MANAGEMENT OF CANCER
- Treatment option offered to patents with
cancer are based on treatment goals for
each specific type, stage, and grade of
cancer.
- The range of treatment goals is to cure,
completely eradicate the malignant disease,
to control prolong progression of the cancer
cell, or palliation involves relief of
symptoms.
CANCER TREATMENTS
- Surgery
- Chemotherapy
- Radiation therapy
- Hematopoietic stem cell transplantation
(HSCT)
- Immunotherapy
SURGERY
Diagnostic Surgery
- Definitive method for obtaining tissue to
identify the cellular characteristics that
influence all the treatment methods.
- Also called BIOPSY
- Obtain sample tissue for histologic analysis
of cells suspected to be malignant.
- The biopsy is taken in actual tumor in most
instance but could also get in sample of
lymph nodes near a suspicious tumor. The
cancer can metastasize from the primary
site by lymphatic circulation.
- The use of injectable dyes and nuclear
medicine imaging to detect the sentinel
lymph nodes which is near the primary site
of tumor and surrounding tissue drain.
- Sentinel lymph nodes biopsy (SLNB) also
sentinel lymph node mapping minimally
non-invasive surgical approach. This
replaces lymphadenectomy (more invasive
lymph node dissections.
BIOPSY TYPES
1. Excisional Biopsy
- used for small, easily accessible tumors.
- the surgeon can remove the entire tumors. In
many cases, the surgeon can remove the entire
tumor as well as the surrounding marginal
tissue.
- the entire tissue specimen for the
determination of stage and grade but also
decreases the chance of seeding tumor cells
(disseminating cancer cells throughout
surrounding tissues.)
2. Incisional Biopsy
- performed if the tumor mass is too large to be
removed
- wedge of tissue from the tumor is removed for
analysis.
- the cell of the tissue wedge must be
representative of the tumor mass so that they
can provide an accurate diagnosis.
 The incisional and excisional biopsy are
performed through ENDOSCOPY
 But there is also surgical procedure that
required to determine the anatomic
extent of stage of the tumor (e.g.,
laparotomy)
3. Needle Biopsy
- performed to sample suspicious masses that
are easily and safely accessible, such as some
masses in the breast, thyroid, lung, liver, and
kidney.
- surrounding tissues are minimally disturbed,
thus decreasing the like hood of seeding cancer
cells.
- FINE NEEDLE ASPIRATION (FNA) BIOPSY
involves aspirating cells rather than intact tissue
Select techniques used for localized
through a needle that is guided into a suspected
destruction of tumor tissue
diseased area.

- often, x-ray, computed tomography (CT) TYPE OF PROCEDURE DESCRIPTION

scanning, ultrasonography, or magnetic
Use of chemicals or
resonance imaging (MRI) used to help locate chemotherapy applied
the suspicious area and guide placement of CHEMOSURGERY directly to tissue to cause
needles. distraction.

Use of liquid nitrogen or a

SURGERY AS PRIMARY TREATMENT very cold probe to freeze
CRYOABLATION
tissue and cause cell
- DEBULKING removing the entire tumor or destruction.
as much as is feasible as well as any Use of electric current to
involved surrounding tissues, including ELECTROSURGERY
destroy tumor cells.
regional lymph node. Use of light and energy
aimed at an exact tissue
location and depth to
TWO COMMON SURGICAL APPROACHES
LASER SURGERY vaporize cancel cells (also
1. LOCAL EXCISION referred to as
- Warranted when the mass is small. It photocoagulation or
includes removal of the mass and a small photoablation.
margin of normal tissue that is easily
accessible. METHODS OF TREATMENT

2. WIDE OR RADICAL EXCISIONS (en bloc 1. Prophylactic

dissection)
- Include removal of the primary tumor,
lymph nodes, adjacent involved structures,
and surrounding tissues that may be at high
risk for tumor spread.
- Surgical method may result in disfigurement
and altered functioning, necessitating
rehabilitations, reconstructive procedure, or
both.
SALVAGE SURGERY
- Extensive surgical approach to treat the
local recurrence of cancer after the use of a
less extensive primary approach.
- E.g., Mastectomy to treat recurrent breast
cancer after primary lumpectomy and
radiation is an
- Also called risk reduction surgery.
- involves removing non-vital tissues or organs
that are at increased risk of developing cancer.
The following factors are considered when
discussing possible prophylactic surgery:
 Family history and genetic
predisposition
 Presence or absence of signs and
symptoms
 Potential risks and benefits
 Ability to detect cancer at an early stage
 Alternative options for managing
increased risk
 The patient’s acceptance of the
postoperative outcome
  E.g., colectomy, mastectomy, and
oophorectomy.
NURSING RESPONSIBILITIES
- Preoperative education and counselling, as
well as long-term follow-up, are provided.
- Prophylactic surgery is discussed with
patients and families along with other
approaches for managing increased risk of
cancer development
2. Palliative
- To relieve symptoms and to improve the
patient’s quality of life.
- performed to relieve symptoms such as
ulceration, obstruction, hemorrhage, pain, and
malignant effusions.
- can performed as a supportive treatment to
relieve symptoms along with other potentially
curative cancer treatments.
NURSING RESPONSIBILITIES
- Surgical cure is not possible, honest and
informative communication with the
patient and family about the goal of
palliative surgery is essential to avoid false
hope and disappointment.
3. Reconstructive
- may follow curative and extensive surgery in
an attempt to improve function or obtain a
more desirable cosmetic effect.
- it may perform in one operation or in stage.
- reconstructive surgical options with the
patient before the primary surgery is
performed.
- reconstructive surgery may be indicate for
breasts, head and neck, and skin cancer.
NURSING RESPONSIBILITIES
- Nurse assesses the patients need and the
impact that altered functioning and body
image may have on quality of life.
- Provide patients and families with
opportunities to discuss these issues.
- Individual needs of the patient undergoing
reconstructive surgery and their families
must be accurately recognized and
addressed.
NURSING MANAGEMENT
Perioperative Nursing Care
- Surgical care is individualized according to
age, organ impairment, specific deficits,
comorbidities, cultural implications, and
altered immunity.
- Combining other treatments methods, such
as radiation and chemotherapy, with
surgery also contributes to postoperative
complications, such as infection, impaired
wound healing, altered pulmonary or renal
function, and the development of venous
thromboembolism.
Preoperatively
- Nurse provides the patient and family with
verbal and written information about the
surgical procedures as well as other
interventions that may take place
intraoperatively.
- Instruct concerning prophylactic antibiotics
requirements, diets, and bowel preparation
are also provided.
- The patient and family require time and
assistance to process this information,
possible changes, and expected outcomes
resulting from the surgery.
- The nurse may be asked to explain and
clarify information for patients and families
that was provided initially but was not
 grasped because of intense anxiety. It is
important that the nurse, as well as other
members of the health care team, provide
information that is consistent.
Postoperatively
- Nurse assesses patient responses to surgery
and monitors the patients for possible
complications, such as infection, bleeding,
thrombophlebitis, wound dehiscence, fluid
and electrolyte imbalance, and organ
dysfunction.
- The nurse provides for the patient’s
comfort.
- Post operative education addresses wound
care, pain management, activity, nutrition,
and medication information.
- Plans of discharge, follow up, home care,
and subsequent treatment and
rehabilitation are initiated as early as
possible to ensure continuity of care from
hospital to home or from a cancer referral
center to the patient’s local hospital and
health care provider.
CHEMOTHERAPHY
- Involves the use of antineoplastic drug in an
attempt to destroy cancer cell by interfering
with cellular functions, including replication
and DNA repair.
- Used primarily to treat systemic disease
rather than localized lesions that are
amenable to surgery or radiation.
Neoadjuvant – chemotherapy may be
combined with surgery, radiation therapy, or
both to reduce tumor size preoperatively.
Adjuvant – destroy any remaining tumor cells
postoperatively
Primary – treat some forms of leukemia or
lymphoma.
The goals of chemotherapy:
1. Cure
2. Control
3. Palliation
CELL KILL AND CELL CYLE
- Each time a tumor is exposed to
chemotherapy, a percentage of the tumor
cells (20% to 99%, depending on dosage and
agent) are destroyed.
- Repeated doses of chemotherapy are
necessary over a prolonged period to
achieve regression of the tumor.
- Eradication of 100% of the tumor is
impossible; the goal of chemotherapy is to
eradicate of enough of the tumor so that
the remaining malignant cell can be
destroyed by the body immune system.
Actively proliferating cells within a tumor
- The most sensitive to chemotherapy (the
ratio of dividing cells to resting cells is
referred to as the growth fraction.
Nondividing cells
- Future proliferation are the least sensitive
to antineoplastic are the least sensitive to
antineoplastic medications and
consequently are potentially dangerous.
- However, nondividing cell must be
destroyed to eradicate the disease.
- Repeated cycles of chemotherapy or
seducing of multiple chemotherapeutics
agents is used to achieve more tumor cell
destruction by destroying the non-diving
tumor cells as the begin active cell division.
 The cell cycle time is the time required for one DRUG CLASS AND
MECHANISM OF ACTION
cell to divide and reproduce two identical EXAMPLES
daughter cells. ALKYLATING AGENTS
 Busulfan, Bond with DNA, RNA, and
RNA and protein carboplatin, protein molecules leading
G1 PHASE
synthesis occurs chlorambucil, to impaired DNA
S PHASE DNA synthesis occurs cisplatin, replication, RNA
cyclophosphamide, transcription, and cell
Premitotic phase; DNA
dacarbazine, functioning; all resulting in
G2 PHASE synthesis is complete,
altretamine cell death.
mitotic spindle forms
ifosfamide,
Duplicated
melphalan,
MITOSIS chromosomes separate,
nitrogen mustard,
and cell division occurs
oxaliplatin.

TOPOISOMERASE I Induce breaks in the DNA

INHIBITORS strand by binding to
CLASSIFICATIONS OF CHEMOTHERAPEUTIC enzyme topoisomerase,
AGENTS preventing cells from
dividing.
- Agents that exert their maximal effect
during specific phases of the cell cycle are ANTIMETABOLITES Interferes with the
termed cell CYCLE-SPECIFC AGENTS (e.g., biosynthesis of metabolites
docetaxal, vinblastine, etoposide) or nucleic acids necessary
for RNA and DNA
- CELL-NONSPECIFIC AGENTS synthesis; inhibits DNA
chemotherapeutic agents that act replication and repair.
independently of the cell cycle phases.
- These agents usually have a prolonged ANTITUMOR ANTIBIOTICS Interfere with DNA
synthesis by binding DNA;
effect on cells, leading to cellular damage or
prevent RNA synthesis
death.
MITOTIC SPINDLE Arrest metaphase by
INHIBITORS inhibiting mitotic tubular
Chemotherapeutic agents are also classified by formation (spindle); inhibit
chemical group, each with a different DNA and protein synthesis
mechanism of action.

 Alkylating agents - Chemotherapeutic agents from multiple

 Nitrosoureas categories may be used together to
 Antimetabolites maximize cell destruction.
 antitumor antibiotics - The use of combination therapy also helps
 topoisomerase inhibitors prevent the development of drug resistant
 plant alkaloids (mitotic inhibitors) cells
 hormonal agents
 miscellaneous agents
ADMINSTRATION OF CHEMOTHERAPEUTICS - Chemotherapy is given only by those who
AGENTS gave the knowledge and established
competencies for vesicant and
- Chemotherapy can be given in the hospital,
extravasation management.
outpatient center, or home setting by
- Vesicant chemotherapy should never be
multiple routes.
given in peripheral veins involving the hand
- The route of administration depends on the
or wrist.
type of agent; the required does; and the
- Peripheral administration is permitted for
type, location, and extent of malignant
short duration infusion only, and placement
disease being treated. Standards for the
of the venipuncture sites should be on the
safe administration of chemotherapy.
forearm area using a soft, plastic catheter.
DOSAGE
For any frequent or prolonged administration of
- Based primarily on the patient’s total body antineoplastic vesicants,
surface area, weight, previous exposure and
 Right atrial silastic catheters
response to chemotherapy or radiation
 Implanted venous access devices
therapy, and function of major organ
 Peripherally inserted central catheters
systems.
(PICCs)
EXTRAVASATION
Should be inserted to promote safety during
- Intravenously administered chemotherapy medications administration and reduce
agents are additionally classified by their problems with access to the circulatory system.
potential to damage tissue if they
inadvertently leak from a vein into
surrounding tissue; this leakage is called HYPERSENSITIVITY REACTION
extravasation.
- When signs and symptoms of HRS occur,
VESICANTS the medications should be discontinued
immediately, and emergency procedures
- Agents that cause inflammation, tissue
initiated.
damage, and possibly necrosis of tendons,
muscles, nerves, and blood vessels if TOXITY
extravasation occurs.
- Cells with rapid growth rates (e.g.,
E.g., commonly used agents classified as epithelium, bone marrow, hair follicles,
vesicants include: sperms) are very susceptible to damage,
and the effects may manifest in virtually any
 Dactinomycin
body system.
 Daunorubicin
 Doxorubicin
 Nitrogen mustard GASTROINTESTINAL SYSTEM
 Mitomycin
- Side effects of chemotherapy are nausea
 Vinblastine
and vomiting, which may persist for 24 to
 Vincristine
48 hours; delayed nausea and vomiting may
occur up to 1 week after administration.
ACUTE CHEMOTHERPAHY-INDUCED NAUSEA
AND VOMITING (CINV)
- Experienced in the first 24 hours after
chemotherapy with a maximal intensity
after 5-6 hours
DELAYED CINV
- Occurs 24 hours posttreatment and may
last as many as 7 days with a maximal
intensity 48-72 hours after administration.
PHARMACOLOGICAL THERAPHY
- Corticosteroids, phenothiazines, sedatives,
and histamines are helpful, especially when
used in combination with serotonin
blockers to provide antiemetic protections.
NONPAHARMACOLOGICAL APPROACHES
- Relaxation techniques, imagery,
acupressure, or acupuncture can help
decrease stimuli contributing to symptoms
and may be most helpful for patients with
anticipatory nausea and vomiting.
- Small frequent meals, bland foods, and
comfort foods may reduce the frequency or
severity of symptoms.
STOMATITIS
- Commonly associated with chemotherapy
agents because of the rapid turnover of
epithelium that lines the oral cavity.
- Antimetabolites and antitumor antibiotics
are the major culprits in mucositis and other
gastrointestinal symptoms, which can eb
severe in some patients.
HEMATOPOIETIC SYSTEM
- Many chemotherapy agents cause some
degree of myelosuppression (depression of
bone marrow function)
- Neutropenia (decreased granulocytes),
anemia (decreased red blood cells [RBCs],
thrombocytopenia (decreased platelets),
and increased risk of infection and bleeding.
RENAL SYSTEM
- Cisplatin, methotrexate, and mitomycin are
particularly toxic to the kidneys.
- Intracellular contents are released into
circulation, resulting in hyperkalemia,
hyperphosphatemia, and hypocalcemia and
obstructive nephropathy.
NURSING MANAGEMENT
- The monitoring of laboratory values,
including blood urea nitrogen (BUN), serum
creatinine, creatinine clearance, and serum
electrolytes is essential.
- Adequate hydration and diuresis to prevent
formation of uric acid crystals and
administration of ALLOPURINOL may be
used to prevent renal toxicity.
CARDIOPULMONARY SYSTEM
- Anthracyclines (e.g., daunorubicin,
doxorubicin) are known to cause
irreversible cumulative cardiac toxicities
when total dosage reaches 400 mg/m2.
- Patients at increased risk for the
development of cardiac toxicities include:
extreme ages
 > 65 years
 <18 years
 Female gender
 African American race
 Chest radition
 Kidney failure
  Preexisting cardiac disease
(hypertension)
REPRODUCTIVE SYSTEM
- Testicular and ovarian function can be
affected by chemotherapeutic agents,
resulting in possible infertility.
- Women may develop problems with
ovulation or early menopause, whereas
men may develop temporary or permanent
azoospermia.
NURSING MANAGEMENT
hematologic, hepatic, renal, cardiovascular,
neurologic, and pulmonary systems are
critical in evaluating the body’s response to
chemotherapy.
ASSESSING FLUID AND ELECTROLYTE STATUS
- Anorexia, nausea, vomiting, altered taste,
mucositis, and diarrhea put patients
nutritional and fluid and electrolyte
disturbance.
- Therefore, it is important for the nurse to
assess the patient’s nutritional and fluid and
electrolyte status on an ongoing basis and
to identify creative ways to encourage an
adequate fluid and dietary intake.

- Options available for women prior to

initiation of chemotherapy include CARE OF CLIENTS WITH PROBLEMS IN
CRYOPRESERVATION (freezing) of oocytes, CELLULAR ABBERATIONS
embryos, or ovarian tissue.
- Patients and their partners are informed BONE MARROW TRANSPLANTATION
about potential changes in reproductive
function resulting from chemotherapy.
- Patients are advised to use reliable methods
of birth control while receiving
chemotherapy and not to assume that
infertility has resulted.

NEUROLOGICAL SYSTEM

- VINCRISTINE, can cause cumulative

peripheral nervous system damage with
sensory alterations in the feet and hands.
These sensations can be described as
tingling, pricking, or numbness of the
extremities; burning or freezing pain; sharp,
stabbing, or electric shock-like pain; and
extreme sensitivity to touch.

NURSING MANAGEMENT
- Laboratory and physical assessment of
metabolic indices and the dermatological,