Oncology: Nursing Management in Cancer Care

Topic Outline
1. Etiology and Risk Factors of Cancer
2. Pathophysiology of the Malignant Process
3. Detection and Prevention of Cancer
4. Diagnosis of Cancer
5. Major Management of Cancer

Learning Objectives
After going through this topic, you will be able to:
• Discuss the etiology and pathophysiology of cancer
• Differentiate between benign and malignant tumors.
• Identify agents and factors that are carcinogenic.
• Describe the role of nurses in health education and prevention in decreasing the incidence of
cancer.
• Differentiate among the goals of cancer care: prevention, diagnosis, cure, control, and palliation.
• Describe the roles of surgery, radiation therapy, chemotherapy, hematopoietic stem cell
transplantation, and symptom management in treating cancer.
• Identify potential complications for the patient with cancer and discuss associated nursing care.

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Introduction
Cancer is characterized by abnormal, unrestricted cell proliferation. It is a group of distinct diseases with
different causes, manifestations, treatments, and prognoses. Malignant tumors invade healthy tissues and
compete with normal cells for oxygen, nutrients, and physical space.
Cancer is a group of complex diseases with various manifestations, depending on which body system is
affected and the type of tumor cells involved. A disease that is universal in scope since it can affect people of any
age, gender, ethnicity, geographical region, level of education, and affluence. Although the incidence and mortality
rates of cancer have continued to decline since 1990, it remains one of the most feared diseases. The fear
engendered by even the suggestion of a cancer diagnosis often evokes feelings of hopelessness and helplessness
(Galway et al., 2012).
Nursing care for a person with cancer is holistic and comprehensive. Nurses are involved in all phases of
the cancer experience: prevention, detection, diagnosis, treatment, rehabilitation, palliative, and terminal care.
This study guide/module focuses on the general pathogenesis, pathophysiology, and etiology of cancer;
identifies current diagnostic and treatment modalities; and discusses nursing care appropriate for people with
cancer.

Pre-assessment
True/False: Write T if the statement is True and F if the statement is False
1. Passive smoke (i.e., secondhand smoke) has been linked to lung cancer; nonsmokers who live with a
smoker have about a 20% to 30% greater risk of developing lung cancer.
2. Patients with seed implants typically aren’t able to return home; radiation exposure to others is
probable.
3. Genetic mutations may lead to abnormalities in cell signaling transduction processes that can in turn
lead to cancer development.
4. Pain and fatigue are the two most common side effects of chemotherapy.
5. Prophylactic cancer vaccines have been proven to prevent prostate, breast, and lung cancers.

True/False: 1. True; 2. False; 3. True; 4. False; 5. False

Key Answer to Pre-assessment

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 CANCER

A general name that given to a large group of diseases characterized by uncontrolled growth and spread
of abnormal cells. Oncology is the study of cancer.

Pathogenesis
➢ Cellular Transformation and Derangement Theory
o Conceptualizes that normal cells may be transformed into cancer cells due to exposure to some
etiologic agents.
➢ Failure of the Immune Response Theory
o Advocates that all individuals possess cancer cells. However, the cancer cells are recognized by
the immune response system. So, the cancer cells undergo destruction. Failure of the immune
response system leads to an inability to destroy cancer cells.

Etiologic Factors (Carcinogens)

1. Viruses & Bacteria
• “oncogenic viruses”
o Prolonged or frequent viral infections may cause the breakdown of the immune system or
overwhelm the immune system.
• Helicobacter pylori (gastric lymphoma); Human papillomavirus (cervical cancer, anal cancers, upper
airway cancers); Epstein-Barr virus (lymphoma, nasopharyngeal cancers, gastric cancer, Kaposi
sarcoma); Cytomegalovirus (Kaposi sarcoma, colon cancer); Hepatitis B and C (hepatocellular
cancer).
2. Chemical Carcinogens: act by causing cell mutation or alteration → altered cell replication.
• Industrial Compounds

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o Vinyl Chloride (plastic manufacture), asbestos, benzene, nickel, chromate.
o Hydrocarbons (auto and truck emissions, oil refineries), air pollution.
o Fertilizer and weed killers.
o Aniline dyes (beauty shop and home use).
• Drugs
o Tobacco & alcohol. Tobacco is the single greatest cause of cancer-related deaths while
excessive alcohol intake is associated with cancers of the mouth, larynx, throat, esophagus,
liver, and breast, especially when combined with smoking.
3. Physical Agents
• Radiation
o From X-rays or radiation therapy
o Sunlight and ultraviolet rays is related to an increased risk of skin cancers
• Chronic Physical Irritation/trauma: overuse of any organ/body.
o Pipe smoking
o Multiple deliveries
o Jagged tooth, irritation of the tongue.
4. Hormonal Agents
• Imbalance of endogenous or exogenous hormones, such as estrogen or Diethylstilbestrol (DES) as
replacement therapy increases the incidence of vaginal and cervical carcinoma.
5. Genetics
• Oncogene (hidden/repressed genetic code for cancer that exists in all individuals) → when exposed to
carcinogens → changes in cell structures → becomes malignant.
• Regardless of the cause, several cancers are associated with familial patterns.
6. Dietary Factors
• Excessive intake of fat
• Nitrates & nitrites-containing food (bacon) and processed meats
• Salt-cured or smoked meats (Polycyclic Hydrocarbons)
• Aflatoxins (mold in nuts and grains, milk, cheese, peanut butter)

Predisposing Factors
1. Age
• Older individuals are more prone to cancer. Approximately 87% of people diagnosed with cancer
are over age 50.
2. Sex
• Women: more prone to breast, uterus, and cervical cancer.
• Men: prostate, lung cancer

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 3. Urban vs. Rural residence
• Cancer is more common among urban dwellers.
4. Geographic Distribution
• Due to the influence of environmental factors such as national diet, ethnic customs, and type of
pollution.
5. Occupation
• People in certain jobs are more susceptible to cancer because of greater contact with carcinogens.
Farmers and construction workers are exposed to solar radiation; healthcare workers such as x-
ray technicians and biomedical researchers are exposed to ionizing radiation and carcinogenic
substances; asbestos exposure is a problem for people who work in old buildings with asbestos
insulation in the walls.
6. Heredity
• Greater risk with (+) family history. Breast, colon, lungs, ovarian, and prostate have shown some
familial relationships
7. Stressors
• Depression, grief, anger, aggression, despair, or life stresses decrease immunocompetence.
8. Precancerous lesion
• May transform into cancer lesions and tumors (Eg. pigmented moles, burn scars, senile keratosis,
leukoplakia, benign polyps of the colon and stomach).
9. Obesity
• Studies have linked obesity to breast and colorectal CA.

Comparison of the Characteristics of Benign and Malignant Neoplasm

Characteristics Benign Malignant
Mode of Growth Remains localized Infiltrates and invades

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surrounding tissue
Speed of Growth Grows slowly Usually grows rapidly
Capsule Encapsulated Not capsulated
Cell characteristics Well-differentiated Poorly differentiated
Recurrence Extremely unusual Common
Metastasis Never occur Very common
Effect of Neoplasm Not harmful to the host Always harmful to the host
Prognosis Very good prognosis Poor prognosis

Metastasis: the spread of the cancer cells from the primary tumor to the distant sites

Three stages
1. Invasion of neoplastic cells from the primary tumor into the surrounding tissues with penetration of
blood and lymph.
2. Spread of tumor cells through lymph and circulation or by direct expansion.
3. Establishment and growth of tumor cells at secondary sites.

Pathophysiologic Basis of Malignant Neoplasia

1. Proliferation of cancer cells disrupts normal cell growth and interferes with tissue function.
• Pressure - due to an increase in the size of neoplastic growth.
• Obstruction - as the tumor continues to grow, hollow organs and vessels become compressed and
obstructed.
o Examples: esophagus, ureters, bowel, blood vessels lymphatic system.
• Pain due to:
o Pressure on nerve endings
o Distension of organs or vessels
o Lack of oxygen to tissues and organs
o Release of pain mediators by the tumor
• Effusion (late sign of CA)
o When lymphatic flow is obstructed, there may be effusion in cavities.
• Ulceration and Necrosis
o Result as the tumor erodes blood vessels and pressure on the tissue causes ischemia→ tissue
damage and bleeding→ infection
• Vascular Thrombosis, Embolus, Thrombophlebitis
o Tumors tend to produce abnormal coagulation factors that cause increased clotting
(pulmonary emboli)

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 2. Paraneoplastic Syndrome- malignant cells produce enzymes, hormones, and other substances.
• Anemia
o Cancer cells produce chemicals that interfere with RBC production.
o Iron uptake is greater in the tumor than that deposited in the liver.
o Blood loss may result from bleeding
• Hypercalcemia
o Tumors of the bone, squamous cell lung cancer, and cancer of the breast produce parathyroid-
like hormones that increase or accelerate bone breakdown and release of calcium
o Also results from the metastasis to the bones.
o Enhanced by immobilization and dehydration.
• DIC (Disseminated Intravascular Coagulation)
o More likely to occur in the CA of the lungs, pancreas, stomach, and prostate.
o Precipitated by the release of tissue thromboplastin or endothelial injury.
3. Anorexia-Cachexia Syndrome
• The final outcome of unrestrained CA cell growth
• Malignant neoplasm deprives normal cells of nutrition.
• Tumors produce alterations in the enzyme system necessary for normal metabolism.
• Tumor revert to anaerobic metabolism → consumes glucose; depletes glycogen stores in the liver
and converts glucose to lactate.
• Protein deletion, serum albumin levels decrease.
• Tumors take up Na
• Ca cells produce anorexigenic substances that act in the satiety center of the hypothalamus,
causing anorexia
• Taste sensation diminishes or becomes altered and the individual may have aversion to eating.

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Prevention and Detection:
Cancer’s 7 early warning signals include:

C- change in bowel and bladder habits O- obvious change in wart or mole

A- sore that does not heal N- nagging cough or hoarseness of voice
U- unusual bleeding or discharge
T- thickening or lump in the breast or elsewhere U- unexplained anemia
I- indigestion or difficulty in swallowing S- sudden weight lose

Primary Prevention: concerned with reducing the risks of disease through health promotion and risk reduction
strategies.
1. Achieve and maintain healthy body weight.
a. Be as lean as possible throughout life without being underweight.
b. Limit the consumption of high-calorie foods and beverages.
c. Waist circumference should be below 37 inches (94 cm) for men and 31.5 inches (80 cm) for
women.
2. Adopt a physically active lifestyle.
a. Adults should engage in 150 minutes of moderate-intensity or 75 minutes of vigorous activity
each week, preferably spread throughout the week.
b. Limit sedentary behavior such as sitting, lying down, watching TV, and other forms of screen-
based entertainment.
3. Consume a healthy diet, with emphasis on plant sources
a. Cut down on total fat intake.
b. Eat more high-fiber foods: fruits and vegetables, whole grain cereals.
c. Include food rich in vitamins A & C in the daily diet.
d. Include cruciferous vegetables in the diet: broccoli, cabbage, and cauliflower.
e. Be moderate (limit) in the consumption of alcoholic beverages.
f. Be moderate in the consumption of salt-cured, smoked-cured, and nitrate-cured foods.
g. Limit intake of processed and red meats. Red meat three to four times a week only and on other
days eat fish, poultry, beans, and lentils.
4. Other accepted risk-reduction measures
a. Avoid tobacco use (account for approximately 83% of lung cancer and 30% of all cancer deaths).
b. Avoid exposure to known carcinogens
c. Avoid excessive exposure to sunlight, especially during the hours of 10 A.M. and 4 P.M., and cover
exposed skin with sunscreen with a skin protection factor of 15 or higher.
d. Vaccinations—HPV causes most cervical, vulvar, vaginal, anal, and oropharyngeal cancers in
women and most oropharyngeal, anal, and penile cancers in men.

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Secondary Prevention: involves screening and early detection activities that seek to identify early-stage cancer
in individuals who lack signs and symptoms suggestive of cancer.

Cancer site Test or Procedure Population Frequency

Colorectal Sigmoidoscopy M & F, aged ≥ 50 years Every 5 years
Fecal occult blood test M & F, aged ≥ 50 years Every year
(FOBT) or fecal
immunochemical test (FIT)
Coloscopy M & F, aged ≥ 50 years Every 10 years
Prostate Digital rectal examination M, aged ≥ 50 years Every year
Prostate-specific antigen M, aged ≥ 50 years Every year
(PSA)
Cervix Pap test F, aged 21-30 years Every 3 years
Co-testing with HPV test F, aged 30-65 years Every 5 years
and Pap test
Endometrial Endometrial tissue sample F, at menopause At menopause &
thereafter at the
discretion of the
physician.
Breast Breast self-exam F, aged ≥20 years Every month
Clinical breast examination F, aged 20-40 years Every 3 years
& if ≥ 40 years Every year
Mammography F, aged ≥ 40 Every year
Cancer-related check-up M & F, aged ≥ 40 years Every 3 years
& if ≥ 50 years Every year

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Tertiary Prevention: focus on monitoring for and preventing recurrence of primary cancer as well as screening
for the development of second malignancies in cancer survivors.

Staging: the process of determining the extent of disease, including tumor size and spread or metastasis to
distant sites
Grading: identification of the type of tissue from which the tumor originated and the degree to which the tumor
cells retain the functional and structural characteristics of the tissue of origin (differentiation).

TNM System
T- tumor; tumor size
N- nodes (lymph); presence or absence of regional lymph node involvement
M- metastasis; presence or absence of distant metastasis
Primary Tumor (T)
Tx Primary tumor cannot be assed
T0 No evidence of primary tumor
Tis Carcinoma or tumor in situ
T1, T2, T3, T4 Progressive increase in tumor size & or extent of the primary tumor
Regional Lymph Node (N)
Nx Regional lymph node cannot be assessed
N0 No regional lymph node metastasis
N1, N2, N3 Increasing involvement of regional lymph node
Distant Metastasis (M
Mx Distant metastasis cannot be assessed
M0 No evidence of distant metastasis
M1, M2, M3 Ascending degrees of distant metastasis

Stages of Tumor
Stage I: tumor less than 2 cm, negative lymph node involvement, no detectable metastases.
Stage II: tumor greater than 2 cm but less than 5 cm, negative or positive unfixed lymph node involvement, no
detectable metastases.
Stage III: large tumor greater than 5 cm, or a tumor of any size with an invasion of the skin or chest wall or
positive fixed lymph node involvement on the clavicular area without evidence of metastases.
Stage IV: tumor of any size, positive or negative lymph node involvement, and distant metastases.

Different Therapeutic Modality for Management of Cancer

1. Surgical Intervention
2. Chemotherapy

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 3. Radiation Therapy
4. Bone Marrow Transplantation: procedure includes aspirating bone marrow cells from a compatible donor
and infusing them into the recipient.

Surgical Management: surgical removal of tumors

Types of Surgical Procedures and Objectives:
1. Preventive or prophylactic surgery: removal of precancerous lesions or benign tumors (e.g., unusual skin
growth, colorectal polyps).
2. Diagnostic Surgery: is done to confirm or rule out malignancy from analysis of tissue samples obtain from
incisional (removal of part of a larger tumor by cutting through the skin), excisional (removal of an entire
tumor through operation), or needle biopsy (use of a needle to extract a small amount of tissue from
tumors).
3. Curative Surgery: removal of entire tumor tissue (may include regional lymph nodes and neighboring
structures) while limiting structural and functional impairment.
4. Reconstructive or rehabilitative surgery: aims to improve that client’s quality of life by restoring maximal
function and appearance; repairing defects from previous radical surgical resection (e.g. breast
reconstruction)
5. Palliative surgery is done to:
a. retard tumor growth and metastasis
b. decrease tumor size
c. relief distressing manifestations of cancer when cure is no longer possible (e.g., obstruction of the
GI tract, pain produced by tumor extension into surrounding nerves).

Chemotherapy: involves administering antineoplastic drugs given systemically to promote cell death by
interfering with cellular functions and reproduction. Chemotherapy predictably affects normal, rapidly growing

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cells.

Objectives:
1. Curative therapy: to destroy all malignant tumor cells without excessive destruction of normal cells.
2. Adjuvant chemotherapy: administering chemotherapy agents in combination with surgery or radiation
therapy or both to destroy any remaining tumor cells postoperatively.
3. Neoadjuvant chemotherapy: administering chemotherapy agents in combination with surgery or radiation
therapy or both to reduce the size of the tumor preoperatively.
4. Palliative treatment: used when a cure is not possible to control cancer and minimize side effects from
the disease; given to relieve or diminish distressing symptoms.

Contraindications
1. Infection
2. Recent surgery
3. Impaired Renal or Hepatic function
4. Pregnancy
5. Bone Marrow Depression

Replicative Cell Cycle Pattern

G0 (gap 0): resting phase
1. G1 (gap one) postmitotic phase: Ribonucleic acid (RNA) and proteins
(enzymes for DNA synthesis) are manufactured.
2. S (synthesis) phase: DNA is replicated in preparation for cell division.
3. G2 phase (premitotic): DNA synthesis is complete, & mitotic spindle forms
4. M (mitosis) phase: cell division occurs.

Routes of administration:
1. Systemic Chemotherapy: oral, subcutaneous, Intravenous (IV) push (bolus) or infusion over a specified
period, and intramuscular.
2. Regional Chemotherapy: intrathecal/intraventricular (given by lumbar puncture), intra-arterial,
intraperitoneal cavity, intravesical (into uterus or bladder); topical.

Classification of Chemotherapeutic Agents

Cell cycle-specific agents: are effective against actively dividing cells only during certain phases of the cell cycle.
1. Antimetabolites: interferes with the biosynthesis of metabolites or nucleic acids necessary for RNA & DNA
synthesis. Inhibits DNA replication and repair. Cell cycle-specific (S phase)

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 methotrexate, edatrexate, 5- fluorouracil, 6- mercaptopurine, 6- thioguanine, pentostatin,
➢
hydroxyurea, cytarabine, fludarabine, capecitabine,
gemcitabine
2. Topoisomerase I & II inhibitors: induce breaks in the DNA
strands by binding to enzyme topoisomerase I, preventing the
cell from dividing. Cell cycle-specific (S phase)
➢ Topoisomerase I inhibitors: irinotecan & topotecan
➢ Topoisomerase II inhibitors: etoposide & teniposide
3. Mitotic Spindle Inhibitors
a. Plant alkaloids: arrest metaphase by inhibiting mitotic
tubular formation (spindle); inhibit DNA and protein
synthesis. Cell cycle-specific (M phase)
➢ vincristine, vinblastine, & vinorelbine
b. Taxanes: arrest metaphase by inhibiting tubulin
depolymerization. Cell cycle-specific (M phase)
➢ Paclitaxel, docetaxel
c. Epothilones: alters microtubules and inhibit mitosis
➢ ixabepilone

Cell cycle-nonspecific agents: act during all phases of the cell cycle.
1. Alkylating agent: bond with DNA, RNA, and protein molecules leading to impaired DNA replication, RNA
transcription, and cell functioning; all result in cell death
➢ Busulfan, carboplatin, cisplatin, oxaliplatin, cyclophosphamide, thiopeta, melphalan, nitrogen
mustard.
2. Nitrosoureas: similar to alkylating agents; cross the blood-brain barrier.

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➢ carmustine, lomustine or semustine, streptozocin
3. Antitumor antibiotics: interfere with DNA synthesis by binding DNA; prevent RNA synthesis.
➢ Dactinomycin, bleomycin, mitomycin, plicamycin, doxorubicin, daunorubicin, epirubicin, and
idarubicin.
4. Hormonal agents: bind to hormone receptor sites that alter cellular growth
➢ androgens & antiandrogens, estrogen & antiestrogens, progestin & antiprogestin.
5. Miscellaneous agents: inhibits protein, DNA, and RNA synthesis
➢ asparaginase, procarbazine

Safe Handling of Chemotherapeutic Agents

1. Wear a mask, gloves, and back-closing gown
2. Skin contact with the drug must be washed immediately with soap and water. Eyes must be flushed
immediately with a copious amount of water.
3. Sterile or alcohol wet cotton pledgets should be used- wrapped around the neck of the ampule or vial
when breaking and withdrawing the drug.
4. Wipe the external surface of syringes and IV bottles.
5. Avoid self-inoculation by needle stabbing.
6. Clearly label the hanging IV bottle with ANTINEOPLASTIC CHEMOTHERAPY.
7. Contaminated needles and syringes must be disposed of in a clearly marked special container “leak-proof”,
“puncture-proof”
8. Disposed half-empty ampules, vials, I.V. bottles by putting them into a plastic bag, seal, and then into
another plastic bag or box, clearly marked before placing them for removal. Label as “Hazardous waste”.
9. Hand washing should be done before and after the removal of gloves.
10. Trained personnel only should be involved in the use of drugs.

Summary Effects of Chemotherapy:

1. Antineoplastic drugs affect both normal and cancer cells by disrupting function and division at various
points of the cell cycle.
2. Most cancer drugs are most effective against cells that multiply rapidly- neoplasms, bone marrow cells,
cells of the GI tract, and cells in the skin or hair follicles.
3. Chemotherapy agents should not be used during pregnancy and lactation.

Radiation Therapy: involves directing high-energy ionizing radiation to destroy malignant tumor cells without
harming surrounding tissue. Interrupts cellular growth by damaging cellular DNA.
Types of Ionizing Radiation:
1. Electromagnetic radiation (x-rays and gamma rays)
2. Particulate radiation (electrons, beta particles, protons, neutrons, and alpha particles)

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Objectives:
1. Curative therapy: aim to eradicate all disease
2. Adjunct to other therapy
3. Palliative therapy: to relieve the symptoms of metastatic disease.

Sources of Radiation Therapy

1. External Radiation Therapy (Teletherapy): administered through an X-ray machine.
• Reassure the patient that the procedure is painless
• The patient will remain alone in the treatment room
• Inform the patient that there is no residual radioactivity. There is no need for isolation.
2. Internal Radiation Therapy (Brachytherapy): involves placing specially prepared radioactive material
directly into or near the tumor itself through internal implants or into the systemic circulation. There is a
need to implement isolation.
Types:
a. Sealed Source: a radioisotope enclosed in a sealed container (applicators, needles, seeds, beads,
or catheter) into body cavities or interstitial compartments.
b. Unsealed source: used in systemic therapy and administered IV or orally.

Principles of Radiation Protection:

1. Distance
• Maintain a distance of at least 3 feet when performing a nursing procedure.
2. Time
• Limit contact for 5 minutes each time, a total of 30 minutes per shift.
3. Shielding
• Use lead shields during contact with the client

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4. Other safety precautions
• Personnel who may be exposed to penetrating radiation should wear dosimeter badges.
• No pregnant staff/visitors permitted near the radiation source
• Utilized long-handled forceps or tongs when picking up any accidentally dislodge radioactive
implants.
• Notify the radiologist of any implants that have moved out of position
• Wash hands with soap and water after caring for a patient who is being treated with a radioisotope.
• If the patient has a cobalt implant in the uterus, the following are important nursing interventions:
o Position the bed so that the patient’s back is toward the door.
o Enema is done before the procedure; a low-fiber diet is provided.
o Urinary catheter is inserted into the patient to prevent bladder distention.
o Complete bed rest is necessary.
o Place dislodge radioisotope in a lead container.

Nursing Interventions for Chemotherapy and Radiation Therapy Side–Effects

1. G.I. System
a. Nausea and vomiting: the most common side effects of chemotherapy, which may persist for 24 to 48
hours.
• Administer antiemetics such as serotonin-receptor blockers such as ondansetron (Zofran),
granisetron (Kytril), dolasetron (Anzemet), and palonosetron (Aloxi); dopaminergic receptor
blockers such as metoclopramide (Reglan) and prochlorperazine (Compazine).
• Ensure adequate hydration
• Prevent unpleasant sights and odors in the environment
• Relaxation techniques, imagery, and acupressure
• Small frequent meals, bland foods, and comfort foods
b. Diarrhea
• Replace fluid-electrolytes losses & with a low-fiber diet.
c. Stomatitis (because of the rapid turnover of epithelium that lines the oral cavity)
• Provide good oral care
• Use of a soft-bristled toothbrush
• Use normal saline mouth rinses
• Avoid irritants such as commercial mouthwash, alcoholic beverages, and tobacco.
• Avoid hot and spicy food or hard to chew and those with extreme temperatures.
• Provide liquid or pureed diet
• Rinse with viscous lidocaine before meals
• Administer systemic analgesic as prescribed

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2. Integumentary System
a. Alopecia
• Prevent or minimize hair loss through:
o Cut long hair before the treatment
o Use a mild shampoo and gently pat dry
o Avoid excessive brushing or combing of hair
o Wear hair net
• Ways to assist in coping with hair loss
o Purchase wig or hairpiece before hair loss
o Wear a scarf, hat, or turban
o Reassure that it is temporary. Hair grows back in 3 to 4 months after chemotherapy
b. Skin Reaction: erythematous and dry/wet desquamation reactions to external radiation therapy
• In erythematous area
o Observe for early signs of skin reaction and report.
o Keep the treatment area dry.
o Wash the area with lukewarm water only, no soap, and pat dry.
o Do not apply ointments, powder, or lotion to the treatment area.
o Avoid rubbing and scratching the area
o Do not apply heat or ice to the area
o Avoid direct exposure to sunlight in the area
o Use soft cotton fabrics for clothing
o Apply vitamin A and D ointment to the area
o Do not erase markings on the skin. These serve as a guide for areas of irradiation.
• In moist or wet desquamation occurs:
o Do not disrupt any blisters

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o Avoid frequent washing of the area
o If the area weeps, apply a non-adhesive absorbent dressing
3. Hematopoietic System
a. Anemia
• Assess skin color and capillary refill
• Determine if the patient complains of fatigue, weakness, or dizziness
• Monitor blood count
• Provide frequent rest periods between daily activities
• Avoid overexertion
• Administer erythropoietin as prescribed
• Administer blood products as prescribed
b. Leukopenia and Neutropenia
• Assess for signs of infection. Report fever, chills, diaphoresis heat, pain erythema, or exudates
on any body surface.
• Take daily temperature
• Monitor WBC count
• Place the patient in a private room (single-patient room)
• Reinforce good personal hygiene
• Stress the importance of strict hand washing
• Avoid performing an invasive procedure
• Avoid fresh fruits, raw meat, fish, meat, and vegetables; remove fresh flowers and potted
plants
• Avoid crowds or people with an infection
• Change IV sites every other day
• Change all solutions and IV infusion sets every 48 hours
• Administer colony-stimulating factors & macrophage colony-stimulating factors as prescribed
• Administer antibiotics as prescribed
c. Thrombocytopenia
• Monitor platelet count
• Assess for bleeding
• Monitor emesis, urine, and stool daily for occult blood
• Assess for signs & symptoms of intracranial bleeding
• Protect patients from trauma
• Instruct the patient and family to use a soft toothbrush and electric razor for shaving
• Avoid invasive procedures such as injections
• Avoid medication that will interfere with clotting such as ASA, NSAIDs
• Avoid straining at stools (may cause rectal bleeding)

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 • Administer Interleukin 11 as prescribed
• Administer platelets transfusion as prescribed in severe cases
4. Genitourinary System
a. Hemorrhagic cystitis
• Provide 2-3 liters of fluid per day
• Aggressive IV hydration
• Scheduling frequent times of voiding
b. Renal stone
• Monitor BUN and serum creatinine level
• Adequate hydration
• Alkalinization of urine
• Allopurinol
c. Urine color changes
• Reassure that it is harmless
5. Reproductive System
a. Premature menopause or amenorrhea
• Reassure that the menstruation resumes after chemotherapy.
b. Reproductive dysfunction (cells of testes and ova are damaged from the therapy)
• Inform the patient of the opportunity for sperm and ova banking before treatment for patients
of childbearing age
• Use reliable methods of birth control
6. Fatigue as a result of high metabolic demand for tissue repair and toxic waste removal.
a. Encourage rest periods during the day
b. Promote an adequate amount of sleep
c. Encourage the patient to ask for assistance if needed

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d. Promote high protein & calorie intake
7. Weight loss due to anorexia, pain, and effect of cancer
a. Prevent unpleasant sights and odors in the environment during mealtime
b. Involve patient in dietary planning
c. Encourage food high in calories and protein
d. Small frequent meals
e. Encourage frequent oral hygiene
f. Proper positioning during mealtime
g. Provide enteral feeding or parenteral nutrition as prescribed
8. Biochemical
a. Hyperuricemia due to cell destruction from chemotherapy which may cause secondary gout and
obstructive uropathy.
b. Monitor uric acid levels
c. Allopurinol (Zyloprim) as prescribed
d. Encourage high fluid intake
9. Social Isolation
a. Frequent telephone calls
b. Provide diversional activities
c. Frequent staff checks on the client

Hematopoietic Stem Cell Transplantation (HSCT)

Bone marrow transplantation and peripheral stem cell transplantation are effective, lifesaving procedures
for several malignant and non-malignant diseases. The use of HSCT in the treatment of certain adult hematologic
malignancies (i.e., malignant myeloma, acute leukemias, and non-Hodgkin lymphoma) is considered the standard
of care.
Types of HSCT
1. Allogeneic HSCT: stem cells are acquired from a donor other than the patient (maybe a related donor such as
a family member or a matched unrelated donor).
2. Autologous (from the patient): the patient receives their own stem cells back following myeloablative
(destroying bone marrow thru high-dose chemotherapy and, occasionally, total-body irradiation)
chemotherapy. The primary aim of this therapy is “rescue”. It enables the patient to receive intensive
chemotherapy and or/radiation by supporting them with their previously harvested stem cells until their
marrow is generating blood cells again on its own. It is indicated to treat hematologic malignancies.
3. Syngeneic: involves obtaining stem cells from one identical twin and infusing them into the other. Identical
twins have identical HLA (Human Leukocyte Antigen) types and are a perfect match. Therefore, there is no
risk for graft-versus-host disease.

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Harvest Procedure for Hematopoietic Stem Cells
➢ Harvesting of stem cells residing in the bone marrow, which is done in the operating room using general or
spinal anesthesia. Multiple bone marrow aspirations usually from the iliac crest (sometimes from the sternum)
are carried out to obtain a specific quantity of stem cells. The entire bone marrow harvest procedure takes
about 1 to 2 hours and the patient can be discharged following recovery. Post-harvest, the donor may
experience pain at the collection site. It can be treated with mild analgesics. The donor’s body will replenish
the bone marrow removed in a few weeks.
➢ Harvesting of stem cells can be done by obtaining peripheral stem cells from the peripheral blood in an
outpatient procedure. It is done using cell separator equipment that automatically separates the stem cells
from the blood circulation through the machine and returns the remaining blood components to the donor.
The procedure takes about 2-4 hours or longer.
➢ Umbilical cord blood is also rich in hematopoietic stem cells and successful allogenic transplants have been
performed. Cord blood can be HLA-typed and cryopreserved.
➢ Stem cell infusions are administered IV and can be injected via the slow bolus method or infused like a blood
transfusion
➢ Usually, 2 -4 weeks are required for the transplanted marrow to start producing hematopoietic blood cells.
During this time, patients are at high risk for infection, sepsis, and bleeding. Therefore, the patient should be
protected from exposure to infection and supported with electrolyte supplements, nutrition, and blood
component transfusion (as needed) to maintain adequate levels of circulation RBCs and platelet.

Complications of Hematopoietic Stem Cell Transplantation

➢ Bacterial, viral, and fungal infections are common, prophylactic antibiotic therapy may reduce their incidence.
➢ Allogenic transplantation may cause graft-versus-host disease also known as the “Rejection Reaction”. This
occurs when the T-lymphocytes from the donated marrow (graft) recognize the recipient (host) as foreign and

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begin to attack certain organs like the skin, liver, and Gi tract.

Common Complementary Therapies for Cancer

Botanical Herbs are believed to be the most ‘natural’ and ‘safe’ plants ingested with the hope of a cure
agents for cancer. Commonly used botanical agents include echinacea, essiac, ginseng, green tea,
pau d’arco, and hoxsey. The safety of many of these botanical agents has not been proven,
especially as a complement to medical treatment.
Nutritional Chemical compounds include vitamins, minerals, enzymes, amino acids, and essential fatty
supplements acids or proteins (such as shark cartilage). They are believed to have the ability to promote
health and help cure cancer. The safety of certain compounds such as vitamins has been
established; however, in megadoses, many of the compounds can be toxic and have potential
interactions with some therapeutic agents used for cancer, such as chemotherapy.
Dietary The ingestion of only natural substances is believed to have the effect of purifying the body
regimens and slowing down the growth of cancer. Popular regimens include the grape diet, the carrot
juice diet, and garlic, onions, and liver intake. However, the effectiveness of these dietary
regimens remains to be established.
Mind-body The harmony of mind and body is believed to facilitate physiological and psychological healing.
modalities Such modalities include relaxation, meditation, or imagery. Recent research has shown that
these modalities have helped individuals with cancer adjust to the experience of cancer.
Energy healing The human body is believed to be an energy field and cancer might be the result of a disturbed
energy field. Energy therapies, such as therapeutic touch and healing touch, can affect the
energy field of the human body and promote physiological healing. Therapeutic touch uses
the hands-on or near the body with the intent to promote healing. Healing touch uses energy
healing techniques to heal by restoring the harmony and balance of the body. Clinical practice
and research on energy healing have shown positive findings of energy healing in a variety of
people.
Spiritual Faith in God or a higher power of the universe is believed to help cancer healing. Spiritual
approaches approaches include faith healing, prayer to God, prayer groups, and chain prayer. Research
has shown that faith in God or a higher power also helped individuals with cancer to adjust to
the experience of cancer.
Miscellaneous Aromatherapy has been used for people with cancer to relieve nausea, vomiting, or retching,
therapies and to decrease anxiety. However, aromatherapy might not be appropriate for people who
are highly sensitive to strong fragrances. Music, art, and humor therapies have also been used
to help people with cancer to reduce anxiety, to express feelings of loss, and to promote
optimism.

Oncologic Emergencies: a group of life-threatening metabolic syndromes or abnormalities associated with

cancer and/or cancer treatment.

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Spinal Cord Compression
It is commonly caused by compression of the cord and its nerve roots by a metastatic paravertebral tumor
that extends into the epidural space; vertebral bone metastasis leading to bone collapse and displacement
impinging on the spinal cord or nerve roots; and less commonly, primary malignancy of the cord. This can result
in neurologic impairment or permanent loss of function such as paraplegia if not treated immediately. Is most
commonly associated with pressure from expanding tumors of the breast, lung, or prostate, and with lymphoma
or metastatic disease

Clinical Manifestations
1. Back pain is the initial symptom in 95% of cases of spinal cord compression.
2. Neurologic dysfunction and related motor and sensory deficits
3. Later, bowel and bladder dysfunction (lumbosacral compression)
4. Finally, motor loss from subtle weakness to paralysis

Management: treatment goals are to relieve pain, minimize complications, and preserve or restore neurologic
function.

1. Corticosteroids are the initial treatment until more definitive treatment can be instituted, reducing
inflammation and swelling at the site, increasing neurologic function, and relieving pain.
2. Radiation therapy for the tumor in the spinal column is the most common treatment.
3. Surgical decompression like laminectomy

Nursing Management
1. Control pain with pharmacologic and nonpharmacologic measures
2. Prevent complications of immobility resulting from pain and decrease function

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3. Maintain muscle tone by assisting with range-of-motion exercises
4. Institute intermittent urinary catheterization and bowel training programs for a patient with bladder and
bowel dysfunction.

Superior Vena Cava Syndrome (SVCS)

Obstruction and thrombosis of the superior vena cava that is caused by direct compression by a tumor or
an enlarged lymph node, resulting in impaired venous drainage of the head, neck, arms, and thorax to the heart
and decrease cardiac output. Typically, it is associated with lung cancer or lymphoma. If untreated, it may lead
to cerebral anoxia, laryngeal edema, bronchial obstruction, and death.

Clinical Manifestations
1. Facial swelling or edema (most common initial finding)
2. Early symptoms include progressive dyspnea, cough, dysphagia, hoarseness, and chest pain.
3. Edema of the neck, arms hands, and thorax
4. Jugular vein distention and engorged including temporal and arm vein
5. Late symptoms include respiratory distress → sitting up and leaning forward to breathe, headache, vision
disturbances, dizziness and syncope, lethargy, irritability, and mental status changes

Management
1. External beam radiation to shrink tumor size and relieve symptoms
2. Chemotherapy
3. Anticoagulant to thrombolytic therapy for intraluminal thrombosis
4. Intravascular stent for chronic or recurrent SVCS
5. Supportive measures such as oxygen therapy, corticosteroids, and diuretics (in case of fluid overload

Nursing Management
1. Instruct the patient to avoid tight to restrictive clothing and jewelry on fingers, wrist, neck
2. Instruct the patient to maintain semi-Fowler’s position
3. Limit patient activity and provide a quiet environment.
4. Monitor the patient’s fluid volume status; administration of fluids cautiously to minimize edema.

Hypercalcemia
It results when the calcium released from the bone is more than the kidney can excrete or the bone can
absorb. Occurs most commonly in patients with carcinoma of the lung, breast, and renal cells; multiple myeloma;
and adult lymphomas.

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12
Clinical Manifestations
1. Early symptoms include anorexia, weakness, fatigue, polyuria, and polydipsia (due to dehydration)
2. Late symptoms include apathy, profound muscle weakness, nausea, vomiting, constipation (due to ileus),
lethargy, confusion, and dysrhythmias.

Management
1. Hydration and diuresis—IV normal saline (0.9% NaCl) is the initial treatment for patients with acute
hypercalcemia and clinical symptoms to dilute the calcium and promote its renal excretion. Diuresis is
induced with furosemide. (Thiazide diuretics aggravate hypercalcemia and should be avoided.)
2. Pharmacotherapy
a. Bisphosphonates (primary drug therapy), administered IV; pamidronate or zoledronic acid inhibits
osteoclast resorption in the bone; and Calcitonin (Miacalcin).
b. Use of dietary and pharmacologic intervention such as stool softener and laxatives for constipation
c. Antiemetic therapy for nausea and vomiting

Nursing Management
1. Instruct the patient and family to consume 2-4 liters of fluid daily unless contraindicated by existing renal
or cardiac disorders.
2. Promotion of mobility and emphasis on the importance of preventing demineralization, breakdown of
bones, and constipation
3. Administer normal saline infusions and medications as prescribed.
4. Safety precautions for a patient with impaired mental and mobility status.

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Tumor Lysis Syndrome
A life-threatening emergency for people with cancer due to massive and rapid destruction or death of
cancer cells caused by cytotoxic treatment such as chemotherapy, radiation, or biological therapy which may lead
to the release of intracellular potassium, phosphorous and nucleic acid into the circulation → hyperkalemia,
hyperphosphatemia (leading to hypocalcemia) and hyperuricemia → life-threatening end-organ effects on the
myocardium, kidney, and central nervous system.

Clinical Manifestations (depends on the extent of metabolic abnormalities)

1. Neurologic: altered mental status, muscle cramps, tetany, fatigue, weakness, paresthesia, and seizures.
2. Elevated blood, cardiac dysrhythmias, congestive heart failure, fluid overload, edema, cardiac arrest.
3. GI: nausea, vomiting, abdominal cramps, diarrhea, increased bowel sounds.
4. Renal: flank pain, oliguria, anuria, renal failure, acidic urine pH.
5. Other: gout

Management
1. Aggressive fluid Hydration 1-2 days before and after the initiation of cytotoxic therapy to increase urine
volume and eliminate uric acid and electrolytes to prevent renal failure and restore electrolyte balance
2. Diuretic therapy (loop or osmotic diuretic) to promote urinary excretion of uric acid and phosphate.
3. Administration of allopurinol to inhibit the conversion of nucleic acid to uric acid.
4. Administration of IV sodium bicarbonate, hypertonic dextrose, and regular insulin to temporarily shift
potassium into cells.
5. Administration of oral phosphate binder such as aluminum hydroxide to promote the excretion of
phosphate through the bowel.
6. Administration of sodium polystyrene sulfonate (Kayexalate) to promote the excretion of potassium
through the bowel
7. Initiation of hemodialysis to people unresponsive to standard approaches to hyperkalemia, hyperuricemia,
or hyperphosphatemia.
Nursing Management
1. Institute essential preventive measures (like fluid hydration, and medications) as prescribed
2. Assess the patient for signs and symptoms of electrolyte imbalances.
3. Monitor serum electrolyte and uric acid levels for evidence of fluid volume overload secondary o aggressive
hydration.

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 Interactive Link
https://tinyurl.com/43av8z8w (Chemotherapy)
https://tinyurl.com/avna9ncv (Radiation Therapy)

Summary
Factors believed to cause cancer are called carcinogens. These include chemical agents, environmental
factors, dietary substances, viruses, defective genes, and hormones. Three basic methods used in the treatment
of cancer include surgery, radiation therapy, and chemotherapy.
Cancer can affect people of any age, gender, ethnicity, or geographical region. The incidence of cancer
increases with advancing age.
The diagnosis and treatment of cancer is a pivotal life-changing event that prompts individuals to make an
immediate and ongoing adjustment to this life-threatening illness.
Effective physical and psychosocial adjustment to cancer diagnosis and treatment has been shown to lead
to successful completion of treatment, enhancement of the person’s ability to cope with the disease, improvement
of the person’s quality of life, and, ultimately, improvement of survival.
The goals of cancer treatment are cure and control of cancer, as well as management of cancer-related and
treatment-related symptoms.
Chemotherapy uses cytotoxic medications to cure or control cancer by interrupting cell metabolism and
replication and by interfering with the ability of the malignant cell to synthesize vital enzymes and chemicals.
Pain management is an important component of care for people with cancer. It is estimated that 20% to
50% of people with early-stage cancer and up to 95% of people with advanced cancer experience pain.

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Complementary therapies are therapies that people choose as a complement to medical treatment.
Common complementary therapies for cancer include botanical agents, nutritional supplements, dietary regimens,
mind-body modalities, spiritual approaches, and miscellaneous therapies.

Readings and References

➢ Smeltzer, Suzanne C. (2014). Brunner & Suddarth’s. Textbook of Medical-Surgical Nursing-13th Edition,
Wolters Kluwer/Lippincott Williams & Wilkins
➢ Lemone et al. (2017). Medical-Surgical Nursing Critical Thinking for Person-Centered Care, 3rd Edition,
Pearson Australia.
➢ Nettina, Sandra N. (2019). Lippincott Manual of Nursing Practice, 11th Edition, Wolters Kluwer.
➢ Lewis et al. (2014). Medical-Surgical Nursing Assessment and management of Clinical Problems, 9th
Edition. Mosby, an imprint of Elsevier Inc.
➢ Udan (2017). Medical-Surgical Nursing Concepts and Clinical Applications, 3rd edition, APD Educational
Publishing House.

Review Questions
1. The nurse is presenting a community education program related to cancer prevention. Based on current
cancer death rates, the nurse emphasizes what is the most important preventive action for both women
and men?
a. Smoking cessation
b. Routine colonoscopies
c. Protection from ultraviolet light
d. Regular examination of reproductive organs
2. What factor differentiates a malignant tumor from a benign tumor?
a. It causes death.
b. It grows at a faster rate.
c. It is often encapsulated.
d. It invades and metastasizes.

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14
 3. Cancer cells go through stages of development. What accurately describes the stage of promotion (select
all that apply)?
a. Obesity is an example of a promoting factor.
b. The stage is characterized by an increased growth rate and metastasis.
c. Withdrawal of promoting factors will reduce the risk of cancer development.
d. Tobacco smoke is a complete carcinogen that is capable of both initiation and promotion.
e. Promotion is the stage of cancer development in which there is an irreversible alteration in the
cell’s DNA.
4. The patient was told she has carcinoma in situ, and the student nurse wonders what that is. How should
the nurse explain this to the student nurse?
a. Evasion of the immune system by cancer cells
b. Lesion with histologic features of cancer except for the invasion
c. Capable of causing cellular alterations associated with cancer
d. Tumor cell surface antigens that stimulate an immune response
5. A patient’s breast tumor originates from the embryonal ectoderm. It has moderate dysplasia and
moderately differentiated cells. It is a small tumor with minimal lymph node involvement and no
metastases. What is the best description of this tumor?
a. Sarcoma, grade II, T3, N4, M0
b. Leukemia, grade I, T1, N2, M1
c. Carcinoma, grade II, T1, N1, M0
d. Lymphoma, grade III, T1, N0, M0
6. The nurse is counseling a group of individuals over the age of 50 with an average risk for cancer about

NCM-112
screening tests for cancer. Which screening recommendation should be performed to screen for colorectal
cancer?
a. Barium enema every year
b. Colonoscopy every 10 years
c. Fecal occult blood every 5 years
d. Annual prostate-specific antigen (PSA) and digital rectal exam
7. A small lesion is discovered in a patient’s lung when an x-ray is performed for cervical spine pain. What
is the definitive method of determining if the lesion is malignant?
a. Lung scan
b. Tissue biopsy
c. Oncofetal antigens in the blood
d. CT or positron emission tomography (PET) scan
8. Which classification of chemotherapy drugs is cell cycle phase–nonspecific, breaks the DNA helix which
interferes with DNA replication, and crosses the blood-brain barrier?
a. Nitrosoureas
b. Antimetabolites
c. Mitotic inhibitors
d. Antitumor antibiotics
9. When teaching a patient with cancer about chemotherapy, which approach should the nurse take?
a. Avoid telling the patient about possible side effects of the drugs to prevent anticipatory anxiety.
b. Explain that antiemetics, antidiarrheals, and analgesics will be provided as needed to control side
effects.
c. Assure the patient that the side effects from chemotherapy are uncomfortable but never life-
threatening.
d. Inform the patient that chemotherapy-related alopecia is usually permanent but can be managed
with the lifelong use of wigs.
10. Which normal tissues manifest early, acute responses to radiation therapy?
a. Spleen and liver
b. Kidney and nervous tissue
c. Bone marrow and gastrointestinal (GI) mucosa
d. Hollow organs such as the stomach and bladder

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15
 11. The patient with advanced cancer is having difficulty controlling her pain. She says she is afraid she will
become addicted to opioids. What is the first thing the nurse should do for this patient?
a. Administer a nonsteroidal anti-inflammatory drug.
b. Assess the patient’s vital signs and behavior to determine the medication to use.
c. Have the patient keep a pain diary to better assess the patient’s potential addiction.
d. Obtain a detailed pain history including quality, location, intensity, duration, and type of pain.
12. Which factors will assist a patient in coping positively with having cancer (select all that apply)?
a. Feeling of control
b. Strong support system
c. Internalization of feelings
d. Possibility of cure or control
e. A young person will adapt more easily
f. Not having had to cope with previous stressful events

Key Answer and Rationale

1. a. Lung cancer is the leading cause of cancer deaths in the United States for both women and men and smoking
cessation is one of the most important cancer prevention behaviors. Approximately one-half of cancer-related deaths
in the U.S. are related to tobacco use, unhealthy diet, physical inactivity, and obesity. Cancers of the reproductive
organs are the second leading cause of cancer deaths.
2. d. The major difference between malignant and benign cells is the ability of malignant tumor cells to invade and
metastasize. Benign tumors can cause death by expansion into normal tissues and organs. Benign tumors are more
often encapsulated and often grow at the same rate as malignant tumors.
3. a, c, d. Promoting factors such as obesity and tobacco smoke promote cancer in the promotion stage of cancer

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development. Eliminating risk factors can reduce the chance of cancer development as the activity of promoters is
reversible in this stage. Increased growth, invasion, and metastasis are seen in the progressive stage.
4. b. Carcinoma in situ has the histologic features except for invasion. Evasion of the immune system by cancer cells by
various methods is an immunologic escape. Oncogenic factors are capable of causing cellular alterations associated
with cancer. Tumor cell surface antigens that stimulate an immune response are tumor-associated antigens.
5. c. The breast cancer origination gives it the anatomic classification of a carcinoma. Grade II has moderate abnormal
cells with moderate differentiation. T1 N1 M0 represents a small tumor with only minimal regional spread to the lymph
nodes and no metastasis. Sarcomas originate from embryonal mesoderm or connective tissue, muscle, bone, and fat.
Leukemias and lymphomas originate from the hematopoietic system. The other histologic grading and TNM
classifications do not represent this patient’s tumor.
6. b. Healthy men and women should have a colonoscopy every 10 years, an annual fecal occult blood test, or a barium
enema every 5 years. These frequencies may change depending on the results. Annual PSA and digital rectal exams
screen for prostate problems, although the decision to test is made by the patient with his health care provider.
7. b. Although other tests may be used in diagnosing the presence and extent of cancer, a biopsy is the only method by
which cells can be definitely determined to be malignant.
8. a. Nitrosureas are cell cycle phase–nonspecific, break the DNA helix, & cross the blood-brain barrier. Antimetabolites
are cell-cycle phase-specific drugs that mimic essential cellular metabolites to interfere with DNA synthesis. Mitotic
inhibitors are cell cycle phase-specific drugs that arrest mitosis. Antitumor antibiotics bind with DNA to block RNA
production.
9. b. Patients should always be taught what to expect during a course of chemotherapy, including side effects and expected
outcomes. The side effects of chemotherapy are serious but patients must be informed about what measures can be
taken to help them to cope with the side effects of therapy. Hair loss related to chemotherapy is usually reversible and
wigs, scarves, or turbans can be used during and following chemotherapy until the hair grows back.
10. c. Tissue that is actively proliferating, such as GI mucosa, esophageal & oropharyngeal mucosa, and bone marrow,
exhibits early acute responses to radiation therapy. Radiation ionization breaks chemical bonds in DNA, which renders
cells incapable of surviving mitosis. This loss of proliferative capacity yields cellular death at the time of division for
both normal cells & cancer cells but cancer cells are more likely to be dividing because of the loss of control of the
cellular division. Cartilage, bone, kidney, & nervous tissues that proliferate slowly manifest subacute or late responses.
11. d. The priority in pain management is to obtain a comprehensive history of the patient’s pain. This will determine the
medications most useful for this patient’s pain to enable giving the dose that relieves the pain with the fewest side
effects. Teaching the patient about the lack of tolerance and addiction associated with effective cancer pain
management will also be important for this patient’s pain management.
12. a, b, d. Feeling in control, having a strong support system, and having the potential to cure or control cancer will have
a positive effect on coping with the diagnosis. The other options will make coping more difficult for the patient.

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