Cancer

Dr. Tracey Hodges,

Ed.D, MSN, RN
 ETIOLOGY AND EPIDEMIOLOGY
GENDER AND SITE AGE
 Basal and Squamous cell skin  CA is a disease of aging
cancers  Age 20
 Men – less than 1%
– Prostate  Age 50
– Lung – 7%
– Colon  Age 60
– Rectum
– >16% for men
 Women – >10% for women
– Breast
– Lung
– Colon
– Rectum
 ETIOLOGY AND EPIDEMIOLOGY
RACE AND ETHNICITY GEOGRAPHIC FACTORS
 Delayed diagnosis, unequal  Worldwide distribution of CA due
to significant differences among
socioeconomic status, and
different populations
unequal access to care  Primary CA of liver common in
– African-American men Indonesia and parts of Africa and
– Caucasian women Asia
 Breast CA more common in U.S.
– African-American women
and Western Europe than in
– Hispanic-Americans, Japan
Asian-Americans/Pacific  Ugandans, Nigerians, and South
African blacks have lower
Islanders, and Native
incidence of CA of the lung,
Americans stomach, large intestine, uterus,
and kidney compared to Western
countries
MULTISTEP PROCESS OF
CARCINOGENESIS
 MULTISTEP PROCESS CONT’D
 3 overlapping and complex
stages

– Initiation

– Promotion

– Progression
 RISK FACTORS
Endogenous External
 Age  Tobacco

 Genetic Factor  Radiation

 Hormonal factors  Nutrition

 Inactivity and obesity

 Infectious organisms
 RISK FACTORS: AGE

 Median age
– 67

 3 theories
– Exposure
– Decreased cellular repair
– Immune system
 RISK FACTORS: GENETIC

 Inherited
– 5 to 10%
 autosomal dominant
 autosomal recessive
 X-linked recessive
 Usually autosomal dominant
– breast and ovarian
 RISK FACTORS: HORMONAL

 Hormones influence  Hormone Therapy

carcinogenesis in 3 ways: Treatment (HRT)
– Preparatory action on – risks and benefits must
target tissues be investigated
– Allowing the process to
progress
– A conditioning effect on
the tumor
 RISK FACTORS:
PRECANCEROUS LESIONS
 RISK FACTORS: IMMUNOLOGIC

 Higher incidence of CA in
– Older population
 immune system
– Immunodeficiency
– Immunosuppressant
drug therapy
 RISK FACTORS:
DRUGS AND CHEMICALS

 Oral contraceptives
 Cancer therapy
RISK FACTORS: RADIATION
IONIZING RADIATION
 RISK FACTORS:
RADIATION CONTINUED
UV Radiation Radon
RADIATION CONTINUED
ELECTROMAGNETIC RADIATION
 RISK FACTORS:
LIFESTYLE PRACTICES

 Smoking and tobacco use

 Nutrition
 Obesity
 Sexual and reproductive factors
 Viruses and other microorganisms
 Psychosocial factors
LIFESTYLE PRACTICES CONTINUED
SMOKING AND TOBACCO USE
 Single most lethal cause of CA  Chronic Diseases
in the U.S. – CV disease
 Lung Cancer – Acute and chronic respiratory
 Other Cancers diseases
– Mouth  Detrimental effects on
– Pharynx – Fertility
– Larynx
– Bone mass
– Esophagus
– Pancreas
– Dentition
– Kidney
– Bladder
– Colon
– Rectum
LIFESTYLE PRACTICES CONTINUED
NUTRITION Obesity

 High-fat diet  Colon

 Red meat  Breast
– Colon and prostate Cancer  Endometrial
 Alcohol  Renal
– Mouth
– Larynx
 Esophageal
– Esophagus
– Liver
LIFESTYLE PRACTICES CONTINUED

Sexual and Reproductive Factors

 STDs linked to cancer
 Early menarche
 Late menopause
LIFESTYLE PRACTICES CONTINUED

VIRUSES AND OTHER MICROORGANISMS

 Cervical CA
– HPV
– Older age
– oral contraceptives
– Smoking
– HIV
 Upper pharynx CA and non-
Hodkin’s lymphoma
– EBV
 carcinoma and lymphoma
of the stomach
– Helicobacter pylori
LIFESTYLE PRACTICES CONTINUED
PSYCHOSOCIAL FACTORS

 Stress due to psychosocial trauma, loss of a

significant other, and personality variables, such as
helplessness and repression have been suggested
as etiologic factors for cancer
 PHYSIOLOGY
NORMAL CELLULAR PROLIFERATION
CELL CYCLE DIFFERENTIATION
 G1, RNA and protein  Body tissue
synthesis occurs – Stem Cells
 S – a period of DNA  Immature with no specific
synthesis cell lineage
 G2 – further RNA and  Rapid growth into the cells
needed
protein synthesis and – Kidney
development of mitotic – Muscle
spindle
 M - Mitosis
 PATHOPHYSIOLOGY
Alterations in Cell Growth
 Hyperplasia
– Increase in cell number
 Hypertrophy
– Increase in cell size
 Metaplasia
– Reversible process in which one
adult cell type in an organ is
replaced by another adult cell type
 Dysplasia
– Alteration in adult cells
characterized by changes in their
size, shape, and organization
 Neoplasia
– Abnormal cellular division not
necessary for normal cell growth
and repair
 Anaplasia
– Total loss of differentiation
 Metastasis
– Migration of cancer cells to other
body organs/locations
PATHOPHYSIOLOGY CONTINUED
Sites of Metastases

 Site depends on  Common sites for

– Venous or lymphatic metastasis
drainage of the organ – Liver
involved – Lung
– The type of CA – Bone
– Tissue factors in – Brain
potential metastatic – Adrenal glands
sites
 PATHOPHYSIOLOGY CONTINUED
CLASSIFYING AND NAMING NEOPLASMS
 2 main cell types  Carcinomas may be further
– Epithelial divided
– Mesenchymal (connective – adeno
tissue)  arising from glandular
 Carcinoma epithelium or squamous
– malignant tumor of – Teratoma
epithelial cells  contains all 3 types of
 Sarcoma embryonal tissue
– malignant tumor of – Blastomas
connective tissue  arise during blastula
embryonic phase
 PATHOPHYSIOLOGY CONTINUED
GRADING STAGING
 Grading  Staging
– examines the CA for its maturity
– describes the extent of the tumor
and characteristics throughout the body
 3 types
– clinical staging
 Tumors graded by Arabic – surgical staging
numerals into 4 grades, the – pathologic staging
higher number, the more
abnormal and aggressive  TNM system
– T Primary tumor
– N Regional lymph nodes
– M Metastasis

See Box 23-3, p. 524

 CLINICAL MANIFESTATIONS

 Tumors can cause  Lung CA– persistent

obstructive problems if cough and hemoptysis
within tubular structures  Changes in bowel
(trachea, ureter, or GI habits or blood in stool
tract)
can be early signs of
 Intraspinal and colon CA
intracranial tumors– S&S
of increased pressure
 Changes in appearance
or texture of breast
 Systemic S&S: Fatigue,
tissue or lumps can be
loss of appetite, weight
loss signs of breast CA
 COLLABORATIVE CARE MANGEMENT
Diagnostic Tests

CYTOLOGY TESTS
LAB TESTS
 CBC  Study of cells
 Chemistry profile – Pap smear
 Body fluids
 Presence of tumor markers or
proteins associated with
specific cancers
– PSA, CEA
 Radioimmunoassays
 COLLABORATIVE CARE MANGEMENT
Diagnostic Tests

BIOPSY AND ENDOSCOPY

TUMOR IMAGING
 Radiographs or X-rays  Only definitive way to
 CT scans
diagnose CA
 Positron emission tomography
 Can be aspirational
(PET) studes
 Barium enema (needle) or incisional
 Nuclear medicine procedures  Specimen is used to
(person ingests radiolabeled examine the tissue
material) histologically
 Fiberoptic tubes with light
sources used to illuminate
body surfaces
 COLLABORATIVE CARE MANGEMENT
Cancer Treatment

 Medications  Monoclonal antibodies

 Biotherapy – Bind to almost any antigen
– Effective in the serologic
 Cytokines detection of tumors
– Interferons – Usually given IV
– Interleukins – May have fever, chills, and
rigors during administration of
– Hematopoietic growth
the drug
factors  Cellular therapies
 Immunomodulators
 Retinoids
 COLLABORATIVE CARE MANGEMENT
Cancer Treatment
ADVERSE EFFECTS OF BIOTHERAPY
 Flulike side affects– fever,
chills, rigors, h/a, and malaise
– NSAIDs
 Nurses
– help patients identify ways to
conserve energy
– encourage use of relaxation and
stress-reducing activities
– Must assess mental status due to
neurologic toxicities
 CV and pulmonary toxicities:
arrhythmias and hypotension,
fluid retention
– Nurse must monitor I&O
 GI effects: anorexia, nausea,
diarrhea
– Nurses must optimize nutritional
intake and use of antiemetics and
antidiarrheal meds
 COLLABORATIVE CARE MANGEMENT
Cancer Treatment
Surgical Management
 4 major forms of cancer  Surgery is the oldest and
therapy: most widely used option
– Chemotherapy  Surgery may be used for
– Radiotherapy staging, cure, adjuvant
– Biotherapy treatment, control of
– Surgery oncologic emergencies,
or palliation of symptoms
 See Box 23-11, p. 531
COLLABORATIVE CARE MANGEMENT
Cancer Treatment
DIET

 Role of diet in CA has

been under investigation
for years
 Role of high-fat and
obesity has been studied
COLLABORATIVE CARE MANGEMENT
Cancer Treatment
HEALTH PROMOTION AND PREVENTION
 PRIMARY PREVENTION  SECONDARY
– Attempts to reduce a PREVENTION
person’s exposure to – Aimed at early diagnosis
known CA risk factors that and treatment
might lead to disease – Screenings
 Pap smear
 PSA
 CXR
COLLABORATIVE CARE MANGEMENT
Cancer Treatment
RADIOTHERAPY
 Use of radiation in the tx of
diseases
 Ionizing radiation contains
energy that is capable of
causing cellular damage or cell
death
 Cells in the M phase of the cell
cycle are most sensitive to
radiation; but can be effective
in the S phase
COLLABORATIVE CARE MANGEMENT
Cancer Treatment
EXTERNAL RADIOTHERAPY
 Can be used alone or in
conjunction with surgery
 Pre-op
– Used to decrease size of the
tumor
 Post-op
 Used to eradicate any residual tumor
and subclinical disease
COLLABORATIVE CARE MANGEMENT
Cancer Treatment
INTERNAL RADIOTHERAPY
Sealed
Unsealed
 Delivers a concentrated dose
of radiation directly to the • Delivered by mouth or by
malignant lesion or tumor

 Placement of the sealed IV

container is done in the OR,
radiation dept, or tx room
• Special Precautions
 X-rays are used to confirm
placement
 PROTECTION OF HEALTH CARE
WORKERS FROM RADIATION

 Radiation tx rooms are

shielded with concrete and
lead walls
 Patients with internal
radiation sources with
gamma rays are cared for in
a length of time that is
protective to the health care
worker
 Exposure controlled in 3
ways: time, distance, and
shielding
 SIDE EFFECTS OF RADIOTHERAPY

 Acute toxicities  Long-term effects

– Cataracts
 Late toxicities – Pulmonary fibrosis
– Strictures
 Most patients experience
– Erythema
– Dry desquamation
– Alopecia
– Fatigue
– Bone marrow suppression
See Table 23-16, p. 540
 NURSING MANAGEMENT FOR RADIOTHERAPY

HEALTH HISTORY PHYSICAL EXAM

 Dx and tx history  Self-care abilities
 Medical history  Nutritional status
 Family history  Elimination pattern
 Chronic illnesses  Mobility status
 Medications  Skin and mucous membrane
 Allergies integrity
 Social support
 Financial resources
 Knowledge of tx plan
 Fears and concerns
 CHEMOTHERAPY
 May be used for cure, long-
term control of cancer
growth, or for palliation to
temporarily shrink a tumor
mass
 Most chemotherapy agents
cause cell death by
interrupting cell growth and
replication at some point
 Drugs classified by their
mechanism of action
 Most effective when the tumor
is small and growing rapidly
(cell population growth)
 Thought to kill a fixed % of
total # of CA cells; so it is
scheduled in multiple courses
of time (cell-kill hypothesis)
 Combination chemotherapy
used since drugs that attack
tumor cells in various ways
may produce maximal tumor
kill
 CHEMOTHERAPY CONTINUED
 Most effective when
sufficient doses are
delivered within a specified
time
 Malignant neoplasms may
become resistant; may be
primary or secondary
 MDR can occur
 Different classifications
 Normal cells are also
affected
 Bone marrow, GI epithelium,
and hair follicles most
sensitive to chemotherapy
 Fatigue and organ toxicities
also seen
 CHEMOTHERAPY EFFECTS
BONE MARROW

 Myelosuppression  Nadir
– Neutropenia – most often 7 to 10 days after
– Thrombocytopenia med is administered
– enemia  Most serious Complication
 Prone to infection and – Infection
bleeding  Stomatitis
 CHEMOTHERAPY EFFECTS
CONTINUED
GASTROINTESTINAL ALOPECIA
 N/V  Not caused by all chemo
 Constipation drugs
 Diarrhea  Ranges from mild
 GI tract susceptible to thinning on scalp to
complication of infection and
bleeding complete loss of body
hair
 Hair loss usually begins 2
to 3 weeks after start of
therapy
 CHEMOTHERAPY EFFECTS
CONTINUED
FATIGUE SEXUAL DYSFUNCTION

 A common side effect  Affects germinal epithelium of

 Compromises the
patient’s quality of life
 Complaining of feeling
weak with no energy
ovary and testes
 Reproductive dysfunction often
experienced during and after
chemotherapy
 Women may become
amenorrheic during chemo
 Testicular damage results in
decreased sperm production
 CHEMOTHERAPY EFFECTS
CONTINUED
SPECIFIC ORGAN TOXICITIES
 Heart  Kidney
– Electrocardiogram changes – With high doses of drugs
– Heart failure  Bladder
 Lungs – Hemorrhagic cystitis
– Pulmonary Fibrosis
 Liver
– With high doses of drugs
 CHEMOTHERAPY ADMINISTRATION

 Must be given by specially trained R.N.

 Chemo meds– Serious side effects
 Doses usually based on person’s body surface area
 Route of choice chosen to deliver the optimal dose
 Can be given orally, Sub Q, IM, IV, or topically
 Can also be instilled directly into the bladder,
peritoneum, cerebrospinal fluid, or tumor bed
 IV ADMINISTRATION
 IV most common route for
chemo administration
 May have a centrally placed
VAD; can be short or long-
term
 Port
 PICC line
 Complications with access
devices: infection,
thrombosis, occlusion, air
embolism
 Chemo drugs can cause
tissue damage
 See safety in handling
chemo drugs, p. 553
 NURSING MANAGEMENT FOR
CHEMOTHERAPY
 Health history
 Physical exam, p. 553
 Risk for infection: nurse
must assess for S&S,
minimize source of infection,
teach patient S&S
 Mucous membrane integrity
usually altered: dryness,
painful ulcerations, and
infections, nurse must
assess these areas
 Bleeding precautions
 Assess for S&S of bleeding
 Fatigue; alternate periods of
rest with activity
 GI tract: anorexia, N/V;
administer anti-emetics, and
anti-nausea meds, give oral
supplements if necessary
 DISTURBED BODY IMAGE

 Alopecia—very disturbing to the patient

 Weight loss, changes in body function
 Refer to appropriate places, help client to
identify resources
 Fertility—sperm banking for men;
contraception
 Patient teaching
 CANCER PAIN
 Pain one of most feared  Goal of pain management is
symptoms of CA relief from pain
 30% of patients experience  May be prescribed non-
pain while undergoing tx; opioid analgesics, opioids,
90% as CA progresses and
metastasizes or other agents
 Pain may be:  Pain may not be effectively
 Somatic managed: person may fear
addiction
 Visceral
 Neuropathic
 RESOURCES

 Number of organizations, see box 23-11, p.

561