N107 Nursing Interventions 2 Date: 01-29-18 · Trans # 02-02.

1
2ND SEM · AY 17-18
Nursing Care of Clients with Cancer (Intro)
Professor Lydia Manahan

OUTLINE B. Global Cancer Burden

I. Oncology  1 in 8 deaths worldwide
A. Oncology Nursing  International Agency for Research (2012)
B. Global Concern Burden o 14.1 M cases
1. Incidence and Prevalence o 8.2 M deaths
2. WHO reports of incidence o (2013) 14.9 M
3. What % of Americans will get cancer  By 2030
II. Cancer Background o 21.7 M cases
A. Pathophysiology o 13 M deaths
1. Brenbulum Theory o Incidence is increasing since 1990
III. Oncology Processes  2020
A. Angiogenesis o 16-20 million new cancer cases each year
B. Metastasis
o ¾ of these in developing or resource-poor countries
C. Proliferation
D. Differentiation 1. Incidence and Prevelance
IV. Reactive and Neoplastic Growth Processes
 2nd leading cause of death
V. Biology of abnormal cells
VI. Theories of Carcinogenesis  1 out of 3 persons will be affected by cancer sometime in
A. Telomeres their lifetime
B. Oncogenesis  Cancer of lung=leading cause of cancer deaths in both
VII. Risk Factors men and women
A. Host Risk Factors
 Cancer of colon=2nd largest incidence
B. Environmental Risk Factors
C. Risk factors for Cancer  Breast and Prostate=highest gender incidence
D. Normal vs Malignant Cell Characteristics 2. WHO reports of Incidence
E. Immune system and Cancer  Key factor is growing population and increased number of
VIII. Oncology Nurse older people
A. NCP  Lack of access to information about prevention, early
B. Responsibilities detection and treatment
C. Holistic Nursing Considerations
 Inadequate medical and public health infrastructure
D. Levels of Cancer prevention and Control
1. Primary prevention  Diagnosed at a late stage
2. Secondary prevention  Suffer needlessly from inadequate palliative care
E. Promotion and Prevention  Palliative care: a now growing concern.
IX. Cancer Screening
A. Criteria for screening Top 4 Causes of Cancer deaths
B. Screening for early detection Male Female
C. Diagnostic Examinations/ Studies Lung Lung
D. Tumor markers Prostate Prostate
X. Staging And Grading Tumors, And Interventions Colon/Rectum Colon/Rectum
A. Cancer staging Pancreas Pancreas
B. Tumor grading 3. What % of Americans will get Cancer?
C. Surgery  Lifetime Risk of Developing Cancer
D. Radiation Therapy o Approximately 40.4% of men and women will be
E. Chemotherapy
diagnosed with cancer at some point during their
F. Biotherapy
lifetime
G. Bone Marrow transplantation
 Prevalence of Russia
I. ONCOLOGY o In 2015, there will be an estimated 14.5 million people
 branch of medicine that deals with the study, detection, living with cancer in the United States (~5% of the
treatment and management of cancer population)
 Incidence of Cancer in the US
A. Oncology Nursing
o Men have a 1 in 2 lifetime risk of developing cancer,
 Roles of nurses in detecting, treating and managing cancer
while women have a 1 in 3 risk
and cancer patients.
o Incidence and mortality rates higher for African
American than Anglo Americans

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N107 Nursing Care of Clients with Cancer
o Most cancers are curable if treated early
II. CANCER BACKGROUND
 Family of complex diseases
 Affect different organs and organ systems
 Normal cells mutate into abnormal cells that take
over tissue
 Eventually harm and destroy host
 Historically, cancer is a dreaded disease
A. Pathophysiology
 Carcinogenesis/ Oncogenesis
 Tumor development slow and insidious
 Initiator-Promoter Theory
 Loss of cellular control mechanisms (ie apoptosis)
 Loss of differentiation
Some books say that it takes 18 years for symptoms to
appear.
1. Berenblum Theory
INITIATION  PROMOTION  PROGRESSION
 Initiation
o Multiple theories as to when the genes in the
cells are damaged
o Possibly in utero, from physical or chemical
exposure, latent oncogenes, viruses, or a lack of
suppressor genes from our parents, and at this
point the cell is not dividing
 Promotion
o The stage when the abnormal cell starts to
divide, may be stimulated by environmental
changes, hormones, drugs, or irritants
 Progression
o The phase when the abnormal cells have
continued to grow into a Primary Tumor, may
produce angiogenesis factors which supply
blood and vascular nourishment to the tumor.
The tumor may have subcolonies of cells with
different genes and features.
III. ONCOLOGY PROCESSES
A. Angiogenesis
 Angiogenetic switch: ability of the tumor to promote
formation of new capillaries from pre-existing host
vessels
 Stimuli for angiogenesis: hypoxia, inflammation, and
genetic lesions
B. Metastasis
 The movement of cancer cells into other organs of
the body, thus creating new tumor sites.
C. Proliferation
 Normally: cells produced=cells die
UPCN 2019
 Total number of cells in the body remains constant
D. Differentiation
 Is when the stem cell (from bone marrow) matures
into a specific type of cell
 Normally, after a cell has divided, it becomes either a
permanent cell or stable cell
 These cells stop reproducing and become productive
 Regulated by a feedback system
 Affected by various stimuli
o Stress
o Infection
o Hemorrhage
o Bone marrow depletion
o Drug therapy
IV. REACTIVE AND NEOPLASTIC GROWTH PROCESSES
 Differentiation
 Atrophy: decrease in cell size
 Hypertrophy: increase in cell size
 Hyperplasia: increase in the number of normal cells
in a normal arrangement in a tissue or organ. Usually
leads to an increase in the size or part (tissue mass)
and an increase in functional activity
o Types:
o Physiologic: due to an external stimulus and
subsides when the stimulus is removed
o Neoplastic Hyperplasia or Neoplasia: due in part
to a heritable abnormality within the involved
cells (alter the genetic mechanisms of involved
cells)
 Metaplasia: replacement of one type of fully
differentiated cell by another fully differentiated cell in
another part of the body where the second cell type
does not normally occur
 Dysplasia: alteration in the size, shape, and
organization of differentiated cells. Pre-malignant
change. Change is usually a response to an irritant. It
reverts to normal when the irritant is removed but
may transform to a neoplasia.
 Anaplasia: tumor cells that that are completely
undifferentiated and bear no resemblance to cells of
tissues of their origin. Irreversible change
** Once a cell is mutated, it can’t turn back. Dysplasia >
Metaplasia, chance in developing cancer
V. BIOLOGY OF ABNORMAL CELLS
 They have continuous or inappropriate, usually faster
growth or larger growth patterns
 They have no specific morphology and often do not
resemble their parent cells= anaplastic
 They do not respond to signals for apoptosis =
programmed cell death
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 Have a large nuclear - cytoplasmic ratio; the nucleus o Cancer is a genetic disease
may occupy most of the cell area o The malignant phenotype often requires
 They lose some or all of their normal cell functions mutations in several different genes
 They do not make fibronectin, and thus cannot o Germline cells: passed to future generations
connect easily and break off easily o Somatic cells: not passed to progeny
 They are able to migrate throughout the body=  Chronic Inflammation: an important factor in the
metastasis development of cancer
 They invade other tissues and types of cells o Cytokine release from inflammatory cells
 They are not controlled by contact o Free radicals
 They have more or less chromosomes than the o Mutation promotion
parent cells= Aneuploid, or a mutation of gene. o Decreased response to DNA damage
 Virus: not sufficient of cancer development but
** Cancer has exponential growth constitute one alteration in the multistep process of
cancer
VI. THEORIES OF CARCINOGENESIS
1. Cellular Mutation  Implicated:
o Epstein Barr virus: Burkitt’s lymphoma
 Cells begin to mutate (change the DNA to unnatural
o Hepatitis virus-hepatocellular Ca
cell reproduction)
2. Oncogenes/Tumor Suppressor Genes o HPV-cervical cancer
Abnormalities o Retrovirus-T cell leukemia
 Oncogenes are genes that promote cell proliferation
C. Environmental Risk Factors
and can trigger cancer
 Chemical Carcinogens
 Tumor suppressor genes normally suppress
 Radiation
oncogenes but are damaged
o Ionizing radiation in atomic bomb survivors
** all of us have cancer cells, it is up for us that the cancer o Sunlight and melanoma
cells do not grow faster than the anti-oncogenes.  Lifestyle
 Tobacco
A. Telomeres o Multipotent carcinogenic mixture
 The ability to bypass telomere-based growth o Linked to cancers of the lungs, aerodigestive
limitations is a critical step in the evolution of tract, liver, pancreas, kidney, lower urinary tract,
malignancies cervix uteri, and myeloid leukemia
 End of chromosomes which gradually shortens with  Alcohol Consumption
every cell replication o Risk factor for oral cavity, pharynx, hypopharynx,
 Replicative senescence: cell growth arrest due to larynx, esophagus, and liver cancers
loss of telomeres o Cigarette/alcohol combination multiplies the
person’s risk
B. Oncogenesis  Ionizing Radiation
 Cells in the replicative senescence can go through o Emission from X-rays, radioisotopes, and other
the cell cycle if the p53 and pRB are nonfunctioning radioactive sources
 Telomerase: allows telomere extensions and are o Exposure causes cell death gene mutations, and
found high in cancer thus allowing cellular chromosome aberration
proliferation o Bystander effects: genetic instability
o Poor gene repair
VII. RISK FACTORS o Changes in gap junction- intercellular
A. Host Risk Factors
communication
 Age
 Ultraviolet Radiation
 Heredity: familial predisposition and genetic make- o Physical source is sunlight
up o Ultraviolet A (UVA) and ultraviolet B (UVB)
 Hormones: drives cell division of a malignant o Promotes skin inflammation and release of free
phenotype
radicals
 Immunologic mechanism: o Causes basal cell carcinoma, squamous cell
o Impaired immune surveillance
carcinoma, and melanoma
o HIV-related cancers
 Occupational Hazards
 Exposure to Mutagens

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 Substantial number of occupational carcinogenic C. Normal vs Malignant Cell characteristics

origins NORMAL MALIGNANT
o Asbestos Limited cell division Rapidly dividing/multiplying
o Dyes, rubber, explosives, rubber cement, heavy Undergo apoptosis Do not undergo apoptosis
metals, and air pollution, etc. Controlled growth Uncontrolled growth
o Radon Well-differentiated Anaplastic morphology
o Peanuts – have aflatoxin Adhere tightly together Adhere loosely together
 Physical Activity Contact: inhibited Able to move / metastasize
o Reduces cancer risk Euploid Aneuploid
o Decreases insulin and insulin-like growth factors Metastasis – The rapid multiplication of malignant
o Decreases obesity neoplasms which spread to distant body parts through the
o Decreases inflammatory mediators and free bloodstream or the lymph system
radicals
D. Immune System and Cancer
o Increases gut motility
 Body defenses against tumor
 Sexual reproductive behavior
1. T Cell System/ Cellular Immunity
o Carcinogenic type of HPV
 Cytotoxic T Cells kill tumor cells
 Diet
2. B Cell System/ Humoral Immunity
 Xenobiotics
 B cells can produce antibody
o Toxic, mutagenic, and carcinogenic chemicals in
3. Phagocytic Cells
food  Macrophages can engulf cancer debris
o Activated by Phase 1 activation enzymes
o Defense mechanism (Phase 2 detoxification VIII. ONCOLOGY NURSE
enzymes) Nurses are expected to:
 Examples:
o Compounds produced in the cooking of fat,  Assess a patient’s physical and emotional status,
meat, or proteins past health history, health practices
o Alkaloids or mold by-products  Know both the patient’s and the family’s knowledge
of the disease and its treatment
Cancer is primarily a disease of aging  Review the treatment plan with the oncologist
 Be aware of expected outcomes and possible
B. Risk Factors for Cancer complications as well
1. Non-controllable/ Non-modifiable
 Heredity A. NCP
 Age Promotion of:
 Gender
 Poverty  patient’s understanding of therapy goals, treatment
2. Controllable/Modifiable schedules, and possible side effects of therapy
 Stress, diet, occupation, infection, tobacco use,  physical and psychological preparation for therapy
alcohol use, use of recreational drugs, obesity, and  physical and psychological comfort
sun exposure  compliance

**Root Words A. Responsibilities

 Chemotherapy administration
 Neo: new  Ensure correct dose and drug are administered by
 Plasia: growth the correct route to the right patient
 Plasm: substance  Symptom management / palliative care
 Trophy: size  Supportive care
 +Oma: tumor  Two areas deserve special mention
 Statis: location o Pain management
 A: none o Survivorship
 Ana: lack  Collaboration between and among patient, family,
 Hyper: excessive members of the health team and stakeholders
 Meta: change
 Dys: bad, derenged B. Holistic Nursing Considerations
1. Primary Level Care

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 Prevention and screening/client education IX. CANCER SCREENING

2.Secondary Level Care A. Criteria for Screening
 Diagnostic Testing 1. Population who has high incidence of cancer
 Treatment and Side Effects of Surgery, Radiotherapy, 2. Disease is detectable in its presymptomatic
Chemotherapy stage
3. Tertiary Level Care 3. There is an effective test for screening
 End of life and psychosocial issues 4. Effective treatment is available
5. The potential benefits of screening outweigh
C. Levels of Cancer Prevention & Control risks and costs
1. Primary Prevention  Knowing the screening program is not enough
 Focuses on avoiding and eliminating the condition o Detect disease early in its natural history, when
that cause cancer to develop (cancer has NOT yet treatment is more effective, leading to better
developed or is in a pre-cancerous stage) outcomes
 Health promotion, educate community about cancer o Cancer screening involves testing large numbers
risk, encourage healthy lifestyle of individuals who have no symptoms
o Having the treatment
STEPS to Cancer prevention
E. Screening for Early detection
1.Protective Factors  Breast Cancer
 Increase consumption of fresh vegetables esp. o SBE for all ages
cabbage family (cruciferous veg: helps convert o 20-39 : clinical breast exam every 3 years
estrogen to a form less Ca producing) o >/= 40: yearly breast exam by professional
 Increase fiber (breast, prostate & colon) (CBE)
 Increase Vit. A (esophagus, larynx, lungs) o Baseline mammogram (35-39)
 Increase Vit C (stomach & esophageal) o Yearly mammogram after 40
 Practice weight control (uterus, gallbladder, breast & o (+) family hx  mammogram at 30
colon)
2. Risk factors WHO 2018 mammography screening recommendations
 Reduce dietary fats (breast, colon & prostate
 Reduce salt cured, smoked, nitrate cured food - In well-resourced settings, organized population-
(esophageal & gastric cancers) based mammography screening programs ae
 Stop cigarette smoking recommended for women aged 50-69 years,
 Reduce alcoholic intake (+ smoking leads to mouth, every 2 years
throat, larynx, & esophagus) - In these settings, screening programs for women
 Avoid overexposure to sun (skin) 40-49 years of age and 70-75 years of age is
suggested only if it is conducted in the context of
2. Secondary Prevention rigorous research, monitoring and evaluation.
 Refers to early detection before manifestations  Cervical Cancer
become readily apparent to client coupled with o Pap smear three years after onset of vaginal
PROMPT TREATMENT (cancer may be curable in intercourse but not later than 21 (age 18-20)*
early stage) o Annually for 2 years
 Importance of knowing that genetics is a risk factor: o After age 30 and with two normal test at least
Provide individualized education & recommendations every 2-3 years till 65
for continued surveillance & care in high risk o (+) high risk  annually
populations (increasing efforts to facilitate early o Pelvic exam every year
detection) o Endometrial tissue sample at menopause
 Colorectal Cancer
D. Promotion and Prevention o Annual DRE starting age 40
 75% of cancer can be cured if detected early; 75% of o Annual stool exam at age 40
cancer is due to lifestyle o Annual inspection of colon (sigmoidoscopy at
o Practice self-examination and avail of screening age 50 every 3-5 years) or
procedures o Colonoscopy every 10 years
o Available screening procedure  Prostate Cancer
o Good knowledge of family history o Same as above
o (+) DRE & stool then PSA

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 Testicular Cancer  Tumor cell markers (biological markers) are

o Common in men ages 15-34 substances produced by cancer cells or that are
o Testicular Self-Exam (TSE) found on plasma cell membranes, in the blood, CSF,
 Lung Cancer or urine
o Chest X-ray yearly for high risk (smokers) o Hormones
o Sputum cytology o Enzymes
 Oral Cancer o Genes
o Self-examination o Antigens
o Annual exam of mouth & teeth o Antibodies
 Tumor markers are used to:
F. Diagnostic Examinations/ Studies o Screen and identify individuals at high risk for
 Radiologic Testing cancer
o Plain Radiographs o Diagnose specific types of tumors
o Computed tomography o Observe clinical course of cancer
o Ultrasonography
o Magnetic Resonance Imaging 1. hCG (human chorionic gonadotropin) : testicular
 Can locate and describe the gross extent of a cancer
mast or tumor but cannot differentiate 2. CA-125 (Cancer Antigen 125) : ovarian cancer
between malignant or benign 3. PSA (Prostate-specific antigen) : Prostate
 Direct Visualization Cancer
o Sigmoidoscopy 4. αFP (alpha fetoprotein) : liver and testicular
o Cystoscopy cancer
o Endoscopy 5. CEA (Carcinoembryonic antigen) : colorectal,
o Bronchoscopy pancreatic, lung and stomach cancer
o Exploratory Surgery
X. STAGING AND GRADING TUMORS, AND INTERVENTIONS
 Biopsy
 Staging: determines the extent of the spread of
o The only way to be certain of malignancy
o The visualization of changed cells cancer
 Grading: evaluates tumor cells in comparison to
microscopically
normal cell
1. Cytology Specimens A. Cancer staging
 Specimens can be obtained from tumors that tend to
 The process of describing the local extent off the
shed cells from their surface. (Ex. pap smear)
disease or the spread of cancer from the original site.
2. Needle Biopsy 2.1 Fine Needle Aspiration
 Essential in determining the choice of therapy and
Biopsy (FNAB)
assessing prognosis
 Tumor cells are withdrawn from the tumor by a
 The degree of DIFFERENTIATION
needle and syringe.
o Stage 1: Low grade; localized
3. Incisional Biopsy
o Stage 2: regional extends beyond organ of origin
 Only part of the tumor is removed
4. Excisional Biopsy but remains nearby
 Entire tumor is surgically removed for examination o Stage 3: extended beyond regional site of origin
 Used for small tumors (2-3 cm in size) crossing several tissue planes up to lymphatics
 May serve as a treatment if the tissue margins or blood
contain no tumor cells o Stage 4: high-grade; widely disseminated

The earlier cancer is detected, the more likely it is to be C. Tumor Grading

controlled
Cancer check up is recommended every 3 years for
persons ags 20 to 39 and annually for those 40 and over
G. Tumor markers
 A biologic event of malignancy
 An advantage for the medical and para medical
group
 Class I. Normal Cell; Well differentiated
 Class II. Abnormal Cell; Moderately differentiated
 Class III. Suspiciously malignant; Poorly
differentiated
 Class IV. Probably malignant; Very poorly
differentiated
 V. Malignant; Undifferentiated

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D. Surgery  Cancer Prevention

 The oldest form of cancer treatment and still the most  Improvement in Quality of Life
common today
 Surgery is classified as: -- TULOG MUNA… --
o Curative (to heal or restore to health)
o Palliative (to relieve symptoms in more
advanced stages)
o Reconstructive (may follow curative or radical
surgery to reestablish function or rebuild for
better cosmetic effect)

E. Radiation Therapy
 Second most common treatment radiation therapy, or
radiotherapy, uses high-energy ionizing radiation to
kill cancer.
 Two types:
o External
o Internal

F. Chemotherapy
 May be used to cure, prevent, or relieve cancer
symptoms
 Drugs used in chemotherapy are called
antineoplastics because they inhibit the growth and
reproduction of malignant cells.
 Chemotherapy is the treatment of choice for
metastatic cancers. It is also the treatment most
responsible for increasing cancer cure rates in recent
years.

G. Biotherapy
 Performed with biologic response modifiers (BRMs),
agents that stimulate the body’s natural immune
system to control and destroy malignant cells.
 Most BRMs are still being evaluated in trial studies.

H. Bone marrow Transplantation

 Used for cancers that respond to high doses of
chemotherapy or radiation therapy
 Treatment involves aspirating and storing a fraction
of bone marrow, exposing the client to high-dose
drug therapy or total body irradiation, and then
reinfusing the bone marrow after the treatment is
complete.
 4 Main Classifications of Cancer
1. Lymphomas : cancers occurring in infection-
fighting organs, such as lymphatic tissue
2. Leukemias : cancers occurring in blood-forming
organs, such as the spleen, and in bone marrow
3. Sarcomas : cancers occurring in connective tissue
such as bone
4. Carcinomas : cancers occurring in epithelial tissue,
such as the skin
 The Goals
 Cancer Cure

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