Oncology

ONCOLOGY

Peter Glen L. Reyes, PTRP,RN,MAN

CANCER CELLS 

BREAST CANCER

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CANCER CELL

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LUNG CANCER

Epidemiology, Etiology, Terms 

Disorders that can involve all body organs with manifestations that vary according to the body system affected and type of tumor cells

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Cells lose their normal growth controlling mechanisms and the growth of cells is uncontrolled. Cancer produces serious health problems such as impaired immune and hematopoietic function, altered GIT structure and function, sensory deficits and decreased respiratory function.

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Epidemiology, Etiology, Terms 

Cancer is the second most common cause of death in the USA

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Sites in men associated with greatest mortality: lung, colon, rectum and prostate

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Sites in women with greatest mortality: breast, lung, colon, and rectum

Etiology 

Generally unknown but may be caused by interacting factors

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Theories include predisposing factors: constant irritation environmental carcinogens radiation

METASTASIS 

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LOCAL SEEDING –distribution of shed cancer cells occur in the local area of the primary tumor BLOOD BORNE –tumor cells enter the blood, which is the most common cause of cancer spread LYMPHATIC SPREAD –primary sites rich in lymphatics are more susceptible to early metastatic spread

Hyperplasia involves an increase in the number of cell in a tissue; may be a normal or an abnormal cellular  Metaplasia refers to the conversion of one type of response

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cell in a tissue to another type not normal to that tissue. It results from an outside stimulus affecting parent stem cells and may be reversible or progress to dysplasia Dysplasia refers to a change in size, shape, or arrangement of normal cell into bizarre cells; may precede an irreversible neoplastic change Anaplasia involves a change in the structure of cells and in their orientation to one another, characterized by a loss of differentiation and a return to a more primitive form. The resulting poorly differentiated, irregularly shaped cells are nearly always malignant

CELL DIVISION 

MUTATION

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DYSPLASIA

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HYPERPLASIA

Neoplasia refers to the abnormal benign or  malignant cell growth Benign neoplasm: usually harmless, does not infiltrate other tissues

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Malignant neoplasm: always harmful, may spread or metastasize to tissues far from the original site

CANCER CLASSIFICATION 

SOLID TUMORS – associated with organs from which they develop such as breast cancer or lung cancer

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HEMATOLOGICAL CANCER –originate from the blood cell-forming tissue, such as leukemia, lymphomas, and multiple myeloma

Cancer terminology primary site of neoplasm is its site of origin  secondary sites represent metastasis  types of neoplasms: benign and malignant

four types of malignant carcinomas: usually solid neoplasms tumors arising from epithelial 

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cell sarcomas: from muscle, bone, fat and other connective tissuesarcomas: from muscle, bone, fat and other connective tissue lymphomas: originate in the lymphatic system leukemias: originate in the blood system

TYPES OF CANCER

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SQUAMOUS CELL CARCINOMA

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LARGE CELL CARCINOMA

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History and physical exam - depends on location of tumor

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Biopsy: obtaining tissue for histological examination

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Imaging: CT scan, MRI

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BONE MARROW ASPIRATION 

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Usually involves aspiration of the marrow to diagnose diseases like leukemia, aplastic anemia Usual site is the sternum and iliac crest Pre-test: Consent Intratest: Needle puncture may be painful Post-test: maintain pressure dressing and watch out for bleeding

DIAGNOSTIC TESTS MRI  Uses magnetic waves  Patients with pacemakers, orthopedic metal prosthesis and implanted metal devices cannot undergo this procedure  NPO 4-6 hours before procedure

MRI  

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A. Definition 1. This procedure utilizes magnetism and radio waves to produce images of cross-sections of the body 2. The MRI machine registers the existence of odd-number edatoms in the cross sections of the body, yielding data about the chemical makeup of the tissues 3. MRI can produce accurate images of blood vessels, bone marrow, gray and white brain matter, the spinal cord, the globe of the eye, the heart, abdominal structures, and breast tissue, and can monitor blood velocity.

MRI  

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Nursing care 1. Assess ability to withstand confining surroundings because client must remain in the tunnel-like machine for up to 90 minutes; open MRI may be an option for clients who cannot tolerate closed spaces 2. Instruct client to toilet prior to test, since this will be impossible during the procedure 3. Advise client to remove jewelry, clothing with metal fasteners, dentures, hearing aids, and glasses prior to entering scanner.

MRI  

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4. Since this procedure is contraindicated for certain clients, before the test assess for: a. Metal prostheses, such as orthopedic screws, since the magnetic force can dislodge the devices. b. Pacemakers, since the scanner deactivates pacemaker. c. Dysrhythmias, because the magnetic field can affect the conduction system of the heart d. Unstable medical conditions, since monitoring of the client is limited during the test. 5. Evaluate client's response to procedure.

DIAGNOSTIC TESTS CT scan  With radiation risk  If contrast medium will be used- ensure consent, assess for allergies to dyes and iodine or seafood, flushing and metallic taste are expected as the dye is injected

Computerized Tomography (CT)  

A. Definition 1. Cross-sectional visualization of the brain determined by computer analysis of relative tissue density as an x-ray beam passes through; also known as computerized axial tomography (CAT) scan

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2. Provides valuable information about location and extent of tumors, infarcted areas, atrophy, and vascular lesions 3. May be done with or without intravenous injection of dye for contrast enhancement

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B. Nursing care 1. Explain procedure; inform the client that it will be necessary to lie still and that the equipment is complex but will cause no pain or discomfort; infants and cognitively impaired or anxious clients may need to be sedated 2. If the facility is small, arrange transportation to a larger facility that has the required equipment

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3. Evaluate for possible allergy to iodine, a component of the contrast material 4. Withhold food for approximately 4 hours prior to testing; dye may cause nausea in sensitive patients 5. Remove wigs, clips, and pins prior to the test 6. Evaluate client's response to procedure.

Staging and grading

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Staging: describe and classify extent of a malignancy when it is diagnosed

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Grading: describe the degree of malignancy according to the type of tumor cell

Treatment in General 

Objective: to remove all traces of the cancerous tissue

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Treatment plan based on stage and grade of tumor

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Surgery: specific to site of malignancy

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Metastatic Disease 

Spread of malignancy beyond the primary site; means of metastasis: 

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Tumor invades adjacent tissue

Tumor sheds cells into body cavities Tumor cells spread via the lymphatic system or blood stream

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Major cause of death from cancer 

Most common sites: 

to lung from primary sites in colon, rectum, breast, renal system, testes and bone

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to liver from primary sites in lung, colon, rectum, breast and renal system

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to CNS from primary sites in lung and breast

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to bone from primary sites in lung, breast, renal system and prostate

FACTORS THAT INFLUENCE CANCER DEVELOPMENT 

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Chemical carcinogen – industrial chemicals, drugs, and tobacco Physical carcinogen – radiation (diagnostics, sun, ultraviolet) Viral –viruses capable of causing cancer are known as oncoviruses such as Epstein-Barr, heap B, and human papillomavirus H. pylori –is associated with increased risk of gastric cancer

CAUSES        

SUN EXPOSURE PRESERVATIVES SMOKED FOODS CARCINOGENS RADIATION TOBACCO H.PYLORI INDUSTRIAL AGENTS

FACTORS THAT INFLUENCE CANCER DEVELOPMENT 

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Obesity and dietary factors –preservatives, additives, and nitrates Genetic predisposition Age Immune function –higher in immunosuppressed persons, such as AIDS px., organ transplant taking immunosuppressive meds.

NUTRITIONAL GUIDELINES TO REDUCE THE RISK OF MANY TYPES OF CANCER   

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Avoid obesity Decrease total dietary fat intake Eat more high-fiber foods, such as whole grain, cereals, fruits, and vegetables Include foods rich in vitamins A and C in the daily diet Include cruciferous vegetables (e.g. cabbage, broccoli, bruselle’s sprouts, kohirabi, cauliflower) in the diet Consume alcoholic beverages only in moderation Consume salt-cured, smoked, and nitrite-cured foods only in moderation

OTHER ACCEPTED RISKREDUCTION MEASURES INCLUDE  

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Avoid tobacco use Avoid excessive sun exposure, particularly between 10 a.m. and 3 p.m. Avoid exposure to industrial agents known to increase cancer risk

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Cancer Pain Management 

Although clients with cancer may experience pain at any time during their disease, pain is usually a late symptom of cancer

EARLY DETECTION       

Mammography Pap’s test Stools for occult blood Sigmoidoscopy and colonoscopy BSE TSE Skin infection

MAMMOGRAPHY

CAUTION 

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Change in the bladder and bowel habits Any sore that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere I Obvious change in wart or mole Nagging cough or hoarseness

SIGNS OF CANCER

PREVENTION 

AVOIDANCE of known or potential carcinogens and avoidance or modification of the factors associated with the development of cancer cells

BREAST SELF EXAMINATION 

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PERFORM 7 TO 10 DAYS AFTER MENSTRUATION Postmenopausal clients should select a specific day of the month and perform BSE monthly on that day

Breast self examination

TESTICULAR SELF EXAMINATION

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Performed on the same day of each month Best time is right after shower

TESTICULAR SELF EXAMINATION

DIAGNOSTIC TESTS/BIOPSY 

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Definitive means of diagnostic cancer and provides histological proof of malignancy Involves the surgical incision of a small piece of tissue for microscopic examination

BIOPSY/TYPES  

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Needle-aspiration of cells Incisional-removal of suspected tissue from a larger mass Excisional-complete removal of the entire lesion

OTHER DIAGNOSTIC TESTS        

Bone marrow examination Chest radiograph Computed tomography Pap’s smear Liver function tests MRI Protoscopic examination Mammography

SIGMOIDOSCOPY

PAP TEST

COLONOSCOPY

PAIN CONTROL

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Causes of Pain

Bone destruction Obstruction of an organ Compression of peripheral nerves Infiltration, distention of tissues Inflammation, necrosis

INTERVENTIONS  

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Asses the client’s pain Collaborate with the other health team to develop a pain management program Mild or moderate pain may be treated with salicylates, acetaminophen, NSAIDS Severe pain is treated with opioids Monitor vital signs and for side effects of medication Monitor for effectiveness of medications Provide non-pharmacological techniques of pain control, i.e. relaxation, biofeedback, massage, heat/cold application

REMINDER 

“DO NOT UNDER-MEDICATE THE CANCER CLIENT WHO IS IN PAIN”

SURGERY-indicated to diagnose, stage, and treat cancer 

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Prophylactic-an attempt to remove the tissue or organ at risk and thus prevent the development of cancer Curative-all gross and microscopic tumor is removed or destroyed Control/debulking-removing a large portion of a local tumor such as ovarian cancer Palliative-performed to reduce pain, relieve airway obstruction, relieve obstruction in the GI or urinary tract, relieve pressure in the brain or spinal Cord, performed to improve quality of life during the survival time Reconstructive or rehabilative -improve quality of life by restoring maximal function and appearance, i.e. breast reconstruction after mastectomy

SIDE EFFECTS OF SURGERY    

Loss or loss of function of a specific body part Reduced function as a result of organ loss Scarring or disfigurement Grieving about the altered body image or imposed change of lifestyle

CHEMOTHERAPY 

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Kills or inhibits the reproduction of neoplastic cells and kills the normal cells Highly toxic agents that attack all rapidly dividing cells , both normal and malignant Most agents modify or interfere with DNA synthesis

ANTINEOPLASTICS (CYTOTOXIC, ANTIPROLIFERATIVE AGENTS) Alkalyting agents (cytoxan): produce breaks in DNA molecule and cross-linking of strands thus interfering with DNA replication; most effective in hematologic malignancies Antitumor antibiotics (biomycin): bind directly with DNA changing its configuration and inhibiting replication Antimetabolites :5-fluorouracil, floxuridine: inhibit DNA synthesis; most effective against rapidly growing tumors enzymes necessary for cell function and replication Plant alkaloids: vincristine: bind to substances needed to form mitotic spindle, thus preventing cell division Hormone and hormone inhibitors: alters the endocrine environment to make it less conducive to cell growth; used in cancers of the breast, prostate, and other reproductive organs

Chemotherapy drugs 

Anti neoplastic drugs: vincristine,etc

ROUTES OF ADMINISTRATION 

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Intravenous (peripheral or central nervous access) Oral Intraarterial Intraperitoneal Intrapleural

Use 

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To cure, control or palliate results of neoplasm May be used as an adjunct to surgery and radiation

ADVERSE EFFECTS: RESULTS FROM THE DAMAGE TO NORMAL CELLS         

Nausea/vomiting, stomatitis, alterations in taste, anorexia Diarrhea, constipation Alopecia, dermatitis, pruritus, paresthesia, rash, bruising Hemorrhagic cystitis Cardiomyopathy Fatigue, dyspnea, fever, chills Sterility, amenorrhea Depression, anxiety Myelosuppression

NURSING INTERVENTIONS             

Monitor lab studies as ordered Monitor IV site for extravasation Maintain strict asepsis Administer antiemetic agents as ordered and prophylactically before chemotherapy Give antihistamines as ordered Withhold food and liquids for 4 to 6 hours before treatment Between treatments, give small, frequent, bland meals Give antidiarrheals as ordered Monitor signs of dehydration and encourage fluids as tolerated Provide frequent oral hygiene, lubricate lips as indicated For stomatitis, use topical anesthetics before eating and as indicated Apply lotion to skin as indicated; avoid harsh, drying soaps Provide a restful environment, emotional support, and anxiolytics as ordered

TEACH CLIENT 

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Medications and side effects Alopecia is temporary Avoid bruising, aspirin products, and persons with infection Conserve energy Recognize signs of bleeding, anemia, infection Use soft-bristle toothbrush Avoid use of razors

Anti neoplastic drugs: vincristine,etc

SPeCIAL NURSING CONSIDERATIONS 

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Exposure to chemotherapeutic agents can lead to adverse reactions Contact dermatitis Nausea and vomiting Diarrhea

Exposure during pregnancy can lead to   

increased risk of fetal abnormalities ectopic pregnancies spontaneous abortions

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Salamat po