Biology of cancer tumor spread

1. BIOLOGY OF CANCER & TUMOR
SPREAD
MARY ELAINET.TAPEL, RN., MAN

2. CANCER
 it is a tissue overgrowth that is independent of the laws
governing the remainder of the body.
 it is derived from the Greek word for , crab
(Karkinoma), which the physician Hippocrates used to
describe the appendage-like projections extending from
tumors
 any malignant tumor , or neoplasm

3. TUMOR
 originally referred to any swelling but is now generally
reserved for new growth, or neoplasm
 not all tumors or neoplasms are cancer

4. TUMOR CLASSIFICATION AND
NOMENCLATURE

5. BENIGNTUMORS
 they are not cancers
 they are usually well encapsulated and well
differentiated, retain some normal tissue structure, and
do not invade the capsule, nor do they spread to
regional lymph nodes or distant locations
 named according to the tissues from which the arise
with the suffix “oma” like lipoma (benign tumor of fat
cells)

6. MALIGNANTTUMORS
 more rapid growth rates and with specific microscopic
alterations, including loss of differentiation, absence of
normal tissue organization; lack of a capsule; invasion
into blood vessels, lymphatics, and surrounding
structures; and distant spread (metastasis)
 the hallmark of malignant cells is anaplasia (loss of
differentiation, nuclear irregularities, and loss of normal
tissue structure

7. BENIGNVS. MALIGNANTTUMORS
BENIGN
 Grow slowly
 Microscopically well-differentiated
with a low mitotic index
 well-differentiated: looks like the
tissue from which it arose
 Have well defined capsule
 are not invasive
 Do not metastasize
MALIGNANT
 grow rapidly
 anaplastic and have a high mitotic
index
 poorly differentiated: does not look
like the tissue from which it arose
 not encapsulated
 invade local structures & tissues
 spread distantly through
bloodstream & lymphatics

8. CANCER
 named according to the cell type of origin
 Carcinoma: cancer arising in epithelial tissue
 Adenocarcinoma: arise from ductal or glandular
epithelium like mammary adenocarcinoma
 Sarcoma: arising from connective tissue like
rhabdomyosarcoma (skeletal muscle)
 Lymphoma: cancer of lymphatic tissue
 Leukemia: cancer of blood forming cells

9. CARCINOMA IN SITU (CIS)
 refers to preinvasive epithelial tumors or glandular or squamous
cell origin
 have not broken through basement membrane of the
epithelium
 It can be found in the cervix, skin, oral cavity, esophagus, and
bronchus.
 in glandular epithelium, in situ lesions occur in stomach,
endometrium, breast, and large bowel

10. STAGES OF CANCER SPREAD
 Stage 1: confined to the organ of origin
 Stage 2 or B: cancer that is locally invasive
 Stage 3 or C: spread to regional structures such as
lymph nodes
 Stage 4 or D: spread to distant sites, such as liver cancer
spreading to lung

11. CELL DIFFERENTIATION
 AUTONOMY: cancer cells independence from normal
cellular controls
 ANAPLASIA: is the loss of differentiation, which is the
process of developing specialized functions and
organization
 anaplastic cells have variable size and shape, or
pleomorphic

12. TUMOR MARKERS/ BIOLOGIC MARKERS
 are substances produced by cancer cells that are found
on tumor plasma membranes or in the blood, spinal
fluid, or urine
 includes hormones, enzymes, genes, antigens, and
antibodies

13. USES OFTUMOR MARKERS
 to screen and identify individuals at risk for cancer
 to help diagnose the specific type of tumor in
individuals with clinical manifestations relating to
cancer
 to follow the clinical course of cancer

14. EXAMPLE OFTUMOR MARKER
 Alpha-Fetoprotein (AFP): hepatic, germ cel
 Carcinoembryonic Antigen (CEA): Colon, liver, pancreas,
lung, breast Cancer
 Beta- human chorionic gonadotropin (B-hCG): Germ
Cell, teratomas, islet cell
 Prostate-specific antigen (PSA): Prostate
 Catecholamines: Pheochromocytoma (adrenal &
medulla)

15. EXAMPLE OFTUMOR MARKER
 Homovanillic acid/ vanillylmandelic acid (HVA/VMAI):
Neuroblastoma
 Uninary Bence-Jones protein: Multiple Myeloma
Adrenocorticotropic hormone (ACTH) = Pituitary
adenomas


16. GENETIC BASIS OF CANCER
Cancer is caused by mutations of genes

17. CLONAL SELECTION
 each individual requires a number of genetic”hits” or
mutations over time
 when sufficient mutations have occurred, cancer develops
 as an individual mutation occurs in a single cell, it may
acquire some of the characteristics of a cancer, example
increased growth rate or decreased apoptosis or death rate.
That cell will have a selective advantage over its neighbors;
its progeny can accumulate faster than its nonmutant
neighbors (Clonal proliferation or clonal expansion)

18. CLONAL SELECTION
as a clone with a mutation proliferates, it may become
an early stage tumor
 the progressive accumulation of distinct advantageous
mutations leads from normal to a fully malignant
cancers

19. WHATTYPE OF GENES MUST BE MUTATED
TO CAUSE A CANCER?
 the prevailing view is that a number of cellular control
pathways must be altered for a cell to become fully
malignant:
1. Cancer cells must have mutations that enable them to
proliferate in the absence of growth signals
 some cancers secrete growth factors that stimulate
their own growth (autocrine stimulation)

20. 2. Other cancers have an increase in growth factor
receptors example breast cancer.The epidermal growth
factor receptor is regulated and likely sends growth
signals into the cell even when external growth factors
are at very low levels.Alternatively, the signal cascade
from the cell surface receptor to the nucleus may be
mutated in the “on “ position

21. ANGIOGENESIS
 new blood vessel growth
 these angiogenic factors, such as vascular endothelial
growth factor (VEGF), are required in small cancers to
permit continued tumor expansion
 in order to suppressVEGis given like, antiangiogenesis
drug (bevaizumab (Avastin), a monoclonal antibody that
binds to and inactivatesVEGF

22. TELOMERES AND IMMORTALITY
 a hallmark of cancer cells is immortality
 the only cells in the body that ar usually “immortal” are
germ cells and some stem cells.
 one block to unlimited cell division is a specialized
structure at the end of each chromosome called
telomere

23. TELOMERE
 is a specialized, multicopy repeat DNA sequence that
protects and maintains the ends of the chromosomes,
and telomeres are maintained by a specialized enzyme
called telomerase.This is present in germ cells. Other
cells lack telomerase

24. ONCOGENES ANDTUMOR-SUPPRESSOR
GENES: ACCELERATORS AND BRAKES
 ONCOGENES: are mutant genes that in their normal
nonmutant state direct synthesis of proteins that
positively regulate (accelerate) proliferation
 TUMOR-SUPPRESSOR GENES: encode proteins that in
their normal state negatively regulate (put the brakes
on) proliferation (antioncogenes)

25. TYPES OF CANCER GENES
Dominant Oncogenes
 Gene products that normal
promote growth
 activated by overexpression,
increased copy number or
gain of function mutations
Tumor Suppressors
 Genes and proteins that
normally inhibit growth or
protect the genome
 Inactivated by loss of
function mutation, loss of
heterozygosity

26. MUTATIONS THAT CREATE
ONCOGENES

27. POINT MUTATIONS
 are small-scale changes in DNA
The alteration of one or a few nucleotide base pairs
 This can have profound effects on the activity of
proteins
 a point mutation in ras converts it from a regulated
proto-oncogene to an unregulated oncogene, an
accelerator of cell proliferation

28. CHROMOSOMETRANSLOCATIONS
 are genetic lesion found in cancer
 can activate oncogenes by either of 2 distinct
mechanism:
1. Translocation can cause excess and inappropriate
production of a proliferation factor.
2. Production of novel proteins with growth-promoting
properties

29. CHROMOSOME AMPLIFICATION
 are genetic abnormality that turns on oncogenes
amplifications are result of duplication of a small piece
of a chromosome over and over again, so that instead of
the normal two copies of gene, there are tens or even a
hundred of copies.
 it results in increased expression of an oncogene or, in
some cases, drug resistant genes

30. TUMOR SUPPRESSOR GENES
 are genes whose major function is to negatively regulate cell
growth
 it slow the cell cycle, inhibit proliferation from growth signals,
and stop cell division when cells are damaged
 tumor suppressors must be inactivated to allow cancer to occur

31. LOSS OF HETEROZYGOSITY (LOH)
 loss of chromosome region in a tumor
 loss of heterozygosity unmasks mutations in recessive
tumor suppressor genes

32. GENE SILENCING
 is the heritable manner of regulation of gene expression
by an epigenetic mechanism that does not require
mutations or changes in DNA sequence

33. 4 PRIMARY MECHANISM FOR THE
SPREAD NEOPLASM
1. Vascular system – cancer cells penetrate vessels and circulate
until trapped. The cancer cells may penetrate the vessel wall and
invade adjacent organs and tissues
2. Lymphatic system – cancer cells penetrate the lymphatic
system and are distributed along lymphatic channels
3. Implantation – cancer cells implant into a body organ. Certain
cells have an affinity for particular organs and body areas
4. Seeding – a primary tumor sloughs off tumor cells into a body
cavity, such as the peritoneal cavity

34. ETIOLOGY OF CANCER
A.Viruses – incorporate into genetic structure of the cell
B.Physical agents – exposure to sunlight, radiation, chronic
irritation or inflammation, and tobacco use
C.Chemical agents – produce toxic effects by altering DNA
structure in body sites distant from chemical exposure (ex.
Dyes, asbestos, tars, smoke, etc.); most often affects liver,
lungs, and kidneys.
D.Genetic and familial factors – DNA damage occurs in cells
where chromosomal patterns are abnormal (ex. Wilm’s tumor,
acute leukemias, etc.)

35. ETIOLOGY OF CANCER
E. Dietary factors – risk of cancer increases with long term
ingestion of fats and oils from animal sources; alcoholic
beverages, salt-cured, smoked meats, and nitrate containing
foods
F. Hormonal agents – tumor growth promoted by
disturbances in hormonal balance of the body’s own
(endogenous) hormones or administration of exogenous
hormones (ex. Diethystilbestrol (DES), prolonged estrogen
replacement, oral contraceptives)

36. CANCER PREVENTION

37. 10 STEPS OF CANCER
PREVENTION:
1. Increase intake of fresh vegetables (especially of those of the
cabbage family)
2. Increase fiber intake – reduces risk of breast, prostate, and
colon cancer
3. Increase intake of vitamin A – reduces risk of larynx,
esophageal, lung cancer
4. Increase intake of foods rich in Vitamin C – may protect
against stomach and esophageal cancer
5. Keep weight in normal range – obesity associated with cancer
of uterus, gall bladder, breast, and colon

38. 10 STEPS OF CANCER
PREVENTION:
6. Reduce amount of intake of dietary fat – increased risk of
breast, colon, and prostate cancer
7. Reduce intake of salt-cured, smoked, and nitrate -cured
foods (linked to stomach and esophageal cancer)
8. No cigarette smoking (increased risk of lung cancer)
9. Reduce intake of alcohol (increased risk of liver cancer)
10. Avoid overexposure to sunlight (risk of skin cancer)

39. SECONDARY PREVENTION
1.PAP test – for sexually active women, and/ or women over
age 18, it is recommended that the test be done annually
2.Digital rectal examination – men and women annually after
age 40
3.Proctosigmoidoscopy – after age 50, should be done
every 3 to 5 years in both men and women
4.Check for occult blood in stool – done after age 50 on an
annual basis

40. SECONDARY PREVENTION
5. Mammography – Baseline between ages 35 – 40,
then again 40 -49, then yearly after age 50
6. Breast self-examination – conducted monthly
7. Pelvic examinations – every 3 years from age 20-
40, yearly after age 40
8. Testicular self-examination – monthly from age 20
-40

41. TERTIARY PREVENTION
 improved screening, diagnosis, and treatment
approaches
 tertiary prevention is focused on monitoring for and
preventing recurrence of the primary cancer as well as
screening for the development of second malignancies
in cancer survivors

42. CANCERS EARLY WARNING SIGNS
(ADULTS)
C – Change in bowel or bladder habits
A – A lesion or sore that does not heal
U – Unusual bleeding of discharge
T – Thickening or lump in the breast
I – Indigestion or difficulty swallowing
O – Obvious changes in wart or mole
N – Nagging cough or persistent hoarseness

43. CANCERS EARLY WARNING SIGNS
(CHILDREN)
1. Marked changes in bowel and bladder habit; nausea and
vomiting for no apparent cause
2. Generally run-down condition; increased susceptibility to
infection
3. Spontaneous bleeding episode (epistaxis); failure to stop
bleeding in normal time period
4. Swellings, lumps or masses anywhere in the child’s body
5. Persistent crying or pain for which there is no apparent cause
6. Any change in size of mole or birthmark
7. Unexpected stumbling or lack of coordination in the child

44. ETIOLOGY OF CANCER

45. VIRUSES AND BACTERIA
 10% - 12% of all cancers worldwide are linked to viral
infections
 DNA viruses insert a part of their own DNA near the
infected cell genes causing cell division
 The newly formed cells that now carry viral DNA lack
normal controls on growth

46. CHEMICAL AGENTS
 Most hazardous chemicals produce their toxic effects
by altering DNA structures
 Tobacco use is thought to be the single most lethal
chemical carcinogen; it accounts for about 30% of all
cancer related deaths

47. PHYSICAL AGENT
 Physical factors associated with carcinogenesis include
exposure to sunlight, radiation, chronic irritation or
inflammation, tobacco carcinogens, industrial
chemicals, and asbestos

48. GENETICS AND FAMILIAL FACTORS
 Familial predisposition may be due to a combination of
genetic, environmental, and lifestyle factors.
 Cancer has been associated with extra chromosomes,
or translocated chromosomes
 hereditary cancer syndromes represent a cluster of
cancers identified by a genetic alteration that is
inherited across generations

49. GENETICS AND FAMILIAL FACTORS
 the hallmarks of families with a hereditary cancer
syndrome include
 cancer in two or more first-degree relatives,
 onset of cancer in family members younger than 50 years
 the same type of cancer in several family members
 individual family members with more than one type of cancer
 a rare cancer in one or more family members
 autosomal dominant inheritance pattern of cancer affecting
several generations of a family

50. LIFESTYLE FACTORS
 the risk of cancer increases with long-term ingestion of
carcinogens or co-carcinogens or the absence of
protective substances in the diet
 Dietary substances that appear to increase the risk of
cancer include fats, alcohol, salt-cured or smoked
meats, nitrate- and nitrate-containing foods, and red
and processed meats

51. LIFESTYLE FACTORS
Obesity has been linked to the development of cancers
of the breast, colon, rectum, endometrium, esophagus,
kidney, and pancreas, etc.
 excess fat may cause chronic inflammation resulting in
DNA damage, increased levels of certain hormones
(estrogen, insulin, adipokines), and disruptions in levels
of cell growth regulators

52. HORMONAL AGENTS
 tumor growth maybe promoted by disturbances in
hormonal balance, either by the body’s own
(endogenous) hormone production or by administration
of exogenous hormones

53. ROLE OF THE IMMUNE
SYSTEM

54. RESPONSES OFTHE IMMUNE SYSTEMTO
CANCER CELLS
1. Proliferation of cytotoxic (cell-killing)T lymphocytes
capable of direct destruction of cancer cells
2. Induction of cancer cell apoptosis
3. Recruitment of additional immune system cells (B-cell
lymphocytes that produce antibodies, natural killer
cells, and macrophages) that contribute to the
destruction and degradation of cancer cells

55. DIAGNOSIS OF CANCER

56. PURPOSES OF DIAGNOSTICTESTING
 determine the presence & extent of cancer
Identify possible disease metastasis
Evaluate the function of involved and uninvolved body
systems or organs
 obtain tissue and cells for analysis, including evaluation
of tumor stage and grade

57. ROLE OF NURSES INTHE DIAGNOSTIC
TESTING
 help address the patient’s fear and anxiety by explaining
the tests to be performed, the sensations likely to be
experienced, and the patient’s role in the test procedures
 encourage the patient and family to voice their fears about
the tests results
 supports the patient and family throughout the diagnostic
evaluation
 reinforces and clarifies information conveyed by the
primary provider

58. ROLE OF NURSES INTHE DIAGNOSTIC
TESTING
 encourages the patient and family to communicate,
share their concerns, and discuss their questions and
concerns with one another

59. TUMOR STAGING AND GRADING
 accomplished prior to the treatment to provide baseline
data for evaluating outcomes of therapy and to
maintain a systematic and consistent approach to
ongoing diagnosis and treatment

60. STAGING
 describes the of the tumor, the existence of local
invasion, lymph node involvement, and distant
metastasis
 the tumor, nodes, and metastasis (TNM) system is used
in staging

61. TNM STAGING
 T – Primary Tumor
 T0 – no evidence of tumor
 T1s = carcinoma in situ
 T1-T4 = ascending degrees of increase
in tumor size and involvement
 N – Regional Lymph Nodes
 N0 – no clinical evidence of regional
node involvement
 Nx – regional lymph nodes cannot
be evaluated clinically
 N1-N3 – ascending degrees of
nodal involvement
 M – Metastasis
 M0 – no evidence of distant
metastasis
 Mx – distant metastasis cannot be
assessed
 M1- ascending degrees of
metastatic involvement, including
lymph nodes

62. GRADING
 is the pathologic classification of tumor cells
 grading systems seek 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
 can be done through scraping, body fluids, secretions,
washings, biopsy, or surgical excision
 the grade corresponds with a numeric value ranging from I - IV

63. GRADING OFTUMOR
Grade I tumor: well differentiated tumors, closely
resemble the tissue of origin in structure & function.
Grade IV:Tumors that do not clearly resemble the tissue
of origin in structure or function are described as poorly
differentiated or undifferentiated.This tumor tend to
be aggressive, less responsive to treatment, and
associated with a poorer prognosis as compared to well-
differentiated, grade I

64. GRADING OF CANCER
Grade 1:Tumor cells and tissue looks most like healthy
cells and tissue.These are called well-differentiated
tumors and are considered low grade.
Grade 2:The cells and tissue are somewhat abnormal
and are called moderately differentiated.These are
intermediate grade tumors.

65. GRADING OF CANCER
Grade 3: 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.
Grade 4:These undifferentiated cancers have the most
abnormal looking cells.These are the highest grade and
typically grow and spread faster than lower grade
tumors.

66. BIOPSY
 Needle – tissues obtained by aspiration, or with a large bore
needle ; a sample is removed
 Incisional – tumor mass may be too large for removal; this may
be done for staging the disease level
 Excisional – involves removal of the entire tumor
 Endoscope biopsy – direct biopsy through an endoscopy of the
area (gastrointestinal, respiratory, genitourinary tracts)

67. OTHER DIAGNOSTIC STUDIES
 X-ray examination
 Computerized axial tomography
(CAT)
 Cytology studies
 Radioisotope scans
 Magnetic Resonance Imaging
(MRI)
 Mammography
 Lymphangiography
 Position emission
tomography (PET)
 Ultrasound
 Tumor markers
 Colposcopic exam of cervix

68. GOALS OF CANCERTHERAPY
 Cure – client will be disease-free and live to normal life
expectancy
 Control – client’s cancer is not cured but controlled by therapy
over long periods of time
 Palliative – maintain as high a quality of life for the client when
cure and control are not possible
 Prophylaxis – provide treatment when no tumor is detectable
but when client is known to be at risk for tumor development,
spread, or recurrence

69. SURGERY

70. SURGERY
Diagnostic surgery – obtains tissue samples for
diagnostic purposes and determine methods of
treatment
Staging surgery – determines the extent of the cancer,
presence, and location of metastatic lesions
Curative surgery – removal of cancers that are localized
to the area of origin; extent of resection determined by
the type of tumor

71. SURGERY
 Palliative Surgery – does not impair the growth or spread of the
cancer, but improves the client’s quality of life. May be done to
relieve pain, decrease obstruction, relieve pressure, and to
prevent hemorrhage
 Reconstructive Surgery – restoration of the client’s form,
function, and appearance after radical surgery for cancer
 Preventive surgery – for clients who are in a high-risk category,
certain surgical procedures may prevent the future development
of cancer

72. CHEMOTHERAPY

73. CHEMOTHERAPY
 involves the use of antineoplastic drugs in an attempt
to destroy cancer cells by interfering with cellular
functions, including replication and DNA repair
 used primarily to treat systemic disease rather than
localized lesions that are amenable to surgery or
radiation

74. CHEMOTHERAPY
it maybe combined with radiation, surgery or both to
reduce tumor size preoperatively, to destroy any
remaining tumor cells postoperatively, or to treat some
forms of leukemia or lymphoma
 the goals of chemotherapy must be realistic because
they will determine the medications that are used and
the aggressiveness of the treatment plan

75. CLASSIFICATION OF
CHEMOTHERAPY

76. CELL CYCLE-SPECIFIC AGENTS
 exert their maximal effect during specific phases of the
cell cycle
 example: docetaxal, vinblastine, etoposide
 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

77. CELL CYCLE-NONSPECIFIC AGENTS
 act independently of the cell cycle phases
 example: busulfan, cicplatin, bleomycin
 have a prolonged effect on the cells, leading to cellular
damaged or death

78. CLASSIFICATION OF CHEMOTHERAPY
BASED ON CHEMICAL GROUP
 alkylating agent
 nitrosoureas
 antimetabolites
 antitumor antibiotics,
topoisomerase inhibitors
 plant alkaloids

79. ADJUNCT CHEMOTHERAPEUTIC AGENTS
 additional medications are given with chemotherapy
agents to enhance activity or protect normal cells from
injury
 example leucovorin is often given with fluorouracil to
treat colorectal cancer
 Leucovorin, a compound similar to folic acid, helps
fluorouracil bind with an enzyme inside of cancer cells
and enhances the ability of fluorouracil to remain in the
intracellular envirnment

80. ADMINISTRATION OF
CHEMOTHERAPEUTIC AGENT

81. DOSAGE
 based on the patient’s total body surface area, weight,
previous exposure and response to chemotherapy or
radiation therapy, and function of major organ systems.
 determined to maximize cell kill while minimizing
impact on healthy tissues and subsequent toxicities

82. EXTRAVASATION
 IV chemotherapy can damage tissue if it leak to
surrounding tissue ranging from mild to severe tissue
damage depending on whether the agent is classified as
an irritant or vesicant
 Irritant agents induce a localized inflammatory reaction
at the infusion site but do not cause permanent tissue
damage

83. EXTRAVASATION
 Vesicants are agents that cause inflammation, tissue
damage, and possibly necrosis of tendons, muscles,
nerves, and blood vessels if extravasation occurs

84. HYPERSENSITIVITY REACTIONS
 many chemotherapy agents pose a high risk and have
been associated with life-threatening outcomes
 associated manifestations of HSRs: rash, urticaria,
fever, hypotension, cardiac instability, dyspnea,
wheezing, throat tightness, and syncope
 desensitization may be possible if specific
chemotherapy agent is needed

85. TOXICITY
 it can be acute or chronic
 cells with rapid growth rates are very susceptibel to
damage, and the effects may manifest in all body
system

86. GASTROINTESTINAL SYSTEM
 most common side effects are nausea and vomiting,
which may persist for 24 to 48 hours; delayed may occur
up to 1 week after administration.
 corticosteroids, phenothiazines, sedatives, and
histamine are helpful, especially when used in
combination with serotonin blockers to provide
antiemetic protection

87. HEMATOPOIETIC SYSTEM
 many chemotherapy agent causes some degree of
myelosuppression, resulting in leukepenia, neutropenia,
anemia, thrombocytopenia, and increased risk of
infection and bleeding
 colony-stimulating factor and granulocyte macrophage
colony-stimulating factor can be given after
chemotherapy to stimulate the bone marrow to
produceWBCs, especially neutrophils, at an accelerated
rate, thus decreasing the duration of neutropenia

88. HEMATOPOIETIC SYSTEM
 Erythropoietin (EPO) stimulates RBC production, thus
decreasing the symptoms of treatment-induced chronic
anemia and reducing the need for blood transfusion
Interleukin 11 (IL-11) stimulates the production of
megakaryocytes (precursor to platelet) and can be used
to prevent and treat severe thrombocytopenia but with
caution because of possible toxicity

89. RENAL SYSTEM
 some chemotherapy agent cause renal dysfunction by
damaging the blood vessels or filtering structures of the
kidney
 manifestation can range from asymptomatic elevation
of serum electrolytes and creatinine levels to acute
kidney injury
 ex. Cisplatin, methotrexate, and mitomycin

90. RENAL SYSTEM
 monitoring of BUN, serum creatinine, creatinine
clearance and serum electrolytes is essential
 adequate hydration and diuresis to prevent formation
of uric acid crystals and administration of allopurinol
may be used to prevent toxicity
 Amifostine has the ability to minimize renal toxicity
associated with cisplatin, cyclophosphamide, and
ifosfamide therapy

91. RENAL SYSTEM
 Hemorrhagic cystitis is a bladder toxicity that can result
from cyclophosphamide and ifosfamide, and alkylating
agent therapy
 Hematuria can range from microscopic to frank
bleeding with symptoms ranging from transient
irritation during urination, dysuria, and suprapubic pain
to life-threatening hemorrhage
 management: IV hydration, frequent voiding and
diuresis

92. CARDIOPULMONARY SYSTEM
 Cardiac toxicity
 Antracyclines (daunorubicin, doxorubicin) cause
irriversible cardiac toxicity when total dosage reaches
400 mg/m2
 Bleomycin, carmustine, busulfan, mitomycin C, and
paclitaxel/ docetaxel have toxic effect on lung function

93. REPRODUCTIVE SYSTEM
 infertility
 problem in ovulation and early menopause
 men: azoospermia ( absence of spermatozoa)
 patients and their partner are informed about potential
changes in reproductive function
 teratogenic effect of chemotherapy

94. NEUROLOGIC SYSTEM
 chemotherapy-induced neurotoxicity
 metabolic encephalopathy (ifosfamide, methotrexate,
and cytarabine)
 tingling, pricking, or numbness of the extremities,
burning or freezing pain, sharp, stabbing, or electric
shock-like pain, and extreme sensititivity to touch
Progressive motor axon damage can lead to loss of deep
tendon reflexes, with muscle weakness, loss of balance
and coordination, and paralytic ileus

95. COGNITIVE IMPAIRMENT
 trouble with remembering dates, multitasking,
managing numbers and finances, organization, face or
object recognition, inability to follow directions, feeling
easily distracted, and motor and behavioral changes

96. FATIGUE
 an unusual, persistent, and subjective sense of tiredness
that is not proportional to recent activity and interferes
with usual functioning

97. NURSING MANAGEMENT

98. NURSING MANAGEMENT (CHEMOTHERAPY)
 Assess client for symptoms of bone marrow depression
(increased bruising and bleeding, sore throat, fever)
 Prevent exposure of client to people with communicable
diseases
 Safety guidelines for administration: avoid any accidental
spillage; wear latex gloves when handling drugs; use Luer-lok
fittings on all IV tubing; dispose of all equipment used to
administer antineoplastic agents according to policies and
procedures governing toxic and chemical waste disposal (leak-
proof and puncture-proof containers)

99. NURSING MANAGEMENT (CHEMOTHERAPY)
 Prior to therapy, establish a baseline regarding I & O, bowel habits,
oral hygiene, psychological status, and family relationships
 Inform client of side effects and nursing measures to reduce resulting
discomfort
 Monitor I & O; maintain adequate hydration to prevent urinary
complications
 Inform client that alopecia, if it occurs, is usually transient
 Check for possible drug interactions with chemotherapeutic agents

100. RADIATION THERAPY

101. RADIATIONTHERAPY
radiation destroys the cell’s ability to reproduce by
damaging the cellular DNA. Cells that are rapidly
reproducing are vulnerable to the effects of radiation.
Normal healthy cells recover more effectively from the
damage caused by radiation

102. TYPES OF RADIATIONTHERAPY
External beam therapy (teletherapy): radiation source is
outside the body.The radiation source is directed
toward the area of the tumor and draining lymphatics.
 Decreases the incidence of skin surface damage
 Client should not wash off the markers for the radiation
sites.

103. TYPES OF RADIATIONTHERAPY
 Implant therapy (brachytherapy, closed therapy, sealed source
of radiation is implanted directly into the tumor or into a body
cavity around a tumor.
 Delivers a large amount of radiation to a small area of the body.
May be used to treat uterine and cervical cancer
 A hollow applicator may be inserted surgically and the radioactive
source inserted in a treatment area and removed when the client
returns to the room.This decreases risk of accidental exposure due
to displacement

104. TYPES OF RADIATIONTHERAPY
Unsealed source (radiopharmaceutical or isotope) –
radioisotopes may be given IV, or into a body cavity, or
orally. Body fluids become contaminated

105. ADVERSE EFFECTS OF RADIATION
THERAPY
 a. Skin reactions
 1. Skin erythema
 2. Dry desquamation of the skin in the treatment field
 3.Wet desquamation particularly in areas of skin folds
(breast, perineum, axilla); skin may be blistered
 4. Loss of hair on the skin in the treatment field
 5. Skin pigmentation and discoloration
 b. Gastrointestinal disturbances

106. SAFETY PRECAUTIONSTO PREVENT EXPOSURE
a.Time – client care should be coordinated to provide for client
needs, but limit the nurse’s exposure time
b. Distance – the greater the distance from the source the less the
exposure. Except when giving direct care, attempt to maintain
distance of six feet from the source of radiation
c. Shielding – in practice lead shielding is difficult to work with,
generally not necessary if time and distance principles are
observed

107. NURSING IMPLICATIONS FOR A CLIENT WITH AN
INTERNAL RADIATION SOURCE (SEALED
SOURCE)
a. Private room and bath
b. A lead container and tongs should be present in the
client’s room
c. If implant becomes dislodged, it should be picked up
with the forceps and returned to the lead container.
Notify radiation therapist or officer immediately
d. Observe time, distance, and shield precautions

108. NURSING IMPLICATIONS FOR A CLIENT WITH AN
INTERNAL RADIATION SOURCE (SEALED
SOURCE)
e. Examples include uterine implants, testicular implants,
implants used in head and neck tumors
f. Inform all people coming in contact with the client of
the specific precautions necessary
g. Utilize badges or radiation monitors for caregivers
having direct client contact
h. Know where the radiation source is

109. NURSING IMPLICATIONS FOR A CLIENT WITH AN
INTERNAL RADIATION SOURCE (SEALED
SOURCE)
i. Client’s excretions are not radioactive because
radioisotopes are not in the circulation
h. List on the chart
1.Type of radiation
2.Time inserted
3. Anticipated removal time
4. Specific precaution for the type of radiation utilized

110. NURSING IMPLICATIONS FORTHE CLIENT
RECEIVING SYSTEMIC RADIATIONTHERAPY
a. Systemically administered radionuclides
(radioisotopes) may cause radioactive body secretions
b. May be necessary to have the linens and trach checked
for radioactivity prior to removing them from the room
c. Keep linens and trash in room until they have checked
for radioactivity by radiation therapy department

111. RADIATION SAFETY PRECAUTIONS
Private room and bath
Plan care so minimal time is spent in the room
When prolonged care is required, wear a lead shield or
apron
Wear a monitoring device to measure exposure
Mark on the room and in the Kardex that pregnant
women, infants, and young children should not come in
contact with the client during treatment

112. RADIATION SAFETY PRECAUTIONS
Check all linens and materials removed from the bed for
presence of foreign bodies that could be a source of
radioactivity
Keep long-handled forceps and lead container in the
room of a client with an implant in place
Do not wash off marks placed on client’s body for
purpose of identifying area for external radiation

113. IMMUNOTHERAPY
based on the theory that certain substances
stimulate the immune response and/ or attack the
tumor cells directly

114. LONG-TERM EFFECTS OFTREATMENT ON
THE CHILD
Impaired growth and development, especially from
radiation to growth centers of the bone during early
childhood and adolescence
Damage to the central nervous system
Gonadal aberrations, including reproductive, hormonal,
genetic, and teratogenic effects; decreased fertility
likely in adolescent receiving radiation, as in Hodgkin’s
disease

115. LONG-TERM EFFECTS OFTREATMENT ON
THE CHILD
Disturbances to other organs, including pneumonitis,
pericarditis, pleurisy, hypothyroidism, and cystitis
Development of a secondary malignancy, especially
after successful treatment of acute lymphocytic
leukemia, lymphoma,Wilm’s tumor, and retinoblastoma

116. NURSING INTERVENTION

117. TO MAINTAIN CLIENT AT OPTIMUM
PSYCHOSOCIAL LEVEL
 Encourage verbalization
 Assist client to understand disease process and therapeutic regime
 Include family in the care
 Assist client to cope with changes in body image due to alopecia
 Inform client if hair loss is anticipated, alopecia is most often temporary
and regrowth may begin before chemotherapy ends
 Encourage to select and wear a wig or turban
 Prevent or minimize hair loss by inducing scalp hypothermia

118. TO MAINTAIN CLIENT AT OPTIMUM
PSYCHOSOCIAL LEVEL
Instruct client with regards to hair care
 Use mild protein-based shampoo and cream conditioner
to help prevent hair dryness
 Advise client to shampoo only every 3 to 5 days
 Teach client to pat, not rub, hair dry after shampooing to
avoid excessive handling of brittle hair

119. TO MAINTAIN CLIENT AT OPTIMUM
PSYCHOSOCIAL LEVEL
Instruct client with regards to hair care
client to avoid excessive brushing to prevent tearing or
unnecessary manipulation of hair
Suggest client sleep on a satin pillowcase to decrease
hair tangles and friction
Encourage client to discontinue use of electric hair
dryers, hot rollers or crimpers, hair clips, sprays, dyes,
or permanents to prevent further hair damage

120. TO MAINTAIN CLIENT AT OPTIMUM
PSYCHOSOCIAL LEVEL
 Assess client’s support systems
 Recognize client’s emotional outbursts and anger as part of his
coping process
 Encourage measures to maintain ego
 Allow him to participate in his own care and make decisions
 Maintain active listening
 Encourage personal lifestyle (clothing, makeup, hobbies,
etc.)

121. TO MAINTAIN NUTRITION
 Diet – appropriate to age level
 Increase calories, increase protein
 Supplemental vitamins
 Small frequent feedings
 Increase fluid intake
 Between-meal supplements
 Hyperalimentation

122. TO MAINTAIN NUTRITION
Prevent and/ or decrease complications associated with
nutrition
Anorexia
Nausea and vomiting
Stomatitis

123. TO MAINTAIN NUTRITION
Meticulous oral hygiene (brushing with a nonabrasive
dentifrice (such as baking soda or saline) and flossing
after each meal and at bedtime
Observe oral mucosa daily
Provide nonirritating foods
Keep mucous membranes moist; encourage fluid intake
to prevent dehydration

124. TO MAINTAIN NORMAL ELIMINATION
PATTERN
Provide adequate fluids and fiber in diet to prevent
constipation
Prevent and/ or decrease complications of diarrhea
Antidiarrheal medications
Low residue, high protein, bland diet
Evaluate lab reports for electrolyte values

125. TO MAINTAIN NORMAL ELIMINATION
PATTERN
Evaluate fluid status
Prevent anal excoriation
Thorough cleansing of rectal area with mild soap and
water
Avoid irritation of the rectal area
Use ointments and sprays to decrease discomfort and
promote healing

126. TO MAINTAIN NORMAL ELIMINATION
PATTERN
3. Fresh fruits and vegetables should be eaten only after cooked,
peeled or washed thoroughly
4. Prevent urinary tract infections, primarily cystitis
a. Maintain adequate fluid intake (3000 cc per day)
b. Administer ascorbic acid to promote urine acidity
c. Frequent assessment of cystitis
d. Avoid bladder catheterization if possible
e. Encourage frequent voiding

127. TO MAINTAIN NORMAL ELIMINATION
PATTERN
5. Assess for the development of vesicovaginal or
rectovaginal fistulas
6. Minimize embarrassment of incontinence and provide
appropriate hygiene measures

128. TO PREVENT AND/ OR DECREASE
INFECTIOUS PROCESS
Careful assessment of temperature elevations
Administer antibiotics
Meticulous personal hygiene
Child should be isolated from communicable diseases,
especially chicken pox. Evaluate optimum time for child
to return to school

129. TO PREVENT AND/ OR DECREASE
INFECTIOUS PROCESS
Frequent assessment for potential infectious processes.
Explain how skin reactions following radiation therapy
may not develop for 10 – 14 days, and may not subside
until 2 – 4 weeks following treatment

130. TO PREVENT AND/ OR DECREASE
HEMATOLOGICAL COMPLICATIONS
Evaluate for decreasing platelets and thrombocytopenia
Institute bleeding precaution if platelet count is less
than 50,000/mm3
Administer platelets and whole blood transfusions as
indicated

131. TO PREVENT AND/ OR DECREASE
HEMATOLOGICAL COMPLICATIONS
Evaluate areas of potential bleeding
 Nosebleed (epistaxis)
 Urinary tract (hematuria)
 Stool (melena/ hematochezia)
 Mucous membranes
 Advise client to use electric razor and a soft-bristle
toothbrush

132. TO PREVENT AND/ OR DECREASE
HEMATOLOGICAL COMPLICATIONS
Anemia
Maintain adequate rest; encourage client to pace
activities to avoid fatigue
Maintain adequate oxygenation
Assess for problems with erythropoiesis
Evaluate respiratory and cardiac systems for
mechanisms of compensation
Encourage a diet high in protein, vitamins, and iron

133. TO MAINTAIN ACTIVITY LEVEL
Encourage daily activities within limitations of disease
process
Assist client to evaluate activity patterns and encourage
periods of rest
Avoid fatigue

134. TO RELIEVE PAIN
Evaluate client’s and family’s response to pain
Evaluate characteristics of pain
Promote general comfort
Administer medications for pain relief

135. TO RECOGNIZE COMPLICATIONS SPECIFIC
TO RADIATION AND CHEMOTHERAPY
Alopecia
Hemorrhagic problems
Gastrointestinal distress
Skin reactions
Decreased immune response

136. TO RECOGNIZE COMPLICATIONS SPECIFIC
TO RADIATION AND CHEMOTHERAPY
Bone marrow depression (myelosuppression)
Thrombocytopenia
Anemia
Neutropenia

137. SELF-CARE
 Limit number of people having direct contact with client
 Good oral hygiene – no flossing, soft toothbrush, avoid irritating foods
 Client should avoid coming in direct contact with animal excreta (cat litter
boxes, bird cages, etc.)
 Teach client to take his temperature daily and report temperature over
100oF (38oC)
 Use antipyretics cautiously – tend to mask infection
 Peak of neutropenia occurs within 7 to 14 days after the administration of
the chemotherapy

138. SELF-CARE
 Teach and manage radiation induced skin reactions
 Moisturize skin 3-4 x/ day with Eucerin or Lubriderm
 Gentle cleansing with normal saline; gently patted or air-dried;
expose areas for 10-15 minTID, if moist desquamation occurs
 Avoid use of perfuses, deodorants, and talcs
 Wear loose-fitting cotton clothing
 If dry desquamation, apply topical steroids, cornstarch, or
Benadryl