Oncology Nursing

Ma. Tosca Cybil A. Torres, RN, MAN

Objectives
After 2H of active lecture-discussion. The students will be able to: 1. 2. 3. 4. 5. Define CANCER Present their group audio-visual presentation focusing on CANCER prevention and awareness Identify the responsibilities of the nurse in CANCER care Have a preview on the different types of CANCER Include Christian Valuing in the care of clients with CANCER.

Cancer
malignant neoplasm is a class of diseases in which a group of cells display
uncontrolled growth (division beyond the normal limits) invasion (intrusion on and destruction of adjacent tissues) metastasis (spread to other locations in the body via lymph or blood).

Responsibilities of the Nurse in CANCER care

Support the idea that cancer is a chronic illness that has acute exacerbations rather than one that is synonymous with DEATH and SUFFERING Assess own level of knowledge relative to the pathophysiology of the disease process Make use of current research findings and practices in the care of the client with cancer and his or her family Identify patients at high risk for cancer

Responsibilities of the Nurse in CANCER care

Participate in PRIMARY and SECONDARY prevention efforts Assess the nursing care needs of the patient with cancer Assess the learning needs, desires, and capabilities of the patient with cancer Identify nursing problems of the patient and the family Assess the social support networks available to the patient

Responsibilities of the Nurse in CANCER care

Plan appropriate interventions with the patient and the family Assist the patient to identify strengths and limitations Assist the patient to design short-term and longterm goals for care Implement NCPs that interfaces with the medical regimen and that is consistent with the established goals Collaborate with the members of a multidisciplinary team to foster continuity of care

Responsibilities of the Nurse in CANCER care

Evaluate the goals and resultant outcomes of care with the patient, family, and members of the multidisciplinary team Reassess and redesign the direction of care as determined by the evaluation

PATHOPHYSIOLOGY OF THE MALIGNANT PROCESS

Cancer begins when an abnormal cell is transformed by the genetic mutation of the cellular DNA. Abnormal cell forms a clone and begins to proliferate abnormally, ignoring growth- regulating signals in the environment surrounding the cell. Cells acquire invasive characteristics, and changes occur in the surrounding tissues. Cells infiltrate tissues and gain access to the lymph and blood vessels, which carry the cells to other parts of the body (metastasis).

 Cancer

is not a single disease with a single cause; rather it is a group of distinct diseases with different causes, manifestations, treatments, and prognoses.

PROLIFERATIVE PATTERNS
Cancerous cells:
malignant neoplasms
demonstrate uncontrolled cell growth that follows no physiologic demand.

Patterns of cell growth:

Hyperplasia: increase in the number of cells of a tissue; most often associated with periods of rapid body growth. Metaplasia: conversion of one type of mature cell into another type of cell. Dysplasia: bizarre cell growth resulting in cells that differ in size, shape or arrangement from other cells of the same tissue. Anaplasia: cells that lack normal cellular characteristics and differ in shape and organization with respect to their cells of origin; usually, anaplastic cells are malignant. Neoplasia: uncontrolled cell growth that follows no physiologic demand.

CHARACTERISTICS OF MALIGNANT CELLS

Cell membranes are altered, which affects fluid movement in and out of the cell. Contains proteins (tumor- specific antigens), which develop as they become less differentiated (mature) overtime. Contain less fibronectin, a cellular cement; therefore, they are less cohesive and do not adhere to adjacent cells readily. Nuclei are large and irregularly shaped (pleomorphism).
Nucleoli are larger and more numerous. Chromosomal abnormalities (translocations, deletions, additions)

Mitosis occurs more frequently.

As the cells grow and divide, more glucose and oxygen are needed.

CHARACTERISTICS OF BENIGN AND MALIGNANT NEOPLASMS

CHARACTERISTICS Cell characteristics

BENIGN Well- differentiated cells that resemble normal cells of the tissue from which the tumor originated. Tumor grows by expansion and does not infiltrate the surrounding tissues; usually encapsulated.

MALIGNANT Cells are undifferentiated and often bear little resemblance to the normal cells of the tissue from which they arose. Grows at the periphery and sends out processes that infiltrate and destroy the surrounding tissues.

Mode of growth

Rate of growth

Rate of growth is usually Rate of growth is slow. variable and depends on level of differentiation; the more anaplastic the tumor, the faster its growth. Does not metastasis. spread by Gains access to the blood and lymphatic channels and metastizes to the other areas of the

Metastasis

General effects

Is usually a localized phenomenon that does not cause generalized effects unless its location interferes with vital functions. Does not usually cause tissue damage unless its location interferes with blood flow.

Often causes generalized effects, such as anemia, weakness, and weight loss.

Tissue destruction

Often causes extensive tissue damage as the tumor outgrows its blood supply or encroaches on blood flow to the area; may also produce substances that causes cell damage.

Ability to cause death Does not usually cause Usually causes death death unless its location unless growth can be interferes with vital controlled. functions.

INVASION AND METASTASIS

Invasion: growth of the primary tumor into the surrounding host tissues.
Mechanical pressure may force finger-like projections of tumor cells into surrounding tissues and interstitial spaces. Malignant cells are less adherent and may break off from the primary tumor and invade adjacent structures. Malignant cells produce or possesses destructive enzymes (proteinases) such as collagenenases, plasminogen activators, and lysosomal hydrolyses that destroys surrounding tissue, including the structural tissues of the vascular basement membrane, facilitating invasion of malignant cells.

Metastasis: dissemination or spread of malignant cells from the primary tumor to distant sites by direct spread of tumor cells to by cavities or through lymphatic and blood circulation.

METASTATIC MECHANISMS
Lymphatic spread
Most common mechanism. Tumor emboli enter through interstitial fluid that communicates with lymphatic fluid or by invasion. After entering the lymphatic circulation, may lodge in the lymph nodes or pass between lymphatic and venous circulation.

Hematogenous spread
Malignant cells are disseminated through the blood stream. Few malignant cells survive the turbulence of arterial circulation, insufficient oxygenation, or destruction by the bodys immune system. Those that survive are able to attach to endothelium and attract fibrin, platelets and clotting factors to seal themselves form immune system vigilance.

Angiogenesis
Ability of the malignant cells to induce the growth of new capillaries from the host tissue to meet their needs for nutrients and oxygen.

THREE STEPS OF CARCINOGENESIS (MALIGNANT TRANSFORMATION)

Initiation
Initiators (carcinogens) escape normal enzymatic mechanisms and alter the genetic structure of the cellular DNA where permanent mutation occurs.

Promotion
Repeated exposure to promoting agents (cocarcinogens) causes the expression of abnormal or mutant genetic mutation even after long latency periods.

Progression
Cellular changes formed during initiation and promotion now exhibit increased malignant behaviour. These cells now show a propensity to invade adjacent tissues and to metastasize.

ETIOLOGY

 Viruses and Bacteria

Viruses as a case are hard to determine because they are difficult to isolate. Infectious causes are considered when specific cancers appear in cluster. Viruses incorporate themselves in the genetic structure of the cells, thus altering future generations of that cell population- perhaps leading to cancer. Examples: Epstein- Barr virus: nasopharyngeal cancers, some type of nonHodgkins lymphoma and Hodgkins disease. Herpes simplex virus type II, cytomegalovirus, and human papillomavirus types 16, 18, 31 and 33: dysplasia and cancer of the cervix. Hepatitis B virus: cancer of the liver. HIV: Kaposis Sarcoma H. Pylori: gastric malignancy secondary to inflammation and injury of the gastric cells.

 Physical agents
Exposure to sunlight or radiation, chronic irritation or inflammation, and tobacco use.

Chemical agents
75% are thought to be related to the environment Tobacco smoke: single most lethal carcinogen (30% of cancer deaths) Others: aromatic amines and aniline dyes; pesticides and folmaldehydes; arsenic soot, and tars; asbestos; benzene; betel nut and lime; cadmium; chromium compounds; nickel and zinc ores; wood dust; beryllium compounds; and polyvinyl chloride. Most chemicals alters DNA structure in body sites distant from chemical exposure. Most often affected: liver, lungs and kidneys

 Genetic and familial factors

Genetics, shared environments, cultural or lifestyle factors, or chance alone. 5% to 10% of cancers of adulthood and childhood display a familial predisposition. Cancers associated with family inheritance: retinoblastomas, malignant neurofibromatosis, and breast, ovarian, endometrial, colorectal, stomach, prostate, and lung cancers.

 Dietary factors
35% of all environmental cancers Dietary substances associated with an increased cancer risk: Fats, alcohol, salt- cured or smoked- meats, foods containing nitrates and nitrites, and high- caloric dietary intake. Foods that lower cancer risks: High- fiber foods, cruciferous vegetables (cabbage, broccoli, cauliflower, Brussel sprouts, kohlbari), carotenoids (carrots, tomatoes, spinach, apricots, peaches, dark- green and deep- yellow vegetables) Obesity: associated with endometrial cancer, postmenopausal breast cancer, cancers of the colon, kidney, and gallbladder.

 Hormonal agents
Disturbances in hormonal balance either by the bodys own (endogenous) hormone production or by administration of exogenous hormones. Endogenous: cancers of the breast, prostate and uterus Oral contraceptives and prolonged estrogen replacement therapy: hepatocellular, endometrial, and breast cancers. Hormonal changes with reproduction are also associated with cancer incidence. Increased numbers of pregnancies are associated with a decreased incidence of breast, endometrial and ovarian cancers.

Common Sites of Metastasis for Different Cancer Types

1. Breast Cancer bone, lung, liver, brain 2. Lung Cancer brain, bone, liver, lymph nodes, adjacent structures 3. Colorectal Cancer liver, lymph nodes, adjacent structures 4. Prostate Cancer Bone(esp. spine and legs), pelvic nodes 5. Melanoma GIT, lymph nodes, lung, brain 6. Primary Brain Cancer CNS

Risk factors for a specific type of cancer

1. Breast cancer
family history (immediate female relatives) high-fat diet obesity after menopause early menarche, late menopause alcohol consumption postmenopausal estrogen and progestin first child after age 30 multiple sexual partner having sex at early age exposure to human papilloma virus smoking

1. Cervical cancer

Risk factors for a specific type of cancer

3.

Colorectal cancer
family history (immediate relatives) low fiber diet history of rectal polyps

3.

Esophageal Cancer
heavy alcohol consumption Smoking

3.

Lung Cancer
cigarette smoking asbestos, arsenic, and radon exposure secondhand smoke TB

Risk factors for a specific type of cancer

6.

Skin Cancer
excessive exposure to UV radiation (sun) fair complexion work with coal, tar, pitch or creosote multiple or atypical nevi (males)

6.

Stomach Cancer
family history diet heavy in smoked, pickled or salted foods

6.

Testicular Cancer
undescended testicles consumption of hormones by mothers during pregnancy

6.

Prostate Cancer
increasing of age family history diet high in animal fat

Cancer Classification
1.Solid Tumors : Associated with the organs from which they developed, such as breast or lung cancer 2.Hematological Cancers : Originate from blood-cell forming tissues, such as the leukemias and the lymphomas

Grading and Staging

- Are methods used to describe the tumor, these methods describe the extent of the tumor, the extent to which malignancy has increased in size, the involvement of regional nodes, and metastatic development.

Grading
Grading: refers to classification of tumor cells. Seek to define the type of tissue from which the tumor originated and the degree to which the tumor cells retain the functional and histologic characteristics of the tissue of origin. Can be obtained through cytology (examination of cells from tissue scrapings, body fluids, secretions or washings), biopsy or surgical excision.

GRADING
GradeX : Grade cannot be determined GradeI : Cells differ slightly from normal cells and are well differentiated (Mild Dysplasia) GradeII : Cells are abnormal and are moderately differentiated ( Moderate Dysplasia) GradeIII : Cells are very abnormal and are poorly differentiated ( Severe Dysplasia) GradeIV : Cells are immature (anaplasia) and undifferentiated, cell of origin is difficult to

Staging
Staging: determines the size of the tumor and the existence of the metastasis. TNM system:
T: The Extent of the primary tumor N: The absence or presence of regional lymph node metastasis. M: The absence or presence of distant metastatsis.

Primary Tumor (T)

TX: primary tumor cannot be assessed. T0: No evidence of primary tumor. Tis: Carcinoma in situ T1, T2, T3, T4: Increasing size and/ or local extent of the primary tumor.

Regional Lymph Nodes (N)

NX: regional lymph nodes cannot be assessed. N0: no regional lymph node metastasis. N1, N2, N3: increasing involvement of regional lymph nodes.

Distant Metastasis (M)

MX: distant metastasis cannot be assessed. M0: no metastasis M1: distant metastasis

Cancer Prevention, Screening and detection

Prevention is a priority in oncology nursing because at least one third of all cancers are preventable.

Cancer is also curable if detected and treated early. The principal role of an oncology nurse as a provider of information and education in the prevention and early detection of cancer requires a basic understanding of the etiology and epidemiology of the disease.

The most successful approach to caner control is the prevention of cancer.

Prevention and Detection Measures

1. Promoting cancer awareness
Warning Signs of Cancer
C hange in bowel or bladder habbits A ny sore that does not heals U nusual bleeding or discharge T hickening or lump in breast or elsewhere I ndigestion O bvious change in wart or mole N agging cough or hoarseness U nexplained anemia S udden and unexplained weight loss

2. Promoting risk factors awareness

3. Promoting healthy behaviors

Good nutrition and diet Tomatoes, spinach, red wine, nuts, broccoli, oats, salmon, garlic, green tea, blueberries

4. Limiting alcohol consumption 5. Hepa B virus infant vaccination 6. Control of STDs 7. Changing risk behaviors 8. Teaching skills for early detection programs 9. Promoting participation in early detection programs

Recommendations of the American Cancer Society for early cancer detection 1. For detection of breast cancer
Monthly BSEs Women at age 40 should have a yearly mammogram and breast examination by a health care provider

2. For detection of colon and rectal cancer

All aged 50 and up should have a yearly fecal occult blood test Digital rectal exam and flexible sigmoidoscopy every 5 years Colonoscopy with Ba enema every 10 years

3. For detection of uterine cancer

Yearly Pap smear for sexually active females and any female over age 18 At menopause, high-risk women should have an endometrial tissue sample

4. For detection of prostate cancer

Beginning age 50, yearly digital rectal examination and prostate-specific antigen (PSA) test

Cancer Screening
-refers to detection of disease through tests, exams, and other procedures An ocology nurse should have good hx taking skills. She should be able to note down all possible clinical as well as behavioral clues through PE

DIAGNOSTIC TESTS
Biopsy - is the definitive means of diagnosing cancer and provides histological proof of malignancy. - involves the surgical incision of a small piece of tissue of microscopic examination Types: a. Needle : Aspiration of Cells b. Incisional : Removal of a wedge of suspected tissue from a larger mass c. Excisional : Complete removal of the entire lesion d. Staging : Multiple needle or incisional biopsies in tissues where metastasis is suspected or likely.

Other means of Detection

Mammography Papanicolaous (Pap) test Stools for occult blood Sigmoidoscopy Colonospcopy Skin Inspection

Tumor Markers
protein substances found in the blood or body fluids derived from the tumor itself

Tumor Markers
a. Oncofetal antigens
Normally present in fetal tissue;may indicate an anaplastic process in tumor cells
Ex:
Carcinoembryonic Antigen (CEA) Alpha-feto protein

Tumor Markers
b. Hormones
ADH Calcitonin Catecholamines HCG PTH

Tumor Markers
c. Isoenzymes
increased when a tissue is experiencing rapid and excessive growth as a result of a tumor
Neurospecific enolase (NSE) Prostatic acid phosphatase (PAP)

Tumor Markers d. Tissue-specific antigens

identifies the type of tissue affected by malignancy
prostatic-specific antigen (PSA)

Management of Cancer

Radiation therapy
Used to kill a tumor, reduce tumor size, relieve obstruction or decrease pain Causes lethal injury to DNA Classification:
Internal radiation therapy (brachytherapy) External radiation therapy (teletherapy)

Brachytherapy
a. Sources
Implanted into the affected tissue or body cavity Ingested as a solution Injected as a solution into the bloodstream or body cavity Introduced through a catheter into the tumor Fatigue Anorexia Immunosuppression

a. Side effects:

Brachytherapy
c. Client education
Avoid close contact with others until the treatment is completed Maintain daily activities unless contraindicated Rest Maintain a balanced diet Maintain fluid intake If implant is temporary, the client should be on bed rest Excreted body fluids may be radioactive; double flush toilets after use

Brachytherapy
d. Nursing management
Minimize time spent in close proximity to the radiation sources Limit contact time to 30 mins per 8H shift Minimum distance should be 6 ft Use lead shields Place the client in a private room Limit visits to 10-30 minutes Ensure proper handling and disposal of body fluids Pregnant women and children are not allowed inside the clients room

Teletherapy
Treatment is usaully given 15-30 minutes per day, 5x per week, for 2-7 weeks Client does not pose a risk of radiation exposure to other people Side effects:
Tissue damage to target area (erythema, sloughing, and hemorrhage) Ulcerations of oral mucous membranes Nausea, vomiting, and diarrhea Radiation pneumonia Fatigue Alopecia Immunosuppression

Teletherapy
Client education
Wash marked area of the skin with plain water only and pat dry. Do not use soaps, deodorants, lotions, perfumes, powders, or medications on the site during the duration of the treatment. Do not wash off the treatment site marks Avoid rubbing, scratching, or scrubbing the treatment site. Do not apply extreme temperatures to the treatment site. If shaving is necessary, use electric razor. Wear soft, loose-fitting clothing over the treatment area Protect skin from sun exposure during the treatment and for at least 1 year after the treatment is completed. When going outdoors, use sun blocking agents with SPF of at least 15. Maintain proper rest, diet, and fluid intake Hair loss may occur. Choose a wig, hat or scarf to cover and protect the head.

Chemotherapy
Involves the administration of cytotoxic medications and chemicals to promote death of tumor cells. Route of adminstration:
IV Oral Intrathecal Topical Intra-arterial Intracavity Intravesical

a. Alkylating agents

Classification of Chemotherapeutic agents

Non-phase-specific and act by interfering with DNA replication

Cyclophosphamide (Cytoxan) Busulfan (Myleran) Mecholorethamine (Mustargen)

b. Antimetabolites

Classification of Chemotherapeutic agents

Interfere with metabolites or nucleic acids necessary for RNA and DNA synthesis
5-fluorouracil (5-FU) Methotrexate

c. Cytotoxic antibiotics

Classification of Chemotherapeutic agents

Disrupt or inhibit DNA or RNA synthesis

Bleomycin (Blenoxane) Doxorubicin (Adriamycin)

d. Hormones and hormone antagonists

Classification of Chemotherapeutic agents

Phase-spcific (G1) and act by interfering with RNA synthesis

Diethylstilbestrol (DES) Tamoxifen (Nolvadex) Prednisone

e. Plant alkaloids

Classification of Chemotherapeutic agents

Vinca alkaloids are phase-specific, inhibiting cell division Etoposide acts during all cell-cycle phases, interfering with DNA and cell division at metaphase

Nursing implications for the administration of chemotherapy IV routes may be obtained by subclavian catheters,
implanted ports, or peripherally inserted catheters. Extravasation is the major complication of IV chemotherapy. Extreme care must be used when administering vesicant agents WARNING: NEVER TEST VEIN PATENCY WITH CHEMOTHERAPEUTIC AGENTS. Monitor client closely for anaphylactic reactions or serious side effects. Discontinue infusion according to protocol if reaction occur Use caution when preparing, administering, or disposing chemotherapeutic agents

a. Bone marrow suppression leads to:

Nursing management of the common side effects of Chemotherapy

Leukopenia (immunosuppression)
Avoid crowds, people with infections, and small children when WBC count is low Avoid undercooked meat and raw fruits and vegetables

Thrombocytopenia
Use electric razor when shaving Avoid contact sports If trauma occurs, apply ice and seek medical assistance Avoid dental work or other invasive procedures Avoid aspirin and aspirin-containing products

b. GI effects (anorexia, nausea, vomiting, and diarrhea)

Client education
Eat small, frequent, low-fat meals Avoid spicy and fatty foods Avoid extremely hot foods

Nursing management of the common side effects of Chemotherapy

Administer antiemetics prior to chemotherapy Weigh client routinely

c. Stomatitis and mucositosis

Client education

Nursing management of the common side effects of Chemotherapy

Use a soft toothbrush. Mouth swabs may be needed during an acute episode Avoid mouthwashes containing alcohol. Do not use lemon glycerin swabs or dental floss Consider using chlorhexidine mouthwash to decrease risk of haemorrhage and protect gums from trauma For xerostomia, apply lubricating and moisturizing agents to protect the mucous membranes from trauma and infection Consider using artificial saliva and hard candy or mints Avoid smoking and alcohol Drink cool liquids, and avoid hot and irritating foods

d. Alopecia (hair loss)

Nursing management of the common side effects of Chemotherapy

Encourage the client to choose a wig before hair loss occurs Care of hair and scalp includes washing hair two to three times a week with mild shampoo. Pat hair dry and avoid the use of blow dryer.

Surgery
Primary treatment Prophylactic Palliative Reconstructive

Types of Cancer

Testicular Cancer
Arises from germinal epithelium from the spermproducing germ cells or from nongerminal epithelium from other structures in testicles. Testicular Cancer most often occurs between the ages of 15 and 40 Metastasis occurs to the lung, liver, bone and adrenal glands. Prevention : Routine Testicular Examination

Assessment
Painless testicular swelling occurs. Dragging sensation is evident in the scrotum. Palpable lymphadenopathy, abdominal masses, and gynecomastia may indicate metastasis. Late signs include back or bone pain and respiratory symptoms.

Interventions
- Prepare the client for radiation therapy or unlateral orcheictomy as prescribed . - Discuss reproduction, sexuality and fertility information and options with the client For Post Op: - Monitor for signs of bleeding and wound infection. - Monitor Intake and output - Notify the physician if chills, fever, increasing pain or tenderness at the incision site, or drainage of the incision occurs. - Instruct the client to perform a monthly testicular selfexamination on the remaining testicle.

Cervical Cancer
Pre-invasive cancer is limited to the cervix Invasive cancer is in the cervix and other pelvic structures. Metastasis usually is confined to the pelvis, but distant metastasis occurs through lymphatic spread. Pre malignant changes are described on a continuum from dysplasia , which is the earliest premalignant change.

Precipitating Factors
1. 2. 3. 4. 5. 6. Low socioeconomic groups Early first marriage Early and frequent intercourse Multiple sex partners High parity Poor hygiene

Screening and early detection

a. The practice of good perineal needs must be emphasized b. Avoid sex in an early age, avoid numerous partners, and practice the use of condom c. Cancer warning signs: abnormal vaginal bleeding, and spotting after having sex d. Early detection includes Pap smear for women over age 18.

Assessment
Painless vaginal bleeding postmenstrually and postcoitally Foul-smelling or serosanguineous vaginal discharge Pelvic, lower back, leg or groin pain Anorexia and weight loss Leakage of urine and feces from the vagina Dysuria Hematuria Cytological changes on Papanicolaous Test

Interventions
Nonsurgical Chemotherapy Cryosurgery External Radiation Internal Radiation Implants (Intracavitary) Laser Therapy Surgical Hysterectomy Pelvic Exenteration

POST OP CARE
ESTROGEN replacement immediate post op if the ovaries were removed No vaginal entry, douching, or intercourse for 4-6 weeks Avoid bending knees

Ovarian Cancer
Ovarian cancer grows rapidly , spreads fast and is often bilateral. Metastasis occurs by direct spread to the organs in the pelvis, by distal spread through lymphatic drainage or by peritoneal seeding Prognosis is usually poor because the tumor usually is detected late. An exploratory laparotomy is performed to diagnose and stage the tumor.

Assessment
1. 2. 3. 4. Abdominal discomfort or swelling Gastrointestinal disturbances Dysfunctional vaginal bleeding Abdominal mass

Interventions
1. External radiation is used if the tumor is invaded other organs. 2. Chemotherapy is used postoperatively for all stages of ovarian cancer. 3. Intraperitoneal chemotherapy involves the instillation of chemotherapy into the abdominal cavity. 4. Immunotherapy alters the immunological response of the ovary and promotes tumor resistance. 5. Total abdominal hysterectomy and bilateral salpingo-oophorectomy may be necessary.

Endometrial Cancer
Is a slow growing tumor associated with the menopausal years. Metastasis occurs through the lymphatic system to the ovaries and pelvis; via the blood to the lungs, liver and bone; or intraabdominally to the peritoneal cavity.

Precipitating Factors
1. 2. 3. 4. 5. 6. History of uterine polyps Nulliparity Polycystic ovary disease Estrogen stimulation Late menopause Family history

Assessment
- Postmenopausal bleeding - Watery, serosanguineous discharge - Low back, pelvic, or abdominal pain - Enlarged uterus in advanced stages

Interventions
Nonsurgical interventions 1. External radiation or internal radiation is used alone or in combination with surgery, depending on the stage of cancer. 2. Chemotherapy is used to treat advanced or recurrent disease. 3. Progestational therapy with medication such as medroxyprogesterone (Depo-Provera) or megestrol acetate (Megace) is used for estrogen dependent tumors. 4. Tamoxifen (Novaldex), an antiestrogen, also maybe prescribed. Surgical interventions Total abdominal hysterectomy and bilateral salpingooophorectomy

Breast Cancer
Breast cancer is classified as invasive when it penetrates the tissue surrounding the mammary duct and grows in an irregular pattern. Metastasis occurs via lymph nodes. Common sites of metastasis are the bones, lungs; metastasis also occurs to the brain and liver. Diagnosis is made by breast biopsy through a needle aspiration or by surgical removal of the tumor with microscopic examination for malignant cells. Prevention : Monthly BSE

Precipitating Factors
Family history Early menarche and late menopause Previous cancer of the breast, uterus or ovaries Nulliparity Obesity High dose radiation exposure to chest High fat diet

Guideline prevention, screening and early detection

Advice clients to reduce the amount of fat in the diet. Early detection includes: a. BSE once a month b. Yearly breast exam by a health care provider c. Baseline mammogram b/w the ages 35-39 d. Yearly mammogram after the age 40(if with family hx of breast Ca, mammogram should be started at age 30)

Assessment
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Mass felt during BSE Mass usually felt in the upper outer quadrant or beneath the nipple. A fixed, irregular noncapsulated mass A painless mass except in late stages Nipple retraction or elevation Asymmetry, with affected breast being higher Bloody or clear nipple discharge Skin dimpling, retraction, or ulceration Skin edema or peau d orange skin Axillary lymphadenopathy Lymphedema of the affected arm Symptoms of bone and lungs metastasis Presence of the lesions on mammography

Nonsurgical Interventions
1. Chemotherapy 2. Radiation therapy 3. Hormonal manipulation via the use of medication in postmenopausal women or other medications such as tamoxifen (Novadex) for estrogen receptor positive tumors

Surgical Interventions
1. Surgical breast procedures with possible breast reconstruction 2. Oophorectomy for estrogen receptor positive tumors 3. Ablative therapy with adrenalectomy or chemical ablation, which blocks the production of cortisol, androstenedione, and aldosterone.

Gastric Cancer
Gastric cancer is a malignant growth in the stomach.

Risk Factors
Diet high in complex carbohydrates , grains and salt, and low in fresh, green leafy vegetables and fresh fruit Smoking Alcohol ingestion The use of nitrates History of gastric ulcers

Assessment
1. 2. 3. 4. 5. 6. 7. 8. 9. Fatigue Anorexia and weight loss Nausea and vomiting Indigestion and epigastric discomfort A sensation of pressure in the stomach Dysphagia Anemia Ascites Palpable mass

Interventions
1. 2. 3. 4. 5. 6. 7. Monitor vital signs. Monitor hemoglobin and hematocrit and administer blood transfusions as prescribed. Monitor weight. Assess nutritional status; encourage small, bland, easily digestible meals with vitamin and mineral supplements. Administer pain medications as prescribed. Prepare the client for chemotherapy or radiation as prescribed. Prepare the client for surgical resection of the tumor as prescribed.

Surgical Interventions
Subtotal Gastrectomy Billroth I - also called gastroduodenostomy - partial gastrectomy, with remaining segment anastomosed to the duodenum Billroth II - also called gastrojejunostomy - partial gastrectomy, with remaining segment anastomosed to the jejunum. Total Gastrectomy - Also called esophagojejunostomy - removal of the stomach with attachment of the esophagus to the jejunum or duodenum.

Pancreatic Cancer
Is the most common neoplasm affecting the pancreas. The occurrence of pancreatic cancer has been linked to diabetes mellitus, alcohol use, history of previous pancreatitis, smoking, ingestion of high fat diet, and exposure to environmental chemicals. Symptoms usually do not occur until the tumor is large; therefore the prognosis is poor.

Assessment
Nausea and vomiting Jaundice Unexplained weight loss Clay-colored stools Glucose intolerance Abdominal pain

Interventions
1. Radiation 2. Chemotherapy 3. Whipples procedure, which involves a pancreaticoduodenectomy with removal of the distal third of the stomach, pancreaticojejunostomy, gastrojejunostomy and choledochojejunostomy 4. Postoperative care measures are similar to care of a client with pancreatiitis and the client following gastric surgery.

Intestinal Tumors
Intestinal tumors are malignant lesions that develop as polyps in the colon or rectum. Complications include bowel perforation with peritonitis, abscess and fistula formation, hemorrhage and complete intestinal obstruction. Metastasis occurs via the circulatory or lymphatic system or by direct extension to other areas in the colon or other organs.

Assessment
1. 2. 3. 4. 5. Blood in the stools Anorexia, vomiting and weight loss Malaise Anemia Abnormal stools
a. b. c. Ascending colon tumor : Diarrhea Descending colon tumor : Constipation or some diarrhea, or flat ribbonlike stool resulting from partial obstruction Rectal tumor : Alternating constipation and diarrhea

6. 7. 8.

Guarding or abdominal distention Abdominal mass (late sign) Cachexia (late sign)

Interventions
1. Monitor for signs of complications, which include bowel perforation with peritonitis, abscess or fistula formation, hemorrhage and complete intestinal obstruction. Monitor for signs of bowel perforation, which include low blood pressure, rapid and weak pulse, distended abdomen and elevated temperature. Note that an early sign of intestinal obstruction is increased in peristaltic activity, which produces an increased in bowel sound; as the obstruction progresses, hypoactive sounds are heard Prepare for radiation preoperatively to facilitate surgical resection, and postoperatively to decrease the risk of recurrence or to reduce pain , hemorrhage, bowel obstruction, or metastasis. Chemotherapy is used postoperatively to assist in the control of symptoms and the spread of the disease.

2. 3.

4.

5.

Colon Cancer
Colon cancer is cancer of the large intestine (colon), the lower part of your digestive system Most cases of colon cancer begin as small, noncancerous (benign) clumps of cells called adenomatous polyps. Over time some of these polyps become colon cancers.

Assessment:
A change in your bowel habits, including diarrhea or constipation or a change in the consistency of your stool for more than a couple of weeks Rectal bleeding or blood in your stool Persistent abdominal discomfort, such as cramps, gas or pain Abdominal pain with a bowel movement A feeling that your bowel doesn't empty completely Weakness or fatigue Unexplained weight loss

Risk factors:
Age. A personal history of colorectal cancer or polyps. Inflammatory intestinal conditions. Inherited disorders that affect the colon. Family history of colon cancer and colon polyps. Diet low in fiber and high in fat and calories. A sedentary lifestyle. Diabetes. Obesity. Smoking. Alcohol. Radiation therapy for cancer.

Screening and early detection

Colorectal Ca a. Cancer signs: rectal bleeding, change in stools, pain in the abdomen, and pressure on the rectum b. Early detection includes an annual digital rectal exam starting at age 40, an annual stool blood test starting age 50 and an annual inspection of the colon (sigmoidoscopy) at the age 50

Lung Cancer
Is a malignant tumor of the lung that may be primary or metastatic. The lungs are the common target of metastasis. Bronchiogenic carcinoma spreads through direct extension and lymphatic dissemination. The four major types of lung cancer include small cell (oat cell), epidermal (squamous cell), adenocarcinoma, and large cell anaplastic carcinoma.

Diagnosis
Diagnosis is made by a chest x-ray, which will show a lesion or mass, and bronhoscopy and sputum studies, which will demonstrate a positive cytological study for cancer cells.

Causes
Cigarette smoking Exposure to environmental pollutants Exposure to occupational pollutants

Screening and early detection

a. do not smoke is an important msg b. Guidelines to reduce exposure to cancercausing substances in workplaces should be followed

Assessment
dyspnea (shortness of breath) hemoptysis (coughing up blood) chronic coughing or change in regular coughing pattern wheezing chest pain or pain in the abdomen cachexia (weight loss), fatigue and loss of appetite dysphonia (hoarse voice) clubbing of the fingernails (uncommon) dysphagia (difficulty swallowing).

Interventions
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Monitor vital signs. Monitor breathing patterns and breath sounds and for signs of respiratory impairment. Assess for tracheal deviation Administer analgesics as prescribed for pain management. Place in Fowlers position for ease in breathing. Administer oxygen as prescribed and humidification to moisten and loosen secretions. Monitor pulse oximetry. Provide respiratory treatments as prescribed. Administer bronchodilators and corticosteroids as prescribed to decrease bronchospasm , inflammation and edema. Provide a high-calorie, high protein, high vitamin diet. Provide activity as tolerated , rest periods and active and passive rangeof-motion exercises. Monitor for bleeding, infection and electrolyte imbalances.

Laryngeal Cancer
Laryngeal cancer is a malignant tumor of the larynx. Laryngeal cancer presents as malignant ulcerations with underlying infiltration. Metastasis to the lungs is common. Diagnosis is made by laryngoscopy and biopsy showing a positive cytological study for cancer cells.

Causes
Cigarette smoking Exposure to environmental pollutants Exposure to radiation Voice strain

Assessment
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Persistent hoarseness and sore throat Painless neck mass A feeling of a lump in the throat Burning sensation in the throat Dysphasia Change in voice quality Dyspnea Weakness and weightloss Hemopytysis Foul breath odor

Interventions
Place in Fowlers position to promote optimal air exchange. Monitor respiratory status. Monitor for signs of aspiration of food and fluids. Administer oxygen as prescribed. Provide respiratory treatments as prescribed. Provide activity as tolerated. Provide a high-calorie, high-protein, high-vitamin diet. Provide nutritional support via total parenteral nutrition, nasogastric tube feedings, gastrostomy or jejunostomy tube as prescribed. Administer analgesics as prescribed for pain.

Prostate Cancer
This slow-growing cancer of the prostate gland is usually a Androgen dependent type of carcinoma. The risks increases in men with each decade after age 50. Prostate cancer can spread via direct invasion of surrounding tissuesor by metastasis, through the bloodstream and lymphatics, to the bony pelvis and spine. Bone metastasis is a concern.

Assessment
1. 2. 3. 4. 5. 6. Asymptomatic Hard, pea-sized nodule palpated on rectal examination. Hematuria Late symptoms such as weightloss, urinary obstruction, and pain radiating form the lumbosacral area down the leg. Prostatic-specific antigen test is not necessarily an indicator of malignancy and use is routine to monitor the clients response to therapy Spread and mestastasis is indicated by elevated serum acid and phosphatase.

Risk Factors:
Age. Race or ethnicity. Family history. High-fat diet High testosterone levels. Occupations exposed to harmful chemicals

Screening and early detection

a. There are no preventive guidelines b. Early detection includes an annual digital rectal exam at age 40

Interventions
Non-surgical 1. Prepare the client for hormone manipulation therapy as prescribed. 2. Prepare the client for radiation therapy, which may be prescribed alone or along with surgery and may be prescribed preoperatively or post-operatively to reduce the lesion and limit metastasis. 3. Prepare the client for the administration of chemotherapy in cases of hormone-resistant tumors. Surgical 1. TURP 2. Suprapubic Prostatectomy 3. Retropubic Prostatectomy 4. Perineal Prostatectomy

Skin Cancer
Is a malignant lesion of the skin, which may or may not metastasize. Causes include chronic friction and irritation to a skin area and exposure to ultraviolet rays . Diagnosis : Is confirmed by a skin biopsy that is positive for cancer cells.

Types of Skin Cancer

Basal cell the most common type of skin cancer, basal cell cancer arises from the basal cells contained in the epidermis. Squamous cell the second most common type of skin cancer in whites, it is a tumor of the epidermal keratinocytes and can infiltrate surrounding structures, metastasize to lymphnodes, and be subsequently fatal. Malignant melanoma cancer of the melanocytes, can metastasize to the brain , lungs, bone, liver and skin.

Assessment
a. Change in color, size, or shape of pre existing lesions b. Pruritus c. Local Soreness Appearance of Skin Cancer Lesions: - A waxy nodule - An irregular, circular, bordered lesions with hues of tan, black, or blue - A small, red, nodular lesion - An oozing, bleeding, crusting lesion

Nursing Interventions
a. b. c. d. e. f. g. Instruct the client regarding preventive measures. Instruct the client to monitor for lesions that do not heal or that change characteristics. Instruct the client to have moles or lesions removed that are subject ot chronic irritation. Instruct the client to avoid contact with chemical irritants. Intsruct the client to wear layered clothing and use sun screening lotions with an appropriate skin protection factor when outdoors. Instruct the client to avoid sun exposure between 11 am to 3 pm. Assist with surgical excision of the lesion as prescribed.

Leukemia
A malignant exacerbation in the number of leukocytes, usually at an immature stage, in the bone marrow. May be acute, with a sudden onset and short duration, or chronic, with a slow onset and persistent symptoms over a period of years. Leukemia affects the bone marrow causing anemia, leukopenia, the production of immature cells, thrombocytopenia and a decline in immunity. The Cause is unknown and appears to involve gene damage of cells, leading to the transformation of cells from a normal state to a malignant state.

Risk Factors : Genetic Viral Immunological Environmental factors Exposure to radiation Medications

Classification of Leukemia
Acute Lymphocytic Leukemia mostly lymphoblasts , age of onset is less than 15 years. Acute Myelogenous Leukemia mostly myeloblasts present in bone marrow, age of onset is between 15 and 39 years Chronic Myelogenous Leukemia mostly granulocytes present in bone marrow, age of onset is after 50 years Chronic Lymphocytic Leukemia mostly lymphocytes present in bone marrow, age of onset is after 50 years

Assessment
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Anorexia, fatigue, weakness, weight loss Anemia Bleeding (nosebleeds, gum bleeding, rectal bleeding, increased menstrual flow) Petechiae Prolonged bleeding after minor abrasions or lacerations Elevated Temperature Lymphadenopathy and splenomegaly Palpitations, tachycardia, orthostatic hypotension Pallor, dyspnea on exertion Headache Bone pain and joint swelling Normal, elevated or reduced white blood cell count Decreased hemoglobin and hematocrit levels Decreased platelet Positive bone marrow biopsy identifying leukemic blast phase cells

Hodgkins Disease
Is a malignancy of the lymph nodes that originates in a single lymph node or a single chain of nodes. The disease usually involves lymph nodes, tonsils, spleen, and bone marrow and is characterized by the presence of the Reed-Sternberg cell in the nodes. Possible causes include viral infections and previous exposure to alkylating chemical agents.

Staging in Hodgkins Disease

Stage I Involvement of s single lymph node region or an extra lymphatic organ or site Stage II Involvement of two or more lymph node regions on the same side of the diaphragm or localized involvement of an extralymphatic organ or site Stage III Involvement of lymph node regions on both side of the diaphragm Stage IV Diffuse or disseminated involvement of one or more extralymphatic organs with or without associated lymph node involvement

Assessment
1. 2. 3. 4. 5. 6. 7. 8. 9. Fever Malaise, fatigue, and weakness Night sweats Loss of appetite and significant weight loss Anemia and thrombocytopenia Enlarged lymph nodes, spleen and liver Positive biopsy of lymph nodes, with cervical nodes most often affected first Presence of Reed-Sternberg cells in nodes Positive computed tomography scan of the liver and spleen

Nursing Interventions
1. 2. 3. 4. 5. 6. For Stages I and II without mediastinal node involvement, the treatment of choice is extensive external radiation of the involved lymph node regions. With more extensive disease, radiation along with multi agent chemotherapy is used. Monitor for side effects related to chemotherapy or radiation therapy. Monitor for signs of infection and bleeding. Maintain infections and bleeding precautions. Discuss the possibility of sterility with the male client receiving radiation, and inform the client of options related to sperm banks

Multiple Myeloma
A malignant proliferation of plasma cells and tumors within the bone. An excessive number of abnormal, plasma cells invade the bone marrow, develop into tumors , and ultimately destroy bone; invasion of the lymph node, spleen, and liver occurs. The abnormal plasma cells produce an abnormal antibody (myeloma protein or Bence Jones protein) that is found in the blood and urine.

Assessment
1. 2. 3. 4. 5. Bone pain, especially in the pelvis, spine and ribs Weakness and fatigue Recurrent infections Anemia Bence Jones proteinuria and elevated total serum protein level 6. Osteoporosis 7. Thrombocytopenia and Granulocytopenia 8. Elevated calcium and uric acid levels 9. Renal failure 10. Spinal cord compression and paraplegia

Interventions
Monitor for signs of bleeding, infection, and skeletal fractures. Encourage fluids up to 3 to 4 L a day to offset potential problems associated with hypercalcemia, hyperuricemia and proteinuria. Encourage ambulation to prevent renal problems and to slow down bone resorption. Provide skeletal support during moving, turning and ambulating to prevent pathological fractures Provide a hazard free enviroment. Instruct the client in home care measures and the signs and symptoms of infection.