INTRODUCTION TO CANCER  Viruses

 Chemical carcinogens
TERMINOLOGY RELATED TO ONCOLOGY/CANCER NURSING
 Physical stressors
 Cancer – a disease of the cell in which the normal  Hormonal factors
mechanisms of the control of growth and proliferation  Genetic factors
have been altered. It is invasive, spreading directly to CAUSES OF CANCER
surrounding tissues as well as to new sites in the body.
Also called malignant neoplasm  Some chemicals
 Some viruses or bacteria
 Benign Neoplasm – a harmless growth that does not  Radiation
spread or invade other tissues.
EXAMPLES OF HUMAN CANCER VIRUS
 Neoplasia – abnormal cellular changes and growth of
new tissues VIRUS TYPE OF CANCER
Epstein-Barr virus Burkitt’s lymphoma
 Hyperplasia – increase in cell number Human papillomavirus Cervical Cancer
Hepatitis B Virus Liver Cancer
 Hypertrophy – increase in cell size
Human T-cell Adult T-cell leukemia
 Metaplasia – replacement of one adult cell type by a Lymphotrophic virus
different adult cell type Kaposi’s sarcoma- Kaposi’s sarcoma
associated herpesvirus
 Dysplasia – changes in cell size, shape, organization

 Anaplasia – reverse cellular development to a more PATHOPHYSIOLOGY

primitive or embryonic cell type
1. Formation of the abnormal cells
 Metastasis – spread of cancer cells to distant parts of the 2. Cell growth and proliferation
body to set up new tumors. 3. Metastasis

 Oncology – the medical specialty that deals with the
diagnosis, treatment and study of cancer
 Adenocarcinoma – cancer that arises from grandular
tissues. Examples: cancer of the breast, lung, thyroid,
colon and pancreas.
 Carcinoma – a form of cancer that is composed of
epithelial cells; develops in tissue covering or lining
organs of the body such as skin, uterus, or breast.
 Sarcoma - a cancer of supporting or connective tissues
such as cartilage, bones, muscles or fats.
 Carcinogens – factors associated with cancer causation,
e.g., radiation, chemicals, viruses, physical agents.
CANCER
 a complex of diseases which occurs when normal cells
mutate into abnormal cells that take over normal tissue,
eventually harming and destroying the host
 A large group of diseases characterized by:
 Uncontrolled growth and spread of abnormal cells
 Proliferation (rapid reproduction by cell division)
 Metastasis (spread or transfer of cancer cells from
one organ or part to another not directly connected)
ETIOLOGY / CAUSATIVE FACTORS
CLASSIFICATION OF CANCER
According to behaviour of tumor:
BENIGN - (not cancer) tumor cells grow
only locally and cannot spread by invasion or metastasis
MALIGNANT- (cancer) cells invade neighbouring tissues,
enter blood vessels, and metastasize to different sites
PATTERNS OF CELL PROLIFERATION
HYPERPLASIA
- Tissue growth based on an excessive rate of cell division,
leading to a larger than usual number of cells; the
process of hyperplasia is potentially reversible; can be a
normal tissue response to an irritating stimulus. An
example is a callus
DYSPLASIA
- Bizarre cell growth differing in size, shape and cell
arrangement
METAPLASIA
- conversion of one type of cell in a tissue to another type
not normal for that tissue
ANAPLASIA
- change in the DNA cell structure and orientation to one  Physical Stress:
another, characterized by loss of differentiation and a  Psychological Stress
return to a more primitive form.
ASSESSMENT:
NEOPLASIA
 Nursing History
- Uncontrolled cell growth, either benign or malignant o Health History –
o Cancer signs: CAUTION US!
METASTASIS (3 stages)
WARNING SIGNS OF CANCER
 Invasion
 Spread  Change in bowel or bladder habits
 Establishment and growth  A sore that does not heal
 Unusual bleeding or discharge
DIFFIRENT KINDS OF CANCER
 Thickenings or lumps
CARCINOMAS  Indigestion or difficulty in swallowing
 Obvious change in a wart or mole
 Lungs  Nagging or persistent cough or hoarseness
 Breast (women)  Unexplained anemia
 Colon  Sudden unexplained weight loss
 Bladder
 Prostate (men) PHYSICAL ASSESSMENT

LEUKEMIAS  Inspection
 Palpation
 bloodstream  Auscultation
LYMPHOMAS LABORATORY & DIAGNOSTIC TESTS
 lymph nodes  Cancer detection examination
SARCOMAS  Laboratory tests
o Complete blood cell count (CBC)
 fat o Tumor markers – identify substance (specific
 bone proteins) in the blood that are made by the
 muscle tumor
 PSA (Prostatic-specific antigen):
NAMING CANCERS
prostate cancer
PREFIX MEANING  CEA (Carcinoembryonic antigen): colon
Adeno - gland cancer
Chondro - Cartilage  Alkaline Phosphatase: bone metastasis
Erythro - Red blood cell  Biopsy
Hemangio - Blood vessels
Hepato - Liver DIAGNOSTIC TESTS
Lipo - Fat  Determine location of cancer:
Lympho - Lymphocyte
Melano - Pigment cell o X-rays
Myelo - Bone marrow
Myo - Muscle o Computed tomography
Osteo - bone o Ultrasounds

o Magnetic resonance imaging

EFFECTS OF CANCER
o Nuclear imaging
 Disruption of Function-
 Hematologic Alterations: o Angiography
 Hemorrhage:
 Anorexia-Cachexia Syndrome:  Diagnosis of cell type:
 Pain:
 o Tissue samples: from biopsies, shedded cells o Secondary Prevention
(e.g. Papanicolaou (PAP) smear), & washings
CANCER PREVENTION:
o Cytologic Examination: tissue examined under
 carcinogenic chemicals
microscope
 carcinogenic radiation
 Direct Visualization:  cancer viruses or bacteria

o Sigmoidoscopy TO REDUCE THE OCCURRENCE OF CANCER:

o Cystoscopy  Don't use tobacco

 Eat a healthy diet
o Endoscopy  Maintain a healthy weight and be physically active
 Protect yourself from the sun
o Bronchoscopy
 Get vaccinated
o Exploratory surgery; lymph node biopsies to  Avoid risky behaviours
determine metastases  Get regular medical care

TUMOR STAGING AND GRADING BIOPSY

 Staging - a surgical procedure to obtain tissue from a living

 Grading
 The TNM system is based on:
o the extent of the tumor (T),
o the extent of spread to the lymph nodes
(N),
o The presence of metastasis (M).
organism for its microscopical examination, usually to
perform a diagnosis.
WHY ARE BIOPSIES DONE?
- A mammogram shows a lump or mass, indicating the
possibility of breast cancer.

PRIMARY TUMOR (T) - A mole on the skin has changed shape recently and
melanoma is possible.
TX Primary tumor cannot be evaluated
T0 no evidence of primary tumor - A person has chronic hepatitis and it's important to know
Tis Carcinoma in situ ( early cancer that has not if cirrhosis is present.
spread to neighbouring tissue)
T1, T2, T3, Size and /or extent of the primary tumor CHARACTERISTICS OF LESIONS THAT RAISE THE SUSPICION
T4 OF MALIGNANCY.

• Erythroplasia- lesion is totally red or has a speckled red

REGIONAL LYMPH NODES (N) appearance.

NX Regional lymph nodes cannot be evaluated • Ulceration- lesion is ulcerated or presents as an ulcer.
N0 No regional; lymph node involvement (no
• Duration- lesion has persisted for more than two weeks.
cancer found in the lymph nodes)
N1, N2, N3 Involvement of regional lymph nodes • Growth rate- lesion exhibits rapid growth
(number of /or extent of spread)
• Bleeding- lesion bleeds on gentle manipulation

DISTANT METASTASIS (M) • Induration- lesion and surrounding tissue is firm to the
touch
MX Distant metastasis cannot be evaluated
M0 No distant metastasis ( cancer has not spread • Fixation- lesion feels attached to adjacent structures
to other parts of the body)
M1 Distant metastasis ( cancer has spreads to
distant parts of the body) HOW TO PREPARE FOR A BIOPSY

• Ask your doctor or nurse whether you can eat or drink

IMPLEMENTATION / MANAGEMENT anything before the biopsy.
 Prevention and detection • Also ask if you should take your regular medications that
o Primary Prevention day. For certain biopsies, your doctor will want to know if
 you are taking blood thinners or aspirin. Tell your doctor • Aspiration biopsy
about all medications and supplements you are taking.
ASPIRATION BIOPSY
• Tell your doctor about any drug allergies or other medical
• Aspiration biopsy is the use of a needle and syringe to
conditions you may have.
remove a sample of cells or contents of a lesion.
• A member of your health care team will explain the
• The inability to withdraw fluid or air indicates that the
procedure to you.
lesion is probably solid
• You will be asked to sign a consent form that states you
INDICATIONS:
understand the benefits and risks of the biopsy and agree
to have the test done.  To determine the presents of fluid within a lesion
• Talk with your doctor about any concerns you have.  To a certain the type of fluid within a lesion
 When exploration of an intraosseous lesion is indicated
PREREQUISITES FOR A BIOPSY
PROCEDURES:
• CBC, platelets, coagulation studies
 An 18-gauge needle is connected to a 5 or 10 ml syringe
• cross-sectional imaging - to evaluate local anatomy and is inserted into the center of the mass via a small
hole in the lesion.
• treatment center performing biopsy must be capable of
proper diagnosis and treatment  The tip of the needle may need to be positioned in
multiple directions to locate a potential fluid center.
INDICATIONS FOR BIOPSY
 The material withdrawn during aspiration biopsy can be
 Inflammatory changes of unknown cause that persist for
submitted for pathologic examination and/or culturing
long periods
 The aspiration of blood might indicate a vascular
 Lesion that interfere with local function
malformation within the bone.
 Bone lesions not specifically identified by clinical and
 Any intra-bony radiolucent lesion should be aspirated
radiographic findings
before surgical intervention to rule out a vascular lesion.
 Any lesion that has the characteristics of malignancy
 If the lesion is determined to be vascular in nature, the
 aggressive bone or soft tissue lesions
flow rate (high versus low) should be determined
 soft tissue lesions larger than 5cm, deep to fascia, or
because uncontrollable hemorrhage can occur if incised
overlying bone/neurovascular structures
 unclear diagnosis in a symptomatic patient
 solitary bone lesions in a patient with history of • Surgical biopsy
carcinoma
• Needle biopsy
WHEN A BIOPSY IS NOT INDICATED?
• Fine needle aspiration biopsy.
 asymptomatic latent bone lesions or a symptomatic
• provides cytologic (cellular) specimen
active bone lesions which appear entirely benign on
imaging don't necessarily need a biopsy • frequently used for carcinoma
 soft tissue lesion which are completely benign on MRI
don't necessarily need a biopsy (e.g. lipoma, • not typically used for sarcoma
hemangioma)
• Vacuum-assisted biopsy.
TYPES OF BIOPSIES
• Shave biopsy.
• Image-guided biopsy.
• Core needle biopsy.
• Fluoroscopy
• allow for tumor structural examination
• X-ray
• can evaluate both the cytologic and stromal
• Magnetic resonance imaging (MRI) scan elements of the tumor

• CT-guided biopsy. • frequently used for soft tissue sarcoma

• Ultrasound-guided biopsy. • 85-95% accuracy in diagnosis

EXCISIONAL BIOPSY
INDICATIONS:
• Should be employed with small lesions. Less than 1cm
• The lesion on clinical exam appears benign.
• When complete excision with a margin of normal tissue is
possible without mutilation.
TECHNIQUE
• An excisional biopsy implies the complete removal of the
lesion.
• A perimeter of normal tissue (2-3 mm) surrounding the
lesion is included with the specimen.
• Excisional biopsy should be performed on smaller lesions
(less than 1 cm in diameter) that appear clinically benign.
• Pigmented and vascular lesions should be removed, if
possible, in their entirety. This avoids seeding of the
melanin producing tumor cells into the wound site or in
the case of a hemangioma, allows the clinician to address
the feeder vessels.
INCISIONAL BIOPSY
• The intent of an incisional biopsy is to sample only a
representative portion of the lesion.
• If the lesion is large or has many differing characteristics,
more than one area may require sampling.
INDICATIONS:
• whenever the lesion is difficult to excise because of its
extensive size
• In cases where appropriate excisional surgical
management requires hospitalization or complicated
wound management.
TECHNIQUE
• Representative areas are biopsied in a wedge fashion.
• Margins should extend into normal tissue on the deep
surface.
• Necrotic tissue should be avoided.
• The sample should be taken from the edge of the lesion
to include surrounding normal tissue
• It should be deep enough to include underlying changes
of the surface lesion.
PRINCIPLE OF THE OPEN INCISIONAL BIOPSY
• Incision
• use longitudinal incision in the extremities
• allows for extension of the incision for definitive
management
• Approach
• do not expose neurovascular structures
• all tissue exposed during the biopsy is
considered contaminated with tumor
• maintain meticulous hemostasis
• post-operative hematomas are considered
contaminated with tumor
• release tourniquet prior to wound closure
• Biopsy
• perform through the involved compartment of
the tumor
• for bone lesions with a soft tissue mass, it is ok
to perform the biopsy using the soft tissue mass
• Closure
• if using a drain, bring drain out of the skin in line
with surgical incision
• allows drain site to be removed with definitive
surgical extensile incision
• Endoscopic biopsy.
• Laparoscopic biopsy.
• Liquid biopsy.
PUNCH BIOPSY
• Another tool that can be used for incisional or excisional
purposes.
• biopsy is especially well suited for diagnosis of oral
manifestations of mucocutaneous and vesiculoulcerative
diseases
TECHNIQUE
• biopsy punches should range in size from 2-10 mm in
diameter
• The smaller diameters should be avoided due to the risk
of over-manipulating and crushing the tissue.
• The technique is easily performed with a low incidence of
postsurgical morbidity.
• Suturing in regards to a punch biopsy procedure is
usually not required as the surgical wounds heal by
secondary intention.
DISADVANTAGE: • Block anesthesia is preferred to infiltration

• One disadvantage of using the biopsy punch is that it is • When blocks are not possible distant infiltration may be
difficult to obtain adequate, representative tissue. used

BRUSH BIOPSY • Never inject directly into the lesion

• Firm pressure with a circular brush is applied, rotated TISSUE STABILIZATION

five to ten times, causing light abrasion.
• Digital stabilization
• The cellular material picked up by the brush is
• Specialized retractors/forceps
transferred to a glass slide, preserved, and dried.
• Retraction sutures
LOCATION OF BIOPSIES
• Towel Clips
• Bone marrow biopsy.
HEMOSTASIS
• Bone marrow aspiration and biopsy
• Suction devices should be avoided
• Liver biopsy.
• Gauze compresses are usually adequate
• Kidney biopsy.
• Gauze wrapped low volume suction may be used if
• Capsule biopsy
needed
• Prostate biopsy
INCISION
• Skin biopsy
• Incisions should be made with a scalpel.
• Bone biopsy
• They should be converging
WHO DOES A BIOPSY AND WHO ANALYZES THE SAMPLE?
• Should extend beyond the suspected depth of the lesion
• A surgeon
• They should parallel important structures
• A radiologist
• Margins should include 2 to 3mm of normal appearing
• An oncologist tissue if the lesion is thought to be benign.

• A gastroenterologist • 5mm or more may be necessary with lesions that appear

malignant, vascular, pigmented, or have diffuse borders.
• A pathologist
HANDLING OF THE TISSUE SPECIMEN
• A cytologist
• Special care should be undertaken to hold the specimen
• A dermatologist
gently at the periphery of the sample.
• A gynecologist
• Injection of large amounts of anesthetic solution in the
• A family practice doctor biopsy area, while providing hemostasis, can produce
hemorrhage, which masks the normal cellular
• Other specialists architecture.
DURING THE PROCEDURE • Infiltration of local anesthetic around the lesion is
acceptable if the field is wide enough in relation to the
• Local anesthesia is injected.
lesion;
• Conscious sedation or monitored anesthesia is
• Injection directly into the lesion should be avoided.
administered.
• Use of electrocautery to excise the specimen remains a
• General anesthesia
common complicating factor in determining an accurate
PRINCIPLES OF SURGERY microscopic diagnosis.

ANESTHESIA • Heat produced by these units alters both the epithelium

and the underlying connective.
• Small tissue biopsies to rule out malignancy are usually Surgical incision should be designed to allow adequate access
non diagnostic if excised by electrocautery, as the for incisional/excisional biopsy.
presence of epithelial atypia is typically obscured
• Incisions should be over sound bone
• If electrocautery is to be used, the incision margin should
• Cortical perforation must be considered when
be far enough away from the interface of the lesion to
designing flaps
prevent thermal changes at that interface
• Flaps should be full thickness
SPECIMEN CARE
• Major neurovascular structures should be avoided
• The specimen should be immediately placed in 10%
formalin solution, and be completely immersed. • Osseous windows should be submitted with the
specimen
MARGIN OF THE BIOPSY
• Osseous preformations can be enlarged to gain
• Margins of the tissue should be identified to orient the
access
pathologist. A silk suture is often adequate. Illustrations
are also very helpful and should be included. • Avoid roots and neurovascular structures
SURGICAL CLOSURE • The tissue consistency and nature of the lesion will
determine the ease of removal
• Primary closure of the wound is usually possible
• Incisional biopsies only require removal of a section
• Mucosal undermining may be necessary
of tissue
• Elliptical incision on the hard palate or attached gingiva
• Soft tissue overlying the lesion should be
may be left to heal by secondary intention.
reapproximated following thorough irrigation of the
BIOPSY DATA SHEET operative site.

• A biopsy data sheet should be completed and the • The specimen should be handled as previously
specimen immediately labeled. All pertinent history and described
descriptions of the lesion must be conveyed.
AFTER THE PROCEDURE
• It should include the name of the clinician, date the
THE RISK OF A BIOPSY
specimen was obtained pertinent characteristics of the
specimen. • Infection
• Bleeding
BIOPSY REPORT
• Severe pain
• The location/site, size, color, number, borders or • Fever
margins, consistency, and relative radiodensity of the
WHEN TO REFER FOR BIOPSY
lesion are all important findings that should be included
in the description of the specimen. • When the health of the patient requires special
management that the dentist feel unprepared to handle
• If the lesion is evident on radiographs, it is very
important to submit good quality radiographs with the • The size and surgical difficulty is beyond the level of skill
specimen to aid in pathologic correlation and diagnosis. that the dentist feels he/she possesses
INTRAOSSEOUS AND HARD TISSUE BIOPSY • If the dentist is concerned about the possibility of
malignancy
• Intraosseous lesions are most often the result of
problems associated with the dentition. QUESTIONS TO ASK YOUR HEALTH CARE TEAM
INDICATIONS FOR INTRAOSSEOUS BIOPSY • What to expect from your biopsy
• What happens after the biopsy?
• Any intraosseous lesion that fails to respond to routine
treatment of the dentition. CANCER TREATMENTS
• Any intraosseous lesion that appears unrelated to the CANCER CARE TEAM
dentition.

PRINCIPLE OF SURGERY
All those involved with a patient during and after their care is • is used to supplement surgery is used to destroy
part of the Cancer Care Team. This includes: detached cancer cells.
• Radiotherapy or chemotherapy provided following
• The Treatment Team
surgery are forms of adjuvant therapy.
o Physicians
Purpose: to ensures that cancer cells are destroyed, thereby
o Nurses improving the patient’s prognosis.

o Radiation therapists TYPES OF CANCER TREATMENT THAT ARE USED AS

ADJUVANT THERAPY INCLUDE:
o Physicists
• Chemotherapy.
o Dosimetrists • Hormone therapy.
• Radiation therapy.
o Social workers • Immunotherapy.
o Receptionists • Targeted therapy.

• Family and Friends HOW EFFECTIVE IS ADJUVANT THERAPY?

PURPOSE OF CANCER TREATMENTS:  Type of cancer.

 Stage of cancer.
• cancer improves  Number of lymph nodes involved.
 Hormone receptivity.
• the disease is brought under control
 Other cancer-specific changes.
• cancer recurrence is prevented

• the symptoms caused by the tumor are alleviated SUPPORTIVE THERAPY

CANCER MANAGEMENT It alleviates symptoms caused by cancer or its treatment. It

Specific to type, stage, grade of cancer
Cure - complete eradication of malignant disease
Control – prolonged survival and containment of cancer cell
growth
Palliation – relief of symptoms associated with the disease
MAIN FORMS OF CANCER TREATMENT ARE:
• cancer surgery (surgical treatment/surgical Interventions)
can improve the patient’s wellbeing during and after the
period of treatment.
For instance, the anti-nausea medication used during
chemotherapy is a form of supportive therapy.
Cancer pain treatment is another form of supportive therapy.
PALLIATIVE CARE
It alleviates the patient’s physical and psychological
symptoms to improve the quality of life.

Palliative care is used in cancer treatment or to treat the

• Radiotherapy/Radiation Therapy
symptoms arising from cancer treatment. Palliative care can
• hormone therapy be provided for months or even years.

• Chemotherapy The most common symptoms treated in palliative care are

• ImmunoTherapy
• Bone Marrow Transplantation
DIFFERENT TYPES OF CANCER TREATMENT
COMBINATION THERAPY
- Refers to the combined use of many treatment forms,
such as surgery, radiotherapy and drugs. 
- Purpose: to increase the patient’s scope for recovery.
pain, constipation, nausea, confusion and fatigue.
Palliative care is provided in tandem with curative treatment
immediately following cancer diagnosis.
TREATMENT FATIGUE
Up to 50% – 90% of cancer patients suffer from treatment
fatigue during their illness and periods of treatment.
This involves: extreme tiredness and fatigue that does not
pass simply with sleeping and resting.

ADJUVANT/ SUPPLEMENTARY THERAPY CANCER SURGERY

• Surgery is the first option in the treatment of many firm
malignant tumors.
• Surgery is done to treat cancer and removes the
cancerous tumor and the healthy tissue surrounding it to
prevent the spread of the tumor locally.
The extent of surgery to treat cancer and its successful
outcome vary according to
• the type of cancer,
• its stage,
• size,
• distribution
• location
• it is often accompanied by radiotherapy, drug therapy,
such as cytotoxic drugs, or both.
• Sometimes surgery does not aim to remove the entire
tumor. If the tumor mass is sizeable, surgery may be used
to reduce the size of the tumor so that it can be
eradicated by chemotherapy of radiotherapy. Metastases
from the primary tumor can also be removed surgically.
SURGERY USED TO TREAT CANCER AT DIFFERENT STAGES
1. Radical surgery or curative surgery- involves the removal of
the entire detectable tumor.
• It aims to operate on cancers so that you are cured
of it.
2. Surgery for symptomatic relief -Surgery aims to relieve the
symptoms caused by cancer.
• Examples of surgery for symptomatic relief are
procedures to bypass or open up obstructions of the
bile duct or intestine caused by cancer.
3. Conserving surgery -Nowadays many surgical treatments
for cancer favor what is called conserving surgery.
• For instance, conserving breast cancer surgery aims
to avoid removing the breast. But if the cancer has
advanced to a certain stage, conserving surgery is
not an option.
4. Surgery for metastases-Some metastases can be removed
by surgery, for instance from the liver, lungs or bones.
5. Recurrent cancer surgery-If possible, locally recurrent
cancer is removed surgically. Radiotherapy and/or
chemotherapy are given following surgery, unless they had
already been given earlier.
6. Surgery for cancer prevention-Nowadays, various forms of
preventive surgery can be used to prevent some cancers or
remove cancer precursors. Preventive surgery can, for
instance, treat colorectal cancer precursors. Women with the
so-called breast cancer gene can also have a preventive
mastectomy.
7. Prophylactic surgery- involves the removing of non vital
tissues or organs that are likely to develop cancer.
Factors to be considered when electing prophylactic surgery:
 Family history and genetic predisposition
 Presence or absence of symptoms
 Potential risks and benefits
 Ability to detect cancer at an early stage
 Patient’s acceptance of the postoperative
outcomes
8. Palliative surgery- performed in an attempt to relieve
complications of cancer such as ulcerations, obstructions,
hemorrhage, pain and malignant effusions.
Goals of treatment:
To make the patient as comfortable as possible & to promote
a satisfying and productive life for as long as possible.
Palliative surgery- is done for relief of distressing signs &
symptoms or for retardation of metastasis. This is an attempt
to improve quality of life.
Examples of palliative surgery are as follows:
• Reduce pain by interrupting nerve pathways or
implanting pain control pumps.
• Relieve airway obstruction
• Relieve obstructions in the GI & GU tracts
• Relieve pressure in the brain & the spinal cord
• Prevent hemorrhage
• Remove infected & ulcerating tumors
• Drain abscesses.
9. Reconstructive surgery- In some cancer cases a part of the
body has to be removed surgically, such as a breast or
testicle.
• Reconstructive surgery can replace the part of the
body either using tissue from the patient’s own body
or using external material, such as silicone.
• Reconstructive surgery can significantly improve the
patients’ quality of life. It is nowadays carried out as
early as possible.
10. Diagnostic Surgery. This is done by cytologic specimen
collection & biopsy
11. Preventive Surgery. This involves removal of
precancerous lesions or benign tumors, e.g. patients with
familial polyposis & ulcerative colitis undergo subtotal
colectomies to prevent colon cancer
12. Curative Surgery. Involves removal of an entire tumor &
surrounding lymph nodes. Cancers that are localized to the
organ of origin and the regional lymph nodes are potentially
curable by surgery
NURSING MANAGEMENT IN CANCER SURGERY
PREOPERATIVE
1. Complete thorough pre operative assessment for all
factors that may affect patients undergoing surgical
procedures
2. Provide education and emotional support by assessing
the patient and family needs and exploring with the
patient and the family their fears and coping
mechanisms.
3. Encourage the patient and the family to take an active
role in decision making when possible.
4. Communicate with the physician and other health care
team members to be certain the information provided is
consistent
POST OPERATIVE
1. Assess the patient’s responses to the surgery
2. Monitor for possible complications such as: infection,
bleeding, thrombophlebitis, wound dehiscence, fluid and
electrolyte imbalance, & organ dysfunction
3. Provide comfort by addressing to the wound care,
activity, nutrition, & medication information
4. Plan for discharge, follow-up and home care and
treatment as early as possible to ensure continuity of
care
5. Encourage patient and family to use community
resources for support and information
INTRODUCTION TO RADIATION ONCOLOGY
Radiation therapy, or radiotherapy, is the use of various
forms of radiation to safely and effectively treat cancer and
other diseases.
Radiation therapy has been an effective tool for treating
cancer for more than 100 years.
About two-thirds of all cancer patients will receive radiation
therapy as part of their treatment.
Radiation oncologists are doctors trained to use radiation to
treat cancer.
BRIEF HISTORY OF RADIATION THERAPY
The first patient was treated with radiation therapy in 1896,
just two months after the discovery of the X-ray.
Rapid technology advances began in the early 1950s, with the
invention of the linear accelerator.
Planning and treatment delivery advances have enabled
radiation therapy to be more effective and precise, while
decreasing the severity of side effects.
HOW DOES RADIATION THERAPY WORK?
Radiation therapy works by damaging the DNA within cancer
cells, destroying their ability to reproduce and causing the
cells to die.
When the damaged cancer cells are destroyed by radiation,
the body naturally eliminates them.
Normal cells can be affected by radiation, but they can repair
themselves in a way cancer cells cannot.
WHEN IS RADIATION USED?
The best treatment plan for each patient is frequently
determined by a team of doctors, including a radiation
oncologist, a medical oncologist and a surgeon.
Sometimes radiation therapy is the only treatment a patient
needs.
Other times, it is combined with other treatments, such as
surgery and chemotherapy.
Radiotherapy
It is a common form of cancer treatment.
Radiotherapy uses high energy, ionizing radiation, known as
radioactivity.
Along with surgery, radiotherapy is another important form
of treatment of localized cancer.
RADIOTHERAPY IS USED TO:
• destroy malignant tumors
• boost the outcomes of surgical or other treatment
(adjuvant therapy)
• alleviate symptoms
• reduce metastases
About half of cancer patients receive radiotherapy at some
stage in their treatment.
Radiotherapy is usually aimed directly at your tumor or
metastases.
With the treatment of widely distributed cancer,
radiotherapy may sometimes be given for the whole of the
upper body.
Radiotherapy can be given externally by a machine or
internally by introducing a radioactive source into the body in
different ways.
There are a variety of methods of internal radiotherapy.
With radioisotope therapy or radiopharmaceutical therapy- a
radioactive medicine is introduced into the body
intravenously or orally.
The radioactive medicine directly affects the tumor and
healthy tissue is harmed only slightly.
If the cancer is localized, the choice between surgery and
radiotherapy depends on the effectiveness of the treatment
and its drawbacks.
The importance of radiotherapy in cancer treatment has
increased in particular with the development of conservation
treatment methods.
IS RADIATION THERAPY SAFE?
New advances in technology and treatment delivery continue
to make radiation safe and effective.
A team of medical professionals develop and review the
treatment plan for each patient to minimize side effects and
assure that the area where the cancer is located is receiving
the dose of radiation needed.
The treatment plan and equipment are constantly reviewed
to ensure the proper treatment is being given.
WHY USE RADIATION THERAPY?
To cure cancer:
• Destroy tumors that have not spread to other body
parts.
• Reduce the risk that cancer will return after surgery
or chemotherapy.
• Shrink the cancer before surgery.
For palliation (to reduce symptoms):
• Shrink tumors affecting quality of life, like a lung
tumor that is causing shortness of breath.
• Alleviate pain or neurologic symptoms by reducing
the size of a tumor.
MEET THE RADIATION ONCOLOGY TEAM
A team of highly trained medical professionals work together
to make sure you receive the best possible care while you are
undergoing radiation therapy.
Radiation Oncologist
• Oversees the radiation therapy treatments, including
working with other members of the radiation
therapy team to develop the treatment plan and
ensure that each treatment is given safely and
accurately.
Medical Radiation Physicist
• Ensures that complex treatment plans are properly
tailored for each patient and directs quality control
programs for equipment and procedures.
Dosimetrist
• Works with the radiation oncologist and medical
physicist to calculate the proper dose of radiation
given to the tumor.
Radiation Therapist
• Administers the daily radiation under the radiation
oncologist’s prescription and supervision.
Radiation Oncology Nurse
• Cares for the patient and family by providing
education, emotional support and tips for managing
side effects.
Additional Members of the Team
• Social workers, nutritionists, dentists, physical
therapists and patient navigators may also assist in a
patient’s care during their treatment.
WHAT TO EXPECT:
Referral
• A cancer is diagnosed.
• The diagnosing or referring physician reviews
potential treatment options with patient.
• Treatment options may include radiation therapy,
surgery, chemotherapy or a combination.
• It is important for a patient to ask referring physician
about all possible treatment options available to
them
Consultation
• Radiation oncologist discusses the radiation therapy
treatment options with patient.
• A treatment plan is developed.
• Care is coordinated with other members of patient’s
oncology team.
 • The radiation oncologist will discuss with the patient
which type of radiation therapy treatment is best for
their type of cancer
Simulation
A CT scan of the area of the body to be treated with radiation.
The CT images are reconstructed and used to design the best
and most precise treatment plan.
Patient is set up in treatment position on a dedicated CT
scanner.
• Immobilization devices may be created to assure patient
comfort and daily reproducibility.
• Reference marks or “tattoos” may be placed on patient.
CT simulation images are often fused with other scans such at
MRI or PET scans to create a treatment plan.
Treatment Planning
• The radiation oncologist works with the medical
physicist and dosimetrist to create an individualized
treatment plan for the patient.
• The treatment is mapped out in detail including the
type of machine to be used, the amount of radiation
that is needed and the number of treatments that
will be given.
• Radiation oncologist and dosimetrist creating a
treatment plan
Treatment Process
• Each day the patient will check in at the cancer
center for treatment
• They will then be verified as the correct patient and
be set up for their treatment
• The radiation oncologist will monitor the treatments
and the patient will meeting with them weekly to
discuss their treatment.
• During their check in at the cancer center, a patient’s
identity will be verified.
HOW IS RADIATION THERAPY DELIVERED?
Radiation therapy can be delivered either externally or
internally.
• External beam radiation therapy typically delivers
radiation using a linear accelerator.
• Internal radiation therapy, called brachytherapy,
involves placing radioactive sources into or near the
tumor.
The type of treatment used will depend on the location, size
and type of cancer.
TYPES OF RADIATION THERAPY
EXTERNAL RADIATION THERAPY
Teletherapy, DXT
• This is administered through a high-energy x-ray or
gamma X-ray machine
• E.g. linear accelerator, cobalt, betatron, or a machine
containing radioisotope
• The major advantage of high-energy radiation is its skin-
sparing effect. The maximum effect of radiation occurs at
tumor deep in the body, not on the skin surface.
• There is no need for isolation
TYPES OF EXTERNAL RADIATION THERAPY
The type of equipment used will depend on the location, size
and type of cancer.
Three-dimensional conformal radiation therapy (3D-CRT)
A technique where beams of radiation used in treatment are
shaped to match the tumor and are delivered accurately from
several directions.
Intensity modulated radiation therapy (IMRT)
A form of 3-D CRT in which the physician designates specific
doses of radiation that the tumor and normal surrounding
tissues receive.
A multileaf collimator is used to shape the radiation beam to
match the tumor, sparing surrounding healthy tissue
Proton Beam Therapy
A type of radiation therapy that uses high-energy beams
(protons) rather than X-rays to treat certain types of cancer.
Most commonly used in the treatment of pediatric, CNS and
intraocular cancers.
Stereotactic Body Radiotherapy or Stereotactic Radiosurgery
A specialized form of radiation therapy that focuses high-
power energy on a small area of the body. Despite its name,
radiosurgery is a treatment, not a surgical procedure.
Radiosurgery generally implies a single high dose or just a few
high dose treatments.
INTERNAL RADIATION THERAPY (BRACHYTHERAPY)
This is administered within or near the tumor or into the
systemic circulation
Radioactive material is placed into tumor or surrounding
tissue.
• Also called brachytherapy.
• Radiation sources are placed close to the tumor so
large doses can damage the cancer cells.
• Allows minimal radiation exposure to normal tissue.
• Radioactive sources used are thin wires, ribbons,
capsules or seeds.
• These can be either permanently or temporarily
placed in the body
Radioactive seeds for a permanent prostate implant, an
example of low-dose-rate brachytherapy.
2 MAJOR TYPES OF INTERNAL RADIATION THERAPY
Sealed source (brachytherapy) – the radioisotope is placed
within or near the tumor. The radioactive material is enclosed
in a sealed container.
• Sealed source is used for both intracavity &
interstitial therapy
• Intracavity RT is used to treat cancers of the uterus &
cervix. The radioisotope is placed in the body cavity,
generally for 24-72 hours (cesium 137 or radium 226
Unsealed source (brachytherapy) – the radioisotopes maybe
administered intravenously, orally or by instillation directly
into the body cavity
The radioisotope circulates through the client’s body.
Therefore the client’s urine, sweat, blood, vomitus contain
the radioactive isotope
PERMANENT VS. TEMPORARY IMPLANTS
Permanent implants
• release small amounts of radiation over a period of
several months
• Examples include low-dose-rate prostate implants
(“seeds”),
• Patients receiving permanent implants may be
minimally radioactive and should temporarily avoid
close contact with children or pregnant women.
Temporary implants
• left in the body for several hours to several days
• Patient may require hospitalization during the
implant depending on the treatment site ,
• Examples include low-dose-rate gynecologic
implants and high-dose-rate prostate or breast
implants
COMBINING RADIOTHERAPY AND SURGERY
Radiotherapy can be given either before or after surgery.
For instance, if surgery is not sufficiently extensive or there is
a major risk of tumor recurrence, treatment is usually
supplemented by giving radiotherapy after surgery.
Before surgery, radiotherapy may be used to reduce a tumor.
The most effective way to combine radiotherapy and
chemotherapy is to give them at the same time because they
reinforce one another’s effectiveness.
This is called CHEMORADIOTHERAPY It has improved
treatment outcomes in many types of cancer, such as with
certain lung cancers and cancers of the head and neck areas.
The simultaneous use of chemotherapy nevertheless
increases the side effects of radiotherapy.
HAVING RADIOTHERAPY
Planning radiotherapy takes into account not only your tumor
but also information on the possible spread of the cancer.
Radiotherapy is completely painless and is targeted directly at
the tumor or metastases.
Radiotherapy is usually divided over a 2 – 8 week period. It is
generally provided in small single daily doses five days a
week.
Each treatment takes a few minutes.
Dividing radiotherapy into several small parts reduces the
harm caused to healthy tissue and improves the effectiveness
of the therapy.
Patients usually go about their lives as normal during the
period of treatment. In some cases accelerated radiotherapy
may be given instead of phased radiotherapy. Radiotherapy is
often a well-tolerated form of treatment, but it does have
side effects.
SIDE EFFECTS OF RADIOTHERAPY
Radiotherapy affects normal cells in the body and not only
cancer cells. The impact on healthy tissue depends for the
most part on the size of the radiation dose, the duration of
treatment and what part of the body receives radiation.
Adverse side effects only appear in the area of your body
where the radiation is applied.
The side effects of radiotherapy may already appear during
the treatment period, immediately after treatment or later,
even after some years. The immediate side effects of
radiotherapy are quickly apparent in dividing tissue such as in
the skin, mucous membranes and bone marrow. Most side
effects can nowadays be effectively prevented and treated.
Below we list the most common side effects of radiotherapy.
You will be able to get more detailed information on the side
effects and their treatment from the medical staff treating
you.
DAMAGE TO THE MOUTH AND PHARYNX MUCOSA
Nearly all patients who receive radiotherapy to the head and
neck area suffer damage to their mouth and pharynx mucosa.
This is painful, makes it difficult to eat, is prone to infection
and endangers dental health. Radiotherapy given to the area
of the saliva glands may also cause dry mouth.
Damage to the mucosa in your mouth can be treated with
preventive dental care, by treating infections, using painkillers
and ensuring that you get sufficient nutrition.
INTESTINAL DAMAGE
Radiotherapy to your intestinal tract easily produces
immediate side effects. Radiation given in the abdominal and
pelvic area can cause nausea, diarrhoea and irritation of the
bowel and rectal area.
The degree of damage depends on the composition of the
area being treated and the size of the single and total dosage
of radiation. Chemotherapy given at the same time increases
and complicates the side effects. Radiotherapy given to the
oesophagus can bring about a feeling of burning below the
sternum, as well as pain and difficulty swallowing.
SKIN
Following radiotherapy your skin may become reddened and
peel. Skin redness may begin after 2 – 3 weeks and peeling
generally after 4 – 5 weeks after the start of radiotherapy.
Your skin may also become darker. It is important to protect
the skin area under radiotherapy from sunlight, as your skin
remembers the dose of radiotherapy it receives for your
entire lifetime.
BONE MARROW
Blood cells are produced in the bone marrow contained in
your larger bones. Radiotherapy given to the pelvic and spinal
area may cause a drop in white blood cell, blood platelet and
haemoglobin counts. This is usually temporary and your
blood count will gradually improve.
EXTERNAL GENITAL AND BLADDER IRRITATION
If a woman’s vulva and mucous membrane areas are given
radiotherapy it may cause soreness. The areas are painful and
may become infected.
Acute bladder irritation from radiotherapy occurs in the
treatment of bladder cancer, endometrial cancer or prostate
cancer. In this situation you feel a frequent need to urinate,
there may be blood in your urine and you may have a
distended lower stomach. Urinating may also be painful.
NURSING MANAGEMENT IN RADIATION THERAPY
• Assess the patient’s skin, nutritional status, and the
general feeling of well-being
• Assess frequently for the changes skin and oral
mucosa. Instruct the patient to avoid the use of
ointment and lotion to prevent skin irritation. Gentle
oral hygiene is essential to remove debris, prevent
irritation, and promote healing.
NURSING RESPONSIBILITIES FOR EITHER EXTERNAL OR
INTERNAL RADIATION THERAPY
• Carefully assess and manage any complications,
usually in collaboration with the radiation oncologist.
• Assist in documenting the results of the therapy; for
example, clients receiving radiation for metastases
to the spine will show improved neurologic
functioning as tumor size diminishes.
• Provide emotional support, relief of physical and
psychologic discomfort, and opportunities to talk
about fears and concerns. For some clients, radiation
therapy is a last chance for cure or even just for
relief of physical discomfort.
EXTERNAL RADIATION
Prior to the start of treatments, the treatment area will be
specifically located by the radiation oncologist and marked
with colored semi-permanent ink or tattoos.
Treatment is usually monitor given 5 days per week for 15 to
30 minutes per day over 2 to 7 weeks.
Nursing Responsibilities or for adverse effects:
• skin changes, such as blanching, erythema,
desquamation, sloughing, or hemorrhage;
ulcerations of mucous membranes; nausea and
vomiting, diarrhea, or gastrointestinal bleeding.
• Assess lungs for rales, which may indicate interstitial
exudate. Observe for any dyspnea or changes in
respiratory pattern.
• Identify and record any medications that the client
will be taking during the radiation treatment.
• Monitor white blood cell counts and platelet counts
for significant decreases.
CLIENT AND FAMILY TEACHING
• Wash the skin that is marked as the radiation site only
with plain water, no soap; do not apply deodorant,
lotions, medications, perfume, or talcum powder to the
site during the treatment period. Take care not to wash
off the treatment marks.
• Do not rub, scratch, or scrub treated skin areas. If
necessary, use only an electric razor to shave the treated
area.
 • Apply neither heat nor cold (e.g., heating pad or ice
pack) to the treatment site.
• Inspect the skin for damage or serious changes, and
report these to the radiologist or physician.
• Wear loose, soft clothing over the treated area.
• Protect skin from sun exposure during treatment and
for at least 1 year after radiation therapy is discontinued.
Cover skin with protective clothing during treatment;
once radiation is discontinued, use sun-blocking agents
with a sun protection factor (SPF) of at least 15.
• External radiation poses no risk to other people for
radiation exposure, even with intimate physical contact.
• Be sure to get plenty of rest and eat a balanced diet.
INTERNAL RADIATION
The radiation source, called an implant, is placed into the
affected tissue or body cavity and is sealed in tubes,
containers, wires, seeds, capsules, or needles.
An implant may be temporary or permanent.
Internal radiation may also be ingested or injected as a
solution into the bloodstream or a body cavity or be
introduced into the tumor through a catheter.
The radioactive substance may transmit rays outside the
body or be excreted in body fluids.
NURSING RESPONSIBILITIES
• The radiation source, called an implant, is placed into
the affected tissue or body cavity and is sealed in
tubes, containers, wires, seeds, capsules, or needles.
• An implant may be temporary or permanent.
• Internal radiation may also be ingested or injected as
a solution into the bloodstream or a body cavity or
be introduced into the tumor through a catheter.
• The radioactive substance may transmit rays outside
the body or be excreted in body fluids.
CLIENT AND FAMILY TEACHING
• While a temporary implant is in place, stay in bed
and rest quietly to avoid dislodging the implant.
• For outpatient treatments, avoid close contact with
others until treatment has been discontinued.
• If the radiologist indicates the need for such
measures, dispose of excretory materials in special
containers or in a toilet not used by others.
• Carry out daily activities as able; get extra rest if
feeling fatigued.
• Eat a balanced diet; frequent, small meals often are
better tolerated.
• Contact the nurse or physician for any concerns or
questions after discharge.
FOLLOW SPECIAL PRINCIPLES OF TIME, DISTANCE, AND
SHIELDING (DTS)
Maximize distance- The greater the distance from the
radiation source the less the exposure dose of ionizing rays.
Maintain a distance of at least 3 feet when not performing
nursing procedures.
a. Intensity of radiation is related to distance from
client.
b. Duration of safe exposure increases as distance is
increased; work as far away from source as possible.
Minimize time- Limit contact with the client for 5 minutes
each time, total of 30 minutes per 8-hour shift
a. Radiation exposure proportional to amount of
time spent with client.
b. Plan care to be delivered in shortest amount of
time to meet goals—be efficient with time.
c. Review procedures before beginning them.
Utilize shielding- use lead shield during contact with the
patient.
a. Use lead shields or other equipment to reduce
transmission of radiation.
Store radioactive material in lead-shielded container
when not in use.
b. Pregnant staff should not be assigned to clients
receiving internal RT.
c. staff members caring for the client with internal RT
should wear dosimeter badge while in the client’s
room
d. Prevent feelings of isolation, maintain contact with
the client while keeping distance from radiation
exposure. Talk with the client from the doorway of
the room.
RADIATION SAFETY MEASURES
• Wear radiation badges to monitor total amount of
radiation exposure. Cumulative dose (measured in
millrems) not to exceed 1250 every 3 months.
• Observe for displacement or dislodgement of radiation
source every 4-6 hours
• Check that sealed lead container is kept in client’s room
in case of accidental dislodgement
• Collect body waste until it can be determined that
radiation source is not dislodged
• Radiation source removed at prearranged time – after
removal, client is no longer radioactive
• Do not allow persons under age 18 or pregnant women
to visit or care for clients with radioactive implant
• Never touch a dislodged sealed source – use long- • The client should be given low fiber diet to inhibit
handled tongs or contact radiation safety personnel defecation during the procedure until the device is
• Mark client’s room and chart with radiation safety removed in 2 to 3 days. To prevent dislodgement of
precautions. the radioisotope

FOLLOW RADIATION PRECAUTIONS FOR ISOTOPE IMPLANT. TEACHING GUIDELINES REGARDING EXTERNAL RADIATION
THERAPY
All body secretions considered contaminated—use special
techniques for disposal. • It is painless
• Lie very still on a special table while the intervention
If client vomits within first 4 hours—everything vomitus
is given & you may be placed in a special position to
touches is considered contaminated.
maximize tumor irradiation
Use disposable gown, dishes, etc. • Each treatment usually lasts for few minutes. You
may hear sounds of the machine being operated , &
Limit contact with hospital personnel and visitors. Visitors the machine may move during the therapy
must limit exposure to 1 hour/ day and keep a distance from • As a safety precaution for the therapy personnel,
the client. you will remain alone in the treatment room while
the machine is in operation
OTHER PRINCIPLES OF RADIATION PROTECTION
• The technologist will be right outside your room
If the client with cancer of the cervix has radioisotope implant observing you through a window or by a closed-
into the uterus, the following nursing interventions should be circuit TV. You may communicate
implemented: • There is no residual radioactivity after radiation
therapy. Safety precautions are necessary only
• Client’s back is turned towards the door. To during the time your actually receiving irradiation.
minimize exposure of healthcare staff to You may resume normal activities of daily living
radioisotope entering the client’s room
• Encourage the client to turn to sides at regular CLIENT EDUCATION ON SKIN CARE IN EXTERNAL RADIATION
intervals THERAPY
• The client should be in complete bed rest. To
• Keep the skin dry
prevent dislodgement of the radioisotope
• Do not wash the treatment area until you are
• The client should be given enema before the
instructed to do so. When permitted, wash the
procedure. Bowel movement during the procedure
treated skin gently with mild soap, rinse well, & pat
may cause dislodgement of the radioisotope.
dry. Use warm water or cool water, not hot water.
• The client should be given low fiber diet to inhibit
• do not remove the linens or ink marks placed on
defecation during the procedure until the device is
your skin
removed in 2 to 3 days. To prevent dislodgement of
• Avoid using powders, lotions, creams, alcohol and
the radioisotope
deodorants on the treated skin
• The client should be given enema before the
• Wear loose-fitting clothing to avoid friction over the
procedure. Bowel movement during the procedure
treatment area
may cause dislodgement of the radioisotope.
• Do not apply tape to the treatment area if dressings
• The client should be given low fiber diet to inhibit
are applied
defecation during the procedure until the device is
• Shave with an electric razor. Do not use pre-shave or
removed in 2 to 3 days. To prevent dislodgement of
after-shave lotions
the radioisotope
• Protect your skin from exposure to direct sunlight,
• The client should be given enema before the
chlorinated swimming pools, & temperature
procedure. Bowel movement during the procedure
extremes (e.g. hot water bottles, heating pads, ice
may cause dislodgement of the radioisotope.
packs)
• The client should be given low fiber diet to inhibit
• Consult your radiation therapist or nurse about the
defecation during the procedure until the device is
specific measures for individual skin reactions
removed in 2 to 3 days. To prevent dislodgement of
the radioisotope
NURSING INTERVENTION FOR SIDE EFFECTS OF RADIATION
• The client should be given enema before the
THERAPY
procedure. Bowel movement during the procedure
may cause dislodgement of the radioisotope.
1. SKIN REACTIONS
Protect your skin from exposure to direct sunlight,
chlorinated swimming pools, & temperature extremes (e.g.
hot water bottles, heating pads, ice packs)
Consult your radiation therapist or nurse about the specific
measures for individual skin reactions
NURSING INTERVENTIONS:
• Observe for early signs of skin reaction & report to
the physician
• Keep area dry
• Wash area with water, no soap & pat dry (donot
rub). Mild soap is permitted.
• Protect your skin from exposure to direct sunlight,
chlorinated swimming pools, & temperature
extremes (e.g. hot water bottles, heating pads, ice
packs)
• Consult your radiation therapist or nurse about the
specific measures for individual skin reactions
2. INFECTION DUE TO BONE MARROW SUPPRESION
• Monitor blood counts weekly, especially the
WBC
• Good personal hygiene, nutrition, adequate rest
• Teach the client signs of infection to report to
the physician
3. HEMORRHAGE – PLATELETS ARE VULNERABLE TO
RADIATION
• Monitor platelet count
• Avoid physical trauma or use of aspirin (ASA)
• Teach signs of hemorrhage to report (e.g. gum
bleeding, nose bleeding, black stools)
• Monitor stool and skin for signs of hemorrhage
• Use direct pressure over injection sites until
bleeding stops
4. FATIGUE
• Result of high metabolic demands for tissue
repair & toxic waste removal
• Plenty of rest & good nutrition
5. WEIGHT LOSS
• Anorexia, pain & effect of cancer
6. STOMATITIS & XEROSTOMIA (DRY MOUTH)
ULCERATION OF ORAL MUCOUS MEMBRANE OCCURS
• Administer analgesics before meals as
prescribed
• Bland diet, avoid smoking & alcohol
• Good oral hygiene with saline rinses every 2
hours
• Sugarless lemon drops or mint to increase
salivation
7. DIARRHEA, N/V, HEADACHE, ALOPECIA & CYSTITIS MAY
ALSO OCCUR
8. SOCIAL ISOLATION IS ALSO EXPERIENCE BY THE CLIENT
DUE TO FEAR OF CONTAMINATING OTHERS WITH
RADIATION
COMPLEMENTARY AND ALTERNATIVE METHODS AND
CANCER
COMPLEMENTARY AND ALTERNATIVE MEDICINE
People with cancer may use Complementary and Alternative
Medicine to:
• Help cope with the side effects of cancer treatments,
such as nausea, pain, and fatigue
• Comfort themselves and ease the worries of cancer
treatment and related stress
• Feel that they are doing something to help with their
own care
• Try to treat or cure their cancer
INTEGRATIVE MEDICINE
• is an approach to medical care that combines
standard medicine with CAM practices that have
shown through science to be safe and effective.
STANDARD MEDICAL CARE
•  is practiced by health professionals who hold an
M.D. (medical doctor) or D.O. (doctor of
osteopathy) degree. It is also practiced by other
health professionals, such as physical therapists,
physician assistants, psychologists, and registered
nurses.
COMPLEMENTARY MEDICINE
• is used along with standard medical treatment but
is not considered by itself to be standard treatment.
ALTERNATIVE MEDICINE
•  is used instead of standard medical treatment.
–
TYPES OF COMPLEMENTARY AND ALTERNATIVE MEDICINE
MIND-BODY THERAPIES
• Meditation
• Biofeedback
• Hypnosis
• Yoga
 • Tai Chi  will sedate them and cause respiratory depression.
Fact: As patients become tolerant to the analgesic effect of a
• Imagery 
drug, they develop tolerance to potential respiratory
• Creative outlets depression as well.

BIOLOGICALLY BASED PRACTICES Fallacy #4: Patients in pain are easily recognized because they
act as if they are in pain.
• Vitamins and dietary supplements. Fact: As patients adapt to chronic pain, usual signs of
• Botanicals, which are plants or parts of plants. One discomfort may be absent
type is cannabis.
• Herbs and spices such as turmeric or cinnamon. Fallacy #5: Older people don’t feel pain like younger ones do
Special foods or diets. and they are unable to tolerate strong opioids because of the
potentially dangerous side effects.
MANIPULATIVE AND BODY-BASED PRACTICES Fact: Like other adults, elderly cancer patients require
aggressive pain assessment and management
• Massage
• Chiropractic therapy • effective cancer pain management through a
• Reflexology patient-focused approach by “optimally matching
the options for cancer pain control with individual
BIOFIELD THERAPY
needs, preferences, and likely responses
• Reiki
WHAT CAUSES CANCER PAIN?
• Therapeutic touch
• Pain from the tumor: Most cancer pain occurs when
WHOLE MEDICAL SYSTEMS
a tumor presses on bone, nerves or organs. The pain
• Ayurvedic medicine may vary according to location. For example, a small
• Traditional Chinese medicine tumor near a nerve or the spinal cord may be very
• Acupuncture painful, while a larger tumor elsewhere may not
• Homeopathy cause discomfort.
• Naturopathic medicine • Treatment-related pain: Chemotherapy,
radiotherapy and surgery can cause pain. Also,
THE SAFETY OF COMPLEMENTARY AND ALTERNATIVE certain painful conditions are more likely to occur in
MEDICINE patients with a suppressed immune system, which is
• Herbal supplements may be harmful when taken by often a result of these therapies.
themselves, with other substances, or in large • Post-operative pain: Relieving pain resulting from
doses.  surgery helps people recuperate more quickly and
• Tell your doctor if you're taking any dietary heal more effectively.
supplements, even vitamins, no matter how safe you WHAT ARE THE SYMPTOMS OF CANCER PAIN?
think they are. 
• Talk with your doctor about what you should be • Pain that doesn’t seem to go away or that goes away
eating.  and comes back before your next dose of pain
medicine is due (This might mean that your medicine
CANCER PAIN plan needs to be changed.)
Fallacy #1: Taking morphine or other opioids to relieve cancer • Trouble sleeping
pain will cause addiction. • Lack of interest in things you used to enjoy
Fact: The use of opioids for pain relief is an accepted medical • New areas of pain or a change in your pain
practice and fear of addiction should not be a basis for • Less ability to move around or do things
withholding or under medicating a patient in pain THE DOCTOR WILL PRESCRIBE DRUGS BASED ON WHETHER
Fallacy # 2: Analgesics used early in treatment won’t be THE PAIN IS MILD, MODERATE, OR SEVERE.
effective later on. • 0 means no pain.
Fact: Patients who develop a tolerance to the effects of • 1 to 3 means mild pain.
opioids can achieve pain relief by increasing the dose, which • 4 to 6 means moderate pain.
is only limited by side effects • 6 means severe pain.
Fallacy #3: A dose that is high enough to relieve the pain of • 7 to 9 means very severe pain.
tolerant patients • 10 means worst pain possible.
PAIN CAN BE MANAGED BEFORE, DURING, AND AFTER
TESTS AND PROCEDURES.
• Some tests and procedures are painful. It helps to
start pain control before a procedure begins. Some
drugs may be used to help you feel calm or fall
asleep. Therapies such as imagery or relaxation can
also help control pain and anxiety related to
treatment. Knowing what will happen during the
procedure and having a family member or friend
stay with you may also help lower anxiety.
TREATMENT CHOICES FOR CANCER PAIN
The type of pain experienced influences the choice of
medications and their use. Some of the factors that influence
the treatment choices include:
• The location of the pain
• The severity of the pain
• The type of pain – such as sharp, tingling or aching
• Whether the pain is persistent, or comes and goes
• What activities or events make the pain worse
• What activities or events make the pain better
• Current medications
• How much current medications ease the pain
• The impact the pain has on lifestyle, such as poor
quality of sleep or loss of appetite.
DIFFERENT CANCER TREATMENTS MAY CAUSE SPECIFIC
TYPES OF PAIN.
• Postoperative pain.
• Spasms, pain, stinging, and itching caused by
intravenous chemotherapy.
• Mucositis (sores or inflammation in the mouth or
other parts of the digestive system) caused by
chemotherapy or targeted therapy.
• Ostealgia (bone pain) caused by treatment with
filgrastim or pegfilgrastim, which are granulocyte
colony-stimulating factors that help the body make
more white blood cells.
• Peripheral neuropathy (pain, numbness, tingling,
swelling, or muscle weakness in hands or feet)
caused by chemotherapy or targeted therapy.
• Pain in joints and muscles throughout the body
caused by paclitaxel or aromatase inhibitor therapy.
• Osteonecrosis of the jaw caused by bisphosphonates
given for cancer that has spread to the bone.
• Avascular necrosis caused by long-term use of
corticosteroids.
• Pain syndromes caused by radiation therapy,
including:
• Pain from brachytherapy.
• Pain from lying in the same position during
treatment.
• Mucositis (inflammation of the mucous membranes
in areas that were treated with radiation)
• Dermatitis (inflammation of the skin in areas that
were treated with radiation)
• Pain flares (a sudden increase of pain in the treated
area)
HOW DO YOU TREAT CANCER PAIN?
Mild to Moderate Pain
Over-the-counter-Pain relievers: Acetaminophen (Panadol,
Tylenol) and a group of pain relievers called nonsteroidal anti-
inflammatory drugs (NSAIDs) such as aspirin and ibuprofen
(Advil) can treat mild to moderate pain. Many of these are
over-the-counter drugs that do not require a prescription, but
some do require a prescription. Patients should check with a
doctor before using these medicines, especially if they are
getting chemotherapy. NSAIDs can interfere with blood
clotting, cause gastrointestinal and kidney problems, and may
lead to increased risk of heart attack or stroke.
• Aspirin-like drugs – these medications are used for
bone pain, and pain caused by inflammation (such as
pleurisy). Some people experience stomach
problems, such as indigestion and bleeding, with this
type of medication. Aspirin itself is generally
avoided, because it is too hard on the stomach if
taken regularly.
• Paracetamol – is important in cancer pain control. It
is usually well tolerated, doesn’t affect the stomach
and won’t thin the blood. It is helpful to reduce
fevers and relieve bone pain, and is often used along
with opioids.
Moderate to Severe Pain
Medications derived from opium (opioids). Opioids are
prescription medications used to treat moderate to severe
pain. Examples of opioids include morphine and oxycodone .
Some opioids are short-acting medicines, so pain relief comes
quickly but you may need to take them more often. Other
opioid drugs are long-acting medicines, so pain relief takes
longer but the medicine doesn't need to be taken as often.
Sometimes short-acting and long-acting opioids are used
together.
• Opioids – such as codeine and morphine. Some of
the side effects may include nausea, vomiting,
drowsiness and constipation. There is no danger of
addiction if taken for pain relief purposes. There are
several newer opioids available, so one can usually
be found to suit. Many people worry about taking
opioids, because they are afraid to become addicted
or think they should wait until they are very ill before
they use these drugs. Evidence shows that it is far
 better to find a suitable opioid and use it regularly
from the time when your pain becomes constant.
This makes it easier to maintain the activities and
interests you enjoy.
Tingling and Burning Pain
Other prescription medicines. Other types of medicine can
help relieve pain, including antidepressants, anti-seizure
drugs and steroids.
• Antidepressants: Certain antidepressants are used
to relieve pain even if the person isn't depressed.
Amitriptyline and nortriptyline (Aventyl, Pamelor),
and duloxetine (Cymbalta) are antidepressants
sometimes used to treat pain.
• Anticonvulsants (anti-seizure medications): Despite
the name, anticonvulsants like gabapentin (Horizant,
Neurontin) and carbamazepine (Carbatrol, Equetro,
Tegretol) are used not only for seizures, but also to
control burning and tingling pain, painful symptoms
of nerve damage.
Pain caused by swelling
◦ Other drugs: Corticosteroids such as prednisone
(Sterapred) are used to lessen swelling, which often
causes pain.
◦ Procedures to block pain signals. A nerve block
procedure can be used to stop pain signals from
being sent to the brain. In this procedure, a numbing
medicine is injected around or into a nerve.
◦ Integrative therapies. Some people find some pain
relief through acupuncture, massage, physical
therapy, relaxation exercises, meditation and
hypnosis.
MANAGING CANCER PAIN-RELIEVING MEDICATION
General suggestions include:
• Take your medications regularly, according to the
advice of your doctor. Each type of medication has a
different lifetime in the body and so must be taken
at the frequency suited to that drug.
• Get to know your medication – how it works, how
long it lasts in the body, what its side effects are and
any other particularities.
• Always make sure you have an up-to-date record of
your current medication and dose. Your doctor,
nurse or pharmacist can help you with this.
• Always make sure you have enough medication on
hand to last for at least one week.
• Take enough medication before bed to ensure an
uninterrupted sleep. For example, if you are using a
preparation that lasts for four hours, you might try
taking a double dose before retiring at night, to
allow you eight hours sleep, rather than having to
disturb your sleep four hours later for the next dose.
• If necessary, you may need to set your alarm during
the night so that you don’t miss a dose. If you are
waking in the morning with significant pain, this may
help improve your pain control.
• Have your medications reviewed regularly by your
doctor. Dosages may need to be increased or
decreased, depending on what is happening to your
cancer and to you.
HOW ELSE CAN CANCER PAIN BE TREATED?
Relaxation and cancer pain management
Helpful therapies may include:
• Breathing and relaxation – scientific studies
have shown that correct breathing, using the
diaphragm and abdomen, can soothe the
nervous system and manage stress.
• Hypnotherapy – is the use of imagery to induce
a dreamy, relaxed state of mind. Hypnotherapy
can also help to ease some of the side effects of
cancer treatment, such as nausea.
• Massage – the skin is the largest organ of the
human body and is packed with nerve endings.
Massage works by soothing soft tissue and
encouraging relaxation.
• Meditation – is the deliberate clearing of the
mind to bring about feelings of calm and
heightened awareness. The regular practice of
meditation offers many long-term health
benefits, such as reduced stress and blood
pressure.
• Tai chi – is a Chinese form of non-combative
martial arts that consists of gentle movements
to clear the mind and relax the body.
• Yoga – is an ancient Indian system of postures
synchronised with the breath.
Other techniques that may be helpful to ease chronic pain
include:
• Acupuncture
• Transcutaneous electrical nerve stimulation (TENS)
therapy
WHEN MEDICINE IS NOT ENOUGH
• Radiation therapy
• Nerve blocks/implanted pump
• Neurosurgery
• Surgery
WHAT ARE SOME REASONS FOR NOT RECEIVING ADEQUATE
TREATMENT FOR CANCER PAIN?
 • Reluctance of doctors to ask about pain or offer
treatments
• Given current concerns about opioid use and abuse,
many doctors might be reluctant to prescribe these
medications.
• Reluctance of people to mention their pain.
• Fear of addiction to opioids.
• You might develop a tolerance for your pain
medication
• Fear of side effects.
HOW CAN YOU HELP YOUR DOCTOR UNDERSTAND YOUR
CANCER PAIN?
• How severe the pain is
• What type of pain (stabbing, dull, achy) you have
• Where you feel the pain
• What brings on the pain
• What makes the pain worse or better
• What pain relief measures you use, such as
medication, massage, and hot or cold packs, how
they help and any side effects they cause
WHAT STEPS CAN YOU TAKE TO ENSURE YOU'RE RECEIVING
ADEQUATE CANCER PAIN TREATMENT?
1. talk to your doctor or health care provider about
your pain.
2. you and your doctor can set a goal for pain
management and monitor the success of the
treatment. Your doctor should track the pain with a
pain scale, assessing how strong it is. The goal should
be to keep you comfortable. If you aren't
comfortable, talk to your doctor.
WHAT THE PATIENT WITH CANCER CAN DO
• Talk with your cancer team about your pain – where
it is, when it began, how long it lasts, what it feels
like, what makes it better, what makes it worse, and
how it affects your life.
• If the prescribed pain medicines don’t work as
expected, let your cancer team know.
• Rate your pain using a pain rating scale, such as 0 =
no pain to 10 = the worst pain you can imagine. You
can use this scale to explain your pain to others.
• Take your pain medicine exactly as prescribed. (For
chronic pain, medicine should be given around the
clock on a schedule, rather than only when pain is
severe.) Check with your cancer team if this schedule
needs to be adjusted.
• As the pain is relieved with medicines, increase your
activity level.
• Don’t wait until the pain is severe before taking
medicine for breakthrough pain.
• Avoid suddenly stopping any of your pain medicines.
Instead, reduce the dose slowly as the pain
decreases. Ask your cancer team before you do this,
or if you have questions.
• Some people feel nauseated even when they’re
taking the right dose of pain medicine. If your pain
medicine makes you feel sick, ask your cancer team
about changing it or trying something to control the
nausea.
• Some pain medicines make you sleepy or dizzy. This
often gets better after a few days, but you may need
help getting up or walking. Don’t try to drive or do
anything dangerous until you are sure of the effects.
• People taking pain medicines are normally given
laxatives or stool softeners to prevent constipation, a
common side effect.
• Keep track of any other side effects you notice.
Discuss them with your cancer team.
• Do not crush or break your pain pills unless you get
the OK from your cancer team. If medicines are in
time-release form, taking broken pills can be
dangerous.
• If pain medicines are not keeping your pain under
control, ask your cancer team about other measures.
If you keep having trouble, ask to see a pain
specialist.
• Keep at least a one-week supply of pain medicines
on hand. Most pain medicines can’t be refilled by
phone, so you’ll need a written prescription.
WHAT CAREGIVERS CAN DO?
• Watch the patient for signs of pain. Ask the patient
about pain if you notice grimacing, moaning, tension,
or reluctance to move around in bed.
• Try warm baths or warm washcloths on painful
areas. (Avoid areas where radiation was given.) If
this doesn’t help, you can try ice or cool packs.
Gentle massage or pressure might also help some
types of pain.
• Watch for confusion and dizziness, especially after
starting a new medicine or changing the dose. Help
the patient walk until you know they can do it alone
safely.
• Suggest enjoyable activities to distract the patient.
• Plan activities for when the patient is most
comfortable and awake.
• Offer plenty of fluids and food with fiber.
• If the patient seems forgetful, help them track when
pain medicines are due to avoid over- or under-
dosing.
• Help the patient remember to take stool softeners or
laxatives suggested to prevent constipation.
• If the patient is having trouble taking pills, ask the
cancer care team about medicines that come in
liquids, lozenges, suppositories, skin patches, or
other forms.
 • Check with the cancer team before you crush or 4. Employee or contactor for service.
dissolve pain pills to make them easier to swallow.
5. Contractual relationships
Some pills can cause a dangerous overdose if
broken. – Independent nurse practitioner
• Talk with the cancer team so that you understand
which medicines are for pain and how each is to be – Nurse employed by a hospital
used.
6. Citizen
• Be sure that the patient has a complete list of all the
medicines they are taking, including pain medicines. – Rights
• If you help the patient use pain patches, be sure you
know how to avoid touching the part with the pain – Responsibilities
medicine on it and how to dispose of used patches RESPONDENT SUPERIOR
safely.
• Keep pain medicines away from others, especially • Let the master answer
children and pets. • The nurse may also be held liable as an individual in
• When you are caring for someone with pain, plan case of inappropriate behavior.
time for activities you enjoy and take care of
INAPPROPRIATE BEHAVIORS
yourself. A support group for family members may
be helpful. • Hitting the client in any part of the body
• Assisting in criminal abortion
CALL THE CANCER TEAM IF THE PATIENT:
• Taking drugs from the client’s supply for personal
• Has new or worse pain use.
• Can’t take anything by mouth, including the pain
AREAS OF POTENTIAL LIABILITY IN NURSING
medicine
• Doesn’t get pain relief, or if the relief doesn’t last 1. Crime-
long enough
• Has trouble waking up, or if you have trouble Classifications:
keeping them awake • Felony
• Becomes constipated, nauseated, or confused • Manslaughter
• Has any questions about how to take the medicines • Misdemeanor
• Develops a new symptom (for instance, is unable to
walk, eat, or urinate) 2. Tort –It could be:
ETHICO – MORAL – LEGAL RESPONSIBILITIES IN NURSING a. Intentional Torts
• Fraud
ETHICAL PRINCIPLES OF PROFESSIONAL PATIENT • Invasion of privacy
RELATIONSHIPS • Defamation
• Slander
• VERACITY
• FIDELITY
b. Unintentional
• PRIVACY
• Negligence
• CONFIDENTIALITY
• Malpractice
PRIVILEGED COMMUNICATION
ELEMENTS OF PROOF OF NURSING NEGLIGENCE &
• Is the information given to a professional person MALPRACTICE
who is forbidden by law by disclosing the
• Duty of the nurse to the client
information in a court without the consent of the
• A breach of the duty on the part of the nurse
person who provided it
• An injury to the client
LEGAL ROLES OF NURSES • A casual relationship between the breach of duty
and the client’s subsequent injury
1. Provider of service.
POTENTIAL NEGLIGENCE SITUATIONS IN NURSING
2. Liability.
• Sponge count error
3. Standards of care. • Burning a client
 • Client falls 3. I have the right to be cared for by those who can
• Failure to observe and take appropriate actions maintain a sense of hopefulness, however changing
loss. /damage of client property this might be.
4. I have the right to express my feelings and emotions
POTENTIAL MALPRACTICE SITUATIONS IN NURSING
about my approaching death in my own way.
• Mistaken identity 5. I have the right to participate in decisions concerning
• Failure in reporting crimes, torts, and unsafe my care.
practices 6. I have the right to expect continuing medical and
• Failing to Properly Monitor nursing attention even though “cure” goals must be
• Errors in Medication changed to “comfort” goals.
• Routine Procedure Errors 7. I have the right not to die alone.
• Documentation Mistakes 8. I have the right to be free from pain.
9. I have the right to have my question answered
CLASSIFICATIONS OF CRIMES honestly.
10. I have the right not to be deceived.
• Assault
11. I have the right to have help from and for my family
• Battery
in accepting my death.
• False imprisonment
12. I have the right to die in peace and dignity.
SELECTED FACTS OF NURSING PRACTICE 13. I have the right to retain my individuality and not be
judged for my decisions which may be contrary to
1. Informed consent beliefs of others.
2. Death & related issues 14. I have the right to discuss and engage my religious
a. Postmortem care and/or spiritual experiences, whatever these may
b. Autopsy mean to others.
c. Organ donation 15. I have the right to expect that the sanctity of the
d. Inquest human body will be respected after death.
e. Euthanasia 16. I have the right to be cared for by caring, sensitive,
3. DNR (Do not resuscitate) orders knowledgeable people who will attempt to
understand my needs and will be able to gain some
4. Abortions satisfaction in helping me face my death.
A PATIENT’S BILL OF RIGHTS LIVING WILLS AND ADVANCE DIRECTIVES FOR MEDICAL
DECISIONS
1. Right to Appropriate Medical Care and Humane
Treatment. The most common types of advance directives:
2. Right to Informed Consent.
3. Right to Privacy and Confidentiality. • Living Will
4. Right to Information. • Durable Power Of Attorney For Health Care 
5. The Right to Choose Health Care Provider and o (Sometimes Known As The Medical power
Facility. of attorney)
6. Right to Self-Determination.
THE LIVING WILL
7. Right to Religious Belief.
8. Right to Medical Records.  • The living will is a legal document used to state certain
9. Right to Leave. future health care decisions only when a person becomes
10. Right to Refuse Participation in Medical Research.  unable to make the decisions and choices on their own.
11. Right to Correspondence and to Receive Visitors. 
• It is only used at the end of life if a person is
12. Right to Express Grievances. 
terminally ill (can't be cured) or permanently
13. Right to be informed of His Rights and Obligations as
unconscious.
a Patient. 
• The living will describes the type of medical
THE DYING PERSON’S BILL OF RIGHTS
treatment the person would want or not want
1. I have the right to be treated as a living human being to receive in these situations.
until I die
2. I have the right to maintain a sense of hopefulness
however changing its focus may be.
 • It can describe under what conditions an
attempt to prolong life should be started or
stopped.
• This applies to treatments including, but not
limited to dialysis, tube feedings, or actual life
support (such as the use of breathing machines).
THERE ARE MANY THINGS TO THINK ABOUT WHEN
WRITING A LIVING WILL. THESE INCLUDE:
• If you want the use of equipment such as
dialysis machines (kidney machines) or
ventilators (breathing machines) to help keep
you alive.
• Do not resuscitate orders (instructions not to
use CPR if breathing or heartbeat stops).
• If you want fluid or liquid (usually by IV) and/or
food (tube feeding into your stomach) if you
couldn't eat or drink.
• If you want treatment for pain, nausea, or other
symptoms, even if you can't make other
decisions (this may be called comfort
care or palliative care).
• If you want to donate your organs or other body
tissues after death.
• It is important to know that choosing not to
have aggressive medical treatment is different
from refusing all medical care. A person can still
get treatments such as antibiotics, food, pain
medicines, or other treatments. It is just that the
goal of treatment becomes comfort rather than
cure.
• You may end or take back a living will at any
time.
• Living will laws vary from state to state. Be sure
to know your specific state laws. If you spend
most of your time in more than one state, be
sure to speak to your health care provider and
review each of the states’ laws. Also, check your
state so you know if you have to renew your
living will, and if so, how often you have to do it.
• A living will is a written, legal document that
spells out medical treatments you would and
would not want to be used to keep you alive, as
well as your preferences for other medical
decisions, such as pain management or organ
donation.
• In determining your wishes, think about your
values. Consider how important it is to you to be
independent and self-sufficient, and identify
what circumstances might make you feel like
your life is not worth living. Would you want
treatment to extend your life in any situation?
All situations? Would you want treatment only if
a cure is possible?
• You should address a number of possible end-
of-life care decisions in your living will. Talk to
your doctor if you have questions about any of
the following medical decisions:
• Cardiopulmonary resuscitation (CPR) restarts
the heart when it has stopped beating.
Determine if and when you would want to be
resuscitated by CPR or by a device that delivers
an electric shock to stimulate the heart.
• Mechanical ventilation takes over your
breathing if you're unable to breathe on your
own. Consider if, when and for how long you
would want to be placed on a mechanical
ventilator.
• Tube feeding supplies the body with nutrients
and fluids intravenously or via a tube in the
stomach. Decide if, when and for how long you
would want to be fed in this manner.
• Cardiopulmonary resuscitation (CPR) restarts
the heart when it has stopped beating.
Determine if and when you would want to be
resuscitated by CPR or by a device that delivers
an electric shock to stimulate the heart.
• Mechanical ventilation takes over your
breathing if you're unable to breathe on your
own. Consider if, when and for how long you
would want to be placed on a mechanical
ventilator.
• Tube feeding supplies the body with nutrients
and fluids intravenously or via a tube in the
stomach. Decide if, when and for how long you
would want to be fed in this manner.
• Cardiopulmonary resuscitation (CPR) restarts
the heart when it has stopped beating.
Determine if and when you would want to be
resuscitated by CPR or by a device that delivers
an electric shock to stimulate the heart.
• Mechanical ventilation takes over your
breathing if you're unable to breathe on your
own. Consider if, when and for how long you
would want to be placed on a mechanical
ventilator.
• Tube feeding supplies the body with nutrients
and fluids intravenously or via a tube in the
stomach. Decide if, when and for how long you
would want to be fed in this manner.
DURABLE POWER OF ATTORNEY FOR HEALTH
CARE/MEDICAL POWER OF ATTORNEY
• A durable power of attorney for health care, also
known as a medical power of attorney, is a legal
document in which you name a person to be
a proxy (agent) to make all your health care
decisions if you become unable to do so.
 • Before a medical power of attorney can be used to
guide medical decisions, a person's physician must
certify that the person is unable to make their own
medical decisions.  seriously ill person can fill in and ask their health care
• The person you name as a proxy or agent should be
someone who knows you well and someone you
trust to carry out your wishes. Your proxy or agent
should understand how you would make decisions if
you were able, and should be comfortable asking
questions and advocating to your health care team
on your behalf. Be sure to discuss your wishes in
detail with that person. You may also choose to
name a back-up person in case your first choice
becomes unable or unwilling to act on your behalf.
• A medical or health care power of attorney is a type
of advance directive in which you name a person to
make decisions for you when you are unable to do
so. In some states this directive may also be called a
durable power of attorney for health care or a health
care proxy
• Depending on where you live, the person you choose
to make a decision on your behalf may be called one
of the following:
o Health care agent
o Health care proxy
o Health care surrogate
o Health care representative
o Health care attorney-in-fact
o Patient advocate
• Choosing a person to act as your health care agent is
important. Even if you have other legal documents
regarding your care, not all situations can be
anticipated and some situations will require
someone to make a judgement about your likely
care wishes. You should choose a person who meets
the following criteria:
o Meets your state’s requirements for a
health care agent
o Is not your doctor or a part of your medical
care team
o Is willing and able to discuss medical care
and end-of-life issues with you
o Can be trusted to make decisions that
adhere to your wishes and values
o Can be trusted to be your advocate if there
are disagreements about your care
o The person you name may be a spouse,
other family member, friend or member of
a faith community. You may also choose
one or more alternates in case the person
you chose is unable to fulfill the role.
POLST (PHYSICIAN ORDERS FOR LIFE-SUSTAINING
TREATMENT)
• A POLST form also helps describe your wishes for health
care, but it is not an advance directive.
• A POLST form has a set of specific medical orders that a
provider to sign.
• A POLST form addresses your wishes in an emergency,
such as whether to use CPR (cardiopulmonary
resuscitation) in an emergency, or whether to go to a
hospital in an emergency and be put on a breathing
machine if necessary, or stay where you are and be made
comfortable.
• In some states, advance health care planning includes a
document called physician orders for life-sustaining
treatment (POLST). The document may also be called
provider orders for life-sustaining treatment (POLST) or
medical orders for life-sustaining treatment (MOLST).
• A POLST is intended for people who have already been
diagnosed with a serious illness. This form does not
replace your other directives. Instead, it serves as doctor-
ordered instructions — not unlike a prescription — to
ensure that, in case of an emergency, you receive the
treatment you prefer. Your doctor will fill out the form
based on the contents of your advance directives, the
discussions you have with your doctor about the likely
course of your illness and your treatment preferences.
• A POLST stays with you. If you are in a hospital or nursing
home, the document is posted near your bed. If you are
living at home or in a hospice care facility, the document
is prominently displayed where emergency personnel or
other medical team members can easily find it.
• Forms vary by state, but essentially a POLST enables your
doctor to include details about what treatments not to
use, under what conditions certain treatments can be
used, how long treatments may be used and when
treatments should be withdrawn. Issues covered in a
POLST may include:
 Resuscitation
 Mechanical ventilation
 Tube feeding
 Use of antibiotics
 Requests not to transfer to an emergency room
 Request not to be admitted to the hospital
 Pain management
• A POLST also indicates what advance directives you have
created and who serves as your health care agent. Like
advance directives, POLSTs can be cancelled or updated.
DO NOT RESUSCITATE (DNR) ORDERS
• Resuscitation means medical staff will try to re-start
your heart and breathing using methods such as CPR
(cardiopulmonary resuscitation) and AED
(automated external defibrillator).
 • In some cases, they may also use life-sustaining
devices such as breathing machines.
• You don't need to have an advance directive or living
will to have do not resuscitate (DNR) and do not
intubate (DNI) orders. To establish DNR or DNI
orders, tell your doctor about your preferences. He
or she will write the orders and put them in your
medical record.
• Even if you already have a living will that includes
your preferences regarding resuscitation and
intubation, it is still a good idea to establish DNR or
DNI orders each time you are admitted to a new
hospital or health care facility.
In the hospital
• A Do Not Resuscitate or DNR order means that if you
stop breathing or your heart stops, nothing will be
done to try to keep you alive. If you are in the
hospital, you can ask your doctor to add a DNR order
to your medical record.
• You would only ask for this if you don’t want the
hospital staff to try to revive you if your heart or
breathing stopped.
• Some hospitals require a new DNR order each time
you are admitted, so you might need to ask every
time you go into the hospital.
• But remember that this DNR order is only good while
you are in the hospital. Outside the hospital, it’s a
little different.
Outside the hospital
• Ask your health care provider how you can get a
wallet card, bracelet, or other DNR documents to
keep when you are at home or not in the hospitals.
• Some states have standard DNR forms that are
meant to be used outside the hospital.
• The non-hospital DNR is intended for Emergency
Medical Service (EMS) teams.
• Unless you have a valid and visible DNR order, the
EMS teams who answer 911 calls are required to try
to revive and prolong life in every way they can.
• A non-hospital DNR must be signed by both the
patient and the health care provider.
• Talk to your health care team if you would like a DNR
order to keep with you.
Organ and tissue donation
• Organ and tissue donation can be included in your
advance directive. Many states also provide organ
donor cards or add notations to your driver's license.
CREATING ADVANCE DIRECTIVES
• Advance directives need to be in writing. Each state has
different forms and requirements for creating legal
documents. Depending on where you live, a form may
need to be signed by a witness or notarized. You can ask
a lawyer to help you with the process, but it is generally
not necessary.
• Links to state-specific forms can be found on the
websites of various organizations such as the American
Bar Association, AARP and the National Hospice and
Palliative Care Organization.
• Review your advance directives with your doctor and
your health care agent to be sure you have filled out
forms correctly. When you have completed your
documents, you need to do the following:
• Keep the originals in a safe but easily accessible place.
• Give a copy to your doctor.
• Give a copy to your health care agent and any alternate
agents.
• Keep a record of who has your advance directives.
• Talk to family members and other important people in
your life about your advance directives and your health
care wishes. By having these conversations now, you help
ensure that your family members clearly understand
your wishes. Having a clear understanding of your
preferences can help your family members avoid conflict
and feelings of guilt.
• Carry a wallet-sized card that indicates you have advance
directives, identifies your health care agent and states
where a copy of your directives can be found.
• Keep a copy with you when you are traveling.
REVIEWING AND CHANGING ADVANCE DIRECTIVES
• You can change your directives at any time. If you
want to make changes, you must create a new form,
distribute new copies and destroy all old copies.
Specific requirements for changing directives may
vary by state.
• You should discuss changes with your primary care
doctor and make sure a new directive replaces an
old directive in your medical file. New directives
must also be added to medical charts in a hospital or
nursing home. Also, talk to your health care agent,
family and friends about changes you have made.
• Consider reviewing your directives and creating new
ones in the following situations:
o New diagnosis. A diagnosis of a disease that
is terminal or that significantly alters your
life may lead you to make changes in your
living will. Discuss with your doctor the kind
of treatment and care decisions that might
be made during the expected course of the
disease.
o Change of marital status. When you marry,
divorce, become separated or are widowed,
 you may need to select a new health care - Cancer is aggressive and fast growing breast cancer in
agent. which cancer cells infiltrate the skin and lymph vessels of
o About every 10 years. Over time your the breast. .
thoughts about end-of-life care may
METASTATIC BREAST CANCER
change. Review your directives from time to
time to be sure they reflect your current - Is classified as stage 4 breast cancer that has spread to
values and wishes. other parts of the body.
BREAST CANCER PAGET DISEASE
Breast cancer is a disease in which cells in the breast grow out - Is a rare type of cancer affecting the skin of the nipple
of control, it is originated in the breast tissue. and often the areola, which is the darker circle of skin
around the nipple
It can be started in different parts of the breast:
RISK FACTORS
 Lobules are the glands that produce milk
 Ducts are the tubes that carry milk to the nipple • Mutations in BRCA genes
 Connective tissue which consist of fibrous and fatty • Individual assigned female at birth
tissue, surrounds and holds everything together. • Personal and/or family history of breast or ovarian
cancer
TYPES OF TUMOR
• Increased exposure to hormones (e.g. estrogen,
IN SITU CARCINOMA progesterone)
• Advanced age
- It occurs within the lobules and ducts
SIGN & SYMPTOMS
INFILTRATING CARCINOMA
• Mostly asymptomatic
- Spread around the area of breast and different part of • Palpable lump if > 2 cm
the body • Visible breast changes
DUCTAL CARCINOMA IN SITU (DCIS) o Swelling of 1 breast
o Thickening of breast skin
- A non-invasive cancer where abnormal cells have been o Nipple discharge
found in the lining of the breast milk duct.  o Nipple inversion
o “peau d’orange”
INVASIVE DUCTAL CARCINOMA

- Also called as an infiltrative ductal carcinoma an invasive DIAGNOSTIC TEST

cancer where abnormal cancer cells that began forming • Clinical breast examination
in the milk ducts have spread beyond the ducts into • Mammogram
other parts of the breast tissue. • Percutaneous needle biopsy
LOBULAR CARCINOMA IN SITU • Stereotactic needle biopsy
• Excisional biopsy
- Is a condition where abnormal cells are found in the • Ductal lavage and nipple aspiration
lobules into the surrounding breast tissue
CLINICAL MANAGEMENT
INVASIVE LOBULAR CARCINOMA
• Decreased chance of recurrence
- Cancer that begins in the lobules (milk glands) of the • Decreased risk of metastasis
breast and spreads to surrounding normal tissue. It can • Removal of lesion
also spread through the blood and lymph systems to o Lumpectomy
other parts of the body. o Mastectomy
o Lymph removal
TRIPLE NEGATIVE BREAST CANCER
• Radiation therapy
- kind of breast cancer does not have any of the receptors • Systemic treatment options
that are commonly found in the breast cancer o Chemotherapy
o Hormonal therapies
INFLAMMATORY BREAST CANCER
o Targeted therapies
NURSING MANAGEMENT
NURSING ASSESSMENT
• Past Health History
History of breast disorders
• Menstrual history: early menarche with late menopause
• Pregnancy history
• Previous endometrial, ovarian, or colon cancer
• Medications: hormones, oral contraceptives, infertility
treatments
• Surgical and treatment history: exposure to therapeutic
radiation
PHYSICAL ASSESSMENT
• Investigate the presence of nipple discharge, pain, rate of
growth of lumps, breast asymmetry
• Note the size and location of lump(s)
• Investigate the presence of hard, irregular, non-
mobile lumps
• Investigate the thickening of breast, nipple inversion or
retraction, erosion, edema, or dimpling
• Assess the physical characteristics of the lesion, such as
consistency, mobility, and shape
• If nipple discharge present, note the color and
consistency
• Assess axillary and supraclavicular lymph nodes
NURSING DIAGNOSIS
• Decision conflict related to lack of knowledge about
treatment option and their effects
• Fear and or anxiety related to diagnosis of breast cancer
• Acute pain related to tissue trauma and manipulation
• Disturbed body image related to physical and emotional
effects of treatment
PLANNING (GOALS)
• Actively participate in the decision making process
related to treatment
• Adhere to the therapeutic plan
• Communicate about and manage the side effects of
adjuvant therapy
• Access and benefit from the support provided by
significant others and health care providers
PATIENT OUTCOMES
• Pain management
• Adjustment to body changes due to surgery and
satisfaction with body appearance
• Uses effective coping strategies and uses personal
support system
NURSING IMPLEMENTATION
•  Health education
• Evaluate patient feelings
• Provide information relevant to the decision, clarify
unresolved issues, support the patient and family
• Provide complete and accurate answers to their
questions
• Encourage patient and family to verbalize feelings,
perceptions, and fear.
•  Provide preoperative instructions on pain control
and what to expect after surgery (e.g. reporting of
complications, dressing and drain care, turning,
coughing, deep breathing)
•  Facilitate contact with individuals with similar
change in body image.
•  Explain the specific follow up plan to the patient and
emphasize the importance of ongoing monitoring.
•  Advise the patient to report symptoms such as
fever, inflammation at surgical site, erythema,
unusual swelling, weakness, SOB, and changes in
mental status
MANAGING PROBLEMS CAUSED BY CHEMOTHERAPY
● Mucostitis
○ Assess oral mucosa daily
○ Give analgesics if pain is present while eating,
swallowing, and talking
○ Encourage nutritional supplements  if intake
decreasing
○  Teach patient to avoid irritants such as spicy or
acidic foods (select moist, bland, and softer
foods), tobacco, alcohol
● Nausea and vomiting
○ Encourage patient to eat and drink when not
nauseated
○ Administer antiemetics prophylactically before
chemotherapy and as needed basis
●  Anorexia
○ Monitor weight
○ Encourage patient to eat small, frequent meals
of high-protein, high-calorie foods
● Diarrhea and Constipation
o Diarrhea: give antidiarrheal drugs as needed,
low-fiber, low-residue diet, and fluid at least
3L/day
o Constipation: give stool softener as needed, high
fiber foods, and plenty of fluids
 Anemia
○ Monitor hemoglobin and hematocrit levels
○ Administer iron supplements and erythropoietin
○ Encourage intake of foods that promote RBC
production (red meats, liver, eggs, dairy foods,
fish)
PROGNOSIS
0 PATHOPHYSIOLOGY AND ETIOLOGY
Abnormal cells in lining of the ducts or sections of the breast.
The cause of most brain tumors, which occur in various areas
Results in increased risk of developing cancer in both breasts
of the brain remains unknown. A small percentage are
congenital, such as hemangioblastomas. Genetic factors are
1
associated with two types of brain tumors, astrocytoma, a
Cancer in the breast tissue tumor less than 1 inch across
gliomal tumor in the frontal lobe, and neurofibromatosis.
Other causative factors include viral infection, exposure to
2
radiation, head trauma, and immunosuppression. The brain
Cancer in the breast tissue tumor less than 2 inches across.
also is the site of metastatic lesions from primary tumors,
Cancer may also spread to auxiliary lymph nodes
especially those of the lung and breast.
3 MANIFESTATIONS
Tumor is larger than 2 inches across with extensive spread to
auxiliary or nearby lymph nodes. Possible dimpling, Manifestations can develop as a result of the growth of the
inflammation or change of skin color tumor, while others are related to the location of the lesion.
Some of the more common manifestations include changes in
4 cognition or consciousness, a headache that is usually worse
Spread of cancer beyond the immediate region of the breast in the morning, seizures, and vomiting.

Compression of brain tissue and the invasion of the brain

tumor into the cerebral tissue may lead to changes typically
BRAIN CANCER seen with cerebral edema and IICP. Cerebral blood supply
may diminish as the tumor compresses blood vessels. Shifts in
A brain tumor is a growth of abnormal cells within the
brain tissue can occur, leading to brain herniation syndromes
cranium. Brain tumors occur in all age groups. Some types are
and, if untreated, death.
more common in people younger than 20 years of age; others
more frequently affect older people. • Motor cortex tumor produces seizure-like
movements localized on one side of the body, called
PRIMARY TUMOR
Jacksonian seizures.
• Primary brain tumors originate from cells and structures
• An occipital lobe tumor produces visual
within the brain.
manifestations: contralateral homonymous
SECONDARY TUMOR hemianopsia (visual loss in half of the visual field on
the opposite side of the tumor) and visual
• Secondary, or metastatic, brain tumors develop from
hallucinations.
structures outside the brain and occur in 20% to 40% of
all patients with cancer. • A cerebellar tumor causes dizziness, an ataxic or
staggering gait with a tendency to fall toward the
CLASSIFICATIONS
side of the lesion, marked muscle incoordination,
• Benign or malignant and nystagmus (involuntary rhythmic eye
• The type of cells involved movements), usually in the horizontal direction.
• The site of tumor
• A frontal lobe tumor frequently produces personality
disorders, changes in emotional state and behavior,
COMMON SITES FOR BRAIN TUMOR and an uninterested mental attitude. The patient
often becomes extremely untidy and careless and
• 3rd ventricle area may use obscene language.
• Lateral ventricle
• Corpus callosum DIAGNOSTIC FINDINGS
• Cerebrum
Helps confirm the diagnosis, which reveal the tumor’s size
• Pineal area
and location.
• Cerebellum
• 4th ventricle • CT scan
• Brain stem • MRI
• Acoustic nerve • brain scan
• Pituitary area • Cerebral angiography
• Optic chlasm

MEDICAL MANAGEMENT
Metastatic tumors and some primary tumors are inoperable,
and radiation therapy and chemotherapy are the only
treatment choices. Clients who cannot withstand surgery,
chemotherapy, or radiation therapy are kept as comfortable
and free from pain as possible. Intra-arterial or intrathecal
administration of antineoplastic drugs is used to destroy the
tumor or slow tumor growth. Symptomatic drug therapy
includes corticosteroids and osmotic diuretics to reduce
cerebral edema, analgesics, anticonvulsants, and antibiotics.
Complications, such as increased ICP, paralysis, mental
changes, infection, seizures, and prolonged immobility, are
treated symptomatically.
SURGERY
Surgery is the preferred treatment of primary tumors, to
remove the tumor if possible, to reduce the size of the tumor,
or for symptom relief (palliation). Some of the more common
intracranial neurosurgical procedures follow:
• Burr hole: A hole made in the skull with a special drill.
The hole may facilitate the evacuation of an
extracerebral clot, or a series of holes may be made in
preparation for craniotomy
• Craniotomy: A surgical opening into the cranial cavity. A
series of burr holes are made and the bone between the
holes is cut with a special saw called a craniotome. The
tumor is excised, and the bone flap is returned to the
opening.
• Craniectomy: An excision of a portion of the skull and
complete removal of the bone flap. This procedure may
be done to provide decompression after cerebral edema.
Pressure on the brain structures is lessened by providing
space for expansion.
• Cranioplasty: Plastic repair to the skull in which
synthetic material is inserted to replace the cranial bone
that was removed. This procedure may be performed
after a large craniectomy. The plastic repair restores the
contour and integrity of the cranium.
RADIATION THERAPY
Radiation therapy may be administered alone or as adjunctive
therapy with surgery. Radiation is often the treatment of
choice for surgically inaccessible tumors; it may also be used
to decrease the size of a tumor prior to surgery. Tumors that
were not completely excised by surgery may also be treated
with radiation.
NURSING MANAGEMENT
Before the client is discharged, the nurse evaluates the
client’s and families immediate and long-term needs. The
nurse develops an individualized teaching plan that addresses
the following components:
• Medication regimen
• Appointments for chemotherapy or radiation therapy
• Adverse effects of chemotherapy or radiation and
techniques for managing them
• Nutritional support
• Home care considerations
• Rehabilitation (exercises, physical therapy)
• Referrals to support services for physical, emotional, and
financial assistance
LUNG CANCER
Lung cancer is a types of cancer that begins in the lungs. Your
lungs are two spongy organs in your chest that take in oxygen
when you inhale and release carbon dioxide when you exhale.
Lung cancer is the leading cause of cancer deaths worldwide.
People who smoke have the greatest risk of lung cancer
though lung cancer can also occur in people who have never
smoked. The risk of lungs cancer increase with the length of
time and number of cigarettes you've smoked. If you quit
smoking even after smoking for many years you can
significantly reduce your chances of developing lung cancer.
Lung cancer also known as lung carcinoma is a malignant lung
tumor characterized by uncontrolled cell growth in tissues of
the lung. Lung carcinomas drive from transformed malignant
cells that originate as epithelial cells or from tissues
composed of epithelial cells.
TYPES OF LUNG CANCER
SMALL CELL LUNG CANCER (SCLC)
• About 10% to 15% of all lung cancers are SCLC and it is
sometimes called oat cell cancer.
• This type of lung cancer tends to grow and spread faster
than NSCLC. About 70% of people with SCLC will have
cancer that has already spread at the time they are
diagnosed. Since this cancer grows quickly, it tends to
respond well to chemotherapy and radiation therapy.
Unfortunately, for most people, the cancer will return at
some point.
NON SMALL CELL LUNG CANCER (NSCLC)
• About 80% to 85% of lung cancers are NSCLC. The main
subtypes of NSCLC are adenocarcinoma, squamous cell
carcinoma, and large cell carcinoma. These subtypes,
which start from different types of lung cells are grouped
together as NSCLC because their treatment and
prognoses (outlook) are often similar.
ADENOCARCINOMA
Adenocarcinomas start in the cells that would normally
secrete substances such as mucus.is usually found in the
outer parts of the lung and is more likely to be found before it
has spread.
People with a type of adenocarcinoma called
adenocarcinoma in situ (previously called bronchioloalveolar
carcinoma) tend to have a better outlook than those with
other types of lung cancer.
SQUAMOS CELL CARCINOMA
Squamous cell carcinomas start in squamous cells, which are
flat cells that line the inside of the airways in the lungs. They
are often linked to a history of smoking and tend to be found
in the central part of the lungs, near a main airway
(bronchus).
LARGE CELL (UNDIFFERENTIATED) CARCINOMA
Large cell carcinoma can appear in any part of the lung. It
tends to grow and spread quickly, which can make it harder
to treat. A subtype of large cell carcinoma, known as large cell
neuroendocrine carcinoma, is a fast-growing cancer that is
very similar to small cell lung cancer.
RISK FACTORS
A number of factors may increase your risk of lung cancer.
Some risk factors can be controlled for instance quitting
smoking. And other factors can’t be controlled such as your
family history.
Smoking- your risk of lung cancer increase with the number
of cigarettes you smoke each day and the number of years
you have smoked. Quitting at any age can significantly lower
your risk of developing lung cancer.
Exposure to secondhand smoke- even if you don’t smoke
your risk of lung cancer increase if you’re exposed to
secondhand smoke.
Previous radiation therapy- if you’ve undergone radiation
therapy to the chest for another type of cancer, you may
have an increased risk of developing lung cancer.
Exposure to asbestos and other carcinogens- workplace
exposure to asbestos and other substances known to cause
cancer such as arsenic chromium and nickel can increase your
risk of developing lung cancer especially if you're a smoker.
exposure to radon gas- radon is produced by the natural
breakdown of uranium in soil, rock and water that eventually
becomes part of the air you breathe unsafe levels of radon
can accumulate in anything building including homes.
Family history of lung cancer- people with a parent sibling or
child with lung cancer have an increased risk of the disease.
SYMPTOMS
Lung cancer typically doesn't cause signs and symptoms in its
earliest stages signs and symptoms of lung cancer typically
occur when the disease is advanced.
• a new cough that doesn't go away
• coughing up blood, even a small amount
• shortness of breath
• chest pain
• hoarseness
• losing weight without trying
• bone pain
• Headache.
DIAGNOSTIC TEST AND LABORATORIES
People with an increased risk of lung cancer may consider
annual lung cancer screening using low-dose CT scans.
• Lung cancer screening is generally offered to older adults
who have smoked heavily for many years or who have
quit in the past 15 years.
• Imaging tests- An X-ray image of your lungs may reveal
an abnormal mass or nodule. A CT scan can reveal small
lesions in your lungs that might not be detected on an X-
ray.
• Sputum cytology- If you have a cough and are producing
sputum, looking at the sputum under the microscope can
sometimes reveal the presence of lung cancer cells.
• Tissue sample (biopsy) - A sample of abnormal cells may
be removed in a procedure called a biopsy.
CLINICAL MANAGEMENT
Lung cancer is treated in several ways, depending on the type
of lung cancer and how far it has spread. People with non-
small cell lung cancer can be treated with surgery,
chemotherapy, radiation therapy, targeted therapy, or a
combination of these treatments. People with small cell lung
cancer are usually treated with radiation therapy and
chemotherapy.
Surgery- An operation where doctors cut out cancer tissue.
Chemotherapy- Using special medicines to shrink or kill the
cancer. The drugs can be pills you take or medicines given in
your veins, or sometimes both.
Radiation therapy- Using high-energy rays (similar to X-rays)
to kill the cancer.
Targeted therapy- Using drugs to block the growth and
spread of cancer cells. The drugs can be pills you take or
medicines given in your veins. You will get tests to see if
targeted therapy is right for your cancer type before this
treatment is used.
NURSING MANAGEMENT
• Elevate the head of the bed to ease the work of
breathing and to prevent fluid collection in upper body
(from superior vena cava syndrome).
• Teach breathing retraining exercises to increase
diaphragmatic excursion and reduce work of breathing.
• Augment the patient’s ability to cough effectively by
splinting the patient’s chest manually.
• Instruct the patient to inspire fully and cough two to
three times in one breath.
• Provide humidifier or vaporizer to provide moisture to
loosen secretions.
• Teach relaxation techniques to reduce anxiety associated
with dyspnea. Allow the severely dyspneic patient to
sleep in reclining chair.
• Encourage the patient to conserve energy by decreasing
activities.
• Ensure adequate protein intake such as milk, eggs, oral
nutritional supplements; and chicken, fowl, and fish if
other treatments are not tolerated – to promote healing
and prevent edema.
• Advise the patient to eat small amounts of high-calorie
and high-protein foods frequently, rather than three
daily meals.
• Suggest eating the major meal in the morning if rapid
satiety is the problem.
• Change the diet consistency to soft or liquid if patient has
esophagitis from radiation therapy.
• Consider alternative pain control methods, such as
biofeedback and relaxation methods, to increase the
patient’s sense of control.
• Teach the patient to use prescribed medications as
needed for pain without being overly concerned about
addiction.
PROGNOSIS
• About 1 in 3 people with the condition live for at least 1
year after they're diagnosed and about 1 in 20 people live
at least 10 years.
• However, survival rates vary widely, depending on how
far the cancer has spread at the time of diagnosis. Early
diagnosis can make a big difference.
COLORECTAL CANCER
Cancer that begins in the colon is called a colon cancer, while
cancer in the rectum is known as a rectal cancer. Cancers that
affect either of these organs may be called COLORECTAL
CANCER. Though not true in all cases, the majority of
colorectal cancers generally develop over time from
adenomatous (precancerous) polyps. Polyps (growths) can
change after a series of mutations (abnormalities) arise in
their cellular DNA.
The term colorectal cancer actually refers to two diseases.
Colon cancer is cancer found in the tissues of the colon, and
rectal cancer forms in the tissues of the rectum. Both cancers
have the same characteristics and the same risk factors. In
some cases, they are treated the same way, while at other
times the treatments are different.
TYPES OF COLORECTAL CANCER
1. ADENOCARCINOMA
"Adeno" is a prefix meaning gland. "Carcinoma" is a type of
cancer that grows in epithelial cells, which line the surfaces
inside and outside the body. Adenocarcinomas develop in the
lining of the large intestine (colon) or the end of the colon
(rectum). They often start in the inner lining and spread to
other layers.
Subtypes of Adenocarcinoma
Mucinous adenocarcinoma
• Made up of about 60 percent mucus. The mucus may
cause cancer cells to spread more quickly and become
more aggressive than typical adenocarcinomas.
Signet ring cell adenocarcinoma
• Accounts for less than 1 percent of all colon cancers.
Named for its appearance under a microscope, signet
ring cell adenocarcinoma is typically aggressive and may
be more difficult to treat.
2. GASTROINTESTINAL CARCINOID TUMORS
• Carcinoid tumors develop in nerve cells called
neuroendocrine cells, which help regulate hormone
production. These tumors are among a group of cancers
called neuroendocrine tumors (NETs). Carcinoid tumor
cells are slow-growing and may develop in the lungs
and/or gastrointestinal tract.
3. GASTROINTESTINAL STROMAL TUMORS
• Rare type of colorectal cancer that forms in special cells
found in the lining of the gastrointestinal (GI) tract called
interstitial cells of Cajal (ICCs). GISTs are classified as
sarcomas, or cancers that begin in the connective tissues,
which include fat, muscle, blood vessels, deep skin
tissues, nerves, bones and cartilage. The diagnostic
process may involve an endoscopy, colonoscopy, biopsy
and various imaging tests.
4. COLON AND RECTAL LEIMYOSARCOMAS
• leiomyosarcoma essentially means “cancer of smooth
muscle.” The colon and rectum have three layers of the
 type of muscle affected by leiomyosarcoma, and all three
work together to guide waste through the digestive tract.
• In the early stages, leiomyosarcoma in the colon or
rectum may not cause symptoms. As the cancer
progresses, symptoms may include fatigue, weight loss,
vomiting blood, changes in stools and other stomach
problems.
RISK FACTORS
Non-Modifiable:
• Age
• Gender: male
• Genetic factor: FAP & HNPCC
• Inflammatory Bowel Disease
• Hormonal changes
Modifiable:
• Lifestyle: Smoking, Red meat, lack of fiber
• Obesity
• Environmental factors
SIGN & SYMPTOMS
• A change in bowel habits
• Diarrhea, constipation, or feeling that the bowel
• does not empty completely
• Bright red or very dark blood in the stool
• Stools that look narrower or thinner than normal
• Discomfort in the abdomen, including frequent gas
pains, bloating, fullness, and cramps
• Weight loss with no known explanation
• Constant tiredness or fatigue
• Unexplained iron-deficiency anemia, which is a low
number of red blood cells
DIAGNOSTIC TEST
Fecal occult blood test (FOBT) – checks for hidden blood in
the stool. Sometimes cancers or polyps can bleed and this
test is used to pick up small amounts of bleeding. Have this
test every year.
Flexible sigmoidoscopy – an exam where a health care
provider looks at the rectum and the lower part of the colon
using a sigmoidoscope, a tube with a light on the end. Have
this test every 5 years.
Colonoscopy – an exam when a health care provider looks at
the rectum and the entire colon using a colonoscope, an
instrument with a light on the end. If polyps are found, they
can be removed. Have this test every 5 to 10 years.
Double contrast barium enema (DCBE) – a series of x-rays of
the colon and rectum. You are first given an enema with
barium in it, which outlines the colon and rectum on the x-
rays. Have this test every 5 to 10 years (only if not having a
colonoscopy every 10 years).
Digital rectal exam – a health care provider inserts a
lubricated, gloved finger into the rectum to feel for any
problem areas. Have this test every 5 to 10 years at the time
of other screening tests (flexible sigmoidoscopy, colonoscopy,
or DCBE).
THERAPEUTIC INTERVENTION/ MEDICAL MANAGEMENT
Treatment of cancer depends on stage of disease and related
complications. Obstruction is treated with intravenous fluids
and nasogastric suction and with blood therapy if bleeding is
significant. Supportive therapy and adjuvant therapy (e.g.,
chemotherapy, radiation therapy, and immunotherapy) are
included.
Surgical Management
• Surgery is the primary treatment for most colon and
rectal cancers ; the type of surgery depends on the
location and size of tumor, and it may be curative or
palliative.
• Cancers limited to one site can be removed to a
colonoscope
• Laparoscopy colostomy with polypectomy.
• Neodymium-yttrium-aluminum-garnet (Nd:YAG)
laser is effective in some lesions
• Bowel resection with anastomosis and possible
temporary or permanent colostomy or illeostomy
( less than 1/3 of patients) or coloanal resevoir
(colonic J pouch).
Pharmacologic Intervention
• Narcotic analgesic is often administered as patient-
controlled anesthesia to manages surgical pain or
pain from metastasis
Nursing Management
Assessment:
• Collect subjective data about:
o Presence of fatigue
o Abdominal or rectal pain
o Past and present elimination pattern
o Characteristics of stool
o Family history and fat and fiber intake
o Alcohol intake and smoking
o Weight loss
• Auscultate the abdomen for bowel sounds
• Palpate the abdomen for distension and solid masses
NURSING DIAGNOSIS
• Imbalanced nutrition, less than body requirements,
related to nausea and anorexia
• Risk for deficient fluid volume related to vomiting and
dehydration
• Anxiety related to cancer diagnosis and impending
surgery
• Disturbed body image related to colostomy
PLANNING AND GOALS
• Attainment of optional nutrition
• Maintenance of fluid and electrolyte balance
• Reduction of anxiety
• Attainment of optimal wound healing
• Expressing feelings and concern about colostomy and the
impact in self
NURSING INTERVENTION
Patient preparation for surgery
• Build the patient’s stamina days before surgery
• Cleanse the bowel the day before surgery
• If possible, provide a diet high in calories, protein,
and carbohydrate for several days before surgery
• Provide full liquid diet if prescribed 24 to 48 hours
before surgery to reduce bulk
• Clean the bowel with laxatives and/or enemas the
evening before and the morning of surgery
• Record intake and output to provide an accurate
record of fluid balance
• Insert nasogastric tube if ordered to drain
accumulated fluids and prevent abdominal
distention
• Monitor the patient for increasing abdominal
distention, loss of bowel sounds, and pain or rigidity,
which may indicate intestinal obstruction or
perforation
• Observe the patient for signs of hypovolemia
(tachycardia, hypotension, decreased pulse volume)
• Assess hydration status
Providing emotional support
• Assess the patient’s level of anxiety
• Suggest methods for reducing anxiety such as deep
breathing exercises and visualising a patient who
successfully recovered from surgery and cancer
• Provide factual information about the colostomy site
to reduce the patient’s fear that everybody will be
aware of the ostomy
Providing postoperative care
• Pain management
• Abdominal assessment for bowel sounds
• Mobilise the patient out of bed on the 1st day postop
Maintaining optimal nutrition
• Teach patients undergoing surgery about the health
benefits of consuming healthy diet
• Perform complete nutritional assessment to
evaluate the nutritional status of the patient
• Advise the patient on avoiding foods that cause
excessive odor and gas such as foods in cabbage
family, eggs, asparagus, fish, and beans
• Help the patient identify any foods or fluids that may
cause diarrhea including fruits, high fiber foods,
soda, coffee, tea or carbonated drinks
• Advise a fluid intake of at least 2 L/day
Supporting a positive body image
• Encourage the patient to verbalise feelings and
concerns about altered body image, and to discuss
the surgery and the stoma if one was created
• If applicable, teach the patient about colostomy
care in an open, accepting manner and encourage
him to talk about this feeling about the stoma
PROGNOSIS
A prognostic factor is an aspect of the cancer or a
characteristic of the person that the doctor will consider
when making a prognosis. A predictive factor influences how
a cancer will respond to a certain treatment. Prognostic and
predictive factors are often discussed together. They both
play a part in deciding on a treatment plan and a prognosis.
1. Stage
• Stage is the most important prognostic factor for
colorectal cancer. The lower the stage at diagnosis,
the better the outcome. Tumors that are only in the
colon or rectum have a better prognosis than those
that have grown through the wall of the colon or
rectum, or have spread to other organs (called
distant metastases).
2. Surgical margins
• When a colorectal tumour is removed, the surgeon
also removes a margin of healthy tissue around it.
The prognosis is better if there are no cancer cells in
the tissue removed with the tumour than if there are
cancer cells in the tissue (called positive surgical
margins).
3. Cancer cells in lymph and blood vessels
• Cancer cells can move or grow into nearby lymph
vessels and blood vessels. This is called
lymphovascular invasion. Tumours that don’t have
 lymphovascular invasion have a better prognosis
than tumours that have lymphovascular invasion.
4. Cancer cells in lymph and blood vessels
• Cancer cells can move or grow into nearby lymph
vessels and blood vessels. This is called
lymphovascular invasion. Tumours that don’t have
lymphovascular invasion have a better prognosis
than tumours that have lymphovascular invasion.
5. Bowel obstruction or perforation
• A bowel obstruction is a blockage in the intestine. A
bowel perforation is a hole or tear in the intestine.
People who have a bowel obstruction or perforation
at the time of diagnosis have a poorer prognosis.
6. Grade
• High-grade colorectal cancer means that the cancer
cells are poorly differentiated or undifferentiated.
High-grade cancers have a poorer prognosis than
low-grade cancers.
7. Type of tumor
• Mucinous adenocarcinoma, signet ring cell
carcinoma and small cell carcinoma have a poorer
prognosis than other types of colorectal tumors
8. Microsatellite instability (MSI)
• MSI is a change to the DNA in a cell. Some colorectal
cancer cells show MSI. Tumors that have cells with
high MSI have a better prognosis than tumors with
low MSI (called microsatellite stable or MSS tumors).
High MSI is seen in 20% of people with stage 2
disease, 10% of people with stage 3 disease and less
than 5% of people with stage 4 disease.
9. KRAS gene mutation
• KRAS is a gene that can be changed (mutated) in
some colorectal cancer cells. KRAS gene mutations
mean that the cancer cells are unlikely to respond to
targeted therapy drugs. People with colorectal
cancer cells that have the KRAS gene mutation have
a poorer prognosis because targeted therapy drugs
will not work on the tumor.
10. BRAF gene mutation
• BRAF gene mutations mean that the cancer cells may
be more aggressive. As a result, people with cancer
cells that have the BRAF gene mutation have a
poorer prognosis. Less than 10% of all colorectal
cancers have the BRAF gene mutation.
LIVER CANCER
Liver cancer is a type of cancer that starts in the liver. Cancer
starts when cells in the body begin to grow out of
control. Liver cancer is generally classified as primary or
secondary.
TYPES OF LIVER CANCER
PRIMARY LIVER CANCER - cancer that begins in the tissue of
the liver.
• Hepatocellular Carcinoma (HCC) – formation of
cancer cells in the tissues of the liver, is the most
common type of liver cancer.
• Intrahepatic Cholangiocarcinoma (Bile Duct Cancer)
- is liver cancer that occurs in the ducts that drain
bile from the liver to the small intestine.
• Angioarcoma and Hemangiosarcoma - These are
rare cancers that begin in cells lining the blood
vessels of the liver. People who have been exposed
to vinyl chloride or to thorium dioxide (Thorotrast)
are more likely to develop these cancers. Some other
cases are thought to be caused by exposure to
arsenic or radium, or to an inherited condition
known as hereditary hemochromatosis.
• Hepatoblastoma - This is a very rare kind of cancer
that develops in children, usually in those younger
than 4 years old. The cells of hepatoblastoma are
similar to fetal liver cells.
SECONDARY METASTATIC LIVER CANCER - occurs when
cancer spreads to the liver from other parts of the body.
• Benign liver tumors - sometimes grow large enough
to cause problems, but they do not grow into nearby
tissues or spread to distant parts of the body.
• Hemangioma - The most common type of benign
liver tumor, hemangiomas, start in blood vessels.
• Hepatic adenoma - Hepatic adenoma is a benign
tumor that starts from hepatocytes (the main type of
liver cell).
• Focal nodular hyperplasia - Focal nodular
hyperplasia (FNH) is a tumor-like growth made up of
several cell types (hepatocytes, bile duct cells, and
connective tissue cells).
RISK FACTORS
• Chronic infection with HBV or HCV
• Cirrhosis
• Certain inherited liver diseases
• Diabetes
SIGN & SYMPTOMS
• Abdominal discomfort, pain and tenderness
• Jaundice
 • Pale, chalky stools and dark urine
• Nausea
• Vomiting
• Loss of appetite
• Feeling full
• Bruising or bleeding easily
• General weakness and fatigue
• Fever
• Unexplained weight loss
DIAGNOSTIC TEAST AND LABORATORIES
Physical Exam and Health History – A physical exam of the
body will be done to check a person’s health, including
checking for signs of disease, such as lumps or anything else
that seems unusual. A history of the patient’s health habits
and past illnesses and treatments will also be taken.
Alpha-fetoprotein (AFP) tumor marker test –An AFP tumor
marker test is a blood test that measures the levels of AFP in
adults. Tumor markers are substances made by cancer cells or
by normal cells in response to cancer in the body.  Localized treatments for liver cancer are those that are
Liver function tests - These blood tests measure the amounts
of certain substances released into the blood by the liver. A
higher-than-normal amount of a substance can be a sign of
liver cancer.
CT Scan - This procedure uses a computer linked to an x-ray
machine to make a series of detailed pictures of areas inside
the body, such as the abdomen, taken from different angles.
Magnetic Resonance Imaging (MRI) - This procedure uses a
magnet, radio waves, and a computer to make a series of
detailed pictures of areas inside the body, such as the liver.
This procedure is called magnetic resonance angiography
Ultrasound exam - This procedure uses high-energy sound
waves (ultrasound) that are bounced off the liver and make
echoes. The echoes form a picture of the liver called a
sonogram.
Biopsy - During a biopsy, cells or tissues are removed so they
can be viewed under a microscope by a pathologist to check
for signs of cancer.
Procedures used to collect the sample of cells or tissues
include the following:
1. Fine-needle aspiration biopsy
2. Core needle biopsy
3. Laparoscopy
CLINICAL MANAGEMENT
SURGERY
Surgery is the removal of the tumor and some surrounding
healthy tissue during an operation. It is likely to be the most
successful disease-directed treatment, particularly for
patients with good liver function and tumors that can be
safely removed from a limited portion of the liver.
TWO TYPES OF SURGERY
Hepatectomy - A hepatectomy can be done only if the cancer
is in 1 part of the liver and the liver is working well. The
remaining section of liver takes over the functions of the
entire liver. The liver may grow back to its normal size within
a few weeks. A hepatectomy may not be possible if the
patient has advanced cirrhosis, even if the tumor is small.
Liver Transplant - During liver transplant surgery, your
diseased liver is removed and replaced with a healthy liver
from a donor. Liver transplant surgery is only an option for a
small percentage of people with early-stage liver cancer.
LOCALIZED TREATMENTS OPTION FOR LIVER CANCER
INCLUDE:
administered directly to the cancer cells or the area
surrounding the cancer cells.
Heating cancer cells - Radiofrequency ablation uses electric
current to heat and destroy cancer cells. Using an imaging
test as a guide, such as ultrasound, the doctor inserts one or
more thin needles into small incisions in your abdomen.
When the needles reach the tumor, they're heated with an
electric current, destroying the cancer cells. Other procedures
to heat the cancer cells might use microwaves or lasers.
Freezing cancer cells - Cryoablation uses extreme cold to
destroy cancer cells. During the procedure, your doctor places
an instrument (cryoprobe) containing liquid nitrogen directly
onto liver tumors. Ultrasound images are used to guide the
cryoprobe and monitor the freezing of the cells.
Injecting alcohol into the tumor - During alcohol injection,
pure alcohol is injected directly into tumors, either through
the skin or during an operation. Alcohol causes the tumor
cells to die.
Injecting chemotherapy drugs into the liver -
Chemoembolization is a type of chemotherapy treatment
that supplies strong anti-cancer drugs directly to the liver.
Placing beads filled with radiation in the liver - Tiny spheres
that contain radiation may be placed directly in the liver
where they can deliver radiation directly to the tumor.
RADIATION THERAPY
This treatment uses high-powered energy from sources such
as X-rays and protons to destroy cancer cells and shrink
tumors. Doctors carefully direct the energy to the liver, while
sparing the surrounding healthy tissue.
TARGETED DRUG THERAPY
Targeted drug treatments focus on specific abnormalities
present within cancer cells. By blocking these abnormalities,
targeted drug treatments can cause cancer cells to die.
IMMUNOTHERAPY
Immunotherapy uses your immune system to fight cancer.
Your body's disease-fighting immune system may not attack
your cancer because the cancer cells produce proteins that
blind the immune system cells. Immunotherapy works by
interfering with that process. Immunotherapy treatments are
generally reserved for people with advanced liver cancer.
CHEMOTHERAPY
Chemotherapy uses drugs to kill rapidly growing cells,
including cancer cells. Chemotherapy can be administered
through a vein in your arm, in pill form or both.
Chemotherapy is sometimes used to treat advanced liver
cancer.
NURSING MANAGEMENT
1. Give analgesics as ordered and encourage the patient to
identify care measures that promote comfort.
2. Provide patient with a special diet that restricts sodium,
fluids, and protein and that prohibits alcohol.
3. To increase venous return and prevent edema, elevate
the patient’s legs whenever possible.
4. Keep the patient’s fever down.
5. Provide meticulous skin care.
6. Turn the patient frequently and keep his skin clean to
prevent pressure ulcers.
7. Prepare the patient for surgery, if indicated.
8. Provide comprehensive care and emotional assistance.
9. Monitor the patient for fluid retention and ascites.
10. Monitor respiratory function.
11. Explain the treatments to the patient and his family,
including adverse reactions the patient may experience.
PROGNOSIS
The 5-year survival rate for liver cancer tends to be better if
the cancer is found and treated at an earlier stage.
Here are the 5-year survival rates for liver cancer, according
to the National Cancer Institute:
o Overall, the 5-year survival rate for liver cancer is
about 17%.
o For people whose cancer is found before it’s spread
outside the liver, the 5-year survival rate is about
31%.
o The 5-year survival rate for liver cancer that has
reached nearby organs or lymph nodes is about 11%.
o If liver cancer has spread to other parts of the body,
the 5-year survival rate is about 3%.
o These numbers are adjusted to account for the fact
that some people with liver cancer may die from
other causes.
CERVICAL CANCER
Cervical cancer is a type of cancer that occurs in the cells of
the cervix — the lower part of the uterus that connects to the
vagina.
The cervix is made of two parts and is covered with two
different types of cells.
• The endocervix is the opening of the cervix that leads
into the uterus. It is covered with glandular cells.
• The exocervix (or ectocervix) is the outer part of the
cervix that can be seen by the doctor during a speculum
exam. It is covered in squamous cells.
TYPES OF CERVICAL CANCER
SQUAMOUS CELL CARCINOMAS
 These cancers develop from cells in the exocervix. Squamous
cell carcinomas most often begin in the transformation zone
(where the exocervix joins the endocervix).
ADENOCARCINOMAS
Adenocarcinomas are cancers that develop from glandular
cells. Cervical adenocarcinoma develops from the mucus-
producing gland cells of the endocervix.
ADENOSQUAMOS CARCINOMAS OR MIXED CARCINOMAS
Less commonly, cervical cancers have features of both
squamous cell carcinomas and adenocarcinomas.
RISK FACTORS
• Many sexual partners
• Early sexual activity
• Other sexually transmitted infections (STIs)
• A weakened immune system
• Exposure to miscarriage prevention drug
• Family history of cervical cancer
• Sex with uncircumcised men
• Smoking and exposure to secondhand smoke
• Chronic cervical infection
• Early childbearing
SIGN & SYMPTOMS
• vaginal bleeding between periods
• menstrual bleeding that is longer or heavier than usual
• pain during intercourse Loop electrosurgical excision procedure (LEEP). 
• bleeding after intercourse • The use of an electrical current passed through a
• pelvic pain thin wire hook. The hook removes the tissue. It can
• a change in your vaginal discharge such as more be used to remove micro invasive cervical cancer.
discharge or it may have a strong or unusual colour or
smell Hysterectomy. 
• vaginal bleeding after menopause. • The removal of the uterus and cervix. A
hysterectomy can be either simple or radical. A
DIAGNOSTIC TEST AND LABORATORIES simple hysterectomy is the removal of the uterus
and cervix. A radical hysterectomy is the removal of
• Bimanual pelvic examination and sterile speculum
the uterus, cervix, upper vagina, and the tissue
examination
around the cervix. A radical hysterectomy also
• Pap test
includes an extensive pelvic lymph node dissection,
• Human papillomavirus (HPV) typing test
which means lymph nodes are removed. This
• Colposcopy
procedure can be done using a large cut in the
• Pelvic examination under anesthesia
abdomen, called laparotomy, or using smaller cuts,
• X-ray
called laparoscopy.
• Computed tomography (CT or CAT) scan
• Magnetic resonance imaging (MRI)
• Positron emission tomography (PET) or PET-CT scan Bilateral salpingo-oophorectomy. 
• Biomarker testing of the tumor
• If needed, this surgery is the removal of both
• Biopsy
fallopian tubes and both ovaries. It is done at the
same time as a hysterectomy.
OTHER TYPES OF BIOPSIES
Radical trachelectomy. 
• Endocervical curettage (ECC)
• Loop electrosurgical excision procedure (LEEP) • A surgical procedure in which the cervix is removed,
• Conization (a cone biopsy) but the uterus is left intact. It includes pelvic lymph
node dissection (see above). This surgery may be
used for young patients who want to preserve their
OTHER TEST
fertility. This procedure has become an acceptable
• Cystoscopy alternative to a hysterectomy for some patients.
• Sigmoidoscopy (also called a proctoscopy)
Exenteration.
CLINICAL MANAGEMENT • The removal of the uterus, vagina, lower colon,
rectum, or bladder if cervical cancer has spread to
• Surgery these organs after radiation therapy (see below).
• Radiation therapy Exenteration is rarely recommended. It is most often
• Chemotherapy used when cancer has come back after radiation
• Targeted therapy therapy.
• Immunotherapy
• Physical, emotional, and social effects of cancer Radiation Therapy
• Treatment options by stage • Radiation therapy is the use of high-energy x-rays or
• Metastatic cervical cancer other particles to destroy cancer cells. The most
• Remission and the chance of recurrence common type of radiation treatment is called
• If treatment does not work external-beam radiation therapy, which is radiation
given from a machine outside the body. When
SURGERY radiation treatment is given using implants, it is
called internal radiation therapy or brachytherapy. A
Conization.  radiation therapy regimen, or schedule, usually
• The use of the same procedure as a cone biopsy to consists of a specific number of treatments given
remove all of the abnormal tissue. It can be used to over a set period of time that combines external and
remove cervical cancer that can only be seen with a internal radiation treatments. This combined
microscope, called micro invasive cancer. approach is the most effective to reduce the chances
the cancer will come back, called a recurrence. For
 early stages of cervical cancer, a combination of
radiation therapy and low-dose weekly
chemotherapy is often used .
CHEMOTHERAPY
• Chemotherapy is the use of drugs to destroy cancer
cells, usually by keeping the cancer cells from
growing, dividing, and making more cells.
• Although chemotherapy can be given orally (by
mouth), all the drugs used to treat cervical cancer
are given intravenously (IV). IV chemotherapy is
either injected directly into a vein or given through a
thin tube called a catheter, which is a tube
temporarily put into a large vein to make injections
easier.
TARGETED THERAPY
Targeted therapy is a treatment that targets the cancer’s
specific genes, proteins, or the tissue environment that
contributes to cancer growth and survival. This type of
treatment blocks the growth and spread of cancer cells and
limits damage to healthy cells. If cervical cancer comes back
after treatment, called recurrent cancer, or if cervical cancer
has spread beyond the pelvis, called metastatic disease, it can
be treated with a platinum-based chemotherapy combined
with the targeted therapy bevacizumab (Avastin).
IMMUNOTHERAPY
Immunotherapy uses the body's natural defenses to fight
cancer by improving your immune system’s ability to attack
cancer cells. The immune checkpoint inhibitor
pembrolizumab (Keytruda) is used to treat cervical cancer
that has recurred or spread to other parts of the body during
or after treatment with chemotherapy.
PHYSICAL, EMOTIONAL, AND SOCIAL EFFECTS OF CANCER
Cancer and its treatment cause physical symptoms and side
effects, as well as emotional, social, and financial effects.
Managing all of these effects is called palliative care or
supportive care. It is an important part of your care that is
included along with treatments intended to slow, stop, or
eliminate the cancer. Palliative care focuses on improving
how you feel during treatment by managing symptoms and
supporting patients and their families with other, non-
medical needs.
Palliative treatments vary widely and often include
medication, nutritional changes, relaxation techniques,
emotional and spiritual support, and other therapies.
TREATMENT OPTIONS BY STAGE
Radiation therapy alone or surgery is generally used for an
early-stage tumor. These treatments have been shown to be
equally effective at treating early-stage cervical cancer.
Chemoradiation (a combination of chemotherapy and
radiation therapy) is generally used for people with a larger
tumor, an advanced-stage tumor found only in the pelvis, or if
the lymph nodes have cancer cells. Commonly, radiation
therapy and chemotherapy are used after surgery if there is a
high risk of the cancer coming back or if the cancer has
spread.
METASTATIC CERVICAL CANCER
For many people, a diagnosis of metastatic cancer is very
stressful and difficult. You and your family are encouraged to
talk about how you feel with doctors, nurses, social workers,
or other members of your health care team. It may also be
helpful to talk with other patients, such as through a support
group or other peer support program.
REMISSION AND THE CHANCE OF RECURRENCE
A remission is when cancer cannot be detected in the body
and there are no symptoms. This may also be called having
“no evidence of disease” or NED. A remission may be
temporary or permanent. This uncertainty causes many
people to worry that the cancer will come back. While many
remissions are permanent, it is important to talk with your
doctor about the possibility of the cancer returning.
If the cancer returns after the original treatment, it is called
recurrent cancer. Recurrent cancer may come back in the
same place (called a local recurrence), nearby (regional
recurrence), or in another place (distant recurrence).
IF TREATMENT DOES NOT WORK
People who have advanced cancer and who are expected to
live less than 6 months may want to consider hospice care.
Hospice care is designed to provide the best possible quality
of life for people who are near the end of life. You and your
family are encouraged to talk with the health care team
about hospice care options, which include hospice care at
home, a special hospice center, or other health care
locations. Nursing care and special equipment can make
staying at home a workable option for many families. Learn
more about advanced cancer care planning.
NURSING MANAGEMENT
• Listen to the patient’s fears and concerns, and offer
reassurance when appropriate.
• Encourage the patient to use relaxation techniques to
promote comfort during the diagnostic procedures.
• Monitor the patient’s response to therapy through
frequent Pap tests and cone biopsies as ordered.
• Watch for complications related to therapy by listening
to and observing the patient.
• Monitor laboratory studies and obtain frequent vital
signs.
• Understand the treatment regimen and verbalize the
need for adequate fluid and nutritional intake to
promote tissue healing.
• Explain any surgical or therapeutic procedure to the
patient, including what to expect both before and after
the procedure.
• Review the possible complications of the type therapy
ordered.
• Remind the patient to watch for and report
uncomfortable adverse reactions.
• Reassure the patient that this disease and its treatment
shouldn’t radically alter her lifestyle or prohibit sexual
intimacy.
• Explain the importance of complying with follow up visits
to the gynecologist and oncologist.
PROGNOSIS
• More than 90% of women with stage 0 survive at least 5
years after diagnosis.
• Stage I cervical cancer patients have a 5-year survival rate
of 80% to 93%.
• Women with stage II cervical cancer have a 5-year
survival rate of 58% to 63%.
• The survival rate for women with stage III cervical cancer
is 32% to 35%.
• Sixteen percent or fewer women with stage IV cervical
cancer survive 5 years.
years. More than 75% of prostate cancer diagnoses are made
at one of these stages.
TYPES OF PROSTATE CANCER
● Adenocarcinoma of the prostate
- Adenocarcinomas develop in the gland cells that
line the prostate gland and the tubes of the
prostate gland. Gland cells make prostate fluid.
● Transitional cell carcinoma of the prostate
- This type of cancer usually starts in the bladder
and spreads into the prostate. But rarely it can
start in the prostate and may spread into the
bladder entrance and nearby tissues.
● Squamous cell carcinoma of the prostate
- These cancers develop from flat cells that cover
the prostate. They tend to grow and spread
more quickly than adenocarcinoma of the
prostate.
 Small cell prostate cancer
- Small cell prostate cancer can also be classed as
a type of neuroendocrine cancer. They tend to
grow more quickly than other types of prostate
cancer.
MANIFESTATION OF PROSTATE CANCER
GENITOURINARY
• Dysuria
• Frequency of urination
• Reduction in urinary stream
• Nocturia
• Hematuria
• Abn prostate on digital rectal examination

PROSTATE CANCER MUSCULOSKELETAL

• Bone or joint pain
Prostate cancer begins when cells in the prostate gland start • Migratory bone pain
to grow out of control. The prostate is a gland found only in • Back pain
males. It makes some of the fluid that is part of semen. The
prostate is a small walnut-shaped gland in males that SYSTEMIC
produces the seminal fluid that nourishes and transports • Weight loss
sperm. • Fatigue

Cancer of the prostate is the most common type of cancer NEUROLOGIC

and the second leading cause of death in North America. It is • Nerve pain
primarily a disease of older men, increasing in incidences with • Bilateral lower extremity weakness
age, with the majority of cases diagnosed in men older in 65 • Bowel or bladder dysfunction
years. When diagnosed early prostate cancer is curable. • Muscle spasms
When the cancer is confined to the prostate at diagnosis, the
DIAGNOSTIC TEST
5 year survival rate is 100%. Even when the cancer has spread
regionally, approximately 95% of clients are alive after 5
The definitive diagnosis can be made only by biopsy; Urinary Incontinence
however, other tests may suggest the presence of prostate
cancer. • Assess the degree of incontinence and its effect on
• Prostate-specific antigen (PSA) levels lifestyle.
• Transrectal ultrasonography • Teach kegel exercises to helo restore continence.
• Bone scan, MRI, or CT scans • Teach methods to contrl dampness and odor from
• Digital Rectal Examination stress incontinence.
• Do not attempt to prevent accidental voiding by
CLINICAL MANAGEMENT restrincting fluids
• Manage occasional episodes with absorbent pads
SURGERY worn inside the underwear and changed as needed.
• Refer to physical therapy or a continence specialist
Surgery for prostate cancer includes several types of for additional measures to promote continence.
prostatectomies. For early disease in older men, cure may be • Explore options such as external collection device for
achieved with a simple prostatectomy the man with total incontinence.
• Encourage verbalizing feelings about the impact of
RADICAL PROSTATECTOMY incontinence on his quality of life

Involves removal of the prostate, prostatic capsule, seminal

Sexual Dysfunction
vesicles, and a portion of the bladder neck

• Assess the man’s pre-treatment sexual function

RETROPUBIC PROSTATECTOMY
• Teach the man about the actual or potential effects
of therapy on sexual function.
Most often performed because it allows adequate control of
• Provide an opportunity for the man and his partner
bleeding, visualization of the prostate bed and bladder neck,
to discuss about the diagnosis and treatment on
and access to pelvic lymph nodes.
sexual function.
• Discuss medical and surgical treatments for erectile
PERINEAL PROSTATECTOMY
dysfunction.
• Refer for sexual counselling as appropriate.
Often preferred for older men or those who are poor surgical
risks. This approach require less time, and involves less
Acute/Chronic Pain
bleeding

• Assess the intensity, location, and quality of the

SUPRAPUBIC PROSTATECTOMY
client’s pain.
• Provide optimal pain relief with prescribed
Is rarely used, usually when problems with the bladder are
analgesics
expected. Control of bleeding is more difficult because the
• Teach the client and family non-invasive methods of
surgical approach is through the bladder.
pain control.
RADIOTION THERAPY
PROGNOSIS
May be used as a primary treatment for prostate cancer
STAGE 1 PROSTATE CANCER
HORMONAL MANIPULATION
Stage 1 is the least advanced form of prostate cancer. Cancer
in this stage is small and hasn’t spread past the prostate
Androgen deprivation therapy is used to treat advanced
gland. It’s characterized by a PSA of less than 10 ng/mL, a
prostate cancer.
grade group score of 1, and a Gleason score of 6.
NURSING MANAGEMENT
Stage 1 prostate cancer has a 5-year survival rate of nearly
100 percent.
The nursing care of men with prostate cancer must be
holistic, sensitive and individualized. The nursing diagnoses
STAGE 2 PROSTATE CANCER
discussed for the man with BPG may also be appropriate.
In stage 2, the tumor is still confined to your prostate and
hasn’t spread to lymph nodes or other parts of your body. A
doctor may or may not be able to feel the tumor during a
prostate exam, and it may appear on ultrasound imaging. The
survival rate is still near 100 percentTrusted Source.

The PSA score for stage 2 is less than 20 ng/mL.

STAGE 3 PROSTATE CANCER

At stage 3, cancer cells may or may not have spread outside

the prostate to other tissues. The survival rate of prostate
cancer that hasn’t spread to distant parts of your body is still
close to 100 percent.

STAGE 4 PROSTATE CANCER

Stage 4 is the most advanced stage of prostate cancer and is

divided into two letter groups. Stage 4 prostate cancer can
have any grade group, PSA value, and Gleason score.

By stage 4, cancer has typically spread to distant parts of your

body. If it has spread to other organs, the 5-year survival rate
drops to about 30 percent.

LEUKEMIA (Cancer in Blood)

SLIDE 177