Cancer

1. Cellular Aberration
What is CANCER?
• Cancer is defined as a type of disease that affects
multiple systems, not a single condition with a single
cause; instead, it is a group of distinct diseases with
different causes, manifestations, treatments, and
prognoses. This may occur at any age; however,
people over 65 years old are at higher risk. Because
cancer can involve any multiorgan system, and
treatment approaches have the potential for
multisystem effects, cancer nursing practice overlaps
numerous nursing specialties.
• Cancer nursing practice encompasses the holistic care
of patients throughout the cancer trajectory from
prevention through end-of-life care. Despite
significant advances in comprehending cancer,
including its causes, prevention, early detection,
diagnostic tools, prognostic indicators, treatment,
and symptom management, many people still
associate it with pain and death. Nurses need to
identify their perception of cancer and set realistic
goals to meet the challenges inherent in caring for
patients with cancer.
• It is term as an abnormal growth & spread of cells,
cell division in cancer is both abnormal &
uncontrolled. There were 3 Factors contribute to the
development of cancer-heredity, environment,
lifestyle.
• Heredity- Even though cancer has a genetic basis, all
cancer is not inherited. Usually cancer begins with the
change of DNA (deoxyribonucleic acid) level of
cell.10-15% causes are inherited e,g,-breast ,colon,
prostate, wilm’s tumor, retinoblastoma. Individual
with increased risk of breast and ovarian if she has a
mutated BRCA1 or BRCA2 gene.
What is the gene factor BRCA 1 & 2 means and its relationship to
HER2/Neu diagnostic test?
BRCA 1 –breast cancer gene 1 accounts to breast cancer while
BRCA 2 can impact the development of breast cancer,
gallbladder, pancreas, ovary etc.
This is a tissue test to check if a certain protein involved in cell
growth (HER2/neu) is present in some types of cancer cells.
Some cancers, especially invasive breast cancers, have more
HER2/neu protein than normal. HER2-positive breast cancer is a
breast cancer that tests positive for a protein called human
epidermal growth factor receptor 2 (HER2). This protein
promotes the growth of cancer cells.
Environment- Factors include pollutants, bacteria, contaminants
in water, exposure to some environmental chemicals, viruses,
bacteria, radiation, asbestos, certain medical drugs &
hormones.
• Air pollutants- vinyl chloride, lead, insecticides linked
to development of cancer.
• Radiation-UV form sunlight, X-rays and exposure to
radioactive chemicals.
• Pesticides such as those used by farmers &
manufacturers have been linked to blood & lymphatic,
brain, lung, stomach, prostate, lip & skin cancer.
• Occupation-wielder, chrome platers, leather tanner,
exposed to chromium link to lung cancer.
• Water pollutants-beryllium, cadmium, dioxide,
arsenic can have linked to lung and kidney cancer.
Lifestyle
Lifestyle choices e.g., cigarette/tobacco smoking 30% of all
cancer linked to smoking. Excessive intake of alcohol 2 or more
drinks daily can be linked to head, neck, laryngeal, esophageal,
hepatocellular cancer. Marijuana abuse can lead to lung cancer.
Diet high in red and preserved meat can lead to colorectal &
breast/endometrial cancer. Helicobacter pylori is linked to
stomach cancer.
Malignant- cell that invades & destroy nearby tissue.
Uncontrolled, unregulated cell division & divide at a high rate
which regard to normal mitotic limitation. Malignant cell
function less like the cell from which they arose. They invade
other tissues and secrete enzymes that leads to abnormal
interaction within nearby cells. Malignant cells have minimal to
no fibronectin which they break off & invade the blood &
lymphatic system or lymph vessels that carry them to distant
sites. They lack contact inhibition & continue to divide even
when surrounded on all sides by other malignant cell causing
the cell to pile up on top of one another. Malignant cells are a
result of a change in the DNA structure within a cell, the
chromosomes are abnormal in number, shape & functions.
Word/definition you should know to understand
cancer
Benign cell growth- surrounded by a fibrous capsule grows
locally but may affect vital organs & hormone production can
cause patient to obstruction problem, pain, seizure, or over
production of hormones.
Neoplasm-abnormal cell mass can be benign or malignant.
Carcinogenesis- process which normal cell is transformed into
malignant or cancerous cell; other term-oncogenesis.
Anaplasia- Loss of structure differentiation within a cell or
group of cells often with increased capacity for multiplication, as
in a malignant tumor.
Metastasis- spreading of a disease(cancer) to another part of the
body
Topic 2-
What are the pathophysiologic mechanism involving in
cellular aberration?
4 Stages of Carcinogenesis
Initiation-non-reversible event that occurs when carcinogen
(Chemical, radiation, viral, bacterial, familial tendency) invades
and damages the DNA of the cell causing a change in DNA
structure. This structural DNA change is evidence by either gene
such as an oncogene (gene normally directs cell growth & if
altered can promote or allow uncontrolled growth of cancer)
being TURNED ON & gene such as tumor suppressor gene being
TURNED OFF.
Promotion- reversible event. e’g. tobacco/cigarette smoking
potentiate the
effects of initiator.
Carcinogenesis - progression; growing in size; angiogenesis-
malignant cells/tumors formed its own blood supply &
established formation of new blood vessels to nourish itself &
sustain growth.
Metastasis- spread of malignant tumor to other location thru
invading nearby tissue.
Staging & Grading...
Staging is the extend or spread of the tumor within the body
from the site of origin. Grading is the degree of malignancy or
cell differentiation of the tumor cells.
TNM-Staging solid tumor
T-primary tumor
N-Nodal/ lymph nodes involvement
M-presence of absence of metastasis
Primary tumor Tx –means cannot be assessed.
To- No evidence of tumor
Tis- tumor in situ
T1, T2, T3,T4- dependent on size & reflective of increasing in
size.
Nx- cannot be assessed
No-no evidence of regional lymph nodes metastasis
N1, N2, N3…-dependent or increasing extent of involvement
Mx- unable to assess presence or absence of metastasis.
Mo- no presence of metastasis
M1, M2…-presence of metastasis
Grading
• Classified as I, II, III, IV; Gx, G1, G2, G3, G4
G1 or I- Has better prognosis and is highly differentiate cell
which resembles the normal cell from which they have arose as
the grade increase, degree of differentiation decrease;
considered low grade.
G2 or II- The cells and tissue are somewhat abnormal and are
called moderately differentiated. These are intermediate grade
tumors;
G3 or III- Cancer cells and tissue look very abnormal. These
cancers are considered poorly differentiated, since they no
longer have an architectural structure or pattern. Grade 3
tumors are considered high grade.
G4 or IV- no specific differentiation, tumors are anaplastic,
highly aggressive and rapidly multiplying, considered highest
grade is terms of undifferentiated cell growing and spreading.
Stages of Cell Cycle
Mitosis (1hr-3 hrs)-duplicated chromosomes separate & cell
division occurs.
Prophase- chromosomes condense & become visible
Metaphase-the second stage of cell division, between prophase
and anaphase, during which the chromosomes become attached
to the spindle fibers.
Anaphase- The stage of meiotic or mitotic cell division in which
the chromosomes move away from one another to opposite
poles of the spindle.
Telophase- the final phase of cell division, between anaphase
and interphase, in which the chromatids or chromosomes move
to opposite ends of the cell and two nuclei are formed.
Cytokinesis-To successfully make new diploid cell. the
cytoplasmic division of a cell at the end of mitosis or meiosis,
bringing about the separation into two daughter cells.
G1, first growing Phase (9hrs)-RNA & protein synthesis occurs
S (synthesis phase) Chromosomes replicated; interphase (DNA
synthesis 22 hours to many years)
G2 (2hrs) Growth phase-premitotic phase, DNA synthesis is
complete, Mitotic spindle forms.
Process of cell metastasis
Normal Cell
DNA Damage
(Acquired- Environmental, Lifestyle Factor)
Radiation
Chemical

2. Virus/bacteria
Failure of DNA Repair
(inherited; mutated in genes affecting DNA repair, genes
affecting cell growth or apoptosis)
Mutation in the genome of somatic cells-any cell of a living
organism other than the reproductive cells.
Activation of oncogene; inactivation of tumor suppressor genes,
alteration in genes that regulate apoptosis
Unregulated cell proliferation, decreased apoptosis
resulting to
clonal expansion
(angiogenesis, escape from immunity, additional
mutation)
Tumor progression Malignant neoplasm invasion &
metastasis
Topic 3- What is the various modalities of care in patient with
cellular aberration?
Prevention
• Primary- vaccines, health counselling to those cancer
cases caused by environmental factor,2/3 of cancer
cases comprises this factor. UV protection, tobacco
cessation, reduce or lessen alcohol intake. Some
vitamins are anti-oxidant or chemoprotective/cancer
protective. Dietary consumption of large amounts of
calories and food high in fat. Awareness to exposure
of viruses and bacteria can develop cancer.
• Secondary- Screening
• C-change of bladder and bowel habits
Sore that does not heal
• U- Unusual bleeding in any body orifice.
• T- thickening or the presence of a lump in breast,
testicle, or any part of the body.Indigestion or difficult
swallowing.
• O-Obvious change in a wart, mole, in color size and
texture.
• N- Nagging cough or hoarseness that is prolong
• Tertiary-Chemoprevention and health counselling to
patient already diagnosed with cancer or those who
are survivors. Activities centered on diet, exercise,
avoidance of exposure and healthy lifestyle.
• Chemoprevention-incorporation of drug, food, or
other agents.
• e.g.Tamoxifen-synthetic hormone to reduce risk of
recurrence of breast cancer; NSAID & ASPIRIN- lessen
risk of colon cancer.
Treatment Overview
1. Cure,
2. control, & manage chronic illness
3. palliation (to ease symptoms)
Common treatment
Surgery- used to diagnosed, biopsy, and stage tumor to remove,
decrease size or destroy tumors; relieve symptoms and
discomfort often associated with cancer; for reconstruction.
Nursing responsibility on pre-operative, post-operative care,
manage or prevention of surgical complication, and long term
implication
pharmacotherapy, chemotherapy, & radiation
-Treatment depends on cancer types, disease progression, or
spread and individual patient’s response
Radiation therapy (ionizing radiation)- use high energy ionizing
rays to damage or kill cells by preventing them from growing
and dividing. Only cells in the area being treated and targeted
and is applicable in early stage of cancer to cure and control.
• Internal radiation- brachytherapy (insertion of
radioactive implant directly into the tissue.
• External treatment- watch out for common
complication of radiation enteritis, nausea, vomiting,
abd’l cramps, watery stools). Management is on
dietary modification such as increase fiber and watch
out for signs of dehydration.
Topic 4- What are the pharmacologic management in cellular
aberration?
CHEMOTHERAPY
Antineoplastic –drug that prevents, kills or blocks the growth
and spread of cancer cells
Systematic treatment modality
Characteristics Benign Malignant
Cell Well
differentiated
cells
resemble
normal cells
of the tissue
from which
the tumors
originated
Cells are undifferentiated
& may have little
resembles to the normal.
Mode of
Growth
Tumor grows
by
expansion,
does not
infiltrate the
surrounding
tissues,
encapsulated
Grows at the periphery &
overcomes contact
inhibition to invade &
infiltrate surrounding
tissues.
(Contact inhibition is a
regulatory mechanism
that functions to remain
cells from growing into a
layer one cell thick (a
monolayer). If a cell has
plenty of available
substrate space, it
replicates rapidly and
moves freely.)
Rate of
Growth
Rate of
growth is
usually slow
Growth is variable &
depends on level of
differentiations, the more
anaplastic the tumor; the
faster its growth.
Metastasis Does not
spread by
metastasis
Gain access to the blood
& lymphatic channels &
metastasizes to other
areas of the body or
growth across body
cavities such as
peritoneum.
General
Effects
Localized, no
cause of
generalized
effects unless
its location
interfere with
vital
functions.
Often cause generalized
effects e.g. anemia,
weakness, systemic
inflammation, weight
loss, cancer related
anorexia, cachexia
syndrome-general
reduction in vitality &
strength of body & mind
resulting from a
debilitating chronic
disease.
Tissue
Destruction
No tissue
damage
unless its
location
interferes
with blood
flow.
Often cause extensive
tissue damage as the
tumor outgrows its blood
supply or encroaches on
blood flow to the area
may also produce
substance that cause cell
damage.
Ability to
cause death
Not usually
cause death
unless its
growth and
location
Eventually cause death
unless growth can be
controlled.
interferes
with vital
functions.
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.
 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.

3.  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.
 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.
 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.
 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.
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.
 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
 Alopecia. Altered skin integrity is a common effect and can
include alopecia or hair loss.

4.  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.
 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 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,
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.
 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.
 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

5. retroviruses, adenoviruses, vaccinia virus, fowlpox,
herpes simplex viruses, and Epstein-Barr viruses.
Approaches in Gene Therapy
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.
 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
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
 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
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.
Practice Quiz: Cancer
Here are some practice questions for this study guide. Please
visit our nursing test bank page for more NCLEX practice
questions.
1. The nurse teaches a patient with cancer of the liver about
high-protein, high-calorie diet choices. Which snack choice by
the patient indicates that the teaching has been effective?
A. Fresh fruit salad.
B. Orange sherbet.
C. Strawberry yogurt.
D. French fries.
1. Answer: C. Strawberry yogurt
 C: Yogurt has high biologic value because of the
protein and fat content.
 A: Fruit salad does not have high amounts of protein
or fat.
 B: Orange sherbet is lower in fat and protein than
yogurt.
 D: French fries are high in calories from fat but low in
protein.
2. After the nurse has explained the purpose of and schedule for
chemotherapy to a 23-year-old patient who recently received a
diagnosis of acute leukemia, the patient asks the nurse to repeat
the information. Based on this assessment, which nursing
diagnosis is most likely for the patient?
A. Acute confusion related to infiltration of leukemia cells into
the central nervous system.
B. Knowledge deficit: chemotherapy related to a lack of interest
in learning about treatment.
C. Risk for ineffective health maintenance related
to anxiety about new leukemia diagnosis.
D. Risk for ineffective adherence to treatment related
to denial of need for chemotherapy.
2. Answer: C. Risk for ineffective health maintenance related
to anxiety about new leukemia diagnosis

6.  C: The patient who has a new cancer diagnosis is
likely to have high anxiety, which may impact learning
and require that the nurse repeat and reinforce
information.
 A: The patient’s history of a recent diagnosis suggests
that infiltration of the leukemia is not a likely cause of
the confusion.
 B&D: The patient asks for the information to be
repeated, indicating that lack of interest in learning
and denial are not etiologic factors.
3. A hospitalized patient who has received chemotherapy
for leukemia develops neutropenia. Which observation by the RN
caring for the patient indicates that the nurse should take
action?
A. The patient’s visitors bring in some fresh peaches from home.
B. The patient ambulates several times a day in the room.
C. The patient uses soap and shampoo to shower every other
day.
D. The patient cleans with a warm washcloth after having
a stool.
3. Answer: A. The patient’s visitors bring in some fresh peaches
from home.
 A: Fresh, thinned-skin peaches are not permitted in a
neutropenic diet because of the risk of bacteria being
present.
 B: The patient should ambulate in the room rather
than the hospital hallway to avoid exposure to other
patients or visitors.
 C: Because overuse of soap can dry the skin and
increase infection risk, showering every other day is
acceptable.
 D: Careful cleaning after having a bowel movement
will help to prevent perineal skin breakdown and
infection.
4. While being prepared for a biopsy of a lump in the right
breast, the patient asks the nurse what the difference is between
a benign tumor and a malignant tumor. The nurse explains that
a benign tumor differs from a malignant tumor in that benign
tumors
A. Do not cause damage to adjacent tissue.
B. Do not spread to other tissues and organs.
C. Are simply an overgrowth of normal cells.
D. Frequently recur in the same site.
4. Answer: B. do not spread to other tissues and organs.
 B: The major difference between benign and
malignant tumors is that malignant tumors invade
adjacent tissues and spread to distant tissues and
benign tumors never metastasize.
 A: Both types of tumors may cause damage to
adjacent tissues.
 C: The cells differ from normal in both benign and
malignant tumors.
 D: Benign tumors usually do not recur.
5. A patient who smokes tells the nurse, “I want to have a
yearly chest x-ray so that if I get cancer, it will be detected
early.” Which response by the nurse is most appropriate?
A. “Chest x-rays do not detect cancer until tumors are already at
least a half-inch in size.”
B. “Annual x-rays will increase your risk for cancer because of
exposure to radiation.”
C. “Insurance companies do not authorize yearly x-rays just to
detect early lung cancer.”
D. “Frequent x-rays damage the lungs and make them more
susceptible to cancer.”
5. Answer: A. “Chest x-rays do not detect cancer until tumors
are already at least a half-inch in size.”
 A: A tumor must be at least 1 cm large before it is
detectable by an x-ray and may already have
metastasized by that time.
 B: Radiographs have low doses of radiation, and an
annual x-ray alone is not likely to increase lung
cancer risk.
 C: Insurance companies do not usually authorize x-
rays for this purpose, but it would not be appropriate
for the nurse to give this as the reason for not doing
an x-ray.
 D: A yearly x-ray is not a risk factor for lung cancer.