Cellular Aberration:

Oncology Nursing
Session 1.a
 Verse to Ponder

Jeremiah 29:11
• "For I know the plans I have for you," declares the LORD, "plans to prosper
you and not to harm you, plans to give you hope and a future."
Epidemiology
of Cancer
Overall, the
incidence • More than 1.4 million Americans are diagnosed
each year with cancer, affecting one of various body
of cancer is sites.
higher in men • Cancer is second only to cardiovascular disease as a
than in women leading cause of death in the United States.
and higher in • Although the number of cancer deaths has
industrialized decreased slightly, more than 560, 000 Americans
were expected to die from a malignant process in
sectors and 2008.
nations.
• The leading causes of
cancer deaths in the
United States, in order
of frequency, are lung,
prostate, and colorectal
cancer in men and
lung, breast, and
colorectal cancer
women.
• For all cancer sites combined, African American men have
a 15% higher incidence rate and a 38% higher death rate
than Caucasian men.
African-American women have a 9% lower incidence
rate, but an 18% higher death rate than Caucasian
women for all cancer sites combined.
• Asia has a lower overall cancer incidence
rate (152.2/100,000; ranked 5/6) compared to more
developed continents such as North America
(315.6/100,000), Oceania (298.4/100,000) and Europe
(255.4/100,000).
• 189 of every 100,000 Filipinos are afflicted with cancer while
four Filipinos die of cancer every hour or 96 cancer patients
every day, according to a study conducted by the University of
the Philippines’ Institute of Human Genetics, National Institutes
of Health (DOH).
Pathophysiology: Cancer
• Cancer is a disease
process that
begins when an
abnormal cell is
transformed by
the genetic
mutation of the
cellular DNA.
Proliferative patterns

• Cancerous cells are

described as malignant
neoplasms because
they demonstrate
uncontrolled cellular
growth that follows no
physiologic demand
(neoplasia).
 Characteristics of malignant cells
• Cells are undifferentiated and often bear little resemblance to the normal cells;
• They grow at the periphery and sends out processes that infiltrate and destroy
the surrounding tissues;
• The rate of their growth is variable and depends on level of differentiation;
• They can gain access to the blood and lymphatic channels and metastasizes to
other areas of the body; they often cause generalized effects such as anemia,
weakness, and weight loss;
• They often cause extensive tissue damage and causes death unless growth can
be controlled.
 Malignant Cellular Membranes

• The cell membranes are altered in cancer cells, which affect fluid movement in
and out of the cell.
• The cell membrane of malignant cells also contains proteins called tumor-specific
antigens (eg, carcinoembryonic antigen [CEA] and prostate-specific antigen
[PSA]), which develop over time as the cells become less differentiated (mature).
These proteins distinguish malignant cells from benign cells of the same tissue
type. They may be useful in measuring the extent of disease in a person and in
tracking the course of illness during treatment or relapse.
• Malignant cellular membranes also contain less fibronectin, a cellular cement.
They are therefore less cohesive and do not adhere to adjacent cells readily.
 Malignant Nucleus

• Typically, nuclei of cancer cells are large and

irregularly shaped (pleomorphism).
• Nucleoli, structures within the nucleus that house
ribonucleic acid (RNA), are larger and more
numerous in malignant cells, perhaps because of
increased RNA synthesis.
• Chromosomal abnormalities (translocations,
deletions, additions) and fragility of chromosomes
are commonly found when cancer cells are
analyzed.
 Mitosis in Malignant Cells

• Mitosis (cell division) occurs more frequently in malignant

cells than in normal cells. As the cells grow and divide,
more glucose and oxygen are needed.
• If glucose and oxygen are unavailable, malignant cells use
anaerobic metabolic channels to produce energy, which
makes the cells less dependent on the availability of a
constant oxygen supply.
Invasion and Metastasis
Malignant disease processes have the ability to allow the
spread or transfer of cancerous cells from one organ or body
part to another by invasion and metastasis
 Invasion
• Invasion, which refers to the growth of the
primary tumor into the surrounding host tissues,
occurs in several ways.
• Mechanical pressure exerted by rapidly
proliferating neoplasms may force fingerlike
projections of tumor cells into surrounding tissue
and interstitial spaces.
• Malignant cells are less adherent and may break
off from the primary tumor and invade adjacent
structures.
• Malignant cells are thought to possess or produce
specific destructive enzymes (proteinases), such
as collagenases (specific to collagen), plasminogen
activators (specific to plasma), and lysosomal
hydrolyses. These enzymes are thought to destroy
surrounding tissue, including the structural tissues
of the vascular basement membrane, facilitating
invasion of malignant cells.
• The mechanical pressure of a rapidly growing
tumor may enhance this process.
 Metastasis

• Malignant disease
processes have the ability
to allow the spread or
transfer of cancerous
cells from one organ or
body part to another by
invasion (growth of the
primary tumor into the
surrounding host tissues)
and metastasis
(dissemination or spread
of malignant cells from
the primary tumor to
distant sites.
 Lymphatic Spread
• Lymphatic spread (the transport of tumor cells
through the lymphatic circulation) is the most
common mechanism of metastasis.
• Tumor emboli enter the lymph channels by way of
the interstitial fluid, which communicates with
lymphatic fluid.
• Malignant cells also may penetrate lymphatic
vessels by invasion.
• After entering the lymphatic circulation, malignant
cells either lodge in the lymph nodes or pass
between the lymphatic and venous circulations.
• Tumors arising in areas of the body with rapid and
extensive lymphatic circulation are at high risk for
metastasis through lymphatic channels.
• Breast tumors frequently metastasize in this
manner through axillary, clavicular, and thoracic
lymph channels.
 Hematogenous Spread
• Hematogenous spread is the dissemination
of malignant cells via the bloodstream and is
directly related to the vascularity of the
tumor.
• Few malignant cells can survive the
turbulence of arterial circulation, insufficient
oxygenation, or destruction by the body’s
immune system.
• Structure of most arteries and arterioles is
far too secure to permit malignant invasion.
Those malignant cells that do survive are
able to attach to endothelium and attract
fibrin, platelets, and clotting factors to seal
themselves from immune system
surveillance.
• The endothelium retracts, allowing the
malignant cells to enter the basement
membrane and secrete lysosomal enzymes.
These enzymes destroy surrounding body
tissues, allowing implantation.
 • Carcinogenesis is a malignant transformation that
involves initiation (initiators such as chemicals,
physical factors, and biologic agents, escape normal
Carcinogenesis enzymatic mechanisms and alter the genetic structure
of the cellular DNA),
• promotion (repeated exposure to cocarcinogens
causes the expression of abnormal or mutant genetics
information)
• progression (the altered cells exhibit increased
malignant behavior).
 Promotion: Cellular Oncogenes
• Care responsible for the vital cellular functions of growth and
differentiation. Cellular protooncogenes
• act as an “on switch” for cellular growth.
• Protooncogenes are influenced by multiple growth factors that
stimulate cell proliferation, such as epidermal growth factor (EGF)
and transforming growth factor alpha.
• Another protooncogene that plays an important role in cancer
development is the k-ras (KRAS2) oncogene located on
chromosome 12.
• Just as proto-oncogenes “turn on” cellular
growth, cancer suppressor genes “turn
off,” or regulate, unneeded cellular
proliferation.
Suppressor genes
• The p53 (TP53) gene is a tumor suppressor mutate or lose
Malignant cells are
gene that is frequently implicated in many allowed to
their regulatory
human cancers. reproduce
capabilities
• This gene determines whether cells will
live or die after their DNA is damaged.
• Apoptosis is the innate cellular
process of programmed cell death.
• Mutant TP53 is associated with a poor
prognosis and may be associated with
determining response to treatment.

cells begin to
produce mutant
survival advantage
decrease apoptotic cell populations
Alterations in TP53 for mutant cell
signals that are different
populations.
from their original
cellular ancestors.
 Cancer:
Etiology
 Virus and Bacteria
• Viruses are thought to incorporate themselves in the genetic structure of cells, thus altering future
generations of that cell population, perhaps leading to cancer.
• Epstein-Barr virus is highly suspect as a cause in Burkitt lymphoma, nasopharyngeal cancers, and
some types of non-Hodgkin and Hodgkin lymphoma.
• Bacteria have been evaluated as a cause of cancer over the years but with little evidence to support
the link of bacteria to cancer.
• Chronic inflammatory reactions to bacteria and the production of carcinogenic metabolites are
possible mechanisms under investigation.
• In the early 1990s, the International Agency for Research on Cancer (IARC) identified Helicobacter
pylori (H. pylori) as the first bacterium to be termed a definite cause of cancer in humans.
• H. pylori has been associated with an increased incidence of gastric malignancy related to chronic
superficial gastritis, with resultant atrophic and metaplastic changes to the gastric mucosa
(Schottenfeld & Bebbe-Dimmer, 2006).
*repeated injury
 Physical Agents

• Physical factors associated with carcinogenesis include exposure to

sunlight or radiation, chronic irritation or inflammation, and tobacco
use.
• Excessive exposure to the ultraviolet rays of the sun, especially in fair-
skinned, blue- or green-eyed people, increases the risk of skin cancers.
• Factors such as clothing styles (sleeveless shirts or shorts); use of
sunscreens; occupation; recreational habits; and environmental
variables, including humidity, altitude, and latitude, all play a role in
the amount of exposure to ultraviolet light.
• Exposure to ionizing
radiation can occur with
repeated diagnostic x-ray
procedures or with
radiation therapy used
to treat disease.
Fortunately, improved x-
ray equipment minimizes
the risk of extensive
radiation exposure.
• Radiation therapy used in
disease treatment and exposure
to radioactive materials at
nuclear weapon manufacturing
sites or nuclear power plants are
associated with a higher
incidence of leukemias, multiple
myeloma, and cancers of the
lung, bone, breast, thyroid, and
other tissues.
• Background radiation from
the natural decay processes
that produce radon has also
been associated with lung
cancer. Homes with high
levels of trapped radon
should be ventilated to allow
the gas to disperse into the
atmosphere.
 Chemical Agents

• About 75% of all cancers are thought to be related to the environment.

• Most hazardous chemicals produce their toxic effects by altering DNA
structure in body sites distant from chemical exposure.
• The liver, lungs, and kidneys are the organ systems most often affected,
presumably because of their roles in detoxifying chemicals.
• Tobacco smoke, thought
to be the single most
lethal chemical
carcinogen, accounts for
at least 30% of cancer
deaths.
• Smoking is strongly
associated with cancers
of the lung, head and
neck, esophagus,
stomach, pancreas,
cervix, kidney, and
bladder and with acute
myeloblastic leukemia.
• More than 4,000 individual chemicals
have been identified in tobacco and
tobacco smoke, including more than 60
chemicals that are known carcinogens.
• Tobacco may also act synergistically with
other substances, such as alcohol,
asbestos, uranium, and viruses, to
promote cancer development.
• Chewing tobacco is associated with
cancers of the oral cavity, which
primarily occurs in men younger than 40
years of age.
• Considerable research has also
substantiated the effect of secondhand
cigarette smoke as an environmental
risk factor for both smokers and
nonsmokers (American Cancer Society
[ACS], 2008c;2008d).
• Many chemical substances found in the workplace have proved to be
carcinogens or cocarcinogens. In the United States, carcinogens are classified
by two federal agencies: the National Toxicology Program of the Department
of Health and Human Services and the Environmental Protection Agency’s
Integrated Risk Information System (IRIS).
• The extensive list of suspected chemical substances continues to grow and
includes aromatic amines and aniline dyes; pesticides and formaldehydes;
arsenic, soot, and tars; asbestos; benzene; betel nut and lime; cadmium;
chromium compounds; nickel and zinc ores; wood dust; beryllium
compounds; and polyvinyl chloride.
 Genetics and Familial
Factor
• Almost every cancer type has been shown to run in families. This
may be due to genetics, shared environments, cultural or lifestyle
factors, or chance alone.
• Genetic factors play a role in cancer cell development.
• Abnormal chromosomal patterns and cancer have been
associated with extra chromosomes, too few chromosomes, or
translocated chromosomes.
\ Switch places
• Specific cancers with underlying genetic abnormalities include
Burkitt lymphoma, chronic myelogenous leukemia, meningiomas,
acute leukemias, retinoblastomas, Wilms tumor, and skin
cancers, including malignant melanoma.
• Approximately 5% of cancers in adults
display a pattern of cancers suggestive of
a familial predisposition.
• The hallmarks of families with a
hereditary cancer syndrome include
cancer in two or more first-degree or
second-degree relatives, early onset of
cancer in family members younger than
50 years of age, the same type of cancer
in several family members, individual
family members with more than one
type of cancer, and a rare cancer in one
or more family members.
• There is also evidence of an autosomal
dominant inheritance pattern of cancers
affecting several generations of the
family.
• Discoveries of mutations in genes related to critical
cell control functions, such as tumor suppression,
DNA repair mechanisms, and oncogenes, have
enabled the appropriate identification of families at
risk for these syndromes.
• Examples of these syndromes include hereditary
breast and ovarian cancer syndrome (BRCA1 and
BRCA2) and multiple endocrine neoplasia syndrome
(MEN1 and MEN2).
• Cancers associated with familial inheritance
syndromes include nephroblastomas,
pheochromocytomas, and breast, ovarian,
colorectal, stomach, thyroid, renal, prostate, and
lung cancers (Nussbaum, McInnes & Willard, 2007).
 Dietary Factors

• Dietary factors are also linked to environmental cancers. Dietary

substances can be proactive (protective), carcinogenic, or
cocarcinogenic.
• The risk of cancer increases with long-term ingestion of carcinogens
or cocarcinogens or chronic absence of protective substances in the
diet.
• Dietary substances that appear to increase the risk of cancer include
fats, alcohol, salt-cured or smoked meats, nitrate-containing and
nitrite-containing foods, and red and processed meats.
 Alcohol
• Alcohol increases the risk
of cancers of the mouth,
pharynx, larynx,
esophagus, liver,
colorectum, and breast.
• Alcohol intake should be
limited to no more than
two drinks per day for men
and one drink per day for
women.
• Greater consumption of vegetables
and fruits is associated with a
decreased risk of lung, esophageal,
stomach, and colorectal cancers
(Kushi, Byers, Doyle, et al., 2006).
• A high caloric dietary intake is also
associated with an increased cancer
risk.
• Obesity is clearly associated with
endometrial cancer,
postmenopausal breast cancers, and
colon, esophagus, and kidney
cancers.
• There is evidence that obesity also
increases the risk for cancers of the
pancreas, gallbladder, thyroid, ovary,
cervix, prostate, and for multiple
myeloma and Hodgkin lymphoma
(Kushi, et al., 2006).
 Hormonal Agents
• Tumor growth may be promoted by disturbances in hormonal balance, either by the body’s own
(endogenous) hormone production or by administration of exogenous hormones.
• Cancers of the breast, prostate, and uterus are thought to depend on endogenous hormonal levels for
growth.
• Diethylstilbestrol (DES) - long been recognized as a cause of vaginal carcinomas.
• Oral contraceptives and prolonged estrogen therapy are associated with an increased incidence of
hepatocellular, endometrial, and breast cancers, but they decrease the risk of ovarian cancer.
• The combination of estrogen and progesterone appears safer than estrogen alone in decreasing the
risk of endometrial cancers;
• However, studies support discontinuing hormonal therapy containing both estrogen and progestin
because of the increased risk of breast cancer, coronary heart disease, stroke and blood clots
(Chlebowski, Anderson, Pettinger, et al., 2008).
• Hormonal changes related to the female
reproductive cycle are also associated
with cancer incidence. Early onset of
menses under age 12 and delayed onset
of menopause after age 55, nulliparity
(never giving birth), and delayed childbirth
after age 30 are all associated with an
increased risk of breast cancer.
• Increased numbers of pregnancies are
associated with a decreased incidence of
breast, endometrial, and ovarian cancers.
END OF SESSION 1
Cellular Aberration:
Oncology Nursing
Session 1.b
Role of the
Immune
System
• In humans, malignant cells are capable of developing on a
regular basis. However, some evidence indicates that the
immune system can detect the development of malignant cells
and destroy them before cell growth becomes uncontrolled.
• When the immune system fails to identify and stop the growth
of malignant cells, clinical cancer develops.
 Who are at risk?

• Patients who are immunocompromised have an increased incidence of

cancer.
• Organ transplant recipients who receive immunosuppressive therapy to
prevent rejection of the transplanted organ have an increased incidence of
lymphoma, Kaposi’s sarcoma, squamous cell cancer of the skin, and cervical
and anogenital cancers (Herman, Rogers & Ratner, 2007).
• Patients with immunodeficiency diseases, such as acquired
/ lack CD4 cells

immunodeficiency syndrome (AIDS), have an increased incidence of Kaposi’s

sarcoma, lymphoma, rectal cancer, and head and neck cancers (Grulich,
Vajdic & Cozen, 2007).
• Some patients who have received alkylating chemotherapeutic
agents to treat cancer have an increased incidence of secondary
malignancies (Tward, Glenn, Pulsipher, et al., 2007).
• Autoimmune diseases, such as rheumatoid arthritis and Sjögren
syndrome, are associated with increased cancer development
(Wolf & Michaud,2007).
• Finally, age-related changes, such as declining organ function,
increased incidence of chronic diseases, and diminished
immunocompetence, may contribute to an increased incidence of
cancer in older people.
 Normal Immune Responses

• Normally, an intact immune system has the ability to combat

cancer cells in several ways.
• Usually, the immune system recognizes as foreign certain
antigens on the cell membranes of many cancer cells.
• These antigens, known as tumor- associated antigens (also called
tumor cell antigens), are capable of stimulating both cellular and
humoral immune responses.
 T lymphocytes that are
T lymphocytes recognize
Cytotoxic T- tumor antigens
toxic to the tumor cells
are stimulated
lymphocytes

• Along with the lymphocytes proliferate

Kill and destroy
macrophages, T and are released into the
malignant cells
lymphocytes, the circulation.

soldiers of the cellular

immune response, are
responsible for
stimulate other
recognizing tumor- components of the
associated antigens. immune system to rid
the body of malignant
cells.
T-cells attacking cancer cells
• Certain lymphokines, which are substances produced by
lymphocytes, are capable of killing or damaging various types of
malignant cells.
• Other lymphokines can mobilize other immune system cells, such
as macrophages, that disrupt cancer cells.
• Interferon, a substance produced by the body in response to viral
infection, also possesses some antitumor properties.
• Antibodies produced by B lymphocytes, associated with the
humoral immune response, also defend the body against
malignant cells. These antibodies act either alone or in
combination with the complement system or the cellular immune
system.
• Natural killer (NK) cells are a
major component of the body’s
defense against cancer.
• NK cells are a subpopulation of
lymphocytes that act by directly
destroying cancer cells or by
producing lymphokines and
enzymes that assist in cell
destruction.
 Immune System Failure

• If the body fails to recognize the malignant cell as different

from “self ” (ie, as nonself or foreign), the immune response
may not be stimulated.
• When tumors do not possess tumor-associated antigens that
label them as foreign, the immune response is not alerted.
This allows the tumor to grow too large to be managed by
normal immune mechanisms.
• Tumor antigens may combine with the antibodies produced by the
immune system and hide or disguise themselves from normal
immune defense mechanisms. These tumor antigen–antibody
complexes can suppress further production of antibodies.
• Tumors can also alter their appearance or produce substances
that impair usual immune responses. These substances promote
tumor growth and increase the patient’s susceptibility to infection.
• After prolonged contact with a tumor antigen, the body may be
depleted of the specific lymphocytes and no longer be able to
mount an appropriate immune response.
• Abnormal concentrations of host suppressor T lymphocytes may
play a role in cancer development.
• Suppressor T lymphocytes normally assist in regulating antibody
production and diminishing immune responses when they are no
longer required.
• Low levels of antibodies and high levels of suppressor cells have
been found in patients with multiple myeloma, a cancer
associated with hypogammaglobulinemia (low amounts of serum
antibodies).
• Carcinogens, such as viruses and certain chemicals, including
chemotherapeutic agents, may weaken the immune system and
ultimately enhance tumor growth.
 Detection and
Prevention of Cancer
 Primary Prevention

• Primary prevention is concerned with reducing the risks

of disease through health promotion strategies.
• It is estimated that almost one third of all cancers
worldwide could be prevented through primary
prevention efforts (Williams-Brown & Singh, 2005).
*health teaching
 Health Promotion Strategies
• Reduce the risk of cancer is to help patients avoid
known carcinogens.
• Encouraging patients to make dietary and lifestyle
changes (smoking cessation, decreased caloric
intake, increased physical activity) that studies
show influence the risk for cancer.
 Medication tamoxifen
(Nolvadex) can reduce the
incidence of breast cancer
by 50% in women at high
risk for breast cancer
(Fisher, Constantino,
Wickerham, et al., 2005).
Currently, the NCI (2008)
lists 110 ongoing clinical
trials exploring
chemoprevention
strategies.
 Secondary Prevention
• Secondary prevention programs promote screening and early detection
activities such as breast and testicular self-examination and Papanicolaou
(Pap) tests.
• Improved survival rates if diagnosed early: breast or prostate cancer.
• Organizational program/charity work: These events offer education and
examinations such as mammograms, digital rectal examinations, and PSA
blood tests for minimal or no cost. These programs often target people who
lack access to health care insurance or who cannot afford to participate on
their own.
• Nurses in all settings can develop
programs that identify risks for
patients and families and that
incorporate teaching and counseling
into all educational efforts,
particularly for patients and families
with a high incidence of cancer.
Nurses and physicians can
encourage people to comply with
detection efforts as suggested by
the ACS.
 Women, aged 20 years:
Breast self-examination
(BSE)

• Beginning in their early 20s,

women should be told about
the benefits and limitations of
BSE.
• The importance of prompt
reporting of any new breast
symptoms to a health
professional should be
emphasized.
Women, aged 20 years: Clinical breast
examination (CBE)

• For women in their 20s and

30s, it is recommended that
CBE be part of a periodic
health examination, preferably
at least every 3 years.
• Asymptomatic women aged 40
years should continue to
receive a clinical breast
examination as part of a
periodic health examination,
preferably Annually.
 Colorectal: Men and
women, aged > 50 years
• Mammography: Begin annual mammography at
age 40 years.*
• Fecal occult blood test (FOBT)† : Annual, starting at
age 50 years
• (FOBT)† and flexible sigmoidoscopy,‡ or
sigmoidoscopy every 5 years, starting at age 50
years.
• Colonoscopy every 10 years, starting at age 50
years.
 Prostate: Men, aged 50
years

• Digital rectal examination (DRE) and

prostate-specific antigen (PSA) test: The
PSA test and the DRE should be offered
annually, starting at age 50 years.
 Cervix :Women, aged 18
years
• Pap test: Cervical cancer screening should
begin approximately 3 years after a woman
begins having vaginal intercourse, but no
later than age 21 years.
• Screening should be done every year with
conventional Pap tests or every 2 years
using liquid-based Pap tests.
• At or after age 30 years, women who have
had normal test results in a row may get
screened every 2 to 3 years with cervical
cytology (either conventional or liquid-
based Pap test) alone, or every 3years with
a human papillomavirus DNA test, plus
cervical cytology.
• Women aged 70 years who have had or
more normal Pap tests and no abnormal
Pap tests in the 10 years
• women who have had a total hysterectomy
may choose to stop cervicalcancer
screening.
ONCOLOGY
NURSING
SESSION 2.A

DIAGNOSIS OF CANCER AND

TUMOR STAGING
  neo+ =new
 +plasia =growth
 +plasm= substance

LET’S REVIEW  +trophy =size

CANCER  +oma =tumor
TERMINOLOGY
 a+ =none
 ana+=lack
 hyper+ =excessive
 meta+ =change
 dys+= bad, impaired
CANCER TERMINOLOGY

 Atrophy
 Hypertrophy
 Hyperplasia
 Metaplasia
 Dysplasia
 Anaplasia
 Neoplasia
 BREAST CANCER
 Family History

 High-fat Diet

 Obesity after
ETIOLOGY OF  Menopause
COMMON  Early Menarche,
CANCERS  Late Menopause

 Alcohol Consumption

 Postmenopausal Estrogen and Progestin

 First Child after Age 30

  Family History
COLORECTAL
 Low Fiber Diet
CANCER
 History of Rectal Polyps
ESOPHAGEAL  Heavy Alcohol Consumption

CANCER  Smoking
  Cigarette Smoking

 Asbestos

LUNG CANCER  Arsenic

 Radon Exposure

 Secondhand Smoke

 TB
  Multiple Sexual Partner

CERVICAL  Having Sex at Early Age (younger than 18 years of age)

CANCER  Exposure to Human Papilloma Virus

 Smoking
SKIN CANCER

 Excessive Exposure to UV Radiation (Sun)

 Fair Complexion

 Work With Coal, Tar, Pitch or Creosote

 Multiple or Atypical Nevi (Males)

  Family History
STOMACH
 Diet Heavy in Smoked,
CANCER
 Pickled or Salted Foods
  Increasing Of Age
PROSTATE
 Family History
CANCER
 Diet High in Animal Fat
WARNING
SIGNS OF
CANCER
 Determine Determine presence, extent of tumor

Identify Identify possible disease metastasis

DIAGNOSIS OF
CANCER
Evaluate functions of involved and uninvolved body
Evaluate systems and organs

Obtain tissue and cells for analysis, including evaluation of

Obtain tumor stage and grade
DIAGNOSTIC
AIDS
DIAGNOSTIC
AIDS USED TO
DETECT
CANCERSED TO
DETECT
CANCER
TUMOR MARKER
IDENTIFICATION
 Analysis of substances found
in body—tissues, blood, or
other body fluids that are
made by the tumor or
cancers by the body in
response to the tumor.
GENETIC PROFILING
 Analysis for the presence of
mutations (alterations) in
genes found in tumors or
body tissues.
 Assists in selection of
treatment, prediction of,
response to therapy, and risk
of progression or recurrence.
MAMMOGRAPHY

USE OF X-RAY IMAGES OF

THE BREAST
MRI
 Use of magnetic fields and
radiofrequency signals to
create sectioned images of
various body structures
CT SCAN

 Use of narrow-beam x-ray to

scan successive layers of tissue
for a cross-sectional view
FLUOROSCOPY
 Use of x-rays that identify
contrasts in body tissue
densities; may involve the use
of contrast agents
ULTRASONOGRAPHY
(ULTRASOUND)
 High-frequency sound waves
echoing off body tissues
Abdominal are converted
electronically into images;
used to assess tissues deep
within the body
ENDOSCOPY
 Direct visualization of a body
cavity or passageway by
insertion of an endoscope
into a body cavity or opening;
allows tissue biopsy, fluid
aspiration, and excision of
small tumors. Used for
diagnostic and therapeutic
purposes.
NUCLEAR MEDICINE
IMAGING
 Uses intravenous injection or
ingestion of radioisotope
substances followed by
imaging of tissues that have
concentrated the
radioisotopes.
POSITRON EMISSION
TOMOGRAPHY (PET)
 Through the use of a tracer,
provides black and white or
color-coded images of the
biologic activity of a
particular area, rather than its
structure. Used in melanoma
detection of cancer or its
response to treatment.
RADIOIMMUNOCONJUGATES
 Monoclonal antibodies are
labeled with a radioisotope
and injected intravenously
into the patient; the
antibodies that aggregate at
the tumor site are visualized
with scanners
TUMOR STAGING
AND GRADING

 Staging: determines the size of

the tumor, the existence of local
invasion, lymph node
involvement, and distant
metastasis
 Grading: pathologic
classification of tumor cells: I-IV
GRADING

 Degree to which the tumor cells retain the functional and histologic characteristics of the tissue of
origin (differentiation)
 The grade corresponds with a numeric value ranging from I to IV

 Grade I tumors, also known as well-differentiated tumors, closely resemble the tissue of origin in
structure and function
 grade IV tumors tend to be more aggressive, less responsive to treatment, and associated with a
poorer prognosis
 T1 - mucosa & submucosa
T2 - muscle layer
T3 - subserosa & serosa
T4 - spreads outside

N0 - No nodes
N1 - 1-3 nodes
N2 - 4+

VIDEO FOR M0 - no
M1 - Metastasis
TUMOR
STAGING AND Number System:
I - contained within organ (T1, N0, M0)
GRADING II - within organ but larger +/- lymph nodes (T2-3, N0-1, M0)
III - spread into surrounding tissues + lymph nodes (T4, N1-2, M0)
IV - metastasis (any T, any N, M1)
END OF SESSION 2.A
Good Day Gallants!
Continually
Surrounded
“The LORD’s unfailing
love surrounds the man
who trusts in him.
Rejoice in the LORD
and be glad, you
righteous; sing, all you
who are upright in
heart!” Psalm 32:10,11
Oncology Nursing
Session 2.b
MANAGEMENT OF CANCER
 Cancer Management

The range of possible treatment goals may include

complete eradication of malignant disease (cure),
prolonged survival and containment of cancer cell
growth (control), or relief of symptoms associated
with the disease (palliation).
 DIAGNOSTIC

Surgical Treatment
P R I M A R Y T R E AT M E N T

PROPHYLACTIC

PA L L I AT I V E

RECONSTRUCTIVE
 Diagnostic
Surgery
Diagnostic surgery, such as a biopsy, is usually performed to obtain a
tissue sample for analysis of cells suspected to be malignant.

Sentinel lymph node biopsy (SLNB), also known as sentinel lymph

node mapping, is a minimally invasive surgical approach that in some
instances has replaced more invasive lymph node dissections
(lymphadenectomy) and their associated complications such as
lymphedema and delayed healing. SLNB has been widely adopted for
regional lymph node staging in selected cases of melanoma and
breast cancer (Chen, Iddings, Scheri, et al., 2006).
Biopsy Types \ most definitive

Excisional biopsy is most frequently used for easily accessible

tumors of the skin, breast, and upper or lower gastrointestinal
and upper respiratory tracts. In many cases, the surgeon can
remove the entire tumor as well as the surrounding marginal
tissues.
The removal of normal tissue beyond the tumor area decreases
the possibility that residual microscopic disease cells may lead
to a recurrence of the tumor.
This approach not only provides the pathologist, who stages
and grades the cells, with the entire tissue specimen but also
decreases the chance of seeding the tumor (disseminating
cancer cells throughout surrounding tissues).
 Incisional
biopsy
It is performed if the tumor mass is
too large to be removed. In this
case, a wedge of tissue from the
tumor is removed for analysis. The
cells of the tissue wedge must be
representative of the tumor mass
so that the pathologist can provide
an accurate diagnosis.
If the specimen does not contain
representative tissue and cells,
negative biopsy results do not
guarantee the absence of cancer.
Needle biopsies
Performed to sample
suspicious masses that are
easily accessible, such as
some growths in the
breasts, thyroid, lung, liver,
and kidney
Surgery as Primary
Treatment
/ can be done in clinics
Local excisions is performed on an outpatient
basis, is warranted when the mass is small. It
includes removal of the mass and a small margin of
normal tissue that is easily accessible.
/ done in or
Wide or radical excisions (en bloc dissections)
include removal of the primary tumor, lymph nodes,
adjacent involved structures, and surrounding
tissues that may be at high risk for tumor spread
(Szopa, 2005).
Video-assisted
endoscopic surgery
Increasingly replacing surgery
associated with long incisions and
extended recovery periods to
minimize surgical trauma and
shorten patient recovery time
without compromising surgical
outcomes (Swanson, Herndon,
D’Amico, et al., 2007).
Salvage
surgery
An additional treatment option
that uses an extensive surgical
approach to treat the local
recurrence of a cancer after
the use of a less extensive
primary approach.
Example: A mastectomy to
treat recurrent breast cancer
after primary lumpectomy and
radiation.
 Prophylactic Surgery
Prophylactic surgery involves removing nonvital tissues or
organs that are at increased risk to develop cancer. The
following factors are considered when physicians, nurses,
patients, and families discuss possible prophylactic
surgery:
• Family history and genetic predisposition
• Presence or absence of symptoms
• Potential risks and benefits
• Ability to detect cancer at an early stage
• The patient’s acceptance of the postoperative outcome
 Palliative surgery is performed in an attempt to relieve
Palliative Surgery
\ to treatsymptoms
complications of cancer, such as ulceration,
obstruction, hemorrhage, pain, and malignant effusion
 Reconstructive
Surgery
Reconstructive surgery may follow
curative or radical surgery in an
attempt to improve function or obtain
a more desirable cosmetic effect. It
may be performed in one operation or
in stages. The surgeon who will
perform the surgery discusses
possible reconstructive surgical
options with the patient before the
primary surgery is performed.
Reconstructive surgery may be
indicated for breast, head and neck,
and skin cancers.
Nursing
Management
in Cancer
Surgery
The nurse provides
education and
emotional support by
assessing the needs of
the patient and family
and by discussing their
fears and coping
mechanisms.
 Nursing
Management in
Cancer Surgery
(Post-operatively)
❖ Assesses the patient’s responses to the
surgery.

❖Monitors the patient for possible

complications, such as infection, bleeding,
thrombophlebitis, wound dehiscence,
fluid and electrolyte imbalance, and organ
dysfunction.

❖The nurse also provides for the patient’s

comfort.

❖Postoperative teaching addresses wound

care, activity, nutrition, and medication
information.
Radiation
Therapy
 Radiation therapy may be use prophylactically to prevent
the spread of a primary cancer to a distant area (eg,

Prophylactic irradiating the brain to prevent leukemic infiltration or

metastatic lung cancer).

and Palliative radiation therapy is used to relieve the symptoms

Palliative
of metastatic disease, especially when the cancer has spread
to the brain, bone, or soft tissue, or to treat oncologic
emergencies, such as superior vena cava syndrome,
bronchial airway obstruction, or spinal cord compression.
Effects of Radiation to Cells and
Tissues
❖Two types of ionizing radiation—electromagnetic radiation (x-rays and gamma rays) and particulate
radiation (electrons, beta particles, protons, neutrons, and alpha particles)— can lead to tissue
disruption.
❖Direct alteration of the DNA molecule within the cells of the tissue = Most harmful tissue
destruction.
❖Ionizing radiation breaks the strands of the DNA helix, leading to cell death.
❖ It can also lead to the formation of free radicals and irreversibly damage DNA.
❖ If the DNA is incapable of repair, the cell may die immediately, or it may initiate cellular suicide, a
genetically programmed cell death (Bruner, Haas & Gosselin- Acomb, 2006; Yarbro, Hansen-Frogge &
Goodman, 2005).
 ❖One that can be destroyed by a dose of radiation that still
allows for cell regeneration in the normal tissue.
Radiosensitive ❖Tumors that are well oxygenated also appear to be more

Tumor sensitive to radiation.

❖In theory, therefore, radiation therapy may be enhanced if

more oxygen can be delivered to tumors.
 Radiation Dosage
The lethal tumor dose is defined as that dose that will eradicate 95% of the tumor yet
preserve normal tissue.
In external beam radiation, the total radiation dose is delivered over several weeks in
daily doses called fractions. This allows healthy tissue to repair and to achieve greater
cell kill by exposing more cells to the radiation as they begin active cell division.
Repeated radiation treatments over time (fractionated doses) also allow for the
periphery of the tumor to be reoxygenated repeatedly, because tumors shrink from the
outside inward. This increases the radiosensitivity of the tumor, thereby increasing
tumor cell death (Bruner, et al., 2006; Yarbro, et al., 2005).
Administration of
Radiation
❖Primary applications include teletherapy
(external beam radiation),
❖brachytherapy (internal radiation),
❖systemic (radioisotopes),
❖contact or surface molds.
 External beam radiation therapy (EBRT) is the most commonly used
form of radiation therapy.

Gamma rays generated from the spontaneous decay of naturally

External occurring solid source of radioactivity, such as cobalt-60, is one of

the oldest forms of EBRT.

Radiation With the advent of modern linear accelerators, the use of solid
radioactive elements are confined primarily to the GammaKnifeTM
stereotactic radiosurgery unit, which is used as a one-time, high-
dose delivery of EBRT for treatment of benign and malignant
intracranial lesions.
 Internal Radiation:
Brachytherapy
Brachytherapy may be delivered as a temporary or a permanent
implant.

Temporary applications may be delivered as high-dose radiation

(HDR) for short periods of time or low-dose radiation (LDR) for a
more extended period of time.

The primary advantage of HDR sources of brachytherapy is that

treatment time is shorter, there is reduced exposure to personnel,
and the procedure can typically be performed as an outpatient
procedure over several days.

HDR brachytherapy can be used for intraluminal, interstitial,

intracavitary, and surface lesions.
 Toxicity of radiation therapy is localized to the
region being irradiated.
Toxicity may be increased if concomitant
Toxicity chemotherapy is administered.
Acute local reactions occur when normal cells
in the treatment area are also destroyed and
cellular death exceeds cellular regeneration.
 Localized in the region being irradiated and may be
increased if concomitant chemotherapy is given.

Acute or early toxicities most often begin within 2 weeks

Radiation of the initiation of treatment occur when normal cells
within the treatment area are damaged and cellular
Effects death exceeds regeneration.

Body tissues most affected are those that normally

proliferate rapidly, such as the skin, the epithelial lining of
the gastrointestinal tract, and the bone marrow.
Systemic Early effects
Radiation ◦ fatigue, malaise, and anorexia that may be secondary to
substances released when tumor cells are destroyed.
Effects- ◦ tend to be temporary and most often subside within 6
months of the cessation of treatment.

Early
 Approximately 6 months to years later

Systemic
Usually a result of permanent damage to tissues, loss of
elasticity, and changes secondary to a decreased
vascular supply
Radiation Severe effects

Effects-Late ◦ fibrosis, atrophy, ulceration, and necrosis

May effect
◦ lungs, heart, central nervous system, and bladder
 Nursing
Care of the Promote healing, patient comfort, quality of life

Patient Assessment
◦ Skin

Undergoing ◦ Nutritional status

◦ Well-being

Radiation Protecting caregivers

Therapy
 Protecting care givers:
Safety Precautions
(Brachytherapy)
❖assigning the patient to a private room,

❖posting appropriate notices about radiation safety precautions,

❖having staff members wear dosimeter badges,

❖making sure that pregnant staff members are not assigned to

the patient’s care,

❖Prohibiting visits by children or pregnant visitors,

❖limiting visits from others to 30 minutes daily,

❖Visitors maintain a 6-foot distance from the radiation source.

Chemotherapy
 Chemotherapy

The goal of treatment is eradication of enough of the tumor so that the

remaining tumor cells can be destroyed by the body’s immune.
Actively proliferating cells within a tumor are the most sensitive to
chemotherapeutic agents (the ratio of dividing cells to resting cells is
referred to as the growth fraction).
Nondividing cells capable of future proliferation are the least sensitive
to antineoplastic medications and consequently are potentially
dangerous.
Mitosis
 Certain chemotherapeutic agents that are
specific to certain phases of the cell cycle are
termed cell cycle–specific agents.
These agents destroy cells that are actively
Classification of reproducing by means of the cell cycle;
Chemotherapeutic
Agents most affect cells in the S phase by interfering
with DNA and RNA synthesis.
vinca or plant alkaloids, are specific to the M
phase, where they halt mitotic spindle
formation.
 ❖Chemotherapeutic agents that act
independently of the cell
❖Cycle phases are termed cell cycle–
nonspecific agents.
Classification of ❖These agents usually have a prolonged effect
Chemotherapeutic on cells, leading to cellular damage or death.
Agents Many treatment plans combine cell cycle–
specific and cell cycle–nonspecific agents to
increase the number of vulnerable tumor cells
killed during a treatment period (Polovich,
White & Kelleher, 2005).
Extravasation
Antineoplastic chemotherapeutic agents are
additionally classified by their potential to damage soft
tissue if they inadvertently leak from a vein
(extravasation).

The consequences of extravasation range from mild

discomfort to severe tissue destruction, depending on
whether the agent is classified as a non-vesicant,
irritant, or vesicant.

Irritant agents induce inflammatory reactions but

usually cause no permanent tissue damage.
 If deposited into the subcutaneous
or surrounding tissues
(extravasation), cause inflammation;
tissue damage; and possibly
necrosis of tendons, muscles,
nerves, and blood vessels
Vesicant
Use central line and make sure its
patent
 cisplatin (Platinol-AQ),
dactinomycin
(Cosmegen),
daunorubicin (DaunoXome),

Medications doxorubicin, nitrogen

mustard (Mustargen),
classified as mitomycin (Mutamycin),
vesicants paclitaxel (Taxol),
vinblastine (Velban),
vincristine (Oncovin),
vindesine (Eldisine),
vinorelbine (Navelbine)
Indications of extravasation during administration of
vesicant agents include the following:

❖Absence of blood return from the intravenous (IV)

catheter
❖ Resistance to flow of IV fluid
❖Burning or pain, swelling or redness at the site
 Stop the infusion.

Cold compresses are indicated for doxorubicin

extravasation but are of no benefit for taxane or
oxaliplatin (Eloxatin) extravasation.
Management Warm compresses are recommended for vinca
of alkaloid extravasation.
Extravasation
Aspiration of any infiltrated medication from the
tissues a

Injection of a neutralizing solution into the area to

reduce tissue damage
 Vesicant chemotherapy should never be administered in
peripheral veins involving the hand or wrist
Peripheral administration is permitted for short duration
infusions only, an
Placement of the venipuncture site should be on the

Prevention of forearm area using a soft, plastic catheter.

For any frequent, or prolonged administration of
Extravasation antineoplastic vesicants, right atrial silastic catheters,
implanted catheters (PICC) should be inserted to
promote safety during administration and reduce
problems with access to the circulatory system.
Indwelling or subcutaneous catheters require vigilant
nursing are. Complications associated with their use
include infection and thrombosis (Arch, 2007).
 Hypersensitivity Reactions
The usual chemotherapy hypersensitivity reaction is categorized as a type I immediate,
immunoglobulin E mediated reaction.
Type I hypersensitivity reactions may present as a local reaction and then rapidly progress to
systemic anaphylaxis, or the initial presentation may be an acute life-threatening anaphylaxis.
Symptoms
◦ generalized itching with localized or generalized urticaria;
◦ flushing of the face, hands, or feet;
◦ chest tightness;
◦ agitation;
◦ nausea and vomiting;
◦ dyspnea and bronchospasm;
◦ difficulty speaking;
◦ feeling of impending doom;
◦ hypotension
Chemotherapy Toxicity
GI: Nausea and Vomiting
❖ Usually occurs 24-48 hours post chemo.
❖Delayed nausea and vomiting may persist for as long as 1 week after
chemotherapy.
❖Serotonin blockers, such as ondansetron (Zofran), granisetron (Kytril),
dolasetron (Anzemet), and palonosetron (Aloxi), which block serotonin receptors
of the gastrointestinal tract and CTZ,
❖Dopaminergic blockers, such as metoclopramide (Reglan), which block
dopamine receptors of the CTZ.
GI: Nausea and Vomiting
Neurokinin 1 receptor antagonists (eg, aprepitant [Emend]),= block the activity
of substance P, a potent neurotransmitter involved in stimulating nausea and
vomiting.
Nonpharmacologic approaches to manage Nausea and vomiting
❖ Relaxation techniques, imagery, and acupressure = help decrease stimuli
contributing to symptoms.
❖Small frequent meals
❖Bland foods and comfort foods = reduce the frequency or severity of vomiting.
GI: Diarrhea
Antimetabolites and antitumor antibiotics = major culprits in
mucositis and other gastrointestinal symptoms, including
diarrhea, which can be severe in some patients.
Hematopoietic System:
Myelosuppression
Myelosuppression is predictable, and patients usually
reach their nadir counts (point at which blood counts are
lowest) 7 to 14 days after chemotherapy has been
administered. At this time nurses anticipate associated
toxicities, especially febrile neutropenia (fever associated
with neutrophil count less than 1500 cells/mm3).
Myelosuppression: Medical
Management
Colony-stimulating factors (granulocyte colony-stimulating
factor [G-CSF] and granulocyte macrophage colony-
stimulating factor [GM-CSF])= can be administered after
chemotherapy to stimulate the bone marrow to produce
WBCs, especially neutrophils, at an accelerated rate, thus
decreasing the duration of neutropenia.
Myelosuppression: Medical
Management
Erythropoietin (EPO) stimulates RBC production, thus decreasing the
symptoms of chronic anemia and reducing the need for blood
transfusions.
Interleukin 11 (IL-11) stimulates the production of platelets and can
be used to prevent and treat thrombocytopenia (platelet count less
than 100,000) but has had limited use because of toxicities such as
fatigue, edema, dysrhythmias, and syncope.
Renal System
Cisplatin, methotrexate (Trexall, Rheumatrex), and mitomycin are particularly
toxic to the kidneys.
Rapid tumor cell lysis after chemotherapy results in increased urinary excretion
of uric acid, which can cause renal damage.
Intracellular contents are released into the circulation, resulting in hyperkalemia,
hyperphosphatemia, and hypocalcemia.
Renal Toxicity: Management
❖Monitor BUN, Creatinine levels, serum electrolyte levels is essential.
❖Adequate hydration,
❖Diuresis,
❖ Alkalinization of the urine to prevent formation of uric acid crystals,
❖Allopurinol
❖Amifostine has demonstrated an ability to minimize renal toxicities associated
with cisplatin, cyclophosphamide (Cytoxan), and ifosfamide (Ifex) therapy.
Cardiopulmonary System
Anthracyclines (daunorubicin and doxorubicin) =known to
cause irreversible cumulative cardiac toxicities, especially when
total dosage reaches 600 mg/m2 and 550 mg/m2, respectively.
Dexrazoxane (Zinecard) has been utilized as a
cardioprotectant when doxorubicin is needed in individuals who
have already received a cumulative dose of 300 mg/m2 and
continuation of therapy is deemed beneficial.
Cardiopulmonary System
Bleomycin (Blenoxane), carmustine (BCNU), and busulfan (Busulfex,
Myleran) have cumulative toxic effects on lung function, resulting in
pulmonary fibrosis.
Monitored closely for changes in pulmonary function, including
pulmonary function test results.
Cardiopulmonary System
Capillary leak syndrome with resultant pulmonary edema is a toxic effect of
cytarabine (DepoCyt, Tarabine) (AraC), mitomycin C, cyclophosphamide, and
BCNU.
Subtle onset of dyspnea and cough may progress rapidly to acute respiratory
distress and subsequent respiratory failure
Reproductive System
Normal ovulation, early menopause, or permanent sterility
may occur. In men, temporary or permanent azoospermia
(absence of spermatozoa) may develop.
Neurologic System
Vincristine = Peripheral neuropathy
Oxaliplatin = frightening neurotoxicity presentation that is often precipitated by
exposure to cold and is characterized by pharyngolaryngeal dysesthesia
consisting of lip paresthesia, discomfort or tightness in the back of the throat,
inability to breathe, and jaw pain.
❖Avoid drinking cold fluids or going outside with hands and feet exposed to cold temperatures
to avoid exacerbation of these symptoms.

❖Cisplatin= Peripheral neuropathy; Hearing loss ( acoustic nerve damage)

Chemotherapy Nursing Care
Assessing Fluid and Electrolyte Status
Modifying Risks for Infection and Bleeding
Administering Chemotherapy
Protecting Caregivers
Bone Marrow Transplant
A bone marrow transplant is a procedure that infuses healthy
blood-forming stem cells into your body to replace your
damaged or diseased bone marrow. A bone marrow transplant
is also called a stem cell transplant.
Hematopoietic Stem Cell
Transplantation (HSCT)

Used to treat several malignant and nonmalignant diseases

Types of HSCT
◦ Allogeneic (donor other than patient)
◦ Autologous (from the patient)
◦ Syngeneic (from an identical twin)
◦ Myeloablative (high dose chemo-kills everything)
◦ Nonmyeloablative (mini transplant)
Bone
Marrow
Transplant
Process
Graft-versus-tumor effect is the good response
that happens when the donor cells attack any of
the recipient's cancer cells that may remain after
chemotherapy.
Graft-versus-host

Major cause of morbidity and mortality in the allogeneic transplant population.

Occurs when the donor lymphocytes initiate an immune response against the
recipient's tissues (skin, gastrointestinal tract, liver) during the beginning of
engraftment

To prevent GVHD, patients receive immunosuppressant drugs, such as cyclosporine

May be acute (within first 100 days) or chronic (occurring after 100 days)
Clinical Manifestations
Diffuse rash progressing to blistering and desquamation similar to second-degree burns

Mucosal inflammation of the eyes and the entire gastrointestinal tract with subsequent diarrhea
that may exceed 2 L per day

Biliary stasis with abdominal pain, hepatomegaly, and elevated liver enzymes progressing to
obstructive jaundice
 Nursing Management in HSCT

Implementing pretransplantation care

Providing care during treatment
Providing posttransplantation care
◦ Caring for recipients
◦ Caring for donors
 ONCOLOGY
NURSING
SESSION 3.A
OTHER CANCER TREATMENT MODALITIES
OTHER CANCER
TREATMENT
MODALITIES
HYPERTHERMIA
Hyperthermia (thermal
therapy), the generation of
temperature greater than
physiologic fever range
(greater than 41.5°C
[106.7°F]), has been used for
many years to destroy
cancerous tumors.
• Most effective when
combined with radiation
therapy, chemotherapy, or
biologic therapy.
THERMAL THERAPY: SIDE EFFECTS

• Skin burns and tissue damage, fatigue, hypotension,

peripheral neuropathies, thrombophlebitis, nausea,
vomiting, diarrhea, and electrolyte imbalances.
• Resistance to hyperthermia may develop during the
treatment because cells adapt to repeated thermal insult.
THERMAL THERAPY: NURSING CARE

• Health Education
• Assessment and monitoring of the side
effects
• Local skin care
TARGETED THERAPY

• Targeted therapies seek to minimize the negative

effects on healthy tissues by disrupting specific
cancer cell functions such as malignant
transformation, cell communication pathways
(called signal transduction), processes for growth
and metastasis, and genetic coding.
BIOLOGIC RESPONSE MODIFIER (BRM) THERAPY

• Involves the use of naturally occurring or recombinant

(reproduced through genetic engineering) agents or
treatment methods that can alter the immunologic
relationship between the tumor and the cancer patient
(host) to provide a therapeutic benefit.
NON-SPECIFIC BIOLOGIC RESPONSE MODIFIERS

• Bacille Calmette-Guérin (BCG) and Corynebacterium

parvum.
• BCG bladder instillation (intra-vesicular) is a standard form
of treatment for localized bladder cancer.
MONOCLONAL ANTIBODIES

• Monoclonal antibodies (MoAbs), another type of BRM, have

become available through technologic advances, enabling
investigators to grow and produce targeted antibodies for specific
malignant cells.
• MoAbs bind with specific tumor cell antigens and block the ability
of the tumor cell to reproduce, or deliver cytotoxic agents directly
to the tumor cell causing cell death.
 EPIDERMAL GROWTH FACTOR RECEPTORS AND TYROSINE KINASE
PATHWAYS.
• The epidermal growth factor
receptor (EGFR) is a receptor
tyrosine kinase receptor that is
frequently expressed
in epithelial tumors. The EGFR was the
first receptor to be proposed as a
target for cancer therapy, and after 2
decades of intensive research, there
are several anti-EGFR agents available
in the clinic.
• Tyrosine kinase inhibitors are smaller
molecules that target the intracellular
signaling pathways and are given orally.
VASCULAR ENDOTHELIAL GROWTH FACTORS.

• VEGF is essential for the growth and proliferation of malignant

cells and when activated stimulates growth of new blood vessels.
• VEGF is overexpressed in many solid tumors and is associated with
advanced tumor stage and poor prognosis (Viele, 2005).
• In colorectal cancer, increased VEGF expression has been
correlated with increased vascularity, invasiveness, metastasis, and
poor prognosis.
BEVACIZUMAB (AVASTIN)

• is a MoAb directed towar VEGF to prevent the activation of endothelial cells

and inhibit growth of new blood vessels.
• Side effects of bevacizumab
• Delays in wound healing,
• Hemorrhage,
• Hypertension,
• Thromboembolism
• Proteinuria.
CYTOKINES

• Cytokines, substances produced by cells of

the immune system to enhance the
production and functioning of components
of the immune system, are also the focus
of cancer treatment research.
• Cytokines are grouped into families, such
as interferons, interleukins, colony-
stimulating factors, and tumor necrosis
factors.
INTERFERONS
• Interferons (IFNs) are cytokines with
both antiviral and antitumor
properties.
• Multiple antitumor effects of IFNs
include anti-angiogenesis, direct
destruction of tumor cells, inhibition
of growth factors, and disruption of
the cell cycle.
• Administered by subcutaneous,
intramuscular, intravenous, and
intracavitary routes.
INTERLEUKINS

• Interleukins (ILs) are a subgroup of cytokines known as lymphokines and monokines produced by lymphocytes
and monocytes.
• IL-2 is an approved treatment option for renal cell cancer and metastatic melanoma in adults.
• IL-2 stimulates the production and activation of several different types of lymphocytes, enhances the
production of other types of cytokines, and affects both humoral and cell-mediated immunity.
• Side effects of ILs include flulike symptoms, fatigue, and anorexia as well as serious side effects (eg, profound
diarrhea, pulmonary edema, hypotension, and oliguria).
• When combined with other cytokines, IL-2 can cause hypersensitivity reactions or cardiac dysrhythmias and
hypotension.
RETINOIDS
• Retinoids are vitamin A derivatives (retinol, all-
transretinoic acid [ATRA], and 13-cis-retinoic acid)
that play a role in growth, reproduction, apoptosis,
epithelial cell differentiation, and immune function.
• ATRA (tretinoin [Renova, Retin-A]) is used in
treating acute promyelocytic leukemia, a rare form
of leukemia, and cutaneous T-cell lymphoma.
• Synthetic retinoid agents such as 4HRP
(Fenretinide) have been shown to play a role in
cellular apoptosis and are being evaluated for
prevention of second breast cancers.
 CANCER VACCINES

• Cancer vaccines are used to mobilize the body’s immune response to

recognize and attack cancer cells.
• Autologous vaccines are made from the patient’s own cancer cells, which are
obtained during diagnostic biopsy or surgery. The cancer cells are killed and
prepared for injection back into the patient
• Allogeneic vaccines are made from cancer cells that are obtained from other
people who have a specific type of cancer. These cancer cells are grown in a
laboratory and eventually killed and prepared for injection
CANCER VACCINES

• Prophylactic vaccines are given to prevent disease.

• Quadrivalent human papillomavirus (HPV) recombinant vaccine
(Gardasil). It is administered over a series of three doses to
females aged 9 to 26.
• Therapeutic vaccines are given to kill existing cancer cells and to
provide long-lasting immunity against further cancer development.
 GENE THERAPY
• Gene therapy includes approaches that correct genetic defects or manipulate genes
to induce tumor cell destruction in the hope of preventing or combating disease.
• Tumor-directed therapy is introduction of a therapeutic gene (suicide gene) into
tumor cells in an attempt to destroy them. This approach is very challenging because
it is difficult to identify which gene would be the most beneficial. In addition, patients
with widespread disease would require multiple injections to treat every site of
disease.
• Active immunotherapy is the administration of genes that will invoke the antitumor
responses of the immune system (Liu, 2003).
• Adoptive immunotherapy is the administration of genetically altered lymphocytes
that are programmed to cause tumor destruction (Yang, et al., 2007).
COMPLEMENTARY AND ALTERNATIVE MEDICINE

• Many of the CAM modalities can be a

source of comfort and emotional
support for the patient, but
assessment of CAM use is important
for patient safety.
MIND AND BODY BIOFIELD THERAPIES

• Mind–body and biofield therapies have a

holistic focus on channeling positive energy,
promoting relaxation, and reducing stress
and have been reported as being beneficial
to patients as measured by wound healing
and reduction in pain, edema, and anxiety
(Hibdon, 2005).
CAM: HERBAL-DRUG-INTERACTION

• Herbal–drug interaction is the effect of St. John’s wort on the efficacy of

irinotecan (Camptosar), cyclophosphamide, tamoxifen, cyclosporine, warfarin
(Coumadin), and indinavir (Crixivan).
• Each nursing assessment should include an open discussion with patients
about their use of CAM.
• This requires that nurses develop the appropriate familiarity and knowledge
related to CAM in order to direct patients to safe, reliable, and credible
sources for information.
UNPROVEN UNCONVENTIONAL THERAPIES

• Unconventional treatments are those without scientific

evidence of the ability to cure or control cancer. In addition
to being ineffective, some unconventional treatments may
also be harmful to the patient and may cost thousands of
dollars.
• Truthful responses given in a nonjudgmental manner to
questions and inquiries about unproven methods of cancer
treatments may alleviate the fear and guilt on the part of the
patient and family that they are not “doing everything we
can” to obtain a cure.
Oncology
Nursing
Session 3.b
NURSING CARE OF PATIENTS WITH
CANCER
Maintaining
Tissue
Integrity
Stomatitis
Nursing Diagnosis:

Impaired oral mucous membrane: stomatitis

GOAL: Maintenance of intact oral mucous

membranes
Preventive
a. Advise patient to avoid irritants such as commercial mouthwashes, alcoholic

beverages, and tobacco.

b. Brush with soft toothbrush; use nonabrasive toothpaste after meals and bedtime; floss
every 24 hours unless painful or platelet count falls below 40,000 cu/mm.
Mild Stomatitis: generalized erythema, limite
ulcerations, small white patches: Candida)
c. Use normal saline mouth rinses every 2 hours while awake;
every 6 hours at night.

d. Use soft toothbrush or toothette.

e. Remove dentures except for meals; be certain dentures fit

well.

f. Apply water soluble lip lubricant.

g. Avoid foods that are spicy or hard to chew and those with
extremes of temperature.
Severe stomatitis: (confluent ulcerations with bleeding and
white patches covering more than 25% of oral mucosa)
❖Obtain tissue samples for culture and sensitivity tests of areas of infection.
❖Assess ability to chew and swallow; assess gag reflex.
❖Use oral rinses (may combine in solution saline, anti-Candida agent, such as Mycostatin,
and topical anesthetic agent as described below) as prescribed or place patient on side and
irrigate mouth; have suction available.
❖Remove dentures.
❖Use toothette or gauze soaked with solution for cleansing.
❖Use water soluble lip lubricant.
❖Provide liquid or pureed diet.
❖Monitor for dehydration.
 NURSING DIAGNOSIS: Impaired tissue integrity:
alopecia
GOAL: Maintenance of tissue integrity; coping
with hair loss

Prevent or minimize hair loss through the following:

a. Use scalp hypothermia and scalp tourniquets, if appropriate.

b. Cut long hair before treatment.

c. Use mild shampoo and conditioner, gently pat dry, and avoid
excessive shampooing.

d. Avoid electric curlers, curling irons, dryers, clips, barrettes,

hair sprays, hair dyes, and permanent waves.

e. Avoid excessive combing or brushing; use wide-toothed

comb.
 Prevent trauma to scalp.
◦ a. Lubricate scalp with vitamin A and D ointment to
decrease itching.
◦ b. Have patient use sunscreen or wear hat when in
the sun.

Suggest ways to assist in coping with hair loss:

◦ a. Purchase wig or hairpiece before hair loss.
Alopecia: ◦ b. If hair loss has occurred, take photograph to wig
shop to assist in selection.

Intervention ◦ c. Begin to wear wig before hair loss.

◦ d. Contact the American Cancer Society for donated
wigs, or a store that specializes in this product.
◦ e. Wear hat, scarf, or turban.

Encourage patient to wear own clothes and retain social

contacts.
Explain that hair growth usually begins again once
therapy is completed.
NURSING
DIAGNOSIS:
Imbalanced
nutrition, less than 1. Assess the patient’s previous experiences and expectations of
body requirements, nausea and vomiting, including causes and interventions used.

related to nausea 2. Adjust diet before and after drug administration according to
patient preference and tolerance.
and vomiting
GOAL: Patient 3. Prevent unpleasant sights, odors, and sounds in the
environment.
experiences less 4. Use distraction, music therapy, biofeedback, self-hypnosis,
nausea and vomiting relaxation techniques, and guided imagery before, during, and
after chemotherapy.
associated with
chemotherapy;
weight loss is
minimized
Continuation…
5. Administer prescribed antiemetics, sedatives, and corticosteroids before
chemotherapy and afterward as needed.
6. Ensure adequate fluid hydration before, during, and after drug administration;
assess intake and output.
7. Encourage frequent oral hygiene.
8. Provide pain relief measures, if necessary.
CHART
16-7
NURSING DIAGNOSIS: Imbalanced nutrition: less than body requirements, related to anorexia, cachexia, or
malabsorption
GOAL: Maintenance of nutritional status and of weight within 10% of pretreatment weight

1. Teach patient to avoid unpleasant sights, odors, sounds in the environment during mealtime.

2. Suggest foods that are preferred and well tolerated by the patient, preferably high-calorie and
high-protein foods.

3. Encourage adequate fluid intake, but limit fluids at mealtime.

4. Suggest smaller, more frequent meals.

5. Promote relaxed, quiet environment during mealtime with increased social interaction as
desired.

6. If patient desires, serve wine at mealtime with foods.

7. Consider cold foods, if desired.

8. Encourage nutritional supplements and high-protein foods between meals.

Continuation…
9. Encourage frequent oral hygiene.
10. Provide pain relief measures.
11. Provide control of nausea and vomiting.
12. Increase activity level as tolerated.
13. Decrease anxiety by encouraging verbalization of fears, concerns; use of relaxation
techniques; imagery at mealtime.
14. Position patient properly at mealtime.
15. For collaborative management, provide enteral tube feedings of commercial liquid diets,
elemental diets, or blenderized foods as prescribed.
16. Provide parenteral nutrition with lipid supplements as prescribed.
Fatigue in Cancer
NURSING DIAGNOSIS: Fatigue
GOAL: Increased activity tolerance and decreased fatigue level

1. Encourage rest periods during the day, especially before and after physical exertion.

2. At minimum, promote patient’s normal sleep habits.

3. Rearrange daily schedule and organize activities to conserve energy expenditure.

4. Encourage patient to ask for others’ assistance with necessary chores, such as
housework, child care, shopping, cooking.

5. Encourage reduced job workload, if necessary and possible, by reducing number of hours
worked per week.

6. Encourage adequate protein and calorie intake.

Continuation…
7. Encourage use of relaxation techniques, mental imagery.

8. Encourage participation in planned exercise programs.

9. For collaborative management, administer blood products as prescribed.

10. Assess for fluid and electrolyte disturbances.

11. Assess for sources of discomfort.

12. Provide strategies to facilitate mobility.

Pain in Cancer
 NURSING DIAGNOSIS: Chronic pain
GOAL: Relief of pain and discomfort

1. Use pain scale to assess pain and discomfort characteristics: location, quality, frequency, duration, etc.

2. Assure patient that you know that pain is real and will assist him or her in reducing it.

3. Assess other factors contributing to patient’s pain: fear, fatigue, anger, etc.

4. Administer analgesics to promote optimum pain relief within limits of physician’s prescription.

5. Assess patient’s behavioral responses to pain and pain experience.

6. Collaborate with patient, physician, and other health care team members when changes in pain management
are necessary.

7. Encourage strategies of pain relief that patient has used successfully in previous pain experience.

8. Teach patient new strategies to relieve pain and discomfort: distraction, imagery, relaxation, cutaneous
stimulation, etc.
NURSING DIAGNOSIS: Anticipatory grieving related to loss; altered role functioning
GOAL: Appropriate progression through grieving process

1. Encourage verbalization of fears, concerns, and questions regarding disease, treatment,

and future implications.

2. Explore previous successful coping strategies.

3. Encourage active participation of patient or family in care and treatment decisions.

4. Visit family frequently to establish and maintain relationships and physical closeness.

5. Encourage ventilation of negative feelings, including projected anger and hostility, within
acceptable limits.
Continuation…
6. Allow for periods of crying and expression of sadness.

7. Involve spiritual advisor as desired by the patient and family.

8. Advise professional counseling as indicated for patient or family to alleviate

pathologic grieving.

9. Allow for progression through the grieving process at the individual pace of the
patient and family.
NURSING DIAGNOSIS: Disturbed body image and situational low self-esteem related to
changes in appearance, function, and roles
GOAL: Improved body image and self-esteem

1. Assess patient’s feelings about body image and level of self- esteem.

2. Identify potential threats to patient’s self-esteem (eg, altered appearance,

decreased sexual function, hair loss, decreased energy, role changes). Validate
concerns with patient.

3. Encourage continued participation in activities and decision making.

4. Encourage patient to verbalize concerns.

Continuation…
5. Individualize care for the patient.

6. Assist patient in self-care when fatigue, lethargy, nausea, vomiting, and other
symptoms prevent independence.

7. Assist patient in selecting and using cosmetics, scarves, hair pieces, and
clothing that increase his or her sense of attractiveness.

8. Encourage patient and partner to share concerns about altered sexuality and
sexual function and to explore alternatives to their usual sexual expression.

9. Refer to collaborating specialists as needed.

COLLABORATIVE PROBLEM: Potential complication: risk for bleeding problems
GOAL: Prevention of bleeding

Assess for potential for bleeding: monitor

platelet count.
Mild risk: 50,000–100,000/mm3 (0.05–0.1 1012/L)

Moderate risk: 20,000–50,000/mm3 (0.02–0.05 1012/L)

Severe risk: less than 20,000/mm3 (0.02 1012/L)

 Assess for bleeding:

a. Petechiae or ecchymosis

b. Decrease in hemoglobin or hematocrit

c. Prolonged bleeding from invasive procedures, venipunctures,

minor cuts or scratches

d. Frank or occult blood in any body excretion, emesis, sputum

e. Bleeding from any body orifice

f. Altered mental status

Instruct patient and family about
ways to minimize bleeding:
a. Use soft toothbrush or toothette for mouth care.

b. Avoid commercial mouthwashes.

c. Use electric razor for shaving.

d. Use emery board for nail care.

e. Avoid foods that are difficult to chew.

 Draw Draw all blood for lab work with one daily
venipuncture.

Initiate Avoid Avoid taking temperature rectally or administering

measures to
suppositories and enemas.

minimize
Avoid Avoid intramuscular injections; use smallest needle

bleeding. possible.

Apply Apply direct pressure to injection and venipuncture

sites for at least 5 minutes.
Continuation…
e. Lubricate lips with petrolatum.

f. Avoid bladder catheterizations; use smallest catheter if catheterization is necessary.

g. Maintain fluid intake of at least 3 L per 24 hours unless contraindicated.

h. Use stool softeners or increase bulk in diet.

i. Avoid medications that will interfere with clotting (eg, aspirin).

j. Recommend use of water-based lubricant before sexual intercourse.

 a. Bed rest with padded side rails.
When b. Avoidance of strenuous activity.
platelet count c. Platelet transfusions as prescribed; administer
is less than prescribed diphenhydramine hydrochloride (Benadryl)
20,000/mm3, or hydrocortisone sodium succinate (Solu-Cortef) to
prevent reaction to platelet transfusion.
institute the d. Supervise activity when out of bed.
following:
e. Caution against forceful nose blowing.
Complication:
Infection
 Gram-positive bacteria (Streptococcus, enterococci, and
Staphylococcus species) and gram-negative organisms
(Escherichia coli, Klebsiella pneumoniae, and Pseudomonas
aeruginosa)= most frequently isolated causes of infection.

Fungal organisms, such as Candida albicans, also contribute

Complication: to the incidence of serious infection.

Infection
Viral infections in immunocompromised patients are caused
most often by herpes viruses and respiratory viruses.

WOF Septic Shock: Altered mental status, either subnormal

or elevated temperature, cool and clammy skin, decreased
urine output, hypotension, tachycardia, other
dysrhythmias, electrolyte imbalances, tachypnea, and
abnormal arterial blood gas values.
Oncological Emergencies
Continuation…
Cancer
Survivorship
End of
session!