UNDERSTANDING CANCER
Essential Concepts of Cancer
What is Cancer? Normal Cell Growth vs. Cancer Cell Growth Etiology and Causative Factors Pathophysiology Classification of Tumors Effects of Cancer
Nursing Process
Assessment Laboratory & Diagnostic Tests Tumor Staging and Grading Nursing Diagnoses & Planning Implementation and Management
Treatment Modalities
Chemotherapy
End-of-life Issues
What Is Cancer?
CANCER is a complex of diseases which occurs when normal cells mutate into abnormal cells that take over normal tissue, eventually harming and destroying the host
WHAT IS CANCER
A large group of diseases characterized by:
Uncontrolled growth and spread of abnormal cells Proliferation (rapid reproduction by cell division) Metastasis (spread or transfer of cancer cells from one organ or part to another not directly connected)
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Loss of Normal Growth Control
Normal cell division
Cell Suicide or Apoptosis Cell damage no repair
Cancer cell division
First mutation
Second mutation
Third Fourth or mutation later mutation Uncontrolled growth
Oncogenes
Normal cell
Normal genes regulate cell growth
Cancer cell
Oncogenes accelerate cell growth and division
Mutated/damaged oncogene
Example of Normal Growth
Dead cells shed from outer surface
Epidermis
Cell migration
Dividing cells in basal layer
Dermis
The Beginning of Cancerous Growth
Underlying tissue
Tumors (Neoplasms)
Underlying tissue
Invasion and Metastasis
1 Cancer cells invade surrounding tissues and blood vessels
2 Cancer cells are transported by the circulatory system to distant sites
3 Cancer cells reinvade and grow at new location
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ETIOLOGY/CAUSATIVE FACTORS
Viruses Chemical carcinogens Physical stressors Hormonal factors Genetic factors
What Causes Cancer?
Some viruses or bacteria
Some chemicals
Radiation
Heredity Diet Hormones
Population-Based Studies
Regions of Highest Incidence
U.K.: Lung cancer
JAPAN: Stomach cancer
CANADA: Leukemia U.S.: Colon cancer BRAZIL: Cervical cancer
CHINA: Liver cancer
AUSTRALIA: Skin cancer
Genes and Cancer
Viruses
Chemicals
Radiation
Heredity
Chromosomes are DNA molecules
Viruses
Virus inserts and changes genes for cell growth
Cancer-linked virus
Examples of Human Cancer Viruses
Some Viruses Associated with Human Cancers
Bacteria and Stomach Cancer
Patients tissue sample
H. pylori
Tobacco Use and Cancer
Some Cancer-Causing Chemicals in Tobacco Smoke
High-Strength Radiation
High
Leukemia Incidence
Low
Least X-ray Dose (atomic radiation)
Most
AIDS and Kaposis Sarcoma
Without disease
HIV infection
Depressed immune system
KSHV infection
Kaposis sarcoma
Heredity and Cancer
All Breast Cancer Patients
Inherited factor(s) Other factor(s)
Heredity Can Affect Many Types of Cancer
Inherited Conditions That Increase Risk for Cancer
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PATHOPHYSIOLOGY
ABNORMAL CELL FORMED BY MUTATION OF DNA CELL GROWS AND PROLIFERATES METASTASIS OCCURS WHEN ABN. CELLS INVADE OTHER TISSUE,THROUGH LYMPH AND BLOOD
Cancer development linked to immune system failure Example of clients susceptible to developing cancer
Classification of Cancer
According to Behavior of Tumor Benign - tumors that cannot spread by invasion or metastasis; hence, they only grow locally
Malignant - tumors that are capable of spreading by invasion and metastasis. By definition, the term cancer applies only to malignant tumors
Malignant versus Benign Tumors
Benign (not cancer) tumor cells grow only locally and cannot spread by invasion or metastasis Malignant (cancer) cells invade neighboring tissues, enter blood vessels, and metastasize to different sites
Time
Why Cancer Is Potentially Dangerous
Brain
Melanoma cells travel through bloodstream Liver
Melanoma (initial tumor)
Patterns of cell Proliferation
Hyperplasia Dysplasia Metaplasia Anaplasia Neoplasia
Hyperplasia
tissue growth based on an excessive rate of cell division, leading to a larger than usual number of cells; the process of hyperplasia is potentially reversible; can be a normal tissue response to an irritating stimulus. An example is a callus
Normal
Hyperplasia
Dysplasia
Bizarre cell growth differing in size, shape and cell arrangement
Normal
Hyperplasia
Mild dysplasia
Carcinoma in Situ
Normal
Hyperplasia
Mild dysplasia
Carcinoma in situ (severe dysplasia)
Cancer (invasive)
Patterns of cell Proliferation
Metaplasia
conversion of one type of cell in a tissue to another type not normal for that tissue
Anaplasia
change in the DNA cell structure and orientation to one another, characterized by loss of differentiation and a return to a more primitive form.
Neoplasia
uncontrolled cell growth, either benign or malignant
Metastasis
Metastasis: 3 stages
Invasion neoplastic cells from primary tumor invade into surrounding tissue with penetration of blood or lymph. Spread tumor cells spread through lymph or circulation or by direct expansion Establishment and growth tumor cells are established and grow in secondary site: lymph nodes or in organs from venous circulation
Cancer Tends to Involve Multiple Mutations
Benign tumor cells grow only locally and cannot spread by invasion or metastasis Malignant cells invade neighboring tissues, enter blood vessels, and metastasize to different sites
Time Mutation Cells inactivates proliferate suppressor gene Mutations inactivate DNA repair genes Proto-oncogenes mutate to oncogenes More mutations, more genetic instability, metastatic disease
Mutations and Cancer
Genes Implicated in Cancer
Cancer Tends to Corrupt Surrounding Environment
Growth factors = proliferation
Invasive
Matrix Proteases Fibroblasts, adipocytes Blood vessel
Cytokines
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Cytokines, proteases = migration & invasion
Classification of Tumors
CARCINOMAS: EPITHELIAL TISSUE
BODY SURFACES, LINING OF BODY CAVITIES ETC: (ADENOCARCINOMA)
SARCOMAS: CONNECTIVE TISSUE
STRIATED MUSCLE, BONE, ETC (OSTEOSARCOMA)
LYMPHOMAS AND LEUKEMIAS
HEMATOPOIETIC SYSTEM
NERVOUS TISSUE TUMORS
EX. NERVE CELLS-NEUROBLASTOMA
MYELOMA
Develops in the plasma cells of bone marrow
Different Kinds of Cancer
Some common carcinomas:
Lung Breast (women)
Leukemias:
Bloodstream
Lymphomas:
Lymph nodes
Colon
Bladder Prostate (men)
Some common sarcomas:
Fat Bone
Muscle
Naming Cancers
Cancer Prefixes Point to Location
Prefix adenochondroMeaning gland cartilage
erythro-
red blood cell
hemangio- blood vessels hepatolipolymphomelanomyelomyoosteoliver fat lymphocyte pigment cell bone marrow muscle bone
Women, Tobacco & Lung Cancer
Women who smoke like men,
die like men.
U.S. Surgeon General David Satcher
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Effects of Cancer
Disruption of Function- can be due to obstruction or pressure Hematologic Alterations: can impair function of blood cells Hemorrhage: tumor erosion, bleeding, severe anemia Anorexia-Cachexia Syndrome: wasted appearance of client
Effects of Cancer
Paraneoplastic Syndromes: ectopic sites with excess hormone production
Parathyroid hormone hypercalcemia secretion of insulin hypoglycemia Antidiuretic hormone (ADH) fluid retention, HTN & peripheral edema
Adrenocorticotropic hormone (ACTH): cause excessive secretion of cortisone (ie: fluid retention, glucose levels)
Effects of Cancer
Pain: major concern of clients and families associated with cancer Physical Stress: body tries to respond and destroy neoplasm Psychological Stress
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ASSESSMENT
Nursing History
Health History chief complaint and history of present illness (onset, course, duration, location, precipitating and alleviating factors) Cancer signs: CAUTION US!
Warning Signs of Cancer
CAUTION US!
Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickenings or lumps Indigestion or difficulty in swallowing Obvious change in a wart or mole Nagging or persistent cough or hoarseness Unexplained anemia Sudden unexplained weight loss
Warning Signs of Cancer
Change in bowel or bladder habits
A person with colon cancer may have diarrhea or constipation, or he may notice that the stool has become smaller in diameter A person with bladder or kidney cancer may have urinary frequency and urgency
Warning Signs of Cancer
A sore that does not heal
Small, scaly patches on the skin that bleed or do not heal may be a sign of skin cancer A sore in the mouth that does not heal can indicate oral cancer
Warning Signs of Cancer
Unusual bleeding or discharge
Blood in the stool is often the first sign of colon cancer Similarly, blood in the urine is usually the first sign of bladder or kidney cancer Postmenopausal bleeding (bleeding after menopause) may be a sign of uterine cancer
Warning Signs of Cancer
Thickenings or lumps
Enlargement of the lymph nodes or glands (such as the thyroid gland) can be an early sign of cancer Breast and testicular cancers may also present as a lump
Warning Signs of Cancer
Indigestion or difficulty in swallowing
Cancers of the digestive system, including those of the esophagus, stomach, and pancreas, may cause indigestion, heartburn, or difficulty swallowing
Warning Signs of Cancer
Obvious change in a wart or mole
Moles or other skin lesions that change in shape, size, or color should be reported
Warning Signs of Cancer
Nagging or persistent cough or hoarseness
Cancers of the respiratory tract, including lung cancer and laryngeal cancer, may cause a cough that does not go away or a hoarse (rough) voice
Warning Signs of Cancer
Unexplained anemia
Sudden unexplained weight loss
Physical Assessment
Inspection skin and mucus membranes for lesions, bleeding, petechiae, and irritation
Assess stools, urine, sputum, vomitus for acute or occult bleeding Scalp noting hair texture and hair loss
Palpation
Abdomen for any masses, bulges or abnormalities Lymph nodes for enlargement
Auscultation of lung sounds, heart sounds and bowel sounds
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Laboratory & Diagnostic Tests
Cancer detection examination Laboratory tests
Complete blood cell count (CBC) Tumor markers identify substance (specific proteins) in the blood that are made by the tumor
PSA (Prostatic-specific antigen): prostate cancer CEA (Carcinoembryonic antigen): colon cancer Alkaline Phosphatase: bone metastasis
Biopsy
Diagnostic Tests
Determine location of cancer:
X-rays Computed tomography Ultrasounds Magnetic resonance imaging Nuclear imaging Angiography
Diagnosis of cell type:
Tissue samples: from biopsies, shedded cells (e.g. Papanicolaou (PAP) smear), & washings Cytologic Examination: tissue examined under microscope
Direct Visualization:
Sigmoidoscopy Cystoscopy Endoscopy Bronchoscopy Exploratory surgery; lymph node biopsies to determine metastases
Cancer Detection and Diagnosis
Early Cancer May Not Have Any Symptoms
Cervical Cancer Screening
Normal Pap smear
Abnormal Pap smear
Breast Cancer Screening
Prostate and Ovarian Cancer Screening
Colon Cancer Screening
Biopsy
Pathology
Proteomic profile
Patients tissue sample or blood sample
Genomic profile
Microscopic Appearance of Cancer Cells
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Tumor Staging and Grading
Staging determines size of tumor and existence of metastasis Grading classifies tumor cells by type of tissue The TNM system is based on the extent of the tumor (T), the extent of spread to the lymph nodes (N), and the presence of metastasis (M).
Primary Tumor (T) TX T0 Tis T1, T2, T3, T4 NX N0 N1, N2, N3 Primary tumor cannot be evaluated No evidence of primary tumor Carcinoma in situ (early cancer that has not spread to neighboring tissue) Size and/or extent of the primary tumor Regional lymph nodes cannot be evaluated No regional lymph node involvement (no cancer found in the lymph nodes) Involvement of regional lymph nodes (number and/or extent of spread) Distant metastasis cannot be evaluated
Regional Lymph Nodes (N)
Distant Metastasis (M) MX
M0
M1
No distant metastasis (cancer has not spread to other parts of the body)
Distant metastasis (cancer has spread to distant parts of the body)
NURSING DIAGNOSES
Acute or chronic pain Impaired skin integrity Impaired oral mucous membrane Risk for injury Risk for infection Fatigue Imbalanced nutrition: less than body requirements
NURSING DIAGNOSES
Risk for imbalanced fluid volume Anxiety Disturbed body image Deficient knowledge Ineffective coping Social isolation
OUTCOME IDENTIFICATION
1. 2. 3. 4. 5. Pain relief Integrity of skin and oral mucosa Absence of injury and infection Fatigue relief Maintenance of nutritional intake and fluid and electrolyte balance 6. Improved body image 7. Absence of complications
OUTCOME IDENTIFICATION
8. Knowledge of prevention and cancer treatment 9. Effective coping through recovery and grieving process 10.Optimal social interaction
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Prevention and detection
Primary Prevention
IMPLEMENTATION/MANAGEME NT
Reducing modifiable risk factors in the external and internal environment
Secondary Prevention
Recognizing early signs and symptoms and seeking prompt treatment Prompt intervention to halt cancerous process
Cancer Prevention
Carcinogenic chemicals Carcinogenic radiation
Cancer viruses or bacteria
Avoid Tobacco
Lung Cancer Risk Increases with Cigarette Consumption
15x
10x
Lung Cancer Risk
5x
0
Non-smoker
15 Cigarettes Smoked per Day
30
Protect Yourself From Excessive Sunlight
Limit Alcohol and Tobacco
Combination of Alcohol and Cigarettes Increases Risk for Cancer of the Esophagus
40x 30x Risk Increase 20x 10x
Alcoholic Drinks Consumed per Day
AND
Packs of Cigarettes Consumed per Day
Diet: Limit Fats and Calories
Correlation Between Meat Consumption and Colon Cancer Rates in Different Countries
40
Number of Cases (per 100,000 people)
30
20
10
80
100
200
300
Grams (per person per day)
Diet: Consume Fruits and Vegetables
Avoid Cancer Viruses
HPV Infection Increases Risk for Cervical Cancer
High
Cervical Cancer Risk
Low Noninfected women Women infected with HPV
Avoid Carcinogens at Work
Some Carcinogens in the Workplace
Industrial Pollution
Incidence of Most Cancers
1930
1950 Year
1970
1990
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TREATMENT MODALITIES
Aimed towards:
CURE - free of disease after treatment normal life Control - Goal for chronic cancers Palliative Care: Quality of life maintained at highest level for the longest possible time
Surgery surgical removal of tumors; most commonly used treatment
Preventive or prophylactic Diagnostic surgery Curative surgery Reconstructive surgery Palliative surgery
Chemotherapy use of antineoplastic drugs to promote tumor cell death, by interfering with cellular functions and reproduction
Radiotherapy directing high-energy ionizing radiation to destroy malignant tumor cells without harming surrounding tissues
Teletherapy (external): radiation delivered in uniform dose to tumor Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is placed in tumor or next to it
Immunotherapy use of chemical or microbial agents to induce mobilization of immune defenses.
Biologic response modifiers (BRMs) use of agents that alters immunologic relationship between tumor and host in a beneficial way
Bone marrow peripheral stem cell transplantation aspirating bone marrow cells from compatible donor and infusing them into the recipient
Gene therapy transfer of genetic materials into the clients DNA
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NURSING MANAGEMENT
1. Promote measures that relieve pain and discomfort.
Pharmacologic and non-pharmacologic interventions
2. Promote measures to maintain intact skin integrity 3. Promote measures that maintain oral mucosa 4. Promote measures to prevent injury from abnormal bleeding
Monitor platelet count; avoid aspiring products,etc
NURSING MANAGEMENT
5. Promote measures that identify and prevent infection
Monitor WBC count; encourage frequent handwashing and overall cleanliness
6. Help decrease the clients fatigue and increase his activity level 7. Promote measures that ensure adequate nutritional intake
High protein, high calorie diet
8. Ensure adequate fluid and electrolyte balance
NURSING MANAGEMENT
9. Promote measures to enhance body image.
Take an honest gentle, caring approach; encourage client to express and verbalize feelings
10. Promote measures that address preventing complications of cancer therapy 11. Instruct client and family about the disease process and treatments; provide necessary information for self-care. 12. Help client and family cope effectively 13. Promote measures to reduce social isolation.
Care of Clients Receiving Chemotherapy
Classes of Chemotherapy Drugs: Alkylating agents:
Action: create defects in tumor DNA Ex: Nitrogen Mustard, Cisplatin Toxic Effects: reversible renal tubular necrosis
Classes of Chemotherapy Drugs
Antimetabolites:
Action: phase specific Ex: Methotrexate; 5 fluorouracil Toxic Effects: nausea, vomiting, stomatitis, diarrhea, alopecia, leukopenia
Classes of Chemotherapy Drugs
Antitumor Antibiotics:
Action: non- phase specific; interfere with DNA Ex: Actinomycin D, Bleomycin, adriamycin (doxorubicin) Toxic Effect: damage to cardiac muscle
Classes of Chemotherapy Drugs
Miotic inhibitors:
Action: Prevent cell division during M phase of cell division Ex: Vincristine, Vinblastine Toxic Effects: affects neurotransmission, alopecia, bone marrow depression
Classes of Chemotherapy Drugs
Hormones:
Action: stage specific G1 Ex: Corticosteroids
Hormone Antagonist:
Action: block hormones on hormone- binding tumors ie: breast, prostate, endometrium; cause tumor regression Ex: Tamoxifen (breast); Flutamide (prostate) Toxic Effects: altered secondary sex characteristics
Effects of Chemotherapy
Tissues: (fast growing) frequently affected Examples: mucous membranes, hair cells, bone marrow, specific organs with specific agents, reproductive organs (all are fetal toxic; impair ability to reproduce)
Chemotherapy Administration
Routes of administration:
Oral Body cavity (intraperitoneal or intrapleural) Intravenous
Use of vascular access devices because of threat of extravasation (leakage into tissues) & longterm therapy
Chemotherapy Administration
Types of vascular access devices:
PICC lines: (peripherally inserted central catheters) Tunneled catheters: (Hickman, Groshong) Surgically implanted ports: (accessed with 90o angle needle- Huber needles)
Nursing care of clients receiving chemotherapy
Assess and manage:
Toxic effects of drugs (report to physician) Side effects of drugs: manage nausea and vomiting, inflammation and ulceration of mucous membranes, hair loss, anorexia, nausea and vomiting with specific nursing and medical interventions
Nursing care of clients receiving chemotherapy
Monitor lab results (drugs withheld if blood counts seriously low); blood and blood product administration Assess for dehydration, oncologic emergencies Teach regarding fatigue, immunosuppression precautions Provide emotional and spiritual support to clients and families
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REFERENCE
National Cancer Institute Brunner and Suddarths Medical Surgical Nursing
