Cancer: Overview

 Uncontrolled cell growth

 Most common cause of death – Heart disease but 50% of deaths occur before 65 years of age
 NED: No Evidence of Disease (vs. cure)
 HCP prefer “NED” rather than cure
 More positive term
 Not usually use “cure” especially with certain type of cancer (slow-type of cancer, such as prostate) because
there could be tumor cells, small numbers that non detectable to any technology that we have.
 Fear
 Cancer is detected late and it doesn’t have a good prognosis. Keep a psychosocial mind especially with the
stigma around it.

2 Major Dysfunctions in the Process of Cancer: Cells go through different phases of reproduction

1. Defect in Cellular Proliferation

• Normal: Equilibrium with cell death and cell growth (die/born of cells)
• In cancer cells, we have a disequilibrium:
 Loss of contact inhibition
 Normally when a normal cell comes in contact with another cell, its growth /spread is
inhibited.
 With cancer cells, they have a loss of contact inhibition. A cancer cells come on top of another
cells and invade or spread the growth of cancer cells.
 Cell growth rate
 Misconception: Cancer cells grow at a faster rate than normal cells = THIS IS NOT TRUE.
Cancer cells and normal cells grow at the same rate. But SOME CELLS grow at a
different rate, for example: Hair, GI cells (fastest growing cells in the body)
 Cancer cells reproduce at the same rate as those cells from which they arise, but they
divide haphazardly (or inconsistent) and continuously. Normally, we have the cells that
divide and have two cells. A cancer cell may divide and may produce 3-4 cells.

2. Defect in Cellular Differentiation

• Normal: orderly pattern – we have cells that mature in orderly fashion. From the state of immaturity to
maturity.
a) Immaturity
b) Maturity
• Mature cells perform 1 function: FUNCTION ONLY AS at which they arise
• Ex: Stomach cell cannot function as a lung cell
• Proto oncogenes:
• Regulate normal cells
• Helps to keep cells in a state of maturity (where they should be) and continue to function
• Oncogenes:
• Tumor-inducing genes caused by mutations
• Caused tumors to arise
• Tumor-suppressor genes:
• Function to regulate cell growth
• Suppress growth of tumors
• But Mutations cause them to become inactive (INEFFECTIVE)à loss of suppression of tumor
growth
• Makes an individual more susceptible to the development of TUMOR GROWTH if there are
mutations in the tumor suppressor genes.
• Benign Cells: Well-differentiated
 In a Mature state we are able to identify cells and differentiate from other cells.
• Malignant Cells:
• Well & poorly differentiated (Can’t tell where the cells came from or origin)
• Less adhesive (Cells don’t stick together and contribute to metastasis)
• Invade and metastasize

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 • Not encapsulated (Not contained, their borders are usually irregular; allows them more easy access to
spread/invade and promotes metastasis.
• Unable to perform normal functions of specialized tissue (If an individual has liver cancer, tumor in
liver, liver cells cannot functioning like normal liver cells)

Cancer Development
 Usually multifactoral
 Carcinogen: an agent capable of producing alterations that change the genetic structure of the cell

1. Initiation: Carcinogen Exposure

Chemical Carcinogens
1) Cigarette smoke
2) Asbestos
3) Uranium
4) Nitrates
5) Hydrocarbons
6) Estrogen
7) Dietary factors (high fat diet has been link to CA)
Physical Carcinogens
1) Ionizing radiation (radiation from autonomic bomb)
2) Ultraviolet radiation
3) Foreign bodies
4) Viruses (HBV has been link to liver CA)
Not everyone who is exposed carcinogen will end up with cancer.
1 -Carcinogens can be:
• Detoxified
• Harmlessly excreted
2 - Cells damaged by carcinogens may:
• Self-repair
• Die
• Replicate into daughter cells with same genetic alteration

Gene Susceptibility (see BREAST CANCER lecture)

• Area of intense research
• Identification of cancer-related genes: increase susceptibility to development of certain cancers
• Ex: BRCA-1 or BRCA-2: 50-85% risk of developing breast cancer
2. Promotion
• 2nd stage in cancer development
• At least 2 genetic alterations per cell must occur to cause cancer
• Promoting agents chance of cancer
• Activity of promoting agents is reversible
• Promotion Agents (these agents are eliminated, risk of cancer formation decreases)
1) Cigarette smoking
2) Dietary fat intake
3) Alcohol consumption
4) Obesity
5) Severe stress
Provide patient education
Key concept in Cancer Prevention

3. Progression
• 3rd stage in cancer development
• Increased growth rate of the tumor
• Increase in invasiveness of tumor; metastasis
• Irreversible stage

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Tumor Metastasis
• Spreading of tumor to distant sites
• Tumor angiogenesis: development of blood supply within tumor
• Angiogenesis is where the blood supply developed within the tumor where they get its nutrients and nourishments to
grow.
• Other ways they Can occur:
• Vascular- penetration of blood vessels
• Lymphatic- cancer cells break free from tissue & invade lymph vessel
• Implantation-cancer cells embedded along surfaces of body organs
 Seen with patient going to surgery and have a tumor removed. Sometimes there might be some tumor
cells in some instruments and can be embedded along the surfaces of body organs inadvertently
Role of the Immune System
• Oncofetal Antigens:
• Tumor antigen found in cancer cells and fetal cells
• Represent a shift of cancer cells to immature metabolic pathway, like fetal cells
• Used to diagnosis success of treatment or recurrence of cancer
• Blood tests (draw blood level). We would NOT expect high levels in an adult person but we would expect to
see them in a FETAL cells. This blood cells represent being at an immature state. Cancer cells are not able to
stay in a mature state.
1) CEA (Carcinoembryonic Antigen): colon cancer ------ The treatment is effective if we see a DROP
of CEA level. Cells are now in a mature state and function as colon cells. Can also be used or drawn
after a year or 2 to check for recurrence meaning No immature colon cells and no cancer activity.
2) AFP (Alphpafetaprotein): primary liver cancer (hepatoma) or metastatic liver growth
3) CA-125: Ovarian
4) CA-19: Pancreas, colon, breast
5) PSA: (prostate specific antigen)- prostate

Classification of Cancer
TNM Classification System (the higher the number, the worst is the cancer)
• T – Tumor T0 – T4 (has a big tumor)
 T1 tumor < 2 centimeters
 T2 tumor is between 2-5 center
 T3 tumor > 5 cm
 T4 tumor fixed already in the tumor
• N - Node N0 – N4; Nx (No lymph nodes involvement, better prognosis, cancer is more localized).
 N1 one lymph nodes involved
 N2 few more localized lymph nodes
 N3 distant lymph nodes involvement
 Nx – not able to determine the lymph node involvement for some reason
• M – Metastasis – M0 – M4 = the more advance the metastasis, the worst is prognosis

• Histologic Grading
 Grade I – cells differ slightly; well differentiated = can tell what cells they are
 Grade II – cells more abnormal; moderately differentiated = cells look different
 Grade III – cells very abnormal; poorly differentiated
 Grade IV – cells are immature; cell of origin is difficult to determine

**IMPACT OF TREATMENT FOR PATIENT HAVING GRADE IV: TREATMENT IS GIVEN BASED ON THE WHAT TYPE
OF CELLS. THIS IS ONLY EXPERIMENTAL. WE DO NOT KNOW WHICH CELL AND WHAT TREATMENT TO GIVE

7 Warning Signs of Cancer

C hange in bowel or bladder habits
A sore that does not heal
U nusual bleeding or discharge from any body orifice
T hickening of lump in breast or elsewhere
I ndigestion or difficulty swallowing
O bvious change in a wart of mole
N agging cough or hoarseness

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Diagnosis

Biopsy:
 Looks at the cells under microscope for cellular changes
 Definitive diagnosis is done through BIOPSY by someway looking at the cell
 To determine what type of cancer and the site of origin.
 Sputum specimen (lung cancer cells = pt can cough up sputum)
 Thoracentesis
• Benign vs. malignant = where it the cancer from (site of origin)
• Anatomic location of tissue = If tumor is wrapped around the main artery, it is too risky and can cause hemorrhage.
Use debulking procedure. If it’s lung cancer, will only take specimen because there are many types of lung cancer. If it’s
brain cancer – can tell by CAT scan or MRI if the tumor is malignant/benign or encapsulated/invasive. Often times can
tell how the tumor looks or spread in the brain and type of cancer… BUT THE RULE OF THUMB IS a BIOPSY:
definitively diagnose by looking at the cell at the microscope for cellular changes
• Degree of cellular differentiation = looking at the histological grading. Help determine the prognosis as well as the
treatment.

Treatment Goals
• No Evidence of Disease: free of disease and normal lifespan
• Control: for “chronic” cancers. Example chronic lymphocytic leukemia (control and slow down the growth)
• Palliation: Relief of sign and symptoms and maintaining Quality of life (QOL)
Clinical Trials for New Drugs and Treatments

o Is experimental
o Patient rights guarded by Institutional Review Boards (IRBs) in agency conducting research
o No coercion, medication or treatments are free of charge
o Can withdraw anytime
 Phase I:
o Usually drug treatment
o Tested on small group (20-80) that are enrolled
o Safe dose range and side effect identification

 Phase II:
o Larger group to further evaluate safety

 Phase III:
o Last step before the FDA approval
o Large group to confirm effectiveness
o Monitoring for side effects
Treatment: Surgery
o Surgical removal of the tumor
 Ex: Mastectomy, thyroidectomy, bowel resection for colon cancer
o Debulking procedure: Remove as much tumor as possible and can have radiation or chemotherapy often times to help
remaining tumor. Tumor not totally removed d/t wrapped around a major blood vessel or vital organs. Too risky to
totally removed the tumor surgically or it’s impossible because of its location.

Treatment: Radiation
• Causes DNA damage & cell death
• Normal cells can recover if radiation is not greater than the maximum dose
 Regulated by the government
 Figured out by skilled person
• Works best when cells are dividing (G2 or M (Mitosis phase))
1. External Beam (xray machine)
o Patient is never radioactive = the beam is directed to the patient
o In order to be radioactive, patient need to be admitting the radiation. Patient is NOT the source of radiation
o Sometimes used with internal radiation
o Needs lotion without additives
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 2. Internal / Brachytherapy
o Radioactive materials are implanted in the tumor
o Used when high doses are needed to kill the tumor cells
o Patient is radioactive = doses of radioactive are implanted in the tumor.
o Use ledge shield and private room
o Call radiation safety department if the radiation source/ribbon is on the bed. Use forceps to pick it up.
Stay in the ledge shield and put radiation in the lid bucket.
o Brachytherapy:
 Temporary – radiation source placed in catheter or tube and kept in place several days
 This catheter holds the radiation source
 Radiation source threaded into the catheter. Stay in place for 2-3 days
 Gyne tumors, head & neck tumors
 Pt in radiation precaution:
• Private room to minimize exposure to other people
 Uncomfortable: Neck: you can lay on it, you can turn one way or sticking out in their neck
Vagina: lay in bed constantly, can’t get off and walk, legs has to be spread open because these
are protruding, Foley catheter, hard to move side to side, they can’t sit, they have to lay down.
 Permanent – such as seeds planted in the prostate and left there (NOT SURGICALLY REMOVED)
because in radiation there is a half life. Everyday half of the dose of radiation is admitted and
radioactivity decreases by half so eventually there will be NO MORE radiation in the seed. Radiation
precautions for 2-3 days depending on how much radiation they have. Allowed to go home with few the
restrictions. For examples: Not to have their grandkids sit in their lap for few more days
 Prostate
o Caregiver Safety
• Time (film badge / dosimeter)
 Spend less amount of time with patient as possible
 Explain to patient that you are not avoiding but protecting yourself
 Sign up sheet outside the patient’s door, you write your name and the time you went into the
room. Put on a dosimeter (film badge) or a pen like. You hold it up to the light and it has a
line on it to read the numbers before you go into the room. For example, if it’s #27 , you put it
in the pocket and go in to provide the care to the patient , you come out of the room and you
look at light and its 29 = so then you write down 29. Radiation physiologist (safety officer)
check to make sure that the caregiver is NOT over expose to the radiation. How much
radiation the caregivers are exposed to is all regulated by the Federal government.
• Distance
 Spend less amount of time with patient as possible
 Maintain some distance between you and the patient because the closer you are to the
radiation source, the more radiation you will received.
 Stay far away from the patient and explain why
 Explain it, if you can by the door.
• Shielding
 Stay at the ledge shield (or behind) when providing care = it protects the caregiver’s
reproductive organs
 Pregnant caregivers or visitors are NOT allowed

o Side Effects of RADIATION

1. Fatigue (unknown)
2. Anorexia
3. Bone Marrow Suppression in treatment field = especially if the pt has radiation to the lung, bone
or the pelvic area where there is a lot of bone marrow, they are at more risk for bone marrow
suppression
4. Reproductive Effects
5. Skin reactions
o Dry desquamation
o Results in pruritus
o Reddened area

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 o Lubricate with lotion that contains NO metal, alcohol, perfume or additives (that
interferes with radiation). Alcohol will further dry out the skin.
o Wet desquamation
o Example: Chest that it looks wet. Skin is seeping. At risk for infection
o Results in drainage and discomfort
o Keep clean, protect from further damage, prevent infection

Protection of Irradiated Skin:

 Protect from extreme temperature: avoid hot/cold/ice packs & heating pads
 Avoid tight clothing, rubbing, harsh chemicals, deodorants
 Do not remove port markings
• Is the sharpie marker for radiation which is used to direct the beam
• It is meticulously calculated for specific area

Treatment: Chemotherapy
o Drug therapy aimed at cancer cure, control, or palliation
o Works at the cellular level
o Cell cycle non-specific: effect cells that are in cellular process of replication, proliferation and resting phases
o Cell cycle phase-specific: effect cells that are in cellular process of replication and proliferation
o Often administered in combination with one another

Cell Cycle Non-Specific

o Alkylating Agents: (act with DNA to hinder cell growth and division)
 Cyclophosphamide (Cytoxan): Given IV , PO
• SIDE EFFECTS: THROMBOCYTOPENIA AND LEUKOPENIA
• Empty bladder q 2 hrs to prevent bladder problem (cystitis). Increase fluid will dilute urine
• Risks for infection d/t bone marrow suppression. Taken 3-6 months
(Cyclophosphamide suppresses production of blood cells from the bone marrow, including white
blood cells (leukopenia), red blood cells (anemia) and platelets (thrombocytopenia). Leukopenia
reduces the ability of the body to fight infection, thrombocytopenia impairs the ability of blood to
clot, and anemia reduces the ability of blood to carry oxygen.)
• LEUKOPENIA( WBC infection)
 Avoid people who are known to be sick, has colds or pneumonia
 Avoid patient who are known to be sick
 Frequent hand washing
 Report fever 100.1 F
 Avoid crowds
 Reverse isolation if WBC below 1,000
o Don’t give fresh fruits/vegetables. Ok to cook vegetables
o Avoid flowers d/t contagious bacteria

o Anti-tumor Antibiotics: (act with RNA to make body less favorable environment for growth of cancer cells)
 Doxorubicin (Adriamycin): Given IV
• SIDE EFFECT: CARDIOTOXICITY
• Vesicant drug
• Makes urine turn red. It is expected and harmless side of the medications

o Corticosteroids: (alter endocrine environment to make less conducive to growth of cancer cells)
 Dexamethasone (Decadron): Given PO
• NOT considered specifically given for chemotherapy drugs
• Adding steroids to a chemotherapy regimen helps facilitate cancer to cell die. Alter the endocrine
environment to make those cancer cell less able to survive or reproduce
• Treatment for N/V associated with cancer chemotherapy
• SIDE EFFECTS: peptic ulceration and thromboembolism

Cell Cycle Phase-Specific

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 o Antimetabolites: (foster cancer cell death by interfering with cellualr metabolic process)
 5-Fluorouracil (5-FU): Given IV
• TOXICITY: CARDIOTOXICITY, HEMATOLOGIC AND GI
• COMMON ADVERSE EFFECTS: alopecia, cutaneous changes, photosensititiy and increased
pigmentation of the skin
• DOSE- LIMITING SIDE EFFECTS: MYELOSUPPRESSION (bone marrow) evidenced by anemia,
leucopenia and thrombocytopenia, nausea, vomiting, anorexia, diarrhea, and stomatitis
• Nadir is the period during which the maximum cytotoxic effect of the drug is exerted on the bone
marrow, causing the lowest blood cell count. A WBC nadir occurs within 10-14 days after the drug is
given; recovery is within 21 days (Ashenbrenner, 2006, p. 616).

o Plant Alkaloids: (makes body less favorable environment for growth of cancer cells)
 Vincristine (Oncovin): Given IV
• Vesicant drug
• MOST COMMON DOSE LIMITING ADVERSE EFFECTS: NERVOUS SYTEM TOXICITY
such as motor, sensory and autonomic neuropathies. S/S: loss of deep tendon reflexes, numbness and
tingling of the hands and feet, foot drop, myalgias, weakness, and jaw pain (Ashenbrenner, 2006, p.
619).

o Miscellaneous: (alter endocrine environment to make less conducive to growth of cancer cells)
 Tamoxifen (Nolvadex)
• SIDE EFFECTS: NAUSEA/VOMITING, THROMBOCYTOPENIA (risk for infection), hot
flashes (Ashenbrenner, 2006, p. 652).
• Used for Breast cancer
Routes of Administration
• Oral (pill)
• Intracavitary (pleural – chest tube, peritoneal - catheter)
• Intrathecal
o In the spinal column and ventricles of the brain– patient can have spinal tap or a lumbar puncture
o Inject the medication into the spinal column
• Intraventricular - Ommaya reservoir
o Another method into the brain
o Implant surgically an Ommaya into ventricles of the brain
o Physician can inject chemotherapy drugs directly into the ventricles to go into the brain
o Because chemo drugs do not cross the blood brain barrier so patient with primary brain cancer or brain
metastasis can receive chemotherapy drug directly to the Ommaya reservoir (site)
• Intravesical
o In the bladder by putting Foley and inject chemo into the Foley.
o Clamp the Foley and let the chemo take effect.
o Open the Foley and let the chemo drain out of the bladder.
• Intra-arterial
o IV line into the artery
o Patient with primary hepatic cancer. We can put a catheter into the hepatic artery and directly give chemo right
into that liver
• Intravenous
o Most common
o Route of choice is through Central venous access devices = because many of the IV DRUGS are vesicants
(infiltrate). When IV drugs come out of the vein (infiltrates), they cause tissue necrosis. So we want to
eliminate the risk or decrease the risk of extravasations (infiltration of the vesicants) by a central line, where
there is less infiltration than with the peripheral line.
o IV push
o IV drip
o Peripheral IV line and it infiltrates of the vesicant drug (DOPAMINE )
o Chemotherapy drugs are notorious for being vesicant (complication of IV chemotherapy:
Extravasation)

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Treatment Plan:
o Combination therapy- effectively kills cancer cells and allows normal cells to repair and proliferate
o Nadirs occur at different time intervals (lowest level of WBC & RBC)
 Lowest level of WBC and RBC
 Myelosuppression (bone marrow suppression) common side effects of the drugs
 Make sure all of the NADIRS of these drugs do not reach at the same time because it could lower their blood
cell count (bottom out).
 DO NOT GIVE THE DRUGS ALL AT ONCE
 If the protocols call for all the drugs to be given on day 1, then IV drips on day 2. Make sure that those drugs
have different nadirs.
 Always make sure that their WBC, RBC and platelet count are OK
 More critical and most threatening to monitor prior to therapy: WHITE BLOOD CELL because most
patient die from infection during the treatment. They are susceptible to infection.
 If WBC is below 1,000, HOLD THEIR CHEMOTHERAPY or else their dose are decreased. Notify the
physician/ pharmacist adjusts the dose.
o Dose calculated based on body weight or BSA

MOPP Protocol
o M nitrogen Mustard
o O Oncovin
o P Procarbazine
o P Prednisone
Safe Handling Precautions
o During preparation and administration (Aschenbreener, 2006, p. 610)
o Avoid inhalation and direct contact with skin: cutaneous reactions may occur
o Chemotherapy Spill Kit
o OSHA & ONS guidelines

Side Effects of CHEMOTHERAPY:

1. Nausea/vomiting:
a) (IV Zofran) – treat/prevent nausea and vomiting
b) (IV or Oral) Reglan – increases GI motility or relieve symptoms of diabetic gastroporesis
c) Small frequent feedings especially right before their treatment
d) Give antiemetics: 4-6 hrs before their treatment and hold their food/fluid 46 hours before their treatment
e) Can cause by dehydration and electrolyte imbalance, weight loss and metabolic alkalosis

2. Alopecia:
a) Temporary hair loss
b) Grows back before the chemo cycles are compeletely done. It comes back in different texture.
c) Hair falls out in clomp. Use wig
d) Can start using wig before hair starts receding

3. Stomatitis/Mucositis:
a) Cells in the GI tract reproduce more quickly
b) Sores in the mouth
c) Can extend to the esophagus
d) Painful and uncomfortable
e) Don’t want to eat because it hurts
f) Give Viscous Xylocaine
o Clear thick liquid and swallow it
o It numbs those sores in the patient’s mouth
o Decrease pain and help them to be able to eat
o Nursing intervention:
 Provide oral care
 Lip care: chopstick and Vaseline
 Increase fluid r/t infection (stomatitis/mucositis)
 No alcohol base: it will dry out mouth
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  Rinse mouth: hydrogen peroxide and water
 Give popsicles
4. Hyperuricemia
a) Increase uric acid in the blood
b) Uric acid is a breakdown product of the dead cancer cells
c) Give Allupurinol ( use for GOUT also)
d) Increase fluid for this drug to avoid crystal formation in the urine

5. Myelosuppression (bone activity is reduced resulting in fewer RBC, WBC and platelet)
a) Bone marrow suppression
b) Signs and symptoms:
• Fatigue
• Anemia
• SOB (↓ oxygen that carry RBC),
• Encourage rest periods d/t fatigue.
• Monitor hemoglobin and hematocrit

6. Risk for infection

a) Neutropenic Precautions/Reverse Isolation
• Put patient in private room so patient can be protected against any bugs (colds) that we are giving to
them
• RN comes in gowns, gloves and mask
• Patient has bone marrow suppression. Patient doesn’t have much defenses

b) Neupogen (Filgrastim):
• Used to increase their neutrophil count (to increase WBC count)
• Administered by IV infusion or daily SubQ injections
• Most common adverse effects: MEDULLARY BONE PAIN
• Most serious adverse effect: NONE (Aschenbrenner, 2006, p. 577).

7. Risk for bleeding

a) Neumega
• Prevent THROMBOCYTOPENIA (decrease platelet count) in cancer patients
o Signs and symptoms of bleeding in stools, mouth/gums, nose and urine
o Excessive bruising (avoid physical contact such as football)
o Avoid shaving. Use electric razor
o Blood pressure and when we take cuff = we see Petechiae – a capillary rupture
o Avoid IM injections. Give oral tablet instead to avoid IM injection
o Signs of the brain bleeding = change of LOC. Patient can be confused d/t metastasis,
dehydration, infection
o If platelet counts drops below 50,000: We see signs of bleeding
• Most common adverse effect: weight gain r/t fluid retention (Aschenbrenner, 2006, p. 579).

b) Procrit/ Epogen
• Giving patient erythropeoitin which stimulates the red blood cell production
• Given to patient with bone marrow suppression
• Treat anemia associated with CRF to elevate or maintain the RBC level
• Common adverse effect: HYPERTENSION (Aschenbrenner, 2006, p. 571).

Treatment: Biologic Response Modifiers

o Agents that alter the response of the host to the tumor cell
• Interferons: have antiviral and antiproliferative properties
• Interleukens: activate immune system or alter the functional capacity of cancer cells; clinical trials
• Monoclonal antibodies: goal is to stimulate and immune response; clinical trials

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 Example: Remicade- used in conjunction with the traditional chemotherapy drugs as a
way to treat cancer. Side effect: high incidence of TB

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