Oncology

Neoplasia
 new, altered and abnormal
development of cells that may be
benign or malignant
 Tumor – mass or swelling in or on the
body
BENIGN MALIGNANT

 Grows slowly  Grows rapidly

 Remains localized  Infiltrates
surrounding tissues
 Encapsulated
 Not encapsulated
 Well differentiated
 Poorly differentiated
 Extremely unusual  Common after sx
 Very common
 Never occur  Always harmful
 Not harmful to host  Poor prognosis

Agents that can
Predispose to Cancer
 Chemical carcinogens
 These act by causing cell mutation or alteration in cell
enzymes & proteins causing altered cell replication.
 Tobacco – associated with a number of cancers,
particularly cancers of the lung, larynx, mouth,
esophageal, stomach, pancreas, kidney, bladder and
cervix
 Ether and coal tar – are also associated with lung cancer
 Asbestos – associated with lung cancer and
mesothelioma (cancer that affects the thin membranes
lining the abdomen and chest)
 Benzene – associated with leukemias and Hodgkin
lymphoma
 Some other examples are: Industrial compounds (i.e.
arsenic, beryllium, cadmium), Spoilt Foods, and
preservatives like nitrites.
Physical Agents
 Physical irritation/trauma
 Radiation (x-rays, gamma and ultraviolet
radiation) from diagnostic or therapeutic x-
rays, radioisotopes, sunlight
 These will usually cause cancer after long
time of exposure and interaction
Genetics
 The human DNA has specific genes for
cancer called Oncogene. When this gene is
exposed to carcinogens, there will be
changes in cell structure, and growth
behavior, leading to become malignant
cells.
 Viruses
 DNA viruses:
 Hepa B (HBV) – associated with hepatocellular carcinoma
 Herpes simplex virus (HSV) – associated with Kaposi’s sarcoma
(a type of skin cancer typically in AIDS patient)
 Human papillomavirus (HPV) – can lead to cancers of cervix,
anus and penis
 Epstein Barr virus (EBV) – associated with lymphoma
 Merkel cell Polyomavirus (MCV) – associated with the
development of Merkel cell carcinoma (rare but aggressive
form of skin cancer)
 RNA viruses
 Human T-lymphotropic virus (HTLV) – associated with leukemia
 Hepa C viruses (HCV) – associated with hepatocellular
carcinoma
Immune system
alterations
 as seen in patients with
immunodeficiency disease, the elderly
and those receiving immunosuppressant
drugs
 Hormonal factors
 Breast cancer – associated with increased estrogen levels in the
body (nulliparity, early menarch, late menopause, obesity,
estrogen replacement therapy, estrogen-containing contraceptives)
 Endometrial cancer – also associated with increased levels of
estrogen (nulliparity, early menarch, late menopause, obesity,
estrogen replacement therapy)
 Ovarian cancer – associated with exposure to exogenous female
sex hormones (estrogen replacement therapy and long-acting
hormonal contraceptives)
 Oral contraceptives – decrease risk of ovarian and endometrial
cancers, but increase risk of breast cancer
 Estrogen replacement therapy – increases risk of breast, ovarian,
endometrial and brain cancers
 Prostate cancer – the androgen receptor helps prostate cancer
cells to survive
 Dietary factors
 High fat diet and low fiber intake for colon cancer
 Cooking food at high temperatures, for example grilling
or barbecuing meats, can lead to the formation of
minute quantities of many potent carcinogens that are
comparable to those found in cigarette smoke
 Aflatoxin (produced by the mold Aspergillus that
colonizes nuts and grains) can lead to liver cancer
 Other dietary carcinogens – nitrosamines (from
processed foods, like hotdogs and bacons), acryl
amides (from deep-fried foods) and trans-fat or
unsaturated fat (from fast food, snack food, fried food)
Predisposing Factors
 Age – older people are more prone. This is
a very important factor for cancer
development.
 Sex – women for breast, men for prostate
 Urban versus Rural residence
 Geographic distribution
 Occupation
 Heredity
 Stress
 Obesity (breast and colorectal)
 Predisposing factors
 Precancerous lesions – these can lead to transformation
into cancer
 Actinic keratosis or solar keratosis – thick, scaly, or crusty
patches of skin; may progress to squamous cell carcinoma
 Barrett's esophagus – an abnormal change (metaplasia) in the
cells of the inferior portion of the esophagus; may progress to
esophageal cancer
 Atrophic gastritis – chronic inflammation of the stomach mucosa,
leading to loss of gastric glandular cells and their eventual
replacement by intestinal and fibrous tissues; may progress to
gastric carcinoma
 Cervical dysplasia or Cervical intraepithelial neoplasia (CIN) –
abnormal growth (dysplasia) of squamous cells on the surface of
the cervix; may progress to cervical cancer
 Warning Signals of Cancer
 C – Change in bowel or bladder habits
 A – A sore that does not heal
 U – Unusual bleeding/discharge; unexplained
anemia and sudden weight loss
 T – Thickening or lumps in breast or
elsewhere
 I – Indigestion or difficulty of swallowing
 O – Obvious change in wart or mole
 N – Nagging cough or hoarseness of voice
 Sites of Cancer and
Danger Signals
 Breast – lump, thickening, dimpling in breast; unusual
size and shape of breast; one breast unusually lower;
retraction, sore or bleeding in the nipple
 Colon & rectum – change in bowel habits/bleeding
 Kidney & bladder – urinary difficulty/bleeding
 Lung – persistent cough/lingering respiratory ailment
 Prostate – urinary difficulty
 Mouth, larynx & pharynx – sore that does not heal,
difficulty in swallowing & hoarseness
 Skin – sore that does not heal, change in wart or
mole
 Stomach – indigestion
 Uterus – unusual bleeding or discharge
Top 3 Leading Types of
Cancers
 Male
 Prostate
 Lung and Bronchus – most mortality
 Colon and Rectum
 Female
 Breast
 Lung and Bronchus – most mortality
 Colon and Rectum
*In the Phils, cervical cancer ranks 2nd
Metastasis
 Direct seeding of body cavities or surfaces –
whenever malignant neoplasm penetrates into a
natural “open field”; involves peritoneal cavity
(most often), pleural, pericardial, subarachnoid
space and joints
 Lymphatic spread – pattern of lymph node
involvement follows the natural route of drainage;
this is the most common mode of spread
 Hematogenous spread – malignant cells are
disseminated through the blood stream; Liver &
lungs – most frequently involved in hematogenous
dissemination
 Direct transplantation of tumor cells (ex: on
surgical instrument) – theoretically, it can occur but
exceedingly rare
Tumor Staging
 Stage I – malignant cells confined to tissue of
origin
 Stage II – limited local spreading to near
lymph nodes
 Stage III – tumor is larger, or spread into
nearby tissue, or both; regional lymph nodes
affected
 Stage IV – metastasis to distant parts of the
body
TNM Classification
 primary tumor (T)
 extent of regional lymph node
metastasis (N)
 absence or presence of distant
metastasis (M)
TNM Classification
 Primary Tumor (T)
 Tx – primary tumor cannot be assessed
 T0 – no evidence of primary tumor
 Tis – carcinoma in situ
 T1, T2, T3, T4 – increasing size and/or local extent of the
primary tumor
 Regional Lymph Nodes (N)
 Nx – regional lymph nodes cannot be assessed
 N0 – no regional lymph node metastasis
 N1, N2, N3 – increasing involvement of regional lymph
nodes
 Distant Metastasis (M)
 Mx – distant metastasis cannot be assessed
 M0 – no distant metastasis
 M1 – distant metastasis
Goals of Cancer Therapy
 Cure – the aim of this modality is to
make sure that the client will be
disease-free & live normal expectancy
 Control – not curing but controlling by
therapy over long periods of time
 Palliative – cure & control not
possible; but maintain quality of life as
high as possible
Therapeutic Modalities
 Surgery
 Preventive – removal of precancerous lesions/benign tumors
 Diagnostic – biopsy
 Curative – removal of an entire tumor (en bloc resection)
 Reconstructive – improvement of structure/function of an organ
 Palliative – relief of distressing signs & symptoms (ex.
oophorectomy w/ breast cancer to reduce estrogen secretion
retarding metastasis)
 Chemotherapy – this involves administering cytotoxic drug to
intervene and interrupt the cell cycle
 Immunotherapy or biotherapy – involves treatment with
agents derived from biologic sources or with agents that
affect biologic responses like interferons, interleukins, and
monoclonal antibodies
 Radiotherapy – used for radiosensitive cancers like skin
cancer, head and neck tumors, cervical cancer, seminoma
and early stage Hodgkin’s; the response of the cancer cells
depend on the type and phase of cell cycle
Chemotherapy
 use of drugs to retard the growth of or destroy
cancerous cells; use to cure, for palliation, combined
w/ surgery, combined with radiation
 Classification
 Cell-cycle specific: attack cells at a specific point in the
process of cell division
 Cell-cycle non-specific: act at one time during cell division
 Administration
 IV – most common route
 Arterial infusion - direct
 Regional perfusion
 Intraperitoneal
 Oral, IM (less common)
 Nursing Interventions for General
Chemotherapeutic Side Effects
 GI system (NDx: Imbalanced Nutrition: Less than body
requirements; Impaired oral mucous membranes)
 N & V. Antiemetic are given; withhold food/fluid before start of
chemo
 Diarrhea. Replace fluid-electrolyte losses, low-fiber diet
 Constipation. Increased fluid intake & fibers
 Anorexia. Encourage high protein and high calorie diet, serve food in
ways to make it appealing small frequent feedings, avoid giving
fluids while eating; light exercise before meals to stimulate appetite;
red meats may taste bitter (use of plastic utensils may help)
 Xerostomia (dry mouth). Ice chips, hard candy, gentle mouth care
with 1/2 strength non alcohol mouth wash and water
 Stomatitis. Provide good oral care; avoid hot & spicy food; eat soft
foods; soft toothbrush, Rinse with normal saline or sodium
bicarbonate (baking soda) 4x/day; Avoid ALCOHOL-based rinses
 Drug-food interaction. Specific antineoplastics can have serious
interactions with food; foods high in Tryamine (aged cheese, beer,
bananas, caffeine, yogurt and liver) cause hypertensive crises when
eaten after taking procarbazine
 Nursing Interventions for General
Chemotherapeutic Side Effects
 Integumentary system (NDx: Impaired skin
integrity, Disturbed body image)
 Pruritus, urticaria. Provide good skin care
 Drying and flaking of skin. Handle skin gently; Do
NOT rub affected area; Lotion may be applied;
Wash skin only with SOAP and Water
 Alopecia/skin pigmentation/nail changes. Reassure
that it is temporary & encourage to wear wigs,
hats, or head scarf; but anticipate change in
texture and color; alopecia begins within 2 weeks
of therapy and regrowth within 8 weeks of
termination
 Nursing Interventions for General
Chemotherapeutic Side Effects
 Hematopoeitic (NDx: Risk for injury, Risk for
infection)
 Anemia. Provide frequent rest periods
 Neutropenia. Protect from infection; Avoid people with
infection, crowds; neutropenic precautions—private room,
maintain aseptic technique and strict hand washing, fresh
flowers, fruits and vegetables are prohibited because they
harbor bacteria; Avoid frequent invasive procedures; Fever is
the most important sign; Administer prescribed antibiotics X
2weeks
 Bleeding. Thrombocytopenia (<100,000) is the most common
cause; <20, 000 spontaneous bleeding; Protect from
trauma; Avoid ASA; Use soft toothbrush; Use electric razor;
Avoid frequent IM, IV, rectal and catheterization; Soft foods
and stool softeners
Nursing Interventions for General
Chemotherapeutic Side Effects
 Genito-Urinary system
 Urine color changes. Reassure that it is harmless
 Nephrotoxicity. Some chemotherapeutic agents can
damage the kidneys; monitor BUN and creatinine
 Reproductive system
 Premature menopause/amenorrhea. Reassure
menstruation resumes after chemotherapy
 Sterility and impotence. May be temporary or permanent;
may advise men to bank sperm
 Miscellaneous
 Fatigue. Plan daily activities to allow alternating rest
periods; Light exercise is encouraged; Small frequent
meals
Chemotherapeutic Agents
 Alkalating agents – cell-cycle nonspecific
 Ex. cyclophosphamide, cisplatin, ifosfamide,
busulfan, carboplatin, chlorambucil
 SE: hemorrhagic cystitis (cyclophosphamide)
and renal toxicity (cisplatin)
 Nitrosureas – similar to alkalating agents;
cross the blood-brain barrier
 Ex. carmustine, lomustine and steptozocin
 Antitumor antibiotics – cell-cycle nonspecific
 Ex. doxorubicin, daunorubicin, bleomycin,
plicamycin
 SE: cardiac toxicity (doxorubicin, daunorubicin)
Chemotherapeutic Agents
 Antimetabolites – cell-cycle specific (S
phase)
 Ex. methotrexate, 6-mercaptopurine, 5-
fluorouracil, cytarabine and 6-thioguanine
 SE: renal toxicity (methotrexate)
 Natural products – cell-cycle specific (M
phase)
 Ex. plant alkaloids (vinblastine, vincristine) and
taxanes (paclitaxel, docetaxel)
 SE: cause peripheral neuropathy
Chemotherapeutic Agents
 Topoisomerase I inhibitors – cell-cycle
specific (G1 phase)
 Ex. irinotecan, topotecan
 Topoisomerase II inhibitors – cell-cycle
specific (S phase)
 Ex. etoposide, amsacrine
 Hormones – cell-cycle specific (M phase)
 Ex. tamoxifen, androgens, flutamide,
aminogluthetimide, corticosteroids
 SE: hypercalcemia (tamoxifen), masculinization
(androgens); gynecomastia (flutamide); sodium
and water retention and cushing’s disease
(corticosteroids)
Immunotherapy
 use of biologic response modifiers destroy
or interfere with tumor activities; to help
modify the host’s biologic response to tumor
cells
 Types:
 Interferons
 Lymphokines & cytokines (interleukin-2)
 Monoclonal antibodies (traztuzumab)
 Colony stimulating factors
 Side effects: Influenza-like symptoms,
fatigue, N&V, neutropenia (INF),
cardiotoxicity (traztuzumab)
Radiation Therapy
 Use of ionizing radiation to cause damage
and destruction to cancerous growths
 Effect: Radiation  damage at the cellular
level
 Indirectly: water molecules w/in the cell are
ionized
 Directly: causes strand breakage in the double
helix of DNA
 Not every cell is damaged beyond repair
 Use to cure, for palliation, combined w/
surgery
 PreOP: to reduce size of tumor
 PostOP: to retard or control metastasis
Administration (Radiation Tx)
 External – involves electromagnetic rays
 Orthovoltage machines – superficial lesions
 Megavoltage (Cobalt-60) – deeper structures
 Linear accelerators – deep lesions; less harmful
 Internal (Brachytherapy) –
injection/implantation of radioisotopes
proximal to cancer site for a specific period
of time
 Sealed implants – radioisotope with a container
and doesn’t contaminate body fluid
 Unsealed (radioactive iodine) – radioisotope
without a container and contaminates body fluid
Principles of Radiation
Protection (DTS)
 Distance. Maintain a distance of at least
3 ft. when not performing nursing
procedures.
 Time. Limit contact for 5 min each time,
a total of 30min/shift.
 Shielding. Use lead shield during contact
with client.
Bone Marrow
Transplantation
 Used to treat
 Acute lympphoblastic leukemia
 Acute myelogenous leukemia
 Aplastic anemia
 Chronic myelogenous leukemia
 Types:
 Allogeneic BMT: bone marrow comes from a
healthy donor (usually immediate family
member)
 Autologous BMT: client is given own bone
marrow
Diagnostic Tests
 Blood Tests
 Blood chemistries
 Complete blood count and other
specialized assay can provide important
information about the extent of
malignancy and the effectiveness of
therapy.
 Tumor markers
Cytologic tests
 These tests help detect suspected primary or
metastatic disease and monitor therapy
 They cannot determine the location and size of a
malignancy
 ASPIRATION TESTS – fine needle aspiration of
body fluids permits evaluation of a palpable mass,
a lymph node or a lesion that has been localized x-
rays.
 BONE MARROW ANALYSIS allows examination of
bone marrow aspirate to identify leukemic cells;
most common collection site is the iliac crest; other
sites: sternum (adult) and tibia (infants)
 PAPANICOLAOU TESTS – is widely used to detect
cervical cancer, endometrial and extrauterine
malignancy in an asymptomatic patient.
Diagnostics
 Endoscopy
 These can be performed on the entire GIT,
respiratory tract, urinary tract and peritoneal
cavity.
 Histologic tests
 Biopsy is a common procedure that provides a
detailed description that helps classify
malignancy
 Nuclear imaging and Scanning
 Include CT, MRI and Radionuclide imaging
Diagnostics
 Radiographic test
 Are used to visualize internal body structures to
detect, identify, and localize malignancy and
guide biopsy.
 These include CXR, mammography
 Ultrasonography
 This non-invasive procedure is used to evaluate
organs and localize masses except the lungs and
bones.
 Stool occult examination
 Permits early detection of colorectal cancer,
providing positive results in 80% of patients
with this disorder
 Nursing Interventions for
Cancer
 Relieve anxiety and ineffective
coping
 Management to promote nutrition
 Management to relieve pain
 Management to improve body image
 Management to assist in the grieving
process
 Manage side effects of chemotherapy
and radiotherapy
Nursing Care of Terminally
Ill Patient
 directed towards making the patient
physically & psychologically as
comfortable as possible
Nursing Care of Terminally
Ill Patient
 Nutrition
 High calorie & protein diet
 Small frequent feedings
  fluids intake, 1000-1500ml above the N
 Activity
 Prevent tissue breakdown & vascular
complications
 Frequent turning, skin massage, air mattresses
 Active and passive ROM
Nursing Care of Terminally
Ill Patient
 Observe for toxic reactions to tx
(diarrhea)
 Supportive measures & drugs for pain
relief
 Maintain open communication with
patient & family
 Control of odor
 Infectious organisms cause formation of
offensive odors
 Frequent change of dressings
Oncologic emergencies
 Hypercalcemia
 Most common life-threatening disorder
associated with cancer
 Lung cancer, breast cancer and multiple
myeloma are the most prevalent malignancies
associated with hypercalcemia
 The cause of hypercalcemia is when cancer
spreads to or invades the bones and when
malignant cells release certain factors that cause
calcium to be released from the bone
Oncologic emergencies
 Syndrome of inappropriate antidiuretic
hormone
 Found in small cell carcinoma of the lung and
brain tumors (but also found in pneumonia,
head trauma, strokes, meningitis and
encephalitis)
 Characterized by excessive release of
antidiuretic hormone (ADH or vasopressin) from
the posterior pituitary gland or another source
 The result is hyponatremia, and sometimes fluid
overload
Oncologic emergencies
 Disseminated intravascular coagulation – a
pathological activation of coagulation (blood
clotting) mechanisms that leads to the formation of
small blood clots inside the blood vessels
throughout the body
 Superior vena cava syndrome
 Result of the direct obstruction of the superior vena cava
by malignancies such as compression of the vessel wall by
right upper lobe tumors or thymoma and/or mediastinal
lymphadenopathy
 The most common malignancies that cause SVCS is
bronchogenic carcinoma
 Leads to shortness of breath is the most common
symptom, followed by trunk or extremity swelling
Oncologic emergencies
 Spinal cord compression
 Develops when the spinal cord is compressed by
bone fragments from a vertebral fracture
 The most common causes of cord compression
are tumors, but abscesses and granulomas (e.g.
in tuberculosis) are equally capable of producing
the syndrome
 Back pain, a dermatome of increased sensation,
paralysis of limbs below the level of
compression, decreased sensation below the
level of compression, urinary and fecal
incontinence and/or urinary retention
General Promotive and
Preventive Nursing Management
 Lifestyle Modification
 Nutritional management
 Screening
 Early detection
Cancer Prevention Detection
 Lung  Do not smoke  None

 Uterine  Having one sexual  Regular pap

Cervix partner lower risk; smear every 1-3
clean safe sex; years
vaccination
 Liver  Vaccination vs.  None
Hepatitis B virus;
Minimal alcohol intake;
avoid moldy foods
Cancer Prevention Detection
 Colon  Prudent diet of a  Regular medical
and variety of foods also check-ups after 40
rectum with high fiber and years of age, yearly
low fat intake.
occult blood test in
stools; digital rectal
 Avoid smoking exam; sigmoidoscopy
 Mouth tobacco, betel quid
chewing. Modify
 Through dental
consumption of check-ups each year
alcohol; cavity and
dental hygiene.
Cancer Prevention Detection
 Breast  No conclusive  Monthly self-exam
evidence and annual doctor
exam; mammography
for high risk groups of
for >=50 yrs. Old;
Female
 Skin  Avoid excessive  Skin self exam
sun exposure
Prostate
 No conclusive
  Digital trans-rectal
evidence
exam (early
diagnosis)
THANK YOU!