NEOPLASTIC DISORDERS

CLASSIFICATION OF NEOPLASMS
Benign neoplasia
1. Cells adhere to one another, and
growth remains circumscribed
2. Generally not life-threatening
unless they occur in restricted
area (e.g., skull)
3. Classified according to tissue
involved
- glandular tissue [adenoma]
- bone [osteoma]
- nerve cells [neuroma]
- fibrous tissue [fibroma]
Malignant neoplasia
1. Cells are undifferentiated (anaplasia) and rapidly dividing
2. Cells infiltrate surrounding tissue
3. May spread (metastasize) by direct extension, lymphatic permeation and embolization;
diffusion of cancer cells can occur by
- mechanical means
- produce secondary lesions
4. Membranes of malignant cells contain specific proteins (tumor-specific antigens)
5. Tumors are classified according to tissue involved
- glandular epithelial tissue [adenocarcinoma]
- epithelial surface tissue [carcinoma]
- connective tissue [sarcoma]
- melanocytes [melanoma]
6. Tumors are often classified by universal system of staging classification, TNM system
a. T designates primary tumor
b. N designates lymph node involvement
c. M designates metastasis d. A number (0 to 4)

after any of above letters designates degree of involvement e. TIS designates carcinoma in situ
or one that has not infiltrated
RELATED PHARMACOLOGY
Basic Concepts
A. Destroy malignant cells by interfering with reproduction of cancer cell
B. Act at specific points in cycle of cell division (cell-cycle specific) or at any phase in cycle of cell division (cell-cycle nonspecific)
C. Affect any rapidly dividing cell within body
- thus having potential for toxicity development in healthy, functional tissue (bone marrow, hair follicles, GI mucosa);
- combination therapy: reduce possibility of toxicity and maximize therapeutic effect (CHOP: cyclophosphamide (Cytoxan),
DOXOrubicin, vinCRIStine, prednisone)
D. Available in
- oral, parenteral (IM, Sub-Q, IV)
- intra-arterial, intrathecal
- topical preparations

Major Side Effects

- Anorexia, nausea, vomiting, stomatitis (irritation of GI tract; quick uptake by rapidly dividing alimentary tract tissue)
- Diarrhea (irritation of GI tract; quick uptake by rapidly dividing alimentary tract tissue)
- Bone marrow depression (quick uptake by rapidly dividing myeloid tissue)
- Blood dyscrasias (neutropenia, anemia, and thrombocytopenia) resulting from bone marrow depression
- Alopecia (rapid uptake by rapidly dividing hair follicle cells)
- CNS disturbances (neurotoxicity)
- Hepatic disturbances (hepatotoxicity)
- Tumor lysis syndrome: release of large quantities of breakdown products, causing hyperkalemia, hyperuricemia,
hyperphosphatemia, and acute renal failure
- Acute renal failure (direct kidney toxic effect)
- Cardiomyopathy (irreversible myocardial toxicity, congestive heart failure [CHF], ventricular dysrhythmias)
- Metabolic abnormalities (hypercalcemia, hyperuricemia)
- Allergic reactions, anaphylaxis with BCG vaccine
Alkylating Agents Monoclonal Antibodies
Cell-cycle nonspecific; attack DNA of rapidly dividing cells Exogenous antibodies produced in laboratory by combining specific
- Nitrosourea: carmustine (BiCNU) cancer cells with antibody-producing B cells; derived from different
- Nitrogen mustard: chlorambucil (Leukeran), sources: mouse (murine), combination of mouse and human sources
cyclophosphamide (Cytoxan) (chimeric), or humanized
- Inorganic heavy metal: cisplatin (Platinol-AQ), carboplatin - rituximab (Rituxan), for non-Hodgkin’s lymphoma
(Paraplatin) - trastuzumab (Herceptin) for certain types of breast cancer
- gemtuzumab ozogamicin (Mylotarg) for leukemia
Vinka Alkaloids - alemtuzumab (Campath) for B-cell chronic lymphocytic
Cell-cycle specific; work during “M” phase; interfere with mitosis leukemia
- Vincristine - ibritumomab tiuxetan (Zevalin) for B-cell non-Hodgkin’s
lymphoma
Antibiotics - cetuximab (Erbitux) for advanced colorectal cancer
Cell-cycle nonspecific; inhibit DNA and RNA synthesis of rapidly
dividing tissue Antimetabolites
- mitomycin (Mutamycin) Cell-cycle specific; inhibit protein synthesis in rapidly dividing cells
- DOXOrubicin during “S” phase
- fluorouracil or 5-FU (Carac, Efudex, Fluoroplex)
- hydroxyurea (Hydrea)
- methotrexate (Trexall)
 Hormones
Tissue-specific; inhibit RNA and protein synthesis in tissues that are
dependent on opposite (sex) hormone for development
- androgens
- estrogens (estramustine [Emcyt]
- progestins, steroids (prednisone)
- hormone antagonists (mitotane [Lysodren]
- cortisol antagonist, estrogen antagonist (anastrozole
[Arimidex], tamoxifen citrate)
- luteinizing hormone–releasing hormone agonist
(leuprolide [Lupron]
Other Immune Agents
Introduction of noncancerous antigens or other agents into body to
stimulate production of lymphocytes and antibodies
- Bacille Calmette-Guérin (BCG) vaccine (TICE BCG):
provides active immunity
- Interferon alfa-2a (Roferon-A), interferon alfa-2b (Intron
A): suppresses cell proliferation
- Filgrastim (Neupogen): granulocyte colony–stimulating
factor

Miscellaneous Agents
- Leucovorin calcium: reduced form of folic acid; acts as
antidote to folic acid antagonists
Paclitaxel (Taxol): inhibits reorganization of microtubule network
that is needed for interphase and mitotic cellular functions; causes
abnormal bundles of microtubules during cell cycle and multiple
esters of microtubules during mitosis

PURPOSE EXAMPLES METHODS OF DELIVERIES MAJOR SE

RADIATION ✓ Diagnosis ✓ Alpha particle: fast- ✓ External beam ✓ Localized skin
✓ Treatment: moving helium radiotherapy or irritation; erythema to
Disrupts tissue by - Curative nucleus; slight teletherapy delivers moist desquamation
altering function - palliative, penetration radiation to a tumor by an
during DNA adjuvant ✓ Beta particle: fast- external machine (cobalt ✓ Vary based on site and
synthesis - in conjunction moving electron; or linear accelerator) at a size of treatment field
with moderate penetration predetermined distance - GI tract: nausea,
Rapidly chemotherapy ✓ Gamma ray: similar to vomiting, diarrhea,
reproducing or surgery light ray; high ✓ Internal radiation therapy xerostomia, mucositis,
malignant cells are penetration or brachytherapy delivers dysphagia
most sensitive to ✓ Gold (198Au): radiation by systemic, - Gonads: temporary or
radiation effective for interstitial, or intracavity permanent sterility
complications of means 1. Systemic - Bone marrow:
ascites and pleural (metabolized): leukopenia,
effusion administration by thrombocytopenia,
✓ Sodium iodide (131I): intravenous or oral routes anemia
effective for thyroid 2. Interstitial: - Respiratory tract:
gland implantation of needles, pneumonitis, cough,
✓ Sodium phosphate wires, or seeds into tissue dyspnea
(32P): effective for 3. Intracavity radiation: - Genitourinary tract:
erythrocytes placement of an implant cystitis, urethritis
✓ Proton therapy: into a body cavity; may
accurately targets require a surgical
tumor, thereby procedure
minimizing collateral
tissue damage
TYPES MAJOR SE
BONE MARROW ✓ Autologous: Infection, fever, chills
TRANSPLANTATION ➢ bone marrow is removed from client
➢ reinfused after high-dose chemotherapy ✓ Venous occlusive disease: vascular injury to liver as result
Treatment of ✓ Allogeneic: of high-dose chemotherapy during first 30 days after
hematologic ➢ bone marrow from donor with transplant
cancer compatible human leukocyte antigen ✓ Graft-versus-host disease: transplanted bone marrow
(HLA) activates immune response against recipient’s tissue
Treatment of ➢ infused after client’s own bone marrow is ✓ Bone marrow: failure to respond and proliferate limits
certain solid tumor destroyed by chemotherapy or radiation blood-making capacity, leading to hemorrhage and
recurrences that ✓ Syngeneic: infection
require ablative ➢ bone marrow is obtained from identical ✓ GI: stomatitis, nausea, vomiting, diarrhea
chemotherapy, twin ✓ Cardiovascular: hypotension, hypertension, tachycardia,
which destroys ✓ Peripheral stem cell transplantation: chest pain
bone marrow ➢ after stem cell production is stimulated ✓ Respiratory: shortness of breath, pneumonia
by administration of growth factor
➢ cells are collected by apheresis and
reinfused after high-dose chemotherapy
General Nursing Care of Clients with Neoplastic Disorders
1. Onset and progression of clinical indicators
2. General health and nutritional status
3. Understanding of disease and treatment plan
4. Laboratory results (e.g., CBC, electrolytes, levels of tumor-specific antigens)
Planning/Implementation
Assessment/Analysis
1. Instruct regarding measures to limit
infection (e.g., avoiding crowds; hand
washing; remaining in home [safer than
hospital environment because hospitals
harbor pathogens to which client is not
usually exposed]); instruct to report body
temperature higher than 100° F (37.7° C)
2. Use special measures to limit injury (e.g.,
gentle oral hygiene, nonalcohol-based
mouthwash; move slowly and support joints
to prevent pathologic fractures)
3. Explain side effects that influence
appearance and encourage positive coping
strategies (e.g., purchase of wigs, scarves,
hats)
4. Administer prescribed medications to reduce
or eliminate nausea (e.g., antiemetics)
5. Monitor blood values during therapy
a. WBCs, RBCs, platelets
b. Tumor markers:
➢ Alpha fetoprotein—liver, testes
➢ CA-125—GI, ovaries
➢ carcinoembryonic antigen (CEA): breast
colon, lung
➢ prostate specific antigen (PSA)—
prostate
6. Administer prescribed colony-stimulating
factors to increase production of
➢ WBCs and RBCs
➢ epoetin alfa (Epogen)
➢ filgrastim (Neupogen)
➢ administer prescribed platelet
transfusions
7. Offer emotional support to client and family;
answer questions and encourage
verbalization of fears
8. Encourage delegation and organization of
activity to conserve decreasing energy
9. Encourage to enroll in American Cancer
Society’s “Look Good, Feel Better” program
10. Support natural defense mechanisms
➢ encourage intake of foods rich in
immune-stimulating nutrients,
especially vitamins A, C, and E, mineral
selenium
11. Implement measures to support nutritional
intake
12. Encourage women of childbearing age to use
birth control measures while receiving
therapy because of mutagenic/ teratogenic
effects; avoid use of birth control pill
13. Counsel regarding use of sperm or ova
harvesting if permanent infertility may result
14. Encourage fluid intake (3000 mL/24 hr);
monitor I&O
15. Assess for presence of pain; administer
analgesics or antidepressant to control pain;
provide nonpharmacologic comfort measures
16. Encourage to become involved in decision
making; support decisions whenever possible
17. Help to discriminate between scientifically
based therapy versus fraudulent therapy
18. Provide specific care for clients receiving
chemotherapy
➢ Monitor IV infusion site for infiltration
of chemotherapeutic agent capable of
causing tissue necrosis (vesicant)
➢ Follow established protocols for
handling chemotherapeutic agents and
equipment to minimize nurses’ exposure
➢ Institute protective isolation if WBC
count decreases below 1000/mm3
➢ Observe for signs of bleeding; avoid
anticoagulants because of decreased
platelets
➢ Prevent bleeding (avoid use of rectal
thermometers, enemas, IM injections,
and razor blades)
➢ Monitor renal function for
nephrotoxicity
➢ Monitor vital signs; monitor for cardiac
toxicity
➢ Encourage checking with health care
provider before consuming OTC drugs,
such as aspirin; avoid alcoholic
beverages
➢ Follow sterile protocol when accessing
implantable port; use noncoring needle
(Huber) to access port; when not in use,
heparin or saline flushes are used to
maintain port patency depending on
manufacturer’s directions
19. Provide specific care for clients receiving
external radiation
➢ Assess skin for erythema or moist
desquamations avoid
o Creams
o Soaps
o Powders
o cosmetics, perfumes
o deodorants in area during
treatment periods
➢ Instruct to wear loose-fitting cotton
clothing; protect skin from sunlight
➢ Promote use of gentle detergents (e.g.,
Dreft or Ivory Snow) to wash clothing
➢ Teach to avoid sources of
o heat or cold (e.g., heating pads,
sunlamps, ice bags, cold weather)
o salt water, chlorinated pool
o do not shave hair within treatment
field during therapy
➢ Apply nonadherent dressing to areas of
skin breakdown
➢ Reassure others that client is not a
source of radiation
 20. Provide specific care for clients receiving 21. Provide specific care for clients receiving
internal radiation radiation via an unsealed source (IV, oral, or
➢ Explain procedures involved and side direct instillation into body cavity)
effects that may occur ➢ Isotope may be excreted in body waste
➢ Explain need for isolation: explain to o instruct to flush toilet several
client and visitors times after each use for
o amount of time visitors can spend several days
in room o additional precautions may be
o proximity to client will be limited to necessary depending on
avoid overexposure to radiation radioisotope used
o restrict children and pregnant ➢ Provide paper plates and disposable
women from visiting utensils
o health team members must use
dosimeter badge to monitor 22. Begin palliative care early in cancer
exposure treatment
➢ Inspect implant for proper positioning 23. Inform about and support choice of hospice
and prevent dislodgement of intercavity care when curative options are exhausted;
radiation implants to avoid irradiation of recommend multidisciplinary services to
adjacent healthy tissue support quality rather than quantity of
o bed rest remaining life (e.g., pain management,
o urinary retention catheter spiritual support)
o low-residue diet
o antidiarrheal agents
➢ Use principles of time, distance, and
shielding to minimize staff exposure
➢ Provide only necessary hygiene while
implant is in place
➢ Ascertain if body excreta has to be
placed in lead containers for disposal
when systemic metabolized radiation is
used
➢ If radiation source becomes dislodged
use long-handled forceps to place in
lead container to prevent
contamination of environment;
immediately inform radiation therapist
and radiation safety officer
➢ Radiation for prostate cancer: assess for
signs of bladder irritability such as
nocturia, urgency, dysuria
➢ Radiation for cervical cancer: keep
supine with head of bed flat or only
slightly elevated, maintain patency of
urinary catheter, provide low-residue
diet
Evaluation/Outcomes
➢ Remains free from infection
➢ Verbalizes feelings about disease and treatment
➢ Maintains skin and mucous membrane integrity
➢ Maintains body weight within expected range
➢ Verbalizes details concerning self-care related to treatment regimen
Nursing Care to Promote Nutritional Intake