Neurolemic sarcoma – nerve sheath
Leukemia – blood
ONCOLOGY NURSING
Common Terminologies
Oncogene – cancer genes that alter normal genes
Proto oncogenes – repressed oncogene that can
activated by etiologic and risk factors
Anaplasia – no resemblance to tissues of origin
Metaplasia – replacement of the original cell with
another type of cell
Carcinoma – cancer cell composed of epithelial cells
that can spread
Neoplasm – growth of new tissue
Tumor – same with neoplasm
Dysplasia – alteration in the size, shape and
organization of differentiated cells
Hyperplasia – an increase in the number of normal
cells
Cancer Cells
Tumor can be:
BENIGN
Localized
Encapsulated
Hyperplasia,
↑ functional activity
function of the
No metastasis
Fatal if it occurs in
restricted area (skull)
Fully differentiated
Slow growth
MALIGNANT
Systemic
Non encapsulated
Anaplasia, metaplasia
(↑ or ↓
organ involved)
With metastasis
(direct invasion,
lymphatic,
embolism, diffusion)
Harmful
Hardly differentiated
Rapid growth
Cancer
●
Synonymous to death and pain
●
Chronic disease that has acute exacerbation
●
Not a single disease with single cause
●
Common in men
●
Leading cancer is lung cancer
●
Male: prostate
●
Female: breast
Classification of Cancer:
Squamous cell carcinoma – surface epithelial
Adenosarcoma – glandular epithelial
Fibrosarcoma – fibrous connective tissue
Liposarcoma – adipose tissue
Chondrosarcoma – cartilage
Osteosarcoma – bone
Hemangiosarcoma – blood vessels
Lymphangiosarcoma – lymph vessels
Leiomyosarcoma – smooth muscles
Rhabdomyosarcoma – striated muscles
Glioma – glial cells
Classification of Benign:
Glandular tissue – adenoma
Bone – osteotoma
Nerve cells – neuroma
Fibrous tissue - fibroma
Etiology
Exact cause is still unknown
Viruses – cancer of the liver, burkitt’s lymphoma
Chemical Agents – tar, asphalt, arsenicals, fuels, oil
Drugs – chemodrugs
Physical Agents – radiation
Dietary Factors - Increased - fats, alcohohol, salt
cured or smoked meats, food with nitrates/niritites,
high caloric dietary intake.
● Decreased - high-fiber foods
Predisposing Factors:
Age – (60% of cancer clients are over 65 y/o)
Sex – Breast cancer for females and Prostate CA for
males
Geographic location – cancer of the stomach
(Japan)
Occupation – factory workers (lung cancer)
Hereditary – breast, ovaries and colon
Diet – cured and salted foods (stomach)
Stress – decreased immune system
Precancerous lesions – moles, polyps (colon and
stomach)
Early Detection: (SECONDARY)
●
Chest xray and sputum cytology (lung cancer)
●
Physical exam (every year for over 40 y/o) skin,
lymph nodes, mouth, thyroid, breast, testes,
rectum, prostate
●
Oral Exam - annually
●
TSE – monthly following shower
●
Digital Rectal Exam – annually for 40y/o and
above
●
Sigmoidoscopy – for 50 y/o and above annually
for 2 years then every 3 years if negative
●
Fecal Occult Blood – doctor’s recommendation
●
BSE – every month after menstruation
●
Breast Clinical Exam – done by physician (every
3 years for 20-40 y/o then yearly for over 40
y/o)
●
Mammography – once for 35-40 y/o, then
yearly for over 50 y/o
●
Pap smear – age 18 and all sexually active
women then yearly after 3 negative results
●
Pelvic Exam – same with pap smear
●
Endometrial tissue sampling – menopause
Factors that lead to Cancer
●
Smoking – lung cancer
●
Sunlight (10am to 2pm) – basal/squamous
cell (skin cancer)
●
Ionizing Radiation – medical and dental
xrays
●
Nutrition and diet (high fats and low fiber
diet)
●
Alcohol – liver, oral and esophagus cancer
●
Chewing of tobacco (mouth, larynx and
throat)
●
Estrogen – endometrial cancer
●
Occupational hazards (nickel and asbestos)
7 Warning Signals (CAUTION US)
C
A
U
T
I
O
N
U
S
hange in bowel and bladder habits
sore that does not heal
nusual bleeding or discharge
hickening or lump in breast or elsewhere
ndigestion or difficulty in swallowing
bvious change in wart or mole
agging cough or hoarseness of the voice
nexplained anemia
udden weight loss
Antigen-skin-testing
Staging and Grading
T Tumor
T0-T4
N Node
N0-N3
M Metastasis
M0-M1
Normal
Stage I
Stage II
Stage III
Stage IV
Tis – carcinoma in situ (non-infiltrating)
X – can’t be assessed
Staging System
T – Tumor
N – Node
M – Metastasis
Normal
Stage I
Stage II
Stage IV
U
B
B
L
terus annual pap smear
reast regular BSE
asic PE yearly for all adults
ung control or preferably stop smoking,
annual chest xray for high risk
O ral annual oral exam by the doctor
C olon or Rectum DE,
Proctosigmoidoscopy (40y/o)
S kin avoid undue exposure to sunlight (10-2 PM)
Diagnostic Exam
Biopsy
FNA
Incision
Excision
CT scan
MRI
PET
Direct Visualization
– Bronchoscopy
– Gastroscopy
– Proctosigmoidoscopy
Mammogram
Pap smear
UTZ
Angiogram
Lymphangiogram
Blood Studies
T0-T4
N0-N3
M0-M3
Tis – carcinoma in situ (non-infiltrating)
X – can’t be assessed
Stage III
7 SAFEGUARDS
T0, N0, M0
T1, N0, M0
T2, N1, M0
T3, N2, M0
with metastasis
T0, N0, M0
T1, N0, M0, < 2cm diameter
of the tumor
T2, N1, M0, > 2 < 5cm diameter
of the tumor
T3, N2, M0, > 5cm diameter
of the tumor
any size of the tumor with metastasis
Grading System
– Microscopic study of the cell
– The poorer the differentiation of the cells the
poorer is the prognosis
Carcinogenesis: Process of cancer formation
●
Initiation – exposure to carcinogens
●
Promotion – exposure to carcinogenic
chemicals will promote the function of
proto oncogenes
●
Transformation – conversion to malignant
cell
●
Progression – malignant behavior of the
cells
Stages of Metastatic Process
●
Invasion of adjacent tissue
●
Spread of cancer cells
●
Establishment and growth at secondary site
Effective Test must be
●
Specific for the type of Cancer
●
Reliable
●
Economical on terms and benefits
●
Acceptable to the client (most important)
Points to Remember
●
Normal cells and cancer cells are both affected
●
Most client fear of death upon confirmation
of Cancer
●
The goal is to destroy malignant cells without
harming normal cells by:
●
Clients usually ignored cardinal signs of
Cancer
●
Fractionation-small frequent dose
●
●
Alternating the site
Most often cancer is detected during
routine exam
●
●
Alpha particle-fast moving helium nucleus (slight
penetration)
Questions that need to be answered:
Example (Is the disease curable or not?)
●
Beta particle-fast moving electron (moderate
penetration)
●
Gamma ray-similar to light ray (high penetration)
●
Sodium Iodide (131 I)-for thyroid gland
●
Gold (198 Au)-effective for ascites and pleural
effusion
●
Sodium Phosphate (32 P)-for RBC
Destroys the ability of the cell to reproduce by
damaging the DNA
Client Reaction during Diagnoses
Client will use coping strategies to ↓ his anxiety
level such as:
●
Denial-
●
Rational inquiry-seek more information
●
Affect Reversal-make light of the situation
(laughing etc.)
●
Mutuality-share concerns and talk with
other persons
●
Suppression-conscious forgetting
●
Displacement or redirection-do other things
Client Reaction during Diagnoses
●
Confrontational
●
Redefine or revise
●
Passive acceptance
●
Disengagement
●
Externalization or Projection
●
Moral masochism
●
Compliance and cooperational
Intervention Phase
●
Therapeutic communications (silence, non
judgemental, acceptance, active
friendliness, setting limits)
●
Strategizing how to use effective coping
mechanism (client and SO)
●
Cancer management will involve surgery,
radiation, chemo and immunotherapy in
combination.
Surgery
Used in diagnosing, staging and treating the client
FNA, I&E biopsy
Cytology specimens
• Palliative – relieves pain, airway obstruction.
• Reconstructive – restore maximal function and
appearance
• Preventive – removal of target organ
Radiation Therapy
●
Range will be 2,000-5,000 centigrays (cGy)
↑
5,000 cGy will  SE
Radiation Safety
●
Distance - the greater the distance the
lesser the exposure
●
Time - the less time spent close to radiation
the less exposure (max of 30 min per shift)
●
Shielding - use lead aprons and gloves
●
Standards - kept as low as reasonably
achievable
●
Monitoring device - film badge (measure
the whole exposure of the nurse)
Types of RADIATION
External Radiation
– Administered by high energy xray machine
(radioisotope Cobalt for Prostate and Lung
CA)
Internal Radiation
– Via injection or orally
Internal Radiation
UNSEALED SOURCE
●
Radioisotope is administered IV or orally
●
NaP04 (32 P) IV for polycythemia vera
●
(131 I) PO for Grave’s disease
●
Potential hazard exist because it’s not
encased
●
Isotope maybe excreted via body fluids
●
Flush the toilet several times after use
●
Protect staff and visitors
●
Marked room and kardex with
RADIATION HAZARD
SEALED SOURCE
●
radioisotope is placed into needles, beads,
seeds, ribbons or catheter then implanted
directly into the tumor.
●
Requires a private room and bathroom
●
Room must be lead-shield proof
●
Lead container and long forcep on bedside
●
Check linen and other materials for the
presence of isotope
Chemotherapy
●
Use of chemicals to destroy cancer cells
●
Interferes DNA & RNA activities associated
with cell division
●
Often used in combination with radiation
therapy
Cytotoxic - is an agent capable of destroying cells
Cytotoxic drug - alkylating and antimetabolites
Antineoplastic Drugs
Alkylating Agents
Attack the DNA of rapidly dividing cell
Nitrosurea: Carmustine (BCNU)
Nitrogen Mustard: Chlorambucil (Leukeran)
Cyclophosphamide (Cytoxan)
Vinca Alkaloids
Interfere with mitosis (M phase)
Vincristine (Oncovin) Vinblastine (Velban)
Antimetabolites
Inhibits protein synthesis (S phase)
Azathioprine (Imuran)
Fluorouracil (5-FU)
Methotrexate (Mexate) given with leucovorin to
protect normal cells
Antibiotics
Inhibit RNA
Doxorubicin HCl (Adriamycin) Mithramycin
(Mithracin)
Antimetabolites
Inhibits protein synthesis (S phase)
Azathioprine (Imuran)
Fluorouracil (5-FU)
Methotrexate (Mexate) given with leucovorin to
protect normal cells
Antibiotics
Inhibit RNA
Doxorubicin HCl (Adriamycin) Mithramycin
(Mithracin)
Hormone
Inhibit RNA and protein synthesis in tissues that
are dependent on the opposite sex
Androgens, Estrogens, Progestins, Steroids
(Analogue, Exogenous)
Hormone Antagonist: Mitotane (Lysodren)
cortisol antagonist, Tamoxifen Citrate
(Nolvadex) estrogen antagonist
Immune Agents
Introduction of an agent to stimulate
production of antibodies
Bacillus Calmette-Guerin (BCG)
C&R Goal:
●
Destroy all malignant cells without
excessive destruction of normal cell
●
Control growth of tumor when cure is not
possible
Note: all rapid dividing cells (GI mucosa, hair
follicles and bone marrow) are susceptible to the
action of chemo and radiation therapy.
Reasons of Combining Drugs
Synergy - two or more agents works together to
enhance the effect
Adjuvant - an additional treatment
↑’s malignant cell destructions, ↓’s the SE
Principle of MDT is instituted to avoid and prevent
the SE
C&R SIDE EFFECTS
Common: nausea and vomiting
Stomatitis
Alopecia (2-3 weeks to occur)
Bone marrow depression
Neurologic/Sensory/Perceptual
Meningeal irritation
CN and peripheral neuropathy
Cerebellar toxicity
Ototoxicity
Cardiac
Pericardial Effusion
Arrhythmias
CHF
Pulmonary
Pleural Effusion
Pneumonitis
GIT
Stomatitis
Esophagitis
Pharyngitis
Taste alteration
Anorexia
Nausea and vomiting
Constipation and diarrhea
Weight loss
C&R SIDE EFFECTS
GUT
Nephrotoxicity
Hemorrhagic cystitis
Hyperuricemia
Urine color changes
Reproductive
Loss of libido
Impotence
Amenorrhea
Irregular menses
Menopausal symptoms
Azoospermia
Sterility
Gynecomastia
Hepatic
Hepatotoxicity
Integumentary
Alopecia
Dermatitis and ulcers
Hematopoietic
↓ bone marrow activity
anemia, prone to infection and bleeding tendency
Metabolic
TLS and Hyperkalemia
Perceived Change in Body Image
Obvious reminder of disability
need for prosthesis (breast, leg and eye)
• need for hardware (wheel chair, crutches)
• need for medication (CR therapy)
• extent of disability or limitation
Type of loss
●
symbols of sexuality
●
social acceptability (colostomy)
●
ability to communicate (laryngectomy, aphasia)
●
anatomic changes (amputation)
Terminally Ill
●
50% die from the disease
●
time from diagnosis to death ranges from
weeks- years
●
not all clients become terminally ill
●
others die during initial treatment; others
die from complications of treatment
●
Endpoint: no response to treatment and
progressions cannot be controlled
●
Lung Cancer
●
Breast Cancer
●
Cancer of the Stomach
●
Cancer of the Colon
●
Cancer of the Liver
●
Cancer of the Pancreas
●
Wilm’s Tumor
●
Hodgkin’s and Non Hodgkin’s
●
Leukemia
●
Prostate Cancer
Brain Tumor
●
Common: cerebellar astrocytoma, brain
stem glioma, medulloblastoma (brain stem)
●
s/sx: increased ICP, headache, n&v,
projectile vomiting, decreased LOC,
seizures, papilledema
●
Intervention: symptomatic, surgery,
radiation and chemotherapy (vincristine
and cyclophosphamide)
●
Follow peri-op craniotomy
Cancer of the Larynx
●
Cause: smoking
●
s/sx: hoarseness of the voice, dysphagia,
coughing, bloody sputum
●
Intervention: laryngectomy and radical neck
dissection
●
Most preventable type of cancer
HOSPICE CARE
●
standard of care for terminally ill cancer
clients
●
symptom control
●
Cause: smoking
●
pain management
●
●
providing comfort and dignity
Types: adenocarcinoma (common), small
cell (fatal)
●
24 hour – 7 day coverage
●
●
services are given based on client’s need
not on its ability to pay
s/sx: chronic cough, wheezing, dyspnea,
repeated unresolved URTI, chest/shoulder
pain, hemoptysis, hoarseness, dysphagia,
head and neck edema
●
Intervention: chemo and radiation, surgery
(wedge, segment, lobe, entire lung)
Ethical Issues
●
●
caring can be just successful as curing;
when curing is not an option
care is exercised during the final stage of
life
Goals of Intervention
●
to care without functional and structural
impairment
●
if cure is not possible goals must
= prevent further metastasis
= relieve symptoms
= maintain high quality of life
CANCER
●
Brain Tumor
●
Cancer of the Larynx
Lung Cancer
Breast Cancer
●
s/sx: non tender fixed lump (tail of spence),
dimpling, bleeding
●
Stage I (<2cm) Stage II (>2<5cm + Nodes)
Stage III (>5cm + nodes) Stage IV
(metastasis)
●
Intervention: chemo and radiation, surgery
Lumpectomy, segmental mastectomy
(lobe), simple mastectomy (entire breast),
MRM, RM, URBAN
●
Follow post-op nursing
management
Cancer of the Stomach
●
Most common GI cancer, cured foods, low in
fiber
●
●
s/sx: vague fullness, bleeding LATE: ascites,
palpable mass
●
Intervention: C&R, surgery (billroth I&II)
●
Obstruction of the lymph nodes
●
Follow post-op procedures
●
s/sx: edema
●
Hodgkin’s – painless, localized (left
thoracic duct and right lymphatic
duct), lymph node biopsy reveals
REED-STERNBERG cell or GIANT cell
Filgrastim (Neupogen) = stimulates
neutophils production
Hodgkin’s and Non-Hodgkin’s
Lymphoma
Cancer of the Colon
●
Cause: low fiber high cholesterol diet, POLYPS
●
s/sx: change in BM, bleeding, obstruction
●
Adenocarcinoma
●
Non-Hodgkin’s – painful, systemic
●
Intervention: C&R, surgery
●
●
Follow post-op procedures
CHLORAMBUCIL (LEUKERAN) PO 10
mg OD
●
Colostomy care
Cancer of the Liver
●
Usually a complication of CIRRHOSIS or from
metastasis
●
Hepatic failure
●
s/sx: similar to cirrhosis
●
Intervention: C&R, (Fluorouracil 5 FU, Cytoxan,
Oncovin), liver transplant
●
GALL BLADDER CA – 1 YEAR SURVIVAL
Wilm’s Tumor
Nephroblastoma
Renal parenchyma, left kidney (unilateral)
Cancer of the Pancreas
●
Mostly adenocarcinomas
●
Head of the pancreas
●
s/sx: obstruction of the CBD, anorexia, weight
loss, pain (upper abdomen, left hypochondriac),
jaundice
●
Dx: increased serum lipase and bilirubin
●
Intervention: C&R, surgery (WHIPPLE’S,
pancreatoduodenectomy, anastomosis of
stomach, duodenum, CBD and pancreatic duct)
Prostate Cancer
●
BPH – cancer of the prostate
●
s/sx: asymptomatic
●
Dx: elevation of CEA, PSA, AP
●
Intervention: Prostatectomy
●
Follow post-op procedure of prostatectomy
●
TESTICULAR CA – (curable) CRYPTORCHIDISM
●
Stage I kidney, stage II beyond
kidney encapsulated, stage III
abdomen, stage IV metastasis,
stage V bilateral
●
s/sx: during bathing and dressing
mass will be noticed, non-tender,
IVP reveals mass,
●
”NO PALPATION”
●
Intervention: Nephrectomy (good
prognosis)
Cancer of the Skin
●
Types: basal cell (common), squamous cell
(rapid), malignant (less frequent)
●
Precancerous: leukoplakia (mouth and lips),
nevi (moles, color change to black, bleeding,
irritation), senile keratosis (brown scalelike
spots among elderly)
●
Cause: UV light, chemicals and irritation
●
Intervention: protection against sunlight,
irritants and chemicals, lotion (para-amino
benzoic acid), report change in lesion,
CHEMOTHERAPY & IMMUNOTHERAPY
Leukemia
●
ALL – immature proliferation
●
CLL – same, adult
●
AML – reduction of granulocytes
●
CML – myeloid stem cell, blood cells
●
s/sx: related to blood level
derangement
●
DX: bone marrow biopsy
Set A
CANCER POST TEST
1. Which of the following would be considered an
iatrogenic cause of cancer?
A. ionizing radiation from radon
b. ionizing radiation from uranium ore
c. xrays to treat tumor
d. ultraviolet radiation from the sun
2. A nurse is providing health education in a
community setting about measures to avoid
excessive sun exposure. Which of the following
statement is true:
a. reapply sun screen only when you go to the
water
b. avoid peak exposure hours from 10 AM to 2 PM
c. wear loosely woven clothing for added
ventilation
d. apply sunscreen after exposure
3. A nurse is palpating a female clients breast. The
area of the breast in which tumors are commonly
found in the?
A. upper inner quadrant
b. lower inner quadrant
c. lower outer quadrant
d. upper outer quadrant
4. Which of the following statements would be
correct about pap smear?
A. it is recommended every other year
b. repeat every 3 years after 4 consecutive
negative results
c. it should be done at age 18 or earlier if sexually
active
d. colposcopy is needed after 4 negative results
5. What is the single most important risk factor for
cancer?
A. family history
b. lifestyle
c. age
d. menopause or hormonal events
6. Which of the following is an environmental
factor of cancer?
A. gender
b. air pollution
c. immunologic status
d. age
7. Kris is on the terminal stage of breast cancer.
Her doctor decided to perform an operation to
lessen her intractable pain. This operation is
considered as:
a. reconstructive
b. curative
c. palliative
d. rehabilitative
8. Which of the following nursing interventions
would be most helpful in making the respiratory
effort of a client with metastatic lung cancer more
efficient?
a. teaching the diaphragmatic breathing
techniques
b. administering cough suppressants as ordered
c. teaching and encouraging pursed lip breathing
d. placing the client in a low semi fowlers position
9. To manage possible nausea and vomiting, the
nurse should discuss,
a. eating frequent, small meals through out the
day
b. eating three normal meals a day
c. eating only cool foods with no odor
d. limiting the amount of food intake
10. What are the common side effects of chemo
and radiation therapy?
A. stomatitis, nausea and vomiting, depression
B. stomatitis, loss of hair and anemia
C. fatigue, alopecia and bone marrow depression
D. dysphagia, anemia and fatigue
11. Common site of metastatic activity?
A. bone
B. brain
C. lungs
D. liver
12. What is the early sign of Cancer of the Larynx?
A. hoarseness of the voice
B. dysphagia
C. coughing
D. bloody sputum
13. Common type of lung cancer?
A. Small oat cell
B. Squamous
C. Large cell
D. adenocarcinoma
14. All of the following are considered early sign of
breast cancer EXCEPT?
A. bloody discharge
B. dimpling or “peau d’ orange”
C. tender lump
D. fixed lump
15. What is the early sign of Stomach Cancer?
A. Melena
B. Hematochezia
C. Vague fullness of the stomach
D. Ascites
• 16.
T1N2M1 means?
A. normal
B. stage I
C. stage III
D. stage IV
• CANCER POST TEST
Matching Type
• I. CA liver
a. mole
• II. CA pancreas
b. painful adenopathy
• III. Wilm’s
c. bone
marrow biopsy
• IV. Hodgkin’s
d. kernicterus
V. Non Hodgkin’s e. painless adenopathy
VI. CA skin
f. increased ICP
VII. Leukemia
g. whipple’s procedure
h. no palpation
Set A Key Answers
CANCER POST TEST
Matching Type
I. CA liver
a. mole
II. CA pancreas
b. painful adenopathy
III. Wilm’s
c. bone marrow biopsy
IV. Hodgkin’s
d. kernicterus
V. Non Hodgkin’s
e. painless adenopathy
VI. CA skin
f. increased ICP
VII. Leukemia
g. whipple’s procedure
h. no palpation
Set A Key Answers
Set B
CANCER POST TEST
1. A client with nagging cough makes an appointment
to see the physician, after reading that this is one of 7
warning signals of cancer. What is another warning
sign of cancer?
A. rashes
B. nausea and vomiting
C. alopecia
D. dysphagia
CANCER POST TEST
2. Which type of cancer causes the most death in
women?
A. breast
B. ovarian
C. lung
D. all of the above
3. To elicit more information regarding hoarseness of
the voice the nurse should ask which question?
A. do you eat high fats low fibers
B. do you strain your voice
C. do you smoke cigarettes
D. do you eat spicy foods
4. What is the most common adverse effect of
chemotherapy?
A. alopecia
B. stomatitis
C. nausea and vomiting
D. anemia
5. A client is receiving an internal radioactive implant
and discovers the implant in the bed linen, what
should a nurse do?
A. report to the physician at once
B. pick up with a long-handled forceps and put it in a
lead container
C. put the implant back in place using long handled
forceps
D. leave the room immediately and notify the
radiation department
6. Which of the following is likely to decrease pain of
stomatitis secondary to CHEMO?
A. recommend to discontinue therapy
B. provide a solution of hydrogen peroxide and water
for use as mouth rinse
C. monitor platelet count
D. check regularly for s/sx of stomatitis
7. The nurse instructs the client the diagnosis of breast
cancer is confirmed by?
A. BSE breast self examination
B. mammography
C. FNAB fine needle aspiration biopsy
D. chest xray
8. For client newly diagnosed with radiation induced
thrombocytopenia, the nurse should include which
specific intervention?
A. bedrest must be encouraged
B. reverse isolation upon admission
C. check petechia every shift
D. all of the above
9. Risk for impaired skin integrity from external
radiation had been made, what will be your nursing
intervention?
A. apply talcum powder on the site
B. remove tumor skin marking after radiation
C. wear protective gears when giving direct care
D. avoid use of soap on the irradiated areas
10. Which of the following organs is an occasional site
of metastasis activity?
A. liver
B. colon
C. lungs
D. brain
E. bones
Set B Key Answers
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
D
C
C
C
B
B
C
C
D
B