CELLULAR ABERRATION Cancer

Case Report
Five weeks ago AZ, a 42 y.o. white woman, who does regular SBE, noted a nontender left breast nodule about the size of a marble. She tracked it through one menstrual cycle to see if it would resolve, but it did not. She is G2P2 with first pregnancy at 35. Has regular menses with LMP two weeks ago. No h/o breast problems or symptoms. At age 75 her maternal grandmother was diagnosed with breast cancer. No other family h/o breast cancer or ovarian cancer.

What is it?

CANCER
It is a term used for diseases in which abnormal cells divide without control and are able to invade other tissues. Cancer cells can spread to other parts of the body through the blood and lymph systems.

Review: On Normal Cells

1. Have limited cell division (mitosis) Reason for cell Division:  To develop normal tissue  To replace lost or damaged normal tissue 2. Undergo Apoptosis normal cell have finite life span. With each round of cell division, the telomeric DNA at the ends of the chromosomes shorten  When this DNA is gone, the cell responds to signals for programmed cell death apoptosis  The purpose of apoptosis is to ensure each organ has adequate number of cells at their functional peak

Review: On Normal Cells

3. Show specific morphology - Each normal cell has a distinct and recognizable appearance, size, and shape 4. Have a small Nuclear-cytoplasmic ratio - The size of normal cell nucleus is small compared with the size of the rest of the cell

Review: On Normal Cells

5. Perform specific differentiated Functions - Every normal cell has at least one special function: Eg. Skincells makes keratin; liver cells makes bile; cardiac muscle to contract; nerve cell conduct impulses; RBC make Hb to carry O2 6. Adhere tightly together - - normal cells make proteins (Fibronectin) that protrude from the cell surface, allowing cells to binds closely and tightly together except RBC and WBC no fibronectin

Review: On Normal Cells

7. Are non migratory - Since they bound together, they do not wander from one tissue into the next 8. Grow in an orderly manner and well regulated - Normal cell wont divide unless body condition are optimal for cell division 9. Are contact are inhibited 10. Are Euploid have 23 pairs of chromosomes

Normal Growth
To illustrate what is meant by normal growth control, consider the skin. The thin outermost layer of normal skin, called the epidermis, is roughly a dozen cells thick. Cells in the bottom row of this layer, called the basal layer, divide just fast enough to replenish cells that are continually being shed from the surface of the skin. Each time one of these basal cells divides, it produces two cells. One remains in the basal layer and retains the capacity to divide. The other migrates out of the basal layer and loses the capacity to divide. The number of dividing cells in the basal layer, therefore, stays the same.

Back to CANCER: What is it?

A large group of diseases characterized by: Uncontrolled growth and spread of abnormal cells Proliferation (rapid reproduction by cell division) Metastasis (spread or transfer of cancer cells from one organ or part to another not directly connected)

Cancerous Growth
During the development of skin cancer, the normal balance between cell division and cell loss is disrupted. The basal cells now divide faster than is needed to replenish the cells being shed from the surface of the skin. Each time one of these basal cells divides, the two newly formed cells will often retain the capacity to divide, thereby leading to an increase in the total number of dividing cells.

Angiogenesis
The metastatic cascade begins and ends with angiogenesis. It is the ability of cancer cells to secretes substances that stimulate blood vessel growth I. Inability of the immune system to recognize cancer cell 2 critical components of the Immune Response: 1. The ability to recognize a pathogen as foreign 2. The ability to mount a response to eliminate the pathogens

Angiogenesis
II. Failure of Immune Defense Apoptosis- falling off Two pathways to Cell death: 1. Necrosis cell death resulting from injury 2. Apoptosis cellular suicide results in cells rapidly shrinking with loss of their intercellular contents

Tumors (Neoplasms)
This gradual increase in the number of dividing cells creates a growing mass of tissue called a "tumor" or "neoplasm." If the rate of cell division is relatively rapid, and no "suicide" signals are in place to trigger cell death, the tumor will grow quickly in size; if the cells divide more slowly, tumor growth will be slower. But regardless of the growth rate, tumors ultimately increase in size because new cells are being produced in greater numbers than needed. As more and more of these dividing cells accumulate, the normal organization of the tissue gradually becomes disrupted.

CANCER CELL INVADE SURROUNDING TIssues and blood vessels

CANCER cells are transported by the circulatory system to distant sites Cancer cells reinvade and grow at new location

Cancer Staging and Grading

Stage Stage I-small cancer cell found only in the organ where it started Stage II -larger cancer cell that may or may not have spread to the lymph nodes Stage III -larger cancer cell that is also in the lymph nodes Stage IV -The cancer has spread to another organ(s).

Cancer Staging and Grading

Grade G1-Well-differentiated (Low grade) G2-Moderately differentiated (Intermediate grade) G3-Poorly differentiated (High grade) G4-Undifferentiated (High grade)

What Causes Cancer?

Some viruses or bacteria

Some chemicals

Radiation

Heredity Diet Hormones

CANCER: What Causes it?

1. Radiation X-rays/radioactive isotopes, from sunlight, ultraviolet rays 2. Chemicals Tobacco, dyes, polycyclic hydrocarbons(truck emissions. Oil refineries), air pollution; fertilizers, weed killers; dyes; drugs - tobacco, cytotoxic drugs, hormones; food preservative

CANCER: What Causes it?

3. Physical agent: radiation; Physical irritation/trauma 4. Hormonal Agents: estrogens, Diethystilbestrol(DES) 5. Genetics and familial factors oncogene(hidden/repressed genetic code for cancer that exist in all individual) -- when exposed to carcinogens-----.changes cell structure-- become malignant; associated with familial patterns

CANCER: What Causes it?

6. Virus

CANCER: What Causes it?

7. Dietary factors

Predisposing Factors
1. Age older individual prone to cancer expose to carcinogen longer 2. Sex: women- breast cancer, uterus, cervix; men prostate, lung cancer 3. Urban vs Rural residence common in urban due to greater exposure to carcinogens

Predisposing Factors
4. Geographic distribution eg in Japan Ca in stomach, US breast 5. Occupation chemical factory worker, radiology 6. Heredity +family Hx

Predisposing Factors
7. Stress depression, grief, anger, aggression, despair = dec. immunocompetence(affect hypothalamus and pituitary gland). Immunodeficiency may spur the growth and proliferation of Ca cells 8. Precancerous lesion 9. Obesity: studies linked obesity to breast and colorectal Ca

Pathophysiology
ABNORMAL CELL FORMED BY MUTATION OF DNA

CELL GROWS AND PROLIFERATES

METASTASIS OCCURS WHEN ABN. CELLS INVADE OTHER TISSUE,THROUGH LYMPH AND BLOOD Cancer development linked to immune system failure Example of clients susceptible to developing cancer

PathoPhysiology

Patterns of Cell Proliferation

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

Patterns of Cell Proliferation

Dysplasia Bizarre cell growth differing in size, shape and cell arrangement

Patterns of Cell Proliferation

Dysplasia Bizarre cell growth differing in size, shape and cell arrangement Metaplasia conversion of one type of cell in a tissue to another type not normal for that tissue

Patterns of Cell Proliferation

Anaplasia change in the DNA cell structure and orientation to one another, characterized by loss of differentiation and a return to a more primitive form. Neoplasia uncontrolled cell growth, either benign or malignant Metastasis

Benign and Malignant

ASSESSMENT Nursing History

Health History chief complaint and history of present illness (onset, course, duration, location, precipitating & alleviating factors) Warning Signal of Cancer Cancer signs: CAUTION US!

CAUTION US!
Change in bowel/bladder habits A sore that does not heal Unusual bleeding or discharge Thickenings or lumps Indigestion or difficulty in swallowing
Obvious change in a wart or mole Nagging or persistent cough or hoarseness Unexplained anemia Sudden unexplained weight loss

Warning Signs of Cancer

Change in bowel or bladder habits A person with colon cancer may have diarrhea or constipation, or he may notice that the stool has become smaller in diameter A person with bladder or kidney cancer may have urinary frequency and urgency

A sore that does not heal

Small, scaly patches on the skin that bleed or do not heal may be a sign of skin cancer A sore in the mouth that does not heal can indicate oral cancer

Unusual bleeding or discharge

Blood in the stool is often the first sign of colon cancer Similarly, blood in the urine is usually the first sign of bladder or kidney cancer Postmenopausal bleeding (bleeding after menopause) may be a sign of uterine cancer

Thickenings or lumps
Enlargement of the lymph nodes or glands (such as the thyroid gland) can be an early sign of cancer Breast and testicular cancers may also present as a lump

Indigestion or difficulty in swallowing

Cancers of the digestive system, including those of the esophagus, stomach, and pancreas, may cause indigestion, heartburn, or difficulty swallowing

Obvious change in a wart or mole

Moles or other skin lesions that change in shape, size, or color should be reported

Nagging or persistent cough or hoarseness

Cancers of the respiratory tract, including lung cancer and laryngeal cancer, may cause a cough that does not go away or a hoarse (rough) voice

Unexplained anemia Sudden unexplained weight loss

The Cancer Detection Examination

1. Cytologic Examinatiomn or Papanicolaou test( Pap smear)  Class 1 Normal  Class 11 inflammation  Class 111 mild to moderate dysplasia  class1V probably malignant  ClassV malignant 2. Biopsy 5. radiodiagnostic techniques(radioisotopes) 3. UTZ 6. CT scan 4. MRI 7. Antigen skin test 5. X-rays 8. Lab test

Diagnostic Surgery Cytologic specimen Needle Biopsy Excisional and IncisionalBiopsy Surgery as treatment Surgery for recurrence and metastasis Palliative surgery Reconstructive surgery Preventive surgery

Laboratory test:
CBC Alpha-feto-protein Human Chorionic Gonadotropin(HCG) Prostatic Acid phosphatase

Tumor markers identify substance (specific proteins) in the blood that are made by the tumor

Prostatic specific Antigen(PSA) Carcinoembryonic Antigen(CEA) Alkaline Phosphatase: bone metastasis

DIAGNOSTIC EXAMINATION
CT SCAN Purpose: provides photograph of tissue densities with use of radiation Nursing Responsibilities: If dye will be used, keep the patient NPO for 4 HR before the test and check for allergies Contraindication Pregnant women Obesity(more than 300 lbs) Claustrophobic patients Allergy to dye Client with unstable VS

(ERCP) Endoscopic Retrograde

Cholangiopancreatography
- Provide radiographic visualization of the bile and pancreatic duct - Contraindicated in Pancreatitis - Keep the client NPO before and after the procedure - Keep Narcan at bedside - Inform the client that he or she may havehoarse and sore throat several days after the procedure

Endoscopy
Assessment of the esophagus and stomach Obtain consent Remove denture NPO 6- 8 hr before the procedure Resume feeding after gag reflex return

Hysterosalphingography
To determine patency of the fallopian tube and to detect pathology in the uterine cavity Involve X-ray examination and administration of a radiopaque dye into the uterine cavity

IVP
Visualization of the urinary tract Obtain consent NPO for8- 10 hr before the procedure Administer Laxative t clear bowels before the procedure Check for allergy to iodine, seafoods or shellfish before the procedure Keep Epinephrine at bedside to counteract possible allergy Increase fluid intake after the procedure to facilitate excretion of the dye

Liver Biopsy
Rule out liver disorder Obtain consent Obtain the result of homeostasis tests before the biopsy since bleeding is a common complication Position the patient on the left side or supine during Biopsy Instruct client to inhale, exhale and hold position of the liver and to prevent accidental puncture to the diaphragm Position the client on the right side after biopsy for two hrs. to prevent hemorrhage Maintain bed rest for 24 hr after the procedure

Lung Scan
Determine lung perfusion when pulmonary emboli and infarction are suspected Obtain consent Remove jewelry from the chest area Administer sedative as prescribed Wear gloves within 24 hr after the procedure when urine is being discarded Involved injection of radioactive isotope into the body

Mammography
To determine the presence of breast tumor Instruct the client to avoid the use of deodorant, talcum powder, lotion, perfume and any ointment on the day of the exam as these contain Calcium oxalate which may crystallize and may give a False positive result Instruct the client that the breast will be placed between two x-ray plates Provide health teaching related to a self breast exam Best done a week after menstruation Position: lying down with pillow under the shoulder of the breast being examined

Papanicolaou test
- A smear method of examining stained exfoliative cells also called pap smear - It evaluate the cellular maturity, metabolic activity and morphological variations of cervical tissue

NURSING DIAGNOSES
Acute or chronic pain Impaired skin integrity Impaired oral mucous membrane Risk for injury Risk for infection Fatigue Imbalanced nutrition: less than body requirements Risk for imbalanced fluid volume Anxiety Disturbed body image Deficient knowledge Ineffective coping Social isolation

OUTCOME IDENTIFICATION
1.Pain relief 2.Integrity of skin and oral mucosa 3.Absence of injury and infection 4.Fatigue relief 5.Maintenance of nutritional intake and fluid and electrolyte balance 6.Improved body image 7.Absence of complications

1. Knowledge of prevention and cancer treatment 2.Effective coping through recovery and grieving process 3.Optimal social interaction

Implementation
Prevention and detection Primary Prevention Reducing modifiable risk factors in the external and internal environment Secondary Prevention Recognizing early signs and symptoms and seeking prompt treatment Prompt intervention to halt cancerous process

Cancer Prevention:
Skin avoid overexposure to sunlight Oral - annual oral examination. Breast monthly BSE from age 20. TSE for male Lungs avoid cigarette smoking; annual chest X-ray Colon Digital rectal examination for persons over age 40. Rectal biopsy, proctoscopic examination, Guaiac stool examination for persons age 50 and bove Uterus Annual Pap s smear from age 40 Basic annual physical examination and blood examination

Dietary Recommendations Against Ca

Avoid obesity Cut down on total fat intake Eat more high fiber foods raw fruits and vegetable, whole grain cereals Include foods rich in Vit A and C in daily diet Include cruciferous vegetables in the dietbroccoli, cabbage, cauliflower, brussel sprouts Be moderate in the consumption of alcohol beverages Be moderate in the consumption of salt cured, smoked-cured nitrate-cured foods

Cancer Prevention
Carcinogenic chemicals Carcinogenic radiation Cancer viruses or bacteria

Avoid Tobacco
Lung Cancer Risk Increases with Cigarette Consumption
15x Lung Cancer Risk

10x

5x

0
Non-smoke

15 Cigarettes Smoked per Day

30

Protect Yourself From Excessive Sunlight

Limit Alcohol and Tobacco

Combination of Alcohol and Cigarettes Increases Risk for Cancer of the Esophagus

40x 30x Risk Increase 20x 10x Alcoholic Drinks Consumed per Day Packs of Cigarettes Consumed per Day AND

Diet: Limit Fats and Calorie

Correlation Between Meat Consumption and

Colon Cancer Rates in Different Countries

40 30 Number of Cases (per 100,000 people) 20

80

100

200 0

300

Diet: Consume Fruits and Vegetables

Avoid Cancer Viruses

HPV Infection Increases High

Risk for Cervical Cancer

Cervicall Cancer risk

Low
Noninfected Women Women Infected with HPV

Avoid Carcinogens at Work

Some Carcinogens in the Workplace
Carcinogen Arsenic Asbestos Benzene Chromium Leather dust Naphthylamine Radon Soots, tats, oil Vinyl chloride Wood dust Occupation Mining, pesticide workers Construction workers Petroleum, rubber, chemical worker Metal workers, electroplaters Shoe manufacturing Chemical, dye ,rubber workers Underground mining Coal, gas petroleum workers Rubbers workers, polyvinyl chloride manufacturing Furniture manufacturing Type of Cancer Lung, skin, liver Lung , mesothelioma leukemia lung Nasal, bladder bladder lungs Lung, skin, liver liver nasal

Industrial Pollution