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KNOW LEWIS CHAPTER 16 FOR EXAM 1 CANCER

I did not prepare this but I added some Lewis references that follow the summary Must know
pain management and end of life care with any disease process that is related.
Cancer
Most cancer affects people older than 6 years of age but can happen at any age.
Cancer is a disease of abnormal growth, division and cell differentiation.
Second leading cause of death in the U.S.
Affects all ages and men and women the ratio is 2:1
There are over 200 types of cancer and it can affect any organ.
Cancer
The cells that infiltrate tissues and gain and gain access to lymph and blood vessels, which carry
the cells to other areas of the body is called metastasis.
Cancer is a disease process that begins when an abnormal cell is transformed by the genetic
mutation of the cellular DNA. This abnormal cell forms clones (two daughter cells) and begins to
proliferate abnormally ignoring growth-regulating signals in the environment surrounding the
cell.
The cells develop their own characteristics and changes occur in surrounding tissues.

General types
Adenocarcinomas: glandular tissue
Sarcomas: connective, muscle and bone tissue
Glionas: tissue of the brain and spinal cord
Melanomas: pigmented cells
Lymphomas: lymphatic tissue
Leukemia: Leukocytes
Erythroleukemia: erythrocytes
Cancer cells
Have tumor: associated antigen on their surface. Lymphocytes detect and destroy the cells.
Through immunologic surveillance tumor cells are destroyed. Unfortunately, sometimes this
doesnt work.


Proliferate Patterns
Cancerous cells are described as malignant neoplasms.
Benign and malignant cells differ in many cellular growth characteristics, including method and
rate of growth, ability to metastasize or spread, general effects, destruction of tissue, and ability
to cause death.
The degree of anaplasia (lack of differentiation of cells) ultimately determines the malignant
potential.
Characteristics of malignant cells
Contain proteins called tumor-specific antigens.
They contain less fibronectin, which is a cellular cement.
They are therefore less cohesive and do not adhere to adjacent cells as readily.
RNA are larger and more numerous in malignant cells, perhaps because of RNA synthesis.
Mitosis (cell division) occurs more frequently in malignant cells than in normal cells.
Invasion and metastasis
Occurs in malignant disease process and have the ability to spread or transfer cancerous cells
form one organ or body part to another by invasion and metastasis.
Invasion can couple of ways:
Mechanical pressure exerted by rapidly proliferating neoplasm may force finger like projections
of tumor cells into surrounding tissue and intestinal spaces.
Additionally
Malignant cells are less adherent and may break off from the primary tumor and invade adjacent
structure(s).
They are thought to produce specific destructive enzymes, such as collagenases (specific to
collagen), plasminogen activators (specific to plasma) and lysosmal hydrolyses.
These enzymes are thought to destroy surrounding tissue, including the structural tissues of the
vascular basement membrane, facilitating invasion of malignant cells.
Metastasis is the dissemination or spread of malignant cells, from the primary tumor to distant
sites by direct spread of tumor cells to body cavities or through lymphatic and blood circulation.


Metastasis
Cancer cells first develop from a mutation in a single cell. Then it can spreads in 3 ways:
By circulation through the blood and lymphatic system.
By accidental transplantation during surgery
By spreading to adjacent organs and tissues.
METASTATIC MECHANSIMS
Lymphatic spread: the most common which is transport of tumor cells through the lymphatic
circulation.
Tumor emboli enter the lymph channels by way of the interstitial fluid that communicates with
lymphatic fluid.
After entering the lymphatic circulation, malignant cells either lodge in the lymph nodes or pass
between lymphatic and venous circulation.
Hematogenous spread
Disseminated through the bloodstream.
Few malignant cells can survive the turbulence of the arterial circulation, insufficient
oxygenation, or destruction by the bodys immune system.
The malignant cells that do not survive the hostile environment are able to attach to endothelium
and attract fibrin, platelets, and clotting factors to seal themselves from immune system
surveillance.
Angiogenesis
Malignant cells also have the ability to induce the growth of new capillaries form the host tissue
to meet their needs for nutrients and oxygen.
This is called angiogenesis.
This is how emboli enter the systemic circulation and travel to distant sites.




Malignant transformation/carcinogenesis (see Lewis p.264)
Is thought to be a three step process
Initiation
Promotion
Progression
Initiation
Initiators or carcinogens escape normal enzymatic mechanisms and alter the genetic structure of
the cellular DNA and a cellular mutation occurs. This is irreversible.
Many carcinogens can be detoxified by protective enzymes but if they fail, can alter the cellular
DNA.
DNA repair is possible but must occur before division or daughter cells will have the same
alteration.
Promotion
Repeated exposure to carcinogens causes the expression of abnormal or mutant genetic
information. There may be a long latency period (up to 40 years) then the tumor suppressor
genes become mutated and lose their ability to turn off.
Promoters include dietary fat, obesity, cigarette smoking, alcohol, ad severe stress.
Activity of promoters is reversible and withdrawal of the promoters can reduce the risk of
neoplasms.
Progression
The cellular changes formed during initiation and promotion now exhibit increased malignant
behavior.
Can invade adjacent tissue and metastasize.
Most frequent sites of metastasis are the brain, bone and liver.
The Ca cells lose their contact inhibition and this is how they progress.
Etiology/carcinogens
Chemical - 6,000 chemicals like soot, tar, nicotine, asbestos, smoked foods, arsenic, chemo
drugs, alcohol, high fat and beef diet. Smoking is the #1 killer. It accounts for at least 30%
OF CANCER DEATHS.
Virus and bacteria: HIV, HPV (HUMAN PAPILLOVIRUS) , EBV (EPSTEIN VIRUS) , H2V2,
HEP B
Physical- Implants, cellophane, sunlight, radiation, radon
Genetic (directly inherited) and familial factors: Runs in the family. Inherited (genetics),
environmental, cultural or lifestyle factors or chance alone.
Etiology/carcinogens
Dietary factors: carcinogenic factors or non-carcinogenic factors.
Hormonal factors: Hormonal imbalance either by your own bodys hormone production or by
administration of endogenous hormones.

Tumor Staging and Grading (see Lewis p.268 269)
Staging determines the size of the tumor and the existence of metastasis.
T refers to the extent of the primary tumor
N refers to lymph node involvement
M refers to the extent of metastasis.
Grading refers to the classification of the tumor cells.
See Staging or TNM classification system (Lewis Tables 16-4, 16-5)
Diagnostic Methods
X-ray
Endoscopic exams
Urine and stool
Chem 7 and CBC
Ultrasound
MRI
CT
Biopsy
Pap smear
Tumor markers
Polymerase chain reaction
Screening test: Stool guaiac, CEA, Pap, PSA, mammogram



Cancer treatment
Goal of treatment is: curative, control, or palliative
Types of treatment include: surgery, radiation, chemo, hormonal therapy, biotherpay
Surgery is the oldest form of CA treatment (best results with slow growing tissue). Only enough
tissue that is necessary is removed.
Management of cancer
Should be based on the type of cancer.
The range of treatment goals range from (Cure), containment of cell growth (control), or relief of
symptoms associated with the disease (palliation).
Open communication is vital, the patient and family must have a clear understanding of the
treatment options.
There are multiple methods to treat CA (radiation therapy, chemo, biologic response modifier
therapy, etc..)
Diagnostic surgery
Biopsy is performed to obtain a tissue sample for analysis of cells suspected to be malignant.
There are three types of biopsy.
Excisional biopsy: Must common because of easily accessibility of the skin, breast, upper and
lower resp. tract. In many cases the surgeon can remove the entire tumor.
Incisional biopsy: This is done if the tumor is too large. A wedge is removed.
Needle biopsy: done to sample suspicious masses that are easily accessible. The procedure is
fast, relatively inexpensive and easy to perform.
Surgery as primary treatment
When surgery is the primary treatmen removing the entire tumor is the goal.
Local excision: done when the mass is small.
Wide or radical excision: removal of the primary tumor, lymph nodes, etc that might be high risk
for tumor spread.
Video assisted surgery
Electro surgery (electrical current to destroy the tumor)

Surgery as primary treatment
Cyrosurgery uses liquid nitrogen to freeze tissue to cause cell destruction.
Chemosurgery: topical chemo and layer by layer surgical removal of abnormal tissue.
Laser surgery: makes use of light and energy aimed at an exact tissue location and depth to
vaporize cancer cells.
Prophylactic surgery
Removing non-vital tissues or organs that are likely to develop cancer. Colectomy and
mastectomy are the two most common types.
The following factors are considered before performing this surgery.
Family history
Presence or absence of symptoms
Potential risk and benefits
Ability to detect cancer at an early state
Patients acceptance of the post op outcome.

Palliative surgery
Making the patient as comfortable as possible because surgical cure is not an option. The goal is
maintaining a higher quality of life (not curative).
Honest and informative communication with the patient and family about the goal of surgery is
essential to avoid false hope and disappointment.
Reconstructive surgery

This is done after curative or radical surgery to improve function or obtain a more desirable
cosmetic effect.
Could be done in stages or in one operation.
Nursing management in cancer surgery
Education
Emotional support
Encouraging them to take active roles in decision making when possible.
Communicate frequently with the doc to get correct information so that you may give that info to
the family.
Never tell the family something the physician has not told them yet.

Radiation therapy
This is used to interrupt cellular growth.
Radiation can cure some types of cancer such as non Hodgkins, localized ca of the head and
neck and cancers of the uterine cervix.
Radiation can also be used as a form of palliative care to reduce the symptoms of metastasis
disease.
Radiation therapy
Electromagnetic rays (x-ray and gamma rays) and particles (electrons, protons, neutrons and
alpha particles) can lead to tissue destruction.
The most harmful tissue disruption is the alteration of the DNA molecule within the cells of the
tissue.
Cells are the most vulnerable to the disruptive effects of radiation during DNA synthesis and
mitosis.
So the body tissues that are undergoing frequent cell division are the most sensitive.
External radiation
Can be used to destroy cancerous cells at the skin surface or deeper in the body.
The higher the energy, the deeper the penetration into the body.
Some centers are using intraoperative radiation therapy (IORT). Which involves using a single
dose of high fraction radiation therapy to expose the tumor bed while the body cavity is open
during surgery.
Toxicity is minimized because the radiation is precisely targeted to the diseased areas, and
exposure to overlying skin and structure.
Internal radiation
Brachytherapy: delivers a high dose of radiation to a localized area.
Can be implanted by way of needle, seeds, beads, or catheters into the body cavity.
Usually done to treat gynecologic cancers
Read Lewis


Radiation dosage
It depends on the sensitivity of the target tissue to radiation and on the tumor size.
The lethal tumor dose is defined as that dose that will eradicate 95% of the tumor yet preserve
normal tissue.
Repeated radiation treatments over time also allow for the periphery of the tumor to
reoxygentaed repeatedly because tumors shrink from the outside inward.
Toxicity
Toxicity of radiation is usually localized to the region being irradiated.
Toxicity may be increased when the patient is also on chemotherapy.
Acute local reaction occurs when normal cells in the treatment area are also destroyed and
cellular death exceeds cellular regeneration.
Body tissues most affected are those that normally proliferate rapidly, such as skin, epithelial
lining of the GO tract, and the bone marrow.
Toxicity
Alopecia (Rare Head/Neck Usually seen in some chemotherapy)
Shedding of skin (desquamation)
After treatment these things can correct themselves.
Xerostomia (dryness of mouth), change and loss of taste and decreased salivation.
Thrombocytopenia
Nursing management of radiation therapy
Protecting the skin and oral mucosa (make sure you instruct the patient not to use things that will
irritate the skin. No lotions, ointments, powders on the area.
Protecting the caregivers (protect from radiation) Shielding equipment.
Chemotherapy
Antineoplastic agents are used in an attempt to kill tumor cells by interfering with cellular
functions and reproduction.
Used to treat systemic disease rather than lesion that are localized and amenable to surgery or
radiation.

Cell kill and the cell cycle
IMPORTANT
Each time a tumor is exposed to a chemo agent a percentage of tumor cells is destroyed.
Needs to be repeated to achieve regression of the tumor.
The goal is to eradicate enough of the tumor so that the remaining rumor cells can be destroyed
by the bodys immune system.
Reproduction of both healthy and malignant cells follows the cell cycle pattern.
Cell kill and the cell cycle
The cell cycle is the time required for one tissue cell to dived and reproduce two identical
daughter cells.
The cell cycle of any cell has four distant phases, each with a function.
G1 phase: RNA and protein synthesis
S phase: DNA synthesis occurs
G2: premiotic phase: DNA synthesis is complete.
Mitosis: cell division occurs.
IMPORTANT
Please read and understand cell cycle (Lewis p. 262).
Classification of chemotherapeutic
Many of these drugs are specific to the cell cycle.
(READ Lewis p 273 277 Table 16-7 16-8)
Administration of chemo agents
Can be administered in the hospital, clinic or home setting by topical, oral, IV, IM , sub Q,
arterial, etc. to name a few.
Administration type depends on the type of agent, the required dose and the type location and
extent of tumor being treated.
Dosage
Dosage of antineoplastic agents is based primarily on the patients total body surface.
Special care must be taken whenever IV vesicant agents (Lewis Fig. 16-11) are administered.
Vesicants: are those agents that, if deposited into the subcutaneous tissue (see extravasation),
cause tissue necrosis and damage to underlying tendons, nerve, and blood vessels.
Dosage
Careful selection of peripheral veins, skilled venipuncture, and careful drug administration are
essential (ports and tunnels are preferred).
Indications of extravasation:
Absence of blood return from the IV catheter.
Resistance to flow of IV fluid
Swelling, pain, or redness at the site.
Toxicity
Can be acute or chronic
SE: nausea, vomiting the most common
To minimize discomfort some antiemetic medications are necessary (when should the
antiemetic be administered?) for the first week at home after chemo. Relaxation techniques and
imagery.
Alternating the patients diet to include small frequent meals, bland foods, and comfort foods may
reduce the frequency or severity of these symptoms.
Toxicity
Myelosuppression (depression of the bone marrow)
Neutropenia
Chemo can damage the kidneys
Decreased cardiac ejection fracture (volume of blood ejecting from the heart on each beat) and
signs off CHF can be seen.
Toxicity
Reproductive system (testicular and ovarian function can be destroyed. (What is the implication
for the patient who is still in their child bearing years?)
Neurological system: Peripheral neuropathies, loss of deep tendon reflexes and paralytic ileus.

Management of Chemo
Assess fluid and electrolytes
Modify risk for infection
Administering Chemo
Implementing safeguards

Bone marrow transplant
(READ and understand Lewis p. 290 292)
Nursing management of bone marrow transplant
Implementing pre transplantation care
Providing care during treatment
Proving post transplantation care
Caring for the donors






Hyperthermia
Has been used for many years to destroy tumors in human cancers.
Research has shown that malignant cells are more sensitive than normal cells to the harmful
effects of high temp for several reasons.
Malignant cells lack repair mechanisms necessary to repair cell damage by elevated temp.
Must tumor cells lack an adequate blood supply to provide needed oxygen during periods of
increased cellular demand
Lack blood vessels of adequate size for dissipation of heat.
Hyperthermia
Hyperthermia is most effective when combined with radiation.
Side Effects:
Skin burns, and tissue damage, fatigue, hypotension, peripheral neuropathy, n/v, and electrolyte
imbablance.
Biologic Response Modifiers
BRM s are naturally occurring or recombinant agents or treatment methods that can alter the
immunologic relationship between the tumor and the cancer patient to provide a therapeutic
benefit.
The goal is to destroy or stop the malignant growth.
The different types are nonspecific biologic response modifiers, cytokines, interferons,
interleukins, colony stimulating factors, tumor necrosis factor and retinoids
Nonspecific biologic response modifiers
BCG is injected and these agents serve as antigens that stimulate an immune response;
The hope is that the stimulated immune system will then eradicate malignant cells.
Monoclonal antibodies
Another type of BRM that became available through technologic advances, enabling
investigators to grow and produce specific antibodies for specific malignant cells.

Cytokines
Substances produced by cells of the immune system to enhance the production and function of
components of the immune system.
They are grouped in families: Interferons, interleukins, colony-stimulating factors and tumor
necrosis factors.
Interferons
The exact antitumor effects of IFN have not been thoroughly established, it is thought that they
either stimulate the immune system or assist in preventing tumor growth.
It is administered through subcutaneous, IM, and IV.
Interleukins
Primarily produced by lymphocytes and monocytes. They act by signaling and coordinating
other cells of the immune system.
Nursing interventions
Maintain tissue integrity
Managing stomatitis (inflammation of oral tissue) develops within 5-10 days after the patient
relieves certain chemo s. Good oral hygiene.
Explain alopecia
Managing malignant skin lesions
Promoting nutrition
Relieving pain
Decreasing fatigue improving body image and self esteem
Assisting in the grieving process
Potential complications
Septic shock
Infection
Bleeding and hemorrhage

Care of the patient with advanced cancer
Hospice
Figures: 16-1,4,6,7,8,10,16,
Tables: 16-4,5,6,*7*,9,10,*12*,13,*14*,15,16, 19,20