Oncology Nursing: the patient with cancer

Outline:
 Definition.  Incidence  Mortality rate.
 Characteristic of benign and malignant neoplasms.  Pathphysiology
 Names of selected benign and malignant tumours.  Malignant cell characteristics.
 Characteristics of benign and malignant neoplasms.  Carcinogenesis.
 Etiology: Role of the immune system.  Ten steps of cancer prevention.
 Role of the nurse in breast self examination.  Diagnosis of cancer.
 Management.
 Surgery.  Radiotherapy.  Chemotherapy.
 Nursing care of the patient with cancer.

Cancer Nursing: Oncology Nursing:

Is an area of practice; that covers all age groups and is carried out in many health care settings including:
 The home.  Community
 Acute care institutions and rehabilitation centers and are designed for the care of cancer patients.

Incidence:
 Cancer affects all age groups, most cancers occur over 65 years of age. Men experience higher
incidence than women. It is higher in industrial areas.

Mortality rate:
 It is the second leading cause of death after cardiovascular disease.

Pathophysiology of the malignant process:

 Abnormal cells arise from normal cells due to poorly understood mechanism. These cells
proliferate  invade surrounding tissues  infiltrate this tissue  gain access to lymph & blood
vessels  (transported through it to distant organs)  metastasis (cancer spread) to other parts.

Table: Characteristics of benign and malignant neoplasms:

Names of detected benign and malignant tumors according to tissues:
Tissue type Benign Malignant
1. Epithelial tumours (T)
 Surface Papilloma Squamous cell carcinoma
 Glandular Adenoma Adenocarcinoma
2. Connective tissue T:
 Fibrous Fibroma Fibrosarcoma.
 Adipose Lipoma Liposarcoma

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  Cartilage Chondroma Chondrosarcoma
 Bone Osteoma Osteosarcoma
 Blood Vessels Hemangioma Hemangiosarcoma
 Lymph vessels Lymphangioma Lymphangiosarcoma
3. Muscle T:
 Smooth Leiomyoma Leiomyosarcoma
4. Nerve cell T:
 Nerve cell Neuroma
 Glial cells (in brain) Glioma
5. Hematologic T:
 Granulocytic Myelocytic leukaemia
 Erythrocytic Erythroleukaemia
 Plasma cells Multiple myeloma
 Lymphoid Lympohoevtie leukaemia

Malignant cell characteristics:

1. Nuclei are large and irregular. 2. Nucleoli are large and numerous.
3. Chromosomes are abnormal and fragile.
4. Mitosis (cell division) is rapid. 5. Invasion and metastasis.

It has the ability to spread & transfer cancer cells from one organ to another by:
a) Invasion: growth of primary tumor into the host surrounding it  mechanical pressure. It may
possess certain enzymes that destroy normal cells.
b) Metastasis: dissemination of malignant cells from primary tumor to distant sites by  direct
tumor cells spread to body cavities or through lymphatic & hematogenous circulation.
 Tumor emboli  enter lymph channels by way of interstitial fluid that communicates with the
lymphatic fluid, or may penetrate lymph vessels by invasion.
 After entering lymph circulation it may become lodged in lymph nodes or pass between lymph
& venous circulation. Breast tumors frequently metastasize through axillary & clavicular L.N.
 In general, there is a tendency for malignancy of specific cells to spread to specific organs
depending on many factors e.g. organ vascularity, immune defenses of the tissues.

Characteristics of benign and malignant neolasms:

Characteristic Benign Malignant
1. Cell characteristic Resembles normal cells Little resemblance to normal cells
2. Mode of growth grows by expansion, does not Grows at the periphery, infiltrate and
infiltrate, encapsulated destroy the surrounding tissue
3. Rate of growth slow usually rapid
4. Metastasis does not' spread by metastasis Reach blood & lymph vessels and
metastasizes to other body parts
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5. Recurrence does not recur when removed Tends to recur when removed
6. Destruction of does not cause tissue damage Cause extensive tissue damage due to
tissues pressures e.g. on blood supply
7. General effects usually localized Anemia, weakness, weight loss
8. Ability to cause rarely cause death, unless located Cause death, unless it growth IS controlled
death near vital functions

Carcinogenesis:
Malignant transformation needs 2 steps:
a. Initiation: Initiatiors e.g. chemicals, physical factors, or biologic agents release enzymes that cause
alterations in the cells.
b. Promotion: repeated exposure to these agents  abnormal genetic formation  the cells produce
abnormal cells different from the original.

Carcinogens:
They are agents that initiate or promote cellular transformation.

Etiologies:
1. Viruses: Viruses are thought to incorporate themselves into genetic structure of cells → thus
altering future generation e.g. Herpes simplex virus and hepatitis B virus.
2. Physical agents: e.g. exposure to sun light, radiation, chronic irritation; inflammation e.g.
repeated x-ray procedures, radioactive materials at atom bomb sites. e.g. of chronic irritations: lip
cancer among pipe smokers, oral cancer in prolonged tobacco use or ill fitting dentures, melanoma
with chronically irritated moles, liver cancer with liver cirrhosis etc ...
3. Chemical agents: e.g. in work industries. The liver and kidneys are commonly affected due to
their detoxification of chemicals.
4. Genetic and familial factors:
a) Abnormal chromosomal patterns → specific cancers e.g. leukemia, skin cancer.
b) Familial inheritance → e.g. breast, stomach, prostate, lung cancer.
5. Dietary factors: can be either: Proactive (protective) or – carcinogenic.
Long term ingestion of carcinogens of chronic absence of proactive substances in diet  cancer.
6. Hormonal agents: Tumor growth is promoted by hormonal imbalance from either: -
 Body’s own hormonal production.
 Administration of exogenous hormones e.g. cancer breast, uterus, prostate, depend on
endogenous hormonal level for growth.
e.g. administration of oral contraceptives are associated with liver and vaginal carcinoma.

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The role of the immune system:
- Cancer is related to failure of normal immune system.
- Cancer cells have surface antigen → T lymphocytes (the soldier of the immune response) →
proliferate & kill cancer cells (cytotoxic effect).
- Tumor cells secrete a substance that destroys body defenses → inc. susceptibility to infection in
cancer patients.

Ten steps of cancer prevention:

Protective factors:
1. Increase fresh vegetables. 2. Increase fiber intake.
3. Increase intake of vitamin A. 4. Increase intake of vitamin C.
5. Practice weight control.
Risk factors:
6. Reduce amount of dietary fat. 7. Stop cigarette smoking.
8. Cut down of salt cured, smoked and nitrate cured foods,
9. Reduce alcohol intake. 10. Avoid exposure to sun.

Role of the nurse in detection and prevention of cancer:

Provide education to community about cancer prevention e.g.
 Health behavior.  Risk factors.  Screening methods.
  Sun exposure, tobacco use and alcohol consumption
 Dietary habits  Exercise  General health habits.

Breast self examination (BSE):

BSE must be given top priority; teaching all women; how & when to examine their breasts.
It should be performed monthly.
1. BSE is begun with inspection using a mirror,
2. Arms are extended high above head in a search for  abnormal motion or skin retraction (a
danger sign of cancer).
3. Pressure is placed on back of head  to tense the pectoralis major that underlie mammal tissues.
4. Inward pressure on hips serves  to tense pectoralis major muscles. Skin retraction is observed.
5. Wet soapy skin  facilitates manual breast examination for lumps. Wet permits easy hand motion
6. Tub bathing provides optimal time for discovering lumps. Reclining position flattens breast
tissue on the chest well.
7. Palpatory examination is best performed in supine position with the side to be examined elevated
on pillow. Lumps are most evident when breast is flattened and evenly distributed on chest wall.
8. Self examination is completed with a squeeze of the nipple to detect abnormal discharge.

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Diagnosis of cancer includes:
 Assessment of physiologic and functional changes.
 Diagnostic evaluation for:
 To determine the extent of the disease.
 To determine presence of the tumor.  Spread or metastasis,
 Functions of involved and uninvolved body organs.
 Obtaining cells for analysis for cancer, stage and grade.

Role of the nurse:

Patient and family is usually fearful about the procedure and anxious about the result.
 Give information about the test and role of the patient in it.
 Let patient and family express their fear and worry.
 Encourage them to communicate and share concerns.

Management of cancer:
Goals:
1. Eradication of malignant disease (cure). 2. Prolonged survival with the presence of malignancy.
3. Relief of symptoms associated with the cancer process i.e. (palliative).
Modalities:
1) Surgery  Means removal of the entire cancer. It may be:
a. The primary method of treatment. b. Diagnostic
c. Prophylactic. d. Palliative e. Reconstructive
a- Surgery as a primary treatment:
Removal of entire tumor is called "debulking", attempts to remove wide tissues margins to "get all the
cancer cells" is not realistic since there is often micrometastasis. Therefore, after surgery one or more
other treatment modalities are indicated to increase cancer cells destruction.
b- Diagnostic surgery: is done to:
1. Obtain biopsy (excision of a piece of tissue from a suspicious growth).
2. Analyze the tissues and cells of suspected malignancy.
c- Prophylactic surgery:
Involves removal of lesions that are apt to develop into cancer (e.g, polyps in the colon).
d- Palliative surgery
When cure is not possible, goal is to provide patient with comfort & productive life e.g. remove cancer
complications as ulcerations, pressure, obstruction, hemorrhage, pain e.g. surgery to nerve block for pain.
e- Reconstructive surgery: Follow curative or radical surgery to produce  better function or cosmetic
effect.
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Nursing consideration:
 Patient is often anxious about surgery procedure, possible finding, postoperative limitations, changes
in function, prognosis.
 Offer assistance to deal with possible changes.
 Offer pre and postoperative care.
 Offer information (if asked) about diagnosis in line with physician  maintained consistent approach.
 Plan for discharge and follow up plans.

2) Radiation therapy
Definition: it is the use of ionizing radiation to interrupt cellular growth.
Causes:
 When treatment goal is curative e.g. cancer head and neck, cancer cervix, Hodgkin's disease.
 Control tumor growth, when it cannot be removed surgically e.g. when nodal metastasis is present.
 Prophylactically e.g. to prevent leukaemia from infiltration into brain.
 Palliative; to relieve symptoms of metastasis e.g. brain, bone, soft tissue.
Type one ionizing radiation:
1) Electromagnatic: (i.e. x-rays and Gamma rays).
2) Heavier particulate radiation: (electrons, protons, neutrons, alpha particles, beta particles).
Effect:
 Either types leads to tissue disruption by ionization.
Cells most vulnerable to radiation effects are those of rapid mitosis. These are:
 Cancer cells.  Epithelium.  Gastrointestinal cells.
 Lymphatic.  Bone marrow.  Gonads.
Slowing growing cells are radioresistant as;
 Muscles  Cartilage  Connective tissue.

Mechanisms of delivering radiation:

1. External mechanisms: Several methods are used, depending on tumor depth to be radiated.
2. Internal radiation implants:
Deliver high dose of radiation to localized area. Radiation may be implanted by way of needles, seeds,
beads or catheters. As the distance from radiation source   dosage delivered to patient 
Patient receiving internal radiation emit; principles of time, distance, and shielding should be used in
planning care for these patients to minimize exposure of personnel to it.

Radiation dosage: depends on: -

 Tumor size.  Sensitivity of tumor to radiation.

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Toxicity of radiation therapy
It is usually localized to the region being irradiated

1. Local reactions:
Normal cells in treatment area are destroyed  fall of cellular regeneration or alteration of integrity.
These local reactions include:
 Alopecia. (Fall of hair).  Erythema (redness)
 Shedding of skin (desquamation). Reepithelialization occurs once treatment has been stopped.
 Alteration in oral mucous membrane include:
 Stomatitis.  Dryness of mouth (xerostomia).
 Decrease salivation.  Oesophageal irritation.
 Chest pain.  Dysphagia.
 Anorexia, nausea, vomiting, diarrhea (if stomach and colon are in the irradiated field).
 Anemia, leukopenia and thrombocytopenia (if bone marrow producing sites are in the
irradiated field) → risk of bleeding and infection.

2. General systemic side effects include:

 Fatigue.  Malaise  Headache  Nausea  Vomiting

These are thought to be due to substances released on the tumor breakdown & are usually temporary.

3. Late effects:
Chronic fibrosis in various body tissues due to decrease vascular supply and are irreversible.

Nursing intervention of patients on radiation therapies.

 Answer patients question.
 Allay his fears regarding its effects.
 Explain procedure of delivering radiation.
 Describe equipment used, duration (minutes only) a needed for immobilization during procedure
and absence of sensation (i.e. no pain).
 Patients with radio-active implants need explanation of limitation of visitors & health personnel.
 Give attention to nutritional status, skin and sense of well being.
 Inspect oral mucosa for changes.
 Avoid skin irritation and applying powder, ointments, lotions or creams.
 Gentle oral hygiene to prevent debris of irritation.
 Assist in daily activities and personnel hygiene if weakness and fatigue are experienced.
 Explain symptoms are due to treatment, are temporary & don’t represent disease deterioration
 For patients with radioactive implant, patient is usually either on bed rest or confined to his room.
 Follow instruction of radiology department about maximum time to be spent in patient's room.

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  Shielding equipment to be used.
 Inform patient about the rational for these precaution so as not to feel unduly isolated.

3) Chemotherapy:
 "It is the use of anti-neoplastic drugs to promote tumor cell death by interfering with cellular
functions and reproduction"
 It is used primarily to treat systemic disease rather than lesions that are localized and amenable to
surgery or irradiation. It may be combined with surgery or radiation or both to reduce tumor size
preoperatively
 Destroy remaining tumor cells postoperatively.  Treat some forms of leukemia.
Goals:
 Cure  Control  Palliative
 About 20-99% of the tumor cells exposed to chemotherapeutic agent are destroyed.
 Repeated doses are necessary over a prolonged period of time  regression of disease. 100%
eradication is impossible but the goal of treatment is that the remaining cells can be destroyed by the
body's immune system.
 Actively proliferating cells within tumor are the most sensitive to chemotherapeutic agents:
Nondividing cells capable of future proliferation are the least sensitive to anti-neoplastic drugs.

Administration Routes:
1. Topical. 2. Oral. 3. l.V. 4. I.M.
5. Subcutaneous 6. Arterial. 7. Intracavity. 8. Intrathecal

The route of administration depends on the drugs, required dose, type and extent of tumor being treated.
Dosage: depends on:
 Patient's total body surface area.  Physical status.
 Previous response to chemotherapy.

Toxicity of chemotherapeutic drugs: May be acute or chronic

(1) Gastrointestinal system:
a. Nausea.
These can be relieved by: -
 Relaxation techniques
c. Stomatitis
b. Vomiting: caused by irritation of mucosa
 Alteration of patient's diet
d. Anorexia e. Mucositis

Frequent monitoring of RBCs is essential, protect patient from infection and injury especially if WBCs is low.
(2) Renal system:
Harmful effect to kidneys occurs during drug excretion & accumulation of waste products of cell breakdown
(e.g. uric acid).

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Nursing measures:
 Monitor blood for BUN, serum creatinine.
 Adequate fluid hydration.
 Alkalinization of urine to prevent formation of uric acid crystals.
(3) Cardiopulmonary system:
 Antitumor antibiotics can cause cumulative cardiac toxicities.
- Monitor ECG and signs of heart failure.
 Cumulative toxic effects on the lungs lung fibrosis.
- Monitor pulmonary functions.
(4) Reproductive system:
Testicular and ovarian functions may be affected sterility.
- Patients must be informed these changes.
(5) Neurologic system:
 Peripheral neuropathy.
 Loss of deep tendon reflex and paralytic ileus.
These changes are reversible.

Table (3): Classification of antineoplastic drugs:

Category Action Side effects
1. Alkalynating Alter DNA structure Bone marrow Suppression Nausea,
e.g. nitrogen mustard vomiting,
2. Nitrosourease Inhibit RNA & DNA synthesis Alopecia
e.g. ramastine
3. Aritimetabolites prevent RNA synthesis Bone marrow Suppression
e.g. cytarabine
4. Antitumor antibiotics Decrease mitosis Bone narrow Suppression
e.g. adriamycin
5. Plant alkaloide - Inhibit RNA synthesis Anorexia, nausea, vomiting
e.g. vincristine
6. Hormonal agents -Bind to hormone site that alter
e.g. androgens Estrogen cellular growth
Progesterone Steroids
Nursing intervention of patients on chemotherapy
 The nurse' has an important role in assessing and managing chemotherapy problems.
 Assess patient's nutrition, fluid & electrolyte (due to nausea, vomiting, altered taste, & diarrhea).
 Use creative ways to improve appetite.
 Due to depression of Bone marrow & immune system patient will be liable to  anemia, infection,
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 bleeding disorders,
 Identify factors that further increase this risk  asepsis and gentle handling.
 Monitor blood cell count closely.
 Report untoward blood test results, signs of infection and bleeding.
 Instruct family, members about previous measures at home.
 Observe for risk and consequences of extravasations and report it immediately if it occurred.
 Handling of chemotherapeutic agents → exposure of nurses to small doses by direct contact,
ingestion or inhalation secondary → formation of cancer and chromosomal abnormality (inheritable
changes in genes of cells). Specific precautions have to be followed by those involved in preparation
and administration of cytotoxics

Nursing care of the patient with cancer: Nursing process:

A. Assessment:
 Assess factors predisposing to bleeding or/and infection.
 Monitor lab results especially complete blood picture.
 Inspect common sites for infection and bleeding  pharynx, skin, urinary and respiratory tract.
 Assess for sepsis especially with invasive procedures. ( WBCs {leukopenia or granulocytopenia}):
o Oesinophils o Neutrophiles o Basophiles
 Certain phagocytes are very important to combat infection.
 Monitor patient for signs of bleeding.
 Skin and tissue integrity may be altered in cancer due to many reasons, e.g.
o Skin lesions and ulcerations o Alopecia
o Oral mucous membrane lesions.
 Nutritional state alteration and weight loss:
o Monitor weight daily. o Monitor caloric intake.
o Anorexia and situation aggravating or relieving it.
o Diet history. o Nausea, vomiting, diarrhea
 Clinics results as:
o Serum protein levels o Hb o Hct o Serum ion levels
 Pain and discomfort: is caused by malignancy.
o pressure of tumor o diagnostic tests
o Cancer treatments. o Assess source and site.
o Assess factors increasing perception of pain. o Assess pain.
 Psychological and mental state
 Assaults to body image:
Potential threats to self image, self concept and self-esteem present due to
 disfiguring surgery  hair loss
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  cachexia  skin changes
 altered communication  sexual dysfunction
The nurse should assess these threats and ability of patient to cope.
B. Nursing diagnosis: Examples:
 Potential for infection related to altered immunological response
 Potential for injury related to bleeding disorders.
 Alteration in nutrition less than body requirements related to anorexia.
 Altered body image related to change in appearance.
 Grieving related to anticipated loss.
C. Nursing goals and interventions
1) Prevention of infection:
Causes of infection:
 Skin & mucous membrane alterations.   defense mechanisms
 Impaired nutrition due to anorexia, nausea, vomiting etc.  Antibiotic
 Malignancy impairs resistance to combat organisms.  Cancer is immunosuppressive.
 Decreased WBCs due to bone marrow suppression by cytotoxics,
Infection in immunosuppressed patient is often "nosocomial"  result of organisms that become part
of resident flora after being acquired from hospital environment e.g. gram negative & positive bacilli.

Fever is the important sign:

 Administer antibiotics as indicated in schedules.  Report fever immediately.
 Carry out collection of specimens urine, blood etc. for culture and sensitivity.
 Strict asepsis of invasive equipment.  Hand washing & appropriate hygiene.
 Protect patient from exposure to infection and avoid crowded places.
 Observe for implantation, septicemia and septic shock.  Coughing & deep breathing exercise.
2) Prevention of injury related to bleeding disorders: is due to
thrombocytopenia. This is usually caused by:
 Bone marrow depression by cytotoxics.  Enlarged spleen
 Tumor filtration of bone marrow.
It is platelet count less than 100.000/cumm; 20.000 spontaneous bleeding
 Monitor blood values.  Observe for bleeding.
 Reduce trauma, use soft bristled tooth brush, use electric razor, ovoid unnecessary invasion.
 Avoid falls of trauma.  Soft food.
 Increase fluid  Stool softeners.  Gentle handling.

3) Maintenance of tissue integrity  Skin reaction to radiation, stomatitis, alopecia,

metastatic skin lesions.
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 1. Skin reaction to radiation
a- Gentle skin handling. b- Loose clothes.
c- Rubbing, use of hot or cold water, soap, powders, lotions, cosmetics, are avoided.
d- Aseptic technique. e- Do not disturb blisters.

2. Stomatitis range from mild erythematic edema, to painful ulcer & bleeding + infection:
o Restrict food difficult to chaw. o Use soft brushes.
o Maintain adequate fluid and food intake. o Lubricate lips.
o Apply topical antifungal & anesthetic sprays. o Avoid too hot or spicy food.

3.Alopecia: may be temporary or permanent (due to damage stem cells & hair follicles).
o Deal with rejection, fear, anxiety and isolation.
o Encourage patient to use a wig or hair piece, attractive scarves.

4.Malignant skin lesions:

May appear with local extension or embolization into epithelium
If there is erythema → wounds, infection and necrosis → Purulent and malodorous → pain,
discomfort very common with breast cancer,

Nursing measures:
 Assessment.  Cleanliness
 Reduction of flora  Control of bleeding
 Protect against pain and trauma.  Control of odor.

5.Maintenance of nutritional status:

Anorexia is due to - Altered taste → salty, bitter, sour mouth → protein, caloric malnutrition. This is due to: -
o chemotherapy o decrease digestion
o fear pain, depression, isolation o malabsorption.
o Cachexia (Wasting syndrome)
Causes:
o Increase energy expenditure due to anaerobic metabolism of tumor. o Food intake.
o Competition of tumor cells for nutrients. o Anorexia
N. measures:
o Overcome factors related to it. o Offer preferences
o Eliminate factors related to anorexia o Small preferences.
o Small frequent meals with supplements. o Measures to relieve diarrhea.
o Oral hygiene and pain relieving measures o Parenteral hyperalimentation
o Vitamin supplement. o Tube feeding.

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 6.Relief of pain: 60-90% of all ca patients have pain. It is usually chronic but may be acute.
Causes:
 Infiltration or compression of nerves (sharp, burning).
 Lymphatic or venous obstruction (dull throbbing pain)
 Ischemia by tumor occluding arterial circulation.
 Obstruction of hollow viscera e.g. colon (dull and poorly localized).
 Cancer pain is irreversible; controllable & not quickly resolved.
 Bone destruction.  Trauma with surgery?
 Inflammation, ulceration and necrosis (skin lesions).  Stomatitis.
Nursing measures:
o Adequate rest, sleep. o Diversion.
o Mood elevation o Empathy.
o Antidepressants, anti-anxiety, analgesics, on a regular schedule (not as needed).

7.Progression through the grieving process:

8.Improved body image and self esteem:
o Encourage independent decision making. o Express feeling
o Encourage participation in activities o Assist in coping
o Be a good listener and counselor. o Referral.

9. Rehabilitation:
There are changes in emotion, life style and daily habits.
Problems faced include:
o Attitudes of others. o Functional ability.
o Assess changes in body image. o Referral
o Use prosthetic devices. o Encourage return to work or social activities.
o Collaborate activities of health team. o Educate employers and the public in general.

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