BLADDER CANCER Bladder cancer is a type of cancer that begins in your bladder a balloon-shaped organ in your pelvic area

a that stores urine. Bladder cancer begins most often in the cells that line the inside of the bladder. Bladder cancer typically affects older adults, though it can occur at any age. The great majority of bladder cancers are diagnosed at an early stage when bladder cancer is highly treatable. However, even early-stage bladder cancer is likely to recur. For this reason, bladder cancer survivors often undergo follow-up tests to look for bladder cancer recurrence for years after treatment. SYMPTOMS Blood in urine (hematuria) urine may appear dark yellow, bright red or cola colored. Or urine may appear normal, but blood may be detected in a microscopic examination of the urine Frequent urination Painful urination Back pain Pelvic pain CAUSES It's not always clear what causes bladder cancer. Bladder cancer has been linked to smoking, a parasitic infection, radiation and chemical exposure. Bladder cancer develops when cells in the bladder begin to grow abnormally. Rather than grow and divide in an orderly way, these cells develop mutations that cause them to grow out of control and not die. These abnormal cells form a tumor. Types of bladder cancer Different types of cells in your bladder can become cancerous. The type of bladder cell where cancer begins determines the type of bladder cancer. Your bladder cancer type determines which treatments may work best for you. Types of bladder cancer include: Transitional cell carcinoma. Transitional cell carcinoma occurs in the cells that line the inside of your bladder. Transitional cells expand when your bladder is full and contract when your bladder is empty. These same cells line the inside of your ureters

and your urethra, and tumors can form in those places as well. Transitional cell carcinoma is the most common type of bladder cancer in the United States. Squamous cell carcinoma. Squamous cells appear in your bladder in response to infection and irritation. Over time they can become cancerous. Squamous cell bladder cancer is rare in the United States. It's more common in parts of the world where a certain parasitic infection (schistosomiasis) is a prevalent cause of bladder infections. Adenocarcinoma. Adenocarcinoma begins in cells that make up mucus-secreting glands in the bladder. Adenocarcinoma of the bladder is rare in the United States. Some bladder cancers include more than one type of cell. RISK FACTORS Smoking. Smoking cigarettes, cigars or pipes may increase your risk of bladder cancer by causing harmful chemicals to accumulate in your urine. When you smoke, your body processes the chemicals in the smoke and excretes some of them in your urine. These harmful chemicals may damage the lining of your bladder, which can increase your risk of cancer. Increasing age. Your risk of bladder cancer increases as you age. Bladder cancer can occur at any age, but it's rarely found in people younger than 40. Being white. Whites have a greater risk of bladder cancer than do people of other races. Being a man. Men are more likely to develop bladder cancer than women are. Exposure to certain chemicals. Your kidneys play a key role in filtering harmful chemicals from your bloodstream and moving them into your bladder. Because of this, it's thought that being around certain chemicals may increase your risk of bladder cancer. Chemicals linked to bladder cancer risk include arsenic and chemicals used in the manufacture of dyes, rubber, leather, textiles and paint products. Previous cancer treatment. Treatment with the anti-cancer drug cyclophosphamide (Cytoxan) increases your risk of bladder cancer. People who received radiation treatments aimed at the pelvis for a previous cancer may have an elevated risk of developing bladder cancer. Taking a certain diabetes medication. People who take the diabetes medication pioglitazone (Actos) for more than a year may have an increased risk of bladder cancer. Other diabetes medications contain pioglitazone, including pioglitazone and metformin (Actoplus Met) and pioglitazone and glimepiride (Duetact). Chronic bladder inflammation. Chronic or repeated urinary infections or inflammations (cystitis), such as may happen with long-term use of a urinary catheter, may increase your risk of a squamous cell bladder cancer. In some areas of the world,

squamous cell carcinoma is linked to chronic bladder inflammation caused by the parasitic infection known as schistosomiasis. Personal or family history of cancer. If you've had bladder cancer, you're more likely to get it again. If one or more of your immediate relatives have a history of bladder cancer, you may have an increased risk of the disease, although it's rare for bladder cancer to run in families. A family history of hereditary nonpolyposis colorectal cancer, also called Lynch syndrome, can increase your risk of cancer in your urinary system, as well as in your colon, uterus, ovaries and other organs. COMPLICATIONS Bladder cancer often recurs. Because of this, bladder cancer survivors often undergo follow-up testing for years after successful treatment. What tests you'll undergo and how often will depend on your type of bladder cancer and your treatment, among other factors. Ask your doctor to create a follow-up plan for you. In general, doctors recommend a test to examine the inside of your urethra and bladder (cystoscopy) every three to six months for the first few years after bladder cancer treatment. Then you may undergo cystoscopy every year. Your doctor may recommend other tests at various intervals as well. People with aggressive cancers may undergo more frequent screening. Those with less aggressive cancers may undergo screening tests less often. TESTS & DIAGNOSTCS Diagnosing bladder cancer Tests and procedures used to diagnose bladder cancer may include: Cystoscopy. During cystoscopy, your doctor inserts a narrow tube (cystoscope) through your urethra. The cystoscope has a lens and fiber-optic lighting system, allowing your doctor to see the inside of your urethra and bladder. You usually receive a local anesthetic during cystoscopy to help make you comfortable. Biopsy. During cystoscopy, your doctor may pass a special tool through the scope and into your bladder in order to collect a cell sample (biopsy) for testing. This procedure is sometimes called transurethral resection (TUR). TUR can also be used to treat bladder cancer. TUR is usually performed under general anesthesia. Urine cytology. A sample of your urine is analyzed under a microscope to check for cancer cells in a procedure called urine cytology. Imaging tests. Imaging tests allow your doctor to examine the structures of your urinary tract. Tests to highlight the urinary tract sometimes use a dye, which is injected into a vein before the procedure. An intravenous pyelogram is a type of

X-ray imaging test that uses a dye to highlight your kidneys, ureters and bladder. A computerized tomography (CT) scan is a type of X-ray test that allows your doctor to better see your urinary tract and the surrounding tissues. Staging bladder cancer Once it's confirmed that you have bladder cancer, your doctor may order additional tests to determine the extent (stage) of the cancer. Staging tests may include: CT scan Magnetic resonance imaging (MRI) Bone scan Chest X-ray Bladder cancer stages The stages of bladder cancer are: Stage I. Cancer at this stage occurs in the bladder's inner lining but hasn't invaded the muscular bladder wall. Stage II. At this stage, cancer has invaded the bladder wall but is still confined to the bladder. Stage III. The cancer cells have spread through the bladder wall to surrounding tissue. They may also have spread to the prostate in men or the uterus or vagina in women. Stage IV. By this stage, cancer cells may have spread to the lymph nodes and other organs, such as your lungs, bones or liver. TREATMENT Your treatment options for bladder cancer depend on a number of factors, including the type and stage of the cancer, your overall health, and your treatment preferences. Discuss your options with your doctor to determine what treatments are best for you. Surgical procedures The types of surgical procedures available to you may be based on factors such as the stage of your bladder cancer, your overall health and your preferences. Surgery for early-stage bladder cancer If your cancer is very small and hasn't invaded the wall of your bladder, your doctor may recommend: Surgery to remove the tumor. Transurethral resection (TUR) is often used to remove bladder cancers that are confined to the inner layers of the bladder. During TUR, your doctor passes a small wire loop through a cystoscope and into your bladder. The loop is used to burn away cancer cells with an electric current. In some cases, a high-energy laser may be used instead of electric current. TUR may cause painful or bloody urination for a few days following the procedure.

Surgery to remove the tumor and a small portion of the bladder. During segmental cystectomy, sometimes called partial cystectomy, the surgeon removes only the portion of the bladder that contains cancer cells. Segmental cystectomy may be an option if your cancer is limited to one area of the bladder that can easily be removed without harming bladder function. Surgery carries a risk of bleeding and infection. You may experience more frequent urination after segmental cystectomy, since the operation reduces the size of your bladder. Over time, this may improve. Surgery for invasive bladder cancer If your cancer has invaded the deeper layers of the bladder wall, you may consider: Surgery to remove the entire bladder. A radical cystectomy is an operation to remove the entire bladder, as well as surrounding lymph nodes. In men, radical cystectomy typically includes removal of the prostate and seminal vesicles. In women, radical cystectomy involves removal of the uterus, ovaries and part of the vagina. Cystectomy carries a risk of infection and bleeding. In men, removal of the prostate and seminal vesicles may cause erectile dysfunction. But in many cases, your surgeon can attempt to spare the nerves necessary for an erection. In women, removal of the ovaries causes infertility and premature menopause. Surgery to create a new way for urine to leave your body. Immediately after your radical cystectomy, your surgeon works to create a new way for you to expel urine. Several options exist. Which option is best for you depends on your situation and your preferences. Your surgeon may create a tube (urinary conduit) using a piece of your intestine. The tube runs from your kidneys to the outside of your body, where your urine drains into a pouch (urostomy bag) you wear on your abdomen. In another procedure, your surgeon may use a section of intestine to create a small reservoir for urine inside your body (cutaneous continent urinary diversion). You can drain urine from the reservoir through a hole in your abdomen using a catheter a few times each day. In select cases, your surgeon may create a bladder-like reservoir out of a piece of your intestine (neobladder). This reservoir sits inside your body and is attached to your urethra, which allows you to urinate normally. You may need to use a catheter to drain all the urine from your neobladder. Biological therapy (immunotherapy) Biological therapy, sometimes called immunotherapy, works by signaling your body's immune system to help fight cancer cells. Biological therapy for bladder cancer is typically administered through your urethra and directly into the bladder (intravesical therapy).

Biological therapy drugs used to treat bladder cancer include: An immune-stimulating bacterium. Bacille Calmette-Guerin (BCG) is a bacterium used in tuberculosis vaccines. BCG can cause bladder irritation and blood in your urine. Some people feel as if they have the flu after treatment with BCG. A synthetic version of an immune system protein. Interferon is a protein that your immune system makes to help your body fight infections. A synthetic version of interferon, called interferon alfa-2b (Intron A), may be used to treat bladder cancer. Interferon alfa-2b is sometimes used in combination with BCG. Interferon alfa-2b can cause flu-like symptoms. Biological therapy can be administered after TUR to reduce the risk that cancer will recur. Chemotherapy Chemotherapy uses drugs to kill cancer cells. Chemotherapy treatment for bladder cancer usually involves two or more chemotherapy drugs used in combination. Drugs can be given through a vein in your arm (intravenously), or they can be administered directly to your bladder by passing a tube through your urethra (intravesical therapy). Chemotherapy may be used to kill cancer cells that might remain after surgery. It may also be used before surgery. In this case, chemotherapy may shrink a tumor enough to allow the surgeon to perform a less invasive surgery. Chemotherapy is sometimes combined with radiation therapy. Radiation therapy Radiation therapy is used infrequently in people with bladder cancer. Radiation therapy uses high-energy beams aimed at your cancer to destroy the cancer cells. Radiation therapy for bladder cancer usually comes from a machine that moves around your body, directing the energy beams to precise points. Radiation therapy can be used after surgery to kill cancer cells that might remain. Radiation therapy is sometimes combined with chemotherapy. NURSING INTERVENTIONS Encourage the patient to express feelings and concerns about the extent of the cancer. To relieve discomfort administer ordered analgesics for pain as necessary. Implement comfort measures and provide distractions that will enable the patient to relax. As appropriate, implement measures to prevent or alleviate complications of treatment. Monitor the patients intake and output. Question him regularly about changes in his

urine elimination pattern to detect changes in his condition. Observe the patients urine for signs of hematuria (reddish tint to gross bloodiness). Monitor the patients laboratory tests, such as changes in white blood cell differential, indicating possible bone marrow suppression from chemotherapy. If the patient is being given intravesical chemotherapy, watch closely for myelosuppression, chemical cystitis, and skin rash. Instruct the patient and the family about the types of treatment that are being planned for him. Teach the patient and family to recognize and to manage adverse effects of chemotherapy. Stress the importance of notifying the doctor if the patient developssigns and symptoms of urinary tract infection or other sudden changes in his condition.

BREASTCANCER BREASTCANCER is the leading type of cancer in women. Most breast cancer begins in the lining of the milk ducts, sometimes the lobule. The cancer grows through the wall of the duct and into the fatty tissue. Breast cancer metastasizes most commonly to auxiliary nodes, lung, bone, liver, and the brain. The most significant risk factors for breast cancer are gender (being a woman) and age (growing older). Other probable factors include nulliparity, first child after age 30, late menopause, early menarche, long term estrogen replacement therapy, and benign breast disease. Controversial risk factors include oral contraceptive use, alcohol use, obesity, and increased dietary fat intake. About 90% of breast cancers are due not to heredity, but to genetic abnormalities that happen as a result of the aging process and life in general. A womans risk of breast cancer approximately doubles if she has a first -degree relative (mother, sister, daughter) who has been diagnosed with breast cancer. About 20-30% of women diagnosed with breast cancer have a family history of breast cancer

Breast cancer is cancer that forms in the cells of the breasts. After skin cancer, breast cancer is the most common cancer diagnosed in women in

the United States. Breast cancer can occur in both men and women, but it's far more common in women. Public support for breast cancer awareness and research funding has helped improve the diagnosis and treatment of breast cancer. Breast cancer survival rates have increased, and the number of deaths has been declining, thanks to a number of factors such as earlier detection, new treatments and a better understanding of the disease.

SYMPTOMS Signs and symptoms of breast cancer may include: A breast lump or thickening that feels different from the surrounding tissue Bloody discharge from the nipple Change in the size or shape of a breast Changes to the skin over the breast, such as dimpling Inverted nipple Peeling, scaling or flaking of the nipple or breast skin Redness or pitting of the skin over your breast, like the skin of an orange When to see a doctor If you find a lump or other change in your breast even if a recent mammogram was normal make an appointment with your doctor. CAUSES It's not clear what causes breast cancer. Doctors know that breast cancer occurs when some breast cells begin growing abnormally. These cells divide more rapidly than healthy cells do and continue to accumulate, forming a lump or mass. The cells may spread (metastasize) through your breast to your lymph nodes or to other parts of your body. Breast cancer most often begins with cells in the milk-producing ducts (invasive ductal carcinoma). Breast cancer may also begin in the glandular tissue called lobules (invasive lobular carcinoma) or in other cells within the breast. Researchers have identified things that can increase your risk of breast cancer. But it's not clear

why some people who have no risk factors develop cancer, yet other people with risk factors never do. It's likely that breast cancer is caused by a complex interaction of your genetic makeup and your environment. Inherited breast cancer Doctors estimate that only 5 to 10 percent of breast cancers are linked to gene mutations passed through generations of a family. A number of inherited mutated genes that can increase the likelihood of breast cancer have been identified. The most common are breast cancer gene 1 (BRCA1) and breast cancer gene 2 (BRCA2), both of which increase the risk of both breast and ovarian cancer. If you have a strong family history of breast cancer or other cancers, blood tests may help identify mutations in BRCA or other genes that are being passed through your family. Consider asking your doctor for a referral to a genetic counselor, who can review your family health history. A genetic counselor can also discuss the benefits, risks and limitations of genetic testing with you. RISK FACTORS: Factors that are associated with an increased risk of breast cancer include: Being female. Women are much more likely than men are to develop breast cancer. Increasing age. Your risk of breast cancer increases as you age. A personal history of breast cancer. If you've had breast cancer in one breast, you have an increased risk of developing cancer in the other breast. A family history of breast cancer. If your mother, sister or daughter was diagnosed with breast cancer, particularly at a young age, your risk of breast cancer is increased. Still, the majority of people diagnosed with breast cancer have no family history of the disease. Inherited genes that increase cancer risk. Certain gene mutations that increase the risk of breast cancer can be passed from parents to children. The most common gene mutations are referred to as BRCA1 and BRCA2. These genes can greatly increase your risk of breast cancer and other cancers, but they don't make cancer inevitable. Radiation exposure. If you received radiation treatments to your chest as a child or young adult, your risk of breast cancer is increased. Obesity. Being obese increases your risk of breast cancer. Beginning your period at a younger age. Beginning your period before age 12 increases your risk of breast cancer. Beginning menopause at an older age. If you began menopause at an older age, you're more likely to develop breast cancer.

Having your first child at an older age. Women who give birth to their first child after age 35 may have an increased risk of breast cancer. Having never been pregnant. Women who have never been pregnant have a greater risk of breast cancer than do women who have had one or more pregnancies. Postmenopausal hormone therapy. Women who take hormone therapy medications that combine estrogen and progesterone to treat the signs and symptoms of menopause have an increased risk of breast cancer. The risk of breast cancer decreases when women stop taking these medications. Drinking alcohol. Drinking alcohol increases the risk of breast Diagnosing breast cancer Tests and procedures used to diagnose breast cancer include: Breast exam. Your doctor will check both of your breasts, feeling for any lumps or other abnormalities. Mammogram. A mammogram is an X-ray of the breast. Mammograms are commonly used to screen for breast cancer. If an abnormality is detected on a screening mammogram, your doctor may recommend a diagnostic mammogram to further evaluate that abnormality. Breast ultrasound. Ultrasound uses sound waves to produce images of structures deep within the body. Ultrasound may help distinguish between a solid mass and a fluid-filled cyst. Removing a sample of breast cells for testing (biopsy). Biopsy samples are sent to a laboratory for analysis where experts determine whether the cells are cancerous. A biopsy sample is also analyzed to determine the type of cells involved in the breast cancer, the aggressiveness (grade) of the cancer, and whether the cancer cells have hormone receptors or other receptors that may influence your treatment options. Breast magnetic resonance imaging (MRI). An MRI machine uses a magnet and radio waves to create pictures of the interior of your breast. Before a breast MRI, you receive an injection of dye. Other tests and procedures may be used depending on your situation. Staging breast cancer Once your doctor has diagnosed your breast cancer, he or she works to establish the extent (stage) of your cancer. Your cancer's stage helps determine your prognosis and the best treatment options. Complete information about your cancer's stage may not be available until after you undergo breast cancer surgery. Tests and procedures used to stage breast cancer may include: Blood tests, such as a complete blood count Mammogram of the other breast to look for signs of cancer

Breast MRI Bone scan Computerized tomography (CT) scan Positron emission tomography (PET) scan Not all women will need all of these tests and procedures. Your doctor selects the appropriate tests based on your specific circumstances. Breast cancer stages range from 0 to IV, with 0 indicating cancer that is very small and noninvasive. Stage IV breast cancer, also called metastatic breast cancer, indicates cancer that has spread to other areas of the body. TREATMENT Your doctor determines your breast cancer treatment options based on your type of breast cancer, its stage and grade, whether the cancer cells are sensitive to hormones, your overall health and your own preferences. Most women undergo surgery for breast cancer and also receive additional treatment, such as chemotherapy, hormone therapy or radiation. There are many options for breast cancer treatment, and you may feel overwhelmed as you make complex decisions about your treatment. Consider seeking a second opinion from a breast specialist in a breast center or clinic. Talk to other women who have faced the same decision. Breast cancer surgery Operations used to treat breast cancer include: Removing the breast cancer (lumpectomy). During lumpectomy, which may be referred to as breast-sparing surgery or wide local excision, the surgeon removes the tumor and a small margin of surrounding healthy tissue. Lumpectomy is typically reserved for smaller tumors. Removing the entire breast (mastectomy). Mastectomy is surgery to remove all of your breast tissue. Most mastectomy procedures remove all of the breast tissue the lobules, ducts, fatty tissue and some skin, including the nipple and areola (simple mastectomy). In a skin-sparing mastectomy, the skin over the breast is left intact to improve reconstruction and appearance. Removing a limited number of lymph nodes (sentinel node biopsy). To determine whether cancer has spread to your lymph nodes, your surgeon will discuss with you the role of removing the lymph nodes that receive the lymph drainage from your tumor. If no cancer is found in those lymph nodes, the chance of finding cancer in any of the remaining lymph nodes is small and no other nodes need to be removed. Removing several lymph nodes (axillary lymph node dissection). If cancer is found in the sentinel node, your surgeon will discuss with you the role of removing

additional lymph nodes in your armpit. Removing both breasts. Some women with cancer in one breast may choose to have their other (healthy) breast removed (contralateral prophylactic mastectomy) if they have a very increased risk of cancer in the other breast. Discuss your breast cancer risk with your doctor, along with the benefits and risks of this procedure. Complications of breast cancer surgery depend on the procedures you choose. Surgery carries a risk of bleeding and infection. Some women choose to have breast reconstruction after surgery. Discuss your options and preferences with your surgeon. Consider a referral to a plastic surgeon before your breast cancer surgery. Your options may include reconstruction with a synthetic breast implant or reconstruction using your own tissue. These operations can be performed at the time of your mastectomy or at a later date. Radiation therapy Radiation therapy uses high-powered beams of energy, such as X-rays, to kill cancer cells. Radiation therapy is typically done using a large machine that aims the energy beams at your body (external beam radiation). But radiation can also be done by placing radioactive material inside your body (brachytherapy). External beam radiation is commonly used after lumpectomy for early-stage breast cancer. Doctors may also recommend radiation therapy after mastectomy for larger breast cancers or cancers that have spread to the lymph nodes. Side effects of radiation therapy include fatigue and a red, sunburn-like rash where the radiation is aimed. Breast tissue may also appear swollen or more firm. Rarely, more-serious problems may occur, such as damage to the heart or lungs or, very rarely, second cancers in the treated area. Chemotherapy Chemotherapy uses drugs to destroy cancer cells. If your cancer has a high risk of returning or spreading to another part of your body, your doctor may recommend chemotherapy to decrease the chance that the cancer will recur. This is known as adjuvant systemic chemotherapy. Chemotherapy is sometimes given before surgery in women with larger breast tumors. The goal is to shrink a tumor to a size that makes it easier to remove with surgery. Chemotherapy is also used in women whose cancer has already spread to other parts of the body. Chemotherapy may be recommended to try to control the cancer and decrease any symptoms the cancer is causing. Chemotherapy side effects depend on the drugs you receive. Common side effects include hair loss, nausea, vomiting, fatigue and an increased risk of developing infection. Rare side effects can include premature menopause, damage to the heart

and kidneys, nerve damage, and, very rarely, blood cell cancer. Hormone therapy Hormone therapy perhaps more properly termed hormone-blocking therapy is often used to treat breast cancers that are sensitive to hormones. Doctors sometimes refer to these cancers as estrogen receptor positive (ER positive) and progesterone receptor positive (PR positive) cancers. Hormone therapy can be used after surgery or other treatments to decrease the chance of your cancer returning. If the cancer has already spread, hormone therapy may shrink and control it. Treatments that can be used in hormone therapy include: Medications that block hormones from attaching to cancer cells.Selective estrogen receptor modulator (SERM) medications act by blocking estrogen from attaching to the estrogen receptor on the cancer cells, slowing the growth of tumors and killing tumor cells. SERMs, which can be used in both pre- and postmenopausal women, include tamoxifen, raloxifene (Evista) and toremifene (Fareston). Possible side effects include hot flashes, night sweats and vaginal dryness. More significant risks include blood clots, stroke, uterine cancer and cataracts. Medications that stop the body from making estrogen after menopause. Called aromatase inhibitors, these drugs block the action of an enzyme that converts androgens in the body into estrogen. These drugs are effective only in postmenopausal women. Aromatase inhibitors include anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin). Side effects include hot flashes, night sweats, vaginal dryness, joint and muscle pain, as well as an increased risk of bone thinning (osteoporosis). A drug that targets estrogen receptors for destruction. The drug fulvestrant (Faslodex) blocks estrogen receptors on cancer cells and signals to the cell to destroy the receptors. Fulvestrant is used in postmenopausal women. Side effects that may occur include nausea, hot flashes and joint pain. Surgery or medications to stop hormone production in the ovaries. In premenopausal women, surgery to remove the ovaries or medications to stop the ovaries from making estrogen can be an effective hormonal treatment. Targeted drugs Targeted drug treatments attack specific abnormalities within cancer cells. Targeted drugs approved to treat breast cancer include: Trastuzumab (Herceptin). Some breast cancers make excessive amounts of a protein called human growth factor receptor 2 (HER2), which helps breast cancer cells grow and survive. If your breast cancer cells make too much HER2, trastuzumab may help block that protein and cause the cancer cells to die. Side effects may include

headaches, diarrhea and heart problems. Pertuzumab (Perjeta). Pertuzumab targets HER2 and is approved for use in metastatic breast cancer in combination with trastuzumab and chemotherapy. This combination of treatments is reserved for women who haven't yet received other drug treatments for their cancer. Side effects of pertuzumab may include diarrhea, hair loss and heart problems. Ado-trastuzumab emtansine (Kadcyla). This drug combines trastuzumab with a cell-killing drug. When the combination drug enters the body, the trastuzumab helps it find the cancer cells because it is attracted to HER2. The cell-killing drug is then released into the cancer cells. Ado-trastuzumab emtansine may be an option for women with metastatic breast cancer who've already tried trastuzumab and chemotherapy. Lapatinib (Tykerb). Lapatinib targets HER2 and is approved for use in advanced or metastatic breast cancer. Lapatinib can be used in combination with chemotherapy or hormone therapy. Potential side effects include diarrhea, painful hands and feet, nausea, and heart problems. Bevacizumab (Avastin). Bevacizumab is no longer approved for the treatment of breast cancer in the United States. Research suggests that although this medication may help slow the growth of breast cancer, it doesn't appear to increase survival times. ASSESSMENT A firm lump or thickness in breast, usually painless; 50% are located in the upper outer quadrant of the breast. Spontaneous nipple discharge; may be bloody, clear or serous. Asymmetry of the breast may be noted as the woman changes positions; compare one breast with the other. Nipple retraction or scalliness, especially in Pagets disease. Enlargement of auxiliary or supraclavicular lymph nodes may indicate metastasis. DIAGNOSTIC EVALUATION Mammography (most accurate method of detecting non-palpable lesions) shows lesions and cancerous changes, such as microcalcification. Ultrasonography may be used to distinguish cysts from solid masses. Biopsy or aspiration confirms diagnosis and determines the type of breast cancer. Estrogen or progesterone receptor assays, proliferation or S phase study (tumor aggressive), and other test of tumor cells determine appropriate treatment and prognosis.

Blood testing detects metastasis; this includes liver function tests to detect liver metastasis and calcium and alkaline phosphatase levels to detect bony metastasis. Chest x-rays, bone scans, or possible brain and chest CT scans detect matastasis. PHARMACOLOGIC INTERVENTIONS Chemotherapy is the primary used as adjuvant treatment postoperatively ; usually begins 4 weeks after surgery (very stressful for a patient who just finished major surgery). Treatments are given every 3 to 4 weeks for 6 to 9 months. Because the drugs differ in their mechanisms of action, various combinations are used to treat cancer. Principal breast cancer drugs include cyclosphosphamide, methotrexate, fluorouracil, doxorubicin, and paclitaxel. Additional agents for advanced breast cancer include docetaxel, vinorelbine, mitoxantrone, and fluorouracil. Herceptin is a monoclonal antibody directed against Her-2/neu oncogene; may be effective for patients who express this gene Indications for chemotherapy include large tumors, positive lymph nodes, premenopausal women, and poor prognostic factors. Chemotheraphy is also used as primary treatment in inflammatory breast cancer and as palliative treatment in metastatic disease or recurrence. Anti-estrogens, such as tamoxifen, are used as adjuvant systemic therapy after surgery. Hormonal agents may be used in advanced disease to induce remissions that last for months to several years.

SURGICAL INTERVENTIONS Surgeries include lumpectomy (breast-preventing procedure), mastectomy (breast removal), and mammoplasty (reconstructive surgery). Endocrine related surgeries to reduce endogenous estrogen as a palliative measure. Bone marrow transplantation may be combined with chemotherapy

NURSING INTERVENTIONS Monitor for adverse effects of radiation therapy such as fatigue, sore throat, dry cough, nausea, anorexia. Monitor for adverse effects of chemotherapy; bone marrow suppression, nausea and vomiting, alopecia, weight gain or loss, fatigue, stomatitis, anxiety, and depression.

Realize that a diagnosis of breast cancer is a devastating emotional shock to the woman. Provide psychological support to the patient throughout the diagnostic and treatment process. Involve the patient in planning and treatment. Describe surgical procedures to alleviate fear. Prepare the patient for the effects of chemotherapy, and plan ahead for alopecia, fatigue. Administer antiemetics prophylactically, as directed, for patients receiving chemotherapy. Administer I.V. fluids and hyperalimentation as indicated. Help patient identify and use support persons or family or community. Suggest to the patient the psychological interventions may be necessary for anxiety, depression, or sexual problems. Teach all women the recommended cancer-screening procedures. CERVICAL CANCER Cancer of the cervix is one type of primary uterine cancer (the other being uterine-endometrial cancer) and is predominately epidermoid. Invasive cervical cancer is the third most common female pelvic cancer. Cervical cancer is a type of cancer that occurs in the cells of the cervix the lower part of the uterus that connects to the vagina. Various strains of the human papillomavirus (HPV), a sexually transmitted infection, play a role in causing most cases of cervical cancer. When exposed to HPV, a woman's immune system typically prevents the virus from doing harm. In a small group of women, however, the virus survives for years, contributing to the process that causes some cells on the surface of the cervix to become cancer cells. You can reduce your risk of cervical cancer by undergoing screening tests and receiving a vaccine that protects against HPV infection.

Nursing care plan physical examination and assessment Because early cervical cancer is usually asymptomatic, establish a thorough history with particular attention to the presence of the risk factors and the womans menstrual history. Establish a history of later symptoms of cervical cancer, including abnormal bleeding or spotting (between periods or after menopause); metrorrhagia (bleeding between normal menstrual periods) or menorrhagia (increased amount and duration of menstrual bleeding); dysparuenia and postcoital bleeding; leukorrhea in increasing amounts and changing over time from watery to dark and foul; and a history of chronic cervical infections. Determine if the patient has experienced weight gain or loss; abdominal or pelvic pain, often unilateral, radiating to the buttocks and legs; or other symptoms associated with neoplasms, such as fatigue. Conduct a pelvic examination. Observe the patients external genitalia for signs of inflammation, bleeding, discharge, or local skin or epithelial changes. Observe the internal genitalia. The normal cervix is pink and nontender, has no lesions, and has a closed os. Cervical tissue with cervical cancer appears as a large reddish growth or deep ulcerating crater before any symptoms are experienced; lesions are firm and friable. The Pap smear is done before the bimanual examination. Palpate for motion tenderness of the cervix (Chandeliers sign); a positive Chandeliers sign (pain on movement) usually indicates an infection. Also examine the size, consistency (hardness may reflect invasion by neoplasm), shape, mobility (cervix should be freely movable), tenderness, and presence of masses of the uterus and adnexa. Conduct a `rectal exam; palpate for abnormalities of contour, motility, and the placement of adjacent structures. Nodular thickenings of the uterosacral and cardinal ligaments may be felt. Uneasiness, embarrassment about a pelvic examination, or fear of the unknown may be issues for the patient. Determine the patients level of knowledge about a pelvic exam and what she expects. Determine her recommended Pap test screening schedule, as well as how she obtains the results and their meaning. If the patient requires follow-up to a positive Pap smear, assess her anxiety and coping mechanisms. Stressors may be fear of the unknown, of sexual dysfunction, of cancer, or of death, or she may have self-concept disturbances. SYMPTOMS

You may not experience any cervical cancer symptoms early cervical cancer generally produces no signs or symptoms. As the cancer progresses, the following signs and symptoms of more advanced cervical cancer may appear: Vaginal bleeding after intercourse, between periods or after menopause Watery, bloody vaginal discharge that may be heavy and have a foul odor Pelvic pain or pain during intercourse CAUSES Cervical cancer begins when healthy cells acquire a genetic mutation that turns normal cells into abnormal cells. Healthy cells grow and multiply at a set rate, eventually dying at a set time. Cancer cells grow and multiply out of control, and they don't die. The accumulating abnormal cells form a mass (tumor). Cancer cells invade nearby tissues and can break off from an initial tumor to spread elsewhere in the body (metastasize). What causes cervical cancer isn't clear. However, it's certain that the sexually transmitted infection called human papillomavirus (HPV) plays a role. While HPV is a very common virus, most women with HPV never develop cervical cancer. This means other risk factors such as your genetic makeup, your environment or your lifestyle choices also determine whether you'll develop cervical cancer. Types of cervical cancer The type of cell where the initial genetic mutation occurred determines the type of cervical cancer you have. The type of cervical cancer you have helps determine your prognosis and treatment. The main types of cervical cancer are: Squamous cell carcinomas. These begin in the thin, flat cells (squamous cells) that line the outer portion of the cervix, which projects into the vagina. This type accounts for the great majority of cervical cancers. Adenocarcinomas. These occur in the glandular cells that line the cervical canal. These cancers make up a smaller portion of cervical cancers. Sometimes both types of cells are involved in cervical cancer. Very rare cancers can occur in other cells in the cervix. NURSING INTRVENTIONS Listen to the patients fears and concerns, and offer reassurance when appropriate. Encourage the patient to use relaxation techniques to promote comfort during the diagnostic procedures. Monitor the patients response to therapy through frequent Pap tests and cone biopsies as ordered. Watch for complications related to therapy by listening to and observing the patient.

Monitor laboratory studies and obtain frequent vital signs. Understand the treatment regimen and verbalize the need for adequate fluid and nutritional intake to promote tissue healing. Explain any surgical or therapeutic procedure to the patient, including what to expect both before and after the procedure. Review the possible complications of the type therapy ordered. Remind the patient to watch for and report uncomfortable adverse reactions. Reassure the patient that this disease and its treatment shouldnt radically alter her lifestyle or prohibit sexual intimacy. Explain the importance of complying with follow up visits to the gynecologist and oncologist. RISK FACTORS These factors may increase your risk of cervical cancer: Many sexual partners. The greater your number of sexual partners and the greater your partner's number of sexual partners the greater your chance of acquiring HPV. Early sexual activity. Having sex at an early age increases your risk of HPV. Other sexually transmitted infections (STIs). If you have other STIs such as chlamydia, gonorrhea, syphilis or HIV/AIDS you have an increased risk of having HPV. A weak immune system. Most women who are infected with HPV never develop cervical cancer. However, if you have an HPV infection and your immune system is weakened by another health condition, you may be more likely to develop cervical cancer. Cigarette smoking. Smoking and an HPV infection may work together to cause cervical cancer. EXAMS AND DIAGNOSTICS Screening When cervical cancer is detected in its earliest stages, treatment is more likely to be successful. Most guidelines suggest beginning screening for cervical cancer and precancerous changes at age 21. Screening for cervical cancer includes: Pap test. During a Pap test, your doctor scrapes and brushes cells from your cervix the narrow neck of the uterus and sends the sample to a lab to be examined for abnormalities. A Pap test can detect abnormal cells in the cervix, including cancer cells and cells that show changes (dysplasia) that increase the risk of cervical cancer. HPV DNA test. If you are age 30 or older, your doctor may also use a lab test called

the HPV DNA test to determine whether you are infected with any of the types of HPV that are most likely to lead to cervical cancer. Like the Pap test, the HPV DNA test involves collecting cells from the cervix for lab testing. Diagnosis If you experience signs and symptoms of cervical cancer or if a Pap test has revealed cancerous cells, you may undergo further tests to diagnose your cancer. To make a diagnosis, your doctor may: Examine your cervix. During an exam called colposcopy, your doctor uses a special magnifying instrument (colposcope) to examine your cervix for abnormal cells. If your doctor identifies unusual areas, he or she may take a small sample of cells for analysis (biopsy). Take a sample of cervical cells. During a biopsy procedure, your doctor removes a sample of unusual cells from your cervix using special biopsy tools. Remove a cone-shaped area of cervical cells. A cone biopsy (conization) so called because it involves taking a cone-shaped sample of the cervix allows your doctor to obtain deeper layers of cervical cells for laboratory testing. Your doctor may use a scalpel, laser or electrified wire loop to remove the tissue. Staging If your doctor determines that you have cervical cancer, you'll undergo further tests to determine the extent (stage) of your cancer. Your cancer's stage is a key factor in deciding on your treatment. Staging exams include: Imaging tests. Tests such as X-rays, computerized tomography (CT) scans, magnetic resonance imaging (MRI) and positron emission tomography (PET) help your doctor determine whether your cancer has spread beyond your cervix. Visual examination of your bladder and rectum. Your doctor may use special scopes to see inside your bladder (cystoscopy) and rectum (proctoscopy). Your doctor then assigns your cancer a stage typically a Roman numeral. Stages of cervical cancer include: Stage I. Cancer is confined to the cervix. Stage II. Cancer at this stage includes the cervix and vagina but hasn't spread to the pelvic side wall or the lower portion of the vagina. Stage III. Cancer at this stage has moved beyond the cervix to the pelvic side wall or the lower portion of the vagina. Stage IV. At this stage, cancer has spread to nearby organs, such as the bladder or rectum, or it has spread to other areas of the body, such as the lungs, liver or bones. TREATMENT Treatment for cervical cancer depends on several factors, such as the stage of the

cancer, other health problems you may have and your preferences about treatment. Treatment options may include: Surgery. Surgery to remove the uterus (hysterectomy) is typically used to treat the early stages of cervical cancer. A simple hysterectomy involves the removal of the cancer, the cervix and the uterus. Simple hysterectomy is typically an option only when the cancer is at a very early stage invasion is less than 3 millimeters (mm) into the cervix. A radical hysterectomy removal of the cervix, uterus, part of the vagina and lymph nodes in the area is the standard surgical treatment when there's invasion greater than 3 mm into the cervix. A hysterectomy can cure early-stage cervical cancers and prevent cancer from coming back, but removing the uterus makes it impossible to become pregnant. Radiation. Radiation therapy uses high-powered energy to kill cancer cells. Radiation therapy can be given externally using external beam radiation or internally (brachytherapy) by placing devices filled with radioactive material near your cervix. Both methods of radiation therapy can be combined. Radiation therapy can be used alone, with chemotherapy, before surgery to shrink a tumor or after surgery to kill any remaining cancer cells. Premenopausal women may stop menstruating as a result of radiation therapy and begin menopause. Chemotherapy. Chemotherapy uses drugs to kill cancer cells. Chemotherapy drugs, which can be used alone or in combination with each other, are usually injected into a vein, and they travel throughout your body killing rapidly growing cells, including cancer cells. Low doses of chemotherapy are often combined with radiation therapy, since chemotherapy may enhance the effects of the radiation. Higher doses of chemotherapy are used to control advanced cervical cancer that may not be curable. Certain chemotherapy drugs may cause infertility and early menopause in premenopausal women.

COLORECTAL CANCER The colon and rectum are part of the large intestine. Colorectal cancer occurs when tumors form in the lining of the large intestine. It is common in both men and women. The risk of developing colorectal cancer rises after age 50. You're also more likely to get it if you have colorectal polyps, a family history of colorectal cancer, ulcerative colitis or Crohn's disease, eat a diet high in fat, or smoke. Symptoms of colorectal cancer include Diarrhea or constipation

A feeling that your bowel does not empty completely Blood (either bright red or very dark) in your stool Stools that are narrower than usual Frequent gas pains or cramps, or feeling full or bloated Weight loss with no known reason Fatigue Nausea or vomiting Because you may not have symptoms at first, it's important to have screening tests. Everyone over 50 should get screened. Tests include colonoscopy and tests for blood in the stool. Treatments for colorectal cancer include surgery, chemotherapy, radiation, or a combination. Surgery can usually cure it when it is found early.

Colorectal cancer, commonly known as colon cancer or bowel cancer, is a cancerfrom uncontrolled cell growth in the colon or rectum (parts of the large intestine), or in theappendix. Genetic analysis shows that essentially colon and rectal tumours are genetically the same cancer.[1] Symptoms of colorectal cancer typically include rectal bleeding and anemia which are sometimes associated with weight loss and changes in bowel habits. Most colorectal cancer occurs due to lifestyle and increasing age with only a minority of cases associated with underlying genetic disorders. It typically starts in the lining of the bowel and if left untreated, can grow into the muscle layers underneath, and then through the bowel wall. Screening is effective at decreasing the chance of dying from colorectal cancer and is recommended starting at the age of 50 and continuing until a person is 75 years old. Localized bowel cancer is usually diagnosed through sigmoidoscopy orcolonoscopy. Cancers that are confined within the wall of the colon are often curable with surgery while cancer that has spread widely around the body is usually not curable and management then focuses on extending the person's life via chemotherapy and improving quality of life. Colorectal cancer is the third most commonly diagnosed cancer in the world, but it is more common in developed countries.

Description

Adenocarcinoma is the most common type of colon cancer and may spread by direct extension through the walls of the intestine or through the lymphatic or circulatory system. Metastasis is most often to the liver. Dukes Classification of Colorectal Cancer Stage A: confined to bowel mucosa, 80-90 % 5 years survival rate Stage B: invading muscle wall Stage C; Lymph node involvement Stage D: Metastases or locally unresectable tumor, less than 5% , 5 years survival rate. Causes/ Risk Factors Modifiable Diet: Whether diet plays a role in developing colon cancer remains under debate. The belief that a high-fiber, low-fat diet could help prevent colon cancer has been questioned. Studies do indicate that exercise and a diet rich in fruits and vegetables can help prevent colon cancer. Obesity: Obesity has been identified as a risk factor for colon cancer. Smoking: Cigarette smoking has been definitely linked to a higher risk for colon cancer. Drug effects: Recent studies have suggested that estrogen replacement therapy and nonsteroidal anti-inflammatory drugs such as aspirin may reduce colorectal cancer risk. Non-Modifiable Most colorectal cancers arise from adenomatous polyps-clusters of abnormal cells in the glands covering the inner wall of the colon. Over time, these abnormal growths enlarge and ultimately degenerate to become adenocarcinomas. People with any of several conditions known as adenomatous polyposis syndromes have a greater-than-normal risk of colorectal cancer.

In these conditions, numerous adenomatous polyps develop in the colon, ultimately leading to colon cancer. The cancer usually occurs before age 40 years. Adenomatous polyposis syndromes tend to run in families. Such cases are referred to

as familial adenomatous polyposis (FAP). Celecoxib (Celebrex) has been FDA approved for FAP. After 6 months, celecoxib reduced the mean number of rectal and colon polyps by 28% compared to placebo (sugar pill) 5%. Another group of colon cancer syndromes, termed hereditary nonpolyposis colorectal cancer (HNPCC) syndromes, also run in families. In these syndromes, colon cancer develops without the precursor polyps. HNPCC syndromes are associated with a genetic abnormality. This abnormality has been identified, and a test is available. People at risk can be identified through genetic screening. Once identified as carriers of the abnormal gene, these people require counseling and regular screening to detect precancerous and cancerous tumors. HNPCC syndromes are sometimes linked to tumors in other parts of the body. Also at high risk for developing colon cancers are people with any of the following: Ulcerative colitis or Crohn colitis (Crohn disease) Breast, uterine, or ovarian cancer now or in the past A family history of colon cancer The risk of colon cancer increases 2-3 times for people with a first-degree relative (parent or sibling) with colon cancer. The risk increases more if you have more than one affected family member, especially if the cancer was diagnosed at a young age. Assessment Ascending (Right) Colon Cancer Occult blood blood in stool Anemia Anorexia and weight loss Abdominal pain above umbilicus Palpable mass Distal Colon/ Rectal Cancer Rectal bleeding Change bowel habits Constipation or diarrhea

Pencil or ribbon shaped stool Tenesmus Sensation of incomplete Diagnostic Evaluation Fecal occult blood test (FOBT) - checks for hidden blood in the stool. Sometimes cancers or polyps can bleed and this test is used to pick up small amounts of bleeding. Have this test every year. Flexible sigmoidoscopy - an exam where a health care provider looks at the rectum and the lower part of the colon using a sigmoidoscope, a tube with a light on the end. Have this test every 5 years. Colonoscopy - an exam when a health care provider looks at the rectum and the entire colon using a colonoscope, an instrument with a light on the end. If polyps are found, they can be removed. Have this test every 5 to 10 years. Double contrast barium enema (DCBE) - a series of x-rays of the colon and rectum. You are first given an enema with barium in it, which outlines the colon and rectum on the x-rays. Have this test every 5 to 10 years (only if not having a colonoscopy every 10 years). Digital rectal exam - a health care provider inserts a lubricated, gloved finger into the rectum to feel for any problem areas. Have this test every 5 to 10 years at the time of other screening tests (flexible sigmoidoscopy, colonoscopy, or DCBE). Primary Nursing Diagnosis Pain related to tissue injury from tumor invasion and the surgical incision Therapeutic Intervention / Medical Management Treatment of cancer depends on stage of disease and related complications. Obstruction is treated with intravenous fluids and nasogastric suction and with blood therapy if bleeding is significant. Supportive therapy and adjuvant therapy (e.g., chemotherapy, radiation therapy, immuno therapy) are included. Surgical Management Surgery is the primary treatment for most colon and rectal cancers ; the type of surgery depends on the location and size of tumor, and it may be curative or

palliative. Cancers limited to one site can be removed to a colonoscope Laparoscopy colostomy with polypectomy. Neodymium-yttrium-aluminum-garnet (Nd:YAG) laser is effective in some lesions Bowel resection with anastomosis and possible temporary or permanent colostomy or illeostomy ( less than 1/3 of patients) or coloanal resevoir (colonic J pouch). Pharmacologic Intervention Narcotic analgesic is often administered as patient-controlled anesthesia to manages surgical pain or pain from metastasis Nursing Intervention Administer chemotherapy agents as ordered, provide care for the client receiving chemotherapy. Provide care for the client receiving radiation therapy. Provide care for the client with bowel surgery. Documentation Guidelines Response to diagnosis of colorectal cancer,diagnostic tests,and treatment regimen Description of all dressings, wounds, and drainage collection devices: Location of drains; color and amount of drainage; appearance of the incision; color of the ostomy stoma; presence, amount,and consistency of ostomy effluent Discharge and Home Healthcare Guidelines PATIENT TEACHING Teach the patient the care related to the abdominal incision and any perineal wounds. Give instructions about when to notify the physician (if the wound separates or if any redness, bleeding, purulent drainage, unusual odor, or excessive pain is present). Advise the patient not to perform any heavy lifting (􏰀10 lbs),pushing,or pulling for 6 weeks after surgery. If the patient has a perineal incision, instruct her or him not to sit for long periods of time and to use a soft or wafflepillow rather than a rubber ring whenever in the sitting position.

Teach the patient colostomy care and colostomy irrigation. Give the following instructions for care of skin in the external radiation field:Tell the patient to wash the skin gently with mild soap,rinse with warm water,and pat the skin dry each day; not to wash off the dark ink marking that outlines the radiation field; to avoid applying any lotions, perfumes,deodorants,and powder to the treatment area; to wear nonrestrictive soft cotton cloth- ing directly over the treatment area; and to protect skin from sunlight and extreme cold. Explain the purpose, action,dosage,and side effects of all medications prescribed by the physician. FOLLOW-UP Stress the need to maintain a schedule for follow-up visits recommended by the physician. Encourage patients with early-stage disease and complete healing of the bowel to eat a diet consisting of a low-fat and high-fiber content with cruciferous vegetables (Brussels sprouts,cauliflower,broccoli,cabbage). Most colorectal tumors grow undetected as symptoms slowly develop. Survival rates are best when the disease is discovered in the early stages and when the patient is asymptomatic. Unfortunately,50% of patients have positive lymph node involvement at the time of diagnosis. Participation in procedures for the early detection of colorectal cancer needs to be encouraged. Suggest follow-up involvement with community resources such as the United Ostomy Association and the American Cancer Society.

ENDOMERIAL CANCER Endometrial cancer is one of the most common cancers in women. Usually begins in the endometrium, the lining of the uterus a hollow, pear-shaped pelvic organ where fetal development occurs. Endometrial cancer is most common after the reproductive years, between the ages of 60 and 70. Endometrial cancer is sometimes called uterine cancer, but there are other cells in the uterus that can become cancerous such as muscle or myometrial cells. These form much less common cancers called sarcomas and account for less than 5 percent of uterine cancers.