INTRODUCTION

INTRODUCTION TO CANCER

Terminologies:

1. Oncogenesis/Carcinogenesis – genetic mechanism where normal cells or genes are

transformed into cancer cells. Caused by imbalance or alteration between PROTO
ONCOGENES (growth promoting regulatory cells) and ANTI-ONCOGENES (growth
inhibiting regulatory genes).
2. Carcinogen – substance or agent that can cause cancer.
3. Oncology – branch of medicine which involves the study and treatment of tumors or
cancer.
4. Oncology nurse – has a special training in such modalities such as chemotherapy.
Have special skills in assisting the client and family with the psychosocial issues
associated with cancer & terminal illness.

CANCER

 Cancer is a group of cells that grows out of control, taking over the function of the
affected organ. Cancer cells are described as poorly constructed, loosely formed, and
without organization.
 Cancer cells continue to grow and divide even when there is no need to do so. Instead
of dying, they outlive normal cells and continue to form new abnormal cells. They
compete with normal cells for the blood supply and nutrients that normal cells need.
 Cancer cells often travel to other parts of the body where they begin to grow and replace
normal tissue. This process is called metastasis.
 The immune system seems to play a role in the development and spread of cancer.
When the immune system is intact, isolated cancer cells will usually be detected and
removed from the body. When the immune system is impaired as in people with
immunodeficiency diseases, people with organ transplants who are receiving
immunosuppressant drugs, or in AIDS, there is usually an increase in cancer incidence.

PATHOPHYSIOLOGY:

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 a clone and begins to proliferate
abnormally, ignoring growth-regulating signals in the environment surrounding the cell. The cells
acquire invasive characteristics, and changes occur in surrounding tissues. The cells infiltrate
these tissues and gain access to lymph and blood vessels, which carry the cells to other areas
of the body.

Cancer Cell Proliferation – genetic mutation of cellular DNA results to an abnormal cell. This
cell may create a clone and begins to proliferate, ignoring growth – regulating signals. Patterns
of growth may be hyperplasia, metaplasia, dysplasia, anaplasia, and neoplasia.
Tumor
 Normal cells that reproduce abnormally result in neoplasms, or tumors.
 Neoplasm is a term that combines the Greek word neo, meaning “new,” and plasia,
meaning “growth,” to suggest new tissue growth.
 A neoplasm is an enlargement of tissue and the formation of an abnormal mass.
 A neoplasm develops as cells multiply. Not all neoplasms contain cancer cells; however,
a neoplastic cell is responsible for producing a tumor and shows a lively growing cell.

Comparison between Benign and Malignant Tumor

Benign Malignant
Growth Rate Typically slow expansion Often rapid with cell numbers
doubling normal cell growth;
malignant cells infiltrate
surrounding tissue

Cell Features Typical of the tissue of origin Atypical in varying degrees of

the tissue or origin; altered
cell membrane; contains
tumor-specific antigens

Tissue Damage Minor Often causes necrosis and

Metastasis
Recurrence after treatment
Not seen; remains localized at
origin site
Seldom recurrence after
surgical removal
ulceration of tissue
Often spreads to form tumors
in other parts of the body
Recurrence can be seen after
surgical removal and
following radiation and
chemotherapy

Related terminology Hyperplasia, polyp, and Cancer, malignancy, and

benign neoplasia malignant neoplasia
Prognosis Not injurious unless location Death if uncontrolled
causes pressure
or obstruction to vital organs

Malignant Cell

 Cell membrane – tumor specific antigen (protein)

 Nucleus – Pleomorphism (large and irregular)
 Mitosis – more frequent
 Malignant may metastasis or invade distant sites of the body.
 Mode of Metastasis:
Invasion, which refers to the growth of the primary tumor into the surrounding host
tissues, occurs in several ways. Mechanical pressure exerted by rapidly proliferating
neoplasms may force fingerlike projections of tumor cells into surrounding tissue and
interstitial spaces. Malignant cells are less adherent and may break off from the primary
tumor and invade adjacent structures.
 a. Lymphatic spread – tumor emboli may enter lymph channels via interstitial fluid or
they may invade/penetrate lymphatic vessels. Most common mechanism of
metastasis.
b. Hematogenous spread – dissemination of malignant cell through the blood stream.
Malignant cells will attach to the endothelium and will attract fibrin, platelet, which will
result to sealing.
c. Angiogenesis – ability to induce the growth of new capillaries from the host to meet
their needs for nutrients and oxygen.

CARCINOGENESIS
Molecular Process
Malignant transformation, or carcinogenesis, is thought to be at least a three-step cellular
process, involving initiation, promotion, and progression.

1. Initiation
 During initiation, initiators (carcinogens), such as chemicals, physical factors, and
biologic agents, escape normal enzymatic mechanisms and alter the genetic structure of
the cellular DNA. Normally, these alterations are reversed by DNA repair mechanisms or
the changes initiate programmed cellular death. Occasionally, cells escape these
protective mechanisms, and permanent cellular mutations occur.

2. Promotion
 During promotion, repeated exposure to promoting agents (cocarcinogens) causes the
expression of abnormal or mutant genetics information even after long latency periods.
Latency periods for the promotion of cellular mutations vary with the type of agent and
the dosage of the promoter as well as the innate characteristics of the target cell.
 Cellular oncogenes are responsible for the vital cellular functions of growth and
differentiation. Cellular proto-oncogenes act as an “on switch” for cellular growth. Proto-
oncogenes are influenced by multiple growth factors that stimulate cell proliferation
 Just as proto-oncogenes “turn on” cellular growth, cancer suppressor genes “turn off,” or
regulate, unneeded cellular proliferation. When suppressor genes mutate or lose their
regulatory capabilities, malignant cells are allowed to reproduce.
 The p53 (TP53) gene is a tumor suppressor gene that is frequently implicated in many
human cancers. This gene determines whether cells will live or die after their DNA is
damaged. Apoptosis is the innate cellular process of programmed cell death.
Alterations in TP53 may decrease apoptotic signals, thus giving rise to a survival
advantage for mutant cell populations.

3. Progression
 During progression, the altered cells exhibit increased malignant behavior. These cells
have a propensity to invade adjacent tissues and to metastasize. Agents that initiate or
promote cellular transformation are referred to as carcinogens.
RISK FACTORS:

1. Viruses: Oncogenic virus - Viruses are thought to incorporate themselves in the

genetic structure of cells, thus altering future generations of that cell population, perhaps
leading to cancer.
a. Retroviruses – HTVL-1 (Leukemia), HIV
b. DNA viruses – papillomavirus, EB virus, Hepatitis B
c. Epstein Barr virus – Burkitt Lyphoma
d. Bacteria – helicobacter pylori
2. Physical agents: Radiation - Exposure to ionizing radiation can occur with repeated
diagnostic x-ray procedures or with radiation therapy used to treat disease. Excessive
exposure to the ultraviolet rays of the sun, especially in fair-skinned, blue- or green-eyed
people, increases the risk of skin cancers.
a. High frequency/Ionizing – medical equipment, occupation, nuclear warfare
b. Lower frequency – UV radiation
c. Very Low frequency radiation – electrical appliance, transformers, power lines
3. Chemical Agents - About 75% of all cancers are thought to be related to the
environment. Most hazardous chemicals produce their toxic effects by altering DNA
structure in body sites distant from chemical exposure. The liver, lungs, and kidneys are
the organ systems most often affected, presumably because of their roles in detoxifying
chemicals. Many chemical substances found in the workplace have proved to be
carcinogens or cocarcinogens. The extensive list of suspected chemical substances
continues to grow and includes:
a. Tobacco
b. Aromatic amines
c. Aniline Dyes
d. Pesticides
e. Formaldehydes
f. Arsenic
g. Soot
h. Tars
i. Asbestos
j. Benzene
k. Betel nut and lime
l. Cadmium
m. Chromium compounds
n. Polyvinyl chloride
4. Genetics
a. Cancer in two or more relatives
b. Cancer in family members younger than 50
c. Same type of cancer in several family members
d. Family members with more than one type of cancer
e. Rare cancer in one or more family members
5. Dietary Factors – The risk of cancer increases with long-term ingestion of carcinogens
or cocarcinogens or chronic absence of protective substances in the diet.
a. Fats
b. Alcohol
c. Salt cured or smoked meat
d. Nitrate and nitrite containing foods – bacon
e. Sweeteners
f. Nitrosamine – rubber baby nipples
 g. Aflatoxins – nuts, peanut butter, cheese, ,olds
h. Talc – chewing gum, polished rice salami
6. Hormonal Agents – Diethystilbesterol, estrogen, progesterone. Tumor growth may be
promoted by disturbances in hormonal balance, either by the body’s own (endogenous)
hormone production or by administration of exogenous hormones.

CANCER CACHEXIA
 Many cancers are associated with weight loss and wasting of body fat and muscle
tissue, accompanied by profound weakness, anorexia, and anemia. This wasting
syndrome is often referred to as the cancer anorexia-cachexia syndrome.
 The cause of the cancer anorexia-cachexia syndrome is probably multifactorial, resulting
from tumor or host deprived factors that cause anorexia directly by acting on satiety
centers in the hypothalamus or indirectly by injuring tissues that subsequently release
anorexigenic substances.

ROLE OF THE IMMUNE SYSTEM

 In humans, malignant cells are capable of developing on a regular basis. However,
some evidence indicates that the immune system can detect the development of
malignant cells and destroy them before cell growth becomes uncontrolled. When the
immune system fails to identify and stop the growth of malignant cells, clinical cancer
develops.
 Patients who are immunocompromised have an increased incidence of cancer. Organ
transplant recipients who receive immunosuppressive therapy to prevent rejection of the
transplanted organ have an increased incidence of lymphoma, Kaposi’s sarcoma,
squamous cell cancer of the skin and cervical and anogenital cancers.
 Patients with immunodeficiency diseases, such as acquired immunodeficiency syndrome
(AIDS), have an increased incidence of Kaposi’s sarcoma, lymphoma, rectal cancer, and
head and neck cancers
 Age-related changes, such as declining organ function, increased incidence of chronic
diseases, and diminished immunocompetence, may contribute to an increased incidence
of cancer in older people.

DETECTION AND PREVENTION OF CANCER

PRIMARY PREVENTION
 Primary prevention is concerned with reducing the risks of disease through health
promotion strategies. By acquiring the knowledge and skills necessary to educate the
community about cancer risk, nurses in all settings play a key role in cancer prevention.
One way to reduce the risk of cancer is to help patients avoid known carcinogens.
 Another strategy involves encouraging patients to make dietary and lifestyle changes
(smoking cessation, decreased caloric intake, increased physical activity) that studies
show influence the risk for cancer. Nurses use their teaching and counseling skills to
provide patient education.
SECONDARY PREVENTION
 Secondary prevention programs promote screening and early detection activities.

American Cancer Society (ACS) Guidelines of High Risk Individuals

1. Fecal Occult Blood Test (Guaic Test)

- 50 years old
- Yearly
Nursing Considerations:
- 2-3 days prior to the exam, instruct to patient to abstain from:
 Red meat, wine, raisins, chocolate, Ferous Sulfate, NSAIDS, Anticoagulants,
Corticosteroid
This will yield a false positive result
 Vitamin C and Vitamin K
This will yield a false negative result
Results:
Green (-)
Blue (+)

2. Sigmoidoscopy
- Lower GI endoscopic procedure
- 50 years old above
Nursing Considerations:
- Instruct the client:
 2-3 days before procedure: decrease fiber diet
 1 day before the procedure: Clear Liquid Diet (CLD)
 Night before: NPO, Laxative
 The day of the procedure: Enema

3. Digital Rectal Exam

- 50 years old above
Contraindications:
 Heart problems
 Imporforated anus

4. Pap Smear
- 18 years old above
- Should began approximately 3 years after a woman begins having vaginal
intercourse, but no later than 21 years old
- Every 3 years if 3 (-) results; yearly if there is one (+) result
- Yearly for sexually active and 40 years old above
Preparation:
  Avoid coitus 3 days before exam
 Avoid douching 1 day prior to exam
 No pap smear during menstruation

5. Breast Self-Examination
- 20 years old
- 7 days or 1 week after menstruation during shower
- 40 years old yearly

6. Mammography
- 25-40 years old yearly

7. Testicular Self-Examination
- Monthly
- Same day of each month
- 12-15 years old
- During shower

STAGING AND GRADING

Staging - determines the size of the tumor and the existence of local invasion and distant
metastasis.

TNM Classification System

T – Primary Tumor
Tx – Primary tumor cannot be assessed
To – no evidence of primary tumor
Tis – confined within the cortex (carcinoma in situ)
T1, T2, T3, T4 – invade beyond the cortex; increasing in size or extent or primary tumor

N – Regional Lymph Node

Nx – regional lymph nodes cannot be assessed
No – no regional lymph node metastasis
N1, N2, N3 – increasing involvement of regional lymph nodes

M – Distant Metastasis
Mx – presence distant metastasis
Mo – no distant metastasis
M1 – with distant metastasis

Grading - refers to the classification of the tumor cells. Grading systems seek to define the type
of tissue from which the tumor originated and the degree to which the tumor cells retain the
functional and histologic characteristics of the tissue of origin (differentiation).
Hispathologic Grade
Gx – grade cannot be assessed
G1 – well differentiated
G2 – moderately differentiated
G3 – poorly differentiated
G4 – undifferentiated

MANAGEMENT OF CANCER
Treatment options offered to cancer patients should be based on treatment goals for each
specific type of cancer. The range of possible treatment goals may include complete eradication
of malignant disease (cure), prolonged survival and containment of cancer cell growth
(control), or relief of symptoms associated with the disease (palliation).

1. Surgery - it may be diagnostic, curative/ablative, prophlylactic, palliative (debulking) or

reconstructive. Removal of entire cancer is the ideal and most frequent used treatment
method.

Biopsy - is usually performed to obtain a tissue sample for analysis of cells suspected to be
malignant. The choice of biopsy is determined by the size and location of the tumor.
.
1. Excisional – It is the removal of entire tumor. This is most frequently used for easily
accessible tumors of the skin, breast, and upper or lower gastrointestinal and upper
respiratory tracts
2. Incisional – is performed if the tumor mass is too large to be removed. In this case, a
wedge of tissue from the tumor is removed for analysis. The cells of the tissue wedge
must be representative of the tumor mass so that the pathologist can provide an
accurate diagnosis. If the specimen does not contain representative tissue and cells,
negative biopsy results do not guarantee the absence of cancer.
3. Needle biopsy – are performed to sample suspicious masses that are easily accessible,
such as some growths in the breasts, thyroid, lung, liver, and kidney. Needle biopsies
are most often performed on an outpatient basis. They are fast, relatively inexpensive,
easy to perform, and usually require only local anesthesia.

Prophylactic
Prophylactic surgery involves removing nonvital tissues or organs that are at increased risk to
develop cancer. The following factors are considered when physicians, nurses, patients, and
families discuss possible prophylactic surgery:
 Family history and genetic predisposition
 Presence or absence of symptoms
 Potential risks and benefits
 Ability to detect cancer at an early stage
 The patient’s acceptance of the postoperative outcome

Palliative Surgery
When cure is not possible, the goals of treatment are to make the patient as comfortable as
possible and to promote quality of life as defined by the patient and his or her family. Palliative
surgery is performed in an attempt to relieve complications of cancer, such as ulceration,
obstruction, hemorrhage, pain, and malignant effusion
Reconstructive Surgery
Reconstructive surgery may follow curative or radical surgery in an attempt to improve function
or obtain a more desirable cosmetic effect. It may be performed in one operation or in stages.
The surgeon who will perform the surgery discusses possible reconstructive surgical options
with the patient before the primary surgery is performed. Reconstructive surgery may be
indicated for breast, head and neck, and skin cancers. The nurse recognizes the patient’s needs
and the impact that altered functioning and body image may have on quality of life. The nurse
provides the patient and family with opportunities to discuss these issues. The individual needs
of the patient undergoing reconstructive surgery must be accurately assessed and addressed.

RADIATION THERAPY
Radiation may be used to cure cancer, as in thyroid carcinomas, localized cancers of the head
and neck, and cancers of the uterine cervix. Radiation therapy may also be used to control
malignant disease when a tumor cannot be removed surgically or when local nodal metastasis
is present, or it can be used neoadjuvantly (prior to local definitive treatment) with or without
chemotherapy to reduce the size of a tumor to enable surgical resection.

2 TYPES OF IONIZING RADIATION

1. Electromagnetic ray (x-ray & gamma rays)
2. Particulate radiation (electrons, beta particles, protons, neutrons, and alpha particles)

The most harmful tissue disruption is the direct alteration of the DNA molecule within the cells of
the tissue. Ionizing radiation breaks the strands of the DNA helix, leading to cell death. It can
also lead to the formation of free radicals and irreversibly damage DNA. If the DNA is incapable
of repair, the cell may die immediately, or it may initiate cellular suicide, a genetically
programmed cell death.

Administration of Radiation
1. External Radiation (Teletherapy)
 The energy utilized in EBRT is either generated from a linear accelerator or from
a unit that generates energy directly from a core source of radioactive material
such as a GammaKnifeTM unit. Through computerized software programs, both
approaches are able to shape an invisible beam of highly charged electrons to
penetrate the body and target a tumor with pinpoint accuracy.
 Depending on the size, shape, and location of the tumor, different energy levels
are generated to produce a carefully shaped beam that will destroy the targeted
tumor, yet spare the surrounding healthy tissue and vital organs in an effort to
reduce the treatment toxicities for the patient.
Nursing Intervention:
 Inform they are not radioactive after the procedure
 Wash the area with very warm water with minimal soap
 Pat dry
 Don’t remove the markings
 Never apply medication without prescription
 Side effects depends on the site
 2. Internal Radiation (Brachytherapy)
 Internal radiation implantation, or brachytherapy, delivers a high dose of radiation
to a localized area.
 Internal radiation can be implanted by means of needles, seeds, beads, or
catheters into body cavities (vagina, abdomen, pleura) or interstitial
compartments (breast, prostate).
 Brachytherapy may be delivered as a temporary or a permanent implant.
Temporary applications may be delivered as high-dose radiation (HDR) for short
periods of time or low-dose radiation (LDR) for a more extended period of time.
The primary advantage of HDR sources of brachytherapy is that treatment time is
shorter, there is reduced exposure to personnel, and the procedure can typically
be performed as an outpatient procedure over several days. HDR brachytherapy
can be used for intraluminal, interstitial, intracavitary, and surface lesions.

Types of Brachytherapy
a. Intraluminal brachytherapy – involves the insertion of catheters or hollow tubes into
the lumens of organs so that the radioisotope can be delivered as close to the tumor bed
as possible. Obstructive lesions in the bronchus, esophagus, or bile duct can be treated
with this approach.

b. Intracavitary radioisotopes – are frequently used to treat gynecologic cancers. In

these malignancies, the radioisotopes are inserted into specially positioned applicators
after their placement is verified by x-ray. Treatment can be achieved with either HDR or
LDR brachytherapy sources depending on the extent of disease. LDR therapy requires
hospitalization as the patient is treated over several days. Nursing care of the
hospitalized LDR patient is essential to maximize effective safe delivery of the therapy
and prevention of complications. The patient is maintained on bed rest in a specially
prepared private room typically for 72 hours and log-rolled to prevent displacement of
the intracavitary delivery device. An indwelling urinary catheter is inserted to ensure that
the bladder remains empty. Low-residue diets and antidiarrheal agents are provided to
prevent bowel movements during therapy, which would displace the radioisotopes.
Visitors and personnel must limit their time and proximity to the patient due to the risk of
radiation exposure. HDR intracavitary brachytherapy is typically delivered as an
outpatient procedure in the radiation therapy department over several days.

c. Interstitial implants – used in treating such malignancies as prostate, pancreatic, or

breast cancer, may be temporary or permanent, depending on the radioisotopes used.
These implants usually consist of seeds, needles, wires, or small catheters positioned to
provide a local radiation source and are infrequently dislodged.

d. Systemic brachytherapy – involves the IV administration of a therapeutic radioactive

isotope targeted to a specific tumor. Radioactive iodine (I131) is a widely used form of
systemic brachytherapy and is the primary treatment for thyroid cancer.
Nursing Interventions:
 Patient must be in Private Room
 Minors are not allowed inside the room
 Linens should stay inside the room
 Tell the patient that he/she is radioactive until 2 days
  Flush the toilet 3x after use

Nursing Care:
a. General Manage side effects, DTSV
 Distance (6 feet away from patient)
 Time (5 minutes/contact = maximum of 30 minutes/shift)
 Shield (lead shield, aprons)
 Visiting precaution (partial isolation) – pregnant nurses/visitors are not allowed

b. External/Teletherapy
 Don’t wash skin marks
 Keep skin clean and dry
 Protect skin from friction, sunlight
 Isolation – protect client, during sessions, turn on red bulb on the door to protect
others

c. Internal Radiation (Sealed, Unsealed)

 Bed rest and log roll
 Know the half-life of the radioisotopes
 IFC – Teflon for unsealed
 Low residue diet and anti-diarrheal meds as ordered
 Check implants every 24 hours, but, don’t touch insertion site
 Prepare pick up forceps and pig container at bedside (sealed radiation)
 Sexual activity resumes 7-10 days after radiation was stopped
 Strict isolation – red bulb on door

Side effects of Radiation: Toxicity greatly affects cells that proliferate rapidly (skin)
a. Integumentary – xerosis, pruritis, oozing, depigmentation, desquamation, alopecia. No to
lotion, creams, powders unless prescribed.
b. GI – Mucositis: Stomatitis, xerostamia, poor appetite, N/V, decreased salivation,
dysphagia and diarrhea. No to mouthwash with alcohol content.
c. Hematopoietic myelosuppression: anemia = fatigue, leukopenia = infections,
thrombocytopenia = bleeding. Monitor lab results. No to use of razor blades.
d. Pelvis – cystitis, vaginitis
e. General – malaise

CHEMOTHERAPY
In chemotherapy, antineoplastic agents are used in an attempt to destroy tumor cells by
interfering with cellular functions, including replication. It affects both normal and cancer cells.
Given in repeated cycles. Can be administer through IV or orally.

CLASSIFICATION OF CHEMOTHERAPEUTIC AGENTS

Cell-cycle Specific Agent – these agents destroy cells that are actively reproducing by means
of the cell cycle; most affect cells in the S phase by interfering with DNA and RNA synthesis.
 a. Anti-metabolites – blocks enzymes needed to synthesis. Methotrexate, Cytarabine,
Pentostatin.
b. Topoisomerase Inhibitor – blocks enzymes needed for synthesis. Irinotecan,
Topotecan.
c. Mitotic Inhibitors – blocks mitotic production. Vincristine, Vinblastine.

Cell-cycle Nonspecific Agent – it acts independently of the cell cycle phases.

a. Alkylating Agents – breaks DNA helix. Bulsufan
b. Antibiotics – blocks DNA synthesis and also prevents RNA synthesis. Bleomycin,
Doxorubicin.
c. Hormonal Agents – blocks hormone receptor sites that alter cellular growth. Androgen
and anti-androgen, estrogen and anti-estrogen.
d. Monoclonal antibodies – destroys cancer cells and spare normal cells. Rituximab,
Gentuzumab.
Nursing Care:
 Notify physician for contraindications:
 Present Infection
 Recent surgery/radiation (unless used in conjunction)
 Impaired renal/hepatic function, myelosuppression
 Pregnancy
 Assess F&E status – because of GIT side effects
 Modify risk for infection and bleeding – aseptic technique, gentle handling, monitor lab
results.
 Administer chemotherapy accurately
 Hand properly – gloves, mask, gown, store in biologically safe cabinets, dispose
safely; as hazardous waste
 Choose appropriate route of administration – Luer lock fittings of IV
 Avoid EXTRAVASATION especially of vesicant potent drug. Indications: No back
flow, resistance, swelling, pain, tenderness. Nsg. Mgt: stop the drug, Ice pack
except for vinca alkaloids, physician aspirates and give neutralizing agent
(NaCHO3), document.
 Monitor caregivers for possible exposure – urinalysis, s/s (n/v, dizziness,
alopecia, nasal ulcerations.

SIDE EFFECTS OF CHEMOTHERAPY

a. GIT – n/v (1st 24 – 48 hours or delayed up to 1 week after chemo), diarrhea, mucositis:
stomatitis
b. Hematopoietic – myelosuppression; NADIR, anemia, bleeding
c. Renal – increased BUN, Creatinine, Hyperkalemia/phosphatemia, hypocalcemia.
Alkalinize urine give allopurinol.
d. Cardiopulmonary – heart failure, pulmonary fibrosis
e. Reproductive – teratogenic, early menopause, temporary azoospermia, and sterility.
Birth control, Sperm banking
f. Neurologic – temporary peripheral meuropathies, loss of DTR, paralytic ileus, hearing
loss
g. General – fatigue
h. Hypersensitivity/Anaphylaxis – ADVERSE EFFECT
BONE MARROW THERAPY/TRANSPLANTATION
Donor cells can be obtained by the traditional harvesting of large amounts of bone marrow
tissue under general anesthesia in the operating room. However, a second method, referred to
as peripheral blood stem cell transplantation (PBSCT), has gained widespread use. This
method of collection uses apheresis of the donor to collect peripheral blood stem cells (PBSCs)
for reinfusion.

Types of BMT
Types of BMT based on the source of donor cells include:
 Allogeneic: from a donor other than the patient; donor may be a related donor (ie, family
member) or a matched unrelated donor (national bone marrow registry, cord blood
registry)
 Autologous: from the patient
 Syngeneic: from an identical twin

1. Allogeneic BMT (AlloBMT), used primarily for disease of the bone marrow, depends on
the availability of a human leukocyte antigen–matched donor. This greatly limits the
number of possible transplants. An advantage of AlloBMT is that the transplanted cells
should not be immunologically tolerant of a patient’s malignancy and should cause a
lethal graft-versus-tumor effect, in which the donor cells recognize the malignant cells
and act to eliminate them.AlloBMT may involve either ablative (high-dose) or nonablative
(mini-dose) chemotherapy. In ablative AlloBMT, the recipient must undergo ablative
doses of chemotherapy and possibly total body irradiation to destroy all existing bone
marrow and malignant disease. The harvested donor marrow or PBSCs are infused
intravenously into the recipients, and they travel to sites in the body where they produce
bone marrow and establish themselves. (IV Infusion 48 – 72 hours) Once engraftment is
complete (2 to 4 weeks, sometimes longer), the new bone marrow becomes functional
and begins producing RBCs, WBCs, and platelets.

In nonablative AlloBMT, the chemotherapy doses are lower and are aimed at
suppressing the recipient’s immune system to allow engraftment of donor bone marrow
or PBSCs. The lower doses of chemotherapy create less organ toxicity and thus can be
offered to older patients or those with underlying organ dysfunction for whom high-dose
chemotherapy would be prohibitive. After engraftment, it is hoped that the donor cells will
create a graft-versus-tumor effect.

To prevent graft-versus-host disease (GVHD), patients receive immunosuppressant

drugs, such as cyclosporine (Sandimmune), methotrexate, tacrolimus (Prograf), or
sirolimus (Rapamune).

2. Autologous BMT (AuBMT) is considered for patients with disease of the bone marrow
who do not have a suitable donor for AlloBMT and for patients who have healthy bone
marrow but require bone marrow–ablative doses of chemotherapy to cure an aggressive
malignancy. Stem cells are collected from the patient and preserved for reinfusion; if
necessary, they are treated to kill any malignant cells within the marrow, called purging.
 3. Syngeneic transplants result in less incidence of GVHD and graft rejection; however,
there is also less graft-versustumor effect to fight the malignancy. For this reason, even
when an identical twin is available for marrow donation, another matched sibling or even
an unrelated donor may be the most suitable donor to combat an aggressive
malignancy.

Nursing Care:
a. Pretransplantation – assess health, financial, support status. Informed consent,
render teachings
b. During transplantation – monitor for side effects of conditioning regimen (high dose
chemo for autologous or synergeneic transplant), bone marrow or stem cell infusion:
V/S, oxygen saturation
c. Post transplantation – care for donor and recipient. First 100 days are crucial.
Monitor response:
 Graft versus disease effect – desirable effect
 Graft versus host effect
 Venous occlusive disease – vascular injury to the liver caused by high dose
of chemotherapy in the first 30 days leading to acute liver dailure that may
lead to death.

HYPERTHERMIA
 Hyperthermia (thermal therapy), the generation of temperatures greater than physiologic
fever range (greater than 41.5°C [106.7°F]), has been used for many years to destroy
cancerous tumors. Malignant cells may be more sensitive than normal cells to the
harmful effects of high temperatures for several reasons. Malignant cells lack the
mechanisms necessary to repair damage caused by elevated temperatures. Most tumor
cells lack an adequate blood supply to provide needed oxygen during periods of
increased cellular demand, such as during hyperthermia. Cancerous tumors lack blood
vessels of adequate size for dissipation of heat. In addition, the body’s immune system
may be indirectly stimulated when hyperthermia is used.

 Hyperthermia is most effective when combined with radiation therapy, chemotherapy, or

biologic therapy. Hyperthermia and radiation therapy are thought to work well together
because hypoxic tumor cells and cells in the S phase of the cell cycle are more sensitive
to heat than radiation; the addition of heat damages tumor cells so that they cannot
repair themselves after radiation therapy.

 Heat can be produced by using radiowaves, ultrasound, microwaves, magnetic waves,

hot-water baths, or even hotwax immersions.

 Hyperthermia may be local or regional, or it may include the whole body. Local or
regional hyperthermia may be delivered to a cancerous extremity (for malignant
melanoma) by regional perfusion, in which the affected extremity is isolated by a
tourniquet and an extracorporeal circulator heats the blood flowing through the affected
part.
  Whole body hyperthermia to treat disseminated disease may be achieved by
extracorporeal circulation, immersion of the patient in heated water or paraffin, or
enclosure in a heated suit

Nursing Care:
a. Educate patient and family on goals and effects of therapy
b. Monitor and manage side effects:
 Skin burns, tissue damage - Local skin care at the site of the implanted
probes is necessary
 Fatigue
 Hypotension
 Peripheral neuropathies
 Thrombophlebitis
 N/V/D and electrolyte imbalances

TARGETED THERAPY/IMMUNOTHERAPY
 Targeted therapies seek to minimize the negative effects on healthy tissues by
disrupting specific cancer cell functions such as malignant transformation, cell
communication pathways (called signal transduction), processes for growth and
metastasis, and genetic coding.

 Actions of targeted therapies include stimulation or augmentation of immune responses

through the use of biologic response modifiers, targeting of cancer cell growth factors,
promotion of apoptosis, and genetic manipulation through gene therapy

1. Biologic response modifier (BRM) therapy involves the use of naturally occurring or
recombinant (reproduced through genetic engineering) agents or treatment methods that
can alter the immunologic relationship between the tumor and the cancer patient (host)
to provide a therapeutic benefit. Although the mechanisms of action vary with each type
of BRM, the goal is to destroy or stop the malignant growth. The basis of BRM treatment
lies in the restoration, modification, stimulation, or augmentation of the body’s natural
immune defenses against cancer

2. Nonspecific Biologic Response Modifiers Some of the early investigations of the

stimulation of the immune system involved nonspecific agents such as bacilli Calmette-
Guérin (BCG) and Corynebacterium parvum. When injected into the patient, these
agents serve as antigens that stimulate an immune response. The hope is that the
stimulated immune system will then eradicate malignant cells. Extensive animal and
human investigations with BCG has shown promising results, especially in treating
localized malignant melanoma. In addition, BCG bladder instillation (intravesicular) is a
standard form of treatment for localized bladder cancer. However, use of nonspecific
agents in advanced cancer remains limited, and research is ongoing to identify other
uses and other agents.

3. Monoclonal Antibodies Monoclonal antibodies (MoAbs), another type of BRM, have

become available through technologic advances, enabling investigators to grow and
produce targeted antibodies for specific malignant cells. Theoretically, this type of
specificity allows MoAbs to destroy the cancer cells and spare normal cells. The
specificity of MoAbs is dependent on identifying key antigen proteins on the surface of
 tumors that are not present on normal tissues. These targets when blocked lead to
apoptosis by disrupting communication between cells. MoAbs bind with specific tumor
cell antigens and block the ability of the tumor cell to reproduce, or deliver cytotoxic
agents directly to the tumor cell causing cell death.
Nursing Care:
a. Monitor therapeutic and adverse effects
b. Promote self-care, home care, family support

UNPROVEN/UNCONVENTIONAL THERAPIES
 No specific basis, costly, dangerous. Forms: machine and devices, drugs and biologic
agent, metabolic and dietary regiments, mystical and spiritual approaches.
Nursing Care:
a. Establish a trusting relationship, promote hope, provide supportive care
b. Render education
c. Encourage to inform the physician regarding use of unconventional methods
d. Keep in my mind the ethical principles – autonomy, beneficence, nonmalifecence,
justice