1. Presented by: Marsha Woodall MBA, MSN, RN
Revised 2012
For NIP 210

2. Objectives:
 Relate the incidence of cancer and determine the role
of nurses in the prevention and early detection of
cancer.
 Differentiate between benign and malignant
neoplasms.
 Identify factors which may contribute to the
development of cancer.
 Explain local and systemic effects of cancer.

3. Objectives cont.
 Review the latest American Cancer Society statistics.
 Identify some specific chemotherapeutic agents.
 Summarize the socio-cultural considerations of caring
for clients with cancer.

4. Epidemiology
 Affects every age group  Leading causes of cancer
 Most occur in people in men: lung, prostate,
over age 65 colorectal
 More than 1.2 million  Leading causes of cancer
Americans are diagnosed in women: lung, breast,
each year colorectal
 More than 560,000
deaths/yr in USA

12. True or False
The risk of dying from cancer in the US is increasing.

15. Pathophysiology of the
Malignant Process
 CANCER is a disease
process that begins when
an abnormal cell is
transformed by the
gentic mutation of the
cellular DNA. This
begins to proliferate
abnormally invading
tissues,lymph & blood
vessels which carry the
cells to other areas of the
body. This is called
METASTASIS.

16. Characteristics of Benign and Malignant Neoplasms
(Refer to Table 23-1 on page 402)
 Benign  Malignant
Cell Characteristics
Mode of Growth
Rate of Growth
Metastasis
General Effects

17. Cancer Development (Malignant
Transformation)
 Initiation
 Promotion
 Progression
 Metastasis
 Extension into surrounding tissues
 Penetration into blood vessels
 Release of tumor cells
 Invasion of tissue

18. Metastatic Mechanisms
 Local Seeding
 Bloodborne Metastasis
 Lymphatic Spread

19. Etiology
 Chemical Agents
 Physical Agents
 Viruses
 Dietary Factors
 Immune function Genetic and Familial Factors
 Age
 Genetic Risk

23. True or False
Regularly eating meat cooked on a charcoal
grill won’t increase you risk for cancer

24. True or False
You can prevent skin cancer by putting on
one application of sunscreen at the start of
each day.

25. True or False
Household bug spray can cause cancer

26. True or False
Living in a polluted city is a greater risk for
lung cancer than smoking a pack of
cigarettes a day

27. True or False
Some injuries can cause cancer later in life.

28. True or False
Electronic devices, like cell phones, can
cause cancer in the people who use them.

29. True or False
What someone does as a young adult has little
impact on his or her chances of getting
cancer later in life.

30. Cancer Assessment Considerations
 See chart 23-9 p. 405
C hange in bowel or bladder habits
A sore that does not heal
U nusual bleeding or discharge
T hickening or lump in breast or other
part of body
I ndigestion or difficulty in swallowing
O bvious change in wart or mole
N agging cough or hoarseness

31. Detection and Prevention of
Cancer
 Primary Prevention: Nurses play a key role
in cancer prevention
 Avoidance of Known carcinogens
 Modification of associated factors
 Removal of “at risk” tissues
 Chemoprevention

32. Detection and Prevention of
Cancer
 Secondary Prevention:
 Promotion of cancer screenings
 Gene therapy for cancer prevention

42. Stages of Cancer Cell Invasion
 In situ – noninvasive neoplasm
 Localized – invasive neoplasm confined to
the organ of origin
 Regional – invasive neoplasm that extends
into surrounding tissue
 Distant – a neoplasm that spreads to distant
parts of the body

43. STAGING: Determines the size of the tumor
and the existence of metastasis. TNM system;
T = extent of primary tumor
N = lymph node involvement
M = extent of metastasis
GRADING: Classification of tumor cells
obtained through cytology (biopsy). I to IV:
I = Closely resemble tissue of origin
IV = Poorly differentiated (more
aggressive and less responsive to
treatment)

44. Question 1
What are the odds of a man dying from
cancer in the U.S.?
A. 1 in 2
B. 1 in 4
C. 1 in 25
D. 1 in 50

45. Question 2
What race has the highest incidence of
cancer?
A. African American
B. Hispanic/Latino
C. Asian
D. Caucasian

46. Question 3
An example of a primary prevention
strategy for reducing cancer risk would be:
A. Yearly mammography for women older
than 40 years
B. Regular physical exercise
C. Colonoscopy at age 50 years and then
every 10 years
D. Avoiding red meat in the diet

52. Cancer Therapy Goals and
Response
Prevention Neoadjuvant
Cure Chemo-
Control prevention
Palliation Myeloablation
Adjuvant Immuno-
suppression
p. 17

53. Management of Cancer
 Surgery
 Diagnostic
 Primary Treatment
 Prophylactic
 Palliative
 Second-look
 Reconstructive or
rehabilitation

54. True or False
Treating cancer with surgery causes it to
spread throughout the body.

55. Treatment Strategies
 Combination versus single-agent
therapy
 Dose or dose intensity of
chemotherapy
p. 18
 Hormone receptor status

56. Measuring Response
 Complete response (CR)
 Partial response (PR)
 Stable disease (SD)
 Progressive disease (PD)
 Relapse
p. 19-20

57.  Radiation Therapy (See charts on p. 420)
 Ionizing
 Control malignant disease
 Palliative
 External (teletherapy)
 Internal (brachytherapy)
 Dosage
 Toxicity
 Skin
 Mucous membranes
 Bone marrow

60. Best Practice for Patient Safety
& quality Care and
patient/family education
 See page 417

61. Chemotherapy
 Antineoplastic agents used to kill
tumor cells by interfering with
cellular functions and reproduction
 Used primarily to treat systemic
disease
 Goals:
 Cure
 Control
 Palliation

62. Cell Cycle
 G1 phase - RNA and
G2
protein synthesis
 S phase - DNA
synthesis
 G2 phase - M
S
premitotic; DNA
synthesis complete
 Mitosis - cell division
occurs
 Go phase - Rest G1
Go

63. Classification of Chemo agents
 Cell cycle - specific drugs
 Cell cycle - nonspecific drugs
 Alkylating agents
 Nitrosureas
 Antimetabolites
 Antitumor antibiotics
 Plant alkaloids
 Hormonal agents
 Miscellaneous agents

65. Alkylating Agents
Breaks DNA helix strand, thereby
interfering with DNA replication
Agents given via different routes depending
on the medication

66. Alkylating Agents
Examples:
 Carboplatin (Paraplatin)
 Cis-Platinum, Platinol
 Cyclophosphamide (Cytoxan)
 Dacarbazin (DTIC)
 Thiotepa (Thioplex)

67. Antimetabolites
 Incorporate into the normal cell
constituents making them nonfunctional
 Inhibit the normal function of a key
enzyme
 Acts in S phase; inhibits production for
DNA synthesis. Leading to strand breaks
of premature chain termination

68. Chemotherapy Agents
Antimetabolites
 capecitabine (Xeloda)
 cytarabine (Cytosar-U)
 floxuridine (FUDR)
 fludarabine (Fludara)
 fluorouracil (Efudex)

69. Antitumor Antibiotics
Inhibit DNA-dependent RNA synthesis or
delay or inhibit mitosis
 bleomycin (Blenoxane)
 dactinomycin (Cosmegen)
 daunorubicin (Cerubidine)
 doxorubicin (Adriamycin PFS)
 epirubicin (Ellence)

70. Nitrogen Mustards
Disrupts normal nucleic acid function in
DNA and RNA to inhibit reproduction
 chlorambucil (Leukeran)
 estramustine (Emcyt)
 mechlorethamine (Mustargen)
 melphalan (Alkeran)
 thiotepa

71. Plant Alkaloids
Inhibit formation of spindle fibers, arresting the
metaphase stage of cell division
 docetaxel (Taxotere)
 etoposide (VePesid)
 irinotecan (Camptosar)
 paclitaxel (Taxol)
 vinblastine (Velban)
 vincristine (Oncovin, Vincasar PFS)

72. Cytoprotective (Rescue) Agents
 Administered to reduce side effects and toxicity of
chemotherapeutic agents
 Chemotherapy agent must be active long enough to
kill malignant cells
 Then the rescue agent is given to prevent destruction
of healthy cells
 amifostine (Ethyol)
 dexrazoxane (Zinecard)
 leucovorin

73. Routes of Administration
 Oral
 Subcutaneous or intramuscular
 Itra-arterial
 Intrathecally
 Intraperitoneal
 Intrapleural
 Intravesicular
 Intravenous
p. 95

74. Intrathecal route

75. Mediport or
Portacath

76. Vesicants
 Agents that cause
extravasation if
deposited into subq
tissue
 Vesicants are:
 Dactinomycin
 Daunorubicin
 Adriamycin
 Nitrogen mustard
 Mitomycin
 Vinblastine
 Vincristine
 Vindesine

77. Indications of Extravasation
 Absence of blood return from the IV
 Flow is resistant
 Swelling, pain, or redness at site
Venous access device
• Referred to as VAD
• Inserted to promote safety while
administering vesicants
• Complications: infection, thrombosis

78. S/S associated with vesicant extravasation,
irritation and flare reaction
 Pain
 Redness
 Swelling
 Blood return
 Ulceration
p. 107

82. Toxicity with chemotherapy
 GI
 Nausea/Vomiting
 Stomatitis/Mucositis
 Myelosuppression
 Leukopenia
 Anemia
 Thrombocytopenia
 Neutropenia
 Renal
 Cisplatin, MTX, Mitomycin = Kidney toxicity
 hyperkalemia, hyperphosphatemia, hypocalcemia
 Monitor BUN, serum creatinine, creat inine
clearance,electrolytes

83. • Cardiopulmonary
– Daunorubicin, Doxorubicin may cause
irreversible cardiac toxicities
– Bleomycin, BCNU, Busulfan cause lung toxicities
(pulmonary fibrosis)
• Reproductive
– possible sterility
• Neurological
– Vincristine can cause peripheral neuropathy, loss
of deep tendon reflexes, paralytic ileus
– Cisplatin can cause peripheral neuropathy and
hearing loss
• Fatigue

84. GENERAL SIDE EFFECTS OF CHEMOTHERAPEUTIC DRUGS
Immediate side effects:
Nausea, vomiting, fever, allergy, hypotension, arrhythmia,
thrombophlebitis
Reversible side effects:
Bone marrow suppression (leucopenia, thrombopenia),
inflamed mucosa, stomatitis, enteropathy, diarrhea, alopecia,
changes in skin pigmentation, hyperkeratosis, hepatotoxicity,
nephrotoxicity, amenorrhea, aspermogenesis
Irreversible side effects:
Cardiotoxicity, hepatotoxicity, nephrotoxicity,
neurotoxicity, ototoxicity, mutagenesis/carcinogenesis-> malignancy
Indirect effects:
Immunosuppression, increased infection rate,
increased blood urea (kidney failure)

85. Systemic side Effects
 Chemotherapy causes side effects by
exerting its greatest effect on rapidly
generating cells
 Chemotherapy + radiation, biologic and/or
hormonal therapy = increased toxic effects
 Physiological deficits and co-morbidities
can enhance toxicities

86. Myelosuppression
 Suppression of bone marrow activity
 Can result in a decrease in any combination
of WBC, RBC or platelets
 Most common dose-limiting toxicity
 Potentially LETHAL

87. Nadir
 Point at which the lowest blood-cell count is
reached
 Usually 7-10 days after treatment
 Onset and duration depends on agent used
 WBC & platelets are usually 1st to drop
 Anemia is seen later

88. Neutropenia
 Bone marrow constantly produces
neutrophils
 Life span of neutrophil is 7-12 hours
 Chemo agents suppress bone marrow and
damage stem cells
 Resulting in decreased neutrophil count
as mature neutrophils die & aren’t
replaced

89. Anemia
 RBC production is result of erythropoiesis,
which is regulated by erythropoietin (EPO)
 Normal erythrocyte life span = 120 days
 Delayed anemia effects due to limited bone
marrow reserve and late effects of treatment
 Difficult to limit to single etiology

90. Thrombocytopenia
 Destruction or injury to stem cells leads
to dysfunction and suppression of platelet
production
 Normal life span – 7-10 days
 No bone marrow reserve of precursors
 Some chemo agents have
thrombocytopenia as their dose-limiting
toxicity

91. Thrombocytopenia assessment
 Petechiae/bruising  Headaches
 Overt bleeding  Hypotension
 Enlarged liver or  Tachycardia
spleen  Prolonged
 Occult or overt menstruation
blood in stool or
urine

92. Risk of Bleeding
Platelet Count Risk level/intervention
 100,000  Chemotherapy reduced or
held
 50,000  Increased risk of bleeding;
initiate precautions (no
injections, etc.)
 Severe risk exists for
 <15,000
spontaneous hemorrhage;
frequent check of platelet
counts/transfusions

93. Nausea and Vomiting
 Anticipatory – occurs before or during treatment (25%
incidence)
 Acute – occurs within 24 hours
 Delayed – occurs at least 24 hours after therapy and
may persist up to 6 days (Cisplatin associated with
highest incidence)

94. Antiemetic Therapy for CINV
 Ondansetron (Zofran)
 Granisetron (Kytril)
 Granisetron transdermal (Sancuso)
 Dolasetron (Anzemet)
 Palonosetron (Aloxi)
Drug combinations are individualized for best effect

95. Mucositis
Clinical Manifestations
 Taste changes  Changes in color of
 Swallowing oral mucosa
difficulty  Oral moisture
 Hoarseness changes
 Pain with  Edema
swallowing or  Ulcerations
talking

96. Mucositis Assessment
 Perform thorough oral assessment:
 Standard instrument
 Penlight
 Gloved finger
 Inspect under tongue and along inner
cheeks, gums, inspect hard & soft palate

100. Mucositis Management
Prevention Treatment
 Oral care protocols  No evidence-based
 Patient education recommendations
 Treat dental problems  Goal is symptom relief,
before cytotoxic therapy prevention of further
 High protein diet
damage
 Oral agents & hygiene
 Fluid intake > 1500 ml/d
 Systemic pain
 Cryotherapy ofr bolus 5-
FU medications
 Culture lesions

101. Hormonal Manipulation
 Some hormones make hormone-sensitive tumors
grow more rapidly.
 Some tumors require specific hormones to divide;
decreasing the hormone amounts to hormone-
sensitive tumors can slow cancer growth rate

102. Side Effects of
Hormone Therapy
 Masculinizing effects in women
 Feminizing effects in men (gynecomastia)
 Risk for venous thromboembolism
 Acne
 Hypercalcemia
 Liver dysfunction
 Bone loss

103. Photodynamic Therapy
 Selective destruction of cancer cells via chemical
reaction triggered by different types of laser light
 Patient teaching
 General sensitivity to light for up to 12 weeks after
injection of photosensitizing drug

104. Fatigue (#1 complaint)
 Definition:
Persistent, subjective sense
of tiredness related to
cancer or cancer treatment
that interferes with usual
functioning

105. Fatigue Risk Factors
 Malnutrition  Comorbidities
 Immobility  Hypoxia
 Insomnia  Infection/fever
 Stress  Pain
 Depression/anxiety  Cancer therapy
 Anemia

106. Immunotherapy: Biological
Response Modifiers (BRMs)
 Modify patient’s biological responses to
tumor cells
 Cytokines—enhance immune system
 Interleukins, interferons
 Side effects—generalized, sometimes
severe inflammatory reactions, peripheral
neuropathy, skin rashes

107. Colony-stimulating factors
 Aranesp and Procrit
 Stimulates erythropoiesis
 Administered SC
 Neupogen
 Regulates the production of neutrophils
within the bone marrow
 Administered SC, IV

108. Colony-stimulating factors
 Neulasta
 Regulates the production of
neutrophils within the bone marrow
 Administered SC
 GM-CSF
 Induces committed progenitor cells to
divide and differentiate in the GM
pathways
 Administered SC, IV

109. Oncologic Emergencies
 Sepsis and disseminated
intravascular coagulation
 Collaborative management includes:
 Prevention (the best measure)
 Intravenous antibiotic therapy
 Anticoagulants, cryoprecipitated
clotting factors

110. Syndrome of Inappropriate Antidiuretic
Hormone (SIADH)
 Water is reabsorbed to excess by the kidney and
put into system circulation.
 SIADH is most commonly found in carcinoma of
the lung
 Collaborative management includes:
 Fluid restriction
 Increased sodium intake
 Drug therapy with demeclocycline that works in
opposition to antidiuretic hormone

111. Spinal Cord Compression
 Tumor directly enters the spinal cord or the vertebrae
collapse from tumor degradation of the bone.
(Continued)

112. Spinal Cord Compression (Continued)
 Collaborative management includes:
 Early recognition and treatment
 Palliative
 High-dose corticosteroids
 High-dose radiation
 Surgery
 External back or neck braces to reduce
pressure in the spinal cord

113. Hypercalcemia
 Occurs most often in clients with bone
metastasis
 Fatigue, loss of appetite, nausea and
vomiting, constipation, polyuria, severe
muscle weakness, loss of deep tendon
reflexes, paralytic ileus, dehydration,
electrocardiographic changes
(Continued)

114. Hypercalcemia (Continued)
 Collaborative management includes:
 Oral hydration
 Drug therapy
 Dialysis

115. Superior Vena Cava Syndrome
 Superior vena cava is compressed or
obstructed by tumor growth.
 Condition can lead to a painful, life-
threatening emergency.
 Signs include edema of face, Stokes’ sign,
edema of arms and hands, dyspnea,
erythema, and epistaxis.
(Continued)

116. Appearance of SVC Syndrome

117. Superior Vena Cava Syndrome (Continued)
 Late-stage signs include hemorrhage,
cyanosis, change in mental status, decreased
cardiac output, and hypotension.
 Collaborative management includes high-
dose radiation therapy, but surgery only
rarely.

118. Tumor Lysis Syndrome
 Large numbers of tumor cells are destroyed
rapidly, resulting in intracellular contents
being released into the bloodstream faster
than the body can eliminate them.
 Collaborative management includes:
 Prevention
 Hydration
 Drug therapy

119. A 40-year-old woman was admitted to the oncology
unit for severe dehydration from nausea and
vomiting associated with chemotherapy 10 days ago.
She has had two adjuvant treatments for breast
cancer with doxorubicin (Adriamycin) and
cyclophosphamide (Cytoxan). She has a Groshong
port that was inserted 2 months ago for
chemotherapy administration.

120. (cont’d)
The health care provider’s orders are as follows:
 Strict I&O every 12 hours
 May use port for blood draws and IV fluids
 Call for vomiting or temp of 100° F or greater
 D5½NS at 125 mL/hr
 Ondansetron (Zofran) 8 mg IV every 8 hrs
 Clear liquid diet and progress as tolerated
 CBC, Ca level, and basic metabolic panel in AM
 Bed rest with bathroom privileges
 Knee-high support stockings
What is the rationale for each of the provider’s orders?

121. (cont’d)
Which of the provider’s orders should be
implemented immediately?
A. Administer D5½NS at 125 mL/hr
B. Administer clear liquid diet
C. Apply support stockings
D. CBC, Ca level, and basic metabolic
panel

122. (cont’d
)
Two hours later, the patient reports
difficulty swallowing because of sores in
her mouth.
1. What does the nurse suspect is the
problem with the patient’s mouth?
2. What nursing interventions should be
implemented?

123. (cont’d
)
Match each chemotherapy side effect below with
the correct intervention.
A. Anemia
B. Neutropenia
C. Thrombocytopenia
1. Inspect IV sites every 4 hours for signs of
infection.
2. Avoid IM injections and venipunctures.
3. Administer epoetin alfa subcutaneously once a
week.

124. Audience Response System Questions
124

125. Question 1
What is the expected outcome related to hair
loss for a patient who is undergoing
chemotherapy?
A.Hair loss may be permanent.
B. Hair regrowth usually begins about 1 month
after completion of chemotherapy.
C.New hair growth will likely be identical to
previous hair growth in color and texture.
D.Viable treatments exist for the prevention of
alopecia.

126. Question 2
A patient who is receiving radiation
therapy for breast cancer would experience
which side effect?
A.Fatigue
B. Mucositis
C.Hair loss
D.Nausea and vomiting

127. Question 3
When is the patient with acute leukemia at
greatest risk of developing tumor lysis
syndrome?
A.After the first cycle of chemotherapy
B. After the second cycle of chemotherapy
C.After the last cycle of chemotherapy
D.Anytime during the patient’s treatment
course