Introduction to Cancer

Arlyce Coumar, MN, RN, OCN

Briana Sanger, MSN, RN, OCN
 Objectives
• Describe basic cellular changes that occur with
carcinogenesis
• Define common terminology used in diagnosis and
treatment of cancer
• Identify events that increase or decrease cancer in
specific populations
• Describe the nurse’s role and scope of practice in the care
of the cancer patient
 World Health Organization
Cancer Statistics
• Cancer is the second leading cause of death globally. In 2018
there were 18.1 million new cases accounting for about 9.6
million deaths, or one in six deaths.
• By 2040, the number of new cancer cases per year is expected to
rise to 29.4 million ad the number of deaths to 16.4 million.
• Generally, cancer rates are highest in countries whose
populations have the highest life expectancy, education level,
and standard of living. But for some cancer types, such as
cervical cancer, the reverse is true, and the incidence rate is
highest in countries in which the population ranks low on these
measures.

World Health Organization, website, accessed 1/14/21

Biology of Cancer
 What is Cancer

• Cancer is a collection of over 200 malignant

diseases
• Characterized by a series of cellular changes
• Cells divide uncontrollably and invade
surrounding tissues
• Arises from the accumulation of multiple
genetic alterations

Eggert, J. (2010). Biology of Cancer. In Eggert, J. (Ed), Cancer Basics (pp. 1-17). Pittsburgh, Oncology Nursing Society .
 Carcinogenesis
• The process by which normal cells are transformed
into cancer cells
• Several factors interact to cause carcinogenesis
• Genetic
• Environmental
• Personal (lifestyle)
• No two diagnoses or cases of cancer are the same
 Characteristics of
Normal Cells

• Have unique functions guided

by cell genetics
• Reproduce themselves exactly
by responding to “GO” signals
• Stop reproducing at the right
time by responding to “STOP”
signals
• Stick together in the right
place
• Self destruct if they are
damaged (apoptosis)

Hanahan, D. & Weinbert, RA. (2011). Hallmarks of cancer: the next generation. Cell, 144 (5), 646-674.
 Normal
Cell
DNA Mutations & Cancer
First
Mutatio
n
Second Most cancers are not the result
Mutatio of an inherited mutation
n
Third
Mutatio
Malignant
n Fourth or Cells
Later
Mutation

Adapted from “The Genetic Basis of Cancer” by W.K. Cavenee and R.L. White, Scientific American 272:72-79, March 1995.
 Behavior of Malignant Cells

• Growth without normal “GO” signals

• Failure to respond to normal “STOP” signals
• Avoidance of programmed cell death (apoptosis)
• Create their own circulatory system to supply nutrients
(angiogenesis)
• May produce higher amounts of specific proteins or
display detectable genetic changes (tumor markers)

Hanahan, D. & Weinbert, RA. (2011). Hallmarks of cancer: the next generation. Cell, 144 (5), 646-674.
 What is a Carcinogen

A carcinogen is any substance that causes cancer:

•Chemical Carcinogens
•Environmental Carcinogens
•Viral Carcinogens
 Carcinogens Effect on Cancer Risk

• Cancer risk increases with age

• Risk from exposure to
carcinogens is cumulative
• There is a lag time from exposure to
development of cancer
• Estimated 6-7 mutations needed for
clinically recognized cancer

Eggert, J. (2010). Biology of Cancer. In Eggert, J. (Ed), Cancer Basics (pp. 1-17). Pittsburgh,
Oncology Nursing Society
 Chemical & Environmental Carcinogens

Factor Carcinogen Associated

Long latency period makes identification of carcinogens difficult
Cancers
Lifestyle Tobacco Lung
Alcohol Esophagus
Industrial Benzene Bladder
Soot/tar/oil Lung, skin
Radon Lung
Drugs DES Vagina
Estrogen Breast, uterus

Eggert, J. (2010). Biology of Cancer. In Eggert, J. (Ed), Cancer Basics (pp. 1-17). Pittsburgh,
Oncology Nursing Society
 Viral Carcinogens

Virus Associated Cancer

Epstein-Barr virus (EBV) Burkitt’s lymphoma

Human immunodeficiency virus Kaposi’s sarcoma

(HIV)

Hepatitis B virus Hepatocellular carcinoma

Liver cancer
Human papillomavirus (HPV) Squamous cell carcinomas
Cervical cancer
Oropharyngeal

Eggert, J. (2010). Biology of Cancer. In Eggert, J. (Ed), Cancer Basics (pp. 1-17). Pittsburgh, Oncology Nursing Society
 Incidence, Prevention,
Detection, and Diagnosis of
Cancers
World Health Organization, International Agency for Research on Cancer
World Health Organization, International Agency for Research on Cancer
 Cancer Prevention
• Actions taken to lower a person’s chance of
getting cancer
• Prevention of cancer has many benefits for
individuals
• Lessens the burden of cancer on a community
and lowers number of deaths caused by cancer
• Understanding risk factors for developing cancer
is important in promoting cancer prevention
Cancer Prevention Overview (PDQ®)–Patient Version. (2020, February 21). Retrieved January 13, 2021,
fromhttps://www.cancer.gov/about-cancer/causes-prevention/patient-prevention-overview-pdq
 Risk Factors for Cancer
Modifiable risk Non-modifiable risk
factors factors
• Tobacco use • Age
• Alcohol use • Biologic sex
• Infection (ex. HIV, HPV) • Family history of cancer
• Obesity • Genetics
• Diet • Race
• Environmental exposure • Ethnicity
• Medications

Cancer Prevention Overview (PDQ®)–Patient Version. (2020, February 21). Retrieved January 13, 2021,
fromhttps://www.cancer.gov/about-cancer/causes-prevention/patient-prevention-overview-pdq
 Methods to Prevent Cancer
• Attempt to avoid or control factors known to
cause cancer
• Promote healthy changes in diet and lifestyle
• Identifying precancerous conditions early
• Vaccines to protect against precancerous
conditions
• Risk-reducing surgeries and procedures
 Cancer Screenings
• Cancer screening looks for signs of cancer before
a person shows symptoms
• Helps identify possible abnormal tissue,
precancerous conditions, or cancer at early
stages
• DOES NOT diagnose cancer – indicates a need for
further follow-up and diagnostic tests
• Early detection of cancer makes it easier to treat
and cure
Cancer Screening Overview (PDQ®)–Patient Version. (2020, August 19). Retrieved January 13, 2021, from
https://www.cancer.gov/about-cancer/screening/patient-screening-overview-pdq#_ 1
 Types of Cancer Screening Tests
• Physical exam and health history
• Pap smear or VIA (Visual Inspection with Acetic Acid)
• Prostate check, breast exam, reported changes of blood in stool
• Laboratory tests
• Checking for elevated levels of tumor markers in blood
• Imaging
• Mammogram
• Procedures
• Colonoscopy

Cancer Screening Overview (PDQ®)–Patient Version. (2020, August 19). Retrieved January 13, 2021, from
https://www.cancer.gov/about-cancer/screening/patient-screening-overview-pdq#_ 1
 Considerations of Screening
• Some methods of screening carry some level of risk
• False positive results
• False negative results
• Unnecessary exposure to radiation
• Procedure risks (bleeding, anesthesia, etc.)
• Emotional stress on patient
• Screening may not be appropriate for every patient
• Risk of screening method for a low-risk patient may outweigh
any potential benefit

Cancer Screening Overview (PDQ®)–Patient Version. (2020, August 19). Retrieved January 13, 2021, from
https://www.cancer.gov/about-cancer/screening/patient-screening-overview-pdq#_ 1
 Benefits of Screening
• Early detection of cancer = greater chance of successful
treatment and cure
• Earlier diagnosis of cancer can lessen the burden of treatment
for patients
• Can be beneficial in controlling incidence of cancer in
populations
• Screening methods that produce consistent and accurate
results and have a relatively low chance of harm can benefit
patients who are at high risk for developing certain cancers

Cancer Screening Overview (PDQ®)–Patient Version. (2020, August 19). Retrieved January 13, 2021, from
https://www.cancer.gov/about-cancer/screening/patient-screening-overview-pdq#_ 1
 Warning Signs Exist for Many Cancers
Breast
• Changes in how the breasts look and feel
• Lump or mass, usually hard and painless
• Swelling in or around the breast,
collarbone, or armpit
• Skin dimpling
• Nipple retraction or discharge
• Nipple or breast redness, dryness, flaking
or thickening
(American Cancer Society, Cancer.org)
Cervical
• Blood spots or light bleeding between
periods
• Menstrual bleeding that is longer and
heavier than usual
• Bleeding after sexual intercourse or pain
during
• Increased vaginal discharge
• Bleeding after menopause
• Unexplained, persistent pelvic and/or back
pain
Warning Signs Exist for Many Cancers
Lung
• Persistent or worsening cough
• Coughing up blood or rust-colored sputum (spit or phlegm)
• Chest pain that is often worse with deep breathing, coughing, or
laughing
• Hoarseness, shortness of breath, or wheezing
• Loss of appetite
• Unexplained weight loss
• Feeling tired or weak
• Recurrent or persistent respiratory infection

(American Cancer Society, Cancer.org)

 Diagnostic Tests
Lab Tests (blood, urine, body fluids)
•Can detect presence of tumor markers or other abnormal lab
results
Imaging Tests (CT, MRI, x-ray, ultrasound, PET scan, etc.)
•Help confirm whether a tumor is present and distinguish from a
benign mass
Biopsy
•Removal and examination of tissue to determine whether cells
are cancerous

How Cancer is Diagnosed. (2019, July 17). Retrieved January 13, 2021, from
https://www.cancer.gov/about-cancer/diagnosis-staging/diagnosis
 Who Diagnoses Cancer
• Oncologist is a doctor who has special training in
diagnosing and treating cancer. Some oncologist
specializes in a particular type of cancer treatment or
disease.
• Pathologist is a doctor who has special training in
identifying diseases by studying cells and tissues under a
microscope.
 Reasons for Staging
• Treatment planning
• Prognostic information
• Evaluate results of treatment
• Facilitates exchange of information between treatment
centers
• Contributes to research
 American Joint Committee on
Cancer Classification
• Evaluates level of cellular change in the tumor compared
to the tissue of origin
• G1: Well-differentiated
• G2: Moderately differentiated
• G3: Poorly differentiated
• G4: Undifferentiated
• Gx: Grade cannot be assessed

Eggert, J. (2010). Staging and Performance Status. In Eggert, J. (Ed), Cancer Basics (pp. 19-34). Pittsburgh,
Oncology Nursing Society
 Grading Classifications
• Low numeric grades (G1 & G2)
• Also called “low-grade” tumors or “well-differentiated” tumors
• Deviate least from normal cells of origin
• High numeric grades (G3 & G4)
• Also called “high-grade” or “poorly-differentiated” tumors
• Most deviant (anaplastic) from normal cells of origin

Eggert, J. (2010). Staging and Performance Status. In Eggert, J. (Ed), Cancer Basics (pp. 19-34). Pittsburgh,
Oncology Nursing Society
 Staging
• Done by the oncologist
• Evaluates the extent of the disease
• Considerations of staging
• Size of tumor
• Invasion of adjacent structures
• Regional lymph node involvement
• Distant metastasis: Has it spread?
• Method of staging depends on diagnosis

Eggert, J. (2010). Staging and Performance Status. In Eggert, J. (Ed), Cancer Basics (pp. 19-34). Pittsburgh,
Oncology Nursing Society
 Clinical Staging Classifications

Stage Description
0 Cancer in situ
1 Tumor limited to tissue of origin; localized tumor
growth
2 Limited local spread
3 Extensive local and regional spread, extends
beyond organ capsule
4 Metastasis
 TNM Staging System

• T = Primary tumor size

• N = Absence or presence of regional lymph node involvement
• M = Absence or presence of distant metastasis

Eggert, J. (2010). Staging and Performance Status. In Eggert, J. (Ed), Cancer Basics (pp. 19-34). Pittsburgh,
Oncology Nursing Society
 TNM Staging System

• Tumor Size
• Tx: Primary tumor can not be assessed
• T0: No evidence of primary tumor
• Tis: Carcinoma in situ
• T1: Localized tumor 2 cm
• T2: Localized tumor < 5 cm
• T3: Advanced tumor > 5 cm
• T4: Massive tumor

Eggert, J. (2010). Staging and Performance Status. In Eggert, J. (Ed), Cancer Basics (pp. 19-34). Pittsburgh,
Oncology Nursing Society
 TNM Staging System

• Lymph Node Involvement

• Nx: Regional lymph nodes can not be assessed
• N0: No evidence of regional node involvement
• N1, N2, N3: Increasing involvement of regional
nodes

• Distant Metastases
• Mx: Distant metastases can not be assessed
• M0: No evidence of distant metastases
• M1: Distant metastases present

Eggert, J. (2010). Staging and Performance Status. In Eggert, J. (Ed), Cancer Basics (pp. 19-34). Pittsburgh,
Oncology Nursing Society
 Metastasis
• Spread of malignant cells away from the primary
tumor
• Common sites of metastasis
• Brain
• Lungs
• Liver
• Bone
• Modes of spread
• Hematological
• Lymphatic
• Seeding
• Manipulation
Eggert, J. (2010). Biology of Cancer. In Eggert, J. (Ed), Cancer Basics (pp. 1-17). Pittsburgh, Oncology Nursing Society
 Staging Examples
6 cm lung tumor that has spread to the lymph nodes and
metastasized to the brain
•Stage 4
•T3 N3 M1
• T3 (advanced tumor size > 5cm)
• N3 (high presence of lymph node involvement)
• M1 (distant metastases present
 Staging Examples
3 cm breast tumor with no evidence of lymph node
involvement or metastasis
•Stage 1 or 2 (depending on extent of local spread)
•T2 N0 M0
• T2 (localized tumor < 5cm)
• N0 (absence of lymph node involvement
• M0 (no evidence of distant metastasis)
 Tumor Nomenclature

Eggert, J. (2010). Biology of Cancer. In Eggert, J. (Ed), Cancer Basics (pp. 1-17). Pittsburgh, Oncology Nursing Society
 Treatment Modalities
• Surgery
• Radiation
• Chemotherapy, Biotherapy, Targeted
Therapy, Immunotherapy
• Hormonal Therapy
• Complementary/Alternative Therapy
 Goals of Treatment
• Curative
• Goal is to completely cure the person of their cancer with
no/minimal chance of recurrence
• Control
• Goal is to keep the cancer from progressing or worsening when
total cure is not possible
• Palliation
• Goal is to promote patient’s comfort and quality of life over
treatment of the cancer itself, even if that means the cancer
progresses or worsens
Best Possible Outcome in Cancer Treatment

BETTER SURVIVAL
 Nurse’s Role in Cancer Prevention
and Treatment
Self Patient Community

Understand role in Advocate for patient’s Identify access barriers

healthcare team goals and wishes and potential solutions

Acknowledge oncology Healthcare team works Promote health, early

is a rapidly evolving together for the patient detection, and screening
specialty through education

Engage in learning Provide evidence-based Work to decrease stigma

opportunities to clinical care associated with
enhance knowledge diagnosis
Questions?
 Helpful Resources
• American Cancer Society (cancer.org)
• International Association of Cancer Registries (GLOBOCAN)
(www.iarc.who.int/)
• National Cancer Institute: Comprehensive Cancer Information
(cancer.gov)
• National Comprehensive Cancer Network (nccn.org)
• The Cancer Atlas (canceratlas.cancer.org)