Cancer
A term used for diseases in which abnormal cells divide without control and are able to invade other tissue
Malignancy
Progressive, resistant to treatment and tending to cause death; synonymous with cancer
Pathophysiology: Cancer Development
� Neoplastic cells originate from normal body cells
� Benign cells grow by expansion, whereas cancer cells grow by invasion.
� Most tumors arise from cells that are capable of cell division.
� A key feature of cancer cells is loss of apoptosis; cells have
Cell Cycle
One cell divides into two cells during mitotic cell division. These two cells are identical to each other and to the original cell
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Phases
� G0 - resting stage
� G1�getting ready for division
� S�doubling DNA
� G2�making important proteins
� M (mitosis)
Characteristics of Normal Cells
� Have limited cell division
� Undergo apoptosis
� Show specific morphology - Distinct & recognizable appearance, size & shape
� Small nuclear/cytoplasmic ratio
� Perform specific differentiated functions - Ex: Skin cells make keratin
� Adhere tightly tog
Characteristics of Benign Cells
� Normal cells growing in the wrong place
� Continuous or inappropriate cell growth
� Specific morphology - Strongly resemble their parent tissue
� Are euploid
� Small nuclear/cytoplasmic ratio
� Perform differentiated functions
� Adhere tightly together
Characteristics of Cancer Cells
� Have rapid or continuous cell division
� Do not respond to signals for apoptosis
� Show anaplastic morphology - Lose the appearance of their parent cell
� Have a large nuclear-cytoplasmic ratio - Small cells with a large nucleus
� Lose some or all diffe
Cancer Development
Malignant transformation occurs through these steps:
� Initiation
� Promotion
� Progression
� Metastasis
Initiation
Carcinogens change the activity of the cell's genes
Ex: chemicals, physical agents, viruses
Promotion
Promote or enhance growth of initiated cell
Ex: hormones and body proteins such as insulin make altered cells divide more frequently
Progression
Continued change or growth of a cancer
� Tumor makes TAF (tumor angiogenesis factor), provide blood supply for tumor
Metastasis
The process by which cancer spreads from one place to another
Occurs through a progression of steps:
� Extension into surrounding tissues
� Blood vessel penetration
� Release of tumor cells
� Invasion
� Local seeding
� Blood borne metastasis
� Lymphatic s
Etiology of Cancer
� Viruses & bacteria - Herpes simplex virus type II
� Physical agents - Radiation, sunlight
� Chemical agents - tobacco
� Genetic - Breast, prostate
� Dietary - Fats, alcohol, salt-cured or smoked meats
� Hormonal agents - Breast, prostate
Role of Immune System
When a cell becomes cancerous, the immune system is thought to be able to recognize it as abnormal and destroy it before it replicates or spreads.
� Cytotoxic T cells (Tc cells)--kill tumor cells directly
� Natural killer cells (CD16)--destroy unhealthy o
Susceptibility to cancer
Cancer is more likely to progress in people whose immune system is altered or impaired
� people with AIDS,
� people receiving immunosuppressive drugs,
� people with certain autoimmune disorders, and
� Older people, in whom the immune system works less wel
Immunologic Escape
Mechanism by which cancer cells evade immune system
Metastatic Sites
� Lung: spinal cord, brain, liver & bone
� Breast: Regional lymph nodes, vertebrae, brain, & liver
� Colon: Liver, lung, brain, & ovary
� Prostate: bladder, bone, liver
*Cancer Classification
Cancer grading and staging help standardize diagnosis and treatment prognosis.
� Grading on the basis of cell appearance and activity compares the cancer cell with its normal parent tissue.
*Gx
Grade cannot be determined
*G1
Tumor cells are well differentiated & closely resemble the normal cells from which they arose
*G2
Tumor cells are moderately differentiated, normal plus malignant cells
*G3
Tumor cells poorly differentiated, have few normal characteristics
*G4
Tumor cells have no normal cell characteristics
*Staging Of Malignant Tumors
Staging classifies clinical aspects of the cancer and determines exact location and degree of metastasis at diagnosis.
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TNM classification
� T=Primary tumor
� N=Regional lymph nodes
� M=Distant metastasis
*Tumor Staging/TNM Classification
� Tx - Primary tumor cannot be assessed
� T0 - No evidence of primary tumor
� TIS - Cancer in situ
� T1,T2,T3,T4 Progressive > in tumor size & involvement
� Nx - Regional lymph nodes cannot be assessed clinically
� N0 - Lymph nodes normal
� N1,N2,N3,N4 Ab
Cancer Prevention
� Avoidance of known or potential carcinogens
� Modification of associated factors
� Removal of "at-risk" tissues
� Chemoprevention
� Screening programs
� Gene therapy
� Prevention & Control
Primary Prevention
Focus on reducing the risks of cancer in healthy people.
Secondary Prevention
Involves detection and screening to achieve early diagnosis & prompt intervention.
Tertiary Prevention
Care & rehabilitation of patient with cancer.
*Seven Warning Signs
CAUTION
� Change in bowel or bladder habits
� A sore that does not heal
� Unusual bleeding or discharge
� Thickening or lump in breast or elsewhere
� Indigestion or difficulty in swallowing
� Obvious change in wart or mole
� Nagging cough or hoarseness
Diagnostic Tests
� Tumor markers - used to determine the patient's response to therapy & to detect residual disease
� PSA (prostatic-specific antigen) - Used to detect prostate cancer
� CEA (Carcinoembryonic Antigen) - Used to predict colon & breast cancer
� AFP (Alpha-fe
Diagnostic Tests
� X-Ray: extremely important in early diagnosis - Ex. Mammography, lung ca.
� Computed Tomography/CT scans: allows the visualization of cross-sections of anatomy
� Magnetic Resonance Imaging/MRI -three dimensional images using magnetic field
� Positron-em
*Cancer Management: Surgery
� Prophylaxis - Removal of non-vital tissues or organs that may develop cancer
� Diagnosis - Remove all or part of a lesion for examination and testing
� Cure - Surgery alone to remove all visible and microscopic tumor
� Control or Cytoreductive Surgery -
*Cancer Management: Surgery
� Palliation - Relieve complications such as ulcerations, obstructions, hemorrhage, pain & malignant effusions
� Determination of therapy effectiveness "second look" - Assess disease status
� Reconstruction or Rehabilitative - Cosmetic, increase function
Diagnostic/Biopsy
� Needle - aspirate cells using a needle
� Incisional - remove a wedge of tissue for analysis
� Excisional - completely remove an entire lesion
� Staging - perform needle aspirations or incisional biopsies to confirm metastasis
Teletherapy
External radiation
� A uniform dosage is delivered at some distance from the client
Brachytherapy
Internal radiation
� The radioactive material is placed directly into the tumor site
� Unsealed - Oral, IV, or instillation into body cavities. Mode of elimination: urine, feces, sputum
� Sealed - Seeds or needles are implanted within the tumor
� Nursing
Cancer Management: Radiation
Interrupt cellular growth by causing lethal injury to DNA
� Goal: is to achieve maximum tumor control with minimum damage to normal tissue
� Consists of delivering ionizing radiation
Nursing Care: Radiation Therapy
� Provide accurate objective facts to help client cope.
� Do not remove markings.
� Wash skin gently with water alone or mild soap and water.
� Do not use lotions or ointments.
� Wear soft clothing over area
� Avoid direct exposure of skin to the sun.
� C
Side Effects of Radiation Therapy
� Vary according to the site
� Local skin changes & hair loss that will likely be permanent depending on the total absorbed dose
� Altered taste sensations
� Fatigue
� Inflammatory responses that cause tissue fibrosis and scarring
� May cause bone marrow
Cancer Management: Chemotherapy
Involves the use of cytotoxic medications & chemicals. Method of choice when there is suspected or confirmed spread of malignant cells
� Method used when the risk of recurrence is high
� May be used as palliative measure to relieve pain or increase comfor
Chemotherapy Drugs
� Antimetabolites
� Antitumor antibodies
� Alkylating agents
� Antimitotic agents
� Topoisomerase inhibitors
� Miscellaneous chemotherapeutic agents
� Combination chemotherapy
*Treatment Issues
� Drug dosage - BSA-body surface area
� Drug schedule - Regular schedule. Ex: every 3-4 weeks x 6-12 times
� Protocols - Ex: MOPP�Mustard, Oncovin, Procarbazine, Prednisone
� Drug administration - Extravasation, Vesicant (will cause necrosis)
� Nadir (low
Chemotherapy Administration
� Administered orally, subcutaneous, intravenous, intramuscular, intra-cavity
� Given by a certified registered nurse
� Prolonged administration: use IVAD such as PICC, Hickman, Port-a-cath
� Extravasation
� Carefully monitor patient's signs & symptoms in
Antimetabolites
� Phase-specific - Work best in the S phase & have little effect in G0. Interfere with the biosynthesis of metabolites or nucleic acids necessary for RNA & DNA synthesis
� Side Effects: N & V, stomatitis, diarrhea, alopecia, leukopenia, liver & pulmonary
Alkylating Agents
� Non-phase specific- Create defects in tumor DNA. Work on cells (in G0 phase)
� Side Effects: can cause permanent bone marrow failure, irreversible infertility, hemorrhagic cystitis
*Side Effects of Chemotherapy
� Normal, rapidly dividing cells most affected: the skin, hair, intestinal tissues, spermatocytes, and blood-forming cells
� Alopecia, hair loss
� Nausea and vomiting
� Hematopoietic (blood forming) system - WBC, RBC, Platelets
� Anxiety, sleep disturbanc
Nursing Interventions - Alopecia
� Causes anxiety, depression
� Develops within 2-4week
� Re-growth begins within 4 weeks after last treatment
� Avoid chemical treatments, hair coloring, comb gently
� Suggest scarves/wigs to cover the head
Nursing Interventions - Nausea & Vomiting
� Frequent meals, bland foods
� Relaxation techniques, guided imagery, distraction
� Eliminate odors
� ATC dosing of anti-emetics
Nursing Interventions - Mucositis/ Stomatitis
� Affects entire GI tract
� Sores in the mucous membranes
� Avoid spicy foods & extreme temperatures
� Use H2O soluble moisturizers, Mycostatin, Viscous Lidocaine, Magic Mouthwash
� Soft toothbrush, good mouth care
Colony-Stimulating Factors
Induce more rapid recovery of the bone marrow after suppression by chemotherapy
� Anemia? Erythropoietin/Epogen/Procrit
� Leukopenia? Filgrastim/Neupogen
� Thrombocytopenia? Oprelvekin /Neumega
Nursing Interventions - Bone Marrow Suppression
� Most life-threatening
� Neutropenia - Implement Neutropenic Precautions
� Thrombocytopenia - Bleeding Precautions
� Anemia - Energy conservation
� Administer Colony-stimulating factors
� Cognitive changes - Active listening, Advise recovery is expected
Nursing Interventions - Renal
-- rapid tumor cell lysis after chemo causes increase in uric acid
� Give Allopurinol
� Increase fluid intake
� Monitor labs: BUN, Serum Creatinine
Nursing Interventions - Cardiopulmonary
irreversible cardiac and pulmonary toxicities with certain drugs
� Watch for s/s of congestive heart failure, pulmonary fibrosis
� Reproductive--permanent sterility, early menopause
� Discuss sperm bank
Immunotherapy: Biological Response Modifiers
Drugs that modify the client's biologic responses to tumor cells
� Cytokines: enhance the immune system. Ex: Interleukins, Interferon
� Side effects: Generalized and sometimes severe inflammatory reactions, skin rashes, peripheral neuropathy, increased de
Hormone Therapy
Hormone antagonists
� Bind at the hormone receptor site, which deprives the tumor of its hormones, slowing down tumor growth. Ex: Breast, Prostate
� Side effects: alterations in the secondary sexual characteristics. Ex. Tamoxifen
Gene Therapy
Experimental as a cancer treatment
� Renders tumor cells more susceptible to damage or death by other treatments
� Injection into tumor cells, enabling the immune system to better recognize cancer cells as foreign and kill them. Ex: Monoclonal antibodies
Monoclonal Antibodies
Combination of immunotherapy and gene therapy. Take advantage of differences in cancer cells that are not present or only slightly present in normal cells
� Monoclonal Antibodies - Target specific proteins needed for cell growth
� Anti-sense drugs - Bind
Cancer Pain
� Acute Pain: primary symptom associated with diagnosis, pain related to cancer treatment, i.e., surgery, radiation, chemotherapy
� Chronic Pain: related to cancer treatment, a consequence of progression of the disease
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Causes of cancer pain
� Direct tu
Hospice
Multidisciplinary team
� designed to provide comfort
� to assist in a peaceful death
� to provide support to caretakers
� The focus of care is on the family, not just the patient