cancer notes

modifiable risk factors of Cancer:

 tobacco, alcohol, sun
modifiable risk  do not eat recommended amounts of fruits and vegetables
factors  physically inactive
 obese / unhealthy weight
development of cancer:
exposure to carcinogens
 genetic
 chemical
exposure to carcinogens  environmental
 viral
 immunological
 unknown
initiation
initiation  mutation of genetic structure ( irreversible
 has potential to develop into clone of neoplastic cells
 cell unable to properly differentiate
defect in cellular proliferation
 cancer cells are characterized by the loss of contact
inhibition
development of o grow on top of one another and on top of or
cancer defect in cellular between normal cells
proliferation  cancer cells respond differently than normal cells to
intracellular signals regulating equilibrium
o divided indiscriminately
o avoid Apoptosis

 promotion: environment that promotes altered cell’s reproduction

o characterized by the reversible proliferation of altered cells
o activities of promotion: obesity, smoking, alcohol, exposure to environmental carcinogens) are reversible
 latent period: initial genetic alteration to clinical evidence of cancer
 progression
 metastasis
o local to adjacent tissue ( direct extension
o distant to other sites
 hematogenous; lymphatic spread
 angiogenesis: gets its own blood supply
role of immune system
 immune response is to reject or destroy cancer cells if perceived as non-self
o may be inadequate as cancer cells arise from normal human cells
role of immune  some cancer cells have changes on their surface antigen
system o tumor-associated antigens ( TAAs
 many cancer cells ( breast, lung .. ) escape immune system detection by binding with the inhibitory protein
receptors on the surface of T cells and natural killer cells

TNM classification system

 Primary tumour T  T0: no evidence of primary tumor
 Tis carcinoma is stu
 T1-4 ascending degrees of increase in tumor size and involvement
Regional lymph  N0 no evidence of disease in lymph nodes
nodes ( N  N1-4 ascending degrees of nodal involvement
 Nx regional lymph nodes unable to be assessed clinically
Distant metastases  M0 no evidence of distant metastases
M  M1 distant metastatic involvement, including didstant nodes
stage ( clinical manifestations)
 based off TNM classification
 determines the extent of the disease process of cancer within the body by stages
 0: cancer in stu
 1: tumour limited to tissue of origin, localized tumour growth
 2: limited local spread
 3: extensive local and regional spread
 4: metastasis
classification of cancer:
 anatomic site classification identified by
o tissue origin
o anatomic site
o behavior of the tumors
o carcinomas originate from epithelium
o sarcomas originate from connective tissue
classification o lymphoma and leukemias originate from bone marrow
system  histological analysis classification
o appearance of cells and degree of differentiation are evaluated
o grade 1: cells differ slightly from normal cells and are well differentiated
o grade 4: cells immature and primitive and undifferentiated; cell of origin difficult to determine
where different cancers start:
· adenocarcinoma: originates in glandular epithelial tissue
· blastoma: originates in embryonic tissue of organs
· carcinoma: originates in epithelial tissue: tissue that lines organs and tubes
· leukemia: originates in tissues that form blood cells ( marrow
· lymphoma: originates in lymphatic tissue
· myeloma: originates in bone marrow
· sarcoma: originates in connective or supportive tissues: bone, cartilage, muscle
· scotoma: originate in scrotum
prevention and detection of cancer
· know your risks
· reduce or avoid exposure to known or suspected carcinogens
· eat balanced diet
· exercise regularly
· adequate rest
· health examination on regular basis
· follow screening recommendations
know 7 warning signs ( caution) of cancer
1. change in bowel or bladder habits
2. a sore that does not heal
3. unusual bleeding or discharge
4. thickening or lump in breast or elsewhere
5. indigestion or difficulty in swallowing
6. obvious change in wart or mole,
7. unintentional weight loss

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 classification 8. nagging cough or hoarseness
system
diagnosis of cancer
· client may experience fear and anxiety
· clear, consistent and repeated explanations may be necessary
· diagnostic plan includes
diagnosis of o physical examine
cancer o specific studies: lab and imaging
· biopsy involves histologic examination by a pathologist of a piece of tissue: needle, incisional, excisional
o will reveal the appearance / type of tissue, differentiation of the cells, and if tissue is bengin or malignant
collaborative care of cancer:
· factors that determine treatment modality
o cell type, location and size of tumor
o extent of disease
o genetic profile of the cancer cell
· curative therapy: may involve surgery alone or extended periods of systemic therapy
· control treatment plan: has initial course and maintenance therapy
· palliation goal: is relief or control of symptoms and maintain of quality of life
· clinical trials
1. phase 1: small group of ppl tested to evaluate safety of a treatment, determine dosage, identify SE
2. phase 2 : larger group to test efficacy and further evaluate safety
collaborative care 3. phase 3: largest group tested to confirm efficacy, monitor SE, collect info, allowing drug or treatment to be
of cancer used safely
· surgery: is used to cure or control disease process of cancer
 cancer arising at slow rate of proliferation or replication
 a margin of normal tissue must surround tumor
· radiation therapy
o breaks DNA bond
o more mitotic cells are more sensitive
o multi-angled approach spares normal tissues
· side effects of RT + chemo
o GI, hematological, integumentary, GU, nervous, respiratory, cardiovascular, biochemical,
multidimensional effects; nursing interventions; outcomes
chemotherapy
 goal is to reduce number of tumor sites
o several factors determine response of cancer cells
o cancer cells can escape death by staying in the G0 phase
o main problem is presence of drug-resistant resting and non-cycling cells
o to reduce toxicity and G0 status, chemo is cycled
 methods of administration
o oral ( second most common
o IV
Chemotherapy o intracavitary
o intrathecal ( into CSF )
o intra-arterial
1. directly into tumor or through venous system
2. pros and cos to both
o perfusion: continuous hyperthermic peritoneal perfusion chemotherapy
o continuous infusion
o SQ
o topical
 catheter / port care is a nursing opportunity
chemotherapy effects on normal tissues

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  acute toxicity:
o pre-medicating: vomiting, allergic reactions
o arrythmias / EKG changes
 delayed effects
o mucositis
o alopecia
o bone marrow suppression
treatment plan of chemo
 drugs usually given in combination, same rationale as described during leukemia portion of heme lecture
 carefully calculated according to body weight or body surface area ( BSA
· Nadir ( low point of blood counts
nursing management of chemo
 must differentiate between tolerable side effects and toxic side effects
o chemo may need to be modified if too toxic
chemotherapy  serious reactions must be reported: some toxicities are not reversible
 administration of antiemetic drugs
 monitor lab results, particularly WBCs, platelets, RBCs
o assess for signs of bleeding if platelets count falls below 50,000, may need to stop/hold some meds
o assess for febrile neutropenia
 WBC < 1000
 this is considered an oncologic emergency
 a dangerously low WBC counts may require a change of treatment
 Neupogen may be given
nursing management + implementation of chemo
 engage the person in decision making by ensuring that he/she has information at each phase of care
 encourage discussion bw person and family
 support the person to express concerns
 engage others who are cancer survivors to talk with the person
 provide consistent psychosocial and supportive care
biological therapy:
 biological therapy is a type of treatment that works with the immune system
 BCG or bacillus Calmette-Guerin treats bladder cacncer
biological  iL-2 or interleukin 2 treats certain types of cancer
therapy  interferon alpha treats certain types of cancer
 Rituximab treats non-Hodgkin’s lymphoma
 trastuzumab treats breast cancer
bone marrow and stem cell transplantation
· uses very high doses of chemo or radiation therapy
· HLA-matched routinely to reduce recipient’s rejection risk
· procedure with many risks, including death
bone marrow · highly toxic
& · harvesting ( where to get the cells from … )
stem cell o bone marrow: procedure conducted in the OR, multiple aspirations carried out
transplantation  usually iliac crest or sternum
 may be treated for removal cancer cells if autologous
 cryopreserved
o peripheral blood
 less painful to donate; ess S/E
· complications
o Graft-versus-host disease
 T-lymphocytes from donated marrow recognize recipient as foreign
 attack organs such as skin, liver, and intestines
complications of cancer:

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 · malnutrition
· altered taste sensation
· infection
complications of · superior vena cava syndrome
cancer · spinal cord compression
· tumor lysis syndrome:
o hyperkalemia, hyperuricemia, hyperphosphatemia, hypocalcemia, renal insufficiency/damage ( Azotemia
( high BUN and creatinine

management of cancer pain

· pt report should always be believed and accepted as primary pain assessment data
· drug therapy should be use following WHO analgesics ladder
Management of · non-pharmacological interventions can be effectively used
cancer
psychological support of cancer
· emphasis placed on maintaining optimal quality of life
· positive attitude of pt, family, HCPs has significant positive impact on quality of life for pt
lung cancer
 squamous cell carcinomas; small cell carcinoma; adenocarcinoma; large cell carcinoma
collaborative care of lung cancer:
Lung cancer  surgical therapy, radiation therapy, chemo, biological therapy
 prophylactic cranial irradiation ( PCI) , small cell
 SIADH
 for obstruction lesions
o bronchoscopic laser therapy, phototherapy ( rare); airway stenting, cryotherapy
Prostate cancer:
 malignant tumor of prostate
 most common male cancer, excluding skin cancer
 3rd leading cause of death in men
 direct extension involves seminal vesicle, urethral mucosa, bladder wall, external sphincter
 cancer later spreads through lymphatic system to the regional lymph nodes
 veins from the prostate seem to be mode of hematogenous distant spread
 age, ethnicity, and family hx are nonmodifiable risk faction
clinical manifestations of prostate cancer
 usually asymptomatic in early stages
 eventually may experience S/S similar to BPH
Prostate cancer Dysuria Hesitancy Dribbling Inability to urinate
Frequency Urgency Hematuria
Nocturia Retention Interruption of urinary stream
 in addition to not being able to pee
o pain in lumbosacral area that radiates to hips or legs, when coupled with urinary symptoms, could indicate
metastasis
o once cancer has spread to distant sites, pain management becomes major problem
diagnostic studies of prostate cancer
 two primary screening tools
Prostate-specific  elevated levels indicate prostatic pathology: not necessarily cancer
antigen PSA blood test  marker of tumor volume when cancer exists
 also used to monitor success of treatment
Digital rectal exam  abnormal prostate findings include hardness
 nodular and asymptomatic

collaborative care of prostate cancer

 TNM system used to stage prostate cancer

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 o based on size ( volume) and spread
 grading of tumour is done using Gleason Scale
 Biopsy
 conservative therapy
o watchful waiting when
 life expectancy is less than 10 yrs
 presence of significant comorbid disease
 presence of low-grade, low-stage tumor
Prostate cancer  surgical therapy
o radical prostatectomy
o nerve-sparing surgical procedure
o cryosurgery
 radiation therapy
o external beam radiation: most widely used method of radiation for prostate cancer
o brachvtherapy
 immunotherapy for prostate cancer
o sipuleucel-T:
 administer in 6 cycles ( collection + infusion), each two weeks apart
 S/E: infusion reaction ( chills, fever), tachycardia, N/V, thrombosis
o if cancer escapes immune detection by activating the “inhibitory” receptor on T cells, perhaps a mab that “blocks”
immune cell’s inhibitory receptor protein will the immune system sensitive to cancer cells
control strategy of breast cancer
 screening tests: mammograms / breast exams  local therapy ( surgical/radiation therapy) adjuvant therapy
( chemo + hormone therapy)
risk factors of breast cancer
 age at menarche and at menopause
 BRCAI and BRCA2 genes
 family history
 ethnicity
 nulliparity
genetics of breast cancer:
 BRCA 1 &2
 hereditary breast cancers account for approx. 5-10% of all breast cancers
 specific hereditary predispositions for breast cancer. e.g: inheriting a mutation in either BRCA1 or BRCA2 gene
incidences of breast cancer
breast cancer  by stage- percent of breast cancers discovered by stage: localized 62%; regional 29%; distant 6%; unstaged 3%
tumour size at presentation
 approx.. 0.5 cm in a woman who has a regular yearly mammogram
 approx. 1cm in a woman who does a regular breast self exam
 approx.. 3++ cm in women who do not have a yearly mammogram nor do a regular Breast Self Exam
screening and prevention
 50 biennially
 screen for it, diet, exercise, weight loss, decrease ETOH intake, HRT, breast feeding
clinical presentations of breast cancer
 women come with and without issues
o screening required
o palpable mass, breast axilla
o pain
o nipple discharge
o skin changes, itching, sores
o swollen breasts
mammogram:
 one mammogram exposes you to the same amount of radiation as being out in the sun for 4 hrs on a 74 degree
day

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  goal is to detect any changes
 two types of mammograms screening and Diagnostic
 this is ONLY approved screening method for breast cancer detection
 screening recs similar to colon cancer: age 50 to start, younger if higher risk
ultrasound:
 a secondary testing procedure to evaluate a mass identified on mammohram or physical exam
 useful in assisting biopsy need
 usually the solid masses can be differentiated from cystic masses through the use of US
 US is not a screening test but an adjunct test to help determine if a biopsy is needed
 US does not always give us definitive answers
genetics that influence treatment ( not BRCA)
 estrogen receptor:
o overexpression of the ER gene leads to an increased number of ER proteins on the cell surface
o circulating estrogen binds to these proteins, signaling cell growth
 progesterone receptors
o same idea as ER, but progesterone binds to receptor
 human epidermal growth factor receptor 2 ( HER-2
o same idea as ER and PR, but epidermal growth factor ( EGF) bings to receptor
local control of breast cancer
 lumpectomy, breast conservation
breast cancer  partial or segmental mastectomy
 total or single mastectomy
 modified radical mastectomy
sentinel lymph node biopsy:
 a surgeon injects a radioactive substance, a blue dye, or both near the tumor to locate the position of the sentinel
lymph nodes
 the sentinel node is then checked for presence of cancer cells by pathologist
 SLNB is usually done at the same time the primary tumour is removed, however, the procedure can also be done
either before or after removal of the tumor
breast cancer staging:
 DCIS: non-invasive breast cancer
 Stage 1-3  larger lesions, some lymph node involvement, but considered to eb local disease
 stage 4: metastatic disease
treatments for breast cancer
 adjuvant therapy: any treatment given after primary therapy to increase the chance of long-term survival
 neoadjuvant therapy: treatment given before primary therapy
 surgery ( this is primary tx in local breast cancer
 chemotherapy
 radiation
 reconstruction
 chemo/biologic/hormone meds
triple positive  pt receive hormone blockade, HER-2 blockade, classic ( traditional
( ER, PR, HER-2 + ve) cell-cycle interfering) chemotherapy
 HER2+: trastuzumab
 ER and/or PR: tamoxifen
Triple negative  pt’s cancers will not respond to hormone blockade or HER-2 blockade,
( ER,PR,HER-2 -ve) thus only classic chemotherapy is used
Combination of  ER/PR +ve: hormone blockade and classic chemo
above  ER/PR -ve, HER-2 -ve: hormone blockade and classic chemo
nursing management of breast cancer
 educate
 teach
 become active
 lobby

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  care
breast cancer  keep informed
liver cancer
 third most common cancer in the world
 more common in males
 risk for HCC include
o cirrhosis of the liver
o hepatitis C
o chronic hepatitis B
o alcoholic cirrhosis
o nonalcoholic fatty liver disease
clinical manifestation of liver cancer
 cirrhosis: upper abdominal pain
 weight loss
 early satiety
 palpable mass
 paraneoplastic syndromes
 hypoglycemia
 erythrocytosis
 hypercalcemia
 intractable diarrhea
 intraperitoneal bleeding
liver cancer  obstructive jaundice
 central tumor necrosis
metastasis of liver cancer
 lung
 intra-abdominal lymph nodes
 bone
 adrenal gland
diagnosis of liver cancer
 alpha-fetoprotein
 MRI
 CT
contrast-enhanced abdominal US
 to biopsy or not biopsy
treatment modalities of liver cancer
 surgical resection
 liver transplantation
 locoregional ablation therapies
 external beam radiotherapy
 systemic chemotherapy and immunotherapy
prognosis of liver cancer
 the severity of the underlying liver disease
 tumor size
 extension of tumor into adjacent structures
 the presence or absence of metastases

pancreatic cancer
 high lethal malignancy; 4th leading cancer-related death; prognosis is poor
 risk factors:
o cigarette smoking
o obesity and physical inactivity
o diet
o HBV and HCV

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 o hereditary
clinical manifestations of pancreatic cancer
 weight loss
 anorexia
 abdominal pain
 epigastric pain
 dark urine
 jaundice
 nausea and vomiting
 back pain
 steatorrhea
 hepatomegaly
 cachexia
 Courvoisier’s Sign
metastasis of the pancreatic cancer
 liver; peritoneum; lungs; bone
pancreatic cancer advanced disease of pancreatic cancer
 ascites
 periumbilical mass
 left supraclavicular lymphadenopathy
diagnostics in pancreatic cancer
 ERCP
 MRCP
 transabdominal US
 CT
biopsy
 serum markers: carbohydrate antigen
treatment of pancreatic cancer
 initial systemic chemotherapy for metastatic pancreatic cancer
 resectable pancreatic cancer
 chemotherapy and radiation
 pancreaticoduodenectomy ( Whipple procedure
skin cancer
 most common cancer worldwide
 nonmelanoma or melanoma
 risk factors
o fair skin
o blonde or red hair
skin cancer o eye colour
o chronic skin exposure
o tanning salons
o immunosuppression
o genetics

nonmelanoma skin cancer:

basal cell carcinoma
 common skin cancer
 low metastatic potential
 but invasive, aggressive, and destructive to surrounding structure
 clinical manifestations
o nodular

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 o superficial
basal cell carcinoma o morpheaform / infiltrate
 diagnosis
o clinical and dermoscopic examination
o biopsy
 treatment
o standard surgical excision
o MOHS micrographic surgery
o second-line therapies
 imiquimod
 fluorouracil
Skin cancer Squamous cell carcinoma:
 frequent occurrence on previously damaged skin
 superficial
Squamous cell  early firm nodules
carcinoma  late covering of the lesion with scale or horn
 treatment: similar to basal cell carcinoma
 untreated: metastasis to lymph nodes
Malignant melanoma
 arises in the melanocytes
 majority of skin cancer death
 skin: cutaneous melanoma
 risk factors
o genetics
o one or more blistering sunburn
o exposure to radiation
o gender: males more than females
 clinical manifestations:
o occur in existing nevi or modes
Malignant melanoma o often dark brown or black
o changes in moles: size, color, shape
 diagnosis
o hx and risk factors
o skin examination
o ugly duckling signs
o ABCD: asymmetry, border, irregularity, color variegation,
diameter > 6 mm (criteria)
 biopsy
o excisional
o incisional
 treatment
o wide surgical excision
o sentinel lymph nodes
o adjunct therapy
.

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