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CANCER

Also known as MALIGNANT NEOPLASIA


Synonymous : Tumor, malignancy, carcinoma, and
abberect cell growth
It is an umbrella use to described a group of more
than 100 different diseases that are characterized
by DNA damage that causes abnormal cell growth
and development

Historical Background:
Cancer is the disease of the cell in which the normal
mechanism of cell growth and proliferation are
disturbed. It was recognized in Ancient times by skilled
observer who gave its name, or CANCERI in Latin
word which means CRAB, because it stretched out in
many directions like the legs of the crab.

Definition of Related Terminologies:


Cancer a disease process whereby cell
proliferates abnormally, and is ignoring growth
regulating signals in the environment surrounding
tissue.
Benign a harmless growth that does not spread
or invade other tissues
Malignant defined as harmful tumors, capable of
spread and invasion of other tissue
Neoplasm derived from Greek word neos or new
and plasis molding abnormally new growth or
formation of tissue that serve no useful purpose.
Dysplasia bizarre cell growth resulting in cells that
differ in size, shape and arrangement from other
cells of the same type or tissue.
Anaplasia cells that lack normal cellular
characteristics and differ in shape and organization
with respect to their cells origin, and are usually
malignant.
Hyperplasia an increase in the number of normal
cells in a normal arrangement in a tissue or organ.
Carcinoma refers to any form of cancer that is
composed of epithelial cells that tends to infiltrate
surrounding tissues.
Oncogene refers to the cancer genes that are
altered version of normal genes.
Proto-oncogene refers to repressed oncogene
existing in normal which can be activated by many
different factors which can cause the host cell to
become malignant.
Cachexia a severe weight loss accompanied by
progressive weakness, loss of appetite, wasting and
anemia that is usually associated with advanced
cancer.

Metastasis refers to the spread of cancer cells


from the primary tumor to distant sites.
Chemotherapy use of drugs to kill tumor cells
by interfering with cellular function and
reproduction.
Mitochondria are sausage-shaped structures
in the cytoplasm, sometimes described as the
power house of the cell.
Ribosomes are tiny granules composed of
RNA and protein. When present in free units or
in small clusters in the cytoplasm, the ribosomes
make proteins for use within the cell.
Endoplasmic Reticulum is a series of
interconnecting membranous canals in the
cytoplasm. 2 types: smooth and rough
Golgi Apparatus consists of stacks of closely
folded flattened membranous sacs
Lysosomes are one type of secretory vesicle
formed in the Golgi Apparatus. They contain a
variety of enzymes involved in breaking down
fragments of organelles and large molecules
e.g. RNA, DNA, CHO, CHON inside the cell into
smaller particles that are either recycled or
extruded from the cell as waste material.
Lysosomes in WBC contain enzymes that digest
foreign materials such as microbes.
Microfilaments are tiny strands of CHON that
provide structural support and maintain the
characteristics shape of the cell.
Microtubules are contractile CHON structures
in the cytoplasm involved in the movement of
the cell and organelles within the cell, the
movement of cilia (small projections from the
free boarder of some cells) and possibly the
organization the plasma membrane.

CELLS
Are the smallest functional unit of the body, they
are grouped together to formed tissue. E.g.
blood, muscles, bones, different tissue formed
together to form an organ like heart and brain
Is the structural and functional unit of all living
matter
Cells are made up of:
1.Protoplasm, which is mainly water
containing various organic and inorganic
substances
2.As well as several important organelles or
little organs
The cells are surrounded by a membrane that
determines to some extent which substances
will enter the cell from liquid cellular environment
1

The chemical composition of protoplasm is very


complex. About 99% of the protoplasm is carbon,
hydrogen, oxygen, and nitrogen. The remaining 1%
is sulfur, sodium, chloride, potassium, phosphorus,
magnesium, and calcium. Iron, copper, iodine,
fluorine, and several other elements are present in
trace amounts
Nucleus directs the activity of the cells. It is
located near the center of the cell.
CHROMOSOMES within the nucleus are made up
of thousands of genes. A human gene is a segment
of DNA molecule, the hereditary material.
DNA each of the 46 chromosomes of the normal
human cell contains DNA, which is shaped like a
long spiral ladder. The rungs of the ladder are paired
bases. Adenine (A), Guanine (G), Cytosine (C), and
thymine (T). The pairing of the bases is A to T and G
to C, so therefore, the sequence of the bases on
one side of the ladder determines the sequence
along the other side. The sides of the ladder are
sugar phosphate chains twisted into a double helix.
Two new DNA molecules being formed from a
parent DNA. With each nuclear division , exact
duplicate DNA molecules are formed and ultimately,
two identical daughter cells

CELLS
The human body develops from a single cell called
ZYGOTE resulted form fusion of ovum (female egg)
and spermatozoa (male germ cell)
A cell consists of plasma membrane inside which
there are a number of organelles floating in watery
fluid called cystosal.
Every cell in the body contains nucleus, which
contain genetic material which directs the activities
of the cell
CELL DIVISION:
MITOSIS body growth, replacement of cells that
have a short life span, and repair of injured tissues
depend on the reproduction of cells. The most
common form of cell division
MEIOSIS this is the process of cell division that
occurs in the formation of reproductive cells when
pairs of chromosomes separate and one from each
pairs move to opposite poles of the parent cell,
when it divides each daughter cell has only 23
chromosomes called halfloid number
MUTATION cells are said to mutate when their
genetic make up is altered
Different stages of Mitosis:

Inter phase. This is the stage or period when


cells are not undergoing division. During this
period, the Duplication of DNA takes place
Prophase. The centrioles separate and begin to
move to opposite sides of the cells.
Chromosome threads become more tightly
coiled and the two halves called chromatids can
be seen.
Metaphase. The nuclear membrane dissolves,
and the fine tubules are seen extending toward
the midline of the cell. The chromosomes form a
line in the middle of the cell attaching
themselves to the tubules
Anaphase. The two chromatids of each
chromosomes are completely separated from
each other and can be considered
chromosomes. The tubules pull them to their
respective sides of the cell
Telephase. The cell membrane constricts at the
midpoint, the chromosomes begin to uncoil, and
the nuclear membranes of the daughter cells are
formed. Finally, mitosis is complete with two new
cells formed, each with 46 chromosomes
containing the hereditary code of the cell

CYTOPLASM AND ORGANELLES


The nucleus s surrounded by cytoplasm.
Within the cytoplasm are organelles that carry
out the many functions of the cells. These
functions are determined by DNA, and the
instructions are carried into the cytoplasm by
RNA.
The most important organelles are:
1. Ribosomes
2. Endoplasmic Reticulum
3. Mitochondria
4. Lysosomes
5. Centrioles
6. Golgi complex
7. Microtubules
8. Microfilaments
Protein synthesis takes place in the ribosomes
which are attached to the endoplasmic reticulum
(ER). Some of the ER have no ribosomes, and
these synthesize lipids. Both types of ER have
fluid filled channels that appear to connect all
parts of the cytoplasm. This suggests that ER
may function as a transportation system within
the cell.
The
mitochondria are frequently called
powerhouses of the cells because they contain
enzymes and other molecules that carry out the
energy-producing reactions of the cells. This
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energy results from the breakdown of high energy


phosphate compound. ATP is resynthesized from
the utilization of foodstuff, chiefly CHO.
The lysosomes contain powerful enzymes and are
considered the digestive organs of the cells. These
organelles also function to remove damaged cells or
damaged portions of the cells. Rupture of the
lysosomes will result in the death of the cells.
The centrioles play a major role in cellular division.
These organelles are located close to the nucleus of
the cell and become active during cellular division
or mitosis
Enzymes and hormones that have been
manufactured by the cell are transported through
the cell membrane by the Golgi complex. Once
outside the cell, they enter the bloodstream where
they can be taken where needed in the body.
Microtubules and microfilaments are believed to be
involved, directly and indirectly, in attainment and
maintenance of cell shapes. These organelles also
probably contribute to the motility of the cell.
Other organelles found in cytoplasm are RNA, some
DNA, glycogen, lipids, CHON, and inorganic
substances. Some cellssuch as muscle and nerve
cells also contain fibrils, microscopic threadlike
structures

Characteristics of Cancer Cells


Cancer cells use glucose more rapidly, possibly
resulting from more rapid transport into the cells.
Synthesize protein faster
Cancer cells have abnormally large nuclei often with
irregularly clamped chromation
ABNORMAL CELL GROWTH
Carcinomas most cancers derived from epithelial
tissues, skin, linings of digestive, urinary, and
respiratory tracts
Adenocarcinomas glandular tissues
Sarcomas connective, muscle and bone tissues
Gliomas tissues of the brain and spinal cord
Myelomas pigmented cells
Lymphomas and leukemia lymphatic tissue
plasma cells, bone marrow, and blood forming
tissues
Benign Tumor
Fibroma fibrous connective tissues
Lipoma Fat tissues
Leiomyomas smooth muscle tissue
MALIGNANT CELLS
Have two defining characteristics:

1.They can no longer divide and differentiate


normally
2.They have acquired the ability to invade
surrounding tissues and travel to distant
sites
CHARACTERISTICS
OF BENIGN AND
MALIGNANT TUMOR
CELL CHARACTER
B Well differentiated cells of the tissue from
which tumor originated
M Cells are undifferentiated and often beat little
resemblance to the normal cell of the tissue
MODE OF GROWTH
B Tumor grows by expansion and does not
infiltrate the surrounding tissue, usually
encapsulated
M Malignant grows at the periphery and send
out process that infiltrate and destroy the
surrounding tissues
RATE OF GROWTH
B Rate of growth is usually slow
M Rate of growth is variable
METASTASIS
B Do not spread by metastasis
M Gain access to the blood and lymphatic
channels and metastasize to other areas of the
body
GENERAL EFFECTS
B It is usually a localized phenomenon that does
not cause generalized effect unless its location
interferes with vital signs functions
M Often cause generalized effects, such as
anemia, weakness and weight loss
TISSUE DESTRUCTION
B Does not usually cause tissue damage unless
its location interferes with blood flow
M Often cause extensive tissue damage as the
tumor outgrow its blood supply or encroaches on
blood to the area, may also produce substance
that cause cell damage
ABILITY TO CAUSE DEATH
B Does not usually cause death unless its
location interferes with vital signs function
M Usually causes death unless growth can be
controlled
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CANCER EPIDEMIOLOGICAL DATA


INCIDENCE cancer is higher in men than in
women and higher in industrialized sectors and
nations.
MORBIDITY RATE cancer is the second only to
CVD as the leading cause of death in US resulting
in over 550,000 deaths annually
OCCURRENCE certain cancer such as cervical,
prostatic, esophageal, lung and colorectal affect
more blacks than whites, some occupation expose
patient industrial carcinogen
MORTALITY RATE Africans and Americans has
an increased morbidity and mortality for these
groups are largely related to economic factors,
education, and barrier to health care rather than to
racial characteristics.
GENDER - females between ages 20 and 40 years
old are three times as likely to develop cancer as
men and women
1.Females most common cancer are breast,
colon, lungs and uterus
2.Males most common cancer are lungs, GIT,
prostate and bladder
HOW DOES CANCER HAPPEN?
It involves 3 steps
CARCINOGENESIS

INITIATION

PROMOTION

3.Drugs such as Nicotine


PROGRESSION
Is the late promotion phase in which the tumor
invades, metastasizes, and becomes resistant
to drugs. This step is irreversible.
Enhance invasiveness
Altered appearance and biochemical activity
E- Tumor development
E- Cells mutate so they are not all identical and
have differing sensitiveness to treatment
METASTASIS
Tumor develops internal BV
Tumor cells extend into normal tissues by
producing an enzymes that dissolve substances
that hold normal cells together
Tumor penetrates capillaries, other body
structures, and cavities
Tumor cells are transported throughout the body
, most destroyed by bodys defenses
Tumor cells are trapped in capillary bed and
form a fibrin meshwork that prevents detection
by immune system
Enzymes dissolve lining of BV, cell invades
surrounding tissues
Cell attempt to establish
blood supply to
support development of metastatic colony
E- Transformed cells relocate by direct
extension, invasion, establishment of remote
sites

PROGRESSION

CARCINOGENESIS
The production of cancerous cells
INITIATION
Refers to the damage or mutation of DNA that
occurs when the cell is exposed to an initiating
substances or event such as chemicals, virus or
radiation during DNA replication
Irreversible changes occur in DNA
E-Cell appears somewhat abnormal
E-Cell continues to function normally
PROMOTION
Involves the mutated cells exposure to factors
(promoters) that enhance its growth
E-Latent periods before increased growth forms
tumors
PROMOTERS may be:
1.HORMONES
2.FOOD ADDITIVES such as Nitrates

CANCER CELLS METASTISIZE IN 3 WAYS


By circulation through the blood and LS
By accidental transplantation during surgery
By spreading to adjacent organs and tissues
CAUSES
Researchers have identified 100 cancer genes
ONCOGENES activates cell division and
influence embryonic development, or it is the
development of tumor
TUMOR SUPPRESOR GENES Halt cell
division
Normal human cells typically contain protooncogenes (oncogene precursor) and tumorsuppressor genes, which remain dormant unless
they are transformed by genetic or acquired
mutation, ( viruses, radiation, environmental and
dietary carcinogens, and hormones
OTHER FACTORS
AGE
4

NUTRITIONAL STATUS
HORMONAL BALANCE
RESPONSE TO STRESS

RISKS FACTORS
Air Pollution
Tobacco
Alcohol
Sexual and Reproductive Behavior
Occupation
Ultraviolet Radiation
Ionizing Radiation
Hormones
Diet
AIR POLLUTION
Arsenic a very poisonous oxygen compound, steel
gray poisonous chemical element as in alloy
Benzene colorless volatile flammable liquid
hydrocarbon , used as solvent e.g. dyes
Hydrocarbons organic compound composed of
H20 and carbon
Polyvinyl Chlorides
Cigarette smoke
Radon, normal background radiation ex rock and
soil (formed from decay of radium from
radiotherapy)
TOBACCO
Contains 2 carcinogens that causes mutations:
NITROSAMINES
POLYCYCLIC HYDROCARBONS
SEXUAL AND REPRODUCTIVE BEHAVIOR
The age of first sexual intercourse and the number
of sexual partners are positively correlated with
womans risk of cervical cancer
A woman who has had only one sexual partner is at
risk if that partner has had multiple partners
Virus transmission Human Papillomavirus HPV
OCCUPATION
Asbestos such as insulation installer and miners are
at risks for a type of cancer called mesothelioma
Workers involved in the production of dyes, rubber,
paint are at increased risks of bladder cancer
ULTRAVIOLET RADIATION
Causes genetic mutation
It releases tumor necrosis factor alpha in exposed
skin which diminishes the immune response
IONIZING RADIATION

Such as X-Rays is associated with leukemia,


thyroid, breast, lung, stomach, colon, UT CA,
and multiple myeloma
Low doses can cause DNA mutations and
chromosomal abnormalities while large doses
can inhibit cell division
This can affect CHO, CHON, Lipid, nucleic acids
Enhance genetic abnormalities

HORMONES
Sex steroid hormones: Estrogen, Progesterone,
and testosterone are promoters of breast,
endometrial, ovarian, or prostate cancer
ESTROGEN stimulates the proliferation
of
breast and endometrial cancer: like early
menarche or late menopause, long term use of
estrogen replacement without progesterone
supplementation
(counteracting
estrogen
stimulatory effects)
The male sex hormones stimulate the growth of
prostatic tissue
DIET
Obesity related to production of estrogen by
fatty tissue ( Endometrial CA )
High consumption of dietary fat ( Ex Breast ,
Rectal )
High consumption of smoked foods, salted fish,
meats or foods containing nitrates (Gastric CA )
Naturally occurring carcinogens : hydrazines
and aflatoxins ( Liver CA )
Carcinogens produced by microorganisms in
stored foods ( Stomach CA )
Diet low in fiber ( Colorectal CA)
WARNING SIGNS OF CANCER
C - Change in bowel or bladder function
A - A sore that does not heal
U - Unusual bleeding or discharge
U - Unusual paleness
U - Unusual weight loss
T - Thickening or lumps elsewhere
I - Indigestion or difficulty of swallowing
O - Obvious changes in warts or mole
N - Nagging cough or hoarseness
HEALTH EDUCATION AND PREVENTION CARE
IN THE INCIDENCE OF CANCER
SEVEN SAFEGUARD AGAINST CANCER
1.BREAST Regular monthly self-examination of
breasts for lumps, nodules or changes in
contour
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2.Colon & Rectum Annual proctoscopic examination


in persons over 40 years old
3.Lung- Control and preferably elimination of cigarette
smoking habit, annual CXR
4.Oral- Annual examination of mouth and teeth
5.Skin-Avoidance of undue exposure to sunlight
6.UTERUS- Annual Papanicolaou smear for all female
adults
7.Basic- yearly complete PE for all adult men and
women, annual UA and blood work.

DIET
Increase consumption of fresh vegetables
specially those of cabbage family
Increase Fiber in the diet
Increase intake of Vitamin A
Increase intake of foods rich in Vitamin C
Practice Weight Control
Reduce the amount of Dietary Fat
Cut down on Salt-Cured, Smoked, Nitrate-Cured
Foods

The nurse should educate the public with the


following:
Reduce or avoid exposure to known or suspected
carcinogens and cancer promoting agents
Eat balanced diet that includes vegetables, fresh
fruits, wholegrains, adequate amount of fiber, and
low level of fats and preservatives
Participate in regular exercise regimens
Obtain adequate, consistent, periods of rest 6-8
hours per night
Have a health examination on consistent basis that
includes health history, physical examination and
specific diagnostic tests for common cancer
Eliminate, reduce or change the perceptions of
stressors and enhance the ability to positively cope
with the stressors
Enjoy consistent periods of relaxation and leisure.
Know the 7 or 9 cancer warning signs
Learn and practice self examination of breast and
testicles
Seek immediate medical care if cancer is suspected

EARLY DETECTION
Nurse can organize and participate in screening
programs such as government programs
promoting awareness for cancer
Urge the client to have a routine PE that
includes cancer screening such as BE, Paps
Smear and Examination of stool specimen for
colorectal cancer.

STEPS IN CONTROLLING CA
1.EDUCATION- Both professional and laymen
persons concerning the warning signs of Cancer, its
detection and prevention.
2.Increased Government Control of Potential
Carcinogens e.g.
Strong drive to control air and water pollution
Government specification have been developed to
protect factory workers, x-ray technicians and
others against undue exposure to ionizing
radiation.
3.Change in habits or customs that are known to
predispose cancer
Quit smoking
Sunbathers are cautioned about the danger of
overexposure to strong sunlight
Pediatricians are strongly urging circumcision of
newborn males because uncircumcised males
have high incidence of penile cancer

BREAST
The risks of cancer occurs with persons who:
Has early menarche
Late menopause
Fibrocystic disease
Infertility
More than age of 30years for first pregnancy
Has personal history of breast cancer mother or
sister with history of breast cancer
Obesity
Whose age is 35-65 years

The screening measure will be:


Monthly BSE
Breast examination by health professional every
3 years for women aged 20-40 and every year
after the age of 40
Baseline mammogram of the age 40 and every
1-2 years between ages 40-49 and every year
after the age of 50
Observation by patient for lungs or thickening
discharge from nipple, pain in the breast
LUNG CA
1.History of 20 / pack years of smoking (1 pack a
day for 20 years)
2.Exposure to air-borne carcinogens especially
asbestos, uranium, hydrocarbon
3.Age range 40-80 years
4.Chronic Lung Diseases
6

NOTE:
Observe patient for change in respiratory status,
increased frequency of infections, change in cough,
sputum, breathing, and voice. Some doctors advise
annual CXR
COLON AND RECTUM
1.History of familial polyposis, ulcerative colitis,
Crohns disease
2.Personal or family history of colon and rectal cancer
3.High fat diet and low in fiber
4.Age range 40-75 years
The method of screening test will be:
Fecal occult blood test on stools every after age of
50 years
DRE annually after age of 40 years
Sigmoidoscopic examination (preferably flexible)
every 3-5 years after 50 years or colonoscopy every
10 years or double contrast barium enema every 510 years
Observations by patients for change in bowel
pattern ex diarrhea, constipation, pain, flatus, black
tarry stools, bleeding
PROSTATE
The risk of prostatic cancer occurs with the
presence of prostatic hyperplasia and presence
prostatic infection.
The methods of screening of such case will be:
1.DRE at age of 40 and annually thereafter
2.PSA blood test every year
3.Observation on men aged 50 and older for
dysuria, blood in urine, difficulty in producing
stream of urine.
CERVIX
Who has a history of early intercourse before the
age of 20 years with multiple partners
Who maintains poor personal hygiene including
poor menstrual hygiene
Who has history of herpes virus type II infections
and cervical dysplasia
For such cases screening measures will include:
Pap test and pelvic examination every year for
those who are or have been sexually active or who
have attained the age of 18 years
Colposcopy if suspicious area is noted
Observation by patient for abnormal vaginal
bleeding or discharge, pain, or bleeding with sexual
intercourse

ENDOMETRIUM
The risks of endometrial cancer occurs with a
persons having infertility, ovarian dysfunction,
obesity, uterine bleeding, estrogen therapy over
a long period of time, diabetes and age range
30-80 years
Screening measures includes:
1.Pap test every year
2.Pelvic examination every year
Endometrial biopsy every year for women of
menopause and
3.Observation by patient for a abnormal
uterine bleeding pain, change in menstrual
pattern
SKIN
The risks of skin cancer occurs with person,
having prolonged exposure to sun and previous
radiation exposure, fair, thin skin and positive
family history of dysplasia nevus syndrome
Screening measures includes:
1.Self examination monthly with suspicious
lesions evaluated promptly, physical
examination every year, and observation by
patient for sore that does not heal, change
in wart or mole
CANCER RELATED CHECK UP
Male and Female 20-40
1.Check up every 3 years : thyroid, oral cavity,
lymphnodes, testes, ovaries
Male and Female 40 and older
1.Check up every 3 years : thyroid, oral cavity,
lymphnodes, testes, ovaries
To sum up, the early detection of CA in
asymptomatic population are as follows:
Chest X-Ray- it is no longer recommended for
smokers to screen for lung cancer, but can be
done.
Sputum Cytology- DO
PE-for both male and females, after the age of
40 years, yearly including examination of skin,
lymph nodes, mouth, thyroid, breast, testes,
rectum, prostate.
Health Teachings: For both male and females,
who attained the age of 20 years. It has to be
done every 3 years to teach about diet,
exercise, health habits, breast and testicular self
examinations, avoidance of sunlight, and
smoking cessation.
BSE For females who have attained menarchy
or 20 years and above, every month after
menses before menopause, after menopause,
7

monthly or specified day such as the first or last of


the month.
Mammography for women who are between 35-40
years of age, baseline mammogram, between the
age 40-49 yrs mammogram should be done every
1-2 years and yearly after 50 years.
Pap smear for females who are above 18 years of
age and sexually active women should have pap
smears regardless of age, should be performed
yearly until there are 3 negative examinations in a
row, at this point they can be performed yearly or as
the AP advises.
Pelvic Examinations for females who are between
20-40, and 40 above, every 3 years , earlier if
sexually active, yearly after 40 years
Endometrial tissue sample: for females at
menopause, high risks women (obese, abnormal
uterine bleeding, estrogen therapy, history of
infertility, diabetes, HPN, failure to ovulate) should
have this performed at menopause.
Testicular self-examination for males, monthly, on
a set date such as the first of the month following a
shower
BSE for females every 3 years for those who are
between 20-39 years and annually for those who
are above 40.
DRE for both male and females who are above
40, annually rectal cancer and prostate in men.
Fecal occult blood for both male and females
those who are above 20 years, done on advice of
AP.
Proctoscopy, flexible sigmoidoscopy for both men
and women who are above 50 years every 3-5
years

Diagnostic of Cancer
Health history
1. Emphasis on risks factors, exposure to
carcinogens, drug ingestions, related habits,
ingestion of alcohol, lifestyle, pattern, degree
of coping with stress
Identification of risks factors
Physical Examination
Diagnostic Studies
Clinical Manifestations usually appear once tumor
has grown to a sufficiently large size to cause the
ff:
Pressure on surrounding organs or nerve
Distortion of surrounding tissues
Obstruction of the lumen of tubes
Interference with blood supply of surrounding
tissues

Interference with the organ function


Disturbance with body metabolism
Parasitic use of the bodys nutritional supplies
Mobilization of the bodys defensive responses,
resulting in inflammatory changes

Common Clinical Manifestations:


Weight loss
Weakness or fatigue
CNS alterations
Pain
Hematologic and metabolic alterations
Note -are related to tumor growth
Anorexia, weakness, fatigue are related to
bodys inability to consume and use nutrients
appropriately
Pain is a result of obstruction or destruction of
a vital organ, pressure on sensitive tissue or
bone, involvement of nerves
Client with difficulty of vision, speech,
coordination or memory may be experiencing
primary or metastatic CNS disease. Increase
ICP cause by tumor may cause headache,
lethargy, nausea, and vomiting.
Unexplained anemia may indicate malignancy
Localized Tumor
produces manifestations
related to increased pressure or obstruction in
a single region
Metastatic disease and extensive tumors of
major organs may display a variety of local
and systemic manifestations
CLASSIFICATION OF CANCER STAGING OR
GRADING
HISTOLOGIC GRADING
TNM SYSTEM CLASSIFICATION
INTERNATIONAL
FEDERATION
OF
GYNECOLOGY AND OBSTETRICS (IFGO)
CERVICAL CANCER STAGES
HISTOLOGIC GRADING
G1 G2 G3 G4
This is useful to the physician in knowing
whether the tumor maybe expected to respond
to radiation treatment as well as in planning all
other aspect of the patient treatment
Grade 1 tumor is the most differentiated (more
like the parent tissue) and therefore the least
malignant. Grade 4 is the least differentiated
(more unlike the parent tissue) and high degree
of malignancy
TNM SYSTEM CLASSIFICATION
8

Determination of the extent of the spread of cancer (


staging ) and the site of the original tumor is vital for
planning therapy
T-Tumor N- Regional lymph nodes M- distant
metastasis
Adding the number to the letter indicates the extent
of malignancy

IFGO CERVICAL STAGING


Defines the cervical cancer in stages
Stage 0 carcinoma in situ, intraepithelial carcinoma
Stage 1 Cancer confined to the cervix
(extension
to the corpus should be disregard)
Stage 2 Cancer beyond the cervix but not to the
pelvic wall
Stage 3 Extension to the pelvic wall, on rectal
examination, no cancer free space between tumor
and the pelvic wall involves the lower third of the
vagina, may block the uterus
Stage 4 Extension beyond the true pelvis or
involvement of the bladder or the rectal mucosa
CLASSIFICATION OF CANCER
STAGE 1 The malignant cells are confined to the
tissue origin. There is no invasion of other tissues
STAGE 2 There is limited spread of CA in local area,
usually nearby lymphnodes
STAGE 3 the tumor is larger has spread from the
site of origin into nearby tissues, or both. Regional
lymph nodes are likely to be involved
STAGE 4 The cancer had metastasized to distant
parts of the body
UNDERSTANDING TNM STAGING
T for PRIMARY TUMOR
1. TX Primary Tumor cant be assessed
2. T0 No evidence of primary tumor
3. Ts Carcinoma in situ
4. T1, T2, T3, T4 Increasing size or local
extent or both of primary tumor
N for Nodal Involvement
Nodal involvement reflects the tumors spread to the
lymph node as follows:
1. NX Regional lymph nodes cant be
assessed
2. N0 No evidence of regional lymph node
metastasis
3. N1, N2, N3 Increasing involvement of
regional nodes
M for Distant Metastasis

Metastasis denotes the extent or spread of


disease. Levels range from MX to M4 as follows:
1. MX Distant metastasis cant be
assessed
2. M0 No evidence of distant metastasis
3. M2, M3 , M4 Multiple foci or multiple
organ metastasis

X-ray
Are ordered to identify and evaluate changes in
tissue densities e.g. barium enema (GIT),
excretory urography (UT), lymphangiography
GASTROSCOPY
Allows direct visualization, evaluation of mucosa
lesion and gastroscopic biopsy
CT SCAN
Evaluates successive layers of tissue by using
narrow beam
X-ray to provide a cross
sectional view structure. It also reveal different
characteristics of tissue within an organ. ex
neurologic, pelvic
MRI
Use of magnetic field and radiofrequency
signals to create sectional images of various
body structures. For Neurologic, Pelvic,
Abdominal, Thoracic CA
UTZ
High frequency sound waves echoing of body
tissues are converted electronically into images,
used to assess tissue deep within the body. For
abdominal and Pelvic CA

ENDOSCOPY
Direct visualization of body cavity or
passageway by insertion of an endoscope into
the body cavity, to allow tissue biopsy, fluid
aspiration, excision of small tumor. For bronchial
and GIT CA
NMI-Nuclear Machine Imaging
Uses IV injection or ingestion of radioisotope
substances followed by imaging of tissue that
has concentrated the radioisotopes. For bone,
liver, kidney, thyroid, brain, spleen CA
PET
9

Computed cross sectional images of increased


concentration of radio isotopes in malignant cells
provide information about biologic activity of
malignant process and responses to treatment. For
lung, colon, liver, pancreatic, breast, esophagus CA,
Hodgkins and Non Hodgkins lymphoma, and
melanoma
RADIOIMMUNOCONJUGATE
Monoclonal antibodies are labeled with a radio
isotopes and injected IV into the patient, the
antibodies that aggregate at the tumor site are
visualized with scanners. For colorectal, breast,
ovarian, head and neck CA, lymphoma and
melanoma.
HCG Studies
Is a glycoprotein hormone with alpha and beta sub
units, which are normally produce by developing
placenta and may be produced by some germ cell
tumor, elevated level have been associated with a
poor outcome in client with colorectal CA.
Otoscopy
Is the visualization of the tympanic membrane , any
trauma causing bleeding may be diagnosed as well
as vascular tumors of the middle ear
COLONOSCOPY
Is visualization of the mucosa of the entire colon
and terminal ileum e.g. diverticuli polyps, tumors,
ulcerative colitis, parasitic disease or other causes
of diarrhea
PROCTOSCOPY
Endoscopic direct visualization and examination of
the lining of the rectum and the anal canal using a
rigid protoscope. E.g. unexplained anemia and
diarrhea
SIGMOIDOSCOPY
It is a 50cm fiber optic tube with a lighted mirror lens
system that illuminates the sigmoid colon for
visualization
COLPOSCOPY
Visual examination of the vagina and cervix using a
lighted colposcope that magnifies the mucosal
surfaces
DIGITAL RECTAL EXAMINATION
It is a valuable screening for cancer of the prostate
gland for man older than 40 years old. It enables the

examiner to assess the size, consistency and


shape of the prostate and the presence of any
nodules
CSF
It is a nuclear medicine study of the brain and
cerebral blood flow injection of the radio
isotopes into the sub arachnoid space through
the internal or lumbar puncture, the head of the
scanned at regular intervals determined the
amount of time it takes for the radio isotopes to
clear from the circulating CSF, several views are
taken at specific time over 24-48 hours e.g.
brain atrophy, tumor cyst and subdural
hematoma
SCHILLERS TEST
A procedure for indicating areas of abnormal
epithelium in the vagina or on the cervix of the
uterus as a guide in selecting biopsy sites for
cancer detection
BIOPSY
Is the removal of a small piece of living tissue
from an organ or other part of the body for
microscopic examination to confirm a establish
diagnosis, estimate prognosis, or follow the
cause of the disease
SCANNING
A technique for carefully studying an area, organ
or system of the body by recording and
displaying an image of the area
HISTOPATH
The study of disease involving the tissue cells
BENCE JONES PROTEIN
A protein found almost exclusively in the urine of
patients with multiple myeloma
PROSTATE
Specific antigen PSA a protein produced by the
prostate that may be present at elevated levels
in patients with cancer or other disease of the
prostate
EXCRETORY GRAPHY
The radiographic examination of the urinary tract
with the use of contrast medium injected into the
blood filtered by the kidneys and pass through
the tract
10

MAMMOGRAPHY
The radiographic examination of the soft tissues of
the breast. Routine test reduces the breast CA
mortality rate at 25% to 35% in asymptomatic
women in middle age
ENDOSCOPIC
RETROGRADE
CHOLANGIOGRAPHY(ERCP)
An endoscopic test that provides radiographic
visualization of the bile and pancreatic ducts
FOUR GOALS OF CANCER
CURE To eradicate the cancer and promote longterm survival
CONTROL To arrest tumor growth
PALLIATION To alleviate symptoms when the
disease is beyond control
PROPHYLAXIS To promote treatment when no
tumor is detectable, but the patient is known to be at
high risk for tumor development or occurrence

CANCER IS CATEGORIZED BY TYPE:


PRIMARY To eradicate the disease
ADJUVANT To eliminate microscopic diseases
and promote cure or improve the patients response
SALVAGE OR PALLIATIVE To manage recurrent
disease
TREATMENT
SURGERY
RADIATION THERAPY
CHEMOTHERAPY
IMMUNOTHERAPY OR BIOTHERAPY
HORMONE THERAPHY
* Each can be used alone or in combination called
MULTIMODAL THERAPY
SURGERY
May be performed to diagnose the disease or
Diagnostic Surgery
Initiate primary treatment Debulking or removal of
entire tumor
Achieve palliation or Palliative Symptom
Occasionally done for prophylaxis
Types of Surgical procedures used in surgical
management of cancer are as follows:
BIOPSY: IS THE SURGICAL
REMOVAL OF A
PIECE OF TISSUE SAMPLE FROM THE
QUESTIONABLE AREA, AND THE TISSUE
SAMPLE IS SENT TO THE PATHOLOGY
LABORATORY FOR DIAGNOSTIC VERIFICATION.

THE SAMPLE IS OBTAINED THROUGH THE


NEEDLE BIOPSY, INCISIONAL OR EXCIONAL
BIOPSY.
RECONSTRUCTIVE
/
REHABILITATIVE
SURGERY: RESTORATION OF FORM AND
FUNCTION IS POSSIBLE IN VARYING
DEGREES DEPENDING ON THE SITE AND
EXTENT OF SURGERY: QUALITY LIFE
RESTORING MAXIMAL FUNCTION AND
APPEARANCE
PALLIATIVE SURGERY: REFERS TO A
SURGERY THAT ATTEMPTS TO RELIEVE
THE COMPLICATIONS OF CANCER EX.
REDUCE PAIN, OBSTRUCTION IN GI AND
GU TRACT, RELIEVE PRESSURE ON THE
BRAIN AND SC, PREVENT HEMORRHAGE,
REMOVE ULCERATING TUMOURS, AND
DRAIN ABSCESS
ADJUVANT SURGERY: REFERS TO THE USE
OF VARIOUS SURGICAL TECHNIQUES TO
FACILITATE THE OVERALL MANAGEMENT
SURGERY OF PRIMARY LESSION: IS THE
REMOVAL OF THE PRIMARY SITE OF
MALIGNANCY. THE GOAL OF THERAPY IS
CURE
SURGERY OF THE METASTATIC TUMOUR
OR RESECTION OF METASTASIS IS USED IN
SELECTED CASE WHERE A CURE CAN BE
OBTAINED
OR
REASONABLE
PROLONGATION OF SURVIVAL IS POSSIBLE.
The primary cancer must be controlled.
PREVENTIVE/PROPHYLACTIC SURGERY: IS
THE REMOVAL OF LESION THAT IF LEFT IN
THE BODY ARE APT TO DEVELOP INTO
CANCER
CURATIVE SURGERY: IS THE REMOVAL OF
THE PRIMARY SITE OF MALIGNANCY AND
ANY LYMPH NODES TO WHICH THE
NEOPLASM HAS EXTENDED EX. RADICAL
NECK
DISSECTION,
LUMPECTOMY,
MASTECTOMY,
PNEUMONECTOMY,
ORCHIECTOMY, THYROIDECTOMY, AND
BOWEL RESECTION
DEBULKING SURGERY: IS THE REMOVAL OF
BULK OF THE TUMOUR; SHOULD BE
PERFORMED BEFORE THE START OF
CHEMOTHERAPY WHEN EVER POSSIBLE.
EX ATTACHED TO VITAL ORGANS

PROCEDURES
USED
TO
PROVIDE
SUPPORTIVE CARE:
Insertion of feeding tubes in the esophagus or
stomach
11

Creation of colostomy to allow rectal abscess to


heal
Suprapubic cystotomy for the patient with advance
prostate cancer
Vascular access devices
Radiotherapy implants
Peritoneal access, ventricular access
Drainage of peritoneal or pleural effusions

RADICAL OR MODIFIED RADICAL EXCISION


REMOVES THE PRIMARY TUMOR ALONG WITH
LYMPH NODES, NEARBY STRUCTURES THAT
MAY BE AT RISKS FOR DISEASE SPREAD
WIDE AND LONG EXCISION
A COMMON METHOD OF SURGICAL REMOVAL
OF A SMALL TUMOR MASS
PALLIATIVE SURGERY
IS USED TO RELIEVE COMPLICATIONS SUCH
AS PAIN, ULCERATIONS, OBSTRUCTION,
HEMORRHAGE, OR PRESSURE
1. CORDOTOMY TO RELIEVE INTRACTABLE
PAIN AND BOWEL RESECTION
2. OSTOMY TO REMOVE A BOWEL
OBSTRUCTION
TO REMOVE HORMONE PRODUCING GLANDS,
THEREBY LIMITING THE GROWTH OF
HORMONE-SENSITIVE TUMOR
PROPHYLACTIC SURGERY
DONE IF THE PATIENT HAS PERSONAL OR
FAMILIAL RISKS FACTORS FOR A PARTICULAR
TYPE OF CANCER
1. Prophylactic Mastectomy
RADIATION THERAPY
Involves the use of high energy radiation to treat
cancer
It aims to destroy
dividing cancer cells while
damaging normal cells as little as possible
Is the use of ionizing radiation. The unit of measure
for radiation doses is now the Gray, formerly the rad.
One gray equals 100 rads
RT is used to treat cancer because malignant cells
are more sensitive than are normal cells to
radiation.
RT has immediate and delayed effects on the cells:
1. The immediate effect is cell death due to
damage cell membrane
2. The delayed effect is alteration of DNA, which
impairs the cell activity to reproduce

Types of cancer cells vary in their sensitivity to


radiation. A tumor is considered radiosensitive if
it can be destroyed by radiation at a dose that is
tolerated by surrounding tissue cells

TYPES OF RADIATION
Internal Radiation requires the introduction of
radioactive substances into the body
External Radiation is given by a way of a
beam directed at the tumor
TYPES OF RADIATION
1. External Radiation
Radiation treatment can be given by external
beam radiation delivered from the source
placed at some distance from the target site. It
is usually administered by high energy X-ray
machine e.g. the betatron and linear
accelerator or machine containing a
radioisotope (cobalt 60)
The main advantage of high-energy radiation
is its skin sparing effect. This means the
maximum effect of radiation occurs within the
tumor deep in the body and not on the skin
surface. Neutron beam therapy is delivered
from a cyclotron particle accelerator is
currently used to treat many types of cancer
With external RT, the source of the
radioactivity is located outside the body.
A special type of x ray machine is used to
deliver a beam of radiation to the area being
treated. Beams may be directed from several
different angles to provide the greatest dose to
the tumor and minimal exposure to other
tissues.
The number of treatments given is based on
the radiologists recommendation.
It is not unusual for a patient to be treated 5x
a week for 2-8 weeks. A variation of therapy is
intraoperative radiation therapy (IORT), a
technique in which the tumor bed is radiated
directly during surgery.
Patient Preparation:
Before the patient first treatment, the patient
goes through a treatment simulation to
determine the exact dosage needed, the site to
be treated, and the treatment schedule.
The patient is positioned in various ways while
radiographs are taken
The radiologist then marks the skin over the
area to be treated.
12

The markings are usually made with waterproof ink,


however, tiny permanent markings are sometimes
made. The markings must remain visible throughout
the course of radiation. Instruct patient not to
remove markings until given permission to do so.
For actual treatment, various devices are used to
shield healthy tissues

2. Internal Radiation
Internal RT involves the placement of specially
prepared radioisotopes directly enter near the
tumor itself. This is known as the brachy therapy
in which the implantation or insertion or
radioactive materials directly into the tumor area
and left in place for several days. This method is
commonly used for tumor of the head and neck, a
gynecologic malignancies
Sources of radiation used for therapy include
radioactive forms of iodine, phosphorous, radium,
radon, cesium, iridium.
The source may either sealed on unsealed
Patient may being treated with internal radiation
emit radiation and do pose a threat to others until
the source is remove or excreted. An exception is
the patient with small radioactive beads
permanently implanted to treat localized prostate
cancer or inoperable lung cancer.
Types of Internal RT:
1.Sealed source- in which the radioactive material is
enclosed in a sealed container. Sealed source RT
includes intracavity and interstitial therapy. In
intracavity therapy, the
radioisotopes usually
cesium 137 or radium 226 , is placed in the
applicator, then placed in body cavity for carefully
calculated time usually 24-72 hours (uterus and
cervix) Interstitial therapy, the radioisotopes of
choice iridium 192, iodine 125, cesium 137, gold
198, or radon 222; is placed in needles, seeds,
ribbons, or catheters and then implanted directly
into the tumors (prostate cancer)
1. one example of sealed source radiation is
cesium, which is contained in a sealed
applicator that is inserted into the body
cavities to treat cancer of the mouth, tongue,
vagina, and cervix.
2. It may be placed in threads, beads, needles
or seeds and implanted into the body tissues,
or enclosed in a mold or applied externally.
3. The radiologists will determine how long it will
be left in place
4. The patients body fluids are not radioactive
and neither are objects touched by the

patient, because radiation source is


closed, and radiation is only emitted while
it is in the patient
Safety measures to protect visitors and nurses
1. The patient is placed in private room,
preferably in lined with lead
2. A sign is placed on the door to the
patients room indicating that the room is
radioactive
3. Anyone who will enter the room for any
reason is informed of the proper
precautions to be taken. NO PREGNANT
NO VISITOR YOUNGER THAN 18 YO
4. The amount of radiation exposure is
reduced by limiting the time spent in the
room and by working as far as possible.
Nurses must wear film badges to monitor
the radiation exposure
5. Work must be organized efficiently. 30
minutes every shift. Portable leads can be
used. Lead aprons do not provide
adequate protection
6. Recognize that sealed sources can be
dislodge accidentally.
specific positions may be ordered
check bedpans and linens for any
dislodged sources
notify AP and radiation safety personnel
do not touch with bear hands, forceps
and a lead container known as pig, that
are routinely placed in the room are
used to retrieve and contain the source
Unsealed-sources RT are used in systemic
therapy. Radioisotopes may be administered IV
into a body cavity orally. E.g. Sodium Phosphate
P32 is adm. IV to treat polycythemia vera, Iodine
131 per oral in very low doses to treat graves
disease
1. Body fluid may be contaminated, you
must wear gloves when working with the
patient
2. Contaminated fluids, dressings, and like
may require special care, follow the SOP
3. Disposable utensils are recommended
4. Equipment used in the room may need to
be checked for radioactivity before it can
be removed form the room. The
radiologist can advise the staff on specific
precautions and how long they are
necessary
13

Measurement of Radiation:
Curie - (ci) a measure of the number of atoms of a
particular radioisotopes that disintegrate in one
second.
Rontgen ( R ) a measure of the radiation required to
produce a standard number of ions in air, a unit of
exposure to radiation
Rad measurement of radiation dosage absorbed
by the tissue
Rem measurement of the biologic effectiveness of
various forms of radiation on the human cell (1Rem1Rad)
Gray(Gy)-100 rads 1 Gy
Grays and centigrays are the units currently used in
clinical practice
Safety precaution in RT
Distance The greater the distance from the
radiation source, the less exposure dose of ionizing
rays. ( 4 ft from the source of radiation, the person is
exposed approximately the amount of radiation
the person would receive at 2 ft.
Time Minimal exposure time should be promoted,
although patient care needs must still be met. A
nurse exposure is generally limited to 30 minutes of
direct care per 8 hours shift.
Shielding The dose of X-rays and gamma rays is
reduced as the thickness of the lead shield is
increased.
GUIDING PRINCIPLE FOR RT
DOSE ADMINISTERED BE LARGE ENOUGH TO
ERADICATE THE TUMOR BUT SMALL ENOUGH
TO MINIMIZE THE ADVERSE EFFECTS TO THE
SURROUNDING NORMAL TISSUES KNOWN AS
THERAPEUTIC RATIO
GUIDING PRINCIPLES FOR RADIATION THERAPY
Place the client in private room
Plan care well so that minimal time is spent in direct
contact with the client. Do not spend more than 30
minutes per shift with the client
Stand at the client shoulder ( for cervical implants )
or at the foot of the bed ( for head and neck
implants ) avoiding close contact with unshielded
areas, use a lead shield.
Do not care for more than one client
with a
radiation implant at one time.
All HCP should wear a appropriate monitor devices
The room should be marked with appropriate signs
stating the presence of radiation, do not allow
children under 18 years or pregnant to visit, limit
visitors time to 30 minutes at a distance of at least 6

feet from the radioactive source , do not care for


these patients if you ( female nurse ) are
pregnant
Carefully check all linens or other materials
from the bed for the presence of implants
Keep long handled forceps and lead lined
container available on the nursing unit or in the
clients room while the implant is in placed.
RADIATION APPLIED EXTERNALLY CAN
CAUSE INJURY ONLY DURING THE TIME
THE TX IS BEING ADMINISTERED
PATIENT IS NEVER RADIOACTIVE
WEAR FILM BADGE TO MONITOR
CUMULATIVE EXPOSURE LEVEL
EXCRETED IN URINE, SALIVA, AND
SWEAT
EXPOSURE RISKS DECREASES WITH
DISTANCE
LEAD-LINED CONTAINER AND LONG
HANDED FORCEPS MUST ALWAYS BE
AVAILABLE TO CONTAIN SOURCE IF
DISLODGE
PLACE PATIENT IN PRIVATE ROOM WITH
RADIATION HAZARD SIGN ON DOOR
ROTATE NURSING CARE AMONG NURSES
PREGNANT NURSES
SHOULD
NOT
PROVIDE CARE
IF RECEIVING INTERNAL BRACHYTHERAPY,
REINFORCE IMPORTANCE OF ACTIVITY
RESTRICTIONS ( BED REST AND DIET
RESTRICTIONS)

SYSTEMIC ADVERSE EFFECTS OF RADIATION


THERAPHY
WEAKNESS
FATIGUE
ANOREXIA
NAUSEA
VOMITING
ANEMIA
WHAT ARE THE CELLS MORE VULNERABLE
TO RADIATION?
BONE MARROW
LYMPH
GI EPITHELIUM
GONADS
* THEY UNDERGO FREQUENT CELL DIVISION
NURSING CARE
ANTIEMETICS
STEROIDS
14

FREQUENT SMALL MEALS


FLUID MAINTENANCE
REST
HAVE FREQUENT BLOOD COUNTS: WBC AND
PLATELET
SKIN CARE MEASURES BY COVERING
IRRITATED AREAS WITH LOOSE COTTON
CLOTHING TO PROTECT FROM SUNLIGHT
AVOID USING COLOGNE, DEODORANTS, AND
OTHER TOPICAL AGENTS

NURSES ROLE IN INTERNAL RT


Familiarize yourself with the clients chart:
Learn what type of radioisotopes being used
The type of source (ex The radioisotopes sealed in
an applicator, the mode of administration, the date
when treated started and the number of days
during which the client must be isolated.)
Familiarize yourself with the radioisotopes being
used ex half life or type of radiation emitted
Familiarize yourself with the hospital
policy
concerning radiation safety
Isolate the patient receiving RT
CHEMOTHERAPY
INCLUDES
A WIDE RANGE OF ANTI
NEOPLASTIC DRUGS, WHICH MAY INDUCE
REGRESSION OF THE TUMOR AND ITS
METASTASIS
TO IMPROVE PATIENTS QUALITY OF LIFE BY
TEMPORARILY RELIEVING PAIN AND OTHER
SYMPTOMS
EVERY DOSE OF CHEMOTHERAPEUTIC AGENT
DESTROYS ONLY A PERCENTAGE OF TUMOR
CELLS
Antineoplastic Drugs
Drugs that promote tumor cell destructions by
interfering with cellular function and reproduction
Several factors will determine the response of
cancer cells to chemotherapy are as follows:
Mitotrio rate of the tissue, from which the tumour
arises. The more rapid the mitotic rate, the greater
the response to Chemotherapy. E.g. leukemia,
choriocarcinoma of the placenta, wilms tumor with
surgery, and neuroblastoma. This cancer cells have
rapid rate of cellular proliferation.
Size of the tumor-the smaller the number of cancer
cells , the greater the response to chemotherapy
Age of the tumor. The younger the tumor, the
greater the response to chemotherapy. Younger
tumors have greater % of proliferating cells.

Location of tumor. Certain anatomic sites


provide a protected environments from the
effects of chemotherapy. E.g. only few drugs
cross the blood brain barrier (bleomycin)
Presence of resistant tumor cells. Mutation of
cancer cells within the tumor mass can result in
varient cells that are resistant to chemotherapy.
Resistance can also occur because of the
biochemical inability of some cancer cells to
convert the drug to its active form.
Physiologic and psychologic status of the host. A
state of optimum health and positive attitude will
allow
better
withstand
aggressive
chemotherapy.

ALKYLATING AGENTS
INHIBIT CELL GROWTH AND DIVISION BY
REACTING WITH DNA AT ANY PHASE OF
THE CELL CYCLE. THEY PREVENT CELL
REPLICATION BY BREAKING AND CROSS
LINKING DNA
Nitrogen Mustard (Mechlorethemine)
Cyclophosphamide ( Cytoxan )
Chlorambucil ( Leukeran )
Busulfan ( Myleran )
Melphalan ( Alkeran )
Thiotepa ( Thiotepa )
Ifosfamide ( Ifex )
ANTIMETABOLITES
PREVENT CELL GROWTH BY COMPETING
WITH METABOLITES IN THE PRODUCTION
OF
NUCLEIC
ACID,
SUBSTITUTING
THEMSELVES
FOR
PURINES
AND
PYRIMIDINES WHICH ARE ESSENTIAL FOR
DNA AND RNA SYNTHESIS.
Methotrexate
6 mercaptopurine ( 6 MP )
6 Thioguanine
( 6 TG )
5 Fluorouracil
( 5 Fu )
Cystosine arabinoside ( A-RA-C ) Cytosar 4
Fludarabine Phosphate
Deoxycoformycin ( Pentastatin )
ANTITUMOR ANTIBIOTICS
BLOCK CELL GROWTH BY BINDING WITH
DNA AND INTERFERING WITH DNA
DEPENDENT RNA SYNTHESIS. THEY BIND
TO DNA AND GENERATE TOXIC OXYGEN
FREE RADICALS THAT BREAK ONE OR
BOTH STRANDS OF DNA
Deunorubicin
( Cerubidins )
15

Doxorubicin
Dactinomycin
Bleomycin
Mitomycin
Picamycin
Idarubiun
Mitoxantrone

( Adriamycin )
( Cosmegen )
( Blenoxane )
( Mutamycin )
( Mittracin, mitramycin )
( Idamycin )
( Novamtrone )

PLANT VINCA ALKALOIDS


PREVENT
CELLULAR REPRODUCTION
DISRUPTING MITOSIS
Vincristine ( Oncovin)
Vinblastine ( Velban )
Vindesine sulfate

Estrogen Anatgonist
Tamoxifen (norvadex)
leuprolide ( lupron )

BY

HORMONES AND HORMONE ANTAGONISTS


IMPAIR CELL GROWTH BY ONE OR BOTH OF
TWO MECHANISMS. THEY ALTER CELL
ENVIRONMENT THEREBY AFFECTING CELL
MEMBRANE PERMEABILITY AND INHIBIT THE
GROWTH OF HORMONE
SUSCEPTIBLE
TUMORS BY CHANGING THEIR CHEMICAL
ENVIRONMENT
1. Androgens
2. Corticosteroids
3. Estrogen
4. Progesterone
5. Estrogen antagonists
6. antiadrenal
Androgen
Testosterone propionate
Fluoxymesterone (Halotestin)
Dromostanolone (Drolban)
Testosactone (Teslac)
Methytestosterone
Costicosteroids
Cortisone Acetate
Prednisone
Dexamethasone
Methyl prednisolone sodium (solu-medrol)
Hydrocortison sodium succinate (solu-cortef)
Estrogen
DES Diethyl stilbestrol
Ethinyl estradiol (estriny)
Progesterone
Hydroxy progesterone caporate (prodrox)
Megestrol ( Megace )
Metroxyprogesterone (Provera)
Estramustine (Emcut)

HORMONAL THERAPHY ADVERSE EFFECTS:


HOT FLUSHES
SWEATING
IMPOTENCE
DECREASED LIBIDO
NAUSEA
VOMITING
BLOOD DYSCRASIA
Nursing Intervention in Chemotherapy
Alkalating Agent:
Gastrointestinal Toxicity
Document nausea and vomiting times and
amount
Administer antiemetic drug PRN
Hydrate
to 2000 ml/24 hours if not
contraindicated
Record intake and output
Avoid noxious odors
Use relaxation techniques or distractions
Provide small frequent feedings
Alkalating Agents:
Hematopoetic Toxicity
Monitor WBC, CBC, RBC, platelet count
biweekly for pancytopenia
Observe for signs and symptoms of infections,
bleeding and anemia
Provide rests periods and 8 hour sleep per night
Teach benefits of good personal hygiene
Provide comfort and suggestion measures
Genitourinary Toxicity
Inform that hemorrhagic cystitis can occur with
cytoxan and infosfamide therapy
Administer mesna (urothelial protection agent )
to help to prevent cystitis
Encourage hydration and complete and frequent
emptying of bladder
Reproductive Toxicity
Inform of possibility of temporary or permanent
infertility and danger to growing fetus
Provide reproductive counseling as needed
Antimetabolites:

16

1. Hematopoietic bone marrow suppression,


anemia, leukopenia, thrombocytopenia
2. Gastrointestinal mucositis or stomatitis,
diarrhea, nausea, and vomiting
Note: intervention is the same as alkalating agents
For mucosites and stomatitis
Inspect the oral cavity daily for presence of sores,
change in taste and sensation
Teach the oral care and encourage immediately
after meals and at bed time, soft toothbrush and
prescribed mouthwash (peroxide, oral saline, baking
soda, and water or provide anesthetic agent for
mouth sores (stomatitic cocktail)
Report signs and symptoms of oral infection
Soft diet with non irritating foods high in CHON,
calories, offer high caloric liquid supplements
For diarrhea:
Low residue diet, high in CHON, and calories,
maintain hydration
Monitor and document number and frequency of
stools
Administer antidiarrhea medication as needed
Provide meticulous skin care in perineal area
Promote good hygiene habits
Antitumour antibiotics:
1. Hematopoietic- Bone marrow suppression
2. GI-mucositis, stomatitis, anorexia, nausea
and vomiting
3. Integumentary- alopecia, tissue necrosis if
extravasate
4. Cardiac and pulmonary toxicity
Note: for alopecia, warn for potential hair loss and
ways of minimizing loss
For extravasation:
Monitor IV infusion to prevent infiltration. When
filtrated stop immediately and institute agency
protocol to prevent tissue necrosis-notify doctor
immediately and keep extravasation kit available at
all times
For Cardiac Toxicity:
May occur with bleomycin (pneumonitis and
progressive pulmonary fibrosis), should not exceed
a lifetime dose of 400 iu.
Assess respiratory status and document changes

1.Androgens alter pituitary function and directly


affects the malignant cell. Toxicity of androgens
include fluid retention and masculinization.
2.Corticosteroids lyse lymphoid malignancies and
have indirect effects on malignant cells. The
major toxicity include fluid retention, HPN,
diabetes, and increase susceptibility to infection.
3.Estrogen
and
progesterone
suppress
testosterone production in males may alter the
response of breast cancer to prolectin and
promote differentiation of malignant cells. The
major toxicities include fluid retention,
feminization, and uterine bleeding.
4.Estrogen antagonists compete with estrogen for
binding with estrogen receptor sites on
malignant cells. Toxicities are minimal with
occasional headache and hotflush
5.Antiadrenals produce the equivalent of a
medical adrenalectomy, thereby inhibiting the
formations of estrogen and adrogenesis and
functions of nuclei acids and inhibit RNA and
DNA synthesis. These agents are cycle nonspecific toxicity in adrenal insufficiency.
For fluid retention
1.Warn of potential weight gain
2.Weight biweekly
3.Maintain intake and output if needed
For feminization in males
1.Inform about chance of gynecomastia-change in
voice, distribution of body fat and hair, and
cardiovascular problem
2.Assess fears and concerns and provide
psychological support as needed
For virisization in females
1.Discuss the risk for facial hair, lowered voice,
clitoral enlargement-fluid retention.
2.Assess fears and concerns and provide
psychological support
For uterine bleeding
1.Prepare postmenopausal woman for occurrence
2.Provide support and reassurance
For diabetes
1.Inform patient of potential occurrence
2.Monitor blood sugar changes
3.Observe for signs and symptoms of diabetes

Hormonal Agents:
For adrenal insufficiency
17

1.Instruct on need to comply with replacement therapy


while on medication
2.Reassure that need for therapy will cease when
drug is discontinued
BIOTHERAPHY
ALSO KNOWN AS IMMUNOTHERAPHY
RELIES
ON TREATMENT KNOWN AS
BIOLOGICAL MODIFIERS
EX.
RITUXIMAB MONOCLONAL ANTIBODY,
EFFECTIVE TO TREAT RELAPSED OR
REFRECTORY B CELL NON HODGKINS
LYMPHOMA
INTERFERONS,
INTERLEUKINS,
HEMATOPOIETIC GROWTH FACTORS
ADVERSE REACTIONS: FLULIKE

Pancreatic Cancer
Anatomy and Physiology
Pancreas is located retroperitoneal, posterior to the
stomach in the inferior part of the left upper
quadrant.
It is a complex organ composed of both endocrine
and exocrine tissues that perform several function.
Endocrine part
Consist of islet of langerhans which produces insulin
and glucagon, which are very important in
controlling blood levels of nutrients such as glucose
and amino acid.
Exocrine Part
It is a compound of acinar gland.
The acini produce digestive enzymes.
Cluster of acini are connected by small ducts, which
join to form larger ducts and the larger ducts join to
form the pancreatic duct.
Pancreatic enzymes
HCO3 neutralize acid
Trypsin, chymotrypsin digest CHON
Carboxypeptidase digest CHON
Amylase digest CHO
Lipase digest lipid
Nucleases digest nucleic acid
Pancreatic cancer
The incidence of pancreatic cancer has decreases
slightly over the past 25yrs in non-Caucasian men

It is the fifth leading cause of death in the United


States
Occurs more frequently in the fifth to seventh
decades of life
Cancer may arise in any portion of the pancreas
Tumors in the body and tail of the pancreas are
more difficult to pick up early as they do not
cause obstructive jaundice at an early stage.
Most tumors occur in the head of the pancreas
Risk factors
Cigarette smoking
Exposure to industrial chemicals or toxins in the
environment
Diet high in fat
Chronic pancreatitis
Hereditary pancreatitis
Signs and Symptoms
Pain
Jaundice
Progressive weight loss
Midabdominal discomfort
Early Symptoms include:
General discomfort or pain around the stomach
area
Sickness
Bowel disturbances
Diabetes
Jaundice
Skin itching
Later signs:
Loss of appetite
Unexplained weight loss
Back pain
Low mood and depression
The most obvious symptom is:
jaundice (a yellow discoloration of the eyes and
skin) which is often associated with dark urine
and pale motions (stools) and itching of the skin.
If the head of the pancreas is enlarged or
abnormal then the bile duct may become
blocked as it enters the pancreas, this blockage
causes a build up of bile which causes the
jaundice, dark urine, pale motions and itching.
The symptoms should rapidly disappear once
the blockage is cleared or bypassed by surgery
or insertion of a stent.

18

If the cancer blocks the pancreatic duct this will lead


to poor digestion, loose motions and weight loss.
This can be relieved by clearing the blockage or by
giving pancreatic enzyme tablets. Steatorrhoea is
the medical term for the loose, pale, fatty, floating,
offensive bowel motions which occur when the
pancreas is not releasing digestive juices into the
intestines and there is failure to absorb fats from the
gut.
Weight loss is common because of the interference
with digestion (due to blocked bile and/or pancreatic
ducts or interference with production of pancreatic
enzymes) and sugar metabolism, loss of appetite
and the action of cancer itself.
Diabetes can be caused by pancreatic failure, it is
usually characterized by weight loss, lethargy, thirst,
blurred vision, increased volumes of urine and
drowsiness. Diabetes may already be present in a
number of patients prior to developing the cancer or
become apparent soon after it is diagnosed or
following surgery.
Pain is also a common symptom of pancreatic
cancer once the tumours are large enough to press
on other organs or the spine and nerves. However
only about half of all pancreatic cancer patients
have any pain at the time of their diagnosis and pain
is more common in cancers of the body and tail of
the pancreas. Patients describe it as a dull pain that
feels like a screwdriver boring into you. The pain is
very typically worse when you lie down and is better
if you sit or lean forward. It can start in the stomach
area and spread around to the back. It can be worse
after meals. Patients may also have a generally
tender or painful abdomen if the liver, pancreas or
gall bladder are inflamed or enlarged. In the case of
enlarged liver or gall bladder this pain will be on the
right hand side of the body.
When the pancreas is inflamed (e.g. acute
pancreatitis) it often causes pain, this is usually felt
in the central or upper part of the abdomen and is
often associated with back pain. The pain may be
sharp, aching or burning in nature. Some patients
with pancreatic cancer may also have pancreatitis
either due to disease in the pancreas. The presence
of pancreatitis can complicate diagnosis as it may
mask pancreatic cancer in diagnostic imagery.
A feeling of nausea and actual sickness/vomiting
may be the result of a number of things. It may be
associated with a blocked bile-duct and hence
jaundice or due to an inflamed pancreas. The
change in chemical balance of the body caused by
these conditions can make you feel sick. If the
duodenum becomes blocked or restricted by cancer

or inflammation this can stop food passing


through and cause vomiting.
Some patients may develop high temperature
(fever) and start shivering and feel cold despite
the high temperature. This can be a side-effect
of a blocked bile-duct (jaundice) or an inflamed
pancreas.
Endocrine type cancers can also have
symptoms associated with excessive production
of different types of hormones and these are
described on our page on pancreatic cancer
types.
Diagnostic findings
MRI
Gastrointestinal x-ray
Percutaneous fine needle biopsy
Treatment
If the tumor is respectable and localized the
surgical procedure to remove it is usually
extensive
The patient may be treated with radiation and
chemotherapy
Interstitial implantation of radioactive sources
has also been used, although the rate of
complication is high.
A large billiary stent inserted percutaneously or
by endoscopy may be used to relieve jaundice.
Pharmacologic treatment
Administer opiods
Give analgesic for patient with severe,
escalating pain
Nursing Interventions
If the patient elects to receive chemotherapy, the
nurse focuses on teaching prevention of side
effects and complication on the agents used
The nurse instruct the family about changes in
patients status that should be reported to the
physician
Home care, fluid and nutritional status
Assess for skin integrity
Assess for pain management
Teach patient and family strategies to prevent
skin breakdown and pain relief
COLON and RECTAL CANCER
A malignant neoplastic disease of a large
intestine characterized by a change in bowel
habits and the passing of blood (melena), which
maybe occult initially.
19

Malignant tumors of the large bowel usually occur


after 50 years of age.
Its slightly more frequent in women than to men.
This is the second leading cause of cancer death.
Is the fourth most common malignancy in United
States.
CAUSES:
Polyp formation
Genetic defects on chromosomes 2, 5, 17, and 18
Family history of colon cancer related to genetic
syndromes, such as HNPCC (Hereditary
nonpolyposis colorectal cancer) syndrome of familial
adenomatous polyposis (FAP). Both are rare
diseases.
Eating a high-fat, low-fiber/calcium diet
Lack of exercise
ANATOMY AND PHYSIOLOGY OF COLORECTAL
CANCER
Knowledge of anatomy and physiology allows for
easy understanding of most anorectal pathology.
Likewise anatomy and physiology is important for
managing certain clinical conditions involving the
colon such as constipation, carcinoma, ischemic
and diverticular disease. A review of anatomy and
physiology of the colon, rectum, and anus with
clinical correlation is presented.
Colon
The colon is approximately five feet (1.5 meters) in
length, begins at the ileocecal valve, and ends at the
rectosigmoid junction. Arterial blood supply to the
colon from cecum to splenic flexure is through the
superior mesenteric artery which gives rise to the
ileocolic, right colic, and middle colic arteries. The left
and sigmoid colon is supplied by the inferior
mesenteric artery which gives rise to the left colic and
sigmoidal arteries.
There can be several anatomic variations in the colic
arteries including absent middle colic artery, absent
right colic artery, common trunk for right and ileocolic
artery, and the presence of an Arc of Riolan between
the middle and left colic artery. The colonic wall
histologically from lumen outward consists of:
1.a simple columnar epithelium which forms crypts
2.lamina propria
3.muscularis mucosa
4.Submucosa
5.muscularis propria formed by an inner circular and
outer longitudinal layer of smooth muscle, and
1.serosa.

The typical colonic malignancy is an


adenocarcinoma. Once the neoplastic epithelial
cells penetrate the muscularis mucosa and into
the submucosa, a malignant (the ability to
metastasize) adenocarcinoma is formed. The
mainstay for treatment is operative resection of
the involved colonic segment along with the
draining lymph nodes located in the mesentery.
Neoplastic cells confined by the muscularis
mucosa are termed carcinoma-in-situ or severe
dysplasia and are not as yet malignant thereby
typically eliminating the need for segmental
colonic resection.
The outer longitudinal smooth muscle of the colon
thickens in three locations called tenia coli. The
rectosigmoid junction is the point at which the
three tenia fan out and form a complete outer
longitudinal layer. This anatomic point has clinical
significance. Carcinomas proximal to this point are
colonic; whereas distal tumors are rectal and as
such may benefit from adjuvant radiation therapy.
Likewise, operative resection for classic sigmoid
diverticular disease should include the
rectosigmoid junction with the anastomosis
located at the upper rectum.
The function of the colon is
1.absorption of water and electrolytes, and
2.propulsion and storage of unabsorbed fecal
waste for evacuation.
Approximately one liter of fluid chyme enters the
cecum each day with an average of only 100cc
excreted in the feces. Parasympathetc innervation
by preganglionic vagal fibers and pelvic fibers
result in colonic motility. Sympathetic innervation
by the superior mesenteric plexus, inferior
mesenteric plexus, and the hypogastric plexus
inhibits colonic motility. It appears that the major
control of motility depends on the colonic wall
intrinsic
plexus
(myenteric
or
Auerbachs/submucous or Meissners). An
absence of intrinsic plexuses occurs in
Hirschsprungs Disease resulting in tonic wall
contraction and functional obstruction.
Rectum
The rectum is the terminal portion of the large
intestine beginning at the confluence of the three
tenia coli of the sigmoid colon and ending at the
anal canal. Generally the rectum is 15 cm in
20

length, is intraperitoneal at its proximal and anterior


end, and is extraperitoneal at its distal and posterior
end. The epithelial lining or mucosa of the rectum is of
a simple columnar mucous secreting variety.
Therefore, the characteristic malignancy of the rectum
is an adenocarcinoma.

Crampy pain in the abdominal region which


does not subside.
Frequent feeling of bloating in the abdominal or
bowel region
Unexplained weight loss
Unexplained fatigue

Anal Canal
The anal canal begins a few centimeters proximal to
the classic and well visualized dentate line and it ends
at the anal verge. The anal canal is about 5 cm in
length. Histologically the proximal end of the anal
canal is the point at which the columnar epithelium of
the rectum becomes a transitional epithelium. This
epithelium transitions to a stratified squamous variety
at the dentate line. The distal most end of the anal
canal is the anal verge which is the point where the
stratified squamous epithelium becomes true skin
marked by the presence of hair follicles and sweat
glands.

DIAGNOSTIC PROCEDURES
Fecal occult blood test (FOBT) this screening
uses guaiac base test with dietary restrictions or
an immunochemical test without dietary
restrictions. Two samples from each three
consecutives stools will be examine without
dehydration patients with a positive test on any
specimen should be follow up with colonoscopy.
Colonoscopy this short preventive procedure
allow your position to look inside your large
intestine using a colonoscopy, to look for early
warning signs of colon or rectal cancer, if
anything abnormal is seen in your colon such as
polyp or inflamed tissue, the physician can
remove all or part of using tiny instruments pass
through the scope. That tissue (biopsy) is then
sent to a laboratory for testing. It takes 30-60
minutes.
Flexible Sigmoidoscopy a thin lightened tube
called a sigmoidscope is utilize to look inside the
rectum or the lower colon for polyps, tumor or
other abnormalities. Only the lower one fourth to
one third of the colon is visualized.
Double Contrast Barium Enema this test is
used to obtain an X-ray of the colon and rectum
it consist of white chalky substance given to
patients prior to the X-ray. The barium outlines
the colon and the rectum on the X-rays to help
the doctors may also expand the colon by gently
pumping air during the test to look for small
tumors.
NURSING DIAGNOSIS
Acute pain
Nutritional imbalances; less than body
requirements
Constipation
Fatigue

The anal verge is readily identified by noting the point


at which hair shafts are seen. The anoderm is a term
used to describe the zone between the dentate line
and the anal verge. Perianal skin then describes the
anatomic area beyond the anal verge. Malignancies of
the perianal skin are typical skin cancers usually
squamous cell carcinomas. Anal canal carcinomas are
described as epidermoid carcinoma, squamous cell
carcinoma, cloacogenic carcinoma, or baseloid
carcinoma depending on their particular histologic
features. The importance of locating and anatomically
defining the particular malignancy of the anorectal
region is in their treatment.
THE RISK FACTORS
High fat diet
High consumption of alcohol
Low activity level
History of smoking tobacco
Inhalation of asbestos, fibers and
History of irradiation
diabetes
night shift work in relation with
melatonin hormone
Low fiber intake
Age of 50 yrs old above
Family History
Anger turned inward(depression)
SIGN and SYMPTOMS
Bright red blood in the stool
Persistent diarrhea and constant constipation

THERAPY
CHEMOTHERAPY Chemotherapy is a form of
drug which is used to eliminate cancer cells. It is
given through the veins with the used of an IV
which can kept in place for treatment.
2 types of chemotherapy
21

1.Adjuvant chemotherapy this type of therapy is


used after surgery has been performed. It removes
cancer cell that may have traveled to other sites of
the body.
2.Neoadjuvant chemotherapy this type of therapy is
used before surgery takes place in order to shrink
the size of the cancerous tumor.
RADIATION THERAPHY radiation therapy is used
mainly with rectal cancers. This form of therapy
does not remove cancer cells which may have
spread to other sites of the body. It is used before
surgery for tumor shrinkage, and after surgery for
prevention of local recurrence.
COLORECTAL CANCER SCREENING screening
for colorectal cancer has been proven to decrease
randomized mortality clinical trials. Unfortunately,
most individuals are not screened due to either fear
or adequate education regarding the benefits.
ESOPHAGEAL CANCER
Esophageal cancer is a serious form of a rare
malignant neoplastic cancer that starts in the inner
layer of your esophagus, the 10-inch long tube that
connects your throat and stomach. The most common
symptom of esophageal cancer, usually occurring late
in the disease, is difficulty of swallowing and a
sensation of food getting stuck in your throat or chest.
Esophagus
It is a mascular tube, lined with moist stratified
squamous epithelium, that extends from the pharynx
to the stomach. It is about 25 cm long and lies anterior
to the vertebrae and posterior to the trachea within the
mediastinum, it passes through the diaphragm and
ends at the stomach. Upper and lower esophageal
sphincters regulate the movement of food into and out
the esophagus, the lower esophageal sphincter is
sometimes called the cardiac sphincter.
Signs and symptoms
Dysphagia (difficulty swallowing) is the first
symptom in most patients.). Initially with solid foods
and eventually with liquids
Odynophagia (painful swallowing)
Burning chest pain. Commonly called heartburn, this
symptom may occur especially after meals or at
night when you're lying down.
Unusual husky or raspy voice. This often results
from acid reflux in your throat or windpipe.
presence of the tumor may disrupt normal
peristalsis (the organised swallowing reflex)
nausea and vomiting

regurgitation of food with foul breaths or


hiccups. This leaves a sour taste and the sense
of food re-entering your mouth.
coughing
Substantial weight loss is characteristic as a
result of poor nutrition and the active cancer. In
addition, cancer in general can cause weight
loss and muscle wasting because it changes the
way your body metabolizes nutrients.
Pain in your throat, in your midchest or between
your shoulder blades.
hematemesis (vomiting up blood). The tumor
surface may be fragile and bleed
If the disease has spread elsewhere:
liver metastasis causes jaundice and ascites
lung metastasis causes shortness of breath
and pleural effusions
Causes
Squamous cell or epidermoid carcinoma.
develops in the flat squamous cells that line the
esophagus. (black Americans)
Adenocarcinoma. This arises in the glandular
tissue in the lower part of the esophagus
nearest the stomach. (common in white
Americans).
Others. These include sarcoma, lymphoma,
small cell carcinoma and spindle cell carcinoma.
In addition, cancer that starts in the breast or
lung can spread (metastasize) through the
bloodstream or lymph system to the esophagus.
Contributing factors
Heavy alcohol consumption.
Tobacco use.
Chronic acid reflux.
Diet.
PATHOPHYSIOLOGY
Contributing factors (Smoking and alcoholism)

chronic esophageal irritation

inflammation of the esophageal mucosa

increases the risk of both squamous cell


carcinoma and adenocarcinoma

Esophageal carcinoma arises in the mucosa

esophageal cell cancer

22

Subsequently, it tends to invade the submucosa and


the muscular layer, eventually, contiguous structures
such as the tracheobronchial tree, the aorta, or the
recurrent laryngeal nerve

The tumor also tends to metastasize to the


periesophageal lymph nodes and, eventually, to the
liver, lungs, or both.
Sometimes esophageal cancer is associated with
certain rare medical conditions, including:
Achalasia. In this disorder, food collects at the
bottom of the esophagus, both because the
esophagus lacks normal peristalsis to move food
along and because the lower esophageal sphincter
doesn't relax normally. For reasons that aren't clear,
having achalasia seems to increase your risk of
esophageal cancer.
Esophageal webs. These thin protrusions of tissue
can appear anywhere in your esophagus. Some
webs cause no symptoms, but others can make
swallowing difficult. When other problems
including anemia and abnormalities of the tongue,
fingernails and spleen occur in conjunction with
esophageal webs, the condition is called PlummerVinson or Paterson-Kelly syndrome. People with this
syndrome are at risk of developing esophageal
cancer.
Tylosis. Excess skin develops on the soles and
palms of people with tylosis, a rare inherited
disorder. Close to half the people with tylosis
eventually develop esophageal cancer. A genetic
defect appears to be responsible for both tylosis and
the associated cancer.
Risk factors
Age. (Range 55-70)
Sex. (most are men)
Race.
Diet. low in fruits and vegetables
Radiation therapy.
Occupational exposure.
Drinking hot liquids.
Barrett's Esophagus.
Human papillomavirus (HPV
Particular dietary substances, such as nitrosamine
Medical History.
Other Types of Irritation.
Decreased risk
Risk appears to be less in patients using aspirin or
related drugs (NSAIDs).

The role of Helicobacter pylori in progression to


esophageal adenocarcinoma is still uncertain,
but, on the basis of population data, it may carry
a protective effect. It is postulated that H. pylori
prevents chronic gastritis which is a risk factor
for reflux, which in turn is a risk factor for
esophageal adenocarcinoma.
diets high in cruciferous (cabbage, broccoli,
cauliflower) and green and yellow vegetables
and fruits are associated with a decreased risk
of esophageal cancer.
Moderate coffee consumption is associated with
a decreased risk
DIAGNOSTIC TEST
A barium swallow (also called an esophagram)
is a series of x-rays of the esophagus. The
patient drinks a liquid containing barium, which
coats the inside of the esophagus. The barium
makes any changes in the shape of the
esophagus show up on the x-rays.
biopsy can show cancer, tissue changes that
may lead to cancer, or other conditions.
Bronchoscopy usually is performed, especially
in tumors of the middle and and the upper third
of the esophagus, to determine whether the
trachea has been affected and to help determine
whether the lesion can be removed.
Mediastinoscopy or endoscopic ultrasound used
to determine whether the cancer has spread to
the nodes and other mediastinal structures
Esophagoscopy (also called endoscopy) is an
examination of the inside of the esophagus
using a thin lighted tube called an endoscope.
An anesthetic (substance that causes loss of
feeling or awareness) is usually used during this
procedure.
CAT (or CT) scan (computed tomography). A
computer linked to an x-ray machine creates a
series of detailed pictures of areas inside the
body.
Bone scan. This technique, which creates
images of bones on a computer screen or on
film, can show whether cancer has spread to the
bones.
Staging the disease
Stage I. The cancer is found only in the top layers
of cells lining the esophagus.
Stage II. The cancer involves deeper layers of the
lining of the esophagus, or it has spread to nearby
lymph nodes. The cancer has not spread to other
parts of the body.
23

Stage III. The cancer has invaded more deeply into


the wall of the esophagus or has spread to tissues or
lymph nodes near the esophagus. It has not spread to
other parts of the body.
Stage IV. The cancer has spread to other parts of the
body. Esophageal cancer can spread almost
anywhere in the body, including the liver, lungs, brain,
and bones.
Treatment
Team of Doctors needed:
1. gastroenterologist (a doctor who specializes in
diagnosing and treating disorders of the digestive
system)
2. surgeon (a doctor who specializes in removing or
repairing parts of the body),
3. medical oncologist (a doctor who specializes in
treating cancer)
4. radiation oncologist (a doctor who specializes in
using radiation to treat cancer)
5. dentist for a dental exam and treatment before
cancer treatment begins.
Surgery is the most common treatment for
esophageal cancer.
Radiation therapy, also called radiotherapy, involves
the use of high-energy rays to kill cancer cells.
Chemotherapy is the use of anticancer drugs to kill
cancer cells.
Laser therapy is the use of high-intensity light to
destroy tumor cells.
Photodynamic therapy (PDT), a type of laser
therapy, involves the use of drugs that are absorbed
by cancer cells; when exposed to a special light, the
drugs become active and destroy the cancer cells.
The doctor may use PDT to relieve symptoms of
esophageal cancer such as difficulty swallowing
Side effects of treatment
Surgery may cause short-term pain and tenderness
in the area of the operation.
Radiation therapy dry, sore mouth and throat;
difficulty swallowing; swelling of the mouth and
gums; dental cavities; fatigue; skin changes at the
site of treatment; and loss of appetite.
Chemotherapy nausea and vomiting, poor
appetite, hair loss, skin rash and itching, mouth and
lip sores, diarrhea, and fatigue. These side effects
generally go away gradually during the recovery
periods between treatments or after treatment is
over.
Laser therapy short-term pain where the treatment
was given, but this discomfort can be controlled with
medicine.

Photodynamic therapy makes the skin and


eyes highly sensitive to light for 6 weeks or more
after treatment. Other temporary side effects of
PDT may include coughing, trouble swallowing,
abdominal pain, and painful breathing or
shortness of breath.
Nursing Diagnosis
Imbalanced nutrition, less than body
requirement, related to difficulty of swallowing
Risk for aspiration related to difficulty of
swallowing or to tube feeding
Acute pain related to difficulty of swallowing,
ingestion of an abrasive agent, tumor, or
frequent episodes of gastric reflux
Management
After surgery, patients may receive nutrients
directly into a vein.
NGT feeding.
Place patient in low fowlers position after
recovery
Monitor nutritional status
Diet (high calorie and high protein)
soft, bland foods moistened with sauces or
gravies
puddings, ice cream, and soups
blendered solid foods
more fruits and vegetables
whole-grain foods over processed or refined
grain products
Limit the amount of red meat and processed
meats
Obtain baseline weight. Record daily weights.
Relieve pain.
Advice patient to quit smoking.
Limit alcohol consumption
GASTRIC / STOMACH
Gastric Carcinoma
Slow growing & it can be years before it grows
very large & produces distinct symptoms
Malignancies of the stomach
Usually occurs in people older than 40 y/o
Men have higher incidence than women
Prognosis is poor because most patient have
metastasis at time of prognosis
Types of Stomach Cancer
Adenocarcinomas. The great majority of
stomach cancers are adenocarcinomas, which
start in the glandular cells in the stomach's
24

innermost lining. Adenocarcinomas account for


about 95 percent of all stomach cancers.
Lymphomas. These are cancers of immune system
tissue in the stomach wall. Some lymphomas are
aggressive, whereas others grow much more slowly.
The latter, known medically as mucosa-associated
lymphoid tissue (MALT) lymphomas, usually stem
from H. pylori infection and are often curable when
found in the early stages.
Carcinoid tumors. A small percentage of stomach
cancers are carcinoid tumors that originate in the
stomach's hormone-producing cells. Carcinoid
tumors tend to grow less quickly and spread
(metastasize) less frequently than do the more
common stomach cancers.
Gastrointestinal stromal tumors (GISTs). Doctors
believe that these rare tumors develop from cells
called interstitial cells of Cajal, which are part of
your autonomic nervous system. Your autonomic
nervous system consists of the nerves that regulate
the part of your nervous system that you can't
control, such as your heart rate, blood pressure and
intestinal function.
Although GISTs can occur anywhere from the
esophagus to the rectum, most are found in the
stomach. Yet GISTs are not the same as other
gastric cancers, differing not only in the cells in
which they originate but also in their prognosis and
treatment. A majority of GISTs have a specific
genetic mutation that allows for treatment with a
new form of cancer-specific therapy.

RISK FACTORS
Sex
Age
Diet
Tobacco Use
Previous Stomach Surgery
Stomach polyps
Family History
Pernicious Anemia
Country of Origin
Obesity
People with blood type A
Organs Commonly Affected
Liver
Pancreas
Esophagus
Duodenum
Metastasis through lymph to the peritoneal cavity
occurs later in the disease

Manifestations (Early Stage)


Asymptomatic
Pain
Indigestion
Heartburn
Bloated feeling after eating
Mild nausea
Loss of appetite
Dysphagia
Over blood lost
Manifestations (Late Stage)
Anorexia
Dyspepsia
Weight loss
Abdominal pain
Constipation
Anemia
Severe nausea and vomiting
Loss of appetite
Weakness
fatigue
Diagnostic Exam
Upper Endoscopy
Stomach X-Ray (Barium Upper GI Series)
Endoscopic Ultrasound
CT Scan
MRI
Chest X-Ray
The following stages are used for gastric
cancer:
Stage 0 (Carcinoma in Situ)
abnormal cells are found in the inside lining of
the mucosal (innermost) layer of the stomach
wall. These abnormal cells may become cancer
and spread into nearby normal tissue. Stage 0 is
also called carcinoma in situ.
Stage I
cancer has formed. Stage I is divided into stage
IA and stage IB, depending on where the cancer
has spread.
Stage IA: Cancer has spread completely
through the mucosal (innermost) layer of the
stomach wall.
Stage IB: Cancer has spread:
completely through the mucosal (innermost)
layer of the stomach wall and is found in up to 6
lymph nodes near the tumor; or
to the muscularis (middle) layer of the stomach
wall.
25

Stage II
cancer has spread:
completely through the mucosal (innermost) layer of
the stomach wall and is found in 7 to 15 lymph
nodes near the tumor; or
to the muscularis (middle) layer of the stomach wall
and is found in up to 6 lymph nodes near the tumor;
or
to the serosal (outermost) layer of the stomach wall
but not to lymph nodes or other organs.
Stage III
divided into stage IIIA and stage IIIB depending on
where the cancer has spread.
Stage IIIA: Cancer has spread to:
the muscularis (middle) layer of the stomach wall
and is found in 7 to 15 lymph nodes near the tumor;
or
the serosal (outermost) layer of the stomach wall
and is found in 1 to 6 lymph nodes near the tumor;
or
organs next to the stomach but not to lymph nodes
or other parts of the body.
Stage IIIB: Cancer has spread to the serosal
(outermost) layer of the stomach wall and is found in
7 to 15 lymph nodes near the tumor.
Stage IV
cancer has spread to:
organs next to the stomach and to at least one
lymph node; or
more than 15 lymph nodes; or
other parts of the body.
Treatment
Gastrectomy
Chemotherapy
Radiation therapy
Medications
Asplatin (Platinol)
Fluouracil (Efudex)
Prevention
Emphasize fruits and vegetables
Avoid nitrites and nitrates
Limit smoked, pickled, and heavily salted foods
Dont smoke
Limit Alcohol Consumption
Limit Red Meat
See your doctor if you have symptoms of an ulcer
After Surgery
Provide meticulous supportive care
Turn patient every 2 hours

Assist patient in coughing and breathing


exercise
Encourage frequent feeding of small amount of
clear liquids
Observe the surgical wound regularly for signs
of infection
Patient Teaching
Take food high in calories, protein, Iron and Vit.
C
Encourage to learn and practice relaxation and
pain management techniques
Increase fluid intake
Liver Cancer
Primary liver cancer begins in the cells of the liver
itself. Although many cancers are declining in the
United States, new cases of primary liver cancer
are increasing.
In the United States, cancer affecting the liver is
more commonly metastatic cancer, which occurs
when tumors from other parts of the body spread
(metastasize) to the liver. Cancers that commonly
spread to the liver include colon, lung and breast
cancers. These cancers aren't called liver cancer.
Instead, they are named after the organ in which
the cancer began such as metastatic colon
cancer to describe cancer that begins in the colon
and spreads to the liver. These metastatic cancers
are treated based on where the cancer began,
rather than being treated as primary liver cancers.
Primary liver cancer is rarely discovered early and
often doesn't respond to current treatments
thus, the prognosis is often poor. Even when
treatments fail to provide much improvement in
the liver cancer itself, pain and other signs and
symptoms caused by liver cancer can be
aggressively treated to improve quality of life. But
the most important news about primary liver
cancer is that you can greatly reduce your risk by
protecting yourself from hepatitis infection and
cirrhosis, the leading causes of the disease.
Signs and symptoms
Most people don't have signs and symptoms in the
early stages of liver cancer, which means the
disease may not be detected until it's quite
advanced. When symptoms do appear, they may
include some or all of the following:
Loss of appetite and weight
26

Abdominal pain, especially in the upper right part of


your abdomen, that may extend into your back and
shoulder
Nausea and vomiting
General weakness and fatigue
An enlarged liver
Abdominal swelling (ascites)
A yellow discoloration of your skin and the whites of
your eyes (jaundice)
Causes
Your liver is a football-sized organ that sits in the
upper right portion of your abdomen, beneath your
diaphragm and above your stomach. Your liver
processes most of the nutrients absorbed from your
small intestine and determines how much sugar
(glucose), protein and fat enter your bloodstream. It
also manufactures blood-clotting substances and
certain proteins. Your liver performs a vital
detoxifying function by removing drugs, alcohol and
other harmful substances from your bloodstream.
Liver cancer occurs when liver cells begin to grow
abnormally. It's not completely understood why this
happens, but researchers believe that cancer starts
with damage to DNA the material that contains
the instructions for every chemical process in your
body, including the rate of cellular growth. DNA
damage causes changes in these instructions. One
result is that cells may begin to grow out of control
and eventually form a tumor a mass of malignant
cells.
Primary liver cancer
Primary liver cancer is divided into several types
based on the type of cells that become cancerous.
Types include:
Hepatocellular carcinoma (HCC). This is the most
common form of primary liver cancer in both
children and adults. It starts in the hepatocytes, the
main type of liver cell.
Cholangiocarcinoma. This type of cancer begins in
the small tube-like bile ducts within the liver. This
type of cancer is sometimes called bile duct cancer.
Hepatoblastoma. This rare type of liver cancer
affects children younger than 4 years of age. Most
children with hepatoblastoma can be successfully
treated.
Angiosarcoma or hemangiosarcoma. These rare
cancers begin in the blood vessels of the liver and
grow very quickly.
Metastatic cancer

In the United States, most cancer found in the liver


has spread there from another part of the body.
Rather than being referred to as liver cancer, this
type of cancer is usually named after the organ
where it originated and is described as
"metastatic." For instance, cancer that has spread
to the liver from the colon is referred to as
metastatic colon cancer.
Metastatic cancers form when malignant cells
detach from the primary cancer and travel through
the body in the circulatory or lymphatic system.
Cancers that begin in certain organs near the liver,
such as the pancreas, can spread directly to the
liver. Most metastatic cancers reach the liver
through the bloodstream. Why the liver is so
commonly affected by metastatic cancer isn't
clear. One reason may be the liver's rich blood
supply.
Risk factors
Primary liver cancer can affect people of all ages
and races, but certain factors may increase your
risk, including:
Sex. Men are more likely to develop liver cancer
than are women, though it isn't clear why.
Age. In the United States and Europe, liver
cancer diagnosis occurs on average at about
age 60. People in Asia and Africa tend to be
diagnosed with liver cancer at younger ages
between 20 and 50.
Chronic infection with HBV or HCV. Chronic
infection with hepatitis B virus (HBV) or hepatitis
C virus (HCV) is by far the most important risk
factor for liver cancer.
Cirrhosis. This progressive and irreversible
condition causes scar tissue to form in your liver
and increases your chances of developing liver
cancer.
Diabetes. People with this blood sugar disorder
have a greater risk of liver cancer than do
people who don't have diabetes. Having both
diabetes and hepatitis C infection increases the
risk even more.
Exposure to aflatoxins. Consuming foods
contaminated with fungi that produce aflatoxins
greatly increases the risk of liver cancer. Crops
such as corn, soybeans and peanuts can
become contaminated with aflatoxins.
Excessive alcohol consumption. Consuming
more than a moderate amount of alcohol can
lead to irreversible liver damage and increase
your risk of liver cancer. Moderate consumption
27

is defined as no more than two drinks a day for men


and one drink for women. A drink is one 4- to 5ounce glass of wine, 12 ounces of beer or a 1.5ounce shot of 80-proof distilled spirits.
Smoking. Smoking tobacco of any kind makes it
more likely that you'll develop liver cancer.
Bile duct disease. A disease called primary
sclerosing cholangitis can cause inflammation and
scarring of the liver's bile ducts. This increases your
risk of bile duct cancer.
Screening
Screening for liver cancer hasn't been definitively
proved to reduce the risk of dying of liver cancer. For
this reason, many medical groups don't recommend
liver cancer screening. However, the American
Association for the Study of Liver Diseases
recommends liver cancer screening for those thought
to have a high risk, including people who have:
Hepatitis B and one or more of the following: Are an
Asian male older than 40, Asian female older than
50 or African and older than 20, have liver cirrhosis,
or have a family history of liver cancer
Liver cirrhosis from alcohol use
Hepatitis C
An inherited form of hemochromatosis
Primary sclerosing cholangitis
Diagnosis
Ultrasound (ultrasonography). This test uses sound
waves to produce a picture of internal organs,
including the liver. Ultrasound is painless and
usually takes less than 30 minutes. While you lie on
a bed or examining table, a wand-shaped device
(transducer) is placed on your body. It emits sound
waves that are reflected from your liver and
transformed into a computer image. Ultrasound
provides information about the shape, texture and
makeup of tumors.
Computerized tomography (CT) scan. This test uses
X-rays to produce cross-sectional images of your
body. You may also have a variation of the test
known as a CT angiogram in which contrast dye
is injected into an artery in your liver. X-rays then
track the dye as it flows through the blood vessels in
your liver. A CT angiogram, which may take up to an
hour to perform, can provide detailed information on
the number and location of liver tumors, but a CT
scan exposes you to more radiation than
conventional X-rays do, and some people may
experience an allergic reaction to the contrast dye.
Magnetic resonance imaging (MRI). MRI creates
images using a magnetic field and radio waves.

Sometimes a contrast dye also may be used.


The test can take from 15 minutes to an hour.
Newer MRIs can show images of the ducts that
transport bile from the liver to the upper part of
the small intestine (duodenum) as well as of the
arteries and veins within the liver.
Liver biopsy. In this procedure, a sample of
tissue is removed from your liver and examined
under a microscope. Liver biopsy is considered
the only definitive way to diagnose liver cancer.
Your doctor may use a thin needle or a lighted
instrument (laparoscope) to obtain the sample.
Biopsy carries a risk of bleeding, bruising and
infection.
Blood tests. Doctors sometimes use a blood test
that checks for the presence of alpha-fetoprotein
(AFP) a type of protein found in small
amounts in adults to detect liver cancer. But
the test isn't perfect. Not all malignant liver
tumors produce AFP, and those that do may be
advanced by the time protein levels become
elevated. In addition, other types of cancer and
even some noncancerous liver diseases can
raise AFP levels.
Staging
Staging tests help determine the size and location
of cancer and whether it has spread. Liver cancer
may be staged in different ways. One method
uses the Roman numerals I through IV, with higher
numbers indicating cancers that are more
advanced. A stage I tumor is small and confined to
one lobe of the liver. By stage IV, several tumors
may exist in different lobes, or malignant cells may
have spread to other parts of the body.
Doctors may also use the following stages to
describe primary liver cancer in adults:
Localized resectable. At this stage, the tumor is
confined to one lobe of your liver and can be
completely removed in an operation. The term
"resectable" refers to a tumor that can be
surgically removed.
Localized unresectable. The cancer is found in
only one part of your liver, but can't be
completely removed, either because the
noncancerous portion of your liver isn't healthy
or because the cancer is located near your
liver's main arteries, veins and bile ducts.
Advanced. This stage of cancer has spread
throughout the liver or to other parts of your
body, particularly the bones or lungs. You're
more likely to have advanced cancer if you also
have cirrhosis or chronic hepatitis.
28

Recurrent. This means the cancer has returned to


your liver or to another part of your body after being
treated.
Stages of primary cancer in children
Doctors use the following stages to describe childhood
liver cancer:
Stage I. At this stage, the cancer can be removed
with surgery.
Stage II. Most stage II liver cancers can be removed
with an operation, but microscopic amounts of
cancer remain in the liver after surgery.
Stage III. At this stage, some of the cancer may be
surgically removed, but some will remain in the
lymph nodes or abdomen.
Stage IV. This stage of cancer has spread to other
parts of the body.
Recurrent. This means the cancer has returned
after it has been treated. It may recur in the liver or
in another part of the body
Complications
People with liver cancer may sometimes experience
the following complications:
Liver failure. This occurs when the liver is no longer
able to function adequately. It usually develops
when there is extensive damage to liver cells.
Kidney failure. The kidneys also may fail, losing their
ability to filter fluids and waste and causing
dangerous levels of these substances to
accumulate in the body.
Spread of the cancer cells (metastasis). Cancer that
spreads to areas outside the liver becomes more
difficult to treat. Liver cancer most commonly
spreads to the lungs and bones
Treatment
Treatments for primary liver cancer depend on the
extent (stage) of the disease as well as your age,
overall health, feelings and personal preferences.
Discuss all of your options carefully with your
treatment team.
The goal of any treatment is to eliminate the cancer
completely. When that isn't possible, the focus may be
on preventing the tumor from growing or spreading. In
some cases palliative care only is appropriate.
Palliative care refers to treatment aimed not at
removing or slowing the disease but at helping relieve
symptoms and making you as comfortable as
possible.
Treatments for primary liver cancer in adults

Surgery. The best treatment for localized


resectable cancer is usually an operation known
as surgical resection. In some cases, the area of
the liver where the cancer is found can be
completely removed. You aren't a candidate for
surgical removal of liver tumors if you have
cirrhosis or only a small amount of healthy liver
tissue. Even when resections are successful,
there is a chance the cancer can recur
elsewhere in the liver or in other areas within a
few years.
Alcohol injection. In this procedure, pure alcohol
is injected directly into tumors, either through the
skin or during an operation. Alcohol dries out the
cells of the tumor and eventually the cells die.
Each treatment consists of one injection,
although you may need a series of injections for
the best results. Alcohol injection has been
shown to improve survival in people with small
hepatocellular tumors. It may also be used to
help reduce symptoms in cases of metastatic
liver cancer. The most common side effect is
leaking of alcohol onto the liver or into the
abdominal cavity.
Radiofrequency ablation. In this procedure,
electric current in the radiofrequency range is
used to destroy malignant cells. Using an
ultrasound or CT scan as a guide, your surgeon
inserts several thin needles into small incisions
in your abdomen. When the needles reach the
tumor, they're heated with an electric current,
destroying the malignant cells. Radiofrequency
ablation is an option for people with small,
unresectable hepatocellular tumors and for
some types of metastatic liver cancers. Although
the procedure has a somewhat higher risk of
serious complications than alcohol injection
does, it appears to provide better outcomes.
Chemoembolization. Chemoembolization is a
type of chemotherapy treatment that supplies
strong anti-cancer drugs directly to the liver.
Chemoembolization isn't curative, but it can
shrink tumors in a certain percentage of people,
which may provide symptom relief and improve
survival. During the procedure, the hepatic
artery the artery from which liver cancers
derive their blood supply is blocked, and
chemotherapy drugs are injected between the
blockage and the liver. The idea is that by
targeting the tumor directly, doctors can use
potent doses of drugs without creating as many
side effects as occur with systemic
chemotherapy. But the fact is that
29

chemoembolization causes many of the same side


effects as other forms of chemotherapy, including
abdominal
pain,
nausea
and
vomiting.
Chemoembolization is less likely to cause some
side effects such as lowered blood cell counts or
hair loss.
Radiation therapy. This treatment uses highpowered energy beams to destroy cancer cells and
shrink tumors. Radiation may come from a machine
outside your body or from radiation-containing
materials inserted into your liver. Radiation may be
used on its own to treat localized unresectable
cancer. Or you may have radiation therapy following
surgical removal of a tumor to help destroy any
remaining malignant cells. Radiation side effects
may include fatigue, nausea and vomiting.
Chemotherapy. This treatment uses powerful drugs
to kill cancer cells. Chemotherapy may be systemic
meaning it travels throughout your body in your
bloodstream or regional. Systemic chemotherapy
is generally not effective in treating liver cancer, but
may be a treatment option in certain cases.
Liver transplantation. In this surgical procedure, a
diseased liver is removed and replaced with a
healthy, donated organ. Liver transplantation may
be an option for some people with small, early-stage
liver tumors and for certain people with bile duct
tumors. In other cases, especially when tumors are
larger or blood vessels are involved, a transplant
may not improve long-term outlook because the
cancer may recur outside the new liver.
Cryoablation (cryosurgery or cryotherapy). This
treatment uses extreme cold to destroy cancer cells.
Cryoablation may be an option for people with
inoperable primary and metastatic liver cancers. It
may also be used in addition to surgery,
chemotherapy or other standard treatments. During
the procedure, your doctor places an instrument
(cryoprobe) containing liquid nitrogen directly onto
liver tumors. Ultrasound images are used to guide
the cryoprobe and monitor the freezing of the cells.
Side effects include damage to the bile ducts and
major blood vessels, leading to bleeding or
infection.
Sorafenib (Nexavar). Sorafenib was approved by
the Food and Drug Administration in 2007 for use in
advanced inoperable liver cancer. Sorafenib is a
targeted therapy designed to interfere with a tumor's
ability to generate new blood vessels. Sorafenib has
been shown to slow or stop advanced liver cancer
from progressing for a few months longer than with
no treatment. More studies are needed to

understand how targeted therapies may be used


to control advanced liver cancer.
Treatments for primary liver cancer in children
Liver cancer in young people is rare. As a result,
most children with the disease are treated at
centers that specialize in childhood cancers. In
general, the treatments available for children are
the same as for adults, and the best approach
depends on the stage and type of cancer as well
as the child's age and overall health.
Clinical trials. Because standard treatments
often aren't effective in treating liver cancer, you
may want to consider participating in a clinical
trial a research study that tries to improve
current treatments or find new treatments. This
can give you access to experimental therapies
that might not otherwise be available. There are
no guarantees with clinical trials, however, and
you should fully understand the potential risks
as well as possible benefits before taking this
step
Prevention
In many cases it's not possible to prevent the
spread of cancer from another site to the liver.
And it may not always be possible to prevent
primary liver cancer. But you can greatly reduce
your risk by taking steps to protect yourself from
hepatitis B and C, cirrhosis and other liver
diseases.
Get vaccinated. The single most effective way to
prevent hepatitis B is to receive the hepatitis B
vaccine, which provides more than 90 percent
protection for both adults and children.
Protection lasts years and may even be lifelong.
The vaccine can be given to almost anyone,
including infants, older adults and those with
compromised immune systems. Infants often
receive the vaccine in the first year of life
typically at 2, 4 and 9 months of age.
Take measures to prevent hepatitis C
Because no vaccine for hepatitis C exists, the
following measures can play a key role in
protecting your health:
Educate yourself and others. Make sure you
understand what viral hepatitis is and how it's
transmitted.
Know the health status of any sexual partner.
Don't engage in unprotected sex unless you're
absolutely certain your partner isn't infected with
HBV, HCV or any other sexually transmitted
30

disease. If you don't know the health status of your


partner, use a new latex condom every time you
have vaginal or anal sex. If you don't have a male
condom, use a female condom.
Don't use IV drugs, but if you do, use a clean
needle. The best way to protect yourself from HCV
is not to inject drugs. But if that isn't an option for
you, make sure any needle you use is sterile, and
don't share it. Contaminated drug paraphernalia is
responsible for about half of all new hepatitis C
cases. Take advantage of needle exchange
programs in your community and consider seeking
help for your drug use.
Avoid body piercing and tattooing. Needles that may
not be properly sterilized can spread the virus.
Be cautious about blood products in certain
countries. Most Americans with HCV became
infected through blood transfusions received before
1992 the year improved blood-screening tests
became available. Although the blood supply is now
well screened in the United States, this isn't always
the case in other countries. If an emergency
requires that you receive blood or blood products in
another country, get tested for HCV and HBV as
soon as you return home.
Avoid or limit alcohol. Alcohol speeds the
progression of any liver disease you may have and
is the leading cause of cirrhosis a key factor in
primary liver cancer.
Avoid medications that may cause liver damage.
Your doctor can advise you about these
medications, which may include over-the-counter
medications as well as prescription drugs. Avoid
mixing alcohol and acetaminophen (Tylenol, others)
a combination known to cause liver damage.
Avoid exposure to environmental toxins. Your liver
filters every substance you ingest, inhale or apply to
your skin. For that reason, avoid unnecessary
chemical exposure.

Breast Cancer
It is common among women. 99% in women; 1% in
men
It is common on left side of the breast
There is no specific cause of breast CA
It is a combination of hormonal, genetic and
possibly environmental events may contribute to its
development.
Significant Risk Factors:
Family history of breast and ovarian CA

Older than age 45


Premenopausal
Other Risk Factors:
Long menstrual cycle
Early onset of menses
Late menopausal
First pregnancy before 20
Increase fat diet
Radiation exposure
Anti-hypertensive therapy
Alcohol/tobacco use
Types of Breast Cancer
1. Inflammatory Breast Cancer
The cancer cell may not grow as a lump that can
be felt in the breast but they grow along and block
the tiny channels in the skin of the breast.
S/Sx:
Breast looks red and inflamed
Symptoms develop quite suddenly
Localized tumor is tender and painful
Often edema and nipple retraction occur
2. Pagets Disease of the Breast
Is an eczema like change in the skin of the
nipples
Often mass cant be palpated underneath the
nipple where the disease arises
Diagnostic test:
Mammography (but result may often be
negative)
Biopsy of the lesion is definitive test
Signs and Symptoms:
Scaly lesion and burning and itching around the
areola complex
Fluid (discharge)
Nipples may intend to be inverted
There may/may not be a lump in the breast
SURGERY: mastectomy

3. Ductal Carcinoma in Situ (DCIS)


Has the capacity to progress to invasive cancer
Cure rate 98-99%
It is the proliferation of malignant cells w/in the
ducts
Lumpectomy is the option but it is case to case
basis
31

SIGNS AND SYMPTOMS:


Microcalcification
Dx: FNAC (fine needle aspiration cytology)
3. Lobular Carcinoma in Situ
It is not a cancer but its presence means
Characterized by proliferation of cell w/in the breast
lobules
It is commonly associated with multicentric disease
and rarely associated with invasive cancer
Treatment:
1.Total mastectomy
2.Chemoprevention
3.Bilateral prophylactic mastectomy to decrease risk.
Anatomy and Physiology
Structure
Breast tissue extends from below the collarbone to
the level of the sixth or seventh rib, and from the
breastbone to the underarm (axilla). In the center of
the breast is the nipple, or mammilla, and areola
(circular area around the nipple). Montgomery's
glands, located around the edge of the areola,
release a fatty substance that protects the nipples
during nursing.
Each breast contains several milk glands with ducts
that carry milk to the nipples. About 15 to 20 ducts
come together near the areola to form reservoirs of
milk to be drawn from the nipple.
Fibrous connective tissue (fascia) lies between the
breast tissue and the skin, and separates breast
tissue from the chest muscles. Coopers ligaments
run from the deep fascia throughout the breast
tissue and attach to the dermis (second layer of
skin).
Lymphatic System
Most lymphatic vessels in the breast drain into a
network of lymph nodes located around the breast's
edges, in the underarm, and near the collarbone.
These lymph nodes are embedded within fat, which
complicates their removal. Axillary (underarm)
lymph nodes are often the first site of breast cancer
metastasis.
Blood Vessels
The internal mammary, axillary (underarm), and
intercostal (between the ribs) arteries supply the
breasts with blood; and the internal mammary,
axillary, and intercostal veins carry blood away from
the breasts. The axillary (underarm) vein has an

irregular anatomy, which complicates surgery


under the arm.
The surface veins of the breast encircle the
nipple and carry blood to the internal mammary,
axillary, and intercostal (between the ribs) veins,
and to the lungs. Breast cancer cells can travel
to the lungs via surface veins and form
metastatic tumors.
The intercostal veins join a complex network of
vertebral veins in and around the spine,
providing a path for breast cancer cells to
spread to bone tissue.
Nerves
The skin of the upper breast is supplied with
nerves (innervated) that branch from a network
of nerves in the neck. Spinal nerves that pass
between the ribs innervate the skin over the
lower portion of the breast.
The long thoracic nerve innervates the muscle
that helps move the upper arm. Surgeons must
be careful not to sever or injure this nerve when
operating near underarm lymph nodes that the
nerve crosses
Muscles
Several mastectomy procedures involve removing
the fascia (fibrous tissue) overlying the chest
muscles or removing the muscles themselves.
Chest muscles located under the breasts include
the following:
Major and minor pectorals attach to the
collarbone; breastbone; bone in the upper arm
(humerus); shoulder joint; third, fourth, and fifth
ribs and the muscles between those ribs
(intercostal muscles)
Serratus magnus attaches to the first eight or
nine ribs and rib muscles, and connects with the
shoulder blades in the back
Rectus abdominus extends from the pubic
bone and attaches to the cartilage of the fifth,
sixth, and seventh ribs

Pathophysiology

32

treatment for histological or cytological


examination. Such procedures include fine-needle
aspiration, nipple aspirates, ductal lavage, core
needle biopsy, and local surgical excision. These
diagnostic steps, when coupled with radiographic
imaging, are usually accurate in diagnosing a
breast lesion as cancer. Occasionally, pre-surgical
procedures such as fine needle aspirate may not
yield enough tissue to make a diagnosis, or may
miss the cancer entirely.

Breast Cancer Staging


Stage I - 2 cm tumor in diameter, node axillary
Stage IIA - 2-5 cm tumor, node negative;
< 2 cm tumor, node positive
Stage IIB - > 5 cm tumor, node negative
2-5 cm tumor, node positive
Stage IIIA - > 5 cm tumor, node positive or < 5 cm
tumor, node positive with lymph nodes attached to
each other or other
Stage IIIB - Tumor penetrated to the skin of breast
or chest wall or spread to internal mammary nodes
Stage IV - Distant metastasis
Diagnostic test
Mammography: Bilateral study is necessary for
screening, diagnosis, and follow-up care. Malignant
and benign breast lesions have the following
mammographic characteristics:
Malignant breast lesions
Irregular speculated mass
Clustered calcifications
Calcifications - Smaller than 0.5 mm in
diameter
Architectural distortion
Focal asymmetric density
Benign breast lesions
Solid- or lucent-centered spheres
Smooth and round calcifications
Calcifications - Larger than 1 mm in diameter
Architectural distortion - Usually not present
Diagnosis
Breast cancer is diagnosed by the examination of
surgically removed breast tissue. A number of
procedures can obtain tissue or cells prior to definitive

Imaging tests are sometimes used to detect


metastasis and include chest X-ray, bone scan,
CT scan, MRI, and PET scanning. While imaging
studies are useful in determining the presence of
metastatic disease, they are not in and of
themselves diagnostic of cancer. Only microscopic
evaluation of a biopsy specimen can yield a
cancer diagnosis. Ca 15.3 (carbohydrate antigen
15.3, epithelial mucin) is a tumor marker
determined in blood which can be used to follow
disease activity over time after definitive
treatment. Blood tumor marker testing is not
routinely performed for the screening of breast
cancer, and has poor performance characteristics
for this purpose.
Medical therapy:
Treatment of in situ disease
Ductal carcinoma in situ
Approximately 85% of DCIS is detected
mammographically
Mastectomy cures 98-99% of all types of DCIS,
with a recurrence rate of only 1-2%. Most
recently, lumpectomy with RT was shown to
yield local recurrence rates of 7-13.4%,
compared with 26.8-43% for local excision
alone. Furthermore, the addition of tamoxifen
resulted in a 44% decrease of invasive breast
cancer in the ipsilateral breast and a 52%
decrease of invasive breast cancer in the
contralateral breast.
Lobular carcinoma in situ
This lesion is usually an incidental finding in
breast biopsy specimens. LCIS is not a cancer;
it is an indicator for increased risk for breast
cancer. This risk is estimated at 1-1.5% per year
and 20-30% over a lifetime. Of invasive
carcinoma developing in this setting, 50% is
ductal carcinoma; the other 50% is lobular
carcinoma.
Patients may be observed or offered
participation in a chemoprevention trial. Bilateral
33

simple mastectomy with immediate reconstruction is


the recommended surgery should the patient elect a
radical treatment. Chemotherapy and RT have no
role in the treatment of this lesion.

Type of treatment: doxorubicin (Adriamycin) (A)


Possible side effects: ECG changes, tachycardia,
nausea and vomiting, stomatitis, hair loss, severe
cellulitis if infiltration occurs

Treatment of invasive disease


Modern treatment of breast cancer is based on a
multimodality approach combining surgery,
chemotherapy, HT, and RT. Treatment is tailored for
an individual patient based on tumor size, axillary
lymph node involvement, ER and PR status (the
most important variables identified by many
historical studies), histologic tumor type,
standardized pathologic grade, and menopausal
status.

Type of treatment: cyclophosphamide (Cytoxan)


(C)
Possible side effects: Nauseaa, vomiting,
anorexia, menstrual abnormalities, hemorrhagic
cystitis

Radiotherapy
RT reduces the risk of local recurrence and has the
potential to decrease long-term mortality from breast
cancer.
RT to the breast (with or without the supraclavicular
area) is indicated after lumpectomy in persons with
early-stage breast cancer as an integral part of the
treatment plan, and it is indicated after mastectomy
in the presence of a large tumor mass (>5 cm),
positive margins, and 4 or more lymph nodes
positive for disease.

Type of treatment: methotrexate (M)


Possible side effects: stomatitis, CNS changes,
hair loss
Type of treatment: 5-fluorouracil (F)
Possible side effects: CNS changes, neurotoxicity,
nausea and vomiting, constipation, stomatitis
Type of treatment: paclitaxel (Taxol) (T)
Possible side effects: nausea, vomiting, stomatitis,
hair loss, diarrhea, hypersensitivity, peripheral
neuropathy
Type of treatment: epirubicin (Ellence) (E)
Possible side effects: nausea and vomiting,
myelosuppression, cardiac toxicity, mucositis

Surgical therapy:
Lumpectomy
Lumpectomy or wide local excision may be
performed with the patient under local anesthesia if
no axillary node dissection is planned. General
anesthesia is preferred for large excisions or if
axillary dissection is intended.

Type of treatment: docetaxel (Taxorene) (T)


Possible side effects: nausea and vomiting,
stomatitis,
hypersensitivity,
neurosensory
disturbances

Mastectomy
Mastectomy (modified radical or simple) implies
removing all the breast tissue and the overlying
skin, including the nipple-areola complex, and
leaving viable skin flaps.
In a simple mastectomy, the dissection is stopped
before the axillary fat pad is entered. In a modified
RM, and according to the surgeon's preference, the
dissection may start with the breast and proceed
through the axilla or it may start in the axilla and
finish in the breast.

Nursing Interventions
Nausea and vomiting: administer antiemetics as
prescribed; monitor I & O
Anorexia: assist patient and family to identify
appetizing foods; provide frequent small meals if
better tolerated than three regular meals, refer
to dietician for assistance in planning palatable,
nutritious meals
Stomatitis: avoid commercial mouthwashes, use
baking soda, salt and H2O rinses or oral
anesthetic agents
Hair loss: avoid brushing, blow drying, frequent
shampooing, encourage use of turbans and
scarves, encourage patient to obtain wig before
hair loss occurs

Chemotherapy and Hormonal Therapy for Breast


Cancer
Chemotherapy
Goals of therapy: Destroy neoplastic cells; decrease
or prevent metastasis

Type of treatment: Combination Therapy (CMF,


CAF, AC, ACT, CEF)

34

CNS changes: monitor for weakness, malaise,


fatigue, seizures, change in cognitive status, assist
with ADLs if fatigue and malaise occurs
Neurotoxicity: monitor DTR, assess gait and muscle
strength, monitor for changes in sensory function
Fluid retention: monitor wt, I & O and skin turgor
Cardiac changes: monitor ECG, cardiac rate and
rhythm, notify physician of dysrhythmias
Constipation: monitor bowel function, administer
stool softener or laxatives as prescribed, encourage
adequate intake of fluids and fibers
Anxiety: administer tranquilizers as prescribed
Hormonal therapy
Type of treatment: Androgens fluorymesterone
(Halotestin)
Goal of therapy: suppress estrogen
Possible side effects: masculinization, fluid retention,
cholestatic jaundice, hypercalcemia
Type of treatment: estrogens diethylstilbestrol (DES)
Goal of therapy: suppress FSH and LH
Possible side effects: nausea, vomiting, anorexia,
dizziness, headache
Type of treatment: Corticosteroids prednisone
Goal of therapy: suppress estrogen production by the
adrenals and decrease urinary estrogen metabolites
Possible side effects: cushings syndrome
Type of treatment: antihormonal agents tamoxifen
(Nolvadex)
Goal of therapy: estrogen antagonist, effective in
decreasing risk for cancer recurrence in post
menopausal women and as a palliative treatment for
recurrent cancer
Possible side effects: weight gain, hot flashes,
nausea, anorexia, lethargy
Type of treatment: antihormonal agents megestrol
acetate (Megace)
Goal of therapy: progestational agent, may decrease
the number of estrogen receptors in breast tissues
Possible side effects: weight gain, hot flashes, vaginal
bleeding, increased BP, peripheral edema, depression
Type
of
treatment:
antihormonal
agents
aminoglutethimide (Cytadren)
Goal of therapy: enzyme antagonist that inhibits
estrogen synthesis
Possible side effects: CNS changes: dizziness,
clumsiness, drowsiness, depression and headache

Type of treatment: antihormonal agents


anastraxole (Arimidix)
Goal of therapy: aromatase inhibitor; blocks
production of estrogen in peripheral tissues
Possible side effects: nausea, hot flashes,
headache, back pain
Nursing intervention:
Hormonal instability: observe for changes (hot
flashes, vaginal bleeding) facial hirsutism,
deepening of voice, fluid retention, cushing
syndrome, increased BP, assess for
thrombophlebitis, monitor serum calcium levels,
educate x on symptom management and assure
patient that most changes are temporary
Prevention
Chemoprevention
Tamoxifen
(Nolvadex). Tamoxifen is
approved for use as a preventive agent in
women age 35 and older who have an
elevated risk of developing breast cancer
within the next five years.
Preventive surgery
Prophylactic mastectomy. This preventive
surgery involves removing one or both of
your breasts to prevent or reduce your risk
of breast cancer. Consider this option if a
person is at high risk of breast cancer,
already had cancer in one breast, have a
family history of breast cancer, received
positive results from genetic testing, or
doctors have identified early signs of cancer
in their breast.
Lifestyle factors
Ask your doctor about aspirin. Taking an
aspirin just once a week may help protect
against breast cancer, but be sure to talk to
your doctor before you start. When used for
long periods of time, aspirin can cause
stomach irritation, bleeding and ulcers. More
serious aspirin side effects include bleeding
in the intestinal and urinary tracts and
hemorrhagic stroke. In general, you're not a
candidate for aspirin therapy if you have a
history of ulcers, liver or kidney disease,
bleeding disorders, or gastrointestinal
bleeding.
Limit alcohol. Drinking alcohol is strongly
linked to breast cancer. The type of alcohol
consumed wine, beer or mixed drinks
35

seems to make no difference. To help protect


against breast cancer, limit the amount of
alcohol you drink to less than one drink a day or
avoid alcohol completely.
Maintain a healthy weight. There's a clear link
between obesity weighing more than is
appropriate for your age and height and
breast cancer. The association is stronger if you
gain the weight later in life, particularly after
menopause.
Avoid long-term hormone therapy. The link
between postmenopausal hormone therapy and
breast cancer has been a subject of debate for
years, partly because research results have
been mixed. Estrogen exposure clearly
contributes to breast cancer risk, but for most
women, the size of the contribution over a
lifetime is small particularly in the absence of
other risk factors, such as family history of the
disease. If you're approaching menopause and
having frequent symptoms, it's probably safe to
take hormones for as long as four to five years.
Any longer does increase your breast cancer
risk, without conferring any clear benefits. The
same is true of hormone therapy after age 60.
Eat foods high in fiber. Try to increase the
amount of fiber you eat to between 20 and 30
grams daily about twice that in an average
American diet. Among its many health benefits,
fiber may help reduce the amount of circulating
estrogen in your body. Foods high in fiber
include fresh fruits and vegetables and whole
grains.
Emphasize olive oil. Oleic acid, the main
component of olive oil, appears both to
suppress the action of the most important
oncogene in breast cancer and to increase the
effectiveness of the drug Herceptin.
Avoid exposure to pesticides. The molecular
structure of some pesticides closely resembles
that of estrogen. This means they may attach to
receptor sites in your body. Although studies
have not found a definite link between most
pesticides and breast cancer, it is known that
women with elevated levels of pesticides in their
breast tissue have a greater breast cancer risk.

Cervical Cancer
Cervical cancer occurs when abnormal cells on the
cervix grows out of control.
Predisposing Factors

Most cervical cancer is caused by a virus called


Human PapillomaVirus, or HPV. You get HPV
by having sex with someone who has it. There
are many types of the HPV virus. Not all types of
HPV cause cervical cancer. Some of them
cause genital warts, but other types may not
cause any symptoms.
You can have HPV for years and not know it. It
stays in your body and can lead to cervical
cancer years after you were infected. This is
why it is important for you to have regular Pap
tests. A Pap test can find changes in cervical
cells before they turn into cancer. If you treat
these cell changes, you may prevent cervical
cancer.
Signs and Symptoms
Abnormal vaginal bleeding or a significant
unexplained change in your menstrual cycle.
Bleeding when something comes in contact with
the cervix, such as during sexual intercourse or
insertion of a diaphragm.
Pain during sexual intercourse.
Abnormal vaginal discharge containing mucus
that may be tinged with blood.
Symptoms that may occur when your cervical
cancer has progressed include:
Anemia because of abnormal vaginal bleeding.
Ongoing pelvic, leg, or back pain.
Urinary problems because of blockage of a
kidney or ureter.
Leakage of urine or fecal content into the vagina
because an abnormal opening (fistula)
Weight loss.
Diagnosis
As part of your regular pelvic exam, you should
have a Pap test. During a Pap test the doctor
scrapes a small sample of cells from the surface
of the cervix to look for cell changes. If a Pap
test shows abnormal cell changes, your doctor
may do other tests to look for precancerous or
cancer cells on your cervix.
Initial treatment
Cone biopsy to remove the cancer.
Simple hysterectomy to remove the uterus and
cervix.
Modified radical hysterectomy and lymph node
dissection to remove the cancer.
36

Radiation therapy, which uses high-dose X-rays or


implants in the vaginal cavity to kill cancer cells.
Chemotherapy, which uses medicines to kill cancer
cells.
Radical trachelectomy to remove the cervix and the
pelvic lymph nodes (lymph node dissection). But the
uterus is left in place. This treatment is done less
often.
Side effects of treatment
Side effects of chemotherapy may include loss of
appetite, nausea, vomiting, diarrhea, mouth sores,
or hair loss.
Side effects of radiation therapy may include fatigue,
skin irritation, or changes in your bowel or urinary
habits.
Side effects of surgery depend on the surgery used
to treat the stage of your cancer. Side effects of
chemotherapy may include loss of appetite, nausea,
vomiting, diarrhea, mouth sores, or hair loss.
Side effects of radiation therapy may include fatigue,
skin irritation, or changes in your bowel or urinary
habits.
Side effects of surgery depend on the surgery used
to treat the stage of your cancer.
Prevention
The Pap test is the best way to find cervical cell
changes that can lead to cervical cancer. Regular
Pap tests almost always show these cell changes
before they turn into cancer. It is important to follow
up with your doctor after any abnormal Pap test
result to treat abnormal cell changes. This may help
prevent cervical cancer.
A new vaccine called Gardasil protects against four
types of HPV, which together cause most cases of
cervical cancer and genital warts. You get three
shots over 6 months. The vaccine is recommended
for girls 11 to 12 years old. It is also recommended
for females 13 to 26 years old who did not get the
vaccine when they were younger.
The virus that causes cervical cancer is spread
through sexual contact. The best way to avoid
getting a sexually transmitted disease is to not have
sex. If you do have sex, practice safer sex, such as
using condoms and limiting the number of sex
partners you have.
Medication Choices
The most common chemotherapy medicines used
for initial treatment or with radiation treatment in
stage IIA, IIB, IIIA, IIIB, and IVA include:
Cisplatin.

Fluorouracil (5-FU).
For advanced stage (stage IVB) cervical cancer
or recurrent cervical cancer, the most common
chemotherapy medicines used are:
Mitomycin.
Paclitaxel.
Ifosfamide.
Topotecan has been approved to use with
cisplatin for advanced cervical cancer. These
drugs may be used when surgery or radiation
cannot be done or are not likely to work. They
can also be used for cervical cancer that has
returned or spread to other organs.
Anatomy and Physiology
Cervix
The cervix (from Latin "neck") is the lower,
narrow portion of the uterus where it joins with
the top end of the vagina. It is cylindrical or
conical in shape and protrudes through the
upper anterior vaginal wall. Approximately half
its length is visible with appropriate medical
equipment; the remainder lies above the vagina
beyond view. It is occasionally called "cervix
uteri", or "neck of the uterus".
A small, cylindrical organ, several centimeters
long and less than 2.5 cm in diameter, which
comprises the lower part and neck of the uterus.
The cervix separates the body and cavity of the
uterus from the vagina. Running through the
cervix is a canal, through which sperm can pass
from the vagina into the uterus and through
which blood passes during menstruation. The
cervical canal, which forms part of the birth
canal during childbirth, dilates (expands) widely
to allow passage of a baby.
The bulk of the cervix consists if fibrous tissue
with some smooth muscle. This tissue makes
the cervix into a form of sphincter (circular
muscle) and allows for the great adaptability in
its size and shape required during pregnancy
and childbirth.
Parts of the Cervix
A. Ectocervix
The portion projecting into the vagina is referred
to as the portio vaginalis or ectocervix. On
average, the ectocervix is 3 cm long and 2.5 cm
wide. It has a convex, elliptical surface and is
divided into anterior and posterior lips.
B. External os
37

The ectocervix's opening is called the external os.


The size and shape of the external os and the
ectocervix varies widely with age, hormonal state,
and whether the woman has had a vaginal birth. In
women who have not had a vaginal birth the
external os appears as a small, circular opening. In
women who have had a vaginal birth, the ectocervix
appears bulkier and the external os appears wider,
more slit-like and gaping.
C. Endocervical canal
The passageway between the external os and the
uterine cavity is referred to as the endocervical
canal. It varies widely in length and width, along with
the cervix overall. Flattened anterior to posterior, the
endocervical canal measures 7 to 8 mm at its widest
in reproductive-aged women.
D. Internal os
The endocervical canal terminates at the internal os
which is the opening of the cervix inside the uterine
cavity.
E. Cervical crypts
There are pockets in the lining of the cervix known
as cervical crypts. They function to produce cervical
fluid.
Cervical mucus
Mucus plug
After a menstrual period ends, the external os is
blocked by mucus that is thick and acidic. This
"infertile" mucus blocks spermatozoa from entering
the uterus. For several days around the time of
ovulation, "fertile" types of mucus are produced:
they have a higher water content, are less acidic,
and have a ferning pattern that helps guide
spermatozoa through the cervix. This ferning is a
branching pattern seen in the mucus when
observed with low magnification.
Some methods of fertility awareness involve
estimating a woman's periods of fertility and
infertility by observing changes in her body. Among
these changes are several involving the quality of
her cervical mucus: the sensation it causes at the
vulva, its elasticity (spinnbarkeit), its transparency,
and the presence of ferning.
Cervical position
After menstruation and directly under the influence
of estrogen, the cervix undergoes a series of
changes in position and texture. During most of the
menstrual cycle, the cervix remains firm, like the tip

of the nose, and is positioned low and closed.


However, as a woman approaches ovulation,
the cervix becomes softer, and rises and opens
in response to the high levels of estrogen
present at ovulation. These changes,
accompanied by the production of fertile types of
cervical mucus, support the survival and
movement of sperm.
Functionality
During menstruation the cervix stretches open
slightly to allow the endometrium to be shed.
This stretching is believed to be part of the
cramping pain that many women experience.
Evidence for this is given by the fact that some
women's cramps subside or disappear after
their first vaginal birth because the cervical
opening has widened.
During childbirth, contractions of the uterus will
dilate the cervix up to 10 cm in diameter to allow
the fetus to pass through.
During orgasm, the cervix convulses and the
external os dilates. Dr. R. Robin Baker and Dr.
Mark A. Bellis, both at the University of
Manchester, first proposed that this behavior
worked in such a way as to draw any semen in
the vagina into the uterus, increasing the
likelihood of conception. Later researchers, most
notably Elisabeth A. Lloyd, have questioned the
logic of this theory and the quality of the
experimental data used to back it.
Pathophysiology
risk factors for cervical cancer

trigger alterations in the cells of the cervix

mitosis rate accelerates

cell accumulates more DNA damage that makes it


capable of invading other tissues

leading to the development of cervical


intraepithelial neoplasia and cancer
Staging
Stage 0 - full-thickness involvement of the
epithelium without invasion into the stroma
(carcinoma in situ)
Stage I - limited to the cervix
IA - diagnosed only by microscopy; no visible
lesions
38

IA1 - stromal invasion less than 3 mm in depth


and 7 mm or less in horizontal spread
IA2 - stromal invasion between 3 and 5 mm with
horizontal spread of 7 mm or less
IB - visible lesion or a microscopic lesion with
more than 5 mm of depth or horizontal spread of
more than 7 mm
IB1 - visible lesion 4 cm or less in greatest
dimension
IB2 - visible lesion more than 4 cm
Stage II - invades beyond cervix
IIA - without parametrial invasion, but involve
upper 2/3 of vagina
IIB - with parametrial invasion
Stage III - extends to pelvic wall or lower third of the
vagina
IIIA - involves lower third of vagina
IIIB - extends to pelvic wall and/or causes
hydronephrosis or non-functioning kidney

Cancer of the Uterus (Uterine Cancer)


The uterus is part of a woman's reproductive
system. It is the hollow, pearshaped organ where a
baby grows. The uterus is in the pelvis between the
bladder a bladder and the rectum.
The narrow, lower portion of the uterus is the cervix.
The broad, middle part of the uterus is the body, or
corpus. The dome-shaped top of the uterus is the
fundus. The fallopian tubes extend from either side
of the top of the uterus to the ovaries.
The wall of the uterus has two layers of tissue. The
inner layer, or lining, is the endometrium. The outer
layer is muscle tissue called the myometrium.
In women of childbearing age, the lining of the
uterus grows and thickens each month to prepare
for pregnancy. If a woman does not become
pregnant, the thick, bloody lining flows out of the
body through the vagina. This flow is called
menstruation.
Fibroids are common benign tumors that grow in the
muscle of the uterus. They occur mainly in women
in their forties. Women may have many fibroids at
the same time. Fibroids do not develop into cancer.
As a woman reaches menopause, fibroids are likely
to become smaller, and sometimes they disappear.
Usually, fibroids cause no symptoms and need no
treatment. But depending on their size and location,
fibroids can cause bleeding, vaginal discharge, and
frequent urination. Women with these symptoms
should see a doctor. If fibroids cause heavy
bleeding, or if they press against nearby organs and
cause pain, the doctor may suggest surgery or other
treatment.

Endometriosis is another benign condition that


affects the uterus. It is most common in women
in their thirties and forties, especially in women
who have never been pregnant. It occurs when
endometrial tissue begins to grow on the outside
of the uterus and on nearby organs. This
condition may cause painful menstrual periods,
abnormal vaginal bleeding, and sometimes loss
of fertility (ability to get pregnant), but it does not
cause cancer. Women with endometriosis may
be treated with hormones or surgery.
Endometrial hyperplasia is an increase in the
number of cells in the lining of the uterus. It is
not cancer. Sometimes it develops into cancer.
Heavy menstrual periods, bleeding between
periods, and bleeding after menopause are
common symptoms of hyperplasia. It is most
common after age 40.
Laparoscopic Hysterectomy Procedure
To prevent endometrial hyperplasia from
developing into cancer, the doctor may
recommend surgery to remove the uterus
(hysterectomy) or treatment with hormones
(progesterone) and regular follow-up exams.
Malignant tumors are cancer. They are generally
more serious and may be life threatening.
Cancer cells can invade and damage nearby
tissues and organs. Also, cancer cells can break
away from a malignant tumor and enter the
bloodstream or lymphatic system. That is how
cancer cells spread from the original (primary)
tumor to form new tumors in other organs. The
spread of cancer is called metastasis.
When uterine cancer spreads (metastasizes)
outside the uterus, cancer cells are often found
in nearby lymph nodes, nerves, or blood
vessels. If the cancer has reached the lymph
nodes, cancer cells may have spread to other
lymph nodes and other organs, such as the
lungs, liver, and bones.
When cancer spreads from its original place to
another part of the body, the new tumor has the
same kind of abnormal cells and the same name
as the primary tumor. For example, if cancer of
the uterus spreads to the lungs, the cancer cells
in the lungs are actually uterine cancer cells.
The disease is metastatic uterine cancer, not
lung cancer. It is treated as uterine cancer, not
lung cancer. Doctors sometimes call the new
tumor "distant" disease.
The most common type of cancer of the uterus
begins in the lining (endometrium). It is called
39

endometrial cancer, uterine cancer, or cancer of the


uterus. In this booklet, we will use the terms uterine
cancer or cancer of the uterus to refer to cancer that
begins in the endometrium.
Risk factors:
Age. Cancer of the uterus occurs mostly in women
over age 50.
Endometrial hyperplasia. The risk of uterine cancer
is higher if a woman has endometrial hyperplasia.
This condition and its treatment are described
above.
Hormone replacement therapy (HRT). HRT is used
to control the symptoms of menopause, to prevent
osteoporosis (thinning of the bones), and to reduce
the risk of heart disease or stroke.
Women who use estrogen without progesterone
have an increased risk of uterine cancer. Long-term
use and large doses of estrogen seem to increase
this risk. Women who use a combination of estrogen
and progesterone have a lower risk of uterine
cancer than women who use estrogen alone. The
progesterone protects the uterus.
Women should discuss the benefits and risks of
HRT with their doctor. Also, having regular checkups
while taking HRT may improve the chance that the
doctor will find uterine cancer at an early stage, if it
does develop.
Obesity and related conditions. The body makes
some of its estrogen in fatty tissue. That's why
obese women are more likely than thin women to
have higher levels of estrogen in their bodies. High
levels of estrogen may be the reason that obese
women have an increased risk of developing uterine
cancer. The risk of this disease is also higher in
women with diabetes or high blood pressure
(conditions that occur in many obese women).
Tamoxifen. Women taking the drug tamoxifen to
prevent or treat breast cancer have an increased
risk of uterine cancer. This risk appears to be related
to the estrogen-like effect of this drug on the uterus.
Doctors monitor women taking tamoxifen for
possible signs or symptoms of uterine cancer.
The benefits of tamoxifen to treat breast cancer
outweigh the risk of developing other cancers. Still,
each woman is different. Any woman considering
taking tamoxifen should discuss with the doctor her
personal and family medical history and her
concerns.
Race. White women are more likely than AfricanAmerican women to get uterine cancer.
Colorectal cancer. Women who have had an
inherited form of colorectal cancer have a higher

risk of developing uterine cancer than other


women.
Other risk factors are related to how long a
woman's body is exposed to estrogen. Women
who have no children, begin menstruation at a
very young age, or enter menopause late in life
are exposed to estrogen longer and have a
higher risk.
Women with known risk factors and those who
are concerned about uterine cancer should ask
their doctor about the symptoms to watch for
and how often to have checkups. The doctor's
advice will be based on the woman's age,
medical history, and other factors.
Symptoms
Unusual vaginal bleeding or discharge
Difficult or painful urination
Pain during intercourse
Pain in the pelvic area
Diagnosis
Pelvic exam -- A woman has a pelvic exam to
check the vagina, uterus, bladder, and rectum.
The doctor feels these organs for any lumps or
changes in their shape or size. To see the upper
part of the vagina and the cervix, the doctor
inserts an instrument called a speculum into the
vagina.
Pap test -- The doctor collects cells from the
cervix and upper vagina. A medical laboratory
checks for abnormal cells. Although the Pap test
can detect cancer of the cervix, cells from inside
the uterus usually do not show up on a Pap test.
This is why the doctor collects samples of cells
from inside the uterus in a procedure called a
biopsy.
Transvaginal ultrasound -- The doctor inserts an
instrument into the vagina. The instrument aims
high-frequency sound waves at the uterus. The
pattern of the echoes they produce creates a
picture. If the endometrium looks too thick, the
doctor can do a biopsy.
Biopsy -- The doctor removes a sample of tissue
from the uterine lining. This usually can be done
in the doctor's office. In some cases, however, a
woman may need to have a dilation and
curettage (D&C). A D&C is usually done as
same-day surgery with anesthesia in a hospital.
A pathologist examines the tissue to check for
cancer cells, hyperplasia, and other conditions.
For a short time after the biopsy, some women
have cramps and vaginal bleeding.
40

These are the main features of each stage of the


disease:
Stage I -- The cancer is only in the body of the
uterus. It is not in the cervix.
Stage II -- The cancer has spread from the body of
the uterus to the cervix.
Stage III -- The cancer has spread outside the
uterus, but not outside the pelvis (and not to the
bladder or rectum). Lymph nodes in the pelvis may
contain cancer cells.
Stage IV -- The cancer has spread into the bladder
or rectum. Or it has spread beyond the pelvis to
other body parts.
Treatment
Surgery
Radiation Therapy
Hormonal Therapy
Side Effects of Surgery
may feel extremely tired
pain
nausea and vomiting
can no longer be pregnant
no menstrual periods
hot flashes and other symptoms of menopause
can affect sexual intimacy
Side Effects of Radiation Therapy
dry, reddened skin
hair loss in the treated area
loss of appetite
extreme tiredness
dryness, itching tightening and burning sensation in
the vagina
Diarrhea
frequent, uncomfortable urination
Side Effects of Hormonal Therapy
fluid retention
increased appetite
gain weight
menstruating women may have changes in their
period
LUNG CANCER
History
Lung cancer was extremely rare before the advent of
cigarette smoking; it was not even recognized as a
distinct disease until 1761. Different aspects of lung
cancer were described further in 1810 Malignant lung
tumors made up only 1% of all cancers seen at

autopsy in 1878, but had risen to 1015% by the


early 1900s. Case reports in the medical literature
numbered only 374 worldwide in 1912, but a
review of autopsies showed that the incidence of
lung cancer had increased from 0.3% in 1852 to
5.66% in 1952. In Germany, in 1929 physician
Fritz Lickint recognized the link between smoking
and lung cancer, which led to an aggressive antismoking campaign. The British Doctors Study,
published in the 1950s, was the first solid
epidemiological evidence of the link between lung
cancer and smoking. As a result, in 1964 the
Surgeon General of the United States
recommended that smokers should stop smoking.
The connection with radon gas was first
recognized among miners in the Ore Mountains
near Schneeberg, Saxony. Silver has been mined
there since 1470, and these mines are rich in
uranium, with accompanying radium and radon
gas. Miners developed a disproportionate amount
of lung disease, eventually recognized as lung
cancer in the 1870s and an estimated 75% of
former miners died from lung cancer. Despite this
discovery, mining continued into the 1950s due to
the USSR's demand for uranium.
I. DEFINITION
Lung cancer is a disease of uncontrolled cell
growth in tissues of the lung. This growth may lead
to metastasis, invasion of adjacent tissue and
infiltration beyond the lungs. The vast majority of
primary lung cancers are carcinomas of the
lung, derived from epithelial cells. Lung cancer,
the most common cause of cancer-related death
in men and the second most common in women,
is responsible for 1.3 million deaths worldwide
annually.
TWO TYPES OF LUNG CANCER:
Small cell lung cancer (SCLC also called "oat
cell carcinoma") -is less common. It tends to
arise in the larger airways (primary and
secondary bronchi) and grows rapidly, becoming
quite large. The "oat" cell contains dense
neurosecretory granules (vesicles containing
neuroendocrine hormones) which give this an
endocrine/paraneoplastic syndrome association.
While initially more sensitive to chemotherapy, it
ultimately carries a worse prognosis and is often
metastatic at presentation. Small cell lung
cancers are divided into Limited stage and
Extensive stage disease. This type of lung
cancer is strongly associated with smoking.
41

Non-small cell lung cancer (NSCLC) - The nonsmall cell lung carcinomas are grouped together
because their prognosis and management are
similar.
o Sub-types of non-small cell lung cancer:
Squamous cell lung carcinoma is more
centrally located and arises more commonly in
the segmental and subsegmental bronchi in
response to repetitive carcinogenic exposure.
Adenocarcinoma the most prevalent
carcinoma of the lung for both men and women.
It presents more peripherally as peripheral
masses or nodules and often metastasizes.
Bronchioloalveolar carcinoma arises from
terminal bronchus and alveoli and is usually
slower growing as compared to other
bronchogenic carcinoma.
Adenosquamous carcinoma
Papillary adenocarcinoma
Mucoepidermoid carcinoma
Adenoid cystic carcinoma and other
specified adenocarcinoma
Large
cell
carcinoma
also
called
undifferentiated carcinoma is a fast-growing
tumor that tends to arise peripherally.
Giant cell and spindle cell carcinoma and
other /unspecified non-small cell lung carcinoma
Bronchial carcinoids account for up to 5% of lung
cancers. These tumors are generally small (3-4 cm
or less) when diagnosed and occur most commonly
in people under 40 years of age. Unrelated to
cigarette smoking, carcinoid tumors can
metastasize, and a small proportion of these tumors
secrete hormone-like substances. Carcinoids
generally grow and spread more slowly than
bronchogenic cancers, and many are detected early
enough to be amenable to surgical resection.
Metastatic cancers The lung is a common place
for metastasis from tumors in other parts of the
body. These cancers are identified by the site of
origin, thus a breast cancer metastasis to the lung is
still known as breast cancer. They often have a
characteristic round appearance on chest x-ray.
Primary lung cancers themselves most commonly
metastasize to the adrenal glands, liver, brain, and
bone.
II.ANATOMY
Functions of the Respiratory System:
Gas exchange it allows oxygen from the air to
enter blood and carbon dioxide to leave the blood
and enter the air. The cardiovascular system

transports oxygen from the lungs to the cells of


the body and carbon dioxide from the cells of
the body to the lungs. The respiratory and
cardiovascular system work together to supply
oxygen to all cells and remove carbon dioxide.
Regulation of blood pH the respiratory system
can alter blood pH by changing blood carbon
dioxide levels.
Voice production air movement past the vocal
cords make sound and speech possible.
Olfaction the sensation of smell occurs when
airborne molecules are drawn into the nasal
cavity.
Innate immunity the respiratory system
provides
protection
against
some
microorganisms by preventing their entry into
the body and by removing them from respiratory
surfaces.
Processes of Respiration:
Ventilation or breathing-the movement of air into
and out of the lungs
Exchange of oxygen and carbon dioxide
between the air in the lungs and the blood
Transport of oxygen and carbon dioxide in the
blood
Exchange of oxygen and carbon dioxide
between the blood and the tissues.
The lungs are the body's major organs of
respiration. The two vital parts that make up the
lungs are located on each side of the chest within
the rib cage. They are separated by the heart and
other contents of the mediastinumthe tissues
and organs of the middle chest (e.g., the heart and
large vessels, windpipe, etc.). The lungs are
shaped rather like an upside-down butterfly. The
top, or apex, of each lung extends into the lowest
part of the neck, just above the level of the first rib.
The bottom, or base, of each lung extends down
to the diaphragm, which is the major breathingassociated muscle that separates the chest from
the abdominal cavity.
Each lung is divided into upper and lower lobes,
although the upper lobe of the right lung contains
another triangular subdivision known as the
middle lobe. The right lung is larger and heavier
than the left lung, which is somewhat smaller in
size because of the position of the heart. At birth,
the lungs are pinkish-white in color; however, with
age, the lungs darken to gray or mottled black
42

because of deposits of carbon and other particles that


are inhaled over the years.
The root connects the lungs to the heart and the
trachea (windpipe). Each root is made up of a main
stem bronchus (large air passage connecting the
windpipe to the right or left lungs), pulmonary artery
(major artery that brings oxygen-poor blood back to
the right or left lungs), pulmonary vein (major vein
receiving oxygen-rich blood from the lobes of the right
or left lungs), the bronchial arteries and veins, as well
as nerves and lymphatic vessels.
A clear, thin, shiny covering known as the serous coat,
or pleura, covers the lungs. The inner, visceral layer of
the pleura is attached to the lungs and the outer,
parietal layer is attached to the chest wall. Both layers
are held in place by a film of pleural fluid in a manner
similar to two microscope slides that are wet and stuck
together. Beneath the pleura is a layer of elastic fibers
that span the lung surface and extend down into its
subdivisions.
The trachea splits into right and left main stem
bronchi. The main stem bronchi are the major air
passages from the trachea to the lungs and are similar
to the trachea in tissue composition. The main stem
bronchi enter each lung and progressively branch off
into paired subdivisions throughout the entire organ
(the 'tracheobronchial tree').
The tracheobronchial tree serves to conduct, humidify,
and heat air that is breathed in, or inspired. At its
endpoints, the tracheobronchial tree connects with the
blood vessels. The lining of the tracheobronchial tree
is composed of columnar epithelium (column-shaped
surface cells) and glands that produce mucus and
serous (clear plasma) fluid. The cilia (hair-like
projections on columnar epithelium) move in a
constant, beating motion to cleanse the airways of
foreign bodies and infectious organisms. In normal
lungs, the cilia are covered by a watery 'mucous
blanket'a gel-like liquid that is moved by the cilia
and aids the lungs' self-cleaning. Lungs that have
been damaged by smoking or other toxic exposures
often have defective or missing cilia and show other
abnormalities in the tissue lining. Coughing triggers a
high-speed flow of air, which mobilizes the mucous
blanket. The sputum produced by such mobilization
contains mucus, nasal secretions, and saliva.
The essential tissue of the lunglung parenchyma
is made up of clusters of spongy air sacs called

lobules. There are about 130,000 primary lobules


in each lung. Each lobule is approximately 3.5
millimeters in diameter and contains about 2,200
alveoli (air sacs and ducts). Tracheobronchial
branches that are larger than 1 millimeter in
diameter and have connective tissue coverings
are called segmental bronchi.
The smallest subdivisions, which are less than 1
millimeter in diameter and do not have connective
tissue coverings, are called bronchioles. The final
branches of the bronchioles are called terminal
bronchioles. The bronchioles end in irregular,
swollen projections known as alveolar ducts
(terminal branches composed of special gasexchanging tissue) and alveolar sacs (blind
passage of an alveolar duct). The fluid that lines
the alveolar regions contains a detergent-like
substance known as surfactant, which reduces
surface tension within the alveoli and keeps them
from collapsing during breathing.
III. SIGNS AND SYMPTOMS (CLINICAL
MANIFESTATIONS)
dyspnea (shortness of breath)
hemoptysis (coughing up blood)
chronic coughing or change in regular coughing
pattern
wheezing
chest pain
cachexia (severe weight loss), weakness,
wasting fatigue, loss of appetite and anemia
dysphonia (hoarse voice)
clubbing of the fingernails (uncommon)
dysphagia (difficulty swallowing)
Risk Factors
Smoking
Cigarette smoking is known to be the cause of
most lung cancers. Lung cancer can also develop
in people who do not smoke, although this is much
rarer. The risk of developing lung cancer increases
with the number of cigarettes smoked, and if
people started smoking at a young age. Filtered
and low-tar cigarettes may slightly reduce a
persons risk of developing cancer, but the risk is
still far greater than that of a non-smoker.
Lung cancer has always been more common in
men, particularly those over 40, as more men
used to smoke than women. However, as more
women have started smoking, the number of
43

women developing lung cancer has gone up


considerably.

Stopping smoking
If a person stops smoking, the risk of lung cancer falls
quite quickly, and after about fifteen years, that
persons chances of developing the disease are
similar to those of a non-smoker.
Passive smoking
It now appears that breathing in other peoples
cigarette smoke, known as passive smoking, slightly
increases the risk of lung disease and cancer,
although the risk is still much less than if you smoke
yourself.
Cannabis
Smoking cannabis may also increase the risk of lung
cancer. Although less is known about the harmful
effects of smoking cannabis, it is believed to cause
similar damage to the cells in the lungs as smoking
tobacco.
Pipes and cigars
Although pipe and cigar smokers have a lower risk of
lung cancer than cigarette smokers, they are at a
much greater risk than non smokers.
Genetic risk
In some families, smokers may be more likely to
develop lung cancer due to inherited faulty genes. At
present, we do not know what these genes are.
Asbestos
People who have been in prolonged or close contact
with asbestos have a higher risk of lung cancer,
especially if they smoke. Asbestos and tobacco smoke
act together to increase the risk. Many people have
been in contact with asbestos during their working
lives. Low-level exposure increases the risk of lung
cancer only slightly, compared to the risk from
smoking, while heavy exposure may result in a much
higher risk of lung cancer. Asbestos exposure also
increases the risk of mesothelioma, a cancer of the
membranes which cover the lungs.
Radon gas
A naturally occurring gas called radon can pass from
the soil into the foundations of buildings. It is now

thought that this gas, in high concentrations, may


increase the risk of developing lung cancer.
Other causes
Contact with certain chemicals and substances
such as uranium, chromium and nickel can
cause lung cancer, but these are very rare causes.
Air pollution has been suggested as a cause of
lung cancer, but this is difficult to prove.
NOTE: Lung cancer is not infectious and
cannot be passed on to other people.
Complications
Lung cancer can cause complications, such as:
Fluid in the chest (pleural effusion). Lung
cancer can cause fluid to accumulate in the
space that surrounds the lungs in the chest
cavity (pleural space). Pleural effusion can result
from cancer spreading outside the lungs or in
reaction to lung cancer inside the lungs. Fluid
accumulating in the chest can cause shortness
of breath. Treatments are available to drain the
fluid from your chest and reduce the risk that
pleural effusion will occur again. Cancer that
spreads to the pleura is considered inoperable,
so surgery isn't an option for treatment.
Cancer that spreads to other parts of the
body (metastasis). Lung cancer often spreads
(metastasizes) to other parts of the body
most commonly the opposite lung, brain, bones,
liver and adrenal glands. Cancer that spreads
can cause signs and symptoms, including pain,
nausea, headaches or others based on what
organ is affected. In some cases, treatments are
available for isolated metastasis, but in most
cases, the goal of treatment for metastasis is
only to relieve signs and symptoms.
Death. Unfortunately, survival rates haven't
improved for people diagnosed with lung cancer.
In most cases, the disease is fatal. Almost 60%,
or three out of every five people, diagnosed with
lung cancer die within a year. Keep in mind,
however, that this number includes people
diagnosed with all types of lung cancer at all
stages of the disease. People diagnosed at the
earliest stages have the greatest chances for a
cure. Your doctor can discuss more relevant
statistics about your chances for survival with
you.
IV. PATHOPHYSIOLOGY
44

Exposure to carcinogens and risk factors such as:


Smoking, Stopping smoking, Passive smoking,
Cannabis, Pipes and cigars, Genetic risk, Asbestos,
Radon gas, other causes.

Initiated by activation of oncogenes or inactivation of


tumor suppressor genes.

Oncogenes are genes that are believed to make


people more susceptible to cancer. Proto-oncogenes
are believed to turn into oncogenes when exposed to
particular carcinogens. Mutations in the K-ras protooncogene are responsible for 2030% of non-small
cell lung cancers.

Chromosomal damage can lead to loss of


heterozygosity.

Inactivation of tumor suppressor genes.

Signs and symptoms manifested

Damage to chromosomes 3p, 5q, 13q and 17p are


particularly common in small cell lung carcinoma. The
TP53 tumor suppressor gene, located on
chromosome 17p, is often affected.

Several genetic polymorphisms are associated with


lung cancer. These include polymorphisms in genes
coding for interleukin-1, cytochrome P450, apoptosis
promoters such as caspase-8, and DNA repair
molecules such as XRCC1.

Lung cancer
V.DIAGNOSTIC PROCEDURES
CXR to search for pulmonary density, a solitary
peripheral nodule (coin lesion), atelectasis and
infection.
CT SCANS used to identify small nodules not
visualized on the CXR and also to examine serially
areas of the thoracic cage not clearly visible on the
CXR.
SPUTUM CYTOLOGY rarely used
FIBEROPTIC BRONCHOSCOPY more commonly
used and provides a detailed study of the
tracheobronchial tree and allows for brushings,
washings, and biopsies of suspicious areas.
Fine-needle aspiration may perform under CT or
fluoroscopic guidance to aspirate cells from a
suspicious area.

Endoscopy with esophageal ultrasound


(EUS) used to obtain a transesophageal
biopsy of enlarged subcarinal lymph nodes that
are not easily accessible by other means.
PTH (parathyroid hormone) Blood levels of
PTH or PTH-related protein may help to
distinguish lung cancer from cancer of the
pleura or other diseases.
CEA (carcinogenic antigen) a cancerspecific immune system protein that is present
in many adenocarcinomas, including lung
adenocarcinoma. Increased preoperative levels
of CEA usually suggest a poor prognosis. A CEA
level greater than 50 may indicate advanced
stage lung cancer and should discourage
treatment by resection.
CYFRA21-1 (cytokeratin fragment 19) a
protein marker of lung cancer.
Metastasis of the cancer can also be assessed by:
Bone scans
Abdominal scans
Positron emission tomography (PET) scan
Liver ultrasound or scans
MRI
Mediastinoscopy or mediastinotomy
VI. MANAGEMENT
a.NURSING INTERVENTION
Pre-operative:
1.consent
2.explain the procedure
3.provide oxygen therapy
4.IV and blood administration
5.administer pain medications
6.educate patient about coughing and deep
breathing exercises and early ambulation
7.Providing psychological support
Post-operative:
1.Relieving breathing problems- maintain
airway patency, O2 therapy (humidified O2
at 6L by cannula after extubation)
2.hemodynamic monitoring
3.positioning: flat on bed with head elevated
20 until V/S (BP) is stabilized
- semi-fowlers position with pillow under
head and neck
4.Reducing fatigue
5.V/S monitoring
6.Managing symptoms
45

- abdominal breathing
- pain relief comfort
- promoting nutrition
- initiate coughing and deep breathing
exercises
- monitor incision for bleeding or subcutaneous
emphysema
7.maintain chest tube drainage
Prevention
There's no sure way to prevent lung cancer, but you
can reduce your risk if you:
Don't smoke. If you've never smoked, don't start.
Talk to your children about not smoking, so they can
understand how to avoid this major risk factor for
lung cancer. Many current smokers began smoking
in their teens. Begin conversations about the
dangers of smoking with your children early, so they
know how to react to peer pressure.
Stop smoking. Stop smoking now. Quitting reduces
your risk of lung cancer, even if you've smoked for
years. Talk to your doctor about strategies and stopsmoking aids that can help you quit. Options include
nicotine replacement products, medications and
support groups.
Avoid secondhand smoke. If you live or work with
a smoker, urge him or her to quit. At the very least,
ask him or her to smoke outside. Avoid areas where
people smoke, such as bars and restaurants, and
seek out smoke-free options.
Test your home for radon. Have the radon levels
in your home checked, especially if you live in an
area where radon is known to be a problem. High
radon levels can be remedied to make your home
safer. For information on radon testing, contact your
local department of public health or a local chapter
of the American Lung Association.
Avoid carcinogens at work. Take precautions to
protect yourself from exposure to toxic chemicals at
work. In the United States, your employer must tell
you if you're exposed to dangerous chemicals in
your workplace. Follow your employer's precautions.
For instance, if you're given a face mask for
protection, always wear it. Ask your doctor what
more you can do to protect yourself at work. Your
risk of lung damage from these carcinogens
increases if you smoke.
Eat a diet full of fruits and vegetables. Choose a
healthy diet with a variety of fruits and vegetables.
Food sources of vitamins and nutrients are best.
Avoid taking large doses of vitamins in pill form, as
there may be unknown harms. For instance,

researchers hoping to reduce the risk of lung


cancer in heavy smokers gave them beta
carotene supplements. Results showed the
supplements actually increased the risk of
cancer in smokers.
Drink alcohol in moderation, if at all. Limit
yourself to one drink a day if you're a woman or
two drinks a day if you're a man. Anyone age 65
and older should drink no more than one drink a
day.
Exercise. Aim to achieve at least 30 minutes of
exercise on most days of the week. Check with
your doctor first if you aren't already exercising
regularly. Start out slowly and continue adding
more activity. Biking, swimming and walking are
good choices. Add exercise throughout your day
park farther away from work and walk the rest
of the way or take the stairs rather than the
elevator.
b.MEDICAL MANAGEMENT
SURGERY
Thoracotomy, the opening of the chest wall for
surgical procedures,
Median sternotomy, surgery performed by
cutting through the breastbone, are standard
methods used for lung cancer surgery.
Alternative approaches include:
Anterior
limited
thoractomy
(ALT),
thoractomy performed on the frontal chest
using a small incision. It is less invasive
than standard thoractomythat is, it
involves less disturbance of the body by
incisions or other intrusive measures. ALT
may result in less surgical blood loss, less
postoperative
drainage,
and
less
postoperative
pain
than
standard
thoracotomy.
Anterioraxillary
thoracotomy
(AAT),
thoracotomy performed on the frontal chest
near the underarm),
Posterolateral
thoracotomy
(PLT)
thoracotomy performed on the back/side
region of the trunk.
Other less invasive procedures for the removal
of tumorous tissue:
Video-assisted
thoracoscopy
(VAT),
otherwise known as video-assisted thoracic
surgery (VATS), uses a video camera to
help visualize and operate upon the lung
within the chest cavity. The surgical
46

incisions made during VAT are much smaller


than those needed for thoracotomy or
sternotomy. It is the most appropriate for Stage
1 and Stage 2 cancers that require lobectomy
(surgical removal of a lung lobule) with
lymphadenectomy (removal of one or more
lymph nodes) and for peripheral (outer edge)
lung tumors that can be removed by wedge
resection. In such cases, follow-up is required to
establish a long-term prognosis.
STAGING
People with non-small cell lung cancer are given
different types of treatment depending on the stage of
their cancer.
Stage 1 non-small cell lung cancer can often be
removed with surgery. If people have other medical
problems, or are not fit enough to have surgery,
radiotherapy may be given to the lung tumour instead.
Chemotherapy is sometimes used after surgery
(adjuvant chemotherapy), to reduce the risk of the
cancer coming back. Chemotherapy is also
sometimes given before surgery and/or radiotherapy.
This is called neo-adjuvant chemotherapy.
Occasionally radiofrequency ablation (RFA) may be
used. This is only likely to be suggested if other
treatments are not suitable for you. It is only available
at some cancer centres.
Stage 2 It may be possible to remove stage 2 nonsmall cell lung cancers with surgery. Radiotherapy
may be used for people who are not fit enough for, or
choose not to have, surgery. Chemotherapy is often
given following surgery or radiotherapy, to reduce the
risk of the cancer coming back.
Stage 3 non-small cell lung cancer can sometimes be
removed with surgery, although this is often not
possible because it may have spread too far.
Chemotherapy, either on its own or combined with
radiotherapy, may sometimes be given before an
operation (neo-adjuvant treatment). If surgery is not
possible, radiotherapy can be given instead.
Sometimes chemotherapy given on its own, or in
combination with radiotherapy, will be the only
treatment used.
Stage 4 If non-small cell lung cancer has spread to
other parts of the body, or is affecting more than one
lobe of the lung, radiotherapy may be used to shrink
the cancer and reduce symptoms. Sometimes
chemotherapy may be given before or after the
radiotherapy and may shrink the cancer and improve
well-being for some people. The aim is to control
symptoms and maintain a good quality of life for as

long as possible. Radiotherapy may also be very


effective in relieving symptoms such as pain.
Chemotherapy
The chart below lists the most commonly used
chemotherapeutic agents for the treatment of lung
cancer.
Brand Name
Generic Name
Platinol
Cisplatin
VP-16; VePesid
Etoposide
Paraplatin
Carboplatin
Taxol
Paclitaxel
Taxotere
Docetaxel
Navelbine
Vinorelbine tartrate
Adriamycin
Doxorubicin
Oncovin
Vincristine sulfate
Ifex
Ifosfamide
Gemzar
Gemcitabine
hydrochloride
Standard chemotherapy for lung cancer typically
consists of combinations of two or more of these
drugs. Such combination therapy has been shown
to improve the overall response to treatment. Wellknown drug pairings in combination therapy
include:
paclitaxel plus carboplatin
cisplatin plus vinorelbine tartrate
cisplatin plus VP-16, and
carboplatin plus VP-16.
Other chemotherapeutic agents that may be used
to treat lung cancer during clinical trials or
alternative programs are:
Brand Name
Generic Name
Neosar
Cyclophosphamide
Methotrexate
Methotrexate
CeeNu
Lomustine (CCNU)
Hycamtin
Topotecan.hydrochloride
Note: not all mentioned chemotherapeutic agents
are approved by the Food and Drug Administration
(FDA) for the treatment of lung cancer.
Anemia (low number of red blood cells) is a
frequent side effect of chemotherapy and may
cause symptoms such as extreme tiredness,
dizziness, or shortness of breath. Epoetin alfa
(Procrit, Epogen)a synthetic hormone that
stimulates red blood cell productionis a
prescription drug available for the treatment of
chemotherapy-related anemia.
47

Non-Small Cell Lung Carcinoma -Gemcitabine


hydrochloride (Gemzar) is a chemotherapeutic drug
that has unique activity against many solid tumors,
including non-small cell lung cancer (NSCLC).
Combination therapy with gemcitabine, cisplatin
(Platinol), and vinorelbine tartrate (Navelbine) has
been found to be safe and very active in persons with
advanced non-small cell lung cancer (NSCLC).
Tumors in such individuals often cannot be removed
by surgery (are unresectable), and so the patient may
not survive for even one year without therapy.
OPTION 1:
Combination chemotherapy with gemcitabine
(Gemzar), cisplatin (Platinol), and vinorelbine
tartrate (Navelbine)
The toxic side effects of combination chemotherapy
are manageable in most patients. They include
neutropenia (reduced number of granular white blood
cells) and thrombocytopenia (reduced number of
blood-clotting platelets).
Another treatment option for NSCLC patients with
advanced disease is alternating chemo-radiotherapy
(e.g., cisplatin and etoposide, followed by
radiotherapy):
OPTION 2:
Combination chemotherapy with etoposide (VP-16,
VePesid) and cisplatin (Platinol), also called "EC"
followed by 60 Gy chest radiation therapy plus
surgical resection of tumor or pneumonectomy (lung
removal) in cases of operable tumor
The toxic side effects of this program are leukopenia
(reduced number of white blood cells) and vomiting.
Chemotherapeutic programs alone have limited
activity against non-small cell lung cancer; however,
new "protective" drugs, cytotoxic (cell-killing) agents,
and radiotherapy techniqueseither alone or in
combinationare promising.
For example, the cell-protecting compound amifostine
(Ethyol; Alza Pharmaceuticals, Palo Alto, CA/US
Bioscience, West Conshohocken, PA) is being tested
for its defense of normal tissue against the toxic
effects of chemotherapy and radiotherapy. This, or
similar medication(s), may permit physicians to use
higher doses of chemotherapeutic agents (e.g.,

cisplatin, carboplatin, paclitaxel), thereby


improving therapeutic results, prognosis, and
survival.
Small Cell Lung Carcinoma (Limited-Stage)
-the following are standard treatment programs for
limited-stage small cell lung cancer (SCLC).
Combination chemotherapywith or without
prophylactic cranial (head) irradiation, or "PCI," for
patients who respond completelymay be
especially beneficial for those with impaired lung
function or poor performance status. Individuals
should be aware that PCI treatment may produce
a condition known as leukoencephalopathy or
leukodystrophy (degeneration of the brain tissue).
Leukoencephalopathy, which appears, on
average, roughly 1 year after irradiation, can
cause intellectual changes, memory alterations,
and motor (movement) abnormalities.
OPTION 1:
Combination chemotherapy with etoposide (VP16, VePesid) and cisplatin (Platinol), also
called "EC" plus 4,000-4,500 cGy chest
radiation therapy, with/without prophylactic
cranial irradiation (PCI).
OPTION 2:
Combination chemotherapy with etoposide (VP16, VePesid), cisplatin (Platinol), and
vincristine sulfate (Oncovin), also called "ECV"
plus 4,000-4,500 cGy chest radiation therapy,
with/without prophylactic cranial irradiation
(PCI).
OPTION 3:
Surgical resection (cutting away the tumor),
followed by combination chemotherapy plus
4,000-4,500 cGy chest radiation therapy,
with/without prophylactic cranial irradiation
(PCI).
A number of recent clinical trials have examined
the treatment of small cell lung cancer. Of late,
some of the most interesting approaches are
treatments with biological agents such as
monoclonal
antibodies
(immune
system
molecules) that are used alone or attached to a
toxin; new chemotherapeutic agents; new
radiation therapy schedules; new radiation
techniques (e.g., three-dimensional treatment
planning); and improved timing of chest radiation.
48

Preliminary findings suggest that biological agents, in


particular, may be active against SCLC; however,
additional time and testing are required.

Combination
chemotherapy
with
cyclophosphamide (Neosar), etoposide (VP16, VePesid), and vincristine sulfate
(Oncovin), also called "CEV".

Small Cell Lung Carcinoma (Extensive-Stage)


A standard treatment method for patients with
extensive-stage SCLC is combination chemotherapy,
with or without prophylactic cranial irradiation (PCI),
for individuals who respond entirely to such therapy.
Some commonplace optionswhich produce similar
survival ratesare:

OPTION 8:
Combination
chemotherapy
with
cyclophosphamide (Neosar), doxorubicin
(Adriamycin), etoposide (VP-16, VePesid),
and vincristine sulfate (Oncovin)
OPTION 9:
Combination
chemotherapy
with
cyclophosphamide (Neosar), doxorubicin
(Adriamycin), etoposide (VP-16, VePesid),
and vincristine sulfate (Oncovin)

OPTION 1:
Combination chemotherapy with cyclophosphamide
(Neosar), doxorubicin (Adriamycin), and
vincristine sulfate (Oncovin), also called "CAV,"
with/without prophylactic cranial irradiation (PCI).

OPTION 2:
Combination chemotherapy with cyclophosphamide
(Neosar), doxorubicin (Adriamycin), and
etoposide (VP-16, VePesid), also called "CAE,"
with/without prophylactic cranial irradiation (PCI).
OPTION 3:
Combination chemotherapy with etoposide (VP-16,
VePesid), and cisplatin (Platinol), or carboplatin
(Paraplatin), also called "EP" or "EC," with/without
prophylactic cranial irradiation (PCI).
OPTION 4:
Combination chemotherapy with ifosfamide (Ifex),
carboplatin (Paraplatin), and etoposide (VP-16,
VePesid), also called "ICE," with/without
prophylactic cranial irradiation (PCI)
Instead of these options, some physicians only use
etoposide (VP-16, VePesid) for chemotherapy in
extensive-stage patients. Other less common
combination chemotherapy programs include:
OPTION 5:
Combination chemotherapy with cyclophosphamide
(Neosar), methotrexate, and lomustine (CCNU,
CeeNU)
OPTION 6:
Combination chemotherapy with cyclophosphamide
(Neosar), methotrexate, lomustine (CCNU,
CeeNU), and vincristine sulfate (Oncovin)
OPTION 7:

Radiotherapy (radiation therapy) also may be


delivered to metastatic areas that are not
immediately destroyed by combination
treatment. In particular, radiation may be
directed at cancer metastases in the brain,
spinal column, and bones.

In contrast to people who have never received


chemotherapy,
patients
with
prior
chemotherapeutic histories often do not respond
as well to additional chemotherapy. Yet such
individualsif medically stablemay be
prescribed new agents that are available in clinical
trials. Paclitaxel (Taxol) and topotecan
hydrochloride (Hycamtin) are drugs that are
undergoing further evaluation in such studies.
Clinical trials normally provide for a change to
standard combination therapy if the patient does
not show a quick response to treatment.
In October 2007, the FDA approved Hycamtin
capsules for patients with relapsed small cell lung
carcinoma following chemotherapy. Side effects
of this drug, which is used at least 45 days after
the end of first-line chemotherapy, include bone
marrow
suppression
(neutropenia,
throbocytopenia, anemia), nausea, and diarrhea.
Targeted drug therapy
Targeted therapies are newer cancer treatments
that work by targeting specific abnormalities in
cancer cells. Targeted therapy options for treating
lung cancer include:
Bevacizumab (Avastin). Bevacizumab stops
a tumor from creating a new blood supply.
Blood vessels that connect to tumors can
49

supply oxygen and nutrients to the tumor, allowing


it to grow. Bevacizumab is usually used in
combination with chemotherapy and is approved
for advanced and recurrent non-small cell lung
cancer. Bevacizumab carries a risk of severe
bleeding.
Erlotinib (Tarceva). Erlotinib blocks chemicals
that signal the cancer cells to grow and divide.
Erlotinib is approved for people with advanced and
recurrent non-small cell lung cancer that haven't
been helped by chemotherapy. Erlotinib side
effects include a skin rash and diarrhea.
VII.

POSSIBLE NURSING DIAGNOSIS

Altered comfort: pain and dyspnea related to


enlarging tumor mass
Ineffective airway clearance related to pain,
weakness, excessive tracheobronchial secretion,
lower respiratory infection
Impaired gas exchange related to retained
secretion, pleural effusion or pneumonia
Altered nutrition: less than body requirements
related to pain, anorexia, weakness, or to effect of
chemotherapy and radiation
Grieving related to loss of personal control or
anticipated death

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