Cancer Management

By
Dr. Shereen Abd Elmoniem Ahmed
Associate professor of Medical Surgical Nursing
Faculty of Nursing, Suez Canal University
 Cancer vs.
tumor and tumors
• Cancer are similar
in a way that both conditions
are characterized by abnormal
cell division that ends up in the
formation of a mass of cells
with no useful function.
• Tumors (also called
neoplasms) are the more
inclusive term for all
abnormal cell growths.
• Thus, it can be said that
cancer is a type of tumor.
 Definition of
cancer
• Cancer is a disease process that begins
when an abnormal cell is transformed by
the genetic mutation of the cellular DNA.
• There are more than 100 to 200 types of
cancer, including breast cancer, skin cancer,
lung cancer, colon cancer, prostate cancer,
and lymphoma.
• Symptoms vary depending on the type.
?How does cancer start • Cancer is when
abnormal cells
divide in an
uncontrolled way.
Some cancers
may eventually
spread into other
tissues.
 • Cancer starts when
gene changes make
one cell, or a few
cells begin to grow
and multiply too
much. This may
cause a growth
called a tumor.
• Cancer grows as
cells multiply over
?How does cancer grow and over
Types of tumors
• A primary tumor is the name for where a cancer starts.
• Cancer can sometimes spread to other parts of the body – this is
called a secondary tumor or a metastasis.
• Cancer and its treatments can affect body systems, such as the
blood circulation, lymphatic and immune systems, and the hormone
system.
• Cancers are divided into groups according to the type of cell they
start from. They include:
1) Carcinomas
2) Lymphomas
3) Leukemias
4) Brain tumors
5) Sarcomas
 • The stage of a cancer
Staging and Grading means how big it is
and whether it has
of Cancer spread.
• Staging determines the
size of the tumor and
the existence of
metastasis.
• Grading refers to the
classification of the
tumor cells.
• Grading looks at
how abnormal the
cancer cells are.
 Cancer
Stage 0
Stages
Stage I Stage II Stage III Stage IV
indicates Cancer is Cancer has Cancer is Cancer has
that the small and grown, but larger and spread from
cancer is hasn't spread hasn't may have where it started
where it anywhere spread spread to the to at least one
started (in else surrounding other body
situ) and tissues and/or organ; also
hasn't the lymph known as
spread nodes (part "secondary" or
of the "metastatic"
lymphatic cancer
system)
 Cancer
grades
Cancer cells that resemble normal cells and
Grade aren't growing rapidly.
I

Grade Cancer cells that don't look like normal cells and
are growing faster than normal cells.
II

Cancer cells that look abnormal and may grow

Grade or spread more aggressively.
III
 Differences Between Benign and Malignant
Characteristics of Benign Tumors TumorsCharacteristics of Malignant Tumors

1. Cells tend not to spread 1. Cells can spread

2. Most grow slowly 2. Usually grow rapidly
3. Do not invade nearby tissue 3. Often invade basal membrane that
4. Do not metastasize (spread) to other surrounds nearby healthy tissue
parts of the body 4. Can spread via bloodstream or
5. Tend to have clear boundaries lymphatic system, or by sending
"fingers" into nearby tissue
6. Under a pathologist's microscope, shape, 5. May recur after removal, sometimes in
chromosomes, and DNA of cells appear areas other the original site
normal
6. Cells have abnormal chromosomes and
7. Do not secrete hormones or other DNA characterized by large, dark nuclei;
substances (an exception: may have abnormal shape
pheochromocytomas of the adrenal
gland) 7. Can secrete substances that cause fatigue
and weight loss (paraneoplastic
8. May not require treatment if not syndrome)
health- threatening
9. Unlikely to recur if removed or require 8. May require aggressive treatment,
further treatment such as radiation or including surgery, radiation,
chemotherapy chemotherapy, and immunotherapy
medications
 Cancer
:Initiation
Processes
the first stage, is when initial cell mutation
i. It may involve one or more cellular changes that are .either
occursspontaneous
or started by exposure to a carcinogen.
ii. damage or mutation to DNA causes excessive cell division due to
activation of oncogene (the portion of deoxyribonucleic acid (DNA)
that regulates normal cell growth and repair) function and decreased
tumor suppressor gene (are the components of DNA that stop,
inhibit, or suppress cell division) function.
.iii Mutations in oncogenes and tumor suppressor genes allow cells to
grow beyond normal body needs.
iv. The new cell clones that arise from the cellular changes typically have
a selective and reproductive advantage over the original cells.
• Promotion: Promotion is the second stage where the transformed
cells are stimulated to divide.
• during promotion ,mutated cells are exposed to promoters
that enhance their growth.
• For example, one tumor promoter is estrogen, a naturally
occurring hormone that by itself will not “initiate” cancer.

• Progression: is the third stage, during progression, tumor cells

compete with one another to survive, leading to more mutations
that make the cells more aggressive, and their growth rate
increases; this allows them to metastasize to the surrounding
tissues
• Metastasis: In metastasis, cancer cells break away from where they
first formed (primary cancer), travel through the blood or lymph system,
and form new tumors (metastatic tumors) in other parts of the body. The
metastatic tumor is the same type of cancer as the primary tumor.
Site of Metastasis for common
tumors
Risk Factors of Cancer
• Environmental exposure to
carcinogens
• Genetic factors
• Age
• Diet
• Hormones
• Immunosuppression
• Viruses and Infections
• Obesity
• Radiation
• Sunlight
• Tobacco & Alcohol
• Stress and Inflammation
 Signs of
Cancer
1. Change in bowel or bladder habits
2. A sore that does not heal
3. Unusual bleeding or discharge
4. Thickening or lump in the breast or elsewhere
5. Indigestion or difficulty in swallowing
6. Obvious change in a wart or mole
7. Nagging cough or hoarseness
8.Sudden Weight loss,
9.poor appetite,
10.fatigue
11.excessive sweating (night sweats)
12. anemia.
 • History & Physical Exam
• depend on clinical manifestations, index of suspicion for a
particular cancer
Diagnostic TestsLab Tests
•
Screening chemistry tests e,g, electrolytes (sodium,
potassium, calcium), renal test BUN, creatinine,
liver test (bilirubin, AST, Alkaline Phosphate,
LDH), bone test (calcium ) depend on individual
condition risk factors.
CBC with differential and platelets.
Tumor Markers: For baseline and observation — to
assess tumor burden and monitor levels of tumor and indicate
a recurrence; prognosis (what treatment to use if the tumor
should recur); most tumor markers are NOT specific, meaning
that positive result does not necessarily mean that the
primary site can be readily identified
 ’Diagnostic Tests cont
• Imaging • Chest x-ray screens for primary
or metastatic disease of lung.

• Endoscopy (used for direct visualization of

body organs/cavities to detect
abnormalities)
Scans (e.g., MRI, CT •
ultrasound: may be done for
& Gallium)
diagnostic purposes, identification of
metastasis and evaluation of response to
treatment.
• Biopsy (fine needle aspiration FNA, needle
core, incisional, excisional) done to
differentiate and delineate treatment and
may be taken from bone marrow, skin,
organ.
 Medical Management
• The range of possible treatment goals may include
complete eradication of malignant disease (cure),
prolonged survival and containment of cancer cell
growth (control), or relief of symptoms associated with
the disease (palliation).
• Treatment depends on: Type of cancer, Location,
Extent of cancer, Stage at which has been
diagnosed, Health and well being of patient.
 Oncological treatment modalities
1. - Surgery
• Surgery may be the primary method of treatment or may be
Diagnostic , prophylactic, palliative, or reconstructive. The goal of
surgery is to remove the tumor or as much as is feasible.
a. Diagnostic surgery
• Biopsy is performed to obtain a tissue sample for analysis of cells
suspected to be malignant. There are three types of biopsy.
• Excisional biopsy: Must common because of easily accessibility of the skin,
breast, upper and lower resp. tract. In many cases the doc can remove
the entire tumor.
• Incisional biopsy: This is done if the tumor is to large. A wedge is
removed.
• Needle biopsy: done to sample suspicious masses that are easily
accessible. The procedure is fast, relatively inexpensive and easy to
perform.
B. Prophylactic surgery
• Removing nonvital tissues or organs that are likely to develop
cancer. Colectomy and mastectomy are the 2 most common types.
• The following factors are considered before performing this
surgery.
• Family history
• Presence or absence of symptoms
• Potential risk and benefits
• Ability to detect cancer at an early state
• Patients acceptance of the post op outcome.
C. Palliative surgery
• Making the patient as comfortable as possible because surgery is
not an option. The goal is quality of life.
• Honest and informative communication with the patient and family
about the goal of surgery is essential to avoid false hope and
disappointment.
D. Reconstructive surgery
• This done after curative or radical surgery to improve function
or obtain a more desirable cosmetic effect.
• Could be done in stages or in one operation.
 Nursing Management Related to Cancer
Surgery
1. Complete a thorough preoperative assessment for all factors
that may affect patients undergoing surgery.
2. Assist patient and family in dealing with the possible changes
and outcomes resulting from surgery; provide education and
emotional support by assessing patient and family needs and
exploring with them their fears and coping mechanisms.
Encourage them to take an active role in decision making when
possible.
3. Explain and clarify information the physician has provided
about the results of diagnostic testing and surgical procedures, if
asked.
4. Communicate frequently with the physician and other health
care team members to ensure that the information provided is
consistent.
Nursing Management Related to Cancer
Surgery
5. assess patient’s responses to the surgery and monitor for
complications such as:
• infection
• Bleeding
• Thrombophlebitis
• wound dehiscence,
• fluid and electrolyte imbalance,
• organ dysfunction.
6. Provide for patient comfort.
7. Provide postoperative teaching that addresses
• wound care
• Activity
• Nutrition
• medications.
8. Initiate plans for discharge, follow-up care, and treatment as
early as possible to ensure continuity of care.
 ’Oncological treatment modalities cont

2 Chemotherapy
• Is one modality of treatment for both cancerous and
non- cancerous conditions.
• In chemotherapy, antineoplastic agents are used in an
attempt to destroy tumor cells by interfering with
cellular functions and reproduction.
 ’Oncological treatment modalities cont
• Goals of chemotherapy are:
1.Curative treatment are aimed at total elimination of
cancerous cells, including those may spread to other
parts of the body.
2.Adjuvant chemotherapy is used in addition to
surgery and/ or radiation to eliminate systemic
microscopic cancerous cells. The purpose of adjuvant
therapy is to provide a complete cure or remission.
3.The intent of palliative chemotherapy is to reduce
tumor size, extend life and improve the overall quality
of life.
 Administration of chemotherapy

• Chemotherapeutic agents may be administered in the

hospital, clinic, or home setting by topical, oral,
intravenous, intramuscular, subcutaneous, arterial,
intracavitary, and intrathecal routes.
• The administration route usually depends on the type of
agent, the required dose, and the type, location, and
extent of tumor being treated.
Chemotherapy side effects by body systems

• Generalized: Genitourinary
• Fatigue , • Acute kidney
• lack of energy injury,
• Hematopoietic: • Cystitis,
• Bone marrow • Hematuria
suppression,
• Neutropenia,
• Thrombocytopenia&
• Anemia
• Gastrointestinal:
• Nausea,
• vomiting,
• diarrhea,
• constipation,
• anorexia,
• mucositis/stomatitis (ulcers in mouth or throughout GI
tract),
• dysgeusia (altered taste )
• dry mouth,
• dyspepsia (heartburn )
• Integumentary: :Neurologic •
• Alopecia (hair loss), • Peripheral neuropathy
• Dermatitis /skin rash, (altered sensation in the
• Urticaria (hives),
hands/feet),
• Pruritis (itching),
• Central neurotoxicity,
• Nail changes,
• Hyperpigmentation • Ototoxicity (ringing in the
(skin discoloration), ears)
• Cardiovascular: • Pulmonary:
• Weakening of heart muscle, • Pulmonary fibrosis,
• Heart failure, • Pneumonitis,
• Peripheral edema • Pulmonary edema

• Vascular: • Reproductive/Sexuality:
• Phlebitis, • Infertility,
• loss of libido,
• Vein Sclerosis (scarring),
• impotence,
• Extravasation
• Amenorrhea ,
• Early menopause
• Psychiatric:
• Anxiety,
• Depression,
• Anger,
• Fear,
• grief/loss,
• body image
distortion
 Nursing Management in
chemotherapy
• Assessing fluid and electrolyte balance. as patients
at risk for nutritional and fluid electrolyte
disturbances.
• Modifying risks for infection and bleeding.
Suppression of the bone marrow and immune
system is expected and frequently serves as a
guide in determining appropriate chemotherapy
dosage but increases the risk of anemia, infection,
and bleeding disorders.
 Nursing Management in
chemotherapy
• Administering chemotherapy. The patient is
observed closely during its administration because of
the risk and consequences of extravasation,
particularly of vesicant agent.
• Protecting caregivers. Nurses must be familiar with
their institutional policies regarding personal
protective equipment, handling and disposal of
chemotherapeutic agents and supplies, and
management of accidental spills or exposures.
 3- Radiation Therapy
Oncological treatment • Is the use of high-energy
’ modalities cont x-ray to treat cancer.
Goals of Radiation
Therapy
• Treatment of cancer
with ionizing
radiation
• Radiation destroys
cells in the area
being treated
• Making it impossible
for these cells to
continue to grow.
 Indications for radiation therapy
 Cure: primary treatment for early stage of Hodgkin's disease,
cervical carcinoma.
 Control: to control the growth or spread of tumors mass. Generally,
not a cure but may curative and/or to allow less allow less radical
surgery
 Neo-adjuvant: to ‘’downstage’’ bulky tumors, such as large breast or
rectal tumors. Intent may be curative and /or to allow less radical surgery
 Adjuvant: to reduce the risk of local recurrence at the site of tumor such
as
breast radiation after lumpectomy, or to treat sanctuary sites such as the
brain after definitive therapy for acute lymphocytic leukemia or small
cell lung cancer .
 Palliation: pain control for sites of bony metastasis, control of
bulky metastasis to reduce morbidity such as massive
lymphadenopathy.
 Oncologic emergencies: spinal cord compression and superior vena
cava syndrome (selected cases).
 Administration of radiation therapy
• External radiation
• Can be used to destroy cancerous cells at the skin surface or deeper in the
body.
• The higher the energy, the deeper the penetration into the body.
• Some centers are using intraoperative radiation therapy (IORT). Which involves
using a single dose of high fraction radiation therapy to expose the tumor
bed while the body cavity is open during surgery.
• Toxicity is minimized because the radiation is precisely targeted to the
diseased areas, and exposure to overlying skin and structure.
• Internal radiation
• Brachytherapy: delivers a high dose of radiation to a localized area.
• Can be implanted by way of needle, seeds, beads, or catheters into the
body cavity.
• Usually done to treat gynecological cancers
 side effects of Radiation
• Alopecia. Altered skin integrity is a common effect and can
include alopecia or hair loss.
• Stomatitis. Alterations in oral mucosa secondary to radiation
therapy include stomatitis or inflammation of the oral tissues,
xerostomia or dryness of the mouth, change and loss of taste, and
increased salivation.
• Thrombocytopenia. Bone marrow cells proliferate rapidly, and if
sites containing bone marrow are included in the radiation field,
anemia, leukopenia, and thrombocytopenia may result.
 Nursing Management in Radiation
Therapy
• Assessment. The nurse assesses the patient’s skin and
oropharyngeal mucosa regularly when radiation therapy
is directed to these areas, and also the nutritional status
and general well-being should be assessed.
• Symptoms. If systemic symptoms, such as weakness and
fatigue, occur, the nurse explains that these symptoms are
a result of the treatment and do not represent
deterioration or progression of the disease.
 Nursing Management in Radiation
Therapy
• Safety precautions. Safety precautions used in caring for a
patient receiving brachytherapy include:
• Assigning the patient to a private room,
• Posting appropriate notices about radiation safety precautions,
• Having staff members wear dosimeter badges,
• Making sure that pregnant staff members are not assigned to
the patient’s care,
• Prohibiting visits by children and pregnant visitors,
• Limiting visits from others to 30 minutes daily, and
• Seeing that visitors maintain a 6-foot distance from the
radiation source.
 Nursing Care of Patients with
Cancer
• Nursing Diagnosis:

Impaired skin integrity: erythematous and wet
desquamation reactions to radiation therapy.
 Impaired oral mucous membrane: stomatitis
 Impaired tissue integrity: alopecia

Imbalanced nutrition, less than body requirements, related
to nausea & vomiting, anorexia, or malabsorption
 Pain
 Fatigue
 Risk for bleeding problems
 Risk for infection
 Nursing Care of Patients with
Cancer
(1) Maintaining Tissue Integrity
• Stomatitis. Assessment of the patient’s subjective experience and an objective
assessment of the oropharyngeal tissues and teeth are important and for the treatment
of oral
mucositis, Palifermin (Kepivance), a synthetic form of human keratinocyte growth
factor, could be administered.
• Radiation-associated skin impairment. Nursing care for patients with impaired skin
reactions includes maintaining skin integrity, cleansing the skin, promoting comfort,
reducing pain, preventing additional trauma, avoid rubbing or scratching the area,
exposing the area to sunlight or cold weather, or wearing tight clothing over the
area and preventing and managing infection.
• Alopecia. Nurses provide information about hair loss and support the patient and
family in coping with changes in body image.
• Malignant skin lesions. Nursing care includes cleansing the skin, reducing superficial
bacteria, controlling bleeding, reducing odor, protecting the skin from further trauma,
 Promoting )2(
Nutrition
Suggest foods that are preferred and well •
.tolerated by the patient, preferably high-calorie and high-protein foods
.Respect ethnic and cultural food preferences •

.Encourage adequate fluid intake, but limit fluids at mealtime •

.Suggest smaller, more frequent meals •
Promote relaxed, quiet environment during •
.mealtime with increased social interaction as desired

.Encourage nutritional supplements and high-protein foods between meals •

Encourage frequent oral hygiene and provide pain relief measures to make •
.meals more pleasant
(3) Relieving Pain

• Assessment. The nurse assesses the patient for the source and
site of pain as well as those factors that increase the patient’s
perception of pain.

• Cancer pain algorithm. Various opioid and nonopioid

medications may be combined with other medications to control
pain.

• Education. The nurse provides education and support to correct

fears and misconceptions about opioid use.
 Decreasing )4(
Fatigue
• Assessment. The nurse assesses physiologic and psychological stressors that
can contribute to fatigue and uses several assessment tools such as a simple
visual analog scale to assess levels of fatigue.

• Exercise. The role of exercise as a helpful intervention has been

supported by several controlled trials.

• Pharmacologic interventions. Occasionally pharmacologic interventions

are utilized, including antidepressants for patients with depression,
anxiolytics for those with anxiety, hypnotics for patients with sleep
disturbances, and psychostimulants for some patients with advanced
cancer or fatigue that does not respond to any medication.
(5) Improving Body Image and Self-esteem

• Assessment. The nurse identifies potential threats to the patient’s

body image experience, and the nurse assesses the patient’s ability to
cope with the many assaults to the body image experienced
throughout the course of the disease and treatment.

• Sexuality. Nurses who identify physiologic, psychologic or

communication difficulties related to sexuality or sexual function are
in a key position to help patients seek further specialized evaluation
and intervention if necessary.
 Monitoring and Managing Potential Complications )7(

• Infection. The nurse monitors laboratory studies to detect any early

changes in WBC counts.

• Assess patient for evidence of infection: Check vital signs every 4 hours,
monitor white blood cell (WBC) count and differential each day, and
inspect all sites that may serve as entry ports for pathogens (eg,
intravenous [IV] sites, wounds, skin folds, bony prominences, perineum,
and oral cavity).

• Report fever, chills, diaphoresis, swelling, heat, pain, erythema, exudate

on any body surfaces. Also report change in respiratory or mental
status, urinary frequency or burning, malaise, myalgias, arthralgias, rash,
• Septic shock. Neurologic assessments are carried out, fluid and
electrolyte status is monitored, arterial blood gas values and pulse
oximetry are monitored, and IV fluids, blood, and vasopressors are
administered by the nurse.

• Bleeding and hemorrhage. The nurse may administer IL-11,

which has been approved by the FDA to prevent severe
thrombocytopenia, and additional medications may be prescribed to
address bleeding due to disorders of coagulation.
Thank you