ONCOLOGY NURSING

Epidemiology
Overall, the incidence of cancer is higher in men than in women and higher in
industrialized sectors and nations.

 More than 1.4 million Americans are diagnosed each year with cancer,
affecting one of various body sites.
 Cancer is second only to cardiovascular disease as a leading cause of death
in the United States.
 Although the number of cancer deaths has decreased slightly, more
than 560, 000 Americans were expected to die from a malignant process in
2008.
 The leading causes of cancer deaths in the United States, in order of
frequency, are lung, prostate, and colorectal cancer in men and lung,
breast, and colorectal cancer women.
 For all cancer sites combined, African American men have a 15% higher
incidence rate and a 38% higher death rate than Caucasian men.
African-American women have a 9% lower incidence rate, but
an 18% higher death rate than Caucasian women for all cancer sites
combined.

Pathophysiology
Cancer is a disease process that begins when an abnormal cell is transformed by
the genetic mutation of the cellular DNA.

 Proliferative patterns. Cancerous cells are described as malignant

neoplasms because they demonstrate uncontrolled cellular growth that
follows no physiologic demand (neoplasia).
 Characteristics of malignant cells. Cells are undifferentiated and often bear
little resemblance to the normal cells; they grow at the periphery and sends
out processes that infiltrate and destroy the surrounding tissues; the rate of
their growth is variable and depends on level of differentiation; they can
gain access to the blood and lymphatic channels and metastasizes to other
areas of the body; they often cause generalized effects such as anemia,
weakness, and weight loss; they often cause extensive tissue damage and
causes death unless growth can be controlled.
1
ONCOLOGY NURSING
 Invasion and metastasis. Malignant disease processes have the ability to
allow the spread or transfer of cancerous cells from one organ or body part
to another by invasion (growth of the primary tumor into the surrounding
host tissues) and metastasis (dissemination or spread of malignant cells
from the primary tumor to distant sites.
 Carcinogenesis. Carcinogenesis is a malignant transformation that
involves initiation (initiators such as chemicals, physical factors, and
biologic agents, escape normal enzymatic mechanisms and alter the
genetic structure of the cellular DNA), promotion (repeated exposure to
carcinogens causes the expression of abnormal or mutant genetics
information), and progression (the altered cells exhibit increased malignant
behavior).
 Role of the immune system. Some evidence indicates that the immune
system can detect the development of malignant cells and destroy them
before cell growth becomes uncontrolled, but when the immune system
fails to identify and stop the growth of malignant cells, clinical cancer
develops.

Detection and Prevention of Cancer

Nurses and physicians have traditionally been involved with tertiary prevention,
the care, and rehabilitation of patients after cancer diagnosis and treatment, but
the American Cancer Society, the National Cancer Institute, clinicians, and
researchers also place emphasis on primary and secondary prevention of cancer.

 Primary prevention. Primary prevention is concerned with reducing risks of

disease through health promotion strategies.
 Secondary prevention. Secondary prevention programs promote screening
and early detection activities such as breast and testicular self-examination
and Papanicolaou (Pap) tests.

Diagnosis of Cancer
A cancer diagnosis is based on the assessment of physiologic and functional
changes and results of the diagnostic evaluation.

2
ONCOLOGY NURSING
 Tumor marker identification. Analysis of substances found in body tissues,
blood or other body fluids that are made by the tumor or by the body in
response to the tumor.
 Genetic profiling. Analysis for the presence of mutations in genes found in
tumors or body tissues.
 Mammography. Mammography is the use of x-ray images of the breast.
 Magnetic resonance imaging (MRI). MRI uses magnetic fields and radio-
frequency signals to create sectioned images of various body structures.
 Computed tomography (CT). CT scan uses narrow-beam x-ray to scan
successive layers of tissue for a cross-sectional view.
 Fluoroscopy. Use of X-rays that identify contrasts in the body tissue
densities; may involve the use of contrast agents.
 Ultrasonography. Ultrasound uses high-frequency sound waves echoing off
body tissues and is converted electronically into images; used to assess
deep tissues within the body.
 Endoscopy. Direct visualization of a body cavity or passageway
by insertion of an endoscope into a body cavity or opening; allows tissue
biopsy, fluid aspiration, and excision of small tumors.
 Nuclear medicine imaging. Uses intravenous injection or ingestion of
radioisotope substances followed by imaging of tissues that have
concentrated the radioisotopes.
 Positron emission tomography (PET). Through the use of a tracer, provides
black and white or color-coded images of the biologic activity of a
particular area, rather than its structure.
 PET fusion. Use of a PET scanner and a CT scanner in one machine to
provide an image combining anatomic detail, spatial resolution, and
functional metabolic abnormalities.
 Radioimmunoconjugates. Monoclonal antibodies are labeled with a
radioisotope and injected intravenously into the patient.

Tumor Staging and Grading

A complete diagnostic evaluation include identifying the stage and grade of the
tumor.
Staging. Staging determines the size of the tumor and the existence of local
invasion and distant metastasis.

3
ONCOLOGY NURSING
 Tumor, nodes, and metastasis (TNM) system. The TNM system is frequently
used, where T is the extent of the primary tumor, N is the absence or
presence and extent of regional lymph node metastasis, and M is the
absence or presence of distant metastasis.
 Grading. Grading refers to the classification of the tumor cells, and it seeks
to define the type of tissue from which the tumor originated and the
degree to which the tumor cells retain the functional and histologic
characteristics of the tissue of origin.
 Grade I to IV. Grade I tumors, also known as well-differentiated tumors,
closely resemble the tissue of origin in structure and function while Grade
IV tumors do not clearly resemble the tissue of origin in structure and
function.

Management of Cancer
Treatment options offered to cancer patients should be based on treatment goals
for each specific type of cancer.

Surgery
Surgical removal of entire cancer remains the ideal and most frequently used
treatment method.

Diagnostic Surgery

Biopsy
 Biopsy. Biopsy is usually performed to obtain a tissue sample for analysis of
the cells suspected to be malignant.
 Types of biopsy. The three most common biopsy methods are the
excisional, incisional, and needle methods.
 Excisional biopsy. Excisional biopsy is most frequently used for easily
accessible tumors of the skin, breast, and upper and lower gastrointestinal
and upper respiratory tracts.
 Incisional biopsy. Incisional biopsy is performed if the tumor mass is too
large to be removed.

4
ONCOLOGY NURSING
 Needle biopsy. Needle biopsies are performed to sample suspicious
masses that are easily accessible, such as growths in the breasts, thyroid,
lung, liver, and kidney.
Surgery as Primary Treatment
When surgery is the primary approach in treating cancer, the goal is to remove
the entire tumor or as much as is feasible and any involved surrounding tissue,
including regional lymph nodes.

 Local excision. Local excision, often performed on an outpatient basis, is

warranted when the mass is small, and it includes removal of the mass and
a small margin of normal tissue that is easily accessible.
 Wide or radical excisions. Wide excisions include removal of the primary
tumor, lymph nodes, adjacent involved structures, and surrounding tissues
that may be at high risk for tumor spread.
 Video-assisted endoscopic surgery. In this minimally invasive procedure,
an endoscope with intense lighting and an attached multichip mini-camera
is inserted into the body through a small incision.
 Salvage surgery. Salvage surgery is an additional treatment option that is
an extensive surgical approach to treat the local recurrence of cancer after
the use of a less extensive primary approach.
 Electrosurgery. Uses electric current to destroy tumor cells.
 Cryosurgery. Uses liquid nitrogen or a very cold probe to freeze tissue and
cause cell destruction.
 Chemosurgery. Uses chemicals or chemotherapy applied directly to the
tissue to cause destruction.
 Laser surgery. Uses light and energy aimed at an exact tissue location and
depth to vaporize cancer cells.
 Photodynamic therapy. Intravenous administration of a light-sensitizing
agent that is taken up by cancer cells, followed by exposure to laser within
24-48 hours.
 Radiofrequency ablation. Uses localized application of thermal energy that
destroys cancer cells through heat.

5
ONCOLOGY NURSING
Prophylactic Surgery
Prophylactic surgery involves removing nonvital tissues or organs that are at
increased risk to develop cancer.

 Examples of prophylactic surgery. Colectomy, mastectomy, and

oophorectomy are examples of prophylactic surgery.
 Qualified patients. Prophylactic surgery is offered selectively to patients
and discussed thoroughly with patients and families.
Palliative Surgery
When a cure is not possible, the goals of treatment are to make the patient as
comfortable as possible.

 Palliative surgery. Palliative surgery is performed in an attempt to relieve

complications of cancer.
 Communication. Honest and informative communication with the patient
and family about the goal of surgery is essential to avoid false hope and
disappointment.
Reconstructive Surgery
Reconstructive surgery may follow curative or radical surgery.

 Reconstructive surgery. Reconstructive surgery may be performed in an

attempt to improve function or obtain a more desirable cosmetic effect.
 Indications. Reconstructive surgery may be indicated for breast, head and
neck, and skin cancers.
Radiation Therapy
More than half of patients with cancer receive a form of radiation therapy at
some point during treatment.

 Uses. Radiation may be used to cure cancer, as in thyroid carcinomas,

localized cancers of the head and neck, and cancers of the uterine cervix; it
may control malignant disease when a tumor cannot be removed surgically
or when local nodal metastasis is present, or it can be used neoadjuvantly.
6
ONCOLOGY NURSING
 Types. Two types of ionizing radiation-electromagnetic radiation (xrays and
gamma rays) and particulate radiation (electrons, beta particles, protons,
neutrons, and alpha particles)- can lead to tissue disruption.
Radiation Dosage
Radiation dosage depends on the sensitivity of the target tissues to radiation, the
size of the tumor, tissue tolerance of the surrounding normal tissues, and critical
structures adjacent to the tumor target.

 Lethal tumor dose. The lethal tumor dose is defined as that dose that will
eradicate 95% of the tumor yet preserve normal tissue.
 Fractions. In external beam radiation, the total radiation dose is delivered
over several weeks in daily doses called fractions.
 Fractionated doses. Repeated radiation treatments over time also allow for
the periphery of the tumor to be reoxygenated repeatedly, because tumors
shrink from the outside inward.
Administration of Radiation
Radiation therapy can be administered in a variety of ways depending on the
source of radiation used, the location of the tumor, and the type of cancer
targeted.

 Teletherapy (external beam radiation). External beam radiation therapy is

the most commonly used form of radiation, in which, depending on the
size, shape, and location of the tumor, different energy levels are
generated to produce a carefully shaped beam that will destroy the
targeted tumor, yet spare the surrounding healthy tissues and organs in an
effort to reduce the treatment toxicities for the patient.
 Brachytherapy (internal radiation). Internal radiation implantation, or
brachytherapy, delivers a high dose of radiation to a localized area and can
be implanted by means of needles, seeds, beads, or catheters into body
cavities (vagina, abdomen, pleura) or interstitial compartments (breast,
prostate).
Toxicity

7
ONCOLOGY NURSING
 Alopecia. Altered skin integrity is a common effect and can include
alopecia or hair loss.
 Stomatitis. Alterations in oral mucosa secondary to radiation therapy
include stomatitis or inflammation of the oral tissues, xerostomia or
dryness of the mouth, change and loss of taste, and increased salivation.
 Thrombocytopenia. Bone marrow cells proliferate rapidly, and if sites
containing bone marrow are included in the radiation field, anemia,
leukopenia, and thrombocytopenia may result.
Nursing Management in Radiation Therapy
 Assessment. The nurse assesses the patient’s skin and oropharyngeal
mucosa regularly when radiation therapy is directed to these areas, and
also the nutritional status and general well-being should be assessed.
 Symptoms. If systemic symptoms, such as weakness and fatigue, occur, the
nurse explains that these symptoms are a result of the treatment and do
not represent deterioration or progression of the disease.
 Safety precautions. Safety precautions used in caring for a patient receiving
brachytherapy include assigning the patient to a private room, posting
appropriate notices about radiation safety precautions, having staff
members wear dosimeter badges, making sure that pregnant staff
members are not assigned to the patient’s care, prohibiting visits
by children and pregnant visitors, limiting visits from others to 30 minutes
daily, and seeing that visitors maintain a 6 foot distance from the radiation
source.

Chemotherapy
In chemotherapy, antineoplastic agents are used in an attempt to destroy tumor
cells by interfering with cellular functions, including replication.

 Goal. The goal of treatment is the eradication of enough tumor so that the
remaining tumor cells can be destroyed by the body’s immune system.
 Proliferating cells. Actively proliferating cells within a tumor are the most
sensitive to chemotherapeutic agents.
 Nondividing cells. Nondividing cells capable of future proliferation are the
least sensitive to antineoplastic medications and consequently are
potentially dangerous.
8
ONCOLOGY NURSING
 Cell cycle-specific. Cell cycle-specific agents destroy cells that are actively
reproducing by means of the cell-cycle; most affect cells in the S phase by
interfering with DNA and RNA synthesis.
 Cell cycle-nonspecific. Chemotherapeutic agents that act independently of
the cell cycle phases are cell cycle nonspecific, and they usually have a
prolonged effect on cells, leading to cellular damage and death.
Antineoplastic Agents
Chemotherapeutic agents are also classified by chemical group, each with a
different mechanism of action.

 Alkylating agents. Alters DNA structure by misreading DNA code, initiating

breaks in the DNA molecule, cross-linking DNA strands
 Nitrosoureas. Similar to the alkylating agents, but they can cross the blood-
brain barrier.
 Topoisomerase I inhibitors. Induce breaks in the DNA strand by binding to
enzyme topoisomerase I, preventing cells from dividing.
 Antimetabolites. Antimetabolites interfere with the biosynthesis of
metabolites or nucleic acids necessary for RNA and DNA synthesis.
 Antitumor antibiotics. Interfere with DNA synthesis by binding DNA and
prevent RNA synthesis.
 Mitotic spindle poisons. Arrest metaphase by inhibiting mitotic tubular
formation and inhibiting DNA and protein synthesis.
 Hormonal agents. Hormonal agents bind to hormone receptor sites that
alter cellular growth; blocks binding of estrogens to receptor sites; inhibit
RNA synthesis; suppress aromatase of P450 system, which decreases level.

Nursing Management in Chemotherapy

Nurses play an important role in assessing and managing many of the problems
experienced by patients undergoing chemotherapy.

 Assessing fluid and electrolyte balance. Anorexia, nausea, vomiting, altered

taste, mucositis, and diarrhea put patients at risk for nutritional and fluid
electrolyte disturbances.
 Modifying risks for infection and bleeding. Suppression of the bone
marrow and immune system is expected and frequently serves as a guide
9
ONCOLOGY NURSING
in determining appropriate chemotherapy dosage but increases the risk of
anemia, infection, and bleeding disorders.
 Administering chemotherapy. The patient is observed closely during its
administration because of the risk and consequences of extravasation,
particularly of vesicant agent.
 Protecting caregivers. Nurses must be familiar with their institutional
policies regarding personal protective equipment, handling and disposal of
chemotherapeutic agents and supplies, and management of accidental
spills or exposures.

Bone Marrow Transplantation

The role of bone marrow transplantation (BMT) for malignant and some
nonmalignant diseases continues to grow.

Type of Bone Marrow Transplant

Types of BMT based on the source of donor cells include:

 Allogeneic. Allogeneic is from a related donor other than the patient;

donor may be a related donor or a matched unrelated donor.
 Autologous. Autologous BMT is from the patient himself.
 Syngeneic. Syngeneic BMT is from an identical twin.
Nursing Management in Bone Marrow Transplantation
Nursing care of patients undergoing BMT is complex and demands a high level of
skill.

 Implementing pretransplantation care. Nutritional assessments, extensive

physical examinations, organ function tests, and psychological evaluations
are conducted, with blood work that includes assessing past antigen
exposure, and the patient’s support system, financial, and insurance
resources are also evaluated.
 Providing care during treatment. Nursing management during bone
marrow infusion or stem cell infusions consists of monitoring the patient’s
vital signs and blood oxygen saturation; assessing for adverse effects such
as fever, chills, shortness of breath, chest pain, cutaneous reactions, nausea,
10
ONCOLOGY NURSING
vomiting, hypotension, or hypertension, tachycardia, anxiety, and taste
changes; and providing ongoing support and patient teaching.
 Providing posttransplantation care. Ongoing nursing assessments such as
psychosocial assessments in follow-up visits are essential to detect late
effects of therapy after BMT, which occur 100 days or more after the
procedure, and donors also require nursing care through being assisted in
maintaining realistic expectations of themselves as well as of the patient.

Targeted Therapies
Targeted therapies seek to minimize the negative effects on healthy tissues by
disrupting specific cancer cell functions such as malignant transformation, cell
communication pathways, processes for growth and metastasis, and genetic
coding.

Biologic Response Modifiers (BRM)

Biologic response modifier therapy involves the use of naturally occurring or
recombinant agents or treatment methods that can alter the immunologic
relationship between the tumor and the host to provide a therapeutic benefit.

 Nonspecific biologic response modifiers. Nonspecific agents such as

Calmette-Guérin (BCG) and Corynebacterium parvum, when injected into
the patient, may serve as antigens that can stimulate an immune response
in the hopes of eradicating malignant cells.
 Monoclonal antibodies. Monoclonal antibodies (MoAbs) have become
available through technologic advances, and this type of specificity allows
MoAbs to destroy the cancer cells and spare normal cells.
 Cytokines. Cytokines, substances produced by cells of the immune system
to enhance the production and functioning of components of the immune
system, are also the focus of cancer treatment research.
 Retinoids. Retinoids are vitamin A derivatives that play a role in growth,
reproduction, apoptosis, epithelial cell differentiation, and immune
function, wherein specific receptors in the cell nucleus are retinoid-
dependent, thus when retinoids bind with these receptors, cell
differentiation and replication are affected.

11
ONCOLOGY NURSING
 Cancer vaccines. Cancer vaccines are used to mobilize the body’s immune
response to recognize and attack cancer cells, as these cancer vaccines
contain either portions of cancer cells alone or portions of cells in
combination with other substances that can augment or boost immune
responses.
Nursing Management in Biologic Response Modifier
Therapy
It is essential for the nurse to assess the need for education, support, and
guidance for both the patient and the family and assist in planning and
evaluating patient care.

 Monitoring therapeutic and adverse effects. The nurse must be familiar

with each agent given and its potential effects, and also, the nurse must be
aware of the impact of these side effects on the patient’s quality of life.
 Promoting home and community-based care. The nurse teaches the
patient and family how to administer BRMs through subcutaneous
injections, provides instructions about side effects and helps the patient
and family identify the strategies to manage many of the common side
effects of BRM therapy.
Gene Therapy
Gene therapy includes approaches that correct genetic defects or manipulate
genes to induce tumor cell destruction in the hope of preventing or combating
the disease.

ADVERTISEMENTS

 Challenges. One of the challenges confronting cancer gene therapy is the

multiple somatic mutations involved in the development of cancer, making
it difficult to identify the most effective gene therapy approach.
 Viruses. Viruses used as vectors that transport a gene into a target cell via
the cell membrane include retroviruses, adenoviruses, vaccinia virus,
fowlpox, herpes simplex viruses, and Epstein-Barr viruses.
Approaches in Gene Therapy

12
ONCOLOGY NURSING
Three general approaches have been used in the development of gene therapies,
with adenoviruses showing effective promise in each approach.

 Tumor-directed therapy. This is the introduction of a therapeutic gene

(suicide gene) into tumor cells in an attempt to destroy them.
 Active immunotherapy. Active immunotherapy is the administration of
genes that will invoke the antitumor responses of the immune system.
 Adoptive immunotherapy. Active immunotherapy is the administration of
genetically altered lymphocytes that are programmed to cause tumor
destruction.
Complementary and Alternative Medicine
Many patients seek a more holistic or nontraditional approach, turning to
complementary and alternative therapies while continuing to utilize conventional
medicine.

 Complementary and Alternative Medicine (CAM). CAM was defined as

diverse medical and health care systems, practices, and products that are
not presently considered to be part of conventional medicine.
 Risk. Because of the possibility of herb-vitamin-drug interactions, there is
concern about the use of biologicals and dietary supplements, which are
not regulated by the FDA nor subjected to rigorous scientific evaluation.
Unproven and Unconventional Therapies
Hopelessness, desperation, unmet needs, lack of factual information, and family
and social pressures are major factors that motivate patients to seek
unconventional methods of treatment.

 Definition. Unconventional treatments are those without scientific evidence

of the ability to cure or control cancer.
Nursing Management in Unconventional Therapies
The most effective way to protect patients and families from fraudulent therapies
and questionable cancer cures is to establish a trusting relationship, provide
supportive care, and promote hope.

13
ONCOLOGY NURSING
 Communication. Truthful responses given in a nonjudgmental manner to
questions and inquiries about unproven methods of cancer treatments may
alleviate the fear and guilt on the part of the patient and the family that
they are not “doing everything we can” to obtain a cure.
 Information. The nurse should inform the patient and family should inform
the patient and family of the characteristics common to fraudulent
therapies so that they will be informed and cautious when evaluating other
forms of “therapy”.
 Collaboration. The nurse should encourage the patient to inform their
physicians about the use of therapies to help prevent interactions with
medications and other therapies that may be prescribed.

Nursing Care of Patients with Cancer

Main Article: 13 Cancer Nursing Care Plans

The outlook for patients with cancer has greatly improved because of scientific
and technologic advances.

Maintaining Tissue Integrity

 Stomatitis. Assessment of the patient’s subjective experience and an
objective assessment of the oropharyngeal tissues and teeth are important
and for the treatment of oral mucositis, Palifermin (Kepivance), a synthetic
form of human keratinocyte growth factor, could be administered.
 Radiation-associated skin impairment. Nursing care for patients with
impaired skin reactions includes maintaining skin integrity, cleansing the
skin, promoting comfort, reducing pain, preventing additional trauma, and
preventing and managing infection.
 Alopecia. Nurses provide information about hair loss and support the
patient and family in coping with changes in body image.
 Malignant skin lesions. Nursing care includes cleansing the skin, reducing
superficial bacteria, controlling bleeding, reducing odor, protecting the skin
from further trauma, and relieving pain.
Promoting Nutrition

14
ONCOLOGY NURSING
 Anorexia. Anorexia may occur because people feel full after eating only a
small amount of food.
 Malabsorption. Surgical intervention may change peristaltic patterns, later
gastrointestinal secretions, and reduce the absorptive surfaces of the
gastrointestinal mucosa, all leading to malabsorption.
 Cachexia. Nurses assess patients who are at risk of altered nutritional intake
so that appropriate measures may be instituted prior to nutritional decline.
Relieving Pain
 Assessment. The nurse assesses the patient for the source and site of pain
as well as those factors that increase the patient’s perception of pain.
 Cancer pain algorithm. Various opioid and nonopioid medications may be
combined with other medications to control pain as adapted from the
World Health Organization three-step ladder approach.
 Education. The nurse provides education and support to correct fears and
misconceptions about opioid use.
Decreasing Fatigue
 Assessment. The nurse assesses physiologic and psychological stressors
that can contribute to fatigue and uses several assessment tools such as a
simple visual analog scale to assess levels of fatigue.
 Exercise. The role of exercise as a helpful intervention has been supported
by several controlled trials.
 Pharmacologic interventions. Occasionally pharmacologic interventions are
utilized, including antidepressants for patients with depression, anxiolytics
for those with anxiety, hypnotics for patients with sleep disturbances, and
psychostimulants for some patients with advanced cancer or fatigue that
does not respond to any medication.
Improving Body Image and Self-esteem
 Assessment. The nurse identifies potential threats to the patient’s body
image experience, and the nurse assesses the patient’s ability to cope with
the many assaults to the body image experienced throughout the course
of the disease and treatment.
 Sexuality. Nurses who identify physiologic, psychologic or communication
difficulties related to sexuality or sexual function are in a key position to

15
ONCOLOGY NURSING
help patients seek further specialized evaluation and intervention if
necessary.
Assisting in the Grieving Process
 Assessment. The nurse assesses the patient’s psychological and mental
status, as well as the mood and emotional reaction to the results of
diagnostic testing and prognosis.
 Grieving. Grieving is a normal response to these fears and to actual or
potential losses.
Monitoring and Managing Potential Complications
 Infection. The nurse monitors laboratory studies to detect any early
changes in WBC counts.
 Septic shock. Neurologic assessments are carried out, fluid and electrolyte
status is monitored, arterial blood gas values and pulse oximetry are
monitored, and IV fluids, blood, and vasopressors are administered by the
nurse.
 Bleeding and hemorrhage. The nurse may administer IL-11, which has
been approved by the FDA to prevent severe thrombocytopenia, and
additional medications may be prescribed to address bleeding due to
disorders of coagulation.
Promoting Home and Community-Based Care
Nurses in the outpatient settings often have the responsibilities for patient
teaching and for coordinating care in the home.

 Teaching patients self-care. Follow-up visits and telephone calls from the
nurse assist in identifying problems and are often reassuring, increasing the
patient’s and the family’s comfort in dealing with complex and new aspects
of care.
 Continuing care. The responsibilities of the home care include assessing
the home environment, suggesting modifications at home or in care to
help the patient and the family address the patient’s physical needs.

16
ONCOLOGY NURSING

DISEASEASE:
I. TESTICULAR CANCER
A. Description
1. Testicular cancer arises from germinal epithelium from the sperm
producing germ cells or from nongerminal epithelium from other
structures in the testicles.
2. Testicular cancer most often occurs between ages 15 to 40 years old
3. The cause of testicular cancer is unkown, but history of undescended
testicle and genetic predisposition have been associated with testicular
tumor development.
4. Metastasis occurs to the lung, liver, bone and adrenal glands via the
blood, and to the retroperitoneal lymph nodes via lymphatic.

B. Early detection: Perform monthly testicular self examination.

1.Performing testicular self examination. Perform monthly, a day of the
month is selected and the examination is performed on the same day
each month.

C. Assessment
1. Painless testicular swelling
2. Dragging or pulling sensation
3. Palpable lymphadenopathy
4. Late signs: back pain and respiratory symptoms

D. Interventions
1. Administer chemotherapy as prescribed
2. Prepare the client for radiation therapy as prescribed
3. Prepare the client for unilateral orchiectomy, if prescribed, for
diagnosis and primary surgical management and radical
orchiectomy .
4. Prepare the client for retroperitoneal lymph node dissection, if
prescribed, to stage the disease and reduce tumor volume so that
chemotherapy and radiation therapy are more effective.
5. Discuss reproduction, sexuality and fertility information and options
with the client.
6. Identify reproductive options such as sperm storage, donor and
adoption
E. POSTOERATIVE INTERVENTIONS
1. Monitor for signs of bleeding and wound infection, antibiotics may
be administered to prevent wound infection.
2. Monitor intake and output.
3. Provide and explain pain management methods. To reduce
swelling in the first 48 hours, apply an ice pack with an intervening
protective layer of cloth

17
ONCOLOGY NURSING
4. Notify the HCP if chills, fever, increasing pain or tenderness at the
incision site or drainage from the incision site occurs
5. After the orchiectomy , instruct the client to avoid heavy lifting and
strenuous activity for the length of time prescribed by the HCP
6. Instruct the client to perform monthly testicular self examination on
the remaining testicle
7. Inform the client that sutures will be removed approximately 7 to 10
days after surgery

II. CERVICAL CANCER

A.Description
1.Preinvasive cancer is limited to the cervix
2. Invasive cancer is in the cervix and other perlvic structures.
3. Metastasis usually is confined to the pelvis, but distant metastasis
occurs through the lymphatic spread.
4 Premalignant changes are described on a continuum from dysplasia,
which is the earliest premalignancy change

B. Risk Factors
1.HPV (Human Papillomavirus)
2.Cigarette smoking
3.Early first intercourse before age 17
4.multiple sex partners

C. Assessment
1. Painless vaginal postmenstrual and postcoital bleeding
2. Foul smelling or serosanguinous vaginal discharge
3.Pelvic,lower back, leg or groin pain
4.Anorexia and weight loss
5.Leakage of urine and feces in the vagina
6.Dysuria
7.Hematuria
8.Cytological changes on Pap test

D.Intervention
a.Non surgical
-Chemotherapy
-Cryosurgery
-External Radiation
-Internal Radiation Implants
-Laser Therapy

E.HYSTERECTOMY
1.Description

18
ONCOLOGY NURSING
-Hysterectomy is performed for microinvasive cancer if childbearing is not desires
-A vaginal approach is most commonly used
-A radical hysterectomy and bilateral lymphnode dissection may be performed for
cancer that has spread beyond the cervix but not the pelvic wall.

2.POSTOPERATIVE
a.Monitor the vital signs
b.Assist with coughing and deep breathing exercises
c. Assits with range of motion exercises and provide early ambulation
d.Apply antiembolism stockings
e.Monitor I and O
f. Monitor bowel sounds
g.Assess incision site for signs of infection
h.Administer pain medication as prescribed
i.Instruct the client to limit stair climbing for 1 month as prescribed and to avoid tub
baths and sitting for long periods.
j.Avoid strenuous activity or lifting anything weighing more than 20 pounds.
k. instruct the client to consume food that promotes tissue healing
l.Instruct the client to avoid sexual intercourse for 3 to 6 weeks as prescribed
m. Instruct the client in th signs associated with complications.

NOTE: Monitor the client for vaginal bleeding. More than 1 saturated pad per hour may
indicate excessive bleeding

III.OVARIAN CANCER
A.Description
-Endometrial cancer is a slow growing tumor arising from the endometrial mucosa of the
uterus, associated with the menopausal age.
-Metastasis occurs through the lymphatic system to the ovaries and pelvis, via the blood
to the lungs, liver and bone

B.Risk Factors
1.Use of estrogen replacement therapy (ERT)
2.Nulliparity
3.Polycsytic ovary diease
4. Increased age
5. Late menopause
6. Family history
7. Obesity
8. Hypertension
9. DM

C.Assessment
1.Abnormal bleeding, especially in postmenopausal women
2.Vaginal discharge
3.Low back, pelvic or abdominal pain

19
ONCOLOGY NURSING
4. Enlarge uterus

D. Nonsurgical Interventions
1.External or internal radiation is used alone or in combination with surgery, depending
on the stage of the cancer.
2. Chemotherapy is used to treat advanced or recurrent disease
3.Progesterone therapy with medication may be prescribed for estrogen dependent
tumors
4. Tamoxifen, an antiestrogen medication, also maybe prescribed.

E.Surgical interventions: Total Abdominal Hysterectomy and bilateral salpingo-

oophorectemy

IV.BREAST CANCER
A.Description
1.Breast cancer is classified as invasive when it penetrates the tissue surrounding the
mammary duct and grows in an irregular pattern.
2.Metastasis occurs via lymph nodes
3. Common sites of metastasis are the bone and lungs; metastasis may also occur to
the brain and liver.
4. Diagnosis is made by breast biopsy through a needle aspiration or by surgical
removal of the tumor with microscopic examination for malignant cells.

B. Risk Factors
1.Age
2. Family History
3.Early menarche and late menopause
4. Previouse cancer of the breast , uterus or ovaries
5.Nulliparity,late first birth
6.Obesity
7.High dose of radiation therapy

C. Assessment
1.Mass felt during BSE
2. Presence of lesion on mammography
3. A fixed, irregular nonencapsulated mass
4.Asymetry
5. Bloody or clear nipple discharge
6. Nipple retraction
7. Skin dimpling
8. Skin edema “ peau d’ orange skin”
9.Axillary lymphadenopathy
10. Lymphedema on the affected arm

D.Early Detection
1.Performing BSE

20
ONCOLOGY NURSING
a.Performing regularly 7 to 10 days after menses
b. Postmenopausal client or clients who have has a hysterectomy should perform BSE
regularly as well

E.Nonsurgical Interventions
1.Chemotherapy
2.Radiation Therapy
3.Hormoal manipulation via the use of medication in postmenopausal women or other
medications for estrogen receptor positive tumors
4.Monoclonal antibodies

F.Surgical Interventions:Surgical breast procedures with possible breast reconstructions

1.Lumpectoy
-Tumor is excised and removed
-Lymph node dissection may also be performed

2.Simple Mastectomy
-Breast tissue and the nipple are removed
-Lymph nodes are usually left intact

3.Modified Radical Mastectomy

-Breast tissue, nipple and lymphnodes are removed
-Muscles are left intact

G.Postoperative Interventions
1.Monitor vital signs
2.Position the client in a semi fowlers position;turn from the back to the unaffected side,
with the affected arm elevated above the level of the heart to promote drainage and
prevent lymphedema
3. Encourage coughing and deep breathing.
4. If a drain is in place, maintain suction and record the amount of drainage and
drainage characteristics; teach the client about home management of the drain.
5. Assess operative site for infection, swelling or the presence of fluid collection under
the skin flaps or in the arm
6. Monitor incision site for restriction of dressing, impaired sensation , or color changes
of the skin.
7. If breast reconstruction was performed, the client will return from surgery usually with
a surgical brassiere and a prosthesis in place.
8. Provide the use of a pressure sleeve as prescribed if edema is severe
9.Maintain fluid and electrolyte balance, administer diuretics and provide a low salt diet
as prescribed for severe lymphedema
10. Consult with the HCP and physical therapist regarding the appropriate exercise
program and assist the client with prescribed exercise.
11. Instruct the client about homecare measures.

21
ONCOLOGY NURSING
NOTE: No IV’s, no injection, no blood pressure measurements, and no venipunctures
should be done in the arm on the side of the mastectomy. The arm on the side of the
mastectomy is protected and any intervention that could traumatize the affected arm is
avoided because the risk for lymphedema on this side.

V. Gastric Cancer
A.Description
1.Gastric cancer is a malignant growth of the mucosal cells in the inner lining of the
stomach, with invasion to the muscle and beyond in advanced disease.
2. No single causative agent has been identified but it is beloved that H.pylori infection
and a diet of smoked, highly salted, processed or spiced foods have carcinogenic
effects; other risk factors include smoking, alcohol and nitrate ingestion, and a history of
gastric ulcers.
3. Complications include haemorrhage, obstruction, metastasis and dumping syndrome.
4. The goal of treatment is to remove the tumor and provide nutritional program.

B.Assessment
1Indigestion
2.Abdominal discomfort
3.Full feeling
4.Epigastric pain
5.Weakness and fatigue
6.Anorexia and weight loss
7.Nausea and vomiting
8.Asensation of pressure in the stomach
9.Dysphagia and obstructive symptoms
10.Iron def anemia
11Ascites
12.Palpable epigastric mass

C.Intervention
1.Monitor vital signs
2.Monitor hgb and hct
3.Monitor weight
4.Assess nutritional status; encourage small, bland easily digestible meals with vitamin
and mineral supplements
5. Administer pain medication as prescribed
6. Prepare the client for radiation or chemotherapy as prescribed
7.Prepare the client for surgical resection of the tumor as prescribed.

Subtotal Gastrectomy
Billroth I
-Also called gastroduodenostomy
-Partial gastrectomy with remaining segment anastomosed to the duodenum

22
ONCOLOGY NURSING
Billroth II
-Also called gastrojejunostomy
-Partial gastrectomy, with remaining segment anastomosed to the jejunum

Total Gastrectomy
-Also called esopahgojejunostomy
-Removal of the stomach with attachment of the esophagus to the jejunum or duoden
um

D.Postoperative Interventions
1.Monitor vital signs
2.Place in Fowlersposition in comfort
3.Adminsiter analgesics and antiemetics, as prescribed
4.Monitor intake and output; administer fluids and electrolytes replacement by IV as
prescribed, administer parenteral nutrition as prescribed.
5. Maintain NPO status as prescribed for 1 to 3 days until peristalsis returns; assess
bowel sounds
6. Monitor nasogastric suction. Following gastrectomy

23