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Lewis: Medical-Surgical Nursing, 9th Edition

Chapter 16



 Cancer encompasses a broad range of diseases of multiple causes that can arise in
any cell of the body capable of evading regulatory controls of proliferation and
 Two major dysfunctions present in the process of cancer are (1) defective cell
proliferation (growth) and (2) defective cell differentiation.
 Cancer cells usually proliferate at the same rate of the normal cells of the tissue
from which they arise. However, cancer cells divide indiscriminately and haphazardly
and sometimes produce more than two cells at the time of mitosis.
 Through differentiation, cells become capable of performing only specific
o Proto-oncogenes are normal cell genes that regulate normal cell processes
to keep them in their mature, functioning state.
o When proto-oncogenes are mutated, they can begin to function as
oncogenes (tumor-inducing genes).
 Tumors can be classified as benign or malignant.
o Benign neoplasms are well-differentiated.
o Malignant neoplasms range from well-differentiated to undifferentiated.

Development of Cancer
 The stages of cancer include initiation, promotion, and progression.
o The first stage, initiation, is a mutation in the cell’s DNA genetic structure
following exposure to a chemical, radiation, or viral agent. The mutation may also
be inherited.
o Promotion, the second stage in the development of cancer, is characterized
by the reversible proliferation of the altered cells.
o Progression, the final stage, is characterized by increased growth rate of
the tumor, increased invasiveness, and spread of the cancer to a distant site
 Metastasis is a multistep process in which tumor cells travel to distant sites via
lymphatic and hematogenous routes. The most frequent sites of metastasis are lungs,
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Key Points 16-2

bone, brain, liver, and adrenal glands.

Role of the Immune System

 Since cancer cells arise from normal, human cells, the immune response that is
mounted against cancer cells may be inadequate to effectively destroy them.
 Cancer cells may display altered cell surface antigens, called tumor-associated
antigens, as a result of malignant transformation. Immunologic surveillance is the
response of the immune system to these antigens.
 The process by which cancer cells evade the immune system is termed
immunologic escape.
 Oncofetal antigens are a type of tumor antigen that can be used as tumor markers
that may be clinically useful to monitor the effect of therapy and indicate tumor

 Tumors can be classified according to anatomic site, histologic grading, and
extent of disease (staging).
 In the anatomic classification of tumors, the tumor is identified by the tissue of
origin, the anatomic site, and the behavior of the tumor (i.e., benign or malignant).
 In histologic grading of tumors, the appearance of cells and the degree of
differentiation are evaluated pathologically. For many tumor types, four grades are used
to evaluate abnormal cells based on the degree to which the cells resemble the tissue of
 The staging classification system is based on a description of the extent of the
disease rather than on cell appearance. Assignment is completed after the diagnostic
workup and determines treatment options.
o The clinical staging classification system uses five stages, from in situ to
o The TNM classification system uses three parameters: tumor size and
invasiveness (T), presence or absence of regional spread to the lymph nodes (N),
and metastasis to distant organ sites (M).


 You have an essential role in the prevention and early detection of cancer.
 As part of your goal related to public education, you need to motivate people to
recognize and modify behavior patterns that may negatively impact health, and to
encourage awareness and participation in health-promoting behaviors.


Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Key Points 16-3

 A diagnostic plan for the person in whom cancer is suspected includes health
history, identification of risk factors, physical examination, and specific diagnostic
studies (including radiographic and laboratory information).
o Diagnostic studies to be performed will depend on the suspected primary
or metastatic site(s) of the cancer.
o Diagnostic studies are used to determine the extent of the disease, tissue of
origin, and characteristics that may influence tumor behavior or treatment
decisions (e.g., receptor status).
o The biopsy procedure is the only definitive means of diagnosing cancer.
Various methods are used to obtain a biopsy depending on the location and size of
the suspected tumor.

 The goal of cancer treatment is cure, control, or palliation. A number of factors
determine the therapeutic approach taken.
o When cure is the goal, treatment is offered that is expected to have the
greatest chance of disease eradication and may involve local therapy (i.e., surgery
or radiation) alone or in combination with or without periods of adjunctive
systemic therapy (i.e., chemotherapy, biologic and targeted therapy).
o Control is the goal of the treatment plan for many cancers that cannot be
completely eradicated but are responsive to anticancer therapies and can be
maintained for long periods with therapy.
o With palliation, relief or control of symptoms and the maintenance of a
satisfactory quality of life are the primary goals rather than cure or control of the
disease process. With palliative treatment, there is an emphasis on minimizing
treatment-related toxicity to the greatest extent possible.
 Modalities for cancer treatment include surgery, chemotherapy, radiation therapy,
and biologic and targeted therapy.

 As primary prevention, surgery can be used to eliminate or reduce the risk of
cancer development in patients who have underlying conditions that increase their risk of
developing cancer (e.g., removing premalignant colon polyps).
 Consideration of surgical intervention involves assessment of tumor stage
(including local extension or metastasis that may limit the effectiveness of surgery), the
technical feasibility of surgical resection, comorbidities that may influence surgical risk,
and expected postoperative functional outcomes.
 The objective of surgery is to remove all or as much resectable tumor as possible
while sparing normal tissue.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Key Points 16-4

 The goal of chemotherapy is to eliminate or reduce the number of malignant cells
present in the primary tumor and metastatic tumor site(s).
 The two major categories of chemotherapy drugs are cell cycle phase–nonspecific
and cell cycle phase–specific drugs.
o Cell cycle phase–nonspecific drugs have their effect on the cells during all
phases of the cell cycle.
o Cell cycle phase–specific drugs exert their most significant effects during
specific phases of the cell cycle.
 Chemotherapy drugs are classified in general groups according to their molecular
structure and mechanisms of action.
 It is very important to know the specific guidelines for the safe preparation and
administration of chemotherapy drugs, since they may pose an occupational health
 Chemotherapy can be administered by multiple routes including oral or IV. The
most common is intravenous administration through central vascular access devices,
peripherally inserted central venous catheters, or implanted infusion ports. The use of
these means reduces the risk of extravasation.
 Increasingly chemotherapy may be self-administered orally by patients. Providing
instruction about proper medication handling and ensuring accurate dosing compliance
are important nursing considerations.
 Regional treatment with chemotherapy involves the delivery of the drug directly
to the tumor site. The most common methods are intraarterial, intraperitoneal, intravesical
bladder, and intrathecal or intraventricular.
 Chemotherapy-induced side effects are the result of the destruction of normal
cells, especially those that are rapidly proliferating such as those in the bone marrow,
lining of the gastrointestinal system, and the integumentary system (skin, hair, and nails).
 The general and drug-specific adverse effects of these drugs are classified as
acute, delayed, or chronic. Some side effects fall into more than one category. Late or
lasting effects can make a significant impact on survivorship.

 Radiation is the emission and distribution of energy through space or a material
 Simulation is a part of radiation treatment planning used to determine the optimal
treatment method by focusing on accurately localizing the tumor/target field and ensuring
set-up position reproducibility.
 Radiation is used to treat a carefully defined area of the body either by itself or in
combination with surgery or chemotherapy. It can also be used as palliative treatment for
symptom control in patients with metastatic disease.

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Key Points 16-5

 Teletherapy or external beam radiation (EBRT) is the most common form of

radiation treatment delivery and involves the delivery of ionizing radiation to kill cancer
cells. With this technique, the patient is exposed to radiation (typically high energy
photons) generated from a megavoltage treatment machine known as a linear accelerator
(or linac)
 Brachytherapy, or internal radiation treatment, consists of the implantation or
insertion of radioactive materials directly into the tumor/involved tissues (interstitial) or
in close proximity adjacent to the tumor (intracavitary or intraluminal).
 Implants may be permanently placed (such as implantation of radioactive seeds or
mesh) or temporary.
 Temporary seeds may be delivered through catheters to the target site for
specified amounts of time and then withdrawn (so the patient is not radioactive after the
procedure), typically with either low-dose rate (LDR) or high-dose rate (HDR)
 The principles of ALARA (as low as reasonably achievable) and time, distance,
and shielding are vital to health care professional safety when caring for a patient with a
source of internal radiation.


 Educating patients about their treatment regimen, supportive care options (e.g.,
antiemetics, antidiarrheals), and what to expect during the course of treatment are
important to help decrease fear and anxiety, encourage adherence, and guide self-
management at home.
 Nursing management of the patient encompasses interventions to counter the
effects of myelosuppression, thrombocytopenia, anemia, nausea and vomiting, anorexia,
stomatitis, diarrhea and constipation, mucositis, and skin reactions.
o Myelosuppression is one of the most common effects of chemotherapy
and, to a lesser extent, with radiation. It can result in life-threatening effects,
including infection and hemorrhage.
o Fatigue is a nearly universal symptom affecting 70% to 100% of patients
with cancer.
o The intestinal mucosa is one of the most sensitive tissues to radiation and
chemotherapy. These injuries result in diarrhea, mucositis, anorexia, nausea, and
o Nausea and vomiting are common sequelae of chemotherapy agents. Some
patients experience anticipatory or delayed nausea and vomiting.
 Both treatments have the potential to produce irreversible and progressive
pulmonary and cardiac toxicities.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Key Points 16-6

 As a nurse, you play a key role in assisting patients to cope with the
psychoemotional issues associated with receiving cancer treatment.


 Chemotherapy and radiation can produce long-term sequelae months to years
after the cessation of therapy that can affect every body system.
 The cancer survivor is at risk for developing secondary malignancies, such as
leukemia, angiosarcoma, and skin cancer. Because these risks are magnified by smoking,
counsel all patients to stop smoking.


 Biologic and targeted therapy can be effective alone or in combination with
surgery, radiation therapy, and chemotherapy.
 Biologic therapy consists of agents that modify the relationship between the host
and the tumor by altering the biologic response of the host to the tumor cells.
 Targeted therapy interferes with cancer growth by targeting specific cell receptors
and pathways that are important in tumor growth.
 Bone marrow depression and fatigue are associated with biologic therapy.
Capillary leak syndrome and pulmonary edema are usually acute or dose limited and may
require critical care nursing.
 Biologic testing can be used to identify whether specific targeted agents will be


 Colony-stimulating factors stimulate the production, maturation, regulation, and
activation of cells of the hematologic system.
 Erythropoiesis-stimulating agents should only be used when treating anemia
specifically caused by chemotherapy using the most recent administration guidelines.


 Hematopoietic stem cell transplantation is an effective, life-saving procedure for a
number of malignant and nonmalignant diseases.
 Hematopoietic stem cell transplants are categorized as allogeneic, syngeneic, or
o In allogeneic transplantation, stem cells are acquired from a donor who
has been determined to be human leukocyte antigen (HLA)–matched to the
o Syngeneic transplantation is a type of allogeneic transplant that involves
obtaining stem cells from one identical twin and infusing them into the other.

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Key Points 16-7

o In autologous transplantation, patients receive their own stem cells back

following myeloablative (destroying bone marrow) chemotherapy.
 Patients need to be prepared with a conditioning regimen prior to transplantation.
During this period when all bone marrow indices are low, it is critical for the patient to be
protected from exposure to infectious agents and supported with electrolyte supplements,
nutrition, and blood component transfusions.
 Common complications include infections and, in allogeneic transplants, graft-
versus-host disease.

 Gene therapy is an investigational treatment that involves using genetic material
to fight disease or replace missing genes to prevent the development of disease.
 In cancer care, some approaches assist the healthy cell’s ability to fight cancer;
others target cancer cells to destroy them or prevent their growth.


 Cancer patients may develop complications related to the continual growth and
the malignancy into normal tissue or to the side effects of treatment.
o Infection is the primary cause of death in a cancer patient.
o The patient with cancer may experience malnutrition, including protein
and nutrient deficiencies, electrolyte depletion, dehydration, weight loss, and
impaired wound healing.
 Oncologic emergencies can result from the cancer or cancer treatment. They are
classified as obstructive, metabolic, or infiltrative. These commonly include superior
vena cava syndrome, spinal cord compression, syndrome of inappropriate antidiuretic
hormone secretion, hypercalcemia, tumor lysis syndrome, disseminated intravascular
coagulopathy, and cardiac tamponade.


 Moderate to severe pain occurs in approximately 50% of patients who are
receiving active treatment for their cancer and in 80% to 90% of patients with advanced
 It is essential to perform a comprehensive pain assessment on an ongoing basis
and to enact a pain management plan that addresses both components of pain if they are

 As a nurse, you are in a key position to assess the patient’s and family’s responses
and support positive coping strategies. Your nursing care can facilitate the development

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Key Points 16-8

of a hopeful attitude about cancer and support the patient and the family during the
various stages of the process of cancer.
 Adaptation and coping with a cancer diagnosis may be influenced by a variety of
patient factors including demographic factors, prior coping strategies, social support, and
religious and spiritual beliefs. Assess the psychosocial concerns and emotional responses
of patients and their families so you can connect patients with appropriate supportive care

 Cancer survivors experience a variety of long-term and late sequelae following
treatment, including a greater risk of functional impairment, noncancer-related death and
comorbidities, including heart disease, diabetes, osteoporosis, and others.
 The impact of a cancer diagnosis can affect many aspects of life, with survivors
commonly reporting financial, vocational, marital, and emotional concerns long after
treatment is over.
 The psychosocial effects can play a profound role in a patient’s life after cancer,
with issues related to living in uncertainty being frequently encountered.


 Underserved populations are at risk for late-stage disease at time of diagnosis.
 Nurses need to know how to assess for cultural differences, identify barriers to
care, and adapt care to meet specific cultural needs.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.