ONCOLOGY NURSING

Classification of Cancer:
Common Terminologies
Oncogene – cancer genes that alter normal genes Squamous cell carcinoma – surface epithelial
Proto oncogenes – repressed oncogene that can Adenosarcoma – glandular epithelial
activated by etiologic and risk factors Fibrosarcoma – fibrous connective tissue
Anaplasia – no resemblance to tissues of origin Liposarcoma – adipose tissue
Metaplasia – replacement of the original cell with Chondrosarcoma – cartilage
another type of cell Osteosarcoma – bone
Carcinoma – cancer cell composed of epithelial cells Hemangiosarcoma – blood vessels
that can spread Lymphangiosarcoma – lymph vessels
Neoplasm – growth of new tissue Leiomyosarcoma – smooth muscles
Tumor – same with neoplasm Rhabdomyosarcoma – striated muscles
Dysplasia – alteration in the size, shape and Glioma – glial cells
organization of differentiated cells Neurolemic sarcoma – nerve sheath
Hyperplasia – an increase in the number of normal Leukemia – blood
cells
Classification of Benign:
Glandular tissue – adenoma
Cancer Cells Bone – osteotoma
Nerve cells – neuroma
Tumor can be: Fibrous tissue - fibroma
BENIGN MALIGNANT
Localized Systemic
Encapsulated Non encapsulated
Etiology
Hyperplasia, Anaplasia, metaplasia Exact cause is still unknown
Viruses – cancer of the liver, burkitt’s lymphoma
functional activity ( or ¯ function of the Chemical Agents – tar, asphalt, arsenicals, fuels, oil
organ involved) Drugs – chemodrugs
No metastasis With metastasis Physical Agents – radiation
(direct invasion,
lymphatic, Predisposing Factors:
embolism, diffusion) Age – (60% of cancer clients are over 65 y/o)
Fatal if it occurs in Harmful Sex – Breast cancer for females and Prostate CA for
restricted area (skull) males
Fully differentiated Hardly differentiated Geographic location – cancer of the stomach
Slow growth Rapid growth (Japan)
Occupation – factory workers (lung cancer)
Hereditary – breast, ovaries and colon
Cancer Diet – cured and salted foods (stomach)
 Synonymous to death and pain Stress – decreased immune system
 Chronic disease that has acute exacerbation Precancerous lesions – moles, polyps (colon and
 Not a single disease with single cause stomach)
 Common in men
 Leading cancer is lung cancer Early Detection: (SECONDARY)
 Male: prostate  Chest xray and sputum cytology (lung cancer)
 Female: breast
 Physical exam (every year for over 40 y/o) skin, U nexplained anemia
lymph nodes, mouth, thyroid, breast, testes, S udden weight loss
rectum, prostate
 Oral Exam - annually
 TSE – monthly following shower
 Digital Rectal Exam – annually for 40y/o and
above 7 SAFEGUARDS
 Sigmoidoscopy – for 50 y/o and above annually
for 2 years then every 3 years if negative U terus annual pap smear
 Fecal Occult Blood – doctor’s recommendation B reast regular BSE
 BSE – every month after menstruation B asic PE yearly for all adults
 Breast Clinical Exam – done by physician (every L ung control or preferably stop smoking,
3 years for 20-40 y/o then yearly for over 40 annual chest xray for high risk
y/o) O ral annual oral exam by the doctor
C olon or Rectum DE,
 Mammography – once for 35-40 y/o, then
Proctosigmoidoscopy (40y/o)
yearly for over 50 y/o
S kin avoid undue exposure to sunlight (10-2 PM)
 Pap smear – age 18 and all sexually active
women then yearly after 3 negative results
 Pelvic Exam – same with pap smear Diagnostic Exam
 Endometrial tissue sampling – menopause
Biopsy
FNA
Factors that lead to Cancer
Incision
 Smoking – lung cancer
Excision
 Sunlight (10am to 2pm) – basal/squamous
CT scan
cell (skin cancer)
MRI
 Ionizing Radiation – medical and dental
PET
xrays
Direct Visualization
 Nutrition and diet (high fats and low fiber – Bronchoscopy
diet) – Gastroscopy
 Alcohol – liver, oral and esophagus cancer – Proctosigmoidoscopy
 Chewing of tobacco (mouth, larynx and Mammogram
throat) Pap smear
 Estrogen – endometrial cancer UTZ
 Occupational hazards (nickel and asbestos) Angiogram
Lymphangiogram
7 Warning Signals (CAUTION US) Blood Studies
Antigen-skin-testing
C hange in bowel and bladder habits
A sore that does not heal Staging and Grading
U nusual bleeding or discharge T Tumor T0-T4
T hickening or lump in breast or elsewhere N Node N0-N3
M Metastasis M0-M1
I ndigestion or difficulty in swallowing
Normal T0, N0, M0
O bvious change in wart or mole Stage I T1, N0, M0
N agging cough or hoarseness of the voice Stage II T2, N1, M0
Stage III T3, N2, M0
 Stage IV with metastasis  Acceptable to the client (most important)

Tis – carcinoma in situ (non-infiltrating) Points to Remember

X – can’t be assessed  Most client fear of death upon confirmation
of Cancer
Staging System  Clients usually ignored cardinal signs of
T – Tumor T0-T4 Cancer
N – Node N0-N3  Most often cancer is detected during
M – Metastasis M0-M3 routine exam
 Questions that need to be answered:
Tis – carcinoma in situ (non-infiltrating) Example (Is the disease curable or not?)
X – can’t be assessed

Normal T0, N0, M0 Client Reaction during Diagnoses

Stage I T1, N0, M0, < 2cm diameter
of the tumor
Stage II T2, N1, M0, > 2 < 5cm diameter
of the tumor
Stage III T3, N2, M0, > 5cm diameter
of the tumor
Stage IV any size of the tumor with metastasis
Grading System
– Microscopic study of the cell
– The poorer the differentiation of the cells the
poorer is the prognosis
Carcinogenesis: Process of cancer formation
 Initiation – exposure to carcinogens
 Promotion – exposure to carcinogenic
chemicals will promote the function of
proto oncogenes
 Transformation – conversion to malignant
cell
 Progression – malignant behavior of the
cells
Stages of Metastatic Process
 Invasion of adjacent tissue
 Spread of cancer cells
 Establishment and growth at secondary site
Effective Test must be
 Specific for the type of Cancer
 Reliable
 Economical on terms and benefits
Client will use coping strategies to ¯ his anxiety level
such as:
 Denial-
 Rational inquiry-seek more information
 Affect Reversal-make light of the situation
(laughing etc.)
 Mutuality-share concerns and talk with
other persons
 Suppression-conscious forgetting
 Displacement or redirection-do other things
Client Reaction during Diagnoses
 Confrontational
 Redefine or revise
 Passive acceptance
 Disengagement
 Externalization or Projection
 Moral masochism
 Compliance and cooperational
Intervention Phase
 Therapeutic communications (silence, non
judgemental, acceptance, active
friendliness, setting limits)
 Strategizing how to use effective coping
mechanism (client and SO)
 Cancer management will involve surgery,
radiation, chemo and immunotherapy in
combination.
Surgery
Used in diagnosing, staging and treating the client
FNA, I&E biopsy
 Cytology specimens
• Palliative – relieves pain, airway obstruction.
• Reconstructive – restore maximal function and
appearance
• Preventive – removal of target organ
Radiation Therapy
 Range will be 2,000-5,000 centigrays (cGy)
- 5,000 cGy will SE
 Normal cells and cancer cells are both affected
 The goal is to destroy malignant cells without
harming normal cells by:
 Fractionation-small frequent dose
 Alternating the site
 Alpha particle-fast moving helium nucleus (slight
penetration)
 Beta particle-fast moving electron (moderate
penetration)
 Gamma ray-similar to light ray (high penetration)
 Sodium Iodide (131 I)-for thyroid gland
 Gold (198 Au)-effective for ascites and pleural
effusion
 Sodium Phosphate (32 P)-for RBC
Destroys the ability of the cell to reproduce by
damaging the DNA
Radiation Safety
 Distance - the greater the distance the
lesser the exposure
 Time - the less time spent close to radiation
the less exposure (max of 30 min per shift)
 Shielding - use lead aprons and gloves
 Standards - kept as low as reasonably
achievable
 Monitoring device - film badge (measure
the whole exposure of the nurse)
Types of RADIATION
External Radiation
– Administered by high energy xray machine
(radioisotope Cobalt for Prostate and Lung
CA)
Internal Radiation
– Via injection or orally
Internal Radiation
UNSEALED SOURCE
 Radioisotope is administered IV or orally
 NaP04 (32 P) IV for polycythemia vera
 (131 I) PO for Grave’s disease
 Potential hazard exist because it’s not
encased
 Isotope maybe excreted via body fluids
 Flush the toilet several times after use
 Protect staff and visitors
 Marked room and kardex with
RADIATION HAZARD
SEALED SOURCE
 radioisotope is placed into needles, beads,
seeds, ribbons or catheter then implanted
directly into the tumor.
 Requires a private room and bathroom
 Room must be lead-shield proof
 Lead container and long forcep on bedside
 Check linen and other materials for the
presence of isotope
Chemotherapy
 Use of chemicals to destroy cancer cells
 Interferes DNA & RNA activities associated
with cell division
 Often used in combination with radiation
therapy
Cytotoxic - is an agent capable of destroying cells
Cytotoxic drug - alkylating and antimetabolites
Antineoplastic Drugs
Alkylating Agents
Attack the DNA of rapidly dividing cell
Nitrosurea: Carmustine (BCNU)
Nitrogen Mustard: Chlorambucil (Leukeran)
Cyclophosphamide (Cytoxan)
Vinca Alkaloids
Interfere with mitosis (M phase)
Vincristine (Oncovin) Vinblastine (Velban)
Antimetabolites
Inhibits protein synthesis (S phase)
Azathioprine (Imuran)
Fluorouracil (5-FU)
Methotrexate (Mexate) given with leucovorin to
protect normal cells
Antibiotics
 Inhibit RNA Stomatitis
Doxorubicin HCl (Adriamycin) Mithramycin Alopecia (2-3 weeks to occur)
(Mithracin) Bone marrow depression

Antimetabolites Neurologic/Sensory/Perceptual
Inhibits protein synthesis (S phase) Meningeal irritation
Azathioprine (Imuran) CN and peripheral neuropathy
Fluorouracil (5-FU) Cerebellar toxicity
Methotrexate (Mexate) given with leucovorin to Ototoxicity
protect normal cells Cardiac
Antibiotics Pericardial Effusion
Inhibit RNA Arrhythmias
Doxorubicin HCl (Adriamycin) Mithramycin CHF
(Mithracin) Pulmonary
Hormone Pleural Effusion
Inhibit RNA and protein synthesis in tissues that Pneumonitis
are dependent on the opposite sex GIT
Androgens, Estrogens, Progestins, Steroids Stomatitis
(Analogue, Exogenous) Esophagitis
Hormone Antagonist: Mitotane (Lysodren) Pharyngitis
cortisol antagonist, Tamoxifen Citrate Taste alteration
(Nolvadex) estrogen antagonist Anorexia
Immune Agents Nausea and vomiting
Introduction of an agent to stimulate Constipation and diarrhea
production of antibodies Weight loss
Bacillus Calmette-Guerin (BCG) C&R SIDE EFFECTS
GUT
C&R Goal: Nephrotoxicity
Hemorrhagic cystitis
 Destroy all malignant cells without Hyperuricemia
excessive destruction of normal cell Urine color changes
 Control growth of tumor when cure is not Reproductive
possible Loss of libido
Note: all rapid dividing cells (GI mucosa, hair Impotence
follicles and bone marrow) are susceptible to the Amenorrhea
action of chemo and radiation therapy. Irregular menses
Menopausal symptoms
Azoospermia
Reasons of Combining Drugs Sterility
Synergy - two or more agents works together to Gynecomastia
enhance the effect Hepatic
Adjuvant - an additional treatment Hepatotoxicity
’s malignant cell destructions, ¯’s the SE Integumentary
Principle of MDT is instituted to avoid and prevent Alopecia
the SE Dermatitis and ulcers
Hematopoietic
C&R SIDE EFFECTS ¯ bone marrow activity
Common: nausea and vomiting anemia, prone to infection and bleeding tendency
Metabolic
TLS and Hyperkalemia
Perceived Change in Body Image
Obvious reminder of disability
need for prosthesis (breast, leg and eye)
• need for hardware (wheel chair, crutches)
• need for medication (CR therapy)
• extent of disability or limitation
Type of loss
 symbols of sexuality
 social acceptability (colostomy)
 ability to communicate (laryngectomy, aphasia) Brain Tumor
 anatomic changes (amputation)
Terminally Ill
 50% die from the disease
 time from diagnosis to death ranges from
weeks- years
 not all clients become terminally ill
 others die during initial treatment; others
die from complications of treatment
 Endpoint: no response to treatment and
progressions cannot be controlled
Cancer of the Larynx
HOSPICE CARE
 standard of care for terminally ill cancer
clients
 symptom control
 pain management
 providing comfort and dignity
 24 hour – 7 day coverage
Lung Cancer
 services are given based on client’s need
not on its ability to pay
Ethical Issues
 caring can be just successful as curing;
when curing is not an option
 care is exercised during the final stage of
life
Goals of Intervention
 to care without functional and structural Breast Cancer
impairment
 if cure is not possible goals must
= prevent further metastasis
= relieve symptoms
= maintain high quality of life
CANCER
 Brain Tumor
 Cancer of the Larynx
 Lung Cancer
 Breast Cancer
 Cancer of the Stomach
 Cancer of the Colon
 Cancer of the Liver
 Cancer of the Pancreas
 Wilm’s Tumor
 Hodgkin’s and Non Hodgkin’s
 Leukemia
 Prostate Cancer
 Common: cerebellar astrocytoma, brain
stem glioma, medulloblastoma (brain stem)
 s/sx: increased ICP, headache, n&v,
projectile vomiting, decreased LOC,
seizures, papilledema
 Intervention: symptomatic, surgery,
radiation and chemotherapy (vincristine
and cyclophosphamide)
 Follow peri-op craniotomy
 Cause: smoking
 s/sx: hoarseness of the voice, dysphagia,
coughing, bloody sputum
 Intervention: laryngectomy and radical neck
dissection
 Most preventable type of cancer
 Cause: smoking
 Types: adenocarcinoma (common), small
cell (fatal)
 s/sx: chronic cough, wheezing, dyspnea,
repeated unresolved URTI, chest/shoulder
pain, hemoptysis, hoarseness, dysphagia,
head and neck edema
 Intervention: chemo and radiation, surgery
(wedge, segment, lobe, entire lung)
 s/sx: non tender fixed lump (tail of spence),
dimpling, bleeding
 Stage I (<2cm) Stage II (>2<5cm + Nodes)
Stage III (>5cm + nodes) Stage IV
(metastasis)
 Intervention: chemo and radiation, surgery
 Lumpectomy, segmental mastectomy
(lobe), simple mastectomy (entire breast),
MRM, RM, URBAN
 Follow post-op nursing
management
Cancer of the Stomach
 Most common GI cancer, cured foods, low in
fiber
 s/sx: vague fullness, bleeding LATE: ascites,
palpable mass
 Intervention: C&R, surgery (billroth I&II)
 Follow post-op procedures
Cancer of the Colon
 Cause: low fiber high cholesterol diet, POLYPS
 s/sx: change in BM, bleeding, obstruction
 Adenocarcinoma
 Intervention: C&R, surgery
 Follow post-op procedures
 Colostomy care
Cancer of the Liver
 Usually a complication of CIRRHOSIS or from
metastasis
 Hepatic failure
 s/sx: similar to cirrhosis
 Intervention: C&R, (Fluorouracil 5 FU, Cytoxan,
Oncovin), liver transplant
 GALL BLADDER CA – 1 YEAR SURVIVAL
Cancer of the Pancreas
 Mostly adenocarcinomas
 Head of the pancreas
 s/sx: obstruction of the CBD, anorexia, weight
loss, pain (upper abdomen, left hypochondriac),
jaundice
 Dx: increased serum lipase and bilirubin
 Intervention: C&R, surgery (WHIPPLE’S,
pancreatoduodenectomy, anastomosis of
stomach, duodenum, CBD and pancreatic duct)
Prostate Cancer
 BPH – cancer of the prostate
 s/sx: asymptomatic
 Dx: elevation of CEA, PSA, AP
 Intervention: Prostatectomy
 Follow post-op procedure of prostatectomy
 TESTICULAR CA – (curable) CRYPTORCHIDISM
Leukemia
 ALL – immature proliferation
 CLL – same, adult
 AML – reduction of granulocytes
 CML – myeloid stem cell, blood cells
 s/sx: related to blood level
derangement
 DX: bone marrow biopsy
 Filgrastim (Neupogen) = stimulates
neutophils production
Hodgkin’s and Non-Hodgkin’s
Lymphoma
 Obstruction of the lymph nodes
 s/sx: edema
 Hodgkin’s – painless, localized (left
thoracic duct and right lymphatic
duct), lymph node biopsy reveals
REED-STERNBERG cell or GIANT cell
 Non-Hodgkin’s – painful, systemic
 CHLORAMBUCIL (LEUKERAN) PO 10
mg OD
Wilm’s Tumor
Nephroblastoma
Renal parenchyma, left kidney (unilateral)
 Stage I kidney, stage II beyond
kidney encapsulated, stage III
abdomen, stage IV metastasis,
stage V bilateral
 s/sx: during bathing and dressing
mass will be noticed, non-tender,
IVP reveals mass,
 ”NO PALPATION”
 Intervention: Nephrectomy (good
prognosis)
Cancer of the Skin
 Types: basal cell (common), squamous cell
(rapid), malignant (less frequent)
 Precancerous: leukoplakia (mouth and lips),
nevi (moles, color change to black, bleeding,
irritation), senile keratosis (brown scalelike
spots among elderly)
 Cause: UV light, chemicals and irritation
 Intervention: protection against sunlight,
irritants and chemicals, lotion (para-amino
benzoic acid), report change in lesion,
CHEMOTHERAPY & IMMUNOTHERAPY
 6. Which of the following is an environmental
factor of cancer?
A. gender
b. air pollution
c. immunologic status
d. age
7. Kris is on the terminal stage of breast cancer.
Her doctor decided to perform an operation to
lessen her intractable pain. This operation is
Set A considered as:
CANCER POST TEST a. reconstructive
1. Which of the following would be considered an b. curative
iatrogenic cause of cancer? c. palliative
A. ionizing radiation from radon d. rehabilitative
b. ionizing radiation from uranium ore 8. Which of the following nursing interventions
c. xrays to treat tumor would be most helpful in making the respiratory
d. ultraviolet radiation from the sun effort of a client with metastatic lung cancer more
2. A nurse is providing health education in a efficient?
community setting about measures to avoid a. teaching the diaphragmatic breathing
excessive sun exposure. Which of the following techniques
statement is true: b. administering cough suppressants as ordered
a. reapply sun screen only when you go to the c. teaching and encouraging pursed lip breathing
water d. placing the client in a low semi fowlers position
b. avoid peak exposure hours from 10 AM to 2 PM 9. To manage possible nausea and vomiting, the
c. wear loosely woven clothing for added nurse should discuss,
ventilation a. eating frequent, small meals through out the
d. apply sunscreen after exposure day
3. A nurse is palpating a female clients breast. The b. eating three normal meals a day
area of the breast in which tumors are commonly c. eating only cool foods with no odor
found in the? d. limiting the amount of food intake
A. upper inner quadrant 10. What are the common side effects of chemo
b. lower inner quadrant and radiation therapy?
c. lower outer quadrant A. stomatitis, nausea and vomiting, depression
d. upper outer quadrant B. stomatitis, loss of hair and anemia
4. Which of the following statements would be C. fatigue, alopecia and bone marrow depression
correct about pap smear? D. dysphagia, anemia and fatigue
A. it is recommended every other year 11. Common site of metastatic activity?
b. repeat every 3 years after 4 consecutive A. bone B. brain
negative results C. lungs D. liver
c. it should be done at age 18 or earlier if sexually 12. What is the early sign of Cancer of the Larynx?
active A. hoarseness of the voice
d. colposcopy is needed after 4 negative results B. dysphagia
5. What is the single most important risk factor for C. coughing
cancer? D. bloody sputum
A. family history 13. Common type of lung cancer?
b. lifestyle A. Small oat cell
c. age B. Squamous
d. menopause or hormonal events
 C. Large cell C. alopecia
D. adenocarcinoma D. dysphagia
14. All of the following are considered early sign of CANCER POST TEST
breast cancer EXCEPT? 2. Which type of cancer causes the most death in
A. bloody discharge women?
B. dimpling or “peau d’ orange” A. breast
C. tender lump B. ovarian
D. fixed lump C. lung
D. all of the above
15. What is the early sign of Stomach Cancer? 3. To elicit more information regarding hoarseness of
A. Melena the voice the nurse should ask which question?
B. Hematochezia A. do you eat high fats low fibers
C. Vague fullness of the stomach B. do you strain your voice
D. Ascites C. do you smoke cigarettes
• 16. T1N2M1 means? D. do you eat spicy foods
A. normal B. stage I 4. What is the most common adverse effect of
C. stage III D. stage IV chemotherapy?
• CANCER POST TEST A. alopecia
Matching Type B. stomatitis
• I. CA liver a. mole C. nausea and vomiting
• II. CA pancreas b. painful adenopathy D. anemia
• III. Wilm’s c. bone 5. A client is receiving an internal radioactive implant
marrow biopsy and discovers the implant in the bed linen, what
• IV. Hodgkin’s d. kernicterus should a nurse do?
V. Non Hodgkin’s e. painless adenopathy A. report to the physician at once
VI. CA skin f. increased ICP B. pick up with a long-handled forceps and put it in a
VII. Leukemia g. whipple’s procedure lead container
h. no palpation C. put the implant back in place using long handled
Set A Key Answers forceps
CANCER POST TEST D. leave the room immediately and notify the
Matching Type radiation department
I. CA liver a. mole 6. Which of the following is likely to decrease pain of
II. CA pancreas b. painful adenopathy stomatitis secondary to CHEMO?
III. Wilm’s c. bone marrow biopsy A. recommend to discontinue therapy
IV. Hodgkin’s d. kernicterus B. provide a solution of hydrogen peroxide and water
V. Non Hodgkin’s e. painless adenopathy for use as mouth rinse
VI. CA skin f. increased ICP C. monitor platelet count
VII. Leukemia g. whipple’s procedure D. check regularly for s/sx of stomatitis
h. no palpation 7. The nurse instructs the client the diagnosis of breast
Set A Key Answers cancer is confirmed by?
Set B A. BSE breast self examination
CANCER POST TEST B. mammography
1. A client with nagging cough makes an appointment C. FNAB fine needle aspiration biopsy
to see the physician, after reading that this is one of 7 D. chest xray
warning signals of cancer. What is another warning 8. For client newly diagnosed with radiation induced
sign of cancer? thrombocytopenia, the nurse should include which
A. rashes specific intervention?
B. nausea and vomiting A. bedrest must be encouraged
B. reverse isolation upon admission
C. check petechia every shift
D. all of the above
9. Risk for impaired skin integrity from external
radiation had been made, what will be your nursing
intervention?
A. apply talcum powder on the site
B. remove tumor skin marking after radiation
C. wear protective gears when giving direct care
D. avoid use of soap on the irradiated areas
10. Which of the following organs is an occasional site
of metastasis activity?
A. liver
B. colon
C. lungs
D. brain
E. bones
Set B Key Answers
1. D
2. C
3. C
4. C
5. B
6. B
7. C
8. C
9. D
10. B