UNDERSTANDING CANCER

ONCOLOGY NURSING

Essential Concepts of Cancer – What is Cancer? – Normal Cell Growth vs. Cancer Cell Growth – Etiology and Causative Factors – Pathophysiology – Classification of Tumors – Effects of Cancer

NURSING PROCESS
– Assessment – Laboratory & Diagnostic Tests – Tumor Staging and Grading – Nursing Diagnoses & Planning – Implementation and Management • Treatment Modalities – Chemotherapy • End-of-life Issues

WHAT IS CANCER?

CANCER is a complex of diseases which occurs when normal cells mutate into abnormal cells that take over normal tissue, eventually harming and destroying the host

WHAT IS CANCER
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)

ONCOLOGY DEFINED

Branch

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

“ROOT WORDS”
Neo- new  Plasia- growth  Plasm- substance  Trophy- size  +Oma- tumor  Statis- location

“ROOT WORDS”
A- none  Ana- lack  Hyper- excessive  Meta- change  Dys- bad, deranged

CHARACTERISTICS OF NEOPLASIA
Uncontrolled growth of Abnormal cells  1. Benign  2. Malignant  3. Borderline

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

LOSS OF NORMAL GROWTH CONTROL

NOMENCLATURE OF NEOPLASIA
Tumor is named according to: 1. Parenchyma, Organ or Cell  Hepatoma- liver  Osteoma- bone  Myoma- muscle

NOMENCLATURE OF NEOPLASIA
Tumor is named according to: 2. Pattern and Structure, either GROSS or MICROSCOPIC  Fluid-filled CYST  Glandular ADENO  Finger-like PAPILLO  Stalk POLYP

NOMENCLATURE OF NEOPLASIA
Tumor is named according to: 3. Embryonic origin  Ectoderm ( usually gives rise to epithelium)  Endoderm (usually gives rise to glands)  Mesoderm (usually gives rise to Connective tissues)

BENIGN TUMORS
Suffix- “OMA” is used  Adipose tissue- LipOMA  Bone- osteOMA  Muscle- myOMA  Blood vessels- angiOMA  Fibrous tissue- fibrOMA

MALIGNANT TUMOR
Named according to embryonic cell origin 1. Ectodermal, Endodermal, Glandular, Epithelial  Use the suffix- “CARCINOMA”  Pancreatic AdenoCarcinoma  Squamos cell Carcinoma

MALIGNANT TUMOR
Named according to embryonic cell origin 2. Mesodermal, connective tissue origin  Use the suffix “SARCOMA  FibroSarcoma  Myosarcoma  AngioSarcoma

“PASAWAY”
1. “OMA” but Malignant
 HepatOMA,

lymphOMA, gliOMA, melanOMA

2. THREE germ layers
 “TERATOMA”

3. Non-neoplastic but “OMA”
 Choristoma  Hamatoma

ETIOLOGY/CAUSATIVE FACTORS
• • • • • Viruses Chemical carcinogens Physical stressors Hormonal factors Genetic factors

CANCER NURSING
Etiology of cancer 1. PHYSICAL AGENTS  Radiation  Exposure to irritants  Exposure to sunlight  Altitude, humidity

CANCER NURSING
Etiology of cancer 2. CHEMICAL AGENTS  Smoking  Dietary ingredients  Drugs

CANCER NURSING
Etiology of cancer 3. Genetics and Family History  Colon Cancer  Premenopausal breast cancer

CANCER NURSING

Etiology of cancer
4. Dietary Habits  Low-Fiber  High-fat  Processed foods  alcohol

CANCER NURSING
Etiology of cancer 5. Viruses and Bacteria  DNA viruses- HepaB, Herpes, EBV, CMV, Papilloma Virus  RNA Viruses- HIV, HTCLV  Bacterium- H. pylori

CANCER NURSING
Etiology of cancer  6. Hormonal agents  DES  OCP especially estrogen

CANCER NURSING
Etiology of cancer  7. Immune Disease  AIDS

BURKITT’S LYMPHOMA - a cancer of the lymphatic system

Classification of Cancer According to Behavior of Tumor • Benign - tumors that cannot spread by invasion or metastasis; hence, they only grow locally • Malignant - tumors that are capable of spreading by invasion and metastasis. By definition, the term “cancer”

Patterns of cell Proliferation • Hyperplasia • Dysplasia • Metaplasia • Anaplasia • Neoplasia

Patterns of cell Proliferation •Metaplasia • conversion of one type of cell in a tissue to another type not normal for that tissue •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 • Metastasis: 3 stages – Invasion – neoplastic cells from primary tumor invade into surrounding tissue with penetration of blood or lymph. – Spread – tumor cells spread through lymph or circulation or by direct expansion – Establishment and growth – tumor cells are established and grow in secondary site: lymph nodes or in organs from venous circulation

CANCER NURSING
Spread of Cancer  1. LYMPHATIC

Most common

2. HEMATOGENOUS
 Blood-borne,

commonly to Liver and Lungs

3. DIRECT SPREAD
 Seeding

of tumors

CANCER NURSING
Body Defenses Against TUMOR  1. T cell System/ Cellular Immunity
 Cytotoxic  B 

T cells kill tumor cells

2. B cell System/ Humoral immunity
cells can produce antibody can engulf cancer cell debris

3. Phagocytic cells
 Macrophages

Classification of Tumors • CARCINOMAS: EPITHELIAL TISSUE – BODY SURFACES, LINING OF BODY CAVITIES ETC: (ADENOCARCINOMA) • SARCOMAS: CONNECTIVE TISSUE – STRIATED MUSCLE, BONE, ETC (OSTEOSARCOMA) • LYMPHOMAS AND LEUKEMIAS – HEMATOPOIETIC SYSTEM • NERVOUS TISSUE TUMORS – EX. NERVE CELLS-NEUROBLASTOMA • MYELOMA – Develops in the plasma cells of bone marrow

Effects of Cancer • Disruption of Function- can be due to obstruction or pressure • Hematologic Alterations: can impair function of blood cells • Hemorrhage: tumor erosion, bleeding, severe anemia • Anorexia-Cachexia Syndrome: wasted appearance of client

Effects of Cancer • Paraneoplastic Syndromes: ectopic sites with excess hormone production – ↑ Parathyroid hormone→ hypercalcemia – ↑ secretion of insulin→ hypoglycemia – ↑ Antidiuretic hormone (ADH) → fluid retention, HTN & peripheral edema • ↑ Adrenocorticotropic hormone (ACTH): cause excessive secretion of cortisone (ie: fluid retention, ↑ glucose levels)

Effects of Cancer • Pain: major concern of clients and families associated with cancer • Physical Stress: body tries to respond and destroy neoplasm

ASSESSMENT • Nursing History – Health History – chief complaint and history of present illness (onset, course, duration, location, precipitating and alleviating factors) – Cancer signs: CAUTION US!

WARNING SIGNS OF CANCER
CAUTION US! – Change in bowel or 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

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

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

PHYSICAL ASSESSMENT
• Inspection – skin and mucus membranes for lesions, bleeding, petechiae, and irritation – Assess stools, urine, sputum, vomitus for acute or occult bleeding – Scalp noting hair texture and hair loss • Palpation – Abdomen for any masses, bulges or abnormalities – Lymph nodes for enlargement • Auscultation – of lung sounds, heart sounds and bowel sounds

Laboratory & Diagnostic Tests • Cancer detection examination • Laboratory tests – Complete blood cell count (CBC) – Tumor markers – identify substance (specific proteins) in the blood that are made by the tumor • PSA (Prostatic-specific antigen): prostate cancer • CEA (Carcinoembryonic antigen): colon cancer • Alkaline Phosphatase: bone metastasis – Biopsy

Diagnostic Tests • Determine location of cancer: – X-rays – Computed tomography – Ultrasounds – Magnetic resonance imaging – Nuclear imaging – Angiography

• Diagnosis of cell type: – ▪Tissue samples: from biopsies, shedded cells (e.g. Papanicolaou (PAP) smear), & washings – ▪ Cytologic Examination: tissue examined under microscope

• Direct Visualization: – ▪ Sigmoidoscopy – ▪ Cystoscopy – ▪ Endoscopy – ▪ Bronchoscopy – ▪ Exploratory surgery; lymph node biopsies to determine metastases

Tumor Staging and Grading • Staging determines size of tumor and existence of metastasis • Grading classifies tumor cells by type of tissue • The TNM system is based on the extent of the tumor (T), the extent of spread to the lymph nodes (N), and the presence of metastasis (M).

Primary Tumor (T) TX - Primary tumor cannot be evaluated T0 - No evidence of primary tumor Tis - Carcinoma in situ (early cancer that has not spread to neighboring tissue) T1, T2, T3, T4 - Size and/or extent of the primary tumor Regional Lymph Nodes (N) NX - Regional lymph nodes cannot be evaluated N0 - No regional lymph node involvement (no cancer found in the lymph nodes) N1, N2, N3 - Involvement of regional lymph nodes (number and/or extent of spread) Distant Metastasis (M) MX - Distant metastasis cannot be evaluated M0 - No distant metastasis (cancer has not spread to other parts of the body) M1 - Distant metastasis (cancer has spread to distant parts of the body)

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

NURSING DIAGNOSES • 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

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

IMPLEMENTATION/MANAGE MENT • 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

SOME CARCINOGENS IN THE WORKPLACE

TREATMENT MODALITIES • Aimed towards: – CURE - free of disease after treatment → normal life – Control - Goal for chronic cancers – Palliative Care: Quality of life maintained at highest level for the longest possible time

• Surgery – surgical removal of tumors; most commonly used treatment • Preventive or prophylactic • Diagnostic surgery • Curative surgery • Reconstructive surgery • Palliative surgery • Chemotherapy – use of antineoplastic drugs to promote tumor cell death, by interfering with cellular functions and reproduction

• Radiotherapy – directing high-energy ionizing radiation to destroy malignant tumor cells without harming surrounding tissues Types: – Teletherapy (external): radiation delivered in uniform dose to tumor; Teletherapy is external beam irradiation and uses a device located at a distance from the patient. It produces X-rays of varying energies and is administered by machines a distance from the body 31½ to 39 inches (80 to 100 cm).

– Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is placed in tumor or next to it; In brachytherapy, the radiation device is placed within or close to the target tissue. Radiation is delivered in a high dose to a small tissue volume with less radiation to adjacent normal tissue, but requires direct tumor access.

• Immunotherapy – use of chemical or microbial agents to induce mobilization of immune defenses. • Biologic response modifiers (BRMs) – use of agents that alters immunologic relationship between tumor and host in a beneficial way

• Bone marrow peripheral stem cell transplantation – aspirating bone marrow cells from compatible donor and infusing them into the recipient • Gene therapy – transfer of genetic materials into the client’s DNA

NURSING MANAGEMENT 1. Promote measures that relieve pain and discomfort. • Pharmacologic and non-pharmacologic interventions 2. Promote measures to maintain intact skin integrity 3. Promote measures that maintain oral mucosa 4. Promote measures to prevent injury from abnormal bleeding • Monitor platelet count; avoid aspiring products, etc

NURSING MANAGEMENT 1. Promote measures that identify and prevent infection • Monitor WBC count; encourage frequent handwashing and overall cleanliness 2. Help decrease the client’s fatigue and increase his activity level 3. Promote measures that ensure adequate nutritional intake • High protein, high calorie diet 4. Ensure adequate fluid and electrolyte balance

NURSING MANAGEMENT 1. Promote measures to enhance body image. • Take an honest gentle, caring approach; encourage client to express and verbalize feelings 2. Promote measures that address preventing complications of cancer therapy 3. Instruct client and family about the disease process and treatments; provide necessary information for self-care. 4. Help client and family cope effectively 5. Promote measures to reduce social isolation.

Care of Clients Receiving Chemotherapy • Classes of Chemotherapy Drugs: • Alkylating agents: – Action: create defects in tumor DNA – Ex: Nitrogen Mustard, Cisplatin – Toxic Effects: reversible renal tubular necrosis

Classes of Chemotherapy Drugs • Antimetabolites: – Action: phase specific – Ex: Methotrexate; 5 fluorouracil – Toxic Effects: nausea, vomiting, stomatitis, diarrhea, alopecia, leukopenia

Classes of Chemotherapy Drugs • Antitumor Antibiotics: – Action: non- phase specific; interfere with DNA – Ex: Actinomycin D, Bleomycin, adriamycin (doxorubicin) – Toxic Effect: damage to cardiac muscle

Classes of Chemotherapy Drugs • Miotic inhibitors: – Action: Prevent cell division during M phase of cell division – Ex: Vincristine, Vinblastine – Toxic Effects: affects neurotransmission, alopecia, bone marrow depression

Classes of Chemotherapy Drugs • Hormones: – Action: stage specific G1 – Ex: Corticosteroids • Hormone Antagonist: – Action: block hormones on hormone- binding tumors ie: breast, prostate, endometrium; cause tumor regression – Ex: Tamoxifen (breast); Flutamide (prostate) – Toxic Effects: altered secondary sex characteristics

Effects of Chemotherapy • Tissues: (fast growing) frequently affected • Examples: mucous membranes, hair cells, bone marrow, specific organs with specific agents, reproductive organs (all are fetal toxic; impair ability to reproduce)

Chemotherapy Administration • Routes of administration: – Oral – Body cavity (intraperitoneal or intrapleural) – Intravenous • Use of vascular access devices because of threat of extravasation (leakage into tissues) & long term therapy

Chemotherapy Administration • Types of vascular access devices: – PICC lines: (peripherally inserted central catheters) – Tunneled catheters: (Hickman, Groshong) – Surgically implanted ports: (accessed with 90o angle needle- Huber needles)

Nursing care of clients receiving chemotherapy • Assess and manage: – Toxic effects of drugs (report to physician) – Side effects of drugs: manage nausea and vomiting, inflammation and ulceration of mucous membranes, hair loss, anorexia, nausea and vomiting with specific nursing and medical interventions

Nursing care of clientsreceiving chemotherapy • Monitor lab results (drugs withheld if blood counts seriously low); blood and blood product administration • Assess for dehydration, oncologic emergencies • Teach regarding fatigue, immunosuppression precautions • Provide emotional and spiritual support to clients and families

COLON CANCER

COLON CANCER
Risk factors 1. Increasing age 2. Family history 3. Previous colon CA or polyps 4. History of IBD 5. High fat, High protein, LOW fiber 6. Breast Ca and Genital Ca

COLON CANCER
Sigmoid colon is the most common site  Predominantly adenocarcinoma  If early 90% survival  34 % diagnosed early  66% late diagnosis

COLON CANCER
PATHOPHYSIOLOGY  Benign neoplasm DNA alteration malignant transformation malignant neoplasm  cancer growth and invasion  metastasis (liver)

COLON CANCER
 ASSESSMENT

FINDINGS 1. Change in bowel habits- Most common 2. Blood in the stool 3. Anemia 4. Anorexia and weight loss 5. Fatigue 6. Rectal lesions- tenesmus, alternating D and C

COLON CANCER
Diagnostic findings 1. Fecal occult blood 2. Sigmoidoscopy and colonoscopy 3. BIOPSY 4. CEA- carcino-embryonic antigen

COLON CANCER
Complications of colorectal CA 1. Obstruction 2. Hemorrhage 3. Peritonitis 4. Sepsis

COLON CANCER
MEDICAL MANAGEMENT 1. Chemotherapy- 5-FU 2. Radiation therapy

COLON CANCER
SURGICAL MANAGEMENT Surgery is the primary treatment Based on location and tumor size Resection, anastomosis, and colostomy (temporary or permanent)

COLON CANCER
NURSING INTERVENTION: COLOSTOMY CARE  Colostomy begins to function 3-6 days after surgery  The drainage maybe soft/mushy or semi-solid depending on the site

COLON CANCER
NURSING INTERVENTION: COLOSTOMY CARE  BEST time to do skin care is after shower  Apply tape to the sides of the pouch before shower  Assume a sitting or standing position in changing the pouch

COLON CANCER
NURSING INTERVENTION: COLOSTOMY CARE  Instruct to GENTLY push the skin down and the pouch pulling UP  Wash the peri-stomal area with soap and water  Cover the stoma while washing the peristomal area

COLON CANCER
NURSING INTERVENTION: COLOSTOMY CARE  Lightly pat dry the area and NEVER rub  Lightly dust the peri-stomal area with nystatin powder

COLON CANCER
NURSING INTERVENTION: COLOSTOMY CARE  Measure the stomal opening  The pouch opening is about 0.3 cm larger than the stomal opening  Apply adhesive surface over the stoma and press for 30 seconds

COLON CANCER
NURSING INTERVENTION: COLOSTOMY CARE  Empty the pouch or change the pouch when
 1/3

to ¼ full (Brunner)  ½ to 1/3 full (Kozier)

BREAST CANCER
The most common cancer in FEMALES  Numerous etiologies implicated

BREAST CANCER
RISK FACTORS 1. Genetics 2. Increasing age ( > 50 yo) 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  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

LUMPECTOMY

QUADRANTECTOMY

BREAST CANCER
NURSING 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
NURSING INTERVENTION : Post-OP 1. Position patient:  Supine  Affected extremity elevated to reduce edema

BREAST CANCER
NURSING 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
NURSING 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
NURSING 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
NURSING 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
NURSING 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
NURSING 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
NURSING INTERVENTION : Post-OP MANAGE COMPLICATIONS  Hematoma  Notify the surgeon  Apply bandage wrap (Ace wrap) and ICE pack

BREAST CANCER
NURSING INTERVENTION : Post-OP MANAGE COMPLICATIONS Infection  Monitor temperature, redness, swelling and foul-odor  IV antibiotics  No procedure on affected extremity

BREAST CANCER
NURSING INTERVENTION : Post-OP TEACH FOLLOW-UP care  Regular check-up  Monthly BSE on the other breast  Annual mammography

THE END
LUALHATI M. FLORANDA RN MAN

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