UNDERSTANDING CANCER ONCOLOGY NURSING

Essential Concepts of Cancer– What is Cancer?– Normal Cell Growth vs. Cancer Cell Growth– Etiology and Causative Factors– Pathophysiology– Classification of Tumors– Effects of Cancer

NURSING PROCESS

– Assessment– Laboratory & Diagnostic Tests– Tumor Staging and Grading– Nursing Diagnoses & Planning– Implementation and Management• Treatment Modalities– Chemotherapy• End-of-life Issues

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 characterizedby:– 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

CHARACTERISTICS OF NEOPLASIA

Uncontrolled growth of Abnormal cells 1. Benign 2. Malignant 3. Borderline

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

LOSS OF NORMAL GROWTH CONTROL

NOMENCLATURE OF NEOPLASIA

Tumor is named according to:1. Parenchyma, Organ or Cell Hepatoma- liver Osteoma- bone Myoma- muscle

NOMENCLATURE OF NEOPLASIA

Tumor is named according to:2. Pattern and Structure, either GROSS or

MICROSCOPIC Fluid-filled CYST Glandular ADENO Finger-like PAPILLO Stalk POLYP

NOMENCLATURE OF NEOPLASIA

Tumor is named according to:3. Embryonic origin Ectoderm ( usually gives rise to epithelium) Endoderm (usually gives rise to glands) Mesoderm (usually gives rise to Connective

tissues)

BENIGN TUMORS Suffix- “OMA” is used Adipose tissue- LipOMA Bone- osteOMA Muscle- myOMA Blood vessels- angiOMA Fibrous tissue- fibrOMA

MALIGNANT TUMOR Named according to embryonic cell origin1. Ectodermal, Endodermal, Glandular,

Epithelial Use the suffix- “CARCINOMA” Pancreatic AdenoCarcinoma Squamos cell Carcinoma

MALIGNANT TUMOR Named according to embryonic cell origin2. Mesodermal, connective tissue origin Use the suffix “SARCOMA FibroSarcoma Myosarcoma AngioSarcoma

“PASAWAY”

1. “OMA” but Malignant HepatOMA, lymphOMA, gliOMA, melanOMA

2. THREE germ layers “TERATOMA”

3. Non-neoplastic but “OMA” Choristoma Hamatoma

ETIOLOGY/CAUSATIVE FACTORS

• Viruses• Chemical carcinogens• Physical stressors• Hormonal factors• Genetic factors

CANCER NURSINGEtiology of cancer

1. PHYSICAL AGENTS Radiation Exposure to irritants Exposure to sunlight Altitude, humidity

CANCER NURSINGEtiology of cancer

2. CHEMICAL AGENTS Smoking Dietary ingredients Drugs

CANCER NURSINGEtiology of cancer

3. Genetics and Family History Colon Cancer Premenopausal breast cancer

CANCER NURSING

Etiology of cancer4. Dietary Habits Low-Fiber High-fat Processed foods alcohol

CANCER NURSINGEtiology of cancer

5. Viruses and Bacteria DNA viruses- HepaB, Herpes, EBV, CMV,

Papilloma Virus RNA Viruses- HIV, HTCLV Bacterium- H. pylori

CANCER NURSINGEtiology of cancer

6. Hormonal agents DES OCP especially estrogen

CANCER NURSINGEtiology of cancer

7. Immune Disease AIDS

BURKITT’S LYMPHOMA - a cancer of the lymphatic system

Classification of CancerAccording 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. By definition, the term “cancer”

Patterns of cell Proliferation• Hyperplasia• Dysplasia• Metaplasia• Anaplasia• Neoplasia

Patterns of cell Proliferation•Metaplasia• conversion of one type of cell in a tissue to

another type not normal for that tissue•Anaplasia• change in the DNA cell structure and

orientation to one another, characterized by loss of differentiation and a return to a more primitive form.

Neoplasia• uncontrolled cell growth, either benign or

malignant

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

CANCER NURSINGSpread of Cancer

1. LYMPHATIC Most common

2. HEMATOGENOUS Blood-borne, commonly to Liver and Lungs

3. DIRECT SPREAD Seeding of tumors

CANCER NURSINGBody 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

Classification of Tumors• CARCINOMAS: EPITHELIAL TISSUE– BODY SURFACES, LINING OF BODY CAVITIES ETC:

(ADENOCARCINOMA)• SARCOMAS: CONNECTIVE TISSUE– STRIATED MUSCLE, BONE, ETC (OSTEOSARCOMA)• LYMPHOMAS AND LEUKEMIAS– HEMATOPOIETIC SYSTEM• NERVOUS TISSUE TUMORS– EX. NERVE CELLS-NEUROBLASTOMA• MYELOMA– Develops in the plasma cells of bone marrow

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 evaluatedT0 - No evidence of primary tumorTis - Carcinoma in situ (early cancer that has not spread to

neighboring tissue)T1, T2, T3, T4 - Size and/or extent of the primary tumorRegional 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 evaluatedM0 - 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 IDENTIFICATION1. Pain relief2. Integrity of skin and oral mucosa3. Absence of injury and infection4. Fatigue relief5. Maintenance of nutritional intake and fluid

and electrolyte balance6. Improved body image7. Absence of complications

OUTCOME IDENTIFICATION1. Knowledge of prevention and cancer

treatment2. Effective coping through recovery and

grieving process3. 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 – directing high-energy ionizing radiation to destroy malignant tumor cells without harming surrounding tissues

Types:– 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).

– 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 MANAGEMENT1. Promote measures that relieve pain and

discomfort.• Pharmacologic and non-pharmacologic

interventions2. Promote measures to maintain intact skin

integrity3. Promote measures that maintain oral mucosa4. Promote measures to prevent injury from

abnormal bleeding• Monitor platelet count; avoid aspiring products,

etc

NURSING MANAGEMENT1. Promote measures that identify and prevent

infection• Monitor WBC count; encourage frequent

handwashing and overall cleanliness2. Help decrease the client’s fatigue and increase

his activity level3. Promote measures that ensure adequate

nutritional intake• High protein, high calorie diet4. Ensure adequate fluid and electrolyte balance

NURSING MANAGEMENT1. Promote measures to enhance body image.• Take an honest gentle, caring approach;

encourage client to express and verbalize feelings2. Promote measures that address preventing

complications of cancer therapy3. Instruct client and family about the disease

process and treatments; provide necessary information for self-care.

4. Help client and family cope effectively5. Promote measures to reduce social isolation.

Care of Clients Receiving Chemotherapy• Classes of Chemotherapy Drugs:• Alkylating agents:– Action: create defects in tumor DNA– Ex: Nitrogen Mustard, Cisplatin– Toxic Effects: reversible renal tubular necrosis

Classes of Chemotherapy Drugs• Antimetabolites:– Action: phase specific– Ex: Methotrexate; 5 fluorouracil– Toxic Effects: nausea, vomiting, stomatitis,

diarrhea, alopecia, leukopenia

Classes of Chemotherapy Drugs• Antitumor Antibiotics:– Action: non- phase specific; interfere with

DNA– Ex: Actinomycin D, Bleomycin, adriamycin

(doxorubicin)– Toxic Effect: damage to cardiac muscle

Classes of Chemotherapy Drugs• Miotic inhibitors:– Action: Prevent cell division during M phase

of cell division– Ex: Vincristine, Vinblastine– Toxic Effects: affects neurotransmission,

alopecia, bone marrow depression

Classes of Chemotherapy Drugs• Hormones:– Action: stage specific G1– Ex: Corticosteroids• Hormone Antagonist:– Action: block hormones on hormone- binding

tumors ie: breast, prostate, endometrium; cause tumor regression

– Ex: Tamoxifen (breast); Flutamide (prostate)– Toxic Effects: altered secondary sex characteristics

Effects of Chemotherapy• Tissues: (fast growing) frequently affected• Examples: mucous membranes, hair cells,

bone marrow, specific organs with specific agents, reproductive organs (all are fetal toxic; impair ability to reproduce)

Chemotherapy Administration• Routes of administration:– Oral– Body cavity (intraperitoneal or intrapleural)– Intravenous• Use of vascular access devices because of

threat of extravasation (leakage into tissues) & long

term therapy

Chemotherapy Administration• Types of vascular access devices:– PICC lines: (peripherally inserted central

catheters)– Tunneled catheters: (Hickman, Groshong)– Surgically implanted ports: (accessed with

90o angle needle- Huber needles)

Nursing care of clients receiving chemotherapy

• Assess and manage:– Toxic effects of drugs (report to physician)– Side effects of drugs: manage nausea and

vomiting, inflammation and ulceration of mucous membranes, hair loss, anorexia, nausea and vomiting with specific nursing and medical interventions

Nursing care of clientsreceiving chemotherapy• Monitor lab results (drugs withheld if blood

counts seriously low); blood and blood product administration

• Assess for dehydration, oncologic emergencies

• Teach regarding fatigue, immunosuppression precautions

• Provide emotional and spiritual support to clients and families

COLON CANCER

COLON CANCERRisk factors1. Increasing age2. Family history3. Previous colon CA or polyps4. History of IBD5. High fat, High protein, LOW fiber6. Breast Ca and Genital Ca

COLON CANCER Sigmoid colon is the most common site Predominantly adenocarcinoma If early 90% survival 34 % diagnosed early 66% late diagnosis

COLON CANCERPATHOPHYSIOLOGY Benign neoplasm DNA alteration

malignant transformation malignant neoplasm cancer growth and invasion metastasis (liver)

COLON CANCERASSESSMENT FINDINGS

1. Change in bowel habits- Most common

2. Blood in the stool3. Anemia4. Anorexia and weight loss5. Fatigue6. Rectal lesions- tenesmus, alternating

D and C

COLON CANCER Diagnostic findings1. Fecal occult blood2. Sigmoidoscopy and colonoscopy3. BIOPSY4. CEA- carcino-embryonic antigen

COLON CANCER Complications of colorectal CA1. Obstruction2. Hemorrhage3. Peritonitis4. Sepsis

COLON CANCER MEDICAL MANAGEMENT1. Chemotherapy- 5-FU2. Radiation therapy

COLON CANCER SURGICAL MANAGEMENTSurgery is the primary treatmentBased on location and tumor sizeResection, anastomosis, and colostomy

(temporary or permanent)

COLON CANCERNURSING INTERVENTION: COLOSTOMY CARE Colostomy begins to function 3-6 days after

surgery The drainage maybe soft/mushy or semi-solid

depending on the site

COLON CANCERNURSING INTERVENTION: COLOSTOMY CARE BEST time to do skin care is after shower Apply tape to the sides of the pouch before

shower Assume a sitting or standing position in

changing the pouch

COLON CANCERNURSING INTERVENTION: COLOSTOMY CARE Instruct to GENTLY push the skin down and

the pouch pulling UP Wash the peri-stomal area with soap and

water Cover the stoma while washing the peri-

stomal area

COLON CANCERNURSING INTERVENTION: COLOSTOMY CARE Lightly pat dry the area and NEVER rub Lightly dust the peri-stomal area with

nystatin powder

COLON CANCERNURSING INTERVENTION: COLOSTOMY CARE Measure the stomal opening The pouch opening is about 0.3 cm larger

than the stomal opening Apply adhesive surface over the stoma and

press for 30 seconds

COLON CANCERNURSING INTERVENTION: COLOSTOMY CARE Empty the pouch or change the pouch

when 1/3 to ¼ full (Brunner) ½ to 1/3 full (Kozier)

BREAST CANCER The most common cancer in FEMALES Numerous etiologies implicated

BREAST CANCERRISK FACTORS1. Genetics2. Increasing age ( > 50 yo)3. Family History of breast cancer4. Early menarche and late menopause5. Nulliparity6. Late age at pregnancy

BREAST CANCERRISK FACTORS7. Obesity8. Hormonal replacement9. Alcohol10. Exposure to radiation

BREAST CANCERPROTECTIVE FACTORS1. Exercise2. Breast feeding3. Pregnancy before 30 yo

BREAST CANCERASSESSMENT FINDINGS1. MASS- the most common location is the

upper outer quadrant2. Mass is NON-tender. Fixed, hard with

irregular borders3. Skin dimpling4. Nipple retraction5. Peau d’ orange

BREAST CANCERLABORATORY FINDINGS

1. Biopsy procedures2. Mammography

BREAST CANCERBreast cancer Staging I - < 2cm II - 2 to 5 cm, (+) LN III - > 5 cm, (+) LN IV- metastasis

BREAST CANCERMEDICAL MANAGEMENT 1. Chemotherapy 2. Tamoxifen therapy 3. Radiation therapy

BREAST CANCER SURGICAL MANAGEMENT

1. Radical mastectomy2. Modified radical mastectomy3. Lumpectomy4. Quadrantectomy

LUMPECTOMY

QUADRANTECTOMY

BREAST CANCERNURSING INTERVENTION : PRE-OP1. Explain breast cancer and

treatment options2. Reduce fear and anxiety and

improve coping abilities3. Promote decision making

abilities4. Provide routine pre-op care:Consent, NPO, Meds, Teaching

about breathing exercise

BREAST CANCERNURSING INTERVENTION : Post-OP1. Position patient: Supine Affected extremity elevated to reduce

edema

BREAST CANCERNURSING INTERVENTION : Post-OP2. Relieve pain and discomfort Moderate elevation of extremity IM/IV injection of pain meds Warm shower on 2nd day post-op

BREAST CANCERNURSING INTERVENTION : Post-OP3. Maintain skin integrity Immediate post-op: snug dressing with

drainage Maintain patency of drain (JP) Monitor for hematoma w/in 12H and apply

bandage and ice, refer to surgeon

BREAST CANCERNURSING INTERVENTION : Post-OP3. Maintain skin integrity Drainage is removed when the

discharge is less than 30 ml in 24 H Lotions, Creams are applied ONLY when

the incision is healed in 4-6 weeks

BREAST CANCER

NURSING INTERVENTION : Post-OPPromote activity Support operative site when moving Hand, shoulder exercise done on 2ndday Post-op mastectomy exercise 20 mins TID NO BP or IV procedure on operative site

BREAST CANCER

NURSING INTERVENTION : Post-OPPromote activity Heavy lifting is avoided Elevate the arm at the level of the heart On a pillow for 45 minutes TID to relieve

transient edema

BREAST CANCER

NURSING INTERVENTION : Post-OPMANAGE COMPLICATIONSLymphedema10-20% of patientsElevate arms, elbow above shoulder

and hand above elbowHand exercise while elevatedRefer to surgeon and physical

therapist

BREAST CANCER

NURSING INTERVENTION : Post-OPMANAGE COMPLICATIONS Hematoma Notify the surgeon Apply bandage wrap (Ace wrap) and ICE

pack

BREAST CANCERNURSING INTERVENTION : Post-OPMANAGE COMPLICATIONSInfection Monitor temperature, redness, swelling

and foul-odor IV antibiotics No procedure on affected extremity

BREAST CANCERNURSING INTERVENTION : Post-OPTEACH FOLLOW-UP care Regular check-up Monthly BSE on the other breast Annual mammography

THE ENDLUALHATI M. FLORANDA RN MAN