NCM 106 CELLULAR ABERRATION

I. PHILIPPINE EPIDEMIOLOGY OF CANCER

Leading Cancer Deaths in the Philippines (GLOBOCAN 2008)

1. Lung (Topmost for men)
2. Liver
3. Breast ( Topmost for women)
4. Colon/Rectum
5. Leukemia
6. Stomach
7. Cervix Uteri
8. Brain/Nervous System
9. Prostate
10 Other Pharynx

CARCINOGENESIS- Transformation of normal cells into cancer cells.

Stages:
1. Initiation- occurs when carcinogen damages DNA
2. Promotion-occurs with additional assaults in further genetic damage.
Malignant Conversion
3. Progression- the cells are increasingly malignant in appearance and behavior and develop into an
invasive cancer with metastasis to distal parts

Risk Factors:
1. Gender- certain cancers are more commonly seen in specific gender.
2. Age-Increased risk for people over age of 65, hormonal changes, altered response and the
accumulation of free radicals.
3. Race and Ethnicity-African-American experience a higher rate of cancer than any other ethnic
group.
4. Genetics- 15% of cancers may be attributed to a hereditary component such as breast, colon,lung,
ovarianand prostate.
5. Hormonal Factors-Diethylstilbestrol (DES), OCP esp. estrogen
6. Immunologic Factors-high incidence rate in immune compromised individuals such as those with
AIDS and organ transplant recipients.
7. Drugs and Chemicals-smoking, drugs such as cisplatin( ovarian tumors) and carboplatin can
increase the risk of leukemia
8. Radiation
 Ionizing-high energy radiation such as X-rays, gamma rays
 UV-sun, tanning beds and welding torches, UVB type causing sunburn and skin cancers.
 Electromagnetic-invisible areas of energy that are produced by electricity. Exposure
reducing levels of the hormone melatonin.
 Radon-a radioactive gas given off by rocks and soil, product of uranium and thorium
breakdown, causing lung cancer
9. Lifestyle
 Smoking-28% smokes, 49% exposure to cigarette smoke
 Nutrition/Diet- steady decline in the consumption of fruits and vegetables.
 Obesity- Prevalence of high fasting blood sugar among adults also increased
  Viruses-Human papilloma virus (HPV) –uterine and cervical Ca, Hepatitis B virus
(HBV)
10. Psychological Factors

THE 9 DANGER SIGNS

C- Change in bowel or bladder
A- Any sore that does not heals
U – Unusual bleeding or discharge
T- Thickening or lump in breast or elsewhere
I- Indigestion
O- Obvious change in wart or mole
N- Nagging cough or hoarseness
U- Unexplained anemia
S- Sudden and unexplained weight loss

PREVENTION OF CANCER

 Primary prevention is concerned with reducing the risks of disease through health promotion
strategies.

 Secondary prevention programs promote screening and early detection activities

Reducing Cancer Risk

Encourage patients to consume these foods:

• Whole grains • Vegetables and fruits, especially those rich in vitamin C (oranges, cantaloupe,
strawberries)
• Cruciferous vegetables (cabbage, broccoli, Brussels sprouts, caulifl ower)
• Grilled meats that have been: • Precooked in a microwave oven • Marinated but basted only
with fresh marinade, not that used to steep raw meat
Encourage patients to avoid these foods:
• Excessive meat, especially when: • Processed (smoked, salted) • Charbroiled or cooked at high
temperatures • Excessive fat, especially saturated fat • Excessive calories, leading to obesity
Encourage patients to limit:
• Alcohol intake to one (women) or two (men) standard drinks per day

ACS Recommendations in Asymptomatic People

1. Cancer-related check-up is recommended every 3 years for people aged 20-40 years and every year for
people age 40 and older.
2. Breast
Women aged 20-39 years -CBE every 3 years and monthly BSE
Women with 40 years and above - -Mammogram annual, CBE(Clinical Breast Exam) annual,
BSE(Self Breast Exam) monthly
3. Colon and Rectum
Fecal Occult Blood Test- annual
Sigmoidoscopy Every 5 years
Colonoscopy Every 10 years
 Double-Contrast Barium enema Every 5 to 10 years
Digital Rectal Exam Every 5
4. Prostate
Prostate-specific antigen (PSA) blood test and digital rectal examination (DRE) to do annually from age
50.
5. Uterus:
Cervix
Women at age 21 may start Papanicolaou Test
Sexually active, 40 years old & above:
 Annual Pap Smear & Pelvic Exam (3 consecutive normal test=less frequent test)
 HPV Test
Endometrium
High Risk & Menopausal stage
 Test of endometrial tissue

Common Causes of Cancer

1. Breast Cancer
 Early Menarche
 Late Menopause
 Nulliparous or older than 30 years at the birth of 1st child
2. Lung Cancer
 Tobacco Abuse
 Asbestos
 Radiation exposure
 Air pollution
. Colorectal Cancer
 Greater incidence in men
 Familial polyposis
 Ulcerative colitis
 High-fat,low-fiber diet
4. Prostate Cancer
 Common among males who are 50 years old and older
 African-Americans high incidence
 Positive family history
 Exposure to Cadmium

5.Cervical Cancer
 Sexual behavior
-First intercourse at an early age
-Multiple sexual partners
-Sexual partners who has had multiple sexual partners
 Human Papilloma virus and AIDS
 Low socioeconomic status
 Cigarette smoking

6. Head and Neck Cancer

 More common among males
 Alcohol and tobacco use
 Poor oral hygiene
 Long term sun exposure
  Occupational exposures-asbestos, tar, nickel, textile, wood or leather
7. Skin Cancer
 Individuals with fair complexion
 Positive family history
 Moles(nevi)
 Exposure to coal tar, creosote, arsenic, radium
 Sun exposure between 11AM to 3 PM

Tumor Grading and Staging

Staging

 determines the size of the tumor and the existence of local invasion and distant
metastasis.
 Uses TNM classification

T- Primary Tumor
Tx- Primary tumor is unable to be assessed
To- No evidence of primary tumor
Tis- Carcinoma in situ
T1,T2,T3,T4-increasing size and/or local extent of primary tumor

N-Presence Or Absence Or Regional Lymph Node Involvement

Nx- Regional lymph nodes are unable to be assessed.
No-no regional lymph node involvement
N1, N2, N3- increasing involvement of regional lymph nodes

M- Absence Or Presence Or Distant Metastasis

Mx-unable to be assessed
Mo-absence of distant metastasis
M1-presence of distant metastasis

Grading

o Refers to the classification of the tumor cells. It seek to define the type of tissue from
which the tumor originated and the degree to which the tumor cells retain the functional
and histologic characteristics of the tissue of origin (differentiation).
o The tumor is assigned 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. Tumors that do not clearly resemble the tissue of origin in structure or function
are described as poorly differentiated or undifferentiated and are assigned grade IV.

Diagnostic Test
A. Cytology Examination – Obtaining specimen for study of the formation, structure, and function of
cells.
A.1 Nursing Responsibilities
1. Explain the procedure to the patient.
2. Advise pt to avoid douche, intercourse, or vaginal suppositories for 24-48 hours prior to the test.
3. Inform pt that bimanual examination of the vagina & examination of the lower abdominal area
and rectal exam may be performed.
Interpretation of Papanicolau Test Results:
Class I- Normal*
Class II – Inflammation**
Class III- Mild to Moderate Dysplasia**
Class- IV Probably Malignant***
Class V- Possibly Malignant***
*requires ff-up exam q 1-3 years
**may require repeat in 3-6 months
***May require biopsy as prescribed
B. Radiology
B.1 Mammography- use of x-ray images of the breast
Nursing Responsibilities:

1. Assess pt’s ability to follow instructions.

2. Advise pt to remove metallic objects and application of creams, powder or deodorant
within examination field, which may alter test results.
3. Inform the patient there may be discomfort due to breast compression for better
visualization of the breast tissue.
4. Explain to the patient that the radiation dose will be kept to an absolute minimum.
Procedure takes approximately 15 to 30 min to complete.
5. Best time to schedule the examination is 1 wk after menses, when breast tenderness is
decreased.

B.2 Fluoroscopy- Use of x-rays that identify contrasts in body tissue skeletal, lung, gastrointestinal
cancers densities; may involve the use of contrast agents. This procedure is also done with other tests such
as:
B.2.1 Barium Enema- this involves insertion of rectal tube into the anus or existing ostomy to instill
Barium sulfate by gravity, and its movement through the colon is observed by fluoroscopy.
Indications:

o Evaluate unexplained weight loss, anemia, or a change in bowel pattern

o Identify and locate benign or malignant polyps or tumors
Nursing Considerations:

1. Assess for allergies to shell fish or iodinated dye. Corticosteroid is given to pt with
allergy.
2. Ensure pt’s strict compliance to dietary, fluid and medication restriction. Bowel
preparation such as laxatives and cleansing enema are given before the procedure.
3. Remove metallic objects within examination field this may impair clear imaging.
4. Note the last dose of anticoagulants, aspirin and other salicylates which can cause
hemorrhage.
5. During examination, patient will assume supine and Sim’s position.
6. Instruct the patient to resume usual diet, medications, or activity, as directed by the
doctor.
7. Instruct the patient to take a mild laxative and increase fluid intake (four 8-oz glasses) to
aid in elimination of barium, unless contraindicated.
8. Carefully monitor the patient for fatigue and fluid and electrolyte imbalance.
9. Instruct the patient that stools will be white or light in color for 2 to 3 days. If the patient
is unable to eliminate the barium, or if stools do not return to normal color, the patient
should notify the doctor.

B.2.2 Barium Swallow

o Evaluates motion and anatomic structures of the esophageal lumen by recording images
of the lumen while the patient swallows a barium solution of milkshake consistency and
chalky taste.
o The barium swallow is often performed as part of an upper gastrointestinal (GI) series or
cardiac series and is indicated for patients with a history of dysphagia and gastric reflux.

Nursing Considerations:

1. Assess patient’s ability to follow instructions.

2. Ensure patient’s compliance to dietary restriction. Allow patient to void prior to
procedure and assist in wearing gown,
3. Advice patient that he will assume standing or supine in front of the x-ray fluoroscopy
screen.
4. Monitor fluids and electrolytes, and fatigue level.
5. Instruct to increase fluids after procedure, white or light stool is expected for 2-3 days.

C. Computed Tomography

 The patient lies on a table and is moved in and out of a doughnut like device called a
gantry, which houses the x-ray tube and associated electronics. The scanner uses multiple
x-ray beams and a series of detectors that rotate around the patient to produce cross-
sectional views in a three-dimensional fashion.
Contraindications:

o Allergy to shellfish or iodinated dye

o Elderly and dehydrated patients (at risk for contrast –induced renal failure)
o Pregnant
o Inability to follow instructions

Nursing Considerations:
1. Check the BUN and Creatinine level.
2. For patients with contrast media: hold metformin (Glucophage) for non-insulin dependent DM
on the day of the test and 48 hrs after to prevent lactic acidosis.
3. Establish an IV line for contrast medium and fluids.
4. Remove dentures and jewelry.
5. Inform the patient of adverse effects of the contrast medium such as nausea, feeling of warmth,
salty or metallic taste and transient headache.
D. Nuclear Imaging Procedures
D.1. Positron Emission tomography (PET)

 Combines the biochemical properties of nuclear medicine with the accuracy of computed
tomography (CT).
 PET uses positron emissions from specific radionuclides (oxygen, nitrogen, carbon, and
fluorine) to produce detailed functional images within the body.
 RESULT: Normal findings in Normal patterns of tissue metabolism, blood flow, and
radionuclide distribution

Nursing Considerations:
1. Assess for inability of the patient to cooperate or remain still during the procedure.
2. Hold medications such as tranquilizers or insulin which can alter results.
3. Avoid use of alcohol, tobacco, or caffeine-containing drinks at least 24 hr before the study,
because the effects of these substances would make it difficult to evaluate the patient’s true
physiological state (e.g., alcohol is a vasoconstrictor and would decrease blood flow to the target
organ).
4. Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit
organ visualization and cause unclear images.
5. Failure to follow dietary restrictions before the procedure may cause the procedure to be
canceled or repeated.
6. Improper injection of the radionuclide that allows the tracer to seep deep into the muscle tissue
produces erroneous hot spots.

E. Ultrasound- uses high-frequency sound waves to produce images of deep soft-tissue structures. The
procedure is noninvasive and uses no x-rays.
Nursing Considerations:
1. Teach the patient that a clear gel will be used to increase the conduction of sound.
2. The patient may required to empty of make bladder full depending on organ to be examined.
 Pelvic Ultz- Full bladder R: To push the intestines away from the pelvic organs
  Abdominal Ultz- 12 hours no food intake and must drink 6 glassess of water before the
test
3. Patient is required to sign a consent if ultz is to be done with biopsy.

F. Magnetic Resonance Imaging- Magnetic resonance imaging (MRI) creates sectional images of the
body. MRI can be done with or without contrast dye and does not use radiation. The patient is placed in a
cylinder-shaped magnetic field.
CONTRAINDICATION: patients with pacemakers, implanted pumps, surgical clips, metal knees or hips,
or some types of tattoos and permanent makeup because metals are attracted by the powerful MRI
magnets and injury can result.
Nursing Considerations:
1. Assess for any metal inside the patient’s body, allergy to shellfish, iodine.
2. May require 12 hours NPO before the test.
3. Check renal function test results.
4. Evaluate patient if claustrophobic, restless and pregnant.

G. Endoscopic Procedures-An endoscopic examination allows the direct visualization of a body cavity
or opening. The procedure involves the insertion of a flexible endoscope containing fiber-optic glass
bundles that transmit light and can produce an image.
Nursing Considerations:
1. Placing patient on NPO.
2. Use of local anesthesia is needed for the throat.
3. Check gag reflex after procedure before resumption of diet.

H. Biopsy- Microscopic examination of a sample of suspected tissue or aspirated body fluid can confirm .

 Needle aspiration biopsy involves insertion of a needle into tissue for fluid or tissue
aspiration. This procedure is less invasive than incisional or excisional biopsy.
 Transcutaneous aspiration involves insertion of a fine needle into tissue such as breast,
prostate, or salivary gland and is used for diagnosing metastatic cancers.
 Frozen section biopsy provides immediate evaluation of a tissue sample during a surgical
procedure.
.
Nursing Considerations:
Open Biopsy:
➧ Instruct the patient that nothing should be taken by mouth for 6 to 8 hr prior to a general anesthetic.
Needle Biopsy:
➧ Instruct the patient that nothing should be taken by mouth for at least 4 hr prior to the procedure to
reduce the risk of nausea and vomiting. Protocols may vary from facility to facility.
General:
➧ Make sure a written and informed consent has been signed prior to the procedure and before
administering any medications.

II. Laboratory Tests

D.1 Complete Blood Count

A. Hemoglobin -measures the amount of hemoglobin in blood. Hemoglobin is the part of an erythrocyte
that carries oxygen.

 Normal hemoglobin range

• Men: 14 to 18 g/dL • Women: 12 to 16 g/dL
• Children: 9.5 to 15.5 g/dL • Newborn: 14 to 24 g/dL

B. Hematocrit (HCT, packed cell volume): The hematocrit test measures the volume in percentage
taken up by erythrocytes in the patient’s blood.
 Normal hematocrit range
 Men: 42% to 52% • Women: 37% to 47%
• Children: 32% to 44% • Newborn: 44% to 64%

C. Leukocyte count (WBC) and Differential

→ Constitute the body’s primary defense system against foreign organisms, tissues, and other
substances.
→The life span of a normal WBC is 13 to 20 days. Old WBCs are destroyed by the lymphatic
system and excreted in the feces.

→Leuckocytosis- Increase during physiological stress and pathological process

→Leukopenia- Decrease count

DIFFERENTIAL COUNT ( According to highest population in circulating blood)

 Neutrophils- the body’s first line of defense through the process of phagocytosis. They
also contain enzymes and pyogens, which combat foreign invaders.
NORMAL: 55-70%
INCREASE: myelocytic leukemia, he, stress, malignancies
DECREASE: bone marrow depression, viral infection

 Lymphocytes- Lymphocytes play a major role in the body’s natural defense system. B
cells differentiate into immune globulin synthesizing plasma cells. T cells function as
cellular mediators of immunity and comprise helper/ inducer (CD4) lymphocytes,
delayed hypersensitivity lymphocytes, cytotoxic (CD8 or CD4) lymphocytes, and
suppressor (CD8) lymphocytes.
NORMAL: 20-40%
INCREASE:Myeloma, Lymphosarcoma
DECREASE: Aplastic anemia, antineoplastic drugs, radiation

 Monocytes is phagocytic cells and become macrophages.

NORMAL: 2-8%
INCREASE = Carcinoma, Cirrhosis, Monocytic Leukemia, SLE, Lymphomas
  Eosinophils does phagocytosis of antigen-antibody complexes, respond to allergic and
parasitic diseases.
NORMAL: 1-4%

 Basophils- least numbers in the circulating blood. They have a phagocytic function
with granules contain heparin, histamines, and serotonin.
NORMAL: 0.5-1%

D. Erythrocyte indices

 Mean corpuscular volume (MCV): This is the size of erythrocytes.

NORMAL: MCV: 80 to 95 fL
 Mean corpuscular hemoglobin (MCH): This is the amount of hemoglobin in an
erythrocyte cell.
NORMAL: MCH: 27 to 31 pg/CELL
 Mean corpuscular hemoglobin concentration (MCHC): This is the concentration of
hemoglobin in an erythrocyte cell.
NORMAL: MCHC: 32 to 36 g/dL
 Red cell distribution width (RDW): This shows the different sizes of erythrocyte cells.
NORMAL: 11.6-14.8

Indications:
 Detect a hematological disorder, neoplasm, or immunological abnormality
 Monitor the response to drugs or chemotherapy, and evaluate undesired reactions to
drugs that may cause blood dyscrasias

E. Platelet Count

→Platelets have an essential function in coagulation, hemostasis, and blood thrombus formation.
⁕Thrombocythemia is used to describe platelet increases associated with chronic
myelo proliferative disorders
⁕Thrombocytopenia is used to describe platelet counts of less than 140 103/microL.

NORMAL: 150,000 to 400,000 mm3

INCREASE: Leukemias (chronic), Malignancies (carcinoma, Hodgkin’s, lymphomas)
DECREASE: Lymphoma, Granulomatous infections, Metastatic carcinoma

Tumor Markers
→ a.k.a biochemical markers found in the blood or body fluids; are proteins, antigens, genes, hormones,
and enzymes produced and secreted by tumor cells.
→ Helps confirm a diagnosis of cancer, detect cancer origin, monitor the effect of cancer therapy, and
determine cancer remission.
A. Oncofetal Antigens

 AFP (Alpha-feto-protein) made by a fetus's liver and yolk sac. It's the main protein during the
first three months of development
NORMAL: less than 10 ng/mL
INCREASE: Liver cancer(more than 500ng/ml), testicular and ovarian cancer

 CEA (Carcinoembryonic Antigen)- is a protein present during fetal development that terminates
at birth.
→Test results are available in 3 days.
NORMAL: Nonsmoker: Less than 3 ng/mL • Smoker: Less than 5 ng/mL
INCREASE: Colon cancer, Rectal cancer

B. Hormones ( present in large quantities)

 HCG( Human Chorionic Gonadotropin)- produced by placenta
INCREASE: Pregnancy, H-mole, Choriocarcinoma

 Antidiuretic Hormone(ADH), calcitonin, catecholamines, parathyroid hormone (PTH)

C. Iso-enzymes(present in a particular tissue may be release into bloodstream due
excessive tissue growth due to tumor.
 PSA(Prostatic Specific Antigen)-prostate gland releases PSA in low amounts.
NORMAL: 2.5-6.5 ng/
INCREASE: prostatitis, prostate cancer, and trauma

D. Tissue Specific Proteins (identify the type of tissue affected by malignancy

 CA 125 - Cancer antigen 125 (CA-125) is a protein attached to the ovarian cancer cells and
other cancer cells.
NORMAL Range: Less than 35 U/mL
INCREASE: Ovarian cancer, Ca of endometrium, fallopian tubes: Liver cancer, Breast cancer

 CA 19-9 - is a protein that exists on the surface of certain cancer cells, detected in blood and body
fluids.
INCREASE LEVEL: Pancreatic Cancer, cholangiocarcinoma, colorectal, ovarian Ca

 Cancer antigen (CA) 15-3 - an antigen, or a substance that stimulates your body's defense system
NORMAL: less than or equal to 30 U/mL
INCREASE: Breast Ca, Ovary and Liver conditions

Nursing Consideration in Taking Blood Specimen.

1. Explain why the blood sample is taken.
2. Assess patient for smoking, ongoing chemo or lately performed radioactive scan.

Nursing Process for the Patient with Cancer

ASSESSMENT:
Activity/Rest
• Weakness
• Fatigue
• Changes in rest pattern and usual hours of sleep per night
Circulation
• Palpitations
• Chest pain on exertion
Ego Integrity
 Denial, withdrawal, anger
 Depression
Elimination
• Changes in bowel sounds
• Abdominal distention
• Diarrhea • Dysuria, frequency, incontinence
Food/Fluid
• Changes in weight, severe weight loss, cachexia
• Wasting of muscle mass
• Changes in skin moisture or turgor
• Edema
• Ulcerations of oral mucosa
Neurosensory
• Dizziness, syncope
• Lack of coordination, unstable balance
• Numbness or tingling of extremities
Pain/Discomfort
• Guarding behaviors, positioning to avoid pain
• Facial mask
• Sleep disturbance
Respiration
• Dyspnea with exertion
• History of chronic respiratory disease
• Smoking—tobacco, marijuana
• Living with someone who smokes
• Asbestos or dust exposure—coal, sandstone, silica, and the like
Safety
• Skin rashes, ulcerations
• Dry, leather-like skin
Sexuality
• Sexual concerns such as impact on relationship, change in level of satisfaction,
impotence, menopausal symptoms
Social Interaction
• Concerns about role function and responsibility
Teaching-Learning
• Family history of cancer, for example multiple family members—mother, grandmother,
aunt, or sister—with breast cancer
Nursing Priorities:
1. Support adaptation and independence.
2. Promote comfort.
3. Maintain optimal physiological functioning.
4. Prevent complications.
5. Provide information about disease process, condition, prognosis, and treatment needs.

Discharge Goals:
1. Dealing with current situation realistically.
2. Pain alleviated or controlled.
3. Homeostasis achieved.
4. Complications prevented or minimized.
5. Disease process, condition, prognosis, and therapeutic choices and regimen
understood.
6. Plan in place to meet needs after discharge.