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Viruses as a cause of human cancers are hard

CELLULAR ABERRATIONS to determine because viruses are difficult to isolate.

Infectious causes are considered or suspected,

Oncology Nursing however, when specific cancers appear in clusters.

Cancer nursing practice covers all age groups Viruses are thought to incorporate themselves in the

and nursing specialties and is carried out in a variety of genetic structure of cells, thus altering future generations

health care settings, including the home, community, of that cell population— perhaps leading to a cancer. For

acute care institutions, and rehabilitation centers. The example, the Epstein-Barr virus is highly suspect as a

scope, responsibilities, and goals of cancer nursing, also cause in Burkitt’s lymphoma, nasopharyngeal cancers,

called oncology nursing, are as diverse and complex as and some types of non-Hodgkin’s lymphoma and

those of any nursing specialty. Because many people Hodgkin’s disease.

associate cancer with pain and death, nurses need to Herpes simplex virus type II, cytomegalovirus,

identify their own reactions to cancer and set realistic and human papillomavirus types 16, 18, 31, and 33 are

goals to meet the challenges inherent in caring for associated with dysplasia and cancer of the cervix. The

patients with cancer. hepatitis B virus is implicated in cancer of the liver; the

human T-cell lymphotropic virus may be a cause of

Cancer some lymphocytic leukemias and lymphomas; and the

Cancer is a complex of diseases which occurs when human immunodeficiency virus (HIV) is associated with

normal cells mutate into abnormal cells that take over Kaposi’s sarcoma. The bacterium Helicobacter pylori

normal tissue, eventually harming and destroying the has been associated with an increased incidence of

host. gastric malignancy, perhaps secondary to inflammation

• A large group of diseases characterized by: and injury of gastric cells.

– Uncontrolled growth and spread of

abnormal cells Physical Agents

– Proliferation (rapid reproduction by cell Physical factors associated with carcinogenesis

division) include exposure to sunlight or radiation, chronic

– Metastasis (spread or transfer of cancer irritation or inflammation, and tobacco use.

cells from one organ or part to another Excessive exposure to the ultraviolet rays of the

not directly connected) sun, especially in fair-skinned, blue- or green-eyed

ETIOLOGY people, increases the risk for skin cancers. Factors such

as clothing styles (sleeveless shirts or shorts), use of

 viruses and bacteria
sunscreens, occupation, recreational habits, and
 physical agents
environmental variables, including humidity, altitude, and
 chemical agents
latitude, all play a role in the amount of exposure to
 genetic or familial factors
ultraviolet light.
 dietary factors, and hormonal agents.
Exposure to ionizing radiation can occur with

repeated diagnostic x-ray procedures or with radiation

Viruses and Bacteria
therapy used to treat disease. Fortunately, improved x-

ray equipment appropriately minimizes the risk for

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extensive radiation exposure. Radiation therapy used in

disease treatment or exposure to radioactive materials at

nuclear weapon manufacturing sites or nuclear power Genetic and Familial Factors

plants is associated with a higher incidence of Almost every cancer type has been shown to

leukemias, multiple myeloma, and cancers of the lung, run in families. This may be due to genetics, shared

bone, breast, thyroid, and other tissues. Background environments, cultural or lifestyle factors, or chance

radiation from the natural decay processes that produce alone. Genetic factors play a role in cancer cell

radon has also been associated with lung cancer. development. Abnormal chromosomal patterns and

Homes with high levels of trapped radon should cancer have been associated with extra chromosomes,

be ventilated to allow the gas to disperse into the too few chromosomes, or translocated chromosomes.

atmosphere.

Specific cancers with underlying genetic

Chemical Agents abnormalities include Burkitt’s lymphoma, chronic

About 75% of all cancers are thought to be myelogenous leukemia, meningiomas, acute leukemias,

related to the environment. Tobacco smoke, thought to retinoblastomas, Wilms’ tumor, and skin cancers,

be the single most lethal chemical carcinogen, accounts including malignant melanoma.

for at least 30% of cancer deaths (Heath & Fontham, Approximately 5% to 10% of cancers of

2001). Smoking is strongly associated with cancers of adulthood and childhood display a familial

the lung, head and neck, esophagus, pancreas, cervix, predisposition. Inherited cancer syndromes, such as

and bladder. Tobacco may also act synergistically with premenopausal breast cancer, tend to occur at an early

other substances, such as alcohol, asbestos, uranium, age and at multiple sites in one organ or pair of organs.

and viruses, to promote cancer development. In cancers with a familial predisposition,

Chewing tobacco is associated with cancers of individuals may develop multiple cancers; commonly,

the oral cavity and primarily occurs in men younger than two or more first-degree relatives share the same cancer

40 years of age. Many chemical substances found in the type. Cancers associated with familial inheritance

workplace have proved to be carcinogens or co- include retinoblastomas, nephroblastomas,

carcinogens. The extensive list of suspected chemical pheochromocytomas, malignant neurofibromatosis, and

substances continues to grow and includes aromatic breast, ovarian, endometrial, colorectal, stomach,

amines and aniline dyes; pesticides and formaldehydes; prostate, and lung cancers.

arsenic, soot, and tars; asbestos; benzene; betel nut and In 1994, the BRCA-1 gene was identified; it is

lime; cadmium; chromium compounds; nickel and zinc linked to breast and ovarian cancer syndrome. The

ores; wood dust; beryllium compounds; and polyvinyl BRCA-2 gene, which has also been identified, is

chloride. associated with early-onset breast cancer (Nogueira &

Most hazardous chemicals produce their toxic Appling, 2000). Work continues to identify other specific

effects by altering DNA structure in body sites distant genes related to cancer incidence (Greco, 2000).

from chemical exposure.

The liver, lungs, and kidneys are the organ Dietary Factors

systems most often affected, presumably because of Dietary factors are thought to be related to 35%

their roles in detoxifying chemicals. of all environmental cancers (Heath & Fontham, 2001).

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Dietary substances can be proactive (protective),

carcinogenic, or co-carcinogenic.

The risk for cancer increases with long-term ingestion of ROLE OF THE IMMUNE SYSTEM

carcinogens or co-carcinogens or chronic absence of In humans, malignant cells are capable of

proactive substances in the diet. developing on a regular basis. Some evidence indicates,

Dietary substances associated with an however, that the immune system can detect the

increased cancer risk include fats, alcohol, salt-cured or development of malignant cells and destroy them before

smoked meats, foods containing nitrates and nitrites, cell growth becomes uncontrolled. When the immune

and a high caloric dietary intake. Food substances that system fails to identify and stop the growth of malignant

appear to reduce cancer risk include high-fiber foods, cells, clinical cancer develops.

cruciferous vegetables (cabbage, broccoli, cauliflower, Patients who for various reasons are

Brussels sprouts, kohlrabi), carotenoids (carrots, immunoincompetent have been shown to have an

tomatoes, spinach, apricots, peaches, dark-green and increased incidence of cancer. Organ transplant

deep-yellow vegetables), and possibly vitamins E and C, recipients who receive immunosuppressive therapy to

zinc, and selenium. prevent rejection of the transplanted organ have an

Obesity is associated with endometrial cancer increased incidence of lymphoma, Kaposi’s sarcoma,

and possibly postmenopausal breast cancers. Obesity squamous cell cancer of the skin, and cervical and

may also increase the risk for cancers of the colon, anogenital cancers. Patients with immunodeficiency

kidney, and gallbladder. diseases, such as AIDS, have an increased incidence of

Kaposi’s sarcoma, lymphoma, and rectal and head and

Hormonal Agents neck cancers. Some patients who have received

Tumor growth may be promoted by disturbances alkylating chemotherapeutic agents to treat Hodgkin’s

in hormonal balance either by the body’s own disease have an increased incidence of secondary

(endogenous) hormone production or by administration malignancies. Autoimmune diseases, such as

of exogenous hormones. Cancers of the breast, rheumatoid arthritis and Sjögren’s syndrome, are

prostate, and uterus are thought to depend on associated with increased cancer development. Finally,

endogenous hormonal levels for growth. age-related changes, such as declining organ function,

Diethylstilbestrol (DES) has long been recognized as a increased incidence of chronic diseases, and diminished

cause of vaginal carcinomas. Oral contraceptives and immunocompetence, may contribute to an increased

prolonged estrogen replacement therapy are associated incidence of cancer in older people.

with increased incidence of hepatocellular, endometrial,

and breast cancers, whereas they appear to decrease Normal Immune Responses

the risk for ovarian and endometrial cancers. The Normally, an intact immune system has the

combination of estrogen and progesterone appears ability to combat cancer cells in several ways. Usually,

safest in decreasing the risk for endometrial cancers. the immune system recognizes as foreign certain

Hormonal changes with reproduction are also associated antigens on the cell membranes of many cancer cells.

with cancer incidence. Increased numbers of These antigens are known as tumor-associated antigens

pregnancies are associated with a decreased incidence (also called tumor cell antigens) and are capable of

of breast, endometrial, and ovarian cancers.

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stimulating both cellular and humoral immune How is it, then, that malignant cells can survive

responses. and proliferate despite the elaborate immune system

Along with the macrophages, T lymphocytes, the defense mechanisms? Several theories suggest how

soldiers of the cellular immune response, are tumor cells can evade an apparently intact immune

responsible for recognizing tumor-associated antigens. system. If the body fails to recognize the malignant cell

When T lymphocytes recognize tumor antigens, other T as different from “self” (non-self or foreign), the immune

lymphocytes that are toxic to the tumor cells are response may not be stimulated. When tumors do not

stimulated. These lymphocytes proliferate and are possess tumor-associated antigens that label them as

released into the circulation. In addition to possessing foreign, the immune response is not alerted. The failure

cytotoxic (cell-killing) properties, T lymphocytes can of the immune system to respond promptly to the

stimulate other components of the immune system to rid malignant cells allows the tumor to grow too large to be

the body of malignant cells. managed by normal immune mechanisms.

Certain lymphokines, which are substances Tumor antigens may combine with the

produced by lymphocytes, are capable of killing or antibodies produced by the immune system and hide or

damaging various types of malignant cells. Other disguise themselves from normal immune defense

lymphokines can mobilize other cells, such as mechanisms. These tumor antigen–antibody complexes

macrophages, that disrupt cancer cells. Interferon (IFN), can suppress further production of antibodies. Tumors

a substance produced by the body in response to viral are also capable of changing their appearance or

infection, also possesses some antitumor properties. producing substances that impair usual immune

Antibodies produced by B lymphocytes, responses. These substances not only promote tumor

associated with the humoral immune response, also growth but also increase the patient’s susceptibility to

defend the body against malignant cells. These infection by various pathogenic organisms. As a result of

antibodies act either alone or in combination with the prolonged contact with a tumor antigen, the patient’s

complement system or the cellular immune system. body may be depleted of the specific lymphocytes and

Natural killer (NK) cells are a major component no longer able to mount an appropriate immune

of the body’s defense against cancer. NK cells are a response.

subpopulation of lymphocytes that act by directly Abnormal concentrations of host suppressor T

destroying cancer cells or by producing lymphokines and lymphocytes may play a role in developing cancers.

enzymes that assist in cell destruction. Suppressor T lymphocytes normally assist in regulating

antibody production and diminishing immune responses

PATHOPHYSIOLOGY when they are no longer required. Low levels of serum

Abnormal cell formed by mutation of DNA then cell antibodies and high levels of suppressor cells have been

grows and proliferates then metastasis occurs when found in patients with multiple myeloma, a cancer

abnormal cells invade other tissue, through lymph and associated with hypogammaglobulinemia (low amounts

blood. of serum antibodies). Carcinogens, such as viruses and

 Cancer development linked to immune system certain chemicals, including chemotherapeutic agents,

failure may weaken the immune system and ultimately enhance

tumor growth.

Immune System Failure

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DETECTION AND PREVENTION

 Primary Prevention
Imaging Tests Used to Detect Cancer

- Is concerned with preventing the onset of

disease; it aims to reduce the incidence of

disease.

- The strategy is to remove causative risk

factors (risk reduction), which protects

health and so overlaps with health

promotion.

- It involves interventions that are applied

before there is any evidence of disease or CLASSIFICATION OF CANCER

injury.

Examples include; protection against the According to Behavior of Tumor

effects of a disease agent, as with • Benign - tumors that cannot spread by invasion
vaccination, changes to behaviors such as or metastasis; hence, they only grow locally
cigarette smoking or diet.  • Malignant - tumors that are capable of

spreading by invasion and metastasis. By

 Secondary Prevention definition, the term “cancer” applies only to

malignant tumors
- Is concerned with detecting a disease in its

earliest stages, before symptoms appear,

Patterns of cell Proliferation
and intervening to slow or stop its
• Hyperplasia - tissue growth based on an
progression.
excessive rate of cell division, leading to a larger

- An example is the Pap test to screen for than usual number of cells; the process of

cancer of the cervix, or a PSA blood test for hyperplasia is potentially reversible; can be a

prostate cancer; other instances include normal tissue response to an irritating stimulus

teaching people about the early signs of an example is a callus.

disease that they should watch for, and what • Dysplasia - Bizarre cell growth differing in size,

type of treatment to seek.  shape and cell arrangement

American Cancer Society Recommendations for Early Detection of Cancer

in Asymptomatic, Average-Risk People • Metaplasia - conversion of one type of cell in a

tissue to another type not normal for that tissue

• Anaplasia - change in the DNA cell structure

and orientation to one another, characterized by

loss of differentiation and a return to a more

primitive form.

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• Neoplasia - uncontrolled cell growth, either accomplished before treatment begins to provide

benign or malignant baseline data for evaluating outcomes of therapy and to

maintain a systematic and consistent approach to

METASTASIS
ongoing diagnosis and treatment. Treatment options and
• 3 stages of Metastasis
prognosis are determined on the basis of staging and

grading.
– Invasion – neoplastic cells from

primary tumor invade into

ASSESSMENT
surrounding tissue with penetration
• Nursing History
of blood or lymph.
– Health History – chief complaint and
– Spread – tumor cells spread through
history of present illness (onset, course,
lymph or circulation or by direct
duration, location, precipitating and
expansion
alleviating factors)
– Establishment and growth – tumor
– Cancer signs: CAUTION US!
cells are established and grow in
• CAUTION US!
secondary site: lymph nodes or in
– Change in bowel or bladder habits
organs from venous circulation
 A person with colon cancer may have

diarrhea or constipation, or he may

notice that the stool has become smaller

in diameter
CLASSIFICATION OF TUMORS
 A person with bladder or kidney cancer
• CARCINOMAS: EPITHELIAL TISSUE
may have urinary frequency and
– BODY SURFACES, LINING OF BODY
urgency
CAVITIES ETC: (ADENOCARCINOMA)
– A sore that does not heal
• SARCOMAS: CONNECTIVE TISSUE
 Small, scaly patches on the skin that
– STRIATED MUSCLE, BONE, ETC
bleed or do not heal may be a sign of
(OSTEOSARCOMA)
skin cancer
• LYMPHOMAS AND LEUKEMIAS
 A sore in the mouth that does not heal
– HEMATOPOIETIC SYSTEM
can indicate oral cancer
• NERVOUS TISSUE TUMORS
– Unusual bleeding or discharge
– EX. NERVE CELLS-
 Blood in the stool is often the first sign of
NEUROBLASTOMA
colon cancer
• MYELOMA
 Similarly, blood in the urine is usually
– Develops in the plasma cells of bone
the first sign of bladder or kidney cancer
marrow
 Postmenopausal bleeding (bleeding

after menopause) may be a sign of

TUMOR STAGING AND GRADING
uterine cancer
A complete diagnostic evaluation includes
– Thickenings or lumps
identifying the stage and grade of the tumor. This is

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 Enlargement of the lymph nodes or • Laboratory tests

glands (such as the thyroid gland) can – Complete blood cell count (CBC)

be an early sign of cancer – Tumor markers – identify substance

 Breast and testicular cancers may also (specific proteins) in the blood that are

present as a lump made by the tumor

– Indigestion or difficulty in swallowing • PSA (Prostatic-specific antigen):

 Cancers of the digestive system, prostate cancer

including those of the esophagus, • CEA (Carcinoembryonic

stomach, and pancreas, may cause antigen): colon cancer

indigestion, heartburn, or difficulty • Alkaline Phosphatase: bone

swallowing metastasis

– Obvious change in a wart or mole – Biopsy

 Moles or other skin lesions that change

in shape, size, or color should be Diagnostic Tests

reported • Determine location of cancer:

– Nagging or persistent cough or – X-rays

hoarseness – Computed tomography

 Cancers of the respiratory tract, – Ultrasounds

including lung cancer and laryngeal – Magnetic resonance imaging

cancer, may cause a cough that does – Nuclear imaging

not go away or a hoarse (rough) voice – Angiography

– Unexplained anemia • Diagnosis of cell type:

– Sudden unexplained weight loss – ▪Tissue samples: from biopsies,

shedded cells (e.g. Papanicolaou (PAP)

Physical Assessment smear), & washings

• Inspection – skin and mucus membranes for – ▪ Cytologic Examination: tissue

lesions, bleeding, petechiae, and irritation examined under microscope

– Assess stools, urine, sputum, vomitus • Direct Visualization:

for acute or occult bleeding – ▪ Sigmoidoscopy

– Scalp noting hair texture and hair loss – ▪ Cystoscopy

• Palpation – ▪ Endoscopy

– Abdomen for any masses, bulges or – ▪ Bronchoscopy

abnormalities – ▪ Exploratory surgery; lymph node

– Lymph nodes for enlargement biopsies to determine metastases

• Auscultation – of lung sounds, heart sounds

and bowel sounds NURSING DIAGNOSES

• Acute or chronic pain

LABORATORY & DIAGNOSTIC TESTS • Impaired skin integrity

• Cancer detection examination • Impaired oral mucous membrane

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• Risk for injury

• Risk for infection

• Fatigue TREATMENT MODALITIES

• Imbalanced nutrition: less than body • Aimed towards:

requirements – CURE - free of disease after treatment

• Risk for imbalanced fluid volume → normal life

• Anxiety – Control - Goal for chronic cancers

• Disturbed body image – Palliative Care: Quality of life maintained

• Deficient knowledge at highest level for the longest possible

• Ineffective coping time

• Social isolation • Surgery – surgical removal of tumors; most

commonly used treatment

OUTCOME IDENTIFICATION • Preventive or prophylactic

1. Pain relief • Diagnostic surgery

2. Integrity of skin and oral mucosa • Curative surgery

3. Absence of injury and infection • Reconstructive surgery

4. Fatigue relief • Palliative surgery

5. Maintenance of nutritional intake and fluid and • Chemotherapy – use of antineoplastic drugs to

electrolyte balance promote tumor cell death, by interfering with

6. Improved body image cellular functions and reproduction

7. Absence of complications • Radiotherapy – directing high-energy ionizing

8. Knowledge of prevention and cancer treatment radiation to destroy malignant tumor cells

9. Effective coping through recovery and grieving without harming surrounding tissues

process – Teletherapy (external): radiation

10. Optimal social interaction delivered in uniform dose to tumor

– Brachytherapy: delivers high dose to

IMPLEMENTATION/MANAGEMENT tumor and less to other tissues;

• Prevention and detection radiation source is placed in tumor or

– Primary Prevention next to it

• Reducing modifiable risk factors • Immunotherapy – use of chemical or microbial

in the external and internal agents to induce mobilization of immune

environment defenses.

– Secondary Prevention • Biologic response modifiers (BRMs) – use of

• Recognizing early signs and agents that alters immunologic relationship

symptoms and seeking prompt between tumor and host in a beneficial way

treatment • Bone marrow peripheral stem cell

• Prompt intervention to halt transplantation – aspirating bone marrow cells

cancerous process from compatible donor and infusing them into

the recipient

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• Gene therapy – transfer of genetic materials into • Alkylating agents:

the client’s DNA – Action: create defects in tumor DNA

– Ex: Nitrogen Mustard, Cisplatin

NURSING MANAGEMENT – Toxic Effects: reversible renal tubular

1. Promote measures that relieve pain and necrosis

discomfort. • Antimetabolites:

• Pharmacologic and non-pharmacologic – Action: phase specific

interventions – Ex: Methotrexate; 5 fluorouracil

2. Promote measures to maintain intact skin – Toxic Effects: nausea, vomiting,

integrity stomatitis, diarrhea, alopecia,

3. Promote measures that maintain oral mucosa leukopenia

4. Promote measures to prevent injury from • Antitumor Antibiotics:

abnormal bleeding – Action: non- phase specific; interfere

• Monitor platelet count; avoid aspiring with DNA

products,etc – Ex: Actinomycin D, Bleomycin,

5. Promote measures that identify and prevent adriamycin (doxorubicin)

infection – Toxic Effect: damage to cardiac muscle

• Monitor WBC count; encourage frequent • Miotic inhibitors:

handwashing and overall cleanliness – Action: Prevent cell division during M

6. Help decrease the client’s fatigue and increase phase of cell division

his activity level – Ex: Vincristine, Vinblastine

7. Promote measures that ensure adequate – Toxic Effects: affects neurotransmission,

nutritional intake alopecia, bone marrow depression

• High protein, high calorie diet • Hormones:

8. Ensure adequate fluid and electrolyte balance – Action: stage specific G1

9. Promote measures to enhance body image. – Ex: Corticosteroids

• Take an honest gentle, caring approach; • Hormone Antagonist:

encourage client to express and – Action: block hormones on hormone-

verbalize feelings binding tumors ie: breast, prostate,

10. Promote measures that address preventing endometrium; cause tumor regression

complications of cancer therapy – Ex: Tamoxifen (breast); Flutamide

11. Instruct client and family about the disease (prostate)

process and treatments; provide necessary – Toxic Effects: altered secondary sex

information for self-care. characteristics

12. Help client and family cope effectively

13. Promote measures to reduce social isolation. Effects of Chemotherapy

• Tissues: (fast growing) frequently affected

CLASSES OF CHEMOTHERAPY DRUGS • Examples: mucous membranes, hair cells, bone

marrow, specific organs with specific agents,

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reproductive organs (all are fetal toxic; impair

ability to reproduce)

• Routes of administration:

– Oral

– Body cavity (intraperitoneal or

intrapleural)

– Intravenous

• Use of vascular access devices

because of threat of

extravasation (leakage into

tissues) & long-term therapy

• Types of vascular access devices:

– PICC lines: (peripherally inserted central

catheters)

– Tunneled catheters: (Hickman,

Groshong)

– Surgically implanted ports: (accessed

with 90 degrees angle needle- Huber

needles)

Nursing care of clients receiving chemotherapy

• Assess and manage:

– Toxic effects of drugs (report to

physician)

– Side effects of drugs: manage nausea

and vomiting, inflammation and

ulceration of mucous membranes, hair

loss, anorexia, nausea and vomiting

with specific nursing and medical

interventions

• Monitor lab results (drugs withheld if blood

counts seriously low); blood and blood product

administration

• Assess for dehydration, oncologic emergencies

• Teach regarding fatigue, immunosuppression

precautions

• Provide emotional and spiritual support to clients

and families

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