The Big “C”: CANCERThe Big “C”: CANCER

By: Diana Blum RN MSNBy: Diana Blum RN MSN

Metropolitan Community CollegeMetropolitan Community College

DefinitionDefinition

According to the American Cancer According to the American Cancer Society:Society:A large group of diseases characterized by A large group of diseases characterized by

uncontrolled growth and spread of abnormal uncontrolled growth and spread of abnormal cellscells

22ndnd leading cause of death in USA leading cause of death in USA

Metastasizing cancer Cell

1 out of 4 Americans will have CA at some time in their life

Common SitesCommon Sites

MENMEN Prostate Lung Colorectal Bladder Lymphoma Melanoma of Skin Oral Kidney Leukemia Stomach

WomenWomen Breast Lung Colorectal Corpus Uteri Ovarian Lymphoma Melanoma of Skin Bladder Cervical Pancreas

Top 3 Cancers that cause DeathsTop 3 Cancers that cause Deaths

MenMen Lung Lung ProstateProstate ColorectalColorectal

WomenWomen LungLung BreastBreast ColorectalColorectal

Early Diagnosis Is Key for survivalEarly Diagnosis Is Key for survival

Normal CellNormal Cell

Single small nucleusSingle small nucleusPerforms a specific function when it Performs a specific function when it

maturesmaturesAble to recognize other cells and identify Able to recognize other cells and identify

tissue of origintissue of originReproduce in a controlled mannerReproduce in a controlled mannerRemain in their tissue of origin except Remain in their tissue of origin except

blood cellsblood cells

Neoplasm (aka TUMOR)Neoplasm (aka TUMOR)

Cells that reproduce abnormally and in an Cells that reproduce abnormally and in an uncontrolled manneruncontrolled manner

Benign TumorsBenign Tumors

HarmlessHarmlessDo not spreadDo not spreadCan create pressure or obstruct organsCan create pressure or obstruct organs

3 types3 typesFibroma: fibrous connective tissueFibroma: fibrous connective tissueLipoma: fat tissueLipoma: fat tissueLeiomyoma: smooth muscle tissueLeiomyoma: smooth muscle tissue

Malignant TumorsMalignant Tumors

Cancer cells characteristicsCancer cells characteristicsChange in appearance from normal Change in appearance from normal

cells/origincells/origin Inability to properly perform functionInability to properly perform functionNot recognized by other cellsNot recognized by other cellsRandom disorganized uncontrolled growth Random disorganized uncontrolled growth

patternpatternContinue to divide when there’s no needContinue to divide when there’s no needCan migrate to other organsCan migrate to other organs

Malignant continuedMalignant continued

Tend to press on normal tissue and organs as Tend to press on normal tissue and organs as the growthe grow

Invasive with all tissuesInvasive with all tissues Regional invasion: movement into adjoining cellsRegional invasion: movement into adjoining cells Metastasis: to spread to distant sitesMetastasis: to spread to distant sites

Most common sites are:Most common sites are: Treatment is more difficult with metsTreatment is more difficult with mets

4 types of Malignancies4 types of Malignancies

Carcinoma: skin, glands, lining of digestive Carcinoma: skin, glands, lining of digestive urinary and reproductive tractsurinary and reproductive tracts

Sarcoma: bone, muscle, other connective Sarcoma: bone, muscle, other connective tissuestissues

Melanomas: pigment cells in the skinMelanomas: pigment cells in the skinLeukemias and lymphomas: blood forming Leukemias and lymphomas: blood forming

tissues: lymphoid tissue, plasma cells, and tissues: lymphoid tissue, plasma cells, and bone marrowbone marrow

Malignant TransformationMalignant Transformation

4 steps4 steps Initiation: DNA exposed to carcinogenInitiation: DNA exposed to carcinogen Promotion: sufficient exposure to agent to Promotion: sufficient exposure to agent to

encourage/enhance cell growthencourage/enhance cell growth Progression: accelerated growth, enhanced invasion, Progression: accelerated growth, enhanced invasion,

altered appearance and activityaltered appearance and activity Metastasis: tumor develops blood vesselsMetastasis: tumor develops blood vessels

Penetrates capillaries and form fibrin network (undetectable Penetrates capillaries and form fibrin network (undetectable by immune system)by immune system)

Dissolve lining of blood vessels to invade surrounding tissueDissolve lining of blood vessels to invade surrounding tissue Set up their own blood supplySet up their own blood supply

Staging Staging

Stage 1Stage 1

The malignant cells are confined to the The malignant cells are confined to the tissue of origin. Not invasive with other tissue of origin. Not invasive with other tissuestissues

Stage 2Stage 2

Limited spread of the cancer in the local Limited spread of the cancer in the local area usually near lymph nodesarea usually near lymph nodes

Stage 3Stage 3

The tumor is larger or has spread from the The tumor is larger or has spread from the local site of origin into nearby tissueslocal site of origin into nearby tissues

regional lymph nodes are likely to be regional lymph nodes are likely to be involvedinvolved

Stage 4Stage 4

The cancer has metastasized to distant The cancer has metastasized to distant parts of the bodyparts of the body

THE TNM Staging SystemTHE TNM Staging System

Specifies the status of the primary Specifies the status of the primary tumor, regional lymph nodes, and tumor, regional lymph nodes, and distant metsdistant mets

T: tumorT: tumorN: regional nodesN: regional nodesM: distant metsM: distant mets

TNM ContinuedTNM Continued

T=primary tumorT=primary tumor T0: no signs of tumor after T0: no signs of tumor after

treatmenttreatment Tis: malignancy in epithelial Tis: malignancy in epithelial

tissue but not in basement tissue but not in basement membranemembrane

T1: minimal size and T1: minimal size and extensionextension

T2, T3:progressive T2, T3:progressive increase in size and increase in size and extensionextension

T4:large size and T4:large size and extensionextension

N=regional nodesN=regional nodes N0:no regional nodes N0:no regional nodes

involvedinvolved N1:minimal node N1:minimal node

involvementinvolvement N2:increased involvement N2:increased involvement

of regional nodesof regional nodes N3:extensive involvement N3:extensive involvement

of regional nodesof regional nodes

M=distant metsM=distant mets M0:no distant metsM0:no distant mets M1:distant mets presentM1:distant mets present

practicepractice

You are caring for a client who has cancer. The You are caring for a client who has cancer. The cancer is staged T4,N3, M1 how would you cancer is staged T4,N3, M1 how would you interpret the information???interpret the information???

Primary tumor is large in size with extension that Primary tumor is large in size with extension that extensively involves the lymph nodes and extensively involves the lymph nodes and distant mets are present.distant mets are present.

Risk Factors Risk Factors

No single cause identifiedNo single cause identified Carcinogens exposureCarcinogens exposure

(chemicals, radiation, viruses)(chemicals, radiation, viruses) Cigarettes, asbestos, nitratesCigarettes, asbestos, nitrates Steroids, estrogens, tar, soot, asphalt, arsenic, Steroids, estrogens, tar, soot, asphalt, arsenic,

corticosteroids, alkylating agentscorticosteroids, alkylating agents Heredity and hormones also play factorHeredity and hormones also play factor

Familial cancers=appear at a high rate than expected. Familial cancers=appear at a high rate than expected. No single gene pinpointedNo single gene pinpointed

Heredity:predictable patterns of inheritance found on Heredity:predictable patterns of inheritance found on a single genea single gene

7 warning signs of Cancer7 warning signs of Cancer

C: change in bowel or bladderC: change in bowel or bladderA: a sore that does not healA: a sore that does not healU: unusual bleeding or dischargeU: unusual bleeding or dischargeT: Thickening or lump in a breast or T: Thickening or lump in a breast or

elsewhereelsewhere I: Indigestion or difficulty swallowingI: Indigestion or difficulty swallowingO: Obvious change in a wart or moleO: Obvious change in a wart or moleN: Nagging cough or hoarsenessN: Nagging cough or hoarseness

Prevention and DetectionPrevention and Detection

Health promotion Health promotion Avoid CarcinogensAvoid Carcinogens ID high risk peopleID high risk people

Health PromotionHealth Promotion

Low fat, low cal, no added preservative, Low fat, low cal, no added preservative, high fiber diet with at least 5 fruits and high fiber diet with at least 5 fruits and veggies dailyveggies daily

Avoid AlcoholAvoid AlcoholAvoid salt cured, smoked, or nitrate Avoid salt cured, smoked, or nitrate

preserved foodspreserved foodsBalance activity and rest with stress Balance activity and rest with stress

managementmanagement

Avoid carcinogensAvoid carcinogens

Avoid over exposure from the sunAvoid over exposure from the sunDo not smoke Do not smoke Avoid second hand smokeAvoid second hand smokeWear a mask at workWear a mask at work

ID High risk peopleID High risk people

This helps researchers recognize factors This helps researchers recognize factors that contribute to cancersthat contribute to cancers

See doctor at least every 6 monthsSee doctor at least every 6 months

Diagnosis Diagnosis H & PH & P Physical ExamPhysical Exam Diagnostic TestsDiagnostic Tests

Biopsy: the removal of cells cut from a sampleBiopsy: the removal of cells cut from a sample Smear: blood cells under microscope to check for leukemiaSmear: blood cells under microscope to check for leukemia CT Scan: used fto detect head and neck Ca, joints and soft CT Scan: used fto detect head and neck Ca, joints and soft

tissuetissue MRI: detects CNS , spinal, neck, bones, joints, lung, kindey, etc.MRI: detects CNS , spinal, neck, bones, joints, lung, kindey, etc. PET(positron Emission Tomography): used to detect solid PET(positron Emission Tomography): used to detect solid

tumors in the brain and breast and to assess cancer treatmenttumors in the brain and breast and to assess cancer treatment Lab: Alpha fetoprotein , Ca50, Ca 125, PSA, etc. (see page 327)Lab: Alpha fetoprotein , Ca50, Ca 125, PSA, etc. (see page 327)

TreatmentsTreatments

Surgery:Surgery:Done for:Done for:

diagnosisdiagnosisSymptom reliefSymptom reliefmaintain functionmaintain functionReconstructionReconstructionPossible curePossible cure

Surgery continuedSurgery continued

Preop/postop care variesPreop/postop care variesThe recommended treatment is based on The recommended treatment is based on

the cancers: type, location, and metsthe cancers: type, location, and mets

RadiotherapyRadiotherapy

Uses ionizing radiationUses ionizing radiationDose: 1 gray equals 100 radsDose: 1 gray equals 100 rads

Used to treat malignant cellsUsed to treat malignant cellsHas delayed and immediate effects Has delayed and immediate effects

Delayed: altered DNA which impairs the cells Delayed: altered DNA which impairs the cells ability to reproduceability to reproduce

Immediate: cell death due to damage of cell Immediate: cell death due to damage of cell membranemembrane

Caregiver Safety with radiationCaregiver Safety with radiation

The less time spent near the source the The less time spent near the source the less exposureless exposure

Unless direct care being given stay 6 ft Unless direct care being given stay 6 ft away from the sourceaway from the source

Effective shielding depends on type of Effective shielding depends on type of rays (the denser the material the more rays (the denser the material the more protection)protection)

External radiationExternal radiation PROCEDUREPROCEDURE

Source is outside the bodySource is outside the body Special xray machine provides treatmentSpecial xray machine provides treatment # of treatments depends on the doctor# of treatments depends on the doctor

Example: 5 times a week for 2-8 weeksExample: 5 times a week for 2-8 weeks PATIENT PREPPATIENT PREP

Treatment simulation to determine exact dosage Treatment simulation to determine exact dosage needed and scheduleneeded and schedule

The skin is marked with permanent, waterproof ink, by The skin is marked with permanent, waterproof ink, by the radiologist for the exact sitethe radiologist for the exact site

Instruct client not to remove markings without Instruct client not to remove markings without permissionpermission

Internal Radiation (Brachytherapy)Internal Radiation (Brachytherapy)

PROCEDUREPROCEDURE SourcesSources

Iodine, phosphorus, radium, iridium, radon, cesiumIodine, phosphorus, radium, iridium, radon, cesium

Instruct client that they pose a threat unitl the Instruct client that they pose a threat unitl the source is removed unless permanently source is removed unless permanently implanted small beads usedimplanted small beads used

2 TYPES2 TYPES SealedSealed UnsealedUnsealed

Sealed Sealed Source is sealed in a container and inserted into Source is sealed in a container and inserted into

the body (CESIUM)the body (CESIUM) Sources may be placed in threads, beads, Sources may be placed in threads, beads,

needles, seeds, or moldsneedles, seeds, or molds To protect visitors from exposure the client To protect visitors from exposure the client

needs:needs: To be placed in isolationTo be placed in isolation Have a sign on the door indicating radiationHave a sign on the door indicating radiation No pregnant women or kids under 18 allowed in roomNo pregnant women or kids under 18 allowed in room Limit time with visitorsLimit time with visitors Have organized schedule for caresHave organized schedule for cares

Between scrotum and anus

Intracavity suchAs bladder

Staff to wear film badges to monitor exposure Staff to wear film badges to monitor exposure Recognize that Sealed sources can become Recognize that Sealed sources can become

dislodgeddislodgedPortable lead shields provides minimal protection Portable lead shields provides minimal protection

Immediately notify MD if source becomes Immediately notify MD if source becomes dislodged.dislodged.

Do not touch source with bare hands Do not touch source with bare hands

Unsealed Unsealed Body fluids may be contaminatedBody fluids may be contaminated

Must wear gloves when working with patientMust wear gloves when working with patientContaminated fluids, dressings, etc may Contaminated fluids, dressings, etc may

require additional precautions depending require additional precautions depending on the agency.on the agency.

Disposable utensils are recommended Disposable utensils are recommended Equipment being removed from room must Equipment being removed from room must

be checked for radiation level firstbe checked for radiation level first

Radiation side effectsRadiation side effects Normal cells may be harmed (hair follicles, bone Normal cells may be harmed (hair follicles, bone

marrow, lining of gi tractand urinary tract)marrow, lining of gi tractand urinary tract) Anemia-deficiency of RBCAnemia-deficiency of RBC Low WBCs Low WBCs

Take 2-6 wks to recoverTake 2-6 wks to recover Bruising/Bleeding( low platelets)Bruising/Bleeding( low platelets)

Takes 2-6 wks to recoverTakes 2-6 wks to recover Alopecia (hair loss)Alopecia (hair loss) AnorexiaAnorexia Dry mouthDry mouth Harms reproductive cellsHarms reproductive cells

See chart 25-8 on page 404See chart 25-8 on page 404

Nursing ImplicationsNursing Implications Teach pt to avoid exposure to sun, trauma, Teach pt to avoid exposure to sun, trauma,

harsh chemicals, soapsharsh chemicals, soaps Teach pt to leave markings alone and to not use Teach pt to leave markings alone and to not use

lotion during treatmentlotion during treatment New hair may be different texture and colorNew hair may be different texture and color Wig is okay to wearWig is okay to wear Encourage dental careEncourage dental care Small frequent feedingsSmall frequent feedings

Monitor I/OMonitor I/O Increase fluid intakeIncrease fluid intake Encourage C &DBEncourage C &DB

ChemotherapyChemotherapy

Use of chemical agents to treat Use of chemical agents to treat (Antineoplastics)(Antineoplastics)Destroy rapidly dividing cellsDestroy rapidly dividing cells

Curative in some casesCurative in some casesDecreases symptoms in othersDecreases symptoms in others

Antineoplastics (see Box 25-2)Antineoplastics (see Box 25-2)

Cell cycle phase specific- only works in a certain Cell cycle phase specific- only works in a certain phasephase

Cell cycle phase non specific-works in all stages Cell cycle phase non specific-works in all stages and phasesand phases

5 types5 types Cytotoxic agents: Taxol, ifex, adriamycin, folexCytotoxic agents: Taxol, ifex, adriamycin, folex Hormones and Hormone antagonists: femara, emcyt, Hormones and Hormone antagonists: femara, emcyt,

evistaevista Biologic response modifiers: interferons, interleukinsBiologic response modifiers: interferons, interleukins Angiogenesis inhibitors: brand new and being studiedAngiogenesis inhibitors: brand new and being studied

Chemo continuedChemo continued

Administered by doctor or certified nurseAdministered by doctor or certified nurseGiven inpt or outptGiven inpt or outptRoutes : po, iv, intracavity, or intrathecalRoutes : po, iv, intracavity, or intrathecal

Intra cavity installed into cavity like bladderIntra cavity installed into cavity like bladder Intrathecal is given in subarachnoid spaceIntrathecal is given in subarachnoid space

Perfusion:technique where drug is injected Perfusion:technique where drug is injected into artery supplying the tumorinto artery supplying the tumor

Side Effects (see table 25-9)Side Effects (see table 25-9) Act on normal cells as wellAct on normal cells as well Same as radiationSame as radiation

Bone marrow supression- most dangerousBone marrow supression- most dangerous N/VN/V alopeciaalopecia

Client is also at risk for toxic effectsClient is also at risk for toxic effects to heart (adriamycin)-causes heart failureto heart (adriamycin)-causes heart failure lung (Blenoxane)-pulmonary fibrosis and lung (Blenoxane)-pulmonary fibrosis and

inflammationinflammation nerve tissue (Velbane, Oncovin)- numbness, tingling, nerve tissue (Velbane, Oncovin)- numbness, tingling,

loss of deep tendon reflexes. loss of deep tendon reflexes. kidney, bladderkidney, bladder

BiotherapyBiotherapy

Agents work by affecting biological Agents work by affecting biological processes including processes including hematopoietic growth factors hematopoietic growth factors

(eyrthropoietin(production of RBC), numega, (eyrthropoietin(production of RBC), numega, colony stimulating factors)colony stimulating factors)

Biologic response modifiers (not first line Biologic response modifiers (not first line treatment; still being studied), andtreatment; still being studied), and

Monoclonal antibodies (specific for proteins Monoclonal antibodies (specific for proteins on surface of cancer cell)on surface of cancer cell)

Transplants and hormone therapyTransplants and hormone therapy

Bone marrow- used with leukemia/lymphomaBone marrow- used with leukemia/lymphoma Stem cell- bone marrow depressionStem cell- bone marrow depression

Both are done to restore blood manufacturing Both are done to restore blood manufacturing cellscells

Hormone therapy-used to supress natural Hormone therapy-used to supress natural hormone secretion, block hormone actions, or hormone secretion, block hormone actions, or provide supplemental hormonesprovide supplemental hormones

Nursing Assessment- diagnostic Nursing Assessment- diagnostic phasephase

Health HistoryHealth History Chief complaint, past medical hx, family history, Chief complaint, past medical hx, family history,

system review (lumps, lesions, pain, fatigue, easy system review (lumps, lesions, pain, fatigue, easy bruising, ha, hemoptysis, vision disturbance, loss of bruising, ha, hemoptysis, vision disturbance, loss of appetite, etc.(see pg 325)appetite, etc.(see pg 325)

ExaminationExamination Vs, ht, wt, inspect face, scalp, mouth for lesionsVs, ht, wt, inspect face, scalp, mouth for lesions Ascultate lungs, and look at respiratory effortAscultate lungs, and look at respiratory effort Inspect breasts for symmetry, dimpling, lumpsInspect breasts for symmetry, dimpling, lumps Palpate abd, scrotum, etcPalpate abd, scrotum, etc

Nursing DX- diagnostic phaseNursing DX- diagnostic phase

Ineffective Coping r/t fear of diagnosis Ineffective Coping r/t fear of diagnosis Goal: acceptance of need for medical Goal: acceptance of need for medical

evaluation and treatment evaluation and treatment Aeb patient seeks medical tx and Aeb patient seeks medical tx and

evaluationevaluation

Interventions- diagnostic phase Interventions- diagnostic phase

Ineffective coping:encourage to learn the Ineffective coping:encourage to learn the warning signswarning signsstress that medical evaluation is needed for stress that medical evaluation is needed for

correct diagnosiscorrect diagnosisAnxiety: remain hopeful, don’t give false Anxiety: remain hopeful, don’t give false

reassurance, don’t use clichés, recognize reassurance, don’t use clichés, recognize the pts feelingsthe pts feelings

Explain proceduresExplain procedures

Treatment phase- assessmentTreatment phase- assessment

Obtain complete drug profileObtain complete drug profileReview systems to check for those related Review systems to check for those related

to txto txAssess pt knowledgeAssess pt knowledgeExplore pt adaptationsExplore pt adaptationsPhysical exam: note general appearance, Physical exam: note general appearance,

LOC, posture, gait, emotional state, head LOC, posture, gait, emotional state, head to toe assessto toe assess

Treatment phase- Nursing DXTreatment phase- Nursing DX

Anxiety related to effects and outcomes of Anxiety related to effects and outcomes of tx tx Goal : reduce anxiety aeb patient states Goal : reduce anxiety aeb patient states

anxiety is reduced and demonstrates a anxiety is reduced and demonstrates a relaxed mannerrelaxed manner

Risk for injuryRisk for injury Ineffective copingIneffective copingAnxietyAnxietyRisk for infectionRisk for infection Imbalanced nutrition< less than body Imbalanced nutrition< less than body

requirementsrequirements

Recovery and rehabRecovery and rehab

Periodic check upsPeriodic check upsRehab restores pt to highest level of Rehab restores pt to highest level of

functioning possiblefunctioning possible

Terminal illnessTerminal illness

22ndnd leading cause of death leading cause of deathOncology clinical nurse is great resource Oncology clinical nurse is great resource

for the patientfor the patient

Oncological emergenciesOncological emergencies

HypercalcemiaHypercalcemia Syndrome of inappropriate antidiuretic hormone Syndrome of inappropriate antidiuretic hormone

(fluid does not come off)(fluid does not come off) Disseminated intravascular coagulation (DIC)Disseminated intravascular coagulation (DIC) Superior Vena Cava Syndrome (redness/edema Superior Vena Cava Syndrome (redness/edema

of face, tachycardia, distended neck veins)of face, tachycardia, distended neck veins) Teach client not to bend forwardTeach client not to bend forward

Spinal cord compression secondary to tumorSpinal cord compression secondary to tumor