NURSING ONCOLOGY

Oncology
Stanley C. Luces MD,

Oncology Branch of medicine that deals with the study, detection, treatment and management of cancer and neoplasia

The Impact of Cancer

Cancer is a leading cause of death worldwide. From a total of 58 million deaths worldwide in 2005, cancer accounts for 7.6 million, or 13 percent, of all deaths. 84 million people will die in the next 10 years if action is not taken, the World Health Organization (WHO) estimates.

The Impact of Cancer

The main types of cancer leading to overall cancer mortality are:
Lung - 1.3 million deaths/year Stomach - almost 1 million deaths/year Liver - 662,000 deaths/year Colon - 655,000 deaths/year Breast - 502,000 deaths/year

Ten Leading Causes of Mortality in the Philippines

Diseases of the heart Diseases of the vascular system Pneumonia Cancer Accidents Tuberculosis COPD DM Diseases of the Respiratory system Nephritis/nephritic syndrome /nephrosis

The Impact of Cancer

In 2005 CANCER killed approximately 44,000 people in the Philippines 33,000 of those people were under the age of 70

The Impact of Cancer

In 2005 TRACHEA, BRONCHUS, LUNG CANCERS are the leading cause of CANCER DEATHS among MEN in PHILIPPINES

The Impact of Cancer

In 2005 BREAST CANCER is the leading cause of CANCER DEATHS among WOMEN in the PHILIPPINES

What is CANCER?

 Cancer is a neoplastic disorder that can involve all body organs. Uncontrolled, disorderly, proliferation of cells, resulting in a benign or malignant tumor or neoplasm.

Benign vs Malignant CANCER?

Characteristics of Neoplasia
Uncontrolled growth of Abnormal cells 1. Benign 2. Malignant 3. Borderline

Properties of Neoplasms
Loss of Contact inhibition Loss of adhesion Loss of anchorage dependence Increased expression of laminin receptors Reduction of cell surface fibronectin

Characteristics of Neoplasia
BENIGN Well-differentiated Slow growth Encapsulated Non-invasive Does NOT metastasize

Characteristics of Neoplasia
MALIGNANT Undifferentiated Erratic and Uncontrolled Growth Expansive and Invasive Secretes abnormal proteins METASTASIZES

CHARACTER

BENIGN

MALIGNANT
Some lack of differentiation
Erratic & may be slow to rapid

Differentiation Well-differentiated / anaplasia

Rate of growth Usually progressive & slow

Local invasion

Usually cohesive & expansive welldemarcated masses

Locally invasive, infiltrating the surrounding normal tissues Frequently present

Metastasis

Absent

Carcinogenesis: the origin of cancer

Cellular Transformation & Derangement Theory= exposure to some etiologic agents Failure of the Immune Response Theory= all individuals possess cancer cells, however, cancer cells are recognized by the immune response system and they undergo destruction. The failure of the immune response system will lead to inability of the WBC to destroy cancer cells

Biology of Host Defenses

Tumor Progression vs Host Defenses

CANCER
Body Defenses Against TUMOR 1. T cell System/ Cellular Immunity
Cytotoxic T cells kill tumor cells

2. B cell System/ Humoral immunity

B cells can produce antibody

3. Phagocytic cells
Macrophages can engulf cancer cell debris

CANCER
Proposed Molecular cause of CANCER: Change in the DNA structure altered DNA function Cellular aberration cellular death cellular repair neoplastic change Genes in the DNA- proto-oncogene And anti-oncogene

CANCER

CARCINOGENSIS Malignant transformation IPP Initiation Promotion Progression

CANCER
CARCINOGENSIS INITIATION Carcinogens alter the DNA of the cell Cell will either die or repair

Carcinogenesis: A Multi-Step Process 2. Promotion 1. Initiation 3. Progression

CANCER

CARCINOGENSIS PROMOTION Repeated exposure to carcinogens Abnormal gene will express Latent period

Carcinogenesis: A Multi-Step Process 2. Promotion 1. Initiation 3. Progression

CANCER
CARCINOGENSIS PROGRESSION Irreversible period Cells undergo NEOPLASTIC transformation then malignancy

Carcinogenesis: A Multi-Step Process 2. Promotion 1. Initiation 3. Progression

Acquisition of growth-promoting mutations is associated with altered cell behavior that is manifest at the histological level. While there is a great deal of effort to identify those changes that occur early in tumor formation, there are few feasible methods for selectively eliminating early precursor cells. Why?

The Metastatic Cascade: 1. Detachment 2. Migration 3. Dissemination 4. Angiogenesis

Metastasis is the hallmark of lethal malignancies

Cancer Arises From Gene Mutations

Germline mutations
Parent Mutation in egg or sperm Child All cells affected in offspring Somatic mutation (eg, breast)

Somatic mutations

Present in egg or sperm Are heritable Cause cancer family syndromes

Occur in nongermline tissues Are nonheritable

Factors that Influence Cancer Development

Environmental factors
Chemical carcinogens Industrial chemicals Drugs Tobacco Physical carcinogens Ionizing radiation Ultraviolet radiation Chronic irritation Tissue trauma

Factors that Influence Cancer Development

Environmental factors
Viral carcinogen
Oncoviruses
Epstein-Barr hepatitis B HPV

Factors that Influence Cancer Development

Dietary factors
High fat Low fiber High animal fat Preservatives

Factors that Influence Cancer Development

Genetic predisposition Age Immune function

Increased incidence of CA among patients who have suppressed immune system

Chromosomal Changes and Cancer

Classes of Regulatory Genes

Protooncogenes

Anti-oncogenes

Genes that regulate Apoptosis

DNA repair Genes

Chromosomal Changes and Cancer

Oncogenes are mutant genes that cause multiple changes in the regulatory control of the cell. Most oncogenes are derived from protooncogenes, normal genes that affect cell growth and differentiation but have the potential to become oncogenic following mutations in their DNA sequences.

Activation of ProtoOncogenes
Point mutations
A point mutation is a single-base change in a gene. This alteration affects cell metabolism and induces malignancy.

Activation of ProtoOncogenes
Gene fusion
A proto-oncogene fuses with an unrelated gene. The hybrid has a different structure and function than the normal ex. Abl proto-oncogene fuses with BCR gene. The hybrid causes CML.

Activation of ProtoOncogenes
Amplification Differences in the
level of expression of encoded proteins can also cause protooncogenes to become oncogenic ex. N-myc genes increases in amount among patients with neuroblastoma

Anti-oncogenes (tumor suppressor genes)

Function in the normal cell to restrict or repress cellular proliferation. When they are genetically inactivated, tumor genesis can occur.

Acquired DNA Damaging agents:

Chemicals Radiation Viruses Successful DNA repair

Normal Cell

Inherited mutations in: - Genes affecting DNA repair

DNA Damage Failure of DNA repair Mutations in the genome of the somatic cells

- Genes affecting cell growth or apoptosis

Activation of growth promoting oncogenes

Alterations of genes that regulate apoptosis

Inactivation of cancer suppressor genes

Expression of altered gene products and loss of regulatory gene products

Malignant Neoplasm

Patterns of Tumor Growth

Direct invasion of local tissue Metastasis to distant organs
Tumors vary in their metastatic potential

Cancers of the head and neck tend to remain localized and spread slowly to distant foci Each cancer exhibits a distinct pattern of spread Growth is more rapid in metastatic sites than in the primary tumor

 Routes of metastasis
Local seeding Blood borne metastasis Lymphatic spread

Common Sites of Metastasis

Cancer Breast Lung Colorectal Site of Metastasis Bone, Lung Brain Liver

Prostate
Brain

Bone, Spine and legs

CNS

Tumor Growth Rate and Prognosis

Fast growing neoplasms including acute leukemias, small cell lung CA; lymphomas are generally highly responsive to chemotherapy Slow growing tumors such as low grade sarcomas are less responsive to these modalities. Surgical resection and radiation therapy are more effective treatment options for these neoplasms.

Cancer Staging
A prognostic strategy that defines a series of categories or stages each of which represents a step in the degree of malignancy and aggressiveness of the tumor. The stage of a tumor describes its size, the extent of regional lymph node spread and the presence or absence of metastasis.

TNM Classification System

Most widely used staging system for carcinomas and sarcomas T size and extent of primary tumor N degree of nodal involvement M presence and extent of distant metastasis

Staging of Malignant Neoplasms Stage Tis T1 T2 Definition In situ, non-invasive (confined to epithelium) Small, minimally invasive within primary organ site Larger, more invasive within the primary organ site Larger and/or invasive beyond margins of primary organ site Very large and/or very invasive, spread to adjacent organs

T3
T4

N0
N1 N2 N3 M0

No lymph node involvement

Regional lymph node involvement Extensive regional lymph node involvement More distant lymph node involvement No distant metastases

M1

Distant metastases present

CANCER
Cancer Grading The degree of DIFFERENTIATION Grade 1- Low grade Grade 4- high grade

 Grading schema based upon the microscopic appearance of a neoplasm with H&E staining higher grade means that there is a lesser degree of differentiation and the worse the biologic behavior of a malignant neoplasm will be A well-differentiated neoplasm is composed of cells that closely resemble the cell of origin, while poorly differentiated neoplasms have cells that are difficult to recognize as to their cell of origin

Grading of Malignant Neoplasms Grade Definition

I
II III IV

Well differentiated
Moderately differentiated Poorly differentiated Nearly anaplastic

3 Levels of Staging Information

Clinical staging Pathologic staging Retreatment staging

Early Detection
Mammography

 Papaniculaous test

 Stool guiac

 Sigmoidoscopy Skin inspection

 Breast Self Examination (BSE) - Performed 7-10 days after menses - Postmenopausal clients or clients who have had a hysterectomy should select a specific day of the month and perform BSE monthly on that day

 Testicular self examination - select a day of the month and perform the examination on the same day each month

TUMOR MARKERS

Seven Warning Signs of Cancer

C A U T I O N

Seven Warning Signs of Cancer

Change in bowel or bladder

habits
A U T I O N

Seven Warning Signs of Cancer

C hange in bowel or bladder habits

Any sore that does not heal

U T I O N

Seven Warning Signs of Cancer

C hange in bowel or bladder habits A- ny sore that does not heal

Unsual bleeding or
discharge
T I O N

Seven Warning Signs of Cancer

C hange in bowel or bladder habits A- ny sore that does not heal U nsual bleeding or discharge

Thickening or lump in
breast or elsewhere
I O N

Seven Warning Signs of Cancer

C hange in bowel or bladder habits A- ny sore that does not heal U nsual bleeding or discharge T hickening or lump in breast or elsewhere

Indigestion
O N

Seven Warning Signs of Cancer

C hange in bowel or bladder habits A- ny sore that does not heal U nsual bleeding or discharge T hickening or lump in breast or elsewhere I ndigestion

Obvious change in wart or

mole
N

Seven Warning Signs of Cancer

C hange in bowel or bladder habits A- ny sore that does not heal U nsual bleeding or discharge T hickening or lump in breast or elsewhere I indigestion O bvious change in wart or mole

Naging cough or
hoarseness

Diagnostic Tests
Biopsy Bone Marrow Examination Chest Xray CBC CT Scan Pap Smear TUMOR MARKERS Liver Function Tests MRIs Presence of oncofetal antigens ex. Carcinoembryonic antigen and alpha fetoprotein Proctoscopic Examination Mammogram Radioisotope scans (liver, brain, bone, and lung)

Biopsy
it is the definitive means of diagnosing cancer and provides histological proof of malignancy involves the surgical incision of a small piece of tissue for microscopic examination

Types
Needle Staging

Types

Incisional

Types

Excisional

Types

Shave

Pain Control
1. Bone destruction 2. Obstruction of an organ 3. Compression of peripheral nerves 4. Infiltration /distention of tissue 5. Inflammation/necrosis 6. Psychological, such as fear or anxiety

Interventions
1. Assess the clients pain. Pain is what the client describes or says that it is 2. Collaborate with other members of the health care team to develop a pain management program 3. Administer oral preparations if possible and if they provide adequate relief 4. Mild or moderate pain may be treated with salicylates, acetaminophen and NSAIDs

Interventions
5. Sever pain is treated with narcotics such as codeine sulfate, meperidine (Demerol), morphine sulfate 6. Subcutaneous injections and continuous intravenous infusions of narcotics provide better pain control than via the oral route 7. Monitor vital signs and side effects of medications

Interventions
8. Institute relaxation techniques, guided imagery, biofeedback and diversion 9. Do not under medicate the cancer client who is in pain.

Treatment Modalities
General Principles in Cancer Treatment 1. Cancer treatment may be either curative or palliative Curative eradicates the tumor and imply that the patient will remain disease-free indefinitely Palliative seeks to prolong life and minimize discomfort when a cure is impossible

Treatment Modalities
2. The treatment program typically includes a combination or surgery, radiation, chemotherapy and some biologic response modifiers 3. Therapy must be customized to meet the specific needs of the patient.

Treatment Modalities
Surgery
used to diagnose, stage and treat cancer

Types
Prophylactic surgery Curative surgery Control (cytoreductive) surgery Palliative surgery Reconstructive or rehabilitative surgery

Treatment Modalities
Chemotherapy
kills or inhibits the reproduction of neoplastic cells and also attacks and kills normal cells the effects are systemic; chemotherapy affects healthy cells and cancerous cells normal cells most profoundly affected include those of the skin, hair and lining of the GIT, spermatocytes and hematopoietic cells

Treatment Modalities
usually several medications are used in combination to increase the therapeutic response combination chemotherapy is planned to avoid prescribing medications with the same nadirs

Treatment Modalities
the preferred route of administration is intravenous side effects include alopecia, nausea and vomiting, mucositis, skin changes , immunosuppression, anemia and thrombocytopenia

Treatment Modalities
Chemotherapeutic Responses Complete Response Partial Response Stable disease Progressive disease

Treatment Modalities
Radiation Therapy destroys cancer cells with minimal exposure of normal cells to the damaging effects of radiation; the cells damaged will die or become unable to divide effective on tissues directly within the path of the radiation beam

Treatment Modalities
side effects include skin changes and irritation, alopecia, fatigue, and altered taste sensation; also the effects vary according to the site of treatment

Types of Radiation Therapy

Teletherapy
Beam radiation; the actual radiation source is external to client The client does not emit radiation and does not pose a hazard to anyone else

Client Education
Wash area with water or mild soap and water, using the hand rather than a washcloth; rinse the soap thoroughly and pat dry with a soft towel or cloth Do not remove the radiation markings from the skin Use no powders, ointments, lotions or creams on the area unless prescribed

Client Education
Wear soft clothing over the area, avoiding belts, buckles, straps or any clothing that binds or rubs the skin Avoid sun and heat exposure

Client Education
Monitor for moist desquamation (weeping of the skin) If desquamation occurs, cleanse the area with warm water and pat dry, apply antibiotic ointment or steroid cream as prescribed, and expose the site to air

Types of Radiation Therapy

Brachytherapy
The radiation source comes into direct, continuous contact with tumor tissues for a specific time The radiation source is within the client; for a period of time, the client emits radiation and can pose a hazard to others

Types of Brachytherapy
Unsealed radiation source The source is not confined completely to one body area, and it enters body fluids and eventually is eliminated via various excreta, which are radioactive and harmful to others

Types of Brachytherapy
Sealed radiation source A sealed temporary or permanent radiation source (solid implant) is implanted within the tumor target tissues The patient emits radiation while the implant is in place but the excreta are not radioactive

Care of the Client with a Sealed Radiation Source

Place the client in a private room Place a caution sign on the clients door Organize nursing tasks to minimize exposure to the radiation source Limit time to 30 minutes per care provider per shift

Care of the Client with a Sealed Radiation Source

Wear a lead shield to reduce the transmission or radiation A nurse should never care for more than one client with a radiation implant at one time Never allow a pregnant nurse to care for a client

Care of the Client with a Sealed Radiation Source

Never allow children under the age of 16 or a pregnant woman to visit the client Limit visitors to 30 minutes per day; visitors should be at least 6 feet from the source

Removal of Sealed Radiation Source

The client is no longer radioactive Inform the patient that sexual partners cannot catch cancer Inform the female patient that she may resume sexual intercourse after 7-10 days, if the implant was cervical or vaginal

Removal of Sealed Radiation Source

Provide a povidone-iodine douche if prescribed if the implant was placed in the cervix Advise the client who had a cervical or vaginal implant to notify the physician if nausea, vomiting, diarrhea, frequent urination, vaginal or rectal bleeding, hematuria , foul smelling vaginal discharge, abdominal pain or distention or a fever occurs

A Dislodged Radiation Source

Do not touch a dislodged radiation source with bare hands Use long-handled forceps to place the source in the lead container kept in the clients room and call the physician If unable to locate the radiation source, bar visitors and notify the physician

Treatment Modalities
Bone Marrow Transplantation used to treat leukemia in clients who have closely matched donors and who are experiencing temporary remission with chemotherapy

Treatment Modalities
the goal of treatment is to rid the client of all leukemic or other malignant cells through treatment with high doses of chemotherapy and whole body radiation because these treatments are lethal to bone marrow, without the replacement of bone marrow function through transplantation, the client would die of infection or hemorrhage

Types of Donor Marrow

Allogeneic: marrow donor is usually a sibling or parent with a similar tissue Syngeneic: bone marrow is from an identical twin Autologous
MOST COMMON TYPE The marrow donor is also the recipient Marrow is harvested during the disease remission and is stored frozen to be re-infused later

Procedure
Harvest

Conditioning

Procedure
Transplantation

Engraftment

 Post-transplantation period
The client remains without any natural immunity until the donor marrow begins to proliferate and engraftment occurs Infection and severe thrombocytopenia are major concerns until engraftment occurs

 Complications
Failure to engraft Graft versus host disease Venoocclusive diease

Oncologic Disorders

Breast Cancer
The most common cancer in FEMALES Numerous etiologies implicated

Breast Cancer
RISK FACTORS 1. Genetics- BRCA1 And BRCA 2 2. Increasing age ( > 50yo) 3. Family History of breast cancer 4. Early menarche and late menopause 5. Nulliparity 6. Late age at pregnancy

Breast Cancer
RISK FACTORS 7. Obesity 8. Hormonal replacement 9. Alcohol 10. Exposure to radiation

Breast Cancer
PROTECTIVE FACTORS 1. Exercise 2. Breast feeding 3. Pregnancy before 30 yo

Breast Cancer
ASSESSMENT FINDINGS 1. MASS- the most common location is the upper outer quadrant 2. Mass is NON-tender. Fixed, hard with irregular borders 3. Skin dimpling 4. Nipple retraction 5. Peau d orange

Breast Cancer
LABORATORY FINDINGS 1. Biopsy procedures 2. Mammography

Breast Cancer
Breast cancer Staging TNM staging I - < 2cm II - 2 to 5 cm, (+) LN III - > 5 cm, (+) LN IV- metastasis

Breast Cancer
MEDICAL MANAGEMENT 1. Chemotherapy 2. Tamoxifen therapy 3. Radiation therapy

Breast Cancer
SURGICAL MANAGEMENT 1. Radical mastectomy 2. Modified radical mastectomy 3. Lumpectomy 4. Quadrantectomy

Breast Cancer
INTERVENTION : PRE-OP 1. Explain breast cancer and treatment options 2. Reduce fear and anxiety and improve coping abilities 3. Promote decision making abilities 4. Provide routine pre-op care: Consent, NPO, Meds, Teaching about breathing exercise

Breast Cancer
INTERVENTION : Post-OP 1. Position patient: Supine Affected extremity elevated to reduce edema

Breast Cancer
INTERVENTION : Post-OP 2. Relieve pain and discomfort Moderate elevation of extremity IM/IV injection of pain meds Warm shower on 2nd day post-op

Breast Cancer
INTERVENTION : Post-OP 3. Maintain skin integrity Immediate post-op: snug dressing with drainage Maintain patency of drain (JP) Monitor for hematoma w/in 12H and apply bandage and ice, refer to surgeon

Breast Cancer
INTERVENTION : Post-OP 3. Maintain skin integrity Drainage is removed when the discharge is less than 30 ml in 24 H Lotions, Creams are applied ONLY when the incision is healed in 4-6 weeks

Breast Cancer
INTERVENTION : Post-OP Promote activity Support operative site when moving Hand, shoulder exercise done on 2ndday Post-op mastectomy exercise 20 mins TID NO BP or IV procedure on operative site

Breast Cancer
INTERVENTION : Post-OP Promote activity Heavy lifting is avoided Elevate the arm at the level of the heart On a pillow for 45 minutes TID to relieve transient edema

Breast Cancer
INTERVENTION : Post-OP MANAGE COMPLICATIONS Lymphedema 10-20% of patients Elevate arms, elbow above shoulder and hand above elbow Hand exercise while elevated Refer to surgeon and physical therapist

Breast Cancer
INTERVENTION : Post-OP MANAGE COMPLICATIONS Hematoma Notify the surgeon Apply bandage wrap (Ace wrap) and ICE pack

Breast Cancer
INTERVENTION : Post-OP MANAGE COMPLICATIONS Infection Monitor temperature, redness, swelling and foul-odor IV antibiotics No procedure on affected extremity

Breast Cancer
INTERVENTION : Post-OP TEACH FOLLOW-UP care Regular check-up Monthly BSE on the other breast Annual mammography

Testicular Cancer
arises from germinal epithelium (from the sperm producing germ cells) or from nongerminal epithelium (from other structures in the testicles)

 most often occurs between the ages of 15 and 40 most common tumor among men metastasis occurs to the lung , liver, bone and adrenal glands prevention : routine testicular selfexamination

Assessment
Painless testicular swelling occurs Dragging sensation is evident in the scrotum Palpable lymphadenopathy, abdominal masses and gynecomastia may indicate metastasis Late signs include back or bone pain and respiratory symptoms

Interventions
Chemotherapy Radiation Orcheictomy Radical retroperitoneal lymphnode dissection (staging) Discuss reproduction , sexuality and fertility info and options with the client

Post operative interventions

Instruct the client that he may resume normal activities within 1 week , except for lifting objects heavier than 20 pounds or stair climbing Perform monthly testicular self examination on the remaining testicle Inform the client that sutures will be removed 7-10 days after surgery

Cervical Cancer
preinvasive cancer is limited to the cervix invasive cancer is in the cervix and other pelvic structures

 metastasis usually is confined to the pelvis, but distant mets occurs through lymphatic spread premalignant changes are described on a continuum from dysplasia which is the earliest premalignancy change to carcinoma in situ the most advance premalignant change

Precipitating Factors
Early age at first intercourse A male partner with multiple previous sexual partners Multiple sexual partners Previous infections with human papilloma virus (HPV)

 High parity Poor hygiene Low socioeconomia groups

Oral contraceptive use Cigarette smoking Lack of circumcision in male sexual partner

Assessment
Painless vaginal bleeding, postmenstrually and post coitally Foul smelling or serosanguineous vaginal discharge Pelvic, lower back, leg, or groin pain Anorexia, and weight loss

 Leakage of urine and feces from the vagina Dysuria Hematuria Cytological changes on Pap smear

Interventions
Laser therapy Cryosurgery
No anesthesia Heavy watery discharge will occur during the procedure Avoid sexual intercourse and the use of tampons while the discharge is present

Conization
For women who still desire to have children

Hysterectomy
For those who dont desire to bear children Vaginal approach is most commonly performed

Post op instructions
Monitor vaginal bleeding ; more than one saturated pad per hour may indicate excessive bleeding Instruct the client to avoid stair climbing for 1 month and to avoid tub baths and sitting for long periods No heavy lifting > 20 lbs Avoid sexual intercourse for 3-6 weeks as prescribed

Pelvic Exenteration
For recurrent cancer Ileal conduit is created on the right side of abdomen if bladder is removed Colostomy is done on the left side for passage of feces

Types Anterior

Organs Removed Uterus, ovaries, fallopian tubes, vagina, bladder, urethra, pelvic lymphnodes Uterus, ovaries, fallopian tubes, descending colon, rectum, anal canal Combination of anterior and posterior

Posterior

Total

Post-op Interventions
Monitor for atelectasis and pneumonia Monitor for hemorrhage m shock and deep vein thrombosis Apply antiembolic stockings as prescribed

Monitor bowel sounds Avoid strenuous activities for 6 months Instruct on ileal conduit and colostomy care Pain meds as ordered

Ovarian Cancer
grows rapidly, spreads fast and is often bilateral metastasis occurs by direct spread to the organs in the pelvis, by distal spread through lymphatic drainage, or by peritoneal seeding

 Prognosis is usually poor because the tumor is usually detected late Exploratory laparotomy is done to diagnose and stage the tumor

Assessment
Abdominal discomfort or swelling GI disturbances DUB Abdominal mass

Interventions
External radiation if other organs are involved Chemotherapy post-op Intraperitoneal chemo involves instillation of chemotherapy into the abdominal cavity TAHBSO

Endometrial Cancer
slow growing tumor associated with the menopausal years metastasis occurs through the lymphatic system to the ovaries and pelvis; via the blood to the lungs, liver and bone; or intraabdominally to the peritoneal cavity

Precipitating Factors
History of uterine polyps Nulliparity Polycystic ovary disease Estrogen stimulation Late menopause Family history

Assessment
Postmenopausal bleeding Watery, serosanguineous discharge Low back, pelvic or abdominal pain Enlarged uterus in advanced stages

Non-surgical Interventions
External radiation or internal radiation Chemotherapy Progestational therapy with medroxyprogesterone or megestrol is used for estrogen-dependent tumors

Surgical Intervention
TAHBSO

Breast Cancer
Rarely found before the age of 25 years old but there is steady rise to the time of menopause Average age of diagnosis is 64 years old

 Increased risk is associated with carcinoma of the contra lateral breast or endometrium The role of postmenopausal hormone replacement therapy or oral contraceptive as risk factors is still controversial. Any risk if present is small.

Precipitating Factors
Family history Early menarche and late menopause Previous cancer of the breast, uterus, or ovaries Nulliparity Obesity High dose radiation exposure to chest

Assessment
Mass felt during BSE Mass usually felt in the upper outer quadrant or beneath the nipple Nipple retraction Asymmetry with the affected breast being higher Bloody or clear nipple discharge Skin dimpling, retraction or ulceration Skin edema or peau dorange skin Axillary lymphadenopathy

Nonsurgical Interventions
Chemotherapy Radiation Hormonal manipulation like Tamoxifen ( for estrogen receptor positive tumors)

Surgical Interventions
Oophorectomy for estrogen receptorpositive tumors Ablative therapy with adrenalectomy or chemical ablation which blocks the production of cortisol androstenedione and aldosterone

Surgical Breast Procedures

Procedure Tissues Removed

Tumor is excised and removed. Lymph node dissection may be performed. Simple Mastectomy Breast tissue and the nipple are removed. Lymph node remain intact.

Lumpectomy

Modified Radical Breast tissue, nipple Mastectomy and lymph nodes are removed. Muscles left intact.

Halsted Radical Mastectomy

Breast tissue, nipple, underlying muscles and lymph nodes are removed

Postoperative Interventions
If a drain (Jackson-Pratt) is in place, maintain suction and record the amount of drainage and prevent lymphadema Monitor incision site for restriction of dressing , impaired sensation, or color changes of the skin

 Place a sign above the bed stating NO IVS, NO INJECTIONS, NO BPS, NO VENIPUCTURES IN AFFECTED ARM. The affected arm is protected for life and any intervention that could traumatize the affected arm is avoided

Client Instructions after Mastectomy

Avoid over use of the affected arm To prevent lymphedema, keep the affected arm elevated Provide incision care with lanolin to soften and prevent wound contracture

 Perform monthly BSE on remaining breast Avoid trauma, cuts, bruises, or burns to affected side Avoid wearing constricted clothing or jewelry on the affected side

Breast Cancer Screening

Mammography :
Annually starting at age 40.

CBE:
Every three years for women in their 20s and 30s and annually for women 40 and older.

BSE:
Monthly starting at age 20

Women known to be at increased risk

Women known to be at increased risk may benefit from earlier initiation of early detection testing and/or the addition of breast ultrasound or MRI.

Assessment
Utilize the ACS 7 Warning Signals CAUTION C- Change in bowel/bladder habits A- A sore that does not heal U- Unusual bleeding T- Thickening or lump in the breast I- Indigestion O- Obvious change in warts N- Nagging cough and hoarseness

Assessment
Weight loss Frequent infection Skin problems Pain Hair Loss Fatigue Disturbance in body image/ depression

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