What Is Cancer?

CANCER is a complex of diseases which occurs when normal cells mutate into abnormal cells that take over normal tissue, eventually harming and destroying the host Most cancers form a tumor but some, like leukemia, do not

A large group of diseases characterized by: Uncontrolled growth and spread of abnormal cells Proliferation (rapid reproduction by cell division) Metastasis (spread or transfer of cancer cells from one organ or part to another not directly connected) Properties: Increased cell proliferation (often autonomous) Insufficient apoptosis Altered cell and tissue differentiation Altered metabolism Genomic instability Immortalization (growth beyond replicative senescence) Invasion into different tissue layers and other tissues (with disturbed tissue architecture) Metastasis into local lymph nodes and distant tissues Oncology :Branch of medicine that deals with the study, detection, treatment and management of cancer and neoplasia Root words Neo- new Plasia- growth Plasm- substance Trophy- size +Oma- tumor Statis- location A- none Ana- lack Hyper- excessive Meta- change Dys- bad, deranged

Uncontrolled growth of Abnormal cells Not all tumors are cancerous; tumors can be benign or malignant. Benign tumors aren't cancerous. They can often be removed, and, in most cases, they do not come back. Well-differentiated Slow growth Encapsulated Non-invasive Does NOT metastasize

Malignant tumors are cancerous. Cells in these tumors can invade nearby tissues and spread to other parts of the body. The spread of cancer from one part of the body to another is called metastasis. Undifferentiated Erratic and Uncontrolled Growth Expansive and Invasive Secretes abnormal proteins Loss of Normal Growth Control Some cancers do not form tumors. For example, leukemia is a cancer of the bone marrow and blood. Nomenclature of Neoplasia Tumor is named according to: 1. Parenchyma, Organ or Cell Hepatoma- liver Osteoma- bone
Myoma- muscle 2. Pattern and Structure, either GROSS or MICROSCOPIC

 Fluid-filled CYST Glandular ADENO Finger-like PAPILLO Stalk POLYP Nomenclature of Neoplasia 3. Embryonic origin Ectoderm ( usually gives rise to epithelium) Endoderm (usually gives rise to glands) Mesoderm (usually gives rise to Connective tissues) BENIGN TUMORS Suffix- OMA is used Adipose tissue- LipOMA Bone- osteOMA Muscle- myOMA Blood vessels- angiOMA Fibrous tissue- fibrOMA MALIGNANT TUMOR 1. Ectodermal, Endodermal, Glandular, Epithelial Use the suffix- CARCINOMA Pancreatic AdenoCarcinoma Squamos cell Carcinoma 2. Mesodermal, connective tissue origin Use the suffix SARCOMA FibroSarcoma Myosarcoma

 AngioSarcoma PASAWAY 1. OMA but Malignant HepatOMA, lymphOMA, gliOMA, melanOMA 2. THREE germ layers TERATOMA 3. Non-neoplastic but OMA Choristoma Hamatoma Patterns of cell Proliferation Hyperplasia Dysplasia Metaplasia Anaplasia Neoplasia Patterns of cell Proliferation Metaplasia conversion of one type of cell in a tissue to another type not normal for that tissue Anaplasia change in the DNA cell structure and orientation to one another, characterized by loss of differentiation and a return to a more primitive form. Neoplasia uncontrolled cell growth, either benign or malignant

Metastasis: 3 stages Invasion neoplastic cells from primary tumor invade into surrounding tissue with penetration of blood or lymph. Spread tumor cells spread through lymph or circulation or by direct expansion

 Establishment and growth tumor cells are established and grow in secondary site: lymph nodes or in organs from venous circulation Spread of Cancer 1. LYMPHATIC Most common 2. HEMATOGENOUS Blood-borne, commonly to Liver and Lungs 3. DIRECT SPREAD Seeding of tumors

Body Defenses Against TUMOR 1. T cell System/ Cellular Immunity Cytotoxic T cells kill tumor cells 2. B cell System/ Humoral immunity B cells can produce antibody 3. Phagocytic cells Macrophages can engulf cancer cell debris

ETIOLOGY/CAUSATIVE FACTORS age Viruses Chemical carcinogens Physical stressors Hormonal factors Genetic factors 2. CHEMICAL AGENTS Smoking Dietary ingredients Drugs 3. Genetics and Family History

1. PHYSICAL AGENTS Radiation Exposure to irritants Exposure to sunlight Altitude, humidity

 Colon Cancer Premenopausal breast cancer 4. Dietary Habits Low-Fiber High-fat Processed foods alcohol 5. Viruses and Bacteria DNA viruses- HepaB, Herpes, EBV, CMV, Papilloma Virus RNA Viruses- HIV, HTCLV Classification of Tumors Effects of Cancer

Bacterium- H. pylori

6. Hormonal agents DES OCP especially estrogen

7. Immune Disease AIDS BURKITTS LYMPHOMA - a cancer of the lymphatic system

Disruption of Function- can be due to obstruction or pressure Hematologic Alterations: can impair function of blood cells Hemorrhage: tumor erosion, bleeding, severe anemia Anorexia-Cachexia Syndrome: wasted appearance of client Paraneoplastic Syndromes: ectopic sites with excess hormone production Parathyroid hormone hypercalcemia secretion of insulin hypoglycemia Antidiuretic hormone (ADH) fluid retention, HTN & peripheral edema Adrenocorticotropic hormone (ACTH): cause excessive secretion of cortisone (ie: fluid retention, glucose levels) Pain: major concern of clients and families associated with cancer Physical Stress: body tries to respond and destroy neoplasm

ASSESSMENT Nursing History Health History chief complaint and history of present illness (onset, course, duration, location, precipitating and alleviating factors) Warning Signs of Cancer Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickenings or lumps Indigestion or difficulty in swallowing Obvious change in a wart or mole Nagging or persistent cough or hoarseness Unexplained anemia Sudden unexplained weight loss Change in bowel or bladder habits A person with colon cancer may have diarrhea or constipation, or he may notice that the stool has become smaller in diameter A person with bladder or kidney cancer A sore that does not heal Small, scaly patches on the skin that bleed or do not heal may be a sign of skin cancer A sore in the mouth that does not heal can indicate oral cancer Unusual bleeding or discharge Blood in the stool is often the first sign of colon cancer Similarly, blood in the urine is usually the first sign of bladder or kidney cancer Postmenopausal bleeding (bleeding after menopause) may be a sign of uterine cancer Thickenings or lumps

 Enlargement of the lymph nodes or glands (such as the thyroid gland) can be an early sign of cancer Breast and testicular cancers may also present as a lump Indigestion or difficulty in swallowing Cancers of the digestive system, including those of the esophagus, stomach, and pancreas, may cause indigestion, heartburn, or difficulty swallowing Obvious change in a wart or mole Moles or other skin lesions that change in shape, size, or color should be reported Nagging or persistent cough or hoarseness Cancers of the respiratory tract, including lung cancer and laryngeal cancer, may cause a cough that does not go away or a hoarse (rough) voice Unexplained anemia Sudden unexplained weight loss Physical Assessment Inspection skin and mucus membranes for lesions, bleeding, petechiae, and irritation Assess stools, urine, sputum, vomitus for acute or occult bleeding Scalp noting hair texture and hair loss Palpation Abdomen for any masses, bulges or abnormalities Lymph nodes for enlargement Auscultation of lung sounds, heart sounds and bowel sounds Laboratory & Diagnostic Tests Cancer detection examination Laboratory tests Complete blood cell count (CBC) Tumor markers identify substance (specific proteins) in the blood that are made by the tumor PSA (Prostatic-specific antigen): prostate cancer

 CEA (Carcinoembryonic antigen): colon cancer Alkaline Phosphatase: bone metastasis Biopsy Diagnostic Tests Determine location of cancer: X-rays Computed tomography Ultrasounds Magnetic resonance imaging Nuclear imaging Angiography Diagnosis of cell type: Tissue samples: from biopsies, shedded cells (e.g. Papanicolaou (PAP) smear), & washings Cytologic Examination: tissue examined under microscope Direct Visualization: Sigmoidoscopy Cystoscopy Endoscopy Bronchoscopy Exploratory surgery; lymph node biopsies to determine metastases Tumor Staging and Grading Staging determines size of tumor and existence of metastasis Grading classifies tumor cells by type of tissue The TNM system is based on the extent of the tumor (T), the extent of spread to the lymph nodes (N), and the presence of metastasis (M). Primary Tumor (T)

TX - Primary tumor cannot be evaluated T0 - No evidence of primary tumor Tis - Carcinoma in situ (early cancer that has not spread to neighboring tissue) T1, T2, T3, T4 - Size and/or extent of the primary tumor Regional Lymph Nodes (N) NX - Regional lymph nodes cannot be evaluated N0 - No regional lymph node involvement (no cancer found in the lymph nodes) N1, N2, N3 - Involvement of regional lymph nodes (number and/or extent of spread) Distant Metastasis (M) MX - Distant metastasis cannot be evaluated M0 - No distant metastasis (cancer has not spread to other parts of the body) M1 - Distant metastasis (cancer has spread to distant parts of the body) NURSING DIAGNOSES Acute or chronic pain Impaired skin integrity Impaired oral mucous membrane Risk for injury Risk for infection Fatigue Imbalanced nutrition: less than body requirements DIAGNOSES Risk for imbalanced fluid volume Anxiety Disturbed body image

 Deficient knowledge Ineffective coping Social isolation OUTCOME IDENTIFICATION 1. Pain relief 2. Integrity of skin and oral mucosa 3. Absence of injury and infection 4. Fatigue relief 5. Maintenance of nutritional intake and fluid and electrolyte balance 6. Improved body image 7. Absence of complications 1. Knowledge of prevention and cancer treatment 2. Effective coping through recovery and grieving process 3. Optimal social interaction IMPLEMENTATION/MANAGE MENT Prevention and detection Primary Prevention Reducing modifiable risk factors in the external and internal environment Secondary Prevention Recognizing early signs and symptoms and seeking prompt treatment Prompt intervention to halt cancerous process Some carcinogens in the workplace TREATMENT MODALITIES Aimed towards: CURE - free of disease after treatment normal life

 Control - Goal for chronic cancers Palliative Care: Quality of life maintained at highest level for the longest possible time Surgery surgical removal of tumors; most commonly used treatment Preventive or prophylactic Diagnostic surgery Curative surgery Reconstructive surgery Palliative surgery Chemotherapy use of antineoplastic drugs to promote tumor cell death, by interfering with cellular functions and reproduction Radiotherapy directing high-energy ionizing radiation to destroy malignant tumor cells without harming surrounding tissues Types: Teletherapy (external): radiation delivered in uniform dose to tumor; Teletherapy is external beam irradiation and uses a device located at a distance from the patient. It produces X-rays of varying energies and is administered by machines a distance from the body 31 to 39 inches (80 to 100 cm). Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is placed in tumor or next to it; In brachytherapy, the radiation device is placed within or close to the target tissue. Radiation is delivered in a high dose to a small tissue volume with less radiation to adjacent normal tissue, but requires direct tumor access. Immunotherapy use of chemical or microbial agents to induce mobilization of immune defenses. Biologic response modifiers (BRMs) use of agents that alters immunologic relationship between tumor and host in a beneficial way Bone marrow peripheral stem cell transplantation aspirating bone marrow cells from compatible donor and infusing them into the recipient Gene therapy transfer of genetic materials into the clients DNA NURSING MANAGEMENT 1. Promote measures that relieve pain and discomfort.

 Pharmacologic and non-pharmacologic interventions 2. Promote measures to maintain intact skin integrity 3. Promote measures that maintain oral mucosa 4. Promote measures to prevent injury from abnormal bleeding Monitor platelet count; avoid aspiring products, etc NURSING MANAGEMENT 1. Promote measures that identify and prevent infection Monitor WBC count; encourage frequent handwashing and overall cleanliness 2. Help decrease the clients fatigue and increase his activity level 3. Promote measures that ensure adequate nutritional intake High protein, high calorie diet 4. Ensure adequate fluid and electrolyte balance NURSING MANAGEMENT 1. Promote measures to enhance body image. Take an honest gentle, caring approach; encourage client to express and verbalize feelings 2. Promote measures that address preventing complications of cancer therapy 3. Instruct client and family about the disease process and treatments; provide necessary information for self-care. 4. Help client and family cope effectively 5. Promote measures to reduce social isolation. Care of Clients Receiving Chemotherapy Classes of Chemotherapy Drugs: Alkylating agents: Action: create defects in tumor DNA Ex: Nitrogen Mustard, Cisplatin Toxic Effects: reversible renal tubular necrosis

Classes of Chemotherapy Drugs Antimetabolites: Action: phase specific Ex: Methotrexate; 5 fluorouracil Toxic Effects: nausea, vomiting, stomatitis, diarrhea, alopecia, leukopenia Classes of Chemotherapy Drugs Antitumor Antibiotics: Action: non- phase specific; interfere with DNA Ex: Actinomycin D, Bleomycin, adriamycin (doxorubicin) Toxic Effect: damage to cardiac muscle Classes of Chemotherapy Drugs Miotic inhibitors: Action: Prevent cell division during M phase of cell division Ex: Vincristine, Vinblastine Toxic Effects: affects neurotransmission, alopecia, bone marrow depression Classes of Chemotherapy Drugs Hormones: Action: stage specific G1 Ex: Corticosteroids Hormone Antagonist: Action: block hormones on hormone- binding tumors ie: breast, prostate, endometrium; cause tumor regression Ex: Tamoxifen (breast); Flutamide (prostate) Toxic Effects: altered secondary sex characteristics Effects of Chemotherapy Tissues: (fast growing) frequently affected

 Examples: mucous membranes, hair cells, bone marrow, specific organs with specific agents, reproductive organs (all are fetal toxic; impair ability to reproduce) Chemotherapy Administration Routes of administration: Oral Body cavity (intraperitoneal or intrapleural) Intravenous Use of vascular access devices because of threat of extravasation (leakage into tissues) & long term therapy Chemotherapy Administration Types of vascular access devices: PICC lines: (peripherally inserted central catheters) Tunneled catheters: (Hickman, Groshong) Surgically implanted ports: (accessed with 90o angle needle- Huber needles) Nursing care of clients receiving chemotherapy Assess and manage: Toxic effects of drugs (report to physician) Side effects of drugs: manage nausea and vomiting, inflammation and ulceration of mucous membranes, hair loss, anorexia, nausea and vomiting with specific nursing and medical interventions Nursing care of clientsreceiving chemotherapy Monitor lab results (drugs withheld if blood counts seriously low); blood and blood product administration Assess for dehydration, oncologic emergencies Teach regarding fatigue, immunosuppression precautions Provide emotional and spiritual support to clients and families Colon cancer

 COLON CANCER Risk factors 1. Increasing age 2. Family history 3. Previous colon CA or polyps 4. History of IBD 5. High fat, High protein, LOW fiber 6. Breast Ca and Genital Ca COLON CANCER Sigmoid colon is the most common site Predominantly adenocarcinoma If early 90% survival 34 % diagnosed early 66% late diagnosis COLON CANCER PATHOPHYSIOLOGY Benign neoplasm DNA alteration malignant transformation malignant neoplasm cancer growth and invasion metastasis (liver) COLON CANCER ASSESSMENT FINDINGS 1. Change in bowel habits- Most common 2. Blood in the stool 3. Anemia 4. Anorexia and weight loss 5. Fatigue 6. Rectal lesions- tenesmus, alternating D and C

 Colon cancer Diagnostic findings 1. Fecal occult blood 2. Sigmoidoscopy and colonoscopy 3. BIOPSY 4. CEA- carcino-embryonic antigen Colon cancer Complications of colorectal CA 1. Obstruction 2. Hemorrhage 3. Peritonitis 4. Sepsis Colon cancer MEDICAL MANAGEMENT 1. Chemotherapy- 5-FU 2. Radiation therapy Colon cancer SURGICAL MANAGEMENT Surgery is the primary treatment Based on location and tumor size Resection, anastomosis, and colostomy (temporary or permanent) Colon cancer NURSING INTERVENTION: COLOSTOMY CARE Colostomy begins to function 3-6 days after surgery The drainage maybe soft/mushy or semi-solid depending on the site

 Colon cancer NURSING INTERVENTION: COLOSTOMY CARE BEST time to do skin care is after shower Apply tape to the sides of the pouch before shower Assume a sitting or standing position in changing the pouch Colon cancer NURSING INTERVENTION: COLOSTOMY CARE Instruct to GENTLY push the skin down and the pouch pulling UP Wash the peri-stomal area with soap and water Cover the stoma while washing the peri-stomal area Colon cancer NURSING INTERVENTION: COLOSTOMY CARE Lightly pat dry the area and NEVER rub Lightly dust the peri-stomal area with nystatin powder Colon cancer NURSING INTERVENTION: COLOSTOMY CARE Measure the stomal opening The pouch opening is about 0.3 cm larger than the stomal opening Apply adhesive surface over the stoma and press for 30 seconds Colon cancer NURSING INTERVENTION: COLOSTOMY CARE Empty the pouch or change the pouch when 1/3 to full (Brunner) to 1/3 full (Kozier) Breast Cancer

 The most common cancer in FEMALES Numerous etiologies implicated Breast Cancer RISK FACTORS 1. Genetics 2. Increasing age ( > 50 yo) 3. Family History of breast cancer 4. Early menarche and late menopause 5. Nulliparity 6. Late age at pregnancy Breast Cancer RISK FACTORS 7. Obesity 8. Hormonal replacement 9. Alcohol 10. Exposure to radiation Breast Cancer PROTECTIVE FACTORS 1. Exercise 2. Breast feeding 3. Pregnancy before 30 yo Breast Cancer ASSESSMENT FINDINGS 1. MASS- the most common location is the upper outer quadrant 2. Mass is NON-tender. Fixed, hard with irregular borders

3. Skin dimpling 4. Nipple retraction 5. Peau d orange Breast Cancer LABORATORY FINDINGS 1. Biopsy procedures 2. Mammography Breast Cancer Breast cancer Staging I - < 2cm II - 2 to 5 cm, (+) LN III - > 5 cm, (+) LN IV- metastasis Breast Cancer MEDICAL MANAGEMENT 1. Chemotherapy 2. Tamoxifen therapy 3. Radiation therapy Breast Cancer SURGICAL MANAGEMENT 1. Radical mastectomy 2. Modified radical mastectomy 3. Lumpectomy 4. Quadrantectomy LUMPECTOMY QUADRANTECTOMY

 Breast Cancer NURSING INTERVENTION : PRE-OP 1. Explain breast cancer and treatment options 2. Reduce fear and anxiety and improve coping abilities 3. Promote decision making abilities 4. Provide routine pre-op care: Consent, NPO, Meds, Teaching about breathing exercise Breast Cancer NURSING INTERVENTION : Post-OP 1. Position patient: Supine Affected extremity elevated to reduce edema Breast Cancer NURSING INTERVENTION : Post-OP 2. Relieve pain and discomfort Moderate elevation of extremity IM/IV injection of pain meds Warm shower on 2nd day post-op Breast Cancer NURSING INTERVENTION : Post-OP 3. Maintain skin integrity Immediate post-op: snug dressing with drainage Maintain patency of drain (JP) Monitor for hematoma w/in 12H and apply bandage and ice, refer to surgeon Breast Cancer

NURSING INTERVENTION : Post-OP 3. Maintain skin integrity Drainage is removed when the discharge is less than 30 ml in 24 H Lotions, Creams are applied ONLY when the incision is healed in 4-6 weeks Breast Cancer NURSING INTERVENTION : Post-OP Promote activity Support operative site when moving Hand, shoulder exercise done on 2ndday Post-op mastectomy exercise 20 mins TID NO BP or IV procedure on operative site Breast Cancer NURSING INTERVENTION : Post-OP Promote activity Heavy lifting is avoided Elevate the arm at the level of the heart On a pillow for 45 minutes TID to relieve transient edema Breast Cancer NURSING INTERVENTION : Post-OP MANAGE COMPLICATIONS Lymphedema 10-20% of patients Elevate arms, elbow above shoulder and hand above elbow Hand exercise while elevated Refer to surgeon and physical therapist

 Breast Cancer NURSING INTERVENTION : Post-OP MANAGE COMPLICATIONS Hematoma Notify the surgeon Apply bandage wrap (Ace wrap) and ICE pack Breast Cancer NURSING INTERVENTION : Post-OP MANAGE COMPLICATIONS Infection Monitor temperature, redness, swelling and foul-odor IV antibiotics No procedure on affected extremity Breast Cancer NURSING INTERVENTION : Post-OP TEACH FOLLOW-UP care Regular check-up Monthly BSE on the other breast Annual mammography THE END LUALHATI M. FLORANDA RN MAN