Cancer Oncology

http://neelabh1221.googlepages.com

Cancer: Etiology
Cancer is a group of diseases characterized by the uncontrolled growth & spread of abnormal cells. Incidence of some cancers are increasing !on"#odg$in%s& melanoma Incidence of some cancers are decreasing 'tomach& uterine cancers Cancer is the 2nd most common cause of death in ('

Cancer: Etiology
#igher death rates among )frican )mericans than Caucasians& especially males r/t later diagnosis

)ffects people of all ages

Occurs most fre*uently in the aged +ore children ,1- yrs die of cancer than any other disease

Cancer: Etiology
Lung cancer is the leading cause of cancer"related death in men ./101 2 3omen .2401 .255-1 6reast 2 prostate cancer ha7e greater incidences& but better cure 2 sur7i7al rates E7ery year& 1.- million people are diagnosed 3ith cancer8 cancer 3ill de7elop in 1 of 2 men and 1 of / 3omen during their li7es. It is estimated that there are no3 more than 15 million cancer sur7i7ors in the (nited 'tates alone& and& gi7en the trend to3ard aging of the population& this number is e9pected to gro3:2;

Cancer 'ur7i7ors by )ge

Cancer 'ur7i7ors by <iagnosis

=ith each passing year& despite being cancer"free& the ris$ of suffering a late complication of cancer or cancer treatment steadily rises.:/;

Cancer 'ur7i7ors
'ur7i7ing cancer used to mean ma$ing it to the >"year mar$ or li7ing through chemotherapy& rather than the hoped"for return to normal health and daily life. ?he cancer sur7i7or must no3 find and adapt to @a ne3 normal.A //-ths of cancer sur7i7ors e9perience late effects or se*uelae of cancer& its treatment& or both effects that threaten the sur7i7orBs physical& psychosocial& and economic 3ell"being. Cate treatment effectsD to9icities that are absent or subclinical at the end of therapy but manifest months or years later as organ inEury becomes e7ident& and long" term effects as ad7erse effects that appear during treatment and continue beyond the end of treatment

Cate Effects and Cong"?erm 'e*uelae of Cancer and Cancer ?reatment :1;
Fhysiological Effects
'econd malignancies /Cymphedema /Ceu$emia !eurocogniti7e deficits Cardiac dysfunction/C)</#?! Genal problems Fremature menopause /'e9ual impairment Chronic fatigue /Fain syndromes Endocrine deficiency /H#& hypothyroidism Immunosuppression (rinary incontinence 6o3el obstruction !europathies Cataracts Osteoporosis /)rthritis 'cleroderma Ci7er failure 6one and soft tissue damage

Cate Effects and Cong"?erm 'e*uelae of Cancer and Cancer ?reatment :1;
Fsychosocial and Economic Effects
<epression Hrief/sadness/helplessness !egati7e coping/)lienation/isolation #ealth 3orries/ )dEustment/6ody image disorder Intimacy/IFG problems Iob insecurity/ discrimination/Jinancial instability #ealth insurance issues

Cancer 'ur7i7orship: !ursing

?he reality is that indi7iduals 3ho ha7e sur7i7ed cancer can be found in e7ery healthcare setting& from primary care to the emergency department8 from the labor and deli7ery unit to the student health clinic. +ost people 3ith cancer are going to come into contact 3ith nurses 3ho are not oncology nurses. )ll nurses need to be better e*uipped about sur7i7orship issues so they can be proacti7e and help these patients li7e as 3ell as possible.

Components of Cancer 'ur7i7orship Care

Fre7ention of recurrent and ne3 cancers& and other late effects 'ur7eillance for cancer spread& recurrence& or second cancer )ssessment of medical and psychosocial late effects Inter7ention for conse*uences of cancer and its treatment .lymphedema1& symptoms& including pain and fatigue& psychological distress e9perienced by ne3 cancer sur7i7ors and their caregi7ers& and concerns related to employment& insurance& and disability Coordination bet3een specialists and primary care pro7iders to ensure that all the sur7i7orBs health needs are met.

Frescription for Ci7ing

?he ideal time to begin filling out A Prescription for Living is during or at the completion of the cancer patientBs treatment. Communicate up"to"date information to the primary care team including any specific short or long"term signs and symptoms that should be monitored in a particular cancer sur7i7or& and 3hy. 'uggestions for any recommended routine screening. ?he Institute of +edicineBs recommendation to introduce cancer sur7i7orship care planning has also spurred legislation. In Jebruary of 2554& a bill 3as introduced in the #ouse of Gepresentati7es to address this issue. ?he Comprehensi7e Cancer Care Impro7ement )ct of 2554 .#ouse Gesolution 154K1 3ould amend title LMIII .+edicare1 of the 'ocial 'ecurity )ct to pro7ide for co7erage of comprehensi7e care planning ser7ices for indi7iduals diagnosed 3ith cancer. It 3ould also ma$e grants a7ailable to establish ne3 palliati7e care and symptom management programs for cancer patients and impro7e the *uality of graduate& postgraduate& and continuing professional education of physicians& nurses and other healthcare pro7iders in palliati7e care and symptom management for cancer patients.

Comprehensi7e Cancer Care Impro7ement

'hift the paradigm of cancer sur7i7orship care from an illness focus to a 3ellness and disease"pre7ention focus ?o 7ie3 cancer sur7i7orship as a chronic condition rather than an acute one ) second goal that emerged from this meeting 3as to de7elop& in collaboration 3ith patients and families& a Eointly crafted e7idence" based 3ellness plan as part of a comprehensi7e cancer sur7i7or care plan Jinally& 3ith 'igma ?heta ?au International& the #onor 'ociety of !ursing& the group plans to de7elop and prioritize a multinational research agenda related to cancer sur7i7orship and translate the findings into clinical practice and policy

Cancer 'ur7i7orship: !ursing

!urses must anticipate and identify potential problems so that they can be addressed
Cancer sur7i7ors often belie7e that their symptoms& such as persistent pain& are una7oidable outcomes of their cancer or treatment that they simply must learn to li7e 3ith Fatients hesitant to raise nonmedical concerns #a7enBt made the connection bet3een their current symptoms and their cancer. +ay not be a3are of the full range of possible se*uelae

Cancer sur7i7ors should be encouraged to report all symptoms to their healthcare pro7iders.

Cancer 'ur7i7orship: !ursing

<iscuss lifestyle factors that affect ris$ and 3ellness& such as diet& e9ercise& smo$ing& and alcohol use& and to ma$e needed community referrals )ssess for comorbid conditions that might threaten 3ellness or impede healthy lifestyle beha7iors& such diabetes& pain& or chronic fatigue. )s$ about the cancer sur7i7orBs in7ol7ement or need for social support groups& financial assistance& transportation& or other ser7ices so appropriate referrals can be considered. . Instruct the cancer sur7i7or to ta$e the sur7i7orship care plan along to any appointments 3ith other pro7iders such as a nutritionist& physical therapist& psychologist& or anyone else in7ol7ed in their care so that a complete picture of the sur7i7orBs care is maintained.

Cancer: Cellular Froliferation

?he rate of normal cellular proliferation is different for each body tissue type Gapid D HI lining& hair follicles& bone marro3 !o proliferation D myocardium& neurons& cartilage

!ormal Cellular Hro3th

Cimited cell di7ision r/t physiological demand Getain distinct 2 recognizable appearance& size 2 shape Ferform specific differentiated functions .ma$e bile& conduct impulses& carry #gb1 )dhere tightly together 2 gro3 in a orderly 2 3ell"regulated manner Contact inhibited !onmigratory

Cellular Hro3th
+ay precede de7elopment of cancer: #ypertrophy Increase in size of cells 3ithout cell di7ision

#yperplasia Increase in the number of cells r/t increased cell di7ision

Cellular Hro3th
+etaplasia
Ge7ersible transformation of 1 cell type into another

Intestine

6one

Cellular Hro3th
<ysplasia
)bnormal differentiation of di7iding cells resulting in different tissue Jibrous dysplasia 6one tissue gre3 into fibrous tissue

!eoplastic Cellular Froliferation

)ll cancer cells ha7e the same cellular characteristics

Cancer cells respond differently to the intracellular signals not more rapid but indiscriminate 2 haphazard di7iding continuous gro3th Fyramid effect Jollo3s no physiologic demand

!eoplastic Characteristics
Cell membranes
Contain less fibronectin are less cohesi7e 2 do not stic$ to neighboring cells Cancer cells are not inhibited by contact 2 gro3 on top of or bet3een normal cells 6rea$ off easily metastasize

!eoplastic Characteristics

Cell membranes
Contain tumor"specific antigens .CE) 2 F')1 3hich de7elop as the cancer cells mature Characteristic of fetal/embryonic appearance 2 function

+ay produce hormones r/t embryonic tissues

!eoplastic Characteristics
Chromosomal abnormalities Increased rate of mitosis 2 gro3th
Increased bodily demand for o9ygen 2 glucose If supply inade*uate& use anaerobic metabolism

Carcinogenesis: Initiation
Cancers are not thought to be the result of a single e7ent. ) combination of negati7e e7ents and missed opportunities are probably re*uired rapid& haphazard e7ent Cause of cancer still un$no3n& but carcinogens are possible origins 'ubstances $no3n to increase the ris$ for the de7elopment of cancer +any are deto9ified by enzymes 2 e9creted If these mechanisms fail& then carcinogens enter the cell 2 damage the <!)

Cancer: Carcinogens
Smoking " 'mo$eless tobacco " <ietary habits " Jre*uent& hea7y use of alcohol E9posure to radiation 2 chemical carcinogens: Chemotherapy Viruses: transform infected cells into malignant cells: Epstein"6arr& #IM& #epatitis 6& human papilloma7irus Genetic susceptibility: increased ris$ for de7elopment of cancer .1501

Carcinogenesis: Fromotion
Ge7ersible proliferation of altered cells increased li$elihood of additional mutations Fromoting factors: obesity8 dietary fat8 cigarette smo$ing8 alcohol consumption8 prolonged& se7ere stress =ithdra3al of factors reduced ris$ for de7elopment of specific cancers Latent period = 1- ! yrs = initiation " promotion stages r#t mitotic rate of tissue of origin

Carcinogenesis: Frogression

Increased gro3th rate of tumor gro3th Gapid gro3th of primary tumor )ngiogenesis creates blood supply Increased rate of metastasis Hro3th penetrates lymph 2 7ascular 7essels Cells transported to other organs

)ngiogenesis
)ngiogenesis gro3th of ne3 capillaries r/t release of gro3th factors 2 enzymes
Creates a 7ascular net3or$ that enables hematogenous spread 'ome cancer treatments target this process

6enign !eoplasms
6enign neoplasms
'lo3 steady gro3th Gemains localized
$enign tumor% parotid gland

(sually contained 3ithin a capsule 'mooth& 3ell"defined& mo7able 3hen palpated =ell"differentiated cells that resemble parent tissue Cro3ds normal tissue Garely recurs after remo7al Garely fatal

+alignant !eoplasms
+alignant !eoplasms
Gate of gro3th 7aries& usually rapid +etastasizes Garely contained 3ithin a capsule Irregular& more immobile 3hen palpated Cittle resemblance to parent tissue +ay be 3ell"differentiated to undifferentiated In7ades normal tissue +ay recur after remo7al Jatal 3ithout treatment

+elanoma

6asal Cell Carcinoma

+etastasis
+etastasis: )bility to spread or transfer cancer cells
E9tension into surrounding tissues " 'ecrete enzymes that open up surrounding tissue Cymphatic spread most common #ematogenous spread can attach to endothelium 2 attract fibrin 2 platelets 2 clot themsel7es to basement membrane to protect from immune system ?ransplantation or direct transport of tumor cells from one site to another. ?ransplantation may occur accidentally during surgery or other procedures 3hen cancer cells are AcarriedN on instruments or glo7es

Hrading 2 'taging of ?umors

?umors are classified according to the parent tissue type 2 location 3ithin the body. Carcinoma" malignant tumors composed of embryonic epithelial cells& 3hich ha7e a tendency to metastasize Sarcoma refers to malignant tumors of embryonic connecti&e tissues& such as muscle or bone& usually presenting as a painless s3elling. +ay affect bones& bladder& $idneys& li7er& lungs& parotids& and spleen Lymphomas & leukemias originate from hematopoietic system

Cancer: Clinical 'taging

Classified 'tage 1"- by the e9tent of disease 2 e9istence of metastasis
Stage !% Cancer in situ Stage ': ?he tumor is small& local& and detected early Stage '': ?he tumor is some3hat larger and has started to spread to nearby lymph nodes Stage ''': ?he tumor has spread e9tensi7ely to nearby lymph nodes Stage 'V: Cancer has metastasized to other parts of the body and is generally in an ad7anced stage.

?!+ .?umor& !odes& +etastasis1 'taging 'ystem

(sed to indicate tumor si(e )*+& spread to lymph nodes ),+- and e.tent of metastasis )/+% Each is rated 5" 'ee te9ts for specific classification criteria ?his system is used to direct treatment& predict prognosis& and contribute to cancer research by ensuring reliable comparison of different patients

<etection 2 Fre7ention of Cancer

Frimary Fre7ention
?each to a7oid $no3n carcinogens +a$e dietary 2 lifestyle changes to reduce the ris$ for cancer

'econdary Fre7ention/'creening
Gole of genetics in cancer cell de7elopment Colon cancer& breast cancer& prostate cancer screenings

Early detection 2 diagnosis

<etermine presence of tumor 2 e9tent Identify metastasis E7aluate function of in7ol7ed 2 unin7ol7ed organs Obtain tissue for analysis 2 tumor grading 2 staging

Cifestyle Changes to Geduce Gis$

'top smo$ing cigarettes 2 use of smo$eless tobacco Cimit e9posure to ultra7iolet radiation
Includes tanning beds 2 sunlamps

Cimit e9posure to en7ironmental 2 chemical carcinogens

Gubber& chlorine& coal& asbestos& 7inyl chloride& dyes& leather processing

Cimit hea7y consumption of alcohol

Joods that Geduce Cancer Gis$

Megetables from the cabbage family 6roccoli& cauliflo3er& 6russels sprouts& all types of cabbage and $ale Megetables and fruits high in beta carotene Carrots& peaches& apricots& s*uash& broccoli Gich sources of 7itamin C Hrapefruit& oranges& cantaloupe& stra3berries& red and green peppers& broccoli& tomatoes

Joods to Geduce Cancer Gis$

?he !ational Cancer Institute has recommended including at least > ser7ings of fruits 2 7egetables in the daily diet Cean meat& fish& s$inned poultry Co3 fat dairy products& including 3hite cheese rather than yello3 #igh fiber )7oid salt cured& smo$ed& or nitrite cured foods

Cancer%s 'e7en =arning 'ignals

C)(?IO! Changes in bo3el or bladder habits ) sore that does not heal (nusual bleeding or discharge ?hic$ening or lump in breast or else3here Indigestion or difficulty in s3allo3ing Ob7ious changes in 3arts or moles !agging cough or hoarseness

Early <etection of Cancer

Flanned periodic e9aminations and the recognition of cancer%s 3arning signals& 3hich enable the indi7idual to obtain medical attention early. Early detection pro7ides the time needed to diagnose and initiate treatment before cancer has reached an ad7anced stage

Colorectal ?ests .+en and =omen1 #ematest stool for blood

e7ery year after age >5 Froctosigmoidoscopy& preferably fle9ible& e7ery > years after age >5 Colonoscopy * 15 yrs is gold standard for colorectal cancer detection

Frostate Cancer <etection

Frostate specific antigen .F')1 test yearly for men o7er >5 yo

Oearly digital e9amination for men o7er -5

Cer7ical Cancer 'creening

Fel7ic e9amination for 3omen must include a Fapanicolaou .Fap1 smear test annually after age 1K .or at age first se9ually acti7e1

6reast Cancer <etection

+onthly self e9amination .'6E1 .men and 3omen1 Fart of physician%s physical e9amination .men and 3omen1 +ammogram: baseline needed at age />"/P& then e7ery year after age -5

Incisional biopsy

Cancer <iagnosis: 6iopsy

E9cisional biopsy

?he only definiti7e 3ay to determine the presence of malignant cells 'mall tissue sample is remo7ed 2 e9amined under a microscope
Incisional biopsy E9cisional biopsy !eedle aspiration biopsy

!eedle aspiration biopsy

Cancer: <iagnosis: Endoscopy

<irect 7isualization through a body ca7ity or a small incision (sed for tracheobronchial tree 2 HI GI'Q: cancer seeding

Cancer: <iagnostic Imaging

Frior to procedure must determine any allergy to iodine because this is part of the contrast used for the testing ?hese procedures are performed under sterile surgical conditions 'igned consent is re*uired

<iagnostic Imaging
C* L"ray 2 computerized scanning

0ltrasound
!onin7asi7e (ses high" fre*uency sound 3a7es

$one Scanning
Gadioacti7e material inEected

<iagnostic Imaging
/1'
Immersing the body in a steady& strong magnetic field.

23*
Gadioacti7e substances introduced IM 2 scanned

Cancer: Caboratory ?ests

)l$aline Fhosphatase 6lood Ce7el Ele7ated 3ith metastasis to bone or li7er 'erum calcitonin le7el Ele7ated 3ith cancer of thyroid& breast& lung Carcinoembryonic antigen .CE)1 Ele7ated 3ith cancer )!< smo$ers (sed to e7aluate cancer treatment Gising le7el means tumor gro3th

Cancer: Caboratory ?ests

F')
Frostate cancer

C)"12>
'ignals recurrence of o7arian cancer

Cancer: Caboratory ?ests

Occult 6lood 'tool ?esting

Cancer +anagement: 'urgery

(sed to remo7e a cancerous lesion. Hoal is to remo7e all malignant cells 3hich may include remo7al of the tumor& surrounding tissue& and regional lymph nodes cure or control cancer so is managed li$e a chronic illness +ay be used in conEunction 3ith chemotherapy and radiation. Geconstructi7e surgery may be needed to impro7e body functions 2 appearance after radical surgeries.

Cancer 'urgery
Cocal e9cisions
'mall mass Gemo7al of mass 2 small margin of normal tissue
'$in cancers

Cancer 'urgery
=ide .radical1 e9cisions
Gemo7al of primary tumor& lymph nodes& adEacent tissues R ris$ for tumor spread Can result in disfigurement 2 altered functioning 6(? chances for cure or control are good

Frophylactic 'urgery
Gemo7al of non7ital tissue or organs li$ely to de7elop cancer r/t genetic disposition .genetic mar$ers1& symptoms
Colectomy +astectomy Oopherectomy

Geduced or lost function

Falliati7e 'urgery
Falliati7e surgery to relie7e or reduce uncomfortable symptoms D procedure to relie7e obstruction& ulceration& hemorrhage& pain
<ebul$ing colostomy laminectomy

=hen cure is not possible& used to promote comfort 2 relie7e complications

(lcerations Obstructions #emorrhage Fain Effusions

Geconstructi7e 'urgery
+ay follo3 curati7e or radical surgery to impro7e function or more desirable cosmetic effect

Often done in stages

Cancer: !ursing Fostoperati7e

Education 2 support
Geinforce information pro7ided by physician Increased an9iety

Fromote nutrition Fro7ide routine post operati7e care

Increased incidence of infection& impaired healing& altered pulmonary or renal function& <M? r/t chemotherapy or radiation therapy

Fromote positi7e self/body image

Gehabilitation 2 reconstruction