Oncology Dead Man’s party

Biology of abnormal cells

Cancer grading and stages
Cancer statistics
Chemotherapeutic agents
Radiation treatments
Bone Marrow and Stem Cell transplants
Onco-gene therapy
 Oncology Objectives
• 1. Identify the different phases of cancer cell
replication.
• 2. Compare the features of a benign versus
malignant tumor
• 3. Recognize the TNM stage and grading system of
cancer tumors.
• 4. Discuss the role of oncogenes and suppressor genes
in cancer development.
• 5. Identify behaviors with corresponding primary
and secondary nursing prevention for risks of cancer
development
• 6. Recognize the different classes of chemotherapies.
• 7. Create appropriate nursing interventions for a case
study of a patient with cancer.
 Oncology Objectives
• 8. Identify appropriate testing for cancer patients.
• 9. Recognize signs and symptoms of chemotherapy side
effects.
• 10. Recognize signs and symptoms of radiation therapy.
• 11. Prioritize nursing interventions for a patient with
neutropenia.
• 12. Prioritize nursing interventions for a patient with
thrombocytopenia.
• 13. Prioritize nursing interventions for a patient receiving
bone marrow or stem cell transplant.
 Oncology Objectives
• 14. List 4 risk factors for the development of
leukemia.
• 15.Compare Leukemia and Lymphoma
pathophysiology, etiology and clinical manifestations.
 Cellular Review

• Evolve 3D Cellular Differentiation on web

site
 Oncology
• Biology of abnormal cancer cells
• They have continuous or inappropriate, usually
faster growth or larger growth patterns
• They have no specific morphology and often do
not resemble their parent cells = anaplastic
• They do not respond to signals for apoptosis =
programmed cell death
 Oncology
• Biology of abnormal cancer cells
• Have a large nuclear – cytoplasmic ratio; the
nucleus may occupy most of the cell area
• They lose some or all of their normal cell
functions
• They do not make fibronectin, and thus cannot
connect easily and break off easily
 Oncology
• Biology of abnormal cancer cells
• They are able to migrate throughout the body =
metastasis
• They invade other tissues and types of cells.
• They are not controlled by contact
• They have more or less chromosomes than the
parent cells = aneuploid
or a mutation of the genes
 Oncology
• Cancer development
• Initiation – there are many theories as to
when the genes in the cells are damaged,
maybe in utero, from physical or chemical
exposure, latent oncogenes, viruses, or a
lack of suppressor genes from our parents,
and at this point the cell is not dividing.
 Oncology
• Skin cells
 Oncology
• Cancer development
• Promotion - the stage when the abnormal
cell starts to divide, may be stimulated by
environmental changes, hormones, drugs, or
irritants
 Oncology
• Cancer development
• Progression – the phase when the abnormal
cells have continued to grow into a Primary
tumor, may produce angiogenesis factors
which supply blood and vascular
nourishment to the tumor. The tumor may
have subcolonies of cells with different
genes and features
 Oncology
• Cancer development
• Metastasis
the movement of cancer cells into other
organs of the body, thus creating new tumor
sites.
 Oncology
• Cancer grading and staging
• Cancer is graded upon the resemblance to normal cells
= G
(The higher the number, the worse the grade of cancer) i.e. G1,
G2, G3, G4

• Staging is based upon

• the presence of a primary tumor = T
• involvement in lymph nodes = N
• and appearance of metastasis = M
• Numbers of the stage range from
x = none to 3 or 4 for each letter
 Oncology
• Is this a high grade or low grade cancer?
• Case study
Julie has a breast lump in her right breast, and
has also found one in her right armpit. Biopsy
and lumpectomy were performed. The tumor
was graded G3, T2, N2, M1.
 Is this a high grade or low grade
cancer?
1. High
2. Low

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 Oncology
• Julie opted to have a lymphectomy of her
right arm lymph nodes, and started radiation
treatment right away. Her doctor also
suggested that she start Adriamycin IV
chemotherapy to get any cells that the
radiation might miss.
 Oncology
• Cancer Risks
• #1 = advancing age
• #2 = smoking tobacco
• Hormones – Prempro caused a substantial increase
in breast cancer on the HERS trial
• Genetic inheritance of oncogenes and autoimmune
diseases
• Environmental exposure
• Excessive intake of dietary fats
 Oncology
• Cancer risks
• High alcohol consumption
• Low dietary vegetables and fiber (sources
of antioxidants)
• Previous Viral infections:
Hepatitis B or C
Herpes viruses
Papilloma viruses (HPV)
Retrovirus HTLV –I
 Oncology
• Types of cancer cells are named for their site of
origin:
• Adenocarcinoma
• Carcinoma in situ (CIS)
• Squamous
• Basal cell
• Astrocytomas
• Melanomas
• Sarcomas
• Lymphomas
 Oncology
• Symptoms of Cancer
• Cachexia – weight loss,unexplained
• Anorexia
• Anemia
• Impaired immune response
• Pain – when the cancer is large enough to
compress nerves or organs
• Lymphadema – when the tumor blocks lymph or
circulatory flow
• Motor or sensory deficits
 Oncology
• The 60 year old client with small cell lung cancer is concerned that
his grown children also might develop the disease. What is the
nurses best response?
– A. “This disease is a random event
and there is no way to prevent it.”
– B. “Because this disease is inherited as a
dominant trait, your children have a 50% risk
for developing it.”
– C. “Cigarette smoking is the main cause of this
disease, and helping your children not to
smoke will decrease their risk.”
– D. “ Lung cancer can be avoided by decreasing
dietary intake of fats and increasing the
amount of regular aerobic exercise.”
 Oncology
• Cancer statistics
• The top four cancers found in the United
States are:
• Lung
• Breast
C
• Prostate
• Colorectal
 Oncology
• Cancer statistics
• Prostate cancer is the most common site of
cancer and the 2nd most common cause of
cancer death in the United States
• The first cause of death in males is Lung
Cancer
Oncology
 Oncology
• Cancer statistics
• Lung cancer has annual
new cases (incidence)
of 173,770 people
per year: 93,110 males and
80,660 females
• Annual mortality: 160,440 per year
consisting of 92,000 males and
68,510 females
 Oncology
• Cancer statistics
• 28% of all cancer deaths are due to lung cancer

• This is the leading cause of cancer death in

both men and women

• There are more deaths from lung cancer than

prostate, breast, and colorectal cancers
combined
 Oncology
• Cancer statistics
• Risks for lung cancer:
• Smoking (75-80% of cases)
• Occupational exposure
• Nutrition/Diet
• Genetic factors
 Oncology
• Cancer statistics

• Prostate cancer is number two cause of cancer in

men

• Breast Cancer is number two cause of cancer in

women

• Most common non-malignant or non-fatal cancer

is non-melanoma type skin cancers
 Oncology
• The client says that she has heard that the origin of most
cancers is “genetic”. What is the nurse’s best response?
– A. “The development of most cancers is
predetermined and not affected by
environmental factors.”
– B. “Cancers arise in cells that have been
damaged,which may be in the genes”.
– C. “ The majority of cancers are inherited”
– D. “Cancer is more common among males than
females.”
 Oncology
• Lab tests for cancer
• Ultrasounds to determine size
• CT scan with contrast– the golden standard
• Genetic markers – BRCA 1 and BRCA 2
• Tumor markers:
CEA – general carcinogenic antigen
PSA – prostate antigen
CA-125 – ovarian
CA-25,27 – breast
HER 2 NEU – breast tissue needed
 Oncology
• Lab tests for cancer
• Liver function tests
• CBC with diff
• Renal function tests
• PET scan – looks for metastasis using a
radioactive glucose solution
• PT, PTT, Fibrinogen, Fibrin levels
 Oncology
• Lab tests for cancer
• Pathology slide of tumor:
(Should be kept for a period of years)

• Determines type of tumor

• Source of tumor
• Aggression of tumor – whether fast growing,
differentiated, or non-differentiated
• Used to determine tumor growth factors and
susceptibility to certain chemotherapies
 Oncology
• Chemotherapy
• Prevention chemotherapy – for high risk
patients, precancerous lesions, or history of
cancer
• Antioxidants, vitamins
• Aldara cream 3x weekly for precancerous
skin lesions
• Aspirin
• Protease inhibitors
 Oncology
• Chemotherapy - typically started after
surgical dissection of tumor, unless the tumor is
non-operative
• Usually given by a long term venous access
device, i.e. PICC line, implanted ports, or direct
catheratization to the tumor.
• Chemotherapy is usually potent and horribly
scarring on normal veins
 Oncology
• Chemotherapy
• Biochemotherapy – used as in-patient or outpatient
settings for cancer, MS, and viral treatments:

Alpha interferon – (IFN)- Alpha 2a,

Roferon, Intron-A-
used for leukemias, AIDS, Hep-C
Beta interferon – Beta 1b
– used for renal carcinoma, melanoma,
AIDS, MS, Hepatitis A, B
 Oncology
• Chemotherapy/Biochemotherapy
• Interleukin I (IL-1)
• Interleukin 2 (IL-2), Proleukin– stimulates
growth of T-cells and NK cytotoxic cells
• – used investigationally for melanoma in Stage II
to Stage IV cases on a monthly basis with a 80%
non-recurrence rate
 Oncology
• Chemotherapy/Biochemotherapy
• Tumor necrosis factor (TNF) – selectively
targets abnormal cells, in nature is produced by
NK cells
 Oncology
• Chemotherapy/Biochemotherapy
• Vaccines
HPV vaccine for cervical cancer
Melanoma vaccine - for stage II only at this time,
or malignant melanoma
 Oncology
• Chemotherapy/Biochemotherapy Monoclonal
antibodies – used for treatment of cancer,
rheumatoid arthritis, transplants, and other
autoimmune diseases. Can be used to stimulate
immune response or suppress it.
Rituximab – Treatment of CD20 –positive non-
Hodgkins B-cell lymphoma
Gentuzumab – treatment of CD33 positive AML
in first relapse in patients who are not candidates
for reg. chemo.
 Oncology
• Chemotherapy/Biochemotherapy Monoclonal
antibodies
• Adalimumab – Humira
–new treatment for severe rheumatoid arthritis,
given s.q every other week
• Alemtuzumab – Campath
- treatment of B-cell lymphoma who have failed
traditional chemotherapy with fludarabine
• Basilixamab – Simulect
- immunosuppressive monoclonal antibody for
renal transplants
 Oncology
• Chemotherapy – Alkylating agents
• Bisulfan oral
• Carboplatin (CBDCA) IV
• Chlorambucil (leukeran) oral
• Cisplatin IV
• Cyclophosphamide(Cytoxan) IV or PO
• Melphalan (Alkeran) oral
• Ifosfamide IV
• Thiotepa IV or PO
 Oncology
• Chemotherapy/ Antibiotics
given IV as chemotherapy
• Adriamycin (Doxirubicin)
• Bleomycin
• Dactinomycin
• Daunorubicin (actinomycin D)
• Idarubicin (idomycin)
• Mitomycin C
• Mithramycin
 Oncology
• Chemotherapy – anti-metabolites
• Cytorubine (Cytosar) IV
• Floxuridine (FUDR) IA or SQ
• Flourourcil (5FU) IV
• Fludara IV
• Hydroxyurea PO or IV
• Methotrexate IV or IM
• 6MP PO
• IRESSA PO
• Xeloda PO
 Oncology
• Chemotherapy- Hormones
• Progestins – uterine cancer
• Estrogens
• Testosterone - myelodysplasias
• Anti-hormones – block hormonal activity in
hormone sensitive cancers:
• Leupron
• Eulexin
• Tamoxifen/Nolvadex
• Arimedex/Arista
 Oncology
• Chemotherapy – Plant alkaloids
• Vinblastine (Velban) IV
• Vincristine (Oncovin) IV
• Vindesine IV
• Eldisine IV

• The first doses of this are usually given in a

hospital setting, are vesicants, and neurotoxic.
Nurses must wear protective gear!
 Which of the following are appropriate protective gear
for the nurse when hanging chemotherapy?
1. Splash goggles
2. Latex gloves
3. Rubber gloves
4. Paper gown
5. Special biohazard
bags for disposal
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 Oncology
• Chemotherapy –Antimitotics
• Dacarbazine (DTIC – Dome) IV
• Leukovorin PO or IV
• Paclitaxol (Taxol) IV
• Topotecan IV
• Gemzar IV
• Docetaxol IV
• Camptothecan (CPT-11) IV
• Taxotere (Ormaplatin) IV
 Oncology
• Side effects of Chemotherapy
• Alopecia
• Fatigue
• Anemia
• Leukopenia
• Thrombocytopenia
• Always – Nausea,Vomiting, Diarrhea
• Neurotoxicity & neuropathies
• Capillary leakage
• Headaches
• Fluid and electrolyte imbalances
 Oncology
• Side effects of Chemotherapy
• Anorexia – change in taste buds
• Back aches
• Joint aches
• Blood clots
• Oral mucositis – (reduced significantly by L-
glutamine amino acids orally)
• Supra opportunistic infections
• Septic DIC
• Tumor lysis syndrome
• Edema or pulmonary edema
 Oncology
• Chemotherapy Nursing Interventions
• Evaluate and assess sites of chronic chemotherapy,
ports, veins, skin area
• Accurate I & O’s
• Monitor for fluid overload or dehydration
• Monitor lab electrolytes before and after infusion
• Monitor BUN and Creatinine
• Monitor CBC with differential during the time of
Nadir
• Monitor PT, PTT
 Oncology
• Cancer Nursing Interventions
• Nutritional assessment and weights
• Dentition – oral checks
• Monitor for signs of suprainfection, low grade
temperatures, rash, etc…
• Vital signs before, during, and after treatments
• Assess bowel status
• Assess pain level
 Oncology
• Cancer Nursing Interventions
• Educate patients and family members:
• side effects of treatments, meds
• care of port and IV sites
• oral hygiene
• symptoms to report, i.e. shortness of breath or signs
of infection
• Increase fluid intake, suck on hard candies to reduce
chemotherapy metallic tastes
 Oncology
• Nursing Diagnoses
• Disturbance in self esteem, body image
• Altered nutrition, less than body requirements
• Risk for fluid volume excess or deficit
• Impaired skin integrity
• Pain, chronic
• Decreased cardiac output
• Self-care deficit
• Sexual dysfunction
 Oncology
• Nursing Diagnoses
• Alteration in tissue perfusion
• Knowledge deficit
• Risk for injury
• Impaired physical mobility
• Sensory perception alterations
• Alterations in bowel patterns
• Alterations in mucous membranes
• Anxiety and Fear
 Oncology
• Nursing Diagnoses
• Depression
• Grief
• Respiratory compromise
• Ineffective coping
• Spiritual distress
• Impaired social interactions
• Sleep pattern disturbance
• Altered family roles
 Oncology
• Pharmacological interventions
• Megace, Marinol – for appetite stimulation
• Premedications for nausea, vomiting, edema,
headaches: usually on the protocol for chemo
Antiemetics;
Zofran – 24 hour control
Tigan, Kytril, ativan, anzamet, Compazine,
benadryl, reglan
Corticosteroids
 Oncology
• Pharmacological interventions
• Analgesics
• IV electrolytes and fluid replacement
• Stool softeners to counteract constipation from
opioids
• GSF for WBC’s
• Epogen/Procrit for anemia
• Leukine/Prokine for leukopenia
• Neupogen for neutrophilia
• Neumega for thrombocytopenia
• Diuretics for edema
 Oncology
• Non-Pharmacological interventions
– Massage
– Reflexology
– Accupuncture
– Musical therapy
– Prayer
– Meditation
– Diversional acitivities
– Dietary counselling
 Oncology
• Radiation therapy
• All types of cells are injured or destroyed
by concentrated radiation. Rapidly dividing
cells are the most sensitive.
 Oncology
• Radiation therapy
• Types :
Gamma knife
Local beam treatment
Local seeding
ARC – stereotactic
Radioimmunotherapy
Fractionation
Total body irradiation
Particle beam therapy, i.e. proton
or neutron therapy
 Oncology
• Radiation therapy side effects
• Side effects depend on the amount and area
being irradiated
• Fatigue
• Nausea and vomiting
• Mild anemia
• Leukopenia
• Diarrhea
• Pain
 Oncology
• Radiation therapy side effects:
• Erythema/burns
• Fatigue
• Pneumonitis
• Esophagitis
• Dysphasia

• (Please educate your patients on

these as doctors are notoriously
bad at pre-educating their patients).
What side effects of radiation therapy would you expect to
see in a 48-year-old woman with breast cancer?

1. Debilitating fatigue
2. Mucositis
3. hair loss
4. nausea and
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2. Anemia
3. Skin care
4. Diet
5. All of the above
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 Oncology
• Nursing interventions for radiation TX
• Assess incidence and severity of side effects
• Maximize radiation protection, all wastes will be
radioactive if isotopes are injected
• Shielding for staff
 Oncology
• Malignant Lymphomas – 2 types
• Hodgkin's Lymphoma – most common cancer in
10 to 20 year olds (young adults). Associated with
an inflammatory process related to +EBV/mono
infection.
• Diagnosis: Classic Reed-Steinberg cell with two
mirrored nuclei, CT scan
• Symptoms: Extreme fatigue, enlarged lymph nodes
that are painless. May progress to weight loss
fevers, night sweats
 Oncology
• Malignant Lymphomas – 2 types
• Hodgkin's Lymphoma
• Treatment – combined radiation and
chemotherapy, stem cell transplants if
resistant type or recurring
• 85% curable
• (90% in some institutions)
 Oncology
• Malignant Lymphomas – 2 types
• Non-Hodgkins Lymphoma – 3 times more
common than Hodgkin’s lymphoma, can either be
T-cell lymphomas, or B-cell lymphomas
• Can be low grade or high grade disease. B-cell
lymphomas = 50% and usually are more aggressive
tumors. Since they grow faster, they are also more
sensitive to radiation and chemotherapy
 Oncology
• Malignant Lymphomas – 2 types
• Non-Hodgkins Lymphoma
• Diagnosis: bone marrow biopsy, CT scan,
lymphoma panel with CD markers
• Symptoms- adenopathy, spleenomegaly with vague
abdominal pain, back pain, and since immunity B or
T-cell function is affected- the patient is more prone
to infections. Subcutaneous T-cell lymphoma is a
classic discoid rash on the upper body and trunk
that does not respond to steroids or creams.
• NHL can progress rapidly to leukemia if untreated.
 Oncology
• Malignant Lymphomas – 2 types
• Non-Hodgkins Lymphoma
• Treatments: Monoclonal antibodies,
chemotherapy with Fludara/Fludarabine,
radiation therapy, and bone marrow implants
 Oncology
• Leukemia– hematopoeitic cancer of the
stem cells. These stem cells proliferate into
non-functional immature white cells.
• More children get leukemia than any other
type of cancer and it is the #1 cause of
death in children.
• Anyone can get leukemia at any age.
 Oncology
• Leukemia -4 types

• Acute lymphoblastic leukemia (ALL)

• Acute myelogenous leukemia (AML)
• Chronic Lymphocytic leukemia (CLL)
• Chronic myelogenous leukemia (CML)
• Anagram – ALL AniMals are CLearLy
CaMeLs
 Oncology
• Leukemia –ALL suspected cause is a T-cell virus
(HTLV-1) – 85% is seen in children, 25% in
adults 30-to-40 y.o.

• Diagnosis: peripheral blood smear after

abnormally high white count, bone marrow biopsy
shows lymphoblasts >50%m may have decrease in
platelets. Lumbar puncture to determine CSF
involvement
 Oncology
• Leukemia –ALL
• Symptoms – fatigue, anorexia, malaise, weight
loss, bleeding, infections, headaches, adenopathy,
spleenomegaly, gingival hypertrophy,
hepatomegaly, bone or joint pain
• Treatment: complete response is a bone marrow
aspirate with < 5% blasts. Chemotherapy –
vincristine, prednisone, danorubicin, methotrexate,
• Maintenance therapy – 6 weeks of
• 6-mercaptopurine and methotrexate low dose
therapy
 Oncology
• Leukemia – AML – more common in patient’s
with chromosomal genetic disorders, exposure to
benzene or radiation. Use of alkylating agents for
breast, ovarian, or myeloma are associated with a
later malignancy of this type.
• Symptoms- are like ALL with the additions of
anemia, thrombocytopenia, visual disturbances,
epistaxis (nosebleeds), headache with vomiting,
dysphagia, papilladema, menorrhagia (lots more
bleeding problems)
 Oncology
• Leukemia – AML
• Diagnosis: peripheral blood smear shows
Auer bodies (rods), platelets less than
20,000/mm3,
bone marrow biopsy
• Prognosis – poor prognosis if patient has
already received radiation or chemotherapy,
or has a WBC >100,000
 Oncology
• Leukemia – AML
• Treatment: Cytaribine chemotherapy in
combination therapy with Danorubicin or
doxirubicin, works 65% of the time.
• Bone marrow transplant or stem cell
transplant.
 Oncology
• Leukemia – CLL – staged 0-5
• chronic diseases have more mature cells, majority
of CLL is B-cell proliferation – 95%. Only 5%
are T-cells, more common in people with
autoimmune diseases, i.e. SJogren’s, SLE,
hemolytic anemia
• Symptoms: skin and respiratory infections,
fatigue, thrombocytopenia, anemia,
spleenomegaly
 Oncology
• Leukemia – CLL
• Diagnosis- peripheral blood smear, bone
marrow biopsy
• Treatments: Gleevac – drug of choice;
chemotherapy in combinations,
spleenectomy, radiation therapy to spleen,
bone marrow transplant, stem cell
transplants
 Oncology
• Leukemia – CML (last is the CaMeL)
- More common after radiation exposure, benzene
exposure, less common than the other types of
leukemia, and occurs most often between 50-60 y.o.
• Diagnosis: hallmark is the presence of the
Philadelphia Chromosome, Chromosome #22 is
missing part of the long arm which is translocated to
Chromosome #9. This is present in 95% of those
patients with CML.
• WBC >100,000 with proliferation of all types of
mature and immature white cells.
• Bone marrow biopsy
 Oncology
Leukemia – CML
• Symptoms: same as other leukemias with chronic
fever, sternal tenderness and dyspnea – usually
due to severe anemias
• Treatments: chemotherapy with Bisulfan and
hydroxurea, other combination chemos,
• Interferon alpha 2b to suppress the expression of
the Philadelphia chromosome.
• Bone marrow transplant or stem cells
 Oncology
• Bone marrow and stem cell implants
New treatments for:
Acute myelogenous leukemias (AML)
Acute lymphoblastic leukemias (ALL)
Myelodysplasia syndromes (MDS)
Chronic myelogenous leukemias that do not respond to
chemotherapy (CML)
Blast crisis
Pediatric acute leukemias
Non-Hodgkins lymphoma
Large B-Cell lymphoma
Multiple myelomas
Bone marrow and stem cell implants
 Oncology
• Bone marrow and stem cell implants
• Procedure= multiple punctures
• Marrow acquisition from donor or when patient
is in remission, or stem cells from umbilical
blood of a matching sibling or family member
• Marrow is filtered to purge tumor cells, fat and
bone particles, then place in a blood bag for
cryopreservation.
 Oncology
• Bone marrow and stem cell implants
Preparing Recipient:
• Marrow recipient is given high dose chemotherapy
alone or in combination with radiation to suppress
immune system, open spaces in the marrow, and
kill remaining cancer cells.
• Bone marrow is thawed and infused through a
central venous catheter
 Oncology
• Bone marrow and stem cell implants
Preparing Recipient:
• Stem cells are infused after thawing
• Post-procedure:
• Patient is supported through the period of aplasia,
10 to 30 days, while in reverse isolation and on
graft immunosuppressants,
• Observed for signs of Graft-versus-host disease
and/or infection
 Oncology
• The waves of the future:
• Stem Cell Research
• Oncogene therapy – now that cancer cells are
being genetically tagged, we can tell which growth
factors are present, and which enzymes turn off
the gene. Soon all gene markers will have a pill
that matches the enzyme, i.e. IRESSA is a
tyramine kinase inhibitor, and stops the tumors
growth that use tyramine kinase
 Oncology
• Stem Cell Induction – there are new drugs out
for stem cell induction to immunosuppress the
patient, even in deadly cancers, i.e. Multiple
Myeloma. Recently, the combination of
lenalidomide(Revalamid), bortezomib
(Velcade) and dexamethasone produced a
98% response rate in patients
 Oncology
• The waves of the future:
• Cancer vaccines
• Oncology is the science of cancer and
treatment of all cancer patients. It is one of
the most demanding and rewarding fields in
medicine.
• The future is open for a cure.
Oncology