ONCOLOGY

DEFINITION
Neoplasia - growth of cells or tissues 1. Erratic, not in accord with normal bodily needs or patterns of growth 2. Development, and not under the control of normal regulatory mechanisms.

In some the rate is fast; in others, slow; but in all cancers the cells never stop dividing.

This distinguishes cancers malignancies from benign growths like moles where their cells eventually stop dividing. Cancers are clones.
Cancers begin as a primary tumor. At some point, however, cells break away from the primary tumor and traveling in blood and lymph establish metastasis in other locations of the body.

Root words

Neo- new Plasia- growth Plasm- substance Trophy- size +Oma- tumor Statis- location

Root words

A- none Ana- lack Hyper- excessive Meta- change Dys- bad, deranged

Review of Normal Cell Cycle 3 types of cells 1. PERMANENT cells- out of the cell cycle

Neurons, cardiac muscle cell

2. STABLE cells- Dormant/Resting (G0)

Liver, kidney
GIT cells, Skin, endometrium , Blood cells

3. LABILE cells- continuously dividing

Cell Cycle G0------------------G1SG2M G0- Dormant or resting G1- normal cell activities S- DNA Synthesis G2- pre-mitotic, synthesis of proteins for cellular division M- Mitotic phase

Proposed Molecular cause of CANCER: Change in the DNA structure altered DNA function Cellular aberration cellular death neoplastic change Genes in the DNA- proto-oncogene And anti-oncogene

CARCINOGENSIS Malignant transformation IPT P Initiation Promotion Transformation Progression

CARCINOGENSIS INITIATION Carcinogens alter the DNA of the cell Cell will either die or repair

CARCINOGENSIS PROMOTION Repeated exposure to carcinogens Abnormal gene will express Latent period

TRANSFORMATION after frequent exposure cancer cell multiplies from normal cells

CARCINOGENSIS PROGRESSION Irreversible period Cells undergo NEOPLASTIC transformation then malignancy

Carcinogenesis
I.

Theory of Immunosurveillance
Failure of the immune system to eradicate abnormal cells

Body Defenses Against TUMOR 1. T cell System/ Cellular Immunity

Cytotoxic T cells kill tumor cells

2. B cell System/ Humoral immunity

B cells can produce antibody

Macrophages can engulf cancer cell debris

3. Phagocytic cells

II. Malignant transformation resulting from damage to the genetic material, or DNA, of the cell 1. The processes of mitosis and protein synthesis are disturbed 2. Changes established in a CA cell is passed on to daughter cells mutation 3. Normal cells undergo apoptosis (spontaneous disintegration); CA cells do not, live indefinitely

CANCER NURSING
Etiology of cancer 1. PHYSICAL AGENTS Radiation: wave of energy
Sunlight, x-rays, radioactive substances, nuclear fission Leukemia occupational hazard of radiologists Hiroshima & Nagasaki atomic bomb survivors Ultraviolet radiation in sunlight

Etiology of cancer
2. CHEMICAL AGENTS Smoking Dietary ingredients Drugs

Hydrocarbons in cigarettes, cigars, & auto exhaust Insecticides, dyes, industrial chemicals, insulation Hormone: Diethylstilbestrol (DES) synthetic oestrogen prescribed in the 1950s, 1960s, and early 1970s to women to prevent miscarriage causes malignant tumor CA of the vagina Drugs: estrogen causes CA by stimulating proliferation of cells in target organs such as uterine lining

CANCER NURSING
Etiology of cancer 3. Genetics and Family History Colon Cancer Premenopausal breast cancer

Oncogene or CA causing gene a piece of DNA whose activation is associated with the conversion of a normal cell into a cancerous cell ras oncogene colon cancer myc lymphoma bcr-abl chronic myelogenous leukemia

Heredity

Defects in the DNA of the egg & sperm cells Tumors arise because of inherited or acquired abnormalities in suppressor genes (regulate growth, promote differentiation, & suppress oncogenes from causing cancer) ex.: retinoblastoma, polyposis coli syndrome, & certain forms of colon, breast, & kidney CA genetic screening to determine presence of cancercausing gene

CANCER NURSING
Etiology of cancer 4. Dietary Habits Low-Fiber High-fat Processed foods alcohol

CANCER NURSING
Etiology of cancer 5. Viruses and Bacteria DNA viruses- HepaB, Herpes, EBV, CMV, Papilloma Virus RNA Viruses- HIV, HTCLV Bacterium- H. pylori

CANCER NURSING

Etiology of cancer 6. Hormonal agents DES OCP especially estrogen

CANCER NURSING

Etiology of cancer 7. Immune Disease AIDS

GENERAL CLASSIFICATION OF NEOPLASMS

Benign Malignant

Remember: Differentiation between the 2 classes.

CANCER NURSING

Spread of Cancer 1. LYMPHATIC

Most common

2. HEMATOGENOUS

Blood-borne, commonly to Liver and Lungs

3. DIRECT SPREAD

Seeding of tumors

Types of Tumors or Neoplasms

NOMENCLATURE OF CANCERS

BENIGN TUMORS: -oma ex: lipoma, fibroma, angioma, osteoma, leiomyoma Adenoma tumors arising in glands Cystadenoma adenomas producing large cystic masses, usually in the ovaries Papilloma epithelial tumors forming microscopic or macroscopic finger-like projections Polyp a tumor projecting from the mucosa into the lumen of a hollow viscus (e.g. stomach or colon) OMA but Malignant

HepatOMA, lymphOMA, gliOMA, melanOMA

MALIGNANT TUMORS: -carcinoma arises from epithelial cells -sarcoma arises from connective tissues

Terminology
Named according to embryonic cell origin 1. Ectodermal, Endodermal, Glandular, Epithelial Use the suffix- CARCINOMA Pancreatic AdenoCarcinoma Squamos cell Carcinoma

Named according to embryonic cell origin 2. Mesodermal, connective tissue origin Use the suffix SARCOMA FibroSarcoma Myosarcoma AngioSarcoma

PLEOMORPHIC ADENOMA

CYSTADENOMA

PAPILLOMA

Types of Malignant Neoplasms

MIXED TUMORS - derived from one germ cell layer and differentiates into more than one parenchymal cell type. (e.g. mixed salivary gland tumors arising from ductal epithelial cells) TERATOMAS - made up of a variety of parenchymal cell types representative of more than one germ cell layer, usually all three (endoderm, ectoderm, mesoderm); commonly found in the testis and ovary

CHORISTOMAS

ectopic, nodular, (pancreatic cells under small bowel)

HAMARTOMAS malformations presenting as mass of disorganized tissue indigenous to a particular site (hamartomas in lungs, bronchi, blood vessels)

ORIGIN

BENIGN

MALIGNANT

Epithelium

Nomenclature of the Commoner Neoplasms

Surface Epithelium secretory epithelium endothelium, lymph vessel endothelium, blood vessel Papilloma adenoma lymphangioma hemangioma epidermoid carcinoma adenocarcinoma lymphangioendothelioma hemangioendothelioma

Connective Tissue
adult fibrous tissue fat cartilage bone embryonic fibrous tissue notochord nerve sheath fibroma lipoma chondroma osteoma myxoma chordoma neurofibroma fibrosarcoma liposarcoma chondrosarcoma osteogenic sarcoma myxosarcoma chordoma neurogenic sarcoma

Nomenclature of the Commoner Neoplasms

ORIGIN
Muscle

BENIGN

MALIGNANT

skeletal muscle
smooth muscle

rhabdomyoma
leiomyoma

rhabdomyosarcoma
leiomyosarcoma

Nerve

neuron

neuroma

neuroma

Hemolymphatic Tissue bone marrow myeloma

lymphoid tissue
Germ Cell Tumors testicular germ cells seminoma

lymphoma

infantile embryonal CA

choriocarcinoma

Cancers Seven Warning Signals

C A U T

I O N

Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or lump in the breast or elsewhere Indigestion or difficulty in swallowing Obvious change in a wart or mole Nagging cough or hoarseness
Based from the American Cancer Society Based from the American Cancer Society

CANCER SCREENING
Breast: Monthly breast self-examination and mammography. Uterine cervix: Pap smear. Prostate: Digital examination of the prostate and serum PSA (prostate specific antigen) level. Colorectal: Digital rectal examination, sigmoidoscopy or colonoscopy, and fecal occult blood (FOBT).

MAMMOGRAPHY

TUMOR MARKERS

Carcinoembryonic Antigen (CEA) : colon CA Alpha-Fetoprotein (AFP): liver, GI tract, germ cell tumors CA 125: ovarian CA CA19-9: colon CA Prostate-Specific Antigen (PSA): prostatic CA

HORMONE MARKERS

Human Chorionic Gonadotropin (HCG): gestational trophoblastic disease, germ cell tumors ENZYME MARKERS Acid Phosphatase : prostatic CA Neuron Specific Enolase : brain CA Galactosyl Transferase II: GI tract malignancies Immunoglobulins: multiple myeloma

BIOPSY

Excision Biopsy Fine needle biopsy Large needle biopsy

CANCER GRADING
It is a measure of its degree of malignancy, based on histologic evaluation of its cells. The Broders classification of squamous-cell carcinomas is an example of a simple grading system: GRADE 1 GRADE 2 GRADE 3 GRADE 4 25% of cells undifferentiated 50% of cells undifferentiated 75% of cells undifferentiated 100% of cells undifferentiated

CANCER STAGING
It is the measure of the extent of a malignant disease at the time of evaluation, expressed in Arabic numerals (1, 2, 3) Staging takes into account the type, size, and extent of the primary tumor (T); the degree of lymph node involvement (N), if any; and the number and location of any distant metastases (M).

T-Tumor Classification
TX: Primary tumor cannot be assessed T0: No evidence of primary tumor Tis: Carcinoma in situ T1: Tumor 2.0 cm or less in greatest dimension T2: Tumor more than 2.0 cm but not more than 5.0 cm in greatest dimension T3: Tumor more than 5.0 cm in greatest dimension T4: Tumor of any size with direct extension to (a) chest wall or (b) skin

N-Nodes Affected (if any)

NX: Regional lymph nodes cannot be assessed (e.g., previously removed) N0: No regional lymph node metastasis N1: Metastasis to movable ipsilateral axillary lymph node(s)

N2: Metastasis to ipsilateral axillary lymph node(s) fixed to each other or to other structures

N3: Metastasis to ipsilateral internal mammary lymph node(s)

M- Metastasis

MX: Presence of distant metastasis cannot be assessed M0: No distant metastasis M1: Distant metastasis present (includes metastasis to ipsilateral supraclavicular lymph nodes)

STAGING
T-N-M Staging System I - < 2cm II - 2 to 5 cm, (+) LN III - > 5 cm, (+) LN IV- metastasis

CANCER TREATMENT

SURGERY - complete resection; curative or palliative CHEMOTHERAPY alkylating agents (nitrogen mustard, chlorambucil) antimetabolites (methotrexate, 5-fluorouracil) antibiotics (doxorubicin, dactinomycin, mithramycin) plant alkaloids (vinblastine and vincristine), hormones adrenal corticosteroids, estrogens, androgens,tamoxifen

CANCER TREATMENT

RADIOTHERAPY Damages rapidly proliferating tissue by ionizing radiation

GENERAL Promotive and Preventive Nursing Management 1. Lifestyle Modification 2. Nutritional management 3. Screening 4. Early detection

Nursing Assessment

Weight loss Frequent infection Skin problems Pain Hair Loss Fatigue Disturbance in body image/ depression

Nursing Intervention

MAINTAIN TISSUE INTEGRITY Handle skin gently Do NOT rub affected area Lotion may be applied Wash skin only with SOAP and Water

Nursing Intervention

MANAGEMENT OF STOMATITIS Use soft-bristled toothbrush Oral rinses with saline gargles/ tap water Avoid ALCOHOL-based rinses

Nursing Intervention
MANAGEMENT OF ALOPECIA Alopecia begins within 2 weeks of therapy Regrowth within 8 weeks of termination Encourage to acquire wig before hair loss occurs Encourage use of attractive scarves and hats Provide information that hair loss is temporary BUT anticipate change in texture and color

Nursing Intervention
PROMOTE NUTRITION Serve food in ways to make it appealing Consider patients preferences Provide small frequent meals Avoids giving fluids while eating Oral hygiene PRIOR to mealtime Vitamin supplements

Nursing Intervention
RELIEVE PAIN Mild pain- NSAIDS Moderate pain- Weak opiods Severe pain- Morphine Administer analgesics round the clock with additional dose for breakthrough pain

Nursing Intervention
DECREASE FATIGUE Plan daily activities to allow alternating rest periods Light exercise is encouraged Small frequent meals

Nursing Intervention
IMPROVE BODY IMAGE Therapeutic communication is essential Encourage independence in self-care and decision making Offer cosmetic material like make-up and wigs

Nursing Intervention
ASSIST IN THE GRIEVING PROCESS Some cancers are curable Grieving can be due to loss of health, income, sexuality, and body image Answer and clarify information about cancer and treatment options Identify resource people Refer to support groups

Nursing Intervention
MANAGE COMPLICATION: INFECTION Fever is the most important sign (38.3) Administer prescribed antibiotics X 2weeks Maintain aseptic technique Avoid exposure to crowds Avoid giving fresh fruits and veggie Handwashing Avoid frequent invasive procedures

Nursing Intervention
MANAGE COMPLICATION: Septic shock Monitor VS, BP, temp Administer IV antibiotics Administer supplemental O2

Nursing Intervention
MANAGE COMPLICATION: Bleeding Thrombocytopenia (<100,000) is the most common cause <20, 000 spontaneous bleeding Use soft toothbrush Use electric razor Avoid frequent IM, IV, rectal and catheterization Soft foods and stool softeners

CANCER STATISTICS
MEN
Lung Prostate Colon & Rectum,

WOMEN
Lung Breast Colon & Rectum

BRONCHOGENIC CARCINOMA

A malignant tumor of the lung arising from bronchial epithelium.

Causes: Cigarette smoking Inhalation of industrial carcinogens (asbestos, silica, chromium, nickel) Exposure to ionizing radiation

History: Gradual onset of cough (or change in a chronic cough), dyspnea, wheezing, hemoptysis, anorexia, weight loss, chest pain. Physical Examination: Weight loss, or signs of bronchial obstruction, pneumonia, atelectasis, cavitation, or pleural effusion.

CARCINOGENS IN CIGARETTES

Diagnostic Tests:

Chest x-ray or CT scan demonstrates a solitary nodule, infiltrate, atelectasis, cavitation, or pleural effusion. Cytologic examination of bronchial washings or pleural fluid, or histologic examination of biopsy material obtained by bronchoscopy or needle aspiration through the chest wall, shows malignant tissue arising from bronchial epithelium.

Course:

Bronchogenic carcinoma is typically advanced and inoperable when first diagnosed. The 5-year survival rate is only 10-15%. Obstruction of airways commonly leads to atelectasis and pneumonia.

Treatment:
chemotherapy.

Surgery,

radiation,

and

BREAST CANCER

Breast Cancer

The most common cancer in FEMALES Numerous etiologies implicated

Breast Cancer
RISK FACTORS 1. Genetics- BRCA1 And BRCA 2 2. Increasing age ( > 50yo) 3. Family History of breast cancer 4. Early menarche and late menopause 5. Nulliparity 6. Late age at pregnancy

Breast Cancer
RISK FACTORS 7. Obesity 8. Hormonal replacement 9. Alcohol 10. Exposure to radiation

Breast Cancer
PROTECTIVE FACTORS 1. Exercise 2. Breast feeding 3. Pregnancy before 30 yo

Breast Cancer
ASSESSMENT FINDINGS 1. MASS- the most common location is the upper outer quadrant 2. Mass is NON-tender. Fixed, hard with irregular borders 3. Skin dimpling 4. Nipple retraction 5. Peau d orange

Breast Cancer

LABORATORY FINDINGS 1. Biopsy procedures 2. Mammography

Breast Cancer

Breast cancer Staging TNM staging I - < 2cm II - 2 to 5 cm, (+) LN III - > 5 cm, (+) LN IV- metastasis

Treatment: Radical mastectomy. Both radiation treatments and chemotherapy are usually administered after surgery. In metastatic disease, elimination of estrogen stimulation through either oophorectomy (removal of the ovaries) administration of tamoxifen, a chemical anti-estrogen, delays progression of disease and mitigates symptoms.

Breast Cancer

MEDICAL MANAGEMENT 1. Chemotherapy 2. Tamoxifen therapy 3. Radiation therapy

Breast Cancer

SURGICAL MANAGEMENT 1. Radical mastectomy 2. Modified radical mastectomy 3. Lumpectomy 4. Quadrantectomy

Breast Cancer
NURSING INTERVENTION : PRE-OP 1. Explain breast cancer and treatment options 2. Reduce fear and anxiety and improve coping abilities 3. Promote decision making abilities 4. Provide routine pre-op care: Consent, NPO, Meds, Teaching about breathing exercise

Breast Cancer
NURSING INTERVENTION : Post-OP 1. Position patient: Supine Affected extremity elevated to reduce edema

Breast Cancer
NURSING INTERVENTION : Post-OP 2. Relieve pain and discomfort Moderate elevation of extremity IM/IV injection of pain meds Warm shower on 2nd day post-op

Breast Cancer
NURSING INTERVENTION : Post-OP 3. Maintain skin integrity Immediate post-op: snug dressing with drainage Maintain patency of drain (JP) Monitor for hematoma w/in 12H and apply bandage and ice, refer to surgeon

Breast Cancer
NURSING INTERVENTION : Post-OP 3. Maintain skin integrity Drainage is removed when the discharge is less than 30 ml in 24 H Lotions, Creams are applied ONLY when the incision is healed in 4-6 weeks

Breast Cancer
NURSING INTERVENTION : Post-OP Promote activity Support operative site when moving Hand, shoulder exercise done on 2ndday Post-op mastectomy exercise 20 mins TID NO BP or IV procedure on operative site

Breast Cancer
NURSING INTERVENTION : Post-OP Promote activity Heavy lifting is avoided Elevate the arm at the level of the heart On a pillow for 45 minutes TID to relieve transient edema

Breast Cancer
NURSING INTERVENTION : Post-OP MANAGE COMPLICATIONS Lymphedema 10-20% of patients Elevate arms, elbow above shoulder and hand above elbow Hand exercise while elevated Refer to surgeon and physical therapist

Breast Cancer
NURSING INTERVENTION : Post-OP MANAGE COMPLICATIONS

Hematoma Notify the surgeon Apply bandage wrap (Ace wrap) and ICE pack

Breast Cancer
NURSING INTERVENTION : Post-OP MANAGE COMPLICATIONS

Infection Monitor temperature, redness, swelling and foul-odor IV antibiotics No procedure on affected extremity

Breast Cancer
NURSING INTERVENTION : Post-OP

TEACH FOLLOW-UP care Regular check-up Monthly BSE on the other breast Annual mammography

Course:

Breast

cancers

spread

to

axillary and

mediastinal lymph nodes, liver, bone, and brain. For a solitary, localized tumor, the 5-year survival rate is 95%.

ADENOCARCINOMA OF THE PROSTATE

A malignant tumor arising from glandular epithelium of the prostate gland. Cause: Hereditary. The tumor is testosterone-dependent History: May be asymptomatic. The first symptom may be bone pain due to metastasis. Physical Examination: Digital rectal examination reveals an unusually firm, nodular, or asymmetric prostate.

Diagnostic Tests. Serum prostate specific antigen (PSA) Course: Slow progression. Metastasis to the spine or pelvis eventually occurs, and urinary obstruction . Treatment. Usually radical prostatectomy, radiation by external beam or implanted radioactive needles (brachytherapy); in advanced disease, castration or administration of estrogen (or an antiandrogen such as flutamide) to suppress tumor growth.

ADENOCARCINOMA OF THE COLON & RECTUM

Colon cancer

COLON CANCER

Risk factors 1. Increasing age 2. Family history 3. Previous colon CA or polyps 4. History of IBD 5. High fat, High protein, LOW fiber 6. Breast Ca and Genital Ca

COLON CANCER

Sigmoid colon is the most common site Predominantly adenocarcinoma If early 90% survival 34 % diagnosed early 66% late diagnosis

COLON CANCER

PATHOPHYSIOLOGY Benign neoplasm DNA alteration malignant transformation malignant neoplasm cancer growth and invasion metastasis (liver)

COLON CANCER

ASSESSMENT FINDINGS 1. Change in bowel habits- Most common 2. Blood in the stool 3. Anemia 4. Anorexia and weight loss 5. Fatigue 6. Rectal lesions- tenesmus, alternating D and C

Colon cancer

Diagnostic findings 1. Fecal occult blood 2. Sigmoidoscopy and colonoscopy w/ 3. BIOPSY 4. CEA- carcino-embryonic antigen 5. Barium enema demonstrates mucosal defects or a space-occupying lesion. 6. Abdominal CT scan, 7. Chest x-ray may show pulmonary metastases.

Colon cancer

Complications of colorectal CA 1. Obstruction 2. Hemorrhage 3. Peritonitis 4. Sepsis

Colon cancer

MEDICAL MANAGEMENT 1. Chemotherapy- 5-FU 2. Radiation therapy

Colon cancer

SURGICAL MANAGEMENT Surgery is the primary treatment Based on location and tumor size Resection, anastomosis, and colostomy (temporary or permanent) abdomino-perineal resection (removal of the entire lower bowel, including the anus) with sigmoid colostomy

Colon cancer
NURSING INTERVENTION Pre-Operative care 1. Provide HIGH protein, HIGH calorie and LOW residue diet 2.Provide information about post-op care and stoma care 3. Administer antibiotics 1 day prior

Colon cancer
NURSING INTERVENTION Pre-Operative care 4. Enema or colonic irrigation the evening and the morning of surgery 5. NGT is inserted to prevent distention 6. Monitor UO, F and E, Abdomen PE

Colon cancer
NURSING INTERVENTION Post-Operative care 1. Monitor for complications Leakage from the site, prolapse of stoma, skin irritation and pulmo complication 2. Assess the abdomen for return of peristalsis

Colon cancer
NURSING INTERVENTION Post-Operative care 3. Assess wound dressing for bleeding 4. Assist patient in ambulation after 24H 5.provide nutritional teaching Limit foods that cause gas-formation and odor Cabbage, beans, eggs, fish, peanuts Low-fiber diet in the early stage of recovery

Colon cancer
NURSING INTERVENTION Post-Operative care 6. Instruct to splint the incision and administer pain meds before exercise 7. The stoma is PINKISH to cherry red, Slightly edematous with minimal pinkish drainage 8. Manage post-operative complication

Colon cancer

NURSING INTERVENTION: COLOSTOMY CARE Colostomy begins to function 3-6 days after surgery The drainage maybe soft/mushy or semi-solid depending on the site

Colon cancer

NURSING INTERVENTION: COLOSTOMY CARE BEST time to do skin care is after shower Apply tape to the sides of the pouch before shower Assume a sitting or standing position in changing the pouch

Colon cancer

NURSING INTERVENTION: COLOSTOMY CARE Instruct to GENTLY push the skin down and the pouch pulling UP Wash the peri-stomal area with soap and water Cover the stoma while washing the peri-stomal area

Colon cancer

NURSING INTERVENTION: COLOSTOMY CARE Lightly pat dry the area and NEVER rub Lightly dust the peri-stomal area with nystatin powder

Colon cancer

NURSING INTERVENTION: COLOSTOMY CARE Measure the stomal opening The pouch opening is about 0.3 cm larger than the stomal opening Apply adhesive surface over the stoma and press for 30 seconds

Colon cancer

NURSING INTERVENTION: COLOSTOMY CARE

Empty the pouch or change the pouch when

1/3 to full (Brunner) to 1/3 full (Kozier)

Course: The overall survival rate in treated colon cancer is about 35%. If

complete resection of primary tumor can be carried out, survival rate is about 55%.

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