1.epidemiology, itiology and classification.CANCER

COLLEGE OF NURSING
G.G.G.HOSPITAL
JAMANGAR
Presented By:
D H RAVAL(Nursing Tutor)
dhraval Wednesday, September 117, 2014

 Oncology is the study of tumor.
 Neoplasia means abnormal new growth, which may be benign or
malignant.
INTRODUCTION:
 Cancer is a term that is used to describe a wide variety of malignant
diseases, the management of which required several medical disciplines
such as preventive approach, radiotherapy, chemotherapy, hormonal
therapy and surgical intervention.

 All cancer are the result of the uncontrolled over
production of some particular cells.
 Normally worn out cells are replaced by a process of cell
division.
 But if cells are produced in excess of what is needed for
replacement, there occurs build up of tissue.
 When these form a mass or tumors, it may cause
symptoms such as swelling, obstruction and pain.

 IN ORDER TO UNDERSTAND THIS YOU NEED TO LEARN
THE BASIC CONCEPT SUCH AS:
 What is cancer cell?
 How does it differ from a normal cell?
 What are the factors that cause cancer cells to develop?
 What are the preventive and control measures and
methods of early detection? And
 What are the common diagnostic procedures?

BASIC CONCEPT OF CANCER:
 The sign of the zodiac Cancer is the CRAB.
 A Crab as you knows moves fast in all directions. Similarly, the disease
cancer also spread in all directions.
 Hence the name cancer remains with this disease.
 Cancer occurs in all strata of our society.
 It affects rich and poor with equally devastating effects.
 It strikes people of all ages, sexes and socioeconomic and cultural
backgrounds.

 But certain cancers are particularly associated with certain age groups and
areas, some occurs most frequently in children , some in old people and
others are more commonly found in the developed counties that the
underdeveloped.
 The largest number of malignant tumor occurs in main four areas of the
body:
 The Lungs
 Colon-rectum
 Breasts and
 Prostate.

 Cancer is one of the major causes of death and also one of the most
vigorously researched and aggressively treated illness of our time.
 Most people until recently believed that cancer was incurable.
 But research and technology along with advances in diagnosis and
treatment have helped cured cancer in many cases.
 It must be realized that although all cancer patient cannot be cured, all
can be helped.
 It is not a contagious disease, there is no stigma attached to having cancer
and these are no known home remedies, patent medicines, or ointment
that will cure it.

 The word “Cancer” abbreviated “Ca” is synonymous with
the term malignant neoplasm.
 Other words connoting malignant neoplasm include
tumor, malignancy carcinoma and aberrant cellular
growth.
 However these terms are not interchangeable.
 Now we can more precisely say that cancer is malignant
neoplasm, a harmful tumor resulting from uncontrolled
growth of the tissues.

 The word neoplasm is derived from the Greek neos which means and plasia
means growth of new tissue.
 It can be either benign or malignant.
 A neoplasm is a new growth of abnormal tissue, which serves no purpose
and which may harm the host organism.
 A benign neoplasm or tumor is usually harmless and does not infiltrate
other tissue whereas a malignant neoplasm is always harmful and may
spread or metastasized to other tissues far from the site of origin.

 Strictly defined a Tumor is any abnormal swelling or enlargement.
 It is the one of four signs of inflammation.
 1. Redness 2. Heat, 3.swelling, or tumor, 4. Pain.
 Thus even though the proliferation of neoplastic cells results in a tumor ,
tumourous swelling are not always neoplastic.
 Neverthless “tumor “ is often used to denote a malignant (Threatening of
life) usually is applied to neoplasm.
 It also describes other conditions, for example malignant hypertension.

 Carcinoma is a specific form of cancer derived from epithelial cells.
 Aberrant cellular growth can refer to any abnormal cellular growth.
 It may or may not give rise to cancer.
 Basically cancer is a disease of the cell in which the normal mechanism of
control of growth and proliferation are disturbed.
 Cancer is also used as a collective term describing a large group of disease
characterized by uncontrolled growth and spread of abnormal cell.

 These tissues arise in different tissues and organs, differ
greatly from one another in appearance and growth
habits may follow different course of development in
their hosts and respond differently to intervention.

EPIDEMIOLOGY OF CANCER:
 It is not possible to estimate precisely the actual number of cancer
patient in the country.
 The Indian council of medical research initiated a National cancer
Registry programme in 1981-1982 by augmenting the population based
cancer registry at Bombay and setting up two more population based
cancer registries at Bangalore and Chennai and three hospital based
cancer registries were subsequently set up at Delhi, Bhopal, Barshi.

 Total population covered by these registries is about 3.5
%.
 Estimated from various national Cancer registry
programs me reports and based on extrapolation to
count for the new population landmark of one Billion,
the estimated number of new cancer cases in India
about 10 lacks (10,00,000) per year.
 The most common form of cancer seen in the male
include cancer of lung, stomach, esophagus ,mouth,
larynx, hypo pharynx tongue, prostate, urinary bladder
and rectum.

 In the female most common cancers of the cervix,
Uterus, breast, mouth, esophagus, ovary, thyroid,
colon, rectum, gall bladder and body of uterus.
 In male lung cancer seems to be the major cause of
mortality from cancer and this has an upward spiral.
 In female traditional cancer of cervix was the leading
cancer, but of late, especially in the urban area, cancer
of the breast seems to be becoming a major problem.

 Cancer of mouth is commonly seen in the both males
and females.
 Cancer of the larynx, pharynx and, esophagus, and
stomach are seen more in the men as compared to
females, while cancer of the gallbladder is seen more
often in women.
 There has been in the patterns of cancer seen in various
parts of the country, as has been brought out in the
different population based cancer registries.

 It would be pertinent to point out that about one third
of the cancers seen in India are tobacco related which
has been directly implicated in the causation of the
cancer of the lungs, larynx, mouth, and esophagus.

CHARACTERISTICS OF MALIGNANT CELL
 Cancer cells are able to divide and multiply but not in a normal manner.
 Cancer cells differ from normal cells in appearance, patterns of growth
and physiologic function. They are usually larger than normal cells and
they have a bigger nucleus.
 They differ in size and shape while normal cells are more homogenous.
 They develop antigens that are completely differing from normal cells.

 Neoplastic cells exist parasites, occupying space and
drawing nutrition and sustenance from the host’s body
while contributing nothing in return.
 Instead of limiting their growth to meet the specific
needs of the body, they continue to reproduce in a
disorderly and un restricted manner.
 Malignant tumors are capable of continued growth that
will compress, invade and destroy normal tissue. These
cells break away from their original sites and are
transported by the blood /lymph to new site where
they begin to grow, and that is called metastasis.

CANCER NURSING
 GENERAL CONSIDERATIONS
 Cancer can be considered a chronic disease requiring ongoing
management, rather than a terminal illness.
 It consists of more than 100 different conditions characterized by
uncontrolled growth and spread of abnormal cells.
 Normal mechanisms of growth and proliferation are disturbed which
results in distinctive morphologic alterations of the cell and aberrations in
tissue patterns.

 The malignant cell is able to invade the surrounding
tissue and regional lymph nodes.
 Primary cancer usually has a predictable natural history
and pattern of spread.
 Metastasis is the secondary growth of the primary
cancer in another organ.
 The cancer cell migrates through a series of steps to
another area of the body.
 This is the reason that cancer cannot always be cured
by surgical removal alone.

 Most patients die as a result of metastases rather than
progression of the primary cancer.
 Metastasis begins with local invasion followed by
detachment of cancer cells that disseminate via the
lymphatics and blood vessels and eventually establish a
secondary tumor in another area of the body.
 Lymph nodes are often the first site of distant spread.

ETIOLOGY, DETECTION, AND PREVENTION
EPIDEMIOLOGY
 In 2003, the American Cancer Society (ACS) estimates 1334,100 new cases
of invasive cancer with 5,56,000 deaths.
 Although overall cancer incidence has decreased in the past 5 years,
blacks are more likely to develop and die from cancer than any other
ethnic group.

 Age is the most outstanding risk factor for cancer.
 Cancer incidence increases progressively with age.
 Approximately 77% of people diagnosed with cancer are over age 55.
 80% of all cancers in America are related to lifestyle habits (ie, smoking,
alcohol consumption, diet) and environmental carcinogens.
 Tobacco is a major cause of cancer related deaths. The ACS estimates 180,000
deaths in 2003 will be attributed to tobacco use.

 Excess alcohol intake is associated with cancers of the mouth, larynx, throat,
esophagus, and liver, especially when combined with smoking.
 In addition, regular consumption of alcohol is associated with an increased risk
of breast cancer. This may be due to alcohol-induced increases in circulating
estrogens.
 Exposure to carcinogens, such as asbestos, benzene, and radiation, increases
the risk of developing certain types of cancer.
 Solar ultraviolet radiation exposure is related to an increased risk of skin
cancers.

 There is a hereditary predisposition to specific forms of cancers that have
been linked to certain events within a gene (ie, BRCA1 and BRCA2 in breast
cancer).
 Infections and viruses are associated with an increased risk of certain forms
of cancer.
 Human papilloma virus cervical cancer
 Epstein-Barr virus lymphoma
 Hepatitis B and C hepatocellular cancer
 Helicobacter pylori may be linked to gastric cancer
 Five-year survival rates are increasing with improved therapy and earlier
detection.

 Ongoing genetic research is searching for the ability to
correct and modify hereditary susceptibility.
 Patterns of incidence and death rates vary with sex,
age, race, and geographic location.

NUTRITION, PHYSICAL ACTIVITY, AND
 Diet does influence the risk oCf cAanNceCr. ER
 Among non-smokers, dietary choices and physical activity are the most
important modifiable risk of cancer.
 The ACS established guidelines on nutrition and physical activity in 2001.
 These recommendations are:

 Consistent with the 2000 Dietary Guidelines for Americans.
 Use the Food Pyramid as a guideline and eat a variety of foods with an emphasis
on plant resources.
 Eat five or more servings of vegetables and fruit daily.
 Choose whole grains over refined grains.
 Limit consumption of red meats, especially high-fat and processed meats.
 Maintain a healthful weight with BMI (Body Mass Index) between 18 and 25.
 Limit alcoholic beverages to no more than 2 drinks per day for men and 1 drink
per day for women.

 ACS recommendations on physical activity:
 Adults should engage in at least moderate activity for 30 minutes 5 or more
days of the week: 45 minutes or more of moderate to vigorous activity 5 or
more days per week may reduce breast and colon cancer.
 Children and adolescents should engage in 60 minutes per day of moderate to
vigorous physical activity at least 5 days per week.

Detection and Prevention
 Primary prevention and secondary prevention are effective measures in
decreasing mortality and morbidity of many cancers.
 Most cancers, however, are diagnosed after reported symptoms.
 The ACS recommends specific primary and secondary prevention
measures to reduce an individual's risk of cancer death.

 The assessment or reduction of risk factors before the disease occurs:
 Make appropriate lifestyle changes.
 Stop smoking.
 Limit alcohol intake.
 Eat a healthy diet as outlined above.
 Be physically active: maintain a healthy weight and follow exercise
PRIMARY PREVENTION:
guidelines outlined above.

 Avoid sun exposure, especially during the hours of 10
A.M. and 4 P.M. and cover exposed skin with sunscreen
with a skin protection factor (SPF) of 15 or higher.
 Those at high risk for certain cancers should consider
genetic counselling and testing.

 Chemoprevention.
 Aspirin low-dose aspirin may reduce risk of breast cancer and colon polyps.
 Tamoxifen can reduce the risk of breast cancer in women who are at high risk
by nearly 50%.
 Finasteride reduces risk of prostate cancer.
 COX-2 inhibitors reduce risk of colorectal cancer in high-risk patients.
 Calcium may reduce risk of colorectal adenomas.
 Beta carotene may reduce risk of lung cancer in smokers.

SECONDARY PREVENTION
 Screening and early detection to improve overall
outcome and survival:
 Performing routine screening tests should be based on
whether these tests are adequate to detect a
potentially curable cancer in an otherwise
asymptomatic person and are also cost effective.

 Although all major authorities recommend routine
screening for certain types of cancer, each has a
different opinion on when screening should begin and
how often.
 Screening should be based on an individual's age, sex,
family history of cancer, ethnic group or race, previous
iatrogenic factors (prior radiation therapy or drugs ),
and history of exposure to environmental carcinogens.
 Testicular cancer is the most common cancer between
ages 20 and 34, the second most common from ages 35
to 39 and the third most common between ages 15 and
19.

 There is an increased risk in males with undescended testicles, gonadal
dysgenesis, and Klinefelter's syndrome.
 There is also an increased risk in men with a family history of testicular
cancer. Although not consistently found to confer a higher risk, infertility
or abnormal semen parameters have been associated with a higher risk of
testicular cancer in some studies.
 The American Urological Association (AUA) recommends annual screening
beginning at age 15 with monthly testicular self examinations.

 Prostate cancer occurs more commonly in men over age
60.
 With more widespread screening, younger men are
being diagnosed in the early stages of the disease.
 The ACS and AUA recommend an annual prostate-specific
antigen (PSA) and digital rectal examination for
men over age 50.
 The AUA also recommends annual testing for men age
40 and over who are at high risk (black race, family
history of prostate cancer).

 Breast cancer is the most common type of cancer in women, and the
incidence increases with age.
 The ACS recommends a clinical breast examination every 3 years from
ages 20 to 39 and annually thereafter.
 Mammography should begin at age 40.
 Colon cancer screening should begin for all men and women over age 50.
 Patients should be screened with yearly fecal occult blood test, or
sigmoidoscopy every 5 years, or double contrast barium enema every 5
years, or colonoscopy every 10 years.

 Lung cancer, although common in both men and women
who have smoked, is not routinely screened for because
there is no cost-effective method that would detect
cancer early enough to make a difference in outcome.

DIAGNOSTIC EVALUATION
 Complete medical history and physical examination.
 Biopsy of tumor site to determine pathologic diagnosis.
 The malignancy is classified according to anatomic extent and histopathologic
analysis.
 Biopsy is obtained from the most accessible site (eg, lymph node versus lung
biopsy).

 All original slides should be reviewed with the pathologist.
 Clinical information should correlate with pathologic diagnosis.
 Be aware of possible errors and differences in interpretation.
 Classification of tumor type is based on tissue and cellular staining.

 Differences in cytoplasmic and nuclear staining distinguish
one cell type from another and identify their stage of
differentiation.
 The grade of the tumor (rating of 1 to 4) is based on how
well differentiated the tissue or cells appear.
 For most tumors the higher grade, the less differentiated,
which is associated with poorer prognosis.

 Flow cytometry testing of tumor tissue determines the
DNA content and indicates potential risk of recurrence.
 Estrogen and progesterone levels are obtained from breast
and possibly ovarian tissue.

Laboratory tests
 Laboratory tests including
 complete blood count (CBC) with differential, platelet count, and
 Blood chemistries including
 liver function tests,
 blood urea nitrogen (BUN), and
 creatinine are done to determine baseline values.
 Further tests depend on cancer diagnosis.
 Blood markers (carcinoembryonic antigen, PSA, CA153, CA125) may be
appropriate to follow response to therapy.

 Imaging procedures chest X-ray,
 nuclear medicine scan,
 computed tomography (CT) scan,
 magnetic resonance imaging (MRI), and
 positron-emission tomography
are used to determine evidence or extent of metastasis.

WARNING SIGNS FOR CANCER
 This warning signs are presented a CAUTION and you need to remember it.
 C: Change in bowel and bladder habits.
 A: A sore throat does not heal.
 U: Unusual bleeding or discharge.
 T: Thickening or lump in breast or elsewhere.
 I: Indigestion or difficulty in swallowing.
 O:Obvious change in wart or mole.
 N: Nagging cough or hoarseness.

 Other symptoms which should be taken seriously
especially when accompanying any of those just
mentioned above.
 Weight loss not due to any change in diet or in else due
to unexplained loss of appetite.
 In exceptional cases , pain , when it is persistant.
 Undue lassitude(Tiredness) or malaise.

STAGING
 Staging is necessary at the time of diagnosis to determine the extent of
disease (local versus metastatic), to determine prognosis, and to guide
proper management.
 The American Joint Committee of Cancer (AJCC) has developed a simple
classification system (TNM) that can be applied to all tumor types.
 It is a numerical assessment of tumor size (T), presence or absence of
regional lymph node involvement (N), and presence or absence of distant
metastasis.

AJCC CLASSIFICATION SYSTEM OF TUMORS
 T= primary tumor
 Tx primary tumor is unable to be assessed
 T0 no evidence or primary tumor
 T carcinoma in situ
 T1, T2, T3, T4 increasing size and/or local extent of primary tumor
 N= presence or absence or regional lymph node involvement
 Nx regional lymph nodes are unable to be assessed

 N0 no regional lymph node involvement
 N1, N2, N3 increasing involvement of regional lymph
nodes
 M= absence or presence or distant metastasis
 Mx unable to assess
 M0 absence of distant metastasis
 M1 presence of distant metastasis

GENERAL CLASSIFICATION OF NEOPLASM
 Neoplastic tumours are classified as either benign or malignant and are also
classified according to the tissue from which they originate.
 BENIGN AND MALIGNANT TUMOURS
 Benign tumours are defined as localized growth of cells that are very
closely related to normal cells except for their abnormal arrangement and
amount.

 If the tumour is located near a vital tube or organ, it
could be fatal, persons with benign tumours have
good prognosis as the tumour can be safely excised.
Malignant tumours on the other hand
may be defined as progressive autonomous
proliferation of tissue not subject to the laws of
governing orderly growth.
 These tumours represent a serious threat to the life
and well being of the host.

CLASSIFICATION ACCORDING TO TISSUE OF
ORIGIN:
 Almost all names for tumours end in the suffix “Oma” meaning
tumour.
 This suffix is usually attached to the term of a parent tissue of the
tumour.
 In this way we can say that adenoma comes from GREEK ‘ADEN’ which
means gland and oma for tumour.
 When neoplasm is formed of more than one parent tissue, than the
name of tumour represents both the tissue.


 For example an adenomyoma is a benign neoplasm
that contains both glandular and muscles cells.
 Because epithelial tissue vary greatly, benign tumours
of epithelial origin are classified according to either
their microscopic appearance e.g. adenoma or their
macroscopic appearance e.g. polyp.

CLASSIFICATION OF NEOPLASMS
ORIGIN BENIGN MALIGNANT
Epithelial tissue
Squamous cells(Skin and
papilloma mucous
membrane)
Grand cells
Pigmented cell
Endothelial tissue
Blood vessels
Lymphoid tissue
Plasma cells
Papilloma
Adenoma Polyp
Nevus
Hemangioma
Carcinoma
Squamous cell carcinoma
Adenocarcinoma
Based cell carcinoma
Malignant Melanoma
Endothelioma
Angiosarcoma
Lymphosarcoma
Leukemia
Malignant lymphoma
Hodgkin’s disease
Multiple myeloma

Connective tissue
Fibrous tissue
Cartilage
Adepose tissue
Bone
Fibroma
Chondroma
Lipoma
Osteoma
Fibrosarcoma
Chondrosarcoma
Liposarcoma
Osteosarcoma
Muscle tissue
Smooth muscle
Straited muscle
Myoma
Leiomyoma
Rhabdomyoma
Myosarcoma
Leiomyosarcoma
Rhabdomyosarcoma

Nerve tissue
Nerve fibers
Glia cells
Meninges
Neuroma
Neurofibroma
Gliaoma
Meningioma
Neurogenic sarcoma
Glioblastoma
Malignant meningioma

1. FIBROMA:
It may grow in anywhere in the body most often in uterus .
They are generally small, but occasionally grown to a great size.
These encapsulated harmless tumors do not cause symptoms unless they
press on a bone or nerve.
They can be removed surgically.
2. LIPOMA:
It arises in adipose tissue.
They rarely cause symptoms, But are poorly encapsulated and may press on
surrounding tissues as they expand.

3. LEIOMYOMA:
It is a benign neoplasm of smooth muscles origin and is the most common
benign tumor in women.
They may develop anywhere in the body, but most commonly in the uterus.
4. CARCINOMA:
It is used for cancer of the epithelial tissues such as skin or stomach lining.
5. SARCOMA:
It is the cancer of the bone, connective tissue, e.g. blood vessels,
lymphatic, nerve tissue, muscles and cartilage.

6. LEUKAMIAS:
These are related to the abnormal uncontrolled multiplication of while blood
cell.
7. LYMPHOMAS:
They are found in lymph nodes of the organs and are characterized by
overproduction of cells in the organ.

. CARCINOMA IN SITU:
It is neoplasm of epithelial tissue that remains confined
to the site of origin.
Carcinoma in situ typically affected the cervix, and it
may occur in squemus epithelial in other parts of body.
This form of cancer can be removed surgically, because
it is localized.
In situ carcinoma can become invasive, eroding, in to
surrounding tissue.

9. The malignant fifrosarcoma are similarly to benign fibromas .
They may originate as benign fibroma, later becoming malignant,
but these fibro sarcomas rarely metastasize and respond to
surgery.
10. Bronchogenic carcinoma :
usually develops in the lower trachea and lower bronchi and very
common form of cancer.
This can be excised surgically but if it metastatisize the surgery is
contraindicated.

MANAGEMENT:
 The method of treatment depends on the type of malignancy, the specific
histologic cell type, stage, presence of metastasis, and condition of the
patient.
 The four modalities of treatment are
 1.surgery,
 2.chemotherapy,
 3.radiation therapy, and
 4.biotherapy or a combination of these
modalities.

SURGICAL MANAGEMENT:
 The principles of surgical management are based on a
cooperative, multidisciplinary approach to various
surgical resources.
 This is key to the management of the cancer patient.
 A surgical intervention usually provides the initial
diagnosis; subsequent procedures may be needed for
treatment.

Diagnosis
 Biopsy: Tissue is necessary to make a diagnosis of breast cancer.
 Fine-needle aspiration (FNA) is used most commonly to differentiate between
solid and cystic masses. It is inexpensive, causes little discomfort, and can be
performed in an outpatient or office setting.
 Core-needle biopsy will yield enough tissue to adequately evaluate the tissue
for immunohistochemistry, ie hormone receptors and HER2/neu status. It is
highly accurate and can be performed in an office or outpatient setting.

• Open biopsy may be required for some lesions to determine a
definitive diagnosis. This is done in the operating room, is more
expensive, and requires a longer period of recovery. The biopsy
may be incisional, sampling only part of the tumor, or
excisional, removing the total tumor.

TREATMENT AND TYPES OF SURGICAL
PROCEDURES:
 Surgical treatment of cancer focuses on:
1. primary treatment,
2. adjuvant therapy,
3. salvage treatment, and
4. palliative treatment.
5. Reconstructive/rehabilitative surgery
6. Preventive/prophylactic surgery

1. Primary treatment
 Primary treatment involves the removal of a malignant
tumor and a margin of adjacent normal tissue.
 Local excision is the simple excision of a tumor and a
small margin of normal tissue.
 Wide excision includes the removal of the primary tumor,
regional lymph nodes, and neighboring structures.

2. Adjuvant treatment
It involves the removal of tissues to decrease the risk of cancer
recurrence.
It includes debulking procedures.
 Debulking surgery is the removal of the bulk of the tumor; should be
performed before the start of chemotherapy whenever possible.
3.Salvage treatment:
It involves the use of an extensive surgical approach to treat a local
recurrence after implementing a less extensive primary approach.

4.Palliative treatment :
It is a surgery that attempts to relieve the complications of cancer (eg,
obstruction of the GI tract, pain produced by tumor extension into
surrounding nerves).
5.Reconstructive/rehabilitative surgery
It is the repair of defects from previous radical surgical resection; can be
performed early (breast reconstruction) or delayed (head and neck
surgery).

6.Preventive/prophylactic surgery
It is the removal of lesions that, if left in the body, are
at risk of developing into cancer. An example is polyps
in the rectum or mastectomy in women who are at high
risk

THANK YOU

1.epidemiology, itiology and classification.CANCER

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