Care of the patient

with CANCER
1
2
Breast Cancer
3 Breast Cancer
Most common cancer in American
women- can also occur in men
Fibroademonas – benign, firm
rubbery texture, mobile well defined
Malignant masses – usually fixed,
irregular, hard and poorly defined
Men can develop breast cancer- less
than 1% incidence
Most occur with genetic mutation
of BRCA1 or BRCA 2
4
Risk factors for Breast Cancer
 Increased age –sporadic not definite
 Family history – especially if premenopausal
 Early menarche – before age 12 yr
 Late menarche – after age 50 yr
 Never had children – nuliparity
 Late age at first pregnancy/birth – after age
30
 High fat diet
 Obesity – especially after menopause
5 Risk factors for Breast Cancer

 BRCA1 gene on chromosome 17

 HER-2 genetic marker in breast cancer tissue
 History of breast cancer – may return
 Alcohol intake – 1 or more drinks daily
 HRT – hormone replacement therapy – after
age 50
Estrogen + progesterone is highest risk
 High dose of radiation therapy
6 Breast Cancer
30% American women have benign
fibrocystic masses that are bilateral,
tender, mobile, firm round and well
defined
Clinical breast exam
Women 20-40 years – every 3 years
Women over age 40 years- every year
+ mammogram
7 Breast Self Exam (BSE)
 Should begin early 30’s
 Clinical breast exam by HCP
 Every 3 years between age 20 – 30
 Every year over age 30
 Identify the lesion using the face of the clock
 Describe size, shape, and consistency
 Assess for:
 Dimpling, peau d’ orange
 Increased vascularity
 Nipple retraction
 Ulceration
8 Signs and Symptoms
 Mammogram changes
 Lump
 Thickening
 Swelling
 Dimpling
 Skin irritation
 Distortion
 Retraction
 Pain
 Nipple discharge
 Orange peel appearance
9 Retraction
10 Peau d’orange
11 Malignant lumps

Hard
Painless
Irregular
shape
Non mobile
12 Diagnosis
Mammogram, US, MRI,
BGSI – breast specific gamma imaging
PEM – positron emission mammography
Biopsy
Fine needle aspiration
Axillary lymph node status
exam 6-10 nodes
Hormone receptor status
13 Receptor positive tumors

Usually well differentiated

Low proliferative indices
Decreased visceral
recurrence are frequently
hormone dependent and
respond to hormone therapy
14 Receptor negative tumor

Poorly differentiated
Frequently recur on visceral sites
Usually unresponsive to
hormonal therapy
15 Treatment

Depends on nodes, age, menstrual

status, estrogen receptors
Small tumors
Lumpectomy & lymph node
dissection and radiation
Modified radical mastectomy –
reconstruction
Simple mastectomy – breast tissue &
nipple removed.
16 Treatment

Sentinel node biopsy- dye is injected

into the tumor site
Tumor is then excised
Surgeon locate the sentinel node and
removes it.
If the sentinel node is negative- do not
remove
If the sentinel node is positive –
remainder of the nodes are removed
17 Treatment – radiation
therapy
For 4-5 weeks
Primary treatment for early stage
and to prevent recur
Shrinks large tumors to operate
Treat pain from metastasis
18
19 New drugs
 Femara (letrozole)
First line hormonal treatment for advanced
breast cancer in post menopausal women

 Trastuzumab
DNA derived monoclonal antibody
Inhibits growth of tumor cells HER2 (human
epidermal growth factor receptor 2)
Given with IV taxol as First line treatment for
breast cancer tumors with HER2 protein
20 Hormone Therapy
 If estrogen receptors are positive, estrogen
promotes growth of the tumor cells

 Tamoxifen (nolvadex)
Anti-estrogen –blocks estrogen receptor sites
of malignant cells
Prevents and treats recurrent breast cancer
Used for 1-2 years to 5 years or longer
May increase the risk of endometrial cancer
21 Stem Cell Transplantation

Autologous
Allogenic
Option for high risk
recurrence
22
 Post op care
23
 Hemovac or JP drains – removed after several
days
 Only in hospital 1-2 days
 Dressing changes
 No BP, lab, IV in arm
 Be careful to avoid trauma or burns
 Restore arm function
◦ Semi fowlers position, arm above heart
◦ Hand exercises –gradually increase to brush hair
and wall climb exercise
 Prevent lymphedema
◦ Elevate the arm
◦ Pressure sleeve
24 Follow up

Every 3 months for 2 years

Every 6 months for 3 years
Every year there after

Self breast exam every month

Yearly mammogram
25 Psychologic Care
Assess meaning of loss of breast
Assess the impact on feminism/woman
hood
Assess the effect on relationships
26 Colorectal cancer

Tumors of the colon and rectum are

relatively common
3rd most common site of new cancer
cases and deaths in US
Considered a disease of western culture
Almost 150,000 new cases and 56,000
deaths annually
27 Colon CA – Risk factors
Increasing age
Family history of polyps or colon cancer
Pervious colon cancer of adenomatous
polyp
History of inflammatory bowel disease
High fat, high protein. (high intake of
beef) low fiber diet
Genital cancers (endometrial, ovarian)
or breast in women
Prevention and early screening are key
to detect and reduce mortality rates
28 Colon CA - Pathophysiology
Exact cause is still unknown – onset is
related to risk factors
95% are adenocarcinoma (arising from
the epithelial lining of the intestine)
May start as a benign polyp but may
become malignant and invade surround
tissue
Cancer cells may migrate from primary
tumor to other body parts – often liver
29 Manifestations
Change in bowel habits – most
common presenting symptoms
Passage of blood in stool – second
most common symptom
Unexplained anemia
Anorexia
Weight loss
Fatigue
30 Signs and locations
Right sided lesions
Dull abdominal pain, melena
Left sided lesions
Abdominal pain and cramps, narrow stools,
constipation, distention (symptom of
obstruction) and bright red blood in stool
(hematochezia)
Rectal lesions
Tenesums (ineffective painful straining at
stool) rectal pain, feeling of incomplete
evacuation after a bowel movement,
alternating constipation and diarrhea, blood
stools
31 Areas Where Cancer Can Occur
32 Gerontological
Considerations
 Incidence increases with age
 Symptoms are often insidious
 Often report symptom of fatigue – iron
deficient anemia may occur
 Early signs – change bowel & occasional
bleed
 Later signs- abdominal pain, obstruction,
tenesmus, rectal bleed
33 Gerontologic considerations
Lack of fiber major causative factor-
prolongs passage of feces in intestines
which extends exposure of
carcinogens
Excess dietary fat
High alcohol consumption
Smoking
Increased physical activity and dietary
folate – may have protective effects
34 Colon CA – Risk Potential
Tumor growth – partial or complete
obstruction of bowel
Extension of tumor and ulceration –
hemorrhage
Perforation
Abscess formation
Peritonitis
Sepsis
shock
35 Colon CA- diagnosis
Abdominal and rectal exam
Fecal occult blood testing
Barium enema
Proctosigmoidoscopy
Colonoscopy with biopsy- definitive test
CEA – carcinoembryonic antigen level
may not be highly reliable as some tumors
do not secrete CEA –better indicator of
prognosis- affected by smoking
With complete excision of tumor- CEA should
be normal in 48 hours
Elevation at a later date indicated recurrence
36 Treatment
Chemotherapy- 5FU + levamisole
Mitomycin is also used. FOLFOX-
metastatic.
Pelvic irradiation at high doses may be
used with chemo
Radiation therapy is used before ,during
and after surgery to shrink the tumor.
Radiation also – inoperative or unrelieved
symptoms- pallitive.
37 Surgical management

 Surgery – primary treatment

 May be curative or palliative
 Advances now allow for sphincter saving
devices that restore continuity in GI tract
 Local cancer – can be removed with
colonoscopy
 Laparoscopy is used as a guide in making
an incision in to the colon – tumor excised
38 Surgical Treatment
 Bowel resection procedure
◦ Segmental resection
◦ Abdominoperineal resection with permanent sigmoid
colostomy
◦ Temporary colostomy
◦ Permanent or temporary ileostomy

◦ P/O complication: Fistula – an abnormal opening

between the vagina and bladder, rectum and vagina
◦ What nursing care interventions would be included in
the patient’s nursing care plan?
◦ Sitz baths, peri-care, peri-pads, low residue diet
39 Abdomino-perineal Resection for
Carcinoma of the Rectum
40 Ostomy Care

Review your notes:

Normal appearance
Ostomy appliance
Emergency situation –
describe assessment

Yes – this will be on the test.

41 Nursing care
Monitor vital signs, hourly output,
Note signs of infection, shock,
hemorrhage
Monitor surgical dressing and wound
Monitor bowel sounds
Monitor labs –H&H, WBC
Pain management
42 Teaching
Ostomy care
Nutrition therapy – to
prevent recur
Identification and
prevention of complication
When to notify Health Care
Provider of complication
 Lung Cancer
43
Bronchogenic Carcinoma
Tumors of the lung may be benign or
malignant
Malignant chest tumor may be primary-
arising within the lung, chest wall or
mediastinum or it can be a metastasis
from a primary tumor site elsewhere in the
body
Lung is a primary site of metastasis due to
high circulatory volume and thus
transport of malignant cells from other
body parts
44 Lung Cancer- Incidence

Leading cancer killer among men and

women in the US
For men- incidence of lung cancer has
remained relatively constant and women
it has begun to plateau after a
continuous rise over the past 30 years
2/3 of the US population with lung cancer
are over age 65 years
Approximately 70% of lung cancer patient
have metastasis by the time of diagnosis –
thus survival rate is low
 Lung CA
45
Lung cancers arise from a single
transformed epithelial cell in the
tracheobronchial airways, in which the
carcinogen binds to and damages the
cell’s DNA
Damaged DNA is passed on to daughter
cells and undergoes further change
Epithelium undergoes malignant
transformation to invasive carcinoma
Evidence indicates CA tends to arise at
sites of previous scarring (TB, fibrosis)
46 Lung CA

Classification and Staging

Most lung cancers are
staged according to the
following
Small cell carcinoma
Non small cell
carcinoma
47 Small cell carcinoma

Represents 15%- 20% of tumors

Most arise in the major bronchi
and spread by infiltration along
the bronchial wall
Accounts for 20%-25% of all
bronchogenic cancers
48 Non small cell carcinoma

Represent the remaining 75%-

80% of tumors
Is further classified by cell type
Squamous cell cancer
Adenocarcinoma
Large cell carcinoma
49 Squamous cell cancer

Usually more centrally

located
Arises more commonly in the
segmental and sub
segmental bronchi
Represents 20% to 30% of
tumors
50 Adenocarcinoma

Most prevalent carcinoma of

the lungs in both men and
women
It occurs peripherally as a
peripheral mass or nodule
and often metastasizes
Represents 30% - 40% of
tumors
51 Large cell carcinoma

Also called
“undifferentiated
carcinoma”
A fast growing tumor that
tends to arise peripherally
Represents 10% of tumors
52 Bronchoalveolar Cell
Cancer
Found in the terminal
bronchi and alveoli
Is usually slower
growing compared
with other
bronchogenic
carcinoma
 Risk factors
53

80%-90% lung cancers caused

by inhaled carcinogens
◦ Tobacco use- most common factor
◦ Second hand smoke (passive
smoke) estimates 3000 deaths /year
◦ Environmental carcinogens – MV
emissions, pollutants from refineries
and manufacturing plants
5
4
Question 1

The nurse understands which is the primary risk factor for lung
cancer?

A. Air pollution
B. Cigarette smoking
C. Chronic exposure to asbestos
D. Occupational radiation exposure
 Risk factors
55

Radon – colorless, odorless gas

found in soil and rocks
Occupational carcinogens –
arsenic, asbestos, mustard gas,
coke oven fumes
Genetics – incidence in close
relatives is 2-3 times that of
general population
Dietary factors – smokers with
diet low in fruit and vegetables
(lack of carotene or vitamin A)
 Clinical Manifestations
56

Cough – changes in character

should arouse suspicion of lung
cancer
◦ Starts dry, persistent without sputum
◦ With obstruction of airways, cough
may become productive due to
infection
◦ Develops insidiously and is
asymptomatic until late in the
course of the disease
57 Clinical manifestaions
S/S depend on the location and size of
the tumor, degree of obstruction and the
extensiveness of the metastasis
Dyspnea in 35% -50% of patients
Hemoptysis
Chest or shoulder pain-may indicate
chest wall or pleural involvement
Pain is a late manifestations – may be
related to metastasis
Recurring fever – response to infection
58 Clinical manifestations
 When tumor spreads to adjacent structures
and regional lymph nodes
Chest pain and tightness
Hoarseness – involve laryngeal nerve
Dysphagia
Head and neck edema
Non specific weakness, anorexia, weight
loss
S/S of pleural or pericardial effusion
 Suspect cancer in patients the repeated,
unresolved URI- especially those with unusual
causative organisms such as fungal
59 Lung Cancer - Diagnosis
 Chest x ray –search for density, a solitary
pulmonary nodule, atelectasis, or infection
 CT scan – small nodules and lymphadenopathy
 Fiberoptic bronchoscopy- detailed study of lung
– brushings, washing, biopsies of suspected areas
 Trans-thoracic Fine Needle Aspiration under CT –
used for peripheral lesion to aspirate cell for
cytology
 Fiberoptic bronchoscopy
 Thoracoscopy
60 Diagnose metastasis
Bone scan
Abdominal scan
PET scan
Liver ultrasound
CT of brain
MRI
Mediastinoscopy or mediastinotomy-
to obtain biopsy samples from lymph
nodes in the mediastinum
61 Medical Management
 Objective – to provide a cure if possible
 Treatment depends on the cell type, the stage of
the disease and the patient’s physiological status
(cardiac and pulmonary)
 May involve surgery, radiation, or chemo- usually
a combination
 Newer and more specific therapies to modulate
the immune system (gene therapy, therapy with
defined tumor antigens) under study
62
Radiation therapy
May offer a cure for small number
Useful in controlling neoplasm that
cannot be surgically resected but are
responsive to radiation
May be used to reduce the size of the
tumor – to make it operable, to reduce
symptoms - cough, chest pain, dyspnea

Radiation therapy is toxic to normal cells –

may cause pneumonitis, esophagitis, and
lung fibrosis- may impair ventilatory and
diffusion capacity and significantly
reduce pulmonary reserve
63 Chemotherapy

Used to alter tumor growth

patterns, to treat distant metastasis
or small cell cancer of the lung
May be used to treat symptoms
especially pain
Choice of agent depends on the
tumor cell, specific phase of the
cell cycle
Combinations are more beneficial
64 Chemotherapy agents used
Platinum analogues – cisplatin &
carbolated
Nonplatinum containing agents –
taxans palliate & doxetaxel
Vinca alkaloids – vincristine and
vindesine
Ironotecan – CPT-11
Epidural growth factor – tyrosin kinase
inhibitors- gefitinib (iressa) and
erlotinib Tarceva- oral form
65 Photodynamic Therapy
Cure for selective lung cancers.
Sensitize cells to light- injection of
drug.
Laser damages cancer cells &
slough off.
Risk for hemorrhage, fistula
formation, & hemoptysis.
Light sensitivity issue for next 3
months.
66 Surgical management

Surgical resection is the

preferred treatment
Contraindications for surgery –
CAD, Pulmonary insufficiency,
other co morbidities
Lobectomy
Pneumonectomy
67 Palliative therapy
Radiation therapy to reduce
tumor size to provide relief of
pain and other symptoms
Bronchoscopic interventions
– open a narrowed bronchus
or airway
Pain management
Hospice care
End of life care
68 Treatment related
complications
Respiratory failure- with prolonged
mechanical ventilation
Radiation therapy – can diminish
cardiopulmonary function – pulmonary
fibrosis, pericarditis, myelitis and cor
pulmonale
Chemotherapy relates complications
Pulmonary toxicity –potential side
effect of chemo
69 Nursing management
Physiologic problems – impaired gas
exchange
Pain management
Prevention of complications
Reduce fatigue
Prevent GI disturbances
Psychological support
Identify potential resources for patient
and family
70 Gerontologic considerations
Most patients are over 65 years old at
the time of diagnosis
Most patients have stage III or IV
Functional status may limit
adaptation
Concomitant medications
Psychological and social support
systems
Chemo and radiation may need to
be adjusted to maintain quality of life
 Prostate Cancer
71
72 Prostate Cancer

Most are slow growing

Usually monitor without
treatment initially
Most are androgenic sensitive
 Signs of CA of Prostate
73
 Early – asymptomatic
 Lumbosacral pain which radiates down the legs – this
indicated metastasis
 Metastasis – lymph, nearby bones, lungs, liver,
 Then S&S of BHP
 Urgency, frequency, hematuria, difficulty starting
stream nocturia
 Scrotal pain or swelling
 Rectal exam –
 Prostate hard, unilaterally enlarged and fixed
 Lymph node enlargement
 Pain during intercourse
74 Examination of the Prostate
75 Prostate Cancer Diagnosis

 PSA – Prostate Specific Antigen

Glycoprotein produced by the prostate
Not an absolute specific test
EPCA – early prostate cancer antigen –
very sensitive for early disease
Below age 50 yr - less than 2.5 ng/ml
Over age 50 yr - 7.5 mg
African American slightly higher level
76 Prostate Cancer Diagnosis

 Rectal exam in men over age 40 yrs

 Transurethral ultrasound
 Needle guided biopsy
 Prostatic isoenzyme acid phosphatase (PAP)
 CT or MRI
 Alkaline phosphatase is elevated with
advanced disease
Elevates with bone metastasis
77 Staging of CA Prostate

Staging
A – asymptomatic
B – confined
C – near structures
D - metastasis
78 Prostate Cancer

Depends on the stage

Older men who are
asymptomatic and have other
illness may do “watchful
waiting”
Continued waiting may be for
10 years or more
79 Treatment – Radiation Therapy
 External Beam – teletherapy
6-7 weeks of daily therapy (5 day/week)
 Brachytherapy- implantation of interstitial
radioactive seeds under anesthesia
80-100 seeds – returns home
Minimal exposure to others but avoid
Pregnant women and children for 2
months
Strain urine to check for seeds
Use condom for intercourse for 2 week
post implant
80 Hormone Therapy
 Most prostate cancer is androgen dependent –
and could be controlled with androgen
withdrawal

Orchiectomy – removal of testes

Reduces hormone levels by 93-94%
Results in significant morbidity
81 Hormone Therapy – Drug induced

Nonsteroidal antiandrogen –
bicalutamide (casodex)

Estrogen therapy – DES (diethylstilbestrol)

Inhibit gonadotropins responsible for
testicular androgenic activity
Side effects – thromboemboli, PE, MI,
and stroke
82 Newer drugs
LHRH- luteinizing hormones-releasing
hormone agonists
Leuprolide {lupron} & Goserelin
{zoladex}
Block androgens and pituitary level
Given q month by sub Q injection
Anti-androgen agents
Flutamide {eulexin}
83 Treatment CA Prostate

Cryosurgery- to freeze the tumor

Chemo
Cyclophosphamide, methotrexate,
doxorubicin, 5FU, cisplatin, mitomycin,
decorbazine, etoposide
Usually a combination of these
84 Treatment
Surgery
Radical Prostatectomy – complete
removal of the prostate, seminal
vesicles, tips of the vas deferens, and
often the surrounding tissue
Laproscopic radical prostatectomy –
new technique – no data to show
effect
85 Prostate Surgery Procedures
86
Prostate Surgery Procedures (cont.)
 Three-Way System for Bladder Irrigation
87
 Testicular Self-Exam
88
89 Skin Cancer
Most common cancer in US
1/8 of all fair skinned Americans
will eventually develop skin
cancer, especially basal cell
carcinoma
Most successfully treated type of
cancer due to readily detected
and treated
90 Skin cancer
Seek advice on skin lesions
Change in color – especially if darkens or
shows evidence of spread
Rapid growth
Change in shape – sharper borders,
becomes irregular. Flat becomes raised
Change in sensation – itch or increasing
tenderness
Change in character
Oozing, crust, bleed or scaling
91
92 Skin cancer
93 Leading cause
Exposure to the sun with
cumulative effect (lifestyle,
sunbathing, sunburns)
New research shows more sun
burns as children the higher
incidence of cancer
Caused also by environmental
factors – holes in the earths ozone
94 Types
Basal Cell Carcinoma (BCC)
Most common type
Appears on sun exposed areas of skin
Begins as a small, waxy nodule with
rolled, translucent pearly borders or
shiny flat, grey or yellowish plaque
As it grows, develops a central
ulceration and sometimes crusting
Most frequently on the face, (nose, ear,
lip)
Rarely mets, but recurrence is common
95 Type
Squamous cell (SCC)
Malignant proliferation arising from
the epidermis
May arise from skin that is normal,
sun damaged or from pre-existing
skin lesions
Greater concern – truly invasive
cancer, metastasizing by blood, or
lymph system
96 Squamous cell Carcinoma
 Mets account for 75% of deaths
 Primary lesions arising from the skin and mucous
membranes

 May develop from a precancerous conditions

such as
Actinic keratosis- sun exposed lesions
Leukoplakia – premalignant lesion of mucous
membrane
Scarred or ulcerated lesions
97 Squamous cell Carcinoma

 Appears as rough, thickened, scaly

tumor- may be asymptomatic or may
involve bleeding
 Border of SCC lesion may be wider,
more infiltrated and or inflammatory
 Common sites – exposed areas of
upper extremities, face, lip, ears, nose,
forehead
 Increased incidence in
immunocompromised patients (HIV)
98 Medical Management
Depends on
 tumor location
cell type depth,
History of previous invasive
procedure
Cosmetic desired effect
Has metastasis occurred
99 Surgical Treatment

Surgery – remove the entire tumor

Moh’s micrographic surgery – most
accurate, layer by layer
Electrosurgery- remove by electric
current
Cryosurgery- destroys tumor by deep
freezing the tissue
10
0 Radiation

Used for cancer of the tip of the

nose, eyelids, and areas in or
near vital structures such as
facial nerves
Limited to older age, deeply
invasive
10
1 Prevention

Sunscreen
Monitor moles for any
changes
Avoid irritants
10
2 Malignant Melanoma

Cancerous neoplasm in which

atypical melanocytes are
present in the epidermis and
the dermis (sometimes
subcutaneous cells)
Most lethal of all skin cancers
1% of all cancer deaths
10
3 Melanoma - Incidence

Increasing incidence due to

sun exposure and change in
ozone layer
Peak incidence between 20-45
years
Mortality rate increasing faster
than any other Cancer except
lung cancer
10
4 Risk Melanoma

UV rays
1/100 Caucasians acquire
it yearly
Melanoma prone families
due to moles (absence of
gene 9p)
10
5 Melanoma signs
 Superficial spreading melanoma
Most common form (middle age)
Occurs anywhere on the body – often trunk
and lower extremities
Appear circular with irregular borders
Flat or papules
Combination of colors with hues of tan,
brown, and black mixed
May also be gray, blue-black or white
May be a dull pink rose color
10
6 Melanoma diagnosis

Biopsy
Thorough skin assessment
Family history
Confirm – chest x ray, CBC,
liver functions, CT scan to
stage the disease
10
7 Prognosis
Poor if lesions >1.5 mm thick or
with lymph node involvement for
long term (5 years)
If on hand, foot, or scalp have
better prognosis
Lesions on torso have ^chance
of metastasis to bone, liver,
lungs, spleen and CNS
Men and elderly have poorer
prognosis
10
8 Medical Management

Treatment depends on level

of invasion and depth of
lesion
Surgical excision
Includes regional lymph
node dissection verse
sentinel node biopsy
10
9 Treatment
Immunotherapy – modifies immune
function and other biologic
responses
Biologic response modifiers –
investigational
Interferon –alpha & interleukin 2
Chemotherapy
Dacarbazine, nitrosurea, cisplatin
May be given directly into the
tumor
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0 Nursing Care

Assess patient’s history for pruritus,

tenderness, pain, and change in
mole
A- asymmetry
B- borders irregular
C – color is variegated
D - diameter