Oncology Nursing

Dr. Amel Gomaa

 Objectives
By the end of this lecture every student should be able to:
 Diffentiate between begnin and malignant tumors
 Identify agents and factors that have been found to be carcinogenic
 Describe the significance of health education and preventive care in
decreasing the incidence of cancer
 Describe radiation as a modality for cancer treatment, and the uses of
radiotherapy
 Identify factors affecting cell response to radiotherapy.
 Describe the special nursing needs of patients receiving radiotherapy
 Discuss the principles of radiation protection
 Describe the types of radiation therapy and related nursing care.
 Discuss side-effects of radiation therapy and nursing care
 ?What Is Cancer
CANCER is a complex of diseases which
occurs when normal cells mutate into
abnormal cells that take over normal tissue,
eventually harming and destroying the host.
 WHAT IS CANCER
A large group of diseases characterized
by:
– Uncontrolled growth and spread of abnormal cells
– Proliferation (rapid reproduction by cell division)
– Metastasis (spread or transfer of cancer cells from
one organ or part to another not directly connected)
 Oncology defined
• Branch of medicine that deals
with the study, detection,
treatment and management
of cancer and neoplasia
 ”Root words“
• Neo- new
• Plasia- growth
• Plasm- substance
• Trophy- size
• +Oma- tumor
• Statis- location
 ”Root words“
• A- none
• Ana- lack
• Hyper- excessive
• Meta- change
• Dys- bad, deranged
 The Four Major Categories of Cancer
• Carcinoma: Cancer arising from epithelial tissue
(for example, basal cell carcinoma)
• Sarcoma: Cancer arising from connective tissue,
muscle, or bone (for example, osteosarcoma)
• Lymphoma: Cancer arising from lymphoid tissue
(for example, lymphoma)
• Leukemia: Cancer of the blood-forming cells in
the bone marrow (for example,acute
lymphocytic leukemia)
 Cancer Terminology
• Epithelial tissues (carcinoma)
• Glandular tissues (adenocarcinoma)
• Connective, muscle, bone tissues (sarcomas)
• Brain spinal cord tissues (gliomas)
• Pigmented cells (melanomas)
• Plasma cells (myelomas)
• Lymphatic tissue (lymphomas)
• Leukocytes (leukemia)
• Erythrocytes (erthroleukemia)
 Characteristics of Neoplasia
• Uncontrolled growth of Abnormal cells
1. Benign
2. Malignant
3. Borderline

• Neoplasia:uncontrolled cell growth, either

benign or malignant
 Characteristics of Neoplasia
BENIGN
• Well-differentiated
• Slow growth
• Encapsulated
• Non-invasive
• Does NOT metastasize
 Characteristics of Neoplasia
MALIGNANT
• Undifferentiated
• Erratic and Uncontrolled Growth
• Expansive and Invasive
• Secretes abnormal proteins
• METASTASIZES
Classification of Cancer
According to Behavior of Tumor
• Benign - tumors that cannot spread by
invasion or metastasis; hence, they only grow
locally
• Malignant - tumors that are capable of
spreading by invasion and metastasis.
Metastasis
• Metastasis: 3 stages
– Invasion – neoplastic cells from primary
tumor invade into surrounding tissue with
penetration of blood or lymph.
– Spread – tumor cells spread through lymph
or circulation or by direct expansion
– Establishment and growth – tumor cells are
established and grow in secondary site:
lymph nodes or in organs from venous
circulation
 Body Defenses Against TUMOR
• 1. T cell System/ Cellular Immunity
– Cytotoxic T cells kill tumor cells
• 2. B cell System/ Humoral immunity
– B cells can produce antibody
• 3. Phagocytic cells
– Macrophages can engulf cancer cell debris
ETIOLOGY/CAUSATIVE FACTORS
• Viruses
• Chemical carcinogens
• Physical stressors
• Hormonal factors
• Genetic factors
 CANCER NURSING
Etiology of cancer
1. PHYSICAL AGENTS
• Radiation
• Exposure to irritants
• Exposure to sunlight
• Altitude, humidity
 CANCER NURSING
Etiology of cancer
2. CHEMICAL AGENTS
• Smoking
• Dietary ingredients
• Drugs
 CANCER NURSING
Etiology of cancer
3. Genetics and Family History
• Colon Cancer
• Premenopausal breast cancer
 CANCER NURSING
Etiology of cancer
4. Dietary Habits
 Low-Fiber
 High-fat
 Processed foods
 alcohol
 CANCER NURSING
Etiology of cancer
5. Viruses and Bacteria
• DNA viruses- HepaB, Herpes, EBV, CMV,
Papilloma Virus
• RNA Viruses- HIV, HTCLV
• Bacterium- H. pylori
 CANCER NURSING
Etiology of cancer
• 6. Hormonal agents
• DES
• OCP especially estrogen
 CANCER NURSING
Etiology of cancer
7. Immune Disease
• AIDS
 Risk Factors for Specific Cancers
Bladder:
• Smoking
• environmental carcinogens such as
dyes, paint, rubber, ink, and leather.
Breast:
 a family history in first-degree relatives
 the birth of the first child after age 30,
 abnormality in genes BRCA-1 and BRCA-2
 Menarche before age 12 and menopause after age 55
 obesity
 the use of birth control pills and hormonal replacement,
 alcohol intake, and a diet high in fat.
Cervical:
• early sexual activity
• early childbearing
• multiple partners
• human papilloma virus (HPV) or human
immunodeficiency virus (HIV)
• infection, smoking
• use of DES by the mother during pregnancy
• chronic cervical infections.
Colon:
• family history,
• polyps,
• chronic inflammatory bowel disease,
• alcohol use,
• smoking,
• and a diet high in fat and protein and low in fiber.
Esophagus:
• use of tobacco,
• use of alcohol,
• and chronic irritation.
 Larynx:
• use of tobacco
• nutritional deficiencies (riboflavin),
• chronic laryngitis
• use of alcohol
• exposure to carcinogens.
Leukemia:
• exposure to ionizing radiation
• use of chemicals and drugs (for example,
anticoagulants),
• genetics, people with Down syndrome,
• people who are immunosuppressed.
Hodgkin’s lymphoma:
 exposure to chemical agents, and viral infections.
Liver:
cirrhosis, hepatitis B, exposure to certain toxins,
smoking, and alcohol use.
Lung:
 smoking and second hand smoke
air pollution, occupational
 exposure to radon, vitamin A deficiency, and heredity.
Multiple myeloma:
chemical and radiation exposure
Ovarian:
• a diet high in fat;
• alcohol use;
• a history of cancer of the breast, endometrium, or colon or a family
history of ovarian or breast cancer;
• anovulation; nulliparity; and infertility.
Non-Hodgkin’s lymphoma:
• viral infections;
• exposure to chemicals and/or ionizing radiation;
• autoimmune disorders.
Pancreas:
• a diet high in fat, smoking, exposure to industrial
• chemicals, diabetes mellitus, and chronic pancreatitis.
Prostate:
• race (African-Americans),
• first degree relatives,
• high-fat diet, and age (55 and older).
Renal:
• tobacco use,
• exposure to industrial chemicals,
• obesity,
• high blood pressure, and dialysis.
Skin:
• exposure to sun,
• exposure to various chemicals (arsenic and coal tar),
• scarring or chronic irritation of the skin,
• and ancestry (highest incidence in those of Celtic
ancestry with red or blond hair, fair skin, and blue
eyes).
Stomach:
• a diet high in smoked foods and lacking in fruits
vegetables,
• gastric ulcers,
• Helicobacter pylori bacteria,
• heredity,
• Pernicious anemia,
• and chronic gastritis.
Testes:
• infections,
• genetic or endocrine factors,
• cryptorchidism.
 CANCER NURSING
Body Defenses Against TUMOR
T cell System/ Cellular Immunity .1 •
Cytotoxic T cells kill tumor cells –
B cell System/ Humoral immunity .2 •
B cells can produce antibody –
Phagocytic cells .3 •
Macrophages can engulf cancer cell debris –
 Effects of Cancer
• Disruption of Function- can be due to obstruction or
pressure

• Hematologic Alterations: can impair function of blood

cells

• Hemorrhage: tumor erosion, bleeding, severe anemia

• Anorexia-Cachexia Syndrome: wasted appearance of

client
 Effects of Cancer
• Paraneoplastic Syndromes: ectopic sites with excess
hormone production
– ↑ Parathyroid hormone→ hypercalcemia
– ↑ secretion of insulin→ hypoglycemia
– ↑ Antidiuretic hormone (ADH) → fluid retention, HTN
& peripheral edema
• ↑ Adrenocorticotropic hormone (ACTH): cause
excessive secretion of cortisone (ie: fluid retention, ↑
glucose levels)
 Effects of Cancer
• Pain: major concern of clients and families
associated with cancer

• Physical Stress: body tries to respond and destroy

neoplasm
 ASSESSMENT
• Nursing History
Health History – chief complaint and history of
present illness (onset, course, duration,
location, precipitating and alleviating factors)
– Cancer signs: CAUTION US!
 Warning Signs of Cancer
CAUTION US!
– Change in bowel or bladder habits
– A sore that does not heal
– Unusual bleeding or discharge
– Thickenings or lumps
– Indigestion or difficulty in swallowing
– Obvious change in a wart or mole
– Nagging or persistent cough or hoarseness
– Unexplained anemia
– Sudden unexplained weight loss
Change in bowel or bladder habits

– A person with colon cancer may have diarrhea or

constipation, or he may notice that the stool has
become smaller in diameter

– A person with bladder or kidney cancer

A sore that does not heal

– Small, scaly patches on the skin that bleed or do not

heal may be a sign of skin cancer

– A sore in the mouth that does not heal can indicate

oral cancer
• Unusual bleeding or discharge

– Blood in the stool is often the first sign of colon

cancer

– Similarly, blood in the urine is usually the first sign

of bladder or kidney cancer

– Postmenopausal bleeding (bleeding after

menopause) may be a sign of uterine cancer
• Thickenings or lumps

– Enlargement of the lymph nodes or glands (such as

the thyroid gland) can be an early sign of cancer

– Breast and testicular cancers may also present as a

lump
• Indigestion or difficulty in swallowing

– Cancers of the digestive system, including

those of the esophagus, stomach, and

pancreas, may cause indigestion,
heartburn, or difficulty swallowing
• Obvious change in a wart or mole

– Moles or other skin lesions that

change in shape, size, or color should
be reported
• Nagging or persistent cough or hoarseness

– Cancers of the respiratory tract, including

lung cancer and laryngeal cancer, may
cause a cough that does not go away or a
hoarse (rough) voice
• Unexplained anemia
• Sudden unexplained weight loss
 Physical Assessment
• Inspection – skin and mucus membranes for
lesions, bleeding, petechiae, and irritation
– Assess stools, urine, sputum, vomitus for acute or
occult bleeding
– Scalp noting hair texture and hair loss
• Palpation
– Abdomen for any masses, bulges or abnormalities
– Lymph nodes for enlargement
• Auscultation – of lung sounds, heart sounds and
bowel sounds
Laboratory & DiagnosticTests
• Cancer detection examination
• Laboratory tests
– Complete blood cell count (CBC)
– Tumor markers – identify substance (specific
proteins) in the blood that are made by the
tumor
• PSA (Prostatic-specific antigen): prostate cancer
• CEA (Carcinoembryonic antigen): colon cancer
• Alkaline Phosphatase: bone metastasis
– Biopsy
Diagnostic Tests
:Determine location of cancer •
X-rays –
Computed tomography –
Ultrasounds –
Magnetic resonance imaging –
Nuclear imaging –
Angiography –
:Diagnosis of cell type •
Tissue samples: from biopsies, shedded cells–
(e.g. Papanicolaou (PAP) smear), & washings
Cytologic Examination: tissue examined under–
microscope
• Direct Visualization:

– ▪ Sigmoidoscopy
– ▪ Cystoscopy
– ▪ Endoscopy
– ▪ Bronchoscopy
– ▪ Exploratory surgery; lymph node
biopsies to determine metastases
Tumor Staging and Grading

• Staging determines size of tumor and existence

of metastasis

• Grading classifies tumor cells by type of tissue

• The TNM system is based on the extent of the

tumor (T), the extent of spread to the lymph
nodes (N), and the presence of metastasis (M).
Primary Tumor (T)

TX - Primary tumor cannot be evaluated

T0 - No evidence of primary tumor

Tis - Carcinoma in situ (early cancer that has not

spread to neighboring

tissue)

T1, T2, T3, T4 - Size and/or extent of the primary

tumor
Regional Lymph Nodes (N)

NX - Regional lymph nodes cannot be evaluated

N0 - No regional lymph node involvement (no

cancer found in the lymph nodes)

N1, N2, N3 - Involvement of regional lymph

nodes (number and/or extent of spread)
Distant Metastasis (M)

MX - Distant metastasis cannot be evaluated

M0 - No distant metastasis (cancer has not

spread to other parts of the body)

M1 - Distant metastasis (cancer has spread to

distant parts of the body)
NURSING DIAGNOSES
• Acute or chronic pain
• Impaired skin integrity
• Impaired oral mucous membrane
• Risk for injury
• Risk for infection
• Fatigue
• Imbalanced nutrition: less than body
requirements
NURSING DIAGNOSES

• Risk for imbalanced fluid volume

• Anxiety
• Disturbed body image
• Deficient knowledge
• Ineffective coping
• Social isolation
OUTCOME IDENTIFICATION
1. Pain relief
2. Integrity of skin and oral mucosa
3. Absence of injury and infection
4. Fatigue relief
5. Maintenance of nutritional intake and fluid
and electrolyte balance
6. Improved body image
7. Absence of complications
OUTCOME IDENTIFICATION

1. Knowledge of prevention and cancer

treatment
2. Effective coping through recovery and
grieving process
3. Optimal social interaction
IMPLEMENTATION/MANAGE MENT
• Prevention and detection
– Primary Prevention
• Reducing modifiable risk factors in the
external and internal environment
– Secondary Prevention
• Recognizing early signs and symptoms and
seeking prompt treatment
• Prompt intervention to halt cancerous process
Some carcinogens in the workplace
TREATMENT MODALITIES
• Aimed towards:
– CURE - free of disease after treatment →
normal life
– Control - Goal for chronic cancers
– Palliative Care: Quality of life maintained at
highest level for the longest possible time
• Surgery – surgical removal of tumors; most
commonly used treatment
• Preventive or prophylactic
• Diagnostic surgery
• Curative surgery
• Reconstructive surgery
• Palliative surgery
• Chemotherapy – use of antineoplastic drugs to
promote tumor cell death, by interfering with
cellular functions and reproduction
RADIOTHERAPY: One way
to stop the ca from
growing is to interfere
with the ca cell’s ability
to multiply. Radiation
at high dosages, causes
changes in the ca cell’s
that stops the cell’s
ability to multiply and
eventually kills the ca
cell. In some cases
destroys ca cell in
others slows down
.growth
 Action of Radiation
• Prevents the reproduction of cells as breaks
DNA strands
• Cells most sensitive to radiation M & G2
phases & least sensitive in S phase
• Cells that are rapidly dividing cells and
undifferentiated are more sensitive to
radiation.
 Radiation SOURCES
• COLBALT 60
• CESIUM 137
• IODINE 131
• IRIDIUM 192
• RADIUM 226
• RADON 222
• STRONTIUM 90
 :Types of Radiation
:External Internal:
Beam radiation Implanted
Teletherapy Brachytherapy
:GAMMA RAYS SEALED:
penetrate deeply Interstitial
:BETA RAYS Intercavity
surface penetration
UNSEALED:
Systemic (IV,
oral)
 Nursing Care of the Client with Sealed
Implant
• Private room with • All dressings & linens saved
bathroom until implant removed
• Radioactive material sign • LEAD CONTAINER & LONG
• Wear dosimeter HANDLED FORCEPS,LEAD
• No pregnant staff GLOVES KEPT IN ROOM IN
• Visitors limited to 30 EVENT OF DISLODGEMENT
mins per day • REMEMBER ALARA
• Visitors are restricted and  TIME
must remain at 6 feet  DISTANCE
distance  SHEILDING
 Nursing Care of Client with UNSEALED Implant
• Presents potential • Articles in room phone, call
contamination hazard/ all light, floors covered plastic
articles in room are
• disposable plastic /paper
considered contaminated
used for dietary trays &
• After d/c articles are
utensils
discarded but taken to
• pts. Flush toilet several
protected area ‘til
times
detectable radioactivity
decays • Keep linen & gowns kept in
• Rubber gloves worn with separate isolation bags
direct care
• No pregnant staff
• Radiotherapy – directing high-energy ionizing
radiation to destroy malignant tumor cells
without harming surrounding tissues
Types:
A- Teletherapy (external): radiation delivered in
uniform dose to tumor; Teletherapy is
external beam irradiation and uses a device
located at a distance from the patient. It
produces X-rays of varying energies and is
administered by machines a distance from the
body 31½ to 39 inches (80 to 100 cm).
 Factors influencing degree & occurrence of
:side effects Radiotherapy

• Body site irradiated

• Dosage
• Extent of body area treated
• Method of radiation delivery
• Age of client
• General health of client
• Previous surgeries & chemotherapy
• Radiosensitivity of tissue/organ treated.
 Symptom Management
• Nausea & vomiting
• Diarrhea
• Xerostomia
• Ocular symptoms ( edema, dryness, photophia)
• Oral mucositis
• Alopecia
• Hyperthermia
• Headache
• Cystitis
• Esophagitis
 General precautions of patient
undertaking radiotherapy

• Clothes !
• Sun !
• Shower & shaving !
• Cosmetic !
• Pregnancy !
• Visitors !
• Sewage !
• Utilities !
 Side effects of radiotherapy to specific areas of the body
Selected Examples:

• Radiotherapy to the head and neck:

-Mouth sores
-Tooth decays
-Pain
-Easily to bleed
-Taste changes
-Dry mouth
-Appetite changes
-Voice changes
-Hair loss
 Side effects of radiotherapy to specific areas of the body

• Radiotherapy to the chest (thorax)

-Difficulty swollowing
-Feeling,sick.
-Weight loss.
-Breathlessness.
 Side effects of radiotherapy to specific areas of the body

• Radiotherapy to the stomach and pelvis

-Diarrhea
-Feeling sick
-Loss of appetite
-Loss of weight
-Pain during urination
B- Brachytherapy:

delivers high dose to tumor and less to other

tissues; radiation source is placed in tumor or
next to it; In brachytherapy, the radiation
device is placed within or close to the target
tissue. Radiation is delivered in a high dose to a
small tissue volume with less radiation to
adjacent normal tissue, but requires direct
tumor access.
• Immunotherapy – use of chemical or microbial
agents to induce mobilization of immune
defenses.

• Biologic response modifiers (BRMs) – use of

agents that alters immunologic relationship
between tumor and host in a beneficial way
• Bone marrow peripheral stem cell
transplantation – aspirating bone marrow
cells from compatible donor and infusing
them into the recipient
• Gene therapy – transfer of genetic materials
into the client’s DNA
NURSING MANAGEMENT

1. Promote measures that relieve pain and discomfort.

Pharmacologic and non-pharmacologic interventions

2. Promote measures to maintain intact skin integrity

3. Promote measures that maintain oral mucosa

4. Promote measures to prevent injury from abnormal

bleeding

• Monitor platelet count; avoid aspiring products, etc

NURSING MANAGEMENT
1. Promote measures that identify and prevent infection

• Monitor WBC count; encourage frequent hand washing and

overall cleanliness

2. Help decrease the client’s fatigue and increase his activity level

3. Promote measures that ensure adequate nutritional intake

• High protein, high calorie diet

4. Ensure adequate fluid and electrolyte balance

NURSING MANAGEMENT
1. Promote measures to enhance body image.
• Take an honest gentle, caring approach;
encourage client to express and verbalize feelings
2. Promote measures that address preventing
complications of cancer therapy
3. Instruct client and family about the disease
process and treatments; provide necessary
information for self-care.
4. Help client and family cope effectively
5. Promote measures to reduce social isolation.