Nursing Oncology Notes

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Oncology

General Information

Definitions

cancer is a term used for diseases in which abnormal cells


divide without control and are able to invade other tissues

cancer types

lymphoma and myeloma: cancers that begin in the


cells of the immune system

carcinoma: cancer that begins in the skin or in tissues


that line or cover internal organs

leukemia: cancer that starts in blood-forming tissue,


e.g., bone marrow, and causes large numbers of
abnormal blood cells to be produced and enter the
blood

sarcoma: cancer that begins in bone, cartilage, fat,


muscle, blood vessels, or other connective or
supportive tissue

central nervous system cancers: cancers that begin in


the tissues of the brain and spinal cord

types of tumors

benign: refers to a tumor or growth that is not


cancerous

malignant: the uncontrolled growth of abnormal cells in


the body, i.e., cancerous cells, which are spread
through metastasis

metastatic cancer: cancer that has spread from the place


where it first started (primary site or site of origin) to another
place in the body (the secondary site)

almost any cancer can form metastatic tumors


most common sites of cancer metastasis: lungs,
bones, liver

Read the World Health Organization's Cancer Fact Sheet for


information about the impact of cancer worldwide.

5. staging: describes and classifies extent or spread of malignancy (most, but not all,
cancers are staged this way)

Cancer Extent of Malignancy


Staging

T based on the size of the original (primary) tumor and whether or not it has grown
into nearby tissues

N whether or not the cancer has spread to the nearby lymph nodes

M whether or not the cancer has spread to distant areas of the body

TNM or Modified Duke System


Developed by the American Joint Committee on Cancer

6. grading: describes the degree of malignancy according to the type of tumor cell

o indicates the degree of cell undifferentiation

o cancers with more abnormal-looking cells tend to grow and spread faster

Cancer Grading Degree of Malignancy

stage 0 carcinoma in situ

stage I localized with tumor limited to the tissue of origin

stage II limited spread

stage III extensive local and regional spreading

stage IV distant metastasis


Cancer Grading Degree of Malignancy

Most cancers are graded using a number from 1 to 3 or 4; the lower the number, the more the cancer cells look like
normal tissue.

2. Etiology

o generally unknown but may be caused by interacting factors

o cellular changes result from an interaction between a person's genetic factors


and 3 categories of external agents

physical carcinogens, e.g., ultraviolet radiation

chemical carcinogens, e.g., asbestos, components of tobacco smoke,


arsenic

biological carcinogens, e.g. infections from certain viruses, bacteria or


parasites

o familial risk for certain cancers, e.g., lung, stomach, breast, colon, rectum, and
uterine

o cancer is the second most common cause of death in the U.S

leading causes of cancer death among men: lung, prostate, colorectal,


liver

leading causes of cancer death among women: lung, breast, colorectal


(see risk factors for developing breast cancer)

The National Cancer Institute has information about the cause,


diagnosis, prevention, and treatment and the continuing care of cancer
patients and their families.

Learn more about cancer and prevention at the American Cancer


Society Web site.

3. Warning signs: The seven warning signs of cancer (see below) and cancer screening
recommendations
Seven Warning Signs of Cancer

C Change in bowel or bladder habits

A A sore that does not heal

U Unusual bleeding or discharge from any part of the body

T Thickening or a lump in the breast or elsewhere

I Indigestion or difficulty swallowing

O Obvious change in a wart or mole

N Nagging cough or hoarseness

National Cancer Institute, U.S. National Institutes of Health

4. Diagnostics

o history and physical exam - depends on location of tumor

o radiographic studies, e.g., chest x-ray, mammogram

o biopsy: obtaining tissue for histological examination

needle biopsy: aspiration of cells

incisional biopsy: removal of a wedge of suspected tissue from a larger


mass

excisional biopsy: complete removal of entire lesion or mass

staging biopsy: multiple needle or incisional biopsies of suspected


metastasis

sentinel lymph node biopsy (SLNB): to determine extent (stage) of


cancer

vacuum-assisted biopsy: vacuum-assisted tissue biopsy (ex:


Mammotome breast biopsy)

o cytological studies, e.g., Papanicolaou's (Pap) smear

o proctoscopic examination, including guaiac for occult blood


o liver function studies

o imaging - using computerized tomography (CT scan), magnetic resonance


imaging (MRI)

o tumor markers - identifying biochemicals made and released by tumor cells, e.g.,
prostate-specific antigen (PSA), carcinoembryonic antigen (CEA), alpha-
fetoprotein

5. Treatment - based on stage and grade of tumor, treatment objective is to remove all traces of
the cancerous tissue

o surgery - specific to site and type of malignancy

o chemotherapy - use of chemical agents in the treatment or control of the disease


(adjuvant therapy)

How Chemotherapy Treatments Are Delivered

topical oral sublingual

subcutaneous intramuscular intravenous

PICC line non-tunneled catheters tunneled catheters

intraventricular (ommaya intraperitoneal (single use, intra-arterial


reservoir) & intrathecal Tenckhoff catheters, Port-a-
(lumbar puncture) cath)

intravesicular (med given intrapleural (chemo is inserted implantable (wafers with meds
through urinary catheter into a chest tube to control are implanted in former site of
directly into the bladder) malignant pleural effusions) brain tumor to kill tumor cells)

o radiation therapy - destroys cancer cells, with minimal exposure of normal cells to the
damaging effects of radiation (adjuvant therapy)

external beam radiation (the source of the radiation is external to the client)

brachytherapy: the radiation source comes into direct, continuous contact


with tumor tissues for a specific time (the source of the radiation is within the
client)

1. unsealed radiation source - administration is by oral or intravenous


route or by installation into a body cavity
2. sealed radiation source - solid implant is implanted with the tumor
target tissues

see lesson 7: Reduction of Risk Potential for more information about


radiation therapy

o biologic therapy - typically used along with conventional cancer treatments (adjuvant
therapy)

immunotherapy - helps repair, stimulate or enhance the body's natural ability


to fight cancer, including cancer vaccines, interferons, and interleukin 2
treatments

targeted therapy - non-chemotherapy drugs used to target cancer cells

monoclonal antibodies: artificially produced antibodies that act against a


particular antigen, including trastuzumab (Herceptin), etanercept (Enbrel),
infliximab (Remicade), abciximab (Reopro)

tyrosine kinase: inhibits growth of cancer cells, such gefitinib (Iressa) for lung
cancer, lapatinib (Tykerb) for breast cancer, and sunitinib (Sutent) for renal
cell carcinoma

o bone marrow transplantation

o stem cell transplantation

6. Nursing interventions

o monitor for effectiveness of all medications

o monitor vital signs

o monitor for post-operative surgical complications

o monitor intake and output

o monitor diagnostic tests and laboratory values, e.g., white blood cell and platelet
counts

o monitor for fever, sore throat, unusual bleeding, or findings of infection

common sites of infection: skin, respiratory and gastrointestinal tracts

ensure frequent and thorough hand hygiene by client, family, staff

o administer chemotherapy as prescribed - usually only chemotherapy certified nurses


can administer
intravenous route is most commonly used

dosing based on total body surface area (BSA), which requires a current and
accurate height and weight

have another RN double-check medication and dosage, both on the order


sheet and with the drug itself

prepare in air-vented space (biohazard cabinet area); wear gloves, gown,


eye protection and mask when handling IV medications

carefully monitor for phlebitis and extravasation

1. stop infusion and notify physician with extravasation

2. treatment may include elevating the extremity, heat or ice application


(dependent upon medication), injection of antidote into site

The Oncology Nursing Society offers a competency course for nurses


responsible for administering chemotherapy.

8. monitor side effects of chemotherapy and treat as indicated

o fatigue

assist client in self-care and mobility activities

allow adequate rest periods during care

o alopecia

o nutrition

assist client in selecting a well-balanced diet

provide small, frequent meals (high calorie, high protein, high


carbohydrate) that require less chewing (soft foods)

provide protein supplements as prescribed

loss of appetite may be the result of taste changes or a bitter taste in


the mouth from medications
o nausea and vomiting

administer antiemetics, e.g., ondansetron (Zofran), several hours


before chemotherapy and for 12 to 48 hours afterwards, as prescribed

delayed nausea and vomiting can occur 7 days post administration

o mucositis

provide mouth rinses every 12 hours, e.g., saline or sodium


bicarbonate and water, as prescribed

offer complete mouth care before and after every meal; instruct client
to use soft toothbrush and avoid dental floss

administer topical anesthetic agents to mouth sores as prescribed

avoid hard or spicy foods

avoid use of alcohol- or glycerin-based mouthwashes or swabs

o skin changes

use electric razor for shaving

avoid rectal suppositories, enemas, and rectal thermometers

o myelosuppression: bone marrow activity is decreased, resulting in fewer red


blood cells, white blood cells, platelets

monitor lab values for neutropenia anemia and thrombocytopenia

initiate neutropenic precautions if white blood cell count decreases

monitor for petechiae, ecchymosis, bleeding of the gums, and


nosebleeds (due to decreased platelet count)

avoid intramuscular injections and venipunctures

administer blood products for anemia as prescribed

o monitor for signs of anaphylactic reaction

obtain allergy history

administer test dose if prescribed by physician


have emergency equipment and medications available

most reactions occur within 15 minutes of starting the infusion

interventions

stop the medication

maintain airway

notify physician

maintain IV access with 0.9% normal saline

place client in supine position with feet elevated (unless


contraindicated)

administer prescribed medications, typically epinephrine,


corticosteroid, and diphenhydramine

9. monitor side effects of radiation therapy and treat as indicated

o follow radiation safety protocol for implanted, sealed radiation source

o local skin changes

gently wash irradiated area with warm water (with or without mild soap); use
hand, not washcloth

take care not to remove skin markings

o alopecia

o fatigue - most common side effect of radiation (see side effects of chemotherapy on
previous page)

o altered sense of taste (see side effects of chemotherapy on previous page)

10. monitor for complications of bone marrow transplantation (see also Infection Precautions for
Bone Marrow Transplant Recipients)

o failure to engraft

o graft-versus-host disease in allogeneic transplants - (cautiously) managed with


immunosuppressive agents
o veno-occlusive disease - treat with fluids and supportive therapy

11. support client and family

o listen to and discuss expected body image changes

o respect client lifestyle choices, religious and cultural preferences

o discuss potential effect of (irreversible) infertility

o discuss end-of-life and grief and loss issues

o initiate appropriate support and resource systems

CANCER Interventions:

C =Comfort
A =Altered body image
N =Nutrition
C =Chemotherapy
E =Evaluate response to medications
R =Respite for caretakers

2. Cancer Pain Management

o Causes of cancer pain

bone destruction

obstruction of an organ

compression of peripheral nerves

infiltration or distention of tissue

inflammation

necrosis

psychological factors, e.g., fear, anxiety

o Use a variety of pain relief measures (see Lesson 5: Basic Care and Comfort
for information regarding non-pharmacologic pain relief measures)
o The World Health Organization has developed a 3-tiered approach for
treating cancer pain

begin with nonopioid analgesics (aspirin, paracetamol) if pain


occurs

if pain persists or increases, administer mild opioids (codeine) for


mild to moderate pain, along with adjuvant medications to calm fears
and anxiety

strong opioids (morphine) should be administered if pain is still not


relieved, along with adjuvant medications to calm fears and anxiety

o Nursing care, related to pain

assess client's pain; pain is what the client describes - do NOT under-
medicate the cancer client who is in pain!

monitor effectiveness of medication

monitor for side effects of medication, e.g., respiratory depression


related to narcotic administration

provide nonpharmacological techniques for pain relief, e.g.,


guided imagery, biofeedback, massage, heat-cold applications,
relaxation techniques

Refer to the World Health Organization's Pain Ladder for cancer pain
relief.

2. Pediatric Oncology
o Overview

Cardinal Findings

Unusual mass

Pallor

Sudden tendency to bruise


Rapid, unexplained weight loss

Change in vision or eye

Recurrent fever

Persistent headache, often with vomiting

Change in balance or gait

Childhood cancers can occur suddenly, without early symptoms

Childhood cancers usually arise from noninherited mutations in genes


of growing cells

There are 12 major types of childhood cancers; leukemias and


cancers of the brain and central nervous system account for more
than half of the new cases

Childhood cancer is highly curable

For all age children, the goal is to prevent fear and misunderstanding

Age appropriate diversional activities:

Toddler washable soft toys, appropriate cartoons, action toys (wagon, push toys)

Pre-school appropriate cartoons, washable stuffed doll, coloring books and crayons, action
toys

Kindergarten appropriate cartoons or video games, coloring book and crayons, washable
stuffed toys

School age appropriate cartoons or video games, coloring book and crayons, school work
when appropriate, computer, beads for creating jewelry

Middle computer or cell phone, appropriate video games, school work when appropriate
School

High School computer or cell phone, appropriate video games, school work when appropriate

2. Leukemias

o Definition: cancer of while blood cells


o Etiology

unrestricted proliferation of immature leukocytes crowd the bone


marrow and flood the bloodstream; this interferes with production of
red blood cells and platelets, resulting in anemia and bleeding
problems and increased risk of infection

account for 25% of all childhood cancers

types: most common is acute (rapidly developing); also chronic (slow


developing)

acute (rapidly developing) - most common

acute lymphocytic leukemia (ALL) - usually found in


children ages 2 to 8 years

acute myelogenous leukemia (AML)

chronic (slow developing)

risks: associated with having received prior radiation or chemotherapy


for other types of cancer, genetic disorders (Down syndrome,
Kleinfelter syndrome, Fanconi's anemia); genetic link

symptoms caused by infiltration and replacement of any tissue of the


body with non-functional leukemia cells

highly vascular organs such as spleen and liver are most severely
affected

o Findings: acute or insidious onset depending on type

anemia, thrombocytopenia, infection, bleeding


lymphadenopathy, hepatosplenomegaly, bone or joint pain

meningeal irritation, i.e., irritable, lethargic, stiff neck

o Diagnostics

history and physical findings

peripheral blood smear

bone marrow aspiration

lumbar puncture

o Management

combination chemotherapy to achieve a remission; intrathecal


administration of methotrexate

radiation with central nervous system involvement

bone marrow transplant

o Nursing interventions

prepare child and family for diagnostic procedures

relieve discomfort

monitor for infection, hemorrhage and anemia

manage problems of drug side effects, i.e., nausea and vomiting,


anorexia, mucosal ulceration, neuropathy, alopecia, moon face

provide nutritional snacks

refer for needed services - financial or home care

teaching points

long term treatment plan

multidisciplinary approach

bone marrow aspiration precautions


encourage parents to ask questions when unsure

school work for child when appropriate

Children, particularly toddlers and pre-schoolers, tend to have bruises


as a result of play. Any unusual bruising -on the back or neck, large or
dark bruises- needs to be checked out. It could be the first sign of
leukemia or it could possibly due to child abuse. If you are unsure, be
sure that another nurse checks the child with you.

3. Hodgkin's disease (Hodgkin's lymphoma)

o Definition: malignancy of the lymph tissue found in the lymph nodes, spleen,
liver, and bone marrow

o Etiology

neoplasm of lymphatic system

characterized by giant, multinucleated cells (Reed-Sternberg cells)

o Findings

characterized by painless enlargement of lymph nodes, particularly in


supraclavicular area

anorexia, weight loss, malaise; painless; night sweats

fever

o Diagnostics

lymphangiography

labs: complete blood count (CBC), erythrocyte sedimentation rate,


urinalysis, kidney function tests, protein levels, liver function tests

bone marrow biopsy

CT scan of the chest, abdomen, pelvis

chest x-ray
PET scan

o Management

chemotherapy and radiation

treatment based on staging of disease (stages I-IV) and age of client

transfusion of blood products (platelets for low platelet counts or


packed cells for anemia)

antibiotics

o Nursing Interventions

prepare for diagnostic procedures

explain side effects of treatment

provide age appropriate diversional activities

refer to appropriate resources if sterility may result from radiation


and/or chemotherapy

teaching points

long term treatment plan

multidisciplinary approach

encourage to ask questions when unsure

school work for child when appropriate

o Possible Complications

prognosis: most curable form of cancer

long term complications of chemotherapy or radiation therapy

4. Neuroblastoma

o Definition: malignant tumor the develops from nerve tissue

o Etiology: unknown

most common extracranial solid tumor of childhood


accounts for almost all cases of cancer under age 1 year

develops from tissues that form the sympathetic nervous system

most neuroblastomas begin in the abdomen (in the adrenal gland or next to
the spinal cord) or in the chest - can spread to the bones, bone marrow, liver,
lymph nodes, skin and around the eyes

often has metastasized by the time it is diagnosed

o Findings: first symptoms are usually fever, malaise and pain; other findings are
tumor-dependent

enlarged abdomen - from tumor or excess fluid

periorbital edema, cyanosis - cancer spread to eye(s)

bone pain or tenderness - cancer spread to bones

dyspnea or chronic cough - cancer spread to lungs/chest

flushed red skin

tachycardia

profuse sweating

o Diagnostics

physical exam - examination of abdomen may reveal a lump, swollen lymph


nodes

bone scan, x-rays

CT and MRI scan of chest and abdomen

biopsy

labs: complete blood count (anemia), coagulation studies (ESR),


hormone tests (especially epinephrine and other catecholamines), 24-hour
urine (for catecholamines, homovanillic acid and vanillylmandelic acid)

o Management: depends on tumor location, metastasis and client's age

ranges from observation only in certain types of neuroblastoma to aggressive


therapy with surgery, radiation therapy, chemotherapy, and stem-cell
transplantation for older children
retinoid therapy, tumor vaccines and immunotherapy (using monoclonal
antibodies)

o Nursing intervention: support family and encourage participation in support groups


and counseling

o Complications

prognosis: varies greatly

metastasis and associated damage and loss of function of involved organ(s)

children treated for neuroblastoma may be at risk for getting a second,


different cancer in the future

5. Osteosarcoma

o Definition: malignant bone tumor that usually develops during a period of rapid
growth (adolescence, young adulthood)

o Etiology: unknown

usually affects teens and people in their 20s

originates from bone-forming mesenchyme

location - most common in distal femur, also in the tibia or humerus

may be a genetic link (gene associated with retinoblastoma)


o Findings: localized pain, limp, decrease in physical activity

o Diagnostics

history, physical assessment

bone scans, x-ray

chest x-ray, CT scan of the chest - for suspected metastasis to chest

o Management

surgery - limb salvage with prosthetic bone replacement or amputation

chemotherapy before and/or after surgery

o Nursing interventions

client and family support following amputation

client and family teaching about stump care

referral to necessary resources for prosthetics, rehabilitation, support and


counseling

o Complications

prognosis: long-term survival is good if cancer has not spread to lungs

limb removal

metastasis

side effects of chemotherapy

6. Ewing sarcoma

o Definition: a rare malignant bone tumor affecting children

o Etiology: unknown

arises not from osteoid tissue but in bone marrow spaces

most common in shaft of femur, tibia, humerus, scapula

more common in males and Caucasian children


can occur any time but usually develops during puberty

o Findings

few symptoms

localized pain, decrease in physical activity

pathologic fracture at site of the tumor

o Diagnostics

biopsy, MRI, x-ray of tumor

bone scan

chest x-ray, CT of chest

o Management

intensive radiation therapy of the malignant bone

combined with chemotherapy

cyclophosphamide (Cytoxan)

doxorubicin (Adriamycin)

etoposide (Vepesid)

ifosfamide (Ifex)

vincristine

after course of chemotherapy and possibly radiation, tumors may be


removed surgically; amputation may be the only choice

o Nursing interventions

assess client's and family's physical and emotional status

client and family education

encourage participation in support groups and counseling

provide nursing care for client undergoing chemotherapy and radiation


therapy
o Complications

treatments have many complications and should be discussed on individual


basis

amputation has short- and long-term side effects

7. Wilms' tumor (nephroblastoma)

o Definition: a rare type of kidney cancer that affects children

o Etiology

causes a tumor on one or both kidneys (more common on left kidney)

most often affects children under age 5 years

risks: certain genetic conditions or birth defects (hypospadias, undescended


testicles, aniridia); family history; female; African American

tumor encapsulated for extended period

o Findings

abdominal mass and swelling

characteristically firm, non-tender

constipation

malaise

high blood pressure

increased growth on one side of body


o Diagnostics

abdominal ultrasound, x-ray

intravenous pyelogram

bone scans

labs: blood urea nitrogen, complete blood count (may show anemia),
creatinine and creatinine clearance, urinalysis

do NOT prod or push on child's belly

o Management

surgery - simple nephrectomy, partial nephrectomy, radical nephrectomy

combination chemotherapy and radiation therapy

o Nursing interventions

use care during bathing and handling to avoid injury to tumor site

support family

encourage genetic counseling


treat effects of radiation and chemotherapy - nausea and vomiting, loss of
appetite, mouth sores, fatigue, loss of hair, weakened immune system

teaching - tell parents to check with health care provider before any
vaccinations

o Complications

prognosis: 90% cure rate if tumor has not spread

hypertension

kidney damage

8. Rhabdomyosarcoma

o Definition: a malignant tumor of the muscles attached to bones; the most common
soft tissue tumor in children

o Etiology: unknown

soft tissue neoplasm

grows from undifferentiated mesenchymal cells of skeletal muscle

location: most common in head and neck, the urogenital tract, arms or legs

may be a genetic factor

highly malignant; often metastasized when diagnosed

o Findings

non-tender, firm mass

related to site of tumor and compression of adjacent organs

symptoms often vague, similar to otitis media or "runny nose"

o Management: depends on the site and type of rhabdomyosarcoma

surgery

high-dose irradiation of the primary tumor

combination chemotherapy

surgical resection
o Nursing intervention

pain management, including administration of pain medication, positioning,


age-appropriate diversional activities

encourage family participation in support group and counseling

o Complications

prognosis: usually good

complications from chemotherapy

metastasis

9. Retinoblastoma

o Definition: a rare, cancerous tumor of the retina

o Etiology:

caused by a mutation in a gene controlling cell division

may have a genetic link

generally affects children under the age of 6 years

o Findings:

may affect one or both eyes

differing iris colors in each eye

leukocoria ("cat's eye reflex") - unusual whiteness noticeable in photographs


taken with a flash

strabismus, poor vision, double vision

eye pain and redness

o Diagnostics

ophthalmoscopic exam under general anesthesia,

MRI and CT scan of the head

head and eye echoencephalogram (ultrasound of the eye)


o Management: treatment depends on stage of tumor with grading

laser surgery or cryotherapy - small tumors

radiation therapy - local tumor or larger tumors

chemotherapy - if tumor has spread beyond the eye(s)

enucleation

o Nursing interventions

assess child for this when parents report a strange light in the child's eye

involve parents in care and teach about diagnostic procedures

genetic counseling for parents

multi-disciplinary support for child following enucleation of an eye

teaching points: care for prosthetic eye

o Complications

prognosis: if the cancer has not spread beyond the eye, almost all clients can
be cured

blindness

10. Circulatory System Oncology


o Non-Hodgkin's lymphoma (NHL)

Definition: cancer of the lymphocytes found in lymphoid tissue, which


includes lymph nodes, spleen, and other organs of the immune system

Etiology: unknown

both B lymphocytes and T lymphocytes can develop into lymphoma


cells (B-cell lymphomas are more common in the U.S.)

risk factors: adults with weakened immune systems or who have had
an organ transplant

types: based on how fast it spreads and by protein (B lymphocytes)


and/or genetic markers (T lymphocytes)

slightly more common in women


Findings: many are dependent upon the location of the cancer (chest,
abdomen, brain)

painless, enlarged lymph nodes in cervical or axillary region

night sweats, fever

itching

weight loss

Diagnostics

physical exam - enlarged lymph nodes

biopsy of suspected tissue (usually lymph node)

bone marrow biopsy

labs: complete blood count, protein levels, liver function, kidney


function and uric acid level

Management: depends on type of lymphoma, stage of the cancer, age and


overall health of client, symptoms

chemotherapy - main type of treatment

radiation - for disease confined to one body area

radioimmunotherapy may be used

bone marrow transplant (using client's stem cells) - when


chemotherapy is ineffective or lymphoma returns

immunologic therapy: rituximab (Rituxan), a monoclonal antibody

Nursing interventions - see Oncology Overview for more specifics

encourage participation in support group and/or counseling

client teaching: oral care, preventing infections during chemotherapy;


self care of central line or PICC line; diet

Complications

prognosis: dependent on 5 factors - client's age, stage of lymphoma,


organs affected outside the lymph system, ability to perform ADLs,
serum level of lactate dehydrogenase (which goes up with amount of
lymphoma in the body)

autoimmune hemolytic anemia

infection

side effects of chemotherapy drugs

11. Respiratory System Oncology


o Cancer of the larynx

Etiology

most tumors of the larynx are squamous cell carcinoma

more common among men, age 50 to 65 years-old

risk factors include cigarette smoking and alcohol consumption

Findings

persistent sore throat

dyspnea

dysphagia

increasing persistent hoarseness

weight loss

enlarged cervical lymph nodes

neck pain/lump in neck (late)

Diagnostics

physical exam - may detect lump on outside aspect of neck

other tests: biopsy, chest x-ray, CT scan of chest, head and/or neck,
MRI of head or neck

Management

either surgery or radiation therapy alone - when tumor is small


chemotherapy, along with radiation - when tumor is larger or has
spread to lymph nodes

surgery: removal of all or part of larynx (laryngectomy)

brachytherapy

Nursing interventions - see Oncology Overview for more specifics

arrange for clients with laryngectomies to meet with members of


support groups

establish a method for communication before surgery to use after


surgery

maintain airway; have suction equipment at bedside

observe for signs of hemorrhage or infection

teach about tracheostomy and stoma care

assist with period of grieving

coordinate nutritional support

Complications

prognosis: throat cancers can be cured in 90% of clients if detected


early

possible airway obstruction

difficulty swallowing

disfigurement of the neck or face

loss of voice and speaking ability

metastasis

Watch a video from MedlinePlus about cancer of the larynx.

Read What Is a Tracheostomy? at the National Heart Lung and Blood


Institute.

Refer to the National Cancer Institute's book Eating Hints: Before,


During and After Cancer Treatment

2. Lung cancer

o Etiology

types of lung cancer

squamous cell carcinoma

small-cell (oat cell) carcinoma

adenocarcinoma

large cell carcinoma

prognosis is generally poor

largely preventable if smokers stop and nonsmokers avoid second


hand smoke

o Findings

hoarse voice

changes in breathing
persistent cough or change in cough

blood-streaked or bloody sputum

chest pain or tightness in chest wall

recurring pneumonia, pleural effusion

weight loss

o Diagnostics

medical imaging examinations

cytological sputum analysis, carcinoembryonic antigen (CEA) test,


complete blood count, liver and kidney function tests

bronchoscopy

biopsy

3. Management

o nonsurgical

adjuvant therapy: chemotherapy and radiation therapy

biological therapies, including monoclonal antibodies (especially


angiogenesis inhibitors), interferons, interleukins, colony-stimulating factors,
vaccines, gene therapy and nonspecific immunomodulating agents

laser therapy to de-bulk tumor

thoracentesis and pleurodesis

o surgical: thoracotomy

wedge resection - part of a lobe

segmental resection- part of a lobe

lobectomy - one or more lobes

pneumonectomy - entire right or left lung

4. Nursing interventions - see Oncology Overview for more specifics


o maintain chest drainage system

o provide routine post operative care

monitor respiratory status frequently

teach effective deep breathing and cough techniques

refer to physical therapy for exercises for shoulder on affected side

relieve pain

o optimize oxygenation

o provide opportunities for the client to talk about cancer; as needed, refer to support
groups

o teach information as based on treatment plan and prognosis

o optimize nutritional status

Health care professionals and clients can access comprehensive


educational materials on cancer and chemotherapy at Medline Plus.

5. Neurological System Oncology


o Brain Tumors

Definition: growth of tissue within skull

may be cancerous or benign

classified according to tissue type

may be primary or metastatic


Findings

increased intracranial pressure

depend on size and location of tumor

frontal lobe: personality changes, focal seizures, visual


disturbances, hemiparesis, aphasia

occipital lobe: focal seizures, visual hallucinations

temporal lobe: seizures, headache

parietal lobe: seizures, visual losses

cerebellum: coordination or walking/mobility difficulties

6. Diagnostics

o history and physical exam

o computerized tomogram (CT) scan

o magnetic resonance imaging (MRI)

7. Management

o goals are to remove the tumor and minimize harm to the nervous system
o depends on location and size of tumor

o treatment for increased intracranial pressure

surgery

craniotomy to remove tumor

stereotactic laser surgery

radiation therapy for malignancy

o pharmacologic: chemotherapy (for malignant tumors)

8. Nursing interventions - see Oncology Overview for more specifics

o care of the client with increased intracranial pressure

o care of the client undergoing surgery

o seizure precautions

o seizure care

o good nutrition and fluid balance

o emotional support

o care of the client undergoing radiation therapy

o care of the client undergoing chemotherapy

9. Gastrointestinal
o Colon cancer

Definition: the development of malignant cells in the epithelium of the large


intestine

Etiology

may develop from adenomatous polyps


risk factors: low residue diet, high-fat diet, refined foods, age over 50
years, history of polyps of the colon and/or rectum, family history,
inflammatory bowel disease, exposure to carcinogens

Pathophysiology

adenocarcinoma is the most common type

most common locations are sigmoid rectum and ascending colon

often metastasizes to the liver

Findings

rectal bleeding

change in bowel habits - constipation, diarrhea

change in shape of stool

anorexia and weight loss

abdominal pain, palpable mass


Visit the American Gastroenterological Association patient center for
more information on colorectal cancer and screenings.

5. Diagnostics

o colonoscopy

o sigmoidoscopy

o digital examination

o stool for occult blood, complete blood count, liver function tests,
carcinoembryonic antigen (CEA) test

o barium enema

o CT scan

o carcinoembryonic antigen (CEA)

6. Complications - obstruction, perforation of the bowel wall by the tumor, metastasis

7. Management

o radiation

o chemotherapy

o local excision and fulguration (small, localized polypoid lesions)

o treatment of choice is surgery - bowel resection, colostomy

right hemicolectomy - involves ascending colon

left hemicolectomy - involves descending colon

abdominal-perineal resection: removal of sigmoid colon and rectum with


formation of a colostomy
8. Nursing interventions - see Oncology Overview for more specifics

o manage pain

o monitor for complications

wound infection

atelectasis

thrombophlebitis

o maintain fluid and electrolyte balance

o care of ostomy

9. Liver Cancer (hepatocellular carcinoma)

o Definition: cancer of the liver

o Etiology

the cause of liver cancer is usually scarring of the liver (cirrhosis), due to
alcohol abuse, hepatitis B or C virus infection, autoimmune diseases of the
liver, hemochromatosis

occurs more often in men

usually seen in people older than age 50


o Findings

abdominal pain or tenderness (upper right quadrant)

easy bruising or bleeding

enlarged abdomen

fatigue

jaundice

o Diagnostics

abdominal CT scan, ultrasound, MRI

liver biopsy

laparoscopy

chest x-ray - to determine if the liver tumor is primary or has metastasized


from a primary tumor in the lungs

liver enzymes, serum alpha fetoprotein, serum bilirubin

o Management

surgery or liver transplant - best for treating small or slow-growing tumors

chemotherapy

radiation treatments

sorafenib tosylate (Nexavar): blocks tumor growth

prevention: childhood vaccination against hepatitis B

immunosuppressive drugs - following liver transplant

1. tacrolimus (Hecoria, Prograf)

2. cyclosporine (Neoral, Gengraf)

3. sirolimus (Rapamune)

4. mycophenolate mofetil (MMF) (Cellcept)


5. corticosteroids

6. azathioprine (Imuran)

7. muromonab-CD3 or OKT3 (Orthoclone)

8. thymoglobulin (Anti-Thymocyte Globulin)

9. IL-2 Receptor Antagonist Antibodies

10. Nursing interventions - see Oncology Overview for more specifics

o encourage participation in support groups

o encourage discussion of end-of-life wishes and efforts to improve quality of life

o overview of post op care following liver transplant

respiratory status - care of client on ventilator

care for intravenous lines (peripheral and arterial)

care for drains/tubes, including Jackson-Pratt, T-tube, nasogastric, Foley

have emergency equipment nearby, e.g., crash cart, Level 1 rapid infuser

monitor neurologic status

renal status - monitor BUN, creatinine; also intake and output

integumentary status - care for incision/dressing (abdominal binder may be


used), care for pruritus with topical lotions, position to reduce risk of skin
breakdown

gastrointestinal status

1. assess for ileus, re-bleeding from preexisting varices, diarrhea, signs


of acute abdomen

2. monitor nutritional status - hyperalimentation, tube feeding

monitor for signs of infection and rejection (which may occur simultaneously)
- fever, decreased quantity/quality of bile, change in liver function test results,
malaise, increased ascites

o care for end stage liver disease (ESLD)

monitor labs - fluid and electrolyte imbalances, platelet counts, serum


ammonia
low protein diet

assist with ambulation, range of motion due to muscle weakness, stiffness

monitor for bleeding, stool for occult blood, hemoglobin and hematocrit

monitor breathing and elevate head of bed

monitor intake and output

monitor for encephalopathy - neurologic signs

monitor for indications of renal failure

monitor skin for breakdown and apply lotion - pruritus is common

administer diuretics for ascites and care for client undergoing paracentesis

monitor and treat nausea and vomiting

prevent or manage constipation

assist with pain management

11. Complications

o poor prognosis

o gastrointestinal bleeding, liver failure, metastasis to other parts of the body

12. Pancreatic Cancer

o Definition: cancer of the pancreas

o Etiology: unknown

more common in people with diabetes, chronic pancreatitis, smokers

may be genetic link

o Findings

dark urine and clay-colored stools

fatigue and weakness

jaundice
loss of appetite and weight loss

nausea and vomiting

abdominal pain or discomfort (right upper quadrant)

o Diagnostics

CT and MRI of the abdomen

endoscopic retrograde cholangiopancreatography (ERCP)

endoscopic ultrasound

pancreatic biopsy

labs: complete blood count, liver function tests, serum bilirubin,


carcinoembryonic antigen (CEA) test

o Management

surgery - pancreaticoduodenectomy (Whipple procedure)

1. may be done but usually cancer is so advanced that surgery is often


not successful

2. involves removing the head of the pancreas, gallbladder, part of the


duodenum, the pylorus, the lymph nodes near the head of the
pancreas

radiation therapy or chemotherapy - when the tumor has not spread out of
the pancreas but cannot be removed

o Nursing interventions - see Oncology Overview for more specifics

pain management

palliative care

manage complications of Whipple procedure - delayed gastric emptying and


other digestive difficulties

o Complications

very poor prognosis

common complications: blood clots, depression, infection, liver problems,


pain, weight loss
13. Genitourinary System Oncology
o Bladder cancer (urothelial cancer)

Definition: cancer that starts in the bladder (from the transitional cells lining
the bladder)

Etiology: unknown

1. classified on the way the tumor grows

1. papillary tumors: wart-like appearance and are attached to a


stalk

2. nonpapillary (sessile) tumors: flat, less common, more


invasive and worst prognosis

2. possible causes: cigarette smoking, chemical exposure (at work),


chemotherapy, radiation treatment, chronic bladder infection or
irritation

Findings

1. abdominal pain

2. blood in the urine

3. bone pain or tenderness (due to metastasis)

4. urination - painful, frequency, urgency, incontinence

5. weight loss

Diagnostics

1. abdominal and/or pelvic CT, MRI

2. bladder biopsy

3. cystoscopy

4. intravenous pyelogram

5. urinalysis and urine cytology

Management

1. stage 0 and I
1. surgery to remove the tumor without removing the bladder -
usually a transurethral resection of the bladder (TURB)

2. chemotherapy

3. immunotherapy: usually the Bacille Calmette-Guerin vaccine


(BCG) or interferon given directly into the bladder using a
Foley catheter

2. stage II and III

1. surgery to remove part of or entire bladder

1. cystectomy - remove bladder

2. ileal conduit, continent urinary reservoir, or orthotopic


neobladder surgery may be performed to help drain
urine after the bladder is removed

2. chemotherapy and radiation therapy either before (to shrink


tumor) and/or after surgery

3. stage IV

1. no surgery

2. chemotherapy may be considered - inserting agents


doxorubicin HCl (Adriamycin PFS), valrubicin (Valstar) and
epirubicin (Ellence)

3. palliative care

4. laser-ablation therapy

Nursing interventions - see Oncology Overview for more specifics

1. palliative care

2. encourage participation in support groups and counseling

3. support change in body image following urinary diversion surgery

4. support clients with changes to their sexuality

Complications

1. prognosis depends on the stage of cancer

2. anemia
3. urinary incontinence

4. urethral stricture

14. Endocrine System Oncology


o Thyroid cancer

Etiology

1. radiation exposure increases risk for thyroid malignancies

2. thyroid malignancy is rare in the U.S. (benign thyroid disease is


relatively common)

3. most thyroid tumors are benign

4. most common types: papillary and follicular

5. greater likelihood of malignancy in clients older than age 60 years


and younger than 30 years-old

Findings: painless, palpable, solitary nodule on thyroid gland

Diagnostics

1. history and physical (palpation of nodule)

2. fine needle aspiration biopsy (FNAB)

3. ultrasound of the thyroid, thyroid scan

4. laryngoscopy

5. serum thyroid-stimulating hormone (low), calcitonin

Management

1. surgical excision - total or subtotal thyroidectomy

2. postoperative radioiodine scanning and ablation

3. RapidArc radiotherapy: a fast and precise form of radiation therapy

4. possibly chemotherapy

5. medications
1. thyroid hormone replacement therapy - usually T4 (Synthroid)
or triiodothyronine (T3, Cytomel)

2. recombinant human TSH (Thyrogen) - in remnant ablation

Nursing interventions - see Oncology Overview for more specifics

1. support clients undergoing radioisotope treatment

2. post-operative care: relieve pain, observe for indications of tracheal


obstruction, swelling, bleeding or laryngeal spasm

Complications

1. injury to the larynx and hoarseness after thyroid surgery

2. low calcium levels from accidental removal of parathyroid glands

3. metastasis

15. Integumentary System Oncology


o Melanoma

Definition: malignant tumors that originate in the pigment-producing


melanocytes in the basal layer of the epidermis

Etiology

1. fair skin, blue or green eyes, or red or blond hair

2. live in sunny climates or at high altitudes

3. have had one or more blistering sunburns during childhood


4. use tanning devices

5. genetic predisposition

Findings - identification of potentially malignant pigmented lesions

1. A for asymmetry

2. B for border irregularity

3. C for color multiplicity

4. D for diameter greater than 1/4 inch

5. E for evolution (change) in size and/or shape

Diagnostics

1. epiluminescence microscopy (magnification and polarized light to


enhance detection)

2. biopsy

3. sentinel lymph node biopsy - to predict progression of disease

16. Nonmelanoma skin cancers - account for more than 90% of skin cancers

o Basal cell carcinoma (BCC)

definition: abnormal, uncontrolled growths or lesions from the skin's basal


cells (the deepest layer of the epidermis)

etiology
1. usually caused by a combination of cumulative UV exposure and
intense, occasional UV exposure

2. almost never metastasizes

3. most common form of skin cancer

finding: look like open sores, red patches, pink growths, shiny bumps, or
scars

management

1. surgery: Mohs micrographic surgery, excisional surgery, curettage


and electrodesiccation, cryosurgery, photodynamic therapy, laser
surgery

2. radiation

3. topical medications

1. imiquimod (Aldara) - for superficial BCC; works by stimulating


the immune system

2. 5-Fluorouracil (5-FU) - for superficial BCC

3. vismodegib (Erivedge) - for more advanced BCC


Black Box Warning - embryotoxic and teratogenic

nursing interventions

1. teaching about skin cancer prevention and identification

2. supportive care for disfigurement

17. Squamous cell carcinoma

o definition: uncontrolled growth of abnormal cells arising in the squamous cells (upper
layers of the epidermis)
o etiology

second most common form of skin cancer

mainly caused by cumulative UV exposure over the course of a lifetime

can be disfiguring and may be deadly if allowed to grow

o findings

look like scaly red patches, open sores, elevated growths with central
depression, or warts; may crust or bleed

usually occurs on any area exposed to sun but may occur on mucous
membranes and genitals

o management

surgery: Mohs micrographic surgery, excisional surgery, curettage and


electrodesiccation, cryosurgery, photodynamic therapy, laser surgery

radiation

topical medications: 5-Fluorouracil (5-FU)

o nursing interventions

teaching about skin cancer prevention and identification

supportive care for disfigurement

18. Actinic keratosis (also called solar keratoses): scaly or crusty growths (lesions) caused by
damage from UV light; the most common pre-cancer
19. Dysplastic nevi (atypical moles): unusual benign moles that resemble melanoma

20. Breast cancer

o definition: cancer that starts in the tissues of the breast types of breast cancer

o etiology

in women, may begin in lining of milk duct or the lobes

higher risk if family history

risk may increase with the use of hormones

types

1. invasive (infiltrating): spreading outside the membrane that lines a


duct or lobule, invading the surrounding tissues

2. noninvasive (in situ) - includes ductal carcinoma in situ (DCIS),


lobular carcinoma in situ (LCIS)

o findings

painless, firm lump - most often immoveable

painless thickening in a breast

enlargement of axillary nodes or supraclavicular nodes

nipple discharge

scaliness or retraction of nipple (seen more in Paget's disease)

pain, ulceration, edema, orange-peel skin (usually late finding)

See pictures of the types of breast cancer at Breastcancer.org.

4. diagnostics

o mammography
o biopsy or aspiration (stereotactic biopsy, Mammotome or vacuum-assisted
biopsy, ultrasound-guided biopsy, ductal lavage)

o tumor cell tests

o tests to determine metastases (bone scan, MRI, CT scan)

o labs: tumor marker tests, including carcinoembryonic antigen (CEA) test,


CA15.3, TRU-QUANT, CA125
5. management

o surgical approach (will depend on the results from the lymph node biopsies and
tumor staging) - from most conservative to radical

1. lumpectomy - tumor removal and small amount of normal tissue around it

2. partial mastectomy - removal of part of breast with cancer and some


surrounding tissue

3. total mastectomy - removal of whole breast

4. modified radical mastectomy - removal of whole breast, many of the lymph


nodes, the lining over the chest muscles

5. radical mastectomy - removal of whole breast, all of the lymph nodes, chest
wall muscles

o radiation therapy

o chemotherapy

1. cyclophosphamide (Cytoxan)

2. methotrexate (Mexate)

3. doxorubicin HCL (Adriamycin)

4. paclitaxel (Taxol)
o endocrine therapy

1. bone marrow transplant

2. oophorectomy

3. adrenalectomy

o hormone therapy

1. tamoxifen (Nolvadex): for premenopausal women with positive nodes or


stage 1 with negative nodes

1. to block the effects of estrogen

2. the course of treatment is commonly a minimum of two years; may


continue with tamoxifen or started with exemestane (Aromasin) or
raloxifene (Evista) for 3 more years depending on hormonal levels in
the breast

2. exemestane (Aromasin) or raloxifene (Evista): for post menopausal women

3. use of other hormones in advanced disease

1. estrogens (DES) or ethinyl estradiol (Estinyl) to suppress FSH and


LH

2. progestins may decrease estrogen receptors

3. androgens may suppress FSH and estrogen production

4. aminoglutethimide blocks estrogen by blocking adrenal steroids

5. corticosteroids from the adrenal glands suppress secretion of


estrogen and progesterone

6. complications of breast cancer

o metastases

o bone pain, neurologic changes, weight loss, anemia

o shortness of breath, cough, pleuritic pain, nonspecific chest discomfort

7. nursing interventions - see Oncology Overview for more specifics

o obtain a health history

o identify the type of education needed


o evaluate the level of anxiety and fear

o determine the levels of coping abilities

o refer available support systems to

1. reduce anxiety

2. provide education

3. enhance coping strategies

o assess for lymphedema and nerve damage following a radical or modified radical
mastectomy (when lymph nodes are removed)

Learn more about breast cancer from The National Breast Cancer
Foundation.

Breastcancer.org provides complete, accurate, and private information


about breast cancer.

4. Male oncology

o Breast cancer in males

cancer resembles the types found in women

a greater incidence in men in their 60's

accounts for about 1% of all breast cancer cases

prognosis is poor because men delay seeking diagnosis and


treatment

gynecomastia is often an associated factor


2. Prostate cancer

o definition: malignant neoplasm, usually adenocarcinoma, of prostate gland

o etiology and epidemiology

more prevalent in African American men

most appear on the peripheral zone of the gland

most are palpable on rectal examination

spreads via the lymphatics, the bloodstream or by local extension

specific etiology unknown; familial history increases risk

o findings

usually asymptomatic in early stages

obstruction of urinary flow that may result in urinary urgency, hesitancy,


dribbling, retention, nocturia, infection, hematuria

pain in an area represents the location of the metastases

lumbosacral

hips
lower legs

rectal discomfort

weight loss

anemia

edema of the lower extremities

o diagnostics

digital rectal examination

needle biopsy of the gland

transrectal ultrasonography

descending urography

serologic markers

prostate specific antigen (PSA)

prostatic acid phosphatase

metastatic evaluations

chest x-ray

intravenous urography (also called intravenous pyelography or


IVP)

CT scan of specific areas or entire body

MRI

3. management

o conservative approach

usually no treatment for men over 70 due to the prostate cancer's slow
progression

analgesics to manage pain - both non-narcotic and narcotic


short course of radiation therapy (site-specific)

administration of IV strontium chloride 89 (beta emitter agent)

placement of suprapubic catheter for obstructed outflow through urinary tract

o surgical approach

radical prostatectomy

laparoscopic dissection of pelvic lymph node

cryosurgery

transurethral resection of prostate (TURP)

o curative approach

external beam radiation

interstitial radiation - the direct implantation of radioactive substances into the


prostate either permanently (seeding) or briefly (high dose rate); also called
brachytherapy, seed implantation

o palliative approach

hormone manipulation
estrogen therapy diethylstilbestrol (DES)

luteinizing hormone-releasing hormone (LHRH)

bilateral orchiectomy (removal of the testes)

use of anti-androgen drugs

flutamide (Eulexin) - blocks the effect of testosterone

drugs are often used in combination therapy

4. nursing interventions - see Oncology Overview for more specifics

o assess

presence of urinary urgency, hesitancy, dribbling, retention, nocturia,


infection, hematuria

presence of palpable lymph nodes

presence of flank pain, weight loss, rectal pain

presence of bladder distention

o control pain to acceptable levels

o reduce anxiety in clients and family members by referrals

o discuss potential changes re: sexual functioning, energy levels

5. complications

o of the cancer - bone metastases

o of hormone manipulation

nausea and vomiting

gynecomastia

sexual dysfunction

hot flashes

UsTOO International is a prostate cancer support group whose goal is


to increase awareness about the disease.

Points to Remember
Clients undergoing chemotherapy should avoid crowds and persons with infections
and to report signs of infection.

Radiation has local effects related to site irradiated; chemotherapy is more systemic.

Biological therapies (interferons, interleukins, colony-stimulating factors, monoclonal


antibodies, vaccines, gene therapy, and nonspecific immunomodulating agents) use
the body's immune system to fight cancer or to lessen the side effects that may be
caused by some cancer treatments.

Although clients receiving internal radiation are not radioactive, the implant or
injection is radioactive; treat waste products and body fluids as radioactive.

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

Be sure to test client for tuberculosis (TB) before cancer treatment using monoclonal
antibodies, especially infliximab (Remicade), since they will allow TB to fulminate.

Melanoma is the most dangerous form of skin cancer and the leading cause of death
from skin disease.

Lung cancer is the leading cause of cancer deaths in both men and women
(exception - the leading cause of cancer deaths in Hispanic women is breast cancer).

Most Pancreatic cancer has a very poor prognosis since it's often advanced when
first discovered.

The cause of liver cancer is cirrhosis, which may occurs with hepatitis B or C.
Individuals should be vaccinated for HBV. The Centers for Disease Control and
Prevention recommends that all "baby boomers" are tested for HCV.

Administration of HPV vaccine Gardasil is recommended for the prevention of


cervical cancer.

Points to Remember - Pediatric


There are 12 major types of childhood cancers; leukemias and cancers of the brain
and central nervous system account for more than half of the new cases.

Children typically have longer treatment plans than adults due to their increased
metabolic rate and rate of cell turnover.

Cure rate is improving for most types of pediatric malignancies.

During nursing assessment of a child with Wilms' tumor, do NOT palpate the
abdomen

Neuroblastoma is a cancer that actually begins in utero.

An active child who suddenly becomes lethargic and exhibits symptoms of childhood
cancer, e.g., weight loss, pain, and fever, should be evaluated by a health care
provider.

Acute leukemia can advance very quickly; a child with anemia and bruising should be
evaluated for leukemia.

Osteosarcoma is more common than Ewing's sarcoma but both are tumors of the
bone.

Pediatric oncologic emergencies include: acute tumor lysis syndrome, superior vena
cava syndrome, septic shock.

Pediatric cancer is a highly charged emotional arena. Be calm and collected in


dealing with both parents and patients

All cancer victims and their families need support and encouragement. Families with
children who have cancers can be especially affected. Other children in the family
may need as much or more attention and support than the parents.

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