Oncology

Cancer
a neoplastic disorder that can invade all body organs.
- cells lose their normal growth controlling mechanism and growth is uncontrolled.


RISK FACTORS:
Familial
Environmental
Smoking
Radiation
Hormones
Virus
Immunologic factors
Diet


Classification:
Cellular origin
a. Carcinoma
b. Adenocarcinoma
c. Sarcoma
d. Embryonal
e. Lymphomas
f. Leukemias

Staging:
TNM system:


American Warning Signs of Cancer:
C hange in bowel & bladder pattern
A sore that does not heal
U nusual bleeding & discharge
T hickening or lump
I ndigestion
O bvious change in wart or mole
N agging cough or hoarseness of voice


A. Cancer Screening Guide

Breast Self-Exam (BSE)
Timing:7-10 days after menses
:menopause: done one particular date monthly
Position: standing or lying down
use inspection & palpation: must be reported

Mammography
Position: horizontal/ oblique
explain procedure
Don’t put deodorant before procedure
CI: pregnant & breast implant

Papsmear
explain procedure
No douching done 24hrs before procedure

Testicular Self-exam
monthly/ after a warm bath
what do you need to look /feel for:
a. painless “pea” sized lump
b. feeling of heaviness
c. painless swelling
d. sudden collection of fluid in the scrotum
e. dull ache in the lower abdomen or in the groin
f. pain in the testicle or in the scrotum

Digital Rectal Exam
Sigmoidoscopy
Position:
Men: bending over the examination table
Women: lithotomy

what to assess in men:
a. prostate gland for alterations in size, consistency & evidence of tumors
b. for acute & chronic infection

what to assess in women:
a. hemorrhoids
b. uterine position

Oncofetal Antigens

Proteins which are typically present only during fetal development but are usually found in adults who has certain kind of cancer.
Example: Alpha-fetoprotein & Carcinoembryonic antigen

Liver Function Test
albumin- 3.9-5 g/dl
alanine transaminase (alt)
aspartate transaminase (ast)
alkaline phosphatase (alp)- 44-147 iu/l

CT SCAN / MRI
Bone marrow exam
Site: Adults – Iliac Spine
Children – Tibia
Explain Procedure
Informed Consent
After procedure: apply pressure at site for 5mins or more
Monitor for signs of bleeding and infection

Biopsy
Explain Procedure
Informed Consent
After procedure: apply pressure at site and rest
Monitor for signs of bleeding and infection

Cancer Therapies
Chemotherapy
Types of Chemotherapeutic Drugs:
1. Alkylating agent
a. Cyclophosphamide (Cytoxan)
SE: alopecia/ gonadal suppression/ tinnitus/ cystitis

2. Antimetabolites
a. Methotrexate (Rheumatrex)
SE: alopecia/ stomatitis/hyperuricemia/ hepatotoxicity
b. Procardazine

3. Plant alkaloids
a. Vincristin(Oncovin)
SE: neuropathy/ neurotoxic/ numbness/ paresthesia/ constipation / phlebitis at IV site
4. Hormones
a. Tamoxifen (Nolvadex)
SE: edema / hypercalcemia
b.Testosterone(Depotestosterone)
SE:edema/hypercalcemia/impotence/gynecomastia in males
c. Prednisone (Deltasone)
SE: edema, impotence

5. Antitumor Antibiotic
a. Doxorubicin (Adriamycin):
SE: Diarrhea
Damage the tissue

Damage the heart
SIDE EFFECTS:
Hair follicles- temporary alopecia
Mucous Membrane- stomatis/ pain/anorexia
Stomach Lining- Nausea/vomiting/alkalosis/hypokalemia/weakness/fatigue
Intestines
Bladder
Sperm-aspermia & sterility
Isolation – offer suggestion of a referral to the cancer society


Common side effects
Bone marrow depression
a. Leukopenia
b. Anemia
c. Thrombocytopenia
2) Alopecia
3) GI tract problem
4) Elevated uric acid

Bone Marrow Transplant


Reverse Isolation Technique (during Bone Marrow Suppression)
1. Private room, laminar air flow, sterile linen, sterile hygiene equipment.
2. Put on shoe covers, put on mask and cap, put on sterile gown, gloves.
3. Remove gown after leaving room.

Radiotherapy
SE: erythema at site with possible dry to wet desquamation
fatigue/ malaise/ nausea/ vomiting/ diarrhea/ esophagitis/ xerostamia
except: alopecia
Nanda: Impaired skin integrity


Principles:
S hielding – lead lined apron
T ime- short: 30 mins per 8hr
D istance- 3-6 ft away (36 inches or more)

Nursing care-
Room precaution
Activity
Urine
Bowel
Diet
Head of Bead: elevated 30degrees
Nanda: patient: Social Isolation
Nurse: Altered protection related to brachytherapy
in cases of dislodgement/ care of intracavitary cessium:
L ead-lined apron
L ong handled forcep
L ead- lined container

Common sites of metastasis
 
Breast cancer : bone, lung
Lung cancer: brain
Colorectal cancer: liver
Prostate cancer: bone, spine and legs
Brain tumors: central nervous system.

Leukemia
Classification
Acute Lymphocytic Leukemia (ALL)
mostly lymphoblasts present in bone marrow.
Age of onset is less than 15 years.
Acute Myelogenous Leukemia (AML)
mostly myeloblasts present in bone marrow.
Age of onset is between 15 and 39 years.
Chronic Myelogenous Leukemia (CML)
mostly granulocytes present in bone marrow
Age of onset is after 50 years
Chronic Lymphocytic Leukemia (CLL)
mostly lymphocytes present in bone marrow
Age of onset is after 50 years.


Assessment
-anorexia, fatigue, weakness, weight loss
-anemia, bleeding, petechiae.
-elevated temperature, lymphadenopathy, splenomegaly
- palpitations, tachycardia, orthostatic hypotension
-pallor, headache, dyspnea
DX:
-decreased hemoglobin, hematocrit, platelet count.
-positive bone marrow biopsy: leukemic blast cells



Treatment:
1. Medications
a. Corticosteriods
b. Antineoplastic agents
c. Xanthine-oxidase inhibitor: Allopurinol (Zyloprim)
2. Bone Marrow Transplant
3. Radiation
4. Blood transfusions
Nx: Assess for transfusion reactions (hemolytic, allergic, febrile rxn)
Remission is characterized by absence of leukemia cells and disorders, and disappearance of all disease symptoms.


Infection is a major cause of death in the immunocompromised client. Use strict aseptic technique, use masks, frequent handwashing, protective isolation procedures.
** Bleeding is another main complication. Use bleeding precautions. – soft foods, avoid injections, bp readings, suppositories, enemas or any unnecessary trauma.

HODGKINS DISEASE
Etiology:
1. unknown
2. slight increase in males
3. increase incidence in early 20s and after 50


Staging:
Stage 1- lesions limited to one lymph node
Stage 2- 2 or more nodes on same side of diaphragm
Stage 3- lymph nodes on both sides of the diaphragm are involved, invt of spleen
Stage 4- diffused involvement of extralymphatic organs

Assessment
fever, malaise, fatigue and weakness, night sweats
loss of appetite and significant weight loss
anemia, thrombocytopenia, enlarged lymph nodes, spleen and liver

Dx:
Lymph node biopsy- presence of REED-sternberg cells



Implementation
radiation therapy
more extensive cases : multiagent chemotherapy
M ustargen- nitrogen mustard- alkylating agents
SE: gonadal suppression/ hyperuricemia
O ncovin(Vincristine)-mitotic inhibitor
Prednisone-
infection and bleeding precautions.

CERVICAL CANCER
Etiology:
low socioeconomic groups
early first marriage
early and frequent intercourse
multiple sex partners
high parity
poor hygiene
Assessment:
- painless vaginal bleeding post menstrual and post coital
- foul smelling serosanguinous discharge
- pelvic, lower back, leg or groin pain
- anorexia and weight loss
- dysuria, hematuria
Dx:
1. Pap smear
2. Schiller test- cervical biopsy

1. Surgery: Hysterectomy
- Conization
2. Radiation: Intracavitary Cessium
Nx: Complete Bed Rest
Low Residue Diet
Nurse Safety: Radiation Bandages
3. Prevention: Annual Papsmear

OVARIAN CANCER
Etiology:
low socioeconomic groups
early first marriage
early and frequent intercourse
multiple sex partners
high parity
poor hygiene
Assessment:
- painless vaginal bleeding post menstrual and post coital
- foul smelling serosanguinous discharge
- pelvic, lower back, leg or groin pain
- anorexia and weight loss
- dysuria, hematuria
Dx:
1. Pap smear
2. Schiller test- cervical biopsy

1. Surgery: Laparotomy, Bilateral salphingo-oophorectomy, TAH-BSO
2. Chemotherapy: Taxol (Placitaxel)
Nx: teratogenic
3. Radiation
4. Immunotherapy
5. Hormonal agents: Tamoxifen (Nolvadex)
Nx: edema, hypercalcemia

ENDOMETRIAL CANCER
Risk Factors:
History of uterine polyps
Nulliparity
Polycystic ovary disease
Estrogen stimulation
Late menopause
Family history

Assessment:
Post menopausal bleeding
Watery serosanguinous discharge
Low back, pelvic or abdominal pain
Enlarged uterus in advanced stages

Dx:
1. Endometrial Biopsy
2. Fractional Curettage

1. Surgery: Total hysterectomy & Bilateral salphingo-oophorectomy

2. Radiation- external/internal

3. Hormonal Agents- Progestational therapy: Depo-provera( medroxyprogesterone) SE: anorexia, nausea, vomiting, edema

4. Chemotherapy- advance stages

BREAST CANCER
Etiology:
Family history
Early menarch or late menopause
Previous cancer of the breast, uterus, or ovaries
Nulliparity
Obesity
High-dose radiation exposure to chest.

Assessment:
Asymmetry of breast
Skin dimpling, flattening or nipple deviation
Skin coloring and thickening, large pores, sometimes called peau d’orange
Changes in the nipple
Painless, singular breast mass

Diagnosis:
1. Noninvasive techniques
a. Mammography
b. Xerography
2. Breast biopsy
TREATMENT:
1. Surgery : Lumpectomy
: Modified Radical Mastectomy
: Radical Mastectomy
Nursing Care:
1. Pressure dressing in place immediately postoperative.
2. Position arm on affected side such that each joint is elevated and positioned higher than the more proximal joint.
3. Do not take blood pressure or perform any injections or venipuncture on the arm of the affected side.
4. Arm exercises are usually started 24 hours after surgery.
2. Radiation
3. Chemotherapy

GASTRIC CANCER
Etiology:
Diet high in complex carbohydrates/ grains/ salt
Low in fresh green leafy vegetables
Smoking
Alcohol
Use of nitrates
History of ulcers

Assessment:
Fatigue, Anorexia, Weight loss
Nauseas, Vomiting, Indigestion
Dysphagia, Anemia, Ascites, Palpable mass

Dx:
1. Gastric analysis- achlorhydria
2. Gastroscopy & biopsy

1. Surgery:
a. Billroth I- gastroduodenostomy
b. Billroth II- gastrojejunostomy
Cx: Dumping Syndrome
c. Total gastrectomy- esophagojejunostomy
Cx: Pernicious Anemia
2. Chemotherapy
3. Radiation

Laryngeal Cancer
Etiology:
Smoking
Environmental pollution
Exposure to radiation
Voice strain

Assessment:
Persistent hoarseness and sore throat
Painless neck mass
Feeling of a lump/burning sensation in the throat
Dysphagia, foul breath odor

Dx:
1. Laryngioscopic Exam
2. Biopsy

1. Endoscopic Removal of early malignancy
2. Surgery: Partial Laryngectomy
: Total Laryngectomy
Nx: pre-op- alternative non verbal com.
post-op- humidifier
3. Radiation
4. Nutrition
5. Speech Pathologist

PROSTATIC CANCER
Etiology:
males over age 55
High androgens
Unknown

Assessment:
Asymptomatic in early stage
Hard, Pea-sized nodule palpated on rectal examination
Hematuria
PSA test is not indicative, is used to monitor response to therapy

Nanda: Altered Bladder Pattern
Dx:
Digital rectal exam: done bet age 40-60 yearly
Tumor Markers:
a. Elevated acid phosphatase
b. Elevated alkaline phosphatase

1. Hormone therapy
2. Radiation
3. Chemotherapy
4. Surgery

Continuous Bladder Irrigation (CBI)
Maintain traction on catheter
Use NS solution or prescribed solution to prevent water intoxication
Run solution at prescribed rate but run rapidly if drainage is bright red until pink.
Discontinue CBI and catheter usually after 24 to 48hrs as prescribed.
Avoid heavy lifting, straining

PANCREAS CANCER
Etiology:
Alcohol/Cigarette Smoking
Pancreatitis
High fat diet

Assessment
Malnutrition
Bloating
Abdominal pain at night
Jaundice

Dx:
inc serum lipase
inc bilirubin
inc serum amylase


1. Surgery: Pancreatoduodenectomy ( Whipples procedure)
Cx: Hypovolemic Shock
2. Radiation
3. Chemotherapy
4. Drugs necessary after surgery:
- pancreatic enzymes
- oral hypoglycemic agents or insulin
- bile salts

LIVER CANCER
Etiology:
Malignancy elsewhere in the body
High incidence in Men

Assessment:
Weakness, Anorexia, Nausea, Vomiting
Right upper quadrant pain
Hepatomegaly
Peripheral edema
Jaundice
Blood-tinged Ascites

Dx:
1. biopsy
2. CBC: blood sugar decreased/ alpha fetoprotein increased

1. Surgery- resection
2. Chemotherapy and Radiation
3. Liver transplant- Sandimmune
Nx: adm 10% glucose for first 48hrs to avoid rapid blood sugar drop
Assess for bleeding (cx: hemorrhage)
Assess for signs of hepatic encephalopathy

BLADDER CANCER
Etiology:
Occurs in men
Peak age 50-70 years old
Exposure to chemicals
Cigarette smoking
Chronic bladder infections

Assessment:
Intermittent painless hematuria
Dysuria
Frequent urination

Dx: biopsy

Management:
1. Surgery
a. Cystectomy
b. Ileal conduit (urinary diversions)
Report signs of impaired healing
Prevent skin breakdown
Prevention of UTIs
Control of odor
Report signs of UTI
2. Radiation
3. Chemotherapy-
methotrexate
doxorubicin,
cisplatin

RENAL CANCER
Etiology:
Men 50-70 years old
Drugs : nephrotoxic
Hereditary

Assessment:
Palpable abdominal mass
Hematuria
Weight loss
Weakness
Anemia

Dx:
1. IVP
2. CT scan
Treatment:
1. Surgery: Nephrectomy
2. Radiation
3. Chemotherapy
4. Immunotherapy-Intravenous Interleukin

TESTICULAR CANCER
Assessment:
Mass palpated in the scrotum
With or without pain
Heaviness in the scrotum
Backache
Pain in the abdomen
Weight loss
Dx:
1. TSE
2. Increase alpha-fetoprotein
Treatment:
1. Surgery- Unilateral Orchiectomy
2. Radiation to lymphatic
3. Chemotherapy- Cysplatin

Nx:
Can resume activities within a week
No lifting >20lbs/ stair climbing
Monthly TSE
Sutures removed 7-10days after surgery

ORAL CAVITY CANCER
Assessment:
Leukoplakia
Oral lesion
Pain
Dysphagia

Nanda: Altered Nutrition less than body requirements

Treatment:
1. Surgery: Glossectomy:
- Radical neck dissection
Cx: hypocalcemia
2. Radiation
3. Chemotherapy
Nx:
1. Monitor for hemorrhage
2. Promote drainage
3. Promote oral hygiene/comfort
4. Promote Nutrition
5. Monitor signs of hypocalcemia

ACOUSTIC NEUROMA
Assessment:
Tinnitus
Loss of hearing
Vertigo/ Vomiting
Headache
Nausea
Seizures
Lethargy

Nanda: Sensory perceptual deficit
High Risk for Injury

Treatment:
1. Surgery- removal of benign tumor
2. Radiation- Gamma knife

RETINOBLASTOMA
Assessment:
Cats eye reflex
White pupilary reflex
Unilateral blindness

Treatment:
1. Surgery- Enucleation- artificial eye- plastic : worn continuously & will only remove during cleansing
2. Radiation- 3-4wks- interstitial seed
3. Chemotherapy
4. Genetic counseling - hereditary