UNDERSTANDING CANCER ONCOLOGY NURSING
Essential Concepts of Cancer– What is Cancer?– Normal Cell Growth vs. Cancer Cell Growth– Etiology and Causative Factors– Pathophysiology– Classification of Tumors– Effects of Cancer
NURSING PROCESS
– Assessment– Laboratory & Diagnostic Tests– Tumor Staging and Grading– Nursing Diagnoses & Planning– Implementation and Management• Treatment Modalities– Chemotherapy• End-of-life Issues
WHAT IS CANCER?
CANCER is a complex of diseases which occurs when normal cells mutate into abnormal cells that take over normal tissue, eventually harming and destroying the host
WHAT IS CANCER
A large group of diseases characterizedby:– Uncontrolled growth and spread of
abnormal cells– Proliferation (rapid reproduction by cell
division)– Metastasis (spread or transfer of
cancer cells from one organ or part to another not directly connected)
ONCOLOGY DEFINED
Branch of medicine that deals with the study, detection, treatment and management of cancer and neoplasia
“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
CHARACTERISTICS OF NEOPLASIA
Uncontrolled growth of Abnormal cells 1. Benign 2. Malignant 3. Borderline
CHARACTERISTICS OF NEOPLASIA
BENIGN Well-differentiated Slow growth Encapsulated Non-invasive Does NOT metastasize
CHARACTERISTICS OF NEOPLASIA
MALIGNANT Undifferentiated Erratic and Uncontrolled Growth Expansive and Invasive Secretes abnormal proteins METASTASIZES
LOSS OF NORMAL GROWTH CONTROL
NOMENCLATURE OF NEOPLASIA
Tumor is named according to:1. Parenchyma, Organ or Cell Hepatoma- liver Osteoma- bone Myoma- muscle
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
NOMENCLATURE OF NEOPLASIA
Tumor is named according to:3. Embryonic origin Ectoderm ( usually gives rise to epithelium) Endoderm (usually gives rise to glands) Mesoderm (usually gives rise to Connective
tissues)
BENIGN TUMORS Suffix- “OMA” is used Adipose tissue- LipOMA Bone- osteOMA Muscle- myOMA Blood vessels- angiOMA Fibrous tissue- fibrOMA
MALIGNANT TUMOR Named according to embryonic cell origin1. Ectodermal, Endodermal, Glandular,
Epithelial Use the suffix- “CARCINOMA” Pancreatic AdenoCarcinoma Squamos cell Carcinoma
MALIGNANT TUMOR Named according to embryonic cell origin2. Mesodermal, connective tissue origin Use the suffix “SARCOMA FibroSarcoma Myosarcoma AngioSarcoma
“PASAWAY”
1. “OMA” but Malignant HepatOMA, lymphOMA, gliOMA, melanOMA
2. THREE germ layers “TERATOMA”
3. Non-neoplastic but “OMA” Choristoma Hamatoma
ETIOLOGY/CAUSATIVE FACTORS
• Viruses• Chemical carcinogens• Physical stressors• Hormonal factors• Genetic factors
CANCER NURSINGEtiology of cancer
1. PHYSICAL AGENTS Radiation Exposure to irritants Exposure to sunlight Altitude, humidity
CANCER NURSINGEtiology of cancer
2. CHEMICAL AGENTS Smoking Dietary ingredients Drugs
CANCER NURSINGEtiology of cancer
3. Genetics and Family History Colon Cancer Premenopausal breast cancer
CANCER NURSING
Etiology of cancer4. Dietary Habits Low-Fiber High-fat Processed foods alcohol
CANCER NURSINGEtiology of cancer
5. Viruses and Bacteria DNA viruses- HepaB, Herpes, EBV, CMV,
Papilloma Virus RNA Viruses- HIV, HTCLV Bacterium- H. pylori
CANCER NURSINGEtiology of cancer
6. Hormonal agents DES OCP especially estrogen
CANCER NURSINGEtiology of cancer
7. Immune Disease AIDS
BURKITT’S LYMPHOMA - a cancer of the lymphatic system
Classification of CancerAccording to Behavior of Tumor• Benign - tumors that cannot spread by
invasion or metastasis; hence, they only grow locally
• Malignant - tumors that are capable of spreading by invasion and metastasis. By definition, the term “cancer”
Patterns of cell Proliferation• Hyperplasia• Dysplasia• Metaplasia• Anaplasia• Neoplasia
Patterns of cell Proliferation•Metaplasia• conversion of one type of cell in a tissue to
another type not normal for that tissue•Anaplasia• change in the DNA cell structure and
orientation to one another, characterized by loss of differentiation and a return to a more primitive form.
Neoplasia• uncontrolled cell growth, either benign or
malignant
Metastasis• Metastasis: 3 stages– Invasion – neoplastic cells from primary
tumor invade into surrounding tissue with penetration of blood or lymph.
– Spread – tumor cells spread through lymph or circulation or by direct expansion
– Establishment and growth – tumor cells are established and grow in secondary site: lymph nodes or in organs from venous circulation
CANCER NURSINGSpread of Cancer
1. LYMPHATIC Most common
2. HEMATOGENOUS Blood-borne, commonly to Liver and Lungs
3. DIRECT SPREAD Seeding of tumors
CANCER NURSINGBody 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
3. Phagocytic cells Macrophages can engulf cancer cell debris
Classification of Tumors• CARCINOMAS: EPITHELIAL TISSUE– BODY SURFACES, LINING OF BODY CAVITIES ETC:
(ADENOCARCINOMA)• SARCOMAS: CONNECTIVE TISSUE– STRIATED MUSCLE, BONE, ETC (OSTEOSARCOMA)• LYMPHOMAS AND LEUKEMIAS– HEMATOPOIETIC SYSTEM• NERVOUS TISSUE TUMORS– EX. NERVE CELLS-NEUROBLASTOMA• MYELOMA– Develops in the plasma cells of bone marrow
Effects of Cancer• Disruption of Function- can be due to
obstruction or pressure• Hematologic Alterations: can impair
function of blood cells• Hemorrhage: tumor erosion, bleeding,
severe anemia• Anorexia-Cachexia Syndrome: wasted
appearance of client
Effects of Cancer• Paraneoplastic Syndromes: ectopic
sites with excess hormone production– ↑ Parathyroid hormone→
hypercalcemia– ↑ secretion of insulin→ hypoglycemia– ↑ Antidiuretic hormone (ADH) → fluid
retention, HTN & peripheral edema• ↑ Adrenocorticotropic hormone
(ACTH): cause excessive secretion of cortisone (ie: fluid retention, ↑ glucose levels)
Effects of Cancer• Pain: major concern of clients and
families associated with cancer• Physical Stress: body tries to respond
and destroy neoplasm
ASSESSMENT• Nursing History– Health History – chief complaint and
history of present illness (onset, course, duration, location, precipitating and alleviating factors)
– Cancer signs: CAUTION US!
WARNING SIGNS OF CANCER
CAUTION US!– Change in bowel or bladder habits– A sore that does not heal– Unusual bleeding or discharge– Thickenings or lumps– Indigestion or difficulty in swallowing– Obvious change in a wart or mole– Nagging or persistent cough or hoarseness– Unexplained anemia– Sudden unexplained weight loss
Change in bowel or bladder habits– A person with colon cancer may have
diarrhea or constipation, or he may notice that the stool has become smaller in diameter
– A person with bladder or kidney cancer
A sore that does not heal– Small, scaly patches on the skin that
bleed or do not heal may be a sign of skin cancer
– A sore in the mouth that does not heal can indicate oral cancer
• Unusual bleeding or discharge– Blood in the stool is often the first sign
of colon cancer– Similarly, blood in the urine is usually
the first sign of bladder or kidney cancer
– Postmenopausal bleeding (bleeding after menopause) may be a sign of uterine cancer
• Thickenings or lumps– Enlargement of the lymph nodes or
glands (such as the thyroid gland) can be an early sign of cancer
– Breast and testicular cancers may also present as a lump
• Indigestion or difficulty in swallowing
– Cancers of the digestive system, including those of the esophagus, stomach, and pancreas, may cause indigestion, heartburn, or difficulty swallowing
• Obvious change in a wart or mole– Moles or other skin lesions that change
in shape, size, or color should be reported
• Nagging or persistent cough or hoarseness
– Cancers of the respiratory tract, including lung cancer and laryngeal cancer, may cause a cough that does not go away or a hoarse (rough) voice
• Unexplained anemia• Sudden unexplained weight loss
PHYSICAL ASSESSMENT
• Inspection – skin and mucus membranes for lesions, bleeding, petechiae, and irritation
– Assess stools, urine, sputum, vomitus for acute or occult bleeding
– Scalp noting hair texture and hair loss• Palpation– Abdomen for any masses, bulges or
abnormalities– Lymph nodes for enlargement• Auscultation – of lung sounds, heart
sounds and bowel sounds
Laboratory & DiagnosticTests • Cancer detection examination• Laboratory tests– Complete blood cell count (CBC)– Tumor markers – identify substance (specific
proteins) in the blood that are made by the tumor
• PSA (Prostatic-specific antigen): prostate cancer• CEA (Carcinoembryonic antigen): colon cancer• Alkaline Phosphatase: bone metastasis– Biopsy
Diagnostic Tests• Determine location of cancer:– X-rays– Computed tomography– Ultrasounds– Magnetic resonance imaging– Nuclear imaging– Angiography
• Diagnosis of cell type:– ▪Tissue samples: from biopsies, shedded
cells (e.g. Papanicolaou (PAP) smear), & washings
– ▪ Cytologic Examination: tissue examined under microscope
• Direct Visualization:– ▪ Sigmoidoscopy– ▪ Cystoscopy– ▪ Endoscopy– ▪ Bronchoscopy– ▪ Exploratory surgery; lymph node biopsies
to determine metastases
Tumor Staging and Grading• Staging determines size of tumor and existence of
metastasis• Grading classifies tumor cells by type of tissue• The TNM system is based on the extent of the
tumor (T), the extent of spread to the lymph nodes (N), and the presence of metastasis (M).
Primary Tumor (T)TX - Primary tumor cannot be evaluatedT0 - No evidence of primary tumorTis - Carcinoma in situ (early cancer that has not spread to
neighboring tissue)T1, T2, T3, T4 - Size and/or extent of the primary tumorRegional Lymph Nodes (N)NX - Regional lymph nodes cannot be evaluated N0 - No regional lymph node involvement (no cancer found in
the lymph nodes)N1, N2, N3 - Involvement of regional lymph nodes (number
and/or extent of spread)Distant Metastasis (M)MX - Distant metastasis cannot be evaluatedM0 - No distant metastasis (cancer has not spread to other parts
of the body)M1 - Distant metastasis (cancer has spread to distant parts of the
body)
NURSING DIAGNOSES• Acute or chronic pain• Impaired skin integrity• Impaired oral mucous membrane• Risk for injury• Risk for infection• Fatigue• Imbalanced nutrition: less than body requirements
NURSING DIAGNOSES• Risk for imbalanced fluid volume• Anxiety• Disturbed body image• Deficient knowledge• Ineffective coping• Social isolation
OUTCOME IDENTIFICATION1. Pain relief2. Integrity of skin and oral mucosa3. Absence of injury and infection4. Fatigue relief5. Maintenance of nutritional intake and fluid
and electrolyte balance6. Improved body image7. Absence of complications
OUTCOME IDENTIFICATION1. Knowledge of prevention and cancer
treatment2. Effective coping through recovery and
grieving process3. Optimal social interaction
IMPLEMENTATION/MANAGE MENT• Prevention and detection– Primary Prevention• Reducing modifiable risk factors in the
external and internal environment– Secondary Prevention• Recognizing early signs and symptoms and
seeking prompt treatment• Prompt intervention to halt cancerous
process
SOME CARCINOGENS IN THE WORKPLACE
TREATMENT MODALITIES• Aimed towards:– CURE - free of disease after treatment →
normal life– Control - Goal for chronic cancers– Palliative Care: Quality of life maintained at
highest level for the longest possible time
• Surgery – surgical removal of tumors; most commonly used treatment
• Preventive or prophylactic• Diagnostic surgery• Curative surgery• Reconstructive surgery• Palliative surgery• Chemotherapy – use of antineoplastic drugs
to promote tumor cell death, by interfering with cellular functions and reproduction
• Radiotherapy – directing high-energy ionizing radiation to destroy malignant tumor cells without harming surrounding tissues
Types:– Teletherapy (external): radiation delivered in
uniform dose to tumor; Teletherapy is external beam irradiation and uses a device located at a distance from the patient. It produces X-rays of varying energies and is administered by machines a distance from the body 31½ to 39 inches (80 to 100 cm).
– Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is placed in tumor or next to it; In brachytherapy, the radiation device is placed within or close to the target tissue. Radiation is delivered in a high dose to a small tissue volume with less radiation to adjacent normal tissue, but requires direct tumor access.
• Immunotherapy – use of chemical or microbial agents to induce mobilization of immune defenses.
• Biologic response modifiers (BRMs) – use of agents that alters immunologic relationship between tumor and host in a beneficial way
• Bone marrow peripheral stem cell transplantation – aspirating bone marrow cells from compatible donor and infusing them into the recipient
• Gene therapy – transfer of genetic materials into the client’s DNA
NURSING MANAGEMENT1. Promote measures that relieve pain and
discomfort.• Pharmacologic and non-pharmacologic
interventions2. Promote measures to maintain intact skin
integrity3. Promote measures that maintain oral mucosa4. Promote measures to prevent injury from
abnormal bleeding• Monitor platelet count; avoid aspiring products,
etc
NURSING MANAGEMENT1. Promote measures that identify and prevent
infection• Monitor WBC count; encourage frequent
handwashing and overall cleanliness2. Help decrease the client’s fatigue and increase
his activity level3. Promote measures that ensure adequate
nutritional intake• High protein, high calorie diet4. Ensure adequate fluid and electrolyte balance
NURSING MANAGEMENT1. Promote measures to enhance body image.• Take an honest gentle, caring approach;
encourage client to express and verbalize feelings2. Promote measures that address preventing
complications of cancer therapy3. Instruct client and family about the disease
process and treatments; provide necessary information for self-care.
4. Help client and family cope effectively5. Promote measures to reduce social isolation.
Care of Clients Receiving Chemotherapy• Classes of Chemotherapy Drugs:• Alkylating agents:– Action: create defects in tumor DNA– Ex: Nitrogen Mustard, Cisplatin– Toxic Effects: reversible renal tubular necrosis
Classes of Chemotherapy Drugs• Antimetabolites:– Action: phase specific– Ex: Methotrexate; 5 fluorouracil– Toxic Effects: nausea, vomiting, stomatitis,
diarrhea, alopecia, leukopenia
Classes of Chemotherapy Drugs• Antitumor Antibiotics:– Action: non- phase specific; interfere with
DNA– Ex: Actinomycin D, Bleomycin, adriamycin
(doxorubicin)– Toxic Effect: damage to cardiac muscle
Classes of Chemotherapy Drugs• Miotic inhibitors:– Action: Prevent cell division during M phase
of cell division– Ex: Vincristine, Vinblastine– Toxic Effects: affects neurotransmission,
alopecia, bone marrow depression
Classes of Chemotherapy Drugs• Hormones:– Action: stage specific G1– Ex: Corticosteroids• Hormone Antagonist:– Action: block hormones on hormone- binding
tumors ie: breast, prostate, endometrium; cause tumor regression
– Ex: Tamoxifen (breast); Flutamide (prostate)– Toxic Effects: altered secondary sex characteristics
Effects of Chemotherapy• Tissues: (fast growing) frequently affected• Examples: mucous membranes, hair cells,
bone marrow, specific organs with specific agents, reproductive organs (all are fetal toxic; impair ability to reproduce)
Chemotherapy Administration• Routes of administration:– Oral– Body cavity (intraperitoneal or intrapleural)– Intravenous• Use of vascular access devices because of
threat of extravasation (leakage into tissues) & long
term therapy
Chemotherapy Administration• Types of vascular access devices:– PICC lines: (peripherally inserted central
catheters)– Tunneled catheters: (Hickman, Groshong)– Surgically implanted ports: (accessed with
90o angle needle- Huber needles)
Nursing care of clients receiving chemotherapy
• Assess and manage:– Toxic effects of drugs (report to physician)– Side effects of drugs: manage nausea and
vomiting, inflammation and ulceration of mucous membranes, hair loss, anorexia, nausea and vomiting with specific nursing and medical interventions
Nursing care of clientsreceiving chemotherapy• Monitor lab results (drugs withheld if blood
counts seriously low); blood and blood product administration
• Assess for dehydration, oncologic emergencies
• Teach regarding fatigue, immunosuppression precautions
• Provide emotional and spiritual support to clients and families
COLON CANCER
COLON CANCERRisk factors1. Increasing age2. Family history3. Previous colon CA or polyps4. History of IBD5. High fat, High protein, LOW fiber6. 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 CANCERPATHOPHYSIOLOGY Benign neoplasm DNA alteration
malignant transformation malignant neoplasm cancer growth and invasion metastasis (liver)
COLON CANCERASSESSMENT FINDINGS
1. Change in bowel habits- Most common
2. Blood in the stool3. Anemia4. Anorexia and weight loss5. Fatigue6. Rectal lesions- tenesmus, alternating
D and C
COLON CANCER Diagnostic findings1. Fecal occult blood2. Sigmoidoscopy and colonoscopy3. BIOPSY4. CEA- carcino-embryonic antigen
COLON CANCER Complications of colorectal CA1. Obstruction2. Hemorrhage3. Peritonitis4. Sepsis
COLON CANCER MEDICAL MANAGEMENT1. Chemotherapy- 5-FU2. Radiation therapy
COLON CANCER SURGICAL MANAGEMENTSurgery is the primary treatmentBased on location and tumor sizeResection, anastomosis, and colostomy
(temporary or permanent)
COLON CANCERNURSING 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 CANCERNURSING 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 CANCERNURSING 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 CANCERNURSING INTERVENTION: COLOSTOMY CARE Lightly pat dry the area and NEVER rub Lightly dust the peri-stomal area with
nystatin powder
COLON CANCERNURSING 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 CANCERNURSING INTERVENTION: COLOSTOMY CARE Empty the pouch or change the pouch
when 1/3 to ¼ full (Brunner) ½ to 1/3 full (Kozier)
BREAST CANCER The most common cancer in FEMALES Numerous etiologies implicated
BREAST CANCERRISK FACTORS1. Genetics2. Increasing age ( > 50 yo)3. Family History of breast cancer4. Early menarche and late menopause5. Nulliparity6. Late age at pregnancy
BREAST CANCERRISK FACTORS7. Obesity8. Hormonal replacement9. Alcohol10. Exposure to radiation
BREAST CANCERPROTECTIVE FACTORS1. Exercise2. Breast feeding3. Pregnancy before 30 yo
BREAST CANCERASSESSMENT FINDINGS1. MASS- the most common location is the
upper outer quadrant2. Mass is NON-tender. Fixed, hard with
irregular borders3. Skin dimpling4. Nipple retraction5. Peau d’ orange
BREAST CANCERLABORATORY FINDINGS
1. Biopsy procedures2. Mammography
BREAST CANCERBreast cancer Staging I - < 2cm II - 2 to 5 cm, (+) LN III - > 5 cm, (+) LN IV- metastasis
BREAST CANCERMEDICAL MANAGEMENT 1. Chemotherapy 2. Tamoxifen therapy 3. Radiation therapy
BREAST CANCER SURGICAL MANAGEMENT
1. Radical mastectomy2. Modified radical mastectomy3. Lumpectomy4. Quadrantectomy
LUMPECTOMY
QUADRANTECTOMY
BREAST CANCERNURSING INTERVENTION : PRE-OP1. Explain breast cancer and
treatment options2. Reduce fear and anxiety and
improve coping abilities3. Promote decision making
abilities4. Provide routine pre-op care:Consent, NPO, Meds, Teaching
about breathing exercise
BREAST CANCERNURSING INTERVENTION : Post-OP1. Position patient: Supine Affected extremity elevated to reduce
edema
BREAST CANCERNURSING INTERVENTION : Post-OP2. Relieve pain and discomfort Moderate elevation of extremity IM/IV injection of pain meds Warm shower on 2nd day post-op
BREAST CANCERNURSING INTERVENTION : Post-OP3. 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 CANCERNURSING INTERVENTION : Post-OP3. 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-OPPromote 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-OPPromote 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-OPMANAGE COMPLICATIONSLymphedema10-20% of patientsElevate arms, elbow above shoulder
and hand above elbowHand exercise while elevatedRefer to surgeon and physical
therapist
BREAST CANCER
NURSING INTERVENTION : Post-OPMANAGE COMPLICATIONS Hematoma Notify the surgeon Apply bandage wrap (Ace wrap) and ICE
pack
BREAST CANCERNURSING INTERVENTION : Post-OPMANAGE COMPLICATIONSInfection Monitor temperature, redness, swelling
and foul-odor IV antibiotics No procedure on affected extremity
BREAST CANCERNURSING INTERVENTION : Post-OPTEACH FOLLOW-UP care Regular check-up Monthly BSE on the other breast Annual mammography
THE ENDLUALHATI M. FLORANDA RN MAN