Oncology Nursing

 Same Pathophysio but different sites

 Principles during prelims are the same

Cancer
- Oncology Nursing
- No Oncology Nursing in the Philippines
- Other countries have oncology nursing
o For Chemotherapy Administration
o Certifications and Trainings
- From the form: Cancri or Crab-like
o It goes in any direction
o No specific direction of growth
 Ex. Lung cancer affecting the brain or liver
o Begins with an abnormal cell that is transformed by the genetic mutation of
cellular DNA
 All cancers are the result of mutations in oncogenes and tumor
suppressor genes
 Oncogenes – precursor for cancer cells
o A group of heterogeneous diseases that share common biologic properties
 The same but different areas of events
o Not a singles disease; disorder of altered cell differentiation and growth
 Breast cancer is not only in the breast
 Cell are transformed from one type of cell into another
 Ex. Stomach cells change shape from example square to circle or
triangle
 Anaplasia – change of one type of cell to another
 A precursor of malignant cells

NEOPLASM vs. TUMOR

Tumor – inflammation or swelling of the cell

Neoplasm – new growth in the tissues (cancer)

- Malignant Neoplasm number 3 in the malignant killers of the filipinos

Population in 2012 – 96.5 Million

People newly diagnosed with cancer
 98,200
Age Standardized rate, incidence per 100,000 people / year
 140.0

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FACTS of CANCER
1. Increasing mortality rate
2. A lot of Filipinos diagnosed with cancers than the westerners
a. Filipino tech is obsolete
b. Filipinos are used to having check-ups during the worst conditions already
3. In the Philippines, leading cancers are as follows:
a. Breast cancer
b. Lung cancer
c. Liver cancer
d. Colon cancer
e. Cervical cancer - Phi
f. Leukemia cancer
g. Stomach cancer
h. Prostate cancer
i. Brain / Nervous System cancer
j. Ovary cancer
4. Phils has highest Breast Cancer Incidence in the World
5. Feb 4: World Cancer Day

GROWTH PATTERNS
Cell Proliferation – cell division to form new cell types

BENIGN Growth Patterns

1. Hypertrophy – enlargement of the cells
a. ex. Muscles
 Why is there no Heart Cancer? Source?
2. Hyperplasia - increase in the number of cells
3. Metaplasia – transformation of cell from one form to another
a. Squamous cells become columnar cells
b. Reversible
4. Dysplasia – abnormal cellular growth
5. Anaplasia – permanent changes in both type and function

BENIGN vs. MALIGNANT

1. Differentiation – exaggerated growth
2. Growth –
a. Benign – slow and big
b. Malignant – small and fast and very dangerous
3. Invasion –
a. Benign – non-invasive, stays in place
b. Malignant – invades other organs, usually adjacent organs

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CANCER NOMENCLATURE
 OMA – suffix
o Presumption of having a cancer or preceding a cancer
i. Carcinoma – parenchymal cells or functional cells
ii. Sarcoma
1. Except: hepatoma (hepatocellular carcinoma), lymphoma,
melanoma, glioma – no BENIGN, always MALIGNANT

CELL CYCLE – reproduction of the cells

1. Mitosis – cellular division
2. Interphase – preparatory phase for cell division

4 PHASES IN ON ONCOLOGY NURSING

1. G1 – pre mitotic phase, metabolically active phase, cells are preparing for cellular
division
a. Restriction Check-point
b. Cells commit suicide if they are not perfect – apoptosis (if non-repairable)
c. p53 – protein or gene responsible for cellular suicide
d. Cells are repaired if possible before G1 phase
2. S-Phase – DNA Replication or the Synthesis Phase; opening-up of the DNA
3. G2 –
a. Checkpoint: Verification Check-Point
4. Mitotic Phase – cellular division
5. G0 – resting Phase

PERMANENT CELLS
1. Cardiac cells
2. Neurons cells

STABLE or LABILE CELLS

- Continuously dividing
- Skin and salivary cells
- Hair, nails
- Linings
- Liver cells – due to metabolic function

CELL CYCLE TIME

- Duration to undergo changes
- Doubling time – is the length of time it takes for a tumor to double its volume
- Tumor Growth
o 10 years - time span of cellular cancer
o Clinically evident – tool for approximating cellular cancer
o Exponential growth of cancer cells

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CARCINOGENESIS
_______ and derangement theory
a. The cells usually undergoing cellular transformation is removed through removal
of stimulus
b. Continuous stimulus deranges the cells
c. Transformation of the cells makes the cells abnormal
d. Slow transformation and change which are copied by the cells thus
“abnormalizes” the cells
2. Failure of the Immune Response Theory
a. The check points in the cell cycle are inactive
b. Copying of the abnormal cells due to failing of the immune system of the body

CARCINOGENESIS
1. 2 stage theory
2. 3 Stage theory
- Initiation > Start; irreversible mutation of a gene that leads to malignant transformation
- Promotion > Stage of duplication; Promoting agent stimulates the growth and division of a
cell; stimulation of the ONCOGENES
*- Progression > Start of cells building their own group
- Transformation > series of changes that lead to the characteristics of undifferentiated cell
- Metastasis > Tumor has properties needed to spread to other organs in the body

CARCINOGENESIS FACTORS
Host
 Female – more common to breast cancer due to change in estrogen
 Male – more common to lung cancer due to smoke
 Status of the Host – Socio-economic Status
 Life Style of the Host

Environmental Agents
 Chemical Agents
o Direct Acting –
 Ionizing radiation, light, cell phone, microwave, tanning beds, Cosmic
Waves, X-rays.
o Indirect Acting (Procarcinogens)
 Radiation
o UV Radiation (A,B,C)
 Chromosomal Damage in cells
 Skin Cancer
 UV-A Rays – strongest type of UV Radiation; Avobenzene – protects body
from UV-A, and automatically UV-B
o Inonizing Radiation
 X-Rays
 Gamma Rays

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  Industrial Sources
o Polyvinyl Chloride
o Cd, Cr
o Ni and Zn ores
 From the Work Place
o Coal tars and soot
o Dyes
o Asbestos
o Ar
o Wood dust
 Dietary Substances
o Alcohol
o Fats
o Nitrites and Nitrates
o Red Meat

Viruses, Bacteria, Parasites

 5 DNA Viruses
o Hepa-B, Hepa-C, HPV, Epstein-Barr Lymphoma, Human Herpes Virus – affecting
HIV Px, giving them Caphosis Sarcoma
 RNA Virus
 MALT – Mucosa Associated Lymphoid Tissue
 H. Pulori
 Schistosoma Hematobium
 Opisthorchis Viverrini – Liver Fluke

Normal Tissue
- Mitotic Division: New Cells = Old / Dying Cells
- Growth Pattern

Malignant Cells
1. Self Sufficiency in growth signals
a. Tumors possess the capability to proliferate without external stimuli
b. Proliferation of Oncogenes
2. Insensitivity to growth-inhibitory signals
a. Tumor suppressor genes

Categories of TSG
 Gate Keepers – controls the rate of proliferation
 Care Takers – ones responsible for controlling the mutation
o Tumor Suppressor Genes – EGF
3. Evasion of Apoptosis
a. Reproduction of abnormal cells due to the invasion of apoptosis
b. Abnormal Cells overcomes the p53

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4. Defects in the DNA Repair
a. Change in the DNA structure
b. No proper signals that limit and control reproduction
c. Check-points are not functional
5. Limitless Replication Potential
a. Uncontrolled reproduction
6. Sustained Angiogenesis (VEGF)
a. Continuation of angiogenesis
b. Number of cells go out of the containing area
7. Ability to invade and metastasize
a. Moving on to other areas

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CANCER TREATMENT MODALITIES

GOAL
1. Cure 2. Control 3. Palliate

1. Cure for Cancer

- Target: 100% cancer kill rate
- Total destruction or cancer kill rate
- Minimal amount of cancer cells in the body
- Person will always be at risk for cancer
- Recurrence of cancer: depends on the immune system
- Cancer may recur in another system or same site
- Chemotherapy targets the cancer cells
2. Control
- Reproduction will be controlled but not totally stopped
3. Palliate
- Management of the symptoms of cancer
- Maintain the quality of life of the Px
QUALITY OF LIFE (QoL) – dignity of the human person

4 DOMAINS OF THE PERSON

1. Psycho-Social Health -
2. Physical Health – body of the person
3. Spiritual Health – religion of the person
4. Mental or Cognitive Health

Comparison of Currently used PS Scales

PS Scales / Scores
ECOG or Zubrod Scale KPS
0 Asymptomatic and fully 100%
awake
1 Symptomatic, Fully awake, 80%-90%
ambulatory, restricted in
strenuous activity
2 Symptomatic, ambulatory, 60%-70%
capable of self-care, more
than 50% of waking hours are
spent out of bed
3 Symptomatic, limited self- 40%-50%
care, spends more than 50%
of time in bed, not bed ridden
4 Completely disabled, no self- 20%-30%
care, bedridden

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Karnofsky’s Performance Scale – KPS (100%-0%)
> The lower the scale, the higher the percentage of dying

ECOG (Eastern Cooperative Oncology Group):

> The higher the number, the higher the chance of dying

DETECTING, DIAGNOSING, AND TREATING CANCER

- Detecting:
> Self-Monitoring
> CAUTION (Acronym)
C – change in bowel or bladder habits
A – a sore that does not heal
U – unusual bleeding
T – thickening or lump
I – indigestion
O – obvious change in the size or color
N – nagging cough
-
U - unexplained
S (p/s) – pernicious anemia / sickle cell anemia
- Diagnosing:
> Biopsy – confirmatory diagnostic test for any cancer type; also used for staging cancer;
Stage 1 and Stage 4 – same
Stage 1 – can be operated upon
Stage 4 – cancer metastasis
> Magnetic Resonance Imaging – detailed supportive test;
> Computed Tomography (CT) – cross-sectional;
> X-ray – supportive only
> Ultrasonography
- Treatment:
> Surgery
> Chemotherapy
> Radiation Therapy
> Monoclonal antibodies – targeted therapies (specific for a cancer type, targets specific cells)
> Stem-Cell Therapy -
- New and Experimental:
> Gene Therapy – experimental; removes specific genes causing the cancer
> Bone Marrow and Stem Cell transplant
> Biological therapies
> Proteasome Inhibitors
> Anti-angiogenesis drugs
> Enzyme activators / blockers

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Model for Palliative Care

3 SPECIFIC GOALS
Cure, Control, Palliation

Oncology Team:
Oncologist – Cancer Doctor
Secondary Oncologist – Assisting Practitioner
General Practitioner (MD) – to detect any co-morbidity present
Oncology Nurse – cancer nursing practitioner
Pathologist – checks the removed part
Radiologist – supportive diagnosis and radiation therapy
Surgeon – for removal of cancer in invasive program
Anaesthetist -
Dietician / Nutrition Specialist -
Oncologic Pharmacist

STAGE 4 PATIENTS
1. Palliative Care
- Given at the start of the stage of cancer
- Patient is already dead
2. Cure and Control
- Becomes small as time progresses
- Hospice: a place for treating chronically ill person
- Limitation on the bereavement care – up until the patient dies
- Bereavement: <6 Months
- >6 Months: Patient will have depression

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TREATMENTS
1. Surgery – simplest and the fastest way to remove cancer
Purpose:
a. Cure – removal of tumor / mass
b. Control – remove marginal tissues or tissues adjacent or beside the mass
c. Palliative – remove tumor / mass blocking vital function
D. Diagnosing, Staging, and Grading
Stage – extent of the disease
Grading – type of the cells

1. Neo-Adjuvant – must have surgery first

2. Adjuvant

Type of radiation according to the area

L – Light
A – Amplification by
S – Stimulated
E – Emission of
R – Radiation

RADIATION – gamma-ray knife or cobalt

Cure – shrink or destroy tumor / mass

Control – decrease in marginal tissues
Palliative – shrink tumor or mass blocking vital functions
> Not used for diagnosis

Principle:
A - as
L - low
A - as
R - reasonably
A – achievable

4 R’s Radiation Principles

R – Repair – allows the body to be able to repair
R – Redistribution -
R – Repopulation – for cancer cells, the outside part of the cells are the active ones
R – Re-Oxygenation – for cancer cells, because the outside part of the tumor is the one active

> In cancer cells, the active ones are the ones outside because they have more nutrients or
receive more nutrients.

Ex. 6000 gy (grays) – removes the cancer but kills the patient

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> Fractionated Dose – portion of the total amount of dosage a patient can tolerate for the
radiation therapy

> Radiosensitive – the cancer cells are sensitive to radiation

> EBRT - External Beam Radio Therapy

> IBRT - Internal Beam Radio Therapy
> Has nurse
> Inserted in to the patient (particularly cervical cancer)
> Nurse uses LEAD APRON (protects the patient)
Dosimeter – measure the dosage of radiation
IBRT – uses lead gown and lead container (sealed and closed)
> Long pick-up forceps – for Sealed Sources
> Sealed Source – the medication that has radiation

Patient:
> Mild, not scented
> Do not rub dried area
> Etc.

FIND: NOMOGRAM by Duboir

Tele therapy

Side Effects of Radiation Therapy:

1. Redness of the skin
2. Skin irritation due to being exposed to radiation
a. Use mild, unscented soap
b. Rub the soap
c. Use lotion in light amounts
3. Fatigue
a. Radiation therapy uses up the energy of the body
4. Bone Marrow Suppression
a. Limited to adult patients
b. Stunted growth of the patient
c. Spongy Bone, Epificial Plate (Growth Plate)

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Chemotherapy
 Directly kills the cancer cells and the normal cells

Purposes
 Not used in palliative purposes
o Makes the patient weaker, using up energy of the patient
1. Primary – main therapy
2. Induction Chemotherapy – high doses (Loading Dose) and then lesser doses
3. Neoadjuvant – removes the part of the tumor prior to treatment; shrinks the cancer
tumor
4. Combination Chemotherapy
5. Adjuvant Therapy – after the primary treatment (surgery) to remove remaining cancer
cells, or as prophylaxis
6. Myeloblative Therapy (Myeloablation) – high dose chemo therapy (already given high
doses for successive therapy)

Factors to Consider
1. Patient Eligibility
2. Cancer cell type
a. The smaller the cancer the more dangerous
3. Rate of drug absorption
a. Dependent on the body mass
4. Tumor Location
a. Chemotherapy is not able to penetrate the blood brain barrier
5. Tumor Load
a. Amount of the tumor
6. Tumor Resistance
a. Resisting factor of the tumor

Routes: Regional Ommaya reservoir

 Topical – topoisomerase (skin cancer - has collecting chamber
 Intra-artery – most common - For pediatrics patients
 Intracavity – CSF - Brain cancer
 Intraperitonial - Lateral Ventricle – produces CSF
 Intrathecal - Blind surgery

Intravenous Routes
- Central Lines (connected to the Inferior or Superior Vena Cava
- Highly Vesicant Drugs (easily destroys the linings of the blood vessels)

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Preparation: BSC
BSC – Biohazard Safety Cabinet
- Has safety vents
Handling
- Must be in complete PPE

CLASSIFICATION
 Cell-cycle non specific
o Alkylatting Agent (MMEANT)
 Mustargens or Mustard Derivatives
 Metal Salts (~platine) – highly emetic drugs
 Ethyl Alkyllating Agents (Ethyl Amines)
 Alkyl Sulfonates
 Nitrosureas – can cross the Blood-Brain Barrier
 Thiazines
o
o Anti-tumor antibiotics
o Hormonal Agents

 Cell-Cycle Specific
o S-Phase = antimetabolics and Topoisomerase Inhibitors
o M-Phase = Mitotic Inhibitors (Vinca Alkaloids and Taxanes (~cristines)
o
 Miscellaneous

Alkylating Agents Common Side Effects

Suppress Bone

Highly Toxic

NADIR – count on WBC is at its owes

Tinca Alkaloids

CHEMOTHERAPY
SFANCH
S – stomatitis or mucositis (use water to clean)
F – Fatigue (due to systemic Chemotherapy effects)
A2 – Anorexia; Anxiety
N – Nausea (bland food, crackers)
C3 – Cardiovascular Changes, Cardio Toxicity, Constipation
H2 – Hairloss (women), Hyper Calcemia
Concern: Nausea and Vomiting
CINV – Chemotherapy Induces Nausea and Vomiting

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Anticipatory Acute Delayed
> 24 hours before therapy > Day 1- > Day 2-5
> Psychological Mechanism > Serotonin dependent > Substance P dependent
> Antiemetics ineffective mechanism (peripheral) mechanism (central)
> Behavioural therapy helpful

Breakthrough Chemotherapy Induces Nausea and Vomiting

- N/V despite chemotherapy

Refractory
- N/V in subsequence cycles of chemotherapy due to failure of the initial treatment

ANTI-Emetics Class (CINV) Example

5-HT3 Antagonist Odansetron
(serotonin dependents) Palonosetron
Granisetron
NK-1 receptor antagonist Aprepitant
(Substance P Dependent)
Centrally acting dopamine Metoclopramide
Domperidone

Behavioral (Attacks the CNS areas of the Brain)

Anticipatory, medulla is attacked thus inducing N/V
- 5-HT3

Motion Sickness (Ear balance, cerebellum)

- cerebellum not stimulated

Blood Borne Emetics (Chemoreceptor Trigger)

-5-HT3

GIT
-all GI contents will be expelled
- 5-HT3

 Dexamethasone – steroids prolong the activity of the 5-HT3 of the patient

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Chemotherapy Administration
Calculation of drug dosage

Mosteller Formula

Ex.
Doxorubicin hcl
Adriamycin PFS, Adriamycin RDF, Rubex
 Dosages (adult)
 60-75 mg/m2 IV as single dose q21D

Note: Dosages come in ranges. Get the higher dose of the medication

Average adult BSA: 1.73m2

Drug Dose for pediatrics: 17 y/o and 11 months

Note: Use only 1 decimal place BEFORE continuing with the formula.

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PREVENTION and DIAGNOSIS

Rx dose = BSA x Ordered (O)

75mg/m2 = 1.7 m2 x O
75/1.7 = O
O = 44.1

WITNESSES for PATIENTS

Living Wills =
DNR (Do not resuscitate) Forms = 24 hours only
DNI (Do not Intubate) Forms = 24 hours only

2 Types of Prevention
1. Primary – steps taken to prevent disease occurrence
2. Secondary – the early detection (at risk)
a. Must follow screening guidelines

Barriers in the Prevention

1. Fear of the Unknown
a. Most common Filipino attitude
2. Prejudice
a. Stereotyping
b. Opinion of other people
3. Financial Concerns
4. Lack of Knowledge
a. Cancer awareness month!
b. Be aware of the cancer month
5. Culture and Environment
a. Information on cancer
6. Equipment

July – UV Safety Month (cancer)

June – cancer survivor month

MAJOR PROMOTERS OF HEALTH

(Cancer Prevention)
> Healthy Diet
> Weight Management
> Exercise

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PRIMARY PREVENTION
> Fiber – 25 – 35g / day
> Top 10 Cancer Foods
- Cruciferous
> BMI (18.5-25 = N>)
Normal = 19.5 – 25
Overweight => 25 – 29.99
Obese = >30 – 35.99
Severely Obese = >36 – 39.99
Morbidly Obese = >40

5 S for SKIN CANCER – PREVENTING UV RAYS

S – Slip on Long sleeves
S – Slop on to skin anti UV
S – Shades and Hats
S – Seek trees and shadows
S – Slide on to Protective Eye Ware

Gardasil – 4 strains including cancer producing (Php 5K)

Cervariz – 2 strains only (genital warts) (Php 3K)

Test Cancer type Sex Age Frequency

Sigmoidoscopy Colon M,W 50+ Q3-5 years
Fecal occult blood test colon M,W 50+ Annually
Digital rectal exam Prostate, M,W 40+ Annually
colorectal
PSA blood test Prostate M 50+ Annually
(0.9 nanoG)
PAP test pelvic exam Cervical, Uterine, W 21-29 Annually For the
Ovarian Sexually active
or age 18+
Endometrial tissue Endometrial W At menopause
sample
Breast exam by Breast W 20-39; 40+
Physician
Mammogram Breast W 40; 40-49; 50+

Tumor Markers – protein excreted by the cancer cells / Supportive DX test / Monitoring Cancer
Progress Tx

CA – Cancer Antigen
CEA – CARCINO EMBRYONIC ANTIGEN – any organ
CA19-9 = GIT

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CA 27 -29 = more specific (breast cancer)
CA 15-3 =
PSA = Prostate Cancer
AFP = Alphafeto Protein (Amniotic fluid, blood)
HCG = Human Chorionic Gonadotropin – (testicular & ovatrian) – secretes
CA 125 – ovarian cancer – only at late stages
 Looks like PMS (Pre Menstrual Syndrome)
 If it happens in the right side, might look like Appendicitis
Thyroglobulin – thyroid or head and neck cancer
Beta2-Macroglubulin (B2M) – Multiple Myeloma

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Biopsy
– getting of a particular part of an organ
- Confirmative

Methods depends on;

1. Tumor Size
2. Type of anticipated Tx
3. Need for surgery and anesthesia

Types:
1. Excisional Biopsy – tissue sample
a. Fine Needle Aspiration Biopsy
b. Core Needle biopsy – bigger needle
c. Ultra-sound guided biopsy
d. Sentinel Lymph Node Biopsy
i. First lymph node that will receive BIOPSY
Lymph Nodes Only
2. Incisional Biopsy – adjacent to the tumor

Excisional – removal of the entire cell

CANCER GRADING
- Classification of cells
- The Broders Classification of a simple grading system
GRADE STAGE
1 Well I Localized
Differentiated
2 Moderately II Lymph Node
3 Highly III Involvement
4 Poorly IV Metastasis
Differentiated

TNM – Tumor Node Metastasis

TUMOR 0 1 2 3
NODE 0 1 2
METASTASIS 0 1 X

Autologous – self
Allogeneic – family members or relatives
Synergetic – twins

Myoblative or Abblative Chemotherapy – High Dosage Therapy

To ensure that there are no more cancer cells present

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