Epidemiology

Overall, the incidence of cancer is higher in men than in women and

higher in industrialized sectors and nations.

 More than 1.4 million Americans are diagnosed each year

with cancer, affecting one of various body sites.
 Cancer is second only to cardiovascular disease as a leading
cause of death in the United States.
 Although the number of cancer deaths has decreased slightly,
more than 560, 000 Americans were expected to die from a
malignant process in 2008.
 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.

Pathophysiology

Cancer is a disease process that begins when an abnormal cell is

transformed by the genetic mutation of the cellular DNA.

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 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.
 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 (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.
 Carcinogenesis. Carcinogenesis is a malignant transformation
that involves initiation (initiators such as chemicals, physical
 factors, and biologic agents, escape normal 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),
and progression (the altered cells exhibit increased malignant
behavior).
 Role of the immune system. Some evidence indicates that
the immune system can detect the development of malignant
cells and destroy them before cell growth becomes
uncontrolled, but when the immune system fails to identify
and stop the growth of malignant cells, clinical cancer
develops.

Detection and Prevention of Cancer

Nurses and physicians have traditionally been involved with tertiary

prevention, the care, and rehabilitation of patients after cancer
diagnosis and treatment, but the American Cancer Society, the
National Cancer Institute, clinicians, and researchers also place
emphasis on primary and secondary prevention of cancer.

 Primary prevention. Primary prevention is concerned with

reducing risks of disease through health promotion strategies.
 Secondary prevention. Secondary prevention programs
promote screening and early detection activities such as
breast and testicular self-examination and Papanicolaou (Pap)
tests.

Diagnosis of Cancer
A cancer diagnosis is based on the assessment of physiologic and
functional changes and results of the diagnostic evaluation.

 Tumor marker identification. Analysis of substances found

in body tissues, blood or other body fluids that are made by
the tumor or by the body in response to the tumor.
 Genetic profiling. Analysis for the presence of mutations in
genes found in tumors or body tissues.
 Mammography. Mammography is the use of x-ray images of
the breast.
 Magnetic resonance imaging (MRI). MRI uses magnetic fields
and radio-frequency signals to create sectioned images of
various body structures.
 Computed tomography (CT). CT scan uses narrow-beam x-
ray to scan successive layers of tissue for a cross-sectional
view.
 Fluoroscopy. Use of X-rays that identify contrasts in the body
tissue densities; may involve the use of contrast agents.
 Ultrasonography. Ultrasound uses high-frequency sound
waves echoing off body tissues and is converted electronically
into images; used to assess deep tissues 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.
 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.
  PET fusion. Use of a PET scanner and a CT scanner in one
machine to provide an image combining anatomic detail,
spatial resolution, and functional metabolic abnormalities.
 Radioimmunoconjugates. Monoclonal antibodies are labeled
with a radioisotope and injected intravenously into the patient.

Tumor Staging and Grading

A complete diagnostic evaluation include identifying the stage and

grade of the tumor.
Staging. Staging determines the size of the tumor and the existence of
local invasion and distant metastasis.

 Tumor, nodes, and metastasis (TNM) system. The TNM

system is frequently used, where T is the extent of the primary
tumor, N is the absence or presence and extent of regional
lymph node metastasis, and M is the absence or presence of
distant metastasis.
 Grading. Grading refers to the classification of the tumor cells,
and it seeks 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.
 Grade I to IV. Grade I tumors, also known as well-
differentiated tumors, closely resemble the tissue of origin in
structure and function while Grade IV tumors do not clearly
resemble the tissue of origin in structure and function.

Management of Cancer

Treatment options offered to cancer patients should be based on

treatment goals for each specific type of cancer.
Surgery

Surgical removal of entire cancer remains the ideal and most

frequently used treatment method.

Diagnostic Surgery

Biopsy

 Biopsy. Biopsy is usually performed to obtain a tissue sample

for analysis of the cells suspected to be malignant.
 Types of biopsy. The three most common biopsy methods are
the excisional, incisional, and needle methods.
 Excisional biopsy. Excisional biopsy is most frequently used
for easily accessible tumors of the skin, breast, and upper and
lower gastrointestinal and upper respiratory tracts.
 Incisional biopsy. Incisional biopsy is performed if the tumor
mass is too large to be removed.
 Needle biopsy. Needle biopsies are performed to sample
suspicious masses that are easily accessible, such as growths
in the breasts, thyroid, lung, liver, and kidney.

Surgery as Primary Treatment

When surgery is the primary approach in treating cancer, the goal is to

remove the entire tumor or as much as is feasible and any involved
surrounding tissue, including regional lymph nodes.

 Local excision. Local excision, often performed on an

outpatient basis, is warranted when the mass is small, and it
includes removal of the mass and a small margin of normal
tissue that is easily accessible.
  Wide or radical excisions. Wide excisions include removal of
the primary tumor, lymph nodes, adjacent involved structures,
and surrounding tissues that may be at high risk for tumor
spread.
 Video-assisted endoscopic surgery. In this minimally
invasive procedure, an endoscope with intense lighting and an
attached multichip mini-camera is inserted into the body
through a small incision.
 Salvage surgery. Salvage surgery is an additional treatment
option that is an extensive surgical approach to treat the local
recurrence of cancer after the use of a less extensive primary
approach.
 Electrosurgery. Uses electric current to destroy tumor cells.
 Cryosurgery. Uses liquid nitrogen or a very cold probe to
freeze tissue and cause cell destruction.
 Chemosurgery. Uses chemicals or chemotherapy applied
directly to the tissue to cause destruction.
 Laser surgery. Uses light and energy aimed at an exact tissue
location and depth to vaporize cancer cells.
 Photodynamic therapy. Intravenous administration of a
light-sensitizing agent that is taken up by cancer cells, followed
by exposure to laser within 24-48 hours.
 Radiofrequency ablation. Uses localized application of
thermal energy that destroys cancer cells through heat.

Prophylactic Surgery

Prophylactic surgery involves removing nonvital tissues or organs that

are at increased risk to develop cancer.

 Examples of prophylactic surgery. Colectomy, mastectomy,

and oophorectomy are examples of prophylactic surgery.
  Qualified patients. Prophylactic surgery is offered selectively
to patients and discussed thoroughly with patients and
families.

Palliative Surgery

When a cure is not possible, the goals of treatment are to make the
patient as comfortable as possible.

 Palliative surgery. Palliative surgery is performed in an

attempt to relieve complications of cancer.
 Communication. Honest and informative communication
with the patient and family about the goal of surgery is
essential to avoid false hope and disappointment.

Reconstructive Surgery

Reconstructive surgery may follow curative or radical surgery.

 Reconstructive surgery. Reconstructive surgery may be

performed in an attempt to improve function or obtain a more
desirable cosmetic effect.
 Indications. Reconstructive surgery may be indicated for
breast, head and neck, and skin cancers.

Radiation Therapy

More than half of patients with cancer receive a form of radiation

therapy at some point during treatment.

 Uses. Radiation may be used to cure cancer, as in thyroid

carcinomas, localized cancers of the head and neck, and
cancers of the uterine cervix; it may control malignant disease
 when a tumor cannot be removed surgically or when local
nodal metastasis is present, or it can be used neoadjuvantly.
 Types. Two types of ionizing radiation-electromagnetic
radiation (xrays and gamma rays) and particulate
radiation (electrons, beta particles, protons, neutrons, and
alpha particles)- can lead to tissue disruption.

Radiation Dosage

Radiation dosage depends on the sensitivity of the target tissues to

radiation, the size of the tumor, tissue tolerance of the surrounding
normal tissues, and critical structures adjacent to the tumor target.

 Lethal tumor dose. The lethal tumor dose is defined as that

dose that will eradicate 95% of the tumor yet preserve normal
tissue.
 Fractions. In external beam radiation, the total radiation dose
is delivered over several weeks in daily doses called fractions.
 Fractionated doses. Repeated radiation treatments over time
also allow for the periphery of the tumor to be reoxygenated
repeatedly, because tumors shrink from the outside inward.

Administration of Radiation

Radiation therapy can be administered in a variety of ways depending

on the source of radiation used, the location of the tumor, and the type
of cancer targeted.

 Teletherapy (external beam radiation). External beam

radiation therapy is the most commonly used form of
radiation, in which, depending on the size, shape, and location
of the tumor, different energy levels are generated to produce
a carefully shaped beam that will destroy the targeted tumor,
 yet spare the surrounding healthy tissues and organs in an
effort to reduce the treatment toxicities for the patient.
 Brachytherapy (internal radiation). Internal radiation
implantation, or brachytherapy, delivers a high dose of
radiation to a localized area and can be implanted by means of
needles, seeds, beads, or catheters into body cavities (vagina,
abdomen, pleura) or interstitial compartments (breast,
prostate).

Toxicity

 Alopecia. Altered skin integrity is a common effect and can

include alopecia or hair loss.
 Stomatitis. Alterations in oral mucosa secondary to radiation
therapy include stomatitis or inflammation of the oral tissues,
xerostomia or dryness of the mouth, change and loss of taste,
and increased salivation.
 Thrombocytopenia. Bone marrow cells proliferate rapidly,
and if sites containing bone marrow are included in the
radiation field, anemia, leukopenia, and thrombocytopenia
may result.

Nursing Management in Radiation Therapy

 Assessment. The nurse assesses the

patient’s skin and oropharyngeal mucosa regularly when
radiation therapy is directed to these areas, and also the
nutritional status and general well-being should be assessed.
 Symptoms. If systemic symptoms, such as weakness
and fatigue, occur, the nurse explains that these symptoms
are a result of the treatment and do not represent
deterioration or progression of the disease.
  Safety precautions. Safety precautions used in caring for a
patient receiving brachytherapy include 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 and pregnant visitors, limiting visits from
others to 30 minutes daily, and seeing that visitors maintain
a 6 foot distance from the radiation source.

Chemotherapy

In chemotherapy, antineoplastic agents are used in an attempt to

destroy tumor cells by interfering with cellular functions, including
replication.

 Goal. The goal of treatment is the eradication of enough

tumor so that the remaining tumor cells can be destroyed by
the body’s immune system.
 Proliferating cells. Actively proliferating cells within a tumor
are the most sensitive to chemotherapeutic agents.
 Nondividing cells. Nondividing cells capable of future
proliferation are the least sensitive to antineoplastic
medications and consequently are potentially dangerous.
 Cell cycle-specific. Cell cycle-specific agents destroy cells that
are actively reproducing by means of the cell-cycle; most affect
cells in the S phase by interfering with DNA and RNA synthesis.
 Cell cycle-nonspecific. Chemotherapeutic agents that act
independently of the cell cycle phases are cell cycle
nonspecific, and they usually have a prolonged effect on cells,
leading to cellular damage and death.
Antineoplastic Agents

Chemotherapeutic agents are also classified by chemical group, each

with a different mechanism of action.

 Alkylating agents. Alters DNA structure by misreading DNA

code, initiating breaks in the DNA molecule, cross-linking DNA
strands
 Nitrosoureas. Similar to the alkylating agents, but they can
cross the blood-brain barrier.
 Topoisomerase I inhibitors. Induce breaks in the DNA strand
by binding to enzyme topoisomerase I, preventing cells from
dividing.
 Antimetabolites. Antimetabolites interfere with the
biosynthesis of metabolites or nucleic acids necessary for RNA
and DNA synthesis.
 Antitumor antibiotics. Interfere with DNA synthesis by
binding DNA and prevent RNA synthesis.
 Mitotic spindle poisons. Arrest metaphase by inhibiting
mitotic tubular formation and inhibiting DNA and protein
synthesis.
 Hormonal agents. Hormonal agents bind to hormone
receptor sites that alter cellular growth; blocks binding of
estrogens to receptor sites; inhibit RNA synthesis; suppress
aromatase of P450 system, which decreases level.

Nursing Management in Chemotherapy

Nurses play an important role in assessing and managing many of the

problems experienced by patients undergoing chemotherapy.
  Assessing fluid and electrolyte balance. Anorexia, nausea,
vomiting, altered taste, mucositis, and diarrhea put patients at
risk for nutritional and fluid electrolyte disturbances.
 Modifying risks for infection and bleeding. Suppression of
the bone marrow and immune system is expected and
frequently serves as a guide in determining appropriate
chemotherapy dosage but increases the risk of anemia,
infection, and bleeding disorders.
 Administering chemotherapy. The patient is observed
closely during its administration because of the risk and
consequences of extravasation, particularly of vesicant agent.
 Protecting caregivers. Nurses must be familiar with their
institutional policies regarding personal protective equipment,
handling and disposal of chemotherapeutic agents and
supplies, and management of accidental spills or exposures.

Bone Marrow Transplantation

The role of bone marrow transplantation (BMT) for malignant and

some nonmalignant diseases continues to grow.

Type of Bone Marrow Transplant

Types of BMT based on the source of donor cells include:

 Allogeneic. Allogeneic is from a related donor other than the

patient; donor may be a related donor or a matched unrelated
donor.
 Autologous. Autologous BMT is from the patient himself.
 Syngeneic. Syngeneic BMT is from an identical twin.

Nursing Management in Bone Marrow Transplantation

Nursing care of patients undergoing BMT is complex and demands a
high level of skill.

 Implementing pretransplantation care. Nutritional

assessments, extensive physical examinations, organ function
tests, and psychological evaluations are conducted, with blood
work that includes assessing past antigen exposure, and the
patient’s support system, financial, and insurance resources
are also evaluated.
 Providing care during treatment. Nursing management
during bone marrow infusion or stem cell infusions consists of
monitoring the patient’s vital signs and blood oxygen
saturation; assessing for adverse effects such as fever, chills,
shortness of breath, chest pain, cutaneous reactions, nausea,
vomiting, hypotension, or hypertension, tachycardia, anxiety,
and taste changes; and providing ongoing support and patient
teaching.
 Providing posttransplantation care. Ongoing nursing
assessments such as psychosocial assessments in follow-up
visits are essential to detect late effects of therapy after BMT,
which occur 100 days or more after the procedure, and donors
also require nursing care through being assisted in
maintaining realistic expectations of themselves as well as of
the patient.

Targeted Therapies

Targeted therapies seek to minimize the negative effects on healthy

tissues by disrupting specific cancer cell functions such as malignant
transformation, cell communication pathways, processes for growth
and metastasis, and genetic coding.
Biologic Response Modifiers (BRM)

Biologic response modifier therapy involves the use of naturally

occurring or recombinant agents or treatment methods that can alter
the immunologic relationship between the tumor and the host to
provide a therapeutic benefit.

 Nonspecific biologic response modifiers. Nonspecific agents

such as Calmette-Guérin (BCG) and Corynebacterium parvum,
when injected into the patient, may serve as antigens that can
stimulate an immune response in the hopes of eradicating
malignant cells.
 Monoclonal antibodies. Monoclonal antibodies (MoAbs) have
become available through technologic advances, and this type
of specificity allows MoAbs to destroy the cancer cells and
spare normal cells.
 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.
 Retinoids. Retinoids are vitamin A derivatives that play a role
in growth, reproduction, apoptosis, epithelial cell
differentiation, and immune function, wherein specific
receptors in the cell nucleus are retinoid-dependent, thus
when retinoids bind with these receptors, cell differentiation
and replication are affected.
 Cancer vaccines. Cancer vaccines are used to mobilize the
body’s immune response to recognize and attack cancer cells,
as these cancer vaccines contain either portions of cancer cells
alone or portions of cells in combination with other
substances that can augment or boost immune responses.
Nursing Management in Biologic Response Modifier Therapy

It is essential for the nurse to assess the need for education, support,
and guidance for both the patient and the family and assist in planning
and evaluating patient care.

 Monitoring therapeutic and adverse effects. The nurse

must be familiar with each agent given and its potential
effects, and also, the nurse must be aware of the impact of
these side effects on the patient’s quality of life.
 Promoting home and community-based care. The nurse
teaches the patient and family how to administer BRMs
through subcutaneous injections, provides instructions about
side effects and helps the patient and family identify the
strategies to manage many of the common side effects of BRM
therapy.

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 the disease.

 Challenges. One of the challenges confronting cancer gene

therapy is the multiple somatic mutations involved in the
development of cancer, making it difficult to identify the most
effective gene therapy approach.
 Viruses. Viruses used as vectors that transport a gene into a
target cell via the cell membrane include retroviruses,
adenoviruses, vaccinia virus, fowlpox, herpes simplex viruses,
and Epstein-Barr viruses.

Approaches in Gene Therapy

Three general approaches have been used in the development of gene
therapies, with adenoviruses showing effective promise in each
approach.

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 Tumor-directed therapy. This is the introduction of a

therapeutic gene (suicide gene) into tumor cells in an attempt
to destroy them.
 Active immunotherapy. Active immunotherapy is the
administration of genes that will invoke the antitumor
responses of the immune system.
 Adoptive immunotherapy. Active immunotherapy is the
administration of genetically altered lymphocytes that are
programmed to cause tumor destruction.

Complementary and Alternative Medicine

Many patients seek a more holistic or nontraditional approach, turning

to complementary and alternative therapies while continuing to utilize
conventional medicine.

 Complementary and Alternative Medicine (CAM). CAM was

defined as diverse medical and health care systems, practices,
and products that are not presently considered to be part of
conventional medicine.
 Risk. Because of the possibility of herb-vitamin-drug
interactions, there is concern about the use of biologicals and
dietary supplements, which are not regulated by the FDA nor
subjected to rigorous scientific evaluation.

Unproven and Unconventional Therapies

Hopelessness, desperation, unmet needs, lack of factual information,
and family and social pressures are major factors that motivate
patients to seek unconventional methods of treatment.

 Definition. Unconventional treatments are those without

scientific evidence of the ability to cure or control cancer.

Nursing Management in Unconventional Therapies

The most effective way to protect patients and families from fraudulent
therapies and questionable cancer cures is to establish a trusting
relationship, provide supportive care, and promote hope.

 Communication. 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 the family that
they are not “doing everything we can” to obtain a cure.
 Information. The nurse should inform the patient and family
should inform the patient and family of the characteristics
common to fraudulent therapies so that they will be informed
and cautious when evaluating other forms of “therapy”.
 Collaboration. The nurse should encourage the patient to
inform their physicians about the use of therapies to help
prevent interactions with medications and other therapies that
may be prescribed.

Nursing Care of Patients with Cancer

Main Article: 13 Cancer Nursing Care Plans

The outlook for patients with cancer has greatly improved because of
scientific and technologic advances.

Maintaining Tissue Integrity

 Stomatitis. Assessment of the patient’s subjective experience

and an objective assessment of the oropharyngeal tissues and
teeth are important and for the treatment of oral
mucositis, Palifermin (Kepivance), a synthetic form of human
keratinocyte growth factor, could be administered.
 Radiation-associated skin impairment. Nursing care for
patients with impaired skin reactions includes maintaining skin
integrity, cleansing the skin, promoting comfort, reducing pain,
preventing additional trauma, and preventing and managing
infection.
 Alopecia. Nurses provide information about hair loss and
support the patient and family in coping with changes in body
image.
 Malignant skin lesions. Nursing care includes cleansing the
skin, reducing superficial bacteria, controlling bleeding,
reducing odor, protecting the skin from further trauma, and
relieving pain.

Promoting Nutrition

 Anorexia. Anorexia may occur because people feel full after

eating only a small amount of food.
 Malabsorption. Surgical intervention may change peristaltic
patterns, later gastrointestinal secretions, and reduce the
absorptive surfaces of the gastrointestinal mucosa, all leading
to malabsorption.
  Cachexia. Nurses assess patients who are at risk of altered
nutritional intake so that appropriate measures may be
instituted prior to nutritional decline.

Relieving Pain

 Assessment. The nurse assesses the patient for the source

and site of pain as well as those factors that increase the
patient’s perception of pain.
 Cancer pain algorithm. Various opioid and nonopioid
medications may be combined with other medications to
control pain as adapted from the World Health Organization
three-step ladder approach.
 Education. The nurse provides education and support to
correct fears and misconceptions about opioid use.

Decreasing Fatigue

 Assessment. The nurse assesses physiologic and

psychological stressors that can contribute to fatigue and uses
several assessment tools such as a simple visual analog scale
to assess levels of fatigue.
 Exercise. The role of exercise as a helpful intervention has
been supported by several controlled trials.
 Pharmacologic interventions. Occasionally pharmacologic
interventions are utilized, including antidepressants for
patients with depression, anxiolytics for those with
anxiety, hypnotics for patients with sleep disturbances, and
psychostimulants for some patients with advanced cancer or
fatigue that does not respond to any medication.

Improving Body Image and Self-esteem

  Assessment. The nurse identifies potential threats to the
patient’s body image experience, and the nurse assesses the
patient’s ability to cope with the many assaults to the body
image experienced throughout the course of the disease and
treatment.
 Sexuality. Nurses who identify physiologic, psychologic or
communication difficulties related to sexuality or sexual
function are in a key position to help patients seek further
specialized evaluation and intervention if necessary.

Assisting in the Grieving Process

 Assessment. The nurse assesses the patient’s psychological

and mental status, as well as the mood and emotional reaction
to the results of diagnostic testing and prognosis.
 Grieving. Grieving is a normal response to these fears and to
actual or potential losses.

Monitoring and Managing Potential Complications

 Infection. The nurse monitors laboratory studies to detect

any early changes in WBC counts.
 Septic shock. Neurologic assessments are carried out, fluid
and electrolyte status is monitored, arterial blood gas values
and pulse oximetry are monitored, and IV fluids, blood, and
vasopressors are administered by the nurse.
 Bleeding and hemorrhage. The nurse may administer IL-11,
which has been approved by the FDA to prevent severe
thrombocytopenia, and additional medications may be
prescribed to address bleeding due to disorders of
coagulation.

Promoting Home and Community-Based Care

Nurses in the outpatient settings often have the responsibilities for
patient teaching and for coordinating care in the home.

 Teaching patients self-care. Follow-up visits and telephone

calls from the nurse assist in identifying problems and are
often reassuring, increasing the patient’s and the family’s
comfort in dealing with complex and new aspects of care.
 Continuing care. The responsibilities of the home care
include assessing the home environment, suggesting
modifications at home or in care to help the patient and the
family address the patient’s physical needs.

1. The nurse teaches a patient with cancer of the liver about high-
protein, high-calorie diet choices. Which snack choice by the
patient indicates that the teaching has been effective?

A. Fresh fruit salad.

B. Orange sherbet.
C. Strawberry yogurt.
D. French fries.

1. Answer: C. Strawberry yogurt

 C: Yogurt has high biologic value because of the protein and

fat content.
 A: Fruit salad does not have high amounts of protein or fat.
 B: Orange sherbet is lower in fat and protein than yogurt.
 D: French fries are high in calories from fat but low in protein.

2. After the nurse has explained the purpose of and schedule for
chemotherapy to a 23-year-old patient who recently received a
diagnosis of acute leukemia, the patient asks the nurse to repeat
the information. Based on this assessment, which nursing
diagnosis is most likely for the patient?

A. Acute confusion related to infiltration of leukemia cells into the

central nervous system.
B. Knowledge deficit: chemotherapy related to a lack of interest in
learning about treatment.
C. Risk for ineffective health maintenance related to anxiety about
new leukemia diagnosis.
D. Risk for ineffective adherence to treatment related to denial of need
for chemotherapy.

2. Answer: C. Risk for ineffective health maintenance related

to anxiety about new leukemia diagnosis

 C: The patient who has a new cancer diagnosis is likely to have

high anxiety, which may impact learning and require that the
nurse repeat and reinforce information.
 A: The patient’s history of a recent diagnosis suggests that
infiltration of the leukemia is not a likely cause of the
confusion.
 B&D: The patient asks for the information to be repeated,
indicating that lack of interest in learning and denial are not
etiologic factors.

3. A hospitalized patient who has received chemotherapy

for leukemia develops neutropenia. Which observation by the RN
caring for the patient indicates that the nurse should take action?

A. The patient’s visitors bring in some fresh peaches from home.

B. The patient ambulates several times a day in the room.
C. The patient uses soap and shampoo to shower every other day.
D. The patient cleans with a warm washcloth after having a stool.

3. Answer: A. The patient’s visitors bring in some fresh peaches

from home.

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 A: Fresh, thinned-skin peaches are not permitted in a

neutropenic diet because of the risk of bacteria being present.
 B: The patient should ambulate in the room rather than the
hospital hallway to avoid exposure to other patients or
visitors.
 C: Because overuse of soap can dry the skin and increase
infection risk, showering every other day is acceptable.
 D: Careful cleaning after having a bowel movement will help to
prevent perineal skin breakdown and infection.

4. While being prepared for a biopsy of a lump in the right breast,

the patient asks the nurse what the difference is between a
benign tumor and a malignant tumor. The nurse explains that a
benign tumor differs from a malignant tumor in that benign
tumors

A. Do not cause damage to adjacent tissue.

B. Do not spread to other tissues and organs.
C. Are simply an overgrowth of normal cells.
D. Frequently recur in the same site.

4. Answer: B. do not spread to other tissues and organs.

 B: The major difference between benign and malignant

tumors is that malignant tumors invade adjacent tissues and
 spread to distant tissues and benign tumors never
metastasize.
 A: Both types of tumors may cause damage to adjacent
tissues.
 C: The cells differ from normal in both benign and malignant
tumors.
 D: Benign tumors usually do not recur.

5. A patient who smokes tells the nurse, “I want to have a

yearly chest x-ray so that if I get cancer, it will be detected early.”
Which response by the nurse is most appropriate?

A. “Chest x-rays do not detect cancer until tumors are already at least a
half-inch in size.”
B. “Annual x-rays will increase your risk for cancer because of exposure
to radiation.”
C. “Insurance companies do not authorize yearly x-rays just to detect
early lung cancer.”
D. “Frequent x-rays damage the lungs and make them more
susceptible to cancer.”

5. Answer: A. “Chest x-rays do not detect cancer until tumors are

already at least a half-inch in size.”

 A: A tumor must be at least 1 cm large before it is detectable

by an x-ray and may already have metastasized by that time.
 B: Radiographs have low doses of radiation, and an annual x-
ray alone is not likely to increase lung cancer risk.
 C: Insurance companies do not usually authorize x-rays for
this purpose, but it would not be appropriate for the nurse to
give this as the reason for not doing an x-ray.
 D: A yearly x-ray is not a risk factor for lung cancer.
Distinctive tumors were first reported in scientific journals in 1775, and
that was scrotal cancer directly associated with chimney sweeps. In
1761, cases of nasal cancer rose among individuals who use snuff or
smokeless tobacco. Since then, cancer has made its identity known as
the disease that plagues the unsuspecting society.

Cancer can occur anywhere in the body. When the body’s normal
control mechanisms become defective, old cells do not die and new
abnormal cells continue to proliferate. Consequently, these extra cells
form tissue masses which deprive the normal and healthy cells of the
nutrients necessary for growth and development.

However, since there is still no cure for cancer, the healthcare industry
advocates for prevention and early detection. Screening tests are made
to subject persons suspected to have cancer but still do not have the
manifestations yet. If the results are highly suggestive, a biopsy is
conducted to confirm the working diagnosis.
Mortality Hit Around the World

World Health Organization (WHO) reported that in 2012, there were 14

million new cases of cancer and 8.2 million cancer-related deaths. Sixty
percent of these new cases are from Africa, Asia, and some parts of
America. In the United States alone, it is estimated that for 2016, there
will be 1.6 million new cases of cancer and cancer-related deaths would
reach half a million.

Nurses as Cancer Insurgents

When facing cancer, nurses understand the importance of early

detection and treatment. This guarantees a relatively higher chance of
surviving the savage disease. The problem with cancer is that it only
signals its existence when it is already severe. Unlike other
diseases, it does not scream pain. Most of the time, before one
becomes aware of its existence, cancer has made a map out of one’s
body and has lodged itself in every corner.

Nurses have witnessed parents become childless and children become

orphaned because of cancer. Therefore, it is important for nurses to
spread awareness on cancer and how it can be prevented in the
earliest time possible. Nurses should learn cancer screening test
guidelines by heart as part of the commitment to saving lives.

Cancer Screening Test Guidelines

Here are the screening test guidelines for different types of cancer
according to American Cancer Society and U.S. Preventive Task Force
Services:

1. Breast Cancer
Seventy percent of women have no known predisposing factors
to breast cancer but certain risk factors have been established. Risk
factors include age 65 and above, two first-degree relatives diagnosed
with breast cancer at an early age, high breast tissue density, and
factors that affect circulating hormones like late menopause, long-term
use of hormonal replacement therapy, and obesity.

Breast cancer screening includes mammography, clinical breast

examination (CBE), and breast self-examination (BSE). It is important
that patients understand what these examinations are all about, how
they are performed, and their limitations.

Mammogram. Image via:

Wikipedia.
Mammography (x-ray of the breast) is done yearly for women age 40
and above. However, for women with increased risk, it may be started
at age 30. CBE is done every 2-3 years among women 20-39 years of
age and then annually after 40 years of age. Basically, this is a physical
exam done by a healthcare provider as part of the regular medical
check-up. Lastly, nurses should teach women 20 years of age and
above on how to perform BSE. This should be done 5-7 days
after menstruation when the breasts are not swollen and tender. For
women with an irregular sexual cycle, a specific date must be chosen
for monthly BSE.

2. Cervical Cancer

Pap Smear
The screening test for cervical cancer is Pap Smear. In 2012, the
American College of Obstetricians and Gynecologists (ACOG) released a
new guideline for this test. First screening should be at age 21. For
women age 21 to 39, screening is done every three years. Until age 60,
screening is done with cytology if Pap Smear is positive or if the patient
is at high-risk for HPV test. For women who have undergone
hysterectomy for benign reasons, routine screening is discontinued.
Lastly, for women age 65 and above, routine screening is discontinued
if three consecutive Pap smear result is negative.

3. Ovarian Cancer
Currently, there is no effective screening test for ovarian cancer
although risk factors would include history of breast or ovarian cancer
in the family and mutation in BRCA1 and BRCA2 genes.

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Pelvic exam

Pelvic exam is done upon check-up and the doctor would request
ultrasound and magnetic resonance imaging (MRI) as needed.

4. Testicular Cancer
 Testicular self exam.
Monthly testicular self-examination (TSE) is recommended for men. A
painless nodule or lump felt is always advised to be reported to the
doctor. TSE should be done after a warm shower so the skin is relaxed.

5. Lung Cancer

Low-dose computer tomography annual screening for lung cancer is

recommended for adults age 55-80 years with smoking history of 30
pack years or have quit smoking within 15 years. Screening is
discontinued if the person has stopped smoking for at least 15 years.

6. Liver Cancer

American Cancer Society has no current recommendations for liver

cancer screening. However, two most commonly requested test
for liver cancer includes ultrasound and alpha-fetoprotein
(AFP) blood test.

7. Colorectal Cancer
Screening recommendations for colorectal cancer include fecal occult
blood test (FOBT), sigmoidoscopy, and colonoscopy.

Colonoscopy
Assessment for risk factors (e.g. polyps, first-degree relative with
colorectal cancer, personal history of ulcerative colitis, etc.) should
begin at age 20. However, for those who are not high risk, routine
screening recommendations should take place between 50 and 75
years of age.

FOBT is conducted annually. Another option is to have sigmoidoscopy

every five years and FOBT every three years. Third option on the list is
to have colonoscopy every 10 years.

8. Prostate Cancer
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Prostate cancer is the leading cancer among men in the U.S. and the
second leading cause of death. Risk factors include age, history of
prostate cancer in the family and African American ethnicity. Screening
recommendations include digital rectal examination (DRE) and
prostate-specific antigen (PSA). However, these two methods are not
highly accurate. DRE can miss as much as 25-35% of tumors and its
sensitivity is only 59%. PSA’s detection rate is only 28-35%. It is being
recommended to combine the two screening options for men above 50
years of age. For men with risk factors, screening should be started at
age 40.

9. Skin Cancer

As of now, there’s not enough evidence to recommend a routine

screening that can detect skin cancers early. However, it is important to
note that fair-skinned individuals aged 65 and older are at increased
risk for melanoma. Having atypical moles and/or more than 50 moles
increase the risk of the person for melanoma too.
Pass The Word

How can you help stop cancer from taking away people’s lives? Take
these screening guidelines to heart and spread awareness about early