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CANCER
● Latin word for “crab” ● Grows rapidly, has bigger nucleus ● Is a collective term describing a large of diseases characterized by UNCONTROLLED GROWTH & SPREAD OF ABNORMAL CELLS ● Abnormal new growth of tissue serves NO USEFUL PURPOSE & MAY HARM HOST ORGANISM ● Remains a national health priority ● 3rd leading cause of morbidity & mortality ● 6 common sites of Cancer in MEN:
- Lungs - Colon/Rectum, - Prostate
- Liver - Prostate - Stomach ● 6 common sites of Cancer in WOMEN:
- Breast - Cervix - Lung
- Colon/Rectum - Ovary - Liver ● 189/every 100,000 Filipinos = Afflicted of Cancer ● 4 Filipinos die/day; Filipinos die of cancer /hr or 96 Cancer pts./day ● Appearance: Larger bigger nucleus ● Patterns of Growth: Uncontrolled ● Function: No purpose ● Mutation inactivates tumor suppressor gene ↓ Cells proliferate ↓ Mutation inactivates DNA repair gene ↓ Mutation of proto-oncogene = oncogene ↓ Mutation inactivates several more tumor suppressor genes = CANCER! NEOPLASM ● Abnormal tissue = grows by cellular proliferation rapidly > normal & continues to grow after stimuli initiates = new growth ceases ● Neo: new, recent; Plasm: thing formed CA - CELLULAR ABERRATION ● Departure from what is normal ● Carcinoma: neoplasm from epithelial tissue ● Oma: denoting = tumor/neoplasm ● Can either be: BENIGN ● Harmless ● Not spread/invade ● Not occupy space ● Encapsulated ● If located w.in vital tube or organ = fatal (if located in vital organ)
MALIGNANT
● Harmful ● Metastasize ● Nonencapsulated CHARACTERISTICS OF BENIGN & MALIGNANT TUMORS BENIGN MALIGNANT Cell Characteristic Well differentiated cells resembles normal cells Undifferentiated & bear little resemblance Mode of Growth Grows by expansion & does not infiltrate Grows at the periphery & sends out processes that infiltrate & destroy surrounding tissue Rate of Growth Slow Variable & depends on level of differentiation, more anaplastic = faster growth Metastasis Not spread by metastasis Gain access to the blood & lymphatic channels & metastasizes → other areas of body General Effects Localized unless interferes w/ vital function Generalized anemia, weakness wt. loss Tissue Destruction No tissue damage unless its location interferes w/ flow Extensive tissue damage; produce substances = cell damage Ability to Cause Death Does not usually cause death unless its location interferes w/ vital function Usually causes death unless growth can be controlled PATHOGENESIS ● Exact cause: UNKNOWN
1. CELLULAR TRANSFORMATION & DERANGEMENT THEORY
- ETIOLOGIC AGENTS ○ Exact mechanism by which these agents transform healthy cells → neoplastic cells remain obscure ○ When defective cells divides, new cell contain defective genetic code w/in the DNA
○ Overtime, defective cells divide & multiply, and malignancy grows
2. IMMUNE RESPONSE FAILURE - CA cells continually form w/in body - Immune system perceives these CA cells as foreign & destroys them - However certain conditions either cause a breakdown or overwhelm the immune system - Thus malignant cells reproduce more rapidly > immune system can destroy them ETIOLOGY ● Results from multiple agents working together 1. CARCINOGENS - Chemicals, biological, physical agents = cellular damage - Viruses: incorporate into the genetic structure of cell oncogene-small segment of genetic DNA that have the ability to transform normal cells → malignant cells - Human Papillomavirus, Hepatitis B & C (Liver), HIV, Eipstein-Barr virus (kidney), Helicobacter Pylori (Lungs, Kidneys) 2. CHEMICAL AGENTS - Produce toxic effects by altering DNA structure in the body sites distant from chemical exposure liver, lungs, & kidneys - Caused by: Benzene, asbestos, vinyl chloride, aniline dyes, arsenics, & petroleum 3. PHYSICAL AGENTS - Cause cellular damage - Ionizing radiation - x-ray, CT scan - Too much sun exposure - Chronic irritation or inflammation & tobacco use - Forms of Radiation = CA ○ UV radiation: Sun causes changes in DNA structure → malignant transformation ○ Ionizing radiation: Cause permanent DNA mutation when exposure is excessive 4. DRUGS & HORMONES - Promotes tumor growth - Carcinogenic (Metronidazole) - Implantation: CA cells implant → body organ - Certain cells have an affinity for particular organs & body areas - Seeding: a primary tumor sloughs off tumor cells → body cavity PREDISPOSING FACTOR ● Age, Sex, Geographical location, Occupation, Hereditary, Diet, Stres, Precancerous lesion ● CLASSIFICATION (based on origin) - Carcinoma: Epithelial tissue - Adenocarcinoma: Glandular tissue (Breast & Prostate) - Sarcoma: Connective & supporting tissue (Bones & Nerves) - Embryonal: Embryonic tissue - Lymphomas: Lymphatic system - Leukemias: Blood forming organs ● CLASSIFICATION (TNM)
- T - tumor size (primary tumor) T1, T2, T3, T
- N - nodal involvement
- M - metastasis
- T - Primary Tumor
- To - no evidence of tumor
- Tis - carcinoma in situ
- T1-4 - ascending degrees of increase in tumor size and involvement
- M – metastasis
- Mo – no evidence of distant metastasis
- Mx – distant metastasis cannot be evaluated
- M1 – ascending degrees of metastatic involvement including lymph nodes
- N - regional Lymph Nodes
- No - no clinical evidence of regional lymph node involvement
- Nx - regional lymph nodes cannot be evaluated
- N1-3 - ascending degrees of nodal involvement ● METASTASIS: Spread of CA
- Vascular system: CA cells penetrate blood vessels & circulation until trapped. CA cells may penetrate the vessel wall & invade adjacent organs & tissues
- Lymphatic system: CA cells penetrate the lymphatic system & distributed along the lymphatic channels
- Implantation: CA cells implant to body organs; Certain cells have an affinity for particular & body areas
- Seeding: Primary tumor sloughs off tumor cells → body cavity ● TUMOR SPECIFIC ANTIGEN (TUMOR MARKERS)
- Proteins contained in cell membrane of malignant cells
- Distinguish malignant from benign cell of same type of tissue
- Chemical in the blood produced by certain cancers
C. Sealed Source
- Brachytherapy : Delivers a high dose of radiation to localized areas. D. Unsealed Source
- Intracavity : Radioisotope placed on applicator
- Interstitial :
Sodium phosphate Iodine 131 137 Celsium 226 Radium Iridium 192 Iodine 125 Cesium 137 Gold 198 Radon 222 **○ Brachytherapy
- Interstitial therapy:** utilizes solid radioactive materials (seed implants); temporary/permanent
- Intracavitary therapy: inserted into cavity ex vagina, cervix
- **Surface radiation
- Others:** systemic IV, oral ex thyroid ○ Radiation safety
- Distance : greater distance from radiation. Lesser exposure to ionizing rays
- Time : less time spent close to radiation exposure = less amount of radiation exposure; nurses - min/8 hr shift; do not linger
- Shielding: lead shields; lead gloves & aprons
- Sealed : can’t contaminate body fluid
- Unsealed : excreted in body fluids; flush the toilet several times ○ To Prevent Displacement
- Bedrest, logrolled
- Indwelling catheter: ensure bladder empties
- Low residue/antidiarrheals no BM during therapy ○ Acute Adverse Effects - Fatigue & malaise
- 2 weeks: skin erythema: folds because of warmth & moist
- GI effects
- Oral effects: xerostomia
- Pulmonary: dyspnea, productive cough, radiation
- Pneomonitis: 1-3 months after
- Renal/bladder: cystitis, urethritis
- Radiation caries affecting the incisal edge of the teeth and the necks of the teeth, complicated by poor hygiene
- After radiation treatment fungal infections such as candida are common, but easily resolved. **3. Chemotherapy
- Biologic Response Modifiers (BRM therapy) NURSING RESPONSIBILITIES
- Private room**
- Post “Radiation Precaution”
- Staff: dosimeter badges
- (-) pregnant, (-) children
- 30 mins
- 6 ft. distance CHEMOTHERAPY ● Alkylators
- Busulfan
- Camrustin
- Carboplatin
- Cisplating ● Antibiotics
- Bleomycin
- Dactinomycin
- Daunorobicin
- Adriamycin NURSING ASSESSMENT ● Integumentary System: Inspect:
- pain, swelling, necrosis, inflammation
- skin rash, pruritus
- assess changes pigmentation
- photosensitivity & tearing
- condition gums, teeth, buccal mucosa, tongue
- stomatitis, ulceration, burning, dysphagia ● GI system Inspect:
- n & v-onset, duration, severity
- hydration status & electrolyte balance
- diarrhea/constipation
- anorexia (taste changes & food preferences)
- daily food intake & eating patterns
- jaundice, RUQ pain, liver function, total bilirubin ● Hematopoietic System Inspect:
- fever x>38.
- Signs of infection
- Auscultate lungs = breath sounds
- Productive cough & SOB
- Elevation of T
- Assess for thrombocytopenia
50,000/mm3- mild risk 20,000/mm3- high risk
- Assess for bleeding
- Assess petechiae, bruising
- Blood in stool, urine or emesis
- Intracranialbleeding-LOC, responsiveness, V/S,
- Pupillary reaction ● Anemia
- Asses skin color turgor & capillary refill
- Dyspnea on exertion, fatigue, weakness,
- Palpitations & vertigo
- Advise rest periods ● Respiratory & Cardiovascular
- Lung sounds
- Dyspnea, SOB
- Apical pulse, radial pulse
- Baseline cardiac studies (ECG, 2d echo) ● Neuromuscular
- Fine motor activities
- Paresthesia: tingling, numbness
- Reflexes
- Weakness, Ataxia, & Gait
- ADL
- Urinary retention/constipation
- Tinnitus, ↓ hearing acuity ● Genitourinary
- Urine output
- Urine frequency, urgency, hesitancy
- Changes in color, ordor, clarity
- Hematuria, oliguria, anuria
- BUN, creatinine NURSING RESPONSIBILITIES ● Use gloves and gowns during preparation and administration ● Antineoplastic agents and their metabolites are found in the excreta and body fluids of client's undergoing therapy ● Gowns and gloves when handling body fluids who have received chemotherapy within 48 hours NURSING PRECAUTION 1. Obtain an allergy history from the client 2. Administer a test dose when ordered by physician 3. Stay with the client the entire time the drug is being administered 4. Have emergency equipment and drugs readily available 5. Obtain baseline vital signs 6. Establish a free-flowing IV line for the administration of fluids and emergency drugs should the need arise HYPERSENSITIVITY REACTION ● Immediately stop drug administration ● Maintain IV access with 0.9 NaCl ● Notify physician ● Maintain airway ● Supine with feet elevated ● v/s every 2 hrs until stable ● administer emergency drug SIGNS & SYMPTOMS ● Hypersensitivity Reaction, Dyspnea, Chest tightness, Pain, Pruritus, Urticaria, Tachycardia, Dizziness, Anxiety, agitation, inability to speak, cyanosis, abdominal pain, nausea, hypotension, decreased sensorium, flushed appearance
ADVERSE EFFECTS
● Graded 0- ● O - normal ● 4 - life-threatening
- delay in therapy
- dose modification
- cessation of the therapy ALOPECIA ● Begins 2 weeks’ after ● Regrowth about 3-5 months ● Use of scalp hypothermia and tourniquet ANOREXIA ● Chemo changes the reproduction of taste buds ● Absent or altered taste - decreased food intake FATIGUE ● Unknown - related to anemia, weight loss, altered sleep pattern and coping. N&V ● Caused by stimulation of the vagus nerve by serotonin released by cells in the upper GIT ● Depends on the chemo drug PATTERNS ● Anticipatory - conditioned response ● Acute - 0-24 hours after chemo ● Delayed - 1-4 days after MUCOSITIS ● Destruction of the oral mucosa, causing an inflammatory response ● Start - burning sensation, breakdown, erythema, pain ● Consistent oral hygiene to prevent infection ANEMIA ● Suppression of the stem cell ● Require RBC transfusion/injection of erythropoietin NEUTROPENIA ● Neutrophil count: 1,500/mm3 or less ● Risk for infection: below 500/mm ● Caused by suppression of stem cell ● Occurs after 7-14 days after start ● Can be prolonged ● Teach patient to avoid infection ● Monitored and treated promptly THROMBOCYTOPENIA ● Caused by suppression of megakaryocytes ● Risk for bleeding- 50,000/mm3 below ● Critical if below 20,000mm ● Teach to avoid injury ● Platelet transfusion TOXIC EFFECTS ● Skin, epithelial lining, GIT, Oral cavity, Bone marrow, Alopecia, erythema, shedding of skin, leukopenia, thrombocytopenia, chronic anemia, stomatitis, xerostomia, decrease taste, decrease salivation.
MAINTAIN TISSUE INTEGRITY
MANAGEMENT OF STOMATITIS
● Use soft-bristled toothbrush ● Oral rinses with saline gargles/tap water ● Avoid ALCOHOL-based rinses ● No dentures ● Lip lubricants ● No spicy, hard to chew, extremes of temperatures ● Gauze soaked in solution MANAGEMENT OF ALOPECIA ● Alopecia begins within 2 weeks of therapy ● Regrowth within 8 weeks of termination ● Encourage to acquire wig before hair loss occurs ● Encourage use of attractive scarves and hats ● Provide information that hair loss is temporary BUT anticipate change in texture and color PROMOTE NUTRITION Antiemetics ● Relaxation, imagery and distraction ● Serve food in ways to make it appealing ● Consider patient's preferences ● Provide small frequent meals ● Avoid giving fluids while eating ● Oral hygiene PRIOR to mealtime ● Vitamin supplements RELIEVE PAIN ● Mild Pain : NSAIDS ● Moderate Pain : Weak opioids ● Severe Pain : Morphine ● ADM analgesics round’clock w/ + dose for breakthrough pain DECREASE FATIGUE ● Plan daily activities to allow alternating rest period ● Light exercise is encouraged ● Small frequent meals IMPROVE BODY IMAGE ● Therapeutic communication is essential ● Encourage independence in self-care and decision making ● Offer cosmetic material like make-up and wigs ● Be honest with the patient ASSIST IN THE GRIEVING PROCESS ● Some cancers are curable ● Grieving can be due to loss of health, income, sexuality, and body image ● Answer and clarify information about cancer and treatment options ● Identify resource people ● Refer to support groups PREVENTION ● Lifestyle changes ● Diet ● Physical Activity ● Sunblock ● Screening and Early Detection
FACTORS THAT AFFECT THE DEVELOPMENT
OF CANCER
● Smoking :
- 87% lung cancer cases, 30% = death
- 2+ packs = 15-25x LC mortality
- 2nd hand & environmental = 3000 d. ● Smokeless Tobacco:
- chewing/snuff = INCREASE risk for mouth, larynx, throat, & esophagus c ● Nutrition:
- Obese: risk for breast, colon, & uterine c
- High-fat diet: breast, colon, & prostate c
- High fiber REDUCES risk of colon
- Vit A & C REDUCES larynx, esophagus, stomach, & lung c.
- Salt-cured, smoked = esophageal & stomach c. ● Sunlight:
- Non myeloma skin cancer = 800,
- Sun exposure = MAJOR FACTOR ● Alcohol:
- Oral, larynx, throat, esophagus, & liver cancers ● Radiation:
- increase lung cancer.
TYPES OF CANCERS
🎗 BREAST CANCER
● Group of malignant diseases commonly occur in the female breast & infrequently in the male breast. ● Risk Factors:
- High fat diet
- Advancing age
- Mother/Sister w/ Breast cancer
- Previous breast CA
- 30 yo @ FTP
- High socioeconomic status
- Early menarche & late menopause
- Nullparity ● Clinical Manifestations:
- UOQ (most breast tissue loc)
- Lesion (non tender)
- Fixed, hard w/ irregular borders ● Symptoms
- Nipple changes
- Bloody discharge
- Lump in breast
- Change in breast color
- Pitting of breast skin
- Breast/nipple pain ● Assessment & Dx Findings
- FNA
- Excisional biopsy
- Incisional biopsy
- Needle localization ● Prognosis
- Smaller tumor - better prognosis
- Depends on whether CA has spread- bones, lungs, liver, pleura, adrenals, skin, & brain ● Standard Treatment Options
- Local: Surgery & Radiation
- Systemic: Hormone therapy, Chemotherapy, Targeted therapy ● Surgical Management
- Goal: eradicate local presence of Ca (remove tumor completely while achieving acceptable cosmetic result)
- Mastectomy w/ or w/o reconstruction & breast conserving surgery w/ rad therapy ● Modified Radical Mastectomy
- removal of entire breast tissue w/ axillary lymph nodes
- pectoralis major, minor remain intact
- maintain & restore normal function - hand, arm, & shoulder girdle on the affected side ● Breast Conserving Surgery : Lumpectomy, Wide Excision, Partial/Segmental Mastectomy ● Quadrantectomy : resection of involved breast Q ff by rad therapy = tx residual ● Complications
- Hematoma: Accumulation of blood
- Infection
- Late accumulation of serosanguious fluid after drain removal
- Nerve trauma w/ resultant phantom breast sensation
- Numbness, tingling, or burning sensations (months-years+) ● Lymphedema
- Disruption of lymphatic & venous drainage chronic swelling of the extremity at any point after surgery ● Radiation Therapy
- Decrease chance of local recurrence & eradicat any residual microscopic CA celss
- Obtain result equal to those of removal of breast
- Begins @6 weeks after surger: to heal incision
- Begins after completion of chemotherapy ● Nursing Interventions
- Pain
- Assess pain
- ADM pain meds.
- Alternative pain relief measures
- Position affected arm on pillows w/ hand elevated (good alignment)
- Discuss phantom limb pain - normal
- Ineffective Breathing
- Deep breathing & coughing exercises
- Splint incision
- Ambulation
- Assess compression of dressing
- Monitor breath sounds
- Impaired Physical Mobility
- Post mastectomy exercises
- Use of arm- washing face, combing hair, applying lipstick, brushing teeth
- Support arm w/ sling to prevent strain on incision
- Self Care Deficit
- Assess ability
- Assist w/ performance
- Increase gradually self-care activities
- Potential for Physical Injury interruption of Lymphatic Circulation On affected arm DO NOT:
- Take blood pressue
- Inject
- Wear constrictive clothes
- Wear jewelry Elevate arm on pillows above level of heart (promote gravity drainage of fluids) Arm & Hand care
- hemoptysis
- chest/shoulder pain: chest wall & pleural
involvement
- pain: metastasis to bone
● Dx
- chest x-ray
- CT scan
- fiberoptic bronchoscopy
- FNA
● Medical Management
- Objective: cure
- Surgery
- Radiation
- Chemotherapy
🎗 LYMPHOMA
● Cancer of lymphocytes
● Neoplasm of cells of lymphoid origin
● Start in lymph nodes → lymphoid tissue in
spleen, GIT, liver, or bone marrow
● 2 categories
1. Degree of cell differentiation
2. Origin of predominant malignant cell
● Hodgkin Lymphoma
- Rare malignancy, high cure rate
- Initiates in single node → spread by
contiguous extension along lymphatic
system → malignant cell =
Reed-Sternberg cell (giantic tumor =
morphologically unique & thought to be
immature lymphoid origin) pathologic
hallmark & essential dx criterion
● Cause : Unknown
- Viral etiology sus
- Eipstein bar
- HIV
- Herpes virus
- Seen in patient receiving
immunotherapy (renal transplant)
● Clinical Manifestation
- usually begins as an enlargement of 1/+
lymph nodes on one side of neck
(painless & firm)
- cervical, supraclavicular, mediastinal
nodes
- X-ray
- Tracheal compression: dyspnea
- Pruritus: unknown cause
- ESR increase: increase disease activity
● Symptoms
- Psychological (fatiue, loa)
- Lymph Nodes (enlargement)
- Lungs (SOB, cough)
- Liver (enlargement)
- Kidney (nephrotic syndrome)
- Bone & joints (pain or tenderness)
- Systemic (wt. loss, loa, fever, ns)
- Diaphragm Spleen (enlarged)
- Muscles (weak)
- Bone marrow (involved)
● Assessment & Dx Findings
- Biopsy of lymph nodes -
Reed-Sternberg Cell
- Staging
- PA- palpate lymph nodes
- Liver & spleen
● Medical Management
- Goal: cure
- Chemotherapy ff by radiation
● Non-Hodgkin Lymphomas
- from neoplastic growth of lymphoid
tissue
- vary morphologically
● Clinical Manifestation
- Lymphadenopathy
- Not diagnosed until in later stages
- Lymphomatous masses can compromise
organ function
- Mass in mediastinum- respiratory
distress
- Abdominal masses- can compromise the
ureter- renal dysfunction
- Splenomegaly- abdominal discomfort-
nausea, early satiety, anorexia, weight
loss
● Dx
- Histopathology, immunophenotyping,
cytogenetic analysis of the malignant
cells
- Staging-not an accurate predictor of
prognosis
● Medical Management
- Radiation
- Chemotherapy
🎗 LEUKEMIA
● prolonged or progressively increasing elevation
in leukocytes
● unregulated proliferation of leukocytes in the
bone marrow
● leaves little room for normal cell production
● there can be proliferation of cells in the liver,
spleen, meninges, lymph nodes, gums and skin
● Cause: unknown
● Risk Factors
- exposure to radiation/chemicals
- genetic disorders
- viral infections
- radiation/chemotherapy = Acute
Leukemia Cell
● Classified accord. to Stem Cell involved:
1. Lymphoid: stem cells = lymphocytes
2. Myeloid: stem cells = nonlymphoid
blood cells
● Classified based on time for symptoms to
evolve & phase of cell development halted
1. Acute: onset of symptoms abrupt
occurring w/in few weeks; progress
rapidly + death w/i week-months w/o
aggressive tx
2. Chronic: symptoms evolve over
months-years, majority of leukocytes
produced = mature; progresses more
slowly, disease trajectory extend = years
● Acute Myeloid Leukemia
- results from a defect in the
hematopoietic stem cells that
- differentiate into all myeloid cells:
monocytes,
- granulocytes(neutrophils, basophils,
eosinophils) erythrocytes
- and platelets
- develops without warning
- symptoms/signs results from the
insufficient production of
- normal blood cells
● Neutropenia
- fever and infection
- weakness and fatigue
- dyspnea on exertion
- pallor from anemia
- petechiae, ecchymosis and bleeding
tendencies from thrombocytopenia
● Leukemic cells proliferate w/in organs
leading to:
- pain from enlarged liver
- hyperplasia of the gums
- bone pain from expansion of the marrow
- petechiae
- ecchymosis- bruising
- gingiva or synovial spaces of joints
- lymphadenopathy
- splenomegaly
- fever- are not always due to infection
● Assessment & Dx
1. CBC- decrease erythrocytes, platelets
2. leukocytes- low, normal, high- vastly
decreased bone marrow analysis- excess
more than 20% immature leukocytes
called blast cells
3. hallmark diagnosis
● Medical Management
- Objective: achieve remission- no
evidence of residual leukemia in the
bone marrow
- chemotherapy
- hematopoietic stem cell transplantation
- radiation therapy
- supportive care
- hydroxyurea/azacytidine- control the
increase of blast cells
- antimicrobial therapy
- transfusions
● Complications (Major COD)
- Bleeding & infection
● Chronic Myeloid Leukemia
- arises from mutation in the myeloid
stem cell
- normal myeloid cells continue to be
produced but there is a pathologic
increase in the production of forms of
blast cells
- wide spectrum of cell types exists within
the blood- blast forms to mature
neutrophils
- because there is an uncontrolled
proliferation of cells, the marrow
expands into the cavities of long bones-
femur and cells are also formed in the
liver, and spleen ( extramedullary
hematopoiesis)
- enlargement- painful
- results from chromosomal translocation
- section of DNA is shifted from
chromosome 22 to chromosome 9
- location:
- BCR gene on chromosome 22
- ABL gene on chromosome 9
- when fused- they produce abnormal
CHON that causes leukocytes to divide
rapidly
- BCR-ABL gene- present in all patients
● Clinical Manifestations
- vary, asymptomatic
- Leukocytosis: detected when CBC is
performed
- 100,000/mm3- SOB, slightly confused,
dto. decrease perfusion to lung & brain
- Leukostasis: excessive volume of
leukocytes inhibits blood flow through
capillaries
