Cellular Aberrations - Abnormal cellular changes and

Oncology Nursing growth of new tissue.

HYPERPLASIA
What is Cancer? - Increase in cell number.
- Cancer was recognized in HYPERTROPHY
ancient times by skilled - Increase in cell size.
observers who gave it the name
“CANCER” because it stretches METAPLASIA
out in many directions like the - Replacement of one adult cell
leg of a crab. type by a different adult cell
- Cancer occurs in all strata of type.
our society. It afflicts all people DYSPLASIA
of all ages, all socio-economic - Changes in cell size, shape and
and cultural backgrounds and organization
both sexes. ANAPLASIA
- Cancer nursing skills are vital in - Reverse cellular development to
healthcare settings because a more primitive or embryonic
clients are seen in home, office, cell type.
clinic, acute care setting and METASTASES
hospice. - Spread of cancer cells to distant
parts of the body to setup new
Terminologies related to Cancer Nursing tumors.
- Occurs in malignant.
CANCER ONCOLOGY
- A disease of the cells in which - Medical specialty that deals
the normal mechanism of the with diagnosis, treatment and
control of growth and study of cancer
proliferation have been altered. ADENOCARCINOMA
MALIGNANT NEOPLASM - Cancer that arises from the
- It is invasive, spreading directly glandular tissue
to surrounding tissue as well as - Example cancer in breast,
to new sites in the body. lungs, thyroid and colon.
CARCINOMA
- A Form of cancer that is
BENIGN NEOPLASM composed of epithelial cells,
- Harmless growth that does not develop in tissue covering the
spread or invade other tissues.
NEOPLASIA
1
 lining organs of the body. Such - these factors act by causing cell
as skin, uterus or breast mutation or alteration in cell enzymes
SARCOMA and proteins causing cell replication.
- A cancer of supporting or o INDUSTRIAL COMPOUNDS
connective tissues such as - Vinyl chloride used for
Cartilage bones, muscles or plastic manufacture,
fats. asbestos factories,
CARCINOGENS construction workers.
o Factors associated with cancer - Polycyclic aromatic
causation. E.g radiation, hydrocarbons such as from
chemicals, viruses and physical refuse burning auto and
agents. truck emissions, oil
refineries, air pollution.
Etiologic Factors to Cancer - Fertilizers weed killers
1. VIRUSES - Dyes analine dyes used in
o ONCOGENIC VIRUSES – beauty shop, hair bleach.
may be one of the multiple o DRUGS
agents acting to initiate - Tobacco tar nicotine, 90%
carcinogens. of all cases of lungs
o PROLONGED OR cancer are due to
FREQUENT VIRAL smoking.
INFECTION – may cause - Alcohol
breakdown of the immune - Cytotoxic drugs
system or overwhelm the o HORMONES
immune system - Estrogen
o VIRAL INFECTIONS – that
- Diethlstillbestrol (DES)
increase risk of certain forms of
o FOOD PRESERVATIVES
cancer are as follows
- Nitrites (bacon, smoked
 HUMAN PAPILLOMA
meat)
VIRUS – cervical cancer
- Talc (polished rice,
 EPSTEIN BARR VIRUS –
salami, chewing gum)
lymphoma
- Nitrosamines (rubber baby
 HEPATITIS B AND C – nipples)
Hepatocellular cancer - Aflatoxins (mold in nuts and
 HELICOBASTER PYLORI grains, milk, cheese, peanut butter)
– gastric cancer 3. PHYSICAL AGENTS

2. CHEMICAL CARCINOGENS
2
  Radiation: from X rays or addition, they have
radioactive isotopes, from
sunlight/ultraviolet rays.
developed alterations in
 Physical irritation or trauma: from the immune system.
pipe smoking, multiple deliveries, o Sex
jagged tooth, irritation of tongue,
over use of any organ/body parts.  The most common type of
4. HORMONES cancer in females is breast
 Estrogen as replacement therapy has been cancer. Whereas the most
found to increase incidence of vaginal,
cervical, uterine cancers. common type of cancer in
males is prostate cancer.
5. GENETICS o Urban vs. Rural Residence
 When oncogene (hidden or repressed
genetic code of cancer that exist in all  Cancer is more common
individual’s) is exposed to carcinogens, among urban dwellers than
changes in cell structure occurs.
among rural residents. This
Comparisons of the Characteristics of Benign and is probably due to greater
Malignant Neoplasm exposure to carcinogens,
Characteristics Benign Malignant more stressful lifestyle and
1. Speed of Grows slowly Grows rapidly
growth greater consumption of
2. Mode of Remains Infiltrates preservative cured food
Growth localized surrounding
tissues. among urban dwellers.
3. Capsules Encapsulated Not encapsulated o Geographic Distribution
4. Cell Well Poorly  The most common type of
Characteristics dedifferentiated dedifferentiated cancer in japan is gastric
mature cell
5. Recurrence Extremely Common cancer. While in the most
unusual when following common type of cancer in
surgically surgery because
removed cancer cells
the US is breast cancer.
spread into other This may be due to
tissues. influence of environmental
6. Metastasis Never occur Very common
7. Effects of Not harmful to Always harmful factors as national diet.
neoplasm host to host o Occupation
8. Prognosis Very good Poor prognosis
 There is greater risk of
exposure to carcinogens
Predisposing Factors to Cancer among chemical factory
o Age workers, farmers,
 Older individuals are more radiology department
prone to cancer because personnel.
they have been exposed to o Heredity
carcinogens longer. In  Positive family history of
cancer increases the risk to
3
 develop the disease. In  Change in bladder habits may
adults, approximately 34 signify bladder or prostate
% of cancers have a cancer.
familial basis. Cancers that A- sore that does not heal
may have familial link  A sore that does not heal
include breast, ovarian, characterize cancer because
colorectal, prostate, the tumor causes impaired
melanoma, uterine, circulation and oxygenation in
leukemia, sarcomas, and the area. This leads to tissue
brain tumors. necrosis, ulceration, bleeding
o Stress and infection.
 Depressions, grief, anger, U- unusual bleeding or discharge
aggression, despair or life  Unusual bleeding or discharge
stresses decrease from the body part affected by
immunocompetence cancer is also due to impaired
because of affection of circulation and oxygenation in
hypothalamus and pituitary the area. This leads to
gland. Immunodeficiency necrosis, ulceration, bleeding
may spur the growth and and infection. Infection causes
proliferation of cancer unusual discharge.
cells. U- unexplained sudden weight loss
 Unexplained sudden weight
loss is due to excessively rapid
metabolism caused by the
o Obesity cancer cells. Rapid
 Studies have linked metabolism is caused by rapid
obesity can lead to breast multiplication of the cancer
cancer and colorectal cells. The normal cells are
cancer. deprived of nutrients by the
Warning Signals of Cancer cancer cells.
C- change in bowel or bladder habits U- unexplained anemia
 Change in bowel habits, e.g.  Unexplained anemia is due to
alternating constipation and the following factors: the
diarrhea is the most cancer cells take up iron faster
characteristic manifestation of than the normal cells; bleeding
colon cancer. contributes to anemia; cancer
cell tends to destroy normal
red blood cells.
4
T- thickening or lump in the breast or versus metastatic), to determine
elsewhere prognosis and to guide proper
 Thickening or lump in any management.
body part may signify
abnormal cellular growth. The American Joint Committee of
I- indigestion or difficulty in Cancer (AJCC) has developed the
swallowing TNM classification system that can
 Indigestion is the usual initial be applied to all tumor types.
manifestation of gastric
cancer. T- tumor size
 Difficulty in swallowing is T- primary tumor
characteristic of cancer of the Tx- primary tumor is unable to be
larynx and cancer or the assessed.
 esophagus. To - no evidence of primary tumor.
O- obvious change in wart or mole Tis – carcinoma in situ
T1, T2, T3, T4 - increasing size
 Obvious change in wart or
and/or local extent of primary tumor.
mole, like sudden growth in
size of wart or mole uneven
N- presence or absence of regional lymph
coloring, change in the texture node involvement.
may signify transformation N - presence or absence or regional
into cancerous lesion. lymph node involvement.
N- nagging cough or hoarseness of Nx - regional lymph nodes are unable
voice to be assessed.
 Nagging cough or hoarseness No - no regional lymph nodé
of voice signifies cancer of the involvement
larynx or cancer of the lungs. N1, N2, N3 – increasing involvement
of regional lymph nodes
Staging and Grading of
Neoplasia M – presence or absence of distant
 Staging - is determining the size metastasis
of the tumor and existence of M - absence or presence or distant
metastases. metastasis
 Grading - is classification of Mx - unable to be assessed
tumor cells. Mo - absence of distant metastasis
 Staging - is necessary at the M1 - presence of distant metastasis
time of diagnosis to determine
the extent of disease (local Cancer Detection Examinations

5
1. Cytologic Examination or  Needle biopsy is done by
Papanicolaou Test (Pap’s Exam, Par aspiration of tumor cells with
Smear) needle and syringe.
- Cytologic specimen can be  Excisional biopsy is done by
obtained from tumors that tend removing the entire tumor. It
to shed cells from their surface, is done when the tumor is
e.g., G.I. tract through small.
endoscopy; respiratory tract  Incisional or subtotal biopsy is
through laryngoscopy and done by taking only a part of
bronchoscopy; genito-urinary the tumor. This is done when
tract through colposcopy of the the tumor is large.
cervix and vagina, cystoscopy
of the bladder, laparoscopy of
the pelvic and abdominal
cavity.
Interpretation of Papanicolaou Test results 3. Ultrasound, Magnetic Resonance
are as follows: Imaging (MRI), Radiodiagnostic
Class I. Normal Tests, Computerized Axial
Class II. Inflammation Tomography (CT Scan), Endoscopic
Class III. Mild to Moderate Dysplasia Examinations.
Class IV. Probably Malignant
Class V. Possibly Malignant 4. Laboratory Blood Tests for Cancer
 Class I result requires follow up  Hematologic (CBC)
examination every 1 to 3 years - Hemoglobin and hematocrit are
as recommended by the low in anemia; may indicate
physician. malignancy.
 Class II and III results may - Leukocytes (wbc’s) are high in
require repeat Pap exam in 3 to leukemia (immature wbc’s),
6 months as prescribed. lymphomas; low in leukemia
 Class IV and V results require (mature wbc’s) and metastatic
biopsy as prescribed. disease to bone marrow.
- Platelets are high in CML
2. Biopsy (chronic myelocytic leukemia),
- Involves obtaining tissue Hodgkin’s disease; low in ALL
samples by needle aspiration, or (acute lymphocytic leukemia),
incision of tumor. AML (acute myelocytic
leukemia), multiple myeloma,
bone marrow depression.
6
 Tumor Markers
AFP (Alpha-feto-protein)
- AFP is elevated in lung,
testicular, pancreatic, colon,
gastric cancers and
choriocarcinoma.
CEA (Carcinoembryonic Antigen)
- CEA is elevated in
colorectal, breast, lung, Treatment Modalities for Cancer
stomach, pancreatic, and
prostate cancers. ● Surgical Interventions

1. Diagnostic Surgery. This is done by cytologic

HCG (Human Chorionic specimen collection and biopsy.
Gonadotropin)
2. Preventive Surgery. This involves removal of
- HCG is elevated in
choriocarcinoma, gem cell precancerous lesions or benign tumors, e.g.,

testicular cancer, ectopic patients with familial polyposis and ulcerative

production_ in lung, liver, colitis undergo subtotal colectomies to prevent

gastric, pancreatic, and colon colon cancer.
cancers. 3. Curative Surgery. This involves removal of an
entire tumor and surrounding Iymph nodes.
Prostatic Acid Phosphatase Cancers that are localized to the organ of origin
- Prostatic acid phosphatase is and the regional lymph nodes are potentially
elevated in metastatic curable by surgery.
prostate cancer,
PSA (Prostatic Specific Antigen) 4. Reconstructive Surgery. This is done for
- PSA is elevated in prostate improvement of the appearance and function of
cancer. the organ affected. This is also an attempt to
improve the client's quality of life.

5. Palliative Surgery. This is done for relief of

distressing signs and symptoms or for retardation
of metastasis. This is an attempt to improve
quality of life.

Examples of palliative surgery are as follows:

a. Reduce pain by interrupting nerve pathways or

implanting pain control

7
pumps. ✔ Rapidly dividing cells like cancer cells are
more vulnerable to radiation. Therefore,
b. Relieve airway obstruction.
radiation kills cancer cells while sparing
c. Relieve obstructions in the Gl and GU tracts. normal cells from excessive cell death.

d. Relieve pressure in the brain and the spinal The types of radiation therapy are as follows:
cord.
1. External Radiation Therapy (Teletherapy,
e. Prevent haemorrhage. DXT). This is administered through a high –

f. Remove infected and ulcerating tumors. energy X -ray or gamma X-ray machine (e.g.
linear accelerator, cobalt, betatron, or a machine
g. Drain abscesses.
containing radioisotope).
● Radiation Therapy
✔ The major advantage of high – energy
✔ Radiation therapy may be used as a
radiation is its skin – sparing effect. The
primary, adjuvant, or a palliative treatment
maximum effect of radiation occurs at
modality. As a primary modality, it is the
tumor deep in the body, not on the skin
only treatment used and aims to achieve
surface.
local cure of the cancer (e.g., early stage
✔ There is no need for isolation.
skin cancer, Hodgkin's disease, carcinoma
of the cervix). 2. Internal Radiation Therapy. This is

✔ As an adjuvant therapy, RT can be done administered within or near the tumor or into the

preoperatively or postoperatively to aid in systemic circulation.

destruction of cancer cells. In addition, it The major types of internal RT are as follows:
can be used in conjunction with
a. Sealed source (brachytherapy). The
chemotherapy to enhance destruction of
radioisotope is placed within or near the tumor.
cancer cells.
The radioactive material is enclosed in a sealed
✔ As a palliative therapy, RT can be used to
container.
relieve pain caused by obstruction,
pathologic fractures, spinal cord ✔ Sealed source is used for both intracavity
compression and metastases. and interstitial therapy.
✔ Radiosensitivity, the relative sensitivity of ✔ Intracavity RT is used to treat cancers of
tissues to radiation, depends on the the uterus and cervix. The radioisotope is
individual cell and the characteristics of placed in the body-cavity, generally for 24
the tissue itself.\ to 72 hours (cesium 137 or radium 226).
✔ RT is the use of high - energy ionizing ✔ In an interstitial therapy, the radioisotope
radiation that destroys a cell's ability is placed in needles beads, seeds, ribbons,
to reproduce by damaging its DNA. or catheters, which are then implanted

8
 directly into the tumor (iridium 192, iodine 2. T-ime. Limit contact with the client for 5
125, cesium 137 goid 198, or radium 222). minutes each time, a total of 30 minutes per 8-
✔ In sealed sources of internal radiation, the hour shift.
radioisotope cannot circulate through the
3.S.hielding. Use lead shield during contact with
client's body nor can it contaminate the
client.
client's urine, sweat, blood or vomitus.
Therefore, the client's excretions are not ✔ Pregnant staff should not be assigned to

radioactive. However, radiation exposure clients receiving internal RT.

can result from direct contact with the ✔ Staff members caring for the client with

sealed radioisotope. such as touching the internal RT should wear dosimeter badge

container with bare hands or from lengthy while in the client's room.

exposure to the sealed radioisotope. ✔ To prevent feelings of isolation, maintain

contact with the client while keeping
distance from radiation exposure. Talk
with the client from the doorway of the
room.
b. Unsealed source. The radioisotopes may be
✔ If the client with cancer of the cervix has
administered intravenously, orally or by
radioisotope implant into the uterus, the
instillation directly into the body cavity.
following nursing interventions should be
✔ In unsealed sources of internal radiation, implemented.
the radioisotope circulates through the ● Client's back is turned towards the door.
client's body. Therefore, the client's urine, To minimize exposure of healthcare staff
sweat, blood and vomitus contain the to radioisotope entering the client's room.
radioactive isotope. ● Encourage the client to tum to sides at
✔ Examples of unsealed sources of RT are regular intervals.
iodine 131 given orally for Grave's disease ● The client should be on complete bed rest.
and thyroid cancer; alrontium chloride 89 To prevent dislodgement of the
is administered intravenously for relief of radioisotope.
painful bony metastases. ● The client should be given enema before

Principles of Radiation Protection- DTS the procedure. Bowel movement during

the procedure may cause dislodgment of
1. D-istance. The greater the distance from the
the radioisotope.
radiation source, the less the exposure dose of
● The client should be given low fiber diet to
ionizing rays. Maintain a distance of at least 3 feet
inhibit defecation during the procedure
when not performing nursing procedures.
until the device is removed in 2 to 3 days.
To prevent dislodgement of the
radioisotope.
9
● The client should have a Foley catheter in ✔ Any emesis (vomiting), especially that
place during the procedure. To prevent occurs shortly after ingestion of oral
bladder distention and subsequently radioisotope, should be covered with
prevent irradiation of the bladder. absorbent pads, and the radiation safety
Irradiation of the bladder may cause fistula officer should be called immediately.
formation between the bladder and the
Chemotherapy
uterus. This causes urine to come out from
the vagina. ✔ The goals of chemotherapy may be cure,

● Have long forceps and lead container control, or palliation of manifestations. It

readily available. Use long forceps to pick is a systemic intervention. It is

up dislodged radioisotope and place it in recommended when:

the lead container. ● Disease is widespread

✔ The client receiving an unsealed source of ● The risk of undetectable disease is

RT: should have a private room and bath. high

✔ All surfaces, including the floor area the ● The tumor cannot be resected and

client will be walking on, are covered with is resistant to RT

Chux or paper. ✔ The objective of chemotherapy is to

✔ Foods are served on disposable plates and destroy all malignant tumor cells without

utensils. excessive destruction of normal cells.

✔ Trash and linens are kept in the client's ✔ Chemotherapy has the following

room and are not removed until the client characteristics

is ready for discharge. In general, linens ● it affects both normal and cancer cells. The

are not changed until they are grossly rapidly dividing cells, both the normal and

soiled. This is to minimize radiation cancer cells are vulnerable to destruction

exposure of caregivers. by chemotherapy by disrupting cell

✔ The client is also instructed to rinse the function and division. Mucous membrane,

sink with copious amount of water after blood cells, hair follicles, skin cells are

tooth brushing and to flush the toilet rapidly dividing cells. Side effects of

several times after each use. To prevent chemotherapy tend to occur in these

radiation contamination of other people structures.

and the environment. ● Chemotherapy has fraction cell kill. Only a

✔ Anyone entering the room wears a new certain number of cancer cells are killed

pair of booties each time to prevent with each course of chemotherapy.

tracking the radioisotope out into the Therefore, chemotherapy must be given in

hallway. a series.

✔ Caregivers should wear gloves when

handling body fluids.
10
Routes of Administration of Chemotherapy ▪ Intracavity therapy instills the medication
directly into an area such as the abdomen,
1. Intravenous Chemotherapy
bladder, or pleural space.
✔ Extravasation (escape from the vein) of
some chemotherapeutic agents can cause
tissue necrosis in the area.
✔ Use of vascular access devices (VAD's)
are now preferred as venous access. This
provides continuous chemotherapy, 4. Intraperitoneal

multiple access, route for administration of ▪ Intraperitoneal chemotherapy is done for

parenteral fluids, antibiotics, and frequent cancer in the intra. abdominal area, e.g.,
blood testing. ovarian cancer this allows high
✔ VAD'S can be implanted (e.g. Port-A- concentration of a chemotherapeutic agent
Cath), central lines (e.g. tunneled and non to be delivered to the actual tumor site
- tunneled), and peripherally inserted with minimal exposure of healthy tissues.
central catheters (PICClines).
Contraindications to Chemotherapy are as
✔ The most commonly reported
follows:
complications of VADs are infection and
obstruction. (Each institution provides 1. Infection. The anti - tumor drugs are
protocol for care of VADS, e.9 changes of immunosuppressives.
dressing, flushing, blood draw, etc.).
2. Recent surgery. The drugs may retard healing
2. Regional Chemotherapy process.

✔ Allows high concentrations of drugs to be 3. Impaired Renal or Hepatic function. The

directed to localized tumors. drugs are nephrotoxic and hepatotoxic.

The methods are as follows: 4. Recent Radiation Therapy. Also

immunosuppressive.

5. Pregnancy. The drugs may cause congenital

1. Topical
defects.
▪ fluorourail cream may be applied to the
6. Bone Marrow Depression. The drugs may
skin to treat actinic keratoses.
aggravate the condition. The wbc levels must be
2. Intra-arterial within normal limits.

▪ Intraarterial infusions enable major organs Safe Handling of Chemotherapeutic Agents

or tumor sites to receive maximal exposure
1. Wear mask, eye shield, gloves and back -
with limited serum level of Medications.
closing gown.
3. Intracavity
11
2. Skin contact with drug must be washed 1. G. system- nausea and vomiting, diarrhea,
immediately with soap and water. Eyes must be constipation
flushed immediately with copious amount of
✔ Administer antiemetic to relieve nausea
water.
and vomiting.
3. Sterile/ alcohol - wet cotton pledgets should be ✔ replace fluid-electrolyte losses, low fiber
used, wrapped around the neck of the ampule or diet to relieve diarrhea.
vial when breaking and withdrawing the drug. ✔ increase fluid intake and fibers in diet to
prevent/ relieve constipation.
4 Expel air bubbles on wet cotton.
2. Integumentary System
5. Vent vials to reduce internal pressure after
mixing. ✔ Pruritus, urticaria and systemic signs
▪ Provide good skin care.
6. Wipe external surface of syringes and IV
✔ Stomatitis (oral mucositis)
bottles
▪ Provide good oral care.
7. Avoid self - inoculation by needle stab ▪ Avoid hot and spicy food

8. Clearly label the hanging IV bottle with with ✔ Alopecia

“ANTINEOPLAST CHEMOTHERAPY." ▪ Reassure that it is temporary.

▪ Encourage to wear wigs, hats or head
9 Contaminated needles and syringes must be
scarf.
disposed in a clearly marked special container.
"leak - proof, "puncture proof" ✔ Skin pigmentation
▪ Inform that it is temporary.
10. Dispose half empty ampules, vials, bottles by
✔ Nail changes
putting into plastic bag, seal and then into another
▪ Reassure that nails may grow normally
plastic bag or box, clearly marked before placing
after chemotherapy.
for removal. Label as "Hazardous waste."
3. Hematopoietic System
11. Hand washing should be done before and after
removal of gloves ✔ Anemia
▪ Provide frequent rest periods.
12. Only trained personnel should be involved in
✔ Neutropenia
use of drugs (preferably, chemotherapy certified
▪ Protect from infection.
nurses).
▪ Avoid people with infection.
13. Ideally, preparation of chemotherapeutic drugs ▪ Report fever, chills, diaphoresis, heat,
should be in laminar flow conditions with filtered pain, erythema, or exudates on any body
air to prevent contamination with microorganisms. surface.
▪ Avoid rectal or vaginal procedures
Nursing Interventions for Chemotherapy Side-
Effects

12
 ▪ Avoid fresh fruits, raw meat, fish,
vegetables, fresh flowers, potted plants
▪ Change IV sites every other day.
▪ Change all solutions and IV infusion sets
every 48 hours.
✔ Thrombocytopenia
▪ Protect from trauma.
▪ Avoid ASA.
▪ Nadir. Is the time after chemotherapy
administration when wbc platelet count is
at the lowest point. It occurs within 7 to 14
days a drug administration.

4. Genito - Urinary System

✔ Hemorrhagic cystitis
▪ Provide 2-3L of fluids per day.
✔ Urine color changes
▪ Reassure that it is harmless.

5. Reproductive System

✔ Premature menopause or amenorrhea

▪ Reassure that menstruation resumes after
chemotherapy

13