ONCOLOGY
ESSENTIAL CONCEPTS OF CANCER
NURSING MANAGEMENT OF PATIENTS WITH CANCER
Cancer Defined
A disease process that begins when an abnormal cell is transformed by the
genetic mutation of cellular DNA (Normal cells mutate into abnormal cells)
Group of complex diseases; affect different organs and organ systems 
The abnormal cells have invasive characteristics and infiltrate other tissues.
metastasis
This phenomenon is
.
Cancer cells are described as malignant. These cells demonstrate
uncontrolled growth that does not follow physiologic demand.



Oncology
Study of cancers 
Oncology nurses specialize in the care, treatment of
clients with cancer
Incidence and Prevalence
Cancer accounts for about 25% of death on yearly basis
Three most common types of cancer 
Among males: 
Prostate, 
Lung, bronchial 
Colorectal 
Among females: 
Breast 
Lung and bronchial 
Colorectal 

Incidence
Incidence rate of all cancers
72.9/100.000
70.7/100.000
75.2/100.000

All Jordanians (2003) 
Male Jordanian
Female Jordanian 
Comparison among Countries
Female
Male
69.2
111.0
Country
Algeria


127.3
304.9
267.2
273.6
253.7
134.3
106.7
327.0
316.6
385.0
450.5
137.6
Kuwait
Denmark
Ireland
USA, white
USA, Black
Jordan
Cancer incidence by site and sex in USA (1994)
Percent
32
16
12
9
7
Female
32
13
13
8
6
Type
Male

Prostate 
Lung 
Colon or rectum 
Urinary Tract 
Leukemia and lymphoma 

Breast 
Colon and rectum 
Lungs 
Uterus 
Leukemia and lymphoma 
Cancer incidence by site and sex in Jordan
(1997)
Percent
10.5
10.3
9
7.3
6.6
5.8
5.8
4.9
4.4
3.8
Male Type

Bladder 
Lungs 
Leukemia 
Prostate 
Lymphoma 
Brain & CNS 
Skin 
Stomach 
Colon 
Larynx 
Cancer incidence by site and sex in Jordan
(1997)
Percent
28.3
5.9
5.4
5.1
5
4.5
4.5
4
3.1
2.9
Female: Type
Breast
Skin 
Leukemia 
Lymphoma 
Colon 
Uterus 
Thyroid 
Brain & CNS 
Stomach 
Cervix 


Risk factors for cancer (1)
some are controllable; some are not
Heredity: 

5 – 10% of cancers; documented with some breast and colon
cancers
Age:


70% of all cancers occur in persons > 65
Lower socio-economic status
Stress 


Leads to greater wear and tear on body in general

Diet: 5.
Certain preservatives in pickled
Salted foods; 
Fried foods; 
High-fat, low fiber foods; 
High fat foods 
Diet high in red meat 

Risk factors for cancer (1)
Occupational risk:

Exposure to know carcinogens, radiation, high stress
Infections:

Especially specific organisms and organ (e.g. 
papillomavirus causing genital warts and leading to
cervical cancer.
Tobacco Use:
Lung

Oral

Laryngeal
Esophageal
Gastric

Pancreatic
Bladder





Alcohol Use:

Same as smoking

Sun Exposure (radiation):
Skin cancer



Nursing role:
Health promotion to lower risks
Routine medical check up and screenings 
Client awareness to act if symptoms of cancer occur 
Screening examination recommendations by American Cancer

Society; specifics are made according to age and frequencies
ACS: recommendation for screening
Breast Cancer:

Self-breast exam

Breast examination by health care professionals
Screening mammogram

Colon and Rectal Cancer:
fecal occult blood

Flexible sigmoidoscopy
Colonoscopy



Cervical, Uterine Cancer:
Papanicolaou (Pap) test
Prostate Cancer:




Digital rectal exam

Prostate-specific antigen (PSA) test

Theories of Carcinogenesis
Cells begin to mutate: 
Change the DNA to unnatural cell reproduction 
Oncogenes/Tumor Suppressor Genes Abnormalities: 
Oncogenes are genes that promote cell proliferation and can 
trigger cancer
Tumor suppressor genes normally suppress oncogenes but are
damaged
Exposure to Carcinogens (1)
Act by directly altering the cellular DNA (genotoxic)
Act by affecting the immune system (promotional)
Depends on: 
Dose (amount)
Duration (time)


Exposure to Carcinogens (2)
Viruses




Viruses break the DNA chain and mutates the normal cells DNA
Epstein-Barr virus 
Human papilloma virus
Hepatitis virus 


Drugs and Hormones 
Sex hormones often affect cancers of the reproductive systems (estrogen in
some breast cancers; testosterone in prostate cancer)
Glucocorticoids and steroids alter immune system


Exposure to Carcinogens (3)
Chemical Agents

Industrial and chemical 
Can initiate and promote cancer 
Examples: hydrocarbons in soot ; arsenic in pesticides; chemicals in tobacco
Physical Agents
Exposure to radiation 
Ionizing radiation found in x-rays, radium, uranium
UV radiation 
Sun, tanning beds 
Immune function




Protects the body from cancerous cells 
Increased rate of cancer in immunocompromised patients

Types of neoplasms
Benign:

Localized growths respond to body’s homeostatic controls 
Encapsulated 
Stop growing when they meet a boundary of another tissue
Can be destructive 
Malignant


Have aggressive growth, rapid cell division outside the normal cell cycle 
Not under body’s homeostatic controls 
Cut through surrounding tissues causing bleeding, inflammation, necrosis
(death) of tissue

Metastasis:
Malignant tumors (neoplasm) can metastasize 
Tumor cells travel through blood or lymph circulation to other body areas and
invade tissues and organs there.
Primary tumor: 
The original site of the malignancy 
Secondary tumor (sites): 
Areas where malignancy has spread i.e. metastasis (metastatic tumor) 
Common sites of metastasis are lymph nodes, Liver, Lungs, Bones, Brain 
50 – 60 % of tumors have metastasized by time primary tumor identified 

Characteristics of neoplasms (1)
Cancerous cells must avoid detection by immune system 
Malignant neoplasms can recur after surgical removal of primary and
secondary tumors and other treatments
Malignant neoplasms vary in differentiation. 
Highly differentiated are more like the originating tissue 

Undifferentiated neoplasms consist of immature cells with no
resemblance to parent tissue and have no useful function

Characteristics of neoplasms (2)
Malignant cells progress in deviation with each generation and do
not stop growing and die, as do normal cells
Malignant cells are irreversible, i.e. do not revert to normal

Malignant cells promote their own survival by hormone production,
cause vascular permeability; angiogenesis; divert nutrition from
host cells


Effects of Cancer (1)
Disturbed or loss of physiologic functioning, from pressure or obstruction
Anoxia 
Necrosis of organs 
Loss of function: 
Bowel or bladder obstruction 
Increased intracranial pressure 
Interrupted vascular/venous blockage 
Ascites 
Disturbed liver functioning 
Motor and sensory deficits 
Cancer invades bone, brain or compresses nerves
Respiratory difficulties 
Airway obstruction 
Decreased lung capacity



Effects of Cancer (2)
Hematologic Alterations:

Impaired function of blood cells 
Secondary to any cancer that invades the bone marrow
(leukemia)
May also be caused by the treatment 
Abnormal WBCs: impaired immunity 
Diminished RBCs 
Diminished Platelets: anemia and clotting disorders 

Effects of Cancer (3)
Infections: fistula development and tumors may become necrotic;
erode skin surface
Hemorrhage: tumor erosion, bleeding, severe anemia

Anorexia-Cachexia Syndrome: wasting away of client

Unexplained rapid weight loss, anorexia with altered smell and

taste
Catabolic state: use of body’s tissues and muscle proteins to

support cancer cell growth
Effects of Cancer (4)
Paraneoplastic Syndromes: 
Ectopic sites with excess hormone production


Parathyroid hormone (hypercalcemia) 
Ectopic secretion of insulin (hypoglycemia) 
Antidiuretic hormone (ADH: fluid retention) 
Adrenocorticotropic hormone (ACTH) 
Effects of Cancer (5)
Pain: major concern of clients and families
Types of cancer pain


Acute: symptom that led to diagnosis 
Chronic: may be related to treatment or to progression of disease
Causes of pain


Direct tumor involvement including metastatic pain
Nerve compression 
Involvement of visceral organs 

Effects of Cancer (6)
Physical Stress:

body tries to respond and destroy neoplasm
Fatigue 
Weight loss 
Anemia 
Dehydration 
Electrolyte imbalances


Effects of Cancer (7)
Psychological Stress

Cancer equals death sentence
Guilt from poor health habits
Fear of pain, suffering, death
Stigmatized 



Collaborative Care (Diagnostic Tests) (1)
Used to diagnose cancer 
Determine location of cancer
X-rays 
Computed tomography 
Ultrasounds 
Magnetic resonance imaging
Nuclear imaging 
Angiography 


Diagnostic Tests (2)
Diagnosis of cellular type of can be done through tissue
samples from biopsies, shedded cells.
Cytologic Examination: 

Tissue examined under microscope
Identification System of Tumors: 
Classification
Grading 
Staging 


Diagnostic Tests (3)
Classification:

according to the tissue or cell of origin, e.g. sarcoma, from supportive
Grading:
Evaluates degree of differentiation and rate of growth
Grade 1 (least aggressive) to Grade 4 (most aggressive)
Staging:





Relative tumor size and extent of disease 
TNM (Tumor size; Nodes: lymph node involvement; Metastases)

Diagnostic Tests (4)
Tumor markers: specific proteins which indicate malignancy
PSA (Prostatic-specific antigen): prostate cancer 
CEA (Carcinoembryonic antigen): colon cancer 
Alkaline Phosphatase: bone metastasis 
Diagnostic Tests (5)
Direct Visualization

Sigmoidoscopy 
Cystoscopy 
Endoscopy 
Bronchoscopy 
Exploratory surgery 
Lymph node biopsies to determine metastases

Diagnostic Tests (6)
Other non-specific tests
CBC, Differential 
Electrolytes 
Blood Chemistries: 
Liver enzymes
RFT 

Treatment (1)
Treatment Goals: depending on type and stage of cancer 
Cure 
Recover from specific cancer with treatment 
Alert for reoccurrence 
May involve rehabilitation with physical and occupational therapy


Control: of symptoms and progression of cancer 
Continued surveillance 
Treatment when indicated (e.g. some bladder cancer, prostate cancer) 
Palliation of symptoms: may involve terminal care if client’s cancer is not
responding to treatment

Treatment Options
Depend on type of cancer:

Alone or in combination 
Chemotherapy (1)

Effects are systemic and kills the metastatic cells 
Often combinations of drugs in specific protocols over varying time periods 
Much more effective then a single agent 
Consider the timing of the nadir of each drug 
The time when the bone marrow activity and WBC counts are at their lowest levels after
chemo
Different times for different drugs 
Cell-kill hypothesis:

with each cell cycle a percentage of cancerous cells are killed but some remain; 
repeating chemo kills more cells until those left can be handled by body’s immune
system

Classes of Chemotherapy Drugs (1)
Alkylating agents

Action: create defects in tumor DNA 
Examples: Nitrogen Mustard, Cisplatin
Antimetabolites:


Action: similar to metabolites needed for vital cell processes 
Metabolites interfere with cell division 
Examples: Methotrexate; 5 fluorouracil 
Toxic Effects: nausea, vomiting, stomatitis, diarrhea, alopecia, leukopenia
Antitumor Antibiotics:


Action: interfere with DNA 
Examples: Actinomycin D, Bleomycin
Toxic Effect: damage to cardiac muscle


Classes of Chemotherapy Drugs (2)
Antimiotic agents

Action: Prevent cell division 
Examples: Vincristine, Vinblastine 
Toxic Effects: affects neurotransmission, alopecia, bone marrow
depression
Hormone agonist


Action: large amounts of hormones upset the balance and alter
the uptake of other hormones necessary for cell division
Example: estrogen, progestin, androgen 

Classes of Chemotherapy Drugs (3)
Hormone Antagonist

Action: block hormones on hormone-binding tumors (breast,
prostate, and endometrium); cause tumor regression

Decreasing the amount of hormones can decrease the cancer
growth rate
Does not cure, but increases survival rates 
Examples: Tamoxifen (breast); Flutamide (prostate) 
Toxic Effects: altered secondary sex characteristics 

Classes of Chemotherapy Drugs (4)
Hormone inhibitors 
Aromatase inhibitors (Arimidex, Aromasin) 
Prevents production of aromatase which is needed for
estrogen production
Used in post menopausal women 
Side effects (Masculinizing effects in women, Fluid 
retention)

Effects of Chemotherapy
Tissues (fast growing) frequently affected
Examples:


Mucous membranes 
Hair cells 
Bone marrow 
Specific organs with specific agents, reproductive organs (all
fetal toxic, impair ability to reproduce).

Administration of chemotherapeutic agents
Trained and certified personnel, according to established guidelines
Preparation 
Protect personnel from toxic effects 
Drugs absorbed through skin and mucous membranes
Protective clothing and extreme care 


Extreme care for correct dosage; double check with physician orders,
pharmacist’s preparation
Proper management clients’ stool 

Routes
Oral 
Body cavity (intraperitoneal or intrapleural)
Intravenous 

Use of vascular access devices because of threat of extravasation
(leakage into tissues) and long-term therapy
If the drug is a vessicant it may result in pain, infection and tissue loss


Types of vascular access devices
PICC lines (peripherally inserted central catheters)

Tunnelled catheters (Hickman, Groshong) 
Surgically implanted ports (accessed with 90o
angle needle)

Portacath
PICC Line
Managing side effects of chemotherapy (1)
Nausea and vomiting

80% of patients will develop it
Antiemetics such as: 

Zofran 
Tigan 
Compazine 
Ativan to control the symptoms 
Monitor for dehydration and need for IV fluids

Managing side effects of chemotherapy
(2)
Bone marrow suppression
Decreased number of RBC


Leads to hypoxia, fatigue 
Hgb 9.5-10 gm/dl require oral iron supplements
Hgb below 8 gm/dl require transfusion 
May use Epogen to stimulate RBC production 

Managing side effects of chemotherapy
(3)
Decrease number of WBC (normal 4,500-11,000 mm3) especially neutrophils
(normal 3,000-7,000 cells/cc)
Neutropenia-count below 2000 
Patient at extreme risk for infection 
May order granulocyte colony stimulating factor (leukine) to stimulate bone marrow to
increase WBC count
Neutropenic precautions 
Private room 
Good handwashing 
Monitor temp q 4 hours, monitor for chills, UTI, pneumonia
Limit visitors to healthy adults 
No flowers or plants 
Monitor neutrophil count 



Managing side effects of chemotherapy
(4)
Thrombocytopenia

Drop in platlet count (normal 150,000-400,000/mm3) below 100,000 
Test pt for bleeding in stool and urine 
Avoid punctures for IV or IM 
Handle pt gently 
Use electric razor 
Avoid placing foley or rectal thermometers 
Avoid oral trauma with soft bristle brushes, avoid flossing, avoid hard candy
Watch for LOC, pupil changes that might indicate intracranial bleeds 
Stool softeners to avoid straining 

Managing side effects of chemotherapy
(5)
Mucocitis
Inflammation and ulceration of mucous membranes and entire GI
tract
Rinse mouth with ½ normal saline and ½ peroxide every 12 hours
Topical analgesic medication 
Avoid mouthwashes with alcohol 
Avoid spicy or hard food 
Watch nutritional status 


Managing side effects of chemotherapy
(6)
Alopecia
Hair loss 
2-3 weeks after treatment is started 
Affects all the hair, including eyebrows, eyelashes 
Within 4-8 weeks after treatment hair begins to grow 
back
Before hair loss, have the pt pick out a wig that is similar
to hair color

Managing side effects of chemotherapy
(7)
Peripheral neuropathy
Numbness and tingling to fingers and toes in a glove and
sock pattern

May cause gait and possible fall problems 
Provide emotional and spiritual support to patient and
families

Surgery
Diagnosis, staging, and sometimes treatment of cancer 
May be prophylaxis or removal of at risk tissue or organ prior to development of
cancer (breast cancer)
Involves removal of body part, organ, sometimes with altered functioning (e.g.
colostomy)
Debulking (decrease size of) tumors in advanced cases 
Reconstruction and rehabilitation (e.g. breast implant post mastectomy) 
Palliative surgery to improve the quality of life 
Removal of tumor tissue that is causing pain or obstruction



Psychological support to deal with surgery as well as cancer diagnosis

Radiation Therapy (1)
Treatment of choice for some tumors to kill or reduce tumor, relieve pain or
obstruction
Destroy cancer cells with minimal exposure to normal cells
Cells die or are unable to divide
Delivery




Teletherapy (external): radiation delivered in uniform dose to tumor 
Beam radiation 
Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is
placed in tumor or next to it in the form of seeds
Radiation source within the patient so pt emits radiation for a period of time and is a 
hazard to others
Combination


Radiation Therapy (2)
Goals
Maximum tumor control with minimal damage to normal tissues
Caregivers must protect selves by using shields, distancing and
limiting time with client, following safety protocols


Private room 
Caution sign on the door for radioactive material 
Dosimeter film badge by staff 
No pregnant staff 
Limit visitors to ½ hour per day and keep them at least 6 ft from the source
Radiation Therapy (3)
Treatment Schedules
Planned according to radiosensitivity of tumor, tolerance of client 
Monitor blood cell counts 
Side Effects 5.
Skin (external radiation): blanching, erythema, sloughing, breakdown
Use mild soak 
Dry skin with a patting motion, not rubbing 
Don’t use powders or lotions unless prescribed by radiologist
Wear soft clothing over the site 
Avoid the sun and heat 



Radiation Therapy (4)
Ulcerated mucous membranes: pain, lack of saliva b.
(xerostoma)
Gastrointestinal: nausea and vomiting, diarrhea, c. 
bleeding, sometimes fistula formation
Radiation pneumonitis d. 
1-3 months after treatment 
Cough, SOB, fever 
Treated with steroids to decrease inflammation


Biological Response Modifiers
Monoclonal antibodies (inoculate animal with tumor
antigen and retrieve antibodies against tumor for
human)
Antibodies target specific substances needed by the
cancer cell for growth (Herceptin for breast cancer)

Gene therapy
experimental 
May insert gene into the tumor cells to make them more susceptible
to being killed by antiviral agents
May insert genes for cytokines that increase their effectiveness in 
killing cancer cells
Angiogenesis inhibitor drugs
Prevent new blood vessels from forming and
delivering blood to the tissue

Bone Marrow Transplant (BMT)
Bone Marrow Transplantation and Peripheral Blood Stem Cell 
Transplantation
Stimulation of nonfunctioning marrow or replace bone marrow 
Common treatment for leukemias 
Pain Control
Includes pain directly from cancer, treatment, or unrelated 
Necessary for continuing function or comfort in terminally ill clients 
Goal is maximum relief with minimal side effects 
Multiple: 
Combinations of analgesics (narcotic and non-narcotic) 
Adjuvants such as steroids or antidepressants 
Iincludes around the clock (ATC) schedule with additional medications for breakthrough pain


Routes of medications 
May involve injections of anesthetics into nerve, surgical severing of nerves radiation 
May need to progress to stronger pain medications as pain increases and client develops
tolerance to pain medication

Nursing Diagnoses for Clients with Cancer
Anxiety

Therapeutic interactions with client and family
Community resources 
‫ المالذ‬
KHCC


Availability of community resources for terminally ill
Disturbed Body Image:
Includes:



Loss of body parts (e.g. amputations)
Appearance changes (skin, hair) 
Altered functions (e.g. colostomy); 
Cachexic appearance 
Loss of energy 
Ability to be productive 

Fear of rejection, stigma
Anticipatory Grieving 

Facing death and making preparations for death 
Offer realistic hope that cancer treatment may be successful
Risk for Infection
Risk for Injury 


Organ obstruction 
Pathological fractures

Altered Nutrition: less than body requirements

Consultation with dietician 
Lab evaluation of nutritional status 
Managing problems with eating: anorexia, nausea and vomiting
May involve use of parenteral nutrition 
Impaired Tissue Integrity


Oral, pharyngeal, esophageal tissues (due to chemotherapy, bleeding due to 
low platelet counts, fungal infections such as thrush)
Teach inspection, frequent oral hygiene, specific non-irritating products, thrush
control
Oncologic Emergencies
Pericaridal Effusion and Neoplastic Cardiac Tamponade
Concern:

Compression of heart by fluid in pericardial sac
Compromised cardiac output 
Treatment:

Pericardiocentesis




Superior Vena Cava Syndrome
Obstruction of venous system with increased venous pressure and stasis
Facial and neck edema 
Respiration distress 
Late signs are: 
Cyanosis 
Decreased cardiac output
Hypotension 
Treatment:



Respiratory support 
Decrease tumor size with radiation or chemotherapy

Compression of the superior vena cava in SVC
syndrome
Sepsis and Septic Shock
Early recognition of infection

Patients at risk secondary to low WBC and impaired
immune system
Treatment:

Prompt intervention with:
Antibiotics 
Vasopressors



Disseminated Intravascular Coagulophathy (DIC)
Triggered by severe illness, usually sepsis in cancer patients 
Abnormal clotting uses up existing clotting factors and platelets 
quickly then the pt hemorrhages
Mortality rate is 70% 
Prevention of sepsis is key

Spinal Cord Compression
Pressure from expanding tumor or vertebral collapse can cause
irreversible paraplegia
Back pain initial symptom with progressive Paresthesia and
paralysis
Paralysis is usually permanent 
Treatment: 
Early detection 
High dose corticosteroid to decrease the swelling



Radiation or Surgical decompression 
Obstructive Uropathy
Concern: 
Blockage of urine flow 
Undiagnosed can result in renal failure 
Treatment: 
Restore urine flow 
Hypercalcemia
High calcium (normal 9-10.5) 
Usually from bone metastases 
May also come from cancer of the lung, head, neck, kidney and lymph nodes that
secrete parathyroid hormone that causes the bone to release calcium
Symptoms include: 
Fatigue, Muscle weakness, Polyuria, Constipation, progressing to Coma, 
Seizures
Treatment: 
Restore fluids with intravenous saline which also increases the excretion of 
calcium
Loop diuretics increase calcium excretion 
Calcium chelators such as mithracin, Inhibit calcium resorption from the bone 
Calcitonin di-phosphonate 
Tumor Lysis Syndrome
Occurs with rapid necrosis of tumor cells with chemotherapy:
When tumor cells die they release potassium and purines 
Potassium (norm 3.5-5.5) 
Elevation Potassium causes: 
Cardiac arrhthymias, Muscle weakness, Twitching, Cramps
Purines convert to uric acid which causes:



Renal failure, Flank pain, Gout when elevated above 10 mg/dl

Hyperphosphatemia with secondary to hypocalcemia causes:
Heart block, HTN, Renal failure
Treatment


Hydration 
Instruct pt to increase fluid intake before and after chemo
May need IV hydration 
Diuretics to increase urine flow 
Allopurinol to increase uric acid excretion 
May need dialysis 



Syndrome of Inappropriate Antidiuretic Hormone
Secretion (SIADH)
Ectopic ADH production from tumor leads to excessive hyponatremia
Holds onto too much fluid which decreases sodium level (normal 
135-145)
Symptoms 
Weakness, Muscle cramps, Fatigue, ALOC, Headache, Seizures
Treatment:


Restore sodium level, Fluid restriction, Increase sodium, Antibiotic, 
Demeclocycline works in opposition to ADH and Limits ADH effect on distal
renal tubules so they can excrete water
