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CELLULAR ABERRATION by Louie A. Gallego, RN Safeguards against cancer Steps in controlling cancer Diet Early detection COMPARISON OF THE CHARACTERISTICS OF BENIGN AND MALIGNANT NEOPLASM Characteristics Benign Malignant Speed of growth Slow growth Aggressive growth; rapid cells division and growth Establish new site malignant lesions Invade surrounding tissues With poor cell differentiated Ability to migrate, cells move to distant areas of the body Destroy surrounding tissues Poor prognosis Can lead to death unless interventions are taken
CELLULAR ABERRATION A group of disorders characterized by abnormal cell growth and the ability to metastasize with potential in killing the host. CANCER The term “cancer” refers to the group of diseases in which cells grow and spread unrestrained throughout the body. Derives from the latin “crab” which means cancer Synonymous with neoplasm Acquire invasive characteristics, changes in occurring in surroundings. Is not a single disease with a single cause. CARCINOGENESIS Process of transformation from normal cell to a neoplastic cell INVASION Occurs when cancer cells infiltrate adjacent tissues surrounding the neoplasm. METASTASIS Occurs when malignant cells travel through the blood or lymph and invade other tissues and organs to form a secondary tumor. DIFFERENTIATION Refers to the process whereby cells develop specific structures and function is order to specialized in certain task. Top 5 cancer incidence by site & sex: MALE FEMALE Prostate Breast Lungs Lungs Colon Colon Urinary Tract Uterus Leukemia Leukemia & Lymphoma MEN High incidence of cancer of the lung and bladder Most common neoplasm aged 20 to 34 is TESTICULAR CANCER WOMEN BREAST CANCER followed by lung and bronchus, colon and rectum Classification of Tumor: 1. Benign- are tumors designated by attaching the suffix – oma to the cells of origin. e.g. Fibroma Chondroma Osteoma 2. Malignant- tumors that are capable of spreading by invasion and metastasis. e.g. Fibrosarcoma Chondrosarcoma
Grows by expansion Mode of growth Cell characteristic Metastasis Localized and encapsulated Well differentiated It does not metastasized No tissue damage Prognosis Very good prognosis Does not cause death unless localization affect vital function
CLASSIFICATION OF CANCER 1. CARCINOMA - Refers to a tumor arises from epithelial tissue, the name of the cancer identifies the location, e.g. basal cell carcinoma 2. SARCOMA - Refers to a tumor arising from supportive tissue; the name of the cancer identifies the specific tissue affected 3. LEUKEMIA - A malignant disorder of the blood-forming tissues of the bone marrow, spleen, and lymph system characterize by unregulated proliferation of WBCs and their precursors. 4. LYMPHOMA - A group of malignant neoplasm that affects the lymphatic system resulting in the proliferation of lymphocytes 5. MYELOMA NOMENCLATURE OF TUMORS Tissue of Origin Benign Malignant Connective tissue and derivatives Fibroma Lipoma Chondroma Fibrosarcoma Liposarcoma Chondrosarcama
Osteoma Blood Vessels Lymph vessels Brain coverings Hematopoietic cells Lymphoid tissue Smooth muscles Striated Muscles Epithelial tumors Stratified squamous Basal cells Liver cells Liver adenoma cell Squamos cell papilloma Leiomyoma Rhabdomyoma Hemangioma Lymphangioma Meningioma
Osteogenic Sarcoma Angiosarcoma Lymphangiosarcoma Invasive Meningioma Leukemias Malignant Lymphomas Leiomyosarcoma Rhabdomyosarcoma
Activation of oncogenes Mutation of the cell
Alteration of genes
Inactivation of cancer suppressor genes
Expression of altered gene products
Squamos carcinoma Basal carcinoma
Placental Hydatidiform Choriocarcinoma epethelium mole (trophoblast) PATHOGENESIS OF CANCER Cellular Transformation and Derangement Theory Failure of the Immune Response Theory Cellular Transformation and Derangement Theory conceptualizes that normal cells may be transformed into cancer cells due to exposure to some etiologic agents Failure of the Immune Response Theory advocates that all individuals possess cancer cells. However, the cancer cells are recognized by the immune response system. So, the cancer cells undergo destruction. Failure of the immune response system leads to inability to destroy the cancer cells. Flow Chart Depicting Molecular Basis of Cancer
Acquired (environmental) DNA damaging agent: --Chemicals Radiation Viruses Normal Cell Successful DNA repair DNA Damage Failure of DNA repair
Carcinogenesis Steps: 1. Imitation 2. Promotions 3. Latency 4. Progression 5. Invasion to neighboring organs Stages of Tumor Progression HYPERTROPY - Increase in size of normal cells ATROPHY - Shrinkage of cell size HYPERPLASIA Increase in number of normal cells METAPLASIA - Conversion from the normal pattern of differentiation of one type of cells into another type of cell not normal for that tissue DYSPLASIA Alteration in the shape, size, appearance, and distribution of cells ANAPLASIA - Disorganized, irregular cells that have no structure and have lots of
differentiation; the result is almost malignant Classification, Grading & Stages TNM Classification T (extent of primary tumor) TX – cannot be adequately assessed TO – no evidence of primary tumor TIS – Tumor in situ – localized; no spread T1- 4 progressive increase in size 1:5 cm < 2:6-9 cm 3:10-15 cm 4:15 cm > N (regional Lymph Node) Nx – cannot be assessed clinically NO – no evidence of regular node metastasis N1 – 4 increasing involvement of nodes Stages 0 – benign state I – spread to nearby tissue II – 2-5 cm sometimes involve lymph III – more than 5 cm spread – advanced spread to connective tissue. IV - Mestastasis Types of Metastasis Extension & Invasion 1. Lymphatic Spread 2. Seeding of body cavities & surfaces 3. Hematogenous spread ETIOLOGIC FACTORS (Carcinogens) 1. Viruses 2. Chemical carcinogens 3. Physical agents 4. Hormones 5. Genetics Viruses “oncogenic viruses” Prolonged or frequent viral infections may cause breakdown of the immune system or overwhelm the immune system. Chemical carcinogens act by causing cell mutation or alteration in cell enzymes and proteins E.g. 1. Industrial compounds – vinyl chloride, polycyclic aromatic hydrocarbons, fertilizers, weed killers, dyes, drugs 2. Hormones – estrogen, diethylstilbestrol (DES) 3. Foods, preservatives – nitrites, talc, food sweeteners, nitrosomines, aflatoxins, polycyclic hydrocarbons Physical agents 1. Radiation – x-ray or radioactive isotopes, sunlight/UV rays 2. Physical irritation or trauma – pipe smoking, multiple deliveries, jagged tooth, irritation of the tongue, “overuse of any organ/body part” Hormones estrogen as replacement therapy incidence of vaginal and adenocarcinoma increases cervical
Genetics oncogene → when exposed to carcinogens → changes in cell structure → becomes malignant PREDISPOSING FACTORS 1. Age – older individuals are more prone to cancer 2. Sex – women (more prone to breast, uterus and cervical cancer) while men (prostate and lung cancer) 3. Urban vs. Rural residence – cancer is more common among urban dwellers 4. Geographic distribution – due to influence of environmental factors such as national diet, ethnic customs, type of solutions. 5. Occupation 6. Heredity – greater risk with positive familial history 7. Stress – depression, grief, anger, aggression, despair of life stresses 8. Precancerous lesions – may undergo transformation cancer lesions and tumors 9. Obesity – studies have linked obesity to breast and colorectal cancer ASSESSMENT 1. NURSING HISTORY 2. PHYSICAL ASSESSMENT 3. DIAGNOSIS ASSESSMENT NURSING HISTORY any previous exposure to known or suspected risk factor health history lifestyle familial history PHYSICAL ASSESSMENT a. Identify WARNING SIGNAL OF CANCER C- change in bladder and bowel habits A- a sore that does not heal U- unusual bleeding or discharges T- thickening or lump in the breast I- Indigestion and difficulty in swallowing O- overt changes in wart or mole N- nagging cough and hoarseness of voice b. Implement SAFEGUARD AGAINST CANCER BASIC. Annual physical exam and blood examination. SKIN. Avoid overexposure to sunlight. ORAL. Annual oral examination. BREAST. Monthly BSE from age 20. COLON. Digital rectal exam for persons over age 40. Rectal biopsy and proctoscopic examination, Guaiac stool exam for persons age 50 and above. UTERUS. Annual Pap’s smear from age 40. LUNGS. Avoid cigarette smoking; annual chest x-ray c. Identify classification of cancer according to type of tissue evolve from. - carcinoma or sarcoma
d. Identify systemic effects 1. Anorexia, weakness, weight loss, muscle wasting. 2. Metabolic disturbances 3. Fluid and electrolyte imbalances 4. Pain 5. Hormonial imbalances e. Assist in diagnostic test DIAGNOSIS ASSESSMENT A. TISSUES SAMPLING B. IMAGING TECHNIQUES C. LABORATORY STUDIES D. ROUTINE LAB EXAMS TISSUES SAMPLING 1. Exfoliative cytology – used to study cells that the body has shed during the normal sequence of body tissue growth and development 2. Biopsy – surgical removal of a piece of tissue for microscopic examination. The most definitive method for diagnosing CA 3 KINDS: a. Needle biopsy – cells are aspirated through placed in the tissue b. Incisional biopsy – removing or taking a small sample out of tissues mass c. Excisional biopsy – involves removal all of the know tumor IMAGING TECHNIQUES DIRECT VISUALIZATION TREATMENT MODALITIES SURGERY
INDIRECT VISUALIZATION DIRECT VISUALIZATION involves introduction of fiber optic endoscopy tubes into hollow organs to view internal surfaces 1. Bronchoscopy Esophagoscopy 2. Gastroscopy 3. Sigmoidoscopy 4. Colonoscopy INDIRECT VISUALIZATION includes radiological and imaging test 1. Mammography 2. Barium enema 3. BSE 4. GI SERIES 5. Computed Tomography 6. MRI 7. Radioisotope studies 8. Ultrasound LABORATORY STUDIES TUMOR MARKERS Biochemical substance synthesized and release by tumor cell 1. Oncofetal antigen 2. Hormones 3. Isoenzymes 4. Tissue ROUTINE LAB EXAMS E.g. ALT, CBC, BILIRUBIN, bleeding time, HCG,
CHEMOTHERAPY BIOLOGIC RESPONSE MODIFIER SURGERY Often the primary treatment for CA and may be performed for various purposes. May be 1. Preventive 2. Diagnostic 3. Curative 4. Palliative RADIATION Often high energy ionizing radiation to treat tumors Used to kill the tumor, reduce the tumor size, relieve obstruction or decrease pain, causes lethal injury to DNA, so it can destroy rapidly multiplying CA cells as well as normal cells e.g. x–rays, gamma rays & radioactive particles THREE SAFETY PRINCIPLES : Time – refers to the length of exposure minimize time spent in close proximity to the radiation source (30 mins in 8 hr. shift) Distance – minimum distance of 6 ft., from the radiation source Shielding - use lead shields and other precautions to reduce exposure to radiation SOURCES EXTERNAL (Teletherapy) INTERNAL (Brachytherapy – sealed) SOURCES OF INTERNAL RADIATION : Implanted into affected tissue or body cavity Ingested as a solution, ingested as solution Injected as a solution into the bloodstream or body cavity Introduced thru a catheter into the tumor Sealed – involves temporarily implanting sealed applicators that contain radioactive substance into various organs of the body Unsealed – involves the administration of isotopes orally or by injection SIDE EFFECTS : Alopecia 1. Wear wig, hat, bonnet, bandana, scarf or anything that could be worn as a head dress. 2. Inform patient that hair will eventually grow back after chemotherapy. Skin reactions (erythema, dry/moist desquamation) 1. Observe for early signs of skin reaction and report. 2. Keep area dry.
RADIATION BONE MARROW TRANSPLANTATION
3. 4. 5. 6. 7. Wash area with WATER ONLY and pat dry. Do not apply ointments, powders or lotions. Do not apply heat, avoid direct sunshine or cold. Use soft cotton fabrics for clothing. Do not erase markings on the skin. These serve as guide for areas of irradiation. It is used in the treatment of leukemia, in conjunction with radiation or chemotherapy, it is usually harvested from the iliac crest then transfused intravenously.
1. Autologous – the client is infused with 2. 3.
own bone marrow harvested during remission disease Syngeneic – marrow donor is an identical twin Allogenic – the client is infused with donor bone marrow harvested from a healthy individual Malnutrition Infection related to immunosuppression Thrombocytopenia
Infection 1. Monitor blood counts weekly. 2. Good personal hygiene, nutrition and adequate rest. 3. Teach signs of infection to report to physician. Hemorrhage 1. Monitor platelet count. 2. Avoid physical trauma or use of aspirin. 3. Teach signs of hemorrhage. 4. Monitor stool and skin for signs of hemorrhage. 5. Use direct pressure over injection sites until bleeding stops. Fatigue 1. Plenty of rest and good nutrition. Weight loss due to anorexia, nausea and vomiting 1. Arrange meal times 2. Encourage bland foods 3. Provide small attractive meals 4. Avoid extremes of temperature 5. Administer antiemetics as ordered before meals Ulceration of oral mucosa (Stomatitis) 1. Administer analgesics before meals. 2. Bland diet 3. No smoking/alcohol 4. Good oral hygiene (saline rinses q2) 5. Sugarless lemon drops or mint to increase salivation. Diarrhea 1. Encourage low residue, bland, highprotein foods 2. Administer antidiarrheal drugs as ordered 3. Provide good perineal care 4. Monitor electrolytes particularly Na, K, Cl Anorexia, nausea and vomiting 1. Arrange meal times 2. Encourage bland foods 3. Provide small attractive meals 4. Avoid extremes of temperature 5. Administer antiemetics as ordered before meals Headache Social isolation BONE MARROW TRANSPLANTATION
SIDE EFFECTS : 1. 2. 3. Nursing Mgt . 1.
Provide private room for the hospitalized client for 6 – 8 wks 2. Encourage contact with significant others 3. Management of side effects CHEMOTHERAPY Uses antineoplastic agents to treat CA cells locally and systematically Provides palliative measure for the pt. Who has widespread metastasis Disrupts the cell cycle in various phases, interfering with cellular metabolism and reproduction. Cell kill hypothesis During each cycle a fixed percentage of cells are killed by chemotherapy, leaving some tumor cells remaining, this necessitates the repeated dosages of chemotherapy in order to reduce the number of cells, allowing the body’s immune system to destroy any remaining tumor cells. CONTRAINDICATIONS Infection Recent Surgery Impaired renal or hepatic function Recent radiation therapy Pregnancy Bone marrow depression Safety precautions in handling chemotherapeutic agents All used and unused equipment and drugs should be treated as hazardous wastes. Place contaminated material in leak proof labeled as “hazardous waste.” Prepare chemotherapeutic agents in a private and clean setting. Strict use of body protection techniques includes gloves, garment with close front, cuffed long sleeves, face shield and mask. Prevent spillage, use luer – lock fitting on syringes and IV sets. Flush immediately with water if it comes in contact with skin and mucous membranes. 5 MAJOR CATEGORIES
Neslie-Page |6 Alkylating agents
Biotherapy Involves replacing altered genes. DIETARY RECOMMENDATIONS AGAINST CANCER Avoid obesity. Cut down on total fat intake Eat more high fiber foods – raw fruits and vegetable, whole grain cereals. Include foods rich in Vitamin A & C in daily diet. Include cruciferous vegetables in the diet (broccoli, cabbage, cauliflower, brussel sprouts) Be moderate in the consumption of alcoholic beverages. Be moderate in the consumption of salt (cured, smoked and nitrate-cured foods).
Hormones and hormones antagonists Vinca Alkaloids
Nursing Interventions 1. GI SYSTEM Nausea and vomiting - Administer antiemetics. Diarrhea - Replace fluid – electrolyte losses, low fiber diet. Constipation – Increase OFI and fiber in diet. 2. INTEGUMENTARY SYSTEM Pruritus, uriticaria – Provide good skin care. Stomatitis – Provide oral care and avoid hot and spicy food. Alopecia – Reassure that it is only temporary and encourage to wear wigs, hats or head scarf. Skin pigmentation – Inform that it is temporary. Nail changes – Reassure that nails may grow normally after chemotherapy. 3. HEMATOPOIETIC SYSTEM Anemia – Provide frequent rest periods. Neutropenia – Protect from infection and avoid people with infection. Thrombocytopenia – Protect from trauma and avoid ASA (Aspirin). 4. GENITO-URINARY SYSTEM Hemorrhagic cystitis – Provide 2 to 3 L of fluids per day. Urine color changes – Reassure that it is harmless. 5. REPRODUCTIVE SYSTEM Premature menopause or amenorrhea – Reassure that menstruation resumes after chemotherapy. BIOLOGIC RESPONSE MODIFIER agents that make CA pts. Biologic response to the tumor cell more effective. 1. Immunotherapy 2. Biotherapy Immunotherapy Stimulates the body’s natural immune system that restrict and destroy CA cells a. Nonspecific b. Monoclonal antibody c. Cytokines - substance that immune system cells produce to enhance the immune system, normal growth regulating molecules possessing anti tumor abilities a. Interleukin - 2(IL-2) b. Interferons c. Hematopoietic growth factors
Antimetabolites Antitumor antibiotics
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