Care of the Clients with Cancer

Introduction
Cancer was recognized in ancient times by skilled
observers who gave it the name “CANCER” (Latin, Cancri,
crab) because it stretches out in many directions like the legs
of the crab.
Cancer occurs in all strata of our society. It afflicts all
people of all ages, all socio-economic and cultural
backgrounds and both sexes. It is much-dreaded disease. It
poses tremendous physiologic, psycho-social, cognitive,
spiritual and economic impact to the afflicted individuals
and their significant others.
 Cancer may spell death to some and mutilation to
others. The legends surrounding cancer (malignant disease)
often focusing on incurability, help foster feelings of
hopelessness and powerlessness. Nurses too, may have the
same negative attitudes that exist in the society. Therefore, it
is imperative for nurses to examine their own feelings and
try to work them through, both by increasing their
knowledge of the disease and its treatment by discussing
feelings openly with members of the health team. These will
enable the nurse help clients and their families.
 Nurses are involved in all phases of the cancer
experience: prevention, detection, diagnosis, treatment,
rehabilitation, survivorship and palliative terminal care.
Cancer nursing skills are vital in all healthcare setting
because clients are seen in the home, office, clinic, acute
care setting, rehabilitation setting and hospice.
Despite significant advances in detection, diagnosis
and treatment, cancer continues to be a significant health
problem. Perhaps, the greatest role any nurse can play is
assisting individuals in the prevention and early detection of
cancer. Cancer nursing is a challenge to the creativity, skill
and commitment of the nurse.
Learning Outcomes
At the end of this chapter, the learner should be
able to:
1. Identify the nurse’s roles in the prevention of cancer
and in health education.
2. Discuss the pathophysiology of cancer and its clinical
manifestations.
3. Apply the nursing process to identify care of the client
in the diagnosis and treatment phase of cancer.
4. Formulate plan of care for the client with early stage
and advanced cancer.
5. Value the nurse’s role in providing the quality,
comprehensive, individualized, ethical and humane
care of clients with cancer.
Terminologies Related to Cancer Nursing
• Cancer. A disease of the cell in which the normal
mechanisms of the control of growth and
proliferation have been altered. It is invasive,
spreading directly to surrounding tissues as well as to
new sites in the body. Also called malignant
neoplasm.
• Benign neoplasm. A harmless growth that does not
spread or invade other tissues.
• Neoplasia. Abnormal cellular changes and growth of
new tissues.
• Hyperplasia. Increase in cell number.
• Hypertrophy. Increase in cell size.
• Metaplasia. Replacement of one adult cell type by a
different adult cell type.
• Dysplasia. Change in cell size, shape, organization.
• Anaplasia. Reverse cellular development to a more
primitive or embryonic cell type.
• Metastases. Spread of cancer cells to distant parts of the
body to set up new tumors.
• Oncology. The medical specialty that deals with the
diagnosis, treatment and tumor.
• Adenocarcinoma. Cancer that arises from glandular
tissues. Examples: cancer of the breast, lung, thyroid,
colon and pancreas.
• Carcinoma. A form of cancer that is composed of epithelial cells;
develops in tissues covering or lining organs of the body such as
skin, uterus, or breast.
• Sarcoma. A cancer of supporting or connective tissues such as
cartilage, bones, muscles, or fats.
• Carcinogens. Factors associated with cancer causation. Example.
Radiation, chemicals, viruses, physical agents.
Pathogenesis of Cancer
• Cellular Transformation and Derangement Theory.
 Conceptualizes that normal cells may be transformed into cancer
cells due to exposure to some etiologic agents.
• Failure of the Immune Response Theory
 Advocates that all individuals possess cancer cells. However, the
cancer cells are recognized by the immune response seystem. So, the
cancer cells undergo destruction. Failure of the immune response
system leads to inability to destroy the cancer cells
Ethiologic Factors to Cancer

Viruses

Chemical carcinogens

Physical agents

Hormones

Genetics
• Viruses
 “Oncogenic viruses” may be one of the multiple agents
acting to initiaye carcinogenesis.
 Prolonged or frequent viral infections may cause
breakdown of the immune system or overwhelm the
immune sysytem.
 Viral infections that increase risk of certain forms of
cancer are as follows:
1. Human papilloma virus –cervical cancer
2. Epstein –Barr virus –lymphoma
3. Hepatitis B and C – hepatocellular cancer
4. Helicobacter pylori – gastric cancer
• Chemical Carcinogens
 These factor act by causing cell mutation or alteration in
cell enzymes and proteins causing altered cell replication.
 Chemical carcinogens are as follows:
1. Industrial Compounds
-Vinyl chloride (used for plastic manufacture, asbestos
factories, construction works).
-Polycyclic aromatic hydrocarbons (such as from refuse
burning, auto and truck emissions, oil refineries, air
pollution).
-Fertilizers, weed killers
-Dyes (analine dyes used in beauty shops, hair bleach)
2. Drugs
-Tobacco (tar nicotine), 90% of all cases of lung cancer are due to
smoking
-Alcohol
-Cytotoxic drugs
3. Hormones
-Estrogen
-Diethylstilbestrol (DES)
4. Foods, preservatives
-Nitrates (bacon, smoked meat)
-Talc (polished rice, salami, chewing gum)
-Food sweeteners
-Nitrosamines (rubber baby nipples)
 -Aflatoxins (mold in nuts and grains, milk, cheese, peanut
butter)
5. Polycyclic hydrocarbons
-charcoal broiling
• Physical Agents
1. Radiation: from X-rays or radioactive isotopes: from
sunlight / ultraviolet rays
2. Physical irritation / trauma: from pipe smoking, multiple
deliviries, jagged tooth, irritation of the tonque, “overuse
of any organ/ body part.
• Hormones
 Estrogen as replacement therapy has been found to
increase incidence of vaginal, cervical, uterine cancers.
• Genetics
 When oncogene (hidden or repressed genetic code for
cancer that exists in all individuals) is exposed to
carcinogens in cell structure occurs, maliginogens, tumor
individuals.
 Regardless of the cause, several cancers are associated
with familial patterns. Examples: retinoblastoma,
peochromocytoma, Wilm’s tumor, lung cancer, breast
cancer.
Predisposing Factors to Cancer
Age
Sex
Urban Residence
Geographic Distribution
Occupation
Heredity
Stress
Precancerous Lesions
Obesity
• Age
 Older individuals are more prone to cancer because they
have been exposed to carcinogens longer. In addition,
they have developed alterations in the immune systems.
• Sex
 The most common type of cancer in females is breast
cancer. Whereas, the most common type of cancer in
males is prostate cancer.
• Urban vs. Rural risedence
 Cancer is more common among urban dwellers than
among rural residents. This is probably due to the greater
exposure to carcinogens, more stressful lifestyle and
greater consumption of preservative- cured foods among
urban dwellers.
• Geographic Distribution
 The most common type of cancer in Japan is gastric
cancer. While the most common type of cancer in the US
is breast cancer. This may be due to influence of
environmental factors as national diet (raw foods greatly
consist Japanese diet), types of pollutions.
• Occupation
 E.g., there is greater risk of exposure to carcinogens
among chemical factory workers, farmers, radiology
department personnel.
• Heredity
 Positive family history of cancer
• Stress
 Depression, grief, anger, aggression, despair, or life
stresses decrease immunocompetence because of
affectation of hypothalamus and pituitary gland.
Immunodeficiency may spur the growth and proliferation
of cancer cells.
• Precancerous Lesions
 Pigmented moles, burn, scars, senile keratosis,
leukoplakia, benign polyps or adenoma of the colon or
stomach, fibrocystic disease of the breast, may undergo
transformation into cancerous lesions and tumors.
• Obesity
 Studies have linked obesity and colorectal cancer.
 Comparison of the Characteristics of Benign and
Malignant Neoplasm
Characteristic Benign Malignant
1.Speed of Growth Grows slowly. Grows rapidly.
2.Mode of Growth Remains localized. Infiltrates surrounding tissues
3.Capsule Encapsulated. Not Encapsulated.
4.Cell CharacteristicWell-differentiated
mature cells; but cells Poorly defferentiated; anaplastic/embryonic type of
poorly function. Cells.
5.Recurrence Extremely unusual Common following surgery beacause cancer cells
when surgically spread into other tissues’
removed.
6.Metastasis Never occur. Very common.
7.Effects of NeoplasmNot harmful to host Always harmful to host. May results in nec-
unless it compres- rosis, ulcerations, hemorrhage infection.
ses tissues or obs-
ruct vital organs.
8.Prognosis Very good. Poor prognosis if cells are poorly diff. and evidence
metastasis exists.
Prevention, Screening, and Early Detection
1. Prevention
 Primary prevention activities are aimed at intervention
before pathologic change has begun. These can help to
reduce cancer risk through alteration of lifestyle
behaviors to eliminate or reduce exposure to carcinogens,
e.g,. Adapting a more healthy diet, limiting exposure to
sun and other sources of ultraviolet radiation, modifying
sexual practices, avoiding cigarette smoking and alcohol
drinking , decreasing exposure to environmental and
occupational carcinogens.
 Summary of American Cancer Society (ACS)
Recommendations for the Early Detection of Cancer in
Asymptomatic People
1. Cancer- related check – up. Is recommended every 3
years for people aged 20-40 years and every year for
people age 40 and older.
2. Breast- Women who are 40 years and older should have
an annual mammogram, an annual clinic breast exam
(CBE) performed by a health care professional, and
should perform monthly breast self examination (BSE).
Women aged 20- 39 should have CBE every three years
and should perform monthly BSE.
3. Colon and Rectum- Men and women aged 50 years or
older should follow one of the ff. examination
scheduled.
 Fecal occult blood tests every year and a flexible
sigmoidoscopy every 5 years.
 Colonoscopy every 10 years.
 Double – contrast barium enema every 5 to 10 years.
 Digital rectal exam should be done at the same time
as sigmoidoscopy, colonoscopy or double – contrast
barium enema.
4. Prostate. Prostate- specific antigen (PSA) blood test
and digital rectal examination (DRE), annually from
aged 50.
5. Uterus
 Cervix- All women who are or have been sexually active
or who are 40 and older should have an annual Pap test
and pelvic examination. After 3 or more consecutive
satisfactory examinations with normal findings, the Pap
test may be performed less frequently. Test for human
papilloma virus (HPV) is recommended.
 Endometrium- Women at high risk for cancer of the
uterus should have a sample of endometrial tissue
examined when menopause begins.
Common Causes of Cancer
1.Breast Cancer
 Early menarche
 Late menopause
 Nulliparous or older than 30 years at the birth of a first child.
2.Lung Cancer
 Tobacco abuse
 Asbestos
 Radiation exposure
 Air pollution
3.Colorectal Cancer
 Greater incidence in men
 Familial polyposis
 Ulcerative colitis
 High –fat, low- fiber diet.
4.Prostate Cancer
 Common among males who are 50 years old and older.
 African Americans have the highest incidence of prostate
cancer in the world
 Positive family history.
 Exposure to cadmium.
5. Cervical Cancer
 Sexual behavior
- First intercourse at an early age.
- Multiple sexual partners.
- Sexual partner has had multiple sexual partner.
 Human papilloma virus and AIDS
 Low socioecenomic status
 Cigarette smoking
6. Head and Neck Cancer
 More common among males.
 Alcohol and Tobacco use.
 Long term sun exposure.
 Occupational exposures – asbestos, tar, nickel, textile, wood,
or leather work, and machine tool exposure.
7. Skin Cancer
 Individuals with fair complexion.
 Possitive family history.
 Moles (nevi)
 Exposure to coal tar, creasote, arsenic, radium
 Sun exposure between 11 AM to 3 PM.
 Dietary Recommendations against Cancer by American
Cancer Society
• Avoid obesity.
• Cut down on total fat intake.
• Eat more high fiber foods, like raw fruits and vegetables,
whole grain cereals
• Include foods rich in Vitamin A and C in daily diet.
• Include cruciferous vegetables in the diet, like broccoli,
cabbage, cauliflower, Brussel sprouts.
• Be moderate in the consumption of alcoholic beverages.
• Be moderate in the consumption of salt- cured, smoked –
cured and nitrite- cure foods.
 High intake of fats may be associated with breast, colon, and
prostate cancer.
 Low intake of fruits, vegetables, complex carbohydrates and
fibers is linked with cancer of the colon, larynx, esophagus,
prostate, bladder, stomach and lungs.
 Salt – cured foods are associated of the esophagus and
stomach.
 Excess alcohol intake is associated with cancer of the mouth,
larynx, esophagus, and liver especially when combined with
smoking
Warning Signals of Cancer
• C- change in bowel or bladder habits
• A- sore that does not heal
• U- unusual bleeding or discharge
• U- unexplained sudden weight loss
• U- unexplained anemia
• T - thickening or lump in the breast or elsewhere
• I - indigestion or difficulty in swallowing
• O- obvious change in wart or mole
• N- nagging cough or hoarseness of voice
Staging and Grading of Neoplasia
• Staging is determining the size of the tumor and existence of
metastasis.
• Grading is classification of tumor cells.
• Staging is necessary at the time of diagnosis to determine the
extent of disease, to determine prognosis and to guide proper
management.
• The American Joint Committee for Cancer (AJCC) has
developed the TNM classification system that can be applied
to all tumor types.
T- tumor size
N- presence or absence of regional lymph node
involvement
M- presence or absence of distant metastasis
Cancer Detection Examinations
1. Cytologic Examination or Papanicolaou Test (Pap’s Exam,
Par Smear)
 Cytologic specimen can be obtained from tumors that tend to
shed cells from their surface, e.g., G.I tract through endoscopy;
reparatory tract through laryngoscopy and bronchoscopy;
genito – urinary tract through coloscopy of the cervix and
vagina, cystoscopy of the bladder, laparoscopy of the pelvic
and abdominal cavity.
 Interpretation of Papanicolaou Test results are as follows:
 Class I. Normal
 Class II. Inflammation
 Class III. Mild to Moderate Dysplasia
 ClassIV. Probably Malignant
 Class V. Possibly Malignant
2. Biopsy. Involves obtaining tissue samples by needle aspiration, or
incision of tumor.
 Needle biopsy is done by aspiration of tumor cells with needle and
syringe.
 Excisional biopsy is done by removing the entire tumor. It is done
when tumor is small.
 Incisional or subtotal biopsy is done by taking only a part of tumor.
This done when the tumor is large.
3. Ultrasound, Magnetic Resonance Imaging (MRI), Radiodiagnostic
Tests, Computerized Axial Tomography (CT Scan), Endoscopic
Examinations.
4.Laboratory Blood Tests for Cancer
 Hematologic (CBC)
 Hemoglobin
 Hamatocrit
 Leukocytes
 Platelets
 Tumor Markers
 AFP (Alpha – feto – protein)
 CEA (Carcinoembryonic Antigen)
 HCG (Human Chronic Gonadotropin)
 Prostatic Acid Phosphatase
 PSA (Prostatic Specific Antigen)
 Hemoglobin and hematocrit are low in anemia; may indicate malignancy.
 Leukocytes (wbc’s) are high in leukemia (immature wbc’s), lymphomas;
low in leukemia (mature wbc’s) and metastatic disease to bone marrow.
 Platelets are high in CML ( Chronic myelocytic leukemia), Hodgkin’s
disease; low in ALL (acute lymphocytic leukemia, AML (acute myelocytic
leukemia), multiple myeloma, bone marrow depression.
 AFP is elavated in lung, testicular, pancreatic, colon, gastric cancers and
choriocarcinoma.
 CEA is elevated in colorectal, breast, lung, stomach, pancreatic, and
prostate cancers.
 HCG is elevated in choriocarcinoma, germ cell testicular cancer, ectopic
production in lung, liver, gastric, pancreatic, and colon cancers.
 Prostatic acid phosphates is elevated in metastatic prostate cancer.
• The different predisposing factors and etiologic factors (refer to earlier
discussions) cause cellular aberrations.
• Cellular aberrations result to the following:
1. Cancer cell proliferation.
2. Paraneoplastic syndrome.
3. Anorexia- cachexia syndrome.
• Cancer cell proliferation disrupts normal cell growrth and interfere with
tissue function, and result to the following;
1. Pressure. Due to increase in size of neoplastic growth.
2. Obstruction. As tumor continues to grow, hollow organs, and vessels
become compressed and obstructed.
3. Pain
 Due to
 Pressure in nerve endings.
 Distention of organs / vessels.
 Lack of oxygen to tissues and organs.
 Release of pain mediators by the tumor.
 A late signs of cancer
4. Effusion
 When lymphatic flow is obstructed, there may be effusion
in serous cavities.
 E.g. effusion into the pleural cavity: pleural effusion;
effusion into the abdominal cavity: ascites.
5. Ulceration and Necrosis
 Results as the tumor erodes blood vessels and pressure on
tissue causes ischemia-tissue damage and bleeding-
infection.
6. Vascular Thrombosis, Embolism, Thrombophlebitis
 Tumors tend to produce abnormal coagulation factors that
caused increased clotting (pulmonary embolism)-life-
threatening).
Paraneoplastic Syndrome- malignant cells produce enzymes,
hormones and other substances.
 Anemia
 Ca cells produce chemicals that interfere with rbc production.
 Iron uptake is greater in the tumor than that deposited in the liver.
 Blood loss that results from bleeding leads to anemia.
 Hypercalcemia
 Tumors of the bone, squamous cell lung cancer, cancer of the
breast, produce a parathyroid- like hormone that increases or
accelerates bone breakdown and release of calcium.
 Also results from metastasis to the bones.
 Enhance by immobilization and dehydration.
 DIC (Dessiminated Intravascular Coagulation)
 More likely to occur in cancer of the lungs, pancreas, stomach,
prostate.
 Precipitated by the release of the tissue thromboplastin or
endothelial injury.
• Anorexia – Cachexia Syndrome
 The final outcome of unrestrained cancer cell growth.
 Malignant neoplasms deprive normal cells of nutrition.
 Tumors take up sodium. Water retention masks
malnutrition and is not immediately reflected as weight
loss.
 Ca cells produce anorexigenic substance that act in the
satiety center of the hyhypothalamus, causing anorexia.
 Taste sensation diminishes or becomes altered and the
individual may have eversion to eating, particularly meat.
Specifically, meat tastes bitter among clients with cancer.
Treatment Modalities for Cancer

Surgical Interventions
Radiation Therapy
Chemotherapy
Immunotherapy
Bone marrow Transplantation
• Surgical Interventions
1.Diagnostic Surgery. This is done by cytologic specimen
collection and biopsy.
2.Preventive Surgery. This involves removal of
precancerous lesions or benign tumors.
3.Curative Surgery. This involves removal of an entire
tumor and surrounding lymph nodes are potentially curable
by surgery.
4.Reconstructive Surgery. This is done for improvement of
the appearance and function of the organ affected.
5.Palliative Surgery. This is done for relief of distressing
signs and symptoms or for retardation of metastasis.
• Radiation Therapy (RT)
 Radiation therapy may be used as a primary, adjuvant, or a palliative
treatment modality.
 As an adjuvant therapy, RT can be done preoperatively or
postoperatively to aid in destruction of cancer cells. In addition, it
can be used in conjunction with chemotherapy to enhance
destruction of cancer cells.
 As a palliative therapy, RT can be used to relieve pain caused by
obstruction, pathologic fractures, spinal cord compression and
metastasis.
 Radio sensitivity, the relative sensitivity of tissues to radiation,
depends on the individual cell and the characteristics of the tissue
itself.
 RT is the use of high – energy ionizing radiation that destroys a
cell’s ability to reproduce by damaging its DNA.
 Rapidly devising cells like cancer cells are more vulnerable to
radiation. Therefore, radiation kills cancer cells while sparing
normal cells from excessive cell death.
 The types of radiation therapy are as follows:
1. External Radiation Therapy (Teetherapy, DXT). This is
administered through a high – energy X-ray or gamma
x-ray machine containing radioisotope).
 The major advantage of high – energy radiation is its skin
– sparing effect. The maximum effect of radiation occurs
at tumor deep in the body, not on the skin surface.
 There is no need for isolation.
2. Internal Radiation Therapy. This is administered within or
near the tumor or into the systemic circulation.
 The major types of internal RT are as follows:
a. Sealed source (brachytherapy). The radioisotope is placed
within or near the tumor. The radioactive material is
enclosed in sealed container.
Principles of Radiation Protection – DTS
1. D-istance. The greater the distance from the radiation
source, the less the exposure dose of ionizing rays. Maintain
a distance of at least 3 feet when not performing nursing
procedures.
2. T-ime. Limit contact with the client for 5 minutes each
time, a total of 30 minutes per 8 –hour shift.
3.S-hielding. Use lead shield during contract with client.
 Pregnant staff should not be assigned to clients receiving
internal RT.
 Staff members caring for the client with internal RT
should wear dosimeter badge while in the client’s room.
 To prevent feelings of isolation, maintain contact with the
client while keeping distance from radiation exposure.
Teaching Guidelines Regarding External Radiation Therapy
1. It is painless
2. Lie very still on a special table while the intervention is being
given and you may be placed in a special position to maximize
tumor irritation
3. Each treatment lasts for few minutes. You may hear sounds of the
machine being operated, and the machine may move during the
therapy.
4. As a safety precaution for the therapy personnel, you will remain
lone in the treatment room while the machine is on operation
5. The technologist will be right outside your room observing you
through a window or by a closed-circuit TV. You may
communicate.
6. There is no residual radioactivity after radiation therapy. Safety
precautions are necessary only during the time you are actually
receiving irradiation. You may resume normal activities of daily
living
Client Education on Skin Care In External Radiation Therapy
Skin care within the treatment area includes the following
 Keep your skin dry.
 Do not wash the treatment area until you are instructed to do so. When
permitted, wash the treated skin gently with mild soap, rinse well, and
pat dry. Use warm water or cool water, not hot water
 Do not remove the lines or ink marks placed on your skin
 Avoid using powders, lotions, creams, alcohol and deodorants on the
treated skin
 Wear loose- fitting clothing to avoid friction over the treatment area
 Do not apply tape to the treatment area if dressings are applied
 Shave with an electric razor. Do not use pre-shave or after- shave lotions
 Protect your skin from exposure to direct sunlight, chlorinated swimming
pool, and temperature extremes (e.g., hot water bottles, healing pads, ice
packs)
 Consult your radiation therapist or nurse about specific measures for
individual skin reaction.
Nursing Intervention for Side Effects of Radiation Therapy
1. Skin reactions
 Erythema, dry/moist desquamation
 Atrophy, telangiectasia, depigmentation, necrotic/ulcerative lesions.
 Nursing Interventions
 Observe for early signs of skin reaction and report to the physician
 Keep area dry
 Wash area with water, no soap, and path dry (do not rub). Mild soap is
permitted
 Do not apply ointments, powders or lotion on the area. Cornstarch may
be used
 Do not apply heat; avoid direct sunshine or cold on the area
 Use soft cotton fabrics for clothing. To prevent skin irritation.
 Do not use erase markings on the skin. These serve as guide for areas of
irradiation.
2. Infection
 This is due to bone marrow suppression
 Nursing Intervention
 Monitor blood counts weekly, especially WBC.
 Good personal hygiene, nutrition, adequate rest.
 Teach the client signs of infection to report the physician
3. Hemorrhage
 Platelets are vulnerable to radiation
 Nursing intervention
 Monitor platelet count
 Avoid physical trauma or use of aspirin (ASA)
 Teach signs of hemorrhage to report (e.g, gum bleeding, nose bleeding,
black stools).
 Monitor stool and skin for signs of hemorrhage
 Use direct pressure over injection sites until bleeding stops.
4. Fatigue
 Result of high metabolic demands for tissue repair and toxic waste
removal
 Plenty rest and good nutrition
5. Weight loss.
 Anorexia, pain and effect of cancer
6. Stomatitis and Xerostomia (Dry mouth)
 Ulceration of the mucous membrane occurs
 Nursing intervention
 Administer analgesics before meals, as ordered
 Bland diet, avoid smoking and alcohol
 Good oral hygiene with saline rinses every 2 hours
 Sugarless lemon drops or mint to increase salivation
7. Diarrhea, nausea and vomiting, headache, alopecia, (hair loss) and cytitis
may also occur
8. Social isolation is also experienced by the client due to fear of containing
others with radiation.
Chemotherapy
 The goal of chemotherapy may be cure, control, or palliation of
manifestation. It is a systemic intervention. It is recommended when:
 Disease is widespread
 The risk of undetectable disease is high
 The tumor cannot be respected and is resistant to RT
 The objective of chemotherapy is to destroy all malignant tumor cells
without excessive destruction of normal cells.
 Chemotherapy has the following characteristics
 It affects both normal and cancer cells. The rapidly dividing cells, both
the normal and cancer cell are vulnerable to destruction by chemotherapy
by disrupting cell function and division. Mucous membrane, blood cells,
hair follicles, skin cells are rapidly dividing cells. Side effects of
chemotherapy tend to occur in these structures.
 Chemotherapy has friction cell- kill. Only a certain number of cancer
cells are killed with each course of chemotherapy. Therefore,
chemotherapy must be given in a series.
• Chemotherapy may be cell- cycle (CCS) or cell- cycle non-specific
(CCNS). CCS chemotherapy may destroy cancer cells at specific stage of
cell division. CCNS chemotherapy may destroy cancer cells at any stage
of cell division. Thus, combination chemotherapy destroys more
malignant cells and produces fewer side effects because each drug strikes
the cancer cell at different stages in the cell cycle
• Classification of Chemotherapeutic Agents.
1. Cell Cycle-Specific Groups
a. Antimetabolites
Cytarabine (Ara-C, Cytosar)
5 Fluorouracil (5FU)
6- Mercaptopurine (6-MP, Purinethol)
Methotrexate (Maxate)
6- Thioguanine (6-TG)
Fludarabine (Fludura)
Pentotastin ( Nipent)
b. Vinca Alkaloids
Vinorelbine (Navaldine)
Vincristine (Oncovin)
Vinblastine (Velban)
c. Epipodophyllotoxins
Etoposide (VP-16)
Teniposide (VM-26, Vumon)
d. Taxanes
Paclitaxel (Taxol)
e. Miscellaneous
L-Asparanginase
2. Cell Cycle-Nonspecific Groups
a. Alkalyting Agents
Busulfan (Mylegran)
Carboplatin (Paraplatin)
Cisplatin (CDDP, Platinol-AQ)
Ifostamide (Ifex)
Thiotepa
b. Antitumor Antibiotics
Chlorambucil (Leukeran)
Bleomycin (Blenoxane)
Dactinomycin (Cosmegen)
Daunorubicin (Cerubidine)
Mitomycin C (Mitomycin)
Mitoxantrone (Novantrone)
Pilcamycin (Mithracin)
c. Hormonal Therapy
Glucocorticoids
Prednisone (Deltasone)
Methylprednisolone (Solu-Medrol,Medrol)
Dexamethasone (Decadron)
Estrogen
Chlorotrianisene (Tace)
Diethylstilbestrol (DES)
Estradol (Estrace)

Antiestrogen
Tomaxifen (Nolvadex)

Progestins
Depo-Provera
Megastrol acetate (Megace)
Leuprolide (Lupron)

Nitrosources
Carmustine (BCNU)
Lomustine (CCNU), Stretozocin (Zanosar)
Routes of Administration of Chemotherapy
1. Intravenous Chemotherapy
 Extravasation (escape from the vein) of some chemotherapeutic agents
can cause tissue necrosis in the area.
 Use of vascular access devices (VADs) are now preferred as a venous
access. This provides continuous chemotherapy, multiple access, route
for administration of parenteral fluids, antibiotics, and frequent blood
testing.
 VAD’s) can be implanted (e.g. Port-A-Cath), central line (e.g. tunneled
and non-tunneled) and peripherally inserted central catheters (PICC
lines)
 The most commonly reported complications of VADs are infection and
obstruction. (each institution provides protocol or care of VADs, e.g,
change of dressing, flushing, blood draw, etc.)
2. Regional Chemotherapy
 Allows high concentrations of drugs to be directed to localized tumors.
 The methods are as follows:
1. Topical
 Fluorouracil cream may be applied to the skin to treat actinic keratones.
2. Intra-arterial
 Intraarterial infusion enable major organs or tumor site to receive maximal
exposure with serum levels of medications.
3. Intracavity
 Intracavity therapy instills the medication directly into an area such as the
abdomen, bladder, or pleural space
4. Intraperitoneal
 Intraperitoneal chemtherapy is done for cancer in the intra-abdominal area, e.g,
ovarian cancer. This allows high concentration of a chemotherapeutic agents to be
delivered to the actual tumor site with minimal exposure of healthy tissue
5.Intrathecal
 Intrathecal chemotherapy involves instilling chemotherapeutic agents into the
CNS through a reservoir placed in the ventricle via an Omnaya reservoir or via
lumbar puncture. This is done because most medications given systematically are
not effective against CNS tumors because they cannot cross the blood-brain
barrier
Contraindication of Chemotherapy are as follows
 Infection. The anti- tumor drugs are immunosuppressive.
 Recent surgery. The drugs may retard healing process.
 Impaired Renal or Hepatic function. The drugs are nephrotoxic and
hepatotoxic.
 Recent radiation therapy. Also immunosuppressive
 Pregnancy. The drugs may cause congenital defects
 Bone marrow Depression. The drugs may aggravate the condition. The
WBC levels must be within normal limits.
Safe Handling of Chemotherapeutic Agents
1. Wear mask, eye shield, gloves and back-closing gown
2. Skin contact with drug must be washed immediately with soap an water.
Eyes must be flushed immediately with copious amount of water.
3. Sterile/alcohol- wet cotton pledgets should be used, wrapped around the
neck of the ampule or vial when breaking and withdrawing the drug.
4. Expel air bubbles on wet cotton.
5. Vent vitals to reduce internal pressure after mixing
6. Wipe external surface of syringes and IV bottles
7.Avoid self-inoculation by needle stab.
8. Clearly label the hanging IV bottle with “ANTINOPLASTIC
CHEMOTHERAPY”
9. Contaminated needles and syringes must be disposed in the clearly
marked special container. “leak –proof”. “puncture-proof”
10. Dispose half-empty ampules, vials, IV bottles by putting into plastic
bag, seal and then into another plastic bag or box, clearly marked before
placing for removal. Label as “Hazardous waste”
11. Handwashing should be done before and after removal of gloves
12. Only trained personnel should be involved in use of drugs (preferably,
chemotherapy certified nurses)
13. Ideally, preparation of chemotherapeutic drugs should be in laminar
flow conditions with filtered air to prevent contamination with
microorganisms.
Nursing Intervention for Chemotherapy Side-Effects
1. GI. Sytem-nausea and vomiting, diarrhea, constipation
 Administer antiemetic to relieve nausea and vomiting
 Replace fluid- electrolytes losses, low- fiber diet to relieve diarrhea.
 Increase fluid intake and fibers in the diet to prevent/relieve constipation
2. Integumentary System
 Pruritus, urticaria and systemic signs
 Provide good skin care
 Stomatitis (oral mucositis)
 Provide good oral care
 Avoid hot and spicy food
 Alopecia
 Reassure that it is temporary.
 Encourage to wear wigs, hats or head scarf
 Skin pigmentation
 Inform that it is temporary
 Nail Changes
 Reassure that nails may grow normally after chemotherapy

3. Hematopoietic System
 Anemia
 Provide frequent rest periods
 Neutropenia
 Protect from infection
 Avoid people with infection
 Report fever, chill, diaphoresis, heat, pain, erythema, or exudates on any
body surface
 Avoid rectal or vaginal procedures
 Avoid fresh fruits, raw meat, fish, vegetables, fresh flowers, potted plants
 Change IV sites every other day
 Change all solution and IV infusion sets every 48 hours.
 Thrombocytopenia
 Protect from trauma
 Avoid ASA.
 Nadir. Is the time after chemotherapy administration when WBC or
platelet count is at the lowest point. It occurs within 7 to 14 days after
drug administration
4. Genito-Urinary System
 Hemorrhagic cystitis
 Provide 2-3L of fluids per day
 Urine color changes
 Reassure that it is harmless
5. Reproductive System
 Premature menopause or amenorrhea
 Reassure that menstruation resumes after chemotherapy
Antiemetics to Relieve Nausea and Vomiting Related to Chemotherapy
 Dronabinol (Marinol)
 Ordansetron (Zofran)
 Granisetron (Kytril)
 Alprazolam (Zanax)
 Lorazepam (Ativan)
 Haloperidol ( haldol)
 Prochlorperazine (Compazine)
Adverse Reaction to chemotherapy are as follows.
1. Hypersensitivity reaction
 The clinical manifestation are as follows
a. Dyspnea
b. Chest tightness or pain
c. Pruritus (itching)
d. Urticaria (wheals)
e. Tachycardia
f. Dizziness
g. Anxiety
h. Agitation
i. Inability to speak
j. Abdominal pain
k. Nausea
l. Hypotension
m. Cloudy mental status
n. Flushed appearance
o. Cyanosis

 If anaphylactic reaction occurs, the ff. interventions are implemeted

a. Stop the drug administration
b. Maintain IV access with 0.9% NS (NaCl)
c. Keep open airway
d. Keep client in modified Trendelenburg position (supine with legs
elevated at 20 to 30 degree), unless contraindicated
e. Notify the physician
f. Monitor the clients vital sign until he is stable
g. Administer epinephrine , aminophylline, diphenhydramine and
corticosteroids as prescribed

2. Extravasation
 Vesicant chemotherapeutic agents can cause or form a blister and cause
tissue destruction. E.g., Adriamycin(Doxorubicin), Oncovin
(Vincristine).
 Irritant drug can produce venous pain at the site and along the vein.
 Pain, erythema, swelling and lack of blood retum indicates an
extravasation
 Nursing intervention
 Stop the drug administration
 Leave the needle in place, and attempt to aspirate any residual drug from
the tubing, needle, and site.
 Administer an antidote, as prescribed. Then remove the needle
 Apply warm or cold compresses as indicated
 Documents the appearance of the site before and after chemotherapy
Oncologic Emergencies
1. Infection and Pain
 Infection arises from neutropenia. People with advanced cancer have pain.
Severe infection and pain can interfere with the person’s ability to enjoy
quality life. Pain management is the priority in care of clients with
advanced cancer.
2. Hypercalemia
 This is due to bone resorption (demineralization). Serum calcium greater
than 11mg/dl
 It is usually occurs in solid tumors like breast, lung, head, neck and renal
cancer. It may also occur in hematologic cancer like multiple myeloma,
leukemia.
 Severe hypercalemia may lead to renal failure, coma, cardiac arrest and
death.
 Calcitation (Maiacalcin) and oral glucocorticoids are given to lower serum
calcium.
3. Tumor Lysis Syndrome
 The destruction of large number of malignant cells may rapidly release
intracellular potassium, phosphorous and nucleic acid into the
circulation.
 Electrolyte imbalances and acute renal failure may occur.
 Clients with malignancies that are very responsive to treatment are at
highest risk, especially if they have large number tumor burden
(lymphomas, leukemias and small cell carcinoma)
 The clinical manifestation of tumor lysis syndrome are as follows:
1. Weakness
2. Nausea
3. Diarrhea
4. Flaccid paralysis
5. ECG changes
6. Muscle cramps or twitching
7. Oliguria
8. Hypotension
9. Edema
10. Altered mental status
 Collaborative management for tumor lysis syndrome include the ff:
1. Intravenous hydration
2. Allopurinol to decrease uric acid concentration
3. Sodium bicarbonate with IV hydration to promote fecal excretion of
excess phosphate
4. Lowering of serum potassium levels with medications, retention
enemas, IV 50% dextrose

4. SAIDH results from the abnormal production of antidiuretic hormone

(ADH). This may be caused by small cell lung cancer, infection, pulmonary
disorders, emotional stress, CNS disorders and some drugs, including
antineoplastic agents like Cytoxan (Cyclophosphamide), Oncovin
(Vincristine), Velban (Vinblastin), Platinol-AQ (Cisplatin)
 SIADH is manifested by water retention and decrease in sodium
 The signs and symptoms of SAIDH are as follows
1. Cofusion
2. Irritability
3. Headache
4. Muscle weakness
5. Lethargy
6. Decreased urine output
7. Edema
8. Nausea and vomiting
9.Anorexia
 The collaborative management of SAIDH are as follows:
1. Fluid excretion (diuretic)
2. IV infusion of hypertonic saline (35 to 5%) if severe, to prevent
pulmonary edema.
3. Monitor intake and output
4. Administer medications like Declomycine (demeclocycline)
5. Disseminated Intravascular Coagulation (DIC)
 This condition is characterized by development of extensive, abnormal
clots in the microcirculation (small blood vessel). The widespread
clotting depletes the general circulation with clotting factors and
platelets, leading to excessive bleeding in different sites of the body.
 Clots that are obstruction the circulation decrease blood flow to major
organs, causing pain, stroke-like manifestation, dyspnea, tachycardia,
oliguria, bowel necrosis.
 In clients with cancer, DIC is usually caused by gram-negative infection
or sepsis, release of clotting factors from cancer cells, or blood
transfusion.
 DIC is most commonly associated with leukemia and adenocarcinomas
of the lung, pancreas, stomach and prostate
 Diagnostic findings that support DIC are prolonged prothrombin time
and activated partial thromboplastin time, very low platelet count and
prolonged clotting times
 The medical management for DIC are as follows:
1. Correction of the basic problem (e.g., infection ).
2. Administer blood products and medication as prescribed
3. IV heparin if with manifestations of thrombosis (although,
controversial)
4. Monitor the client for signs and symptoms if bleeding

6. Spinal Cord compression

 It is caused by direct pressure on or compromise of vascular supply to the
spinal cord
 Back pain is often only presenting clinical manifestation in majority of
clients
 This may result to irreversible neurologic damage with paralysis and loss
of bowel and bladder control
 Treatment is usually RT. A laminectomy may be an alternative. Steroids
may be given to reduce inflammation and swelling around the spinal
cord.
7. Superior Vena Cava Syndrome (SVC)
 It results from external and internal obstruction of the superior vena cava.
The obstruction reduces venous retum to the heart and decreases cardiac
output.
 SVC syndrome is usually secondary to lung cancer or lymphoma.
 The clinical manifestations of SVC syndrome are as follows:
1. Dyspnea
2. Facial swelling
3. Jugular vein distention
4. Sitting up and learning forward to breathe
5. Selling of arms, chest pain, dysphagia
 External-beam RT and curative chemotherapy are used for palliation
8. Cardiac Temponade
 Fluid collects in the pericardial sac (pericardial effusion), it leads to
cardiac temponade
 Pericardiocentesis may be performed to draw off the fluid.
Other Treatment for Cancer
 Biotherapy. Is the use of biologic response modifiers (BRM’s) eg.,
Interferons, Interleukines
 Hematopoietic Growth Factors. eg;., Erythropoietin, Nuepogen,
Neumega
 Monoclonal antibodies
 Bone marrow transplantation
 Psychosocial Aspects of Cancer Care
1. Provide support for the client- your presence, empathy, positive regard.
2. Provide support for the family
3. Promote positive self-concept
4. Promote coping with the cancer experienced
 Hospice care is now trend in the care of clients with terminal cancer (for
those with prognosis of having lifespan of 1 to 6 months)
 The basic characteristics of a hospice program are:
1. Control of manifestation, including pain relief
2. Treatment of the client and family as a unit
3. Provision of care by an interdisciplinary team
4. 24-hour, 7-days-a-week services
5. Coordinated homecare with back- up in patient services
6. Use of trained volunteers to augment staff services.
7. Spiritual support
8. Bereavement follow-up
9. Services given on the basis of need and not on the ability to pay.
10. Structured system of staff support
CARE OF THE CLIENT WITH BREAST CANCER
• The risk factor associated with Breast Cancer are as follows:
 Menarche before age 11.
 Menopause after age 50
 Family history of breast cancer-especially mother or sister
 Nulliparity or birth of first child after age 30
 History of uterine cancer
 Link with obesity, diabetes and hypertension
 Presence of benign breast disease.

• Prevention of Breast Cancer

 BSE (breast self-examination)
 Start from age 20yrs
 Done after menstruation
 During standing position, note especially for symmetry of the breast
 In lying position, elevate shoulders on the side examined with pillow support
 Palpate the breast from center to periphery in circular motion
 Mammogram
 This involves X-ray examination of the breast
 The breast is supported on flat, firm surface
 This involves use of two X-ray films
 Instruct client to avoid use of deodorant, cream powder in the axilla. To
prevent false positive result
• Pathophysiology-classic symptoms that define breast cancer include:
 Firm, nontender, nonmobile mass
 Solitary, irregularly shaped mass.
 Adherence to muscle or skin causing dimpling effect
 Involvement of upper outer quadrant or central nipple portion of breast
 Asymmetry of the breast
 Orange peel skin
 Retraction of the nipple
 Abnormal discharge from the nipple.
• Stages of Breast Cancer
 Stage 1. tumor size is up to 2cm
 Stage II. Tumor size is up to 5cm, with axillary and neck lymph node
involvement
 Stage III. Tumor size is more than 5cm, with axillary and neck lymph
node involvement
 Stage IV. Metastasis to distant organ (live, lung, bone and brain)

Collaborative management for the client with Breast Cancer

 Surgery
 Lumpectomy/Tylectomy. Involves removal of the lamp.
 Simple Mastetomy. Involves the removal of the entire breast muscle and
the nipple remain intact
 Modified radical mastectomy (MRM). Involves removal of the entire
breast and the axillary lymph nodes. The pectoralis muscles are conserved.
 Radical MAstectomy (Halstead Surgery). Involves removal of the entire
breast, pectoralis major and minor muscles and the axillary lymph nodes.
It is followed by skin grafting. This is rarely done nowadays
• Chemotherapy
• Radiation therapy
• Surgery

Care of the client Undergoing Breast Surgery

 Preoperative Care
 Psychosocial Support. Include the husband when necessary
 Teach arm exercises to prevent lymph edema
 Inform about wound suction drainage, eg. Hemovac, Jackson-Pratt
 DBCT exercise to prevent postop respiratory complication
 Postoperative Care
 Place client in semi-fowlers position with arm abducted and elevated on
pillow. Fowler’s position promotes lung expansion. Abduction and
elevation of arm on the affected side promotes venous retum and
prevents lymphedemia
 Monitor Hemovac output (normal drainage is serosanguinous for the
first 24 hours). Serosanguinous drainage is composed of plasma and
small amount of RBC. It is pinkish or reddish in appearance but not
viscous
 Check behind patient for bleeding. Blood flows to the back by gravity
 Reinforce special mastectomy exercises as prescribed. To prevent
lymphedema
 Provide adequate analgesia to promote ambulation and exercise. The
client cooperates ambulation and exercises if she is free from pain or
discomfort
 Encourage regular coughing and deep breathing exercise. To promote
lung expansion and prevent atelectasis
 Prepare client for size and appearance of the incision and provide
support when incision is viewed for first time
 Teach patient to avoid constrictive clothing and report persistent edema,
redness, or infection of incision
 Teach patient importance of continuing monthly breast examination on
remaining breast.
Prevention of Lymphedema
 “AVOIDS”
 Cuts
 Scratches
 Pinpricks
 Hangnails
 Insect bites
 Burns
 Strong detergent

 “DON’T’s” (on the arm on affected side

 carry purse or anything heavy
 Wear wristwatch or jewelry
 Pick at or cut cuticles
 Work near thorny plants or dig in garden
 Reach into hot oven
 Hold cigarette
 Injections, withdrawal of blood, BP-taking

 “DO’s”
 Wear loose rubber gloves when washing dishes
 Wear a thimble when sewing
 Apply lanolin hand cream to prevent dryness
 Contact attending physician if arm gets red, warm, or hard and swollen
 Return for check-up
 Wear “Life guard Med. Aid” tag CAUTION-LYMPHEDEMA