UNDERSTANDING CANCER

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 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)
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Loss of Normal Growth Control

Normal cell division
Cell Suicide or Apoptosis Cell damage no repair

Cancer cell division

First mutation

Second mutation

Third Fourth or mutation later mutation Uncontrolled growth

Oncogenes

Normal cell

Normal genes regulate cell growth

Cancer cell

Oncogenes accelerate cell growth and division

Mutated/damaged oncogene

Example of Normal Growth

Dead cells shed from outer surface

Epidermis

Cell migration

Dividing cells in basal layer

Dermis

The Beginning of Cancerous Growth

Underlying tissue

Tumors (Neoplasms)

Underlying tissue

Invasion and Metastasis

1 Cancer cells invade surrounding tissues and blood vessels

2 Cancer cells are transported by the circulatory system to distant sites

3 Cancer cells reinvade and grow at new location

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ETIOLOGY/CAUSATIVE FACTORS
Viruses Chemical carcinogens Physical stressors Hormonal factors Genetic factors

What Causes Cancer?

Some viruses or bacteria

Some chemicals

Radiation

Heredity Diet Hormones

Population-Based Studies
Regions of Highest Incidence
U.K.: Lung cancer

JAPAN: Stomach cancer

CANADA: Leukemia U.S.: Colon cancer BRAZIL: Cervical cancer

CHINA: Liver cancer

AUSTRALIA: Skin cancer

Genes and Cancer

Viruses

Chemicals

Radiation

Heredity

Chromosomes are DNA molecules

Viruses

Virus inserts and changes genes for cell growth

Cancer-linked virus

Examples of Human Cancer Viruses

Some Viruses Associated with Human Cancers

Bacteria and Stomach Cancer

Patients tissue sample

H. pylori

Tobacco Use and Cancer

Some Cancer-Causing Chemicals in Tobacco Smoke

High-Strength Radiation
High

Leukemia Incidence

Low

Least X-ray Dose (atomic radiation)

Most

AIDS and Kaposis Sarcoma

Without disease

HIV infection
Depressed immune system

KSHV infection
Kaposis sarcoma

Heredity and Cancer

All Breast Cancer Patients

Inherited factor(s) Other factor(s)

Heredity Can Affect Many Types of Cancer

Inherited Conditions That Increase Risk for Cancer

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PATHOPHYSIOLOGY
ABNORMAL CELL FORMED BY MUTATION OF DNA CELL GROWS AND PROLIFERATES METASTASIS OCCURS WHEN ABN. CELLS INVADE OTHER TISSUE,THROUGH LYMPH AND BLOOD
Cancer development linked to immune system failure Example of clients susceptible to developing cancer

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. By definition, the term cancer applies only to malignant tumors

Malignant versus Benign Tumors

Benign (not cancer) tumor cells grow only locally and cannot spread by invasion or metastasis Malignant (cancer) cells invade neighboring tissues, enter blood vessels, and metastasize to different sites

Time

Why Cancer Is Potentially Dangerous

Brain

Melanoma cells travel through bloodstream Liver

Melanoma (initial tumor)

Patterns of cell Proliferation

Hyperplasia Dysplasia Metaplasia Anaplasia Neoplasia

Hyperplasia
tissue growth based on an excessive rate of cell division, leading to a larger than usual number of cells; the process of hyperplasia is potentially reversible; can be a normal tissue response to an irritating stimulus. An example is a callus

Normal

Hyperplasia

Dysplasia
Bizarre cell growth differing in size, shape and cell arrangement

Normal

Hyperplasia

Mild dysplasia

Carcinoma in Situ

Normal

Hyperplasia

Mild dysplasia

Carcinoma in situ (severe dysplasia)

Cancer (invasive)

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 Tends to Involve Multiple Mutations

Benign tumor cells grow only locally and cannot spread by invasion or metastasis Malignant cells invade neighboring tissues, enter blood vessels, and metastasize to different sites

Time Mutation Cells inactivates proliferate suppressor gene Mutations inactivate DNA repair genes Proto-oncogenes mutate to oncogenes More mutations, more genetic instability, metastatic disease

Mutations and Cancer

Genes Implicated in Cancer

Cancer Tends to Corrupt Surrounding Environment

Growth factors = proliferation
Invasive

Matrix Proteases Fibroblasts, adipocytes Blood vessel

Cytokines

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Cytokines, proteases = migration & invasion

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

Different Kinds of Cancer

Some common carcinomas:

Lung Breast (women)

Leukemias:
Bloodstream

Lymphomas:
Lymph nodes

Colon
Bladder Prostate (men)

Some common sarcomas:

Fat Bone

Muscle

Naming Cancers
Cancer Prefixes Point to Location
Prefix adenochondroMeaning gland cartilage

erythro-

red blood cell

hemangio- blood vessels hepatolipolymphomelanomyelomyoosteoliver fat lymphocyte pigment cell bone marrow muscle bone

Women, Tobacco & Lung Cancer

Women who smoke like men,

die like men.

U.S. Surgeon General David Satcher

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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 Psychological Stress

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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

Warning Signs of Cancer

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 may have urinary frequency and urgency

Warning Signs of 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

Warning Signs of 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

Warning Signs of 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

Warning Signs of Cancer

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

Warning Signs of Cancer

Obvious change in a wart or mole
Moles or other skin lesions that change in shape, size, or color should be reported

Warning Signs of Cancer

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

Warning Signs of Cancer

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

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Laboratory & Diagnostic Tests

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

Cancer Detection and Diagnosis

Early Cancer May Not Have Any Symptoms

Cervical Cancer Screening

Normal Pap smear

Abnormal Pap smear

Breast Cancer Screening

Prostate and Ovarian Cancer Screening

Colon Cancer Screening

Biopsy

Pathology

Proteomic profile

Patients tissue sample or blood sample

Genomic profile

Microscopic Appearance of Cancer Cells

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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 T0 Tis T1, T2, T3, T4 NX N0 N1, N2, N3 Primary tumor cannot be evaluated No evidence of primary tumor Carcinoma in situ (early cancer that has not spread to neighboring tissue) Size and/or extent of the primary tumor Regional lymph nodes cannot be evaluated No regional lymph node involvement (no cancer found in the lymph nodes) Involvement of regional lymph nodes (number and/or extent of spread) Distant metastasis cannot be evaluated

Regional Lymph Nodes (N)

Distant Metastasis (M) MX

M0
M1

No distant metastasis (cancer has not spread to other parts of the body)
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. 2. 3. 4. 5. Pain relief Integrity of skin and oral mucosa Absence of injury and infection Fatigue relief Maintenance of nutritional intake and fluid and electrolyte balance 6. Improved body image 7. Absence of complications

OUTCOME IDENTIFICATION
8. Knowledge of prevention and cancer treatment 9. Effective coping through recovery and grieving process 10.Optimal social interaction

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 Prevention and detection

Primary Prevention

IMPLEMENTATION/MANAGEME NT
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

Cancer Prevention
Carcinogenic chemicals Carcinogenic radiation

Cancer viruses or bacteria

Avoid Tobacco
Lung Cancer Risk Increases with Cigarette Consumption
15x

10x

Lung Cancer Risk

5x

0
Non-smoker

15 Cigarettes Smoked per Day

30

Protect Yourself From Excessive Sunlight

Limit Alcohol and Tobacco

Combination of Alcohol and Cigarettes Increases Risk for Cancer of the Esophagus
40x 30x Risk Increase 20x 10x

Alcoholic Drinks Consumed per Day

AND
Packs of Cigarettes Consumed per Day

Diet: Limit Fats and Calories

Correlation Between Meat Consumption and Colon Cancer Rates in Different Countries
40

Number of Cases (per 100,000 people)

30

20

10

80

100

200

300

Grams (per person per day)

Diet: Consume Fruits and Vegetables

Avoid Cancer Viruses

HPV Infection Increases Risk for Cervical Cancer

High

Cervical Cancer Risk

Low Noninfected women Women infected with HPV

Avoid Carcinogens at Work

Some Carcinogens in the Workplace

Industrial Pollution

Incidence of Most Cancers

1930

1950 Year

1970

1990

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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
Teletherapy (external): radiation delivered in uniform dose to tumor Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is placed in tumor or next to it

 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 clients DNA
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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
5. Promote measures that identify and prevent infection
Monitor WBC count; encourage frequent handwashing and overall cleanliness

6. Help decrease the clients fatigue and increase his activity level 7. Promote measures that ensure adequate nutritional intake
High protein, high calorie diet

8. Ensure adequate fluid and electrolyte balance

NURSING MANAGEMENT
9. Promote measures to enhance body image.
Take an honest gentle, caring approach; encourage client to express and verbalize feelings

10. Promote measures that address preventing complications of cancer therapy 11. Instruct client and family about the disease process and treatments; provide necessary information for self-care. 12. Help client and family cope effectively 13. 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) & longterm 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 clients receiving 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
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REFERENCE
National Cancer Institute Brunner and Suddarths Medical Surgical Nursing