• Essential Concepts of Cancer
– – – – – – What is Cancer? Normal Cell Growth vs. Cancer Cell Growth Etiology and Causative Factors Pathophysiology Classification of Tumors Effects of Cancer

• Nursing Process
– – – – – Assessment Laboratory & Diagnostic Tests Tumor Staging and Grading Nursing Diagnoses & Planning Implementation and Management

• Treatment Modalities
– Chemotherapy

• End-of-life Issues

What Is Cancer? CANCER is a complex of diseases which occurs when normal cells mutate into abnormal cells that take over normal tissue. eventually harming and destroying the host .

WHAT IS CANCER • A large group of diseases characterized by: – Uncontrolled growth and spread of abnormal cells – Proliferation (rapid reproduction by cell division) – Metastasis (spread or transfer of cancer cells from one organ or part to another not directly connected) Back .

Loss of Normal Growth Control Normal cell division Cell Suicide or Apoptosis Cell damage— no repair Cancer cell division First mutation Second mutation Third Fourth or mutation later mutation Uncontrolled growth .

Oncogenes Normal cell Normal genes regulate cell growth Cancer cell Oncogenes accelerate cell growth and division Mutated/damaged oncogene .

Example of Normal Growth Dead cells shed from outer surface Epidermis Cell migration Dividing cells in basal layer Dermis .

The Beginning of Cancerous Growth Underlying tissue .

Tumors (Neoplasms) Underlying tissue .

Invasion and Metastasis 1 Cancer cells invade surrounding tissues and blood vessels 2 Cancer cells are transported by the circulatory system to distant sites 3 Cancer cells reinvade and grow at new location Back .

ETIOLOGY/CAUSATIVE FACTORS • • • • • Viruses Chemical carcinogens Physical stressors Hormonal factors Genetic factors .

What Causes Cancer? Some viruses or bacteria Some chemicals Radiation Heredity Diet Hormones .

K.: Lung cancer JAPAN: Stomach cancer CANADA: Leukemia U.Population-Based Studies Regions of Highest Incidence U.: Colon cancer BRAZIL: Cervical cancer CHINA: Liver cancer AUSTRALIA: Skin cancer .S.

Genes and Cancer Viruses Chemicals Radiation Heredity Chromosomes are DNA molecules .

Viruses Virus inserts and changes genes for cell growth Cancer-linked virus .

Examples of Human Cancer Viruses Some Viruses Associated with Human Cancers .

pylori .Bacteria and Stomach Cancer Patient’s tissue sample H.

Tobacco Use and Cancer Some Cancer-Causing Chemicals in Tobacco Smoke .

High-Strength Radiation High Leukemia Incidence Low Least X-ray Dose (atomic radiation) Most .

AIDS and Kaposi’s Sarcoma Without disease HIV infection Depressed immune system KSHV infection Kaposi’s sarcoma .

Heredity and Cancer All Breast Cancer Patients Inherited factor(s) Other factor(s) .

Heredity Can Affect Many Types of Cancer Inherited Conditions That Increase Risk for Cancer Back .


tumors that cannot spread by invasion or metastasis. the term “cancer” applies only to malignant tumors .tumors that are capable of spreading by invasion and metastasis. By definition. they only grow locally • Malignant .Classification of Cancer • According to Behavior of Tumor • Benign . hence.

Malignant versus Benign Tumors Benign (not cancer) tumor cells grow only locally and cannot spread by invasion or metastasis Malignant (cancer) cells invade neighboring tissues. enter blood vessels. and metastasize to different sites Time .

Why Cancer Is Potentially Dangerous Brain Melanoma cells travel through bloodstream Liver Melanoma (initial tumor) .

Patterns of cell Proliferation • • • • • Hyperplasia Dysplasia Metaplasia Anaplasia Neoplasia .

An example is a callus Normal Hyperplasia .Hyperplasia • tissue growth based on an excessive rate of cell division. leading to a larger than usual number of cells. the process of hyperplasia is potentially reversible. can be a normal tissue response to an irritating stimulus.

Dysplasia • Bizarre cell growth differing in size. shape and cell arrangement Normal Hyperplasia Mild dysplasia .

Carcinoma in Situ Normal Hyperplasia Mild dysplasia Carcinoma in situ (severe dysplasia) Cancer (invasive) .

characterized by loss of differentiation and a return to a more primitive form.Patterns of cell Proliferation • Metaplasia • conversion of one type of cell in a tissue to another type not normal for that tissue • Anaplasia • change in the DNA cell structure and orientation to one another. • Neoplasia • uncontrolled cell growth. either benign or malignant .

Metastasis • Metastasis: 3 stages – Invasion – neoplastic cells from primary tumor invade into surrounding tissue with penetration of blood or lymph. Spread – tumor cells spread through lymph or circulation or by direct expansion Establishment and growth – tumor cells are established and grow in secondary site: lymph nodes or in organs from venous circulation – – .

enter blood vessels.Cancer Tends to Involve Multiple Mutations Benign tumor cells grow only locally and cannot spread by invasion or metastasis Malignant cells invade neighboring tissues. and metastasize to different sites Time Mutation Cells inactivates proliferate suppressor gene Mutations inactivate DNA repair genes Proto-oncogenes mutate to oncogenes More mutations. more genetic instability. metastatic disease .

Mutations and Cancer Genes Implicated in Cancer .

adipocytes Blood vessel Cytokines Back Cytokines.Cancer Tends to Corrupt Surrounding Environment Growth factors = proliferation Invasive Matrix Proteases Fibroblasts. proteases = migration & invasion .


Different Kinds of Cancer Some common carcinomas: Lung Breast (women) Leukemias: Bloodstream Lymphomas: Lymph nodes Colon Bladder Prostate (men) Some common sarcomas: Fat Bone Muscle .

Naming Cancers Cancer Prefixes Point to Location Prefix adenochondroMeaning gland cartilage erythro- red blood cell hemangio.blood vessels hepatolipolymphomelanomyelomyoosteoliver fat lymphocyte pigment cell bone marrow muscle bone .

Surgeon General David Satcher Back .Women.S.” U. die like men. Tobacco & Lung Cancer “ Women who smoke like men.

severe anemia • Anorexia-Cachexia Syndrome: wasted appearance of client .can be due to obstruction or pressure • Hematologic Alterations: can impair function of blood cells • Hemorrhage: tumor erosion. bleeding.Effects of Cancer • Disruption of Function.

HTN & peripheral edema • ↑ Adrenocorticotropic hormone (ACTH): cause excessive secretion of cortisone (ie: fluid retention.Effects of Cancer • Paraneoplastic Syndromes: ectopic sites with excess hormone production – – – ↑ Parathyroid hormone→ hypercalcemia ↑ secretion of insulin→ hypoglycemia ↑ Antidiuretic hormone (ADH) → fluid retention. ↑ glucose levels) .

Effects of Cancer • Pain: major concern of clients and families associated with cancer • Physical Stress: body tries to respond and destroy neoplasm • Psychological Stress Back .

course.ASSESSMENT • Nursing History – Health History – chief complaint and history of present illness (onset. location. duration. precipitating and alleviating factors) Cancer signs: CAUTION US! – .

Warning Signs of Cancer • CAUTION US! – – – – – – – – – Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickenings or lumps Indigestion or difficulty in swallowing Obvious change in a wart or mole Nagging or persistent cough or hoarseness Unexplained anemia Sudden unexplained weight loss .

Warning Signs of Cancer • Change in bowel or bladder habits – A person with colon cancer may have diarrhea or constipation. or he may notice that the stool has become smaller in diameter – A person with bladder or kidney cancer may have urinary frequency and urgency .

Warning Signs of Cancer • A sore that does not heal – Small. scaly patches on the skin that bleed or do not heal may be a sign of skin cancer – A sore in the mouth that does not heal can indicate oral cancer .

Warning Signs of Cancer • Unusual bleeding or discharge – Blood in the stool is often the first sign of colon cancer – Similarly. blood in the urine is usually the first sign of bladder or kidney cancer – Postmenopausal bleeding (bleeding after menopause) may be a sign of uterine cancer .

Warning Signs of Cancer • Thickenings or lumps – Enlargement of the lymph nodes or glands (such as the thyroid gland) can be an early sign of cancer – Breast and testicular cancers may also present as a lump .

or difficulty swallowing . heartburn. stomach. including those of the esophagus. may cause indigestion. and pancreas.Warning Signs of Cancer • Indigestion or difficulty in swallowing – Cancers of the digestive system.

or color should be reported . size.Warning Signs of Cancer • Obvious change in a wart or mole – Moles or other skin lesions that change in shape.

may cause a cough that does not go away or a hoarse (rough) voice . including lung cancer and laryngeal cancer.Warning Signs of Cancer • Nagging or persistent cough or hoarseness – Cancers of the respiratory tract.

Warning Signs of Cancer • Unexplained anemia • Sudden unexplained weight loss .

vomitus for acute or occult bleeding Scalp noting hair texture and hair loss – • – – Palpation Abdomen for any masses. bleeding. sputum. heart sounds and bowel sounds Back . bulges or abnormalities Lymph nodes for enlargement • Auscultation – of lung sounds.Physical Assessment • – Inspection – skin and mucus membranes for lesions. petechiae. and irritation Assess stools. urine.

Laboratory & Diagnostic Tests • Cancer detection examination • Laboratory tests – – Complete blood cell count (CBC) Tumor markers – identify substance (specific proteins) in the blood that are made by the tumor • PSA (Prostatic-specific antigen): prostate cancer • CEA (Carcinoembryonic antigen): colon cancer • Alkaline Phosphatase: bone metastasis – Biopsy .

Diagnostic Tests • Determine location of cancer: – – – – – – X-rays Computed tomography Ultrasounds Magnetic resonance imaging Nuclear imaging Angiography .

g. Papanicolaou (PAP) smear).• Diagnosis of cell type: – ▪Tissue samples: from biopsies. shedded cells (e. & washings – ▪ Cytologic Examination: tissue examined under microscope .

lymph node biopsies to determine metastases .• Direct Visualization: – – – – – ▪ Sigmoidoscopy ▪ Cystoscopy ▪ Endoscopy ▪ Bronchoscopy ▪ Exploratory surgery.

Cancer Detection and Diagnosis .

Early Cancer May Not Have Any Symptoms .

Cervical Cancer Screening Normal Pap smear Abnormal Pap smear .

Breast Cancer Screening .

Prostate and Ovarian Cancer Screening .

Colon Cancer Screening .

Biopsy Pathology Proteomic profile Patient’s tissue sample or blood sample Genomic profile .

Microscopic Appearance of Cancer Cells Back .

.Tumor Staging and Grading • Staging determines size of tumor and existence of metastasis • Grading classifies tumor cells by type of tissue • The TNM system is based on the extent of the tumor (T). the extent of spread to the lymph nodes (N). and the presence of metastasis (M).

T4 NX N0 N1. T2. T3. N3 Primary tumor cannot be evaluated No evidence of primary tumor Carcinoma in situ (early cancer that has not spread to neighboring tissue) Size and/or extent of the primary tumor Regional lymph nodes cannot be evaluated No regional lymph node involvement (no cancer found in the lymph nodes) Involvement of regional lymph nodes (number and/or extent of spread) Distant metastasis cannot be evaluated Regional Lymph Nodes (N) Distant Metastasis (M) MX M0 M1 No distant metastasis (cancer has not spread to other parts of the body) Distant metastasis (cancer has spread to distant parts of the body) . N2.Primary Tumor (T) TX T0 Tis T1.

• • • • • • • Acute or chronic pain Impaired skin integrity Impaired oral mucous membrane Risk for injury Risk for infection Fatigue Imbalanced nutrition: less than body requirements

• • • • • • Risk for imbalanced fluid volume Anxiety Disturbed body image Deficient knowledge Ineffective coping Social isolation

1. 2. 3. 4. 5. Pain relief Integrity of skin and oral mucosa Absence of injury and infection Fatigue relief Maintenance of nutritional intake and fluid and electrolyte balance 6. Improved body image 7. Absence of complications

Optimal social interaction Back . Knowledge of prevention and cancer treatment 9.OUTCOME IDENTIFICATION 8. Effective coping through recovery and grieving process 10.

• Prevention and detection
– Primary Prevention

• Reducing modifiable risk factors in the external and internal environment

Secondary Prevention
• Recognizing early signs and symptoms and seeking prompt treatment • Prompt intervention to halt cancerous process

Cancer Prevention
Carcinogenic chemicals Carcinogenic radiation

Cancer viruses or bacteria

Avoid Tobacco
Lung Cancer Risk Increases with Cigarette Consumption


Lung Cancer Risk


15 Cigarettes Smoked per Day


Protect Yourself From Excessive Sunlight .

Limit Alcohol and Tobacco Combination of Alcohol and Cigarettes Increases Risk for Cancer of the Esophagus 40x 30x Risk Increase 20x 10x Alcoholic Drinks Consumed per Day AND Packs of Cigarettes Consumed per Day .

Diet: Limit Fats and Calories Correlation Between Meat Consumption and Colon Cancer Rates in Different Countries 40 Number of Cases (per 100.000 people) 30 20 10 0 80 100 200 300 Grams (per person per day) .

Diet: Consume Fruits and Vegetables .

Avoid Cancer Viruses HPV Infection Increases Risk for Cervical Cancer High Cervical Cancer Risk Low Noninfected women Women infected with HPV .

Avoid Carcinogens at Work Some Carcinogens in the Workplace .

Industrial Pollution Incidence of Most Cancers 1930 1950 Year 1970 1990 Back .

free of disease after treatment → normal life – Control .Goal for chronic cancers – Palliative Care: Quality of life maintained at highest level for the longest possible time .TREATMENT MODALITIES • Aimed towards: – CURE .

most commonly used treatment • • • • • Preventive or prophylactic Diagnostic surgery Curative surgery Reconstructive surgery Palliative surgery • Chemotherapy – use of antineoplastic drugs to promote tumor cell death. by interfering with cellular functions and reproduction .• Surgery – surgical removal of tumors.

• Radiotherapy – directing high-energy ionizing radiation to destroy malignant tumor cells without harming surrounding tissues – Teletherapy (external): radiation delivered in uniform dose to tumor – Brachytherapy: delivers high dose to tumor and less to other tissues. radiation source is placed in tumor or next to it .

• Immunotherapy – use of chemical or microbial agents to induce mobilization of immune defenses. • Biologic response modifiers (BRMs) – use of agents that alters immunologic relationship between tumor and host in a beneficial way .

• Bone marrow peripheral stem cell transplantation – aspirating bone marrow cells from compatible donor and infusing them into the recipient • Gene therapy – transfer of genetic materials into the client’s DNA Back .

• Pharmacologic and non-pharmacologic interventions 2. Promote measures that maintain oral mucosa 4. Promote measures that relieve pain and discomfort. Promote measures to prevent injury from abnormal bleeding • Monitor platelet count. Promote measures to maintain intact skin integrity 3. avoid aspiring products.etc .NURSING MANAGEMENT 1.

encourage frequent handwashing and overall cleanliness 6. Ensure adequate fluid and electrolyte balance . Help decrease the client’s fatigue and increase his activity level 7. Promote measures that identify and prevent infection • Monitor WBC count. Promote measures that ensure adequate nutritional intake • High protein.NURSING MANAGEMENT 5. high calorie diet 8.

Promote measures that address preventing complications of cancer therapy 11. encourage client to express and verbalize feelings 10. • Take an honest gentle. provide necessary information for self-care. caring approach. . Help client and family cope effectively 13.NURSING MANAGEMENT 9. Promote measures to reduce social isolation. Instruct client and family about the disease process and treatments. Promote measures to enhance body image. 12.

Cisplatin – Toxic Effects: reversible renal tubular necrosis .Care of Clients Receiving Chemotherapy • Classes of Chemotherapy Drugs: • Alkylating agents: – Action: create defects in tumor DNA – Ex: Nitrogen Mustard.

alopecia. vomiting.Classes of Chemotherapy Drugs • Antimetabolites: – Action: phase specific – Ex: Methotrexate. diarrhea. stomatitis. leukopenia . 5 fluorouracil – Toxic Effects: nausea.

Bleomycin. adriamycin (doxorubicin) – Toxic Effect: damage to cardiac muscle .phase specific. interfere with DNA – Ex: Actinomycin D.Classes of Chemotherapy Drugs • Antitumor Antibiotics: – Action: non.

bone marrow depression . Vinblastine – Toxic Effects: affects neurotransmission. alopecia.Classes of Chemotherapy Drugs • Miotic inhibitors: – Action: Prevent cell division during M phase of cell division – Ex: Vincristine.

Flutamide (prostate) – Toxic Effects: altered secondary sex characteristics .binding tumors ie: breast. cause tumor regression – Ex: Tamoxifen (breast). prostate. endometrium.Classes of Chemotherapy Drugs • Hormones: – Action: stage specific G1 – Ex: Corticosteroids • Hormone Antagonist: – Action: block hormones on hormone.



bone marrow.Effects of Chemotherapy • Tissues: (fast growing) frequently affected • Examples: mucous membranes. specific organs with specific agents. impair ability to reproduce) . reproductive organs (all are fetal toxic. hair cells.

Chemotherapy Administration • Routes of administration: – Oral – Body cavity (intraperitoneal or intrapleural) – Intravenous • Use of vascular access devices because of threat of extravasation (leakage into tissues) & longterm therapy .

Chemotherapy Administration • Types of vascular access devices: – PICC lines: (peripherally inserted central catheters) – Tunneled catheters: (Hickman.Huber needles) . Groshong) – Surgically implanted ports: (accessed with 90o angle needle.

Nursing care of clients receiving chemotherapy • Assess and manage: – Toxic effects of drugs (report to physician) – Side effects of drugs: manage nausea and vomiting. inflammation and ulceration of mucous membranes. nausea and vomiting with specific nursing and medical interventions . hair loss. anorexia.

immunosuppression precautions • Provide emotional and spiritual support to clients and families Back .Nursing care of clients receiving chemotherapy • Monitor lab results (drugs withheld if blood counts seriously low). blood and blood product administration • Assess for dehydration. oncologic emergencies • Teach regarding fatigue.

REFERENCE • National Cancer Institute • Brunner and Suddarth’s Medical Surgical Nursing .

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