Cancer is caused by genetic mutations that cause uncontrolled cell growth. It is diagnosed through medical exams, imaging, biopsies and tumor marker tests. Treatment may involve surgery, chemotherapy and radiation. Surgery removes tumors while chemotherapy uses drugs to destroy cancer cells. Prevention focuses on healthy behaviors and cancer screening to detect cancers early. Ongoing research aims to better understand and treat cancer.

2. ONCOLOGY
 field or study of cancer

3. INTRODUCTION
Cancer is a disease process that begins when an
abnormal cell is transformed by the genetic mutation of
the cellular DNA.
Although cancer affects people of all ages, most
cancers occur in people older than 65 years of age.
Overall, the incidence of cancer is higher in men than in
women and higher in industrialized sectors and nations.

4. DEFINITION
Cancer is a disease process whereby cells proliferate
abnormally, ignoring growth-regulating signals in the
environment surrounding the cells

5. CONTI…..
benign:
not cancerous; benign tumors may grow but are unable to
spread to other areas
malignant:
having cells or processes that are characteristic of cancer
carcinogenesis:
process of transforming normal cells into malignant cells
neoplasia:
uncontrolled cell growth that follows no physiologic demand

6.  metaplasia: conversion of one type of mature cell into
another type of cell
 metastasis: spread of cancer cells from the primary tumor
to distant sites
CONTI…..

7. Meaning of cancer
C – cellular
A – abnormalities
N – nucleolus
C – Cytoplasm
E – emigration
R – reproduction

8. Tumor cells
Benign malignant

10. T (tumor) - The extent of the primary tumor
N(node) - The absence or presence and extent of regional lymph
node metastasis
M(metastasis) - The absence or presence of distant metastasis
The use of numerical subsets of the TNM components indicates the progressive
extent of the malignant disease.
TNM Classification System

12. Staging of cancer
T—primary tumor
Tx—primary cannot be evaluated
T0—no evidence of primary tumor
Tis—carcinoma in situ
T1, T2, T3, T4—increasing size and/or local extent of primary tumor
N—presence or absence or regional lymph node involvement
Nx—regional lymph nodes are unable to be assessed
N0—no regional lymph node involvement
N1, N2, N3—increasing involvement of regional lymph nodes
M—absence or presence of distant metastasis
Mx—unable to assess
M0—absence of distant metastasis
M1—presence of distant metastasis

13. Grading
Stage 0: Very early cancer on the
inner / outer most layer
Stage I: Cancer is in the inner/
outer layers
 Stage II: Cancer has spread
through the muscle wall
 Stage III: Cancer has spread to
the lymph node
 Stage IV: Cancer that has spread to
other organs

14. CHARACTERISTICS OF BENIGN AND MALIGNANT NEOPLASMS
CHARACT
ERISTICS
BENIGN MALIGNANT
Cell
characterist
ics
Well-differentiated cells that
resemble normal cells of the tissue
from which the tumor originated
Cells are undifferentiated and often bear little
resemblance to the normal cells of the tissue
from which they arose
Mode of
growth
Tumor grows by expansion and
does not infiltrate the surrounding
tissues; usually that infiltrate and
destroy the surrounding
encapsulated
Grows at the periphery and sends out processes
tissues
Rate of
growth
Rate of growth is usually slow Rate of growth is variable and depends on level
of differentiation; the more anaplastic the
tumor, the faster its growth
Metastasis Does not spread by metastasis Gains access to the blood and lymphatic
channels and metastasizes to other areas of the
body

15. General effects Is usually a localized
phenomenon that does not
cause generalized effects
unless its location
interferes with vital
functions
Often causes generalized effects,
such as anemia, weakness, and
weight loss
Tissue
destruction
Does not usually cause tissue
damage unless its location
interferes with blood flow
Often causes extensive tissue
damage as the tumor outgrows its
blood supply or encroaches on blood
flow to the area; may also produce
substances that cause cell damage
Ability to cause
death
Does not usually cause death
unless its location interferes
with vital functions
Usually causes death unless growth
can be controlled

17. CLASSIFICATION
 carcinoma, the majority of cancer cells
are epithelial in origin, beginning in the
membranous tissues that line the surfaces
of the body.
 leukaemia, originate in the tissues
responsible for producing new blood cells,
most commonly in the bone marrow.
Carcinoma
There are different categories of cancer cell, defined according to the cell
type from which they originate.
Leukaemia

18.  lymphoma and myeloma, derived from
cells of the immune system.
 sarcoma, originating in connective
tissue, including fat, muscle and bone.
Central nervous system, derived from
cells of the [body] and spinal cord.
 mesothelioma, originating in
the mesothelium; the lining of body
cavities.
Lymphoma and Myeloma
Sarcoma
Mesothelioma

19. ETIOLOGY
 Viruses and Bacteria, (Epstein-Barr virus , Helicobacter pylori (H. pylori)
 Physical agents, (exposure to sunlight or radiation, chronic irritation or inflammation, and
tobacco use.)
 Chemical agents, (list of suspected chemical substances continues to grow and includes
aromatic amines and aniline dyes; pesticides and formaldehydes; arsenic, soot, and tars; asbestos; benzene;
betel nut and lime; cadmium; chromium compounds; nickel and zinc ores; wood dust; beryllium compounds;
and polyvinyl chloride.)
 Genetic or familial factors, (genetics, shared environments, cultural or lifestyle factors,
or chance alone)
 Dietary factors, and (risk of cancer include fats, alcohol, salt-cured or smoked meats, nitrate-
containing and nitrite-containing foods, and red and processed meats)
 Hormonal agents.

20. It is three-step cellular process involving –
initiation, promotion, and progression
 initiation
 initiators (carcinogens), such as chemicals, physical factors, and biologic
agents, escape normal enzymatic mechanisms and alter the genetic structure
of the cellular DNA. Normally, these alterations are reversed by DNA repair
mechanisms or the changes initiate programmed cellular death. Occasionally,
cells escape these protective mechanisms, and permanent cellular mutations
occur. These mutations usually are not significant to cells until the second
step of carcinogenesis.
Malignant transformation, or
carcinogenesis,

21.  Promotion
 repeated exposure to promoting agents (cocarcinogens) causes the expression of
abnormal or mutant genetics information even after long latency periods. Latency
periods for the promotion of cellular mutations vary with the type of agent and the
dosage of the promoter as well as the innate characteristics of the target cell.
 Cellular oncogenes are responsible for the vital cellular functions of growth and
differentiation. Cellular proto-oncogenes act as an “on switch” for cellular growth.
Proto-oncogenes are influenced by multiple growth factors that stimulate cell
proliferation, such as epidermal growth factor (EGF) and transforming growth
factor alpha.
 Another proto-oncogene that plays an important role in cancer development is the
k-ras (KRAS2) oncogene located on chromosome. Just as proto-oncogenes “turn on”
cellular growth, cancer suppressor genes “turn off,” or regulate, unneeded cellular
proliferation.

22.  When suppressor genes mutate or lose their regulatory capabilities, malignant cells
are allowed to reproduce. The p53 (TP53) gene is a tumor suppressor gene that is
frequently implicated in many human cancers. This gene determines whether cells
will live or die after their DNA is damaged. Apoptosis is the innate cellular process
of programmed cell death. Alterations in TP53 may decrease apoptotic signals, thus
giving rise to a survival advantage for mutant cell populations. Mutant TP53 is
associated with a poor prognosis and may be associated with determining response
to treatment. Once this genetic expression occurs in cells, the cells begin to produce
mutant cell populations that are different from their original cellular ancestors.
 progression
 the altered cells exhibit increased malignant behavior. These cells have a propensity
to invade adjacent tissues and to metastasize. Agents that initiate or promote
cellular transformation are referred to as carcinogens.

23. Carcinogenesis
Mutation inactivates tumor suppressor gene
Cells proliferate
Mutation inactivates DNA repair gene
Mutation of proto-oncogene creates an oncogene
Mutation inactivates several more tumor suppressor genes
cancer

24. warning sign of cancer
 Change in bowel or bladder
habits.
 A sore that does not heal.
 Unusual bleeding or discharge.
 Thickening or lump in the
breast or elsewhere.
 Indigestion or difficulty in
swallowing.
 Obvious change in a wart or
mole.
 Nagging cough or hoarseness

25. Diagnosis
 Complete medical history and physical examination
 Tumor marker identification
 Fine-needle aspiration (FNA)
 Genetic profiling
 Mammography (Use of x-ray images of the breast)
 Magnetic resonance imaging
 Computed tomography (CT)
 Fluoroscopy (Use of x-rays that identify contrasts in body tissue densities; may involve the use of contrast agents)
 Ultrasonography (ultrasound)
 Endoscopy
 Nuclear medicine imaging
 Positron emission tomography (PET)
 Radio-immuno-conjugates

26. Prevention
Detection and Prevention Primary prevention and secondary prevention are
effective measures in decreasing mortality and morbidity of many cancers.
Primary Prevention
The assessment or reduction of risk factors before the disease occurs:
1. Make appropriate lifestyle changes.
2. Stop smoking.
3. Limit alcohol intake
4. Eat a healthy diet as outlined above.
5. Be physically active: maintain a healthy weight and follow exercise
guidelines outlined above.
6. Avoid sun exposure, especially during the hours of 10 a.m. and 4 p.m. and
cover exposed skin with sunscreen with a skin protection factor of 15 or
higher.
7. Those at high risk for certain cancers should consider genetic counseling
and testing.

27. 8. Chemoprevention—the use of natural or synthetic substances to reduce the risk of developing
cancer.
1. Aspirin—doses of at least 75 mg daily can decrease the risk of colorectal cancer.
2. Tamoxifen and raloxifene—can reduce the risk of breast cancer in women who are at high risk
by nearly 50%.
3. Finasteride—may reduce the risk of prostate cancer.
4. COX-2 inhibitors—may reduce the risk colorectal cancer.
5. Vitamin D—may play a role in reducing the risk of breast cancer.
6. Statins—may reduce the risk of prostate, lung, colorectal, and breast cancers.
9. Vaccinations—HPV(Human papilloma virus) is now known to cause about 70% of cervical
cancers. HPV vaccines are aimed at preventing genital warts, precancerous cervical lesions,
cervical cancer, and anal, penile, and oro-pharyngeal cancers in both men and women. The
Advisory Committee on Immunization Practices in conjunction with the Center for Disease
Control and Prevention has established guidelines on the use of this vaccine.
1. Routine HPV vaccination is recommended for males and females ages 11 to 13, may begin as
early as age 9.
2. HPV vaccination is also recommended for males and females ages 13 to 18 to “catch up” missed
doses of the vaccine or complete the vaccination series.
3. HPV vaccination is not currently recommended for persons over age 26.
4. Screening for cervical cancer should continue in both vaccinated and unvaccinated women

28. Secondary Prevention
 1. The goal of screening is early detection to improve overall outcome and
survival. Performing routine screening tests should be based on whether
these tests are adequate to detect a potentially curable cancer in an
otherwise asymptomatic person and are also cost-effective.
 2. Screening should be based on an individual’s age, sex, family history of
cancer, ethnic group or race, previous iatrogenic factors (prior radiation
therapy or drugs), and history of exposure to environmental carcinogens.

29.  patients at high risk may decide to undergo testing. Currently, the
National Comprehensive Cancer Network recommends lung cancer
screening in high-risk individuals using low-dose computed tomography
(CT). High-risk individuals are men or women age 55 to 74 with at least a
30 pack per year history of smoking and smoking cessation for less than 15
years; or men or women at least 50 years old with a 20 or more pack per
year history of smoking and one additional risk factor
 make an informed decision with their health care providers about
whether to be tested for prostate cancer.

30. Types of Surgical Procedures
The role of surgery can be divided into several
approaches: preventive, primary surgery, cyto-reductive,
salvage treatment, palliative treatment, and
reconstructive.
 1. Preventive/prophylactic surgery—removal of
lesions that, if left in the body, are at risk of
developing into cancer; for example, resection of
polyps in the rectum or mastectomy in women who
are at high risk.
 2. Primary surgery—complete surgical removal of a
malignant tumor and may include regional lymph
nodes and neigh-boring structures. This can be
performed laparoscopically in some cases.

31.  3. Cytoreductive surgery—partial removal of bulk of
disease. This is performed when the spread of
tumor precludes the removal of all disease. In some
cases, this approach improves survival when used in
combination with chemotherapy (ie, ovarian
cancer).
 4. Salvage treatment—use of an extensive surgical
approach to treat a local recurrence.
 5. Palliative treatment—attempts to relieve the
complications of cancer (eg, obstruction of the GI
tract, pain produced by tumor extension into
surrounding nerves).
 6. Reconstructive/rehabilitative surgery—repair of
defects from previous radical surgical resection; can
be performed early (breast reconstruction) or
delayed (head and neck surgery).

32. Chemotherapy
 Chemotherapy is the use of antineoplastic drugs to promote tumor cell
destruction by interfering with cellular function and reproduction. It
includes the use of various chemotherapeutic agents and hormones.

33.  The intent of chemotherapy is to destroy as many tumor cells as possible with minimal effect on
healthy cells.
 Cancer cells depend on the same mechanisms for cell division as normal cells. Damage to those
mechanisms leads to cell death.
 Chemotherapy is utilized in different clinical settings:
 Adjuvant(helping) chemotherapy is the use of systemic treatment following surgery and/or
radiation therapy. Adjuvant therapy is given to patients who have no evidence of residual
disease but who are at high risk for relapse.
 Neo-adjuvant chemotherapy is the use of systemic treatment prior to primary surgery or
radiation. The goal is to shrink or downstage the primary tumor to improve the effectiveness
of surgery as well as control/ irradicate microscopic cancer cells. High-dose/intensive
therapy is the administration of high doses of chemotherapy, usually in association with
growth factor support before bone marrow transplant/stem cell rescue.
 Palliative(supportive) chemotherapy is used when a cure is not possible to control the
cancer and minimize side effects from the disease.
Principles of Chemotherapy Administration

34.  Chemotherapeutic agents can be effective on any stage of the cell cycle in
which cells are dividing. The cell cycle is divided into five stages
 G0 (gap 0) resting phase: Cells are not dividing in this stage and, for the most
part, are refractory to chemotherapy.
 G1 (gap one) phase: Ribonucleic acid (RNA) and protein synthesis (enzymes for
DNA synthesis) are manufactured.
 S (synthesis) phase: During a long period, the DNA component doubles for the
chromosomes in preparation for cell division.
 G2 (gap two) phase: This is a short period; protein and RNA synthesis occurs, and
the mitotic spindle apparatus is formed.
 M (mitosis) phase: In an extremely short period, the cell divides into two
identical daughter cells.

35.  Routes of administration:
 Oral—capsule, tablet, or liquid.
 Intravenous (IV)—push (bolus) or infusion over
a specified period.
 Intramuscular.
 Intrathecal/intraventricular—given by injection
via an Ommaya reservoir or by lumbar puncture.
 Intra-arterial.
 Intracavitary—such as peritoneal cavity.
 Intravesical—into uterus or bladder.
 Topical.
 Dosage is based on surface area (mg/m2) in both adults and children.
 Most chemotherapeutic agents have dose-limiting toxicities that require nursing
interventions. Chemotherapy predictably affects normal, rapidly growing cells (eg, bone
marrow, GI tract lining, hair follicles). It is imperative that these toxicities be recognized
early by the nurse.

36. Classification of Chemotherapeutic Agents
CLASSIFICATI
ON
Mechanism of
Action
COMMON THERAPEUTIC USES
Cell Cycle Specificity
Common Side Effects
Alkylators Alter DNA
structure by
misreading
DNA code,
initiating
breaks in the
DNA
molecule,
cross-linking
DNA strands
Cell cycle–nonspecific Bone marrow
suppression, nausea,
vomiting, cystitis
(cyclophosphamide,
ifosfamide),
stomatitis, alopecia,
gonadal suppression,
(overian damage)
renal toxicity
(cisplatin)
Cyclophospha
mide
Lymphomas, leukemias, and a variety of
solid tumors
Busulfan Chromic myleocytic leukemia, bone
marrow transplantation
Carboplatin Ovarian cancer
Chlorambucil Chronic lymphocytic leukemia, Hodgkin’s
disease
Cisplatin Ovarian, testicular, bladder, cervical, non-
small-cell lung cancer, esophageal
Dacarbazine Malignant melanoma, Hodgkin’s
lymphoma, sarcomas
Ifosfamide Testicular, lymphoma, sarcomas, ovarian,
bone
Melphalan Multiple myeloma, ovarian, malignant
melanoma
Oxaliplatin Colorectal cancers
Temozolomide Glioblastoma, astrocytoma, melanoma

37. Nitrosoureas
Carmustine omustine
Semustine streptozocin
(Zanosar)
Similar to the
alkylating agents;
cross the blood–brain
barrier
Cell cycle–
nonspecific
Delayed and cumulative
myelo suppression, especially
thrombocytopenia; nausea
vomiting
Topoisomerase I
Inhibitors
Irinotecan (Camptosar)
Topotecan (Hycamtin)
Induce breaks in the
DNA strand by binding
to enzyme
topoisomerase I,
preventing cells from
dividing
Cell cycle–
specific (S
phase)
Bone marrow suppression,
diarrhea, nausea, vomiting,
hepatotoxicity
Anti tumor Antibiotics
Bleomycin (BLM,
Blenoxane), dactinomycin
(Cosmegen),
daunorubicin
(DaunoXome),
doxorubicin (Adriamycin),
idarubicin
Interfere with DNA
synthesis by binding
DNA; prevent RNA
synthesis
Cell cycle–
nonspecific
Bone marrow suppression,
nausea, vomiting, alopecia,
anorexia, cardiac toxicity
(daunorubicin, doxorubicin)
Conti……

38. Antimetabolites
5-Azacytadine, capecitabine
(Xeloda), cytarabine (DepoCyt,
Tarabine) edatrexate fludarabine
(Fludara), (Gemzar), hydroxyurea
(Droxia, Hydrea), 5-fluorouracil
(5-FU),
Interferes with the
biosynthesis of
metabolites or nucleic
acids necessary for
RNA and DNA
synthesis
Cell cycle–
specific (S
phase)
Nausea, vomiting,
diarrhea, bone marrow
suppression, proctitis,
stomatitis, renal
toxicity
(methotrexate),
hepatotoxicity
Mitotic Spindle Poisons
Plant alkaloids: etoposide
(Toposar), teniposide (Vumon)
vinblastine (Velban), vincristine
(VCR [Oncovin]), vindesine
(Eldisine), vinorelbine
(Navelbine)
Arrest metaphase by
inhibiting mitotic
tubular formation
(spindle); inhibit
DNA and protein
synthesis
tubulin
depolymerization
Cell cycle–
specific (M
phase)
bone marrow
suppression,
neuropathies (VCR),
stomatitis Bradycardia,
hypersensitivity
reactions, bone
marrow suppression,
alopecia,
neuropathies
Conti……

39. Hormonal Agents
Androgens and antiandrogens,
estrogens and antiestrogens,
progestins and antiprogestins,
aromatase inhibitors,
luteinizing hormone–releasing
hormone analogues, steroids
Bind to hormone receptor
sites that alter cellular
growth; block binding of
estrogens to receptor
sites (antiestrogens);
inhibit RNA synthesis;
suppress aromatase of
P450 system, which
decreases level
Cell cycle–
nonspecific
Hypercalcemia,
jaundice, increased
appetite,
masculinization,
feminization, sodium
and fluid retention,
nausea, vomiting, hot
flashes, vaginal
estrogen dryness
Miscellaneous Agents
Asparaginase (Elspar),
procarbazine (Matulane)
Unknown or too complex
to categorize
Varies Anorexia, nausea,
vomiting, bone
marrow suppression,
hepatotoxicity,
anaphylaxis,
hypotension, altered
glucose
metabolism
Conti……

40. CLASSIFICATI
ON
NAME
MEDICATION
ROUTE OF
ADMINISTRATION
COMMON THERAPEUTIC USES
Thiotepa IV, I.M., SC, IT Breast, ovarian, bladder, lymphomas, bone
marrow transplantation
Antibiotics Bleomycin IV, SC, I.M. Head and neck cancers, cervical, lymphomas,
testicular, Hodgkin’s
Dactinomycin IV Ewing’s sarcoma, Wilms’ tumor, testicular
Daunorubicin IV Leukemias
Doxorubicin IV Breast, ovarian, prostate, thyroid, lung, head and
neck cancers, leukemia
Doxorubicin
liposo-mal
IV Ovarian, breast, AIDS-related sarcoma
Epirubicin IV Breast cancer
Mitomycin IV Pancreatic, stomach, colon, lung, bladder,
esophageal
Mitoxantrone IV Prostate acute myelocytic leukemia
Conti……

41. Safety Measures in Handling Chemotherapy
 cytotoxic drugs are considered to be hazardous to health care workers and
special handling is required to minimize the exposure and overall health risks
Personal Protective Equipment
 1. Gloves—wear gloves that are powder-free, such as nitrile, polyurethane, or
neoprene, and have been tested for use with hazardous drugs. Avoid latex drugs
due to potential latex sensitivity. Double gloves are recommended for all
handling.
 2. Gowns—wear a disposable, lint-free gown made of low-permeability fabric.
The gown should have a solid front, long sleeves, tight cuffs, and back closure.
The inner glove should be worn under the gown cuff and the outer glove should
extend over the gown to protect the skin. Gown and gloves are meant for single
use only.

42.  3. Respirators—wear a National Institute for Occupational Health and
Safety approved respirator mask when there is a risk of aero-sol exposure
such as when administering chemotherapy or clean-ing a spill. Surgical
masks do not provide adequate protection.
 4. Eye and face protection—wear a face shield and/or mask that provides
splash protection whenever there is a possibility of splashing.
 5. Wear personal protective equipment whenever there is a risk of
chemotherapy being released into the environment such as preparation or
mixing of chemotherapy, spiking/priming IV tubing, administering the
drug, and when handling body fluids or chemotherapy spills.

43. Personal Safety to Minimize Exposure
 1. Prepare cytotoxic drugs in a vertical laminar flow hood.
 2. Wash hands before donning PPE and change gloves after each use,
tear, puncture, or medication spill or after every 60 minutes of wear.
Wash hands after removing PPE.
 3. Vent vials with filter needle to equalize the internal pressure or use
negative-pressure techniques.
 4. Wrap gauze or alcohol pads around the neck of ampules when
opening to decrease droplet contamination.
 5. Wrap gauze or alcohol pads around injection sites when removing
syringes or needles from IV injection ports.

44.  Use puncture- and leak-proof containers for non-capped, non-clipped needles.
 Prime all IV tubing with normal saline or other compatible solution to reduce exposure.
 Use syringes and IV tubing withluer locks (which have a locking device to hold needle firmly in
place).
 Label all syringes and IV tubing containing chemotherapeutic agents as hazardous material.
 Place an absorbent pad directly under the injection site to absorb any accidental spillage.
 Do not eat, drink, or chew gum while preparing or handling chemotherapy agents.
 Keep all food and drink away from preparation area.
 Avoid hand-to-mouth or hand-to-eye contact while handling chemotherapeutic agents or body
fluids of the patient receiving chemotherapy.
 If any contact with the skin occurs, immediately wash the area thoroughly with soap and water.
 If contact is made with the eye, immediately flush the eye with water and seek medical
attention.
 Spill kits should be available in all areas where chemotherapy is stored, prepared, and
administered.

45. Safe Disposal of Antineoplastic Agents, Body Fluids, and Excreta
1. Discard gloves and gown into a leak-proof container, which should be marked as
contaminated or hazardous waste.
2. Use puncture- and leak-proof containers for needles and other sharp or breakable
objects.
3. Linens contaminated with chemotherapy or excreta from patients who have
received chemotherapy within 48 hours should be contained in specially marked
hazardous waste bags.
4. Wear nonsterile nitrile gloves for disposing of body excreta and handling soiled
linens within 48 hours of chemotherapy administration.
5. In the home, wear gloves when handling bed linens or clothing contaminated with
chemotherapy or patient excreta within 48 hours of chemotherapy administration.
Place linens in a separate, washable pillow case. Wash separately in hot water and
regular detergent.

46. Adverse Effects of Chemotherapy
 All chemotherapy drugs have adverse effects. Adverse effects are exacerbated if the
patient is younger than 1 year or is elderly, has comorbid conditions, or has impaired
renal or hepatic function.
 Alopecia
 1. Most chemotherapeutic agents cause some degree of alopecia. This is dependent on the
drug dose, half-life of drug, and duration of therapy.
 2. Usually begins 2 weeks after administration of chemotherapy. Regrowth takes about 3 to 5
months.
 3. The use of scalp hypothermia and tourniquets is highly controversial.
 Anorexia
 1. Chemotherapy changes the reproduction of taste buds.
 2. Absent or altered taste can lead to a decreased food intake.
 3. Concurrent renal or hepatic disease can increase anorexia.

47.  Diarrhea
 1. Defined as loose or watery stool. If left untreated, can lead to severe
dehydration, electrolyte imbalances, hospitalizations, and treatment delays.
 2. Cause is multi factoral, but up to 90% of all patients receiving
chemotherapy can experience diarrhea.
 Fatigue
 The cause of fatigue is generally unknown but can be related to anemia,
weight loss, altered sleep patterns, and coping.
 Nausea and Vomiting
 1. Caused by the stimulation of the vagus nerve by serotonin released by cells
in the upper GI tract.
 2. Incidence depends on the particular chemotherapeutic agent and dosage.

48.  3. Patterns of nausea and vomiting
 a. Anticipatory—conditioned response from repeated asso-ciation between therapy and vomiting;
can be prevented with adequate anti-emetic control.
 b. Acute—occurs 0 to 24 hours after chemotherapy adminis-tration.c. Delayed—can occur 1 to 6
days after chemotherapy administration; nausea is often worse than vomiting.
 Mucositis
 1. Caused by the destruction of the oral mucosa, causing an in ammatory
response.
 2. Initially presents as a burning sensation with no changes in the mucosa and
progresses to significant breakdown, ery-thema, and pain of the oral mucosa.
 3. Consistent oral hygiene is important to avoid infection.

49.  Neutropenia
 1. Defined as an absolute neutrophil count of 1,500/mm3 or less.
 2. Primary dose-limiting toxicity of chemotherapy.
 3. Risk of infection is greatest with an ANC less than 500/mm3.
 4. Caused by suppression of the stem cell.
 5. Usually occurs 7 to 14 days after administration of chemo-therapy, but depends on the agent used.
 6. Can be prolonged.
 7. Patients should be taught to avoid infection through proper hand washing and hygiene and avoiding
those with illness. Eliminating raw meats, seafood, eggs or unwashed vegetables is also recommended
 8. Patients need to be monitored and treated promptly for fever or other signs of infection.
 9. Can be prevented with the use of growth factors (eg, granulocyte colony-stimulating factor [CSF],).
 Anemia
 1. Caused by suppression of the stem cell or interference with cell proliferation pathways.
 2. May require red blood cell transfusion or injection of erythropoietin or darbepoetin.

50. Radiation Therapy
More than half of patients with cancer receive a form of radiation therapy at
some point during treatment. Radiation may be used to cure cancer, as in thyroid
carcinomas, localized cancers of the head and neck, and cancers of the uterine
cervix. Radiation therapy may also be used to control malignant disease when a
tumor cannot be removed surgically or when local nodal metastasis is present, or
it can be used neo-adjuvantly (prior to local definitive treatment)

51. Two types of ionizing Radiation
 electromagnetic radiation (x-
rays and gamma rays)
 particulate radiation
(electrons, beta particles,
protons, neutrons, and alpha
particles)

52. Radiation Dosage
 The 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. The lethal tumor dose is defined as that dose
that will eradicate 95% of the tumor yet preserve normal tissue.
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.
 applications include teletherapy (external beam radiation), brachytherapy (internal
radiation), systemic (radioisotopes), and contact or surface molds

53.  In external beam radiation, the total radiation dose is delivered over several
weeks in daily doses called fractions. This allows healthy tissue to repair and to
achieve greater cell kill by exposing more cells to the radiation as they begin
active cell division. Repeated radiation treatments over time (fractionated doses)
also allow for the periphery of the tumor to be re-oxygenated repeatedly, because
tumors shrink from the outside inward. This increases the radio-sensitivity of
the tumor, thereby increasing tumor cell death
 Internal radiation implantation, or brachytherapy, delivers a high dose of
radiation to a localized area. The specific radioisotope for implantation is
selected on the basis of its half-life, which is the time it takes for half of its
radioactivity to decay. Internal radiation can be implanted by means of needles,
seeds, beads, or catheters into body cavities (vagina, abdomen, pleura) or
interstitial compartments (breast, prostate).

54. Toxicity
 Toxicity of radiation therapy is localized to the region being irradiated.
Toxicity may be increased if concomitant chemotherapy is administered.
Acute local reactions occur when normal cells in the treatment area are also
destroyed and cellular death exceeds cellular regeneration.

55. Thermal Therapy
 Hyperthermia (thermal therapy), the generation of temperatures greater than
physiologic fever range (greater than 41.5°C [106.7°F]), has been used for many years
to destroy cancerous tumors. Malignant cells may be more sensitive than normal cells
to the harmful effects of high temperatures for several reasons. Malignant cells lack
the mechanisms necessary to repair damage caused by elevated temperatures. Most
tumor cells lack an adequate blood supply to provide needed oxygen during periods
of increased cellular demand, such as during hyperthermia. Cancerous tumors lack
blood vessels of adequate size for dissipation of heat. In addition, the body’s immune
system may be indirectly stimulated when hyperthermia is used

56. Targeted Therapies
 Recent scientific advances have led to an improved understanding of cancer
development. Traditional therapies such as chemotherapy and radiation
affect all actively proliferating cells. As a result, both healthy cells and
malignant cells are subject to harmful systemic effects of treatment.
 Biologic response modifier (BRM) therapy involves the use of naturally
occurring or recombinant (reproduced through genetic engineering) agents
or treatment methods that can alter the immunologic relationship between
the tumor and the cancer patient (host) to provide a therapeutic benefit

57.  Nonspecific Biologic Response Modifiers Some of the early investigations
of the stimulation of the immune system involved nonspecific agents such as
bacille Calmette-Guérin (BCG) and Corynebacterium parvum. When injected
into the patient, these agents serve as antigens that stimulate an immune
response.
 Monoclonal Antibodies (MoAbs), another type of BRM, have become
available through technologic advances, enabling investigators to grow and
produce targeted antibodies for specific malignant cells. Theoretically, this
type of specificity allows MoAbs to destroy the cancer cells and spare normal
cells.

58. Bone Marrow Transplantation
 Although surgery, radiation therapy, and chemotherapy have improved
survival rates for patients with cancer, many cancers that initially respond to
therapy recur. This is true of hematologic cancers that affect the bone marrow
and solid tumor cancers treated with lower doses of antineoplastics to spare
the bone marrow from larger, ablative doses of chemotherapy or radiation
therapy. The role of bone marrow transplantation (BMT) for malignant and
some nonmalignant diseases continues to grow.

59. Types of Bone Marrow Transplant
Types of BMT based on the source of donor cells include:
 Allogeneic: from a donor other than the patient; donor may
be a related donor (ie, family member) or a matched
unrelated donor (national bone marrow registry, cord
blood registry)
 Autologous: from the patient
 Syngeneic: from an identical twin

60. OTHER…
Cancer Vaccines
Gene Therapy
Complementary and Alternative Medicine (CAM)
Unproven and Unconventional Therapies

61. Nursing Management in Cancer
 Patients undergoing surgery for cancer require general perioperative
nursing care
 require specific care related to age, organ impairment, nutritional deficits,
disorders of coagulation, and altered immunity that may increase the risk
of postoperative complications.
 Combining other treatment methods, such as radiation and chemotherapy,
with surgery also contributes to postoperative complications, such as
infection, impaired wound healing, altered pulmonary or renal function,
and the development of deep vein thrombosis.
 preoperative assessment

62. NURSING DIAGNOSIS: Risk for infection related to inadequate defenses related to
myelosuppression secondary to radiation or antineoplastic agents.
Nursing Interventions
1. Assess patient for evidence of infection:
 Check vital signs every 4 hours.
 Monitor white blood cell (WBC) count and differential each day.
 Inspect all sites that may serve as entry ports for pathogens (intravenous sites, wounds,
skin folds, bony prominences, perineum, and oral cavity).
2. Report fever (38.3°C [101°F] or 38°C [100.4°F] for longer than 1 hour), chills, diaphoresis,
swelling, heat, pain, erythema, exudate on any body surfaces. Also report change in
respiratory or mental status, urinary frequency or burning, malaise, myalgias, arthralgias,
rash, or diarrhea.
3. Obtain cultures and sensitivities as indicated before initiation of antimicrobial treatment
(wound exudate, sputum,urine, stool, blood).

63. NURSING DIAGNOSIS: Impaired skin integrity: erythematous and wet desquamation
reactions to radiation therapy
Nursing Interventions
 1. In erythematous areas:
 a. Avoid the use of soaps, cosmetics, perfumes, powders, lotions and ointments, deodorants.
 b. Use only lukewarm water to bathe the area.
 c. Avoid rubbing or scratching the area.
 d. Avoid shaving the area with a straight-edged razor.
 e. Avoid applying hot-water bottles, heating pads, ice, and adhesive tape to the area.
 f. Avoid exposing the area to sunlight or cold weather.
 g. Avoid tight clothing in the area. Use cotton clothing.
 h. Apply vitamin A and D ointment to the area.
 2. If wet desquamation occurs:
 a. Do not disrupt any blisters that have formed.
 b. Avoid frequent washing of the area.
 c. Report any blistering.
 d. Use prescribed creams or ointments.
 e. If area weeps, apply a nonadhesive absorbent dressing.
 f. If the area is without drainage, use moisture and vapor-permeable dressings such as
hydrocolloids and hydrogels on noninfected areas(Swearingen, 2008).
 g. Consult with enterostomal therapist (ET) and physician if eschar forms.

64. NURSING DIAGNOSIS: Impaired oral mucous membrane: stomatitis
Nursing Interventions
 1. Assess oral cavity daily.
 2. Instruct patient to report oral burning, pain, areas of redness, open lesions on the lips, pain associated with
swallowing, or decreased tolerance to temperature extremes of food.
 3. Encourage and assist in oral hygiene.
Preventive
 a. Advise patient to avoid irritants such as commercial mouthwashes, alcoholic beverages, and tobacco.
 b. Brush with soft toothbrush; use nonabrasive toothpaste after meals and bedtime; floss every 24 hours
unless painful or platelet count falls below 40,000 cu/mm.
Mild stomatitis (generalized erythema, limited ulcerations, small white patches: Candida)
 c. Use normal saline mouth rinses every 2 hours while awake; every 6 hours at night.
 d. Use soft toothbrush or toothette.
 e. Remove dentures except for meals; be certain dentures fit well.
 f. Apply water soluble lip lubricant.
 g. Avoid foods that are spicy or hard to chew and those with extremes of temperature.