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UNDERSTANDING

CANCER
• Essential Concepts of Cancer
– What is Cancer?
– Normal Cell Growth vs. Cancer Cell Growth
– Etiology and Causative Factors
– Pathophysiology
– Classification of Tumors
– Effects of Cancer
• Nursing Process
– Assessment
– Laboratory & Diagnostic Tests
– Tumor Staging and Grading
– Nursing Diagnoses & Planning
– Implementation and Management
• Treatment Modalities
– Chemotherapy
• End-of-life Issues
What Is Cancer?

CANCER is a complex of diseases which 
occurs when normal cells mutate into 
abnormal cells that take over normal tissue, 
eventually harming and destroying the host 
WHAT IS CANCER
• A large group of diseases characterized
by:
– Uncontrolled growth and spread of abnormal
cells
– Proliferation (rapid reproduction by cell
division)
– Metastasis (spread or transfer of cancer cells
from one organ or part to another not
directly connected)
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Loss of Normal Growth Control

Normal
cell division

Cell Suicide or Apoptosis

Cell damage—
no repair

Cancer
cell division

First Second Third Fourth or


mutation mutation mutation later mutation
Uncontrolled growth
Oncogenes

Normal cell Normal


genes
regulate
cell growth

Oncogenes
Cancer cell accelerate
cell growth
and division

Mutated/damaged oncogene
Example of Normal Growth

Dead cells
shed from
outer surface

Epidermis
Cell migration

Dividing cells
in basal layer
Dermis
The Beginning of Cancerous Growth

Underlying tissue
Tumors (Neoplasms)

Underlying tissue
Invasion and Metastasis

1
Cancer cells invade
surrounding tissues
and blood vessels
2
Cancer cells are
transported by the
circulatory system
to distant sites
3
Cancer cells
reinvade and grow
Back at new location
ETIOLOGY/CAUSATIVE
FACTORS
• Viruses
• Chemical carcinogens
• Physical stressors
• Hormonal factors
• Genetic factors
What Causes Cancer?
Some viruses or bacteria

Some chemicals Radiation

Heredity
Diet
Hormones
Population-Based Studies
Regions of Highest Incidence
U.K.:
Lung
cancer

JAPAN:
Stomach
cancer CANADA:
Leukemia

U.S.:
CHINA: Colon
Liver cancer
cancer
BRAZIL:
Cervical
AUSTRALIA: cancer
Skin
cancer
Genes and Cancer
Viruses

Chemicals Radiation

Heredity

Chromosomes
are DNA
molecules
Viruses

Virus inserts
and changes
genes for
cell growth
Cancer-linked virus
Examples of Human Cancer Viruses

Some Viruses Associated with Human Cancers


Bacteria and Stomach Cancer

Patient’s H. pylori
tissue sample
Tobacco Use and Cancer
Some Cancer-Causing Chemicals in Tobacco Smoke
High-Strength Radiation

High

Leukemia
Incidence

Low
Least Most
X-ray Dose
(atomic radiation)
AIDS and Kaposi’s Sarcoma

Without
disease

HIV infection
Depressed
immune
system

KSHV infection
Kaposi’s
sarcoma
Heredity and Cancer

All Breast Cancer Patients

Inherited factor(s)
Other factor(s)
Heredity Can Affect Many Types of Cancer

Inherited Conditions That Increase Risk for Cancer

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PATHOPHYSIOLOGY
ABNORMAL CELL FORMED BY MUTATION OF DNA

CELL GROWS AND PROLIFERATES

METASTASIS OCCURS WHEN ABN. CELLS INVADE


OTHER TISSUE,THROUGH LYMPH AND BLOOD

– Cancer development linked to immune system


failure
– Example of clients susceptible to developing cancer
Classification of Cancer
• According to Behavior of Tumor
• Benign - tumors that cannot spread by
invasion or metastasis; hence, they only
grow locally

• Malignant - tumors that are capable of


spreading by invasion and metastasis. By
definition, the term “cancer” applies only
to malignant tumors
Malignant versus Benign Tumors
Benign (not cancer) Malignant (cancer)
tumor cells grow cells invade
only locally and cannot neighboring tissues,
spread by invasion or enter blood vessels,
metastasis and metastasize to
different sites

Time
Why Cancer Is Potentially Dangerous

Brain

Melanoma
cells travel
through
bloodstream

Liver

Melanoma
(initial tumor)
Patterns of cell Proliferation
• Hyperplasia
• Dysplasia
• Metaplasia
• Anaplasia
• Neoplasia
Hyperplasia

• tissue growth based on an excessive 
rate of cell division, leading to a 
larger than usual number of cells; the 
process of hyperplasia is potentially 
reversible; can be a normal tissue 
response to an irritating stimulus. An 
example  is a callus

Normal Hyperplasia
Dysplasia
• Bizarre cell growth differing in size, 
shape and cell arrangement

Normal Hyperplasia Mild dysplasia


Carcinoma in Situ

Normal Hyperplasia Mild Carcinoma in


dysplasia situ (severe
dysplasia) Cancer
(invasive)
Patterns of cell Proliferation
• Metaplasia
• conversion of one type of cell in a tissue to
another type not normal for that tissue
• Anaplasia
• change in the DNA cell structure and orientation
to one another, characterized by loss of
differentiation and a return to a more primitive
form.
• Neoplasia
• uncontrolled cell growth, either benign or
malignant
Metastasis
• Metastasis: 3 stages
– Invasion – neoplastic cells from primary
tumor invade into surrounding tissue with
penetration of blood or lymph.
– Spread – tumor cells spread through
lymph or circulation or by direct
expansion
– Establishment and growth – tumor cells
are established and grow in secondary
site: lymph nodes or in organs from
venous circulation
Cancer Tends to Involve Multiple Mutations
Benign tumor cells Malignant cells invade
grow only locally and neighboring tissues, enter
cannot spread by blood vessels, and
invasion or metastasis metastasize to different sites

Time
Mutation Cells Mutations Proto-oncogenes More mutations,
inactivates proliferate inactivate mutate to more genetic
suppressor DNA repair oncogenes instability,
gene genes metastatic
disease
Mutations and Cancer

Genes Implicated in Cancer


Cancer Tends to
Corrupt Surrounding Environment
Growth factors = proliferation
Invasive

Matrix

Proteases
Fibroblasts,
adipocytes Cytokines
Blood vessel

Back Cytokines, proteases = migration & invasion


Classification of Tumors
• CARCINOMAS: EPITHELIAL TISSUE
– BODY SURFACES, LINING OF BODY CAVITIES ETC:
(ADENOCARCINOMA)
• SARCOMAS: CONNECTIVE TISSUE
– STRIATED MUSCLE, BONE, ETC (OSTEOSARCOMA)
• LYMPHOMAS AND LEUKEMIAS
– HEMATOPOIETIC SYSTEM
• NERVOUS TISSUE TUMORS
– EX. NERVE CELLS-NEUROBLASTOMA
• MYELOMA
– Develops in the plasma cells of bone marrow
Different Kinds of Cancer

Leukemias:
Some common
Bloodstream
carcinomas:
Lung Lymphomas:
Lymph nodes
Breast (women)

Colon Some common


sarcomas:
Bladder
Fat
Prostate (men)
Bone

Muscle
Naming Cancers

Cancer Prefixes Point to Location


Prefix Meaning
adeno- gland
chondro- cartilage
erythro- red blood cell
hemangio- blood vessels
hepato- liver
lipo- fat
lympho- lymphocyte
melano- pigment cell
myelo- bone marrow
myo- muscle
osteo- bone
Women, Tobacco &
Lung Cancer

“ Women who smoke like men,


die like men.”

U.S. Surgeon General David Satcher

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Effects of Cancer
• Disruption of Function- can be due to
obstruction or pressure
• Hematologic Alterations: can impair
function of blood cells
• Hemorrhage: tumor erosion, bleeding,
severe anemia
• Anorexia-Cachexia Syndrome: wasted
appearance of client
Effects of Cancer
• Paraneoplastic Syndromes: ectopic sites
with excess hormone production
– ↑ Parathyroid hormone→ hypercalcemia
– ↑ secretion of insulin→ hypoglycemia
– ↑ Antidiuretic hormone (ADH) → fluid
retention, HTN & peripheral edema
• ↑ Adrenocorticotropic hormone (ACTH):
cause excessive secretion of cortisone
(ie: fluid retention, ↑ glucose levels)
Effects of Cancer
• Pain: major concern of clients and
families associated with cancer
• Physical Stress: body tries to respond
and destroy neoplasm
• Psychological Stress

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ASSESSMENT
• Nursing History
– Health History – chief complaint and history
of present illness (onset, course, duration,
location, precipitating and alleviating
factors)

– Cancer signs: CAUTION US!


Warning Signs of Cancer
• CAUTION US!
– Change in bowel or bladder habits
– A sore that does not heal
– Unusual bleeding or discharge
– Thickenings or lumps
– Indigestion or difficulty in swallowing
– Obvious change in a wart or mole
– Nagging or persistent cough or hoarseness
– Unexplained anemia
– Sudden unexplained weight loss
Warning Signs of Cancer
• Change in bowel or bladder habits
– A person with colon cancer may have
diarrhea or constipation, or he may notice
that the stool has become smaller in
diameter
– A person with bladder or kidney cancer may
have urinary frequency and urgency
Warning Signs of Cancer
• A sore that does not heal
– Small, scaly patches on the skin that bleed or
do not heal may be a sign of skin cancer
– A sore in the mouth that does not heal can
indicate oral cancer
Warning Signs of Cancer
• Unusual bleeding or discharge
– Blood in the stool is often the first sign of
colon cancer
– Similarly, blood in the urine is usually the
first sign of bladder or kidney cancer
– Postmenopausal bleeding (bleeding after
menopause) may be a sign of uterine cancer
Warning Signs of Cancer
• Thickenings or lumps
– Enlargement of the lymph nodes or glands
(such as the thyroid gland) can be an early
sign of cancer
– Breast and testicular cancers may also
present as a lump
Warning Signs of Cancer
• Indigestion or difficulty in swallowing
– Cancers of the digestive system, including
those of the esophagus, stomach, and
pancreas, may cause indigestion, heartburn,
or difficulty swallowing
Warning Signs of Cancer
• Obvious change in a wart or mole
– Moles or other skin lesions that change in
shape, size, or color should be reported
Warning Signs of Cancer
• Nagging or persistent cough or
hoarseness
– Cancers of the respiratory tract, including
lung cancer and laryngeal cancer, may cause
a cough that does not go away or a hoarse
(rough) voice
Warning Signs of Cancer
• Unexplained anemia

• Sudden unexplained weight loss


Physical Assessment
• Inspection – skin and mucus membranes for
lesions, bleeding, petechiae, and irritation
– Assess stools, urine, sputum, vomitus for acute or
occult bleeding
– Scalp noting hair texture and hair loss
• Palpation
– Abdomen for any masses, bulges or abnormalities
– Lymph nodes for enlargement
• Auscultation – of lung sounds, heart sounds
and bowel sounds
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Laboratory & Diagnostic
Tests
• Cancer detection examination
• Laboratory tests
– Complete blood cell count (CBC)
– Tumor markers – identify substance
(specific proteins) in the blood that are
made by the tumor
• PSA (Prostatic-specific antigen): prostate cancer
• CEA (Carcinoembryonic antigen): colon cancer
• Alkaline Phosphatase: bone metastasis
– Biopsy
Diagnostic Tests
• Determine location of cancer:
– X-rays
– Computed tomography
– Ultrasounds
– Magnetic resonance imaging
– Nuclear imaging
– Angiography
• Diagnosis of cell type:
– ▪Tissue samples: from biopsies, shedded cells
(e.g. Papanicolaou (PAP) smear), & washings
– ▪ Cytologic Examination: tissue examined
under microscope
• Direct Visualization:
– ▪ Sigmoidoscopy
– ▪ Cystoscopy
– ▪ Endoscopy
– ▪ Bronchoscopy
– ▪ Exploratory surgery; lymph node biopsies to
determine metastases
Cancer Detection and Diagnosis
Early Cancer May Not Have Any Symptoms
Cervical Cancer Screening

Normal
Pap smear

Abnormal
Pap smear
Breast Cancer Screening
Prostate and Ovarian Cancer Screening
Colon Cancer Screening
Biopsy

Pathology

Proteomic profile

Patient’s
tissue sample or Genomic profile
blood sample
Microscopic Appearance of Cancer Cells

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Tumor Staging and Grading
• Staging determines size of tumor and
existence of metastasis
• Grading classifies tumor cells by type of
tissue
• The TNM system is based on the extent of
the tumor (T), the extent of spread to
the lymph nodes (N), and the presence of
metastasis (M).
Primary Tumor (T)
TX Primary tumor cannot be evaluated
T0 No evidence of primary tumor
Tis Carcinoma in situ (early cancer that has not spread to neighboring
tissue)
T1, T2, T3, T4 Size and/or extent of the primary tumor
Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be evaluated
N0 No regional lymph node involvement (no cancer found in the
lymph nodes)
N1, N2, N3 Involvement of regional lymph nodes (number and/or extent of
spread)
Distant Metastasis (M)
MX Distant metastasis cannot be evaluated
M0 No distant metastasis (cancer has not spread to other parts of the
body)
M1 Distant metastasis (cancer has spread to distant parts of the body)
NURSING DIAGNOSES
• Acute or chronic pain
• Impaired skin integrity
• Impaired oral mucous membrane
• Risk for injury
• Risk for infection
• Fatigue
• Imbalanced nutrition: less than body
requirements
NURSING DIAGNOSES

• Risk for imbalanced fluid volume


• Anxiety
• Disturbed body image
• Deficient knowledge
• Ineffective coping
• Social isolation
OUTCOME IDENTIFICATION
1. Pain relief
2. Integrity of skin and oral mucosa
3. Absence of injury and infection
4. Fatigue relief
5. Maintenance of nutritional intake and
fluid and electrolyte balance
6. Improved body image
7. Absence of complications
OUTCOME IDENTIFICATION
1. Knowledge of prevention and cancer
treatment
2. Effective coping through recovery and
grieving process
3. Optimal social interaction

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IMPLEMENTATION/MANAGE
MENT
• Prevention and detection
– Primary Prevention
• Reducing modifiable risk factors in the external
and internal environment
– Secondary Prevention
• Recognizing early signs and symptoms and
seeking prompt treatment
• Prompt intervention to halt cancerous process
Cancer Prevention

Carcinogenic
chemicals
Carcinogenic
radiation

Cancer viruses
or bacteria
Avoid Tobacco

Lung Cancer Risk Increases


with Cigarette Consumption
15x

10x
Lung
Cancer
Risk
5x

0 15 30
Non-smoker
Cigarettes Smoked per Day
Protect Yourself From Excessive Sunlight
Limit Alcohol and Tobacco
Combination of Alcohol and Cigarettes
Increases Risk for Cancer of the Esophagus
40x

30x
Risk
Increase
20x

10x

Alcoholic Drinks
Consumed per Day
AND
Packs of Cigarettes
Consumed per Day
Diet: Limit Fats and Calories
Correlation Between Meat Consumption and
Colon Cancer Rates in Different Countries

40

30
Number of Cases
(per 100,000
people)
20

10

0 80 100 200 300


Grams (per person per day)
Diet: Consume Fruits and Vegetables
Avoid Cancer Viruses

HPV Infection Increases


High
Risk for Cervical Cancer

Cervical
Cancer
Risk

Low
Noninfected Women
women infected
with HPV
Avoid Carcinogens at Work

Some Carcinogens in the Workplace


Industrial Pollution

Incidence of
Most Cancers

1930 1950 1970 1990


Year

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TREATMENT MODALITIES
• Aimed towards:

– CURE - free of disease after treatment →


normal life
– Control - Goal for chronic cancers
– Palliative Care: Quality of life maintained at
highest level for the longest possible time
• Surgery – surgical removal of tumors; most
commonly used treatment
• Preventive or prophylactic
• Diagnostic surgery
• Curative surgery
• Reconstructive surgery
• Palliative surgery

• Chemotherapy – use of antineoplastic drugs to


promote tumor cell death, by interfering with
cellular functions and reproduction
• Radiotherapy – directing high-energy
ionizing radiation to destroy malignant
tumor cells without harming surrounding
tissues
– Teletherapy (external): radiation delivered in
uniform dose to tumor
– Brachytherapy: delivers high dose to tumor
and less to other tissues; radiation source is
placed in tumor or next to it
• Immunotherapy – use of chemical or
microbial agents to induce mobilization
of immune defenses.

• Biologic response modifiers (BRMs) – use


of agents that alters immunologic
relationship between tumor and host in a
beneficial way
• Bone marrow peripheral stem cell
transplantation – aspirating bone marrow
cells from compatible donor and infusing
them into the recipient

• Gene therapy – transfer of genetic


materials into the client’s DNA

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NURSING MANAGEMENT
1. Promote measures that relieve pain and
discomfort.
• Pharmacologic and non-pharmacologic
interventions
2. Promote measures to maintain intact skin
integrity
3. Promote measures that maintain oral mucosa
4. Promote measures to prevent injury from
abnormal bleeding
• Monitor platelet count; avoid aspiring products,etc
NURSING MANAGEMENT
1. Promote measures that identify and prevent
infection
• Monitor WBC count; encourage frequent
handwashing and overall cleanliness
2. Help decrease the client’s fatigue and
increase his activity level
3. Promote measures that ensure adequate
nutritional intake
• High protein, high calorie diet
4. Ensure adequate fluid and electrolyte balance
NURSING MANAGEMENT
1. Promote measures to enhance body image.
• Take an honest gentle, caring approach; encourage
client to express and verbalize feelings
2. Promote measures that address preventing
complications of cancer therapy
3. Instruct client and family about the disease
process and treatments; provide necessary
information for self-care.
4. Help client and family cope effectively
5. Promote measures to reduce social isolation.
Care of Clients Receiving
Chemotherapy

• Classes of Chemotherapy Drugs:

• Alkylating agents:
– Action: create defects in tumor DNA
– Ex: Nitrogen Mustard, Cisplatin
– Toxic Effects: reversible renal tubular
necrosis
Classes of Chemotherapy
Drugs

• Antimetabolites:
– Action: phase specific
– Ex: Methotrexate; 5 fluorouracil
– Toxic Effects: nausea, vomiting, stomatitis,
diarrhea, alopecia, leukopenia
Classes of Chemotherapy
Drugs
• Antitumor Antibiotics:
– Action: non- phase specific; interfere with
DNA
– Ex: Actinomycin D, Bleomycin, adriamycin
(doxorubicin)
– Toxic Effect: damage to cardiac muscle
Classes of Chemotherapy
Drugs
• Miotic inhibitors:
– Action: Prevent cell division during M phase
of cell division
– Ex: Vincristine, Vinblastine
– Toxic Effects: affects neurotransmission,
alopecia, bone marrow depression
Classes of Chemotherapy
Drugs
• Hormones:
– Action: stage specific G1
– Ex: Corticosteroids
• Hormone Antagonist:
– Action: block hormones on hormone- binding tumors
ie: breast, prostate, endometrium; cause tumor
regression
– Ex: Tamoxifen (breast); Flutamide (prostate)
– Toxic Effects: altered secondary sex characteristics
Effects of Chemotherapy
• Tissues: (fast growing) frequently
affected
• Examples: mucous membranes, hair cells,
bone marrow, specific organs with
specific agents, reproductive organs (all
are fetal toxic; impair ability to
reproduce)
Chemotherapy
Administration
• Routes of administration:
– Oral
– Body cavity (intraperitoneal or intrapleural)
– Intravenous
• Use of vascular access devices because of threat
of extravasation (leakage into tissues) & long-
term therapy
Chemotherapy Administration

• Types of vascular access devices:


– PICC lines: (peripherally inserted central
catheters)
– Tunneled catheters: (Hickman, Groshong)
– Surgically implanted ports: (accessed with
90o angle needle- Huber needles)
Nursing care of clients
receiving chemotherapy
• Assess and manage:
– Toxic effects of drugs (report to physician)
– Side effects of drugs: manage nausea and
vomiting, inflammation and ulceration of
mucous membranes, hair loss, anorexia,
nausea and vomiting with specific nursing
and medical interventions
Nursing care of clients
receiving chemotherapy
• Monitor lab results (drugs withheld if blood
counts seriously low); blood and blood product
administration
• Assess for dehydration, oncologic emergencies
• Teach regarding fatigue, immunosuppression
precautions
• Provide emotional and spiritual support to
clients and families
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REFERENCE
• National Cancer Institute
• Brunner and Suddarth’s Medical Surgical
Nursing