ONCOLOGY / CANCER NURSING

THE CELL
Definition of Related Terms
Cell - The basic unit of living organism; can reproduce itself
Cancer – a disease process whereby cells proliferate abnormally, ignoring growth
regulating signals in the environment surrounding the cells.
Carcinoma – a new growth or malignant tumor that originates from epithelial cells, the skin, GIT,
Lungs, Uterus, breast and other organs.
Benign – usually a reference to growths that are encapsulated, remain localized, and are slow
growing
Malignant - terms for growth that are encapsulated but metastasize and grow. These growths are
cancerous lesions having the characteristics of disorderly, uncontrolled proliferation of
the cell
Tumor - Abnormal swelling usually from inflammation, or from morbid enlargement.
- They are uncontrolled tissue growth that in which cell rapidly multiplies
Oncology - The study of cancer
Staging - a method of classifying malignancies based on the presence and extent of the tumor on
the body
Metastasis - the transfer of disease from one organ or apart to another not directly connected to it.
Undifferentiated cells – cells that lost the capacity for specialized functions
Carcinogenesis – process of transforming normal cells into malignant cells
Carcinogens - agents that initiate or promote cellular transformation.
Oncogene - cancer gene that alters the normal cell
Carcinoma - usually solid tumors arising from epithelial cell
Sarcoma - from muscle, bone, fat and other connective tissue
Lymphoma - malignant tumors in lymphatic system
Leukemia - cancer of the blood
Nadir - lowest point of WBC depression after therapy that has toxic effects on th bone marrow
Metastasis - spread of cancer cells from the primary tumor to distant sites.

Review of Anatomy and Physiology:

Cell

Centrioles - self-replicating organelles

made uf o nine bundles of microtubules and
are found only in animal cells
Cilia and Flagella – essential for locomotion
(single-celled). Cilia function to move fluid
or materials past an immobile
cell as well as moving a cell or
group of cells.
Endoplasmic Reticulum –a network of sacs
that manufactures, processes and
transports chemical compounds for
use inside and outside of the cell. Provides a pipeline between the nucleus and the
cytoplasm.
Golgi Apparatus – The distribution and Shipping department for the cell’s chemical products
Lysosymes - Main function is digestion. Breaks down cellular waste products and debris from
outside the cell into simple compounds, which are transferred to the cytoplasm as new
cell-building materials.
Mitochondria - are oblong shaped. The main power generators, converting oxygen and
nutrients into energy
Nucleus - Serves as the information processing and administrative center of the
cell.
- Stores DNA
- Coordinates cell activities
o Growth
o Intermediary metabolism
o Protein synthesis
o Reproduction (cell division)

Perixosomes - found inside the cytoplasm

Plasma membrane – encloses cell contents. Selectively
Permeable.
Ribosomes - comprised of approx. 60% RNA and 40%
protein

Cell Division
Overview of Mitosis

Cell division is an elegant process that enables organisms to grow and reproduce. Through a sequence of
steps, the replicated genetic material in a parent cell is equally distributed to two daughter cells. While
there are some subtle differences, mitosis is remarkably similar across organisms.

Before a dividing cell enters mitosis, it undergoes a period of growth called interphase. Interphase is the
"holding" stage or the stage between two successive cell divisions.
In this stage, the cell replicates its genetic material and organelles in preparation for division.

Mitosis is composed of several stages:

Prophase

In prophase, the chromatin condenses into discrete chromosomes. The nuclear envelope breaks down
and spindles form at opposite "poles" of the cell.

Metaphase

In metaphase, the chromosomes are aligned at the metaphase plate (a plane that is equally distant from
the two spindle poles).

Anaphase

In anaphase, the paired chromosomes (sister chromatids) move to opposite ends of the cell.

Telophase

In this last stage, the chromosomes are cordoned off in distinct new nuclei in the emerging daughter
cells. Cytokinesis is also occurring at this time.

At the end of mitosis, two distinct cells with identical genetic material are produced.
Before a dividing cell enters mitosis, it undergoes a period of growth called interphase. Some 90 percent
of a cell's time in the normal cellular cycle may be spent in interphase.

Stages of Interphase

• G1 phase: The period prior to the synthesis of DNA. In this phase, the cell increases in mass
in preparation for cell division. Note that the G in G1 represents gap and the 1 represents
first, so the G1 phase is the first gap phase.
•
• S phase: The period during which DNA is synthesized.

In most cells, there is a narrow window of time during which DNA is synthesized. Note that the
S represents synthesis.

• G2 phase: The period after DNA synthesis has occurred but prior to the start of prophase. The
cell synthesizes proteins and continues to increase in size. Note that the G in G2 represents
gap and the 2 represents second, so the G2 phase is the second gap phase.
• In the latter part of interphase, the cell still has nucleoli present.
• The nucleus is bounded by a nuclear envelope and the cell's chromosomes have duplicated
but are in the form of chromatin.
• In animal cells, two pair of centrioles formed from the replication of one pair are located
outside of the nucleus.

Pathogenesis of Cancer
a. Cellular Transformation & Derangement Theory
- Conceptualizes that normal cells may be transformed into cancer cells due to
exposure to some etiologic agents.

b. Failure of the Immune Response Theory

- Advocates that all individuals possess cancer cells. However, the cancer cells are
recognized by the immune response system. So, the cancer cell undergo destruction.
Failure of the immune response system leads to inability to destroy the cancer cells.

ROLE OF THE IMMUNE SYSTEM

-
malignant cells are capable of developing on a regular basis
-
Immune system can detect the development of malignant cells and destroys them
before cell growth becomes uncontrolled.
- Clinical cancer develops when the immune system fails to identify and stop the
growth of malignant cells.
Normal Immune Response
- recognizes as foreign certain antigens(tumor associated antigens) on the cell
membrane of cancer cells
- macrophages, T lymphocytes, soldiers of the cellular immune response
- T-lymphocytes has cytotoxic properties
- Lymphokines – produced by lymphocytes, capable of killing or damaging various
types of malignant cells
- Interferon(IFN) – produce by the body in response to viral infection, possesses anti
tumor properties.
- Natural Killer Cells – subpopulation of lymphocytes, producing lymphokines and
certain enzymes that kills tumors
Immune System Failure
- Body fails to recognize malignant cells as different from “self”
- Immune response may not be activated
- Tumor antigens combine with antibodies produced by the immune system and
hides/disguise themselves from normal immune defense mechanism.

ASSESSMENT
ETIOLOGY:
A. VIRUSES & BACTERIA – viruses incorporate themselves in the genetic structure of cells,
altering future generation of that cell population – perhaps leasing to Cancer.
e.g. Epstein-Barr Virus – Highly suspect as a cause in
- Burkitt’s lymphoma
- Nasopharyngeal Ca
- some types of non-Hodgkin’s Lymphoma
- Hodgkin’s Disease
Herpes Simplex II, CMV, HPV 16, 18, 31, 33
o Dysplasia
o Ca of the cervix
Hepatitis B virus
o Liver Ca
Human T cell lymphotropic Virus
o lymphocytic leukemia
o lymphomas
HIV
o Kaposi’s Sarcoma
Helicobacter pylori (bacteria)
o Gastric Malignancy
B. PHYSICAL AGENTS –
a. Exposure to UV rays of the sun
b. Exposure to Ionizing radiation
c. Chronic inflammation or Irritation
d. Tobacco use
C. CHEMICAL AGENTS –
- 75 % of all Ca are thought to be related to the environment
- Tobacco smoke – single most lethal chemical carcinogen 30% of Ca deaths
- Chemical substances found in workplace (amines, aniline dyes, pesticides and
formaldehydes, arsenic, tars, asbestos, benzene, Cadmiun, Nickel and Zinc ores,
PVC’s etc.)
- Chemical agents alters DNA structure in body sites distant from chemicalexposure
(liver, lungs and kidneys are most commonly affected)
D. GENETIC & FAMILIAL FACTORS
- genetics, shared environments, cultural or lifestyle factors, chance.
E. DIETARY FACTORS
- Proactive (protective) substances – High fiber, cruciferous vegetables, carotenoids,,
Vit. E & C, Zinc and Selenium
- Cacinogenic & Co-Carcinogenic substances – High fat, Low Fiber, Alcohol, Salt-
cured or smoked meats, foods w/ nitrates & nitrites, High Caloric.
F. HORMONAL AGENTS
- Endogenous vs. Exogenous hormones
 - DES (Diethylstilbestrol) – vaginal carcinomas
- Oral contraceptives and prolonged estrogen replacement therapy

Predisposing Factors

Age - Older individuals are more prone to cancer, they have been exposed to carcinogens
longer, they may have developed immune system alteration.
Sex - Women = more prone to breast, uterus, cervical cancer
Men = more prone to prostate, lung cancer
Residence - Urban dwellers are more prone to cancer than Rural dwellers.
Geographic distribution
- Japan = cancer of the stomach
- US = cancer of the breast
- Due to influence of environmental factors such as, national diet, ethnic customs, type
of pollutions
Occupation - Chemical factory workers, farmers, radiology department person
Heredity - Greater risk with positive family history
Stress - Depression, grief, anger, aggression, despair or life stresses decreases
immunocompetence (affect hypothalamus and pituitary gland)
- immunodeficiency may spur the growth and proliferation of cancer cells
Precancerous lesions
- May undergo transformation into Ca lesions and tumors.
- E.g. pigmented moles, burn scars, senile keratosis, leoukoplakia, benign
polyps/adenoma of the colon or stomach, fibrocystic disease of the breast
Obesity - Studies have linked obesity to breast and colorectal Ca

American Cancer Society 7 Warning Signs (CAUTION)

C- Change in bowel or bladder HABITS

A- A sore that does not heal
U- Unusual bleeding or discharges
T- Thickening or a lump in the breast or elsewhere
I– Indigestion and difficulty of swallowing
O- Obvious change in a wart or a mole
N- Nagging cough or hoarseness of the voice
Cancer Classification

1. Solid Tumors – Associated with the organs from which they develop. Such as breast cancer or
lung cancer
2. Hematological Cancer – Originate from blood cell-forming tissues, such as the Leukemia sans
the Lymphomas
Characteristic of Malignant vs. Benign neoplasm
CHARACTERISTICS BENIGN MALIGNANT
Rate of growth Usually slow Variable and depends on level of
differentiation; the more anaplastic
the tumor, the faster its growth
Mode of growth Grows by expansion; does not Grows at he periphery and sends out
infiltrate surrounding tissues; processes that infiltrate and destroy
usually encapsulated surrounding tissues
Cell characteristics Well differentiated cells that Undifferentiated and often bear little
 resembles normal cells of the resemblance to the normal cells of the
tissues from which the tumor tissue from which they arose
originated
Metastasis Not spread by metastasis Gains access to the blood and
lymphatic channels and metastasizes
to other areas of the body
General effects Usually a localized phenomenon Often causes generalized effects such
that does not cause generalized as Anemia, Weakness, and weight
effects unless its location interferes loss
with blood flow
Tissue destruction Does not usually cause tissue Often causes extensive tissue damage
damage unless its location as the tumor outgrows its blood
interferes with blood flow supply or encroaches on blood flow
to the area; may also produce
substances that cause cell damage
Ability to cause death Does not usually cause death Usually causes death unless growth
unless its location interferes with can be controlled
vital functions

Grading and Staging of Tumors

Staging – determines the size of the tumor and the existence of metastasis

TNM system – most frequently used system in classifying the extent of disease.
T – Extent of Primary Tumor
N – Lymph node involvement
M – extent of mmetastasis
Primary Tumor (T)
TX – Primary tumor cannot be assessed
T0 – No evidence of primary tumor
Tis – carcinoma in situ
T1, T2, T3, T4 – increasing size and / or local extent of the primary tumor

Regional Lymph Node (N)

NX – Regional lymph nodes cannot be assessed
N0 – No regional Lymph node metastasis
N1,N2,N3 – Increasing involvement of regional lymph nodes

Distant Metastasis (M)

MX – distant metastasis cannot be assessed
M0 – No distant metastasis
M1 – Distant metastasis

Grading – refers to the classification of the tumor cells.

- seeks to define the type of tissue from which the tumor originated and the degree to
which the tumor cells retain the functional and histologic characteristics of the tissue
of origin.
- done through Cytology, Biopsy, Surgical Excision.

GRADING
Grade I Cells differ slightly from normal cells and are well differentiated (mild dysplasia)
 STAGING
Stage 0 Carcinoma in situ
Stage I Tumor limited to the tissue of origin; localized tumor growth
Grade II Cells are more abnormal and are moderately differentiated (moderate dysplasia)
Stage II Limited local spread
Grade III Cells are very abnormal and are poorly differentiated (severe dysplasia)
Stage III Extensive local and regional spread
Grade IV Cells are immature (anaplasia) and undifferentiated; cell of origin is difficult to determine
Stage IV Metastasis

PRIMARY AND SECONDARY PREVENTION

Primary prevention – concerned with reducing the risk of cancer in healthy people
- Client Education and counseling. (Avoidance of Carcinogens and
dietary and lifestyle changes).

Secondary Prevention – involves detection and screening to achieve early diagnosis and
prompt intervention to halt cancer process.

EARLY DETECTION

1. Mammography
2. Papanicolaou’s (“Pap”) smear
3. Stools for occult blood
4. Sigmoidoscopy: colonoscopy
5. Breast self-examination
6. Testicular Self Examination
7. Skin inspection

DIAGNOSTIC TESTS

1. Blood analysis - an unestablished diagnostic test used by some health care

practitioners to determine a course of treatment
- RBC, WBC, Platelets

2. Bone Marrow Examination – refers to the pathologic analysis of samples of bone

marrow obtained by bone marrow biopsy (Trephine) and bone marrow aspiration.
Bone Marrow Biopsy – removal of soft tissue from inside of the bone. Bone
marrow grows inside some larger bones in the body. It produces platelets and red
and white blood cells.
3. Radiographic / imaging tests
TEST DESCRIPTION DIAGNOSTIC USES
Tumor marker Analysis of substances found in blood or Breast, colon, lung, ovarian,
identification other body fluids that are made by the testicular, prostate Cancer
tumor or by the body in response to the
tumor.
MRI Use of magnetic fields and radiofrequency Neurologic, pelvic,
signals to create sectioned images of abdominal, thoracic cancers
various body structures
CT scan Use of Narrow beam x-ray to scan Neurologic, pelvic, skeletal,
successive layers of tissues for cross- abdominal, thoracic cancers
sectional views
Fluoroscopy Use of x-rays that identify contrasts in body Abdominal and pelvic
tissue densities; may use contrast agents cancers
Endoscopy Direct visualization of a body cavity or Bronchial, GI cancer
passageway by insertion of an endoscope
into a body cavity or opening; allowing
tissue biopsy, fluid aspiration and excision
of small tumors; both diagnostic and
therapeutic
PET scan Computed cross-sectional images of Lung, colon, liver, pancreas,
increased concentration of radioisotopes in breast, esophagus cancer;
malignant cells provide information about Hodgkin’s and non-
biologic activity of malignant cells; helps Hodgkin’s lymphoma and
identify if malignant or just benign Melanoma.
Radioimmunoconjugates Monoclonal antibodies are labeled with a Colorectal, breast, ovarian,
radioisotope and injected intravenously into head and neck cancers;
the patient; antibodies aggregate at the lymphoma and melanoma
tumor site then visualized with scanners
3. Biopsy – the definitive means of diagnosing cancer and provides histological proof of
malignancy
- involves surgical incision of a small piece of tissue for microscopic examination

Types:
a. Needle - Aspiration of cells
b. Incisional - Removal of a wedge of suspected tissue from a larger mass
c. Excisional - Complete removal of the entire lesion
d. Staging - Multiple needle or incisional biopsies in tissues where metastasis
is suspected or likely.

*** > procedure is usually performed in an outpatient surgical setting

> Prepare Client Physically and psychologically and following physicians
Instructions
> Obtain an Informed consent

Pathophysiologic Basis of Malignant Neoplasm

Cancer is a disease process that begins when an abnormal cell is transformed by the genetic
mutation of the cellular DNA. This abnormal cell forms a clone and begins to proliferate abnormally,
ignoring growth regulating signals in the environment surrounding the cell. The cells acquire invasive
characteristics, and changes occur in surrounding tissues. The cells infiltrate these tissues and gain
access to lymph and blood vessels, which carry the cells to other areas of the body. This phenomenon is
called Metastasis.

Cancer is not a single disease with a single cause; rather, it is a group of distinct diseases with
different causes, manifestations, treatments and prognoses.

Proliferative patterns
Hyperplasia - Increase in the number of cells of a tissue; most often associated
with periods of rapid body growth
Metaplasia - conversion of one type of mature cell into another type of cell
Dysplasia - bizarre cell growth resulting in cells that differ in size, shape, or
arrangement from other cells of the same type of tissue.
Anaplasia - cells that lack normal cellular characteristics and differ in shape
and organization with respect to their cells of origin; usually, anaplastic cells are
malignant
Neoplasia - Uncontrolled cell growth that follows no physiologic demand.

Invasion and Metastasis

Metastatic Mechanism
a. Lymphatic spread
b. Hematogenous spread
c. Angiogenesis
- most common. Through the lymphatic circulation.
- malignant cells are disseminated through the
bloodstream. Directly related to the vascularity of
the tumor.
- Ability of malignant cells to induce growth of new
capillaries from the host tissue to meet their needs for nutrients and
oxygen.

Carcinogenesis

- a.k.a. Malignant transformation; has three-step cellular process

a. Initiation – Carcinogens escape normal enzymatic mechanisms and alter the genetic structure
of the cellular DNA (Permanent cellular mutations)

b. Promotion – repeated exposure to co-carcinogens causes the expression of abnormal or mutant

genetic information even after long latency periods.

Cellular oncogenes – responsible for the vital cellular functions of growth and
differentiation.
Cellular Proto-oncogenes – acts as an “ON switch” for cellular growth.
Cancer Suppressor genes – “turn OFF” or regulate unneeded cellular proliferation
- when mutated, rearranged, amplified, or lose their regulatory
capabilities, malignant cells reproduce.
P53 gene - tumor suppressor gene that is frequently mutated in many human
cancers.
- regulates whether cells will repair or die after DNA damage.

c. Progression – Cellular changes exhibit increased malignant behavior.

- cells shows propensity to invade adjacent tissues and to
metastasize.
Cellular Aberration
1. Ca Cell Proliferation – disrupts normal cell growth and interfere with tissue function
Manifestation:
- Pressure
- Obstruction
- Pain
- Effusion
- Ulceration
 - Vascular Thrombosis, Embolus, Thrombophlebitis

2. Paraneoplastic Syndrome – Malignant cells produce enzymes, hormones and other

substances.
Manifestation:
- Anemia
- Hypercalcemia
- Edema
- DIC

3. Anorexia – Cachexia Syndrome

Manifestation:
- Tissue wasting
- Severe weight loss
- Severe Debilitation

 Paradigm (Carcinogenesis and cellular aberration)

THERAPEUTIC MODALITIES FOR CANCER

A. SURGERY
- used to diagnose, stage and treat cancer
Approaches:
a. Local excision – warranted if the mass is small
- removal of the mass and a small margin of normal tissue that is easily accessible
b . Wide or Radical excision – (en bloc dissection) removal of primary tumors,
lymph nodes, adjacent involved structures, and surrounding tissues that may be at high
risk for tumor spread.
- considered if the tumor can be removed completely and the chances of cure or control
are good.

 Salvage Surgery – uses an extensive surgical approach to treat the local recurrence of the cancer
after a less extensive primary approach is used. E.g. mastectomy to treat recurrent breast Ca after
primary lumpectomy and radiation
 Electrosurgery – makes use of electrical current to destroy the tumor cells
 Cryosurgery – uses liquid nitrogen to freeze tissue to cause cell destruction
 Chemosurgery – uses combined topical chemotherapy and layer-by-layer surgical removal of
abnormal tissue
 Laser surgery – makes use of light and energy aimed at an exact tissue location and depth to
vaporize cancer cells
 Stereotactic Radiosurcegy (SRS) – single and highly precise administration of high dose
radiation therapy used in some types of brain and head and neck cancers.

TYPES:
a. Prophylactic Sx – performed in clients with an existing premalignant condition or a known
family history that strongly predisposes the person to the development of cancer
- an attempt is made to remove the tissue or organ at risk and thus prevent
the development of cancer
b. Curative Sx – all gross and microscopic tumor is removed or destroyed
c. Control (Cytoreductive) Sx – a “debulking” procedure that consist of removing part of the
tumor
 - Sx decreases the number of cancer cells and increases the chance that
other therapies will be successful
d. Palliative Sx – performed to improve quality of life during the survival time.
- to reduce pain, relieve airway obstruction, relieve obstructions in
the GI or Urinary tract, relieve pressure on the brain or spinal cord, prevent
hemorrhage, remove infected or ulcerated tumors, or drain abscesses.
e. Reconstructive / Rehabilitative Sx – performed to improve quality of life by restoring
maximal function and appearance suh as breast reconstruction after Mastectomy
Side Effects:
1. Loss or loss of function of a specific body part
2. Reduced function as a result or organ loss
3. Scarring or disfigurement
4. Grieving about altered body image or imposed change in lifestyle

Nursing Management:

 general perioperative nursing care

 Education and emotional support
o Assessing Pt. and Family needs, fears, coping mechanisms
o Encourage to take an active role in decision making when possible
o Explain laboratory findings based on information the physician previously conveyed to
them when the Pt. and the family asks.
 Asses Pt’s response to the Sx
 Monitor for possible complications ( Infection, bleeding, thrombophlebitis, wound dehiscence, F
& E imbalance, and organ dysfunction )
 Provide comfort
 Provide post-op teaching (wound care, activity, nutrition, medication information)

BONE MARROW TRANSPLANTATION

- to treat leukemia in clients who have closely matched donors and who are experiencing
temporary remission with chemotherapy
TYPES:
a. Allogenic – Marrow donor is sually a sibling or parent with a similar tissue type
b. Syngeneic – from an identical twin
c. Autologous – most common type
- marrow donor is also the recipient
- marrow is harvested during disease remission and is stored frozen to be infused later

PROCEDURE:
1. Harvest
2. Conditioning
3. Transplantation
4. Engraftment

COMPLICATIONS:
1. Failure to engraft
2. Graft-versus-Host disease
3. Venoocclusive disease

B. RADIATION THERAPY
 - destroys cancer cells with minimal exposure of normal cells to the damaging effects
of radiation. The cells damaged die or become unable to divide
- effective on tissues directly within the path of the radiation beam.
Side Effects:
 Skin changes and irritation
 Alopecia
 Fatigue
 Altered taste sensation

Types:
a. External ( Teletherapy) – also called beam radiation; radiation source is external to
client.
- client does not emit radiation and does not pose a hazard to anyone else
Client education:
- wash area with mild soap and water using hand rather than washcloth
- rinse thoroughly and pat dry
- do not remove radiation markings from the skin
- no powders, ointments, lotions or creams on the areas unless prescribed
- avoid sun and heat exposure
- monitor for moist desquamation (weeping of the skin)
- if moist desquamation occurs, cleanse the area with warm water ad pat dry, apply
antibiotic ointment as prescribed.

b. Internal (Brachytherapy) – radiation source comes in direct, continuous contact with tumor tissues
for a specific time
- radiation source is within the client, for a period of time, client emits radiation and
can pose hazard to everybody
- Sealed vs. Unsealed source
- Unsealed -via ORAL, IV or instillation to body cavities
- eliminated in various excreta which are radioactive and harmful to others
- Sealed - solid, temporary or permanent, is implanted within the
tumor target tissues
- client emits radiation while the implant is in place, but the excreta are not
radioactive
Care of the client with a sealed radiation Source:
- Private room with a private bath
- Caution sign on the door
- Minimize exposure to the radiation source
- Limit time to 30 mins per care provider per shift
- Wear docimeter badge
- Principles of Timing Distance and Shielding
- Limit Visitors

C. CHEMOTHERAPY
Chemotherapy, in its most general sense, refers to treatment of disease by chemicals that kill cells,
specifically those of micro-organisms or cancer. In popular usage, it will usually refer to antineoplastic
drugs used to treat cancer or the combination of these drugs into a standardized treatment regimen.

In its non-oncological use, the term may also refer to antibiotics (antibacterial chemotherapy). In that
sense, the first modern chemotherapeutic agent was Paul Ehrlich's arsphenamine, an arsenic compound
discovered in 1909 and used to treat syphilis. This was later followed by sulfonamides discovered by
Domagk and penicillin discovered by Alexander Fleming.

Other uses of cytostatic chemotherapy agents (including the ones mentioned below) are the treatment of
autoimmune diseases such as multiple sclerosis and rheumatoid arthritis and the suppression of
transplant rejections

Objectives:
- To destroy all malignant tumor cells without excessive destruction of normal cells
- To control tumor growth if cure is no longer possible
- Used as adjuvant therapy

Contraindications:
- Infection. The anti-tumor drugs are immunosuppresives
- Recent surgery. The drugs may retard healing process
- Impaired renal / hepatic function. The drugs are nephrotoxic & hepatotoxic
- Recent Radiation Therapy. Also immunisuppresive
- Pregnancy. The drugs may cause congenital defects
- Bone Marrow Depression. The drugs may aggravate the condition. The WBC level must be
within normal limits.

AntiNeoplastic Medications
- Kills or inhibit the reproduction of neoplastic cells
- Normal cells are also affected
- Cell cycle phase specific medications
o Affects cells only during a certain phase of the reproductive cycle
- Cell cycle phase non-specific medications
o Affects cells in any phase of the reproductive cycle
- Can use combination medications or with other treatment modalities
Side Effects:
1. G.I. System – Nausea & Vomiting, Diarrhea, constipation, anorexia
2. Integumentary System
a. Pruritus, urticaria & systemic signs
b. Stomatitis
c. Alopecia
d. Skin pigmentation
e. Nail changes
3. Hematopoetic system
a. Anemia
b. Neutropenia
c. Thrombocytopenia
4. Genito – Urinary system
a. Hemorrhagic cystitis
b. Urine color changes
5. Others
 a. Pain
b. Malnutrition
c. Memory loss
d. Weight loss or gain
e. Hemorrhage
f. Secondary neoplasms
g. Cardiotoxicity
h. Hepatotoxicity
i. Nephrotoxicity
j. Ototoxicity
k. tumor lysis syndrome
l. post-chemotherapy cognitive impairment("chemo brain")
m. Infertility

Interventions:

- Monitor V/S and lab values

- Bleeding precaution
- Neutropenic precaution
- Nutrition (High calorie with protein supplements)
- Antiemetics (12-48 hours before)
- Hydration
- Administer Allopurinol for increased Uric Acid
- Health care provider safety
- Advise purchase of wig
- Hair growth occurs several months after the final treatment
- Contraception = teratogenic effects of meds

Classifications

Classification Side effects Examples

I. ALKYLATING Cell cycle Gonadal Nitrogen Mustards Cyclophosphamide
MEDS non- Suppression, (Cytoxan) Ifosfamide(Ifex)
specific Hemorrhagic
cystitis, Alopecia, Nitrosoureas Carmustine(BiCNU)
Hematuria Streptozocin(Zanosar)

Alkylating-like Cisplatine(Platinol) Thiotepa

(Thioplex)
II.ANTI-TUMOR Cell cycle Bone Marrow Bleomycin Sulfate(Blenoxane)
ANTIBIOTICS non- depression, Daunorubicin (Cerubidine)
specific Gonadal Doxorubicin(Adriamycin)
Suppression, Plicamycin(Mithracin)
Vesication Dactinomycin(Actinomycin D)
III. Cell cycle Bone marrow 5-Fluouracil (Adrucil) 6-
ANTIMETABOLITES specific suppression, Mercapturine(Purinethol) Methotrexate
(S Phase) stomatitis, (Folex)
photosensitivity,
hepatotoxicity
IV. MITOTIC Cell cycle Neurotoxicity, Vincristine Sulfate(Oncovin)
INHIBITORS (Vinca specific Leukopenia, Teniposide(Vamon)
Alkalopids) (M Phase) Ptosis,
Constipation,
Peripheral
Neuropathy
V. HORMONAL Slows Leukopenia, ESTROGEN:Diethylstilbestrol ANTI-
MEDS / ENZYMES growth gynecomastia, hot ESTROGEN: Tamoxifen citrate
rate of flashes, sex ANDROGENS:Testosterone ANTI-
tumors characteristic ANDROGENS:Flutamide
alterations PROGESTINS:Medroxyprogesterone(Depo-
provera) OTHERS: Asparginase,Mitotane
VI. OTHERS Immunomodulator agents = Interleukins / Interferon

Colony-stimulating factors = Erythropoietin (Epogen)

CANCER TYPES
BREAST CANCER

Invasive - when it penetrates the tissue surrounding the mammary duct &
grows in an irregular patter

Metastasis - via lymph nodes to Bones, lungs, brain and liver

Precipitating factors:
1. family History
2. Early menarche / late menopause
3. Previous Ca of Breast, Uterus or ovaries
4. Nulliparity
5. Obesity
6. High dose exposure of radiation to chest

Assessment:
BSE - Mass felt ( Upper outer quadrant / beneath the nipples )
- Fixed, irregular, non-encapsulated
- Painless (except in late stages)
- Nipple retraction / elevation
- Assymetry (affected breast higher)
- Discharges (bloody / clear)
- Edema / paeu d’orange sin
- Lymphedema/lymphadenopathy
- Lesion seen on mammography

Diagnosis:
1. Breast biopsy (needle aspiration)
2. Surgical removal of tumor (for microscopic examination)

Intervention:
NON-SURGICAL SURGICAL
-Chemotherapy -Lumpectomy
- Radiation Therapy -Simple mastectomy
-Hormonal manipulation -MRM
 -Halstead radical Mastectomy
-Oophorectomy (for estrogen receptor (+)tumor)
-Ablative therapy w/ adrenalectomy or chemical
ablation (blocks the production of cortisol /
androstenedione / aldosterone)

Post-op:
1. Monitor v/s
2. positioning - (Semifowlers ,Back to unaffected side, affected arm elevated above the level of
the heart)
3. Deep breathing and coughing exercise
4. Monitor operative site for infection/swelling/drainage
5. No IV, Injection, BP taking, venipuctures in affected arm
6. diuretics & low salt diet

CERVICAL CANCER
- Pre invasive Ca (Cervical intraepithelial neoplasia)
o I – Mild dysplasia
o II – Moderate dysplasia
o III – severe dysplasia to carcinoma in situ

- Metastasis confined to the pelvis but may have lymphatic spread

Precipitating factors:
- low social economic groups
- early first marriage
- early & frequent intercourse
- multiple sex partners
- high parity
- poor hygiene

Assessment:
- Painless vaginal bleeding postmenstrually & post coitally
- Foul smelling / serosanguinous vaginal discharge
- Pelvic / lower back/leg/groin pain
- Anorexia & wt. loss
- Leakage of urine & feces from the vagina
- Dysuria
- Hematuria

Diagnosis:
- (cytological changes) on Pap Smear

Management:
NON-SURGICAL SURGICAL
-Chemotherapy - Conization -
cryosurgery - Hysterectomy
- External radiation - Pelvic exenteration
- Internal radiation implants (intracavitary)
- laser therapy
OVARIAN CANCER
- Grows rapidly / spreads fast / often bilateral
- Prognosis usually is poor (tumor detected late)

Assessment:
- Abdominal discomfort / swelling
- GI disturbances
- Dysfunctional vaginal bleeding
- Abdominal mass

Diagnosis:
- Exploratory Laparotomy (to diagnose & to stage tumor)

Intervention:
1. External Radiation
2. Chemotherapy (Post-op / for all stages)
3. Intraperitoneal Chemotherapy (abdominal Cavity)
4. Immunotherapy
5. TAHBSO

HODGKIN’S DISEASE
- (Lymphoma) malignancy of the lymph nodes
- Metastasis – to other lymph nodes and eventually nonlymphoid tissues
- Usually affects lymph nodes, spleen and bone marrow
- Distinguishing sign : Reed-sternberg cell
Etiology:
- viral infection
- previous exposure to alkylating chemical agents

Assessment:
- Fever
- Malaise, fatigue, weakness
- Night sweats
- Loss of appetite and significant wt. loss
- Enlarged lymph nodes, spleen & liver
- Anemia & thrombocytopenia

STAGING in HODGKIN’s DISEASE

I – involvement of a single lymph node region or in extra lymphatic organ / site
II – two or more lymph node regions on the same side of diapraghm or localized
involvement of an extralymphatic organ / site
III – lymph node regions on both side of the diapraghm
IV – diffuse or disseminated involvement of one or more extralymphatic organs
w/ or w/o associated lymph node involvement

Diagnosis:
- Biopsy (cervical nodes affected first) (+) and with REED-STERNBERG CELL
- CT SCAN (Liver & spleen)
Intervention;
1. for stage I & II – extensive external radiation of the involved lymph node regions
2. radiation with multi-agent chemotherapy
3. Maintain infection & bleeding precaution
 4. Inform male clients about possibility of sterility (discuss options like sperm banking)

MULTIPLE MYELOMA
- malignant proliferation of plasma cells and tumors within the bone
- plasma cells  tumors  destroys bones
- abnormal plasma cells produce abnormal antibody (myeloma protein or the Bence-Jones
protein) found in blood and urine.
- Causes decrease production of (immunoglobulins & antibodies)
- Causes increase levels of (Uric acid & calcium) leading to RENAL FAILURE
Etiology:
- unknown

Assessment:
1. Skeletal pain (pelvis, spine, ribs)
2. weakness & fatigue
3. Recurrent infections
4. Anemia
5. Osteoporosis
6. Renal failure
7. Spinal cord compression & paraplegia

Diagnosis:
- Blood tests (elevated serum protein, thrombocytopenia, granulocytopenia, elevated uric acid
& calcium levels)
- Urine exams (presence of Bence-Jones protein)

Intervention:
1. Chemotherapy
2. Supportive care (to control symptoms & prevent complications)
3. Maintain Neutropenic & Bleeding precautions
4. Fluids 3-4 L/day
5. Monitor for signs of Renal Failure
6. Encourage ambulation
7. IV Fluids & diuretics, blood transfusion, analgesics, antibiotics as prescribed

LEUKEMIA

- Leukemia or leukaemia (Greek leukos λευκός, "white"; aima αίμα, "blood") is a cancer of the blood
or bone marrow and is characterized by an abnormal proliferation (production by multiplication) of
blood cells, usually white blood cells (leukocytes). Leukemia is clinically and pathologically subdivided
into several large groups. The first division is between its acute and chronic forms:

• Acute leukemia is characterized by the rapid increase of immature blood cells. This crowding
makes the bone marrow unable to produce healthy blood cells. Acute forms of leukemia can
occur in children and young adults. (In fact, it is a more common cause of death for children in
the US than any other type of malignant disease). Immediate treatment is required in acute
leukemias due to the rapid progression and accumulation of the malignant cells, which then spill
over into the bloodstream and spread to other organs of the body. Central nervous system (CNS)
involvement is uncommon, although the disease can occasionally cause cranial nerve palsies.
• Chronic leukemia is distinguished by the excessive build up of relatively mature, but still
abnormal, blood cells. Typically taking months or years to progress, the cells are produced at a
much higher rate than normal cells, resulting in many abnormal white blood cells in the blood.
 Chronic leukemia mostly occurs in older people, but can theoretically occur in any age group.
Whereas acute leukemia must be treated immediately, chronic forms are sometimes monitored
for some time before treatment to ensure maximum effectiveness of therapy.

Four major kinds of leukemia

Cell type Acute Chronic
Acute lymphocytic leukemia Chronic lymphocytic leukemia
Lymphocytic leukemia
(ALL) (CLL)
(or "lymphoblastic")
Onset: <15y.o. Onset: >50y.o
Chronic myelogenous leukemia
Myelogenous leukemia Acute myelogenous leukemia
(CML)
(also "myeloid" or (AML)
Onset:>50 y.o.
"nonlymphocytic") Onset: 15-39 y.o.
(mostly granulocytes)
Cause:
- Unknown
- Gene damage of cells(suspect)
Risk Factors:
- Genetic
- Viral
- Environmental
- Immunological
- Exposure to Radiation, Chemicals, Medications
Signs / Symptoms:

- people with leukemia may become bruised, bleed excessively, or develop pinprick bleeds
(petechiae).
- Immunosuppression
- anemia
- dyspnea.
- Fever, chills, night sweats and other flu-like symptom
- Weakness and fatigue
- Swollen or bleeding gums
- Neurological symptoms (headaches)
- Enlarged liver and spleen
- Frequent infection
- Bone pain
- Joint pain
- Dizziness
- Nausea
- Swollen tonsils
- Diarrhea
- Paleness
- Malaise
- Unintentional weight loss

Diagnosis

Diagnosis requires blood tests to look for an abnormal number of white blood cells, and a bone marrow
examination to look for abnormal numbers or forms of cells in the bone marrow.

Management:
 - Induction chemotherapy to bring about bone marrow remission.
- Consolidation therapy to eliminate any remaining leukemia cells.
- CNS prophylaxis (preventive therapy) to stop the cancer from spreading to the brain and
nervous system.
- Maintenance treatments with chemotherapeutic drugs to prevent disease recurrence once
remission has been achieved.
- Alternatively, allogeneic bone marrow transplantation may be appropriate for high-risk or
relapsed patients.
- Single agent chemotherapy
- Combination Chemotherapy
- Protective isolation
- Bleeding precaution
- Monitor v/s & lab values
- Nutrition
- Radiation Therapy

LIVER CANCER
- Associated with Chronic liver disease / Hepa-B/ Hepa-C / Cirrhosis

Risk Factors:
- Cigarette Smoking
- Alcohol Use
Metastasis:
- Portal Circulation
- Lymphatic changes
- Direct extension
Signs / Symptoms:
- Pain (RUQ/ Epigastrium/ Bask)
- Wt. Loss / Anorexia
- Loss of strength
- Anemia
- Enlarged liver
- Ascites
- Jaundice
Diagnosis:
- Lab Exams
- Increased serum levels of Alpha FetoProtein (AFP)
- X-rays
- Liver scans
- CT Scan
- UTZ
- MRI
- Arteriography
- Laparoscopy
- PET Scans
- BIOPSY
Management:
NON-SURGICAL: SURGICAL:
- Radiation Therapy - Hepatic Resection
- Chemotherapy - Lobectomy
- Immunotherapy - Cryosurgery
- Percutaneous Billiary Drainage - Liver Transplantation
 - Laser Hyperthermia

LUNG CANCER
- Can be Primary or Metastatic
- Bronchogenic Carcinoma – spreads thru direct extension & lymphatic dissemination

4 major types:
1. Small Cell (Oat cell)
2. Epidermal (Squamous cell)
3. Adenocarcinoma
4. Large cell anaplstic carcinoma
Diagnosis:
- CXR
- Bronchoscopy
- Sputum Studies
Causes:
- Cigarette smoking
- Exposure to Environmental pollutants
- Exposure to Occupational pollutants
Signs / Symptoms:
- Cough
- Dyspnea
- Hoarseness
- Hemoptysis
- Chest pain
- Anorexia / Wt. loss
- Weakness
Interventions:
- Monitor v/s
- Position : High Fowler’s position
- Assess for tracheal deviation
- Oxygen with humidifier
- Pulse oximeter
- Meds: Analgesics, Bronchodilators, corticosteroids
- Nutrition: High calorie, protein, vitamins
NON-SURGICAL SURGICAL
- Radiation therapy - Laser Therapy
- Chemotherapy - Thoracentesis / Pleurodesis
- Immunotherapy - Thoracotomy with pneumonectomy
o Thoracotomy with lobectomy
o Thoracotomy with segmental resection

PROSTATE CANCER
- SLOW GROWING
- Usually androgen dependent type of adenocarcinoma
- Risk = increases in men each decade after 50 y/o
- Metastasis= direct invasion, bloodstream & lymphatics, to bone (a concern)
Diagnosis:
- DRE
- PSAT
- Confirmed if with increased in Serum acid phosphatase
Signs/Symptoms:
- Early stage = asymptomatic
- Hard, peas sized nodule
- Hematuria
- Urinary obstruction
- Pain (Radiating from lumbosacral area down the leg)
Intervention:
NON-SURGICAL SURGICAL
- Hormone manipulation therapy - orchiectomy(palliative)
- Radiation Therapy = decreased testosterone
- Chemotherapy (Hormone resistant tumors) - TURP
o Prostatectomy
o Cryosurgical Ablation

BRAIN TUMOR
- LOCALIZED / INTRACRANIAL LESION
- Effects are due to compression & infiltration of tissues
- Primary vs. secondary
o Primary = Originated from cells & structures within the brain
o Secondary = Metastatic / develops from structures outside the brain
Cause:
- Unknown
Risk Factor:
- Exposure to ionizing radiation
- Greater in men than in women
Signs / Sypmtoms:
1. Increased ICP / Cerebral Edema
2. Seizure activity / focal neurologic signs
3. Hydrocephalus
4. Altered pituitary function
Classification:
I. INTRACEREBRAL TUMORS
a. GLIOMAS – infiltrate any portion of the brain; most common type of brain tumors
i. ASTROCYTOMAS
ii. GLIOBLASTOMA MULTIFORME
iii. OLIGODENDROCYTOMA
iv. EPENDYMOMA
v. MEDULLOBLASTOMA
II. ARISING FROM SUPPORTING STRUCTURES
a. Meningiomas
b. Neuromas
c. Pituitary Adenomas
III. DEVELOPMENTAL TUMORS
a. Angiomas
b. Dermoid, Epidermoid, Teroma, craniopharyngioma
IV. METASTATIC LESIONS
Diagnosis:
- CT SCAN
- MRI
- PET scan
- EEG
 - Cytologic Studies
Management:
NON-SURGICAL SURGICAL
- Chemotherapy - craniotomy
- Radiation therapy - Laser / Radiotion (Iodine 131)
- Brachytherapy - Gamma Knife
- Corticosteroids
- Photodynamic therapy33699