CARE OF PATIENTS WITH

CANCER
Medical – Surgical Nursing 1

KRISTELLE LYNNE O. MANLAPAS, RN MANc

LECTURER
 INTRODUCTION

CANCER
 Recognized in ancient times by skilled observers who gave it the name
“Cancer” (Latin, Canri, Crab) because it stretches out in many directions
like legs of a crab.

 It afflicts people of all ages, all socio economic and cultural backgrounds
and both sexes.

 Nurses are involved in all phases of cancer experience: Prevention,

detection, diagnosis, treatment, rehabilitation, survivorship, palliative and
terminal care.
TERMINOLOGIES
CANCER – a disease of the cell in which the normal mechanisms of the control of growth and
proliferation have been altered.
BENIGN NEOPLASM – a harmless growth that does not spread or invade other tissues
NEOPLASIA – abnormal cellular changes and growth of new tissues
HYPERPLASIA – Increase in cell number
HYPERTROPHY – Increase in cell size
METAPLASIA – Replacement of one adult cell type by different adult cell type
DYSPLASIA – Changes in cell size, shape, organization
ANAPLASIA – Reverse cellular development to a more primitive or embryonic cell type
METASTASES – spread of cancer cells to distant parts of the body to set up new tumors
ONCOLOGY – the medical specialty that deals with the diagnosis, treatment and study of cancer
TERMINOLOGIES
ADENOCARCINOMA – Cancer that arises from glandular tissues; example Breast, lung,
thyroid, colon and pancreas
CARCINOMA – A form of cancer that is composed of epithelial cells; develops in tissues
covering or lining organs of the body such as skin, uterus or breast
SARCOMA – A cancer of supporting connective tissues such as cartilage, bones, muscles, fats
CARCINOGENS – Factors associated with cancer causation, EX: Radiation, chemicals,
viruses, physical agents
PATHOGENESIS OF CANCER
CELLULAR TRANSFORMATION AND DERANGEMENT
THEORY
 Conceptualizes that normal cells may be transformed into cancer
cells due to exposure to some etiologic agents
FAILURE OF THE IMMUNE RESPONSE THEORY
 Advocates that all individuals possess cancer cells. However, the
cancer cells are recognized by the immune response system. So, the
cancer cells undergo destruction. Failure of the immune system
response leads to inability to destroy cancer cells
ETIOLOGIC FACTORS TO CANCER

1. VIRUSES
 “Oncogenic viruses” may be one of the multiple agents acting to initiate carcinogenesis
 Prolonged frequent viral infections may cause breakdown of the immune system or
overwhelm the immune system
 Viral infections that increase risk of certain forms of cancer are as follows:
• HPV – Cervical Ca
• Epstein Barr Virus – Lymphoma
• Hepatitis B and C – Hepatocellular Ca
• Helicobacter Pylori – Gastric Ca
ETIOLOGIC FACTORS TO CANCER

2. CHEMICAL CARCINOGENS
 These factors act by causing cell mutation or alteration in cell enzymes and proteins
causing altered cell replication
 Chemical Carcinogens are as follows:
• Industrial Compounds – Vinyl Chloride (used for plastic manufacture, asbestos factories,
construction works)
• Polycyclic aromatic hydrocarbons (such as from refuse burning, aauto and truck emissions,
oil refineries and air pollution)
• Fertilizers, weed killers
• Dyes (analine dyes used in beauty shops, hair bleach)
ETIOLOGIC FACTORS TO CANCER

 Chemical Carcinogens are as follows: (Cont).

• Drugs – Tobacco (Tar Nicotine) 90% of all cases of lung Ca are due to smoking
• Alcohol
• Cytotoxic drugs OR antineoplastics

 Hormones
• Estrogen  hormone causes cancer cells to multiply and spread
• Diethylstilbrestol (DES) a synthetic form of the female hormone estrogen
ETIOLOGIC FACTORS TO CANCER

Chemical Carcinogens are as follows: (Cont).

 FOOD, PRESERVATIVES
• Nitrites (Bacon, smoked meat)
• Talc (Polished rice, salami, chewing gum)
• Food sweeteners
• Nitrosamines (Rubber baby nipples)
• Aflatoxins – mold in nuts and grains, milk, cheese, peanut butter)
 POLYCYCLIC HYDROCARBONS
• Charcoal Broiling
ETIOLOGIC FACTORS TO CANCER

 Physical Agents
• Radiation – X-rays or radioactive isotopes; from sunlight/ultraviolet rays
• Physical irritation/trauma – from pipe smoking, multiple deliveries, jagged
tooth, irritation of the tongue, overuse of any organ or body part

 Hormones
• Estrogen as replacement therapy has been found to increase incidence of
vaginal, cervical, uterine cancers
ETIOLOGIC FACTORS TO CANCER

 Genetics
• When oncogene is exposed to carcinogens, changes in cell structure occurs,
malignant tumor develops
• Familial patterns. Ex. Retinoblastoma, pheochromocytoma, Wilm’s tumor,
Lung ca, Breast ca
PREDISPOSING FACTORS TO CANCER

 AGE – older individuals are more prone to cancer because they have been exposed to
carcinogens longer
 SEX – the most common type of cancer in females is breast cancer, for males is prostate
cancer
 URBAN VS RURAL RESIDENCE – cancer is most common to urban dwellers than
among rural residents
 GEOGRAPHIC DISTRIBUTION – The most common type of cancer in Japan is Gastric
Ca; while in US is breast Ca
 OCCUPATION
 HEREDITY – breast, ovarian, colorectal, prostate, melanoma, uterine, sarcomas, and
primary brain tumors
PREDISPOSING FACTORS TO CANCER

 STRESS – Depression, grief, anger, aggression, despair, or life stresses

 PRECANCEROUS LESIONS – pigmented moles, burn scars, senile keratosis,
leukoplakia, benign polyps or adenoma of the colon or stomach, fibrocystic disease of the
breast may undergo transformation into cancerous lesions and tumors
 OBESITY – Studies have linked obesity to breast and colorectal cancer
 COMPARISON OF THE CHARACTERISTICS
OF BENIGN AND MALIGNANT NEOPLASM
CHARACTERISTICS BENIGN MALIGNANT
1. Speed of growth Grows slowly Grows rapidly

2. Mode of growth Remains localized Infiltrates surrounding tissue

3. Capsule Encapsulated Not encapsulated

Well – differentiated mature cells; but cells Poorly differentiated; anaplastic/embryonic

4. Cell characteristic
poorly function type of cells

Common following surgery because cancer

5. Recurrence Extremely unusual when surgically removed
cells spread into other tissues

6. Metastasis Never occur Very common

Always harmful to host. May result to necrosis,

Not harmful to host, unless it compresses
7. Effects of neoplasm ulcerations, hemorrhage, infection. Produces
tissues or obstruct vital organs
Cachexia

Poor prognosis if cells are poorly differentiated

8. Prognosis Very good
and evidence of metastasis exists
PREVENTION, SCREENING AND EARLY
DETECTION
PRIMARY PREVENTION
• Primary prevention activities are aimed at intervention before pathologic change has
begun.
 Adapting a more healthy diet
 Limiting exposure to sun and other sources of UV radiation
 Modifying sexual practices
 Avoiding cigarette smoking
 Alcohol drinking
 Decreasing exposure to environmental and occupational carcinogens
PREVENTION, SCREENING AND EARLY
DETECTION (Cont.)
SECONDARY PREVENTION
• Early detection provides the opportunity to detect precancerous lesions or early stage
cancers to treat them promptly
 SUMMARY OF AMERICAN CANCER SOCIETY
RECOMMENDATIONS FOR EARLY DETECTION OF
CANCER IN ASYMPTOMATIC PEOPLE
1. Cancer – related check-up
• Recommended every 3 years for people aged 20-40 years and every year for people aged 40 and older.
2. Breast
• Women who are aged 40 and older should have an annual mammogram, annual clinical breast exam
(CBE) performed by a healthcare professional and should perform monthly breast examination (BSE)
• Women aged 20-39 should have CBE every 3 years and should perform monthly BSE
3. COLON AND RECTUM
• Men and women aged 50 years or older should follow one of the following examination schedules:
• Fecal occult blood tests every year and a flexible sigmoidoscopy every 5 years
• Colonoscopy every 10 years
• Double contrast Barium enema every 5-10 yrs
• DRE should be done at the same time as sigmoidoscopy, colonoscopy, or double – contrast barium
enema
 SUMMARY OF AMERICAN CANCER SOCIETY
RECOMMENDATIONS FOR EARLY DETECTION OF CANCER
IN ASYMPTOMATIC PEOPLE Cont.

4. PROSTATE
• Prostate specific antigen (PSA) and DRE annually from age 50
5. UTERUS
• Cervix – all women who are or have been sexually active or who are 40 and older should have an
annual pap test and pelvic examination. Test for HPV is recommended
• Endometrium – women at high risk for cancer of the uterus should have sample of endometrial tissue
examined when menopause begins.
COMMON CAUSES OF CANCER
1. BREAST CANCER
 Early menarche
 Late menopause
 Nulliparous or older than 30 years at the birth of a first child

2. LUNG CANCER
 Tobacco abuse
 Asbestos
 Radiation exposure
 Air pollution
COMMON CAUSES OF CANCER
3. COLORECTAL CANCER
 Greater incidence in men
 Familial polyposis
 Ulcerative colitis
 High fat, low fiber diet

4. PROSTATE CANCER
 Common among males who are 50 years and older
 African americans have the highest incidence of prostate cancer in the world
 Positive family hx
 Exposure to cadmum
COMMON CAUSES OF CANCER
5. Cervical Cancer
• Sexual behavior – first intercourse at early age; multiple sexual partners; sexual
partner whoa has had multiple sexual partner
• HPV and AIDS
• Low socioeconomic status
• Cigarette smoking

6. Head and Neck cancer

• Common among males
• Alcohol and tobacco use
• Poor oral hygiene
• Long term sun exposure
• Occupational exposure
COMMON CAUSES OF CANCER
7. SKIN CANCER
• Individuals with fair complexion
• Positive family history
• Moles
• Exposure to coal tar, creosote, arsenic, radium
• Sun exposure between 11am to 3pm
DIETARY RECOMMENDATIONS
AGAINST CANCER BY ACS
 Avoid obesity
 Cut down on total fat intake
 Eat more high fiber foods, like raw fruits and vegetables, whole grain cereals
 Include food rich in Vitamin A and C in daily diet
 Include cruciferous vegetables in the diet, like broccoli, cabbage, cauliflower, Brussel
sprouts
 Be moderate in consumption of alcoholic beverages
 Be moderate in consumption of salt – cured, smoke cured and nitrite cured foods
DIETARY RECOMMENDATIONS
AGAINST CANCER BY ACS
 High intake of fats may be associated with breast, colon and prostate cancer
 Low intake of fruits, vegetables, complex carbohydrates, and fibers is linked with cancer
of the colon, larynx, esophagus, and stomach
 Excess alcohol intake is associated with cancer of the mouth, larynx, esophagus, and liver
especially when combined with smoking
WARNING SIGNALS OF CANCER
C – Change in bowel or bladder habits
A – sore that does not heal
U – unusual bleeding or discharge
U – unexplained, sudden weight loss
U – unexplained anemia
T – thickening or lump in the breast or elsewhere
I – indigestion or difficulty in swallowing
O – obvious change in wart or mole
N – nagging cough or hoarseness of voice
STAGING AND GRADING OF NEOPLASIA

 Staging – determining in size of the tumor and existence

of metastases necessary at the time of diagnosis to
determine the extent of disease
 Grading – classification of tumor cells; to determine
prognosis and to guide proper management
STAGING AND GRADING OF NEOPLASIA

AJCC TNM Classification System (All tumor types)

T – Tumor size
N – presence or absence of regional lymph node
involvement
M – presence or absence of distance metastasis
 CANCER DETECTION EXAMINATIONS
 Cytologic Examination or Papanicolau Test (pap’s exam; pap smear)
• Specimen can be obtained from tumors that tend to shed cells from their surface
Interpretation of Papanicolau Test results:

CLASSIFICATION INTERPRETATION
CLASS I NORMAL
CLASS II INFLAMMATION
CLASS III MILD TO MODERATE DYSPLASIA
CLASS IV PROBABLY MALIGNANT
CLASS V POSSIBLY MALIGNANT
 CANCER DETECTION EXAMINATIONS
 BIOPSY – involves obtaining tissue samples by needle aspiration, or incision of tumor.

 ULTRASOUND, MRI, CT SCAN, ENDOSCOPIC EXAMINATIONS

 LABORATORY TESTS FOR CANCER
• CBC – Hgb; Hct; leukocytes; Platelets
• Tumor Markers – AFP (Alpha Feto protein; CEA Carcinoembrynoic antigen; HCG
Human Chorionic Gonagodtrophin; PSA
 PATHOPHYSIOLOGIC BASIS OF
MALIGNANT NEOPLASM
PREDISPOSING FACTORS/ETIOLOGIC FACTORS

CELLULAR ABBERATIONS

CA cell proliferation Malignant cells produce Anorexia and Cachexia

Disrupt normal cell growth enzymes, hormones and other syndrome
and interfere with tissue substances
function (Paraneoplastic Syndrome)
PARANEOPLASTIC SYNDROME
 Malignant cells produce enzymes, hormones and other substances
 triggered by an abnormal immune system response to a cancerous tumor known as a
"neoplasm.
• ANEMIA
 Ca cells produce chemicals that interfere with RBC production
 Iron uptake is greater in the tumor than that deposited in the liver
 Blood loss results from bleeding that leads to anemia

• HYPERCALCEMIA
 Tumors of the bone, squamous cell lung Ca, Breast Ca, produces parathyroid like hormone
that increases calcium release and accelerates bone breakdown
 Also results from metastasis to the bones
 Enhanced by immobilization and dehydration
PARANEOPLASTIC SYNDROME

 Malignant cells produce enzymes, hormones and other substances

• DIC (Dessiminated Intravascular Coagulation)

 More likely to occur in Lung Ca, pancreas, stomach and prostate
 Precipitated by release of tissue thromboplastin or endothelial injury
ANOREXIA-CACHEXIA SYNDROME
 The final outcome of unrestrained cancer cell growth
 progressive weight loss associated with malignancy
 Malignant neoplasms deprive normal cells of nutrition
 Tumors produces alteration in enzyme system necessary for normal metabolism – stored fat is
lost, tissues lose nitrogen
 Tumors revert to anaerobic metabolism – consume glucose, deplete glycogen stores in the liver
 Protein depletion, serum albumin levels decrease
 Tumors take up sodium. Water retention masks malnutrition
 Ca cells produces anorexigenic substances – causing anorexia
 Taste sensation diminishes or becomes altered
TREATMENT MODALITIES FOR CANCER
 SURGICAL INTERVENTIONS
 RADIATION THERAPY
 CHEMOTHERAPY
 IMMUNOTHERAPY
 BONE MARROW TRANSPLANTATION

The choice of Tx modality depends on the type of tumor, the extent of disease and the
client’s co-morbid condition (Ex. Cardiac disease), performance status, and wishes.
SURGICAL INTERVENTIONS
 Diagnostic surgery – Cytologic specimen collection and biopsy
 Preventive Surgery – Removal of precancerous lesions or benign tumors
 Curative Surgery – Removal of an entire tumor and surrounding lymph nodes. Ca
that are localized to the organ of origin and the regional lymph nodes are potentially
curable by surgery
 Reconstructive Surgery – done for the improvement of the appearance and
function of organ affected.
 Palliative Surgery – done in relief of distressing signs and symptoms or for
retardation of metastasis.
EXAMPLES OF PALLIATIVE SURGERY

 Reduce pain by interrupting nerve pathways or implanting pain control pumps

 Relieve airway obstruction, Obstructions in the GI and GU tracts
 Relieve pressure in the brain and in the spinal cord
 Prevent hemorrhage
 Remove infected and ulcerating tumors
 Drain abcessess
 RADIATION THERAPY
 May be used as primary, adjuvant, or a palliative treatment modality.
 Radiosensitivity, the relative sensitivity of tissues to radiation, depends on the individual cell and the
characteristics of the tissue itself.
 RT is the use of high — energy ionizing radiation that destroys a cell's ability to reproduce by damaging its DNA
 Rapidly dividing cells like cancer cells are more vulnerable to radiation. Therefore, radiation kills cancer cells
while sparing normal cells from excessive cell death

PRIMARY MODALITY – it is the only treatment used and aims to achieve local cure of the cancer (e.g., early stage
skin cancer, Hodgkin's disease, carcinoma of the cervix).

ADJUVANT THERAPY - can be done preoperatively or postoperatively to aid in destruction of cancer cells.

PALLIATIVE THERAPY - can be used to relieve pain caused by obstruction, pathologic fractures, spinal cord
compression and metastases.
 RADIATION THERAPY (Cont.)

The types of radiation therapy:

1. External Radiation Therapy (Teletherapy, DXT)

 This is administered through a high energy X —ray or gamma X-ray machine
 The major advantage of high — energy radiation is its skin — sparing effect.
 The maximum effect of radiation occurs at tumor deep in the body, not on the skin surface.
 There is no need for isolation
 RADIATION THERAPY (Cont.)
2. Internal Radiation Therapy
 This is administered within or near the tumor or into the systemic circulation
The major types of internal RT are as follows:
• Sealed source (brachytherapy)
 The radioisotope is placed within or near the tumor.
 The radioactive material is enclosed in a sealed container.
 Sealed source is used for both intracavity and interstitial therapy
 Intra cavity RT is used to treat cancers of the uterus and cervix. The radioisotope is placed
in the body cavity, generally for 24 to 72 hours.
 In an interstitial therapy, the radioisotope is placed in needles, beads, seeds, ribbons, or
catheters, which are then implanted directly into the tumor.
 RADIATION THERAPY (Cont.)
2. Internal Radiation Therapy
 In sealed sources of internal radiation, the radioisotope cannot circulate through the client's
body nor can it contaminate the client's urine, sweat, blood or vomitus.
 Therefore, the clients excretions are not radioactive. However, radiation exposure can
result from direct contact with the sealed radioisotope, such as touching the container with
bare hands or from lengthy exposure to the sealed radioisotope.
 RADIATION THERAPY (Cont.)
• Unsealed Source
 The radioisotopes may be administered intravenously, orally or by instillation directly into the body
cavity.
 In unsealed sources of internal radiation, the radioisotope circulates through the client's body.
Therefore, the client's urine, sweat, blood and vomitus contain the radioactive isotope.
 Examples of unsealed sources of RT are iodine 131 given orally for Grave's disease and thyroid cancer; alrontium chloride 89 is
administered intravenously for relief of painful bony metastases.

 The client receiving an unsealed source of RT: should have a private room and bath
PRINCIPLES OF RADIATION
PROTECTION - DTS

D – DISTANCE
T – TIME
S – SHIELDING
 PRINCIPLES OF RADIATION
PROTECTION
DISTANCE
 The greater the distance from the radiation source, the less the exposure dose of
ionizing rays. Maintain a distance of at least 3 feet when not performing the
nursing procedures.

TIME
 Limit contact with client for 5 minutes each time, a total of 30 minutes per 8 —
hour shift.

SHIELDING
 Use lead shield during contact with client.
PRINCIPLES OF RADIATION
PROTECTION
 pregnant staff should not be assigned to clients receiving internal RT
 Staff members caring for the client with internal RT should wear dosimeter badge
while in the client's room
 To prevent feelings of isolation, maintain contact with the client while keeping
distance from radiation exposure. Talk with the client from the doorway of the
room.
 PRINCIPLES OF RADIATION
 If PROTECTION
the client with cancer of the cervix has radioisotope implant into the uterus, the
following nursing interventions should be implemented:

1. Client's back is turned towards the door. To minimize exposure of healthcare staff to
radioisotope entering the client's room.
2. Encourage the client to turn to sides at regular intervals.
3. The client should be on complete bed rest. To prevent dislodgement of the radioisotope.
4. The client should be given enema before the procedure. Bowel movement during the
procedure may cause dislodgment of the radioisotope.
5. The client should be given low fiber diet to inhibit defecation during tie procedure until
the device is removed in 2 to 3 days. To prevent dislodgement of the radioisotope
 PRINCIPLES OF RADIATION
 If PROTECTION
the client with cancer of the cervix has radioisotope implant into the uterus, the
following nursing interventions should be implemented:

6. The client should have a Foley catheter in place during the procedure. To prevent bladder
distention and subsequently prevent irradiation of the bladder. Irradiation of the bladder may cause
fistula formation between the bladder and the uterus. This causes urine to come out from the vagina.

7. Have long forceps and lead container readily available. Use long forceps to pick up dislodged
radioisotope and place it in the lead container.
 PRINCIPLES OF RADIATION
PROTECTION
All surfaces, including the floor area the client will be walking on, are covered with Chux
or paper.
 Foods are served on disposable plates and utensils
 Trash and linens are kept in the client's room and are not removed until the client is ready
for discharge
 In general, linens are not changed until are grossly soiled. This is to minimize radiation
exposure of caregivers.
 The client is also instructed to rinse the sink with copious amount of water after tooth
brushing and to flush toilet several times after each use. To prevent radiation
contamination of other people and environment.
 Anyone entering the room wears a new pair of booties each time to prevent tracking the
radioisotope out into the hallway
 PRINCIPLES OF RADIATION
PROTECTION
Caregivers should wear gloves when handling body fluids
 Any emesis (vomiting), especially that occurs shortly after ingestion of oral
radioisotope, should be covered with absorbent pads, and the radiation safety
officer should be called immediately.
Teaching Guidelines Regarding External Radiation Therapy

 It is painless
 Lie very still on a special table while the intervention is being given and you may be
placed in a special position to maximize tumor irradiation
 Each treatment usually lasts for few minutes, You may hear sounds of machine being
operated, and the machine may move during the therapy.
 As a safety precaution for the therapy personnel, you will remain alone in treatment room
while the machine is in operation
 The technologist will be right outside your room observing you through a window or by a
closed — circuit TV You may communicate
 There is no residual radioactivity after radiation therapy. Safety precautions are necessary
only during the time you are actually receiving irradiation. You may resume normal
activities of daily living
Nursing Interventions for Side Effects of Radiation Therapy

1. Skin Reactions
 Erythema, dry/ moist desquamation
 Atrophy, telangiectasia, depigmentation, necrotic/ulcerative lesions
Nursing Interventions:
• Observe for early signs of skin reaction and report to the physician
• Keep area dry
• Wash area with water, no soap and pat dry (do not rub) Mild soap is permitted
• Do not apply ointments, powders or lotion on the area. Cornstarch may be used
• Do not apply heat; avoid direct sunshine or cold on the area
Nursing Interventions for Side Effects of Radiation Therapy

Nursing Interventions: Cont.

• Use soft cotton fabrics for clothing. To prevent skin irritation
• Do not erase markings on the skin. These serve as guide for areas of irradiation
Nursing Interventions for Side Effects of Radiation Therapy

2. Infection
 This is due to bone marrow suppression
Nursing Interventions:
• Monitor blood counts weekly, especially WBC
• Good personal hygiene, nutrition, adequate rest
• Teach the client signs of infection to report to physician
Nursing Interventions for Side Effects of Radiation Therapy

3. Hemorrhage
 Platelets are vulnerable to radiation
Nursing Interventions:
• Monitor platelet count
• Avoid physical trauma or use of aspirin (ASA)
• Teach signs of hemorrhage to report (e.g., gum bleeding, nose bleeding, black
stools)
• Monitor stool and skin for signs of hemorrhage
• Use direct pressure over injection sites until bleeding stops
Nursing Interventions for Side Effects of Radiation Therapy

4. Fatigue
 Result of high metabolic demands for tissue repair and toxic waste removal
 Plenty of rest and good nutrition
5. Weight loss
 Anorexia, pain and effect of cancer
6. Stomatitis and Xerostomia (Dry mouth)
 Ulceration of oral mucous membrane occurs
Nursing Interventions:
• Administer analgesics before meals, as prescribed
• Bland diet, avoid smoking and alcohol
• Good oral hygiene with saline rinses every 2 hours
• Sugarless lemon drops or mint to increase salivation
 Nursing Interventions for Side Effects of Radiation Therapy

7. Diarrhea, nausea and vomiting, headache, alopecia (hair loss) and cystitis may also
occur.
8. Social isolation is also experienced by the client due to fear of contaminating
others with radiation