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ONCOLOGY NURSING
JOANNE MARIE S. GARCIA, RN, MAN
https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

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Oncology defined
• Branch of medicine that deals

with the study, detection,
treatment and management of
cancer and neoplasia

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Cancer
• A disease resulting from the

uncontrolled growth of cells,
which causes malignant cellular
tumors.

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STATISTICAL BACKGROUND ON
MORBIDITY AND MORTALITY RATES
• In the Philippines, cancer ranks third
in leading causes of morbidity and
mortality after communicable
diseases and cardiovascular diseases
• In the Philippines, 75% of all
cancers occur after age 50 years,
and only about 3% occur at age 14
years and below

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•If the current low cancer
prevention consciousness persists,
it is estimated that for every 1800
Filipinos, one will develop cancer
annually
•most Filipino cancer patients seek
medical advice only when
symptomatic or at advanced stages:
for every two new cancer cases
diagnosed annually, one will die
within the year

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• The top cancer sites in the Philippines
include those cancers whose major causes
are known (where action can therefore be
taken for primary prevention), such as
cancers of the lung/larynx (anti-smoking
campaign), liver (vaccination against
hepatitis B virus), cervix (safe sex) and
colon/rectum/stomach (healthy diet).
Except for the liver, the top Philippine
cancer sites are also the top cancers
worldwide

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Cancer Yearly Morbidity & Mortality by
Sex & Site

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What Is a Tumor?
• A tumor is an abnormal lump or

growth of cells. When the cells in
the tumor are normal, it is
benign.

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Definition of Benign Tumors:
• Noncancerous. If the cells are

not cancerous, the tumor is
benign. It won't invade nearby
tissues or spread to other areasof the
body (metastasize)Benign
tumors usually don't recur once
removed, but if they do
it is usuallyin the same place.

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Definition of Malignant Tumors:
Cancerous
• A malignant tumor (cancerous
tumor) is one that is invasive and
can spread to other parts of the
body.

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Comparison of Benign & Malignant Tumors
Characteristic Benign malignant

Cell characteristic Well differentiated Undifferentiated little
Resemble normal cells resemblance on normal
cells
Local Invasion Grows by expansion Grows at the periphery,
Not infiltrate the infiltrate and destroys
surrounding tissue the surrounding tissue
Rate of growth Slow, may come to a Erratic & may be slow to

standstill or regress rapid, fast
Metastasis absent Access to blood,
lymphatics and other
areas

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Benign Malignant
General localized Anemia, weakness, weight loss

effects
Tissue No tissue damage Extensive tissue damage

destructio
n
Ability to Does not usually cause Usually causes death
cause death
death

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well-differentiated

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poorly-differentiated

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Proliferative Growth Patterns
• Cell proliferation
• is the process by which cells divide &
reproduce . In normal tissue, cell
proliferation is regulated so that the
number of cells actively dividing is
equal to the number of cells dying or
being shed. Abnormal cell
differentiation & growth results in an
abnormal mass of tissue, called
NEOPLASM

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• NEOPLASIA means “new growth” &
refers to an abnormal mass of tissue
characterized by autonomous , excessive
& uncoordinated growth.
• Although they are not synonymous, the
terms neoplasm & tumor are often used
interchangeably . Neoplasms are
classified as BENIGN OR
MALIGNANT.
• Cancer is the common term for all
malignant tumors

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Benign Growth Patterns
1. Hypertrophy
2. Hyperplasia
3. Metaplasia
• Ex. Metaplasia
• substitution of columnar epithelial cells of the
respiratory tract by squamous epithelial cells in
response to inhaled irritants such as cigarette
smoke. The process is reversible if the stimulus is
removed or metaplasia may prgress to dysplasia
if the stimulus persists.

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4. Dysplasia
• reversible if stimulus is removed.
• Dysplasia often precedes a tissue’s
becoming cancerous, & some forms
of dysplasia are as pre-cancerous
lesions”

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COMMON TERMINOLOGIES
1. Oncogene – cancer genes that alter

normal genes
2. Proto-oncogenes – a normal gene
w/c when altered by mutation ,
becomes an oncogene. It regulates
programmed cell death (
apoptosis)

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3. Anaplasia – no resemblance to
tissues of origin
4. Mutation – occurs when a DNA gene
is damaged or changed as to alter the
genetic message carried by that gene.
5. Mutagen – is an agent of substance
that can bring about a permanent
alteration to the physical composition
of a DNA gene such that the genetic
message is changes

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“Root words”
•Neo- new
•Plasia- growth
•Plasm- substance
•Trophy- size
•+Oma- tumor
•Statis- location

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“Root words”
• A- none
• Ana- lack
• Hyper- excessive
• Meta- change
• Dys- bad, deranged

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TUMOR GROWTH
• The rate of tissue growth in normal &

cancerous tissue depends on three
factors:
1. The duration of the cell cycle
2. The number of cells that are actively
dividing
3. Cell loss

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Pathophysiology
• Cancer characterized by
neoplasms, abnormal growth of
new tissue.
• Neoplasms can be benign (not
progressive, and thus, favorable
for recovery) or malignant
(becoming progressively worse
and often resulting in death).

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Neoplasia
Uncontrolled growth of Abnormal
cells
• 1. Benign
• 2. Malignant
• 3. Borderline

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Characteristics of Neoplasia
• BENIGN
• Well-differentiated
• Slow growth
• Encapsulated
• Non-invasive
• Does NOT metastasize

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Characteristics of Neoplasia
• MALIGNANT
• Undifferentiated
• Erratic and Uncontrolled Growth
• Expansive and Invasive
• Secretes abnormal proteins
• METASTASIZES

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Nomenclature of Neoplasia
Tumor is named according to:

1. Parenchyma, Organ or Cell
• Hepatoma- liver
• Osteoma- bone
• Myoma- muscle

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• Carcinoma – originates in the epithileal
tissue ex. Skin & lining of body tissue
(squamous cell Ca – surface epithelium)
• Adenocarcinoma – originates in
glandular tissue like in the breast &
prostate gland
• Sarcoma – originates in connective &
supportive tissue like in the bone &
nerves..

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• Embryonal – originates in
embryonic tissue
• Lymphomas – originates n the
lymphatic system
• Leukemia – originates in the blood
forming organs ( RBC< WBC, bone
marrow) ( more on WBC)

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Nomenclature of Neoplasia
Tumor is named according to:

2. Pattern and Structure, either
GROSS or MICROSCOPIC
• Fluid-filled CYST
• Glandular ADENO
• Finger-like PAPILLO
• Stalk POLYP

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NOMENCLATURE BENIGN TUMORS
• Suffix- “OMA” is used
• Adipose tissue- LipOMA
• Bone- osteOMA
• Muscle- myOMA
• Blood vessels- angiOMA
• Fibrous tissue- fibrOMA

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MALIGNANT TUMOR
NOMENCLATURE
1. Glandular, Epithelial
• Use the suffix- “CARCINOMA”
• Pancreatic AdenoCarcinoma
• Squamos cell Carcinoma

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MALIGNANT TUMOR
2. connective tissue origin
• Use the suffix “SARCOMA
• FibroSarcoma
• Myosarcoma
• AngioSarcoma

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“PASAWAY”
1. “OMA” but Malignant
– HepatOMA, lymphOMA, gliOMA,
melanOMA
2. THREE germ layers
– “TERATOMA”
3. Non-neoplastic but “OMA”
– Choristoma
– Hematoma

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REVIEW OF NORMAL CELL CYCLE

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3 types of cells
1. PERMANENT cells- out of the cell cycle
• Neurons, cardiac muscle cell
2. STABLE cells- Dormant/Resting (G0)
• Liver, kidney
3. LABILE cells- continuously dividing
• GIT cells, Skin, endometrium , Blood
cells

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Cell Cycle
- Is the coordinated sequence of events
resulting in duplication of the DNA &
division into 2 daughter cells. The 4
Phases of the cell cycle are:
1. G1 or Gap1– lasts from hours to days

or longer, RNA and protein synthesis
occurs in preparation for DNA
replication.

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2. S or Synthesis – lasts approximately 10 to 20
hours, DNA synthesis occurs in preparation for
division.
3. G2 or Gap2 – lasts 2 to 10 hours;DNA replication
ceases while RNA replication continues;
Premitotic phase
4. M or Mitosis –30 to 60 mins; cell division occurs;
G0 – resting phase, the cells perform all functions
other than those related to proliferation

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• M Phase is further subdivided into 5 stages:
• Prophase
• Prometaphase
• Metaphase
• Anaphase
• Telophase
• = after mitosis, the daughter cells enter the
G1 phase & begin the cell reproductive
cycle again or redirect themselves into a
resting phase G0

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CELL CYCLE VIDEO –
AMOEBA SISTERS

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Cell cycle time
= is the time required for one tissue cell to

divide and reproduce two identical
daughter cells
• Doubling time

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• It may take 10 years for a tumor to reach 1 cm in size.
In only another year , that same tumor may grow to 8
cm.Factors that affect doubling time are cell cycle time,
growth fraction, & cell loss by either cell death ,
differentiation or metastasis.
• A tumor is usually clinically undetectable until it has
doubled 30 times & contain more tham 1 billion cells.
At this point, it is approximately 1 cm in size & equals 1
gm in weight. With only 10 more doublings , the tumor
contains more than 1 trillion cells or weighs 1 kg which
is enough to cause DEATH.

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SUMMING IT ALL UP BY PROF DAVE

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ETIOLOGY OF CANCER

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ETIOLOGY OF CANCER
1. PHYSICAL AGENTS
• Radiation
• Exposure to irritants
• Exposure to sunlight
• Altitude, humidity

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ETIOLOGY OF CANCER
2. CHEMICAL AGENTS
• Smoking
• Dietary ingredients
• Drugs

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ETIOLOGY OF CANCER
3. Genetics and Family History

• Colon Cancer
• Premenopausal breast cancer

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ETIOLOGY OF CANCER
4. Dietary Habits
● Low-Fiber
● High-fat
● Processed foods
● Alcohol

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ETIOLOGY OF CANCER
5. Viruses and Bacteria

• DNA viruses- Hep, Herpes, EBV,
CMV, Papilloma Virus
• RNA Viruses- HIV, HTLCV
• Bacterium- H. pylori

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ETIOLOGY OF CANCER
6. Hormonal agents
• OCP especially estrogen
• DES
• HRT

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ETIOLOGY OF CANCER
7. Immune Disease
• AIDS

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CARCINOGENESIS

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Carcinogenic Factors
• 1. Heredity
• 2. Hormonal Factors
• 3. Environmental Agents
– = Urban vs. Rural
– = Geographic Distribution

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• 4. Radiation
• 5. Oncogenic Virus
• 6. Bacteria & Parasites
• 7. Immune System Deficiencies
• 8. Age – older individuals are prone to cancer
• 9. Occupation
• 10. Stress
11. Precancerous lesions
- Pigmented moles, burn scars, benign polyps, adenoma,
fibrocystic disease of the breast
12. Obesity

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1. Heredity
Oncogenes ( hidden/repressed genetic code
for Ca that exist in all individuals
2. Hormones
Oral contraception or HRT, Inc. incidence of
hepatocellular, endometrial and breast Ca

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3. Environmental Factors
A. Viral carcinogens
• Oncogenic viruses
• Epstein Bar virus, burkitt’s lymphoma,
nasopharyngeal Ca, non-Hodgkin and hodgkin’s
lymphoma; Hepa B v.
• Herpes simplex Type II, cytomegalovirus and HPV
type 16,18,31,33, = Cervix Ca
• HIV = kaposi sarcoma
• H. pylori = gastric Ca

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B. Physical carcinogen
- Ultraviolent radiation, especially in fair
skinned blue or green eyed people, ( causes
skin Ca)
- Ex. Sun, tanning beds,germicidal lights
- Radiation from x-ray or nuclear machines (
dx & therapeutic x-rays)

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C. Chemical Agents
- 75% related to environment
- Tobacco smoking, single most lethal
carcinogen, 30% of Ca deaths, lung, head
and neck esophagus, bladder pancreas,
cervix ca
- chewing tobacco, ca of the oral cavity in
men younger than 40 years old

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4. Industrial compounds
- Vinyl chloride (plastics, asbestos)
- Polycyclic aromatic hydrocarbons (burning,
auto and truck emission)
- Fertilizers and weed killers
- Dyes, (analine dyes, hair dyes)

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4. Dietary Factors
- Carcinogenic
high fat low fiber diet,high animal fat intake,
alcohol, salt cured or smoked meats, high
caloric content, processed foods; preservatives,
contaminants, additives & nitrates
- Proactive
high fiber, Cruciferous vegetables ( cabbage,
broccoli, cauliflower, brussels, sprouts)
Carotenoids (carrots, tomatoes, spinach,
apricots, peaches, dark green and yellow
vegetables), vit E, C, zinc and selenium

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5. Genetics
6. Age: Advancing age is a significant risk
factor
7. Immune Function:
a. Immunosuppressed individuals more
susceptible to cancer ( ex. Organ transplant
recipients taking immunosuppressive
medication; AIDS)

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Carcinogenesis
• 1. Initiation
- first step, chemicals, physical factors
and biologic agents, escape the
normal enzymatic mechanisms and
alter the genetic structure of the
cellular DNA
- normally these alterations are
reversed by DNA repair mechanism
or programmed cellular suicide
(apoptosis)

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• 2. Promotion
- Repeated exposure
- Causes expression of abnormal or mutant
genetic information
- Proto-oncogenes, “on switch”
- Ca suppressor genes, “turn off”
- P53 gene, a tumor suppressor gene
regulates whether cells repair or die after
DNA is damaged

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CARCINOGEN
INITIATION
DNA repair
Bind to DNA
Normal Cell
Permanent DNA damage Cell Death
Cell Proliferation
PROMOTION
NEOPLASTIC CELLS

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• 3. Progression
- Third step of cellular carcinogenesis
- The cellular changes formed during
initiation and promotion now exhibit
increased malignant behavior

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What Do These Factors Have In
Common?
Fragments
Direct Damage & Deletions
To DNA
(e.g., CANCER
radiation)
Chemical Base Mutations
Mutagens & Substitutions
(e.g.,
pollutants, Membrane damage
additives,drugs causing internal mutagens
and hormones) Miscellaneous to form
Mutagens (dietary
fat and free radicals)

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Immune response
• T lymphocytes = recognize tumor associated
antigens, possesses cytotoxic abilities
• Lymphokines= capable of killing and damaging
Ca cells
• Macrophages = disrupt Ca cells
• B lymphocytes antibodies = defends the body
against malignant cells
• Natural killer cells = directly destroy Ca

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ROUTES OF TUMOR SPREAD
Tumor spread throughout the body can occur

by direct extension or local invasion of
adjacent organs, metastases by
implantation or serosal seeding, &
metastases to distant organs by the lymph
or circulatory system.
Factors affecting tumor spread:
1. rate of cell growth
2. degree of differentiation
3. location

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Metastatic Process
1. Local invasion – is the first step in metastatic process &
may occur as a function of direct tumor extension.
Mechanism important in local invasion includes:
A. Tumor growth
B. Mechanical pressure
C. Tumor-secreted enzymes
D. Decreased cellular adhesion
E. Increased motility
** Serosal seeding occurs when tumors, which have
invaded a body cavity from surrounding tissue, attach
to the surface of an organ within the cavity. (most often
the peritoneal cavity)

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Metastasis
• - is the spread of cancer cells from a primary tumor to

organs & distant sites in the body
• 1. Lymphatics
= the most common route
Ex. breast tumors, axillary, clavicular, and thoracic LN
Metastatic Cascade:
• Growth & progression of the primary tumor
- rapid growth of the primary tumor. Most tumors must reach 1
billion cells or 1 cm in size before metastasis is possible

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• 2. Angiogenesis at the primary site – extensive vascularization is
necessary for the tumor to exceed 1 mm in diameter. The release of
angiogenic factors by tumor cells is necessary to stimulate new
capillary formation. The growth of the tumor & the rate of spread
are correlated with tumor vascularity.
• 3. Local Invasion – to reach blood vessels or lymphatics, tumor cells
must break down the tissue stroma & the basment membrane
• 4. Detachment & Embolization – millions of cells are shed into the
circulation daily from locally invasive cancer, but fewer than 0.01%
successfully survive to grow into a metastatic lesion. Once into the
circulation, tumor cells are vulnerable to destruction by the host
immune cells.

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• 5. Arrest in distant organ capillary beds –
• 6. Extravasation –
• 7. Proliferation -

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PREVENTION, SCREENING &
DETECTION

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Cancer Diagnosis & Staging
• Diagnosis:
1. Tumor Markers –
a. Prostate Specific Antigen (PSA) can be found in prostate cancer
b. S-100 – can be found in melanoma cells
c. Thyroglobulin – protein made by the thyroid gland
d. Estrogen & Progesterone Receptors – elevated in breast CA
e. CA 15-3 & CA 27-29 – specific test for breast Ca
f. Carcinoembryonic Antigen ( CEA) & CA 19-9 – elevated in colorectal
cancer , condidered “golden standard” tumor marker for colorectal
Ca

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• G. CA-125 -elevated in women with epithelial ovarian
cancer ( most common ovarian cancer )
• H. Human Chorionic Gonadotropin ( HCG) & Alpha-
Fetoprotein (AFP) – ovarian & testicular cancer
• I. Beta-2-Microglobulin (B2M) – elevated in persons with
multiple myeloma, chronic lymphocytic leukemia (CLL) &
some lymphomas as well as some types of kidney disease
• J. HER-2/neu - elevated in breast cancer. Used to predict
response to therapy
• K. CHROMOGRANIN A (CgA) – produced by
neuroendocrine tumors including carcinoid, neuroblastoma
& small cell lung cancers. It is the most sensitive tumor
markar for carcinoid tumors.

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Cancers in which markers
Tumor Markers maybe found
• 1. Carcinoembryonic Antigen • 1. Colon – rectal; breast; lungs
• CEA)
• 2. Alfa-feto protein ( AFP) • 2. Testicular; liver; lungs,
gastric; pancreatic; colon
• 3. Prostatic Acid Phosphatse
• 3. Metastatic prostate
• (PAP)
• 4. primary & metastatic prostate
• 4. Prostate – specific Antigen
• (PSA)
• 5. Ovarian cancer
• 5. Cancer Antigen 125 ( CA)
• 6. Pancreatic
• 6. Pancreatic Oncofetal
• 7. Medullary cancer of the
Antigen
thyroid
• 7. Calcitonin
• 8. throphoblastic tumor, germ
• 8. HCG cell; overy

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• BRCa1- large gene located on chromosome 17 . BRCA1
may be responsible for as much as 90% of hereditary
breast & ovarian cancer. Persons carrying a BRCA1
mutation have up to 85% lifetime risk of developing breast
cancer, compared to a 12% risk in the general population ,
& a 40% lifetime risk of developing ovarian cancer
compared to 2% risk in the general population.
• BRCA2 – is a tumor suppressor gene & is inherited in an
autosomal dominated fashion
• BRCA2 mutations are responsible for about 35% of all
inherited breast cancers . The lifetime risk of developing
breast cancer in a woman with a BRCA2 mutation is 50%
to 85%. However, the lifetime risk of developing ovarian
cnacer is 10% to 20% (lower than BRCA1)

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American Ca Society recommendation
Site Gender Age Evaluation Frequency
Breast Female >/-20 y/o Clinical Q 3 yrs

BE, Q month
BSE
>40 CBE Q year
BSE Q month
Mammog Q year
ram

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Colon/rectum M/F >/- 50y/o Fecal occult Q year
blood starting at age
50
and Flexible Q 5 years
sigmoidoscop
y
or Colonoscopy Q 10 years
or Double Q 5 years
contrast
barium
enema

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Prostate M >50 or < 50 if PSA and DRE Q year
high risk
Cervix F >18 or Pap smear Q year

younger if Pelvic exam
sexually
Endometr Women at active
menopause Report
ial menopaus
unexpected
e bleeding or
spotting
Cancer M/F >20-39 Other Ca Q 3 years

related check >40 types Q year
up

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• B. Staging – determines
the size of the tumor
and the existence of
metastasis
• TNM Classification:
T – tumor size
N – degree of involvement
of lymph nodes
M – absence or presence of
distance metastasis

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• Primary Tumor (T)
TX – primary tumor cannot be assessed
TO – no evidence of primary tumor
Tis – carcinoma in situ
T1,2,3,4 –ascending degrees of increasing size or
local extent of primary tumor
• Regional lymph nodes (N)

NX – regional LN cannot be evaluated
NO – no clinical evidence of regional LN
involvement
N1,2,3,4 – increasing involvement of LN

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• Distant Metastasis (M)
MX – Distance metastasis cannot be assessed
MO – No evidence of distant metastasis
M1,2,3,4 –ascending degrees of distant
metastasis, including lymph nodes
• Grading
- Classification of tumor cells
- Grade I – IV, define the type of tissue which
the tumor originated

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2. Histologic
a. Grade 1 - well differentiated

b. Grade 2 - Moderately
differentiated more abnormal
c. Grade 3 - Poorly
differentiated, Very abnormal
d. Grade 4 - Very immature
cells, undifferentiated ;
anaplastic hard to even
determine the tissue of origin

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Staging:
• Normal T0, N0, M0

• Stage I T1, N0, M0
• Stage II T2, N1, M0
• Stage III T3, N2, M0
• Stage IV with metastasis

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• Staging:
• Stage 0 : Carcinoma in
situ
• Stage I : tumor limited to
the tissue of origin;
localized tumor growth
• Stage II: limited local
spread
• Stage III: Extensive local
& regional spread
• Stage IV with
metastasis

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Screening
a. Early detection and treatment are the

cornerstones of cancer survival
b. Educating the public about a healthy
lifestyle and early detection

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Warning signs of Ca in Adults:
• C – change in bowel or bladder habits

• A – any sore that does not heal
• U – unusual bleeding or discharge
• U – unexplained sudden weight loss
• U – unexplained anemia
• T – thickening or lump
• I – indigestion or difficulty in swallowing
• O – obvious change in wart or mole
• N – nagging cough or hoarseness of voice

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Cancer warning Signs in
Children:
• 1. Weight loss ( unexplained)
• 2. Anemia ( sudden )
• 3. Weakness

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• 1.Marked change in bowel & bladder ; nausea &
vomiting for no apparent cause.
• 2. Generally run down condition and increased
susceptibility to infection
• 3. Spontaneous bleeding episodes like epistaxis ( failure
to stop bleeding in a normal time period)
• 4. Swelling or lump or masses anywhere in the child’s
body
• 5. Persistent crying or pain when there’s no apparent
cause
• 6. Any change in the size of a mole or birthmark
• 7. Unexpected stumbling or lack of coordination in the
child

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Early Detection:
• Mammography
• Papanicolaou ‘s ( “Pap”) test
• Stools for occult blood
• Sigmoisdoscopy, Colonoscopy
• Breast self – examination
• Testicular self – examination
• Skin inspection

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Health education
1. Reduce and avoid exposure to
known carcinogens
2. Eat a balanced diet of
vegetables, fruits and whole
grains, reducing fat and red
smoked and cured meat.
3. Limit alcohol beverages
4. Exercise regularly

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5. Reduce stress and encourage adequate rest
and relaxation
6. Follow screening recommendations
7. Know the warning signs
8. Seek medical attention

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Diagnostic Aids used to detect Cancer:
A. Common Dx Cancer studies:

TUMOR MARKERS
➢ Breast
➢ Colon
➢ Lung
➢ Ovarian
➢ Testicular
➢ Prostate cancer

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Diagnostic Aids used to detect
Cancer:
Magnetic Resonance Imaging
➢ Neurologic
➢ Pelvic
➢ Abdominal
➢ Thoracic cancers

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Cancer:
COMPUTED TOMOGRAPHY
➢ Neurologic
➢ Pelvic
➢ Abdominal
➢ Skeletal
➢ Thoracic cancers

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Cancer:
FLOUROSCOPY
➢ Skeletal
➢ Lung
➢ GI

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Cancer:
ULTRASONOGRAPHY
➢ Pelvic
➢ Abdominal

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Cancer:
ENDOSCOPY
➢ Bronchial
➢ GI

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Cancer:
NUCLEAR MEDICINE IMAGING
➢ Bone
➢ Liver
➢ Kidney
➢ Spleen
➢ Brain
➢ Thyroid

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Cancer:
POSITRON EMISSION
TOMOGRAPHY
➢ Lung
➢ Colon
➢ Liver
➢ Pancreatic
➢ Head and Neck cancers
➢ Hodgkin and Non-Hodgkin
Lymphoma and Melanoma

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Diagnostic Surgery:
B. Biopsy – is the definitive means of diagnosing
cancer & provides histological proof of malignancy
- only true diagnosis of cancer
- it involves the surgical incision of a small piece of
tissue for microscopic examination
1. Excisional biopsy
- is the complete removal of the entire tumor
- provides the pathologist the cells and the entire tissue
- decreases the chance of seeding the tumor

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2. Incisional Biopsy
- used if the tumor mass is too large to be
removed
- a wedge of tissue from the tumor is taken from
a larger mass
- This may be done for staging the disease level
3. Needle Biopsy
- Aspiration of cells
- done on suspicious masses that are easily
accessible
- fast, inexpensive and easily performed

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4. Endoscopic biopsy – direct
biopsy through an endoscopy
of the area ( GIT, GUT,
respiratory ( bronchoscopy)

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Pre-procedure:
a. Depends on the location and type of
biopsy
b. May need to be on NPO if sedation or
contrast is used
c. Inform the client about the procedure

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Post-procedure
a. Control bleeding
b. Monitor for infection
c. Manage pain
d. Inform the client how to
obtain the results

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Client Reaction during Diagnoses
• Client will use coping strategies to his anxiety
level such as:
• Denial-
• Rational inquiry-seek more information
• Affect Reversal-make light of the situation
(laughing etc.)
• Mutuality-share concerns and talk with other
persons
• Suppression-conscious forgetting
• Displacement or redirection-do other things

Page 115 of 176
Points to Remember
• Most clients fear of death upon

confirmation of Cancer
• Clients usually ignored cardinal signs of
Cancer
• Most often cancer is detected during
routine exam
• Questions that need to be answered:
Example (Is the disease curable or not?)

Page 116 of 176
Nursing Diagnosis
• Ineffective coping
• Anticipatory grieving
• Disturbed body image
• Fatigue
• Impaired elimination
• Hopelessness
• Impaired oral mucous membrane

Page 117 of 176
• Nausea
• Impaired nutrition less than body
requirements
• acute pain
• Impaired skin integrity

Page 118 of 176
Signs and symptoms of malignant neoplasia:
• Proliferation of Ca cells
➢ Pressure
➢ Obstruction
➢ Pain ( late sign of Ca )
- Pressure on nerve endings
- Distention of organs/vessels
- Lack of O2 to tissue and organ
- Release of pain mediators

Page 119 of 176
➢ Pleural effusion and ascites
➢ Ulceration and necrosis
- As tumor erodes BV and pressure on tissue
causes ischemia, tissue damage, bleeding
and infection
➢ Vascular thrombosis, Embolus,
Thrombophlebitis
➢ Tumors tends to produce abnormal
coagulation factors

Page 120 of 176
• Paraneoplastic Syndrome:
1. Anemia
- Ca cells produces chemicals that interfere
with rbc production
- Iron uptake is greater in the tumor than that
deposited in the liver
- Blood loss from bleeding
2. Hypercalcemia
- Increases and accelerates bone breakdown
and release of Calcium

Page 121 of 176
3. Anorexia –
-Final outcome of unrestrained Ca growth
-Ca deprive normal cells of nutrition
-Protein depletion, serum albumin decreases
-Tumors take up Na
-Act in the satiety center causing anorexia
-Taste sensation diminishes

Page 122 of 176
• Take pain seriously, recognizing that only the
person in pain knows how it feels.
• Provide information and resources for pain
control.
• Communicate with genuineness, accurate empathy,
and nonpossessive warmth.
• Encourage sufferers to share their feelings and
network with other survivors.
• Respect culture norms and wishes of sufferers,
maximizing their control
• Encourage release of energy through joy-
producing activities.
• Monitor pain medications, effectiveness, and
adverse effects

Page 123 of 176
NURSING INTERVENTION:
• Take pain seriously, recognizing that only the person in pain
knows how it feels.
• Provide information and resources for pain control.
• Communicate with genuineness, accurate empathy, and
nonpossessive warmth.
• Encourage sufferers to share their feelings and network with
other survivors.
• Respect culture norms and wishes of sufferers, maximizing
their control
• Encourage release of energy through joy-producing activities.
• Monitor pain medications, effectiveness, and adverse effects

Page 124 of 176
MANAGEMENT OF CANCER

Page 125 of 176
Goals of Therapy:
1. Curative :
- Patients will be disease free & live a normal life
expectancy

Page 126 of 176
2. Control surgery
• Is a “ debulking procedure” that

consists of removing part of the
tumor.
• Surgery decreases the number of
cancer cells & increases the chance
that other therapies will be successful

Page 127 of 176
3. Palliative Surgery
- when cure is not possible, the goal of
treatment is to make the patient as
comfortable as possible and to promote a
satisfying and productive life for as long as
possible
- Performed to improve quality of life during
the survival time

Page 128 of 176
4. Prophylactic Surgery
- performed in clients with an existing

premalignant condition or a known family
history that strongly predisposes the person to
the development of cancer
- Removal of non-vital structures that are likely
to develop Ca
- An attempt is made to remove the tissue organ
at risk & thus prevent the development of Ca
-

Page 129 of 176
Therapeutic Modalities for Cancer
• 1. Surgery
• 2. Radiation Therapy
• 3. Chemotherapy
• 4. Immunotherapy
• 5. Bone Marrow Transplantation

Page 130 of 176
1. Surgery
= The ideal and most frequently used
= most successful single therapy if cancer has not yet spread
= very often performed on an OPD or short stay basis
a.Diagnostic = primarily for the purpose of obtaining tissue
sample for diagnostic purposes & to determine methods of
treatment
b.Staging = performed to determine the extent of cancer
presence & location of metastatic lesions.
c.Curative =removal of cancer that are blocalized to the area
of origin; extent of ressection is determined by the type of
tumor

Page 131 of 176
•D. Reconstructive = restoration of the
patient’s form, function & appearance of
the radical surgery for cancer
•E. Preventive =n for patient’s that are in
a high risk category, certain surgical
procedures that may prevent further
development of cancer

Page 132 of 176
Tissue Examination:
• Following excision , a frozen section or a permanent paraffin section is
prepared to examine the specimen
• The advantage of the frozen section is the speed with which the section can
be prepared & the dx made because only minutes are required for this test
• Permanent paraffin section takes about 24 hours however, it provides
clearer details than does the frozen section
• INTERVENTION: 1. The procedure is usually done in an out patient
surgical setting
• Obtain an informed consent

Page 133 of 176
CAUSES OF PAIN IN CANCER:
•1. Bone destruction
•2. Obstruction of an organ
•3. Compression of peripheral nerves

Page 134 of 176
2. Radiation Therapy
• Used to control malignant disease when a

tumor cannot be removed surgically
• Destroys the cell’s ability to reproduce by
damaging the cellular DNA
• A radiosensitive tumor is one that can be
destroyed by a dose of radiation that still
allows for cell regeneration in the normal
tissue

Page 135 of 176
• Uses ionizing radiation to kill or limit
the growth of cancer cells. May be
internal or external
• Effect cannot be limited to cancer cells
only
• Cells that are rapidly reproducing are
vulnerable to the effects of radiation
• Normal healthy cells recover more
effectively from the damage caused by
radiation

Page 136 of 176
• is a cancer treatment that uses high doses of
radiation to kill cancer cells and stop them
from spreading. At low doses, radiation is
used as an x-ray to see inside your body
and take pictures, such as x-rays of your
teeth or broken bones.
• Radiation use in cancer treatment works in
much the same way, except that it is given
at higher doses.

Page 137 of 176
Radiation therapy is used to:
•Treat cancer. Radiation can be used to cure, stop,
or slow the growth of cancer.
•Reduce symptoms. When a cure is not possible,

radiation may be used to shrink cancer tumors in
order to reduce pressure. Radiation therapy used in
this way can treat problems such as pain, or it can
prevent problems such as blindness or loss of bowel
and bladder control.

Page 138 of 176
Page 139 of 176
Page 140 of 176
• Cells are most vulnerable to radiation during
DNA synthesis and mitosis
• Most sensitive are those body tissue that
undergo frequent cell division. (BM,
Lymphatic, GIT, gonads)
• Tumors that are well oxygenated are more
sensitive to radiation
• Cells most sensitive during M and G2 phase

Page 141 of 176
Radiosensitivity
• Highly sensitive
- ovaries, testes, bone marrow,
blood, intestines
• Low sensitivity
- muscle, brain, spinal cord

Page 142 of 176
Types:
A. Teletherapy (External Beam radiation)
- x-rays are used to destroy cancerous cells at the
skin surface or deeper
- radiation source is outside the body ( Cobalt)
- radiation source is directed toward the area
- Client is not radioactive during treatment
- Simulation – X-ray or Ct planning session to
identify the field which delivers maximum
radiation to the tumor and minimal to normal
tissue. Involves skin markings
- Administered in fractions of the full dose, 5 days a
week for 4-6 weeks

Page 143 of 176
Client Education: Teletheraphy
* Wash area with water or mild soap & water using the hand
rather than a washcloth; rinse the soap thoroughly, & pat
dry with a soft towel or cloth
*Do NOT remove the radiation markings from the skin
* Use no powders, ointments, lotions or creams on the area
unless prescribed
* Wear soft clothing over the area, avoiding belts, buckles,
straps or any clothing that binds or rubs the skin
* Avoid sun & heat exposure
* Monitor for moist desquamation (weeping of the skin). If
moist desquamation occurs, cleanse the area with warm
water & pat dry, apply antibiotic ointment or steroid
cream as prescribed & expose the site to air

Page 144 of 176
B. Brachytherapy ( Implant Therapy) (Internal)
( closed therapy) Sealed source Therapy)
1.The radiation source comes into direct,
continuous contact with tumor tissues for a
specific time.
2. The radiation source is within the client; for a
period of time, the client emits radiation & can
pose a hazard
3. Brachytherapy includes an unsealed source or a
sealed source of radiation
- Client is radioactive only when implant is in place
- plan cares efficiently to minimize nurses, exposure
to implant, use shielding, wear a film badge and
maintain safe distance.

Page 145 of 176
3. Unsealed radiation source ( Isotope or
radiopharmaceutical )
A. Administration is via the oral or IV route or by
instillation into body cavities
B. The source is not confined completely to one
bodily area, & it enters body fluids & eventually is
eliminated via various excreta, which are radioactive
& harmful to others; most of the source is
eliminated from the body within 48 hours, then
neither the client nor the excreta are radioactive or
harmful.
C. has a very short half life & because it is not
sealed, the body fluids become contaminated

Page 146 of 176
Sealed radiation source
A. A sealed, temporary or permanent radiation
source (solid implant ) is implanted within the
tumor target tissues or into a body cavity
B. The client emits radiation while the implant is
in place, but the excreta are not radioactive.
C. this delivers a large amount of radiation to a
small area of the body

Page 147 of 176
Removal of sealed radiation sources:
A. The client is no longer radioactive
B. Inform the client that sexual partners cannot “catch”
cancer
C. Inform the female client that she may resume sexual
intercourse after 7 to 10 days , if the implant was cervical or
vaginal
D. Provide a povidone –iodine douche if prescribed, if the
implant was placed in the cervix
E. Administer a Fleet enema if prescribed
F. Advise the client who had a cervical or vaginal implant to
notify the physician if nausea, vomiting, diarrhea, frequent
urination , vaginal or rectal bleeding, hematuria, foul-
smelling vaginal discharge, abdominal pain or distention, or
a fever occurs.

Page 148 of 176
Care of the Client with a Sealed Radiation
Source ( Internal Radiation )
* Place the client in a private room with a private bath
* Place a caution sign on the client’s door
A lead container & tongs should be present in the client’s
room
* Organize nursing tasks to minimize exposure to the
radiation source
* Nursing assignments to a client with a radiation
implant should be rotated
* Limit time to 30 minutes per care provider per shift
* Wear a dosimeter film badge to measure radiation
exposure

Page 149 of 176
*Inform all people coming in contact with the
patient the specific precautions necessary.
Wear a lead shield to reduce the transmission of
radiation
* A nurse should never care for more than one
client with a radiation implant at one time
* Do not allow a pregnant nurse to care for the
client
* Do not allow children under the age of 16 or a
pregnant woman to visit the client

Page 150 of 176
* Limit visitors to 30 minutes per day;
visitors should be at least 6 feet from the
source
* Save bed linens & dressings until the
source is removed, then dispose of in the
usual manner
* Other equipment can be removed from the
room at any time
*Examples of the type of radiation therapy
include uterine implant, testicular
implant; implant used in head & neck
tumor.

Page 151 of 176
* Utilize badges or radiation monitors for caregivers having
direct contact with the patient.
* List on the chart:
1. Type of radiation
2. Time inserted & where
3. Anticipated removal time
4. Specific precaution for the type of radiation
– Private room & bath
– Plan care so that minimal time is spent in the room
– When prolonged care is required, wear a lead shield or
apron

Page 152 of 176
• Wear a monitoring device to measure
exposure
• Mark on the room & in the kardex that
pregnant women, infants & young
children should not come in contact
with the patient during treatment
• Check all linens & materials removed
from the bed for the presence of
foreign bodies that could be a source of
radioactivity

Page 153 of 176
• Keep long handled forcep & lead
container in the room of a patient
with an implant in place
• Do not wash off marks placed on
patient’s body for the purpose of
identifying area for external
radiation

Page 154 of 176
A Dislodged Radiation Source
*Do not touch a dislodged radiation source with
bare hands
* If the radiation source dislodges, use long
handled forceps to place the source in the lead
container kept in the client’s room, & call the
radiation therapist & the physician
* If unable to locate the radiation source, bar
visitors & notify the radiation therapist .

Page 155 of 176
-Body fluids of clients treated with systemic
radioactive iodine are radioactive
-( flush toilet 3x)
- fluids of client with implants are not

Page 156 of 176
4. Systemic Radiation Therapy
= radiation source is absorbed
into the circulation & travels
throughout the body

Page 157 of 176
Care of patients receiving Systemic
Radiation Therapy
* Systematically administered radionuclitides (
radioisotope) may cause radioactive body secretions.
> wear gloves when handling patient’s body
secretions
> It may be necessary to have the linens & trash
cgecked for radioactivity prior to removing them
from the room
> keep linens & trash in room until they have been
checked for radioactivity by radiation therapy
deparment

Page 158 of 176
Radiation Safety
Distance - the greater the distance the lesser
the exposure ( 6 feet)
Time - the less time spent close to radiation the
less exposure (max of 30 min per shift)
Shielding - use lead aprons and gloves
Standards - kept as low as reasonably
achievable
Monitoring device - film badge (measure the
whole exposure of the nurse)

Page 159 of 176
Adverse Effects of Radiation Therapy
A. Skin: Itching, redness, burning, sloughing
1.Keep skin free of foreign substance
2.Avoid use of medicated solutions
3.Avoid pressure, trauma, infection
4.Avoid exposure to heat, cold or sunlight

Page 160 of 176
B. GI Disturbances
A. Anorexia, Nausea & Vomiting

1.Provide small, attractive feedings
2.Avoid extremes of temperatures
3.Administer antiemetics before meals

Page 161 of 176
c. Diarrhea
• Encourage low residue, bland,

high protein foods
• Provide good perineal hygine
• Monitor electrolytes, Na,K,Cl

Page 162 of 176
d. Anemia. Leukopenia,
thrombocytopenia
• Isolate patient
• provide frequent rest period
• Encourage high protein diet
• Assess for bleeding
• Monitor lab results CBC, WBC,
Plt

Page 163 of 176
Effects of Radiation Therapy in
Pediatrics:
Long Term of treatment in a child:
1. Impaired growth & development especially from
radiation to growth center of bone during early
childhood & adolesce3nce.
2. Damage to CNS in terms of psychological,
neurologic & intellectual activity.
3. Gonadal aberration including reproductive ,
hormonal , genetic & teratogenic effects.
Decrease fertility in adolescents.

Page 164 of 176
4. Disturbances to other organs including
pneumonitis, pericarditis, pleurisy,
hypothyroididm, (cretinism or dwarfism)
cystitis
5. Development of a secondary malignancy
especially after a successful treatment of
acute lymphocytic leukemia ( ALL – most
common type of cancer among children) ;
lymphomas, Wilm’s tumor , nephroblastoma,
retinoblastoma..

Page 165 of 176
CHEMOTHERAPY
• Kills or inhibits the reproduction of neoplastic cells & also

attacks & kill normal cells
• The effects are systemic: chemotherapy affects healthy
cells & cancerous cells
• Normal cells most profoundly affected include those of the
skin, hair & lining of the GI tract, spermatocytes, &
hematopoietic cells
• Cell cycle phase –specific medications affect cells only
during a certain phase of the reproductive cycle, and cell
cycle phase non- specific medications affect cells in any
phase of the reproductive cycle

Page 166 of 176
• Usually several medications are used in
combination ( combination therapy) to
increase the therapeutic response.
• Combination chemotherapy is planned to
avoid prescribing medications during the
time in which bone marrow activity &
WBC counts are at their lowest or near
the same time to minimize
immunosuppression.

Page 167 of 176
• Antineoplastic therapy maybe combined with
other treatments, such as surgery and radiation.
• The preferred route of administration is
intravenously
• Side effects include alopecia, N & V, mucositis,
skin changes, immunosuppression, anemia &
thrombocytopenia.

Page 168 of 176
Goal:
• Destroy all malignant cells
without excessive destruction of
normal cell
• Control growth of tumor when
cure is not possible
• Note: all rapid dividing cells
(GI mucosa, hair follicles and
bone marrow) are susceptible
to the action of chemo and
radiation therapy

Page 169 of 176
Reasons for combining Drugs:
• Synergy-two or more agents works
together to enhance the effect of one
another
• Adjuvant-an additional treatment
• ’s malignant cell destructions, ’s
the SE
• Principle of MDT may be instituted
to avoid and prevent the SE

Page 170 of 176
Chemotherapy may be given in many
ways:
1. INJECTION = the chemotherapy is
given by a shot in a muscle in your
arm, thigh, or hip or right under
the skin in the fatty part of your
arm, leg or belly
2. Intra-arterial ( IA) = the
chemotherapy goes directly into the
artery that is feeding the cancer

Page 171 of 176
3. Intraperitoneal (IP ) The chemotherapy goes directly
into the peritoneal cavity the area that contains organs
such as your intestines, stomach, liver, and ovaries).
4. Intravenous (IV) = . The chemotherapy goes directly
into a vein.
5. Topically. The chemotherapy comes in a cream that you
rub onto your skin.
6. Orally. The chemotherapy comes in pills, capsules, or
liquids that you swallow.

Page 172 of 176
Contraindication
• Infection
• Recent surgery
• Impaired renal or hepatic
function
• Recent radiation therapy
• Pregnancy
• Bone marrow depression

Page 173 of 176
• Extravasation –
cause tissue necrosis
and damage to
tendons, nerves and
blood vessels

Page 174 of 176
• TOXICITY – nauseas and
vomiting usually last about 1
week

Page 175 of 176
ANTI NEOPLASTIC

Page 176 of 176

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ONCOLOGY NURSING

JOANNE MARIE S. GARCIA, RN, MAN

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• Branch of medicine that deals

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• A disease resulting from the

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• A tumor is an abnormal lump or

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• Noncancerous. If the cells are

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Characteristic Benign malignant

Rate of growth Slow, may come to a Erratic & may be slow to

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General localized Anemia, weakness, weight loss

Tissue No tissue damage Extensive tissue damage

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1. Oncogene – cancer genes that alter

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• The rate of tissue growth in normal &

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https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

Tumor is named according to:

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

Tumor is named according to:

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

1. G1 or Gap1– lasts from hours to days

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

= is the time required for one tissue cell to

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

https://cdn.fbsbx.com/v/t59.2708-21/46820680_209603409951644_77041558183665…_nc_ht=cdn.fbsbx.com&oh=6a23971fd7e7d1667dd968a2b0f2016e&oe=5C01E758&dl=1 29/11/2018, 8G00 PM

3. Genetics and Family History