CANC

ER
• Cancer (medical term: 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), and sometimes metastasis (spread to
other locations in the body via lymph or blood).
• These three malignant properties of cancers
differentiate them from benign tumors , which are self-
limited, do not invade or metastasize.
• Most cancers form a tumor but some, like leukemia, do
not.
 DEFINITIONS
CANCER
It is the uncontrolled growth of abnormal cells
anywhere in a body. These abnormal cells are termed
cancer cells, malignant cells, or tumor cells.

A term for diseases in which abnormal cells divide

without control and can invade nearby tissues.
Cancer cells can also spread to other parts of the
body through the blood and lymph systems.
Tumour
Tumours are groups of abnormal cells that form
lumps or growths. They can start in any one of the
trillions of cells in our bodies. Tumours grow and
behave differently, depending on whether they are
cancerous (malignant), non-cancerous (benign) or
precancerous.
Tumour is a swelling of a part of the body, generally
without inflammation, caused by an abnormal growth
of tissue, whether benign or malignant.
 EPIDEMIOLOGY OF CANCER
 According to UICC
report 2018
 CHARACTERISTICS OF CANCER
CELLS

• Clonality: Originates from a SINGLE STEM CELL

that change in it`s behavior.
• Autonomy: The growth rate is unrestricted
• Anaplasia: Lack of normal, coordinated cellular
differentiation.
• Metastasis: Dissemination to other parts of the body.
 ABNORMALITIES OF CANCER
CELLS
• Abnormal DNA synthesis
• Membrane cells alterations
• Cytoplasmic alterations
• Increase ATP asa activity (Anaerobic shift)
• Increase levels of proteolytic enzymes
• Angiogenesis factor synthesis
DIFFERENCE BETWEEN NORMAL
AND CANCER CELLS
Normal cell Cancer cell
 STRUCTURE AND
NORMAL CELL CANCER CELL
CHARACTERISTICS
Cell shape Uniform Irregular
Spheroid shape, single Irregular shape, multi-
Nucleus
nucleus nucleation common

Chromatin Fine, evenly distributed Coarse, aggregated

Single, inconspicuous Multiple, enlarged

Nucleolus
nucleolus nucleoli

Cytoplasm Large cytoplasmic volume Small cytoplasmic volume

Growth Controlled Uncontrolled

Mature into specialized Remain immature and
Maturation
cells undifferentiated
 STRUCTURE AND
NORMAL CELL CANCER CELL
CHARACTERISTICS

Normal angiogenesis
Tumor-induced
Blood supply (occurs during
angiogenesis
development/ healing)

Favored (for aerobic Not required (thrive in

respiration) but will hypoxic conditions),
Oxygen
undergo anaerobic favor anaerobic
respiration if required respiration

Can spread to different

Remain in their intended
Location locations in the body
location
(metastasis)
PATHOPHYSIOLOGY
• Cancer is, ultimately, a disease of genes. In
order for cells to start dividing uncontrollably,
genes which regulate cell growth must be
damaged.
• Proto-oncogenes are genes which promote
cell growth and mitosis, and tumor suppressor
genes discourage cell growth, or temporarily
halt cell division to carry out DNA repair.
• When normal cells are damaged beyond
repair, they are eliminated by apoptosis (A).
Cancer cells avoid apoptosis and continue to
multiply in an unregulated manner (B).
 GRADING AND STAGING
• 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 a tumor classifies the cellular aspects of the
cancer.
• Staging classifies the clinical aspects of the cancer.
 Purpose of Grading and Staging

• Aid the clinician in the planning of treatment for each

patient
• Assist in the evaluation of treatment modalities
• Facilitate exchange of information between treatment
centers
• Evaluate the outcomes of treatment
• Estimate the prognosis of outcomes by stage and
treatment
 Grading in Cancer
• Grade – X: Grade cannot be determined
• Grade – I: Cells differ slightly from normal cells and
are well differentiated (Mild Dysplasia)
• Grade – II: Cells are abnormal and are moderately
differentiated ( Moderate Dysplasia)
• Grade – III: Cells are very abnormal and are poorly
differentiated ( Severe Dysplasia)
• Grade – IV: Cells are immature (anaplasia) and
undifferentiated, cell of origin is difficult to determine.
 The TNM Staging System
The TNM system is the most widely used cancer staging
system.
In the TNM system:
• The T refers to the size and extent of the main tumor. The
main tumor is usually called the primary tumor.
• The N refers to the number of nearby lymph nodes that
have cancer.
• The M refers to whether the cancer has metastasized.
This means that the cancer has spread from the primary
tumor to other parts of the body.
 When your cancer is described by the TNM system, there
will be numbers after each letter that give more details about the
cancer—for example, T1N0MX or T3N1M0. The following
explains what the letters and numbers mean:
• Primary tumor (T)
TX: Main tumor cannot be measured.
T0: Main tumor cannot be found.
T1, T2, T3, T4: Refers to the size and/or extent of the main
tumor. The higher the number after the T, the larger the tumor
or the more it has grown into nearby tissues. T's may be
further divided to provide more detail, such as T3a and T3b.
• Regional lymph nodes (N)
NX: Cancer in nearby lymph nodes cannot be measured.
N0: There is no cancer in nearby lymph nodes.
N1, N2, N3: Refers to the number and location of lymph
nodes that contain cancer. The higher the number after the N,
the more lymph nodes that contain cancer.
• Distant metastasis (M)
MX: Metastasis cannot be measured.
M0: Cancer has not spread to other parts of the body.
M1: Cancer has spread to other parts of the body.
ETIOLOGY OF CANCER
 CLINICAL MANIFESTATION OF
CANCER
• Fatigue
• Lump or area of thickening that can be felt under the skin
• Weight changes, including unintended loss or gain
• Skin changes, such as yellowing, darkening or redness of
the skin, sores that won't heal, or changes to existing
moles
• Changes in bowel or bladder habits
• Persistent cough or trouble breathing
 CLINICAL MANIFESTATION OF
CANCER

• Difficulty swallowing
• Hoarseness
• Persistent indigestion or discomfort after eating
• Persistent, unexplained muscle or joint pain
• Persistent, unexplained fevers or night sweats
• Unexplained bleeding or bruising
 7 WARNING SIGNS OF CANCER

• Change in bowel or bladder habits.

• A sore that does not heal.
• Unusual bleeding or discharge.
• Thickening or lump in the breast or elsewhere.
• Indigestion or difficulty in swallowing.
• Obvious change in a wart or mole.
• Nagging cough or hoarseness.
 TYPES OF TUMOUR

• Tumor is of two types

Malignant tumor (cancerous)
Benign tumor (non-cancerous)
 Malignant Tumor

• Invade or spread to other parts of the body.

• High rate of division.
• Spread by forming Metastasis.
• Cells travel through circulation.
• Very difficult to treat.
 Benign Tumor
• Do not spread to other part of the body.
• Generally localized and of small size
• Slow rate of division.
• Cells that closely resemble, and may function, like
normal cells.
• Do not break out of originating organ.
• Easily to removed by surgery.
 CLASSIFICATINS OF CANCER
• There are more than 200 types of cancer and we can
classify cancers according to where they start in the
body, such as breast cancer or lung cancer. We can also
group cancer according to the type of cell they start in
• The major types of cancer are:
Carcinoma,  Leukemia.
Sarcoma,  Myeloma
Melanoma,  Mixed types
Lymphoma
 CARCINOMA
• This develops in epithelial tissues,
such as those in the gastrointestinal
tract or mucous membranes.
According to the National Cancer
Institute, an estimated 80 to 90
percent of cancer cases are
carcinomas.
• The most commonly diagnosed
cancers which originates in the skin,
lungs, breasts, pancreas, and other
organs and glands.
• There are different types of epithelial cells and these
can develop into different types of carcinoma. These
include:

Squamous cell carcinoma

Adenocarcinoma

Transitional cell carcinoma

Basal cell carcinoma

 Squamous cell carcinoma
• Squamous cell carcinoma
starts in squamous cells.
These are the flat, surface
covering cells found in
areas such as the skin or
the lining of the throat or
food pipe (oesophagus).
 Adenocarcinoma
• Adenocarcinomas start in
glandular cells called
adenomatous cells.
Glandular cells produce
fluids to keep tissues
moist.
 Transitional cell carcinoma
• Transitional cells are cells
that can stretch as an organ
expands. They make up
tissues called transitional
epithelium. An example is
the lining of the
bladder. Cancers that start in
these cells are called
transitional cell carcinoma.
 Basal cell carcinoma
• Basal cells line the deepest layer of skin cells. Cancers
that start in these cells are called basal cell carcinomas.
 SARCOMA
• These originate in connective
tissue, developing in areas such
as the bones, muscle, fat, and
cartilage. Sarcomas are more
common in young people.
• Sarcomas are much less
common than carcinomas.
There are 2 main types:
Bone Sarcomas
Soft Tissue Sarcomas
 Bone sarcomas
• Sarcomas of bone start
from bone cells.
 Soft tissue sarcomas
• Soft tissue sarcomas are rare
but the most common types
start in cartilage or muscle.
• Cancer of the cartilage is called
chondrosarcoma.
• Cancer of muscle cells is called
rhabdomyosarcoma or
leiomyosarcoma.
 MELANOMA
• It is a form of skin cancer
that begins in the cells
(melanocytes) that control
the pigment in the skin.
 LYMPHOMA
• It happens because some of the lymphatic
system white blood cells (lymphocytes)
start to divide in an abnormal way. And
don't die as they should. These cells start
to divide before they become fully grown
(mature) so they can't fight infection.

• The abnormal lymphocytes start to collect

in the lymph nodes or other places such as
the bone marrow or spleen. They can then
grow into tumours.
 LEUKEMIA
• It is the cancer of the blood.
It is a arises in the bone
marrow, which produces
blood cells.
• Leukaemias are uncommon.
They make up only 3 out of
100 of all cancer cases (3%).
But they are the most
common type of cancer in
children.
 MYELOMA
• Often occurring in the bone
marrow, this type originates
in plasma cells that circulate
as part of the blood.
 MIXED TYPE
• Mixed cancers develop in two different types of cell
from one category or multiple categories.
 DIAGNOSTIC EVALUATION

• History Collection
• Physical Examination
• Laboratory tests
Such as CBC, urine
tests, may help to
identify abnormalities
that can be caused by
cancer.
 DIAGNOSTIC EVALUATION
• Biopsy • Colonoscopy
A biopsy is a A colonoscopy is an exam
used to detect changes or
procedure to
abnormalities in the large
remove a piece of intestine (colon) and rectum.
tissue or a sample During a colonoscopy, a long,
of cells from the flexible tube (colonoscope) is
body so that it can inserted into the rectum. A tiny
be analyzed in a video camera at the tip of the tube
laboratory. allows the doctor to view the inside
of the entire colon.
 DIAGNOSTIC EVALUATION
• Sigmoidoscopy B. Rigid sigmoidoscopy
A. Flexible sigmoidoscopy A proctoscopy (rigid
A flexible sigmoidoscopy is an sigmoidoscopy) is a procedure
exam used to evaluate the to examine the insides of the
lower part of the large rectum and the anus. A
intestine (colon). During a proctoscope is a hollow tube,
flexible sigmoidoscopy exam, a usually with a tiny light at the
thin, flexible tube end, that can also be used to
(sigmoidoscope) is inserted into take tissue samples for biopsies
the rectum. as a cancer screening tool.
 DIAGNOSTIC EVALUATION
• Stool tests B. DNA test
A. Occult test Genetic tests are performed
A fecal occult blood test on a sample of blood, hair,
(FOBT) looks at a sample skin, amniotic fluid (the fluid
of the stool (feces) to that surrounds a fetus during
check for blood. Occult pregnancy), or other tissue to
blood means that can't determine the specific
see it with the naked eye. changes in chromosomes,
DNA, or proteins, depending
on the suspected disorder.
 DIAGNOSTIC EVALUATION
• Mammography • Pap test/Papanicolaou test
Mammography is an x- Papanicolaou test also
ray imaging method used to called as a Pap smear, is a
examine the breasts for the procedure to test for cervical
early detection of cancer and cancer in women.
other breast diseases.
 DIAGNOSTIC EVALUATION
• Human papillomavirus • Imaging tests
(HPV) testing
Computerized
It is used for cervical tomography (CT) scan
cancer screening. This test
Bone scan/X – Ray
is done on a sample of cells
removed from the woman’s Magnetic resonance
cervix. imaging (MRI)
 DIAGNOSTIC EVALUATION
• Positron emission • Alpha fetoprotein blood
tomography (PET) scan test
It is a type of imaging This test is sometimes
test. It uses a radioactive used, along with ultrasound of
substance called a tracer to look the liver, to try to detect liver
for disease in the body. The cancer early in people at high
scan shows how organs and risk of the disease.
tissues are working.
 DIAGNOSTIC EVALUATION
• CA 125 test • PSA test
A CA 125 test measures the This blood test, which
amount of the protein CA 125 is often done along with a
(cancer antigen 125) in the blood. digital rectal exam, is able to
detect prostate cancer at an
A CA 125 test may be used
early stage.
to monitor certain cancers during
and after treatment. A CA 125 test
may be used to look for early signs
of ovarian cancer in people with a
very high risk of the disease.
 MODALITIES OF TREATMENT FOR
CANCER
• There are many types of cancer treatment. The types of
treatment that patient receive will depend on the type of
cancer, stage of cancer and how advanced it is.
• Some people with cancer will have only one treatment.
But most people have a combination of treatments, such
as surgery with chemotherapy and/or radiation therapy.
• Treatment of cancer can involve any of several
modalities:
– Surgical interventions
– Radiation therapy
– Chemotherapy
– Gene therapy
– Stem cell and bone marrow transplants
– Immunotherapy
 1. SURGICAL INTERVENTION
• Surgical removal of the entire cancer remains the ideal
and most frequently used treatment method.
• Surgery is often the first line of choice for solid tumors,
whenever possible.
• Surgery may/may not be combined with other
modalities.
Factors that increase operative risk in cancer
patients:
• Age
• Comorbid conditions
• Debilitation due to cancer
• Paraneoplastic syndrome (associated with cancer occur
when a cancer causes unusual symptoms due to
substances that circulate in the blood stream). E.g. Lung
tumor, renal carcinoma, hepatocellular carcinoma,
breast, ovarian cancer and pancreatic cancer.
 COMMON TYPES OF SURGICAL
INTERVENTION
a. Primary Tumor resection
b. Resection of Metastases
c. Cytoreduction
d. Palliative surgery
e. Reconstructive surgery
f. Diagnostic surgery
 a. Primary Tumor resection
• If a primary tumor has not metastasized, surgery may be
curative.
• Establishing a complete margin of normal tissue around
the primary tumor (as in breast cancer surgery) is
critical for the success of primary tumor resection and
prevention of recurrence.
 b. Resection of metastases
• Surgery to remove one or more metastases (tumors
formed from cells that have spread from the primary
tumor).
• When cancer has metastasized to regional lymph nodes,
nonsurgical modalities may be the best initial treatments, as
in locally advanced lung cancer or head and neck cancer.
• Single metastases, especially those in the lungs or liver, can
sometimes be resected with a reasonable rate of cure.
• Patients with a limited number of metastases,
particularly to the liver, brain, or lungs, may benefit
from surgical resection of both the primary and
metastatic tumor.
• For example, in colon cancer with liver metastases,
resection produces 5-yr survival rates of 30 to 40% if <
4 hepatic lesions exist and if adequate tumor margins
can be obtained.
 c. Cytoreduction
• Cytoreductive surgery (CRS) is a surgical procedure
that aims to reduce the amount of cancer cells in the
abdominal cavity for patients with tumors that have
spread intraabdominally (peritoneal carcinomatosis). It
is often used to treat ovarian cancer but can also be used
for other abdominal malignancies.
 d. Palliative surgery
• When cure is not possible, the goals of treatment are to
make the patient as comfortable as possible and to
promote a satisfying and productive life for as long as
possible.
• Palliative surgery is performed in an attempt to relieve
complications of cancer, such as ulcerations,
obstructions, hemorrhage, pain, and malignant
effusions.
 e. Reconstructive surgery
• Cancer treatment can cause damage to the body that
affects how it works or looks. In order to repair this
damage, patient may need a type of surgery called
reconstructive surgery.
• Reconstructive surgery may improve a patient’s comfort
or quality of life after tumor resection (e.g., breast
reconstruction after mastectomy).
 f. Diagnostic surgery
• Diagnostic surgery, such as a biopsy, is usually
performed to obtain a tissue sample for analysis of cells
suspected to be malignant. In most instances, the biopsy
is taken from the actual tumor.
 2. RADIATION THERAPY
• Radiation therapy works by damaging the DNA within cancer
cells and destroying their ability to reproduce.
• When the damaged cancer cells are destroyed by radiation, the
body naturally eliminates them.
• Normal cells can be affected by radiation, but they are able to
repair themselves.
• Sometimes radiation therapy is the only treatment a patient needs.
• Other times, it is combined with other treatments, like surgery and
chemotherapy.
• Radiation therapy is the use of high-energy ionizing
rays to destroy a cancer cell's ability to grow and
multiply.
• The goal of radiation therapy is to deliver a precisely
measured dose of irradiation to a defined tumor volume
with minimal damage to surrounding healthy tissue.
• This results in eradication of tumor, high quality of life,
prolongation of survival, and allows for effective
palliation or prevention of symptoms of cancer, with
minimal morbidity.
• The total number of fractions administered depends on:
– Tumor size and location
– Cancer type
– Reason for treatment
– Patient’s overall health
– Other treatments the patient is receiving.
 Uses of Radiation Therapy
• Radiation therapy is used two different ways;
a. To cure cancer:
– Destroy tumors that have not spread to other body parts.
– Reduce the risk that cancer will return after surgery or
chemotherapy.
b. To reduce symptoms:
– Shrink tumors affecting quality of life, like a lung tumor
that is causing shortness of breath.
– Alleviate pain by reducing the size of a tumor
 Types of Radiation Therapy
• The type of radiation therapy depends on many factors
including:
– the type of cancer
– the size of the tumor
– the tumor’s location in the body
– how close the tumor is to normal tissues that are sensitive to
radiation
– general health and medical history
– Whether have other types of cancer treatment
– other factors, such as age and other medical conditions
• There are mainly two types of radiation therapy;
a. External beam radiation therapy
b. Internal radiation therapy.
 a. External radiation therapy
• External beam radiation therapy (EBRT) is the most common
form of radiation therapy. Beams of high-energy radiation are
directed at the tumor. The position of the machine can be
changed to aim the beams at different angles.
• External radiation therapy is usually given five days a week
for one to eight weeks, depending on the cancer. On occasion,
a single treatment may be recommended. The daily treatment
usually takes only a few minutes.
• External beam radiation therapy delivers radiation using a
linear accelerator.
 Types of external radiotherapy
• 3D conformal radiation therapy: Computed tomography (CT)
scans and special computer software help create a three-
dimensional computer model of the area to be treated.
Treatments are more precisely targeted to the tumor, sparing
surrounding normal tissue.
• Intensity-modulated radiation therapy (IMRT)/ volumetric
modulated arc therapy (VMAT): Intensity modulated
radiotherapy provides even more precise radiation therapy. This
multi-beam system varies dose intensity and narrows in on
diseased cells. VMAT does this over an arc, which tends to be
faster.
• Image guided radiotherapy (IGRT): Sometimes three
dimensional imaging done before treatment can help ensure the
best alignment to the target. This is usually done by getting a CT
scan prior to each treatment. Other imaging options include X-
rays, ultrasound, systems that track internal seeds and cameras
that track a surface as it moves.
• Stereotactic radiosurgery/ Gamma Knife
radiosurgery: The Gamma Knife is considered the "gold
standard" for radiation treatment for brain tumors or lesions.
The Gamma Knife provides results comparable to or better than
conventional surgery in many cases, without the need for a
surgical incision or long recovery in the hospital.
• Stereotactic body radiation therapy (SBRT): This type of
treatment focuses high doses of intense radiation to targets
outside the head. This type of treatment is usually given in one
to five treatments. Sometimes special systems that control or
track your breathing are necessary to further minimize radiation
to the healthy parts of your body.
• Intraoperative radiation: Intraoperative radiation therapy
(IORT) allows for radiation to be delivered at the time of
surgery, which may help avoid the need for external radiation
later. The radiation is better focused to areas that have some
tumor left behind.
 b. Internal radiation therapy
• Brachytherapy and Radiopharmaceuticals
In some cases internal radiation therapy is as effective
in treating cancer as external.
• Brachytherapy involves implanting a radioactive source, or
"seed," in or around a tumor. The source emits a high dose
of radiation to a small area to kill cancer cells. Implants can
be temporary or permanent.
Examples of temporary brachytherapy implants include
gynecologic, esophageal, orbital (eye) and coronary
artery implants.
  An example of permanent brachytherapy implant is a
low-dose rate prostate seed implant.
• Radiopharmaceuticals are another way of delivering
radiotherapy, in the form of a radioisotope bound to a
carrier. Examples of radio pharmaceuticals include
TheraSphere, used to treat certain liver tumors, and Zevalin,
used to treat certain lymphomas.
Treatment Planning for Radiation Therapy
• Evaluation of tumor extent (staging), including diagnostic
studies before treatment.
• Define the goal of therapy (cure or palliation).
• Select appropriate treatment modalities (irradiation alone or
combined with surgery, chemotherapy, or both).
• All patients undergo simulation and treatment planning.
(Simulation is used to accurately identify target volumes and
sensitive structures. CT simulation allows for accurate three-
dimensional (3-D) treatment planning of target volume and
anatomy of critical normal structures).
• Usual schedule is Monday through Friday.
• Actual therapy lasts minutes. Most time is spent on
positioning.
• Determine optimal dose of irradiation and volume to be
treated, according to anatomic location, histologic type,
stage, potential regional nodal involvement (and other
tumor characteristics), and normal structures in the
region.
 Side Effects of Radiation Therapy
• Side effects, like skin tenderness, are generally limited
to the area receiving radiation. Unlike chemotherapy,
radiation usually doesn’t cause hair loss or nausea.
• Most side effects begin during the second or third week
of treatment. Side effects may last for several weeks
after the final treatment.
• In general, acute side- effects of radiotherapy includes;
Anorexia
Nausea & vomiting
Mucositis
Malaise
Myelosuppression
Oesophagitis
Diarrhoea
Alopecia
Body region/parts Side effects
Skin Ulceration, Erythema
Bone Necrosis, Fracture, Sarcoma
Mouth Ulceration, Xerostomia, Sialitis
Bowel Stenosis, Fistula, Diarrhoea
Bladder Cystitis
CNS Myelopathy
Lung Fibrosis, Dyspnea, Radiation Pneumonitis
Heart Pericardial Fibrosis, Cardiomyopathy
Gonads Infertility
 Nursing Management Patient with Radiation
Therapy
• Teaching is a primary responsibility of nursing care for radiation
patients. (e.g. What is radiation therapy, purpose, duration of
therapy, possible side effects and its management)
• Monitor and assess the patient’s pain level using a standard 0-to-
10 pain scale. Note what pain medications the patient takes and
whether these are effective.
• If appropriate, refer patients with fatigue for physical therapy,
which can ease fatigue and improve stamina.
• Obtain a complete list of the patient’s medications and monitor for
drug interactions. Stress the importance of informing all
healthcare providers of medication changes.
 Protecting the skin and oral mucosa

• The nurse assesses the patient’s skin, nutritional status,

and general feeling of well-being.
• The skin and oral mucosa are assessed frequently for
changes (particularly if radiation therapy is directed to
these areas).
• The skin is protected from irritation, and the patient is
instructed to avoid using ointments, lotions, or powders
on the area.
• Weigh patients weekly on the same scale. If
appropriate, refer them to a dietitian.
• Be aware that patients who have difficulty swallowing
and maintaining adequate nutrition and hydration may
need a percutaneous endoscopic gastrostomy tube.
• A dehydrated patient may require I.V. fluids. Teach the
patient to report dehydration signs and symptoms, such
as weakness, dizziness, and decreased urine output.
 3. CHEMOTHERAPY

• Paul Erlich, considered to be the father of chemotherapy.

• Chemotherapy-is the use of chemicals to treat disease.
• Chemotherapy is the use of antineoplastic drugs to promote
tumor cell destruction by interfering with cellular function
and reproduction.
• It includes the use of various chemotherapeutic agents and
hormones.
• Chemotherapy is a term used to describe any treatments
that utilizes the introduction of chemical agents to an
organism to help control, stop and or terminate the rapid
growth of cells.
• There are 60 types of chemotherapy currently available
and new ones being developed all the time.
 Working mechanism of chemotherapy drugs
• The drugs enter the bloodstream and reach all parts of the body.
• Cytotoxic drugs destroy cancer cells by damaging them so that
they can’t divide and grow.
• The drugs can also affect normal cells.
• In order to damage and kill the cancer cells, the drugs must be
absorbed into your blood and carried throughout your body.
• The way chemotherapy is given depends on the type of cancer.
• The drugs. (for example, some must be injected and some can
be taken by mouth).
 Types of chemotherapeutic agents
• Drugs acting directly on cells ( cytotoxic drugs):
i. Alkylating agents:
a. Nitrogen mustards (Cyclophosphamide, melphalan)
b. Ethylenimine (Thio-TEPA)
c. Alkyl sulfonates (Busulphan)
d. Nitrosoureas (carmustin)
e. Triazine (Decarbazine)
f. Miscellaneous (Hydroxyurea, Procarbzine)
ii. Drugs altering hormonal milieu:
a. Glucocorticoids (Psrednisolone)
b. Estrogen (Diethylstilbestrol)
c. Antiestrogen (Tamoxifen)
d. Androgens (Testosterone)
e. Progestins (Hydroxyprogestrone)
 Routes of administration of Chemotherapeutic
agents
 Oral; capsule, tablet, or liquid
 I.V; push (bolus) or infusion over a specified time period
 Intramuscular
 Intrathecal/intraventricular given by injection via an
Ommaya reservoir or by lumbar puncture
(An Ommaya reservoir is an intraventricular catheter
system that can be used for the aspiration of cerebrospinal
fluid or for the delivery of drugs (e.g. chemotherapy) into
the cerebrospinal fluid.)
 Intra-arterial

 Intracavitary ”such as peritoneal cavity

 Intravesical into uterus or bladder

 Topical
 TOXICITY OF CHEMOTHERAPY
• Toxicity associated with chemotherapy can be acute or
chronic.
• Cells with rapid growth rates (eg, epithelium, bone
marrow, hair follicles, sperm) are very susceptible to
damage, and various body systems may be affected as
well.
 System Toxicity
Gastrointestinal Nausea and vomiting
Myelosuppression (Leukopenia, anemia, thrombocytopenia),
Hematopoietic
increases the risk for infection and bleeding.
Damage in kidney function, Hyperkalemia and
Renal System hyperphosphatemia and diminished levels of calcium
(hypocalcemia).
Cardio – Cardiac Toxicities, Congestive Heart Failure, Pulmonary
pulmonary fibrosis

Testicular and ovarian malfunction, sterility, early menopause,

Reproductive temporary or permanent azoospermia (absence of
spermatozoa), chromosomal abnormalities in offspring

neurologic damage, Peripheral neuropathies, loss of deep

Neurologic
tendon reflexes, and paralytic ileus
 Adverse Effects of Chemotherapy
• Alopecia
• Anorexia
• Anemia
• Fatigue
• Nausea and Vomiting
• Mucositis
• Neutropenia
• Thrombocytopenia
• Hypersensitivity Reactions
 Nursing Management in Chemotherapy
• Assessing fluid and electrolyte balance. Anorexia, nausea, vomiting, altered taste,
mucositis, and diarrhea put patients at risk for nutritional and fluid electrolyte
disturbances.
• Modifying risks for infection and bleeding: Suppression of the bone marrow and
immune system is expected and frequently serves as a guide in determining
appropriate chemotherapy dosage but increases the risk of anemia, infection, and
bleeding disorders.
• Administering chemotherapy. The patient is observed closely during its
administration because of the risk and consequences of extravasation, particularly
of vesicant agent.
• Protecting caregivers. Nurses must be familiar with their institutional policies
regarding personal protective equipment, handling and disposal of
chemotherapeutic agents and supplies, and management of accidental spills or
exposures.
 4. GENE THERAPY
• Gene therapy includes approaches that correct genetic
defects or manipulate genes to induce tumor cell
destruction in the hope of preventing or combating the
disease.
Approaches in Gene Therapy
• Three general approaches have been used in the development of
gene therapies, with adenoviruses showing effective promise in
each approach.
Tumor-directed therapy. This is the introduction of a
therapeutic gene (suicide gene) into tumor cells in an attempt
to destroy them.
Active immunotherapy. Active immunotherapy is the
administration of genes that will invoke the antitumor
responses of the immune system.
Adoptive immunotherapy. Active immunotherapy is the
administration of genetically altered lymphocytes that are
programmed to cause tumor destruction.
 5. STEM CELL & BONE MARROW
TRANSPLANTS
• Stem cells are special cells that can make copies of themselves and
change into the many different kinds of cells that your body needs.
There are several kinds of stem cells and they are found in
different parts of the body at different times.
• Cancer and cancer treatment can damage your hematopoietic stem
cells. Hematopoietic stem cells are stem cells that turn into blood
cells.
• Bone marrow is soft, spongy tissue in the body that contains
hematopoietic stem cells. It is found in the center of most bones.
Hematopoietic stem cells are also found in the blood that is
moving throughout your body.
• A bone marrow/stem cell transplant is a medical procedure
by which healthy stem cells are transplanted into the bone
marrow or blood. This restores the body's ability to create the
red blood cells, white blood cells, and platelets it needs
• The replacement cells can either come from patient’s own
body or from a donor.
• A bone marrow transplant is also called a stem cell transplant
or, more specifically, a hematopoietic stem cell transplant.
• Transplantation can be used to treat certain types of cancer,
such as leukemia, myeloma, and lymphoma, and other blood
and immune system diseases that affect the bone marrow.
 Purposes of bone marrow transplantation
• Replace diseased, nonfunctioning bone marrow with healthy
functioning bone marrow (for conditions such as leukemia, aplastic
anemia, and sickle cell anemia).
• Regenerate a new immune system that will fight existing or residual
leukemia or other cancers not killed by the chemotherapy or radiation
used in the transplant.
• Replace the bone marrow and restore its normal function after high
doses of chemotherapy and/or radiation are given to treat a
malignancy. This process is often called rescue.
• Replace bone marrow with genetically healthy functioning bone
marrow to prevent more damage from a genetic disease process (such
as Hurler's syndrome and adrenoleukodystrophy).
 Types of bone marrow transplants
• There are different types of bone marrow transplants
depending on who the donor is. The different types of
BMT include the following:
i. Autologous bone marrow transplant
ii. Allogeneic bone marrow transplant
iii. Umbilical cord blood transplant
i. Autologous transplant: Stem cells for an autologous
transplant come from patient’s own body. Sometimes,
cancer is treated with a high-dose, intensive chemotherapy
or radiation therapy treatment. This type of treatment can
damage the stem cells and immune system. That's why
doctors remove, or rescue, the stem cells from the blood
or bone marrow before the cancer treatment begins.
After chemotherapy, the stem cells are returned to
patient’s body, restoring the immune system and the body's
ability to produce blood cells and fight infection. This
process is also called an AUTO transplant or stem cell
rescue.
 Steps of Autologous transplant
• Step 1: Collecting the stem cells; This step takes several
days. First, patient will get injections (shots) of a
medication to increase the stem cells. Then the health
care team collects the stem cells through a vein in the
arm or chest. The cells will be stored until they are
needed.
• Step 2: Pre-transplant treatment; This step takes 5 to
10 days. Patient will get a high dose of chemotherapy.
Occasionally, patients also have radiation therapy.
• Step 3: Getting the stem cells back; This step is the
patient’s transplant day. It takes about 30 minutes for
each dose of stem cells. This is called an infusion. The
health care team puts the stem cells back into the
patient’s bloodstream through the catheter. The patient
might have more than one infusion.
• Step 4: Recovery; The doctor will closely monitor the
cells' recovery and growth and the patient will take
antibiotics to reduce infection. The health care team
will also treat any side effects.
ii. Allogenic transplant: Stem cells for an allogenic
transplant come from another person, called a donor. The
donor's stem cells are given to the patient after the patient
has chemotherapy and/or radiation therapy. This is also
called an ALLO transplant.
iii. Umbilical cord blood transplant: Stem cells are taken
from an umbilical cord immediately after delivery of an
infant. These stem cells reproduce into mature, functioning
blood cells quicker and more effectively than do stem cells
taken from the bone marrow of another child or adult. The
stem cells are tested, typed, counted, and frozen until they
are needed for a transplant.
Complications of bone marrow transplant
• Possible complications from a bone marrow transplant include:
Graft-versus-host disease (a complication of allogeneic
transplant only)
Stem cell (graft) failure
Organ damage
Infections
Cataracts
Infertility
New cancers
Death
 6. IMMUNOTHERAPY
• Immunotherapy is a type of biological therapy. Biological
therapy is a type of treatment that uses substances made from
living organisms to treat cancer.
• Cancer immunotherapy, also known as immuno-oncology, is a
form of cancer treatment that uses the power of the body’s
own immune system to prevent, control, and eliminate cancer.
• Immunotherapy is treatment that uses a person's own immune
system to fight cancer.
• Immunotherapy can boost or change how the immune system
works so it can find and attack cancer cells.
 Side effects of immunotherapy
• Fatigue
• Nausea or vomiting
• Mouth sores
• Diarrhea
• High blood pressure
• Fluid buildup, usually in the legs
• Fever or chills
• Pain or weakness
• Headaches
• Rashes or itching
 Types of immunotherapy
• Monoclonal or therapeutic antibodies: They are grown in a lab
and injected into the body. Some mark cancer cells so the immune
system is able to recognize and destroy them. Others are more direct
in their approach, stopping the growth of cancer cells or causing
their self-destruction.
• CAR T-cell therapy: It is also known by many names—including
adoptive cell therapy, adoptive immunotherapy or immune cell
therapy. Essentially, the care team harvests white blood cells from
inside the patient's tumor and grows them in a lab, making changes
to strengthen their natural ability to fight cancer. These cells are
grown in large batches and injected back into the body to fight the
cancer.
• Immune checkpoint inhibitors: Immune checkpoint inhibitors are a
type of drug that removes natural blockades within the body that keep
the immune system in check. Without these natural blockades, it may
overreact—like in autoimmune diseases. But cancers will often use
these blockades, or proteins, to hide from the immune system. With
these blockades deactivated through checkpoint inhibitors, the door is
opened, and your body is able to respond more strongly to the cancer
cells.
• Cancer vaccines; sometimes called immunotherapeutic or treatment
vaccines, boost the immune system response when someone already
have cancer. They aren’t preventative vaccines like those for viruses,
such as the flu. By providing immune cells with a target found on
cancer cells, they prime the body to create antibodies to attack cancer
cells. Vaccines usually contain an immune-stimulating agent to rally the
white blood cell troops specifically against that protein target.
• Cytokines: Cytokines are proteins created by the body
during natural infections that play an important role in
stimulating the immune system cells. By supplementing the
body’s natural cytokines, these treatments help ramp up
immune cells and move them toward their target: the tumor.
• Immune system modulators, sometimes called
immunomodulators, are drugs that ramp up the body’s
immune reaction. Different immunomodulators act in
different ways—some focus specifically on certain parts of
the immune system, while others act across the whole body.
• https://nurseslabs.com/cancer/#
nursing_management_in_chemotherapy
• https://www.cancer.net/navigating-cancer-care/how-ca
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