OUR LADY OF FATIMA UNIVERSITY

NCM 104

Medical Surgical Nursing 2

Anthony P. Toledo, M.D, R.N

 CANCER

• Definition of Cancer
o Cancer is the general name given to a large group of diseases characterized by:
a. uncontrolled growth and spread of abnormal cells.
b. proliferation ( i.e. rapid production by cell division)
c. metastasis ( i.e.., spread or transfer of cancer cells from one organ not directly
connected)
o It affects people of all ages, most cancer occur in people older than 65 years of age.
o It is higher in men than women and higher in industrialized sectors & nations.
o Is second only to cardiovascular disease as the leading cause of death in the United
States.

• Different Kinds of Cancer

o Carcinomas- the most common types of cancer, arise from the cells that cover external
and internal body surfaces. Lung, breast, and colon are the most frequent type of cancers.
o Sarcomas- are cancers arising from cells found in the supporting tissues of the body such
as bone, cartilage, fat, connective tissue, and muscle.
o Lymphomas- are cancers that arise in the lymph nodes and tissues of the body's immune
system.
o Leukemias- are cancers of the immature blood cells that grow in the bone marrow and
tend to accumulate in large numbers in the bloodstream.

• Etiology of Cancer
o Healthy cells are transformed by unknown mechanisms or exposure to certain etiologic
agents, including:
a. viruses ( e.g. Epstein- Barr, herpes simplex type II, cytomegalovirus,
papillomavirus, hepa B)
 b. chemical carcinogens ( e.g. chromium, cobalt , tar, soot, asphalt, nitrogen
mustard, certain plastics, aniline dyes, hydrocarbons in cigarettes smoke, air
pollutants from industry, crude paraffin oil, nickel, asbestos, arsenicals)
c. physical stressors ( e.g. excessive exposure to sunlight or radiation, chronic
irritation )
d. hormonal factors ( e.g. imbalance of endogenous or exogenous hormones, such as
estrogen or diethylstilbestrol)
e. genetic factors ( e.g. abnormal chromosomes patterns, such as in Burkitt’s
lymphoma, chronic myelogenous or acute leukemia and skin cancers; familial
predisposition, such as in breast, endometrial, colorectal, stomach, lung, colon,
and kidney cancers)
f. dietary factors (e.g. fats, alcohol, salt-cured or smoked meats, foods containing
nitrates and nitrites, and a high caloric dietary intake)

• Pathophysiology of Malignant Process

o Cancer is a disease process that:

Begins when an abnormal cell is transformed by the genetic mutation of the cellular
DNA.

The abnormal cell forms a clone and begins to proliferate abnormally, ignoring growth-
regulating signals in the environment surrounding the cell.

The cell acquires invasive characteristics, and changes occur in surrounding tissues.

The cell infiltrates these tissues and gain access to lymph and blood vessels, which carry
the cell to other areas of the body.

Metastasis (cancer spread to other parts of the body).

 Proliferative Patterns
o Neoplasm (new cell growth) has several proliferative patterns:
a. Benign (i.e. usually harmless, does not infiltrate other tissues) and malignant (i.e.
always harmful; may spread or metastasize to tissues far from the original site)
cells display different characteristic of cellular growth; the degree of
differentiation (i.e. anaplasia) determines the potential for malignancy.
 b. Hyperplasia involves an increase in the number of cells in a tissue; it may be a
normal or abnormal cellular response.
c. Metaplasia refers to the conversion of one type of cell in a tissue to another type
not normal for that tissue. It results from an outside stimulus affecting parent stem
cells and may be reversible. It could also progress to dysplasia.
d. Dysplasia refers to change in size, shape, or arrangement of normal cells into
bizarre cells; it may precede an irreversible neoplastic change.
e. Anaplasia involves a change in the DNA cell structure and in their orientation to
one another, characterized by a loss of differentiation and a return to a more
primitive form. The resulting poorly differentiation, irregularly shaped cells
usually are malignant.

 Characteristics of Benign and Malignant Neoplasms

Characteristics Benign Malignant

Well Differentiated cells that Cells are undifferentiated and

resemble normal cells of the often bear little resemblance to
Cell Characteristics
tissue from which the tumor the normal cells of the tissue from
originated. which they arose.
Tumor grows by expansion
Grows at the periphery and sends
and does not infiltrate the
Mode of Growth out processes that infiltrate and
surrounding tissues; usually
destroy the surrounding tissues.
encapsulated.
Is variable and depends on level
of differentiation; the more
Rate of Growth Usually slow
anaplastic the tumor, the faster its
growth.
Gains access to the blood by
Does not spread by lymphatic channels and
Metastasis
metastasis. metastasizes to other areas of the
body.
Is usually a localized
phenomenon that does not Often causes generalized effects,
General effects cause generalized effects such as anemia, weakness, and
unless its location interferes weight loss.
with vital functions.
Tissue Destruction Does not usually cause tissue Often causes extensive tissue
damage unless its location damage as the tumor outgrows its
interferes with blood flow. blood supply or encroaches on
blood flow to the area; may also
 produce substances that cause cell
damage.
Does not usually cause death
Ability to cause Usually causes death unless
unless its location interferes
death growth can be controlled.
with vital functions.

 Invasion and Metastasis

o Invasion- refers to the growth of the primary tumor into the surrounding host tissues,
which occurs in several ways.
a. Mechanical pressure exerted by rapidly proliferating neoplasms may force
fingerlike projections of tumor cells into surrounding tissue and interstitial spaces.
b. Malignant cells are less adherent and may break off from the primary tumor and
invade adjacent structures.
c. Malignant process is thought to possess or produce specific destructive enzymes
(proteinases), plasmonogen activators enzymes & lysosomal hydrolyses. These
enzymes are thought to destroy surrounding tissue, including the structural tissues
of the vascular basement membrane, facilitating invasion of malignant cells.
d. The mechanical pressure of a rapidly growing tumor may enhance this process.
o Metastasis- is the dissemination or spread of malignant cells from the primary tumor
to distant sites by direct spread of tumor cells to body cavities or through lymphatic
and blood circulation. Tumors growing in or penetrating body cavity and seed the
surfaces of other organs.

 Mechanism of Metastasis
o Lymph and blood are key mechanisms by which cancer cells spread.
o Angiogenesis- is a mechanism by which the tumor cells are ensured a blood supply is
another important process.
 Lymphatic Spread
o Lymphatic spread is the transport of tumor cells through the lymphatic
circulation; and the most common mechanism of metastasis.
o Malignant cells may also penetrate the lymphatic circulation by invasion.
Tumor emboli enter the lymph channels by way the interstitial fluid, which
communicate with lymphatic fluid.
 Malignant Cells either lodge in the lymph nodes or pass between the lymphatic &
venous circulation.
Tumors arise in areas of the body with rapid and extensive lymphatic circulations
are high risks for metastasis through lymphatic channels.

 Hematogenous Spread
o Hematogenous spread is the dissemination of malignant cells via the
bloodstream.
o It is directly related to the vascularity of the tumor.
o Few malignant cells can survive the turbulence of arterial circulation, insufficient
oxygenation, or destruction by the body’s immune system.
o The survived malignant cells are able to attach to endothelium and attract fibrin,
platelets, and clotting factors to seal themselves from immune system.
o The endothelium retracts that allows the malignant cells to enter the basement
membrane & secrete lysosomal enzymes.
o These enzymes destroy surrounding body tissues and allow implantation.

 Angiogenesis
o Angiogenesis is the growth of new capillaries from the host tissue by the release
of growth factors and enzymes such as vascular endothelial growth factor
(VEGF).
o These proteins rapidly stimulate formation of new blood vessels, which help
malignant cells obtain the necessary nutrients and oxygen.
o Large tumor emboli that become trapped in the microcirculation of distant sites
may further metastasize to other sites.

 Carcinogenesis (has three steps)

1. Initiation- initiators (carcinogens) escape normal enzymatic mechanisms and
alter the genetic structure of the cellular DNA.
 2. Promotion- repeated exposure to promoting agents (cocarcinogens) causes the
expression of abnormal or mutant genetics information even after long latency
periods.
3. Progression- the cellular changes formed during initiation and promotion
exhibit increased malignant behavior. These cells have a propensity to invade
adjacent tissues and to metastasize. Agents that initiate or promote cellular
transformation are referred as carcinogens.

• Role of the Immune System

o The term "immune system"—as recognized by scientists—refers to the enormously
complex interaction of many types of cells (T-cells, B-cells, N-K cells, helper cells,
suppressor cells, macrophages, etc.), cell products (many lymphokines, cytokines and
cytotoxins), other substances (chemicals, hormones), and physical agents (X-rays,
ultraviolet light).
o Some evidences indicate that the immune system can detect the development of
malignant cells and destroy them before cell growth becomes uncontrolled.
o At this time there is no single, valid measure of an individual's "immunocompetence."
What we do have is various tests related to the body's ability to react to the foreign
proteins found in viruses, bacteria, foods, and other sources.
o These tests include:
1. Protein electrophoresis, to measure the types and amounts of immunoglobulins
in the serum of the patient. Antibodies are immunoglobulins, but not all
immunoglobulins are antibodies.
2. Immunoelectrophoresis, to identify the amount and kind of immunoglobulins
but not specific antibodies.
3. Immunochemical electrophoresis, to identify specific antibodies in the serum.
4. Allergy tests, to determine the presence or absence of antibodies in the blood
stream.
5. Patch testing, using chemicals like CDNB), PPD, mumps skin test, etc., is used
together with allergy tests.
 6. The determination of the proportion of T-4 and T-8 cells in the blood of the patient
(cellular immune system).

 Immunoincompetent patients
a. Organ transplant recipients (under immunosuppressive therapy to prevent
rejection of transplanted organ).
b. AIDS Patients
c. Patients under alkylating chemotherapeutic agents.
d. Patients with Auto immune diseases (such as Rheumatoid Athritis).
e. Patients with declining organ functions (age related).

 Normal Immune Response

o Normally, the body has the ability to combat cancer cells in several ways:

a. TUMOR ASSOCIATED ANTIGENS, are capable of recognizing foreign antigens

and are capable of stimulating both the humoral and cellular immune responses.
b. T LYMPHOCYTES, along with macrophages (soldiers of the cellular immune
response), are responsible for recognizing tumor related antigens and stimulate other
components to get rid of malignant cells, including cytotoxic properties.
c. INTERFERON (IFN), substances produce by the body in response to viral infection,
possesses some anti tumor properties.
d. B LYMPHOCYTES, produces antibodies that also defend the body against
malignant cells
e. NATURAL KILLER CELLS (NK), directly destroy cancer cells and produces
lymphokines and enzymes that assist in cell destruction.

 Immune System Failure

o Properly used, the term "immunosuppressed" refers to evidence based on the
above tests that a malfunction exists in a patient's immune system.
o To define the malfunction, one must identify the specific fault in the system.
 o A conclusion that someone is immunosuppressed should be based on precise and
extensive testing.
o Chemotherapy and radiation therapy sometimes decrease immune function. But
unless there is complete destruction—which is rare—recovery will take place, and
rebound above the normal level of activity may occur.
• Detection and Prevention of Cancer
o Primary Prevention
a. Cancer prevention focuses on reducing modifiable risk factors in the external
and internal environment that increases a person’s susceptibility to cancer
development.
b. General factors that influence cancer incidence and mortality include sex, age,
geographic location, socioeconomic status, ethnic or cultural background,
personal habits, occupation, and personal and family health histories.
o Secondary prevention (involves detection and case-finding efforts to achieve early
diagnosis).
a. Recognizing early signs and symptoms and seeking prompt treatment can
significantly reduce morbidity and mortality of several types of cancer.
b. After early detection, prompt intervention may halt the cancerous process in
some cases.

• Steps to Reduce Cancer Risk

1. Increase consumption of fresh vegetable (especially those of the cabbage family) because
studies indicate that roughage and vitamin-rich foods help to prevent certain kinds of
cancer.
2. Increase fiber intake because high –fiber diets may reduce the risk for certain cancers
(e.g. breast, prostate and colon).
3. Increase intake of vitamin A, which reduces the risk for esophageal, laryngeal and lung
cancers.
4. Increase intake of foods rich in vitamin C, such as citrus fruits and broccoli, which are
thought to protect against stomach and esophageal cancers.
 5. Practice weight control because obesity is linked to cancers of the uterus, gallbladder,
breast and colon.
6. Reduce intake of dietary fat because a high-fat diet increases the risk for breast, colon,
and prostate cancers.
7. Practice moderation and consumption of salt-cured, smoked and nitrate-cured foods;
these have been linked to esophageal and gastric cancers.
8. Stop smoking cigarettes and cigars, which are carcinogens.
9. Reduce alcohol intake because drinking large amounts of alcohol increases the risk of
liver cancers.
10. Avoid overexposure to the sun, wear protective clothing, and use a sunscreen to prevent
skin damage from ultraviolet rays that increase the risk of skin cancer

• Diagnosis of Cancer and Related Nursing Considerations

o Patient with suspected cancer undergo extensive testing to:
1. Determine the presence of tumor and its extent.
2. Identify possible spread (metastasis) of disease or invasion of other body tissues.
3. Evaluate the function of involved and uninvolved body systems and organs.
4. Obtain tissue and cells for analysis including evaluation of tumor stage and grade.

o Diagnostic Aids Used to Detect Cancer

TEST DESCRIPTION DIAGNOSTIC TEST

Tumor marker identification Analysis of substances found in Breast, colon, lung, ovarian,
blood or other body fluids that are testicular, prostate cancers
made by the rumor or by the body in
response to the tumor

Magnetic resonance imaging Use of magnetic fields and Neurologic, pelvic, abdominal,
(MRI) radiofrequency signals to create thoracic cancers
sectioned images of a various body
structures
Computed tomography Use of narrow beam x-ray to scan Neurologic, pelvic, skeletal,
successive layers of tissue for a abdominal, thoracic
cross-sectional view

Fluoroscopy Use of x-rays that identify contrasts Skeletal, lung, gastrointestinal

in body tissue densities; may involve cancers
the use of contrasts agents

Ultrasonography (ultrasound) High-frequency sound waves Abdominal and pelvic cancers

echoing off body tissues are
converted electronically into images;
used to assess tissues deep within
the body

Endoscopy Direct visualization of a body cavity Bronchial, gastrointestinal

or passageway by insertion of an cancers
endoscope into a body cavity or
opening: allows tissue biopsy, fluid
aspiration and excision of small
tumors; both diagnostic and
therapeutic

Nuclear medicine imaging Uses intravenous injection or Bone, liver, kidney, spleen,
ingestion of radioisotope substances brain, thyroid cancers
followed by imaging of tissues that
have concentrated the radioisotopes

Positron emission Computed cross-sectional images of Lung, colon, liver, pancreatic,

tomography (PET Scan) increased concentration of breast, esophagus cancers;
radioisotopes in malignant cells Hodgkin’s and non- Hodgkin’s
provide information about biologic lymphoma and melanoma
activity of malignant cells; help
 distinguish between benign and
malignant processes and responses
to treatment

Radioimmunoconjugates Monoclonal antibodies are labeled Colorectal, breast, ovarian,

with a radioisotope and injected head and neck cancers;
intravenously into the patient; the lymphoma and melanoma
antibodies that aggregate at the
tumor site are visualized with
scanners

o Nursing Interventions
1. The nurse can help relieve the patient’s fear and anxiety by explaining the tests to be
performed, the sensations likely to be experienced, and the patient’s role in the test
procedures.
2. The nurse encourages the patient and family to voice their fears about the test results,
supports the patient and family throughout the test period, and reinforces and clarifies
information conveyed by the physician.
3. The nurse encourages the patient and family to communicate and share their concerns
and to discuss their questions and concerns with each other.

• Tumor Staging and Grafting

o Staging – determines the size of the tumor and the existence of metastasis. The TNM
system is frequently used.
“T” – primary tumor
“N”- lymph node involvement
“M”- metastasis
o Grading - refers to the classification of the tumor cells. It seeks to define the type of
tissue from which cell retain the functional and histologic characteristics of the tissue of
origin.
- The tumor is assigned a numeric value ranging from grade I to IV.
- GX Grade cannot be assessed

G1 Well differentiated (Low grade)

G2 Moderately differentiated (Intermediate grade)

G3 Poorly differentiated (High grade)

G4 Undifferentiated (High grade)