WEEK 15

INTRODUCTION CANCER
- Abnormal growth that is characterized by a continuing, purposeless, unwanted, uncontrolled and
most cancers occur in damaging growth of cells that differ structurally and functionally from normal cells from which they
people > 65 years of developed
age. ➢ Proliferation: rapid reproduction by cell division
➢ Metastasis: spread/ transfer of cancer from 1 organ or part to another directly connected.
higher in men than in - not a single disease with a single cause; rather, it is a group of distinct diseases with different causes,
women manifestations, treatments, and prognoses.

higher in industrialized
sectors and nations.

2nd in Cardiovascular
disease as a leading
cause of death in US

ONCOLOGY
Deals with the study,
detection, treatment
and management of
cancer.
ONCOLOGY NURSE
Specializes in treating
and caring for people
who have cancer.
AGE
Most outstanding risk
factor for cancer;
Cancel increases
progressively with age.
Approx 77% of people
diagnosed with cancer
are over age 55
POPULATION BASED
STUDIES
- UK: lung CA
- JAPAN: Stomach CA
- CHINA: Liver CA
- US: Colon CA
- CANADA: Leukemia
- BRAZIL: Cervical CA
NORMAL CELLS
- Have limited cell division
- Divide for 1 or 2 reasons:
➢ To develop normal tissue
➢ To replace lost or damaged normal
tissue
- Undergo Apoptosis “ Cellular Suicide”;
Normal Cell death
➢ Normal cells have a finite life span
➢ Purpose: to ensure that each organ has
adequate number of cells at their
functional peak
- Show specific morphology
➢ Each normal cell type has a distinct and
recognizable appearance, size and
shape
- Have a small nuclear-cytoplasmic ratio
- Nucleus is small compared with the size of
the rest of the cell, including cytoplasm
- Perform specific Differentiated functions
- Adhere tightly together
- Non-migratory
- Grow in an orderly and well regulated
manner
- Are contact inhibited each cell divides only
when some of its surface is not in direct
contact with another cell
- Clearly demarcated
- Euploid: norm # of chromosomes
➢ Human cells: 23 pair of chromosomes
CANCER CELLS
- Have a rapid or continuous cell division
- Do not Respond to signals for Apoptosis
- Anaplastic Morphology
➢ Cells lose the appearance of parent cells
- Have large Nucleus: Cytoplasm ratio
- Lose some of all differentiated function
➢ Cancer cells serve no useful purpose
- Adhere loosely together
- Able to migrate
- Grow by invasion
- Not contact-inhibited
- Poorly defined tumor boundaries
- Aneuploid: presence of abnormal number of
chromosomes in cell
BEGINNIG OF CANCEROUR GROWTH → NEOPLASM
(TUMORS)
INVASION AND METASTASIS
1. Cancer cells invade surrounding tissue and bld
vessels
2. Transported by circulatory sys in distant sites
3. Reinvade and grow at new location

PREFIX SUFFIX
A- None - Plasia: growth
Ana- Lack - Plasm: substance
Dys – bad - Trophy: size
Hyper- - Oma: tumor
Excessive - Statis: location
Meta – change
Neo- new
 PATTERNS OF CELL GROWTH
- HYPERTROPHY: increase in size
- HYPERPLASIA: increase in number of cells; assoc with period of rapid body growth
- METAPLASIA: conversion of 1 type of cell in a tissue to another type not normal for that tissue
- DYSPLASIA “PRE-CANCER”: bizarre cell growth resulting in cells that differ in size, shape, arrangement from
other cells of the same type of tissue (can be: mild, mod, severe, tumor cell)

- ANAPLASIA: cells that lack norm cellular characteristics & differ in shape and organization with respect to
their cells of origin
➢ Anaplastic cell: malignant; advanced cancer
- NEOPLASIA “Tumor Growth”: uncontrolled cell growth that follows no physiologic demand; overt
CLASSIFICATION OF NEOPLASIA
BENIGN: not cancerous, won’t LOW GRADE MALIGNANT: MALIGNANT: cancerous; can
spread locally aggressive; Borderline spread
- Well-differentiated - Variable growth rate - Undifferentiated
- No infiltration - Locally infiltrative - Infiltrative
- Slow growth - Low/ no metastatic - Erratic, Rapid &
- Encapsulated - Intermediate patient uncontrolled growth
- Noninvasive survival rates; tendency for - Expansive and invasive
- Does not metastasize local recurrence after - Secretes abnormal proteins
APPEARANCE successful surgical removal - Metastasizes: tendency for
- Expansile growth local and distant
- Homogenous cut surface recurrence
- Encapsulated - Poor survival rates
- High patient survival rates APPEARANCE
after successful surgical - Inhomogeneous cut
removal surface
- Necrosis
- Hemorrhage
- Vessel invasions
- Lymphatic invasion
- Ulceration of skin

BORDERLINE/ IN SITU (IN ITS PLACE)

- Tumor that grows only in a specific
area
Bowen’s Disease “Squamous Cell
Carcinoma in situ”
➢ Very early form of skin cancer
that is easily treatable
➢ Main sign: Red, Scaly pathc on
skin
➢ Affect: Squamous Cells
(outermost layer of skin)
 ETIOLOGY/ CAUSES OF CANCER
Internal External
- Heredity: Abnormal chromosomal patterns - Physical Agent: Radiation ( Leukemia
and cancer have been associated with extra incidence)
chromosomes, too few chromosomes, or - Some chemicals: Tobacco (30% of cancer
translocated chromosomes. deaths); 75% of all cancers are thought to be
INHERITED CONDITIONS related to the environment.
Heredited Retinoblastoma ➢ liver, lungs, and kidneys are the organ
retinoblastoma systems most often affected, presumably
Xeroderma Skin because of their roles in detoxifying
Pigmentosum chemicals
Wilm’s Tumor Kidney - Bacteria (H. pylori: Stomach CA)
Li-Fraumeni Syndrome Sarcomas, brain, VIRUS CANCER TYPE
breast, leukemia EBV Burkitt’s Lymphoma
Familial Adenomatous Colon, Rectum nasopharyngeal
polyposis cancers, non- Hodgkin
Paget’s Disease of Bone Bone and Hodgkin
Fanconi’s Aplastic Leukemia, Liver, lymphoma
Anemia skin Human Papillomavirus Cervical CA
Hepa B Virus Liver CA
- Diet: Fats, alcohol, salt-cure/ smoked meats, Human T-cell Adult T-cell Leukemia
nitrites, nitrates, high calorie Lymphotrophic Virus
➢ Obesity: endometrial cancer, Kaposi’s Sarcoma- Kaposi’s Sarcoma
postmenopausal breast cancers, and associated herpesvirus
colon, esophagus, and kidney cancers.
- Hormones: oral contraceptive pills and
prolonged estrogen replacement therapy (
risk for liver “hepatocellular”, Endometrial CA
or breast CA) PATHOPHYSIOLOGY
➢ Endogenous hormonal levels for 1. ABNORMAL CELL FORMED BY MUTATION
growth: CA of breast, prostate, uterus: OF DNA →
➢ Diethylstilbestrol (DES): cause vaginal 2. CELL GROWS & PROLIFERATES →
carcinomas. 3. METASTASIS OCCURS WHEN ABN. CELLS
➢ estrogen & progesterone: Safer than INVADE OTHER TISSUE (THRU LYMPH &
estrogen alone in decreasing the risk of BLOOD)
endometrial cancers; discontinuing
hormonal therapy containing both
estrogen and progestin because of the
increased risk of breast cancer, coronary
heart disease, stroke, and blood clots

CARCINOGENESIS: Process of transforming normal cells into malignant cells; 3-step cellular process
INITIATION PROMOTION
- Anything that can - Enhancement of cellular
penetrate a cell, get into changes that occurred
nucleus & damage DNA can during initiation
damage genes and become - Reversible stage of
“Initiators” (Carcinogens) promotion does not involve
➢ Initiators: chemical, changes in structure of DNA
physical, viruses but rather in the expression
of genome mediated
- result from irreversible through promoter-receptor
genetic alteration interactions
➢ most likely 1 or more
simple mutations, LATENCY PERIOD
transversions, - bet. Cell’s initiation & dev. of
trasnitions, and or an overt tumor
small deletion in DNA - may range from mons-years
PROMOTER:
- potentiates effects of
initiator; may be hormones,
drugs, chmicals
PROGRESSION
- Changes that cancer cell
undergoes to make it more
malignant
- Malignant tumor grows in
size, becomes anaplastic,
less differentiated
- Final irreversible stage of
progression characterized
by: Karyotypic instability &
malignant growth
TUMOR ANGIOGENESIS FACTOR
(TAF)
- Triggers capillaries & other
blood vessels in area to
grow new branches into
tumor for continued
nourishment

METASTASIS: 4TH
- Spread of malignant tumor to other loc. by penetrating into lymph vessels circulating throughout body
- Considered as 2nd Cancer
 IMMUNE SYSTEM & CANCER
“All cancer is the result of an immune system that didn’t destroy mutant cells”
- Immune system: destroys 10, 000 mutated cancer cells every day
- When defense ceases, cancer multiplies

ORGANS OF IMMUNE SYSTEM

1. Tonsils and adenoids
2. Lymph nodes
3. Lymphatic vessels
4. Thymus
5. Lymph nodes
6. Spleen
7. Peyer’s patches
8. Appendix
9. Bone marrow
CUASES OF DISTRESS TO THE IMMUNE SYSTEM
➔ FOOD = ENZYMES destroyed by cooking
➔ PANCREASE doubles its size in trying to keep up with the demand
➔ EXHAUSTION = compromised immune system
➔ Vulnerable CLIMATE to the formation of CANCER

GENETICS AND CANCER AUTOSOMAL DOMINANT: AUTOSOMAL RECESSIVE: X LINKED RECESSIVE: F carrier
affected father carrier M & F → affected male will have
→ 50% chance of having a child → 25% of chances of having a whatever condition assoc with the
(m or f) who will also have the child with the condition; 1 gene in mistake (since he has only 1 X-
condition the pair changed, not expected to chromosomes)
have a s/s (carrier)

PREVENTION PRIMARY PREVENTION SECONDARY PREVENTION

- Role of nurse: to assist px to avoid known carcinogens and to - Regular screening does not
help, adopt dietary and lifestyle changes reduce cancer incidence, but can
- reducing the risks of disease through health promotion greatly reduce some types of CA
strategies. deaths
- 1/3 of all cancers worldwide could be prevented through
primary prevention efforts (Williams-Brown & Singh, 2005). SCREENING PROGRAMS
- encouraging patients to make dietary and lifestyle changes YEARLY MAMMOGRAPHY
(smoking cessation, decreased caloric in- take, increased ➢ WO older than 40
physical activity) that studies show influence the risk for cancer. YEARLY CLINICAL BREAST EXAM
- teaching & counseling skills to provide patient education and ➢ WO older than 40
support public education campaigns through organizations, BREAST SELF-EXAM q MONTH
such as the ACS, that guide patients and families in taking steps ➢ WO 20-39 yo
to reduce cancer risks through health promotion behaviors COLONOSCOPY q 10 YRS
STEPS TO REDUCE CANCER RISKS ➢ At age 50
- Eat more vegetables YEARLY FECAL OCCULT BLOOD
-  fiber intake ➢ All ages (adult)
-  Vit A: reduce risk for esophageal, laryngeal, lung CA YEARLY PROSTATE SPECIFIC ANTIGEN
-  intake of foods rich in Vit C: against stomach & esophageal CA (PSA) test & DIGITAL RECTAL EXAM
- Practice weight control (DRE)
➢ OBESITY: linked to CA of uterus, gall bladder, breast & colon ➢ MEN over 50
- Reduce fat intake YEARLY PAPSMEAR & PELVIC EXAM
- Avoid nitrate cured, smoked, salt-cured ➢ WO 18 yo & 
- Stop smoking
- Reduce alcohol intake: reduce risk for liver CA
- Avoid exposure to sun: wear protective clothing; use sunscreen
 7 WARNING SIGNS OF CANCER ACCORDING TO BEHAVIOR OF TUMOR
- C: Changes in Bowel/ Bladder habits BENIGN MALIGNANT
- A: A sore that does not heal - Cannot spread by - Capable of
- U: Unusual bleeding/ Discharge invasion/ spreading by
- T: Thickening or lump in breast or elsewhere metastasis; only invasion &
- I: Indigestion or difficulty swallowing grow locally metastasis
O: Obvious Change in a wart or mole - “Cancer” applies
- N: Nagging cough/ Hoarseness only to malignant
- U: Unexplained Anemia tumor
- S: sudden unexplained weight loss

DIAGNOSIS HISTORY & PHYSICAL EXAM BIOPSY

- Ask client for s/s - To obtain tissue sample for analysis of suspected
- Look for: Bruising, palpate for masses malignant cells
➢ Most instances → taken from actual tumor
RADIOLOGY A. EXCISIONAL BIOPSY
- MRI: Magnetic Resonance Imaging - most freq. used for easily accessible tumors of
- CT SCAN: Computed Tomography Scan ➢ skin
- Ultrasound ➢ breast
➢ upper & lower GIT
ENDOSCOPY ➢ Upper Respi tract
- Direct visualization of a body cavity or B. INCISIONAL BIOPSY
passageway by insertion of an endoscope into a - Performed if tumor mass is too large tobe
body cavity/ opening removed
- Just a wedge of tissue from tumor is removed
for analysis
B. NEEDLE BIOPSY
- Performed to sample suspicious masses that are
easily accessible
Aspirating tissue fragments through needle
CANCER SURGERY
MANAGEMENT 1. SURGERY (AS A PRIMARY TX) LOCAL EXCISION: Warranted when the mass is small
MAY RANGE FROM GOAL: to remove the entire tumor - WIDE LOCAL EXCISION: used in DFSP (Dermatofibrosarcoma
CURE: Complete or as much as feasible and any protuberans), a rare mesenchymal tumor arising from dermis.
eradication of involved surrounding tissue, Locally aggressive and highly recurrent malignant neoplasm
malignant disease including regional lymph nodes
CONTROL: Prolonged RADICAL EXCISION: removal of primary tumor, lymph nodes, adjacent
survival and involved structures and surrounding tissues that may be at high risk
containment of cancer for tumor spread; may result in Disfigurement and Altered Functioning
cell growth ➢ EX: Radical Cystoprostatectomy & Penectomy: bladder, prostate,
PALLIATION: Relief of sx penis removal while creating a small intestine section for conduit
assoc with cancer
 2. PROPHYLACTIC SURGERY 4. RECONSTRUCTIBE SURGERY
- Removing non vital tissues or organs that are likely - May follow curative/ radical surgery in an
to develop cancer attempt to improve function or obtain a
desirable cosmetic effect
Prophylactic Mastectomy For Breast, Head, Neck, Skin Cancers

3. PALLIATIVE SURGERY
- If the cancer has spread too far to be completely
removed, any surgery being considered would be
palliative (intended to relieve or prevent sx)
SURGICAL BILIARY BYPASS
- If cancer is blocking small intestine; bile is building
up in the gallbladder
- Doctor will cut the gallbladder/ bile duct and sew it
to small intestine to create a new pathway around
blocked area
➢ CANCER OF PANCEREAS (blockage of bile ducts
od the intestine)

RADIATION THERAPY 1. EXTERNAL RADIATION

- Use of ionizing radiation to interrupt cellular growth - Use X rays & Gamma Rays
- It breaks the strands of the DNA helix, leading to cell death (COBALT)
- May be used to control malignant disease when a tumor
cannot be removed surgically or when locally metastasis to
the lymph nodes is present 2. INTERNAL RADIATION
- Body tissues that undergo freq. cell division are most sensitive (BRACHYTHERAPY)
to radiation therapy - INTERNAL RADIATION
IMPLANTATION
TISSUES MOST SENSITIVE TO RDIATION THERAPY - Delivers high dose of radiation
➢ Bone marrow localized area
➢ Skin - Can be implanted by means of
➢ Mucous membranes seeds, beads, or catheters into
➢ Hair cells cavities like vagina, abdomen,
➢ Gonads pleura, interstitial compartments
➢ Lymphatic Tissue (breast)
➢ Epithelium of GIT
BRACHYTHERAPY PRECAUTIONS:
2 SYSTEMIC EFFECTS OF RADIATION THERAPY ➢ Assign the client to private
1. FATIGUE room
- Related to increased energy demands needed to repair ➢ Posting appropriate notice
damaged cells about radiation therapy
- Teach to: conserve energy by prioritizing activities precautions
2. ALTERED TASTE SENSATIONS ➢ Pregnant staff members are
- Caused by metabolites released frm dead and dying cells; prohibited to attend to
most clients would have aversion to taste of red meats clients
OTHER SE ➢ Prohibit visitors by children/
➢ Redness: Mild skin problems at radiation site: pregnant visitors
➢ N&V ➢ Limit Visits (30 mins daily)
➢ Dysphagia + Esophagitis (burning & tightness in chest): ➢ Maintain 6ft distance from
due to radiation to throat & upper chest radiations source
➢ Xerostomia: due to salivary glands damage
➢ Stomatitis: relieved by ice cold liquids (tea or cola)
CHEMOTHRAPY
- Antineoplastic agents: destroy tumor cells by - Each time a tumor is exposed to a
interfering with cellular functions and chemotherapeutic agent, 20-99% of tumor cells
reproductions is destroyed
➢ Busulfan - Normal Cells most affected by chemo are those
➢ Cisplatin that divide rapidly
➢ Methotrexate - Repeated doses are necessary over a prolonged
➢ Bleomycin period to achieve regression of tumor
➢ Doxorubicin - May be administered in hospital, clinical or
➢ Vincristine home setting by:
- Primarily used to treat Systemic Disease rather ➢ ORAL
than lesions that are localized and can be ➢ TOPICAL
removed by surgery ➢ IV, IM, SC
- Combined with radiation may be used before, ➢ ARTERIAL
after or instead of surgery in treating cancer ➢ INTRACAVITARY
 SE
1. ALOPECIA/ HAIR LOSS 4. MUCOSITIS/ SORES IN MUCOUS MEM
- Reassure that hair loss is temporary - May involve entire GI tract esp. in mouth
- Hair regrowth usually begins 1 month after (stomatitis)
chemo completion RX:
- New hair may differ from orig har color, texture, ➢ Good, Freq. oral hygiene
thickness ➢ use of soft bristled toothbrush or
- Assist client in selecting a type of head covering disposable mouth sponges (also have risk
(can disguise hari loss with wigs, caps, scarves, for bleeding)
turbans) ➢ no dental floss & water pressure gum
2. N&V cleaners
- May persist up to 24 hrs after admin ➢ avoid mouthwashes that contain alcohol
RX: ➢ rinse mouth with plain water or Saline
➢ Antiemetics 5. KIDNEY DAMAGE
➢ Relaxation techniques, Imagery - Rapid tumor cell lysis after chemo results in
➢ altering diet  urinary excretion or uric acid causing Renal
3. MYELOSUPPRESSION: Depression of Bone Damage
marrow function 6. CARDIOPULMONARY EFFECS
- Reduces circulating number of - Cardiac Toxicities
➢ Leukocytes (esp. Neutrophils - Toxic effects on lung function
“Neutropenia”) which causes 7. REPRODUCTIVE SYSTEM EFFECTS
immunosuppression - Early menopause
➢ Eruthrocytes (Anemia): feel fatigues, some - Permanent Sterility
hypoxic tissues RX:
➢ Platelets (Thrombocyteopenia): Risk for ➢ Sperm Banking
excessive bleeding 8. NEUROLOGIC DAMAGE
- Peripheral Neuropathies
- Loss of DTR
- Paralytic Ileus
 BRAIN, BREAST, LUNG CANCER
RIBBONS: AWARENESS

BRAIN CANCER PRIMARY BRAIN CANCER

Growth of abnormal - effects of neoplasms are caused by compression Types of Primary Brain Tumors
cells in the tissues of & infiltration of tissue. - from coverings of the brain (dural meningioma)
brain; Brain tumor - variety of physiologic changes result, causing - developing in or on the cranial nerves (acoustic
localized intracranial any or all of the following pathophysiologic neuroma)
lesions that occupies events: - originating within brain tissue (glioma)
space within skull ➢  intracranial pressure (ICP) and cerebral - metastatic lesions originating elsewhere in
edema body.
tumor usually grows as ➢ Seizure activity and focal neurologic signs - Tumors of pituitary and pineal glands &
a spherical mass, but it ➢ Hydrocephalus cerebral blood vessels
also can grow diffusely ➢ Altered pituitary function
and infiltrate tissue. Classification of Brain Tumors in Adults
Intracerebral Tumors Developmental Tumors
PRIMARY - Gliomas: infiltrate any portion of the brain; - Angiomas
- Astrocytoma most common type of brain tumor - Dermoid
(most common in ➢ Astrocytomas (grades I and II) - Epidermoid
Children) ➢ Ependymoma (grades I to IV) - Teroma
➢ ORIG: brain ➢ Glioblastoma multiforme (astrocytoma - Craniopharyngioma
stem, grades III and IV) Tumors Arising From Supporting Structures
cerebellum, ➢ Medulloblastoma - Meningiomas
white matter ➢ Oligodendrocytoma (low and high grades) - Neuromas (acoustic neuroma, schwannoma)
of cerebrum/ - - Pituitary adenomas
s. cord Metastatic Lesions
- Ependymoma GLIOMAS (most common type of intracerebral brain ACOUSTIC NEUROMAS
➢ O: in neoplasm) - tumor of 8th cranial nerve (for hearing and
membrane - Astrocytomas: most common; graded I- IV, balance)
that lines indicating the degree of malignancy - arises within internal auditory meatus, where
ventricles & - Grades: based on cellular density, cell mitosis & it frequently expands before filling
central canal appearance cerebellopontine recess.
of spine - tumors spread by infiltrating into the surrounding - grow slowly; attain considerable size before it
- Medulloblastoma neural connective tissue; therefore cannot be is correctly diagnosed.
(2nd most common totally removed without causing considerable S/S
type in C) damage to vital structures ➢ loss of hearing, tinnitus, episodes of
➢ O: 4th cerebral vertigo and staggering gait.
ventricles & MENINGIOMAS: 15% of all primary brain tumors As the tumor becomes larger
cerebellum; - common benign encapsulated tumors of ➢ painful sensations of the face may occur
invades arachnoid cells on the meninges on the same side (result of tumor’s
meninges - slow growing; most often in middle-aged adults compression of 5th cranial nerve).
- Brainstem glioma (often: women) TX
➢ O: medulla, Preferred treatment for symptomatic lesions - stereotactic radiotherapy rather than open
pons, ➢ surgery with complete removal or partial craniotomy.
midbrain dissection.
- Acoustic neuroma ➢ for stereotactic radiotherapy rather than
➢ O: 8th cranial open craniotomy.
nerve
“acoustic, ANGIOMAS: in cerebellum in 83% of cases PITUITARY ADENOMAS: 10% to 15% of all brain
vestibulococh - masses composed largely of abnormal blood tumors
lear” vessels; in or on the surface of brain. Some persist - symptoms as a result of pressure on adjacent
- Choroid plexus throughout life without causing symptoms; others structures
papilloma cause symptoms of a brain tumor. - hormonal changes:
➢ O: ventricles - Diagnosis: suggested by the presence of another ➢ hyperfunction/ hypofunction of
- Meningioma angioma somewhere in the head or by a bruit (an pituitary
➢ O: meninges abnormal sound) that is audible over the skull.
- Glioblastoma - Because the walls of the blood vessels in angiomas
multiforme (most are thin, these patients are at risk for hemorrhagic
common in adults) stroke.
➢ O: glial cells in - In fact, cerebral hemorrhage in people younger
cerebrum than 40 years of age should suggest the possibility
of an angioma.
 METASTATIC Pathophysiology
- Melanoma: cancer
from mole
- Breast Cancer
- Renal Cell
Carcinoma
- Lung Cancer
- Colorectal

ETIOLOGY
- Race
- Age
- Exposure to
Radiation
- Chemical exposure
- Fam Hx

S/S
- loss of hearing, tinnitus, vertigo,
- staggering gait, painful sensations of face
 S/S
- Headache
- Visual dysfunction
- Hypothalamic disorders
- Sleep disorders
- Appetite disorders
- Temperature disorders,
Emotional disorders
- Increased ICP

S/S
-  systolic BP
- widened pulse pressure
- cardiac slowing

S/S
- Bradycardia
- Hypertension
- Bradypnea
 CLINICAL MANIFESTATION
- Brain tumors can produce both focal or generalized neuro- logic signs and symptoms.
- Generalized symptoms reflect increased ICP, and the most common focal or specific signs and symptoms
result from tumors that interfere with functions in specific brain regions.
INCREASED ICP LOCALIZED/ FOCAL SX
- result from a gradual compression of the brain by the - hemiparesis
enlarging tumor. - seizures
- Effect: disruption of the equilibrium that exists between - mental status changes
the brain, the CSF, cerebral blood. - When specific regions of the brain
- compensatory adjustments (as tumor grow) may occur are affected
through (additional local s/s occur)
➢ compression of intracranial veins • sensory and motor
➢ reduction of CSF volume (by increased absorption or abnormalities
decreased production) • visual alterations
➢ modest decrease in cerebral blood flow, or • alterations in cognition
➢ reduction of intracellular and extracellular brain tissue • language disturbances (e.g.,
mass. aphasia).
- When these compensatory mechanisms fail, pt develops s/s - progression of the signs and
 ICP symptoms: indicates tumor growth
➢ headache, nausea with or without vomiting, and and expansion.
papilledema (edema of the optic disk) ➢ EX: hemiparesis rapid dev:
➢ Personality changes highly malignant glioma than
➢ focal deficit: motor, sensory, cranial nerve dysfunction of a low-grade tumor
ASSESSMENT & DIAGNOSTIC FINDINGS
- Hx of the illness, manner, time frame in which - Positron emission tomography (PET)
the symptoms evolved ➢ supplement MRI scanning in centers where
➢ are key components in the diagnosis of it is available.
brain tumors. ➢ low-grade tumors are associated with
- Neurologic examination hypometabolism and high-grade tumors
➢ indicates the areas of the CNS that are show hypermetabolism.
involved. ➢ information can be useful in making
➢ assist in the precise localization of the treatment decisions
lesion, a battery of tests is performed - Computer-assisted stereotactic (three-
dimensional) biopsy
- Computed tomography (CT) scans, enhanced ➢ diagnose deep-seated brain tumors
by a contrast agent ➢ provide a basis for treatment and
➢ specific information concerning number, prognosis.
size, density of the lesions - Cerebral angiography
➢ extent of secondary cerebral edema. ➢ visualization of cerebral blood vessels
➢ information about ventricular system. ➢ can localize most cerebral tumors.
- Magnetic resonance imaging (MRI) scan - electroencephalogram (EEG)
➢ most helpful diagnostic tool for detecting ➢ detect an abnormal brain wave in regions
brain tumors, particularly smaller lesions, occupied by tumor
and tumors in the brain stem and pituitary ➢ evaluate temporal lobe seizures
regions, where bone is thick. ➢ assist in ruling out other disorders.
➢ In a few instances, the appearance of a - Cytologic studies of the CSF
brain tumor on an MRI scan is so ➢ to detect malignant cells
characteristic that a biopsy is unnecessary, ➢ because CNS tumors can shed cells into the
esp. when tumor is located in a part of CSF.
brain that is difficult to biopsy
MEDICAL MANAGEMENT
- Chemotherapy & External-beam radiation - Intravenous (IV) autologous bone marrow
therapy transplantation
➢ used alone or in combination with surgical ➢ used in some patients who will receive
resection chemotherapy or radiation therapy,
- Radiation therapy: cornerstone of treatment because it can “rescue” the patient from
for many brain tumor the bone marrow toxicity associated with
➢ decreases the incidence of recurrence of high doses of chemotherapy and radiation.
incompletely resected tumors. ➢ fraction of the patient’s bone marrow is
- Brachytherapy (surgical implantation of aspirated, usually from the iliac crest, and
radiation sources to deliver high doses at a stored.
short distance) ➢ patient receives large doses of
➢ promising results for primary chemotherapy or radiation therapy to
malignancies. destroy large numbers of malignant cells.
➢ adjunct to conventional radiation therapy ➢ marrow is then reinfused by IV after
or as a rescue measure for recurrent treatment is completed.
disease.
 SURGICAL MANAGEMENT
- OBJECTIVE: to remove or destroy the entire
tumor without increasing the neurologic deficit
(paralysis, blindness) or to relieve symptoms by
partial removal (decompression).
- variety of treatment modalities may be used;
the specific approach depends on the type of
tumor, its location, and its accessibility
➢ In many patients, combinations of these
modalities are used.
- Most pituitary adenomas
➢ transsphenoidal microsurgical removal,
and the remainder of tumors that cannot
be removed completely are treated by
radiation.
- An untreated brain tumor
➢ ultimately leads to death, either from
increasing ICP or from damage the tumor
causes to brain tissue.
- Conventional surgical approaches: require a
craniotomy: incision into the skull used in
patients with
➢ Meningiomas
➢ acoustic neuromas
➢ cystic astrocytomas of the cerebellum,
➢ colloid cysts of the third ventricle,
➢ congenital tumors (dermoid cyst,
granulomas)
• With improved imaging techniques and
the availability of the operating
microscope and microsurgical
instrumentation, even large tumors can be
removed through a relatively small
craniotomy.
- Rationale for resection In Malignant glioma,
(complete removal of the tumor and cure are not
possible)
➢ relief of ICP
➢ removal of any necrotic tissue
➢ reduction in the bulk of the tumor
• theoretically leaves behind fewer cells to
become resistant to radiation or
chemotherapy.
- Stereotactic approaches
➢ use of a 3-dimensional frame (allows very
precise localization of tumor)
➢ stereotactic frame and multiple imaging
studies (x-rays, CT scans) are used to
localize the tumor and verify its position.
➢ Precise localization of the tumor is
accomplished by the stereotactic approach
and by minute measurements and precise
positioning of the patient.
- New brain-mapping technology
➢ determine how close diseased areas of the
brain are to structures essential for normal
brain function.
➢ Lasers or radiation: delivered with
stereotactic approaches.
➢ Radioisotopes such as iodine 131 can also
be implanted directly into the tumor to
deliver high doses of radiation to the tumor
(brachytherapy) while minimizing effects
on surrounding brain tissue.
- Stereotactic procedures
➢ using a linear accelerator or gamma knife
to perform radiosurgery.
➢ allow treatment of deep, inaccessible
tumors, often in a single session.
- Gamma Knife: leading stereotactic radiosurgery
(SRS) platform
➢ offering unparalleled accuracy in both the
localization and radiation dose delivered to
targeted brain tissue.
- Multiple narrow beams then deliver a very high
dose of radiation.
➢ Advantage: no surgical incision is needed
➢ Disadvantage: lag time between treatment
and the desired result

NURSING MANAGEMENT
- Pt. w/ brain tumor:  risk for aspiration as a result of cranial nerve dysfunction.
- nurse performs
➢ neurologic checks, monitor VS
➢ maintains a neurologic flow chart
➢ spaces nursing interventions to prevent rapid increase in ICP
➢ Reorients the patient when necessary to person, time, place.
- Px with changes in cognition caused by their lesion
➢ frequent reorientation and the use of orienting devices (e.g., personal possessions, photographs, lists,
a clock)
➢ supervision of and assistance with self-care
➢ ongoing monitoring and intervention for prevention of injury.
- Patients with seizures
➢ carefully monitored and protected from injury.
- Motor function: checked at intervals, because specific motor deficits may occur, depending on the tumor’s
location.

- Sensory disturbances are assessed. Speech is evaluated.

➢ Eye movement and pupillary size and reaction may be affected by cranial nerve involvement.
- Psychosocial effects on family caregivers of a family member who has a primary malignant brain tumor may
be significant.
 PREOP CARE POSTOP CARE
- Instruct patient and family about the - Pt functional abilities should be reassessed because
necessity and importance of changes can occur
diagnostic tests to determine the - Meticulous nursing management and care aimed at
exact location of the tumor. prevention of postoperative complications are imperative
- Monitor and record VS & for the patient’s survival.
neurological status accurately q2-4h, - Accurately monitor and record all vital signs and
or as ordered. neurological signs.
- Institute measures to prevent - Administer artificial tears (eye drops) as ordered, to
inadvertent increases in ICP prevent corneal ulceration in the comatose patient.
- Institute seizure precautions at - Maintain skin integrity.
patient’s bedside. - Bone flap may not have been replaced over surgical site;
- Supportive nursing care is given turning patient to the affected side, if the flap has been
depending upon the patient’s removed, can cause irreversible damage in the first 72
symptoms and ability to perform hours.
activities of daily living. - Maintain head of bed at 30ºelevation.
- Administer all doses of steroids and - Perform passive range of motion exercises to all
antiepileptic agents on time extremities every 2-4 hours.
- gag reflex and ability to swallow are - Maintain body temperature.
evaluated. - Institute seizure precautions at patient’s bedside.
- Px w/ diminished gag response: - Maintain accurate record of intake and output.
teaching the patient to direct food - Prevent pulmonary complications associated with bedrest.
and fluids toward the unaffected - Continuously talk to the patient while providing care,
side reorienting him to person, place, and time
- pt sit upright to eat
- semisoft diet
- suction readily available.
PREVENTION
Lifestyle Choices Stress Management and your Immune System
- Diet - Laughter Therapy
- Avoid smoking - Change your mood
- Avoid drinking alcohol - Boost up your immune system by taking
- Proper exercise vitamins and eating nutritious foods
- Sweating is powerful way to cleanse your body - Avoid junk foods!
from accumulated toxins
- Avoid exposure to chemicals
- Avoid or minimize exposure to radiation
Spinal Cord Tumors Tumors within the spine are classified according to their Assessment and Diagnostic Findings
anatomic relation to the spinal cord. Neurologic examination and diagnostic studies
- intramedullary lesions (within spinal cord) are used to make the diagnosis.
➢ Tumor within the spinal cord or exert pressure - Neuro examination: assessment of
on it cause sx ranging from ➢ Pain
o localized or shooting pains ➢ loss of reflexes & sensation or motor
o weakness function
o loss of reflexes above the tumor level ➢ weakness and paralysis.
o progressive loss of motor function ➢ Additional assessment findings
o paralysis. o pain duration for > 1 month
➢ sharp pain occurs in the area innervated by the o elevated erythrocyte
spinal roots that arise from the cord in the sedimentation rate.
region of the tumor - Helpful diagnostic studies include
➢ Increasing sensory deficits develop below the ➢ x-rays, radionuclide bone scans
level of the lesion. ➢ Biopsy, CT scans
- extramedullary-intradural lesions ➢ MRI scans: most commonly used; most
➢ within or under the spinal dura sensitive diagnostic tool; detecting
- extramedullary-extradural lesions epidural spinal cord compression and
➢ outside the dural membrane metastases
MED MANAGEMENT
- Tx of specific intraspinal tumors depends on: Pt with epidural spinal cord
➢ type & location of the tumor compression
➢ presenting symptoms resulting from metastatic cancer
➢ physical status of the patient.
(from breast, prostate, or lung)
- Surgical intervention: primary treatment for most spinal cord
- high-dose dexamethasone
tumors.
(Decadron) combined with
Other tx modalities:
radiation therapy: relieving
➢ partial removal of the tumor
➢ decompression of the spinal cord pain
➢ chemotherapy - Palliative care option for the
➢ radiation therapy (intramedullary tumors & metastatic lesions) medical management of some
- Epidural spinal cord compression occurs in 5- 7% of pt who die of patients
cancer and is considered a neurologic emergency
 SURGICAL MANAGEMENT
- Tumor removal is desirable but not always - Prognosis is related to the degree of neurologic
possible. impairment
- Goal: remove as much tumor as possible ➢ at the time of surgery
while sparing uninvolved portions of the ➢ the speed with which symptoms occurred
spinal cord. ➢ origin of the tumor.
- Microsurgical techniques have improved the - Pt w/ extensive neurologic deficits before
prognosis for patients with intramedullary surgery usually do not make significant
tumors. functional recovery even after successful tumor
removal.
BREAST CANCER ABOUT THE CA RISK FACTORS
mutation takes Infiltrating ductal and lobular carcinomas - Gender (female) and increasing age.
place in cells that line usually spread to bone, lung, liver, adrenals, pleura, - Previous breast cancer: The risk of developing
the lobules that skin, brain. cancer in the same or opposite breast is
manufacture milk or - Infiltrating ductal carcinoma (80% of cases): significantly increased.
more commonly in the most common histologic type of breast cancer - Family history
ducts that carry it to ➢ tumors arise from the duct system and ➢ Having first-degree relative with breast
the nipple invade the surrounding tissues. cancer (mother, sister, daughter) increases
- Infiltrating lobular carcinoma accounts for 10% the risk twofold
area around the center to 15% of cases. ➢ having two first-degree relatives increases
of the breast ➢ tumors arise from the lobular epithelium the risk fivefold.
where most cancers ➢ occur as an area of ill-defined thickening in - Genetic mutations (BRCA1 or BRCA2) account
occur the breast. for majority of inherited breast cancers.
(fairly rare for cancers Less common - Hormonal factors:
to form in the fat or - medullary carcinoma (5% of cases) ➢ early menarche (before 12 yo)
non-glandular tissues of - mucinous carcinoma (3% of cases) ➢ nulliparity
the breast) - tubular ductal carcinoma (2% of cases) have ➢ first birth (after 30 yo)
very favorable prognoses. ➢ late menopause (after 55 yo)
starts with a genetic ➢ hormone therapy (formerly hormone
alteration Inflammatory carcinoma and Paget’s disease replacement therapy)
in a single cell - less common forms of breast cancer. - Other factors
and may take several ➢ exposure to ionizing radiation during
years to become Ductal carcinoma in situ “intraductal carcinoma” adolescence and early adulthood obesity
palpable. - noninvasive ➢ alcohol intake (beer, wine, or liquor)
- but if left untreated → increased likelihood that ➢ high-fat diet (controversial, more research
no specific cause of it will progress to invasive cancer needed)
breast cancer; rather, a
combination of Factors Lifestyle Risks Environmental
- Genetic (cannot be prevented) - Oral Contraceptive Use - Exposure to
- Hormonal - Gender - Not Having Children Estrogen
- possibly - Aging - Hormone Replacement Therapy - Radiation
environmental - Genetic Risk Factors (inherited) - Not Breast Feeding - Electromagnetic
events - Family History - Alcohol Use Fields
- Personal History - Obesity - Xenoestrogens
If lymph nodes are - Race - High Fat Diets - Exposure to
unaffected - Menstrual Cycle - Physical Inactivity Chemicals
the prognosis is better. - Estrogen - Smoking
Exogenous estrogen Other risk factors Genetics
Early diagnosis, before - Hormonal replacement therapy - Radiation exposure - BRCA-1
metastasis (HRT): 30% increased risk with long - Breast disease: Atypical - BRCA-2
The key to improved term use Hyperplasia, Intraductal - P53, Rb-1
cure rates - Oral Contraceptives (OC): risk carcinoma in situ, Intralobular - Her-2/neu
slight, risk returns to normal once carcinoma in situ - c-erB2
ONCOGENE the use of OC’s has been - Obesity - c-myc
“CANCER GENE” discontinued - Diet – Fat, Alcohol
Ratio with suppressor
gene (1:1) Protective Factors Prevention Strategies
- regular vigorous - Patients at high risk for breast cancer may consult with specialists regarding
In cancer exercise (decreased possible or appropriate prevention strategies such as the following:
Oncogene > Suppressor body fat) ➢ Long-term surveillance consisting of twice-yearly clinical breast
gene - pregnancy before examinations starting at age 25 years
age 30 years ➢ yearly mammography
- breastfeeding. ➢ MRI (in BRCA1 and BRCA2 carriers)
- Chemoprevention to prevent disease before it starts
➢ tamoxifen (Nolvadex) or raloxifene (Evista)
- Prophylactic mastectomy (“risk-reducing” mastectomy): strong family
history of breast cancer, a diagnosis of lobular carcinoma in situ (LCIS) or
atypical hyperplasia, a BRCA gene mutation, an extreme fear of cancer
(“cancer phobia”), or previous cancer in one breast
 BENIGN CONDITION
Fibrocystic Change Fibroadenoma

- round, movable benign

- occurs as ducts dilate and cysts form - late teens to late 30’s
- Common in WO: 30-50 years - no premenstrual changes
- estrogen: factor because cysts usually disappear - firm, mobile; not fixed to breast tissue or
after menopause chest wall
- usually larger premenstrually and smaller
postmenstrually because of the retention of fluid in Cystosarcoma Phyllodes
the days preceding the menstrual period - fibroepithelial lesion that tends to grow
- occur singly or in multiple lumps rapidly
- tender, round shaped; soft or firm, mobile - Leaf-liked appearance
Fibrocystic Change: medical management - rarely malignant
- Danazol (antiestrogenic property): severe cases due - surgically excised
to its side effects like flushing, vaginitis and - if it is malignant, mastectomy may follow
virilization
Fibrocystic Change: Nursing intervention
- wear supportive bra day and night for a week
- decrease salt and caffeine intake
- ibuprofen
 Malignant conditions of the breast
Carcinoma In Situ (Non-Invasive)
- proliferation of malignant cells within ducts and
lobules without invasion to the surrounding
tissue
- considered stage 0 breast cancer
Ductal carcinoma in situ (dcis)
- more common; has the capacity to progress to
invasive cancer
most traditional treatment:
• total or simple mastectomy - Tamoxifen for -
women after tx with surgery and radiation
Lobular carcinoma in situ
- proliferation of malignant cells within breast
lobules; rarely associated with invasive cancer
but maybe a marker of increased risk for the
development of invasive cancer
Management:
• long term surveillance
• bilateral prophylactic mastectomy to
decrease risk
• chemoprevention: Tamoxifen (5 years)
Clinical Manifestations
- lesions are nontender, fixed, and hard
with irregular borders; most occur in the
upper outer quadrant.
- Some women have no symptoms; no
palpable lump but have an abnormal
mammogram.
- Advanced signs: skin dimpling, nipple
retraction, or skin ulceration.
SIGNS AND SYMPTOMS
Signs are those that are felt by patient
(subjective).
- lump in a breast; pain (armpits or breast)
that does not seem to be related to the
woman's menstrual period
- Pitting or redness of skin of the breast
(orange-like)
- rash around (or on) one of the nipples
- swelling (lump) in one of the armpits
- area of thickened tissue in a breast
- One of the nipples has a discharge;
sometimes it may contain blood
- The nipple changes in appearance; it may
become sunken or inverted
- The size or the shape of the breast
changes
- nipple-skin or breast-skin may have started
to peel, scale or flake
TUMOR MARKERS
- diagnosis of cancer, to detect recurrence or
identify regression of a known malignancy: CA
15-3 and CA 27-29
- Specific treatment for breast cancer; these
markers are found in the blood of affected
patients
- most useful in evaluating the effectiveness of
treatment for individuals with advanced
disease. The CA 27-29 test may be more
sensitive than CA 15-3
Both tests are commonly used to monitor the
recurrence in women who have been treated for
breast cancer
Invasive Carcinoma
Infiltrating Ductal Carcinoma
- most common type
- 75% of all breast cancers
- hardness on palpation
- usually metastasize to axillary nodes
- poorer prognosis than others
Infiltrating Lobular Carcinoma
- 5% - 10% of breast cancers
area of ill-defined thickening
- several areas of thickening may occur on one or
both breasts
- metastasize to meninges
- Both infiltrating ductal and infiltrating lobular
carcinomas usually spread to the bone, lung,
liver or brain
Inflammatory Carcinoma
- rare type of breast cancer
- localized tumor is tender and painful and the
skin over it is red and dusky
- breast is abnormally firm and enlarged
- often, edema and nipple retraction occur
Management:
• chemotherapy, radiation, surgery
ASSESSMENT & DIAGNOSTIC METHODS
- Breast Exam (Initial assessment)
- Mammography 2D + 3D
- X-ray
- Breast Ultrasound (solid mass vs fluid-filled)
- Biopsy (Confirmatory procedure): percutaneous,
surgical
- Breast MRI (determine extent of cancer)
- Histologic examination of cancer cells.
- Tumor staging & Analysis of additional prognostic
factors
➢ determine the prognosis; optimal treatment
regimen.
- Chest x-rays, CT, MRI, PET scan, bone scans
- Blood work (CBC, comprehensive metabolic panel,
tumor markers [ie, carcinoembryonic antigen (CEA),
CA15-3]).
STAGING (0, I, or IV is fairly straightforward)
- Stage II and III: wide spectrum of breast cancers
➢ Subdivided: IIA, IIB, IIIA, IIIB, IIIC.
- Factors determining stages
➢ number and characteristics of axillary lymph
nodes
➢ status of other regional lymph nodes
➢ involvement of the skin or underlying muscle.
STAGE 1 STAGE 3
- tumor: <2cm - large, > 5cm
- negative lymph node - invasion of any size
involvement with invasion of
- no detectable skin/ chest wall
metastases - Positive fixed lymph
node involvement in
STAGE 2 clavicular area
- tumor: > 2cm (< 5cm) - With evidence of
- negative or positive metastases
unfixed lymph node STAGE 4
- no detectable - Tumor of any size
metastases - Positive or negative
lymph node inv.
- Distant Metastases
 MED MANAGEMENT
(surgery, radiation therapy, chemotherapy, or hormonal therapy or a combination of therapies)
- Modified radical mastectomy: entire breast
tissue removal
➢ nipple–areola complex
➢ portion of the axillary lymph nodes.
- Breast-conserving surgery
➢ Lumpectomy
➢ wide excision
➢ partial or segmental mastectomy
➢ quadrantectomy followed by lymph node
removal for invasive breast cancer.
- Sentinel lymph node biopsy: standard of care
for the treatment of early-stage breast cancer.
- Chemotherapy to eradicate micrometastatic
spread of the disease:
➢ cyclophosphamide (Cytoxan)
➢ methotrexate
➢ fluorouracil
➢ anthracycline-based regimens
o doxorubicin [Adriamycin]
o epirubicin [Ellence])
o taxanes (paclitaxel [Taxol]
o docetaxel [Taxotere]).
- Total mastectomy: removal of
➢ breast & nipple- areola complex
➢ does not include axillary lymph node
dissection (ALND)
- External-beam radiation therapy:
➢ typically whole breast radiation
➢ partial breast radiation (radiation to the
lumpectomy site alone) is now being
evaluated at some institutions in carefully
selected patients.
- Hormonal therapy based on the index of
estrogen and progesterone receptors:
➢ Tamoxifen (Soltamox): primary hormonal
agent; to suppress hormonal-dependent
tumors
others are inhibitors
➢ anastrazole (Arimidex),
➢ etrozole (Femara)
➢ exemestane (Aromasin).
- Targeted therapy:
➢ trastuzumab (Herceptin)
➢ bevacizumab (Avastin).
- Breast reconstruction
 SURGERY RADIOTHERAPY
- Brachytherapy
- Linear accelerator

Nurse’s focus:
- Skin Care
- Prevent fatigue

- Lumpectomy
- Mastectomy: Partial, Simple, Modified Radical
w/ lymph nodes removed, Radical w/ chest
muscle removed
- Reconstructive Surgery

Nurse’s focus:
- Post-Operative Care
- Wound Care
- Rehabilitation plan to achieve optimum level of
functioning
- Psychological care for clients towards changes
in body image

Biological/ Targeted Therapy or Immunotherapy

HOW HERCEPETIN WORKS: Hormone Therapy
Endocrine receptor
- Some breast cancers are stimulated by the
hormone estrogen.
➢ estrogen in the body ‘helps’ the cancer to
grow. This type of breast cancer is called
estrogen receptor positive (ER+).
- Hormone therapy, also called endocrine therapy,
➢ blocks the effect of estrogen on breast
cancer cells.
➢ Different hormone therapy drugs do this in
different ways.
Nurse’s focus: Client’s adherence to treatment
- uses the body's immune system/ hormonal
schedule and duration
system to fight breast cancer cells.
- does less harm to healthy cells
Chemotherapy
- Side effects aren't usually as bad as from better
Nurse’s focus:
known treatments like chemotherapy.
- Alleviate most common SE: nausea/ vomiting,
diarrhea/ constipation
Nurse’s focus:
- Prevent extravasation/ phlebitis
- Allergic reaction
- Encourage adherence to treatment plan and
- Prevent extravasation/ phlebitis
schedule
- Adherence to treatment schedule
 LUNG CANCER 1. small cell lung cancer: 15- 20% of tumors NSCLC CLASSIFICATION
(BRONCHOGENIC - small cell carcinoma and combined small cell
CARCINOMA) carcinoma a. Adenocarcinoma: peripherally as peripheral
- Most small cell cancers arise in the major masses or nodules and usually metastasizes;
70% of patients with bronchi and spread by infiltration along the most common lung cancer in both sexes
lung cancer, the disease bronchial wall.
quite frequently has b. Bronchoalveolar carcinoma: in terminal bronchi
already spread to 2. non–small cell lung cancer (NSCLC) 80% of and alveoli; slower growing in comparison to the
regional lymph nodes tumors other bronchogenic carcinomas
and other areas by the - squamous cell carcinoma (20% to 30%): more
time it is diagnosed centrally located c. Large Cell Carcinoma (undifferentiated
- large cell carcinoma (15%): fast growing and carcinoma): faster growing tumor; arises
the long-term survival tends to arise peripherally peripherally
rate is poor; 5 year - adenocarcinoma (40%), which presents as
survival rate (13%) peripheral masses and often metastasizes and
includes bronchoalveolar carcinoma.
the most common STAGING
cause: inhaled staging helps clinicians better determine prognosis
carcinogens, most and treatment direction
often cigarette smoke
(90%) Stage of the tumor involves
- size of the tumor
Carcinoma usually - its location
arises in areas of - lymph nodes involvement
previous scarring (such - whether the cancer has spread to other organs
as TB, fibrosis, etc.) in
the lungs SCLC:
➢ Limited stage (1 area of chest; usually
arise from single treatable by radiation, etc.)
transformed epithelial ➢ Extensive stage (spread to other parts;
cell in the metastasized, etc.)
tracheobronchial NSCLC: I to IV
airways. ➢ Stage I earliest stage, highest cure rate
➢ Stage IV-metastatic spread; usually fatal

carcinogen (cigarette
RISK FACTORS
smoke, radon gas,
SMOKING: NO. 1 RISK FACTOR
other occupational and
- In U.S. linked to 80-90% of all lung cancers.
environmental agents)
- People who smoke cigarettes are 15-30x more likely to
damages the cell,
get lung cancer or die from lung cancer than those who
causing abnormal
do not smoke.
growth and
- Smoke from other people’s cigarettes, pipes, cigars
development into a
(secondhand smoke) also causes lung cancer.
malignant tumor
- 7,300 people who have never smoked die from lung
cancer each year due to secondhand smoke
RADON: 2ND LEADING
- naturally occurring gas that comes from rocks & dirt and
can get trapped in houses and buildings.
- Radon breaks down into radon progeny which can
attach to dust & particles and are then inhaled.
- Levels are usually highest in basements or crawl spaces,
which is closest to soil and rocks (people who spend a
lot of time in these rooms are at a greater risk)
- Environmental Protection Agency (EPA): radon causes
20,000 cases of lung cancer each year, 2nd leading
cause of lung cancer
- Nearly 1 out of 15 homes in the U.S. is thought to have
high radon levels.
PRIMARY FAM HX
- If you are a lung cancer survivor, there is
a risk that you may develop another
lung cancer, esp. if smoking
- risk of lung cancer may be higher if your
parents, brothers or sisters, or children
have had lung cancer.
➢ could be true because they also
smoke, or they live or work in the
same place where they are
exposed to radon and other
substances that can cause lung
cancer
RADIATION THERAPY TO CHEST
- Cancer survivors who have had radiation
to the chest are at a higher risk for
developing lung cancer.
- EX: include people treated for Hodgkin
lymphoma or women who get radiation
after a mastectomy for breast cancer.

PREVENTION: WORK SAFETY

- Many work environments can harbor
potentially harmful substances known as -
carcinogens (substances which can
cause or increase the risk of acquiring
cancer)
- all workers: follow workplace health and -
safety guidelines to avoid potential
exposure to carcinogens
CHEMICALS INVOLVED (American Cancer Soc.)
Tetrachlorethylene: dry cleaning fluid
- Asbestos: naturally occurring group of minerals
- Benzene: colorless; flammable liquid; gives off a sweet
scent
Arsenic: naturally occurring poisonous substance
- Formaldehyde: odorless chemical used in building
materials
 CLINICAL MANIFESTATION
Lung cancer often develops insidiously; asymptomatic until late in its course
- S/S depend on location, tumor size, degree of - Recurring fever: early symptom
obstruction, and existence of metastases to regional or - Chest pain, tightness, hoarseness,
distant sites. dysphagia, head and neck edema, and
- Most common symptom is cough or change in a chronic symptoms of pleural or pericardial
cough. infusion exist if the tumor spreads to
- Dyspnea may occur early in the disease. adjacent structures and lymph nodes.
- Hemoptysis or blood-tinged sputum may be - Common sites of metastases are lymph
expectorated. nodes, bone, brain, contralateral lung,
- Chest pain/ shoulder pain may indicate chest wall or adrenal glands, liver.
pleural involvement. Pain is a late symptom and may be - Weakness, anorexia, and weight loss
related to bone metastasis. may appear.
SIGNS AND SYMPTOMS
- Cough- The MOST prominent symptom- - Pain –pleuritic or shoulder pain (late in course
monitor if the patient develops any kind of of the disease as well if spread to the bone)
change in character of chronic cough. - Fever: due to constant infections in the lung
➢ dry, persistent hacking cough that may parenchyma
become productive with sputum - Nonspecific S/S- Weight loss and generalized
production if and when infection develops weakness
- Dyspnea/ DOB (esp. early on in the course of - If tumor metastasizes, S/S include more
the disease) pronounced chest pain and tightness, difficulty
- Blood-tinged sputum (hemoptysis) swallowing, edema of head and neck, &
possible pleural/pericardial effusion.
DIAGNOSTIC METHODS
- Chest x-Ray: assess density of the lung, and to - PET, CT scans, bone scans, abdominal scans,
search for a single lung nodule (or coin lesion), and ultrasounds (liver) of various organs and
alveolar collapse, or infection other areas to evaluate for metastasis
- CT scan of Chest: to look for smaller nodules - MRI
that may be difficult to see on the x-ray, or to - Sputum examinations
determine lymph node pathology - endoscopy with esophageal ultrasound,
- Fiberoptic Bronchoscopy: in-detail study of the mediastinoscopy or mediastinotomy, and
tracheobronchial tree and allows for tissue biopsy.
biopsies to be collected - Pulmonary function tests, ABG analysis scans,
- Fine-needle Aspiration (transthoracically under and exercise testing.
CT guidance): collect tissue for examination if it - Staging of the tumor: size of the tumor, its
cannot be collected via bronchoscopy location, whether lymph nodes are involved,
and whether the cancer has spread
MEDICAL MANAGEMENT
OBJECTIVE: provide a cure if possible.
Treatment depends on cell type, stage of the disease, and physiologic status.
- surgery (preferred) - Newer and more specific therapies to modulate
- radiation or chemotherapy—or a combination the immune system (gene therapy, therapy
of these. with defined tumor antigens)

SURGERY
- I and stage II non-small cell: treated with surgery to
remove the tumor
- Video-assisted thoracoscopic surgery (VATS): minimally
invasive surgical technique used to diagnose and treat
problems in your chest
- Resection of tumor lobe
➢ Wedge resection: remove a small section of lung
that contains the tumor along with a margin of
healthy tissue
➢ Segmental resection (segmentectomy): larger
portion of lung, but not an entire lobe
➢ Lobectomy: the entire lobe of one lung
➢ Pneumonectomy to remove an entire lung
PHARMACOLOGICAL
- Expectorants and antimicrobial agents to relieve
dyspnea and infection.
- Analgesics given ATC and PRN for breakthrough, expect
acute and chronic pain.
- Meds to manage side effects of chemo and radiation
(dry mouth)
RADIATION
- Teletherapy: High-powered energy
beams from sources (X-rays and
protons)
- External beam radiation therapy
(EBRT): high doses of radiation to lung
cancer cells from outside the body,
using a variety of machine-based
technologies.
- Stereotactic radiosurgery (track tumor
in real time as you breath to avoid
healthy tissue)
- High dose rate (HDR) brachytherapy
(Internal Radiation): high doses of
radiation from implants placed close to,
or inside, the tumor(s) in the body.
- Brachytherapy: (instill catheter in
bronchial tube)
➢ faster and precise
➢ bleed and SOB relieved when high
dose radiation delivered to tumor.
 CHEMOTHERAPY: TARGETED THERAPY
combination of drugs - more specific to cancer cells.
- cisplatin (Platinol) - attach or block targets on CA Cell
- carboplatin (Paraplatin) + docetaxel (Taxotere) surface.
- gemcitabine (Gemzar) - Certain cancers have specific
- paclitaxel (Taxol and others) biomarkers, used to determine eligibility
- vinorelbine (Navelbine and others), and efficacy.
- pemetrexed (Alimta). ➢ These Biomarkers may receive
treatment with a targeted drug
Adjuvant chemotherapy: Chemo after surgery alone or in combination with
prevent the cancer from returning chemotherapy.
- Treatments
Neoadjuvant chemotherapy: Chemotherapy before surgery o Erlotinib (Gilotrif)
to shrink tumor enough to make it easier to remove with o Gefitinib (Iressa)
surgery or increase effectiveness of radiation. o Bevacizumab (Avastin)

IMMUNOTHERAPY: use of one’s own immune system as treatment against cancer

- Monoclonal antibodies are lab-generated - Therapeutic vaccines target shared or tumor-
molecules that target specific tumor antigens specific antigens.
- Checkpoint inhibitors target molecules serve as - Adoptive T-cell transfer (removed from the
checks and balances in the regulation of patient, genetically modified or treated with
immune responses. chemicals to enhance their activity)
END OF LIFE CARE
MANAGING FACTIGUE CHANGE IN APPETITE
- Fatigue: abnormal and enduring feeling of extreme - Appetite loss caused by changes in taste and
exhaustion that does not improve with rest. smell, dry mouth, changes in stomach and
- improve the causes which exacerbate it, such as bowel, shortness of breath, nausea,
pain, constipation, or medication. vomiting, diarrhea, and constipation.
- Careful balancing of rest and activity is imperative. - Side effects of medication, spiritual distress,
- and stress are also possible causes.
PAIN MANAGEMENT - managed with nutritional support
Pain generates feelings of irritability, sleeplessness, ➢ eating strategies and supplements
decrease in appetite, concentration, etc. ➢ medications that decrease nausea,
- Sx of pain: noisy and labored breathing, sounds of stimulate the appetite; stimulate
pain (groaning or moaning), facial expressions, body peristalsis.
language and movements
- pain does not have to be a part of dying. BREATHING DIFFICULTY MANAGEMENT
- Pain can be controlled and managed. - Shortness of breath and labored breathing
- Medications are common in advanced cancer.
➢ Tylenol - Management can include
➢ opioids such as Morphine. ➢ sitting up or propping oneself on
- Other ways to control pain pillows
➢ nerve blocks ➢ wearing a nasal cannula to deliver
➢ radiation treatment supplemental oxygen or increase
➢ surgery, massage airflow
➢ application of heat or cold ➢ opioid pain
➢ meditation, and entertainment like music or ➢ anxiolytic medications,
movies. ➢ breathing and relaxation techniques
NURSING MANAGEMENT
MANAGING SX RELIEVING BREATHING PROBLEMS
- Instruct patient and family about SE - Maintain airway patency
of specific treatments and strategies - remove secretions through deep breathing exercises, chest
to manage them physiotherapy, directed cough, suctioning, and in some
instances bronchoscopy.
PSYCHOLOGICAL SUPPORT - Administer bronchodilator medications
- Help patient & family deal with poor - supplemental oxygen will probably be necessary.
prognosis and progression of the - Encourage positions that promote lung expansion
disease (when indicated) - perform breathing exercises.
- Suggest methods to maintain the - Teach energy conservation
patient’s quality of life. - airway clearance techniques
- Support patient and family in end-of- - Refer for pulmonary rehabilitation as indicated
life decisions and treatment options. - Reducing Fatigue
- Assist patient and family with - Assess level of fatigue; identify potentially treatable causes.
informed decision-making regarding - Educate in energy conservation techniques and guided
treatment options. exercise as appropriate.
- Refer to physical or occupational therapist as indicated.
 RISK FOR INFECTION
- Teach patient to avoid those with known or
recent infections
- Avoid shaving with a straight edge razor
- Avoid heating pads, ice, adhesive tape, and hot
showers/baths.
- Avoid rectal or vaginal procedures.
- Discuss dental procedures with PCP
- Avoid IM injections
- Avoid insertion of urinary catheters (but if they
are necessary, use aseptic technique)
IMPAIRED TISSUE INTERGRITY: ALOPECIA
- Advise that hair loss may occur on body parts
other than the head
- Explain that hair growth usually begins again
once therapy is completed
- Guide the patient in purchasing a hair piece or
wig before hair loss
- Lubricate scalp with Vitamin A & D ointment to
decrease itching
- Have patient wear hat or sunscreen while
exposed to the sun

IMPAIRED GAS EXCHANGE IMBALANCED NUTRITION: LESS THAN BODY REQ

- Maintain the patient in elevated positions in
order to enhance lung expansion
- Assess respiratory rate, rhythm, and depth.
- Assist with deep breathing exercises and
pursed-lip breathing as appropriate.
- Administer supplemental oxygen as
indicated
- Monitor ABGs, Pulse oximetry, Hbg & Hct
levels.
- Encourage fluid intake (2500 ml/day)
- Maintain patency of chest drainage system
for lobectomy, segmental or wedge
resection patient.
- Avoid positioning patient with a
pneumonectomy on the operative side
- instead, favor the “good lung down”
position
- Prevent unpleasant sights, odors and sounds
during mealtime.
- Ensure adequate fluid hydration, before, during,
and after drug administration
- Adjust diet before and after drug administration
according to patient preference and tolerance.
- Encourage frequent oral hygiene.
- Encourage the patient to use guided imagery and
relaxation techniques during mealtime.
CHRONIC PAIN
- Offer nonpharmacologic strategies to relieve pain
and discomfort.
- Encourage analgesics to be administered AOC
rather than PRN.
- Provide education about the use of analgesics (ie;
adverse effects, potential complications, how to
administer)

TERMINOLOGIES
- neurodegenerative: a disease, process, or condition that
leads to deterioration of normal cells or function of the
nervous system
- papilledema: edema of the optic nerve
- spondylosis: ankylosis or stiffening of the cervical or lumbar
vertebrae lobular carcinoma in situ (LCIS): atypical change
and proliferation of the lobular cells of the breast;
previously considered a premalignant condition but now
considered a marker of increased risk for invasive breast
cancer
- lymphedema: chronic swelling of an extremity due to
interrupted lymphatic circulation, typically from an axillary -
lymph node dissection
- mammoplasty: surgery to reconstruct or change the size or -
shape of the breast; can be performed for reduction or
augmentation
- mastalgia: breast pain, usually related to hormonal
fluctuations or irritation of a nerve
- modified radical mastectomy: removal of the breast tissue,
nipple–areola complex, and a portion of the axillary lymph
nodes
- Paget’s disease: form of breast cancer that begins in the
ductal system and involves the nipple, areola, and
surrounding skin
- prophylactic mastectomy: removal of the breast to reduce the risk
of breast cancer in women considered to be at high risk
- sentinel lymph node: first lymph node(s) in the lymphatic basin
that receives drainage from the primary tumor in the breast;
identified by a radioisotope and/or blue dye
- stereotactic core biopsy: computer-guided method of core needle
biopsy that is useful when masses in the breast cannot be felt but
can be visualized using mammography
- tissue expander followed by permanent implant: series of breast-
reconstructive surgeries after a mastectomy; involves stretching
the skin and muscle before inserting the permanent implant
total mastectomy: removal of the breast tissue and nipple–areola
complex
transverse rectus abdominis myocutaneous (TRAM) flap: method
of breast reconstruction in which a flap of skin, fat, and muscle
from the lower abdomen, with its attached blood supply, is rotated
to the mastectomy site
- ultrasonography: imaging method using high-frequency sound
waves to diagnose whether masses are solid or fluid filled
- open lung biopsy: biopsy of lung tissue performed through a
limited thoracotomy incision
- fine-needle aspiration: insertion of a needle through the chest wall
to obtain cells of a mass or tumor; usually performed under
fluoroscopy or chest computed tomography guidance