into general circulation
-results in hyperkalemia, hyperuricemia, hyperphosphatemia w/ secondary hypocalcemia
-puts pt at risk for renal failure and alterations in cardiac function
57
How is superior vena cava syndrome treated
Radiation to shrink tumor and relieve symptoms, chemotherapy, oxygen therapy, anticoagulative therapy, and diuretics
58
Fluid management for superior vena cava complication
Electrolyte imbalances, administer fluids with caution, assess for dysphagia, esophagitis r/t radiation
59
EOL management for superior vena cava complication
Manage pain and symptoms, oxygen therapy , prevent bleeding with anticoagulant therapy and prevent infection.
60
What meds are used in tumor lysis syndrome
Allopurinol(urinary alkalization, prevents kidney stones and kidney damage leading to RF)
61
Client education-tumor lysis syndrome
Hydration is IMPORTANT, keep UOP at least 150mL/hr
Allopurinol given orally 2-4 days prior to chemo
62
Osteoporosis
Porous bones, osteoclast activity greater than osteoblast activity leading to a decrease in bone density/mass-> risk for fx
63
Diagnostic procedures for osteoporosis
DEXA scan and T scores, Z scores
64
What does a DEXA scan respresents?
The bone density,
65
T scores- what do they represent?
The amount above or below the average healthy individual’s bone mass/density
66
Osteoporosis medications
Calcium, vitamin D supplements and biphosphonates
67
Actions of calcium supplements in osteoporosis
They are absorbed in the bloodstream to help keep up reserves/supplies with the osteoclast activity
68
Actions of vitamin D supplements in osteoporosis
Enhances absorption of calcium
69
Actions of biphosphonates in osteoporosis
Slow bone resorption
70
Nursing considerations-calcium; osteoporosis
Calcium better absorbed with vitamin D (orange juice/acidic drinks or substances)
-supplements needed
71
Nursing considerations-vitamin D supplements; osteoporosis
Helps the absorption of calcium in the gut
72
Nursing considerations- biphosphonates; osteoporosis
Sit up in a chair for min 30 min when taking to avoid esophagitis.
Tx taken for 3 yrs, if DEXA scan performed and if bone density is improved/maintained, Rx is d/c for 3 yrs
DEXA results determine if Rx restarted
73
Osteoarthritis (OA)
Most common form of arthritis, major cause of disability
“Degenerative joint disease”
-progressive deterioration and loss of cartilage and bone in one or more joints
74
Patho of OA
Proteoglycans and water dec in joints, synovial fluid prod dec with age, enzymes breakdown cellular matrix. Cartilage erodes and joint space narrows-bone spurs develop.
Progression:
Fissures, calcifications, ulcerations develop and cartilage thins; inflammatory cytokines enhance deterioration and normal repair process cannot overcome degeneration
75
Rheumatoid arthritis (RA)
systemic autoimmune disorder in which systemic inflammation affects all joints. Usually Bilat
76
S/s osetoarthirits
Develop slowly, pain and tenderness worsens with activity, crepitus, stiffness in am, bone spurs, bony hypertrophy, joint effusions, unilateral, nodes (Heberden’s and Bouchard’s)
77
S/s rheumatoid arthritis
fever, fatigue, swan neck deformity of fingers, boutinierres, ulnar deviation of first metacarpal phalanges
78
Labs-OA
X-rays(determine changes in joints), MRI, CT(examining knee and vertebrae)
ESR and C-reactive protein may be slightly elevated r/t secondary synovitis
79
Labs-RA
ESR(inc)
CBC
Rheumatoid factor (positive in RA)
C-reactive protein(CRP)(measures substance in liver that inc in presence of inflamm)
ANA(antinuclear antibody)(positive in RA and other autoimmune conditions like lupus)
80
Difference between OA and RA S/S
RA=systemic, autoimmune, stiffness ongoing, pain at rest
OA=local, “wear and tear”, stiffness resolves, pain with movement
81
Difference between OA and RA labs
RF=RA, ANA, blood tests with inflammatory markers
OA=imaging to see changes in joints and skeletal structures, no inflammatory markers
82
Pain management-arthritis
NSAIDs, DMARDS, Glucocorticoids
83
NSAIDs-arthritis pain management
RA
Reduce pain and inflammation (ibuprofen, naproxen)
Side effects= tinnitus, stomach irritation, heart problems, liver and kidney damage
84
Dietary supplements-arthritis pain management
OA
Glucosamine(may dec inflammation) and chondroitin(may strengthen cartilage)=most effective non Rx supplements for pain and function
RA
Fish oil(reduce RA pain/stiffness)
Plant oils (pain and morning stiffness relief from evening primrose, borage, black currant—> fatty acid)
85
DMARDS-arthritis pain management
Slow progression of TA and save joints and other tissues from permanent damage
-methotrexate
S/e=liver damage, bone marrow suppression, severe lung infections
86
Glucocorticoids- arthritis pain management
prednisone
Used in RA to reduce inflammation, pain, and slow joint damage
Acute- goal=taper off
Pulse therapy: high dose for short duration
S/e=thinning of bones, weight gain, DM
87
Immunosuppressive agents- arthritis
Biological agents and steroids
88
Biologic agents (BRM)
Newer class of DMARDS
Avatacept, adalimumab, rituximab,etc
Target parts of the immune system that trigger inflammation and causes joint and tissue damage.
Most effective when paired with nonbiologic DMARD(methotrexate)
89
Major side effects of immunosuppressants- arthritis
INFECTION
Myelosupression-pancytopenia
Bone pain
Anemia-fainting/weakness/fatigue-fall precautions
Osteoporosis
GI irritation
90
Pre-op care: joint replacements
assess for mobility issues, need for assistive/adaptive equipment (baseline), discontinue RX that inc r/f clotting and bleeding one week before surgery (NSAIDs, Vit C and E, hormone replacement therapy , oral contraceptives)
91
Post-op care: joint replacements
Prevent hip dislocation, blood clots, infection, anemia
Abduction pillow(hip)
Splint (knee)
Keep heels off bed
Assist with movement slowly
Caution for orthostatic hypotension in older adult
Manage pain
92
Pre-op education: joint replacements
Stop any drugs that cause r/f bleeding and clotting at least a week before surgery (NSAIDs, Vit C and E, hormone replacement, oral contraceptives)
Report any signs of infection/sickness (fever, uncontrolled HTN, DM), report Hx of osteoporosis
93
Post-op education: joint replacements-hip
Do not sit or stand for prolonged period of time
Do not cross legs
Do not bend hips for more than 90 degrees
Do not twist body when standing
Use assistive devices for dressing
Report inc pain to surgeon
Do not overexert
Inspect incision daily for s/s infection
Perform post-op exercise as instructed
94
Post-op education: joint replacements-Knee
Continuous passive motion (CPM)-prevent scar tissue
May swell more than hip surgery-ice packs
Maintain knee in neutral position, no hyperflexion or rotation
95
Nursing interventions to prevent DVT: joint replacements
Foot pumps, compression stockings, ambulating (ERAS programs), ROM exercises, ice packs, SCDs,
96
Anticoagulants-joint replacements
Heparin
97
LMWH-joint replacements
Enoxaparin
SubQ injection
98
Pain meds- joint replacements
Analgesics (opioids, NSAIDs)
99
Antibiotics- joint replacements
Prophylactic-pre op
100
Monitor neurovascular status-joint replacements
5 Ps
-pain
-pallor
-paresthesia
-paralysis
-pulselessness
Cap refill
ROM
Sensation
101
Gout
Gouty arthritis
Crystals deposit in joints and other tissues =inflammation
102
Primary gout
most common type
-Inborn error of purine metabolism(inc Uris acid), -kidneys cannot excrete: deposit in tissues
Strong fam Hx link
Middle age and older men, post menopausal women, peak onset between 40-50 yrs old
103
Secondary gout
Caused by other disease (renal insufficiency \, crash dieting, diuretics, chemo, multiple myeloma)
-older adults with comorbidities common
104
Clinical stages of gout
Asymptomatic hyperuricemia (pt unaware)
Acute gouty arthritis (most common great toe metatarsophalangeal joint)
Chronic gout (3-40 yrs after initial episode, urate crystals under skin and in renal system)
105
Medications for gout management
Acute vs chronic
106
Acute medications for gout management
Colchicine(anti-inflamm)
Corticosteroids(prednisone)
NSAID(ibuprofen)
107
Chronic medications for gout management
Allopurinol(block Utica cid production)
Febuxostat(block can’t hinge into Uris acid)
Probenecid(inc secretion of renal dysfunction)
108
Gout medication education
Take after meals witha full glass of water
64 oz of water is great to reduce renal insufficiency
Avoid aspirin (deactivates meds to tx)
109
Dietary restrictions-gout
Low purine diet
Organ meats, shellfish, oily fish with bones, excessive ETOH
FAD diets, ASA, diuretics should be avoided
110
Classifications of anemia
Macrocyctic(>100), normocytic(>80,<100), microcytic(<80)
111
Macrocytic anemia
MCV>100
Deficiency of B12, folic acid, or IF
-hypothyroidism, alcoholism, liver disease, drugs that inhibit DNA replication (methotrexate, zidovudine)
112
Normocytic anemia
(80
113
Microcytic anemia
(MCV<80)
Heme synthesis defect
Iron deficiency
Globin synthesis defect
Sideroblastic defect
114
Iron deficiency anemia
Most common anemia
microcytic , small pale RBC
Iron studies
Serum ferritin
Serum FE
Transferrin saturation
Total iron binding capacity (TIBC)
Bone marrow aspiration (is suspect leukemia)
115
Iron deficiency anemia Causes
Acute blood loss
Chronic blood loss
Inadequate intake
CONSIDER GI FIRST (GI BLEED)
116
Iron deficiency anemia-S/S
Onset gradual
Hub drops 7-8g/dL
-fatigue weakness SOB pale earlobes palms and conjunctiva
-fingernails brittle and concave, soreness and redness of tongue, corner of mouth dry and cracked
-progression=neuromuscular changes, gastritis, irritability, HA, paresthesia
Elderly= mental confusion, memory loss, disorientation
117
Iron deficiency anemia-dietary management
118
Iron deficiency anemia- medication management
DONT TX ANEMIA W/O KNOWING CAUSE
-1-2 weeks treatment=reversed
Ferrous sulfate 325mg for 6-12 months after bleeding stops
Vit C inc absorption
Empty stomach if tolerated
Stool=dark green to black
Constipation
N/V
Take at bedtime to sleep through icky feelings
119
Hemolytic anemia
Normocytic anemia
Occurs at any age
Need increase in folic acid to inc RBC production
120
Hemolytic anemia - causes
Hemolysis or premature destruction of RBCs
-Autoimmune antibodies
Hodgkin’s/non-hodgkins
-trauma , heart valves, burns, exposure to toxic chem, drugs, sickle cell
121
Hemolytic anemia- S/S
122
Hemolytic anemia- medication management
Increase in folic acid needed to inc production of RBCs
150-400mcg per day
-can be associated with:
Ibuprofen, I-dopa, PCN, ceph abx, tetracyclines, Tylenol, ASA, erythromycin, hydrazine, HCTZ, insulin
123
Anemia of chronic disease
124
Anemia of chronic disease-causes
Inflammation infection tissue injury
-malnutrition
-cancer
Renal insufficiency
-chronic liver disease
125
Anemia of chronic disease-S/S
Fatigue, weakness, bone suppression, bone main, recurrent infections, kidney disease/insufficiency, FTT, low folic acid and Vit C, N/V,jaundice
Normocytic anemia
126
Anemia of chronic disease-dietary management
Increase calcium, vitamin C, folic acid(folate)
127
Effectors of iron absorption
Inhibiting iron absorption:
-coffee, tea, milk, cereals, dietary fiber, carbonated beverages
Dietary supplements with Ca, Zn, Mn, Cu
Antacids, H2 blockers, PPIs
128
Facilitating iron absorption
Vitamin C
Acidic foods
129
Pernicious anemia
MCV>100
Most common cause of -macrocytic anemia in older person (B12/Folate deficiency)
Defective DNA synthesis causes abnormally large and thickened cells
130
Pernicious anemia-causes
B-12 deficiency
Lack of intrinsic factor in the stomach
-gastrectomy, small bowel disease, H-pylori infection, prolonged antacids, strict vegetarian diet
-heavy alcohol ingestion
-cigarette smoking
-autoimmune disorders-particularly those effecting endocrine
131
Pernicious anemia-S/S
Develops slowly over 20-30 years
Early signs:
-infections
-mood swings
-GI/cardiac/Kidney ailments
-Hgb 7-8g/dL, develop classic sings of anemia
-weakness, fatigue, paresthesia of feet and fingers
-weight loss, sore mouth, beefy red tongue, difficulty walking, abdominal pain
132
Pernicious anemia-dietary management
133
Pernicious anemia- medication management
B12 injections for life
Incurable
134
Folic acid anemia
135
Folic acid anemia-Causes
136
Folic acid anemia-S/S
137
Folic acid anemia-Dietary management
138
Folic acid anemia-Medication management
139
Leukemia
140
Leukemia-causes
141
Leukemia-B symptoms
142
Leukemia-B S/S cause
143
Leukemia-survivability
144
Leukemia-old person and survivability
145
Leukemia-young person and survivabilty
146
Leukemia-thrombocytopenic concerns
147
Leukemia-neutropenia concerns
148
Lymphoma-
149
Lymphoma-Causes
150
Lymphoma-B symptoms
151
Lymphoma-B symptoms cause
152
Lymphoma-Treatment
153
Lymphoma-End of life management
154
Lymphoma-Survivability
155
