ONCOLOGIC NURSING

Cellular Abberation
MA.FE M. GADAYAN,RN,MN.
 Biology of Normal Cell
1. Cells grow and increase in number when there is a need
and when satisfied, stops.
• Cells divide by replication – cell division, then they mature
and die.
• Replication of cells normally are in similar structure and
function.
2. Normal Cell Cycle
• G0→G1→S→G2→ M→ G0
• G1 & G2 – stands for gaps; nothing very obvious is
occurring in the nucleus of the cells during these stages,
cells are actually very active, and are growing and
preparing to divide.
• S – stands for synthesis; phase of the cell cycle in
which the DNA is copied or replicated
• M – stands for mitosis; cell actually divides into 2
daughter cells
• G0 – resting on dormant phase, “cell goes on
“vacation”
• In cancer, cells skip G0 phase & goes to
G1; produces more than 2 daughter cells &
never rest
 Proliferation Patterns of Cell Growth
• . Hyperplasia – altered cell divides in an uncontrolled
manner leading to an excess of cells in that region of
the tissue; increase number of cells
• Metaplasia – occurs when type of mature cells is
converted to another type by means of an outside
fluid that affects the parent cell
• Dysplasia – is a bizarre cell growth resulting in cells
that differ in size, shape or arrangement from other
cells of the same tissue.
• Anaplasia – cells lack normal cellular
characteristics and are nearly always
malignant, poorly differentiated, irregularly
shaped or disorganized with respect to
growth and arrangement
• Neoplasia – described as uncontrolled cell
growth that follows no physiologic
demand;can be either benign or malignant
 PATHOPHYSIOLOGY and ETIOLOGY of
CANCER
• EVOLUTION OF CANCER CELLS
– All cells constantly change through growth, degeneration,
repair and adaptation. Normal cells must divide and
multiply to meet the needs of the organism as a whole,
and this cycle of cell growth and destruction ia an integral
part of life processes. The activities of the normal cells in
the human body are all coordinated to meet the needs of
the organism as a whole, but when the regulatory control
mechanisms of normal cells fail, and growth continues in
excess of the body’s needs, neoplasia results
– The term neoplasia refers to both benign and
malignant growths, but malignant cells behave
very differently from normal cells and have
special features characteristic of the cancer
process
– Since the growth control mechanism of normal
cells is not entirely understood, it is not clear
what allows the uncontrolled growth, therefore
no definitive cure has been found
 Characteristics of Malignant Cells
• Differentiation
– Cancer cells are mutated stem cells that have undergone
structural changes so that they are unable to perform the
normal functions of specialized tissue
– They may function in a disorderly way or cease normal
functioning completely, only functioning for their own
survival and growth
– The most undifferentiated cells are also called anaplastic
cells
 This is a fine needle aspirate
of a breast mass that contains
both benign (left) and
malignant (right) cell clumps.
The benign clump consists of
small, uniformly sized and
shaped cells arranged in a
single layer of tightly adherent
cells. The few cells coming off
the clump are devoid of
cytoplasm. The malignant
clump is thicker and is
dyscohesive. The cells are
       larger and vary in size and
shape. Cells come off the
clump with intact cytoplasm.
The nuclear chromatin is
clumped in the malignant cells
and is uniform in the benign
ones.
• Rate of Growth
– Cancer cells have uncontrolled growth or cell
division
– Rate at which a tumor grows involved both
increased cell division and increased survival
time of cells
– Malignant cells do not form orderly layers, but
pile on top of each other to eventually form
tumors
• Spread (Invasion and Metastasis)
– Cancer cells are less adhesive than normal
cells, more easily dissociated from their
location
– Lack of adhesion and loss of contact inhibition
make it possible to spread to distant parts of
the body (metastasis)
– Malignant tumors are not encapsulated and
expand into surrounding tissue
• Etiology (Carcinogenesis)
– Actual cause of cancer is unknown but there
are a number of theories; it is currently thought
that there are probably multiple etiologies

• ENVIRONMENTAL FACTORS
– Majority over 80% of human cancer cells are related to
environmental carcinogens
– Types of Environmental Factors
1. Physical
a. Radiation : x-rays, radium, nuclear explosion or waste,
ultraviolet
b. Trauma or chronic irritation
2. Chemical
a. Nitrates and food additives, polycyclic hydrocarbons,
dyes, alkylating agents
b. Drugs: arsenicals, stilbestrol, urethane
c. Cigarette smoke
d. Hormones
– Immunologic Factors
• Failure of the immune system to respond to and
eradicate cancer cells
• Immunosuppressed individuals are more
susceptible to cancer
– Genetics
• Some cancers show familial pattern
• May be caused by inherited genetic effects
– Viral Theory
• Viruses have been shown to be the certain causes
of cancer in animals
• Oncoviruses
• Epstein Barr Virus are linked to human tumors
 Incidence/Risk Factors
• Age, race, sex
– 50 years old & above
– black more than white
– female – prone to breast & cervical cancer
– male – prone to lung & prostate cancer
• Genetic predisposition
• Immune deficiency
• Smoking
• Excessive alcohol intake
• Hormonal imbalances
• Occupational: exposure to carcinogens (asbestos, vinyl
chloride or benzene)
 Incidence/Risk Factors
• X-ray overexposure
• Long exposure to sunlight
• Diet: high fat, lack of fiber
 Types of Tumors
• Benign – are tumors that cannot spread by
invasion or metastasis

• Malignant – are tumors that are capable of

spreading by invasion and metastasis
 DIAGNOSIS OF CANCER
• Classification and Staging
– Tissue of Origin
a. Carcinoma: arises from surface, glandular or
parenchymal epithelium
a. Squamous cell carcinoma: surface epithelium
b. Adenocarcinoma: glandular or parenchymal
tissue
b. Sarcoma: arises from connective tissue
c. Leukemia, lyphoma and multiple myeloma:
separate categories for each
 Stages for Tumor Growth
• Several staging systems, important in
selection of therapy
– TNM system: uses letters and numbers to
designate the extent of the tumor
– T: stands for primary growth; 1-4 with increasing
size. T1S indicates carcinoma in situ
– N: stands for lymph node involvement; 0-4
indicates progressively advancing nodal
disease
– M: stands for metastasis; 0 indicates no distant
metastases, indicates presence of metastases

– Stages 0-V: all cancers divided into five stages

incorporating size, nodal involvement, and
spread
• 0 – Benign stage
• I – spread to nearby tissue (2cm)
• II – 2-5 cm sometime involve lymph
• III – more than 5cm spread – advance
spread to connective tissue
• IV - metastasis
• Grading – identification of the type of
tissue from which the tumor originated and
the degree to which the tumor cells retain
the functional and structural characteristics
of the tissue of origin;
(G1, G2, G3, G4)
 Cytologic diagnosis of Cancer
• e.g.; Pap smear
– Involves study of shed cells
– Classified by degree of cellular abnormality
• Normal
• Probably normal (slight changes)
• Doubtful (more severe changes)
• Probably cancer or precancerous
• Definitely cancer
 Client Factors
• Early detection of cancer is crucial in reducing
morbidity and mortality. Clients needs to be
taught about:
– Seven warning signs of Cancer
– Breast self-examination (BSE)
– Importance of rectal exam for those over age 40
– Hazards of smoking
– Oral self-examination as well as annual exam
of mouth and teeth
– Hazards of excess sun exposure
– Importance of pap smear
– Physical exam with lab work-up; every 3 years
ages 20-40; yearly age 40 and over
– Testicular self-examination (TSE)
 Seven Warning Signs of Cancer
• C – change in bowel and bladder habits
• A – a sore that doesn’t heal
• U – unusual bleeding or discharge
• T – thickening or lump in the breast (or elsewhere)
• I – indigestion or dysphagia
• O – obvious change in wart or mole
• N – nagging cough or hoarseness
Paget's disease is a benign
appearing eczematoid lesion of the
nipple caused by large malignant
cells (Paget's cells) which arise
from the ducts and which invade
the surrounding nipple epithelium.
In the absence of an underlying
mass, this lesion is usually due to
an intraductal carcinoma. An
underlying palpable mass usually
indicates invasive ductal carcinoma
in which case the prognosis is the
same as that for any other invasive
ductal carcinoma and is reflected by
the status of the axillary lymph
nodes.
 Testicular Cancer
• Most common cancer in young men between
ages of 15 and 34. Most testicular cancers are
found in men themselves, by accident or by
doing TSE
 Testicular Self Examination
• Ideally, it should be performed monthly, after
a warm shower or bath, when the skin of
scrotum is relaxed. Standing in front of a
mirror, the man should gently roll each testicle
between the thumb and fingers of both hands.
The testes are smooth, oval-shaped, and firm
 Warning Signs that Men should Look for:

• Painless swelling
• Feeling of heaviness
• Hard lump (pea size)
• Sudden collection of fluid in the scrotum
• Dull ache in the lower abdomen or in the groin
• Pain in a testicle or in the scrotum
• Enlargement or tenderness of the breasts
• Penile intraepithelial neoplasia
 Treatment of Cancer
• Chemotherapy
– Principles
• Based on ability of drug to kill cancer cells; normal cells
may also be damaged, producing side effects. Effect is
greatest on rapidly dividing cells, such as bone marrow
cells or the GI tract
• Different drugs act on tumor cells in different stages of
the cell growth cycle
 Types of Chemotherapeutic Drugs
• Antimetabolites: foster cell death by interfering with
cellular metabolic process
• Alkylating agents: act with DNA to hinder cell growth
and division
• Plant alkaloids: obtained from a periwinkle plant;
makes the host’s body less favorable environment
for the growth of cancer cells
 Types of Chemotherapeutic Drugs
• Antitumor antibiotics: affect RNA to make
environment less favorable for cancer growth
• Steroids and sex hormones: alter the
endocrine environment to make it less
conducive to growth of cancer cells
 Major Side Effects and Nursing
Interventions
• GI system
– Nausea and Vomiting
• Administer antiemetics routinely every 4-6 hours as
well as prophylactically before chemotherapy is
initiated
• Withhold food/fluids 4-6 hours before chemotherapy
• Provide bland foods in small amounts after treatments
 Major Side Effects and Nursing
Interventions
• Diarrhea
– Administer antidiarrheals
– Maintain good perineal care
– Give clear liquids as tolerated
– Monitor potassium, sodium and chloride levels
 Major Side Effects and Nursing
Interventions
• Stomatitis
– Provide and teach the client good oral hygiene, including
avoidance of commercial mouthwashes
– Rinse with viscous lidocaine before meals to provide an
analgesic effect
– Perform a cleansing rinse with plain water or dilute with
water-soluble lubricant
– Apply water soluble lubricant to lubricate cracked lips
– Advise client to suck on popsicles to provide moisture
• Hematologic system
– Thrombocytopenia
• Teach client the importance of avoiding bumping or
bruising the skin
• Protect client from physical injury
• Avoid aspirin or aspirin products
• Avoid giving IM injections
• Monitor blood counts carefully
• Assess for and teach signs of increased bleeding
tendencies (epistaxis, petechiae, ecchymosis)
Petechiae Ecchymosis
– Anemia
• Provide for adequate rest periods
• Monitor hemoglobin and hematocrit
• Protect client from injury
• Administer oxygen as necessary
– Leukopenia
• Use careful handwashing technique
• Maintain reverse isolation if WBC count drops
below 1000/mm3.
• Assess for signs of respiratory infection
• Instruct client to avoid crowds/persons with known
infection
– Integumentary system – alopecia
• Explain that hair loss is not permanent
• Offer support and encouragement
• Scalp tourniquets or scalp hypothermia via ice pack
may be orderefd
• Advise client to obtain a wig before initiating
treatments
 Radiation Therapy
• Principles
– Radiation therapy uses ionizing radiation to kill
or limit the growth of cancer cells, may be
internal or external
– It not only injures the cell membrane, but
destroys or alters DNA so that the cells cannot
reproduce
– Like chemotherapy, effect cannot be limited to
cancer cells only; all exposed cells, including
normal ones, will be injured.
– Localized effects are related to cellular
breakdown
• Types of energy emitted
– Alpha Rays: cannot pass through skin, rarely
used
– Beta rays: cannot pass through skin, somewhat
more penetrating than alpha rays, generally
emitted from radioactive isotopes, used for
internal source
– Gamma rays (electromagnetic rays): penetrate
deeper areas of body, most common form of
external radiotherapy
• Methods of delivery
– External radiation therapy: beams high energy rays
directly to the affected area
– Internal radiation therapy: radioactive material is
injected or implanted in the client’s body for a
designated period of time
• Sealed implants: a radioisotope enclosed in a
container so it does not circulated in the body,
client’s body fluids should not become
contaminated with radiation
• Unsealed sources: a radioisotope that is not
encased in a container and does circulate in the
body and contaminate body fluids
• Factors controlling exposure
– Time: the shorter the duration, the less the exposure
– Distance: the greater the distance from the radiation
source the less the exposure
– Shielding: all radiation can be blocked; rubber gloves
stop alpha and usually beta rays; thick lead or concrete
stops gamma rays
– Half-life: time required for half of radioactive atoms to
decay
• Each radioisotope has different half-life
• At the end of the half-life, the danger from the exposure
decreases
– These factors affect health care worker’s
exposure as well as clients
• Health care worker at greater risk from
internal than from external sources
• Film badge can measure the amount of
exposure received
• No pregnant nurses or visitors permitted
near radiation source
 Side Effects of Radiation Therapy and
Nursing Inteventions
• Skin: itching, redness, burning, oozing,
sloughing
– Keep skin free from foreign substances
– Avoid use of medicated solutions, ointments or
powders that contain heavy metals such as zinc
oxide
– Avoid pressure, trauma, infection to skin
– Wash affected areas with plain water and pat dry;
avoid soap
• Skin:
– Use cornstarch, olive oil for itching; avoid
talcum powder
– If sloughing occurs, use sterile dressing
– Teach client to avoid exposing skin to heat,
cold, or sunlight and to avoid constricting/
irritating clothing
• Anorexia, nausea and vomiting
– Arrange mealtimes so they do not directly
precede or follow therapy
– Encourage bland foods
– Provide small, attractive meals
– Avoid extremes of temperature
– Administer antiemetics as ordered before
meals
• Diarrhea
– Encourage low-residue, bland, high-protein
foods
– Administer antidiarrheal drugs as ordered
– Provide good perineal care
– Monitor electrolytes, particularly sodium,
potassium and chloride
• Anemia, leukopenia, thrombocytopenia
– Isolate from those with known infections
– Provide frequent rest periods
– Encourage high-protein diet
– Instruct client to avoid injury
– Assess for bleeding
– Monitor CBC, leukocytes and platelets
 Nursing Problems/DiagnosesCommon to
Clients with Cancer
• . Risk for infection related to altered
• immunologic response
• Goal: Prevention of Infection
• Impaired skin integrity: erythematous &
• wet desquamation reactions to radiation
• therapy
• Goal: Maintenance of skin integrity
• Impaired mucous membrane: stomatitis
• Goal: Maintenance of intact oral mucous
• Membranes
• Impaired tissue integrity: alopecia
• Goal: Maintenance of tissue integrity;
• Coping with hair loss
 Nursing Problems/DiagnosesCommon to
Clients with Cancer
• Imbalanced nutrition, less than body
• requirements, related to nausea & vomiting
• Goal: Fewer episode of nausea & vomiting
• Before, during, & after chemotherapy
• Imbalanced nutrition: less than body
• requirements related to anorexia, cachexia,
• or malabsorption
• Goal: Maintenance of nutritional status &
• Of weight within 10% of pre-
• treatment weight
• Fatigue
• Goal: Increased activity tolerance and
• decreased fatigue level
 Nursing Problems/DiagnosesCommon to
Clients with Cancer
• . Anticipatory grieving related to loss,
• altered role functioning
• Goal: Appropriate progression through
• grieving process
• Disturbed body image & situational low
• self-esteem related to changes in
• appearance, function, & roles
• Goal: Impaired body image & self-esteem
• Potential complication: risk for bleeding
• problems
• Goal: Prevention of bleeding
 Nursing Interventions that promote health and
prevent cellular aberrations

• Primary prevention –concerned with

reducing the risks of cancer in healthy people
– Nursing Responsibilities
• Educate the community about cancer risk by:
– assisting clients to avoid known carcinogens
– promote healthful lifestyles
– Implement Safeguard Against Cancer
• Annual Pap Smear
• Annual Colorectal Exam over 40 yrs
• Annual Chest X-ray/No smoking
• Annual mouth/teeth exam
• Avoid unnecessary sunlight exposure
• Annual PE includes urine & blood work
• Monthly breast Exam
– Secondary & Tertiary Prevention
• involves detection & screening to achieve early
diagnosis & prompt intervention to halt the cancer
process
• Assist in Diagnostic Test
– Biopsy – excision of part of tumor mass
– Needle Biopsy – aspiration of cells from
subcutaneous masses or organs such as liver
– Explorative cytology – scraping of any
endothelius (cervix, mucous membrane) &
applying to slide
– Endoscopy – visualization of body cavity
through endoscope
• Computerized Axial Tomography(CAT)
visualization of body part whereby layers of
tissue can be seen utilizing the very narrow
beams of this type of x-ray equipment
• Magnetic Resonance Imaging (MRI)Scan – a
scanning device using a magnetic field for
visualization
• Laboratory Data
• . Promote Healthful Lifestyles
– Increase consumption of fresh vegetables (especially those of the
cabbage family) because studies indicates that roughage and
vitamin-rich foods help to prevent certain kinds of cancer
– Increase fiber intake because high fiber diets may reduce the risk
for certain cancers (breast, prostate & colon)
– Increase intake of foods rich in Vit. A, which reduces the risk for
esophageal, laryngeal, and lung cancers
– Increase intake of foods rich in Vit. C, such as citrus fruits &
brocolli which are thought to protect against stomach and
esophageal cancers.
– Practice weight control because obesity
– is linked to cancers of the uterus, gall-
– bladder, breast& colon, prostate cancers
– Practice moderation in consumption of
– salt-cured, smoked, & nitrate cured
– foods; these have linked to esophageal
– and gastric cancer
– Stop smoking cigarettes & cigars which
– are carcinogens
– Reduce alcohol intake because drinking
– large amounts of alcohol increases the
– risk of liver cancer. People who drink
– heavily & smoke are at greater risk for
cancers of the mouth, throat, larynx and
esophagus
– Avoid overexposure to the sun, wear
protective clothing, and use a sunscreen
to prevent skin damage from ultraviolet
rays that increase the risk of skin cancer.
 Here is an hepatocellular
carcinoma. Such liver
cancers arise in the setting
of cirrhosis. Worldwide, viral
hepatitis is the most
common cause, but in the
U.S., chronic alcoholism is
the most common cause.

The neoplasm is large and bulky and has a

greenish cast because it contains bile. To the
right of the main mass are smaller satellite
nodules.
This is a squamous cell
carcinoma of the lung that
is arising centrally in the
lung (as most squamous
cell carcinomas do). It is
obstructing the right main
bronchus. The neoplasm
is very firm and has a pale
white to tan cut surface.
obstructive disease

. In the center of the

photograph is the sigmoid
colon and rectum of a
patient with
adenocarcinoma of the
rectum. This has invaded
the bladder and has
occluded the orifices of
the ureter on both sides.
The right ureter shows
extreme hydroureter.
 In the upper pole of this kidney is a well
circumscribed tumor which has a yellowish-brown
color and shows central necrosis. This is a renal cell
carcinoma.
End…